Nearly 500,000 persons in the United States developed a Clostridioides difficile infection (CDI) in 2015 and more than 100,000 of these infections were in residents of long-term care facilities ...(LTCF). It is difficult to estimate the true burden of CDI in LTCF as reporting is not required. To gain a better understanding of CDI, the state health department (SHD) encourages LTCF to enroll and report CDI data into the National Healthcare Safety Network (NHSN).
The SHD analyzed CDI data reported into NHSN's Long-Term Care Component from March 2017 to October 2018. Descriptive analyses were performed on CDI LabID events which were categorized as community-onset (CO), long-term care onset (LO) and acute care-transfer-long-term care onset (ACT-LO) according to NHSN definitions. CDI rates were also calculated based on the NHSN definitions.
As of October 2018, 44 out of 320 LTCFs in the state were enrolled in NHSN. The median bed size was 103 (38–444). Between March 2017–October 2018, 29 out of 44 facilities reported 174 CDI LabID events with a range of 1–40. Of the total CDI events, 31 events were CO, 143 were LO and 64 LO events were categorized as ACT-LO. The overall CDI rate was 0.70 per 10,000 resident days. The CDI LO-Incidence rate was 0.52 per 10,000 resident days compared to a rate of 5.05 in acute care hospitals during the same period.
14% of long-term care facilities in the state are reporting CDI data voluntarily into NHSN. These data allow the SHD to better characterize the true burden of CDI statewide. Accurate reporting of infection data is imperative in order to establish a baseline infection rate and guide infection prevention strategies. Based on the variation in the data, the SHD plans to perform external validation of CDI data and education on NHSN definitions.
Problem: Uninsured African Americans are underdiagnosed and often untreated for depression. Individuals usually do not present to their primary care provider with a complaint of depressed mood, ...however, may report symptoms such as decreased energy, general body aches, digestive concerns, somatic complaints, or older adults' memory or cognitive problems. The purpose of this quality improvement pilot project was to examine the results of the implementation of a depression screening (PHQ-9) in a primary care setting for uninsured adults for detection, diagnosis, and treatment of depression in African American clients. Methods: The IOWA model of Evidence-Based Practice guided this pilot project in the examination of depression screening in a primary care clinic. The retrospective study utilized a descriptive analysis conducted over three months with a convenience sample of uninsured African American new clients 18–65 years old. Results: The PHQ-9 screening questionnaire was given to 100% (N = 24) of new clients seen over three months. There were 16.6% (n = 4) whites and 83.3% (n = 20) African Americans. Of the African American clients 25% (n = 5) scored 10 –14 indicating moderate depression; 5% (n = 1) scored six points signaling mild depression; 70% (n = 14) scored zero suggesting none to minimally depressed. Providers reviewed all client’s results and recommended either treatment, counseling, or medication. Implications for Practice: Utilization of the PHQ-9 screening questionnaire with uninsured African American clients in primary care resulted in an increase in the number of African Americans diagnosed and treated for depression. Incorporating depression screening with the initial primary care visit can be beneficial.
Objective
Maternal hepatitis C virus (HCV) infection reported on birth certificates has been shown to underestimate HCV infection. We sought to determine the usefulness of HCV surveillance data for ...(1) quantifying the number of HCV-positive reproductive-aged women with a live birth, (2) comparing maternal HCV surveillance data with reported HCV infection status on birth certificates, and (3) delineating past versus current maternal infection to identify true perinatal exposures.
Methods
We extracted data from January 1, 2013, through December 31, 2017, on birth certificate indication of HCV exposure from the Tennessee Birth Statistical File, and we ascertained indication of HCV exposure by using laboratory data from the Tennessee National Electronic Disease Surveillance System (NEDSS) Base System (NBS). We conducted a sensitivity analysis comparing birth certificate indication of HCV exposure with HCV laboratory data to determine whether true perinatal exposure had occurred.
