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Morris SE, Zipfel CM, Peer K, Madewell ZJ, Brenner S, Garg S, Paul P, Slayton RB, Biggerstaff M. Modeling the Impacts of Antiviral Prophylaxis Strategies in Mitigating Seasonal Influenza Outbreaks in Nursing Homes. Clin Infect Dis 2024; 78:1336-1344. [PMID: 38072652 PMCID: PMC11260992 DOI: 10.1093/cid/ciad764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Indexed: 05/16/2024] Open
Abstract
BACKGROUND Antiviral chemoprophylaxis is recommended for use during influenza outbreaks in nursing homes to prevent transmission and severe disease among non-ill residents. Centers for Disease Control and Prevention (CDC) guidance recommends prophylaxis be initiated for all non-ill residents once an influenza outbreak is detected and be continued for at least 14 days and until 7 days after the last laboratory-confirmed influenza case is identified. However, not all facilities strictly adhere to this guidance and the impact of such partial adherence is not fully understood. METHODS We developed a stochastic compartmental framework to model influenza transmission within an average-sized US nursing home. We compared the number of symptomatic illnesses and hospitalizations under varying prophylaxis implementation strategies, in addition to different levels of prophylaxis uptake and adherence by residents and healthcare personnel (HCP). RESULTS Prophylaxis implemented according to current guidance reduced total symptomatic illnesses and hospitalizations among residents by a median of 12% and 36%, respectively, compared with no prophylaxis. We did not find evidence that alternative implementations of prophylaxis were more effective: compared to full adoption of current guidance, partial adoption resulted in increased symptomatic illnesses and/or hospitalizations, and longer or earlier adoption offered no additional improvements. In addition, increasing uptake and adherence among nursing home residents was effective in reducing resident illnesses and hospitalizations, but increasing HCP uptake had minimal indirect impacts for residents. CONCLUSIONS The greatest benefits of influenza prophylaxis during nursing home outbreaks will likely be achieved through increasing uptake and adherence among residents and following current CDC guidance.
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Affiliation(s)
- Sinead E Morris
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Casey M Zipfel
- Divison of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Komal Peer
- Division of Environmental Health Science and Practice, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Zachary J Madewell
- Center for Global Health, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Stephan Brenner
- Agency for Toxic Substances and Disease Registry, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Shikha Garg
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Prabasaj Paul
- Divison of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Rachel B Slayton
- Divison of Healthcare Quality Promotion, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
| | - Matthew Biggerstaff
- Influenza Division, US Centers for Disease Control and Prevention, Atlanta, Georgia, USA
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Nelson Chang NC, Leecaster M, Fridkin S, Dube W, Katz M, Polgreen P, Roghmann MC, Khader K, Li L, Dumyati G, Tsay R, Lynfield R, Mahoehney J, Nadle J, Hutson J, Pierce R, Zhang A, Wilson C, Haroldsen C, Mulvey D, Reddy SC, Stone ND, Slayton RB, Thompson ND, Stratford K, Samore M, Visnovsky LD. Assessing Pathogen Transmission Opportunities: Variation in Nursing Home Staff-Resident Interactions. J Am Med Dir Assoc 2023; 24:735.e1-735.e9. [PMID: 36996876 DOI: 10.1016/j.jamda.2023.02.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/14/2023] [Accepted: 02/15/2023] [Indexed: 03/29/2023]
Abstract
OBJECTIVES The Centers for Disease Control and Prevention (CDC) recommends implementing Enhanced Barrier Precautions (EBP) for all nursing home (NH) residents known to be colonized with targeted multidrug-resistant organisms (MDROs), wounds, or medical devices. Differences in health care personnel (HCP) and resident interactions between units may affect risk of acquiring and transmitting MDROs, affecting EBP implementation. We studied HCP-resident interactions across a variety of NHs to characterize MDRO transmission opportunities. DESIGN 2 cross-sectional visits. SETTING AND PARTICIPANTS Four CDC Epicenter sites and CDC Emerging Infection Program sites in 7 states recruited NHs with a mix of unit care types (≥30 beds or ≥2 units). HCP were observed providing resident care. METHODS Room-based observations and HCP interviews assessed HCP-resident interactions, care type provided, and equipment use. Observations and interviews were conducted for 7-8 hours in 3-6-month intervals per unit. Chart reviews collected deidentified resident demographics and MDRO risk factors (eg, indwelling devices, pressure injuries, and antibiotic use). RESULTS We recruited 25 NHs (49 units) with no loss to follow-up, conducted 2540 room-based observations (total duration: 405 hours), and 924 HCP interviews. HCP averaged 2.5 interactions per resident per hour (long-term care units) to 3.4 per resident per hour (ventilator care units). Nurses provided care to more residents (n = 12) than certified nursing assistants (CNAs) and respiratory therapists (RTs) (CNA: 9.8 and RT: 9) but nurses performed significantly fewer task types per interaction compared to CNAs (incidence rate ratio (IRR): 0.61, P < .05). Short-stay (IRR: 0.89) and ventilator-capable (IRR: 0.94) units had less varied care compared with long-term care units (P < .05), although HCP visited residents in these units at similar rates. CONCLUSIONS AND IMPLICATIONS Resident-HCP interaction rates are similar across NH unit types, differing primarily in types of care provided. Current and future interventions such as EBP, care bundling, or targeted infection prevention education should consider unit-specific HCP-resident interaction patterns.
