What is the appropriate treatment for outbreaks?

Treatment for Infectious Disease Outbreaks

For infectious disease outbreaks, immediately involve public health authorities and implement a multi-pronged control strategy including hand hygiene, contact precautions, environmental cleaning, active surveillance, and pathogen-specific treatment or chemoprophylaxis. 1

Immediate Outbreak Response Actions

Public Health Notification

• Involve public health authorities immediately for outbreaks (defined as >2 cases in a closed population) 1
• Single cases of certain high-risk pathogens (e.g., meningococcal disease, Group A Streptococcus in healthcare settings) also require immediate notification 1
• Establish an outbreak control team to coordinate response and make decisions about screening, chemoprophylaxis, and environmental interventions 1

Core Infection Control Measures

Hand hygiene is the single most critical intervention and should be implemented immediately with education, monitoring, and feedback 1:

• Use alcohol-based hand rub before and after all patient contacts 1
• Soap and water required when hands are visibly soiled 1
• Prohibit artificial nails among healthcare workers 1

Contact precautions must be implemented for all colonized or infected patients 1:

• Healthcare workers wear gloves and gowns before entering rooms 1
• Remove protective equipment promptly after care and perform hand hygiene 1
• Audit adherence to contact precautions to ensure correct implementation 1

Environmental cleaning procedures require immediate review and intensification 1:

• Specify which items to disinfect, which disinfectant to use, and frequency 1
• Dedicate non-critical patient-care equipment to single patients or cohorts 1
• In high-risk areas (delivery suites, post-natal wards, burns units), decontaminate communal facilities (baths, showers, bidets) between every patient use 1
• Consider ward closure to new admissions to facilitate intensive cleaning 1
• Perform environmental sampling from surfaces that contacted infected patients 1

Active Surveillance and Screening

Implement active screening cultures at hospital admission followed by contact precautions to reduce colonization rates 1:

• Screen high-risk patients or all patients in high-risk units (ICU, cancer wards) based on local prevalence 1
• Use stool/rectal swabs, inguinal area swabs, and samples from manipulated sites (catheters, wounds) 1
• Perform admission, discharge, and weekly screening during outbreaks 1

Screen athletes participating in contact sports routinely during practices and before competitions 1:

• Sports-related skin infections account for 10-15% of time-loss injuries at collegiate level 1
• Screening is particularly important as most sports-related infections spread by contact 1

Pathogen-Specific Treatment Strategies

Influenza Outbreaks in Institutions

When confirmed or suspected influenza A outbreaks occur in institutions housing high-risk persons, start chemoprophylaxis as early as possible 1:

• Administer chemoprophylaxis to all residents regardless of vaccination status 1
• Continue for at least 2 weeks or until approximately 1 week after outbreak ends 1
• Offer chemoprophylaxis to unvaccinated staff providing care to high-risk persons 1
• Consider prophylaxis for all employees regardless of vaccination if outbreak caused by vaccine-mismatched variant strain 1

Additional outbreak control measures beyond antivirals 1:

• Institute droplet precautions 1
• Establish cohorts of patients with confirmed or suspected influenza 1
• Reoffer influenza vaccine to unvaccinated staff and patients 1
• Restrict staff movement between wards or buildings 1
• Restrict contact between ill staff/visitors and patients 1
• Reduce contact between persons taking antivirals for treatment and those taking chemoprophylaxis to limit drug-resistant virus transmission 1

Herpes Zoster (Shingles) Outbreaks

For uncomplicated herpes zoster, prescribe oral acyclovir or valacyclovir and continue until all lesions have scabbed 2:

• This is the key clinical endpoint, not an arbitrary 7-day duration 2
• Treatment may need extension beyond 7 days if lesions remain active 2

For disseminated or invasive herpes zoster, use intravenous acyclovir 2:

• Consider temporary reduction in immunosuppressive medications 2
• Continue treatment at least until all lesions have scabbed 2
• Monitor renal function closely with dose adjustments for renal impairment 2

Infection control for herpes zoster 2:

• Patients must avoid contact with susceptible individuals until all lesions have crusted 2
• Lesions are contagious to individuals who have not had chickenpox 2

Group A Streptococcal (GAS) Outbreaks in Healthcare

Chemoprophylaxis decisions should be made by the outbreak control team on a case-by-case basis 1:

