grant public health potpourri...grant public health potpourri grant-adams medical societ...
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Grant Public Health Potpourri
Grant Adams Medical Societ MeetingGrant-Adams Medical Society MeetingMonday, April 14th, 2008
Alexander L Brzezny MD MPH FAAFPAlexander L. Brzezny, MD, MPH, FAAFPHealth Officer
Grant County Health District
CONFLICTS OF INTEREST: nothing to disclose
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OBJECTIVESOBJECTIVES• Through numbers and comparisons, reaffirm
that Grant (and Adams) County is indeed a “whole another country.” (didn’t we know?)
• Outline why public health challenges are healthcare challenges. g
• Discuss the “superbug” and its continued rise to fame also in our backyardrise to fame also in our backyard.
• Honorably mention the pandemic flu.
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CASE #1: deli sandwich anyone?CASE #1: deli sandwich anyone?
• February 2007: a case of Salmonella reportedFebruary 2007: a case of Salmonella reported to health district (serovar Senftenberg).
• April 2007: a case of Salmonella reported to p phealth district (serovar non-typhi, ID pending).
• Search: whole state of California: 47 cases of Salmonella serovar Senftenberg in 2004.
• In 2007, England and Wales had an outbreak ith at total of 30 caseswith at total of 30 cases…
• May 2007: two cases of Salmonella (serovar Senftenberg) reported to health districtSenftenberg) reported to health district.
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CASE #1 (Quiz)CASE #1 (Quiz)
• What (where) is Senftenberg?What (where) is Senftenberg?• Do we have an outbreak?
Wh t ld d t?• What would you do next?Commence an investigation?Call the state department of health?Call the CDC?Stop eating food?All of the above?
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Senftenberg Brandenburg D EUSenftenberg, Brandenburg, D, EU
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2007 GC S. Senftenberg outbreakSalmonella Senftenberg 2007Salmonella Senftenberg 2007
4
3
Collection of Outliers/Asymptomatic
# of cases
2
# of
cas
es
1
01 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35
Week of 2007
•Epi investigation: highest probability of the source a restaurant in ML (June)F d i ti t d t b t t li lt f S S
Weeks of 2007
•Food prep process investigated step by step: meat slicer cultures + for S.S.•So far: 19 cases of Salmonella Senftenberg Dec 2006-Mar 2008•Cost to date: ~$30,000
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GC PERTUSSIS (2005-2008)( )
YEAR Cases Contacts ProphylaxedYEAR Cases Contacts Prophylaxed Contacts
2005 4 20 20 (100.0%)2006 1 8 7 (87.5%)2007 4 240 222 (92.5%)2008 2 82 75 (91.2%)
TOTAL 11 350 324 (92.6%)• Approximately 30 contacts per case• Approximately $10,000 per case• Cost of DTaP (or Tdap) 10-pack: $12.65-$13.75 ($30-75-$31.75); CDC $$Cost of DTaP (or Tdap) 10 pack: $12.65 $13.75 ($30 75 $31.75); CDC $$• Tdap recommended once in a lifetime 11-12y.o. & once 19-65y.o. (ACIP)
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N MENINGITIDIS (2005-2008)N. MENINGITIDIS (2005 2008)YEAR Cases Contacts Prophylaxed p y
Contacts
