NJDOH Communicable Disease Forum

Transcription

1 NJDOH Communicable Disease Forum Spring 2017 Namitha Reddy Acting Manager, Regional Epidemiology Program New Procedures for Testing Animal Specimens for Rabies Beginning in May 2017, the Public Health and Environmental Laboratories (PHEL) will suspend testing of animal rabies specimens. Rabies testing will be conducted by another certified laboratory. All test results will be faxed directly to Health Officers in the same manner as is currently done. The shipping arrangements will change, once an agreement is finalized with another laboratory. New Procedures for Testing Animal Specimens for Rabies PHEL is planning to conduct a webinar in the near future to fully explain the new procedures for submitting rabies specimens. They will also provide a telephone number and website to address questions from rabies specimen submitters. Health Officers are asked to ensure that all rabies specimens are correctly packaged and shipped promptly in order to prevent samples from decomposing in-transit and being unsatisfactory for testing. Improper packaging may also delay testing. Health Officers will be updated as the procedures become finalized. For additional information, contact the PHEL at Emerging Infections Educational Kit Purpose: Designed to harness an innovative platform to engage New Jersey s Public Health System Vision: Strengthening Information Management and Sharing on Emerging Infectious Diseases (EIDs) Mission: To prepare those within New Jersey s Public Health System for the fight against EIDs, including the Zika Virus, through dissemination of multimedia information and resources About the Emerging Infections Educational Kit Inside the Emerging Infections Educational Kit Conceived May 2016 Funding support from CDC Cooperative Agreement with NJDOH Partnered with QuickSeries Publishing Convened NJDOH subject matter experts for development and review of kit materials Hosted Ad-Hoc Meeting with LHD representatives from the five public health regions to garner feedback and discuss dissemination Launch March 2017 Execution of dissemination strategy What does the eguide provide? Basic epidemiological information on twelve (12) EIDs. Guidance on how to prevent the spread of emerging infections. Information on how to prepare for a disease outbreak. Online resources from CDC, NJDOH, WHO, and more. How can I use the eguide? Develop infectious diseases training. Use as a teaching aid for interactive workshops. Access EID information from NJDOH's Communicable Disease Service*. NOTE: The eguide is not intended to supersede information in the existing NJDOH Communicable Disease Manual. 1

2 Questions about the Kit: Luis E. Torrens, MPH Division of Public Health Infrastructure, Laboratories, and Emergency Preparedness Corynna Limerick, MPH Office of Local Public Health What To Do When You Get The Call : Measles Investigations & Public Health Response Noelle Bessette, MPH Surveillance Specialist New Jersey Department of Health Vaccine Preventable Disease Program Public Health Response After We Get The Call Isolation of case Collection of appropriate specimens for laboratory testing Assess likelihood that it could be measles Symptoms Vaccine status Travel/foreign visitors/exposure Notification to LHD/NJDOH Contact investigations and other response efforts Determine level of public health response Modified response vs. full response Every situation is different so decisions are made on a case-by-case basis in collaboration with LHD/NJDOH Modified Public Health Response When measles can t be ruled out, but suspicion is lower Response will differ case-by-case Collect more information via patient interview, confirm symptoms, have patient start compiling timeline of everywhere they went during infectious period (4 days before rash onset through 4 days after rash onset- total of 9 days) MD office/ hospitals should also identify exposed individuals (i.e. everyone in ED including all staff while suspect case was there through 2 hours after he/she left) and confirm proof of immunity for healthcare workers (HCW) Hold information pending additional testing and patient interviews Full Public Health Response: If measles is confirmed or highly suspected 2

