[MUSIC] So let's switch gears here a little bit and focus on outbreaks of coronavirus disease, 2019. How do we prevent them? How do we manage them? And what are some of the challenges in doing so? During this section, we will discuss factors that contribute to outbreaks of COVID 19 and provide some suggested strategies for prevention. We will also review challenges to control COVID 19 outbreaks once they occur and discuss response strategies to reduce further transmission. We will end the lecture by reviewing a past outbreak and assessing the associative successes and challenges. In general, outbreaks are defined as an increasing cases above what we would normally expect to see over a certain period of time and within a specified population. For some diseases and among certain populations a single case of disease alone may be considered an outbreak. This is usually the case when the disease is rare and or has a serious public health implications. So how do assisted living communities determine when they have an outbreak on their hands. There are two general rules of thumb. The first a single new case of SARS CoV 2 infection in a resident or staff member at an assisted living community would constitute an outbreak. Second, an assisted living community with three or more residents or staff showing signs or symptoms compatible with COVID 19 in a 72 hour period would also be considered in an outbreak. Some of you may be familiar with the epidemiologic principle of the chain of infection. The chain of infection is a module used to describe six different factors that must be present in order for a disease to spread. These six factors are the existence of an infectious agent, a reservoir for the agent to live in, a portal of exit that allows the agent to leave that reservoir, a mode of transmission. A portal of entry into a host and finally, a susceptible hosts. We just mentioned that one case of COVID 19 in an assisted living community constitutes an outbreak. So how does each link in the chain of infection produce one case or, in other words, on outbreak in the community? Well, humans act as a reservoir for COVID19, and they often expel respiratory secretions, which acts as a portal of exit. Therefore, COVID19 is introduced to communities through exposure to infectious humans on their respiratory secretion. But having an infectious individual present for an exposure does not necessarily mean that a resident or staff member will become infected. There are individual level factors that must be present to produce infection. The residents or staff member first needs to come into contact with expelled respiratory secretions. Thes respiratory secretions then need to contaminate an individual's mucous membranes, including their eyes, mouth and or nose. Finally, the human host must not have immunity to SARS CoV 2 in order for infection to develop. So overall, we can break down factors that contribute to COVID19 into factors that introduced COVID 19 into the community. And factors that contribute to infection in residents and staff once a potential exposure is present. So in what instances can COVID19 be introduced to the assisted living community? Opportunities for introduction can occur during resident outings, which may include appointment, day trips, hospital admissions so on and so forth. Introduction can occur during visitation with loved ones. Staff may work across multiple communities and certainly have contact with the broader community during non work hours where they could be introduced to the disease. It is important to note that these activities in and of themselves do not automatically lead to exposure of residents and staff. If appropriate mitigation measures are in place, risk of exposure is significantly reduced, and not all of the instances that I mentioned have the same inherent. Level of risk. In other words, all this is not necessarily to say. Don't do these things. Just the communities must be conscious of these opportunities for exposure during the pandemic. Now let's discuss the second group of factors factors that contribute to an infection once a potential exposure is present. Firstly, breaches and infection prevention can lead to contact with infectious respiratory secretions. Infection prevention measures may include masking respiratory etiquette, hand hygiene and cleaning and disinfection of high touch surfaces. A lack of appropriate distancing and engineering controls such as airflow, physical barriers, etcetera can lead to contact with expelled respiratory secretions, and ultimately it's the individual lacks immunity to the disease, then infection can occur. So what can communities do about these factors? Before we answer that question, I would just like to share that. The following strategies are general recommendations which are discussed throughout other sections and modules of this course in greater detail. First, let's focus on strategies to prevent the introduction of the virus to the communities, residents and staff in the first place. Communities can develop policies and procedures for resident outings and safe visitation. Communities should be conscious of staff who work in other communities and may even want to limit the number of staff who do so. If at all possible, you can remind staff how their actions outside of work affect transmission within the assisted living community. While communities air not responsible for what staff do in their off hours, occasional reminders can go a long way. Routine testing of staff during non outbreak periods is also helpful in keeping those who may