ABSTRACT
Background. In February 2019, California (CA) experienced its first C. auris outbreak in Orange County (OC). The CA Department of Public Health (CDPH) and OC with the Centers for Disease Control and Prevention (CDC), mounted a successful containment response;by November 2019, cases were limited to low-level spread in OC long-term acute care hospitals (LTACH). In May 2020, C. auris cases began to surge in OC, followed by extensive spread in six other southern CA local health jurisdictions (LHJ). CDPH with LHJ and CDC, initiated an aggressive, interjurisdictional containment response. Methods. We carried out response and preventive point prevalence surveys (PPS), onsite infection prevention and control (IPC) assessments, and in-service trainings at outbreak and interconnected hospitals and skilled nursing facilities in six LHJ. Other regional activities included: epidemiologic investigation, contact and discharge tracking and screening;increasing laboratory testing capacity;screening patients admitted to and from LTACH;statewide healthcare facility (HCF) education and outreach;sending regional outbreak HCF lists to all HCF;and biweekly state-LHJ coordination calls. The Antibiotic Resistance (AR) Lab Network supported testing. Results. From May 2020-May 2021, we conducted screening at 226 HCF, and identified 1192 cases at 93 HCF, mostly through screening (n=1109, 93%) and at LTACH (n=906, 76%);we identified 113 (10%) cases at ACH, including 35 (31%) in COVID-19-burdened units. Cases peaked in August 2020 (n=93) and February 2021 (n=191) and have since declined, with C. auris resurgence mirroring COVID-19 incidence. We conducted 98 onsite IPC assessments, and identified multiple, improper IPC practices which had been implemented in response to COVID-19, including double-gloving and -gowning, extended use of gowns and gloves outside patient rooms, and cohorting according to COVID-19 status only. Figure 1. C. auris and COVID-19 Cases in California through May 2021, and C. auris Cases by Local Health Jurisdiction (LHJ) May 2020-May 2021 Conclusion. The C. auris resurgence in CA was likely a result of COVID-19-related practices and conditions. An aggressive, coordinated, interjurisdictional C. auris containment response, including proactive prevention activities at HCF interconnected with outbreak HCF, can help mitigate spread of C. auris and potentially other novel AR pathogens.
ABSTRACT
Background. Skilled nursing facility (SNF) residents comprised 11% of all COVID-19 cases in the United States;however, they account for 43% of deaths with case fatality rates (CFR) of 26.0-33.7%. Methods. We report an outbreak of COVID-19, from June 15 to July 21, 2020 in a 159-bed SNF with a staff of 172 that resulted in an infection rate of 97% in residents and 23% in HCWs (Figure 1). A retroactive review outlined mitigation efforts, discussed challenges, identified risk factors among residents and health care workers (HCW) for acquisition of COVID-19, and reviewed opportunities for improvement (Figure 2). Results. Factors that contributed to the outbreak: delay in test results had an impact on cohorting;suboptimal adherence to the principles of infection prevention and control (IPC) and minimal adherence monitoring;strict criteria were used to screen for infection;the underappreciated transmissibility of COVID-19 from presymptomatic and asymptomatic persons;symptomatic HCWs who continued to work;the changing guidance on, the suboptimal use of, and an inadequate supply of personal protective equipment;poor indoor air quality due to ventilation challenges;and the important role of community/family/interfacility spread on the outbreak. Whole genome sequencing, performed in 52 samples, identified a common strain that was also found in clusters of 2 other facilities: 1 in the same geographic location, the other in a different geographic location but whose HCWs had the same zip codes as the facility (Figure 3). Certified nursing and restorative nursing assistants had the highest risk of infection with an odds ratio (OR) of 4.02 (confidence interval 1.29-12.55, p value: 0.02) when compared to registered and licensed vocational nurses. The residents' CFR was 24%. The OR for death was increased by 10.5 (10.20-11.00) for every decade of life as was morbid obesity (BMI > 35) with an OR of 8.50. BMI as a continuous variable increased risk of mortality for every additional unit, OR 1.07 (Tables 1, 2). Conclusion. While implementation of optimal IPC measures in the pre-COVID-19 vaccination era had no impact on the infections in residents who were likely already infected or exposed at the onset of the outbreak, these measures along with non-pharmacologic strategies were effective in halting the spread among HCWs.
ABSTRACT
Background. The coronavirus-19 disease (COVID-19) outbreak has had a particularly devasting effect on skilled nursing facility (SNF) residents and healthcare workers (HCWs). While representing only 11% of COVID-19 cases, the residents accounted for 43% of deaths in the United States. Methods. We report a retrospective review of the support provided by our local health department (LHD) to long-term care facilities in response to the COVID-19 pandemic. This group comprised of staff from healthcare-associated infections (HAI);the Medical Operations Center (MOC);Testing, Tracing, and Treatment (T3);and the Healthcare Provider Status Taskforce (Table 1 outlines their functions). The HAI team with the State Public Health Department provided infection prevention and control (IPC) outbreak investigation, education, recommendations, and ongoing access to technical assistance. The T3 team focused on rapid response testing and tracing;the HPSTF team collected data and issued questionnaires;the MOC responded to staffing and PPE requests;and the Long-Term Care Facility sector presented routine telebriefings to update the facilities on public health guidance, share resources, and answer questions during and in between briefings. Table 1. Sectors and Function of Response Teams to COVID-19 Results. From March 2020 through May 2021, there were 504 outbreaks in LTCFs;the HAI team performed 281 outbreak investigations (Figure 1). In the same period, 308,264 molecular tests were performed using various platforms;laboratory services were outsourced during peak testing requests (Figure 2);"strike teams were deployed to facilitate testing on 404 occasions. Self-reported fully vaccination rate for SNF staff was 73% (March 2021) and 76% for residents (April 2021). There were 568 staff requested;total orders for PPE were 4,839 and 16,892,823 PPE items were fulfilled (Figure 3). In addition to knowledge gaps in IPC, other challenges included shifting IPC guidance, PPE shortages, timeliness of test results that impacted cohorting, community acquisition of disease with transmission to residents, interfacility spread among staff, staffing shortages, and vaccine hesitancy issues. Figure 1. Number of Outbreaks and Number of Outbreak Investigations Figure 2. Number of Tests Performed by the Public Health Laboratory and the Number of Visits by "Strike Teams" Figure 3. Personal Protective Equipment Fulfillment during COVID-19 Pandemic Conclusion. The management of the recent COVID-19 outbreaks required a multi-pronged approach. Lessons learned are applicable to other highly transmissible infectious diseases.