By Kelli M. Donley
It is the word that every healthcare worker (HCW) dreads: outbreak. With thetumultuous events of the past year, the possibility of widespread disease hasbecome an overriding concern for every infection control practitioner (ICP).
However, many healthcare professionals hesitate to contact public healthofficials. Epidemiologists argue they cannot help fight infections they do notknow about. Merging the talents of public health departments and ICPs some sayis crucial for efficacious outbreak preparedness.
Epidemiologists were faced with an unprecedented health alarm in October2001. Americans in several states were falling ill with various forms ofanthrax. Federal officials sent police officers and Federal Bureau ofInvestigation (FBI) agents to inspect postal facilities, healthcare centers andhomes of those infected. Epidemiologists pushed their way through the crowd ofofficials to uncover the details of the bioterrorism attack.
While a culprit is not behind bars at time of press, public health officialsdid determine the attack was taking place via the mail, with Bacillus anthracisspores 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 theCenters for Disease Control and Prevention (CDC) responded with presentationsand updates.
The CDC's top epidemiological team was working at a frantic pace. TheEpidemic Intelligence Service (EIS) has been compared to the CentralIntelligence Agency (CIA), but with pathogens, not terrorists, being publicenemy No. 1.
Founded in 1951 after the Korean War, EIS officers have been responsible forseveral significant health breakthroughs, including: continuing poliovaccinations in 1955 after a contaminated batch instead infected children; thediscovery of Legionella pneumophila as the cause of death of 34 participants ata 1976 American Legion Convention in Philadelphia; the discovery in 1981 thatHIV/AIDS was transmitted by exposure to blood and bodily fluids; and determiningCryptosporidium, a waterborne parasite, was responsible for a widespreadoutbreak of diarrhea in Milwaukee in 1993.1, 2
Having EIS officers work with local health department officials and ICPsafter the Sept. 11 attack was deemed necessary. There are two distinct types ofoutbreaks: nosocomial and community-based. While many community diseases, suchas tuberculosis or HIV, must be reported by law to the state health department,some nosocomial infections, such as group A strep, Streptococcus pyogenes, andantibiotic resistant strains, do not. Diseases that must be reported vary bystate, creating problems for national health surveillance.
However, some health officials are wary of asking for outside help unlessthey are mandated to do so.
Bruce Polsky, MD, is the chief of the division of infectious diseases andmedical director of the virology laboratory at St. Luke's-Roosevelt HospitalCenter in New York City. Bioterrorism victims were treated at the facility.
"We had cases of cutaneous anthrax," he says, "but they wereall outpatient cases."
Outside of diseases that must be reported, like anthrax, Polsky says askingepidemiologists for help is rarely necessary.
"Of course, if there are certain sorts of infections, we are mandated tocontact the state, but in general, in terms of having epidemiologists come in todo a hospital investigation, that is rare," he says. "Normally, whenwe get involved with the state or with the CDC, the situation involves a stringof hospital admissions for similar conditions. The community will set offconcern and the infection control team will trigger a wider investigation."
However, Marcia Goldoft, MD, MPH, deputy state epidemiologist for Washingtonstate, says community concern should not spurn request for help; the naturalinstinct of HCWs should.
"Fundamentally, epidemiologists rely on practitioners to identifyclusters," she says. "Laboratory testing takes time, so if thepractitioner doesn't notice there is a problem or a cluster, and doesn't contactthe state, either we hear about it too late, or we do not hear about it atall."
Clare Kioski, MPH, CIC and a state epidemiologist in Arizona, specializes intracking noscomial infections. Her work, she says, is dependent on ICPsreporting illness.
"The hospital does not have to contact me, but they can if something isgoing on," she says. Kioski says although she is not currently working onan outbreak, she is constantly monitoring the state's cases of legionella, groupA strep, strep pneumo, invasive strep pneumo and antibiotic resistance.
At time of press, Goldoft and other members of the Washington stateepidemiological 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 totheir facilities and causing havoc. Instead, she is worried HCWs are hesitant todiscuss their problems with infection control because they don't know where toturn.
"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 woulddirectly result in fines. We are non-enforcing and non-regulatory type ofconsultants. We are just there to help."
Libby F. Chinnes, RN, BSN, CIC, an infection control consultant with ICSolutions in Mount Pleasant, S.C., says hospital epidemiologists can be the toolICPs need to get through a difficult situation.
"I have used an epidemiologist routinely in my infection controlpractice," she says. "When consulting with even small acute carefacilities, I routinely recommend the services of a trained hospitalepidemiologist to serve as a resource for the ICP. This person, usually aninfectious disease physician with infection control and prevention training, canbe of tremendous assistance to the ICP regarding infectious diseases andisolation protocols, possible clusters of disease, questions about surveillancedata, 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 healthdepartment epidemiologists handle a potential outbreak, step by step, mayincrease understanding.
"While procedures vary by state, in Washington we initially discuss thematter by phone," she says. "I try to identify what the organism isand how it is likely to have been transmitted. They we try to come up with ascenario to explain what happened. That is really what epidemiologists do;essentially we try to write a script for what went wrong. The goal obviously isobviously to stop it from reoccurring.
"The problem is not obvious, or the ICP would have prevented it in thefirst place. It is often subtle. The next step is something more formal -- wereview the charts and look for anything the patients affected may have incommon. This can come down to extreme detail."
Chinnes says the role of the hospital epidemiologist is to look at thepopulation as a whole for trends, rather than just the individual's illness.