2005 1 8 8 (100.0%)2006 0 0 02007 1 148 148 (100.0%)2008 2 67 65 (97.0%)TOTAL 4 223 221 (99.1%)
• Approximately 35 contacts per case• Approximately $14,000 per case• Tetravalent MENACTRA® to 11-18 y.o. ($75.35 for 5-pack) with Tdapy ($ p ) p
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GC VARICELLA (pedi: 2005-2008)GC VARICELLA (pedi 2005 2008)
YEAR Cases Contacts Prophylaxed Contacts
2006 110 600+ 300 (GCHD only)2006 110 600+ 300 (GCHD only)2007 3 20+2008 9 40+2008 9 40+
• 2006 Outbreak affected Warden, Ephrata, Moses Lake school districts• 2006 Outbreak: $30 000• 2006 Outbreak: $30,000
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GC ACTIVE TUBERCULOSIS ( )(2005-2008)YEAR Cases ContactsYEAR Cases Contacts
2005 3 482006 1 582006 1 582007 2 202008 0 02008 0 0TOTAL 6 126
A i t l 21 t t• Approximately 21 contacts per case• Approximately $22,305 in TST’s and CXR’s to detect one case• Cost per ONE case prevented $10,627 for CXR’s and $66,750 for TST’sDasgupta et al. 2005g p
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GC LATENT TB (LTBI)GC LATENT TB (LTBI)LTBI Cases
233250
284250
300
183 186
100
150
200
0
50
100
2001 2002 2003 2004 2005
2006: 210 LTBI cases 2007: 228 LTBI cases
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GC LATENT TB (LTBI)Region of Origin
GC LATENT TB (LTBI)g g
60 0
70.0
s AFRICA
40.0
50.0
60.0
of P
atie
nts AFRICA
ASIA/SOUTH PACIFIC
EUROPE
20.0
30.0
cent
age
o
LATIN AND SOUTH AMERICA
NORTH AMERICA
RUSSIA/UKRAINE
0.0
10.0
2001 2002 2003 2004 2005
Perc
UNKNOWN
2001 2002 2003 2004 2005
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GC LATENT TB (LTBI)Average Age Comparison
GC LATENT TB (LTBI)
35
40
2025
3035
e Ag
e
NATIVE
1015
20
Ave
rage
FOREIGN
05
2001 2002 2003 2004 2005
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LTBI Treatment Completion rates in GC b M di iGC by Medication
Medication Specific Completion
90100
60708090
of P
atie
nts
INH
20304050
rcen
tage
o
INHRIF
010
2001 2002 2003 2004 2005*
Pe
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Completion Rates for LTBI in GC by p yCountry of Origin
Foreign Born vs. Native Born Recommendation Completion
65 0
55.0
60.0
65.0
ge
45.0
50.0
Perc
enta
g
FOREIGN BORN
NATIVE BORN
35.0
40.0
2001 2002 2003 2004 2005*
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ANIMAL BITES /VECTOR CTRLANIMAL BITES /VECTOR CTRL.YEAR Cases PEP Animals tested
(bites) recommended (bats, cats, skunks, dogs, etc.)
2006 145 1 82006 145 1 82007 116 8 8 TOTAL 261 9 16TOTAL 261 9 16
• There are no known rabies cases in humans or animals in Grant Co.• There was a cat rabies case in Walla Walla in 2002.• Any bat exposures = PEP if not available for testing.• Any raccoon or other wild terrestrial carnivore = PEP if not available.• Therefore, DON’T MESS WITH BATS, RACOONS, etc. (and Texas).
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Healthcare Professionals’ RoleHealthcare Professionals Role• TIMELY REPORTING
immediate VS. within 3 days VS. later (consult the list of notifiable conditions: htt // d h /N tifhttp://www.doh.wa.gov/Notify
• PROPER TEST SELECTION CDC l b t d fi iti it iCDC laboratory definition criteria: IgM for hep A, etc.
