Monthly Infectious Diseases Surveillance Report

Transcription

1 September 2016 Monthly Infectious Diseases Surveillance Report Volume 5, Issue 9 The Monthly Infectious Diseases Surveillance Report is produced by Public Health Ontario (PHO) for the public health community of Ontario. We welcome feedback by to: cdepr@oahpp.ca. Past issues and additional information are available online. In Focus... 2 Significant Reportable Disease Activity... 7 Appendix Reportable Diseases... 10

2 IN FOCUS Carbapenemase-producing Enterobacteriaceae Carbapenemase-producing Enterobacteriaceae (CPE) is a gram-negative bacterium that produces an enzyme capable of breaking down a whole class of beta-lactam agents, including carbapenems, that are considered last-resort antibiotics. 1 Its antibiotic resistance, association with high mortality rates, and potential to spread rapidly from one location to another make CPE a significant public health concern worldwide. 2 CPE produces different types of carbapenemase enzymes, such as Klebsiella pneumoniae carbapenemase (KPC), New Delhi metallo-β-lactamase-1 (NDM-1), Verona integron-encoded metallo-βlactamase (VIM), and oxacillinase (OXA). Since the KPC producer was first discovered in 1996, CPEs have spread throughout the world. Endemic areas have been identified, including KPC producers in the United States, Greece, and Israel; NDM producers in the Indian subcontinent; VIM producers in Greece and Italy; and OXA producers in North Africa and Turkey. 3 CPEs are primarily found in health care settings and as a result, receiving health care in countries where CPE is endemic is a major risk factor for colonization and/or infection with CPE. CPE can be spread from person to person, or through contact with contaminated surfaces such as door handles, chairs, and medical equipment. Recently, acquisition of CPE has also been associated with the use of contaminated endoscopic retrograde cholangiopancreatography, or ERCP a procedure used to study the bile ducts, pancreatic duct, and gallbladder. 4,5 It affects patients, residents, and health care workers and can cause various infections including pneumonia and bloodstream infection. Symptoms of CPE infections may include fever and chills. In the laboratory, CPE is detected initially by observing increased minimum inhibitory concentration (MIC) to carbapenems and the presence of carbapenemase genes is confirmed using PCR testing. Treatment of CPE infections is difficult as currently available antibiotics are not highly effective. Therefore, prevention and control of CPE is a priority. Nomenclature CPE is often confused with carbapenem-resistant Enterobacteriaceae (CRE), carbapenemase-producing organism (CPO), and carbapenem-resistant organism (CRO). Bacteria that are resistant to carbapenems are collectively known as CROs. Among the CROs, those that produce carbapenemase are termed CPOs. CPOs that belong to the Enterobacteriaceae family are also known as CPE. The terms CRE and CPE are often used interchangeably but, in fact, these bacteria differ in terms of resistant mechanisms. CRE may be resistant to carbapenem by producing extended-spectrum beta-lactamase (ESBL) or AmpC betalactamase, together with the loss of porins, or by acquiring the genes to produce carbapenemase. The latter applies to CPE s mechanism of resistance. 6,7 Public Health Ontario (PHO) uses CPE to denote the organism group (i.e., Enterobacteriaceae) and mechanism of resistance (i.e., acquired carbapenemase). Although all antibiotic resistant organisms are concerning, CPE receives particularly greater attention as carbapenemase genes found in these organisms are able to easily move from one species to another, thus having a much higher potential to spread. Figure 1 provides a visual representation of the hierarchy of terms. Monthly Infectious Diseases Surveillance Report Page 2 of 12

3 Figure 1: Hierarchy of terms used to denote carbapenem resistance Surveillance and Epidemiology Otter, adapted with permission Surveillance is considered an important element for the prevention and control of health careassociated infections such as those caused by CPE. 8 Surveillance data estimate the burden of the disease, provide baseline measures for comparison, identify potential risk factors, and provide an opportunity to evaluate infection prevention and control programs and practices in health care settings. In Canada, data on CRE and other health care-associated infections are collected through the Canadian Nosocomial Infection Surveillance Program (CNISP). In Ontario, PHO has implemented a voluntary CPE surveillance program using the results of confirmatory testing conducted at the PHO Laboratories (PHOL) and patient data from hospitals. Data collected through PHO s voluntary surveillance program showed that 631 samples were sent to PHOL in Of these, 18% (115/631) were positive for CPE. Compared with the 2014 positive test results, this proportion of positive samples is lower by 2%. However, the number of isolates submitted for CPE testing was higher in 2015 compared to 2014 (631 vs. 570). Additional information was obtained for the positive samples from 70 patients through their respective admitting hospitals. The median age of CPE-positive patients was 70 years and the majority (66%) were males. Of those with known colonization or infection status, 56% were identified as colonized. Monthly Infectious Diseases Surveillance Report Page 3 of 12

