Monday, July 29, 2019

Updating 2 Outbreaks: Respiratory Illness In Virginia LTCF & iGas in Essex, UK



 A couple of weeks ago, in Fairfax Co. Va Health Advisory: Outbreak of Respiratory Illness at a Long-Term Care Facility, we began to follow reports of an as-yet-unidentified respiratory illness among residents of a long term care facility (LTCF) in Virginia.

Respiratory illness outbreaks in nursing facilities are not uncommon as the residents are usually either elderly, suffer from chronic illnesses, or are otherwise immunocompromised.
But we usually see them during the fall and winter months, not mid-summer.
On July 16, we learned there had been 3 fatalities and 23 hospitalizations among the residents of the facility, and 19 staff members had reported an ILI.  Samples had been sent to the CDC for analysis, but results were still pending.

On July 19th, it was announced that:
Additional laboratory testing from CDC has not identified a specific cause for the increase in respiratory illness. Test results showed several bacteria that are known to colonize the nose and throat and may not be the cause of infection. In addition, several specimens were positive for rhinovirus, the cause of the common cold.

On Friday, July 26th, the local Health Department declared the outbreak over, with the following brief summation:
Outbreak Investigation at Assisted Living Facility in Springfield
July 19, 2019

Update: July 26, 2019

The outbreak of respiratory illness in Greenspring has concluded, as there have been no additional cases reported since July 15. A total of 63 residents became ill within the assisted living and skilled nursing areas (Garden Ridge) during the outbreak. Several residents in the independent living sections of Greenspring became ill but the number who were sick was similar to what is expected at this time of year and there was no evidence of an outbreak affecting independent living. Despite extensive testing of multiple specimens, no specific pathogen was identified as the cause of the outbreak. The facility will initiate a gradual return to normal operations.
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While the lack of a specific cause of this outbreak is disappointing, it isn't all that unusual.  In my first report on this outbreak I cautioned:
Even with the full firepower of the CDC's labs, it is possible that a definitive diagnosis may not achieved. A 2015 study published in the NEJM (see The CDC’s EPIC CA-Pneumonia Study) followed 2500 cases over 5 years and found that in the majority (62%) of cases no definitive pathogenic agent was identified.
It is worth noting that 10 days ago the Virginia Department of Health issued a general Respiratory Illness alert, citing widespread, unseasonable ILI activity. They wrote:
The reports involve different regions of the state and different diseases, including pertussis (whooping cough), influenza, Haemophilus influenzae infection, Legionnaire’s disease, and pneumonia caused by rhinovirus or human metapneumovirus.
It is possible that the reason the CDC was unable to nail down a specific cause of the Virginia LTCF outbreak is because it was due to the introduction of more than one infectious pathogen currently circulating in the community.

Essex County - Credit Wikipedia

Moving on now to the Essex County, UK outbreak of Invasive Group A Streptococcus (iGas) - which we began following more than a month ago (see UK: Essex NHS Reports Outbreak Of Invasive Group A Streptococcus - 12 deaths).
Most of the cases were receiving home healthcare visits for wound care.
While a definitive source of this outbreak is still under investigation, the NHS has taken steps to prevent potential transmission via asymptomatic carriers, and has placed community nurses in the region on prophylactic antibiotics and is working to improve hand hygiene and the use of PPEs by local nurses. 

This outbreak appears to be winding down, as there have been no new updates posted in a week.

Group A Streptococcus (iGAS) outbreak in mid Essex

Latest update - 23 July 2019

NHS Mid Essex Clinical Commissioning Group (CCG) has been informed of one new case of iGAS in mid Essex. In addition, NHS Mid Essex CCG and NHS West Essex CCG have been informed of two cases of iGAS infection within the NHS West Essex CCG boundary. Sadly, one West Essex patient has died.

Following investigation, both of the West Essex patients with iGAS infection have been linked to the mid Essex outbreak. Test results from the mid Essex patient are pending.

The patients affected are older members of the community receiving treatment for wounds in care homes or in their own homes.

As a result of the mid and West Essex cases, the total number of people affected by the iGAS outbreak is now 35 and 13 people have sadly died*.

NHS Mid Essex CCG has set up an incident management team which is working closely with NHS West Essex CCG and partners to manage the outbreak. Public Health England will advise what control measures need to be implemented in West Essex where patients are affected by iGAS.

*Of the 35 patients affected by the iGAS outbreak in mid and West Essex, 31 are confirmed cases and four are probable.

Background (Updated on 23 July):

Those affected within this iGAS outbreak are older people in Braintree District and the neighbouring area in West Essex, Chelmsford City and Maldon District. The majority of patients were receiving treatment for wounds, with some in care homes but most in their own homes.

Earlier in July 2019, Public Health England undertook Whole Genome Sequencing to investigate differences and similarities in the DNA sequence of the iGAS bacteria collected from patients within the mid Essex outbreak. This method allows Public Health England to check which iGAS cases are genetically linked and which are not. This is done by analysing the DNA sequence of each bacterial sample.

The Whole Genome Sequencing confirmed that the single case of iGAS in Basildon in 2018 and single case of iGAS in Southend in February 2019, previously thought to be part of the mid Essex outbreak, are not. These two cases appear to be isolated cases of iGAS that can arise in the community and have now been removed from the outbreak investigation.

Any further information from the Whole Genome Sequencing work will be shared in future updates.
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While we always hope for a definitive, unambiguous resolution to outbreaks such as these, often we are left with something less, although it is not for the lack of trying on the part of public health officials. 
Future updates on both of these events are still possible, however.  
For now they both serve as cautionary tales on the importance of maintaining good `flu & hand hygiene' all-year round, particularly when dealing with the most vulnerable members of our society; the elderly, the immunocompromised, or those with chronic illnesses.