• PROPER TREATMENT• PROPER TREATMENT Health Officer DirectiveCDC /ACIP AAP Red BookCDC /ACIP, AAP Red Book
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NEED YOUR HELPNEED YOUR HELP
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2008-2010 CHALLENGES2008 2010 CHALLENGES• Department of Health submitted three
f t th l i l tperformance measures to the legislature:• #1 INCREASE USE OF UNDERUTILIZED
VACCINES (i DT P Td di FLU VZV)VACCINES (i.e DTaP, Tdap, pedi FLU, VZV)plus INCREASE PARTICIPATION AND USE OF CHILD PROFILE®CHILD PROFILE®
• #2 IMPROVE TIMELY AND COMPLETE REPORTING, INVESTIGATION OFREPORTING, INVESTIGATION OF NOTIFIABLE CONDITIONS
• #3 COMMUNITY OBESITY INTERVENTIONS#3 COMMUNITY OBESITY INTERVENTIONS
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• Chlamydia—Chlamydiareported disease (15-24; per 100K)
Grant: 2,083Adams: 1,994Yakima: 3,435Lincoln: 824SE Asia: 4,289 EU: ~522
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• Chlamydia-Chlamydiatreated (15-24)
Grant: 92%Adams: 77%SKi 96%SKing: 96%
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I fl• Influenza Vaccine (>65)
Grant: 63%Adams 65%Jefferson: 78%Germany: 60%
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H lth• Health Insurance (18 64)(18-64)
Grant: 73%Ad 65%Adams: 65%S.King: 85%
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• Adult• Adult Overweight /Obese/Obese
Grant: 67%Adams: 71%San Juan: 51%Ireland: 57%
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Ph i l• Physical Exercise(>18)(>18)
Grant: 61%Adams: 64%Adams: 64%S. Juan: 75%
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• Di b t (>18)• Diabetes (>18)Grant: 9%Adams: 10%SKing: 6%S. Juan: 3%India: 6%
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T Bi th• Teen Birth (per 10K)
G 38Grant: 38Adams: 59SKi 10SKing: 10Japan: 4UK 33UK: 33Bulgaria 59
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• PEDI Un-intentionalintentional Injury (per 100K)(per 100K)
Grant: 290Adams: 260Adams: 260Island: 155C-Doug: 160gS.Korea: 256UK: 61
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C l t l CA• Colorectal CA screen (>50; FOB d )FOB or endo)
Grant: 53%Adams: 53%Whitman: 67%
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• ExpectedExpected years of life at 20 y o20 y.o.
Grant: 46Sea-King: 53Sea-King: 53S. Juan: 57Mexico: 55Mexico: 55Iceland: 61
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1. National Nosocomial Infections Surveillance (NNIS) System Report,January 1992 through June 2004, issued October 2004. Am J Infect Control. 2004;32:470-485.
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Community MRSA (CA-MRSA)y ( )• Distinct and genetically different S. aureus.
I L A CA MRSA th t• In L.A., CA-MRSA was the most common cause of skin infections coming seen in emergency rooms.rooms.
• A Houston study demonstrated that CA-MRSA accounted for 56% in 2000-2001, 57% in 2002 and 78% in 2003 of in hospitalized children.
• 2007 random sample of HEALTHY individuals (Chicago): 4% MRSA colonization (carriers)(Chicago): 4% MRSA colonization (carriers).
• Estimated overall U.S. MRSA carriers: 2.6%; healthcare: 4.6%healthcare: 4.6%
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Community-Acquired MRSA• Bacteriologic characteristics
Resistant to fewer antimicrobial classes
Different toxin genes (Panton-Valentine leukocidin)
Gene complex = Staph cassette chromosome mecGene complex = Staph cassette chromosome mec(contains the methicillin-resistance gene)• SSCmec type IV and Vyp
Small number of molecular strains identified by fingerprintingg p g
Can survive on some surfaces for > seven months
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Reservoir for the Spread of Antibiotic Resistant Pathogens
Recognized by Microbiology Cultures
Colonized Patients
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Prevalence of MRSA as cause of SSTI in Adult ED Patients – EMERGEncy ID Net, Moran GJ, et al, SAEM 2005
54% 39%15%15%
55%
51% 60% 60%
74%68%
60%
67%
72%
Slide courtesy of Rachel Gorwitz and Greg Moran
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Current Study• Washington State Department of Health North Central
Region 7Five counties:
• Chelan• Douglas• Douglas• Grant• Kittitas• Okanogan
• Data sources:11 hospitals3 clinics2 labs2 labs
• 2003–2006 medical records
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Region 7 MRSA Trend120 2006
100
80y
200580
60
eque
ncy
2004
40
Fre
2003
20
00 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
Monthly0 3 6 9 12 15 18 21 24 27 30 33 36 39 42 45 48
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Region 7 MRSA Study: 2003–2006120
ncy
100
80
Freq
uen
60
40
20
00 10 20 30 40 50 60 70 80 90 100 110
Summary:
0 10 20 30 40 50 60 70 80 90 100 110
Age
Summary:2049 cases ● 47% female, 53% male ● Mean age = 43.8 years
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Region 7 MRSA: In- vs. Outpatient
18 84%
Inpatient
Outpatient18.84% Outpatient
81.16%81.16%
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Region 7 MRSA: In- vs. Outpatient b Aby Age
150
G
100es
Age Groups
Children (0–10)
100
er o
f Cas
e
Adolescents (11–20)
Young adults
50Num
be
g(21–40)
Mid adults (41–60)
0
( )
Older adults (60+)
0Inpatient Outpatient
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Region 7 MRSA: Type by Age400
Age Groups
ases 300
g p
Children(0–10)
Adolescents
ber o
f Ca
200
Adolescents (11–20)
Young adults (21 40)
Num
b
100
(21–40)
Mid adults (41–60)
100
0
Older adults (60+)
SST Respiratory Blood Urine Nasal0
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Antibiotic Resistance
“Awareness of local resistance patterns more important than categorizing community vs. hospital-acquired MRSA.”