3 Contact Investigation: Exposed Individuals Identify persons exposed during infectious period Includes individuals in exposure location through 2 hours after case left Establish presumptive evidence of immunity for contacts Consider post-exposure prophylaxis (PEP) Vaccine (within 72 hours from 1 st exposure) or Immune globulin (IG -within 6 days from 1 st exposure) Note: healthcare workers who receive PEP can NOT return to healthcare setting Quarantine contacts without presumptive evidence of immunity Starting day 5 from 1 st exposure through 21 days after last exposure Includes exposed healthcare workers, household contacts, other close contacts Consult with NJDOH before recommending quarantine Educate contacts on symptoms/ what to do if they become symptomatic Question #1: Which of the following is considered an acceptable form of proof of immunity? 1) Lab confirmation of measles infection or immunity 2) Verbal history of vaccination 3) Written documentation of age-appropriate vaccination 4) All of the above 5) 1 & 3 Measles Proof of Immunity Written documentation of adequate vaccination: 1 or more doses of a measles-containing vaccine administered on or after the first birthday for preschool-age children and adults not at high risk 2 doses of measles-containing vaccine for school-age children and adults at high risk, including college students, healthcare personnel, and international travelers Laboratory evidence of immunity Laboratory confirmation of measles Birth before 1957 HCP born before 1957 who do not have laboratory evidence of immunity, laboratory confirmation of disease, or 2 documented doses of measlescontaining vaccine should be vaccinated In the case of an exposure, HCP born before 1957 with no other proof of immunity will be excluded until able to provide acceptable proof of immunity Contact Investigation: Exposure Settings Compile list of all places suspect case visited during infectious period (4 days before rash onset through 4 days after rash onsettotal of 9 days) Patient should begin compiling timeline upon first LHD contact Will need minute-by-minute breakdown of the 9 days Important details to request: time arrived, time left, name of location, address, transportation method to/from Get this info ahead of time so that if a press release is going to be issued, it is ready to go Note: Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity Exposures at Medical Facilities The Buildings If exposures occur at medical facilities (MD offices, hospitals, etc.), make contact with MD office Confirm dates and times of visit (inquire specifically about additional visits) Facility should begin to confirm HCW proof of immunity (furlough if no proof of immunity or until it can be provided) and pull patient records for all patients who would have been exposed Facility will be tasked with contacting exposed patients Timing of mailing letter vs. phone call Once you have timeline, it is important to determine the type of building each is in (standalone store vs. large high rise) If the exposure setting is in a larger building, you will need to contact the manager to get information on the building s air supply This information can be obtained from the property s managementsome individuals will speak to management, and some others will want you to contact the property s management directly If the location has its own air supply and entrance, others in the building would not be considered exposed If the location shares air, or has a shared entrance (i.e. a central lobby), all others in the air exchange are considered exposed- must obtain information on other businesses in the building (particularly medical offices/daycares/other high risk settings) 3

4 Will there be a press release? Depends on exposures If only exposure is a location where every individual can be identified and contacted, press release is less likely If there are exposures in a setting where not everyone would be able to be identified (i.e. Walmart), a press release is more likely Timing will depend on level of suspicion/ case confirmation What happens after the decision to issue a press release is made? NJDOH press office will communicate with LHD press office and other press offices as requested (i.e. hospital) All entities that will be named should know ahead of time All-hands-on-deck response Start with store manager, will likely end up being transferred to someone at the company s headquarters/legal office Can offer to provide a copy of the press release as soon as it is posted Case #1 Details Recent Measles Investigations Non U.S.-born adult male in Hudson County Recent travel to India (12/3/16-1/15/17) Unknown vaccination status Reported to LHD (unsuccessful LHD phone call, then by fax) on 1/22, received morning of 1/23 Case #1 Timeline 12/3/16-1/15/17: Travel to India 1/17: Dry cough 1/18: Fever (103) 1/19: Walk-in clinic, prescribed azithromycin 1/20: Red eyes, vomiting, rash all over body 1/20: ED visit, diagnosed as drug allergy and given different antibiotic and prednisone 1/22: ED visit for worsening rash all over body, negative rapid flu and strep testing, blood collected for measles and Rocky Mountain Spotted Fever testing 1/23: LHD becomes aware of case and begins follow up Question #2: Based on the available information, what type of public health response would you recommend? 1) Full public health response 2) Modified public health response 3) No public health response 4) None of the above 4

