Epidemiology Update Christine Hahn, MD Idaho Division of Public Health

Transcription

1 Epidemiology Update 2016 Christine Hahn, MD Idaho Division of Public Health

2 Topics Ebola and Zika efforts and update Outbreaks/diseases/trends of interest New public health activities in 2016 Drug overdose prevention funding Syndromic surveillance using data from Idaho hospitals Healthcare-associated infections program Susan Heppler Immunization Progress and challenges in child immunization rates Increasing focus on adult immunization Immunization recommendations changes in /28/2016 2

3 Ebola Clinical Update No specific enhanced screening is required for travelers from Guinea, Sierra Leone, or Liberia. Travelers returning from West Africa should be treated similarly to any other patients who have recently traveled internationally. Travel history should remain part of routine patient evaluation, including during entry to the facility. Source: 10/28/2016 3

4 Ebola Survivor Follow-up Implementation of a National Semen Testing and Counseling Program for Male Ebola Survivors Liberia, MMWR Weekly / September 16, 2016 / 65(36); Liberian Ministry of Health, CDC, WHO and partners Testing and counseling for male survivors All male Ebola survivors aged 15 years with proof of survivorship (e.g., a discharge certificate from an ETU) are eligible Participants graduate from the program after receiving two consecutive negative Ebola virus RNA rrt-pcr results on semen specimens collected at least 1 week apart Source: 10/28/2016 4

5 Ebola: survivor follow-up Prevention of sexual transmission of Ebola in Liberia through a national semen testing and counselling programme for survivors. Lancet Global Health Vol 4 (10), Oct EVD survivors in program; rt RT-PCR results were available from 429 participants. 38 participants (9%) had at least one semen specimen that tested positive for Ebola virus RNA. Of these, 63% tested positive 12 months or longer after recovery. Longest interval between discharge from an ETU and collection of a positive semen sample was 565 days. Men >40 years more likely to test positive than men aged 40 years 84 (74%) of 113 participants who reported not using a condom at enrolment reported using condoms at their first follow-up visit 10/28/2016 5

6 Zika recommendations for HCW Follow Standard Precautions for all patient care ( Be aware of the requirement for Standard Precautions to be used for labor and delivery care ( Internal and external hospital websites should include a link to website ( Appropriate healthcare staff should report suspected cases to state or local health departments Report all pregnant women with laboratory evidence of possible Zika virus infection, with or without symptoms, as well as infants born to these women, to state, or local health department for consideration of enrollment in the US Zika Pregnancy Registry 10/28/2016 6

7 Zika test requests received for public health testing, by sex and reported pregnancy status (n=186) Male Female Female, pregnant Female, not pregnant Female, unknown 62% pregnant 17% male 83% Female 3% 18% Data as of September 27, 2016

8 /28/2016 8

9 10/28/2016 9

10 Outbreaks/Diseases/Trends Influenza Legionella Meningococcal Disease Pertussis Group A Streptococcus Gonorrhea and Syphilis TB 10/28/

11 10/28/

12 10/28/

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14 What happened to FluMist? Trivalent formulation licensed trial: 55% more effecitve than injectable vaccine season: more effective in kids than injectable vaccine season: no effectiveness in children age 2-8 against H1N1 Aug 2014: FluMist preferentially recommended for children : preferential recommendation rescinded : all flu vaccines perform poorly : FluMist effectiveness only 3% in U.S. but injectables work well Why? Unknown Maybe adding 4 th component; Maybe using same strain (2009 pandemic strain) over and over yields decreasing response 10/28/