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Singh BK, Walker J, Paul P, Reddy S, Gowler CD, Jernigan J, Slayton RB. De-escalation of asymptomatic testing and potential of future COVID-19 outbreaks in US nursing homes amidst rising community vaccination coverage: A modeling study. Vaccine 2022; 40:3165-3173. [PMID: 35487811 PMCID: PMC9013672 DOI: 10.1016/j.vaccine.2022.04.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 04/06/2022] [Accepted: 04/11/2022] [Indexed: 11/09/2022]
Abstract
As of 2 September 2021, United States nursing homes have reported >675,000 COVID-19 cases and >134,000 deaths according to the Centers for Medicare & Medicaid Services (CMS). More than 205,000,000 persons in the United States had received at least one dose of a COVID-19 vaccine (62% of total population) as of 2 September 2021. We investigate the role of vaccination in controlling future COVID-19 outbreaks. We developed a stochastic, compartmental model of SARS-CoV-2 transmission in a 100-bed nursing home with a staff of 99 healthcare personnel (HCP) in a community of 20,000 people. We parameterized admission and discharge of residents in the model with CMS data, for a within-facility basic reproduction number (R0) of 3.5 and a community R0 of 2.5. The model also included: importation of COVID-19 from the community, isolation of SARS-CoV-2 positive residents, facility-wide adherence to personal protective equipment (PPE) use by HCP, and testing. We systematically varied coverage of mRNA vaccine among residents, HCP, and the community. Simulations were run for 6 months after the second dose in the facility, with results summarized over 1,000 simulations. Expected resident cases decreased as community vaccination increased, with large reductions at high HCP coverage. The probability of a COVID-19 outbreak was lower as well: at HCP vaccination coverage of 60%, probability of an outbreak was below 20% for community coverage of 50% or above. At high coverage, stopping asymptomatic screening and facility-wide testing yielded similar results. Results suggest that high coverage among HCP and in the community can prevent infections in residents. When vaccination is high in nursing homes, but not in their surrounding communities, asymptomatic and facility-wide testing remains necessary to prevent the spread of COVID-19. High adherence to PPE may increase the likelihood of containing future COVID-19 outbreaks if they occur.
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Affiliation(s)
- Brajendra K Singh
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Joseph Walker
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Prabasaj Paul
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Sujan Reddy
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Camden D Gowler
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - John Jernigan
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
| | - Rachel B Slayton
- CDC COVID-19 Response Team, Centers for Disease Control and Prevention, Atlanta, GA 30329, USA.