5 Case #1 Timeline (cont d) 1/23: LHD becomes aware of case and begins follow up (including patient interview) Case begins compiling timeline of everywhere he was from 4 days before rash onset through 4 days after rash onset was 1/20, so from 1/16 through 1/24 1/23: LHD went to patient s house to collect blood on 3 household contacts (no PMD, titers done at PHEL) and get urine sample from suspect case for viral testing at Wadsworth (CDC VPD Reference Lab) 1/26: Late PM received verbal positive PCR results from Wadsworth 1/27: Press release issued Case #1: Public Health Response Public exposures included: Hospital MD office PATH stations/ trains Work Mall Lab Pharmacy Restaurant Non-public exposures included: Ride sharing services Taxi 2 households Case #1: Exposure Setting Follow Up Hospital MD office Employees immunity confirmed Patients notified NJDOH press release Employees immunity confirmed Patients notified NJDOH press release for building- shared atrium Mall Lab Pharmacy NJDOH press release Employees immunity confirmed Ordering providers notified NJDOH press release (own air exchange/entrance) Employees immunity confirmed Many large buildings- needed to determine air exchanges/ identify & notify exposed individuals PATH stations/ trains NJDOH press release Work Notified employees NJDOH press release NJDOH press release Restaurant Employees notified NJDOH press release Case #1 Wrap Up Case #2 Details No additional cases identified during 21 day incubation period Case confirmed based on positive PCR testing and symptoms 7 month old female in Passaic County Recent travel to Bangladesh (12/19/16-1/10/17) Unvaccinated LHD notification via positive IgM entered into CDRSS on 1/27 Blood collected on 1/23 5

6 Case #2 Timeline 12/19/16-1/10/17: Travel to Bangladesh 1/18: Runny nose, temp of 101 MD visit- pediatrician s office 1/20: Fever (max ) 1/21: Anorexia, congestion, cough, vomiting ED visit #1- ED notes small papular rash on face, negative for strep and flu 1/23: Rash spreads to trunk, arms and legs, no longer on face ED visit #2- bloodwork ordered for measles, taken right into private room 1/27: LHD becomes aware of case via positive IgM in CDRSS and begins follow up Question #3: Based on the available information, what type of public health response would you recommend? 1) Full public health response 2) Modified public health response 3) No public health response 4) None of the above Case #2 Timeline (cont d) Case #2: Public Health Response 1/27: LHD becomes aware of case and begins follow up (including patient interview and trying to obtain vaccination records for parents) Begins compiling timeline of everywhere patient was from 4 days before rash onset through 4 days after rash onset was 1/21, so from 1/17 through 1/25 1/28: Contacted neighbor (multi-family home) 1 child vaccinated, 1 unvaccinated (12 months)- quarantined for whole incubation period 2 adults have proof of immunity from NJ schools 1/30: Case s mom and dad have blood collected for titers at the end of the day at MD office (both positive on 1/31) 1/30: Press release issued Public exposures included: Hospital MD office MD office is in a small strip mall, but was able to quickly establish that MD office has its own entrance and air exchange MD office pulled records for and contacted all patients who could have been exposed in the office in a timely fashion (all were vaccinated) Not in press release as all potentially exposed individuals were promptly contacted 2 ED visits- 2 different campuses of the same hospital system 1 st visit- not in negative pressure 2 nd visit- put into private room, but not negative pressure. Moved to a negative pressure room shortly before discharge Press release issued- no way to know everyone in the ED during the 2 visits Case #2 Wrap Up Case #3 Details Case No additional cases identified during 21 day incubation period Case confirmed based on positive measles IgM and symptoms 46 year old female in Middlesex County No recent travel Unknown vaccination status (verbal report of 2 doses but no dates or records) No known measles cases in NJ; limited exposures- family member was ill and passed away, most of case s time was spent at a hospital with the family member or at home Reported by Infection Control by phone as a rule out measles Blood collected and patient discharged from ED 6

