[PPT] - Whats New from the CDC? What s New from the CDC? Benjamin Park, MD PowerPoint Presentation

SLIDE 1

What’s New from the CDC? What s New from the CDC?

Benjamin Park, MD Mycotic Diseases Branch y U.S. Centers for Disease Control and Prevention, Atlanta, Georgia g

SLIDE 2

CDC Mycotic Diseases Branch CDC Mycotic Diseases Branch Epidemiology Team Staff

Tom Chiller MD MPH – Team Leader
Ben Park MD – Medical Epidemiologist
Julie Harris, PhD - Epidemiologist
Loretta Chang, MD, MPH – EIS Officer
Debra Wagner MSPH

OTIP Coordinator

Debra Wagner MSPH – OTIP Coordinator
Angela Ahlquist, MPH – Surveillance Epi
Shawn Lockhart, PhD – Antifungals Unit
Arun Balajee, PhD – Molecular Epi Unit
Beatriz Gomez, PhD – Diagnostics Development Unit

SLIDE 3

Outbreaks and Investigations

SLIDE 4

Outbreak of Histoplasmosis- Iowa 2008 2008

SLIDE 5

Initial Investigation

2 employees of “Office A” diagnosed with

histoplasmosis within 2 days by a local MD

Local health department finds

− 7 of 9 had histo

Investigation into Office A building begun

− Shares courtyard with Office B − Recent landscaping

SLIDE 6

Initial Investigation Results

Office A employees

− 78% (7/9) had laboratory evidence

Office B employees

− 0% (0/15) had laboratory evidence

19 environmental samples tested by mouse

peritoneal inoculation

− All negative

Was the office building the source?

SLIDE 7

Further Investigation

Contacted other Office A employees who did not

work at that office

23 Office A employees

− 11 attended Office A awards ceremony at G ’ i Governor’s mansion

All were symptomatic and had laboratory evidence of

histoplasmosis histoplasmosis

SLIDE 8

Governor’s Mansion

Des Moines, Iowa
Host tour groups,

g p , ceremonies and official dignitaries

SLIDE 9

51 Cases 51 Cases High Severity of Illness

Characteristic (N=51) No. % ( ) Median estimated time to resolution of symptoms (95% CI)* 56 days (53-58 days) Ongoing symptoms at time of interview 21 58 Hospitalizations Hospitalizations

*Kaplan-Meier Survival Analysis

SLIDE 10

Cohort Study

Risk factors for infection
Multivariable model

− Outside during ceremony

RRadj 3.3 (95% CI 1.6-6.8)

j

− 4:00pm and 5:30pm

RRadj 2.4 (95% CI 1.2-4.9)

j

SLIDE 11

Main Entrance on November 29

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Environmental Sampling

Type of Sample Results yp p Air Filter Negative Air Filter Negative Filter Negative Filter cassette Negative Bat Guano Negative Bat Guano Negative HVAC filter Negative HVAC filter Negative S il N ti Soil Negative

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Probable Source

Construction activity causing aerosolization of

dust near main entrance

1. Activity in attic disturbed bat guano
2. Boards dropped down chute
3. Digging grounding pits
Ceremony attendees entered or spent time
utside mansion via main entrance

SLIDE 14

Other Investigations

Donor derived IFIs

− Coccidioidomycosis (CA), zygomycosis (NC)

Cluster of C. neoformans among

immunocompetent persons in NC

High cocci rates in a metro Phoenix community

(AZ)

Cocci among prison guards, CA
Nosocomial Aspergillus in Neonatal ICU (England)

SLIDE 15

Subtyping Fungi for Outbreaks

Subtyping is an essential component of public health

− Fusarium keratitis contact lens solution outbreak

Many subtyping methods exist but best method for

Many subtyping methods exist, but best method for
utbreaks not clear
Led by Dr. Arun Balajee

y j

− Currently working on Aspergillus, Candida, Zygomycetes, Coccidioides

C i i ti (f ll 2009)

Co-organizing meeting (fall 2009)

− Methods for subtyping Candida, Aspergillus in outbreak settings − All are invited, look for announcements later in year

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Long-Term Studies Long Term Studies

SLIDE 17

TRANSNET

23 U.S. Transplant centers
Prospective surveillance for proven/ probable IFIs

H t i ti t ll t l t − Hematopoietic stem cell transplants − Solid organ transplants

