Transcript Surveillance - IPAC Canada

MRSA Surveillance: to report or
not to report
Dr Bonnie Henry
BC Centre for Disease Control
Surveillance Definition
Surveillance is the ongoing, systematic collection,
analysis, and interpretation of health data essential to
the planning, implementation and evaluation of public
health practice, closely integrated with the timely
dissemination of these data to those who need to
know.
The final link in the surveillance chain is the
application of these data to prevention and control.
Elements of a Surveillance System
1. Data collection: pertinent, regular, frequent, timely
- i.e. ongoing and systematic
2. Consolidation and interpretation: orderly,
descriptive, evaluative, timely
3. Dissemination: prompt, to all who need to know
(data providers and action takers)
4. Action to control and prevent
WHO, 2000
Surveillance: A Classical Model
Health Care System
Event
Public Health Authority
Reporting
Data
Analysis &
Interpretation
Intervention
Decision
(Feedback)
Information
Surveillance is NOT the same as:

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Disease reporting - reporting
provides a foundation for
surveillance
Monitoring or Screening monitoring and screening do not
involve planning, implementation
and evaluation
Objectives of Surveillance
Systems:
1.
2.
3.
4.
Monitor trends
Understanding of diseases and
their determinants
Identify and predict clusters,
outbreaks, threats to health and
emerging issues
Detect changes in health practices
Objectives of Surveillance
Systems cont.:
5.
6.
7.
Facilitate epidemiological research
To assist with planning and policy
Empower individuals, health
providers, governments and
communities with the information
necessary for them to take action
to protect and improve health
Types of Surveillance
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Active
Passive
Enhanced
Sentinel
Rationale for Surveillance System
Development
•
Disease Importance
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•
•
Intervention
•
•
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Impact – burden of disease, PAR of risk factor,
severity, societal impact
Communicability – for infectious diseases
Prevention / Control - ability to intervene effectively
Immediacy of response – needed to control spread or
severity
System
•
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Requirement for reporting – legislated or international
interest
Public perception – concern about risk
Why conduct healthcare
surveillance?
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•
•
•
•
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Determine baseline rates of HAIs
Detect time/space clustering (ie, outbreaks)
Detect changes in rates and/or their
distribution
Identify areas for targeted investigation and/or
research
Determine the effectiveness of IC measures
Monitor compliance with established hospital
policies and practices
Why conduct healthcare
surveillance cont’d?
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Evaluate changes in practice
Meet regulatory and other reporting
requirements
Generate hypotheses concerning risk factors
Guide treatment and/or prevention strategies
Reduce healthcare associated infections
Support evidence-based resource allocation
Targeting your surveillance
Focus on:
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Preventable infections
Frequently occurring infections or events
Infections that cause significant morbidity
or mortality
Infections that are costly to treat
Infections caused by organisms resistant to
multiple antimicrobial agents
Lautenbach E & Woeltje K. eds. Practical Handbook for Healthcare Epidemiologists.
Thorofare, NJ: SLACK Incorporated; 2004.
History of Reporting
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Nationally Notifiable Diseases have been
reviewed in 1988, 1997-8 and in 2006
Framework and criteria developed for the
1997 process
Provincial review in some provinces
Number of diseases added to or removed
from BC list over time including MRSA
Historically there has been no formal
framework or process for adding or
removing from list in BC
Criteria for Reportability
1.
2.
3.
4.
5.
Diseases of Interest
to Organizations to
Inform Prevention
and Regulatory
Programs
5-Year Average
Incidence
Severity
Communicability/Po
tential Spread to the
General Population
Potential for
Outbreaks
6.
7.
8.
9.
10.
Socioeconomic
Burden
Preventability
Risk Perception
Necessity of Public
Health Response
Increasing or
Changing Patterns
MRSA in the USA
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Approximately 32% (89.4 million persons) and 0.8%
(2.3 millions persons) of the U.S. population is
colonized with S. aureus and MRSA respectively.
(Kuehnert MJ et al. Journal of Infectious Diseases. 2006;193:172-9.)