4 Figure 2: Patients with newly confirmed CPE isolates by age group and colonization/infection status: Ontario, 2015 (N=63) Data Source: PHOL, Carbapenemase-producing Enterobacteriaceae database, extracted by PHO [2016/02/29]. Note: Excludes seven cases of unknown colonization/infection status. As in 2014, heart disease and diabetes were the most commonly reported chronic conditions among CPE positive patients in Among the 70 patients, 49 (70%) were hospitalized in the past 12 s. Further, 45 of the 70 patients (64%) had traveled outside of Canada prior to their hospitalization in Ontario. Given that 10% (7/70) of the CPE positive patients did not have travel or receive health services outside Canada, it is possible that CPE transmission may have occurred within our local hospitals and community. Current and past numbers of CPE cases, however, remain small. The Central West Local Health Integration Network (LHIN) had the highest proportion of positive isolates (37%) when compared with other LHINs. The total number of isolates submitted was also highest in Central West, with 21% of the 631 isolates coming from this geographic region (Table 1). This may be related to the travel patterns of the residents and testing practices of hospitals in this region. Monthly Infectious Diseases Surveillance Report Page 4 of 12

5 Table 1: Number and proportion of CPE isolates by Local Health Integration Network: Ontario, 2015 LHIN No. of CPE positive isolates Proportion of all positive isolates (%) Total submitted isolates Central West Toronto Central Central Mississauga Halton Central East Champlain South East Hamilton Niagara Haldimand Brant Erie St. Clair North East South West North Simcoe Muskoka North West Waterloo-Wellington Total * 631 Data Source: PHOL, Carbapenemase-producing Enterobacteriaceae database, extracted by PHO [2016/03/14]. Notes: *Proportion may not add up to 100% due to rounding. The geographic region of the testing laboratory was used for isolates where the reporting hospital was unknown. NDM-1 isolated in E. coli was the most commonly reported carbapenemase enzyme in 2014 and Overall, the number of CPE submissions to PHOL continued to increase in 2015 when compared to previous years, although no seasonal trends in the number of positive isolates have been observed. Further epidemiological information can be found on PHO s CPE surveillance web page. Prevention and Control CPE continues to be a global issue in health care settings. Although it is not yet endemic in Ontario, outbreaks related to travel and hospitalization outside Canada have been reported in the past and continue to increase. Surveillance combined with good hand hygiene practices, antimicrobial stewardship, and improved diagnostics are some approaches to reducing the spread of CPE and ensuring that Ontario stays endemic-free. 9 Monthly Infectious Diseases Surveillance Report Page 5 of 12

6 References: 1. Eshetie S, Unakal C, Gelaw A, Ayelign B, Endris M, Moges F. Multidrug resistant and carbapenemase producing Enterobacteriaceae among patients with urinary tract infection at referral Hospital, Northwest Ethiopia. Antimicrobial Resistance and Infection Control. 2015;4:12. Available from: 2. Lyman M, Walters M, Lonsway D, Rasheed K, Limbago B, Kallen A. Notes from the field: Carbapenem-resistant Enterobacteriaceae Producing OXA-48-like Carbapenemases United States, Morbidity and Mortality Weekly Report. 2015;64(47); Available from: Erratum in: Morbidity and Mortality Weekly Report. 2015; 64(48);1350. Available from: 3. Nordman P, Gniadkowski M, Giske CG, Poirel L, Woodford N, Miriagou V et al. Identification and screening of carbapenemase-producing Enterobacteriaceae. Clinical Microbiology and Infection. 2012;18: Kola A, Piening B, Pape U-F, et al. An outbreak of carbapenem-resistant OXA-48-producing Klebsiella pneumonia associated to duodenoscopy. Antimicrobial Resistance and Infection Control. 2015;4:8. doi: /s Available from: 5. Newson L. Patient: ERCP. [Internet]. Leeds, UK: EMIS Group; Available from: 6. Otter J. Do you know your CRO from your CPO from your CRE from your CPE? 2013; Jul 13. In: Reflections on Infection Prevention and Control blog [Internet]. Available from: 7. Wong T. Carbapenem resistant Enterobacteriaceae: epidemiology, clinical impact and laboratory diagnosis. Presented at the Annual Congress of the British Columbia Society of Laboratory Science, Whistler BC, April [cited 9 September 2016] Available from: 8. Ontario Agency for Health Protection and Promotion (Public Health Ontario), Provincial Infectious Diseases Advisory Committee. Best practices for surveillance of health care-associated infections in patient and resident populations, 3rd ed. Toronto, ON: Queen s Printer for Ontario; [cited 9 September 2016]. Available from: 28%20FINAL.pdf 9. Ontario Agency for Health Protection and Promotion (Public Health Ontario). ASP 101: What is antimicrobial stewardship. Toronto, ON: Queen s Printer for Ontario: Toronto; [Cited 9 September 2016]. Available from: Monthly Infectious Diseases Surveillance Report Page 6 of 12

