Transcript Public Health and Infectious Diseases

Public Health and Infectious Diseases:
Top Updates Relevant to Pharmacists in
New Hampshire
NHPA Continuing Education Event
December 4, 2016
Beth Daly, MPH
Chief, Bureau of Infectious Disease Control
Overview
Reportable Disease Changes
Drug diversion reporting
Antibiogram reporting
Antimicrobial Stewardship Initiatives
Immunization Information System (IIS)
NH Communicable Disease Rules
He-P 301: Administrative rules implementing RSA
141-C for communicable diseases, which includes
List of reportable disease
Control measures such as exclusion and restriction
for sensitive occupations
Immunization requirements for schools
NH DHHS HIV and TB financial assistance
programs
Last updated in June 2008
Reviewed by legislative committee and approved
Changes to Reportable Diseases
Proposed Removals:
Group A/B Strep
VRE
Latent TB Infection provider reporting
lab reporting blood assays only
Hepatitis B laboratory reporting
Proposed Additions:
Acute flaccid myelitis
Add to arboviral: Dengue, Chikungunya, Powassan, Zika
Carbapenem-resistant enterobacteriaceae (CRE)
Leptospirosis
New diagnoses (acute and chronic) of Hep B and C from
healthcare providers only
Hepatitis C Virus (HCV) Epidemiology
Blood borne pathogen
Transmission: contact w contaminated blood
IV drug use
Dialysis
Blood products/transplant before 1992
Clotting factors before 1987
Tattoos
Needle stick injury
Sexual
Vertical
HCV Cluster at Acute Care Hospital
May 15th, 2012: An acute care hospital reports
4 individuals with recently diagnosed HCV
Questions:
Are these new infections?
Do they have a common source?
Investigation steps:
Medical records review
Interview cases
Sequencing in PHL
1206010187-R1
1206050018-R1
1206010120-R1
Analysis of NS5b Region Sequences
1205170046-R1
1206080064-K1
515163-1b
541356-1b
514640-1b
1206010125-R1
517331-1a
1206020034-K2R
= Common source
519281-1a
514366-1a
1206080094-K2
535110-2a
1206080132-K1-F
539954-2a
1205230049-K2
1206040058-122F
512652-2b
512863-2b
537798-6
535318-6
515603-4
1206080014-K1
524253-3a
535886-3a
0.5
0.4
0.3
0.2
0.1
0.0
Nosocomial HCV Transmission
3 main mechanism:
Contaminated equipment
Single dose vial for multiple pts
Drug diversion
Goals of Public Health Investigation
Stop the transmission (find source)
First step
Close cath lab until source is contained
Diagnose all those infected and connect them to care
notify patients and start testing
Understand how it happened to prevent future
outbreaks
PH Activities
Test all employees
Observe procedures
Mock up procedure
Real procedures
Interviews
Staff
Cases (patients)
Review
Medical records
Drug dispensing and administrating
Policies (infection control, narcotics)
Patient testing
CCL Testing Summary
1214 patients indicated for testing
1074 tested (89%)
132 died prior to testing
8 unable to locate or refused testing
32 patients with matching HCV infection
27 patients with evidence of past infection
Some possibly related to outbreak
9 had no common risk factors for HCV
18 patients with unrelated HCV infections
PH Investigation Findings
Narcotic use, control and oversight:
Gaps in processes & procedures
Access
Use
Waste
Oversight - No recent audits
Discrepancies in med record review
Increased use of narcotic for cases
Infected HCW
Co-workers concerns regarding behavior
Only HCW present for all cases
Results: Confirmed Case Medication Use
More than three times higher vs. pre-employment *┼
Two times higher than overall CCL cases during employment
235 mcg
2.96mg
* Unable to provide statistical comparison due to aggregate data
┼ Excludes 2 procedures occurring before time of employment
Investigation expanded
Multi-state Investigation
Criminal Investigation
Final Multistate Outbreak of HCV Summary
HCW worked in 17 facilities in 8 states
>11,000 patients possibly exposed
46 HCV-infected patients identified as being
associated with the outbreak
32 New Hampshire, 7 Maryland, 6 Kansas, 1 Pennsylvania
Infected HCW criminally charged
Charges included fraudulently obtaining drugs and
tampering with a consumer product
Plead guilty to all charges in August 2013
Sentenced to 39 years in prison in December 2013
NH and MD public reports released with numerous
recommendations for prevention
Outbreak Aftermath: Drug Diversion
Prevention and Response Activities in NH
Statewide meetings for healthcare leadership
Educational materials provided to healthcare workers
Facilities have invited experts to assess prevention
programs
Formation of several drug diversion task forces
Development of public health response guidelines
Building key stakeholder relationships
Policy activity
Med Tech registration, drug-free workplace
Required reporting
Other Required Reporting Changes
Any investigation of suspected or actual incident of
drug diversion of injectable medications in a health
care setting
Antibiograms (only for hospitals that generate them)
Antibiogram Reporting
The Problem of Antibiotic Use and
Resistance
CDC. Antibiotic Resistance Threats in the United States, 2013.
