November 4, 2005

Epi Update Managing Staff:

M. Rony François, MD, MSPH, PhD, Secretary, Florida Department of Health
Russell W. Eggert, MD, MPH, Director, Division of Disease Control
Dian K. Sharma, MS, PhD, Bureau Chief, Bureau of Epidemiology, Editor-in-Chief
Jaime Forth, Managing Editor, Bureau of Epidemiology

"The reason for collecting, analyzing and disseminating information on a disease is to control that disease. Collection and analysis should not be allowed to consume resources if action does not follow."

Foege WH., International Journal of Epidemiology 1976; 5:29-37



Methicillin-resistant Staphylococcus aureus in a
Hospital Maternity and Delivery Unit
Volusia County, Florida 2005
by Andre Ourso, MPH
 

Background
Methicillin-resistant Staphylococcus aureus (MRSA) is a common bacterial infection that occurs in most healthcare facilities and has become a common infection in the community. MRSA is resistant to antibiotics called beta-lactams, which include methicillin, oxacillin, penicillin and cephalosporins. Healthcare associated (HA) MRSA occurs in those admitted into hospitals and other healthcare facilities (nursing homes and dialysis centers) and affect persons with weakened immune systems. This type of  MRSA often causes surgical wound infections, urinary tract infections and pneumonia. Nosocomial infection occurs approximately 72 hours after hospitalization. Community associated (CA) MRSA infects usually healthy individuals with no recent history of hospitalization or medical procedures (surgery, catheters). This type of MRSA is often manifest as skin infections, such as pustule lesions, pimples or boils¹.  

The Volusia County Health Department was notified on August 29^th 2005 of a cluster of MRSA infections in the Maternity/ Delivery Unit of Hospital A. The infections involved the skin and were present in both mothers and neonates. The case definition for this outbreak was any mother, neonate or staff member with clinical infection of MRSA who stayed or worked on the maternity unit in the months of July and August 2005 supported by a positive MRSA culture. There were no other cases of MRSA within the unit during the previous nine months. 

Description of Cases
The Infection Control Unit at Hospital A provided the county epidemiologist with a list of suspected cases, symptoms and other epidemiological information. Laboratory results of positive MRSA culture were gathered from facilities where cases sought treatment for the infections including Hospital A, community Hospital B, the Flagler CHD and patients’ pediatricians. There was no commonality with the patient cases primary care physicians. Also, two different OB/GYNs delivered the five neonates; nothing was evident to implicate transmission among the delivery physicians. A total of 6 individuals, one mother and 5 neonates met the case definition. M1 and B2 were the only mother/child combination that both developed a MRSA infection (Table 1). 

 Table 1. Data on Confirmed Cases of MRSA    
M= Mother   B= Baby

The apparent index case was M1. Risk factors for the expectant mothers of the five neonate cases included one mother admitted in June for one day for preterm labor, and two mothers who were group B streptococcus carriers (this includes the index case) and were treated with antibiotics approximately one month before delivery. Otherwise, all mothers and babies were healthy and lacked any serious risk factors for MRSA infection. The average length of stay for mothers was 2.6 days. Onset of clinical infection occurred anytime between 4 days and 19 days after delivery or birth (Table 1).  All cases had infections to the skin and manifested in cellulitis, pustular lesions or rash. 

Environment
The maternity unit at Hospital A is separated into individual private rooms where the labor and delivery take place. There is also an operating room and a seldom-used nursery area. All patient cases were in private rooms. The six patients were admitted into four different rooms. By the time hospital infection control notified VCHD, contact and isolation precautions were already in place. Infection control also reviewed house cleaning procedures and thorough cleaning of the unit was performed throughout the outbreak period. Linens, surfaces and medical devices and instruments were thoroughly cleaned. All neonates use disposable diapers.  

Laboratory Evidence
Antibiotic susceptibility patterns were collected for all patient cases; a total of eight cultures were obtained. All susceptibility cultures were similar. All cases were resistant to penicillin, oxacillin and erythromycin. Five cases that tested for susceptibility on cephalosporins were also resistant to cefazolin and ceftriaxone. All cultures taken from patient cases were susceptible to gentamicin, vancomycin, levofloxacin and rifampin (Table 2). Isolates of the cultures were not available for pulsed field gel electrophoresis (PFGE) analysis; by the time VCHD was notified cultures had been disposed of by hospital and private laboratories. Most labs only keep MRSA cultures for about five days. 

