2023 microbiology columns - Healthcare Hygiene magazine

Should We be Worried About Human Parainfluenza Viruses?

By Rodney E. Rohde, PhD, MS, SM(ASCP) CM, SVCM, MBCM, FACSc

This article originally appeared in the December 2023 issue of Healthcare Hygiene magazine.

Once upon a time, in a 2009 World Health Organization Summary, I read a statement that has always stuck with me as a public health and medical laboratory infectious disease specialist. It stated, “the only thing certain about influenza viruses is that nothing is certain.”

I am an American Society for Clinical Pathology (ASCP) board-certified specialist in virology, specialist in microbiology, and molecular Biology. I started my career in 1992 with the Texas Department of State Health Services in the Bureau of Laboratories and Zoonosis Control Division and transitioned to medical laboratory and academic environment since 2002. I’ve worked in this hybrid profession between public health and medical laboratories for over 30 years, experiencing everything from being involved in the eradication of canine rabies from Texas, to watching West Nile Virus enter New York and burn across the United States, to the 2001 anthrax scare, avian influenza, Ebola, COVID-19, and other diabolical microbial foes.

I respect all microbes and their potential to erupt at any given time. But the respiratory agents that continue to leap from zoonotic origins to human pathways are the ones that always create a storm. Respiratory viruses are often a perfect storm. Influenza and coronaviruses are part of most everyone’s vocabulary these days. What about a group of viruses known as the Human Parainfluenza Viruses (HPIVs)? Remember, with zoonotic and respiratory agents, nothing is certain.

What are Human Parainfluenza Viruses?

The Centers for Disease Control and Prevention share that Human parainfluenza viruses (HPIVs) belong to the Paramyxoviridae family. They are enveloped RNA viruses which have four types (1 through 4) and two subtypes (4a and 4b). The clinical and epidemiologic features for each HPIV type are variable. In the United States, HPIV-1 infections usually peak every other year with infections from HPIV-2 substituting when HPIV-1 is low. HPIV-3 usually has peaks annually, particularly when HPIV-1 and HPIV-2 are low. Infections with HPIV-4 are less well-defined but appear to occur yearly. Like many respiratory viruses, HPIVs commonly infect infants and young children and immunocompromised individuals but anyone can acquire the infection.

Signs, Symptoms, and Illnesses

HPIVs have an incubation period (the time from getting infected with HPIV to onset of symptoms) usually from two to six days. There are four major types of HPIVs.

HPIV-1 and HPIV-2 are most often associated with croup, with HPIV-1 most often identified as the cause in children. Both can also cause upper and lower respiratory illness, and cold-like symptoms.
HPIV-3 is more often associated with bronchiolitis, bronchitis, and pneumonia.
HPIV-4 is recognized less often but may cause mild to severe respiratory tract illnesses.
Most HPIVs cause symptoms much like the common cold. One can experience a range of issues, including fever, running nose, cough, sneezing, and a sore throat. Occasionally, there may be symptoms of ear pain, irritability, and decreased appetite.

Children can show more serious symptoms from HPIVs including:

croup (infection of the vocal cords (larynx), windpipe (trachea) and sometimes into the bronchial tubes (bronchi)
bronchitis (infection of the main air passages that connect the windpipe to the lungs)
bronchiolitis (infection in the smallest air passages in the lungs)
pneumonia (an infection of the lungs)
barking cough
hoarseness
stridor (noisy or high-pitched sound with breathing)
Adults tend to not have as many serious complications with upper respiratory infections and bronchitis as the most common illnesses. Signs and symptoms mirror those less serious ones seen in children. Older adults may be more likely to have pneumonia.

Transmission, Prevention, and Treatment

HPIVs, like many other respiratory agents, are typically spread by direct contact with infectious droplets or by airborne spread when an infected person breathes, coughs, or sneezes. Viral particles within respiratory droplets can remain infectious for several hours in the air and on surfaces. Most people are contagious in the early stages of illness and HPIVs occur year-round.

To date, there is no vaccine to prevent HPIV infection and researchers continue to work to develop vaccines. Unfortunately, there is no specific antiviral treatment for HPIV illness. Most HPIV illnesses are mild and typically require only treatment of symptoms.

In hospital settings, healthcare providers should follow contact precautions, such as handwashing and wearing protective gowns and gloves. For more information, see CDC’s 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings.

The Future

Overall, lower respiratory tract infections (LRI) cause approximately 25 percent to 30 percent of total deaths in preschool children in the developing world. HPIVs are believed to be associated with 10 percent of all LRI cases, thus remaining a significant cause of mortality. While it’s always difficult to predict “Disease X” regarding the next major microbial agent to cause a pandemic or global emergency, we must all keep our radars finely tuned with a One Health strategy to mitigate that perfect storm on the horizon.

Rodney E. Rohde, PhD, MS, SM(ASCP) CM, SVCM,MBCM, FACSc, is the Regents’ Professor, Texas State University System; University Distinguished Chair & Professor, Clinical Laboratory Science (CLS); TEDx Speaker & Global Fellow – Global Citizenship Alliance; Texas State Honorary Professor of International Studies; Associate Director, Translational Health Research Initiative; Past President, Texas Association for CLS.

Coxsackievirus Conundrum: Common in Children, Complex in Adults

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the November 2023 issue of Healthcare Hygiene magazine.

We are all too familiar with the numerous of viruses circulating during the fall season – SARS-CoV-2, influenza, RSV, rhinoviruses, and many more. Alongside those viruses is also coxsackievirus which is a common pathogen known to cause hand-foot-and-mouth disease (HFMD). In the Unites States, most cases occur in the summer and though the fall season. In fact, just last month Duke University reported a large unprecedented outbreak of HFMD, with more than 60 cases within four weeks. In Massachusetts, Holyoke Public Schools reported an outbreak of 14 cases.

Coxsackieviruses are nonenveloped RNA viruses belonging to the enterovirus genus of the Picornaviridae family. Coxsackieviruses are divided into two groups based on their pathogenicity: Group A and Group B. Group A coxsackieviruses primarily infect the skin and mucous membranes, leading to variety of signs and symptoms including painful red blisters in the throat and on the tongue, gums, inside of the cheeks, the palms of hands, and soles of the feet. Group B coxsackieviruses tend to infect the heart, pleura, pancreas, and liver, causing myocarditis, pericarditis, and hepatitis. At least 23 serotypes of Group A and 6 serotypes of Group B are recognized. Coxsackievirus A16 is the most common cause of HFMD in the United States. Other coxsackievirus serotypes can also cause HFMD, such as coxsackievirus A6.

Transmission occurs by direct contact with saliva, respiratory secretions, vesicle fluid, or stool of an infected person as well as by direct contact with contaminated surfaces and objects, such as shared toys or eating utensils.

Viral replication occurs in the upper respiratory tract (primarily in the tonsils) and the gastrointestinal tract. Based on the serotype and corresponding tissue-specific tropism, infection may spread to the central nervous system, skeletal muscles, myocardium, skin, and liver, leading to viremia and development of symptoms after an incubation period of about three to six days. Initial symptoms begin with fever, malaise, sore throat and may lead to the eruption of the characteristic painful vesicles in the mouth and on the hands and feet. The viral load is high between three and seven days of infection. Illness is usually self-limited with recovery within seven to ten days.

