Alice Guh, MD, MPH

1. Public Health Response to Carbapenem-Resistant Enterobacteriaceae:The Role of Health Departments Alice Guh, MD, MPH Division of Healthcare Quality PromotionCenters for Disease Control and Prevention CSTE CRE Panel Session – June 14, 2011 National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion

2. Carbapenem-resistant Enterobacteriaceae (CRE) • Common cause of HAIs • Found in both acute care hospitals and long-term care settings • Since 2004, reports of CRE cases from LTACH and LTCF • Similar to the spread of other MDROs • Movement of colonized patients across the continuum of care contributes to regional transmission • Supported by mathematical modeling Urban C et al. Clin Infect Dis 2008;46:e127030 Endimiani A et al. J AntimicrobChemother 2009;64:1102-1110. Smith DL et al. PNAS 2004;101:3709-14.

3. Inter-Facility Transmission of MDROs (Including CRE) Munoz-Price SL. Clin Infect Dis 2009;49:438-43.

4. Regional Approach to MDRO Prevention is Essential • Rationale for regional approach • What happens in one facility will impact surrounding facilities • Individual facilities can reduce MDRO prevalence only to a certain point • Successful regional coordination by public health • VRE control in Siouxland region • CRE containment in Israel Sohn AH et al. Am J Infect Control 2001;29:53-7. Schwaber MJ et al. Clin Infect Dis 2011;52:848-55.

5. How to Operationalize Public Health Response to Emerging MDROs • Opportunity to apply regional approach to CRE prevention • HDs in unique position to coordinate local and regional response to CRE • Assess CRE prevalence/incidence within their jurisdiction in order to provide situational awareness to facilities • Serve as resource to facilities about prevention options • Informs public health response to other emerging MDROs

6. Development of CRE Toolkit

7. Outline of CRE Toolkit • Facility-level prevention strategy for facilities and HDs • Regional prevention strategy specifically for HDs • Aggressive approach to contain or prevent CRE emergence • Regions with no CRE identified • Regions with few CRE identified

8. Regional Prevention StrategyRegional Surveillance for CRE • Determine CRE prevalence within a given jurisdiction • Make CRE laboratory reportable (in regions with no known or few CRE) • Survey IPs or lab directors • Feedback of surveillance results • Provide specific enough data for facilities to act upon • Facility name, if possibleor • Stratify results by geographic area and/or by facility type

9. Regional Prevention StrategyRegions With No CRE Identified Aggressive efforts at detection: • Perform periodic surveillance and feedback • Frequency may depend on CRE prevalence in neighboring regions (establish mechanism for communication) • Educate facility staff to increase awareness • Epidemiologic importance of CRE • Recommended surveillance and prevention measures* * http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

10. Regional Prevention StrategyRegions With Few CRE Identified Aggressive efforts at containment, may target select areas: • Implement infection prevention measures • Reinforce core prevention measures in all facilities • Facilities with CRE: use supplemental measures • Facilities without CRE: targeted surveillance testing, preemptive CP • Use inter-facility patient transfer forms • Indicate CRE status, open wounds/devices, antimicrobial therapy • Educate facility staff to increase awareness • Perform periodic surveillance and feedback

11. Regional CRE Surveillance by Select Health Departments

12. Development of CRE Survey • Fall 2010 – CRE conference calls with interested HDs to identify actionable steps to take • HDs notified through CSTE HAI listserve • CRE survey template designed to be used by HDs to assess CRE prevalence within their jurisdiction • 7 questions to administer to IPs of acute care facilities • Estimate frequency of CRE colonized- or infected-patients • Assess facility-level surveillance activities for CRE and related prevention measures* * http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

13. State HDs Conducting CRE Survey (n=7)

14. Administration of CRE Survey • Targeted acute care hospitals, but included: • Long-term acute care hospitals (≥3 states) • Critical access hospitals (≥2 states) • Survey methods by HDs • Email /online survey (e.g., Survey Monkey) to IPs • Paper survey at APIC meetings • Date of survey: ranged Sep 2010-Mar 2011 • Survey lasted one day to 2-3 months • Sent reminder emails, phone calls to non-respondents

15. Survey Respondents • Aggregated state-level data across all 7 states: • Median response rate – 67% (range: 26% to 100%) • Breakdown by bed size (n=6 states): Total 360 facilities • ≤50 beds – 30% • 51-200 beds – 39% • 201-500 beds – 27% • >500 beds – 4% • Fairly representative of national data (2008 AHA data) • Except greater % of facilities with ≤50 beds captured in survey

16. CRE Prevalence in Past 12 Months (n=7 states)

17. CRE Surveillance Measures (n=7 states) *Applies to facilities that have not or have rarely identified CRE cases (data available for 6 states)

18. CRE Prevention Measures (n=7 states)

19. Summary of CRE Survey Results • CRE identified in <50% of all responding facilities, still have opportunity to prevent full emergence • Although there is intra-facility transmission, majority of identified cases are imported • Important role of inter-facility patient sharing • Supports the need for regional approach to prevention • Low facility adherence to recommended surveillance practices and need for increased education / awareness • Potential under-reporting of CRE

20. Feedback of Survey Results by HDs • At least 5 states provided feedback to IPs / facilities • Email (memo, monthly HAI newsletter) • Presentation at APIC meeting • Feedback content • Only shared aggregated results • Some stratified by geographical region (n=2), facility type (n=1) • Some provided streamlined 2009 MMWR guidance* (n=3) * http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5810a4.htm

21. interviews with State Health Departments

22. Key Informant Interviews • Primary objective: to understand why some HDs decided to conduct CRE survey and others did not • Participants • All 7 states that conducted CRE survey • 4 additional states that did not conduct CRE survey (participants of initial CRE calls via CSTE HAI listserve) • Standardized script with trained interviewer

23. Key Interview Findings (n=11 states) • All HDs communicated regularly with IPs about HAI topics in previous 12 months (prior to CRE survey) • No difference between states in competing priorities and concerns about CRE survey • Main concern – perception of overburdening IPs • Yet perspectives differed regarding conducting survey: opportunity to learn vs concerns about survey intent and logistics and other data source • Assess for other confounders and contextual factors • Evaluate alternative sources to IPs for information

24. Casting a vision for public Health ACTIOn

25. Anywhere County, USAStatus Report: Emerging MDRO X St. Joseph’s Hosp St. Vincent’s Hosp Appletree Hosp St. Mary’s LTACH Orangetown LTACH Smallville Hosp Peachtree Hosp Smithville LTACH Franklin Hosp Greensville LTCF Magnolia LTCF St. Peter’s Hosp St. Claire’s LTACH Jamesville Hosp Thomasville Hosp

26. Thank you Division of Healthcare Quality Promotion National Center for Emerging and Zoonotic Infectious Diseases