• Routine chemoprophylaxis not recommended following a single case (except mother/baby cases during neonatal period) 1
• During outbreaks, consider chemoprophylaxis based on number of cases, severity, patient vulnerability, and identified source 1
• Length of prophylaxis and antimicrobial choice should be agreed locally based on clinical circumstances 1

Enhanced environmental decontamination is critical 1:

• Review method and frequency of cleaning equipment and ward areas 1
• Decontaminate communal facilities (baths, bidets, showers) between all patients on delivery suites, post-natal wards, and high-risk areas 1
• If epidemiological investigation suggests common environmental exposure, perform environmental sampling using large sterile gauze swabs moistened in 0.9% sodium chloride 1
• Take implicated equipment out of use while awaiting culture results 1

Sports-Related Skin Infection Outbreaks

Treatment varies by specific pathogen but general principles apply 1:

• For head lice: manual removal of nits by fine-toothed combing, then over-the-counter 1% permethrin lotion or pyrethrin with piperonyl butoxide; repeat in 7 days 1
• For infectious mononucleosis: usually no treatment needed; oral acyclovir or valacyclovir for 7 days in select cases 1
• Avoid contact sports until recovered and spleen no longer palpable (typically 4 weeks) for mononucleosis 1

Prevention measures for sports settings 1:

• Ensure ACIP/AAP-recommended vaccines are current (influenza, MMR, varicella, Tdap, meningococcal) 1
• Counsel regarding avoiding sharing drinks, utensils, combs, hair brushes, hats, clothing, and equipment 1
• Hand hygiene is essential during outbreaks 1
• Swimmers should avoid immersion or swallowing potentially contaminated water 1

Healthcare-Associated Outbreak Prevention

Bronchoscopy-Related Outbreaks

Prevent bronchoscopy-associated outbreaks through strict adherence to reprocessing protocols 1:

• Avoid over-reliance on automated endoscope reprocessors which may instill false sense of security 1
• Institute quality control monitoring for all steps in instrument reprocessing 1
• Use predefined protocols for epidemiologic characterization of suspected outbreaks 1
• Use molecular biology techniques (DNA fingerprinting) when outbreaks are suspected 1

For laser photoresection or endobronchial electrosurgery 1:

• Use tight-fitting masks with small pore sizes 1
• Use dedicated smoke evacuators to minimize risk of acquiring laryngeotracheal papillomatosis 1

Nontuberculous Mycobacterial (NTM) Outbreak Prevention

Critical prevention measures for healthcare-associated NTM outbreaks 1:

• Patients with indwelling central catheters should avoid contact or contamination with tap water 1
• Avoid tap water in automated endoscopic washing machines and manual cleaning; use terminal alcohol rinse 1
• Avoid benzalkonium chloride as skin disinfectant as it allows mycobacterial growth 1
• Avoid multidose vials 1
• Do not use tap water or ice prepared from tap water in operating rooms, especially during cardiac surgery or augmentation mammoplasty 1
• Do not wash or contaminate open wounds with tap water 1
• Do not allow patients to drink or rinse mouth with tap water before collecting expectorated sputum specimens 1

Administrative Support and Infrastructure

Provide administrative support including economic and human resources to prevent and control outbreak transmission 1:

• This applies to multidrug-resistant Gram-negative bacteria outbreaks 1
• Administrative support is essential for successful outbreak control 1

Conduct educational programs to ensure healthcare workers understand outbreak control measures 1:

• Education should cover hand hygiene, contact precautions, environmental cleaning, and pathogen-specific interventions 1
• Monitor compliance and provide feedback to achieve greater adherence 1

Common Pitfalls to Avoid

• Do not delay public health notification - early involvement is critical for coordinated response 1
• Do not rely solely on vaccination or single interventions - outbreaks require multiple simultaneous control measures 1
• Do not discontinue environmental cleaning protocols prematurely - maintain intensified cleaning until outbreak is clearly controlled 1
• Do not assume all exposed persons require chemoprophylaxis - outbreak control teams should make case-by-case decisions based on specific circumstances 1
• Do not use tap water in high-risk healthcare settings - this is a common source of NTM and other waterborne pathogen outbreaks 1