Decreasing Antibiotic Production
CDC. Antibiotic Resistance Threats in the United States, 2013.
CDC. Antibiotic Resistance Threats in the United States, 2013.
CDC. Antibiotic Resistance Threats in the United States, 2013.
Enterobacteriaceae
Family of gram-negative bacteria which
include:
Escherichia coli
Klebsiella
Enterobacter
Citrobacter
Serratia
Proteus
Yersinia
Etc.
CDC. Antibiotic Resistance Threats in the United States, 2013.
KPC Producing CRE, 2001
Yigit et al. Antimicro Agents chemother 2001;45(4):1151-61.
CDC Website: http://www.cdc.gov/hai/organisms/cre/cre-toolkit/background.html.
KPC Producing CRE, 2012
CDC Website: http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html.
KPC Producing CRE, 2016
http://www.cdc.gov/hai/organisms/cre/TrackingCRE.html
CDC. Antibiotic Resistance Threats in the United States, 2013.
Antibiotics Increase Risk of C. diff
7-10 fold increase risk of C. diff infection up to a
month after stopping abx1
Risk extends up to 3 months after stopping abx1
At least a 3-fold increased risk of recurrent C. diff
with abx use within 30 days after treatment for
initial C. diff infection2
Restricting antibiotics have lead to improvements
in C. diff infection rates and control of outbreaks
1.
2.
Hensgens MPM, et al. J Antimicrob Chemother. 2012;67:742-748.
Drekonja, et al. Am J. Med 2011;124:1081.e1-e7.
Increasing C. difficile Rates
CDC. Antibiotic Resistance Threats in the United States, 2013.
Percent Gonococcal Resistance
Tetracycline
Resistance
Fluoroquinolone
Resistance
Penicillin
Resistance
Reduced
Cefixime
Susceptibility
CDC. Neisseria gonorrhoeae antimicrobial susceptibility surveillance – the GISP, 27 sites, U.S., 2014.
MMWR Jul 2016;65(7):1-19.
Reduced
Azithromycin
Susceptibility
Reduced Azithromycin Susceptibility by
U.S. Region
CDC. Neisseria gonorrhoeae antimicrobial susceptibility surveillance – the GISP, 27 sites, U.S., 2014.
MMWR Jul 2016;65(7):1-19.
Reduced Ceftriaxone Susceptibility by
U.S. region
CDC. Neisseria gonorrhoeae antimicrobial susceptibility surveillance – the GISP, 27 sites, U.S., 2014.
MMWR Jul 2016;65(7):1-19.
Reduced Ceftriaxone Susceptibility by
Sex of Sex Partner
CDC. Neisseria gonorrhoeae antimicrobial susceptibility surveillance – the GISP, 27 sites, U.S., 2014.
MMWR Jul 2016;65(7):1-19.
NH Gonorrhea Cases by Year
YTD
NH Gonorrhea Cases by Age Group,
2012-2016 YTD Aggregate
Rate of Gonorrhea
by County, 2016 YTD
Rate per 100,000 persons
25% of cases were
either treated
inappropriately, not
treated, or required
public health
intervention to provide
appropriate treatment
National Strategy to Combat Antibiotic
Resistant Bacteria
Purpose is to Identify priorities and coordinate
investments in order to prevent, detect, and
control outbreaks of resistant pathogens
recognized by CDC as urgent or serious threats
Key National Guiding Principles
Misuse & over-use of abx in healthcare and
food production hastens drug resistance
Detecting and controlling abx resistance
requires a “one-health” approach (resistance
arises in humans, animals, and environment)
Evidence-based infection control practices can
prevent the spread of resistant pathogens
Interventions are needed to increase private
sector investment in antimicrobial agents
Five Goals for National Strategy
Goal 1: Slow the emergence of resistant bacteria and
prevent the spread of resistant infections
Goal 2: Strengthen national one-health surveillance
efforts to combat resistance
Goal 3: Advance development and use of rapid and
innovative diagnostic tests for identification and
characterization of resistant bacteria
Goal 4: Accelerate basic and applied research and
development for new antibiotics, other therapeutics,
and vaccines
Goal 5: Improve international collaboration and
capacities for antibiotic resistance
Examples of National Targets for 2020
Reduce by 50% the incidence of overall C. diff
infections compared to estimates from 2011
Reduce by 60% CRE infections acquired during
hospitalization compared to estimates from
2011.
Maintain prevalence of ceftriaxone-resistant
N. gonorrhoeae below 2% compared to
estimates from 2013.
Percentage of NH Acute Care Hospitals with
Following Activities or Interest, 2011
ASP = Antimicrobial Stewardship Program
N=20 hospitals responded
What is Antimicrobial Stewardship
Coordinated interventions to improve and measure
appropriate use of antimicrobials
Achieved through promoting selection of optimal
antimicrobial drug regimen
dosing, route, and duration of therapy
Improves patient outcomes
Reduce adverse events:
Toxicity
Clostridium difficile infections
Improved rates of antibiotic susceptibility
Optimize resource utilization
Barlam TF, et al. CID 2016;62:e51-77.