15 Match looking pretty good so far 133 viruses characterized from May 22-Sep 30: A A (H1N1)pdm09 [8]: All 8 (100%) influenza A (H1N1)pdm09 viruses were A/California/7/2009-like, the influenza A (H1N1) component of the vaccine Note: will be changing! B A (H3N2) [62]: 50 (80.1%) of 62 influenza A (H3N2) viruses were antigenically characterized as A/Hong Kong/4801/2014-like, similar to the influenza A (H3N2) component of the vaccine. Victoria Lineage: All 30 (100%) B/Victoria-lineage viruses were antigenically characterized as B/Brisbane/60/2008-like, which matches vaccine. Yamagata Lineage: All 33 (100%) B/Yamagata-lineage viruses were antigenically characterized as B/Phuket/3073/2013-like, which matches vaccine. 10/28/

16 Resistance pattern so far Majority of recently circulating influenza viruses are susceptible to the neuraminidase inhibitors (oseltamivir, zanamivir, and peramivir) Rare sporadic instances of oseltamivir-resistant and peramivir-resistant influenza A (H1N1)pdm09 viruses and oseltamivir-resistant influenza A (H3N2) viruses have been detected worldwide. 10/28/

17 Number of Cases Reported Legionellosis (Legionnaire s Disease) Cases and rate of disease per 100,000 population: Idaho and U.S, Rate per 100,000 Population 0 0 Idaho incidence U.S incidence Year rate of Report Legionellosis was not tracked nationally until /28/

18 Number of Cases Reported Meningococcal disease, invasive Cases and rate of disease per 100,000 population: Idaho and U.S, Rate per 100,000 Population Idaho incidence Year of Report Idaho incidence rate *2015 data are provisional 10/28/2016 U.S incidence rate 18

19 Number of Cases Reported Pertussis Cases and rate of disease per 100,000 population: Idaho and U.S, Rate per 100,000 Population 0 0 Idaho incidence Year of Report 10/28/2016 Idaho incidence rate U.S incidence rate 19

20 1/2013 2/2013 4/2013 5/2013 6/2013 7/2013 8/2013 9/ / /2013 1/2014 2/2014 3/2014 4/2014 5/2014 6/2014 7/2014 8/2014 9/ / / /2014 1/2015 2/2015 3/2015 4/2015 5/2015 6/2015 7/2015 8/2015 9/ / / /2015 1/2016 2/2016 3/2016 4/2016 5/2016 6/2016 7/2016 8/2016 9/2016 Reports of Invasive Streptococcus pyogenes in Idaho

21 emm Type by Public Health District Eastern Southeastern South Central Central Southwest stg485.0 North Central Panhandle

22 Syphilis Update Syphilis continues to be a concern. In 2015 and 2016, 113 cases have been identified related to an ongoing local outbreak. Men who have sex with men (MSM) have been the highest risk group, although methamphetamine or other drug use and incarceration in the past year have been risk factors among recent male and female cases. Gonorrhea Update Since 2014, gonorrhea rates have been increasing throughout the Pacific Northwest. Between January and June 2016, 150 cases of gonorrhea were reported to CDHD. In comparison, just 17 cases were reported during the same timeframe in Testing Common anatomical sites of infection include the cervix, urethra, rectum, and pharynx. CDHD urges providers to take a comprehensive sexual history to determine risk and perform testing on all potential sites of exposure. Testing Approximately half of the syphilis infections reported to CDHD in 2016 resulted from routine screening. Screening is recommended for asymptomatic adults and adolescents at risk of infection. MSM and persons living with HIV may benefit screening every three months. Please consider syphilis if a patient presents with: Any ano/genital or oral lesion, especially indurated and minimally painful ulcers Any unexplained rash, especially with palmar or plantar involvement Unexplained lymphadenopathy Unexplained ocular disease (i.e., uveitis, panuveitis, diminished visual acuity, blindness, optic neuropathy, interstitial keratitis, anterior uveitis, retinal vasculitis) Testing for syphilis should include both nontreponemal (e.g., RPR or VDRL with titer) and treponemal (e.g., TPPA, FTA-Abs, EIA, CIA) methods. Treatment and Prevention Due to antibiotic resistance concerns, dual antibiotic therapy continues to be recommended. For uncomplicated infections of the cervix, urethra, rectum, and pharynx the recommended regimen remains: Ceftriaxone 250mg IM in a single dose PLUS Azithromycin 1g orally in a single dose. Treatment and Prevention Consider presumptive treatment if a patient is symptomatic, is a contact to a syphilis case, belongs to a high-risk group, or if follow-up is uncertain. Use single dose benzathine penicillin G (e.g., Bicillin-LA), 2.4 million units IM as first-line therapy. Considerations for Pregnant Women Recent sex partners (i.e., within 60 days preceding onset of symptoms or diagnosis) should receive Providers should continue to screen all women serologically for syphilis early in pregnancy, presumptive dual treatment with Ceftriaxone 250mg preferably at the first pregnancy-related visit. Additional serological testing should be IM in a single dose plus Azithromycin 1g orally in a performed at weeks gestation and again at delivery if a woman reports having single dose in addition to evaluation and testing. multiple sex partners, has been diagnosed with a sexually transmitted infection or has a sex partner diagnosed with syphilis. Any woman who has a fetal death after 20 weeks gestation 10/28/2016 should be tested for syphilis, even if screening was performed early in pregnancy. 22