7 SIGNIFICANT REPORTABLE DISEASE ACTIVITY Table 1 provides a list of reportable diseases for which incidence in 2016 was found to be significantly higher (p<0.05) than expected compared to the five-year historical average 15). Both ly and year-to- () comparisons were made for each of the reportable diseases listed in Appendix 1, with the exception of influenza, measles, rubella, and congenital rubella syndrome. Influenza surveillance data are regularly reported through the Ontario Respiratory Pathogen Bulletin. Measles, rubella, and congenital rubella syndrome have been eliminated in Canada, although cases continue to occur related to travel importations. Statistical comparisons are not included for these diseases. Table 1. Summary of statistically significant increases in reportable disease incidence: Ontario, January 1 to July 31, 2016 Reportable disease July July 2016 Historical comparisons Current Current % difference in rates (current minus 5- year ) Monthly Infectious Diseases Surveillance Report Page 7 of 12 % difference in rates ( 2016 minus 5- year ) Chlamydial Infections Cyclosporiasis 1, Gonorrhoea (All Types) Listeriosis Shigellosis Syphilis, Infectious Yersiniosis Ontario Cases: Ministry of Health and Long-Term Care (MOHLTC), integrated Public Health Information System (iphis) database, extracted by PHO [2016/08/10]. Ontario Population: Population estimates [ ]: Statistics Canada, distributed by MOHLTC, received [2014/07/03]. Population estimates [ ]: Statistics Canada, distributed by MOHLTC, received [2015/11/18]. Population projections [ ]: MOHLTC, IntelliHEALTH Ontario, extracted by PHO [2015/03/13]. ŧ Rates listed are cases per 1,000,000 population. Percent (%) difference is calculated using unrounded rates; numbers displayed in these columns may vary from calculations using rounded rates. 1 Statistically significant difference (p<0.05) in incidence reported in year-to- (January 1 to July 31, 2016) compared to the five-year historical average (January 1 to July 31, ), using a likelihood ratio test. 2 Statistically significant difference (p<0.05) in incidence reported in current (July 2016) compared to the five-year historical average (July ), using a likelihood ratio test. annual count

8 Bacterial Sexually Transmitted Infections (STIs) Compared to the five-year historical averages, there were statistically significant increases in the incidence of all three bacterial STIs (chlamydia, gonorrhea, and infectious syphilis) reported between January 1 and July 31, During this period, laboratory-confirmed cases of chlamydia increased 8.3% (from 1,562.0 to 1,692.3 cases per 1,000,000 population), gonorrhea cases increased 30.7% (from to cases per 1,000,000 population), and cases of infectious syphilis increased 32.4% (from 36.3 to 48.1 cases per 1,000,000 population). The potential causes for these concurrent provincial increases in bacterial STIs are under active investigation and are likely multifactorial. PHO will continue to monitor the epidemiology of bacterial STIs in Ontario in subsequent s. Listeriosis The incidence rate for listeriosis for 2016 was significantly higher than the average for the same period in the previous five years. From January 1 to July 31, 2016, 68 cases of listeriosis were reported compared to an expected average of 26 cases. The increase observed in the first half of 2016 can be attributed to two separate outbreaks that began in Certain Dole and PC Organics brands of prepackaged leafy green products were implicated in the first outbreak and Neilson brand partly skimmed chocolate milk was implicated in the second. Additional details about these outbreaks are available in the June 2016 and July 2016 issues of this report. Shigellosis Incidence rates for shigellosis continued to be higher than expected in the first half of The incidence rate for 2016 was significantly higher than the average for the same period in the previous five years. From January 1 to July 31, 2016, 220 cases of shigellosis were reported compared to an expected average of 156 cases. However, the number of cases reported in July indicates that this sustained increase in incidence may be waning with 23 cases reported in 2016 compared to 32 cases on average in July in the preceeding five years. The source of the increase observed in 2015 through to the first half of 2016 was described in the May 2016 issue of this report. PHO continues to collaborate with public health units (PHUs) affected by this increase to identify risk factors, at-risk populations, and prevention and control measures. Yersiniosis A statistically significant increase in the incidence rate of reported cases of yersiniosis was observed. From January to July 2016, 184 cases of yersiniosis were reported compared to an expected average of 110 cases. The cause of the increase is unknown at this time; however, the ly rate was not significantly above expected in July with 19 cases reported in 2016 compared to 16 cases on average in July in the preceeding five years. The information available does not suggest that the increase is due to a single source outbreak. PHO continues to monitor trends and investigate this increase to identify potential clustering. Monthly Infectious Diseases Surveillance Report Page 8 of 12