Table 2. Antibiotic Resistance of Cases
n=6 ( ) indicates number of cases that
were tested for the specific antibiotic.
Labs do not test all or the same antibiotics.

Table 3. Susceptibility Patterns from
Staff Members in Maternity Unit

Nasal swabs were cultured for 35 of 38 staff members for evidence of MRSA carriage. One person had a positive culture for MRSA and the susceptibility pattern was different from the cases with resistance to levofloxacin (Table 3). This individual was sent to a physician for decolonization and was not to return to work until a negative culture is obtained. Additionally a non-random sample of eight culture results and susceptibility patterns from seven ED and inpatient cases were acquired from Hospital A and community Hospital B.  All eight cultures showed resistance to levofloxacin (a fluoroquinolone), and one showed resistance to both levofloxacin and genatmicin (Table 4).

Table 4. Antibiotic Resistance of
Non-maternity Unity of MRSA
Sample n=7
( ) indicates number of susceptibility
tests for the specific antibiotic. Labs
do not test all or the same antibiotics.

Discussion and Recommendations
Implementation of infection prevention and control guidelines probably led to the outbreak subsiding, as no other cases have been reported as of September 9th. Source and mode of transmission cannot be determined since no staff cultures showed a similar antibiotic susceptibility pattern. As with typical MRSA outbreaks, transmission via contaminated hands is a likely source².  Strict hand washing and aseptic techniques should be adhered and enforced. Thorough cleaning of surfaces, beds, cribs and furniture with a disinfectant should be continued before admitting new patients into a room. Consider wiping down mattresses. Linens and diapers should be handled and disposed or laundered appropriately. All instruments should be autoclaved if possible. Examine all patients for pustules or draining lesions before admittance. Any staff with lesions or clinical manifestations of MRSA should be excluded from work immediately. During an outbreak period, staff should be tested for asymptomatic carriage. Most of these procedures were followed before VCHD was notified and this probably limited the outbreak. 

Additionally, when two or more concurrent cases of MRSA occur in a maternity ward an outbreak should be assumed and notification of the local public health agency is warranted. Consider notifying hospital labs to keep clinically important isolates for extended periods of time so the state laboratory may subtype strains through PFGE. During an outbreak period, notify newborn’s pediatricians by letter or fax of potential MRSA and recommend they notify their private referral labs to keep isolates or send them to the state lab or hospital for additional testing.   

This cluster of MRSA is indicative of possible nosocomial spread of CA-MRSA. Its possible transmission may have occurred with the introduction of CA-MRSA into the unit by staff or patients³. The susceptibility patterns of cases differed from other CA-MRSA samples collected from the two hospitals. The pattern of CA-MRSA seen in the maternity unit is not unique and is seen statewide in Florida⁴.  HA-MRSA infections are known to have multi-drug resistance. CA-MRSA infections have susceptibility to multiple classes of antibiotics except the beta-lactams⁵. Cultures of the outbreak cases showed susceptibility to more antibiotics then the sample acquired from Hospitals A and B. The one positive staff member and seven non-random samples all showed resistance to fluoroquinolone and levofloxacin, while the maternity ward cases were all susceptible to levofloxacin. The antibiogram pattern seen in the non-maternity sample (table 4) taken from Hospital A and community Hospital B is not a HA-MRSA strain, but is also not a common CA-MRSA strain seen in the state⁴.   

Additionally, these patient cases lacked traditional risk factors and like community-associated MRSA, all the cases had clinical infections of the skin, another sign of infection with a CA-MRSA strain⁵. Strict hand washing should be stressed in this unit at all times. Also, physicians should administer antibiotics judiciously; broad spectrum antibiotics should be avoided when possible. It is probable that the source of this cluster is not health care associated and was probably brought into the unit through community exposure of staff or patients. This outbreak cluster is indicative of the current problem hospitals face as CA-MRSA becomes more prevalent in health care facilities.    

References
1. Centers for Disease Control and Prevention, CA-MRSA Information for Clinicians. 2005; retrieved from: http://www.cdc.gov/ncidod/hip/ARESIST/ca_mrsa_clinician.htm.
2. Heyman DL, ed. Control of Communicable Diseases Manual. American Public Health Association 2004; 18: 501-504. 
3. Bratu S, et al. Community- associated Methicillin-resistant Staphylococcus aureus in Hospital Nursery and Maternity Units. Emerging Infectious Diseases 2005; 11 (6): 808-813. 
4. Personal correspondence with Roger Sanderson MA, BSN, Bureau Epidemiologist. 
5. Comparison of Community and Health Care- Associated Methicillin- Resistant Staphylococcus aureus Infection. JAMA 2003; 290 (22): 2976-2984. 

