Overview Summer Cmmunicable Disease Frum July 28, 2016 Cntinuing educatin credits grup sign in sheet needed fr persns nt lgged in t webinar Plls Questins Recrding Slides psted n NJLMN under Practice Exchange CDS Training Resurces Website GI Prgram Updates: Cryptspridisis & Giardiasis New investigatin chapters and wrksheets Wrksheets guide investigatrs when interviewing cases infrmatin needs t be entered int CDRSS Updated case definitins Cryptspridisis Case definitin change, Ag+ is nw classified as a Prbable case Giardiasis Case must have symptms and a psitive lab test t be classified as Cnfirmed N symptms indicated in CDRSS wuld make the case Nt a Case. Outbreaks f bth diseases, as well as Shigella, nrvirus and E. cli 0157:H7 assciated with recreatinal water ccur mre frequently in the summer please ask abut water expsures when interviewing cases. http://www.nj.gv/health/cd/crypt/techinf.shtml http://www.nj.gv/health/cd/giardi/techinf.shtml GI Prgram Updates: Cyclspra Case Reprt Frm NEW! NJDOH Cyclspra Surveillance Case Reprt Frm Replaces frmer CDC frm Used by interviewer while interviewing case (shuldn t be faxed t prvider) Must be cmpleted and faxed t CDS: 609 826 5972 Pages 1 2 must be cmpleted fr all cases Pages 3 9 shuld be cmpleted ONLY IF NO INTERNATIONAL TRAVEL IS REPTED Salient infrmatin shuld be entered int CDRSS (e.g. travel histry, dates fr mst cases) http://www.nj.gv/health/cd/cycl/techinf.shtml GI Prgram Updates: Outbreak Cntrl Guidelines Updated! Guidelines fr the Cntrl f Gastrenteritis Outbreaks in Lng Term Care and Other Institutinal Settings (July 2016) Majr changes: 1. Discussin f additinal causative agents ther than nrvirus, e.g., campylbacter, salmnella, etc. 2. Mre detailed labratry cllectin and submissin prtcl (nrvirus & bacterial testing) 3. Case definitin has been expanded (similar t respiratry guidelines): Definitin f a Gastrintestinal Outbreak in LTC Settings One labratry cnfirmed psitive case f nrvirus alng with ther cases f gastrintestinal illness in the facility; Tw r mre labratry cnfirmed psitive cases f an enteric pathgen (e.g., Campylbacter, E. cli, Salmnella, Shigella, etc.) in the facility; A sudden increase ver the nrmal backgrund rate f acute gastrintestinal illness, with r withut lab cnfirmatin (abve the established baseline fr that facility). http://www.state.nj.us/health/cd/manual/gi_ltc.pdf 1
VPDP Reminder Regarding Use f Case Definitins The NJDOH/VPDP fllws the mst current case definitins published n the NNDSS website: http://wwwn.cdc.gv/nndss/ Prvide set f unifrm criteria fr reprting purpses that allws public health t classify and cunt cases cnsistently acrss jurisdictins NOT fr use by healthcare prviders t determine hw t meet an individual patient s health needs (public health vs clinical management) Case definitins are generally updated yearly T search fr ntifiable disease case definitins by name and by year, use the search tls n the left side f the NNDSS website: http://wwwn.cdc.gv/nndss/ 2015 Meningcccal disease; 2014 Pertussis; 2013 Measles, Rubella; 2012 Hepatitis B (acute & chrnic), Mumps; 2010 CRS, Diphtheria, Pli, Tetanus, Varicella Pertussis Case Definitin Updated January 2014 (primarily affecting infants <12m) Apnea added as a symptm Cugh f any duratin w/ any sx AND w/ PCR+ epi link t cnfirmed case = Prbable http://wwwn.cdc.gv/nndss/script/cnditinsummary.aspx?cndid=113 Labratry limitatins make clinical case definitin essential Cugh duratin, specifically whether it lasts 14 days r lnger, is needed D nt wait until day 14 t begin investigatin as it is imprtant t institute public health measures t prevent spread f disease Determine whether patient had whp parxysms psttussive vmiting ( apnea if < 12 m) If yes, check thse symptms in the S&S tab If n, dcument a brief nte in cmments (eg Pt did nt experience whp, parxysms, r pst tussive vmiting ) If nt clear, we will ask abut any that are missing DNC Surveillance 9:30 Welcme Agenda Philadelphia, July 25 28 NJDOH is cllabrating with Philadelphia Department f Public Health n enhanced surveillance including EpiCenter July 21 August 1 NJ DNC Regin: Burlingtn, Camden, Glucester cunties Syndrmes being mnitred: Fever, ILI Specified, Respiratry, Rash, Vmiting, Diarrhea, Heat Related Illness (HRI) Specified, Drugs, Gunsht, Vilence, Tear gas, Mental Health, Out f State, DNC (includes keywrds that may be related t