by Dr. Mark Kristoffer U. Pasayan

1. INFECTION PREVENTION AND
CONTROL IN EMERGING
INFECTIOUS DISEASES
Mark Kristoffer U. Pasayan, MD, FPCP, DPSMID
Internal Medicine – Infectious Diseases

3. SOUTHEAST ASIA IS AN EID HOTSPOT

4. EMERGING INFECTIONS IN THE PHILIPPINES
Ebola Reston in monkeys (Reston, Virginia)
2006
▼
1998
▼▼
2002
▼
2003
2005
▼
Serological Surveillance ABLV
West Nile Virus Pseudo outbreak (RITM as Referral Laboratory)
SARS Outbreak
Pandemic A H1N1
1989
▼
Bioterrorism threat using Bacillus anthracis as biological weapon
▼
Meningococcemia outbreak in CAR2004
2001
2008
2009
▼ Ebola Reston in pigs and humans/ Leptospirosis/ Salmonella typhi
2007
▼
Resistant Shigella flexneri 2a in Cavite, Bohol and Cotabato
2010
▼
Dengue2011
▼
Chikungunya
2012
Leptospirosis
▼
No H5N1, H7N9,
Ebola in PH2013 Pertussis, Measles
▼
2014
▼
Measles, MERS CoV, Henipah
▼
1992
▼
1996
Ebola Reston in monkeys (Sienna, Italy)
Ebola Reston in monkeys (US)
2015 MERS CoV, Ebola Reston
▼

5. EMERGING AND RE-EMERGING
INFECTIOUS DISEASES

6. Middle East respiratory syndrome
coronavirus (MERS-CoV)

7. 1,638 laboratory confirmed cases of MERS-
CoV infection, globally
587 MERS-CoV – related deaths since
September 2012
26 countries have reported cases of MERS-
CoV since September 2012
WHO, as of February 16, 2016

9. A 35-year-old male was tested positive for MERS-
CoV on October 12 in South Korea.
WHO, as of February 14, 2015
Between January 22 and 27 2016, KSA notified
WHO of 5 additional cases of MERS-CoV infection
One laboratory-confirmed case from the
Philippines, reported on July 6, 2015
On 24 January 2016, Thailand notified WHO of 1
laboratory case of MERS-CoV infection

10. What is the mode of human-to-human
transmission of MERS - Coronavirus?
 AIRBORNE
 DROPLET
 CONTACT
 VECTOR-BORNE
MERS-CoV, like other coronaviruses,
is thought to spread from an infected
person’s respiratory secretions, such
as through coughing. However, the
precise ways the virus spreads are
not currently well understood.

11. Ebola Virus Disease

12. 28, 639 cases of Ebola virus disease and
11,316 deaths as of 31 January 2016
WHO, as of January 31, 2016
On 7 November 2015 , WHO
declared that Ebola virus
transmission had been stopped in
Sierra Leone; on 90-day period of
enhance surveillance
On 14 January 2016, a new
confirmed case was reported in
Sierra Leone

13. 28, 639 cases of Ebola virus disease and
11,316 deaths as of January 31, 2016
WHO, as of January 31, 2016
Human-to-human transmission
linked to the most recent cluster of
cases in Liberia was declared to
have ended on 14 January 2016
Guinea was declared free of
Ebola transmission on 29
December 2015

14. What is the mode of human-to-human
transmission of Ebola virus?
 AIRBORNE
 DROPLET
 CONTACT
 VECTOR-BORNE
Ebola among healthcare personnel and other people
is associated with DIRECT CONTACT with
symptomatic people with Ebola (or the bodies of
people who have died from Ebola) and DIRECT
CONTACT with body fluids from Ebola patients.
Airborne transmission of Ebola virus among humans
has never been demonstrated in investigations that
have described human-to-human transmission,
although hypothetical concerns about aerosol
transmission of Ebola virus have been raised

17. Best Defense Strategy:
GOOD BASIC INFECTION
CONTROL PRACTICE
Yes No Yes, with
reservation

18. IPC and EID
Emerging infections associated with healthcare
depends on the full implementation of the core
components of IPC programs.
Healthcare institutions are advised to consider
reinforcing a service for the oversight of HCW’s health
to ensure a safe environment for patients and HCW’s
HCWs are provided with the best locally available
protection for caring for patients infected with an EID,
and are followed up if exposure has occurred.