Antimicrobial Stewardship by Setting
A menu of interventions
Flexible and adaptable to different contexts
Antimicrobial stewardship will not look the
same between organizations
Goals of AS and guiding principles are broadly
applicable
Septimus EJ, and Owens Jr RC. CID 2011;53(S1):S8-S14.
Antimicrobial Stewardship Outcomes
Avoid redundant antibiotics
Avoid antibiotics for non-bacterial syndromes,
contamination, or colonization
Avoid regimens that are too narrow or too
broad
Tailor therapy to culture results
Barlam TF, et al. CID 2016;62:e51-77.
Bringing Together National Strategy on
CARB and Antimicrobial Stewardship in NH
Forming an AS working group
Working and coordinating with QIO
Making CRE reportable
Increase capacity to investigate and prevent
Gonorrhea infections
Evaluate state-wide resistance through
antibiogram data from hospitals
Evaluate antibiotic use patterns
Immunization Information System (IIS)
Reduces healthcare costs
Reducing manually performed vaccination activities
Reducing unnecessary and duplicate vaccinations
Vaccination reminders
Vaccine tracking
Patients and families would benefit from having access
to a complete electronic immunization record
Improves ability to prevent and control outbreaks of
vaccine preventable diseases
Allows for more efficient investigation of cases
Immunization Information System (IIS)
Administrative Rules (He-P 307) establishing the IIS
(registry) became effective 5/20/16
Allows for healthcare providers to view immunization
information for patients
Health care provider includes pharmacists
Allows for healthcare providers to send data to IIS for
patients that do not opt out (voluntary)
System will collect information on all NH residents
regardless of age who do not opt out
Enrolling Patients in IIS
No patient shall be required to participate
No health care provider shall provide the name of any
patient who opts out
Opportunity to opt out shall be provided
At time of immunization by an administering health care
provider
Prior to or at a face-to-face encounter with a current
healthcare provider
Patient shall be provided form to opt out
Patient can change selection at a future point
Not required to provide notice of opportunity to opt
out to same patient more than once
Provider Enrollment
Request access to the system
Verify identify and determine appropriate access
Complete enrollment process:
Site agreement
Participant agreement
Training
Providers can submit data in two ways
Manual data
Automated messaging (HL7)
Providers can review immunization records
IIS Patient Search
IIS Patient Information
IIS Patient Information
IIS Patient Information
IIS Implementation Timeline
Now: Developing supporting documents
Winter: Issue guidance and materials for Opt
Out process
Spring: Identifying pilot sites
July 1: Go live to accept data and establish user
accounts
2-5 year process to get everyone on board
HPV Vaccine Updates
Clinical trials data show 3 doses in younger
adolescents (9-14 years) produced similar immune
response or higher than young adults (16-26 years)
who received 3 doses
CDC recommends 11- to 12-year-olds receive 2 doses
of HPV vaccine at least 6 months apart rather than
the previously recommended 3 doses
Teens and young adults (15-26 years) who start the
series later still need 3 doses
Adolescents aged 9-14 years who already received 2
doses less than 5 months apart will require third dose
3 doses are recommended for people with weakened
immune systems aged 9-26 years
Influenza Vaccine Updates
Currently seeing influenza like illness in a few counties
in NH (not yet widespread)
Respiratory illness increasing for a few weeks
3 samples in PHL positive for AH3
ACIP interim recommendation for 2016-17 season that
live attenuated influenza vaccine (LAIV) not be used
LAIV vaccine effectiveness (VE) data from recent
seasons has shown poor and lower than expected VE
2015-16 season: VE for LAIV was 3% and 63% for IIV
Supply of IIV for 2016-2017 season should be sufficient
LAIV about 8% of flu vaccine supply in US
Assessment Question 1
In the recent revision to the state’s communicable
disease rules, which event must now be reported to
the NH Department of Health and Human Services?
a. Diversion of oral medications intended for use
by a patient
b. Diversion of fentanyl patches intended for use
by a patient
c. Diversion of injectable medications intended
for use by a patient
d. Diversion of any medication intended for use
by a patient
Assessment Question 2
Which of the following are the key guiding principles
for the National Strategy to Combat Antibiotic
Resistant Bacteria?
a. Misuse & over-use of antibiotics in healthcare
and food production hastens drug resistance
b. Detecting and controlling antibiotic resistance
requires a “one-health” approach
c. Evidence-based infection control practices can
prevent the spread of resistant pathogens
d. Interventions are needed to increase private
sector investment in antimicrobial agents
e. All of the above
Assessment Question 3
The new statewide Immunization Information System
will collect what information?
a. Immunization records only for people who
have asked to be included
b. Immunization records for all people in NH
who did not ask to be excluded
c. Immunization records only for children in NH
d. Immunization records only for adults in NH
Questions?
Beth Daly, MPH
Bureau of Infectious Disease Control
29 Hazen Drive
Concord, NH 03301
603-271-4927
[email protected]