the DNC e.g., cnventin, DNC, etc) Daily surveillance summary sent t Health Officers in NJ DNC Regin Passive surveillance fr reprtable diseases and clusters/utbreaks with pssible relevance t DNC 9:40 Rabies update: Management f Dmestic Animal Expsures Kristin Garafal, Zntic Disease Epidemilgist 10:10 Rle f NJDOH Lng term Care Survey/Licensing in infectin cntrl and utbreak investigatin Sue Kelley, Prgram Manager, Lng Term Care Cmplaints, NJDOH Health Facility Survey & Field Operatins 10:40 New CDRSS Preview Simi Octania Ple, Directr, Data Systems & Evaluatin 10:55 Ht Tpic! Travel Related Arbviral Diseases in NJ: Chikungunya, Dengue, and Zika Karen Wrthingtn, Zntic Disease Team 11:25 Feedback and questins 11:30 Adjurn Nurses Nurses Participants must attend the entire sessin in rder t earn cntact hur credits Attendees must participate in all learning activities Verificatin f participatin will be nted by webinar attendance reprts r grup sign in sheet and cmpletin f nline evaluatin Participants cannt miss mre than 5 minutes frm a 30 minute sessin; 10 minutes frm a 60 minute sessin Participants must cmplete the nline prgram evaluatin and include yur name and e mail address t receive nursing certificate N cmmercial supprt has influenced the planning f the educatinal bjectives and cntent f this event N influential relatinships have been disclsed by planners r presenters which wuld influence the planning f this activity. If any arise, an annuncement will be made at the beginning f the sessin There is n endrsement f any prduct by the NJSNA r the ANCC assciated with this sessin 2
RABIES UPDATE: Management f Dmestic Animal Rabies Expsures Overview f animal cnfinement perids utilized in rabies cntrl Kristin Garafal, MPH, CHES Zntic Disease Epidemilgist What is a suspect rabid animal? Any bat, raccn, skunk, fx, r grundhg* Other wildlife* and dmestic animals* shwing clinical signs f rabies (abnrmal behavir with neurlgic impairment) Any animal submitted fr rabies labratry testing but is deemed unsatisfactry fr testing by labratry staff A KNOWN rabid animal is ne that was cnfirmed rabid thrugh labratry testing * Unless fund negative thrugh labratry testing Expsure Categries Categry 1: Visible bite wund frm knwn r suspect rabid animal Categry 2: Direct cntact with knwn r suspect rabid animal; n visible bite wunds Categry 3: Bite wunds f unknwn rigin Categry 4: Pssible cntact with, r in the vicinity f, a knwn r suspect rabid animal; n visible wunds Expsure Categry Categry 1 (visible bite frm knwn r suspect rabid animal) Categry 2 (direct cntact with knwn r suspect rabid animal; n visible wunds) Currently Vaccinated The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Previusly Vaccinated with Dcumentatin The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Vaccinatin Status and Respnse Never Vaccinated Recmmend euthanasia Veterinarian reprts t lcal health department if wner declines euthanasia Health Officer issues ntice t strictly quarantine the expsed animal fr 4 mnths Health Officer apprves the quarantine enclsure befre cnfinement begins Previusly Vaccinated WITHOUT Dcumentatin Treat animal as if never vaccinated (abve) veterinarian may request that Health Officer assist with the Prspective Serlgical Mnitring prtcl (see attached) Health Officer issues ntice t strictly quarantine the expsed animal until serlgy results are interpreted Expsure Categry Vaccinatin Status and Respnse Expsure Categry Vaccinatin Status and Respnse Currently Vaccinated Never Vaccinated Currently Vaccinated Never Vaccinated Categry 1 (visible bite frm knwn r suspect rabid animal) The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Recmmend euthanasia Veterinarian reprts t lcal health department if wner declines euthanasia Health Officer issues ntice t strictly quarantine the expsed animal fr 4 mnths Health Officer apprves the quarantine enclsure befre cnfinement begins Categry 1 (visible bite frm knwn r suspect rabid animal) The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Recmmend euthanasia Veterinarian reprts t lcal health department if wner declines euthanasia Health Officer issues ntice t strictly quarantine the expsed animal fr 4 mnths Health Officer apprves the quarantine enclsure befre cnfinement begins Categry 2 (direct cntact with knwn r suspect rabid animal; n visible wunds) Previusly Vaccinated with Dcumentatin