Linking Role of Epidemiology for Clinical Services - can be accessed: http://nirmalkandel.com/wp-content/uploads/2014/03/Role-of-Epidemiology-for-Clinical-Services_Nirmal-Kandel.pdf

1. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
1 |
3rd Epidemiology National Scientific
Meeting
Role of Epidemiology in
Clinical Services
Dr Nirmal Kandel , MBBS, MA (Anthropology), MPH, EMBA
Public Health Specialist

2. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
2 |
Outlines
 Application of Epidemiology in real life in clinical settings – an example
 Personal Experience
 Application of Epidemiology
– When
– How
– Where
– Why
– What next

3. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
3 |
Background
In 2011, KPC came to one of the nation’s flagship research hospitals, the
Clinical Center at the National Institutes of Health in Bethesda, Maryland,
known as the NIH.
Klebsiella pneumoniae carbapenemase (KPC)

4. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
4 |
43 Lung
Transplant

5. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
5 |
Patient Zero
 A 43-year-old woman with complications from a lung transplant is transferred from a
New York City hospital with a highly resistant superbug known as KPC – June 13,
2011
 The NIH is one of the most prestigious research hospitals in the country, but it has
never had a case of KPC before.
 Immediately went on high alert, implemented IPC measures.
– The woman went into strict isolation:
– Everyone entering her room donned a protective gown and gloves and rigorously washed their
hands.
– Her medical equipment got special decontamination.
– All other patients in the ICU had their throats and groins tested regularly to see if the bug was
spreading.
 The patient was later discharged – July 15, 2011

6. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
6 |
43 Lung
Transplant
34 Tumor

7. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
7 |
Second Infection
 Several weeks later,
 a 34-year-old man hospitalized with a tumor tests positive for KPC.
 The two patients have no known link:
 They spent no time in the ICU together, and
 they had different caregivers and equipment.

8. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
8 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
29
Lymphoma
71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
19
Immuno-
deficiency
29
Aplastic
Anemia

9. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
9 |
Outbreak
 Over the next few months, several more patients test positive for KPC.
 As the NIH attempts to deal with the outbreak, no combination of
antibiotics seems to be able to stop it.

10. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
10 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma
71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
59
Immuno-
deficiency

11. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
11 |
Beyond ICU
 The hospital creates a separate ICU for KPC patients.
 The old ICU is cleaned out and disinfected by robots before patients are
moved back in.
 But somehow, it spreads beyond the ICU.

12. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
12 |
The Victims
 Doctors try several combinations of antibiotics
 even an experimental drug still in development.
 Nothing works.
 And some patients die.

13. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
13 |
Underlying Conditions
 Five other patients die, but the hospital believes their deaths are due to
their underlying health problems, not the KPC infection.
 Ultimately, 11 infected patients die.

14. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
14 |
Hospital Measures
 New ICU was constructed for KPC infection
 To stop the bug, entire sinks have been disassembled and vents cleaned with
bleach.
 The hospital has tested and retested patients and health professionals looking for
carriers of the superbug (using rectal swabs too).
 Test after test never found the bug on hospital workers' hands. Tainted objects like
the ventilator couldn't be ruled out
 It went on an aggressive campaign to demand more stringent hand washing.
 NIH adopted more complex and expensive decontamination, using robot-like
machines to spray germ-killing hydrogen peroxide into the tiniest of crevices in all
affected rooms and equipment.

15. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
15 |
Looking for a link
 Throughout the outbreak, the hospital used epidemiological and genetic
analysis to help understand the transmission sequence.

16. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
16 |
Looking for a link
 They compared samples from each patient, along with information such
as whether patients overlapped in the same ward, to track the most
plausible transmission sequence:
– Black lines mean the infected patient was in the same ward, which likely
provided an opportunity for the KPC to spread to the next patient.
– Red lines indicate the two patients had no overlap, but genetic analysis makes
clear the bacteria in the two patients were closely related and likely spread in a
more complicated path.
– Dotted black lines mean the patients shared a ward, but there’s at least one
other way they might have been infected.
– Dotted red line mean the patients didn’t overlap in a ward, but there’s more
than one way they might have been infected.

17. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
17 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma
71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
59
Immuno-
deficiency

18. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
18 |
43 Lung
Transplant
65
Lymphoma
27
Transplant
54 Solid
Tumor
34 Tumor
45 Solid
Tumor
39 Solid
Tumor
37 Sickle
Cell
Anemia
29
Lymphoma
71
Lymphoma
59
bronchiec
tasis
50
Lymphom
a
72 Solid
Tumor
34
Aplastic
Anemia
19
Immuno-
deficiency
29
Aplastic
Anemia
60
bronchiec
tasis
Young Man
ID
59
Immuno-
deficiency

19. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
19 |
Last Case
 Then, a year after the outbreak, a young man arrives at NIH due to
complications from a bone marrow transplant. He becomes infected
with KPC and dies.
 Finally, the outbreak – contained – December 2012

20. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
20 |
Links
 27 years old female (transplant) had been in the ICU at the same time
as the New York woman and really was the next infected, silently
carrying the bug longer before becoming sick.
 that was enough time for 34 year old man’s (tumor) infection to spread
to 27 year old female, who just got sick faster.

21. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
21 |
Personal Experience
 Was Medical Officer for Surgery - noticed post surgical wound infection
 Observed and triangulate all the causes of wound infection with those
cases
 Simple experimental study carried out
– All the cases of my unit is asked to shave a 2 hours before surgery
– Controls – other unit who were practicing exiting mechanism (shaving a day
before
– After one month – there was significant decrease of wound infection in our unit
than others
– we didn’t do any statistical analysis and I just presented and hospital adopted
since then to apply pre-operative shaving before 2 hours of surgery

22. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
22 |
Application of Epidemiology
– When
• any abnormal events, aberration from normal phenomena
– How
• Abreast with disease endemicity in your area,
• basic with epidemiology techniques
– Where
• OPDs, IPDs, ICUs, Post Ops
– Why
• The first contact of patient or any suspected case is Physician/Clinicians
– What to do
• If you find any abnormalities then inform authorities accordingly

23. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
23 |
References and Acknowledgement
1. Evan S. Snitkin, Adrian M. Zelazny, Pamela J. Thomas, Frida Stock, David K.
Henderson, Tara N. Palmore, Julia A. Segre. Tracking a Hospital Outbreak of
Carbapenem-Resistant Klebsiella pneumoniae with Whole-Genome Sequencing .
Sci Transl Med. 2012 August 22; 4(148): 148ra116.
doi:10.1126/scitranslmed.3004129
2. Authors of this article and the investigation team and all people directly or
indirectly related to control of this outbreak investigation.
Disclaimer: This reference and its content is only used for teaching purpose.

24. Dr Nirmal Kandel, MBBS, MA (Anthropology), MPH, EMBA – Public Health Specialist
24 |
Thank You
Email
kandeln@gmail.com