MRSA Surveillance: to report or not to report Dr Bonnie Henry BC Centre for Disease Control
Surveillance Definition Surveillance is the ongoing, systematic collection, analysis, and interpretation of health data essential to the planning, implementation and evaluation of public health practice, closely integrated with the timely dissemination of these data to those who need to know. The final link in the surveillance chain is the application of these data to prevention and control.
Elements of a Surveillance System • Data collection: pertinent, regular, frequent, timely - i.e. ongoing and systematic • Consolidation and interpretation: orderly, descriptive, evaluative, timely • Dissemination: prompt, to all who need to know (data providers and action takers) • Action to control and prevent WHO, 2000
Surveillance: A Classical Model Health Care System Public Health Authority Reporting Event Data Analysis & Interpretation Decision Intervention Information (Feedback)
Surveillance is NOT the same as: • Disease reporting - reporting provides a foundation for surveillance • Monitoringor Screening - monitoring and screening do not involve planning, implementation and evaluation
Objectives of Surveillance Systems: • Monitor trends • Understanding of diseases and their determinants • Identify and predict clusters, outbreaks, threats to health and emerging issues • Detect changes in health practices
Objectives of Surveillance Systems cont.: • Facilitate epidemiological research • To assist with planning and policy • Empower individuals, health providers, governments and communities with the information necessary for them to take action to protect and improve health
Types of Surveillance • Active • Passive • Enhanced • Sentinel
Rationale for Surveillance System Development • Disease Importance • Impact – burden of disease, PAR of risk factor, severity, societal impact • Communicability – for infectious diseases • Intervention • Prevention / Control - ability to intervene effectively • Immediacy of response – needed to control spread or severity • System • Requirement for reporting – legislated or international interest • Public perception – concern about risk
Why conduct healthcare surveillance? • Determine baseline rates of HAIs • Detect time/space clustering (ie, outbreaks) • Detect changes in rates and/or their distribution • Identify areas for targeted investigation and/or research • Determine the effectiveness of IC measures • Monitor compliance with established hospital policies and practices
Why conduct healthcare surveillance cont’d? • Evaluate changes in practice • Meet regulatory and other reporting requirements • Generate hypotheses concerning risk factors • Guide treatment and/or prevention strategies • Reduce healthcare associated infections • Support evidence-based resource allocation
Targeting your surveillance Focus on: • Preventable infections • Frequently occurring infections or events • Infections that cause significant morbidity or mortality • Infections that are costly to treat • Infections caused by organisms resistant to multiple antimicrobial agents Lautenbach E & Woeltje K. eds. Practical Handbook for Healthcare Epidemiologists. Thorofare, NJ: SLACK Incorporated; 2004.
History of Reporting • Nationally Notifiable Diseases have been reviewed in 1988, 1997-8 and in 2006 • Framework and criteria developed for the 1997 process • Provincial review in some provinces • Number of diseases added to or removed from BC list over time including MRSA • Historically there has been no formal framework or process for adding or removing from list in BC
Diseases of Interest to Organizations to Inform Prevention and Regulatory Programs 5-Year Average Incidence Severity Communicability/Potential Spread to the General Population Potential for Outbreaks Socioeconomic Burden Preventability Risk Perception Necessity of Public Health Response Increasing or Changing Patterns Criteria for Reportability
MRSA in the USA • Approximately 32% (89.4 million persons) and 0.8% (2.3 millions persons) of the U.S. population is colonized with S. aureus and MRSA respectively. (Kuehnert MJ et al. Journal of Infectious Diseases. 2006;193:172-9.) • The proportion of healthcare-associated staphylococcal infections that are due to MRSA has been increasing: 2% of S. aureus infections in U.S. intensive-care units were MRSA in 1974, 22% in 1995, and 64% in 2004. (Klevens RM et al. Clinical Infectious Diseases 2006;42:389-91) • There are an estimated 292,000 hospitalizations with a diagnosis of S. aureus infection annually in U.S. hospitals. Of these approximately 126,000 hospitalizations are related to MRSA. (Kuehnert MJ et al. Emerging Infectious Diseases. 2005;11:868-72.)
MRSA in Canada • 1981: MRSA first reported in Canada • Subsequently MRSA identified in many Canadian health care facilities • 1987-1990: CA-MRSA described in Aboriginal communities • 1995: Nationwide data available in Canada • National MRSA surveillance started in sentinel hospitals • 2001: Canadian Nosocomial Infection Surveillance Program (CNISP) summary of first five years of surveillance
CNISP Surveillance GOALS AND OBJECTIVES The objectives of this surveillance project are as follows: 1. To determine the incidence and burden of illness associated with MRSA in CNISP hospitals. 2. To describe the epidemiology of MRSA in Canada. 3. To characterize the molecular strains of MRSA in Canada.
CNISP MRSA Surveillance • Between 1995 and 2003, MRSA rates increased in CNISP hospitals from 0.46 cases per 1,000 admissions to 5.10 per 1,000 admissions (p = 0.002) • Most of the increase in MRSA cases occurred in central Canada (Ontario and Quebec), although there were also increases elsewhere in the country
Cost of MRSA • Direct health care cost attributable to MRSA in Canada, including cost for management of MRSA-infected and -colonized patients and MRSA infrastructure, averaged $82 million in 2004 and could reach $129 million in 2010. • MRSA is a costly public health issue that needs to be tackled if the growing burden of this disease in Canadian hospitals and in the community is to be limited. • Source: Canadian Journal of Infectious Diseases and Medical Microbiology, Volume 18, No. 1, January/February 2007
Community-Associated Methicillin-Resistant Staphylococcus aureus (CA-MRSA) Reports began in 1980s of MRSA occurring in the community in patients without established risk factors • Younger patients • Indigenous peoples and racial minorities • Skin infections common • Outbreaks: • Injection drug users • Players of close-contact sports • Prison/jail inmates • Group Homes (developmentally disabled) • Men who have sex with men
CA-MRSA vs HA-MRSA isolates *genetic element carrying mecA resistance gene Ref: CDC
Reasons to Report • A growing community-based problem caused by a communicable disease with some family based clustering • No other good mechanism to track the problem • What is its magnitude? Distribution? • Is it changing for the better or worse? • Advice for patients, contacts, household members may benefit from systematic delivery
If yes, what case definition? • Epidemiological Definition? • Phenotypic Definition (R Profile)? • Genetic Definition?
What are We Actually Doing? • Surveillance - reportable in some provinces • Laboratory Reference Work - many provinces • Guidelines (national and local) • Prevention - e.g. Do Bugs Need Drugs • Studies at various sites • CCHSA requirements
Issues • Need to establish surveillance for HAIs BUT • Will making it reportable help? • What about public reporting of rates? • How do we distinguish CA and HA-MRSA? • What about reporting of invasive disease only or reporting of aggregate rates?
Conclusions • Development of surveillance systems for HAI a priority in BC • Need to have connections with Public Health to address the spectrum of illness (we are all in this together!) • Work together to address both needs and to protect patients, HCWs and our community.
Discussion! Thank you! Bonnie.email@example.com