23 Number of Cases Reported 750 Gonorrhea Cases : Idaho, Idaho incidence Year of Report 10/28/

24 Number of Cases Reported 30 Syphilis (primary, secondary, and congenital only) Cases: Idaho, Primary and Secondary Congenital Year of Report 10/28/

25 10/28/

26 Number of Cases Reported Tuberculosis Cases and rate of disease per 100,000 population: Idaho and U.S, Rate per 100,000 Population 0 0 Idaho incidence Year of Report 10/28/2016 Idaho incidence rate U.S incidence rate 26

27 Published 8/10/ /28/

28 The 2003 guidelines 10/28/

29 The new 2016 guidelines 10/28/

30 Screening for LTBI in Adults: U.S. Preventive Services Task Force Recommendation November 3,

31 Potential Impact U.S. Preventive Services Task Force recommendations mandate most insurance plans to cover cost May see an increase in testing Otherwise does not change public health practice 10/28/

32 New Activities in /28/

33 Prescription Drug Overdose: a growing problem Increasing death rates due to the abuse of prescription drugs; parallels an overall increase in use of opiates The number of overdose deaths due to prescription drug abuse exceeds deaths from cocaine, heroin, and methamphetamine combined 10/28/

34 New CDC Grant funding: Prescription Drug Overdose: Data-Driven Prevention Initiative Division of Public Health Manage grant, contracts, and reporting to CDC Participate in Strategic Planning to combat drug overdose in Idaho Educate prescribers Partner with Coroner s Association to evaluate how to improve death certificate reporting of drug overdose deaths Work to improve overall surveillance for drug overdose, including deaths Planning and Data Office of Drug Policy Perform needs assessment Convene Strategic Planning group Develop strategic plan Implement data-sharing MOUs and MOAs as needed Identify, obtain, and coordinate routine ongoing data collection, analysis Issue reports to stakeholders Prevention in Action Board of Pharmacy Implement software to improve use of the Idaho Prescription Drug Monitoring Program (PDMP) database Public Health Districts Educate and train prescribers Train physician champions Idaho State University Develop educational toolkit for prescribers Evaluate success of efforts to increase utilization of PDMP 10/28/

35 Expanded Access Program for Epidiolex Governor s Executive Order in April 2015 to assist children with severe epilepsy which is not controlled on medication Division of Public Health administers the program; FDA allowed Idaho to enroll 25 children in 2015 In 2016, approval received to enroll an additional 15 children Epidiolex is currently not licensed, but being studied in FDAapproved clinical trials across the U.S. Liquid formulation of highly purified plant-derived cannabidiol (CBD) as its active ingredient; administered as drops under the tongue Contains no THC 10/28/