7 Case #3 Timeline 5/12/15: Dry cough 5/15/15: Took a Xanax for the first time, ordered by provider 5/15/15: High fever (102.8) and maculopapular rash 5/16/15: ED visit, taken into negative pressure room No fever at ED Blood collected for testing 5/17/15: LHD coordinates with hospital to have viral specimens collected for testing at CDC (2 NP swabs and urine collected) ED begins pulling records for exposed individuals/employees Question #4: Based on the available information, what type of public health response would you recommend? 1) Full public health response 2) Modified public health response 3) No public health response 4) None of the above Case #3 Timeline (cont d) Case #3: Public Health Response 5/22: Blood from 5/16 collection comes back IgM and IgG positive 5/26: 2 NP swabs and urine all come back PCR positive for measles 5/26: Public health response, all-hands-on-deck All exposed in ED have proof of immunity, patient put directly into negative pressure 5/27: LHD able to re-interview case to get exact times/ locations/ contacts 5/28: LHD collects blood from case s partner for IgG (+ on 6/1) 5/28: Press release issued Public exposures included: Hospital Funeral home Hospital was able to identify all exposed and confirm proof of immunity Funeral home exposures (5/11 and 5/14) 5/11: Arrangements being made, 2 additional families exposed (6 month old and mother who had no proof of immunity quarantined for 21 day incubation period) 5/14: 2 concurrent funerals at funeral home, unable to identify all exposed individuals Press release issued Potential Location Where Case Could Have Been Exposed Case #3 Wrap Up On 5/26 the hospital that the family member was in during patient s incubation period (not infectious period) was notified so it could monitor for other cases that may arise Also inquired as to whether there was anyone there during that time period who had a rash that could have been misdiagnosed No potential source of infection identified No additional cases identified during 21 day incubation period Case confirmed based on positive PCR testing and symptoms 7

8 Lessons Learned from Recent Cases Importance of suspect cases being reported upon suspicion Importance of making contact with a person from LHD or NJDOHleaving a message or sending a fax is not sufficient if measles is being suspected Infants aged 6 11 months should receive 1 dose of MMR vaccine before traveling abroad Will still need MMR or MMRV vaccine at months ( 28 days after the initial dose) and again at 4 6 years Importance of putting suspected case in a negative pressure room if possible (as opposed to a private room) Importance of collecting and confirming exposure details up front in preparation for a timely response Thank you! Noelle Bessette Noelle.Bessette@doh.nj.gov (609) Candida auris: The rise and response to an emerging multidrug-resistant yeast Candida auris in the news Patricia M. Barrett, MSD Antimicrobial Resistance Coordinator, New Jersey Department of Health Rebecca Greeley, MPH Infectious Disease Team Lead, New Jersey Department of Health Communicable Disease Forum April 2017 Source: Candida auris in the field Outline Source: Schelenz et al. Antimicrobial Resistance and Infection Control (2016) 5:35 DOI: /s The rise of Candida auris Reasons for concern Identification Resistance Transmission C. auris in the US and New Jersey Recommendations Response Call for action Takeaways 8

9 Candida auris: Not your Grandparent s Candida Candida: Catch-all for asexual yeasts Hundreds of unrelated species Candida albicans vs nonalbicans Candida Less than half of Candida infections are caused by C. albicans, today Source: Candida auris: An overnight sensation First isolate identified Japan Oldest isolate identified (1996) South Korea Global emergence South Africa Kenya Kuwait India Colombia Spain Pakistan U.S.A. Venezuela Israel Germany U.K With international roots Whole genome sequencing used to review fingerprints of isolates South America Four clades covering three continents Simultaneous development South Asia It s just Candida! What s the big deal, eh? East Asia South Africa Image courtesy of CDC Mycotic Diseases Branch Candida auris: A fast learner Three major classes of antifungals Azoles Fluconazole: 94% resistant Voriconazole: 54% resistant Polyenes Amphotericin B: 35% resistant Echinocandins: 7% resistant Most C. auris isolates are drug resistant 41% multidrug resistant 4% resistant to all three major classes of antifungals Percentages are calculated on susceptibility testing interpretation of 54 isolates, data courtesy of CDC Mycotic Diseases Branch Candida auris: Master of disguise Laboratory instruments (unrecognizable) Results vary by automated methods Missing from reference databases Research use only Older, outdated software Candida auris can be misidentified as: Candida haemulonii Candida famata Candida sake Laboratory protocols (slips through the cracks) No speciation No susceptibility testing By physician request only Candida spp. (inconclusive results) Saccharomyces cerevisiae Rhodotorula glutinis 9