The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Previusly Vaccinated WITHOUT Dcumentatin Treat animal as if never vaccinated (abve) veterinarian may request that Health Officer assist with the Prspective Serlgical Mnitring prtcl (see attached) Health Officer issues ntice t strictly quarantine the expsed animal until serlgy results are interpreted Categry 2 (direct cntact with knwn r suspect rabid animal; n visible wunds) Previusly Vaccinated with Dcumentatin The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Previusly Vaccinated WITHOUT Dcumentatin Treat animal as if never vaccinated (abve) veterinarian may request that Health Officer assist with the Prspective Serlgical Mnitring prtcl (see attached) Health Officer issues ntice t strictly quarantine the expsed animal until serlgy results are interpreted 3
Expsure Categry Categry 1 (visible bite frm knwn r suspect rabid animal) Categry 2 (direct cntact with knwn r suspect rabid animal; n visible wunds) Currently Vaccinated The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Previusly Vaccinated with Dcumentatin The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Vaccinatin Status and Respnse Never Vaccinated Recmmend euthanasia Veterinarian reprts t lcal health department if wner declines euthanasia Health Officer issues ntice t strictly quarantine the expsed animal fr 4 mnths Health Officer apprves the quarantine enclsure befre cnfinement begins Previusly Vaccinated WITHOUT Dcumentatin Treat animal as if never vaccinated (abve) veterinarian may request that Health Officer assist with the Prspective Serlgical Mnitring prtcl Health Officer issues ntice t strictly quarantine the expsed animal until serlgy results are interpreted Prspective Serlgical Mnitring Prtcl Applies t dgs and cats that may have been previusly vaccinated (n prf) Initiatin f prtcl: Animal is seen immediately after expsure by a veterinarian wh immediately ntifies LHD Day 0: Day 5: Cllect 2ml serum and refrigerate Administer rabies vaccinatin Schedule fllw up appintment fr 5 7 days later Cllect secnd serum sample Submit paired serum specimens t apprved rabies labratry (RFIT) Determinatin f Vaccinatin Status Dg r cat wuld remain under strict quarantine until test results are reprted in 3 4 weeks. Rise in titer between paired samples is indicative f past vaccinatin Cnfinement is then reduced t a 45 day bservatin. If n rise in titer: 4 mnth strict cnfinement Guidance dcument: Management f Dmestic Animal Expsures: http://www.state.nj.us/health/cd/rabies/dcuments/appxiii_animal_cnfine.pdf Prspective Serlgical Mnitring Prtcl Frequently Asked Questins Prspective Serlgical Mnitring Prtcl Frequently Asked Questins A dg in my jurisdictin was under a 6 mnth cnfinement when the new guidance came ut. Can I decrease the cnfinement perid t 4 mnths? Only if the dg received a bster vaccinatin within 96 urs f expsure What if the dg r cat cannt return t the veterinarian fr cllectin n the secnd specimen n Day 5? Specimens may be cllected up until Day 7. Delaying cllectin f the specimen prevents accurate interpretatin f the test results as any increase in rabies antibdy titer might be due t the rabies expsure itself rather than an anamnestic respnse t a previus vaccinatin What values will be used t determine if the dg r cat has evidence f a prir rabies vaccinatin and an acceptable anamnestic respnse? At least a tw fld rise in the titer values f the paired specimens, as well as a RVNA titer equal t r abve 1:50 (therwise expressed as a RVNA ptency value equal t r abve 0.5 IU/mL) fr the secnd specimen, prvides evidence f a rbust anamnestic immune respnse after rabies vaccinatin. If the titer is equal t r abve 0.5 IU/mL and there is evidence f an anamnestic respnse, is it impssible fr the animal t g n t develp rabies? A specific value equal t r abve 0.5 IU/mL and evidence f an anamnestic respnse prvides assurance the animal will be prtected. Hwever, there have been rare instances in which vaccinated animals have gne n t develp rabies. Because f this uncertainty, cnfinement with bservatin fr 45 days is warranted regardless f the presence f antibdies. Guidance dcument: Management f Dmestic Animal Expsures: http://www.state.nj.us/health/cd/rabies/dcuments/appxiii_animal_cnfine.pdf Prspective Serlgical Mnitring Prtcl Frequently Asked Questins Prspective Serlgical Mnitring Prtcl Frequently Asked