Georgia epidemiology report, Vol. 14, no. 1 (Jan. 1998)

Georgia

Epidemiology

Report

The Georgia Epidemiology Report is a publication of the Epidemiology Section of the Epidemiology and Prevention Branch, Division of Public Health, Department of Human Resources

January 1998

Volume 14 Number 1

Recommendations for the Control of

Vancomycin-Resistant Enteroccocus

in Long-term Care Facilities

http://www.ph.dhr.state.ga.us
Division Of Public Health
Kathleen E.Toomey, MD, MPH- Director
Epidemiology and Prevention Branch State Epidemiologist Kathleen E. Toomey, MD, MPH- Acting Director
Epidemiology Section Paul A Blake, MD, MPH- Chief
Notifiable Diseases
Jeffrey D. Berschling, MPH; Cherie L. Drenzek, DVM, MS; Katherine Gibbs McCombs, MPH; Karen R. Horvat, MPH; Amri B Johnson, MPH; Jane E. Koehler, DVM, MPH; Preeti Pathela, MPH
Chronic Disease
Ken Powell, MD,MPH- Program Manager , Nancy E. Stroup, Ph.D, Patricia M. Fox, MPH; A. Rana Bayakly, MPH; Mary P. Mathis, PhD, MPH
Tuberculosis
Rose Marie Sales, MD, MPH- Program Manager Naomi Bock, MD, MS; Beverly DeVoe
HIV/AIDS/Sexually Transmitted Diseases
John F Beltrami, MD, MPH- Program Manager Mary Lynn Gaffield, MPH.; Andrew Margolis, MPH
Perinatal Epidemiology
James W. Buehler, MD- Program Manager Mary D. Brantley, MPH; Leslie E. Lipscomb, MPH;
Preventive Medicine Residents
Scott E. Kellerman, MD,MPH; Alexander K. Rowe, MD,MPH; Danielle Sara, MD
EIS Officer
Michael S. Friedman, MD
Georgia Epidemiology Report Editorial Board
Editorial Executive Committee Cherie Drenzek, DVM, MS - Editor Paul A. Blake, MD, MPH Kathleen E. Toomey, MD, M.P.H. Mary D. Brantley, MPH. Jeffrey D. Berschling, MPH
Mailing List Marsha Wilson

in Georgia
Enterococci are gram-positive bacteria that are morphologically similar to streptococci. They are part of the normal flora of the gastrointestinal tract and the female genital tract, and are an important cause of nosocomial infections in the hospital setting. These organisms have traditionally been resistant to a variety of antimicrobials, but were, until recently, consistently sensitive to vancomycin. Since 1989 vancomycin-resistant enterococci (VRE) have emerged as significant nosocomial pathogens in the United States. In 1989, 3% of nosocomial enterococal infections reported from intensive care units to the Centers for Disease Control and Prevention (CDC) National Nosocomial Infections Surveillance System (NNISS) were vancomycin resistant; by 1996 it had risen to 14%. This emergence appears to be directly related to the use, and overuse, of vancomycin, particularly in the hospital setting.
In mid-1995, the CDC published the recommendations of the Hospital Infection Control Practices Advisory Committee for preventing and controlling the spread of vancomycin resistance, with a special focus on VRE. These recommendations refer primarily to VRE control in acute care settings with little mention of VRE control in long-term care facilities such as nursing homes. By the fall of 1996, infection control practitioners and physicians working in long-term care in Georgia were requesting state-based recommendations for preventing the spread of VRE in long-term care facilities. In response to this need, Dr. Kathleen Toomey, Director of the Georgia Division of Public Health (GDPH), convened a working group of representatives from public health, clinical and academic medicine, infection control, laboratories, regulatory affairs, and medical advocacy groups to address the need for recommendations for the control of VRE in longterm care facilities. The recommendations will be available at the end of 1997.
Residents of long-term care facilities may be either colonized or infected with VRE. VRE colonization occurs when the bacteria are present, but not causing disease; colonized sites may include the gastroinetestinal tract, the genitourinary tract, or the skin. Residents are considered infected with VRE when