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Morgan DJ, Zhan M, Goto M, Franciscus C, Alexander B, Vaughan-Sarrazin M, Roghmann MC, Pineles L. The Effectiveness of Contact Precautions on Methicillin-Resistant Staphylococcus aureus in Long-term Care Across the United States. Clin Infect Dis 2021; 71:1676-1683. [PMID: 31637429 DOI: 10.1093/cid/ciz1045] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2019] [Accepted: 10/17/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Methicillin-resistant Staphylococcus aureus (MRSA) is a common cause of health care-associated infections in long-term care facilities (LTCFs). The Centers for Disease Control and Prevention recommends contact precautions for the prevention of MRSA within acute care facilities, which are being used within the United States Department of Veterans Affairs (VA) for LTCFs in a modified fashion. The impact of contact precautions in long-term care is unknown. METHODS To evaluate whether contact precautions decreased MRSA acquisition in LTCFs, compared to standard precautions, we performed a retrospective effectiveness study (pre-post, with concurrent controls) using data from the VA health-care system from 1 January 2011 until 31 December 2015, 2 years before and after a 2013 policy recommending a more aggressive form of contact precautions. RESULTS Across 75 414 patient admissions from 74 long-term care facilities in the United States, the overall unadjusted rate of MRSA acquisition was 2.6/1000 patient days. Patients were no more likely to acquire MRSA if they were cared for using standard precautions versus contact precautions in a multivariable, discrete time survival analysis, controlling for patient demographics, risk factors, and year of admission (odds ratio, 0.97; 95% confidence interval, .85-1.12; P = .71). CONCLUSIONS MRSA acquisition and infections were not impacted by the use of active surveillance and contact precautions in LTCFs in the VA.
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Affiliation(s)
- Daniel J Morgan
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, Division of Genomic Epidemiology & Clinical Outcomes, Baltimore, Maryland, USA
| | - Min Zhan
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, Division of Genomic Epidemiology & Clinical Outcomes, Baltimore, Maryland, USA
| | - Michihiko Goto
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA.,Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Carrie Franciscus
- Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Bruce Alexander
- Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City Veterans Affairs Health Care System, Iowa City, Iowa, USA
| | - Mary Vaughan-Sarrazin
- Department of Internal Medicine, Division of Infectious Diseases, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA.,Department of Internal Medicine, Division of General Internal Medicine, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa, USA
| | - Mary-Claire Roghmann
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, Division of Genomic Epidemiology & Clinical Outcomes, Baltimore, Maryland, USA
| | - Lisa Pineles
- Veterans Affairs Maryland Health Care System, Baltimore, Maryland, USA.,Department of Epidemiology and Public Health, Division of Genomic Epidemiology & Clinical Outcomes, Baltimore, Maryland, USA
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Akinbami LJ, Chan PA, Vuong N, Sami S, Lewis D, Sheridan PE, Lukacs SL, Mackey L, Grohskopf LA, Patel A, Petersen LR. Severe Acute Respiratory Syndrome Coronavirus 2 Seropositivity among Healthcare Personnel in Hospitals and Nursing Homes, Rhode Island, USA, July-August 2020. Emerg Infect Dis 2021; 27:823-834. [PMID: 33622481 PMCID: PMC7920685 DOI: 10.3201/eid2703.204508] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Healthcare personnel are recognized to be at higher risk for infection with severe acute respiratory syndrome coronavirus 2. We conducted a serologic survey in 15 hospitals and 56 nursing homes across Rhode Island, USA, during July 17-August 28, 2020. Overall seropositivity among 9,863 healthcare personnel was 4.6% (95% CI 4.2%-5.0%) but varied 4-fold between hospital personnel (3.1%, 95% CI 2.7%-3.5%) and nursing home personnel (13.1%, 95% CI 11.5%-14.9%). Within nursing homes, prevalence was highest among personnel working in coronavirus disease units (24.1%; 95% CI 20.6%-27.8%). Adjusted analysis showed that in hospitals, nurses and receptionists/medical assistants had a higher likelihood of seropositivity than physicians. In nursing homes, nursing assistants and social workers/case managers had higher likelihoods of seropositivity than occupational/physical/speech therapists. Nursing home personnel in all occupations had elevated seropositivity compared with hospital counterparts. Additional mitigation strategies are needed to protect nursing home personnel from infection, regardless of occupation.
