1. Alice Guh, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention CSTE CRE Panel Session – June 14, 2011 Public Health Response to Carbapenem-Resistant Enterobacteriaceae: The Role of Health Departments 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 Antimicrob Chemother 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 Strategy Regional 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 possible or Stratify results by geographic area and/or by facility type

9. Regional Prevention Strategy Regions 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 Strategy Regions 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)  Utah  Illinois  Virginia  Idaho  South Carolina  West Virginia  Wisconsin

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) Percentage of Facilities Per State CRE PrevalenceMedianRange Identified CRE3010-46 Daily or weekly00-16 Monthly or greater10084-100 ≤48 hrs of admission9274-100 >48 hrs of admission5925-75 Do not know if have CRE1210-18

17. CRE Surveillance Measures (n=7 states) Percentage of Facilities Per State Surveillance measuresMedianRange System for micro lab to alert IP staff 7757-91 Review prior micro data*3729-44 If yes, identified CRE100-17 Conduct point prevalence survey 60-11 If yes, identified CRE330-33 Conduct AST of epi-linked patients 1210-18 *Applies to facilities that have not or have rarely identified CRE cases (data available for 6 states)

18. CRE Prevention Measures (n=7 states) Percentage of Facilities Per State Prevention measuresMedianRange Place on Contact Precautions9586-100 Place in single-patient rooms9673-100

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

26. For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA 30333 Telephone, 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348 E-mail: cdcinfo@cdc.gov Web: www.cdc.gov The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Division of Healthcare Quality Promotion Thank you