___________________________________________________________________________

2016/LSIF/FOR/002

Strengthening Surveillance for Antimicrobial Resistance and Healthcare-Associated Infections

Submitted by: United States

Policy Forum on Strengthening Surveillance and Laboratory Capacity to Fight Healthcare Associated Infections and Antimicrobial

ResistanceHa Noi, Viet Nam

14-15 December 2016

National Center for Emerging and Zoonotic Infectious Diseases

Strengthening Surveillance for Antimicrobial Resistance and Healthcare-Associated Infections

Neil Gupta, MD, MPH International Infection Control Program U.S. Centers for Disease Control and Prevention

Asia-Pacific Economic Cooperation (APEC) Policy Forum Ha Noi, Viet Nam December 14, 2016

WHO Global Report on Surveillance 2014

Widespread high levels of AMR – % of resistance among tested isolates

Significant gaps

– No global system on surveillance of antimicrobial resistance (AMR)

– Lack of harmonized standards, data sharing, and coordination

WHO Global Report on Surveillance 2014

*Domestic data means data obtained from official sources, but not that data necessarily are representative for the population or country as a whole WHO: Antimicrobial Resistance. Global report on surveillance 2014

Healthcare-Associated Infections Healthcare-associated infections (HAIs) are a significant cause of morbidity

and mortality in health care systems globally

HAI incidence1

– European CDC: 7.1 per 100 patients – US CDC: 4.5 per 100 patients – Resource-limited settings: 15.5 per 100 patients

1 Lancet. 2011 Jan 15;377(9761):228-41. Epub 2010 Dec 9.

AMR Surveillance

Global Action Plan on Antimicrobial Resistance Five strategic objectives 1. Improve awareness and understanding 2. Strengthen the knowledge and evidence base through

surveillance and research – Member States request WHO (2015 WHA Resolution) – “…develop and implement an integrated global program for

surveillance of antimicrobial resistance across all sectors…”

3. Reduce the incidence of infection 4. Optimize the use of antimicrobial medicines 5. Develop the economic case for sustainable investment

How Surveillance Can Improve Health Outcomes

Source: The Review on Antimicrobial Resistance, May 2016

AMR Surveillance Is Dependent on Multiple Steps

Clinicians obtain specimen

Laboratory processes and tests specimen

Public health authorities collect, compile, and report data

AMR Surveillance Is Dependent on Multiple Steps

Clinicians obtain specimen

Laboratory processes and tests specimen

Public health authorities collect, compile, and report data

The “culture” of culturing: • Clinician behavior • Lab factors: costs,

turn-around time, dependability

• Affects interpretation of surveillance data

AMR Surveillance Is Dependent on Multiple Steps

Clinicians obtain specimen

Laboratory processes and tests specimen

Public health authorities collect, compile, and report data

Building laboratory capacity: • Guidelines • Training • Equipment & reagents • Quality assurance

AMR Surveillance Is Dependent on Multiple Steps

Clinicians obtain specimen

Laboratory processes and tests specimen

Public health authorities collect, compile, and report data

Public health engagement in surveillance: • Engaging stakeholders • Harmonizing data • Analysis & reporting • Policy development

Global Antimicrobial Resistance Surveillance System Fostering domestic AMR surveillance systems through harmonized global

standards to: – Monitor AMR trends – Detect emerging resistance – Estimate the extent and burden of AMR globally – Inform targeted prevention interventions – Assess impact of interventions

.

Components of a Domestic AMR Surveillance System Domestic coordinating center Domestic reference laboratory Surveillance sites

– Epidemiological capacity • Trained in collecting epidemiological, clinical, and lab data • Reporting platform

– Laboratory capacity • Appropriate standards, guidelines, and protocols • Strong quality management systems, including EQAS

– Diagnostic stewardship

The Need for Surveillance Systems Despite challenges, imperfect surveillance is

still needed Some data are better than no data

– Although sentinel networks may not be representative, population-based surveillance not likely

Ultimately surveillance should inform public health action

Data

Action

Making the Most of Imperfect Surveillance Systems Start small

– We can focus on challenges better in smaller networks – Lab, clinical practice, reporting – Demonstrate the usefulness of data

