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Susan Huang, MD MPH

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Harvard Medical School and Harvard Pilgrim Healthcare ... Dataset: Brigham and Women's Hosp. 2001-6 microbiology lab data. All organisms ... – PowerPoint PPT presentation

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Title: Susan Huang, MD MPH


1
  • (Susan Huang, MD MPH)
  • Ken Kleinman, ScD
  • Department of Ambulatory Care Prevention
  • Harvard Medical School and Harvard Pilgrim
    Healthcare
  • National Institute of General Medical Sciences
  • National Institutes of Health
  • Department of Health and Human Services

2
Hospital Outbreak Detection
  • Required of every hospital by the Joint
    Commission
  • Critical elements are mostly familiar
  • Correct assessment
  • Timely identification
  • Tracking of containment (I.e. When is an outbreak
    over?)

3
Current Issues in Hospital Outbreak Detection
  • Outbreaks can involve
  • Any of hundreds of organisms
  • Any hospital unit
  • Any clinical service
  • Medical equipment

4
Current Issues in Hospital Outbreak Detection
  • Currently Incomplete ascertainment
  • Limited surveillance of organisms, patients
  • Mostly based on clinician report
  • Routine tracking of only a few organisms, e.g.
  • MRSA
  • VRE
  • Other highly resistant bacteria
  • Aspergillus

5
Current Issues in Hospital Outbreak Detection
  • Example of current surveillance MRSA
  • Common current alert method 3 incident cases in
    a unit within two weeks outbreak
  • Simulation study showed 3-7 alerts per year,
    24-110 days in alert with this method, based on
    observed unit characteristics and assuming
    constant risk of infection
  • Close to observed outbreak data

6
WHONET-SaTScan A MIDAS product
  • Uses lab data directly instead of clinician
    report
  • Links microbiologic analysis to statistical
    analysis
  • Enables hospital outbreak detection
  • Hospital-wide
  • By unit and related unit groups
  • By service and related service groups
  • By antibiotic resistance pattern

7
WHONET
  • WHO sponsored free software
  • Describes microbiologic data
  • Management
  • Analysis
  • 1200 laboratories 80 countries17 languages
  • Automatically imports data from labs

www.who.int/drugresistance/whonetsoftware
8
Patients with Staphylococcus aureus Isolates
9
www.satscan.org
10
SaTScan Analysis
  • Assesses temporal trends
  • Compares rates across organisms
  • Assesses organism-specific rates
  • Using prior baseline in past year
  • Stratified by unit, service, organism, antibiotic
    profile
  • Provides daily alerts

11
Outbreak Alert SaTScan Parameters
  • First signal for an event has a maximum length of
    60 days
  • Statistical threshold (novel, in this setting!)
  • One false alert per year per comparison
  • recurrence interval of 1 in 365
  • p0.0027

12
WHONET SaTScan Report
  • Signal Alerts
  • Daily report of all new alerts
  • Repeat alert of same cluster if cases increase
  • Alert Data
  • Type of alert (organism, unit, abx resistance…)
  • 1st alert date
  • 1st culture date
  • Observed cases in outbreak
  • Expected cases in outbreak
  • Recurrence Interval

13
Example WHONET Clusters
Dates are fictitious
Confidential
14
Acinetobacter baumanii Cluster
Dates are fictitious
Confidential
15
Acinetobacter baumanii Isolates
Start date 6/1/05
End date 8/1/05
Dates are fictitious
16
Acinetobacter baumanii Suspicious Susceptibility
Pattern
Start 6/1/05
End 7/28/05
Dates are fictitious
17
Outbreak Detection via WHONET-SaTScan Example
  • Dataset Brigham and Womens Hosp.
  • 2001-6 microbiology lab data
  • All organisms
  • First ever per patient (new acquisition)
  • Isolated gt2 calendar days from admission
  • Elements
  • Patient identifiers Clinical service
  • Organism Antibiotic profile
  • Date of culture Location of culture

18
Evaluation 2001-6 SaTScan Alerts
  • Median 15 alerts per year
  • Outbreak Size
  • 2 patients 24
  • 3-5 patients 46
  • 6-10 patients 16
  • gt10 patients 14
  • Outbreak Type
  • Hospitalwide 12
  • Service 10
  • Unit 25
  • Antibiotic Profile 53

19
Evaluation Sensitivity
  • SaTScan found 5 of 5 of Infection
    Control-determined definitive (large) outbreaks
    2001-2006
  • I.e. no false negatives (treating infection
    control as the gold standard)

20
Evaluation False positives?
Non-identification of outbreaks in real-time IC
surveillance does not imply no outbreak Two
readers (infection control program directors)
were given output of SaTScan as if live, answered
questionnaire
21
Concordance
  • Data 2 Years, 23 outbreak alerts
  • Level of concern
  • True/false not known face validity only
  • Recall more data available here than in original
    surveillance

22
Conclusions and Next Steps
  • Meaningful mining of micro data with SaTScan
  • Detection of all epidemiologically confirmed
    outbreaks
  • Frequency, importance of alerts are reasonable
  • Next steps
  • Survey assessment of additional years
  • Chart review assessment of WHONET-SaTScan
    outbreaks not previously known to IC
  • Development of user-friendly interface

23
Collaborators
  • Deborah S Yokoe, MD MPH
  • John Stelling, MD MPH
  • Martin Kulldorff, PhD
  • Hilary Placzek, MPH
  • Michael Calderwood, MD
  • Thomas F. OBrien, MD
  • and Richard Platt, MD MS

24
WHONET Use in the World
  • African Regional Office of WHO (AFRO)
  • Algeria, Kenya, Namibia, South Africa, Tanzania,
    Zambia
  • Eastern Mediterranean Regional Office of WHO
    (EMRO)
  • Jordan, Kuwait, Lebanon, Libya, Morocco, Oman,
    Pakistan, Saudi Arabia, Tunisia
  • European Regional Office of WHO (EURO)
  • Austria, Belgium, Bulgaria, Croatia, Czech
    Republic, Denmark, Estonia, Finland, France,
    Georgia, Germany, Greece, Iceland, Ireland,
    Israel, Italy, Latvia, Luxembourg, Malta,
    Netherlands, Norway, Poland, Portugal, Romania,
    Russia, Slovakia, Slovenia, Spain, Sweden,
    Ukraine, United Kingdom
  • Pan-American Health Organization (PAHO)
  • Argentina, Bolivia, Brazil, Chile, Colombia,
    Costa Rica, Cuba, Dominican Republic, Ecuador, El
    Salvador, Guatemala, Mexico, Nicaragua, Panama,
    Paraguay, Peru, United States, Uruguay, Venezuela
  • South-East Asian Regional Office of WHO (SEARO)
  • India, Indonesia, Sri Lanka, Thailand
  • Western Pacific Regional Office of WHO (WPRO)
  • China, Hong Kong (China), Japan, Republic of
    Korea, Malaysia, Philippines, Singapore, Taiwan,
    Viet Nam

25
(No Transcript)
26
RIS Histograms Ps. aeruginosa
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