19. Core component for IPC programs
 Organization of IPC programs
 Technical guidelines
 Human resources (training, staffing, occupational health)
 Surveillance of diseases and of compliance with IPC
practices
 Microbiology laboratory support
 Clean and safe environment
 Monitoring and evaluation of IPC program
 Links with public health and other services

20. Principles of Infection Prevention and Control
Strategies Associated with Health Care
CONTROLS
Administrative
Environmental and
EngineeringPPE

21. Administrative Controls
■ Clinical triage
■ IPC infrastructures and activities
■ Education of HCWs
■ Prevention of overcrowding in waiting areas
■ Providing dedicated waiting areas for the ill and placement of
hospital patients
■ Organization of health-care services for adequate provision and
use of supplies
■ Policies and procedures for all facets of occupational health
■ Monitoring of HCW compliance

22. Administrative Controls
Infrastructure of Policies and Procedures
■ Prevent, detect, and control infections
– from first point of patient encounter at triage through discharge
■ Implement occupational health policies and procedures
– e.g. Exclude ill health care personnel from facility
■ Implement source control measures
– e.g. change ventilator circuits between patients
– One-time use of oxygen delivery devices
– Sufficient PPE available at all times
■ Organize health care service delivery
– e.g. Postponement of elective procedures if necessary
– Restrict visitors

23. Administrative Controls
Management of PUIs/Confirmed Cases
■ Timely and Effective Patient Triage
– Prevent overcrowding in (dedicated) waiting areas
– Avoid admitting patients with no risk factors
■ Admitted patients
– Place in one ward, when possible
– Minimum of 1 meter distance between patients with ARI
– Cohorting policies
■ Drafting and access to specific case and clinical management
protocols
■ Safe transport or discharge home

24. Principles of Infection Prevention and Control
Strategies Associated with Health Care
CONTROLS
Administrative
Environmental and
EngineeringPPE

25. Engineering Controls: Objective
Reduce exposures at the source and reduce the
spread of pathogens during health care delivery
using basic health-care facility infrastructure

26. Engineering Controls: Examples
■ Physical barriers or partitions to guide
patients through triage areas
■ Appropriate environmental ventilation
– At least 12 air changes per hour
– Keep doors and windows open onto
well ventilated corridors
– If available, ensure air-handling
systems (with appropriate directionality,
filtration, exchange rate, etc.) are
properly maintained

27. Engineering Controls: Examples
■ Curtains between shared areas
■ Regular and proper technique for
environmental cleaning
■ Closed systems for airway suctioning in
intubated patients

28. Principles of Infection Prevention and Control
Strategies Associated with Health Care
CONTROLS
Administrative
Environmental and
EngineeringPPE

29. Personal Protective Equipment
■ Rational and consistent use of available PPE and
appropriate hand hygiene
PPE is the strongest in the hierarchy of IPC measures to
prevent transmission of EIDs?
Yes No Yes, with
reservation

30. Personal Protective Equipment
■ Rational and consistent use of available PPE and
appropriate hand hygiene
■ PPE is the last and weakest in the hierarchy of IPC
measures AND should not be relied upon as a primary
prevention strategy.
■ In the absence of effective administrative and
engineering controls, PPE HAS LIMITED BENEFIT

31. Personal Protective Equipment
■ Workers must receive training on and demonstrate an
understanding of:
– When to use PPE
– What PPE is necessary
– How to properly don and doff PPE
– How to properly dispose of or disinfect and maintain PPE
– Limitations of PPE
■ Any reusable PPE must be properly cleaned, decontaminated,
and maintained after and between uses.

32. Personal Protective Equipment
PPE use is based on risk assessment of
potential exposure and non-intact skin and
should be applied during all potential
exposure times, removed correctly and
does not eliminate need for hand hygiene

33. Recommended
Personal Protective Equipment
■ Goggles or face shield
■ Fit-tested N95 mask (or P100)
■ Impermeable gown
■ Gloves
■ Shoe cover
■ Additional: cap

34. Personal Protective Equipment
■ General sequence to donning for respiratory
pathogens: gown, respirator, goggles or face
shield, gloves.
■ General sequence to doffing: gloves, goggles
or face shield, gown, then respirator.

35. Personal Protective Equipment
 Except for respirator, remove PPE at doorway or in anteroom.
Remove respirator after leaving patient room and closing
door.
 Careful attention should be given to prevent contamination of
clothing and skin during the process of removing PPE.
 Perform hand hygiene as described above immediately before
putting on and after removing all PPE.

