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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]