According to the Centers for Disease Control and Prevention (CDC), people with HFMD are most contagious during the first week that they are sick and can sometimes spread the virus to others for days or weeks even after symptoms go away. Coxsackieviruses can be detected in the stool for about six weeks after infection and from the oropharynx for about four weeks after infection. Since coxsackieviruses are non-enveloped viruses, they are more resistant to environmental stressors such as desiccation and temperature or humidity changes and may stay viable on hard and nonporous surfaces for up to two weeks in favorable conditions.

HFMD is more common in children, especially in daycare and elementary school settings, compared to adults who likely have cross-immunity from other common enteroviruses or immunologic memory from childhood infections. Although HFMD in adults is rare, incidence has been increasing in recent years with adult patients presenting with atypical clinical presentations: high fever, varied distribution of lesions, marked skin involvement, and a longer course of the disease. Considering fever with rash is a common symptom combination for a variety of infections (such as chickenpox, mpox, rickettsiosis, and syphilis as described in this article) as well as non-infectious causes, understanding clinical history and epidemiological context must be assessed especially in adult patients.

Diagnosis for HFMD is usually clinical, but unfamiliarity with the disease presentation or clinical variability can lead to difficulties in diagnosis. For instance, in May 2022 an outbreak of a febrile rash with red blisters, joint pain and swelling, vomiting and diarrhea in over 100 young children in India was dubbed the “Tomato Flu”, making headlines as a potential new virus. Turns out, it was likely Coxsackievirus A16 based on viral sequencing results. Reverse transcription PCR (RT-PCR) assays may be used as confirmatory testing for atypical or severe cases using vesicle fluid, throat swabs, or stool specimens.

Just like the respiratory viruses we are all too familiar with, infection prevention for coxsackieviruses is no different. Hand washing, avoiding touching eyes and mouth, and cleaning and disinfecting commonly touched surfaces in environments where transmission may occur is are vital. In healthcare settings, standard precautions should be followed and contact precautions for diapered or incontinent children for duration of illness and to control institutional outbreaks.

Priya Dhagat, MS, MLS(ASCP) CM, CIC, is an infection preventionist and the associate director of the system-wide Special Pathogens Program within the Department of Emergency Management at New York City Health + Hospitals, overseeing special pathogen preparedness and response efforts across New York City Health + Hospitals frontline healthcare facilities. Additionally, she supports and offers subject matter expertise for infection prevention topics for the National Emerging Special Pathogens Training and Education Center (NETEC).

Wastewater Surveillance Works

By Rodney E. Rohde, PhD, MS, SM(ASCP) CM, SVCM, MBCM, FACSc

This article originally appeared in the October 2023 issue of Healthcare Hygiene magazine.

Most everyone has now at least heard about “wastewater surveillance” since it was a vital tool during the [ongoing] COVID-19 pandemic. The Centers for Disease Control and Prevention (CDC) launched the National Wastewater Surveillance System (NWSS) in September 2020. CDC developed NWSS to coordinate and build the nation’s capacity to track the presence of SARS-CoV-2, the virus that causes COVID-19, in wastewater samples collected across the country.

CDC’s NWSS works with health departments to track SARS-CoV-2 RNA levels in wastewater. Wastewater surveillance has quickly become a primary tool for communities to act quickly to prevent the spread of COVID-19. While bootstrap epidemiology, alongside public health and medical laboratory testing in healthcare will always be a part of our ability to respond to infectious disease outbreaks, NWSS is transforming independent local efforts into a robust, sustainable national surveillance system.

Wastewater is now a core component of infectious disease monitoring, providing a local or larger geographical snapshot of a variant-specific, community-representative picture of public health trends that captures previously undetected spread and pathogen transmission links. Remember, in the past the primary tool to detect an outbreak relied on classic epidemiology and laboratory testing of patient samples. In other words, one had to notice clustering of cases and ensure follow-up specimen collection and testing from individuals involved in the outbreak. This methodology requires extensive specimen acquisition, clinical testing, and sequencing coordinated across different sites and laboratories. This type of clinical surveillance is expensive, time-consuming, and subject to bias owing to disparities in public participation and frequency of testing and sequencing, which may limit outbreak preparedness and response by public health organizations, especially in underserved communities.

As you can imagine, while this works it can also mean missed opportunities to notice the genesis of a public health emergency.

How does wastewater surveillance work?

When people are infected with a pathogen (e.g., SARS-CoV-2, influenza, Respiratory Syncytial Virus, etc.) they can shed viral RNA (genetic material from the virus or other microbe) in their feces, and this RNA can be detected in community wastewater. Wastewater, also referred to as sewage, includes water from household, airport, hotel, or similar building use (such as toilets, showers, and sinks) containing human fecal waste, as well as water from non-household sources (such as rain and industrial use).

Wastewater from a sewershed (the community area served by a wastewater collection system) is collected as it flows into a treatment plant.
The samples are sent to environmental or public health laboratories for SARS-CoV-2 [or other microbial] testing.
Health departments submit testing data to CDC through the online NWSS Data Collation and Integration for Public Health Event Response (DCIPHER) portal.
The NWSS DCIPHER system analyzes the data and reports results to the health department for use in their COVID-19 response. The results are available to the public through CDC’s COVID Data Tracker.
How can we utilize wastewater surveillance?

Ongoing research by scientists and others in public health prevention and preparedness have found that the examination of sewage can help detect SARS-CoV-2, the virus that causes COVID-19, in community settings prior to clinical surveillance via doctor’s offices or hospitals report to public health officials. However, at the present time while wastewater data can be an important early warning signal, it still should be used alongside other data.

Wastewater surveillance data are most useful when used with other data. Wastewater data showing the percent change in virus levels should be used along with other data such as overall levels of the virus in wastewater, historical wastewater data for that location, geographical context (for example, whether areas have high tourism or neighboring communities with increasing cases), and clinical cases. Prevention efforts may impact changes in the virus wastewater levels.
Early warning systems, such as wastewater surveillance, can detect small changes as a signal for early action. Importantly, when levels of virus in wastewater are low, a modest increase overall in the virus level can appear much larger as numbers are translated into percentages. Data showing changes from 1 unit to 2 units would be a percent change of 100 percent and the same can be said for a change from 500,000 units to 1 million units.
More data over time can give better, more reliable trends. As with any data collection, one watches for sustained increasing levels of the virus in wastewater and uses this data to inform public health decisions. Correlation of other variables is often required.
Current research has also shown that positive correlation between wastewater surveillance and emergency department (ED) visit data for both influenza and RSV, along with the detection of these two pathogens in wastewater before increases in associated ED visits, suggests that wastewater surveillance might help supplement established clinical surveillance for these viruses.

The future of pathogen tracking is here. While the COVID-19 pandemic and subsequent global public health emergency of Mpox had many devastating outcomes, one silver lining has been the evolution of utilizing wastewater surveillance in national and global infectious disease outbreak detection. NWSS participation is expected to grow as health departments and public health laboratories develop their capacity to coordinate wastewater surveillance, including epidemiology, data analytics, and laboratory support. Learn more here.

Leprosy in the Limelight

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the September 2023 issue of Healthcare Hygiene magazine.