"Epidemiology is a population-based science and differs from clinicalmedicine in that medicine focuses on the individual, whereas epidemiologyfocuses on the community as a whole," she says. "Epidemiology makescomparisons by the use of numerical values and looks for groups at high and lowrates of disease so that reasons for disease can be postulated. The ICP shouldenlist the assistance of the epidemiologist to direct the outbreak investigationdetermining the need for emergency meetings, cultures, studies and communicationwith the news media. The epidemiologist should be able to interpret and analyzethe data to draw conclusions upon which preventive and control measures will bebased."
Greg Carter, RN, CIC, manager of infection control and central sterileprocessing at Kettering Medical Center in Dayton, Ohio, says working together isimportant.
"Do not be afraid to ask for help," he advises ICPs. "BothICPs and epidemiologists share the same goal when it comes to communicable andinfectious diseases -- control and prevention."
Goldoft says finding the minute similarities to reach these goals can takeextensive research.
"I worked on a very difficult outbreak in another state that wasLegionnaire's disease," she says. "The cases seemed to be scatteredthrough the hospital. I went through the charts day-by-day and discovered thatat some point, every patient had spent the night in one specific area of thehospital. They had been transferred several times, so their current room did notrelate to their area of exposure. The all had been in the same place at the sametime about one week before. It took painstaking review of the charts. The firstmap I had showed where the patients were currently, and they didn't seem torelate. I had to go through the charts to see that they had been moved severaltimes during their hospitalization. There was one line in the water system thathad been contaminated. If you showered or were in that room, you were athigh-risk. It was a difficult investigation."
Polsky says nosocomial outbreaks can be prevented with education followingbasic rules.
"Outbreaks in my experience generally occur when patients are notappropriately isolated and are not put on appropriate precautions for theirconditions," he says. "When personnel -- nurses, physicians,phlebotomists, etc. -- do not adhere to those precautions when they see apatient, they are potentially spreading whatever it is that you are trying toisolate from other patients. Really, the cornerstone of ensuring adherence iseducation. Make sure that staff is aware of what needs to be done and thereasons 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 toasking 'What type of dressing did you put on the salad.' Yet, the classics areoperating room outbreaks. You have to go through the chart and list every nursethat was in the room, people that may have come in, like anesthesiologists,everything that was brought into the room during surgery, whether materials wereflash sterilized, if all the materials were used, etc ... In every case, youdetermine the cause of infection and make procedure changes so it doesn't happenagain. We educate one on one with HCWs, give occasional lectures, and providematerials."
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 enoughinformation to base a conclusion to the cause?; If it meets the criteria,prepare yourself for a rapid response to the problem; Timing is everything inthe control and prevention of further outbreaks; Know your resources and do notbe afraid of using them."
With the memories of the anthrax scare fresh in their minds, many hospitaladministrators decided immediate review of infection control policies wasnecessary. 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 stateepidemiologist for the Florida Department of Health. Wiersma says he was in hisoffice working late when he heard about the first case of anthrax.
"Our county health department did an extensive investigation before itwas known what we were dealing with," he says. "I flew down withadditional staff and continued the investigation."
Since then, Wiersma says his department has become acutely aware of thepossibilities they face each day. "The new sense of importance of this workhas 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 anincreased awareness of incoming patients," she says. "We had a hugenumber of requests for lectures on how to detect an outbreak. I think what haschanged is that ICPs are now thinking more like epidemiologists. They arethinking to look for outbreaks. There are more ICPs wondering if their nextpatient could be a case of bioterrorism. Before Sept. 11, there wasn't as muchattention paid to looking for clusters."
Chinnes says the attacks on the United States gave HCWs a broader perspectivein their own work.
"Since Sept. 11, we as ICPs have become more proficient at looking atthe whole picture by participating on multidisciplinary teams involving ourfacilities and community to address issues dealing with bioterrorism," shesays. "We are on constant alert for unusual diseases or presentations ofdisease, as well as clusters of illness which may indicate a problem. We mustnow anticipate bioterrorism as an additional underlying cause of theseillnesses. Many facilities have instituted syndrome surveillance in an effort tolook 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 universalprecautions is necessary to monitor, control and prevent future outbreaks.
"The most challenging aspect of infection control remains thebasics," Polsky says. "The basics are adherence by staff ofprecautions as simple as handwashing."
Goldoft agrees. She says her most stringent advice to HCWs is, "Washyour 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 torealize that you are making an impact. If an ICP does a perfect job, nothinghappens -- no one gets sick, no one spends an additional day in the hospital. Itcan seem as though nothing is happening, but the absence of illness and theincrease in handwashing are the hallmarks of an excellent job. You don't getpatients leaping off of the table after surgery, but you do get patients whowalk away from surgery and never have a complication and never realize thatsomeone has put in so much effort to make their hospital stay souneventful."
Jon Rosenberg, MD, an epidemiologist with the California Department of HealthServices in the division of communicable diseases, also says handwashing isessential.
"If you prevent infections, you will also prevent outbreaks," hesays. "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 traditionalinfection control standpoint, you will prevent the most common source ofoutbreaks, which are patient-to-patient from the hands of HCWs."
Wiersma says ICPs must reach out to health officials in their communities toprovide the best service to their patients.
"Always expect the unexpected and realize that the local and statehealth departments are interested in linking what may be going on in yoursetting with another facility many miles away," he says. "Get to knowyour public health officials."
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 monitoredin all states.
acute pelvic inflammatory disease
E. coli 0157:H7
hepatitis non-A, non-B
invasive Haemophilus Influenzae disease
paralytic shellfish poisoning
polio (vaccine related)
toxic shock syndrome
Information from the Washington State Department of Health