Preventing Outbreaks:

September 1, 2002

Preventing Outbreaks:
How Epidemiologists, ICPs Must Work Together to Protect Patients

 By Kelli M. Donley

It is the word that every healthcare worker (HCW) dreads: outbreak. With the
tumultuous events of the past year, the possibility of widespread disease has
become an overriding concern for every infection control practitioner (ICP).

However, many healthcare professionals hesitate to contact public health
officials. Epidemiologists argue they cannot help fight infections they do not
know about. Merging the talents of public health departments and ICPs some say
is crucial for efficacious outbreak preparedness.

Infection Investigators

Epidemiologists were faced with an unprecedented health alarm in October
2001. Americans in several states were falling ill with various forms of
anthrax. Federal officials sent police officers and Federal Bureau of
Investigation (FBI) agents to inspect postal facilities, healthcare centers and
homes of those infected. Epidemiologists pushed their way through the crowd of
officials to uncover the details of the bioterrorism attack.

While a culprit is not behind bars at time of press, public health officials
did determine the attack was taking place via the mail, with Bacillus anthracis
spores infecting some who came in contact with the fateful letters.

With the first case of anthrax reported less than one month after the Sept.
11 attacks, the nation sat on edge waiting for information. Officials at the
Centers for Disease Control and Prevention (CDC) responded with presentations
and updates.

The CDC's top epidemiological team was working at a frantic pace. The
Epidemic Intelligence Service (EIS) has been compared to the Central
Intelligence Agency (CIA), but with pathogens, not terrorists, being public
enemy No. 1.

Founded in 1951 after the Korean War, EIS officers have been responsible for
several significant health breakthroughs, including: continuing polio
vaccinations in 1955 after a contaminated batch instead infected children; the
discovery of Legionella pneumophila as the cause of death of 34 participants at
a 1976 American Legion Convention in Philadelphia; the discovery in 1981 that
HIV/AIDS was transmitted by exposure to blood and bodily fluids; and determining
Cryptosporidium, a waterborne parasite, was responsible for a widespread
outbreak of diarrhea in Milwaukee in 1993.1, 2

Having EIS officers work with local health department officials and ICPs
after the Sept. 11 attack was deemed necessary. There are two distinct types of
outbreaks: nosocomial and community-based. While many community diseases, such
as tuberculosis or HIV, must be reported by law to the state health department,
some nosocomial infections, such as group A strep, Streptococcus pyogenes, and
antibiotic resistant strains, do not. Diseases that must be reported vary by
state, creating problems for national health surveillance.

However, some health officials are wary of asking for outside help unless
they are mandated to do so.

Bruce Polsky, MD, is the chief of the division of infectious diseases and
medical director of the virology laboratory at St. Luke's-Roosevelt Hospital
Center in New York City. Bioterrorism victims were treated at the facility.

"We had cases of cutaneous anthrax," he says, "but they were
all outpatient cases."

Outside of diseases that must be reported, like anthrax, Polsky says asking
epidemiologists for help is rarely necessary.

"Of course, if there are certain sorts of infections, we are mandated to
contact the state, but in general, in terms of having epidemiologists come in to
do a hospital investigation, that is rare," he says. "Normally, when
we get involved with the state or with the CDC, the situation involves a string
of hospital admissions for similar conditions. The community will set off
concern and the infection control team will trigger a wider investigation."

However, Marcia Goldoft, MD, MPH, deputy state epidemiologist for Washington
state, says community concern should not spurn request for help; the natural
instinct of HCWs should.

"Fundamentally, epidemiologists rely on practitioners to identify
clusters," she says. "Laboratory testing takes time, so if the
practitioner doesn't notice there is a problem or a cluster, and doesn't contact
the state, either we hear about it too late, or we do not hear about it at

Clare Kioski, MPH, CIC and a state epidemiologist in Arizona, specializes in
tracking noscomial infections. Her work, she says, is dependent on ICPs
reporting illness.

"The hospital does not have to contact me, but they can if something is
going on," she says. Kioski says although she is not currently working on
an outbreak, she is constantly monitoring the state's cases of legionella, group
A strep, strep pneumo, invasive strep pneumo and antibiotic resistance.

At time of press, Goldoft and other members of the Washington state
epidemiological team were working furiously to determine the source of an E.
coli outbreak that had sickened more than 30 people.

"If it is not reportable, we would never hear about it," she says.