2001 2006
2001-2006
Unique: enrolled and performed follow-up

− 16 808 OTRs 16,808 OTRs

15% of all U.S. solid organ transplants

− 16,220 HSCTs

20% of all U.S. stem cell transplants

SLIDE 18

IFIs in TRANSNET

1,208 proven/ probable IFIs in OTRs

− 639 invasive Candida − 227 Aspergillus − 97 Cryptococcus

983 in HSCTs

− 425 Aspergillus − 276 Candida − 77 zygomycosis

SLIDE 19

Incidence in HSCT

12-month cumulative

incidence post- t l t transplant

− For any IFI: 3.4% A ill 1 6% − Aspergillus: 1.6% − Candida: 1.1%

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Incidence in OTR

12-month cumulative

incidence post- t l t transplant

− For any IFI: 3.1% C did 1 9% − Candida: 1.9% − Aspergillus: 0.7%

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Is Incidence Lower than Reported?

Other reports- higher incidence
Actually large site-to-site variability

− Range in SCTs= 0.9% - 13.2%

Diverse institutions, not all high risk transplants
Likely variability in case finding or diagnostic

methods

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Trend in 12 month CI: SCT Trend in 12-month CI: SCT

Split to “low risk”

p and “high risk” site groups according to % allo HSCTs to % allo HSCTs

− No clear increase

r decrease by

site

By organism

By organism

− No increase in Candida − Increase in Aspergillus?

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OTR: Trend in 12 month CI OTR: Trend in 12-month CI

By organism

− No increase in Aspergillus − Increase in Candida

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Conclusions- TRANSNET

IFIs in transplant recipients remain a substantial

problem

− Candida in OTR − Aspergillus in HSCT

Epidemiology may be shifting

− No decrease in incidence, even in age of prophylaxis prophylaxis − Candida may be increasing in OTR Aspergillus may be increasing in HSCT − Aspergillus may be increasing in HSCT

SLIDE 25

Candidemia in United States

Candida- 3rd or 4th most common nosocomial BSI
Incidence approximately 10 cases/ 100,000

population

− Determined by CDC population-based surveillance

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Population-Based Surveillance

All cases in a certain defined area (usually

geographic) are counted

Only residents of the area − Only residents of the area

Population is defined (denominator)

− Census Census

Incidence can be calculated

− Numerator= number of cases among residents g − Denominator= population

Resource-intensive, but accurate representation of

truth

SLIDE 27

Candida Surveillance Overview

CDC population-based surveillance

− 1992-93: Atlanta and Houston 1998 2000 B lti d C ti t − 1998-2000: Baltimore and Connecticut − 2008-2010: Atlanta and Baltimore

Atlanta surveillance start date: March 01 2008
Atlanta surveillance start date: March 01, 2008

− 25 hospitals in 8 counties, population = 3.6 million

Baltimore surveillance start date: May 01 2008

Baltimore surveillance start date: May 01, 2008

− 15 hospitals in Baltimore city/ county, population = 1.4 million

To date, 821 cases detected total

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Baltimore Baltimore Preliminary Candida Sp.

Species 2008-2010* 1998-2000 Total cases 273 680 Candida albicans 98 (36) 289 (43) Candida albicans 98 (36) 289 (43) Candida glabrata 66 (24) 188 (28) Candida parapsilosis 60 (22) 72 (11) Candida parapsilosis 60 (22) 72 (11) Candida tropicalis 38 (14) 98 (14) Candida krusei 11 (4)

Candida krusei

11 (4) Other 19 (7) 33 (5)

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Atlanta P li i C did S Preliminary Candida Sp.