Questins Can this prtcl be used fr animals ther than dgs r cats, such as ferrets? N. At this time, data regarding anamnestic respnse fllwing revaccinatin with a rabies vaccine are nly available fr dgs and cats Where can I find submissin frms and shipping instructins fr Prspective Serlgical Mnitring? Submissin frms, shipping instructins and ther guidance can be fund n the Kansas State University Rabies Labratry website. http://www.ksvdl.rg/rabieslabratry/rffit test/rffit submissinfrms.html Can titers nw be used in lieu f vaccinatin fr pet licensing? N Titers are used t demnstrate prf f past vaccinatin; they d nt indicate prtectin against rabies if the dg r cat is expsed. Current vaccinatin against rabies is required fr licensure; a titer is nt acceptable in lieu f vaccinatin. 4
Expsure Categry Vaccinatin Status and Respnse Expsure Categry Vaccinatin Status and Respnse Categry 3 (bite wunds f unknwn rigin) Categry 4 (pssible cntact with, r in the vicinity f, a knwn r suspect rabid animal; n visible wunds) Currently Vaccinated r Dcumented Past Vaccinatin Veterinarian administers rabies vaccine Veterinarian issues wner a Rabies The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days Categry 3 (bite wunds f unknwn rigin) Categry 4 (pssible cntact with, r in the vicinity f, a knwn r suspect rabid animal; n visible wunds) Currently Vaccinated r Dcumented Past Vaccinatin Veterinarian administers rabies vaccine Veterinarian issues wner a Rabies The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 45 days N Dcumentatin f Current r Past Vaccinatin Veterinarian administers rabies vaccine Veterinarian issues wner the Rabies The expsed animal shuld be kept under the wner s cntrl and be bserved by the wner fr signs f rabies fr 4 mnths GUIDANCE F FERRETS GUIDANCE F FERRETS Veterinarians r ther persns aware f a ferret expsed t rabies shall reprt the situatin t the lcal health department and the New Jersey Divisin f Fish and Wildlife, Extic and Nngame Permits Office at 908 735 5450 r email EXOTICPERMITS@dep.nj.gv Categry 1 r 2 expsures: Currently vaccinated ferrets: bster and bserved fr 45 days, prvide Rabies Advisry Ntice Unvaccinated ferrets : euthanasia r vaccinate and bserve fr 6 mnths in strict quarantine. Ferrets that are verdue fr a rabies bster vaccinatin: Situatins shuld be evaluated by the Health Officer n a case by case basis taking int cnsideratin factrs such as: the severity f the expsure, time elapsed since last vaccinatin, number f past vaccinatins t determine if the expsed ferret must be either euthanized r receive an immediate bster vaccinatin and placed int bservatin r strict quarantine fr 6 mnths. Owners will receive a Rabies. Categry 3 r 4 expsures: A reprt t the lcal health department is nt necessary fr these expsures. The attending veterinarian shall administer a rabies bster vaccinatin t the expsed animal as sn as pssible and prvide a Rabies Currently vaccinated: bster and bserve fr 45 days Nt currently vaccinated: vaccinate and bserve fr 6 mnths POLL QUESTION Trubleshting: Dmestic Animal Expsures Situatin: A cat in fund in a rm was a dead bat. The bat tests psitive fr rabies. Did anyne see the cat in direct cntact with the bat? Des the bat have markings nting an attack frm the cat? Des the cat have markings nting an attack frm the bat? 5
POLL QUESTION POLL QUESTION POLL QUESTION OTHER RABIES GUIDANCE Trubleshting: Dmestic Animal Expsures Situatin : A seemingly healthy dg bites anther dg What needs t happen? Assess if either animal was displaying clinical signs f rabies. Fights between dgs and cats are nt usually cnsidered rabies expsures unless ne f the animals was als displaying clinical signs f rabies r is fund psitive thrugh testing. Cnfining dgs fr 10 days that bite peple Cnfining dgs fr 10 days that bite humans will cmpletely prtect the bite victim Dgs shedding rabies virus will becme ill and nt survive fr 10 days. Cnfined dgs d nt need t be euthanized and submitted fr testing. Saves imprtant public health resurces and unnecessary euthanasia f dgs. Unvaccinated dgs can be safely cnfined fr 10 days NJDOH Rabies Labs reprt an increase in f healthy dgs submitted fr testing due t bites. Health Officers shuld nly rder biting dgs t be euthanized if they have clinical signs f rabies. Dgs are rarely fund t be rabid in NJ. Only 8 rabid dgs identified since 1989 6
