12/08/2016
What Public Health can
contribute
Dr Anne Sheahan
2nd September 2016
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Summary of Presentation
• Background of outbreaks and public health
• What is surveillance of infectious disease?
• Why is it necessary?
• What is the legislation in this area?
• Examples of public health interventions
• Challenge of antimicrobial resistance
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What do Public Health do?
• What?
• Who?
• Where?
• When?
• Why?
How to prevent it happening again
September 2016
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12/08/2016
19th Century London
• Poor sanitary
conditions
• Cesspools in
basements
• Waste dumped in to
River Thames
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Cholera
• Severe Diarrhoea
• Dehydration – Shock - Death
1831
6,000 RIP
1849
14,000 RIP
1853
10,000 RIP
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1854 Broad Street
Cholera Outbreak
• Talked with locals
• Histories / exposures
• Studied pattern of
disease - mapping
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2
12/08/2016
Public Water
Broad St Pump
• ‘The result of the inquiry, then, is, that there
has been no particular outbreak or prevalence
of cholera in this part of London except among
the persons who were in the
habit of drinking the water of the
above-mentioned pump well.’
• Control measure:
Remove Handle
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US Outbreak 1980’s
The initial cases were a
cluster of injecting drug
users and homosexual men
with no known cause of
impaired immunity who
showed symptoms of
‘Pneumocystis carinii’
pneumonia (PCP)
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US Outbreak 1980’s
• Number of homosexual men developed a
previously rare skin cancer called Kaposi’s
sarcoma
• Many more cases of these rare forms of
pneumonia and sarcoma occurring together
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12/08/2016
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• CDC task force formed to monitor the
outbreak
• "the 4H disease“ (heroin users, homosexuals,
haemophiliacs and Haitians)
• "GRID“ (gay-related immune deficiency)
• 1982: Acquired Immunodeficiency Syndrome
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Transmission
• Sexual
• Control Measures
• Safe Sex
• Blood
• Clean needles
• Mum to baby
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4
12/08/2016
Surveillance – why?
• To allow planning for ID prevention and
control
•
particular diseases of public health
importance e.g. TB, meningococcal
disease, malaria …
•
particular disease problem e.g.
antimicrobial resistance
• National Infectious Disease Legislation
• International requirements
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Notify What?
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12/08/2016
Methods of Notification
Email: via Healthmail
Tel: (021) 4927601
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Surveillance data - how used?
For the prevention, management and
control of ID
• Control spread of disease
• Identify outbreaks early
An episode in which two or more
people, thought to have a common
exposure, experience a similar illness
or proven infection
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Surveillance data - how used?
For the prevention, management and
control of ID
• Monitor disease trends
- changing?
• Provide evidence for public health
interventions
- immunisation programmes
- information campaigns
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Evidence for Intervention
First Example: Meningococcal Disease
• Ireland had highest levels of
meningococcal disease in Europe
• Group B (2/3) and Group C (1/3)
• 11 Group C deaths between July 1999-June
2000
• Highest risk in the under 5’s and 15-18 years
Evidence for public health intervention
Men C vaccine introduced Oct 2000
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7
12/08/2016
Meningococcal Disease
Cork & Kerry 1998-2011
70
All confirmed cases
60
Group B
50
Group C
Other Group
40
30
20
10
19
98
19
99
20
00
20
01
20
02
20
03
20
04
20
05
20
06
20
07
20
08
20
09
20
10
20
11
0
Men C vaccine introduced
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Evidence for Intervention
Second Example: VTEC Infection
• Verocytotoxigenic E.coli (VTEC)
• Potentially very serious ID pathogen
• Caused by no. different strains [best known E.coli
O157]
• 5-10% complication HUS
Haemolytic Uraemic Syndrome
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VTEC Notifications HSE-South 2012
30
- Marked increase
in VTEC
notifications
25
20
- Rural areas in
particular
15
10
- Doubling of rate
of HUS
notifications
5
0
Jan Mar May July Sept Nov
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8
12/08/2016
VTEC Outbreak
Contaminated private well water supplies
↑ average rainfall
Need for public health intervention
National multi-agency expert group established
(HSE, EPA, Local Authorities, FSAI)
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12/08/2016
1928 – Alexander Fleming
“The thoughtless person playing with penicillin
treatment is morally responsible for the death of
the man who succumbs to infection with the
penicillin-resistant organism”
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12/08/2016
Antimicrobial Resistance
Resistant bacteria linked to broad spectrum
bacteria
Spread easily in healthcare settings
Increased mortality, morbidity and financial
cost
1 in 20 people admitted to hospital in Ireland
will develop a HCAI
2-10 times greater risk of death from
resistant bacteria than sensitive one
25,000 deaths p.a. across Europe annually
30-70% of HCAIs are preventable
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March 11th 2013
The chief medical officer, Dame Sally Davies, warns of a
major increase in the number of bugs resistant to antibiotics.