CDC publication: Strategies for Clinical Management of MRSA in the Community
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MRSA—Antimicrobial ResistanceDOH Data (2003–2004) vs. Region 7 Data (2003–2006)
96%
DOH
Region 7
100%
80%
96% 93%
82%
66%
60%
40%
66%
40%
20%
26%31%
7% 7%
Tetra-cycline
Trimeth/Sulfa
0%7%
3% 2% 2% 2%5% 5% 7%
Erythro-mycin
Cipro-floxacin
Clinda-mycin
Genta-mycin
Rifampin
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Region 7: Multiple MRSA Infections
200Multiple Infections
171200
160
120
80Cas
es
34
7 3 240
002 3 4 5 >5
Number of Infections
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BIRD
FLU
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PANDEMIC ANDPANDEMIC AND ALL-HAZARDS
PREPAREDNESS
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World’sBestBest Places
*DHHS, 2006
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Grant County Healthcare Emergencies Alliance
NURSINGNURSINGHOMES
INDIV.EMS PRACTICEEMS
PUBLIC HEALTH
HOSPITALSCLINICS
HEALTH
VOLUNTEER
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Proposed healthcare re-organization* Walk-In Individuals
MORGUE orDeath
COMMUNITYTRIAGE
Phone Calls
HOSPITAL
FREEZER
TRIAGECENTER
“STAY HOME”
“GET SEEN”
HOSPITALSeparate
Entry+
EMSHOMEHEALTH
PATIENT’S
HOME”
DesignatedINFLUENZA
SEEN” TRIAGE Transfer
HOME INFLUENZA CLINIC(S)
RECEIVINGFACILITY
*GCHD, 2006-2008
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NORTH COUNTY TRIAGE (GRAND COULEE)
GRAND COULEE 1.7KELECTRIC CITY 1KHARTLINE 0.25KFORDAIRPOP. 3,000+
EPHRATA 10KCOULEE CITY 1.2KGRANT ORCHARDS LAKEVIEW PARK¼ ROYAL CITY 1K )
EPHRATA
,SOAP LAKE 4KSTRATFORD 0.05KWILSON CREEK 0.3KPOP. 16,550 GRANT COUNTY PROPOSED
TRIAGE SUBDIVISIONSEPHRATA AREATRIAGE(EPHRATA)
CRESCENT BARGEORGE 0.7KQUINCY 12KTRINIDADVANTAGE
TRIAGE SUBDIVISIONS
MOSES LAKE AREA TRIAGE(MOSES L.)QUINCY
AREA
MARLIN/RUFF/KRUPP 0.35KMcDONALDMOSES LAKE 32.5K1/3 ROYAL CITY 1.34kSTRATFORD 0.051KSAND DUNES
WINCHESTERPOP. 12,700+ EPHRATA
TRIAGE(QUINCY)
SAND DUNESWILSON CREEK 0.3KWARDEN 4KWHEELERPOP. 38,541+
SOUTH COUNTY TRIAGE
BEVERLY 0.6KCRAB RIVERDESERT AIRE
TRIAGE (MATTAWA)
MATTAWA 10K (EST.)¼ ROYAL CITY 1KSCHAWANASMYRNAEST. POP. 11,600+
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Triage Facility LayoutTriage Facility LayoutAMBULANCE DOCK
ENTRY
TRIAGE
NON-AMBULATORYTREATMENT AREA
AMBULATORY TREATMENTAREA
WAITAREA(3ft of
) AREA AREA
LOCK
space)
LABORATORY
STORAGEEDUCATION AND DISCHARGE AREA PHARMACY
DOWNAREAADMINCOMM
LABORATORY
PHONES
EXIT
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Spectrum of Disease• Fever• >80% skin and soft tissue
infection (SSTI)AbscessesFurunclesFurunclesCarbunclesCellulitisCellulitis
• Local swelling, redness, heatP i f l l i i l ith• Painful lesion or pimple with or without drainage
• Misdiagnosed as spider bites• Misdiagnosed as spider bites
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(Quick) Case #3If you saw this lesion on the star high school football gplayer's arm three days before the next game, what would you recommend?