not be symptomatic but are still infectious out of work and, of course, screening visitors and staff for symptoms and external exposures. The others, with Covid19 before entry, is helpful in keeping Covid19 out in terms of preventing infections in staff or residents who are around. Others with COVID 19 community should ensure that all policies and procedures to find expected infection prevention social distancing, an engineering control measures masks in a hand. Hygiene supplies should be available for residents, visitors and staff. It is helpful to monitor visitation and provide feedback if risky practices such as a lack of social distancing or a lack of masking occur. Finally, it's helpful to design visitation areas so that chairs and other furniture are physically distance and so that plexi glass or other barriers are available toe further prevent transmission. We have reviewed strategies for preventing outbreaks, but sometimes despite our best efforts, outbreaks occur anyway. There are many challenges associated with controlling them. Because communities often have shared living spaces and staff congregation area. There will be multiple opportunities for exposure to other residents and staff if a case is identified. We also know that perfect adherence to infection control is difficult to achieve, and one of the most significant challenges is the amount of resource is that it takes to respond to an outbreak. Shortages on re sources are not uncommon during the covid 19 pandemic. Additional exposures to staff and residents are possible when one infectious individual is present in the community. Some individuals who are infected with SARS Kobe, too, may not present with clinical signs or symptoms and therefore go undetected as infectious to others. If undetected and transmission based precautions are not implemented, these individuals can spread to other residents and staff who they come in contact with. Communal dining and activities can bring residents closer together, and, if someone is infectious, can lead to further transmission shared bathrooms have been found to be a source of spread, if not adequately disinfected. And if times of youth are not staggered to prevent congregation, residents in the community may wander despite being exposure infected instead of quarantining or isolating in their rooms, staff from I'd care for many residents. If they're infectious, they can expose the patients they work with. They can also pass infection from one resident to another, if the proper personal protective equipment or PPE and infection prevention strategies, aren't adhered to. Other common areas for additional exposure include, staff break room, time clocks and smoking areas. Communities need to be conscious of which of these risks are most likely to impact their residents and staff. Infection control adherence is another known challenge. To prevent transmission of COVID 19, adherence to things like PPE selection, donning and doffing, hand hygiene, respiratory etiquette and cleaning and disinfection, is essential. That is a lot for one person to remember one time alone, let alone all staff remembering these things all the time. As a result, it can be challenging to achieve perfect adherence. Outbreaks also presents a strain on resources, shortages are a common challenge for communities responding to COVID 19 outbreaks. And needed resources usually include things like PPE, testing supplies, staffing and cleaning and disinfection supplies, just to name a few. There are many strategies that are available to help control outbreaks once they occur. Like the prevention strategies we discussed earlier, to strategies mention here, are general and are further discussed in other sections and models of this course. Let's review ways to prevent additional exposures in the community. First, test all previously negative residents and staff when a case is identified to determine whether others are infected. Facilitate individual or distance dining and activities during outbreak response, where possible, to reduce close contact among residents. Cohort residents based on their level of risk and in accordance with your local or state Public Health Department's recommendation. Dedicate staff to work on specific units when possible, to reduce likelihood of widespread exposures, affecting multiple units or areas of the community. Signage, distancing or removal of furniture and visual markers, can be used to encourage distancing in congregation areas, such a staff break rooms and meeting offices. Now let's focus on fostering good adherents to infection control practices, that can help prevent further transmission. Provide staff with access to needed supplies, including PPE, disinfection wipes, thermometers, signs and symptoms screening tools, e.t.c. Frequent re-education and training also goes a long way, in fostering practice. The community can increase audit and feedback, for infection control practices, including hand hygiene and PPE use when indicated. It is also important to increase the frequency of cleaning and disinfection of shared spaces and high touch surfaces. The Centers for Disease Control and your local public health officials are valuable assets, when addressing shortage issues. For PPE shortages, CDC developed an optimization strategy, for conserving PPE, that will help prioritize use. Some local and state health departments may also have cash available to help augment supply levels. Reach out to your health department, if testing assistance is needed and a lab cannot be identified. To prepare for staffing shortages, community