LA-MRSA Past, present and Future Danish perspective. Robert Skov, MD Head, Bacteriological Surveillance and Infection Control Statens Serum Institut

Size: px

Start display at page:

Download "LA-MRSA Past, present and Future Danish perspective. Robert Skov, MD Head, Bacteriological Surveillance and Infection Control Statens Serum Institut"

Carmel Goodwin
7 years ago
Views:

1 LA-MRSA Past, present and Future Danish perspective Robert Skov, MD Head, Bacteriological Surveillance and Infection Control Statens Serum Institut

2 PAST EARLY EXPERIENCES The first Human LA-MRSA case was found in Similar to The Netherlands The first MRSA in pigs were found in 2006 Early 2007, an intersectorial taskforce consisting of National Board of Health, Danish Veterinary and Food Administration, DTU-Food and Statens Serum Institut were formed Prevalence studies in veterinarians - IPVS conference in Copenhagen in / % carried MRSA, 31 were ST398 - Denmark 9/674 veterinarians 3.9% In 2008 EU made the Baseline study examining the presence of MRSA through out Europe Wulf, CMI, 2008, 29; Moodley, Scand J work Environ Health, 2008, 151.

3 EU BASELINE STUDY

4 DEVELOPMENT IN PIGS

5 2009, 2011 AND 2014 INVESTIGATIONS Slaughter (N=789) 13% MRSA positive Pig farms (N= 79), 16 % MRSA positive - Slaughter (N=777), 44 % MRSA positive Breeding herds (N=70) 63% MRSA positive - Slaugther herds (N=205) 68% MRSA positive

6 2009 INVESTIGATION Agersø, Vet Microbiology,

7 OTHER LA- ST/CC TYPES Both animals and humans pigs pigs pigs? humans humans humans Fitzgerald, Trends Micro, 2012

8 OTHER LA- ST/CC TYPES Both animals and humans pigs pigs pigs? Is it the same strains we see in animals vs humans? If so humans what is direction of transmission? To what extent are these strains established as reservoirs in both animals and humans? humans humans Fitzgerald, Trends Micro, 2012

9 DEVELOPMENTS IN HUMANS

10 NEW MRSA CASES HU VS LA-MRSA (CC398) CC398 mmrsa

11 NEW MRSA POSITIVE HU VS LA MRSA CC398 u inf CC398 m inf mmrsa u inf mmrsa m inf

12 CC398 GEOGRAPHY

13 Infections per category Development in no. of infections according to epidemiological classification - Import, Hospital-acquired, Community onset-health care associated, Community-acquired, LA-MRSA

14 BACTEREMIA - MRSA Approx / year 138 from CC398 7 cases cases (48 HU, 8 CC398) MSSA / year (> from ) cases ( MRSA 2,7%) Mortality - HU MRSA 20% - CC persons within 30 days ( kvt 2014) - All 5 persons had severe co-morbidity - None of the 5 had direct contact to swine

15 DEVELOPMENT IN No. of new cases per month

16 2015 VS No. of new cases per month

17 COMMUNITY LA-MRSA In 2014, 141 out of 1277 CC398 cases (11%) had no contact to swine - Resides primarily in areas where CC398 are found in humans with known exposure to LA-MRSA This percentage has remained constant (10-15%) all through the

18 COMMUNITY LA-MRSA In 2014, 141 out of 1277 CC398 cases (11%) had no contact to swine - Resides primarily in areas where CC398 are found in humans with known exposure to LA-MRSA This percentage has remained constant (10-15%) all through the Larsen, Euro Surveill. 2015;20(37):pii=30021

19 RISK FACTORS FOR ACQUISITION OF LA-MRSA WHEN NOT IN CONTACT TO LIVESTOCK

20 RISK FACTORS FOR ACQUISITION OF MRSA Direct and close contact to humans /animals positive for MRSA is by far the most important risk factor for acquisition of MRSA - Even if you are exposed to MRSA it is by far each time you become a carrier of MRSA In practice it requires close frequent contact to become a carrier - Living in the same household Only very small risk for become a carrier if one only have normal social contact - Visit, sport, shopping Transmission can also occur through contact to contaminated surfaces / items - Normally the environmental load is quite low and this route of transmission is of far less importance than direct transmission Sharing of personal items i.e. towels, sports equipment S. aureus can also survive for prolonged time at innate surfaces

21 RISK FACTORS FOR ACQUISITION OF LA-MRSA Presently only limited evidence for route of transmission - Contact with people with exposure to LA-MRSA positive animals? - Environment? - Meat?