Yet Goldoft doesn't think the ICPs are worried about big brother coming in to
their facilities and causing havoc. Instead, she is worried HCWs are hesitant to
discuss their problems with infection control because they don't know where to

"It is probably more that they don't know where to call," she says.
"I have nothing to do with licensing. Of course, if we do find a problem,
the licensing group may come in and ask questions, but nothing I do would
directly result in fines. We are non-enforcing and non-regulatory type of
consultants. We are just there to help."

Libby F. Chinnes, RN, BSN, CIC, an infection control consultant with IC
Solutions in Mount Pleasant, S.C., says hospital epidemiologists can be the tool
ICPs need to get through a difficult situation.

"I have used an epidemiologist routinely in my infection control
practice," she says. "When consulting with even small acute care
facilities, I routinely recommend the services of a trained hospital
epidemiologist to serve as a resource for the ICP. This person, usually an
infectious disease physician with infection control and prevention training, can
be of tremendous assistance to the ICP regarding infectious diseases and
isolation protocols, possible clusters of disease, questions about surveillance
data, assistance with studies and employee exposures, to name a few."

Understanding the Role of Epidemiologists

Godloft says teaching ICPs how their local, county and state health
department epidemiologists handle a potential outbreak, step by step, may
increase understanding.

"While procedures vary by state, in Washington we initially discuss the
matter by phone," she says. "I try to identify what the organism is
and how it is likely to have been transmitted. They we try to come up with a
scenario to explain what happened. That is really what epidemiologists do;
essentially we try to write a script for what went wrong. The goal obviously is
obviously to stop it from reoccurring.

"The problem is not obvious, or the ICP would have prevented it in the
first place. It is often subtle. The next step is something more formal -- we
review the charts and look for anything the patients affected may have in
common. This can come down to extreme detail."

Chinnes says the role of the hospital epidemiologist is to look at the
population as a whole for trends, rather than just the individual's illness.

"Epidemiology is a population-based science and differs from clinical
medicine in that medicine focuses on the individual, whereas epidemiology
focuses on the community as a whole," she says. "Epidemiology makes
comparisons by the use of numerical values and looks for groups at high and low
rates of disease so that reasons for disease can be postulated. The ICP should
enlist the assistance of the epidemiologist to direct the outbreak investigation
determining the need for emergency meetings, cultures, studies and communication
with the news media. The epidemiologist should be able to interpret and analyze
the data to draw conclusions upon which preventive and control measures will be

Greg Carter, RN, CIC, manager of infection control and central sterile
processing at Kettering Medical Center in Dayton, Ohio, says working together is

"Do not be afraid to ask for help," he advises ICPs. "Both
ICPs and epidemiologists share the same goal when it comes to communicable and
infectious diseases -- control and prevention."

Goldoft says finding the minute similarities to reach these goals can take
extensive research.

"I worked on a very difficult outbreak in another state that was
Legionnaire's disease," she says. "The cases seemed to be scattered
through the hospital. I went through the charts day-by-day and discovered that
at some point, every patient had spent the night in one specific area of the
hospital. They had been transferred several times, so their current room did not
relate to their area of exposure. The all had been in the same place at the same
time about one week before. It took painstaking review of the charts. The first
map I had showed where the patients were currently, and they didn't seem to
relate. I had to go through the charts to see that they had been moved several
times during their hospitalization. There was one line in the water system that
had been contaminated. If you showered or were in that room, you were at
high-risk. It was a difficult investigation."

Polsky says nosocomial outbreaks can be prevented with education following
basic rules.

"Outbreaks in my experience generally occur when patients are not
appropriately isolated and are not put on appropriate precautions for their
conditions," he says. "When personnel -- nurses, physicians,
phlebotomists, etc. -- do not adhere to those precautions when they see a
patient, they are potentially spreading whatever it is that you are trying to
isolate from other patients. Really, the cornerstone of ensuring adherence is
education. Make sure that staff is aware of what needs to be done and the
reasons behind the precautions."

Goldoft agrees that after sorting through the web of potential pathogens,
education is key to preventing reoccurrence.

"It is all in the details," she says. "It can come down to
asking 'What type of dressing did you put on the salad.' Yet, the classics are
operating room outbreaks. You have to go through the chart and list every nurse
that was in the room, people that may have come in, like anesthesiologists,
everything that was brought into the room during surgery, whether materials were
flash sterilized, if all the materials were used, etc ... In every case, you
determine the cause of infection and make procedure changes so it doesn't happen
again. We educate one on one with HCWs, give occasional lectures, and provide

Carter says there is a set of rules ICPs should follow to prevent outbreaks.