10 Candida auris: Overstays its welcome Vast environmental contamination Detected on bed, chairs, equipment, tables, IV poles of patient rooms Continued detection more than a month after discharge Can survive on plastic surfaces for more than four weeks Fungal claims don t always work Quaternary ammonium compounds are ineffective No known decolonization regimens Candida auris: Takes advantage of the (healthcare) system Healthcare associated Has not been isolated in the natural environment Similar risk factors for other Candida spp. infections Known cases typically have: History of antifungal therapy Multiple underlying conditions Indwelling devices Catheters, G-tubes, tracheostomy tubes Extensive history in healthcare settings LTACHs, SNFs, acute care hospitals Candida auris: Uses frequentflier miles Infected patients are usually healthcare frequent fliers C. auris affects closely-linked healthcare facilities Network problem, not a facility problem LTACHs as center of networks Similar concerns to the spread of CRE Network analysis of cases of KPC-CRE linked to healthcare facilities in a region Don t panic, but Candida auris is already here Source: Won, S. et al., Emergence and Rapid Regional Spread of Klebsiella pneumoniae Carbapenemase Producing Enterobacteriaceae. Clin Infect Dis 2011; 53 (6): First there were seven And now, we re past the seventies 80 total C. auris cases reported by CDC as of March 16, confirmed, clinical infections 27 colonized cases identified Confirmed clinical Candida auris cases reported by CDC Listed by state of culture collection, March 2017 Source: accessed March 25,

11 Number of Cases 4/11/2017 And now, we re past the seventies 80 total C. auris cases reported by CDC as of March 16, confirmed, clinical infections 27 colonized cases identified North American isolates are closely related to other regions Confirmed clinical Candida auris cases reported by CDC Listed by state of culture collection, March confirmed, clinical cases in New Jersey Source: accessed March 25, 2017 Data and concept courtesy of CDC Mycotic Diseases Branch Candida auris in New Jersey 44 Candida auris cases under investigation as of March 25, confirmed, clinical cases 21 probable cases (C. haemulonii) 9 surveillance cases (colonized) Each case linked to at least one other case One outbreak among a healthcare network 12 Candida auris cases by month of first identifying culture Confirmed, Surveillance New Jersey Residents June 2015 to March 25, Probable, 8 Clinical Confirmed, 6 Clinical And we re doing something about it. Contain, contain, contain! May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr Containment: What we re doing Case definitions Laboratory, healthcare facility guidance Investigation into every report Laboratory testing Selective case finding (backwards) Case tracking (forwards) Outbreak investigation Laboratory testing and support Candida auris draft case definition Case definitions based on proposed national definition Confirmed: Candida auris isolated from any body site. Probable: Candida haemulonii isolated from a normally sterile body site of a patient with a epidemiological link to a known C. auris case. Suspect: Candida haemulonii isolated from a normally sterile body site All cases can be either clinical or surveillance (e.g. infection or colonization) Additional labs for one patient do not indicate a new case. 11