36. Infection prevention and control (IPC)
precautions
■ Standard precautions – cornerstone for
providing safe healthcare, reducing the risks
of further infection and protecting HCWs,
should always be applied in all health care
settings for all patients.

37. Hand
Hygiene
PPE
Prevention
Needle-
stick Injury
Safe
Waste
CDS
Environment
Respiratory
Hygiene

38. ■ The use of PPE does not eliminate the need
for hand hygiene. Hand hygiene is also
necessary while putting on and especially
when taking off PPE.

39. ■ Ensure that cleaning and disinfection
procedures are followed consistently and
correctly
■ Cleaning environmental surfaces with water
and detergent and applying commonly used
disinfectants is an effective and sufficient
procedure.

40. What is the most common mode of
transmission of infection in the healthcare
settings?
Contact Transmission
Droplet Transmission
Airborne Transmission
Inoculation

41. Additional IPC precautions…
■ In addition to Standard Precautions…
– Use a medical mask when in close contact and
upon entering the room or cubicle of the patient
– Perform hand hygiene before and after touching the
patient and his or her surroundings and
immediately after removal of a medical mask

42. IPC precautions for aerosol-generating
procedures
■ There is a consistent association between pathogen
transmission and tracheal intubation
■ There is an increased risk of infection associated with
tracheostomy, non-invasive ventilation and manual
ventilation before intubation

43. When caring for patients with
probable or confirmed EID…
■ Place patients in adequately ventilated single rooms or
‘Airborne Precaution’ rooms
■ When single rooms are not available, place confirmed
patients together and separate them from probable
patients
■ If this is not possible, place patient beds at least 1m
apart
■ Limit the number of HCWs, family members and visitors
in contact with a patient

44. When caring for patients with
probable or confirmed EID…
■ If possible, use either disposable equipment or
dedicated equipment
■ If equipment needs to be shared among patients, clean
and disinfect it after each patient use
■ Avoid the movement and transport of patients out of
barrier nursing room or area unless medically
necessary. If transport is required, use routes of
transport that minimize exposures of staff, other
patients and visitors.

45. Duration of barrier nursing
precautions
■ Fact: duration of infectivity of (some) EIDs is unknown
■ While Standard Precautions should always be applied,
additional barrier nursing precautions should be used
for the duration of symptomatic illness, and continued
for 24 hours after the resolution of symptoms
■ Testing for viral shedding should assist decision-making
when readily available.

46. Collection and handling of laboratory
specimens from patients EIDs of
potential concern
■ Ensure that HCWs who collect specimens use
appropriate PPE
■ Ensure that personnel who transport specimens are
trained in safe handling practices and spill
decontamination procedures
■ Ensure that healthcare facility laboratories adhere to
appropriate biosafety practices and transport
requirements

47. ■ Need for comprehensive strategy to
enhance IPC
– Efforts directed to EIDs must be
aggregated and efficient to build IPC
capacity in the country
■ Need for integrated approach
– WHO: improved liaison/collaboration
among IPC-related initiatives
– DOH: vertical programs
■ Creation of national resources centers that
can foster country capacity building
■ Political will + combination of efforts =
WORKS!

48. EBOLA VIRUS DISEASE MERS-CoV

49. Emerging Threats
■ A new variant of a fatal neurologic illness, Creutzfeldt-Jakob disease, appeared
in the United Kingdom and was possibly transmitted by ingestion of beef from
animals afflicted with bovine spongiform encephalopathy, also known as "mad
cow disease."
■ A new and virulent strain of influenza in Hong Kong raised fears of a global
pandemic
■ The United States had several multistate foodborne outbreaks, including
outbreaks caused by Cyclospora parasites; hepatitis A virus; and Escherichia
coli O157:H7
■ Staphylococcus aureus with reduced susceptibility to vancomycin was
reported for the first time in the United States and Japan
■ A new strain of tuberculosis (strain W), which is multidrug-resistant and
appears more frequently in persons with HIV infection, has become endemic
in New York

50. In recent years, we have seen the emergence and re-emergence of
many infectious diseases.
EID outbreaks highlight the shortcomings in our understanding of the
complexities of infectious diseases.
The reasons for emergence and re-emergence are multiple and
complex.
Clearly, human activities are a key factor for driving disease emergence
and current knowledge of the various emerging viruses is far from
complete.
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51. It could be said that the current global
situation favors disease emergence,
and we may be faced with MORE
outbreaks or pandemics of EIDs in the
FUTURE
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53. Thank you for listening