Last month, news of leprosy (Hansen’s Disease) in Florida made headlines after a case report was published as a research letter by the Centers for Disease Control and Prevention (CDC), sparking fears that the disease is endemic in the state and yet another infectious disease to worry about.

The case report described a 54-year-old man who sought treatment at a dermatology clinic for a painful and progressive rash, with lesions on his extremities, trunk and face. He has lived in Florida his entire life, works as a landscaper, and did not report recent travel, exposure to armadillos, prolonged contact with individuals from leprosy-endemic countries, or contact with someone known to have leprosy. After biopsies from multiple sites, Hansen’s Disease was confirmed. According to the CDC report, leprosy in the United States previously affected persons who had immigrated from leprosy-endemic areas, but roughly 34 percent of new case-patients from 2015 through 2020 appeared to have locally acquired the disease. The absence of traditional epidemiological risk factors in recent cases in Florida likely supports environmental reservoirs as a potential source of transmission, according to the CDC research letter.

However, despite known for being an age-old disease of the past, Hansen’s Disease is quite common. The World Health Organization states that the disease is still reported in over 120 countries with more than 200,000 new cases reported every year, the majority in South-East Asia. In the U.S., there were 159 new cases reported in 2020 (the most recent year for which data are available) and 110 of those new cases were reported in Florida, California, Louisiana, Hawaii, New York, Oregon, and Texas, per the National Hansen’s Disease Program.

Hansen’s Disease is caused by infection with the bacteria Mycobacterium leprae, an acid-fast, gram-positive obligate intracellular bacillus which cannot grow outside of a host cell and is completely dependent on host cells for survival.

Transmission is thought to occur through respiratory droplets produced when an infected person coughs or sneezes. Unlike influenza or COVID-19, prolonged close contact with someone with untreated leprosy over a long period of time is needed to become infected. Contact with infected armadillos, a known animal reservoir for the bacteria, may also lead to infection.

leprae targets, invades, and reprograms key genes of cells in the peripheral nervous system (specifically Schwann cells) thereby disrupting and halting myelination processes. Ultimately, infection affects the skin, peripheral nerves, upper respiratory tract mucosa, and eyes.
Diagnosis is based on hypopigmented or erythematous macules with sensory loss, thickened peripheral nerves, or a positive acid-fast smear or skin biopsy. However, due to the slow-growing nature of M. leprae and an extremely long incubation period, the development of symptoms can be years and most patients present with a form of neuropathy.

If not diagnosed early or left untreated, infection can cause permanent neuropathic damage resulting in paralysis, blindness, disfigurement, and disability. The characteristic skin conditions are a result of uncontrolled bacterial growth within the skin and peripheral nerves that form neuropathic ulcers which can lead to the destruction of muscles, cartilage, and bones. Other key signs and symptoms include discolored skin patches, painless ulcers on the soles of feet, swelling on the face, loss of eyebrows and eyelashes, numbness to affected skin areas, muscle weakness, enlarged nerves, and eye or vision problems.

Although there has been an uptick in cases per the CDC report, the overall risk of infection is still considered to be very low considering more than 95% of all people have natural immunity to the bacteria. During care of patients in healthcare settings, routine infection prevention strategies, including following standard precautions, should be followed.

Historically, leprosy was feared as a highly contagious disease caused by a punishment from God which elicited harsh social stigma, prejudice, and ostracization from communities. We now know that the disease still exists in many countries, takes time to spread to others, and is easily treatable once recognized. Continued education and access to treatment are essential to fight stigma about the disease, even in 2023.

Santacroce L, Del Prete R, Charitos IA, Bottalico L. Mycobacterium leprae: A historical study on the origins of leprosy and its social stigma. Infez Med. 2021 Dec 10;29(4):623-632. doi: 10.53854/liim-2904-18. PMID: 35146374; PMCID: PMC8805473. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8805473/

Hess S, Rambukkana A. Cell Biology of Intracellular Adaptation of Mycobacterium leprae in the Peripheral Nervous System. Microbiol Spectr. 2019 Jul;7(4):10.1128/microbiolspec.BAI-0020-2019. doi: 10.1128/microbiolspec.BAI-0020-2019. PMID: 31322104; PMCID: PMC6700727. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6700727/#:~:text=leprae%20is%20a%20strictly%20obligately%20intracellular%20bacterium%20(9%2C%2014).

Centers for Disease Control and Prevention: Hansen's Disease (Leprosy)

Ongoing Challenges for IP&C: 2024 and Beyond

By Rodney Rhode, PhD, MS, SM(ASCP) CM, SVCM,MBCM, FACSc

This article originally appeared in the August 2023 issue of Healthcare Hygiene magazine.

Infection prevention and control (IP&C) has come a long way in the United States. IP&C was established in the U.S. in the 1950s as a hospital discipline in response to a nationwide epidemic of nosocomial Staphylococcus aureus and the recognition of the need for nosocomial infection surveillance. As we approach 2024, the rapidly changing world of healthcare continues to collide with a dangerous, complex, and ongoing global emergency of antimicrobial resistance. Climate change leading to expanding microbial reach, global travel in less than a 24-hour time span, healthcare and public health systems that may collapse in a single moment continue to challenge our global efforts to maintain quality patient care.

Recently, the American Journal of Infection Control (AJIC) published a major article, “Recommendations for change in infection prevention programs and practice.” The authors provide guidance and recommendations in 14 key areas and why these interventions should be considered for implementation by United States. I will briefly list and discuss these 14 key areas alongside my insight and experience in infectious diseases and related areas in this article.

Core Challenges and Recommendations

1. The standardization of infection prevention is a difficult, challenging, and complex issue to tackle. All successful business models work diligently towards “best practices” and infection prevention must be no different. Staffing levels, reporting structure, and physician participation need scientific evidence for determining the best allocation of time practice.

2. Surveillance. The National Healthcare Safety Network (NHSN) has served as the backbone of HAI surveillance with nearly 25,000 participating medical facilities. Given the scope and complexity of surveillance activities, it has been estimated that 45 percent of an infection preventionist (IP)’s time is consumed by this activity. It is critical for current and future IPs to have a robust and current knowledge of automated surveillance software and platforms.

3. Ongoing, multimodal improvement and strategies for hand hygiene practices and compliance.

4. The environment is a living microbiome. We have long known and researched the sources and routes of pathogen transmission with the patient being the most significant. IP practices must continue to address the patient while keeping the environment in health care and community settings in their scope of cleaning, disinfection, and sterilization.

5. Global burden of bacterial antimicrobial resistance (AMR) has been estimated to be 4.95 million deaths globally. “IPs, in coordination with other key healthcare personnel, should review core information regarding AMR to in order to determine facility policy on such issues as isolation, appropriate therapy, and antibiotic stewardship: ensure accurate microbiology test results using the latest Clinical and Laboratory Standards Institute (CLSI) determination of minimum inhibitory concentration (MIC) antibiotic breakpoints (failure to implement these breakpoints may lead to negative impacts on patient care, infection control, as well as public efforts to limit the spread of such organisms); prioritize pathogens using WHO document that categorizes (Critical, High, Medium) resistant bacteria based on treatment options and potential for spread, for example, carbapenem-resistant A baumannii, P aeruginosa, Enterobacteriaceae; or CDC’s phenotype definitions and Antibiotic Resistance Threats report.”