Results
During the study period, 6731 mothers with live births in Tennessee reported having HCV infection during pregnancy: 3295 (49.0%) had both laboratory and birth certificate indication of HCV infection, 2130 (31.6%) had indication of HCV infection on the laboratory report only, and 1306 (19.4%) had indication of HCV infection on the birth certificate only.
Conclusions
Using data from a public health HCV surveillance system with birth certificate data may improve the identification of HCV-infected pregnant women and perinatally exposed infants. Surveillance systems that include complete reporting of all HCV RNA results can be used to distinguish past from present maternal HCV infection to focus limited public health resources on currently infected mothers and their exposed infants.
Abstract
Background
Centers for Disease Control and Prevention (CDC) guidance recommends coordinated multifacility interventions to contain selected MDRO, such as carbapenem-resistant ...Enterobacterales (CRE). A mathematical model using data from a northeastern state estimated these interventions would lead to 76% relative reduction in CRE prevalence in a hospital network connected through patient transfers, but whether results would be similar using data from another state is unclear.
Methods
We used Tennessee (TN) surveillance and hospital discharge data to estimate CRE transmissibility and patient transfers in a deterministic compartmental model to simulate regional spread of CRE. Simulations were initialized with the first clinical detection of CRE in the hospital with the most outgoing transfers. Interventions were initiated in facilities that detected CRE and those sending or receiving the largest numbers of patients to/from these facilities, including: 1) biweekly point prevalence surveys; and 2) enhanced infection control implemented immediately on CRE detection. We assumed interventions reduced intrafacility transmission by 20%. Surveys stopped after 2 consecutive negative rounds in a facility (Figure 1). We ran simulations using 2 patient transfer networks: 1) all hospitalized patients; and 2) CRE surrogates (patients clinically similar to CRE-infected patients) (Figure 2).Figure 1.Methods: Multifacility Susceptible-Infectious-Susceptible model (a) and simulations schematics (b).
In the multi-facility SIS model, we assume hospitals are at constant occupancy. Each bed was occupied by either an infectious (I) or susceptible patient (S). (b) Interventions outlined in the simulations followed the recommendations of the Interim Guidance for a Public Health Response to Contain Novel or Targeted Multidrug-resistant Organisms (MDROs). Initial detection at the facility with the highest number of outgoing transfers followed by immediate containment efforts and reduced transmissibility in intervened hospitals by 20% by day 30. Simulations were run 35 times. Each run randomly selected a transmissibility value derived from the distribution in our estimates derived from CRE surveillance data in TN.Figure 2.Methods: the patient transfer network of Tennessee (TN) hospitals and communitiesThe network of Tennessee (TN) hospitals and communities, represented by Health Referral Regions (HRRs) according to the Dartmouth Atlas of Healthcare (https://www.dartmouthatlas.org) connected by direct and indirect patient transfers with up to 365 days of intervening community stays. Patient transfer data were sourced from the 2018-2019 TN Hospital Discharge Database. Patients who were not admitted to another facility after being discharged in 2018 were attributed to transfers into the HRR corresponding to the hospital’s address. Each circle represents a short-term acute care hospital (STACH), each square represents a long-term acute care hospital (LTACH), and each triangle represents an HRR. The arrow represents the direction of transfers between hospitals. Node sizes correspond to the number of registered beds, and color represents the Emergency Medical Services (EMS) regions where the facility is located.
Results
CRE case counts 3 years after importation and interventions were 21% lower (interquartile range IQR: 20–23%) than without interventions using the transfer network of all hospitalized patients; interventions were required in 52 (36%) of 144 hospitals. Simulations in the CRE surrogate network resulted in a 26% (IQR: 20–38%) CRE case reduction and interventions in 32 (24%) hospitals.
Conclusion
The estimated CRE prevalence reduction achieved through simulating CDC guidance-recommended interventions in TN was lower than estimates using data from a different state, likely due to state-specific differences in patient transfer network structure and transmission parameters. Containment guided by transfer patterns of patients clinically similar to CRE-infected patients rather than all hospitalized patients requires interventions in fewer hospitals to achieve a comparable impact.