The proportion of healthcare-associated staphylococcal
infections that are due to MRSA has been increasing:
2% of S. aureus infections in U.S. intensive-care units
were MRSA in 1974, 22% in 1995, and 64% in 2004.
(Klevens RM et al. Clinical Infectious Diseases 2006;42:389-91)
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There are an estimated 292,000 hospitalizations with a
diagnosis of S. aureus infection annually in U.S.
hospitals. Of these approximately 126,000
hospitalizations are related to MRSA. (Kuehnert MJ et
al. Emerging Infectious Diseases. 2005;11:868-72.)
MRSA in Canada
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1981: MRSA first reported in Canada
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1987-1990: CA-MRSA described in Aboriginal
communities
1995: Nationwide data available in Canada
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Subsequently MRSA identified in many Canadian
health care facilities
National MRSA surveillance started in sentinel
hospitals
2001: Canadian Nosocomial Infection
Surveillance Program (CNISP) summary of first
five years of surveillance
CNISP Surveillance
GOALS AND OBJECTIVES
The objectives of this surveillance project
are as follows:
1. To determine the incidence and burden of
illness associated with MRSA in CNISP
hospitals.
2. To describe the epidemiology of MRSA in
Canada.
3. To characterize the molecular strains of
MRSA in Canada.
CNISP MRSA Surveillance
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Between 1995 and 2003, MRSA rates
increased in CNISP hospitals from 0.46
cases per 1,000 admissions to 5.10
per 1,000 admissions (p = 0.002)
Most of the increase in MRSA cases
occurred in central Canada (Ontario and
Quebec), although there were also
increases elsewhere in the country
Ref: Simor, 2001: CMAJ
Regional MRSA rates in Canadian
hospitals, 1995-2003
Cost of MRSA
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Direct health care cost attributable to MRSA in
Canada, including cost for management of MRSAinfected and -colonized patients and MRSA
infrastructure, averaged $82 million in 2004
and could reach $129 million in 2010.
MRSA is a costly public health issue that needs to
be tackled if the growing burden of this disease in
Canadian hospitals and in the community is to be
limited.
Source: Canadian Journal of Infectious Diseases and Medical
Microbiology, Volume 18, No. 1, January/February 2007
MRSA in BC
(Hospital Separation data)
Incidence of MRSA Diagnosis in Acute Care
British Columbia
90
MRSA Diagnoses per 100,000 Population
80
70
60
50
40
30
20
10
0
BC
2001/02
2002/03
2003/04
2004/05
29.99
33.78
32.91
45.13
MRSA – As a Proportion of
S. aureus Isolates (BC – AMM)
Percent
16
14
12
10
8
% MRSA
6
4
2
0
2002
2003
2004
MRSA: Community vs Hospital
Community-Associated Methicillin-Resistant
Staphylococcus aureus (CA-MRSA)
Reports began in 1980s of MRSA occurring in
the community in patients without
established risk factors
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Younger patients
Indigenous peoples and racial minorities
Skin infections common
Outbreaks:
 Injection drug users
 Players of close-contact sports
 Prison/jail inmates
 Group Homes (developmentally disabled)
 Men who have sex with men
CA-MRSA vs HA-MRSA isolates
CA-MRSA
HA-MRSA
Antimicrobial
resistance
SCCmec*
Few Agents
Multiple
Agents
Type II
PGFE Types
USA 300, 400
(CMRSA 10)
Common
PVL Toxin
Type IV
*genetic element carrying mecA resistance gene
USA 100, 200
Rare
Ref: CDC
Reasons to Report
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A growing community-based problem
caused by a communicable disease with
some family based clustering
No other good mechanism to track the
problem
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What is its magnitude? Distribution?
Is it changing for the better or worse?
Advice for patients, contacts, household
members may benefit from systematic
delivery
If yes, what case definition?
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Epidemiological Definition?
Phenotypic Definition (R
Profile)?
Genetic Definition?
What are We Actually Doing?
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Surveillance - reportable in some
provinces
Laboratory Reference Work - many
provinces
Guidelines (national and local)
Prevention - e.g. Do Bugs Need
Drugs
Studies at various sites
CCHSA requirements
Issues
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Need to establish surveillance for HAIs
BUT
Will making it reportable help?
What about public reporting of rates?
How do we distinguish CA and HA-MRSA?
What about reporting of invasive disease
only or reporting of aggregate rates?
Conclusions
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Development of surveillance
systems for HAI a priority in BC
Need to have connections with
Public Health to address the
spectrum of illness (we are all in
this together!)
Work together to address both
needs and to protect patients,
HCWs and our community.
Discussion!
Thank you!
[email protected]