9 Cyclosporiasis Statistically significant increases in both the ly and the incidence rates of cyclosporiasis were observed in July From January to July 2016, 183 cases of cyclosporiasis were reported compared to an expected average of 107 cases; of the 183 cases, 97 occurred during the of July, when only 28 cases would be expected. An Outbreak Investigation Coordinating Committee (OICC) was activated on July 15 to investigate non-travel cases of cyclosporiasis cases. The investigation is ongoing and the source of this increase has not been identified. Monthly Infectious Diseases Surveillance Report Page 9 of 12

10 APPENDIX REPORTABLE DISEASES Appendix 1. Confirmed cases of reportable diseases, and probable cases of select reportable diseases, by : Ontario, * Reportable disease 2016 Historical comparisons Monthly Infectious Diseases Surveillance Report Page 10 of 12 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Acute Flaccid Paralysis n/a n/a n/a n/a n/a n/a n/a AIDS Amebiasis Botulism Brucellosis Campylobacter enteritis Chlamydial Infections Cholera Cryptosporidiosis Cyclosporiasis Encephalitis Encephalitis/Meningitis Food Poisoning, All Causes Giardiasis Gonorrhoea (All Types) Group A Streptococcal Disease, Invasive Group B Streptococcal Disease, Neonatal Haemophilus Influenzae B Disease, Invasive Hepatitis A Hepatitis B (Acute) Hepatitis B (Chronic) n/a n/a n/a n/a n/a n/a n/a Hepatitis C HIV Influenza Legionellosis Leprosy Listeriosis Current Current % difference rates (current minus 5- year ) % difference rates ( 2016 minus 5- year ) annual count

11 Reportable disease 2016 Historical comparisons Monthly Infectious Diseases Surveillance Report Page 11 of 12 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Lyme Disease Malaria Measles # # # # # # # Meningitis Meningococcal Disease, Invasive Mumps Ophthalmia neonatorum Paralytic Shellfish Poisoning n/a n/a n/a n/a n/a n/a n/a Paratyphoid Fever Pertussis (Whooping Cough) Q Fever Rabies Rubella # # # # # # # Rubella, Congenital Syndrome # # # # # # # Salmonellosis Shigellosis Streptococcus Pneumoniae, Invasive Syphilis, Early Congenital Syphilis, Infectious Syphilis, Other Tetanus Tuberculosis Tularemia Typhoid Fever Verotoxin Producing E. coli Including HUS West Nile Virus Illness Yellow Fever Yersiniosis Ontario Cases: MOHLTC, iphis database, extracted by PHO [2016/08/10]. Ontario Population: Population estimates [ ]: Statistics Canada, distributed by MOHLTC, received [2014/07/03]. Population estimates [ ]: Statistics Canada, distributed by MOHLTC, received [2015/11/18]. Population projections [ ]: MOHLTC, IntelliHEALTH Ontario, extracted by PHO [2015/03/13]. * Appendix 1 is not an exhaustive list of all reportable diseases in Ontario. Case counts for amebiasis, Lyme disease, mumps, pertussis, and West Nile Virus illness are based on the sum of confirmed and probable cases as reported in iphis. ŧ Rates listed are cases per 1,000,000 population. Percent (%) difference is calculated using unrounded rates; numbers displayed in these columns may vary from hand calculations using rounded rates. Current Current % difference rates (current minus 5- year ) % difference rates ( 2016 minus 5- year ) annual count

12 # Historical comparison data are not provided for measles, rubella, and congenital rubella syndrome because these diseases have been eliminated in Canada. However, as these diseases remain endemic in other countries, imported and import-related cases continue to occur in Ontario. n/a Acute Flaccid Paralysis and Paralytic Shellfish Poisoning became reportable in Ontario in December No historical data are available for comparisons. Also, a provincial case definition for chronic hepatitis B was released in January Please note that chronic and acute hepatitis B case counts are not mutually exclusive and should not be added to obtain a total for hepatitis B cases in Ontario. Historical comparisons are not available as cases of chronic hepatitis B may have been entered using varying criteria prior to this time. Does not include cases for which the Ministry of Health and Long-Term Care was selected as the Diagnosing Health Unit or cases with a Disposition Description set to DOES NOT MEET or ENTERED IN ERROR. Differentials in year-over-year comparisons are reflective of changes in disease incidence and changes in the size of the population. Statistical tests comparing rates were not performed when the rate in previous years was zero. Case counts for tuberculosis and AIDS are based on diagnosis date and not episode date. HIV case counts are based on encounter date. Case counts for all other diseases are based on episode date. Monthly Infectious Diseases Surveillance Report Page 12 of 12