Epidemiology Section, Epidemiology & Prevention Branch, Two Peachtree St., N.W., Atlanta, GA 30303-3186

Phone: (404) 657-2588

FAX: (404) 657-2586

the bacteria cause clinically apparent disease (e.g., wound infection, bacteremia, urinary tract infection, or intra-abdominal infection).
The epidemiology of VRE is not fully understood; however, the following observations have been made:
1) VRE infections tend to occur in critically ill residents or in residents with severe underlying diseases or immunosuppression.
2) Residents who develop VRE infections have often been previously colonized (e.g., in the gastrointestinal tract) with the organism.
3) Prior vancomycin use in the patient has repeatedly been reported as a risk factor for colonization and infection with VRE.
4) Most VRE infections have been attributed to the indigenous flora of residents involved. However, VRE and other enterococci can be transmitted directly by carriage on the hands of personnel or indirectly via contaminated equipment or environmental surfaces.
5) The vanA gene, which confers high-level resistance to vancomycin, is often plasmid-borne and can be transferred from enterococci to a variety of other gram-positive microorganisms (such as Staphylococcus aureus).
VRE infections can cause serious life-threatening illness, particularly in residents with severe underlying diseases. However, wound infections may be relatively mild and may heal without specific therapy, and some authors have noted that VRE do not appear to be highly virulent.
Despite variability in clinical presentation and outcome, VRE infections represent an important clinical and public health problem for several reasons. First, VRE are an important cause of nosocomial infections in the United States, with subsequent increases in morbidity and mortality rates, as well as costs of hospitalization. Second, because resistance can be transferred between organisms, the potential emergence of vancomycin resistance in clinical isolates of Staphylococcus aureus and Staphylococcus epidermidis is of serious concern. Several cases of patients with bacteremia caused by S. epidermidis resistant to vancomycin were recently reported by the CDC, illus-

trating the clinical potential of transfer of vancomycin resistance to staphylococcal species. Furthermore, methicillinresistant S. aureus (MRSA) infections are widespread in many hospitals in the United States, and vancomycin is the drug used to treat such infections, thereby increasing the possibility of vancomycin resistance emerging in staphylococci. Third, cases of VRE infection complicate issues of resident transfer and monitoring, particularly with regard to transfer from the acute care setting to the long-term care setting.
Control of VRE involves the following:
1) careful adherence to appropriate infection control guidelines;
2) clear communication of information [regarding VRE status of residents;] between facilities and providers
3) education of providers about the significance of VRE as a nosocomial pathogen;
4) development of policies regarding the prudent use of vancomycin; and
5) appropriate and standardized laboratory techniques for isolation, identification and antibiotic susceptibility testing of enterococci. All of these issues will be addressed in the GDPH recommendations.
Data on the epidemiology of VRE and the effectiveness of control strategies are limited. Members of the VRE Working Group also recognize that completely halting the spread of VRE within specific institutions or in the community at large is unfeasible. As additional data become available or as the recommendations are implemented and assessed in various clinical-care settings, the recommendations may be changed or modified accordingly. At this time, the recommendations will address only Enterococcus faecalis and Enterococcus faecium with intermediate-or high-level resistance to vancomycin, and not other enterococcus species. For questions regarding the recommendations or questions specific to VRE, please contact the Georgia DHR, Epidemiology and Prevention Branch, Notifiable Disease Unit, at (404) 657-2588.
This report was contributed by Scott Kellerman, MD, MPH, CDC Preventive Medicine Resident, Epidemiology and Prevention Branch, Georgia Division of Public Health.