Disclosures
Peter F. Rebeiro, PhD, MS, Gilead: Advisor/Consultant|Janssen Pharmaceuticals: Advisor/Consultant|National Institutes of Health: Grant/Research Support
Abstract
Background
Injection drug use using nonsterile equipment can lead to transmission of viral, bacterial, and fungal infections. Frontline healthcare workers (HCW) are at high risk for ...substance use disorder due to unprecedented job stress and access to injectable controlled substances. The Tennessee Department of Health (TDH) developed a collaborative investigative process to determine the risk of bloodborne pathogen (BBP) transmission from licensed HCWs engaging in drug diversion. This program recommends public health action and provides consultation to improve drug diversion programs.
Methods
In 2019 TDH formed a drug diversion investigation team (DDIT) consisting of pharmacists, epidemiologists and medical directors from the HAI and HIV/STI/Viral Hepatitis programs. The DDIT responds to notification by the Health-Related Boards (HRB) of a licensed HCW under investigation for diversion of injectable products. The DDIT interviews the investigator and meets the facility drug diversion program to review drug diversion policies and processes. Based on the suspected method(s) and, if known, the individual’s Hepatitis B/C and HIV status, recommendations are made regarding the need for patient notification and testing.
Results
From 2020–2022 the DDIT received notification of 49 licensed HCWs under investigation for diversion of injectable products. Patient notification and testing was recommended in seven facilities for CDC Category A infection control breaches; in two cases, later HCW testing negated the need for further action. Among the 34 facilities queried, only five (14.7%) had existing policies for for-cause BBP testing. Other recommendations to improve diversion programs include infection prevention participation and releasing “not eligible for rehire” status to other facilities.
Conclusion
The TDH DDIT facilitates communication with HRB on reported cases of injectable drug diversion. Joint investigations with facilities raise awareness of the risk of BBP transmission and improve facility diversion programs. Tennessee facilities are adding for-cause BBP testing to their investigation procedures. The TDH DDIT model receives mostly positive responses from facility and health system drug diversion teams and may be considered by other public health jurisdictions.
Disclosures
All Authors: No reported disclosures
Pan-nonsusceptible (pan-NS) organisms require aggressive containment per current guidance. On January 1, 2018, the state public health laboratory (SPHL) alerted the state health department (SHD) to a ...pan-NS Acinetobacter baumannii at Hospital A. Patient A was admitted to Hospital A from a skilled nursing facility with ventilated residents (vSNF) and shared a bathroom with patient B, who later developed pan-NS A. baumannii infection. Prior to the vSNF, patient A was admitted at a long-term acute care hospital (LTACH). The SHD in conjunction with the Centers for Disease Control and Prevention (CDC) and the facilities identified and contained transmission over the next six months.
SHD infection preventionists conducted in-person infection control assessments and addressed gaps with written feedback and phone calls. Admission screening and every two week point prevalence surveys (PPS) were done at the LTACH and vSNF. PPS continued until two consecutive negative rounds with no new cases. Screening was performed from rectal, sputum and wound specimens. Pan-NS cases demonstrated intermediate or resistant interpretations to all antibiotics tested; multidrug-resistant cases showed susceptibility to one antibiotic tested. Isolates were sent to CDC for whole genome sequencing (WGS) and OXA-23 testing.
During January 31–June 27, 2018, the vSNF and LTACH performed six and ten PPS, respectively. PPS and admission screens identified 12 cases, eight of which had OXA-23. WGS showed molecular evidence of transmission in the vSNF. SHD found no hand hygiene monitoring, no contact precaution signage, inconsistent use of personal protective equipment, and inadequate disinfection in the vSNF. LTACH observations included inadequate equipment disinfection. Sustained implementation of recommended infection prevention practices was observed. In June, both facilities had cessation of transmission.
An effective containment response to a multi-facility outbreak was facilitated by the SHD, SPHL, CDC and the impacted facilities.