Species 2008 2010* 1992 1993 Species 2008-2010* 1992-1993 ATL onlya Total cases 375 428 Candida albicans 143 (38) 230 (54) ( ) ( ) Candida glabrata 120 (32) 49 (11) Candida parapsilosis 64 (17) 79 (18) p p ( ) ( ) Candida tropicalis 34 (9) 42 (10) Candida krusei 4 (1) 5 (1) Other 10 (3) 23 (5)

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Antifungal Treatment (n=554)

Antifungal N % g Fluconazole 271 48.92 Micafungin 114 20.58 Caspofungin 100 18 05 Caspofungin 100 18.05 Anidulafungin 24 4.33 Voriconazole 20 3.61 Amphotericin B deoxycholate 9 1.62 Amphotericin B lipid complex 8 1.44 Liposomal amphotericin B 3 0.54 p p Amphotericin B colloidal dispersion 2 0.36 Itraconazole 1 0.18 Flucytosine 1 0 18 Flucytosine 1 0.18 Posaconazole 1 0.18

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Median survival 29 days

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Preliminary Preliminary FLU Susceptibility- All species

Year Site Drug MIC50 MIC90 1992-3 Atlanta/ SF FLU 0.5 16 1998-00 Baltimore/ CT FLU 0.5 8 2008 Atlanta FLU 2 32 2008 Atlanta FLU 2 32 Baltimore FLU 2 32

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C. glabrata
Dramatic rise in C. glabrata isolates susceptible-

dose-dependent or resistant to Fluconazole

S - DD

52% (prev. 26%)

R

16% (prev. 13%)

Additional 7 isolates resistant (Atlanta) to all

azoles, and one or more echinocandins

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Cryptococcus in HIV Globally

One of the most important HIV-related OIs
Probably very common
How to place in context of other diseases?
Calculate the global burden of disease*

− Frequently performed by public health agencies − Important to plan and prioritize needed resources for disease prevention and control

Benjamin J. Park, Kathleen A. Wannemuehler, Barbara J. Marston, Nelesh Govender, Peter G. Pappas, and Tom M. Chiller, Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/ AIDS. AIDS 2009 23:525-30.

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Approximately 1M Cases/ Yr Globally

720 000

800,000

720,000

600,000 700,000 300,000 400,000 500,000

7,80054,4007,800 500 6,500 27,200 120,000 13,600 100

100,000 200,000 N A m e r i c a L a t i n A m C a r i b b W , C E u r

p

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a h a r a n A f r u r

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e , C A s i a S , S E A s i a E a s t A s i a O c e a n i a W N A S u b

E

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*Park BJ, Wannemuehler KA, Marston B, et al. AIDS 2009

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Sub-Saharan Africa- Estimated Deaths/ Yr

1,000,000 1,200,000

WHO estimate**

600,000 800,000

Current study

200,000 400,000

M a l a r i a d i s e a s e s u s t e r d i s . c

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i s b e r c u l

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i s u d i n g H I V l u s t e r d i s . e p a t i t i s B m e n i n g i t i s e p a t i t i s C D i a r r h

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a l d C h i l d h

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T u b e r S T D s e x c l u d T r

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l u H e p B a c t e r i a l m e H e p

*Park BJ, Wannemuehler KA, Marston B, et al. AIDS 2009 *Excluding HIV/ AIDS **WHO. Revised Global Burden of Disease (GBD) 2002 Estimates. 2002 [Available from: http://www.who.int/healthinfo/bodgbd2002revised/en/index.html.

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More Work Needed

CDC is working with partners to explore best

prevention methods

− Primary prophylaxis- no studies in SSA − Pre-emptive treatment using serum CrAg as screening screening

More efforts sorely needed

Tracking epidemiology of disease − Tracking epidemiology of disease − Improved diagnostics Optimize treatment strategies in many areas − Optimize treatment strategies in many areas

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Other Studies

Cryptococcus gattii in Pacific NW
Organ Transplant Infection Project (OTIP) – cohort

study of lung and allo stem cell transplants

Invasive mold infections in Japan
Burden of coccidioidomycosis in Arizona
More to come…

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Future Directions and Challenges in Future Directions and Challenges in Public Health Mycology

Subtyping methods for use in outbreaks
Emerging molds

− How to perform surveillance and identify trends

Prevention of endemic mycoses

− PPE? Avoiding exposure?

Environmental sources/ testing

SLIDE 40

Acknowledgments Acknowledgments

CDC

K d St ff

TRANSNET Investigators

− Kendra Stauffer − Kavita Trivedi − Roque Miramontes

State Health Departments

− NC, IA, CA, WA, OR, ID, MT, MD, GA − Kathleen Wannemuehler − Barb Marston

Morehead State University

− Ted Pass Rit W i ht − Mary Brandt − Millie Schafer − Rita Wright

Disclaimer: 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