Salmonella Gambia: First Detection in the United States

In July 1997, the Georgia Division of Public Health received a report of an illness in a 14 month-old girl caused
by S. Gambia, an extremely rare serotype of Salmonella. S. Gambia (antigen formula 35:/i:/ e,n,z ) was first identi-
15
fied in 1953 in an ill pig in Gambia, West Africa. It is exceedingly rare in the US; there had never before been a

reported human or animal case of this serotype in the United States. The child's family was contacted to inquire about other ill family members, pet exposure, and recent travel. It was discovered that the patient's father had traveled to Gambia, West Africa, in late April and returned in mid-June. Approximately two weeks later, the child was

- 2 -

diagnosed with the S. Gambia infection. The child's father had not experienced any symptoms of illness. He may have been asymptomatically infected case, or perhaps brought back a food product contaminated with S. Gambia from West Africa. Although the mode of transmission could not be determined in this case, it is highly probable that the case contracted S. Gambia from her father.
Salmonellosis, a reportable disease in Georgia, is considered a foodborne disease because contaminated food (usually of animal origin) is the main mode of transmission. The reservoirs for this pathogen include a wide range of wild and domestic animals, such as cattle, swine, poultry, pet iguanas, turtles, dogs, and cats. Human reservoirs are also possible; they include convalescent carriers, and mild or unrecognized cases. Salmonella infections occur worldwide, but they are more extensively reported in the U.S. and Europe perhaps due to better surveillance systems. There are approximately 2,500 known serotypes of Salmonella, but only about 200 serotypes are detected in the U.S.

in any given year. In most countries that maintain Salmonella surveillance systems, a small number of serotypes account for the majority of confirmed cases; S. Typhimurium and S. Enteriditis are the most commonly reported serotypes in the United States.
Serotype information is crucial to determine whether an illness is associated with an outbreak, is endemic, or is a rare occurrence, as it was in this instance. Our thanks to Dr. Mark Stegelman of Egleston Urgent Care and Egleston Children's Hospital Laboratory for submitting the isolate to the GA Public Health Laboratory for serotyping. All Salmonella isolates should be sent to the GA Public Health Laboratory for serotyping. It is a free service, and is vital for public health follow-up and disease prevention.
This report was contributed by Preeti Pathela, MPH, Epidemiology and Prevention Branch, Georgia Division of Public Health.

Kathleen E. Toomey, M.D., M.P.H., Becomes Director of the Division of Public Health

The appointment of Kathleen E. Toomey, M.D., M.P.H., as director of Georgia's Division of Public Health, effective September 16, was announced September 9, 1997 by Tommy C. Olmstead, commissioner of the Georgia Department of Human Resources (DHR). Dr. Toomey was previously the State Epidemiologist and the director of the Epidemiology and Prevention Branch in the Division of Public Health. She replaces Patrick J. Meehan, M.D., who was appointed health director for the Gwinnett-NewtonRockdale district.
Dr. Toomey earned her M.D. and M.P.H. degrees at Harvard University and served her residency in family medicine at the University of Washington in Seattle. She was also a Fulbright Scholar in Peru. Her awards and honors include the CDC Award for Contributions to the Advancement of Women and the Public Health Service Plaque for Outstanding Leadership. She serves on the board of directors of the Alan Guttmacher Institute and the American Public Health Association.

cine, University of California, she worked under the former Assistant Secretary for Health, Phillip R. Lee, M.D.
She also served as an Epidemic Intelligence Service Officer at the CDC, as Clinical Director of the Alaska Native Hospital in Kotzbue, Alaska, and as chairman of the Alaska Council of Clinical Directors. She is a board certified family practitioner.
As the Director of the Epidemiology and Prevention Branch, Dr. Toomey expanded community care as an alternative to hospitalization for people with tuberculosis, strengthened Public Health's ability to respond to outbreaks ranging from meningitis to mosquito-borne diseases, and helped establish a statewide demonstration Chlamydia screening program.
Dr. Toomey will administer programs supported by a $284 million budget, including $155 million in state funds and $129 million in federal funds.