should consult the CDC Staffing Mitigation Strategy document and make a plan to address any shortages that occur ahead of time. Finally, disinfectants have been especially difficult to obtain during the COVID 19 Pandemic. The Environmental Protection Agency, or EPA List N specifies all disinfectants that are registered products and have activity against SARS-COV-2. If your usual brand is not available, consult this list to identify others. Remember to consider how products will affect sensitive surfaces and consider the contact, or dwell time needed for the product to successfully kill SARS-COV-2.. Products should be vetted, using the community's usual product selection process, to ensure that it meets the needs of the community. I would like to conclude. This section with the review of the short outbreak case study, published in the Journal of the American Medical Directors Association in August of 2020. Dumyati et al review a nursing home outbreak in Georgia to illustrate outbreak response to COVID-19. While the affected community was a nursing home and not an assisted living community. I think that you'll find that the recommendations, successes, and challenges noted are applicable to the assisted living setting. This case study outlines the experience of 134 bed nursing home operating at about 75% capacity during an outbreak of COVID-19 from March and April of 2020. Prior to detection of their first case, the nursing home had already implemented limited entry, screening of staff for symptoms and exposure histories, staff temperature checks, universal masking and visitor restrictions. As you could see from the graphic to the right, the building where this outbreak occurred had a COVID-19 unit for any identified positive residents, including separate entrances. There was a new-admission observation unit and two additional resident care units on the opposite side of the building. On March 31st, 2020, a 76 year old male with the catheter associated urinary tract infection met the criteria for COVID-19 enhanced screening. And was therefore placed on transmission based precautions and tested for SARS-CoV-2. On April 1st, the residents test resulted positive. In response to the positive result, all residents were restricted to their rooms and tested for SARS-CoV-2 on April 2nd. On April 3rd, seven more residents results returned positive, all of whom were asymptomatic. The eight known cases were moved to the COVID-19 unit. From April 3rd to April 4th, 119 out of 121 staff were also tested. 15 were positive and were sent home to isolate. From April 5th to April 10th, 6 previously negative residents developed signs and symptoms of COVID-19 and tested positive. All were move to the COVID-19 unit. A week later, on April 17th, another previously negative resident developed signs and symptoms and tested positive as well. Staff began wearing eye protection for any interactions with residents or other staff. So what were some of the prevention successes highlighted in this case study? The nursing home already had limited entry and visitor restrictions in place, and they were screening staff and residents for signs, symptoms, and exposures to COVID-19. Universal masking was in place, and there was an observation unit created in anticipation of accepting new admissions. In terms of challenges, I think it is worth noting that it was early in the pandemic and the prevention guidance was still developing. As a result, routine staff testing in the absence of a known outbreak was not yet recommended by CDC or the Centers for Medicare and Medicaid Services (CMS) for surveillance purposes. Staff also had contact with the broader community, which the article points out was the likely source of infection for many communities at this time. Given that many restrictions on visitations and outing were in place. What were some of the successes and challenges for this nursing home in controlling their outbreak once it was identified? It does appear that they had access to the needed resources for outbreak response. They had physical space to create cohorted units, they had PPE available. They were able to test the entire community. They were rapidly restricting residents to their rooms and cohorted residents accordingly once results returned. They also immediately implemented community wide testing and had rapid turnaround times for results. As with the prevention challenges we discussed earlier, this outbreak occurred early in the pandemic, meaning that COVID-19 outbreak control guidance was still developing. The nonspecific clinical presentation and co-infection of the index resident may have led to delays in detection. Although in this case, COVID-19 screening was successful in bringing the infection to light. The response was. First intensive, as expected, especially considering that the nursing home did test everyone. We currently know that eye contamination leads the transmission of COVID 19. But in April, that was less apparent. The universal eye protection for nursing homes in broader communities with moderate to substantial community transmission was not recommended. That is now a recommendation. Universal eye protection was implemented late in this outbreak, although early in the general context of the larger pandemic, which may have led to additional cases. All in all, outbreak prevention and response presents many challenges. There are many effective strategies that, when implemented, can help prevent and control outbreaks. Reviewing past outbreaks can identify areas for improvement in each individual community. [MUSIC]