6. Colonization with healthcare-associated pathogens (MRSA, VRE, etc.) is directly correlated with increased infection risks. The process of decolonization is an evidence-based intervention for IPs and other health care professionals to consider in practice.

7. The topic of how healthcare and IP should effectively use and decrease contact precautions. Key to this challenge include “which antibiotic resistant bacteria trigger an isolatable condition, and whether the patient is deemed colonized or infected with the particular AMR bacteria, what type of isolation is appropriate, and whether a healthcare facility implements advances in healthcare strategies to reduce transmission risk or bioburden.”

8. As a medical laboratory and public health professional in the area microbiological infectious diseases, I and my colleagues have stressed how critical the issue of diagnostic stewardship is to patient care and quality. Questions that every health care provider and professional should always ask include, has the correct laboratory test been ordered? Has the specimen been collected and transported correctly? Has the test been accurately interpreted and reported? Diagnostic management teams led by a Doctor of Clinical (medical) Laboratory Science (DCLS) and similar professionals are the leaders in this point.

9. Improvement of Healthcare associated infections (HAIs) for bloodstream infection (BSI) “surveillance in surveillance and prevention of BSI including expansion of the definition, improved documentation of clinical findings to prevent missed events and over-diagnosis.” Device-associated BSIs account for significant numbers of HAIs in United States healthcare facilities and evidence supports a need to implement a more comprehensive prevention strategy that addresses all types of intravenous catheters.

10. HAI surveillance and improvement for non-ventilator hospital acquired pneumonia. Non-ventilator hospital acquired pneumonia is the most common in the U.S. affecting about 1% of all hospitalized patients with a crude mortality of 15 percent to 30 percent.

11. HAI surveillance and improvement for ventilator-associated pneumonia (VAP). Updated definitions for ventilator associated events (VAE) will enhance consistency, accuracy, and reproducibility of surveillance information in this category.

12. HAI surveillance and improvement for urinary tract infections (UTIs). UTIs represent a common diagnosis for patients in the ambulatory, acute, and long-term care setting including in patients with asymptomatic bacteriuria being prevalent with older age, diabetes, impaired voiding, and urinary catheterization. A urinalysis and urine culture are too often and mistakenly ordered resulting in a misdiagnosis of an “infection” versus bacteriuria leading to inappropriate antibiotic treatment [see No. 7].

13. HAI surveillance and improvement for surgical site infections (SSI). An ongoing examination of the surgical care bundle(s) is critical for patient care and a reduction in HAIs, AMR, and patient stay.

14. The 21st century has seen a concerning number of old foes and novel microbial agents emerge (or reemerge) globally. Emerging pathogens such as SARS-CoV-2, Ebola, Nipah, Marburg, Candida auris, ringworm, antimicrobial resistant pathogens, and many other dangerous microbes are in the headlines daily. IPs and others must conduct research addressing the appropriate control of patients with emerging diseases to include methodologies to improve early identification, surge management, isolation, and reprocessing.

For the complete recommendations for change in infection prevention programs and practice, see Table 1 in the “Recommendations for change in infection prevention programs and practice” AJIC article.

The Importance of Water Management in Infection Prevention: Is Legionella Lurking in Your Facility?

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the July 2023 issue of Healthcare Hygiene magazine.

As the summer months continue, the warmer temperatures and increased humidity are associated with increased seasonality of legionellosis -- a febrile illness that can lead to severe pneumonia, also called Pontiac fever, or Legionnaires’ disease. Legionella spp. are aerobic, Gram-negative bacilli that are common in the environment but sensitive to dry conditions and can survive in warm and humid weather thereby increasing infection and disease risk in older people and those who have certain risk factors, such as being a current or former smoker, having a chronic disease, or having a weakened immune system. Around 6,000 Legionnaires' disease cases are reported each year in the United States, according to the Occupational Safety and Health Administration (OSHA). Legionella has been detected in spas, hotels, gyms, cruise ships, apartment buildings, and healthcare facilities.

Almost any system or equipment containing nonsterile water has the potential to grow Legionella if certain factors become favorable for Legionella growth. Inadequate disinfection, fluctuations in water temperature and pH, changes in water temperature, biofilm formation, and water stagnation can all impact the water systems. Legionella can then become a health concern if detected in water systems like showerheads and sink faucets, cooling towers, hot tubs, decorative fountains, hot water tanks and heaters, and large complex water systems – such as in healthcare facilities. Infection usually occurs after inhalation of droplets that contain the bacteria.

A robust water management program in healthcare facilities includes risk assessments, surveillance and testing, and action plans, all of which are essential to limit Legionella and other opportunistic waterborne pathogens (e.g., Pseudomonas, Acinetobacter, Burkholderia, Stenotrophomonas, nontuberculous mycobacteria) from growing and spreading in healthcare facilities. Inconsistencies or discrepancies in plans and actions can lead to infection, severe illness and even death, especially in immunocompromised patients. For example, in 2011 and 2012, the VA healthcare system in Pittsburgh experienced an outbreak, which led to 22 infections and five deaths.

Microbiological cultures showed Legionella growth in various locations where environmental samples were obtained, including numerous patient rooms, potable hot water heaters, and a decorative fountain. The outbreak was ultimately linked to contamination of hospital's potable water system during construction activities. In 2016, a 7-month old patient died from Legionnaire's disease at UCSF Benioff Children’s Hospital two weeks after he had undergone a successful bone marrow transplant to cure Wiskott-Aldrich Syndrome. Testing later revealed that Legionella was present in the hospital’s plumbing system, including in the patients’ room. In 2018, University of Wisconsin Hospital reported a Legionnaire’s disease outbreak of 14 cases and three deaths linked to a change in its hot-water system.

As subject matter experts in prevention strategies, infection preventionists play an essential role in water management programs by identifying devices, areas, and infrastructure that may be of concern (e.g., humidifiers, ventilators, CPAP machines, hydrotherapy equipment, sinks, hot tubs, fountains, aerators, faucet flow restrictors, ice machines). Ideally, healthcare water management teams should be multidisciplinary and include members from engineering, infection prevention, maintenance, and housekeeping who should regularly monitor water quality parameters, disinfection, temperature levels, and surveillance and sampling results in effort to continuously identify, minimize, or respond to conditions that may encourage growth of Legionella and other waterborne pathogens.

The Centers for Disease Control and Prevention (CDC) provides numerous resources to support healthcare facilities in developing and maintaining a framework for an effective water management program. Additionally, CMS requires healthcare facilities to develop water management programs that are compliant with American Society of Heating, Refrigerating and Air-Conditioning Engineers guidelines (ASHRAE).

As outlined by the CDC, the following steps are recommended:

Establish a water management program team
Describe the building water systems
Identify areas where Legionella (or other waterborne bacteria) could grow and spread
Decide where control measures should be applied and how to monitor them
Maintain water temperatures outside the ideal range for Legionella growth
Prevent water stagnation
Ensure adequate disinfection
Maintain premise plumbing, equipment, and fixtures to prevent sediment, scale, corrosion, and biofilm
Establish ways to intervene when control limits are not met
Make sure the program is running as designed (verification) and is effective (validation)
Document and communicate all the activities
Priya Dhagat, MS, MLS(ASCP) CM, CIC, is an infection preventionist and the associate director of the system-wide Special Pathogens Program within the Department of Emergency Management at New York City Health + Hospitals, overseeing special pathogen preparedness and response efforts across New York City Health + Hospitals frontline healthcare facilities. Additionally, she supports and offers subject matter expertise for infection prevention topics for the National Emerging Special Pathogens Training and Education Center (NETEC).