Before becoming Georgia's State Epidemiologist, Dr. Toomey was Associate Director for External Relations in the Division of STD/HIV Prevention at the Centers for Disease Control and Prevention (CDC), and a legislative assistant on health issues for Senator John Chafee, Chair of the Senate Republican Task Force on Health in the United States Congress. As a Pew Health Policy Fellow at the Institute for Health Policy Studies at the School of Medi-

The Division of Public Health oversees 4,879 state and county employees in programs aimed at reducing infant mortality and teen pregnancy, tracking and preventing epidemics, and treating low-income children with chronic diseases or disabilities. The Division also conducts child health screening, environmental monitoring and community health planning throughout the State.

- 3 -

The Georgia Epidemiology Report Epidemiology and Prevention Branch Two Peachtree St., NW Atlanta, GA 30303-3186

January 1998

Volume 14 Number 1

Reported Cases of Selected Notifiable Diseases in Georgia Profile* for October 1997

Selected Health Condition Campylobacteriosis
Chlamydia genital infection
Cryptosporidiosis

Total Reported for Oct. 1997
1997 66
817
12

Previous 3 Months Total

Ending in Aug.-Oct.

1995 1996 1997

305

228

210

3317

4868

2678

75

40

45

Previous 12 Months Total

Ending in Nov.-Oct.

1995 1996 1997

590

823

1076

14262 13789

9807

73

95

103

E. coli O157:H7 Giardiasis Gonorrhea Haemophilis influenzae (invasive)

4 117 1127 6

11 204 5800 1

14 309 5537 10

9 358 3481 10

44 858 17556 46

39 754 21361 47

33 548 17528 38

Hepatitis A (acute)

87

Hepatitis B (acute)

8

Lead Poisoning (capillary BLL >= 10 ug/dL)

0

Lead Poisoning (venous BLL >= 10 ug/dL)

0

Legionellosis

1

22

117

221

11

32

36

978

969

370

211

204

118

1

0

1

673 140 2037 734 1

347 58 3082 620 4

93 124 2528 536 25

Lyme Disease

2

Meningococcal Disease (invasive)

3

Mumps

0

Pertussis

0

Rubella

0

1

0

6

24

24

15

2

5

0

12

11

12

0

0

0

7

1

20

108

155

100

11

11

8

19

34

31

0

0

0

Salmonellosis Shigellosis Syphilis - Primary Syphilis - Secondary Syphilis - Early Latent

144

732

493

473

1389 1455

1651

158

315

396

378

1113 895

1654

15

78

55

40

163

221

274

24

198

137

78

385

526

621

79

403

347

220

1086 1375

1737

Syphilis - Other

72

309

242

292

1246 965

1146

Syphilis - Congenital

3

18

5

5

26

42

61

Tuberculosis

12

211

194

98

656

778

783

* The cumulative numbers in the above table reflect the date the disease was first diagnosed rather than the date the report was received at the state office; and therefore are subject to change over time due to late reporting. The 3 month delay in the disease profile for a given month is designed to minimize any changes that may occur. This method of summarizing data is expected to provide a better overall measure of disease trends and patterns in Georgia.

** Other syphilis includes latent (unknown duration), late latent, late with symptomatic manifestations, and neurosyphilis.
AIDS Profile Update

Report Period
Latest 12 Months: 01/97 to 12/97 Five Years Ago: 01/92 to 12/92 Cumulative: 7/81 to 12/97

Total Cases Reported *

Percent Female

Risk Group Distribution (%)

Race Distribution(%)

M S M IDU MSM&IDU HS Blood Unknown White Black Other

1780

20.8

38.2 18.0

4.1

17.3 1.2

21.2

25.2 71.9 2.9

1957

14.2

51.4 22.3

7.6

11.1 1.9

5.7

37.2 61.0 1.8

18767

15.0

51.3 19.1

5.9

11.8 2.0

10.0

39.4 58.5 2.1

MSM - Men having sex with men IDU - Injection drug users HS - Heterosexual

* Case totals are accumulated by date of report to the Epidemiology Section

- 4-