Rle f NJDOH Lng term Care Survey/Licensing in infectin cntrl and utbreak investigatin Sue Kelley, Prgram Manager, Lng Term Care Cmplaints, NJDOH Health Facility Survey & Field Operatins THANK YOU! New Jersey Department f Health Infectius and Zntic Disease Prgram Phne: (609) 826 4872 LTC & Infectin Cntrl Surveyr rle A. standard survey B. cmplaint investigatin Regulatry requirements Outcmes State regulatins Nursing Hmes LTC & Infectin Cntrl Assisted Living Residences (ALR) & Cmprehensive Persnal Care Hmes (CPCH) Residential Facilities [must be attached t anther licensed healthcare prvider IE: ALR, Nursing hme LTC & Infectin Cntrl State regulatry requirement fr the develpment f an infectin preventin cntrl prgram. Nursing Hmes 8:39 19.1(a) Requirement t have an infectin preventin and cntrl prgram. ALR & CPCH 8:36 18.1 The facility shall develp and implement an infectin preventin and cntrl prgram. LTC & Infectin Cntrl Wh is respnsible fr the nging prgram Nursing Hmes 8:39 19.1(b) respnsibility fr prgram assigned t emplyee with educatin, training, cmpleted curse wrk r experience in infectin cntrl r epidemilgy. If services cntracted, facility shall designate an n site emplyee t implement, crdinate and ensure cmpliance with infectin cntrl plicies Residential Facilities 8:43 16.1(a) The facility shall develp and implement an infectin preventin and cntrl prgram. 7
ALR & CPCH LTC & Infectin Cntrl 8:36 18.1(b) Licensed prfessinal nurse in crdinatin with administratr respnsible fr the directin, prvisin and quality f the infectin preventin and cntrl services. Residential Facilities 8:43 16.1(b) Health maintenance and mnitring nurse in crdinatin with administratr respnsible fr the directin, prvisin and quality f the infectin preventin and cntrl services. LTC & Infectin Cntrl Develpment f plicies and prcedures Nursing Hmes 8:39 19.4(d) cntinuus cllectin and analysis f data, including determinatin f nscmial infectins, epidemics, clusters f infectins, investigatins due t unusual pathgen r multiple antibitic resistant bacteria and ccurrence f nscmial infectin that exceeds the usual baseline levels. 19.4(e) making recmmendatins fr crrective actins based n surveillance and data analysis. 19.4(f) system fr investigatin, evaluating and reprting the ccurrence f all reprtable infectins and diseases as specified in Chapter II f the State Sanitary Cde (N.J.A.C. 8:57 1). 19.4(g) maintenance f listing f all residents and persnnel wh have reprtable infectins, diseases r cnductins. LTC & Infectin Cntrl Develpment f plices and prcedures ALR & CPCH 8:36 18.3(a)1 In accrdance with Chapter 11, NJ State Sanitary Cde, Cmmunicable Diseases, at N.J.A.C. 8:57, a system fr investigating, reprting, and evaluating the ccurrence f all infectins r diseases which are reprtable r cnditins which may be related t activities and prcedures f the facility and maintaining recrds fr all residents r persnnel having these infectins, diseases r cnditins. 18.3(a)4 surveillance techniques t minimize surces and transmissin f infectin. 18.3(a)6 prtcls fr ID f residents with cmmunicable diseases and educatin f residents regarding preventin and spread f cmmunicable diseases. LTC & Infectin Cntrl Develpment f plicies and prcedures Residential facilities 8:43 16.3(a)1 In accrdance with Chapter 11, NJ State Sanitary Cde, Cmmunicable Diseases, at N.J.A.C. 8:57, a system fr investigating, reprting, and evaluating the ccurrence f all infectins r diseases which are reprtable r cnditins which may be related t activities and prcedures f the facility and maintaining recrds fr all residents r persnnel having these infectins, diseases r cnditins. 16.3(a)4 surveillance techniques t minimize surces and transmissin f infectin. 16.3(a) prtcls fr ID f residents with cmmunicable diseases and educatin f residents regarding preventin and spread f cmmunicable diseases. LTC & Infectin Cntrl General Licensure Prcedures and Standards applicable t all (state) licensed facilities 8:43E Requirement fr the facility t self reprt 10.11(e ) A health care facility shall reprt incidents f infectius and cmmunicable diseases t the Department pursuant t N.J.A.C. 8:57 LTC & Infectin Cntrl Why is regulatin imprtant; T investigate a cmplaint we must have tw (2) things 1. regulatry requirement 2. an allegatin f a deficient practice (what the facility was r wasn t ding and a negative utcme r ptential fr a negative utcme) 8