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Methcillin Resistant Staphylococcus aureus Outbreak in Corrections and Regional Jails

Methcillin Resistant Staphylococcus aureus Outbreak in Corrections and Regional Jails. West Virginia, 2003 Danae Bixler, MD, MPH BPH / OEHP / DSDC / IDEP. Step 1: Getting to Know MRSA: ‘Classic Epidemiology’. Reservoir: Colonized or infected patients in hospitals and nursing homes

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Methcillin Resistant Staphylococcus aureus Outbreak in Corrections and Regional Jails

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  1. Methcillin Resistant Staphylococcus aureus Outbreak in Corrections and Regional Jails West Virginia, 2003 Danae Bixler, MD, MPH BPH / OEHP / DSDC / IDEP

  2. Step 1: Getting to Know MRSA:‘Classic Epidemiology’ • Reservoir: • Colonized or infected patients in hospitals and nursing homes • Occasionally, colonized or infected HCW • Rarely environment (e.g., burn unit) • Transmission: • On hands of health care workers BPH/OEHP/DSDC/IDEP

  3. ‘Classic’ Risk Factors for Acquiring MRSA • Hospitalization or nursing home stay • Advanced age • Underlying disease – diabetes, renal failure, cancer • Previous antibiotic use • ICU or burn unit stay • Surgical wound or burn • Indwelling line • Proximity to another patient with MRSA BPH/OEHP/DSDC/IDEP

  4. MRSA Recommendations, 1994Infect Control Hosp Epidemiol, 1994; 15:105 • Surveillance cultures recommended: • During outbreaks • Routine housekeeping • Handwashing (soap and water) • Gowns/masks not strongly recommended • Cohorting / isolation may increase use of handwashing BPH/OEHP/DSDC/IDEP

  5. Clinics in Chest Medicine 1999; 20: 303 BPH/OEHP/DSDC/IDEP

  6. Pediatric Deaths from MRSAMMWR, 1999; 48:707 BPH/OEHP/DSDC/IDEP

  7. BPH/OEHP/DSDC/IDEP

  8. MRSA Skin Infections in Mississippi Prisons, 2000MMWR, 2001; 50:919. • 1,757 inmates sampled by swab of anterior nares; risk factors for colonization: • Female • 73 of 1,241 (5.9%) vs 13 of 516 (2.5%) • Incarcerated for > 60 days • 84 of 1,565 (5.4%) vs 1 of 142 (0.7%) BPH/OEHP/DSDC/IDEP

  9. Stapylococcus aureus Fully Resistant to VancomycinMMWR, 2002; 51:565 • As of June, 2002 eight patients with VISA confirmed in USA • June, 2002 first VRSA isolated from patient with: • Renal failure (dialysis) • Diabetes • Peripheral vascular disease • Past history of MRSA BPH/OEHP/DSDC/IDEP

  10. Rhode Island MRSA Recommendations, 2002Infect Control Hosp Epidemiol, 2002; 23:69 • Surveillance cultures (usually nares and draining wounds) • Admissions from LTCF • Admissions from another acute care hospital • Dialysis patients • Readmits within 30 days of previous hospitalization • Pre-operative patients if risk of post-operative MRSA is known to be high BPH/OEHP/DSDC/IDEP

  11. Rhode Island MRSA Recommendations, 2002Infect Control Hosp Epidemiol, 2002; 23:69 • Isolation for all MRSA (+) patients • Gowns / gloves • Private room • Masks for MRSA in sputum • Handwashing • Cohorting acceptable (2 MRSA patients in one room) BPH/OEHP/DSDC/IDEP

  12. MRSA Community Outbreaks, LA County, CA 2002MMWR, 2003; 52:88. • Athletic team • 2 athletes with skin infections; etiology unknown • Men who have sex with men • Investigation pending • LA County Jail • 165,000 persons incarcerated per year • 928 inmates with skin infections • 66 hospitalized • 10 developed invasive disease including endocarditis, bacteremia, osteomyelitis • Further investigation pending BPH/OEHP/DSDC/IDEP

  13. Scenario • March, 2003 • “outbreak’ of methicillin resistant Staphylococcus aureus at MOCC • Line listing requested / received • Site visit to MOCC • All inmates had MRSA on admission • Inmates admitted to MOCC from all over the state • Several facilities involved BPH/OEHP/DSDC/IDEP

  14. More Steps 2: Establish existence of an outbreak • Limited baseline data available • Only anecdotal information 3,4: Verify the diagnosis; Define and identify cases • Positive culture for MRSA AND signs of infection • Site visit to affected institutions BPH/OEHP/DSDC/IDEP

  15. Step 9,10: Control measures / Communication • Letter with preliminary findings and recommendations generated after each site visit: • Improve casefinding: lower threshold for culturing skin infections • Improve isolation procedures • Improve surveillance • Evaluate antibiotic use • Report cases BPH/OEHP/DSDC/IDEP

  16. Step 5: Descriptive Epidemiology

  17. BPH/OEHP/DSDC/IDEP

  18. Demographic Characteristics of Cases • N = 14 inmates with skin infection and positive culture for MRSA • 14 (100%) male • 14 (100%) white • 36 (35) mean median age in years BPH/OEHP/DSDC/IDEP

  19. BPH/OEHP/DSDC/IDEP

  20. BPH/OEHP/DSDC/IDEP

  21. Step 2: Establish existence of an outbreak • Increased use of cultures? • Increased reporting or recognition? • Need baseline data BPH/OEHP/DSDC/IDEP

  22. Step 6: Hypotheses • Risk factors • ‘Classic’ risk factors absent • No single HCW or medical staff explain(s) all cases • Hygiene? • Design of regional jails should reduce risk • Some prisons have large dormitories with limited handwashing facilities • No data on behavior • Sharing clothes / bedding / dressing materials? • No data • Limited access to medical care – not observed • ?Increased background prevalence in the community • No data BPH/OEHP/DSDC/IDEP

  23. Steps 9,10: Control / Communication (Again) • Data and recommendations presented to state DOC / Regional Jail committee on June 4, 2003 • Preliminary communication with WV APIC • More detailed followup planned for state WVAPIC meeting, September 11-12. BPH/OEHP/DSDC/IDEP

  24. Do we have community-acquired MRSA in our State . . . in other populations?

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