A Immediate medical evaluation and careA. Immediate medical evaluation and careB. Cultures and antimicrobial sensitivity
testing of any isolates of Staph. aureusg y pC. Consideration of restricting his playing
in the gameD. All of the above
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Spectrum of Disease• Severe / invasive infection
sitesLungs
Bloodstream
Bone
Joints
Surgical sites
• Complications of precedingComplications of preceding SSTIs or viral respiratory tract infections (especially flu)( y )
• Invasive MRSA is a REPORTABLE DISEASE
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MRSA (the bad and the ugly)
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MRSA: Direct Transmission
• Usually spread by physical contact y p y p yHands
W dWound
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MRSA: Indirect TransmissionTouching of contaminated objects
• SheetsSheets
• Towels
• Clothes
• EquipmentEquipment
• Dressings
• Bar soap
• Personal items (ex: razor)( )
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Community-Acquired MRSA• Rapid emergence of CA-MRSA
• Patients presenting to emergency departments• Patients presenting to emergency departmentsor clinics in increasing numbers
• Epidemiological definition• Epidemiological definitionOnset in the community
• No recent hospitalization• No recent hospitalization• No out-patient surgery• No residence in long-term care facilityNo residence in long term care facility• No dialysis• No invasive medical devices
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Colonization• Nasal colonization = 0.8% (non-institutionalized
individuals)
• Few data on the association between MRSA colonization and infection in the community
• MRSA colonization occurs:NosePhPharynxAxillaRectumRectumPerineum
• Nasal colonization not always present in individualsNasal colonization not always present in individuals with active MRSA infection
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Colonization (cont.)• Few data on the effectiveness of decolonization
to prevent infection in the community or in p yfamilies.
• Healthcare: intranasal mupirocin can be effectiveHealthcare: intranasal mupirocin can be effective at eliminating colonization in the short term.
• Recolonization is common• Recolonization is common.
• Compliance is poor in community ttisetting.
• Resistance develops to topical and systemic agents.
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Protect Yourself: Personal Hygiene• Wash hands thoroughly with soap and water.• Use alcohol-based hand gel (>62%) if soapUse alcohol based hand gel ( 62%) if soap
and water are not available.• Take regular baths or showers.g
• Do not share personal hygiene itemshygiene items.
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If You Have MRSA: No Pools!
• Avoid whirlpools, hydrotherapy pools, cold tubs, swimming pools if you have an open wound
• Wash your hands!Wash your hands!
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MRSA and Your Pet
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Prevention Is Most Important
The single most important thing you can do to prevent the spread of disease:
WASH
YOURYOUR
HANDS!HANDS!
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CA-MRSA in your communityC y y• 4.38 cases per 1000 (E-ta, ML) or about p ( )
1.5 to 2.8 cases per 1000 per year• Total cases under-reported plus otherTotal cases under reported plus other
labs not fully traceable = estimate 1/500 to 1/200 to cases (0 2%-0 5%) per yearto 1/200 to cases (0.2% 0.5%) per year
• 35.2% Staph in Grant County is MRSA (2008 year to date)(2008, year-to-date)
• CA-MRSA is HERE TO STAY
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GOWNS PREVENT HCWs FROM CONTAMINATING THEIR CLOTHES /HANDSCONTAMINATING THEIR CLOTHES /HANDS
14 (40%) of 35 HCWs’ gowns were culture (+) for MRSA and ARE on exiting room (2-200 g (colonies recovered). Clothing underneath was culture (-). 11 (69%) of 16 HCWs wearing f hl l d d hit t h d d t t blfreshly laundered white coats had detectable contamination. 3 of 11 developed (+) hand cultures after touching the white coatcultures after touching the white coat.
Boyce, et al. SHEA 1998, Abstract S74.