Preventing Outbreaks:

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 all."

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 turn.

"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 based."

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

"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 materials."

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 uneventful."

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

"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

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