Link data to action – Demonstrate interventions that can work

Government should be stakeholders or even owners of the system – Inform policy – Influence big “levers” like accreditation, licensing, payments

HAI Surveillance: The U.S. Experience

CDC’s National Healthcare Safety Network

A secure, web-based system for monitoring healthcare-associated infections (HAIs)

Facilities use the NHSN web portal to enter, analyze, and share data Data is used by a variety of stakeholders:

– Facility: inform local quality improvement efforts – State health departments: identify/support low-performing facilities – National: describe burden, financial bonus and/or penalties

Cumulative NHSN Hospital Enrollment by Year, 2007-2015

0

1000

2000

3000

4000

5000

6000

7000

2007 2008 2009 2010 2011 2012 2013 2014 2015

Year

Num

ber o

f hos

pita

ls

Factors Influencing NHSN Growth Since 2005 Increasing state health department involvement in HAI prevention

– 2007: first state law requiring public reporting of HAI rates is passed – 2009: all state health departments receive CDC funding to establish

HAI programs

2010 — national healthcare reform law contained many quality provisions – 2011: all hospitals must report HAI data to NHSN to receive full

insurance reimbursements (“pay for reporting”) – 2013: bonuses and penalties for high and low performing hospitals

(“pay for performance”)

Use of NHSN Data – Assessing National Progress

Yearly domestic and state progress reports

The most recent report found: – A 50% reduction in CLABSIs

between 2008 and 2014 – An 18% reduction in SSIs

following 10 common types of surgeries between 2008 and 2014

– No change in CAUTIs between 2009 and 2014

http://www.cdc.gov/mmwr/volumes/65/wr/mm6509e1.htm

Use of NHSN Data – Public Reporting of Hospital HAI Data

https://www.medicare.gov/hospitalcompare/search.html

As part of healthcare reform quality reporting programs, hospital-specific NHSN data is posted on a public website for consumers

Use of NHSN Data – Tracking Antimicrobial Resistant HAIs

CDC’s “Patient Safety Atlas” uses pathogen and antimicrobial susceptibility data from NHSN to assess domestic and regional AMR patterns in HAIs reported to CDC

http://www.cdc.gov/hai/surveillance/ar-patient-safety-atlas.html

Target hospitals with highest number of excess infections

• Prevention collaborative networks

• Health Departments • Other partners

NHSN Data U.S. hospitals currently

reporting CAUTI, CLABSI, and C. difficile data

Targeting

Partnering for Prevention

Use of NHSN Data – Identifying Areas for Improvement

CDC’s Work in Viet Nam

A Health Threat Anywhere Is a Health Threat Everywhere

Source: The Lancet 380:9857, 1-7 Dec 2012, pp. 1946-55. www.sciencedirect.com/science/article/pii/S0140673612611519

Global Health Security Agenda Action Packages

Antimicrobial Resistance

Zoonotic Diseases

Biosafety/Biosecurity

Immunization

Domestic Laboratory Systems

This image cannot currently be displayed.

Surveillance

Reporting

Workforce Development

Emergency Operations Centers

Linking Public Health with Law Enforcement

and Multisectoral Rapid Response

This image cannot currently be displayed.

Medical Countermeasures and Personnel Deployment

This image cannot currently be displayed.

U.S. National Strategy: International Need

Goal 5: “Improve international collaboration and capacities for antibiotic resistance prevention, surveillance, control, and antibiotic research and development”

AMR and IPC Capacity Building in Viet Nam AMR surveillance among network of 16 laboratories

– Laboratory assessments, capacity building, quality assurance – Domestic policy and technical documents – Reporting platform and epidemiological support

HAI surveillance among 6 “model” hospitals – Surveillance technical documents – Reporting platform and epidemiological support

Infection prevention and control – Domestic technical advisory group support; guideline development – Facility-based improvement programs, outbreak support

For more information, contact CDC 1-800-CDC-INFO (232-4636) TTY: 1-888-232-6348 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.

Cảm ơn