36 Expanded Access Program for Epidiolex Currently, 24 of the first 25 children with severe epilepsy screened for the program are still receiving the drug; no safety problems have been encountered Work has started to enrolled the additional 15 children Due to promising reports from the ongoing clinical trials, this drug is expected to be licensed by the FDA within the next year or two 10/28/

37 CDC National Syndromic Surveillance Program Launched in 2003 Designed to improve nationwide situational awareness and enhance responsiveness to hazardous events and disease outbreaks Utilizes the BioSense Platform 10/28/

38 Current status of hospital participation: Idaho syndromic surveillance Registered for syndromic surveillance data reporting for Meaningful Use n=36 Signed initial BioSense data use agreements with IDHW n=35 Data connections with BioSense platform initiated or established n=24 Test data validated by Idaho syndromic surveillance team n=15

39 Summary of Data Elements Collected for Idaho Syndromic Surveillance from EDs 10/4/2016

40 10/25/2016 HEALTHCARE ASSOCIATED INFECTIONS (HAI)

41 OBJECTIVES National Level Review State Level Review Idaho HAI Data Antimicrobial Stewardship 10/25/2016

42 IDAHO S HAI PROGRAM Susan Heppler, RN HAI Program Manager Kathy Turner, PhD, MPH HAI Program Director Deputy State Epidemiologist Chris Hahn, MD Medical Director State Epidemiologist 10/25/2016

43 FUNDING 2016 Epidemiology and Laboratory Capacity for Infectious Diseases (ELC) $210,995 Activities: HAI Detection and Response Infrastructure and Carbapenem-resistant Enterobacteriaceae (CRE) laboratory capacity 2015 ELC Grant $90,476 Activities: HAI Prevention Infrastructure 2015 ELC domestic Ebola supplement: Infection Control Assessment and Response (ICAR) Program Infection Control Assessment Program: $507,871 10/25/2016

44 ROAD MAP TO ELIMINATION National Action Plan to Prevent Healthcare Associated Infections Phase 1: Acute care Hospitals Phase 2: Ambulatory Surgical Centers, End-Stage Rental Disease Facilities, and Increasing Influenza Vaccinations Among Healthcare Personnel Phase 3: Long-Term Care Facilities 10/25/2016

45 NATIONAL TARGETS 2013 Targets and Progress Made by 2014 Measure (and data source) Original target for 2013 (from 2009 baseline) Progress made by 2014 CLABSI (NHSN) 50% reduction 50% reduction CAUTI (NHSN) 25% reduction No change Invasive MRSA (NHSN) 50% reduction 36% reduction Facility-onset MRSA (NHSN) 25% reduction 13% reduction CDI (NHSN) 30% reduction 8% reduction SSI (NHSN) 25% reduction 18% reduction 10/25/2016

46 NEW NATIONAL TARGETS October 2016 Targets Measure (and data source) CLABSI (NHSN) CAUTI (NHSN) Invasive MRSA (NHSN) Facility-onset MRSA (NHSN) CDI (NHSN) SSI (NHSN) 2020 Target (from 2015 baseline) 50% reduction 25% reduction 50% reduction 50% reduction 30% reduction 30% reduction 10/25/2016

47 STATE PERSPECTIVE

48 MY ROLE Provide overall management of the HAI program Facilitate statewide efforts Oversee and develop program materials Grant application / reporting Evaluate HAI Surveillance Data Validation Lead/participate in multi-disciplinary teams NHSN Group Administrator 10/25/2016

49 HAI ADVISORY WORKGROUP Members Aimee Baerlocker, St Luke s Infection Prevention Jessi Bond, St Luke s Infection Prevention Chris Dent, St Al s Infection Prevention Lisa Higley, Cassia Infection Prevention Martha Jaworski, Qualis Health Joni Packard/Joyce Olson, Portneuf Infection Prevention Kathy Trosin, Bonner General Infection Prevention /Quality Suzanne Walsh, Eastern Idaho Regional Infection Prevention 10/25/2016