The Infection Preventionist Journey

By Rodney E. Rohde, PhD, MS, SM(ASCP) CMSV CM, MBCM, FACSc

This article originally appeared in the June 2023 issue of Healthcare Hygiene magazine.

Over the past 30 years of my career, I’ve navigated multiple degrees and credentials. I often tell my students and colleagues that I consider myself a “hybrid professional” due to having one foot firmly planted in public health and the other foot planted in the medical laboratory space. During this professional and personal journey, I’ve crossed paths that have often been at the intersection of what I am at my core – an infectious disease specialist in microbiology, public health, and molecular diagnostics. Within these streams of specialization, I have the ongoing perspective of the academic experience as University Distinguished Regents’ Professor and chair of the Medical Laboratory Science Program, College of Health Professions at Texas State University. I also serve as the associate director of the Translational Health Research Center which collaborates across all our colleges which conduct health related research. To this point, I am now strategically involved in recruiting, preparing, and graduating future healthcare professionals as credentialed medical laboratory scientists (MLS).

As I’ve navigated my career path, I have continued to recognize that most junior high, high school, and early college students rarely understand the diversity of healthcare, health professions, public health, and medical related careers. Most students and non-students understand the career paths of patient/public-facing majors such as physicians, nurses, pharmacists, physical therapists, and others. However, what I’ve discovered is the total lack of awareness of outstanding college majors (at all levels of academia – associate, bachelor, master, and doctoral degrees) that are often hidden from the public’s view, and in many instances even high school teachers, advisors, counselors, administrators, early college professors, advisors, and other leaders do not know about these college majors.

Unfortunately, many of these college majors have the added issue of major workforce shortages which exacerbates the problem because the pipeline of future professionals has a significant bottleneck. For example, medical laboratory professionals, respiratory therapists, radiation therapists, infection preventionists, transfusion medicine, in-vitro fertilization specialists, echocardiographer, medical librarian, cytotechnologist, histologist, nuclear medicine technologist, organ and tissue procurement technician, medical examiner technician, and so many others are prime career paths with outstanding financial packages and benefits.
While I’ve mentioned many of these hidden professions, I want to focus on the infection preventionist (IP) career because this role has intersected my research and teaching passion – infectious diseases and microbiology. In most cases, an infection preventionist is typically a registered nurse or they have a background in epidemiology or microbiology. For example, I have several alumni from our medical laboratory science program who worked in the medical laboratory environment for several years then became an IP. These individuals also picked up graduate degrees, one at the master’s level (infectious diseases) and the other at the master’s and doctoral level (master’s public health and doctorate in health sciences).

To be clear, some infection preventionists have advanced qualifications, such as a master’s degree in public health or epidemiology which may help with advancement and other career opportunities, but it is not required. If you are a nurse or MLS, you must be certified to work in your state. Infection preventionists usually have three to five years of experience working in epidemiology, disease control, or a closely related field. Strong analytical, communication, and research skills, along with advanced computer and statistical literacy, are essential for carrying out the responsibilities of this role.

As mentioned, there are many healthcare professionals who can become and IP, but it merits attention that it’s critical that an individual has a strong background in understanding, interpreting, and applying knowledge in infectious diseases as it relates to being a detective in the health environment. For example, a PI must be able to interpret microbiological and medical laboratory results surrounding microbial identification, antibiotic susceptibility data, and molecular diagnostic data as it applies to understanding a hospital outbreak in a particular area (pediatric, ambulatory, emergency room, long term care, etc.). A credentialed medical laboratory professional has a very strong theoretical and practical education and experiential learning experience in this realm.

While there are many different types of job descriptions for an IP, I will share one from one of my alumni who has worked in this career path. The job title is an associate director, special pathogens program within the department of emergency management with one of the nation’s largest municipal healthcare delivery systems overseeing special pathogen preparedness and response efforts across multiple acute care hospitals in addition to post-acute, long-term care, and ambulatory care sites.

Additionally, this position provides subject matter expertise for infection prevention topics within the National Emerging Special Pathogens Training and Education Center (NETEC) and is an advisor for infection prevention for Health + Hospitals Institute for Diseases and Disaster Management. The person provides support, resources, consultation, and training to frontline facilities to bolster their bio preparedness efforts.

As a former IP at an acute-care facility, this individual’s efforts focused on hospital-acquired infection surveillance, outbreak investigation, communicable disease exposure prevention, Ebola and pandemic influenza preparedness, and development of infectious disease surveillance guidance for health care workers. The individual has a strong background in microbiology, infectious diseases, and infection prevention, and is board certified in medical laboratory science and infection prevention and epidemiology.

Rodney E. Rohde, PhD, MS, SM(ASCP)CM SVCM, MBCM, FACSc, serves as chair and professor of the Clinical Laboratory Science Program at Texas State University. Follow him on Twitter @RodneyRohde / @TXST_CLS, or on his website: http://rodneyerohde.wp.txstate.edu/

High Fives for Hand Hygiene

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the May 2023 issue of Healthcare Hygiene magazine.

Microorganisms exist everywhere - on our bodies, on the surfaces we touch, in our environment – and our hands play a major role the transmission of blood-borne, fecal, and respiratory tract pathogens. Hand hygiene is the most simple, foundational strategy to prevent the spread of microorganisms and is integral to breaking the cycle of transmission of bacteria, viruses, and fungi, whether it be in our homes or in a healthcare setting. Performing hand hygiene and at the right moments using the proper technique is a proven and steadfast method to prevent hospital acquired infections and spreading multidrug-resistant organisms.

While hand hygiene is routinely taught and monitored in healthcare settings, it can be overlooked or inappropriately performed. Promoting awareness and adherence to hand hygiene requires multimodal interventions, strategies, and campaigns to effectively engage healthcare workers and emphasize the relationship between a basic age-old technique and patient safety.

The World Health Organization has designated May 5, 2023 as World Hand Hygiene Day, a day to “accelerate action to prevent infections and antimicrobial resistance in health care and build a culture of safety and quality in which hand hygiene improvement is given high priority.”

In celebration of World Hand Hygiene Day, here are five interesting facts to promote hand hygiene:

Fingernails harbor the most bacteria on the hand.
The subungual areas of the hand harbor high numbers of bacteria, most frequently coagulase-negative staphylococci and gram-negative rods. The space between the skin and nail creates a perfect environment for growth due to the physical protection of the nail and moisture within the space. Although it may be difficult to clean compared with the rest of the hand, fingernails are often missed as most attention is given to larger surface areas, like the palms. Artificial nails are increasingly reported as having the potential to transmit infections in healthcare settings and are more likely to harbor gram-negative pathogens. Numerous studies have shown an association between nails and hospital acquired infections, including an outbreak of Pseudomonas aeruginosa in a NICU and cluster of hemodialysis-related Serratia marcescens bacteremia.