"ICPS should learn the five key elements in understanding epidemiology,"
he says. "They are: Do you have an outbreak?; Do you have strong enough
information to base a conclusion to the cause?; If it meets the criteria,
prepare yourself for a rapid response to the problem; Timing is everything in
the control and prevention of further outbreaks; Know your resources and do not
be afraid of using them."

September 12

With the memories of the anthrax scare fresh in their minds, many hospital
administrators decided immediate review of infection control policies was
necessary. Some officials say although policy may not have changed post Sept.
11, attitude has.

Steven Wiersma, MD, MPH is the chief of the bureau of epidemiology and state
epidemiologist for the Florida Department of Health. Wiersma says he was in his
office working late when he heard about the first case of anthrax.

"Our county health department did an extensive investigation before it
was known what we were dealing with," he says. "I flew down with
additional staff and continued the investigation."

Since then, Wiersma says his department has become acutely aware of the
possibilities they face each day. "The new sense of importance of this work
has helped," he says.

Goldoft says policy hasn't changed, but practices have become more important.

"I don't know if infection control has changed, but there has been an
increased awareness of incoming patients," she says. "We had a huge
number of requests for lectures on how to detect an outbreak. I think what has
changed is that ICPs are now thinking more like epidemiologists. They are
thinking to look for outbreaks. There are more ICPs wondering if their next
patient could be a case of bioterrorism. Before Sept. 11, there wasn't as much
attention paid to looking for clusters."

Chinnes says the attacks on the United States gave HCWs a broader perspective
in their own work.

"Since Sept. 11, we as ICPs have become more proficient at looking at
the whole picture by participating on multidisciplinary teams involving our
facilities and community to address issues dealing with bioterrorism," she
says. "We are on constant alert for unusual diseases or presentations of
disease, as well as clusters of illness which may indicate a problem. We must
now anticipate bioterrorism as an additional underlying cause of these
illnesses. Many facilities have instituted syndrome surveillance in an effort to
look at groups of signs and symptoms of disease more quickly in patients."

Preparing for the Future

Both epidemiologists and ICPs agree that education about basic universal
precautions is necessary to monitor, control and prevent future outbreaks.

"The most challenging aspect of infection control remains the
basics," Polsky says. "The basics are adherence by staff of
precautions as simple as handwashing."

Goldoft agrees. She says her most stringent advice to HCWs is, "Wash
your hands!" Her guidance for ICPs is more involved.

"I want to reassure ICPs that their work is extremely important,"
she says. " You cannot count infections that do not happen. It is hard to
realize that you are making an impact. If an ICP does a perfect job, nothing
happens -- no one gets sick, no one spends an additional day in the hospital. It
can seem as though nothing is happening, but the absence of illness and the
increase in handwashing are the hallmarks of an excellent job. You don't get
patients leaping off of the table after surgery, but you do get patients who
walk away from surgery and never have a complication and never realize that
someone has put in so much effort to make their hospital stay so

Jon Rosenberg, MD, an epidemiologist with the California Department of Health
Services in the division of communicable diseases, also says handwashing is

"If you prevent infections, you will also prevent outbreaks," he
says. "We know that a substantial amount of infections are not preventable.
From that perspective, if you do the best job that you can from the traditional
infection control standpoint, you will prevent the most common source of
outbreaks, which are patient-to-patient from the hands of HCWs."

Wiersma says ICPs must reach out to health officials in their communities to
provide the best service to their patients.

"Always expect the unexpected and realize that the local and state
health departments are interested in linking what may be going on in your
setting with another facility many miles away," he says. "Get to know
your public health officials."

Did You Know?

The following is a list of diseases that must be reported in Washington.
Other state lists will vary, but the majority of these illnesses are monitored
in all states.

acute pelvic inflammatory disease
botulsim, infant
E. coli 0157:H7
encephalitis, arthropod-borne
foodborne outbreaks
genital herpes
hepatitis A
hepatitis B
hepatitis non-A, non-B
invasive Haemophilus Influenzae disease
Kawasaki syndrome
Lyme disease
meningococcal disease
non-gonococcal urethritis
paralytic shellfish poisoning
polio (vaccine related)
Pseudomonas folliculitis
relapsing fever
toxic shock syndrome
typhoid fever

Information from the Washington State Department of Health