PHIT Force: Various DPH Issues James Lewis Communicable

PHIT Force: Various DPH Issues James Lewis Communicable

PHIT Force: Various DPH Issues James Lewis Communicable Disease Branch North Carolina Division of Public Health 5/10/2019 Overview C auris/CRE screening Candida identification Expanded AST available through ARLN CRE Surveillance update

SIR calculation error on CDC website Antibiotic use reporting potential requirement Travel screening: Ebola and Measles ARLN Services: C auris/CRE screening Outbreak/Sentinel event Roommate Point Prevalence Travel: Overnight Healthcare outside US

CRE screening:Cepheid PCR on rectal swabs Double tipped, rayon/Eswab compatible with Cepheid https://health.maryland.gov/laboratories/Pages/ARLNHome.aspx#CRE C auris screening: PCR on composite axillary/groin swab Rayon tipped/nylon flocked swab https://www.cdc.gov/fungal/candida-auris/recommendations.html https://health.maryland.gov/laboratories/Pages/ARLNHome.aspx#CRE ARLN Services: Candida speciation Commonly misidentified candida: https://www.cdc.gov/fungal/candida-auris/recommendations.html

ARLN Services: Expanded AST testing Hewlett-Packard D300e printer pilot project https://www.cdc.gov/drugresistance/solutions-initiative/innovative-hp-resistance-testin g.html Can test novel drug combinations (i.e. aztreonam-avibactam) Year long project 4 labs Tennessee State Public Health Laboratory, Wisconsin State Laboratory of Hygiene, Minnesota Department of Health Public Health Laboratory, and Wadsworth Center Laboratories

ARLN/DPH gate keepers Goal 3 day turn around from day of request Pan-resistant MBLs (NDM/IMP/VIM) ARLN Services: Expanded AST testing CRE Surveillance Surveillance in NC Sentinel site surveillance

Mar. 2015 Sep. 2016 Targeted recruitment for sentinel surveillance, special projects and outbreak response Nov. 2016 June 2017 July 2017 September 2018

Accepted isolates, no active site recruitment October 2018 Present Reportable, routine surveillance statewide, special projects and outbreak response 8

*Excludes duplicate CRE (Same Carbapenemase/organism; repeat clinical isolates in a 12 month period; screening results subsequent to a clinical result) 9 Sentinel Surveillance 57% of reported CRE reported to NC DPH are carbapenemase producing 10

Sentinel Surveillance ~10 CRE per month 11 Sentinel Surveillance OXA-48 18.45% KPC 76.70% IMP 3.88%

NDM <1% 12 CRE Surveillance Since October 1, 2018 Updated: February 8, 2019 13 52% of isolates submitted to the state lab are CP-CRE 97% KPC

0.9% NDM 1.9% OXA-48 14 Surveillance ~50 CRE per month 15 Epi Curve of Carbapenemase Detection since October 1, 2018 70

60 Number of Isolates 50 40 30 20

10 0 October November Negative December KPC NDM

January OXA VIM February IMI March April

OXA/NDM 16 Carbapenemase by Organism Other E. coli Enterobacter Klebsiella

0 20 40 60 80 100 120

140 160 180 Number of Isolates KPC NDM

OXA OXA/NDM Negative OXA/NDM VIM IMI 17

As of 2019, NC has seen all 5 carbapenemases 2.5% 0.8% 49% 0.3% 0.1% 18

NHSN SIR Calculation error https://gis.cdc.gov/grasp/PSA/HAIreport.html NHSN SIR Calculation error Correct calulation: (National SIR NC SIR )/National SIR = (0.81-0.98)/0.81 = 0.21 0.40 CDC Calulation: National SIR NC SIR/National SIR Order of operations = multiplication, division, addition, subtraction So this comes to 0.81 0.98/0.81 = 0.81 1.21 = 0.40

In short I assume someone forgot to add parentheses in their coding Being addressed Same across all states 2016 & 2017 numbers CLABSI Only Antibiotic Use reporting What information did you hear? No active pursuance of AU reporting in NC at this time Will likely be required at some point but a requirement is likely at least 3 years out I would imagine BUTIts strongly encouraged Ideally would be through NHSN AUR module

https://www.cdc.gov/nhsn/acute-care-hospital/aur/index.html Antibiotic Use reporting From QIN-QIO National LAN Event 5/9/19 Asked about national requirement We will see what happens We would like to pursue a State requirement like MO/TN Travel Screening: Ebola and measles Should hospitals consider heightened surveillance for measles and Ebola (e.g., travel to an endemic state or country-Congo)? We continue to suggest that hospitals ask about travel history, regardless of

circulating or emerging diseases as this can be useful in forming differential diagnoses, determining need for pre-emptive isolation precautions or screening, etc. At the moment, we are not suggesting that hospitals ask specifically about measles or Ebola exposure, but these outbreaks do highlight the importance of ongoing travel screening. Thus far, the ongoing Ebola outbreak in DRC has been identified as posing high risk regionally but a low risk globally. As Im sure you are, we are carefully monitoring the situation and will revise recommendations as needed. Since the beginning of the year, we have been working with one NGO to repatriate HCWs providing care in the Ebola-affected areas of DRC. We have worked specifically with this NGO and partners to coordinate care if needed. To date, all returning travelers have been classified as having no known risk of exposure to Ebola. Travel Screening: Ebola and measles

Ebola and patient triage - would a patient with symptoms and travel history suspicious of Ebola in NC go to the closest hospital for care or to an identified health care facilities with unique capabilities for managing the patient (if so, where)? The Healthcare Preparedness Program within OEMS is working with 8 major medical centers (regional trauma centers) to assure preparation and ability to provide care as an Ebola Assessment Center. It is our expectation that patients with concerning symptoms and potential exposure to Ebola would be routed to one of these facilities for initial assessment if at all possible. Travel Screening: Ebola and measles Summary: Maintain situational awareness

If a case presents concerning for measles or Ebola we would appreciate a call and will be of assistance 919-733-3419 Epidemiologist on call 24/7 Concerning patients would ideally be routed to one of the 8 regional trauma centers. If needed can likely arrange for transfer from there to Emory or NIH for further treatment. Ideally would be aware ahead of time and direct patients to care with pre-notification of the facility, but not always possible. Measles Clinician memo 5/7/19 Questions?

James Lewis [email protected] 919-546-1641

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