Twenty seconds is the recommended time to wash hands. According to a recent study, it takes about 20 seconds of vigorous movement to dislodge viruses and bacteria across all areas of the hands. Researchers used a mathematical model to simulate the movement of particles during hand washing. In the model, two rough surfaces separated by a thin film of liquid moved past each other to mimic hands scrubbing together. The model revealed that it took about 20 seconds to enable the particles to escape into the fluid, which aligns with public health recommendations. However, researchers at Michigan State University noted an average hand-washing time was just 6 seconds, far below the CDC's recommended duration!
Soap cleans the skin by acting as a surfactant and emulsifier. One end of a soap molecule is hydrophilic and will interact with water, while the other end is lipophilic, which repels water but will interact with oils or other biological materials. When soap is lathered, it surrounds the oils and disrupts the chemical bonds that allow microorganisms to adhere to the skin, leading to the formation of micelles that trap the dislodged particles. When hands are rinsed with water, the micelles are lifted and washed away.
Our hands have resident and transient skin flora. Millions of bacteria live on our hands, many good, but also some that can may cause infection. Resident skin flora naturally live on the skin and rarely cause infection in most health individuals. While these bacteria are not typically harmful, they may cause infection in immunocompromised individuals. Examples of resident skin flora include Staphylococcus epidermidis, Staphylococcus hominis, and Coryneform Transient skin flora consists of bacteria, fungi, and viruses that temporarily live on the skin and usually come from contact with patients or contaminated surfaces. Since we touch an average of 300 surfaces every 30 minutes, exposing us to up to 840,000 microorganisms, transient bacteria are more common than we think.
Bacteria and viruses can survive on hands and surfaces for extended periods of time. Staphylococcus aureus can survive on hands for over two hours and on surfaces for up to seven months. VRE can survive on hands or gloves for up to one hour and on surfaces for four months. Clostridioides difficile spores can survive for up to five months. Enveloped viruses such as influenza virus, parainfluenza virus, and cytomegalovirus may survive on the hands up to two hours. Click here to view some jarring images of bacterial growth cultured from several items such as unused gloves, doorknobs, a nurse station mouse, a mobile phone, an ultrasound machine, and a health-care workers’ hands.
For more information and resources for World Hand Hygiene Day, click here: World Hand Hygiene Day (who.int)

Gonorrhea: Not Your Usual STI Anymore

By Rodney E. Rohde, PhD, MS, SM(ASCP) CMSV CM, MBCM, FACSc

This article originally appeared in the April 2023 issue of Healthcare Hygiene magazine.

Antimicrobial resistance (AMR) happens when microbes such as viruses (e.g., HIV), bacteria (e.g., Neisseria gonorrhea and fungi (e.g., Candida auris) develop the ability to resist, and even defeat, the antimicrobial drugs designed to kill them. Unfortunately, AMR has been a threat to our collective and global health since the first antibiotic, penicillin, was found and utilized. To put it plainly, AMR means the germs are not killed and continue to grow. Many pathogenic microbes have become dangerously close to the pre-antimicrobial era with some only have one class or a single antimicrobial available to clinicians for treatment. Gonorrhea has developed resistance to nearly all the antibiotics used for its treatment. Currently, there is one last recommended and effective class of antibiotics, cephalosporins, to treat this common infection. This is an urgent public health threat because gonorrhea control in the United States largely relies on our ability to successfully treat the infection.

Microbes, like N. gonorrhea and others, are built to evolve in a diabolical way to outsmart the antibiotics and other antimicrobial drugs used to kill eliminate deadly infections. Due to this global problem, we must continuously monitor for resistance in not only humans, but also in animal and environmental settings to encourage the research and development of new drugs for gonorrhea treatment. Likewise, we must all work towards better stewardship of our antimicrobial drugs via accurate and appropriate medical laboratory testing that informs pharmaceutical accuracy and reduces empirical selection of a drug.

An Update: Neisseria gonorrhea
On Jan. 19, 2023, health officials in Massachusetts reported the detection of a novel strain of gonorrhea with resistance or reduced susceptibility to the antibiotics used for treatment of the sexually transmitted infection (STI). It's the first detection of the strain in the United States.

The case first presented to primary care with urethritis. The individual reported no known exposure to gonococcal infection or initial disclosure of risk factors. The infection likely initiated in Massachusetts, with no recent travel history reported, however, recent travel by sex partners could not be ruled out. Successful treatment of the patient occurred with ceftriaxone 500 mg IM, the currently recommended treatment for gonorrhea, followed by documented subsequent negative testing at urethral, pharyngeal, and rectal sites. Reduced in vitro susceptibility by the isolate to cephalosporins (ceftriaxone, cefixime, cefoxitin) and azithromycin was demonstrated; and resistance to ciprofloxacin, penicillin and tetracycline, via E-test and agar dilution methods.

The isolate is of a multilocus sequence type (ST), MLST 8123, which was originally identified in the Asia-Pacific region. Sequencing of the isolate confirmed the presence of a mosaic penA60 allele which confers reduced ceftriaxone susceptibility. In the United Kingdome, eight cases with the identical MLST 8123 ST, also exhibited reduced ceftriaxone susceptibility, between December 2021 and June 2022. All UK individuals were successfully treated with ceftriaxone. However, emergence of this strain indicates N. gonorrhoeae’ s ongoing evolution for development of resistance to AMR treatment.

Gonorrhea is the second-most-reported STI in the United States. In Massachusetts, laboratory-confirmed cases more than quadrupled since a nadir of 1,976 in 2009, to 8,133 in 2021. With rising case numbers, Massachusetts Department of Public Health officials reported this particular strain was found in two residents of the state, both of whom were cured. An alert to clinicians in the state has been issued for a heightened lookout for the new strain with a warning that the two cases are an urgent sign that gonorrhea is becoming less responsive to treatment.

Diagnosis
The CDC and U.S. Preventive Services Task Force recommend routine gonorrhea screening for sexually active women younger than 24 years and women 25 years or older who are at increased risk. Screening is also recommended for sexually active men who have sex with men, at least annually but up to every three months if at increased risk. Screening recommendations should be adapted based on anatomy and reported sites of sexual exposure.

Culture and/or nucleic acid amplification testing (NAAT) are available for detecting urogenital (urine, urethral, vaginal, cervical) and extragenital (rectal, oropharyngeal, conjunctival) infection with N. gonorrhoeae. NAAT sensitivity and specificity for detecting N. gonorrhoeae from urogenital and extragenital anatomic sites are superior to culture but vary by NAAT type. However, NAAT is not approved for sequencing or antimicrobial susceptibility testing for clinical purposes. Because N. gonorrhoeae has demanding laboratory growth requirements, optimal culture recovery rates are achieved when swab specimens are inoculated directly and when growth medium is promptly incubated in a carbon dioxide (CO2)-enriched environment. Non-nutritive swab transport systems (e.g.,

Amies agar gel) that may maintain gonococcal viability for less than 24 hours in ambient temperatures, are available for sample transport to clinical microbiology laboratories.

Important Reminders
The CDC named gonorrhea as one of the three most urgent threats posed by antibiotic-resistant bacteria 10 years ago. Both U.S. and world health authorities created public health programs to reduce new cases of gonorrhea in hopes of controlling the bacteria until vaccines and new treatments arrive.
The Massachusetts cases bring strong reminders of the ongoing dangerous AMR threat globally. The cases are the first laboratory confirmed gonorrhea isolates to evolve and sidestep six of the seven drugs tracked by public health and healthcare for potential resistance. The isolates carry a gene mutation (penA60 allele) linked to previous ceftriaxone-resistant cases in Nevada, the United Kingdom, and Asia.