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Evans ME, Roselle GA, Kralovic SM. Contact Precautions for Methicillin-Resistant Staphylococcus aureus in Veterans Affairs Long-term Care Facilities: Analysis of Policies, Not Practice. Clin Infect Dis 2020; 71:2770. [DOI: 10.1093/cid/ciaa146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Martin E Evans
- Veterans Health Administration, MRSA/MDRO Prevention, Office, National Infectious Diseases Service, Specialty Care Services, Veterans Affairs Central Office, Cincinnati, Ohio, USA
- Lexington Veterans Affairs Medical Center, University of Kentucky School of Medicine, Lexington, Kentucky, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Kentucky School of Medicine, Lexington, Kentucky, USA
| | - Gary A Roselle
- National Infectious Diseases Service, Patient Care Services, Veterans Affairs Central Office, Cincinnati, Ohio, USA
- Cincinnati Veterans Affairs Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
| | - Stephen M Kralovic
- National Infectious Diseases Service, Patient Care Services, Veterans Affairs Central Office, Cincinnati, Ohio, USA
- Cincinnati Veterans Affairs Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Infectious Diseases, Department of Internal Medicine, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
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Environmental service workers as potential designers of infection control policy in long-term care settings. Am J Infect Control 2020; 48:398-402. [PMID: 32087975 DOI: 10.1016/j.ajic.2020.01.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2019] [Revised: 01/13/2020] [Accepted: 01/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Long-term care facility residents are at higher risk of methicillin-resistant Staphylococcus aureus infection and colonization than the general population. In 2009, the Department of Veterans Affairs (VA) implemented the "methicillin-resistant S. aureus prevention initiative" in long-term care facilities (ie, Community Living Centers or "CLCs"). METHODS Over 4 months, 40 semistructured interviews were conducted with staff in medicine, nursing, and environmental services at 5 geographically dispersed CLCs. Interviews addressed knowledge, attitudes, and beliefs concerning infection prevention and resident-centered care. A modified constant comparative approach was used for data analysis. RESULTS In CLCs, staff work to prevent and control infections in spaces where residents live. Nurses and Environmental Service Workers daily balance infection prevention conventions with the CLC setting. Infection control team members, who are accustomed to working in acute care settings, struggle to reconcile the CLC context with infection prevention. DISCUSSION The focus on the resident's room as the locus of care, and thus the main target of infection control, misses opportunities for addressing infection prevention in the spaces beyond the residents' rooms. CONCLUSIONS Environmental Service Workers' daily work inside the rooms and within the wider facility produces a unique perspective that might help in the design of workable infection control policies in CLCs.
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The devil is in the details: Factors influencing hand hygiene adherence and contamination with antibiotic-resistant organisms among healthcare providers in nursing facilities. Infect Control Hosp Epidemiol 2019; 40:1394-1399. [PMID: 31647042 DOI: 10.1017/ice.2019.292] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Antibiotic-resistant organism (ARO) colonization rates in skilled nursing facilities (NFs) are high; hand hygiene is crucial to interrupt transmission. We aimed to determine factors associated with hand hygiene adherence in NFs and to assess rates of ARO acquisition among healthcare personnel (HCP). METHODS HCP were observed during routine care at 6 NFs. We recorded hand hygiene adherence, glove use, activities, and time in room. HCP hands were cultured before and after patient care; patients and high-touch surfaces were cultured. HCP activities were categorized as high-versus low-risk for self-contamination. Multivariable regression was performed to identify predictors of hand hygiene adherence. RESULTS We recorded 385 HCP observations and paired them with cultures performed before and after patient care. Hand hygiene adherence occurred in 96 of 352 observations (27.3%) before patient care and 165 of 358 observations (46.1%) after patient care. Gloves were worn in 169 of 376 observations (44.9%). Higher adherence was associated with glove use before patient care (odds ratio [OR], 2.55; 95% confidence interval [CI], 1.44-4.54) and after patient care (OR, 3.11; 95% CI, 1.77-5.48). Compared with nurses, certified nurse assistants had lower hand hygiene adherence (OR, 0.31; 95% CI, 0.15-0.67) before patient care and physical/occupational therapists (OR, 0.22; 95% CI, 0.11-0.44) after patient care. Hand hygiene varied by activity performed and time in the room. HCP hands were contaminated with AROs in 35 of 385 cultures of hands before patient care (0.9%) and 22 of 350 cultures of hands after patient care (6.3%). CONCLUSIONS Hand hygiene adherence in NFs remain low; it is influenced by job title, type of care activity, and glove use. Hand hygiene programs should incorporate these unique care and staffing factors to reduce ARO transmission.
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Frequency of nursing home resident contact with staff, other residents, and the environment outside resident rooms. Infect Control Hosp Epidemiol 2019; 40:815-816. [PMID: 31106727 DOI: 10.1017/ice.2019.117] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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