50 HAI ADVISORY GROUP Our Mission: To reduce the number and impact of HAIs in Idaho by convening a multidisciplinary group of partners to standardize best practices across settings for reporting, monitoring, and preventing HAIs, educating the public and healthcare providers on effective methods to reduce HAIs, and proactively address emerging HAI issues. 10/25/2016

51 IDAHO S HAIS

52 IDAHO S HOSPITALS PPS prospective payer systems Idaho has 14 PPS hospitals CAH critical access hospitals Idaho has 27 CAH hospitals Total of 41 Idaho Hospitals

53 # of infections 100 CATHETER ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) n = /25/2016

54 # of infections 60 CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTIONS (CLABSI) n = /25/2016

55 COLON (COLO) SURGICAL SITE INFECTION (SSI) # of infections n = /25/2016

56 # of infections HYSTERECTOMY (HYST) SURGICAL SITE INFECTION (SSI) n = /25/2016

57 # of infections 700 CLOSTRIDIUM DIFFICILE: COMMUNITY ACQUIRED n = /25/2016

58 # of infections CLOSTRIDUM DIFFICILE: HOSPITAL ACQUIRED n = /25/2016

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61 ANTIMICROBIAL STEWARDSHIP FOCUS ON HOSPITALS 10/25/2016

62 ANTIMICROBIAL RESISTANCE: A GROWING PROBLEM Estimated minimum number of illnesses and deaths caused by Antibiotic Resistance annually: At least 2,049,442 illnesses and 23,000 deaths Costing $20 Billion in excess direct healthcare costs and up to $35 Billion in lost productivity due to hospitalizations and/or sick days each year 10/25/2016

63 NATIONAL ACTION PLAN 2015: 5 year plan Reduce inappropriate antibiotic use by: 20% in-patient 50% outpatient Strengthen surveillance for resistant bacteria Advance development of new diagnostics Accelerate research and development for new antibiotics, other therapeutics, and vaccines Improve international collaboration in combating resistance 10/25/2016

64 FUNDING CARB Nearly Double: >$1 billion investment in FY 2016 ELC funding received in Idaho for CARB activities 10/25/2016

65 NATIONAL ACTION PLAN 2016 GOALS In 2016 the Department of Health and Human Services (HHS) are: 1. reviewing current hospital practices 2. proposing regulations and actions for healthcare facilities to implement robust antimicrobial stewardship programs (ASP) that follow best practices 10/25/2016

66 NATIONAL ACTION PLAN 2017 GOALS By the end of 2017, CMS should have Federal regulations (aka Conditions of Participation) in place that will require the following facilities to have a robust ASP: 1. U.S. Hospitals 2. Critical Access Hospitals 3. Long Term Care Facilities/Nursing Homes Similar requirements will be phased in rapidly for long term acute care facilities, post acute facilities, ambulatory surgery centers, and dialysis centers CMS: Center of Medicare and Medicaid Services 10/25/2016

67 By the end of the 5 year plan: NATIONAL ACTION PLAN 2020 GOALS All states will implement stewardship activities in healthcare settings All federal facilities (VA hospitals) will have robust ASPs 10/25/2016

68 SUMMARY ELC funding is critical to moving forward Roadmap to Elimination Idaho s HAI Program Voluntary reporting of resistant pathogens encouraged 10/25/2016

69 10/25/2016 QUESTIONS OR COMMENTS?

70 A QUESTION FOR YOU... What would you like to see from the HAI Program going forward? Surveillance / data validation? Guidelines / assessments? Communication? Contact Susan HepplerS@dhw.idaho.gov 10/25/2016

71 Immunization major changes 2016 Nasal flu vaccine not recommended for this season Manufacturer hoping to bring revised version out in the coming year but not certain HPV vaccine now only 2 doses for children age 9-14 Great news for kids must be at least 5 months apart New shingles vaccine expected to be licensed soon for persons 50+ Very promising data but some local/systemic side effects and probably will be a 2-dose series 10/28/

72 Thank you!! 10/28/