Population- based Surveillance of Reportable Diseases in Nursing Home

Facilities in Nebraska

Manjiri Joshi, MPH+

Alison Keyser Metobo, MPH +

+Epidemiology Surveillance Response Coordinator

Overview• Background

– Nursing home increased risk for infection – Health outcomes in nursing home residents– Baseline for Nebraska cases

• Objective • Methods

– Estimated incidence rates in nursing home residents– Comparing estimated incidence rates in nursing home

residents and non-nursing home cases• Results • Next Steps

Background

Nursing Home residents are at increased risk for infection

– Advanced Age

– Group Living

– Comorbidities

– Compromised Immunity

– Need for hospitalization

Health outcomes for nursing home residents

• Clostridium Difficile infections• Influenza• Methicillin Resistance Staphylococcus Aureus • Vancomycin resistance Enterococci

Compared Nebraska incidence rates with national incidence rates

– Establish baseline in Nebraska population

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.00

2.00

4.00

6.00

8.00

10.00

12.00

14.00

16.00

Shigellosis

Nebraska Rate

National Rate

Year

Inci

denc

e ra

te

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.00

0.20

0.40

0.60

0.80

1.00

1.20

Meningococcal disease, invasive

Nebraska RateNational Rate

Year

Inci

denn

ce R

ate

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.00

0.50

1.00

1.50

2.00

2.50

3.00

Streptococcus Invasive A

Nebraska RateNational Rate

Year

Inci

denc

e Ra

te

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 20090.00

1.00

2.00

3.00

4.00

5.00

6.00

7.00

8.00

9.00

Streptococcus Pneumonia

Nebraska RateNational Rate

Year

Inci

denc

e Ra

te

• 2010 - revised reportable disease regulations implemented in Nebraska• Conditions added for laboratories reporting via Automated Electronic

Laboratory Reporting (ELR)

•Acinetobacter spp. •Streptococcus pneumoniae

•Enterococcus spp. •Influenza

•Klebsiella spp. •Clostridium difficile

•Staphylococcus aureus Meningococcal disease, invasive (Neisseria meningitidis)

Objectives

• Calculate estimated incidence rates among nursing home residents for selected agents for 2010 A 2011

• Compare estimated incidence rates for nursing home residents and non-nursing home cases who are 65 years and older

METHODS

ELR (All Reportable Conditions)

Nebraska’s Electronic Diseases Surveillance

System (NEDSS)

Different line lists with selected variables are created and exported

as excel files

HL-7

SAS Codes

Nursing home data • “Nursing home associated case”-

– any lab report where patient address = Nursing home address

• Obtained addresses of all 231 licensed Nursing home facilities

• Nursing home line list - 2010 and 2011

• Selected agents

– Clostridium Difficile – Enterococcus Sp.– Influenza– Methicillin Resistant Staphylococcus Aureus (MRSA)– Non MRSA Staph– Streptococcus Pneumonia

** For influenza only positive cases were included

Non-nursing home data • Lab report data (ELR) for 2010 A 2011

• Selected agents

– Clostridium Difficile – Enterococcus Sp.– Influenza– Methicillin Resistant Staphylococcus Aureus (MRSA)– Non MRSA Staph– Streptococcus Pneumonia

** For influenza only positive cases were included

Estimated incidence rates for nursing home residents 2010 A 2011

Total number of licensed beds in Nebraska were used as proxy for convenience as population at risk to calculate the estimated incidence rates in nursing home facilities

* Proxy for population at risk

Incidence Rate = Number of cases Number of licensed beds*

Compare estimated incidence rates for nursing home residents and non-nursing home cases

• Nursing home cases – Assumption : Majority of the population in nursing home was 65 years and above– All the licensed beds in Nebraska were used by this population

Incidence Rate = Number of cases in nursing home who are 65 yrs and older Total number of licensed beds

• Non-nursing home cases – Number of cases for 65 years and above was included– Age specific population for Nebraska was used to calculate the incidence

(Denominator)

Incidence Rate = Number of cases who are 65 yrs and older Population at risk who are 65 yrs and older

RESULTS

Number and proportion of lab reports for which patient address was available

Year Total Count(n)

% of available address

2010 2660 2394 90%

2011 7136 6315 88.49%

Number and proportion for Nursing homes in Nebraska identified in the Lab reports for 2010

and 2011

• Total Number of Beds – 16,975• Median: 62 • Range: 4 -329

Total # of Nursing homes in Nebraska

# identified in 2010, 2011

Percentage %

231 48 20.77

Nursing home associated cases by age and gender -2010 and 2011

Total 2010 2011 Statewide incidence

Male Total

%

FemaleTotal

%

% Missing gender inform.

Age Median

Age Range

Clostridium Difficile 71 32 39 4.18 59.2 36.6 4.22 79 30-97

Enterococcus Sp. 13 11 2 0.77 38.5 30.8 30.76 67 66-91

Influenza 24 0 24 1.41 58.3 41.7 0 79 30-99

MRSA 7 4 3 0.41 71.4 28.6 0 74 66-81

Non MRSA -Staphylococcus Aureus 4 4 0 0.24 25.0 25.0 50 78.5 72-81

Streptococcus Pneumonia 10 6 4 0.59 60.0 40.0 0 58.5 26-104

Estimated incidence rates for nursing home residents using total number of licensed beds (16,975) in

Nebraska

Clostridium Difficile Enterococcus Sp. Influenza MRSA Non MRSA Staph Streptococcus Pneumonia

0.00

0.50

1.00

1.50

2.00

2.50

Incidence rate for 2010 Incidence rate for 2011

Incid

ence

rate

s per

100

0

Conditions

Estimated incidence rates: nursing home residents vs. non nursing cases (65 years and above)

Clostridium Difficile Enterococcus Sp. Influenza MRSA Non MRSA Staph Streptococcus Pneumonia

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

Nursing home Non Nursing home

Conditions

Inci

denc

e ra

te p

er 1

000

Evaluation

• Chart Review

– Validate number of nursing home cases

Next Steps

• Add question to the investigation:• “ If you are a nursing home resident?”

• Nursing home survey– To get number of residents in each nursing home– Age and gender information

Limitation

• Total population in nursing homes• Age specific information for nursing home

cases• Address information

– No consideration for missing address

Acknowledgement

• Bryan Buss*, DVM, MPH, DACVPM• Eryn Murphyᴪ MS• Tom Safranek**, MD

* CDC Career Epidemiology Field Officer (CEFO), Nebraska Department of Health and Human Services**State Epidemiologist, Nebraska Department of Health and Human ServicesᴪEpidemiology Syndromic surveillance Coordinator

THANK YOU !!!

Questions?!manjiri.joshi@nebraska.gov