Andre Ourso is an EIS fellow assigned to the Volusia County Health Department and can be reached at (386) 274.0618.

Regional Epidemiology Seminar to be Held in Volusia County in January 2006
by Linea Sundbye

The next Regional Epidemiology Seminar, co-sponsored by the Bureau of Epidemiology and the Volusia County Health Department will be held in Daytona Beach, Florida on Thursday, January 5th and Friday, January 6th, 2006 at the Volusia County Health Department. Target audiences for regional training programs are county health department staff members who conduct epidemiologic investigations, and infection control practitioners.  

This program will specifically address public health surveillance and communicable disease outbreak investigations as well as epidemiologic response to natural disasters. Carbon monoxide poisoning surveillance, poison control, ESF 8 operations, arboviral surveillance, the medical examiner mortality system and an outbreak scenario will be covered in this training. On-line registration is now available and can be accessed through the Bureau of Epidemiology Internet web site at http://www.doh.state.fl.us/disease_ctrl/epi/conf/training/agenda.htm. The class will be limited to 45 participants. CEUs will be offered for this program to nursing, environmental health professionals and laboratorians. 

Additional information will be provided in future issues of Epi Update and on the Bureau of Epidemiology web page. We intend to offer future training programs in other regions of the state. If you're interested in hosting one of the training sessions or have questions related to this program, please feel free to contact Linea Sundbye at SunCom 205-4444, ext. 2436. 

We are truly excited about the potential this program offers for improving disease prevention in Florida and hope you'll make plans to join us.

Linea Sundbye is the assistant training coordinator for professional training at the Bureau of Epidemiology in Tallahassee. She can be reached at 850.245.4444, ext. 2436.

Florida Refugee Health Program: An
Important Piece of the Public Health Safety Net
by Jill Parker, MSP and Laura A. Smith
 

Refugee health services are an important component of the public health safety net. Last year the Florida Refugee Health Program through the county health departments provided post-migration health screenings and vaccinations to approximately 24,000 persons, mostly from Cuba, Haiti and Colombia, although we serve people from far reaches of the globe, such as the Sudan, Somalia and Myanmar. Refugee Health Program clients typically resettle in Miami-Dade, Hillsborough, Palm Beach, Broward, Orange, Duval, Collier and Pinellas counties. 

Communicable disease control is a focus of refugee health services since many of infectious diseases are endemic to the various countries of origin of refugee health clients (e.g., malaria, dengue, TB, HIV, hepatitis). Within 90 days of their entry to the country, refugee health clients receive a health screening to detect communicable diseases as well as chronic conditions that may impede employment or school entry.   

Prior to immigration the refugee health clients are required to complete an overseas medical examination, but these exam results are not always a reliable safety mechanism to prevent the introduction of communicable disease to the United States; sometimes, there is a time lag of up to one year between the overseas examination and actual immigration. For example, in 2004 there were approximately 81 cases of varicella and 25 cases of measles reported among 4,000 U.S.-bound Liberian refugees. Additionally, in 2005 there were reported cases of TB (including multi drug resistant) among refugees who had immigrated to United States from Thailand. (MMWR, August 5, 2005).   

A variation of these scenarios could happen in Florida if we do not have strong cooperation and open communication among all communicable disease programs, including HIV/AIDS, TB, STD, and epidemiology. Take time to ponder these questions:  How can we learn from each other?  Do we know how other programs operate?  What are the different processes for detection, reporting, and follow-up of communicable diseases across various programs? Are we letting important information fall through the cracks?  How can we make our programs operate more efficiently and become less redundant? 

If you would like to learn more about refugee health services, please contact Laura Smith or Jill Parker at 850.245.4350.

Jill Parker works in the Bureau of Refugee Health in Tallahassee and Laura A. Smith is the Refugee Health Program Administrator. Both can be reached at 850.245.4444, ext. 2306.

 
Bureau of Epidemiology Announces Publication
of New Pregnancy-related Series
 by Curt Miller

The Florida Department of Health, Bureau of Epidemiology is pleased to announce the publication of the entire series of the Florida Pregnancy Risk Assessment Monitoring System (PRAMS) survey datasets beginning with 1993 through 2003. 