22 TRANSMISSION THROUGH MEAT Found in meat both from Denmark and several countries (at least from 2007 and onwards % of samples of pork - 20% of poultry As a consequence millions of people have handled meat throughout the period, however very few cases in large cities both in Denmark and in other countries Furthermore, workers at slaughterhouses working with meat only is very seldom positive Risk assessment: (Denmark and EFSA) - Risk is very limited for transmission through meat the risk is associated to handling of the meat Normal good kitchen hygiene including handwash after touching the meat will eliminate the risk

23 ADAPTATION?

24 RISK FOR ADAPTATION WGS of 89 isolates phisa3 positive Derived clade MRSA Livestock human tet R phisa3 negative Basal clade MSSA Human tet S phisa3 positive Price, mbio, 2012

25 INCIDENCE OF SCN POSITIVE ISOLATES Incidence of SCN positive isolates among patients with infections /93 (3%) with livestock contact 3/48 (6%) without livestock contact /165 (6%) with livestock contact 8/57 (12%) without livestock contact Numbers still small Majority of infections still caused by scn negative isolates, but - increasing No. of SCN positive isolates! - higher proportion of SCN positive isolates in patients without livestock contact

26 INTRA-HOUSEHOLD TRANSMISSION Spread of LA-MRSA in North Jutland County - 36 primary cases 31 carried ΦSa3/IEC-negative LA-MRSA CC household contacts - 16 secondary cases - transmission rate = 16/74 = 21.6% 5 carried ΦSa3/IEC-positive LA-MRSA CC household contacts - 11 secondary cases - transmission rate = 11/17 = 64.7% P = 0.001

27 RISK MANAGEMENT

28 RISK MANAGEMENT 2014 Establishment of a cross ministry Forum for LA-MRSA - FVST, SST, AT DTU-FOOD, DTU-VET, SSI Ministry of Food and agriculture: 5 point action plan - 1: Infection control to keep LA-MRSA from escaping from the stables Change of clothes and handwashing - 2: Demand for farms to have a zoonotic biosecurity plan - 3: Stop for routine batch medication - 4: Establishment of advisory service for LA-MRSA Rådgivningstjenesten for MRSA I dyr - 5: Investigations into the taxation for antibiotics

29 Rådgivningstjenesten for MRSA I dyr 3 year project w 1 infection Control Nurse - Hotline for farmers, employees, health care workers and citizens on questions regarding LA-MRSA Hotline nr: mrsaidyr@ssi.dk - Educational activities, lectures Informational meetings for farmers and employees, food inspectors, town hall meetings

30 Leave MRSA 398 in the stable! Wash hands Use hand desinfection Shower OBS surfaces Keep clothes separated No towels Use paper

31 RISK MANAGEMENT 2015 Settlement in the Danish parliament on LA_MRSA - 15% reduction in use of antibiotics over the next 4 years - Differentiated yellow card - Infection control Bath before leaving the farm after work Strengthening of the advisory service - 1 additional nurse in the advisory service fall 2015 Educational course on Infection control for employees at pig farms - Reseach 35 mill Dkr research project - International focus

32 RESEARCH

33 GATE 1, Study in investigate the effect of hygiene to reduce transmission from pig workers to household members - Gate 1 Performed by SSI, University of Copenhagen, National Research centre for the Working Environment and SEGES 50 farms will be assessed for hygiene level - MRSA levels will be established - Positive household members will be treated Intervention phase where 50% will receive education in infection control - Assessment after 6 months to see the effect

3 YEARS RESEARCH INITIATIVE studies to underpin decisions towards a strategy to control livestock associated LA-MRSA and limit its spread to humans - A

34 3 YEARS RESEARCH INITIATIVE studies to underpin decisions towards a strategy to control livestock associated LA-MRSA and limit its spread to humans - A 3 year research initiative - Commissioned by the Ministry for Environment and Food - DTU-VET, SSI, National Research centre for the Working Environment

35 FUTURE SCENARIOS For CC398 - If status quo Although incidence among persons with contact to swine will level off Incidence among persons with no contact to swine is expected to increase Prevalence is expected to increase Number of severe infections is expected to increase - If adaptation happens then broad dissemination into the general population is to be expected resulting in considerable increase in prevalence of MRSA For other strain types - Depend if other MRSA types will establish themselves in livestock and be able to cross transmit

36 ACKNOWLEDGEMENTS Staphylococcus lab Anders R. Larsen Jesper Larsen Andreas Petersen Øystein Angen Z Islam Raphael Zieber Host Genetics and Mol Diagnostics Paal S. Andersen Marc Stegger Luca Guardabassi, KU Nils Toft and Karl Pedersen, DTU-VET Anne Mette Madsen, NFA Poul Bækbo, SEGES Lance Price, Georgetown University, MD, USA

37 THANK YOU FOR THE ATTENTION National Rådgivningstjeneste for MRSA i dyr Statens Serum Institut Hotline nr: mrsaidyr@ssi.dk

http://www.who.int/csr/disease/avian_influenza/phase/en 4 http://new.paho.org/hq/index.php?option=com_content&task=view&id=1283&itemid=569

Food and Agriculture Organization of the United Nations International Food Safety Authorities Network (INFOSAN) (Update) 30 April 2009 INFOSAN Information Note No. 2/2009 Human-animal interface aspects