12 Candida auris laboratory guidance Candida auris healthcare facility guidance Retrospective microbiology record review for possibly misidentified isolates January 1, 2015 to present See organism list in previous slides Share records review with LHD or Communicable Disease Service Suspect C. auris when non-albicans Candida isolates are identified with unusual antifungal resistance Report and save all suspect C. auris isolates Communicate with infection prevention staff Remember: misidentification varies with laboratory methods! Control measures for colonized and infected cases: Contact precautions Placement in single room, with patient-specific equipment Diligent hand hygiene, gown and glove use whenever entering patient room Only remove after two consecutive, negative skin surveillance cultures Environmental cleaning Daily and terminal cleaning of patient room Thorough cleaning of shared equipment EPA-registered disinfectant effective against Clostridium difficile Notification to receiving healthcare facilities and public health upon patient transfer Candida auris case investigations Single cases of C. auris should be reported to public health Candida auris Case Report Form 90 days before first positive culture Healthcare exposures Link cases in place and time Helps to characterize C. auris Laboratory confirmation at CDC and NYSDOH Wadsworth Mycotic Laboratories Species identification Whole genome sequencing Identifying laboratory microbiology reports are collected Candida auris case investigations Identify healthcare exposures in 90 days before positive lab Notify all facilities Collect case report forms Provide guidance Recommend laboratory review Collection date of first positive Candida auris lab Day 0 Track case through all healthcare future exposures Notify all facilities Provide guidance Recommend laboratory review Colonization testing Monitor for possible transmission Candida auris outbreak investigations Candida auris outbreak: Two or more C. auris cases linked in place in time Outbreaks can span across multiple healthcare facilities Laboratory testing to monitor transmission Point prevalence survey (PPS) Active surveillance testing (AST) Additional control measures Cohorting of cases, healthcare workers Enhanced environmental cleaning Auditing Public health site visit Candida auris laboratory testing Laboratory support is provided by CDC and NYSDOH Wadsworth Mycotic Laboratories Confirmatory testing Testing of any isolates suspected to be Candida auris E.g. Candida spp. not identified, Candida haemulonii MALDI-TOF and DNA sequencing (gold standard) Surveillance testing Culturing of skin swabs with C. auris confirmatory testing Individual cases, case contacts, PPS, or AST Positive cultures indicate colonized cases Whole genome sequencing DNA fingerprinting of all C. auris isolates 12

13 Call for prevention: Local health departments To move from contain to prevent, everyone has a role to play. Discuss C. auris with facilities in your jurisdiction Share recommendations Encourage surveillance and reporting Request retrospective laboratory records review Respond immediately to C. auris reports Collect basic case information Laboratory reports Notify Communicable Disease Service Maintain situational awareness Monitor CDC guidance Watch for NJ LINCS updates Call for prevention: Healthcare facilities Request a retrospective laboratory records review Share with local health and Communicable Disease Service Surveillance plan for Candida auris Ensure communication between Infection Control and Laboratory Identify persons responsible for reporting to public health Response plan for C. auris cases Can all recommendations be followed? Are there existing policies that can be adapted? (e.g. MRSA, CRE) On discharge, how will C. auris history be communicated? Maintain situational awareness Call for prevention: Clinical and reference laboratories Complete the recommended laboratory records review Share with local health and Communicable Disease Service Surveillance plan for Candida auris Can our methods/instruments identify C. auris? What are the most likely misidentifications for our lab? Can susceptibility testing indicate a possible C. auris? What isolates will be saved? Who is responsible for communicating with infection control? Who is responsible for reporting to public health? Maintain situational awareness To sum it all up Special thanks to: Candida auris is an emerging, drug-resistant yeast that is difficult to identify in most clinical laboratories, pervasive in the healthcare environment, and can easily spread through healthcare facility networks. Outbreaks of C. auris are likely to occur and difficult to control. In individual facilities: laboratory and infection control partnership is necessary to identify and contain C. auris. In healthcare networks: clear and consistent communication is needed to prevent transmission of C. auris across facilities. In New Jersey: immediate reporting and swift public health response is necessary to prevent a C. auris epidemic. There is still time to contain C. auris before it before it achieves super-bug status! CDC Mycotic Diseases Branch Staff NYSDOH HAI Program Staff NJDOH Regional Epidemiology Program Staff 13

14 Recommended reading: Thank you! Patricia M. Barrett, MSD CDC web resources: Candida auris main page: Candida auris interim recommendations: Candida auris FAQ s: Publications: MMWR: Investigation of the first seven reported cases of Candida auris [ ] United States, Mary 2013-August 2016: Antimicrobial Resistance & Infection Control: First hospital outbreak of the globally emerging Candida auris in a European hospital: 14