Invasive Bacterial Disease Surveillance in Alaska

1
Invasive Bacterial Disease Surveillance in Alaska
CLSA Conference, May 5, 2009

• Tammy Zulz, MPH
• Public Health Analyst
• Arctic Investigations Program
• Coordinating Center for Infectious Diseases

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Summary

• Arctic Investigations Program (AIP) background
• Laboratory activities
• Surveillance program
• Global picture

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AIP History

• 1948 - USPHS established the Arctic Health
  Research Center as part of the Alaska Native
  Hospital in Anchorage
• Infectious diseases, particularly TB, were the
  leading cause of death in Alaska
• 1973 - Arctic Health Research Center closed,
  staff transferred to CDC

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Arctic Investigations Program

• Located on Alaska Native Tribal Health Consortium
  campus
• Staff includes employees from
• IHS
• Tribal organizations
• State of Alaska
• CDC

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Arctic Investigations Program

• Epidemiology
• 5 physician epidemiologists
• 3 research nurses
• Public health analyst
• Laboratory
• Microbiology (3)
• Molecular Diagnostics (4)
• Computer Statistics
• Administration

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AIP Mission

• To prevent infectious disease morbidity and
  mortality in people of the Arctic and Subarctic
• with special emphasis on diseases of high
  incidence and concern among indigenous people

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AIP Priorities

• Vaccine preventable diseases
• Antimicrobial resistance
• Eliminating health disparities
• Bioterrorism preparedness and response
• Emerging infectious diseases

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Laboratory Activities

• Surveillance
• Streptococcus pneumonaie
• Haemophilus influenzae
• Neisseria meningitidis
• Groups A and B Streptococcus
• Helicobacter pylori
• MRSA
• Respiratory viruses

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Laboratory Activities

• Building Laboratory Capacity
• Develop new assays
• PCR
• for detection and identification of pathogens
• for detection of virulence factors, mechanism of
  resistance
• PFGE for strain subtyping
• Bioterrorism response
• LRN level B/C
• BSL III
• B. anthracis, Y. pestis, F. tularensis, Brucella
  sp

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Laboratory Activities

• Support epidemiologic studies, outbreak
  investigations and vaccine evaluation studies
• H. influenzae type b eradication
• Pneumococcal carriage
• MRSA outbreak
• H. pylori reinfection
• Hepatitis B vaccine in infants/children
• Respiratory virus identification

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Surveillance Organisms

• Streptococcus pneumoniae, 1986
• Haemophilus influenzae, 1980
• Neisseria meningitidis, 2000
• Groups A B Streptococcus, 2000

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Statewide Invasive Bacterial Disease Surveillance
Participating Hospital/Clinic Laboratories
Barrow
Total population 640,000 AK Native 125,000
Kotzebue
Fairbanks
Nome
Palmer Anchorage
Bethel
Petersburg
Valdez
Soldotna
Juneau
Dillingham
Sitka
Kodiak
Ketchikan
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Reportable Organisms

• Previously reportable
• Hi, Nm
• Reportable since January, 2007
• GAS, GBS, Sp
• Case reports to State DPH
• Isolates to CDC/AIP

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Methods

• Labs submit sterile site isolates
• Confirmation and serotyping
• Antimicrobial susceptibility testing
• Clinical and demographic information collected
• Data entered and analyzed
• Annual audits for missing cases
• Yearly reports generated

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Surveillance Cases ReportedAlaska, 2000-2008
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Haemophilus influenzae type b

• Prevention
• Bacterial Polysaccharide Immune Globulin (BPIG)
• Polysaccharide (PRP) vaccine
• Conjugate Vaccines
• PRP-D
• HbOC (HibTITER)
• PRP-OMP (PedvaxHIB)
• HbOC,D,T,P (Tetramune)
• PRP-OMP, Hepb (ComVax)

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Invasive Hib Disease, Children Aged lt5 Years,
Alaska,1980 - 2008
PRP-OMP
PRP-OMP/HbOC
DTwP-HbOC
PRP-OMP-Hep B
Singleton, et al. J Pediatr 2000 137313-20 and
CDC, unpublished
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Remaining challenges..

• Can Hib be eliminated?
• Continued surveillance
• Improve serotyping QC
• Slide agglutination vs PCR
• Reduce Hib carriage
• Will we see replacement of Hib?
• Invasive disease caused by other serotypes or
  nontypeables

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H. influenzae a (Hia) Outbreak

• Last 6 months of 2003
• 5 cases of Hia
• Cases occurred in 3 infants
• 2 infants developed recurrent Hia

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Hia Outside of Alaska

• Utah
• 5 cases of Hia in 1999
• Increased virulence
• Navajo
• A leading cause of pediatric bacterial meningitis
• International Circumpolar Surveillance
• 2000-2006 25 cases in children lt2 in N. Canada

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Hia Unanswered Questions

• Reason for increase
• Changes in carriage?
• Changes in virulence?
• Chemoprophylaxis
• Yes for Hib, but for Hia?
• Factors
• Extent of colonization
• Evidence of secondary transmission

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Prospective Study - HIRRI

• Investigate cases
• Invasive encapsulated H. influenzae
• Alaska children lt 10 y.o.
• Evaluate colonization among
• Close contacts
• Other members of the community

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Objectives

• Describe cases
• Determine nature and extent of Hi colonization
• Determine risk factors for invasive Hi disease
• Characterize the strains of Hi using molecular
  epidemiology
• Prevention and control of disease

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Streptococcus pneumoniae

• Prevention
• 23 valent pneumococcal polysaccharide vaccine
• Pneumovax
• Conjugate vaccine
• PCV7 (Prevnar) 4,6B,9V,14,18C 19A,23F
• Education
• Appropriate antibiotic use

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Invasive Pneumococcal Disease in Alaska, 1996-2000
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Invasive Pneumococcal Disease in Alaska, lt 2 Year
Olds, Pre-Vaccine, 19952000
73
79
Alaska Natives Non-Natives
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Invasive Pneumococcal Disease in Alaska, lt 2 Year
Olds, Pre (19952000) and Post (20012005)
Vaccine Introduction
92
87


Alaska Natives Non-Natives
P lt 0.001, decline in vaccine type
Hennessy, et al, Vaccine, 2005
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Invasive Pneumococcal Disease in Alaska, lt 2 Year
Olds, Pre (19952000) and Post (20012005)
Vaccine Introduction



Alaska Natives Non-Natives
P lt 0.001, decline in Vaccine type P 0.04
for increase in non-Vaccine type
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Trends in Antibiotic Resistance Among Invasive
Pneumococcal Isolates Alaska, 1986 - 2007
Pen-NS non-susceptible, Pen-FR fully
resistant
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International Circumpolar Surveillance
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Objectives

• Establish an integrated network of hospital,
  public health, and reference laboratories
  throughout the Arctic
• Monitor infectious disease rates trends
• Identify risk factors for disease
• Evaluate intervention options
• Monitor intervention effects

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Acknowledgements

• Clinical laboratories in Alaska
• State of Alaska Public Health Laboratory
• State of Alaska Division of Epidemiology
• Arctic Investigations Program