For more information and details regarding laboratory diagnostics, treatment, and public health requirements for reporting, visit: https://www.mass.gov/doc/clinical-alert-on-non-susceptible-gonorrhea-january-19-2023/download

Marburg Virus: Reflections and Reminders Amidst a Current Outbreak

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the March 2023 issue of Healthcare Hygiene magazine.

Nearly one month after the end of an Ebola virus outbreak in Uganda, another viral hemorrhagic fever outbreak strikes again. This time, Marburg virus strikes Equatorial Guinea, a small Central African country nestled between Cameroon and Gabon on the west coast of Africa.

On Feb. 13, 2023, a Marburg virus disease (MVD) outbreak was confirmed in the North Western part of the country, making it the first MVD outbreak that has ever been declared in Equatorial Guinea. Outbreaks and sporadic cases have historically been reported across Africa, including Angola, the Democratic Republic of the Congo, Kenya, South Africa, and Uganda.

The confirmed and suspected cases presented with fever, fatigue, bloodstained vomit and diarrhea. Contact tracing and emergency responses are ongoing as vaccine candidates are evaluated for potential clinical trials, and epidemiological surveillance has intensified in Equatorial Guinea, Cameroon, and Gabon.

What is Marburg Virus Disease?
Marburg virus is an enveloped RNA virus in the filovirus family and is typically transmitted to humans from fruit bats. Human-to-human transmission occurs through direct contact with blood or body fluids from an infected person or contact with contaminated equipment or materials. Following entry into the body, the virus attaches to and replicates in monocytes, macrophages and dendritic cells, and further disseminates to hepatocytes, endothelial cells, fibroblasts, and epithelial cells. As viral replication and pathogenesis continues, clinical manifestations begin abruptly and include flu-like symptoms such as a high fever, severe headache, chills, myalgia, gastrointestinal symptoms, rash, eventually leading to multi-organ failure. With a case fatality rate of 23 percent to 90 percent, supportive care is critical for survival.

An Imported U.S. Case in 2008
The only documented case of MVD in the U.S. was from a traveler in 2008. On Jan. 9, 2008, an infectious disease physician notified the Colorado Department of Public Health of a case of unexplained febrile illness requiring hospitalization in a woman who returned to the United States after a two-week trip to Uganda. The patient was initially seen at an outpatient clinic but was admitted to a hospital after symptoms worsened. Laboratory results revealed hepatitis and acute renal failure, but testing was negative for pathogens that cause febrile illnesses, including viral hemorrhagic fevers. The patient was discharged on Jan. 19, 2008 but returned six months later requesting repeat testing after she learned about a Dutch tourist who visited the same cave she had visited - the Python Cave, known for inhabiting fruit bats that have been found positive for filoviruses – and died from MVD. Repeat testing revealed evidence of prior infection with Marburg virus. The patient likely became infected after exposure to bat secretions while visiting the Python Cave and reported touching guano-covered rocks while climbing into the cave and may have covered her mouth and nose with her hands due to unpleasant smell in the cave. A retrospective contact tracing investigation identified approximately 260 contacts, including health-care workers and laboratory workers. Luckily, secondary transmission did not occur.

Important Reminders
While it may seem like a distant threat, imported cases of viral hemorrhagic fevers over the past several years (for example, Lassa Fever in the UK and Ebola in the U.S.) continue be a reminder that in our increasingly interconnected world, an outbreak anywhere can still pose a risk, albeit low, to healthcare facilities and may lead to a heavy toll on response and recovery efforts if cases go undetected. Restoring the fundamentals of infection prevention and control and providing ongoing education to healthcare professionals on the importance of travel screening and the “identify, isolate, inform” approach will support ongoing healthcare readiness for high-consequence diseases like Marburg.

Infection prevention and control guidelines for MVD are similar to those for Ebola and other viral hemorrhagic fevers. Patients should be isolated in a private room with dedicated bathroom or commode. Preventing direct physical contact is vital to prevent exposures; strict adherence to transmission-based precautions and the use of PPE is required. A U.S. Environmental Protection Agency-registered hospital disinfectant with efficacy against enveloped viruses should be used to disinfect surfaces and single-use medical equipment should be used by healthcare workers. A waste management plan for handling, storage, treatment, and disposal of waste should be developed in compliance with state and local regulations.

The CDC offers guidance for emergency room clinicians to assess viral hemorrhagic fever risk in returning travelers and has developed guidelines for Ebola, which can also be used for Marburg. For more information, refer to:
https://www.cdc.gov/vhf/abroad/assessing-vhf-returning-traveler.html
https://www.cdc.gov/vhf/ebola/clinicians/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fvhf%2Fabroad%2Fvhf-manual.html

Raccoons, Aromatherapy, and Burkholderia

By Rodney E. Rohde, PhD, MS, SM(ASCP) CMSV CM, MBCM, FACSc

This article originally appeared in the February 2023 issue of Healthcare Hygiene magazine.

Over the past year or so, I’ve written about the dangers associated with the bacterial genus Burkholderia. This genus of Proteobacteria include pathogenic members of a diverse group of species responsible for dangerous and often deadly infections. Unfortunately, this group of bacteria can be difficult to isolate and differentiate in the typical clinical microbiology laboratory while becoming more difficult to treat with antibiotic therapy due to resistance.

In a recent CDC Health Alert Network, four cases of melioidosis from Georgia, Kansas, Minnesota and Texas were identified and characterized. The first case (fatal) identified in March 2021 occurred in Kansas. The second and third cases, both identified in May 2021 in Minnesota and Texas, were hospitalized for extended periods of time before being discharged to transitional care facilities. The most recent case died in the hospital and was identified post-mortem in late July 2021 in Georgia. All cases had no history of traveling abroad from the United States. Melioidosis signs and symptoms are varied and nonspecific, and may include pneumonia, abscess formation, and blood infections.

Ultimately, the source of in infections for these four cases was found to be an aromatherapy room spray imported from India.

An Update: Texas Case Investigation
In a strange twist to the Texas case and after it was learned that an aromatherapy product was the source of the outbreak with the prior mentioned four cases, the Texas Department of State Health Services (DSHS) discovered that the Texas patient’s family owned a healthy raccoon as a pet. The family reported to the DSHS that the raccoon had broken a bottle of the aromatherapy spray and walked in and through the liquid.

About two weeks after this exposure, April 3, 2021, the family’s pet raccoon displayed acute neurologic symptoms consistent with neurologic melioidosis and died of unknown cause three days later. The raccoon carcass was wrapped in a cloth robe and buried on the family’s property. Importantly, the aromatherapy bottle (ATS2021) linked to the outbreak contained the strain which exhibits a genetic variant, the bimABm allele, which is a virulence factor associated with neurologic melioidosis.

Modeling studies regarding environmental conditions for B. pseudomallei suggest that certain regions of Texas have soil and climate that are favorable for this dangerous pathogenic bacteria. To be conservative and cautious about introducing and establishing this bacteria in soil where it was not thought to be endemic, staff from Texas DSHS, Environmental Protection Agency (EPA) and CDC visited the family’s property in Texas on April 19, 2022, to ascertain B. pseudomallei contamination and to decontaminate the burial site. Thirty-two environmental samples were collected in and around the burial site and property. The raccoon carcass was buried at approximately one foot, and 12 tissue samples were collected during field necropsy.