In a report published on Monday she says antibiotic-resistant
bacteria with the potential to cause untreatable infections
pose ‘a catastrophic threat' to the population ranked
alongside terrorism on a list of threats to the nation
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Multi-drug resistance
MRSA
VRE (Vancomycin resistant
Enterococci)
Linezolid resistant VRE
Multi-resistant Gram negative bacteria
(ESBLs, MDRKP, CRE)
Penicillin resistant Streptococcus
pneumoniae
Multi and extensively drug resistant TB
Multi-drug resistant gonorrhoea…..
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11
12/08/2016
Trends in K. pneumoniae invasive infections showing
percentage resistance to fluoroquinolones,
aminoglycosides and 3rd-generation cephalosporins
HPSC Data 2004-2014
400
30%
25%
300
20%
250
200
15%
150
%Resistance
Number of isolates
350
10%
100
5%
50
0
0%
2006
Total KPN
2007
2008
2009
%3GC-R
2010
2011
2012
Year
%CIP/OFX-R
2013
2014 2015*
%GEN/TOB/AMK-R
%GEN-R
3GC, 3rd-generation cephalosporins (e.g. cefotaxime, ceftazidime); CIP, ciprofloxacin;
OFX, ofloxacin (CIP and OFX are fluoroquinolones); GEN, gentamicin, TOB,
tobramycin; AMK, amikacin (GEN, TOB and AMK are aminoglycosides)
Trends in E. coli invasive infections showing
percentage 3GC-resistance and ESBL-positivity
HPSC Data 2004-2014
3000
16%
14%
12%
2000
10%
1500
8%
6%
1000
%3GC-R/ESBL+ve
Number of isolates
2500
4%
500
2%
0
0%
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014
Year
Total E. coli
%3GC-R
%ESBL+ve
*2015 data to the end of Q3 only
3GC, 3rd-generation cephalosporins (e.g. cefotaxime, ceftazidime); ESBL,
extended-spectrum beta-lactamase
Threat of Drug Resistant
Bacteria
• National increase in MDRKP by NUG Lab
• Increase in blood stream infections caused by
MDRKP through EARS-Net
• Outbreak of CRE in UL Hospitals
• Patient transfer
• OCT established in HPSC in Oct 2013
• Review existing data
• Request additional data from labs
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12/08/2016
Issues identified
• Resource limitations
• High bed occupancy
• Under-staffing
• Screening - guidelines
• Lack of isolation facilities
• Poor physical infrastructure
• Across all healthcare settings
• Hygiene
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National Taskforce
• All operational divisions
• Action plan to address antimicrobial prescribing
• OOH
• LTCFs
• Restriction in prescribing carbepenems
• Resource CHOs
•
•
•
•
IPCNs
Microbiology advice and support
Antimicrobial pharmacy input
LTCFs
• Provide expertise across HGs and CHOs
• Governance – line management responsibility
September 2016
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Further information
• Health Protection Surveillance Centre www.hpsc.ie
• National Immunisation Office www.immunisation.ie
• European Centre for Disease Control www.ecdc.eu
• Centers for Disease Control and Prevention www.cdc.gov
• World Health Organisation www.who.ie
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