This series of data books presents each year of existing Florida PRAMS data as an organized retrospective of thousands of detailed statistics.  Each of the 11 data books is a comprehensive publication citing detailed results of extensive statistical analysis of the wide range of maternal behaviors, pregnancy-related outcomes, and maternal demographics that are collected and measured via the Florida PRAMS survey.   

These comprehensive data books that will enable all interested parties to have immediate access to the complete range of PRAMS statistics for every year of available Florida PRAMS data. Additionally, this series of data books provides the opportunity for a comparative trend analysis of important Maternal and Child Health issues from one year to another. 

To make navigation through the material as user-friendly as possible, the layout of the bookmarks follows that of the table of contents. Access these individual reports at the Florida Department of Health website at  http://www.doh.state.fl.us/disease_ctrl/epi/prams/prams.htm.

Mr. Miller is a data analyst for the Chronic Disease Surveillance Section in the Bureau of Epidemiology in Tallahassee. If you need more information, call him at 850.245.4444, ext. 2407.

                                                                                                                                                             
Bureau of Epidemiology Grand Rounds Program Rescheduled Due to Hurricane Wilma
by Melanie Black, MSW

Due to hurricane Wilma, the Bureau of Epidemiology monthly Grand Rounds program to have been held on October 25, 2005 has been rescheduled to Tuesday, November 29, 2005 11:00 a.m. -12:00 p.m., EST. Carina Blackmore, MS Vet. Med., PhD, DVM, State Public Health Veterinarian will be presenting on Rabies Prevention and Control in Florida. Dr. Blackmore will discuss risk factors for rabies transmission to humans, the steps of a rabies exposure risk assessment and available intervention strategies including post exposure rabies prophylaxis and the vaccination regimen for pre and post exposure rabies prophylaxis. One hour of continuing education units will be offered for this program to nursing, environmental health professionals and laboratorians. 

The Tuesday, December 27, 2005 program will feature Joann Schulte, DO, MPH, medical epidemiologist, CDC assignee to the Bureau of Epidemiology, Florida Department of Health; and Phyllis Yambor, RN, Bureau of Immunizations, Florida Department of Health presenting on Meningococcal Vaccine Safety: Issues in Surveillance and Epidemiology. This presentation will feature a discussion on the role of epidemiology in monitoring adverse reactions associated with vaccines and the role of the VAERS system, describe the current investigation of possible adverse events related to the newly licensed conjugate meningococcal vaccines and review recent trends in the meningococcal disease in the US and Florida. One hour of continuing education units will be provided to nursing professionals and laboratorians. 

For further information about this program contact Melanie Black, MSW, professional training coordinator at 850.245.4444, ext. 2448.         


Mosquito-borne Disease Summary October 23- 29, 2005
Rebecca Shultz, MPH, Caroline Collins, Tasharra Kenion, Calvin DeSouza, Carina Blackmore, PhD

During the period October 23-29, 2005, the following arboviral activities (St. Louis encephalitis [SLE] virus, eastern equine encephalomyelitis [EEE] virus, Highlands J [HJ] virus, West Nile [WN] virus and dengue virus) were recorded in Florida: 

Dead birds should be reported to www.wildflorida.org/bird/. See the web page for more information at www.MyFloridaEH.com. The Disease Outbreak Information Hotline offers recorded updates on medical alerts status and surveillance at 888.880.5782.

     

           This Week on EpiCom
                                      by Christie Luce

The Bureau of Epidemiology encourages Epi Update readers to not only register on the EpiCom system at https://www.epicomfl.net but to sign up for features such as automatic notification of certain events (EpiCom_Administrator@doh.state.fl.us) and contribute appropriate public health observations related to
any suspicious or unusual occurrences or circumstances. EpiCom is the primary method of communication
between the Bureau of Epidemiology and other state medical agencies during emergency situations.

• Probable case of classical CJD in NW Florida
• Official death count of 21 in 7 FL counties from Wilma as of 10/31

Christie Luce is administrator of the Surveillance Systems Section in the Bureau of Epidemiology. She can be reached at 850.245.4444, ext. 2450.
 

                         Weekly Disease Table
                                                          by D'Juan Harris, MSP

Click here to review the most recent disease figures provided by the Florida Department of Health Bureau of Epidemiology.

D'Juan Harris is a GIS specialist in the Surveillance Systems Section of the Bureau of Epidemiology.
He can be reached at 850.245.4444, ext. 2435.

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