Following sample collection, EPA staff members immediately decontaminated the carcass and excavated soil within a two-foot circumference of the carcass in germicidal bleach (8.25 percent sodium hypochlorite, diluted 1:3 with water) overnight for approximately 15 hours. All samples were tested for B. pseudomallei by PCR and culture at CDC. A portion of four of the 12 tissue samples were formalin-fixed by the Dallas County Health and Human Services Laboratory in Texas and tested for B. pseudomallei by immunohistochemistry (IHC) at CDC.

Laboratory Results
Swabs collected from the raccoon’s intraorbital tissue tested positive by PCR for the presence of B. pseudomallei DNA; however, viable B. pseudomallei was not cultured. All other tissue samples tested negative by PCR or IHC. Contamination of the environment was not detected via no PCR and culture evidence of the pathogen.

The positive PCR result for B. pseduomallei from the raccoon tissue reaffirmed the suspicion that the racoon likely died of acute neurological melioidosis. Per the findings, it is the first reported presumed melioidosis case documented in a raccoon and the first animal case linked to this outbreak. While the pathogen could not be cultured and sequenced, the pet raccoon was most likely infected by the outbreak strain given the animal’s exposure history and that B. pseudomallei has never been isolated from a soil sample in Texas.

While this disease it not usually seen in animal to human transmission, it has been documented and shown to infect a wide range of animal life (fish, reptiles, and mammals). Thankfully, no evidence of environmental contamination by B. pseudomallei from the buried carcass was found. This is important in preventing a foothold for B. pseudomallei in soil where the pathogen is not known to be endemic.

Important Reminders
As many of you know, I have discussed many forms of antimicrobial resistance (AMR) in this column. Surfaces and biofilms intersect with AMR. Animals, including wildlife, livestock, and pets of all kinds can also be important “carriers or vectors” of pathogens. Appropriate precautions for importation and movement of animals, vegetation, or other similar products should be followed. Likewise, hand hygiene and other disinfection (or sterilization) of surfaces and products may be appropriate.

For more information, see: https://emergency.cdc.gov/han/2021/han00448.asp and https://www.cdc.gov/mmwr/volumes/71/wr/mm7150a5.htm

Ebola in Uganda: A Reminder that Vigilance Requires Diligence

By Priya Dhagat, MS, MLS(ASCP) CM, CIC

This article originally appeared in the January 2023 issue of Healthcare Hygiene magazine.

On Sept. 17, 2022, Uganda’s National Public Health Emergency Operations Center was notified of a suspected viral hemorrhagic fever (VHF) case at Mubende Regional Referral Hospital in central Uganda. A 26-year-old male presented with range of symptoms including high fever, abdominal pain, diarrhea, cough, bloody vomit, and bleeding from the eyes, but no recent travel or known Ebola virus exposures. The patient died the following day. A blood sample confirmed Sudan ebolavirus (SVD).

Within the next few days, the Ugandan Ministry of Health declared an outbreak of Ebola in Mubende District and launched a public health emergency response to identify additional cases. Since then, at least 142 people have been infected and 56 people have died across nine districts, including children and healthcare workers.

So, what’s the significance of SVD? Why should we be concerned? The Sudan ebolavirus is genetically distinct from the Zaire ebolavirus -- the cause of the 2014 West Africa Ebola outbreak and the largest outbreak in history since the virus’s discovery in 1976. Although SVD has a lower case fatality rate than the Zaire ebolavirus (40 percent to 60 percent compared to 60 percent to 90 percent), there is currently no proven or licensed vaccines or therapeutics, although a trial using experimental vaccines that are specific to Sudan ebolavirus may be planned for 2023. Ebola isn’t new to Uganda, however. This outbreak marks the fifth SVD outbreak in the country; the last outbreak was roughly a decade ago. Due to the lack of vaccines, concurrent emergency responses to other infectious diseases, deficient infection prevention practices at healthcare facilities, and the likelihood that transmission began weeks before the index case, the risk for disease spread was high. Top of Form

In October 2022, the U.S. government began implementing safety measures in response to the outbreak. Travelers arriving to the U.S. who had been to Uganda within the past 21 days would be redirected to one of five airports where they would be screened for Ebola virus disease (EVD), including temperature checks and completing health questionnaires. The Centers for Disease Control and Prevention (CDC) urged clinicians to obtain a detailed travel history from patients suspected to have EVD and emphasized the importance of infection prevention precautions, personal protective equipment, laboratory biosafety, and waste management.

Federal safety measures and guidance casts a wide net for prevention of disease transmission domestically, but by now it should go without saying that infectious disease threats are growingly common and U.S. healthcare systems must continue to maintain vigilance and incorporate every lesson learned from previous threats into their plans.

The “Identify, Isolate, and Inform” approach for managing Ebola virus, coined in 2015, has been used time and time again over the years and remains a foundational strategy to initially manage patients with communicable diseases. While the phrase easily rolls off the tongue, developing facility specific plans that account for this approach can be anything but easy. Below are a few ways the Identify, Isolate, and Inform approach can be incorporated in planning and preparedness activities:

To Identify:

- Build travel screening questions into registration workflows. This could mean embedding symptom, exposure, and travel history questions into electronic health records or using a paper form during patient registration or intake.

- Ensure signage is visible, prominent, and translated in languages that are appropriate for your patient population. A visual alert can help patients self-identify.

To Isolate:

- Determine the route from point of entry to an isolation room. Consider all points of entry into your facility where patients can present. Mapping this out ahead of time will promote efficient and timely isolation.

- Evaluate the dynamics of the isolation room. Think about the space required for donning and doffing PPE, methods to see and communicate with the patient, and where waste will be stored, considering that anything contaminated with Ebolavirus is considered category A infectious waste and requires a thorough waste management plan.

- Determine the supply and resources needed. This isn’t just limited to PPE (which includes numerous pieces per the CDC), but could mean hand sanitizer, biohazard waste bins and bags, and spill cleanup supply.

- Designate who should support healthcare personnel as a trained observer.

To Inform:

- Create a call tree to support prompt notification to both internal and external stakeholders, such as department and facility leadership, infection prevention and control, environmental services, occupational health, and local public health departments. Ensure staff are aware of the call tree or communication plan.

Every healthcare facility is unique in staffing, space, supply, and its capabilities, which can change over time. Conducting routine risk assessments can identify strengths and vulnerabilities in existing processes. Putting plans to practice by conducting drills creates a no-fault learning environment. Establishing an interdisciplinary work group fosters inclusions and promotes preparedness across different disciplines. Clear, streamlined communication leads to efficient coordination and response. Creating concise and practical resources for frontline staff leads to prompt decision making. Together, this instills a culture of preparedness, prevention, and safety – even for seemingly distant threats.

In 2022 alone, there have been numerous outbreaks of viral hemorrhagic fevers – from Ebola to Marburg, Lassa, and Crimean-Congo hemorrhagic fever. The Uganda Ebola outbreak is yet another reminder that we shouldn’t let down our guard.