A journey towards electronic surveillance

SURVEILLANCE
FROM MANUAL TO AUTOMATED
Brian Kristensen
Head, senior consultant, phd
National Center for Infection Control
Infection preparedness

SURVEILLANCE: BASIC DEFINITION
Surveillance is the systematic, ongoing collection,
collation and analysis of data with timely
dissemination of information to those who require
this information in order to take action
Surveillance, St. Petersburg December 2019 2
Surveillance is an organized and ongoing component of a program to improve
a specific area of population health.
Surveillance systems go beyond the collection of information. They involve
mechanisms by which the knowledge gained through surveillance is delivered
to those who can use it to direct resources where needed to improve health.

WHY IS SURVEILLANCE IMPORTANT
Detect and monitor essential diseases
Identify risk factors for HAI
Evaluate Preventive interventions
Provide information to inform, educate and reinforce
practice

ELEMENTS OF SURVEILLANCE
Planning (what and who)
Data collection
Data analysis
Interpretation of data
Communication of results
Evaluation
Surveillance is an organized and ongoing component of a program to improve
a specific area of population health.
Surveillance systems go beyond the collection of information. They involve
mechanisms by which the knowledge gained through surveillance is delivered
to those who can use it to direct resources where needed to improve health.

SURVEILLANCE: RECOMMENDED STEPS
Best Practices for Surveillance of HAI, Public Health Ontario, 2014

SURVEILLANCE: PLANNING
Patients
Infectious diseases
Pathogens
Susceptibility patterns (AMR)
Department/hospital/region/national
Focus and narrow down
What is relevant?, and prevalent
Mandatory?
Do you want to use data for intervention
Do you have an important problem (e.g. outbreak)

DATA COLLECTION
Use of standardized definitions or local definitions
Important to be clear on what is a case (numerator)
What is the patients at risk (denominator)
Do you want to compare? – back in time, to other hospitals, to other countries
Do you have data on patient at risk
What about data after discharge (e.g. mortality, Surgical wound infection)
What about Long Term Care Facilities

EXAMPLES OF DATA COLLECTION
Data
source
Methodology Benefits Limitations Costs
Total chart
review
ICP specialists look
through all medical
records for sign of
infections 1-2
times/week
Most complete
method of case
finding
May be done
prospectively or
retrospectively
Time
consuming
Missing data
Record not
available
High
Laboratory
reports
ICP specialists
reviews daily
laboratory reports for
positive culture
results that prompt
investigation of
potential HAIs
Often identifies
microorganisms of
special concern (e.g.
MRSA)
Few samples
for culture
Medium,
advantage if
electronic
flagging are
possible
Electronic
screening of
chart
Data mining
Algorithms
Automatic
Fast
Results must be
verified
High (start)

DATA FOR COLLECTION
Intensity of resources associated with active and
passive surveillance

DATA ANALYSIS AND INTERPRETATION
Prevalence (number of cases) vs incidence (cases
per time-period)
Is the feeding of data being changed (e.g. new type
of patients)
Type of infection data
- Syndrome-based (e.g., pneumonia)
- Procedure-based (e.g., SSI at Hip-replacement)
- Device-associated (e.g., iv-catheter-related bacteremias)

COMMUNCATION OF DATA AND EVALUATION
Who will recieve data
How often do you report
How do you report (graph, tables, internally)
Are you monitoring what is relevant now

SURVEILLANCE: DO YOU HAVE A PROBLEM
Using standard deviation
Using Process control charts

POINT PREVALENCE SURVEY (PPS)
Number of HAI in a hospital setting on a single day
- Easy to perform
- ”golden standard”
- Can be reported back to the department at the same day
but
- Time consuming
- Interobservateur variation

PPS: TYPICAL CASE DEFINITION
Results of microbiologcal sampling
- And combinations of symtomps
- And lab-results / or x-ray
- And antibiotic administrered
Antibiotic administrered
- Type, dosages, and indication
Presence of indwelling devices
- E.g., urinary tract catheter, iv-catheter

SURVEILLANCE OF HAI IN DENMARK
until 1989: sporadic reporting of specific nosocomial diseases in limited
settings – primarily surgical numbers for nosocomial infections
1989 – 1994: ”Skildvagten” (the Sentry): Voluntary reporting of a wide
variety of surgical infections, including a high numbers of Danish
hospitals (inspired by HELICS)
1999- 2008: 2 nationwide point-prevalence surveys of nosocomial
infections, voluntary
2008-2014: bi-annually point-prevalence survey, voluntary
2015: The electronic surveillance of HAI – HAIBA - is launched

POINT PREVALENCE SURVEY IN DENMARK
Patient
ID
Urinvejsinfektion Nedre luftvejsinfektion Postoperativ dyb sårinfektion Bakteriæmi/sepsis
5)Andet
fremmedlegeme
Antibiotikabehandli
ng
community
Nosocomial
1)Urinvejskatet
er
(KADel.
SIK/RIK)
community
Nosocomial
2)Menkanisk
vent.
community
Nosocomial
community
Nosocomial
3)Perifervenflon
4)CVK
Egen
afd./afs.
Anden
Afd./afs.
Andethosp.
Privathosp.
Egen
afd./afs.
Anden
Afd./afs.
Andethosp.
Privathosp.
Egen
afd./afs.
Anden
Afd./afs.
Andethosp.
Privathosp.
Egen
afd./afs.
Anden
Afd./afs.
Andethosp.
Privathosp.
Only four infections (>80 % of all infections)
- Urinary tract infections, Pneumonia, surgical site infection and/or bacteremia
Total number of patients in the department
Number of patients
- With surgery,
- Indwelling urinary catheter,
- Intravenous catheter,
- with antibiotic treatment  specified scheme

THE TRANSITION FROM PPS TO HAIBA
PRO
- Was in accordance with increased focus on quality
improvement
- Reporting of HAI was important in the Danish
Quality Model
- The survey process stressed the importance on a
direct dialoque with the clinicians
Point-prevalence studies in Denmark 2008-2013
CON
- Cumbersome and time-consuming
- Data were not updated
- Could data be compared to previous survey

HOW TO EVALUATE THE NUMBERS FROM PPS
Not the same patient population
A snap shot of infections
Was the infections comparable over time
Was the patients comparable over time
fewer hospitals,
changing to one-day surgery, and ambulatory care
shorter hospital-stay,
new kinds of treatment (e.g. cholecystectomy: from open surgery to
endoscopic surgery

THE MICROBIOLOGICAL LAB IS CENTRAL
Microbiological data is crucial for surveillance and
IPC activities.
Lab results must be available in an organized,
accessible and timely manner through proper record
keeping systems.
Monitor lab results for
- Unusual findings e.g. cluster of pathogens that may
indicate an outbreak
- Emergence of multi-drug resistant organisms
- Isolation of highly infectious, unusual and virulent
pathogens

THE NATIONAL DB OF MICROBIOLOGY: MIBA

BUILDING OF NATIONAL DBASE ON CULTURES

MIBA
Complete data at a national level: Both positive and negative
test results
Real time data: is used both for patient-decision treatment
and national surveillance
All data are personalised (the unique CPR number), and can
be linked to other public registries
•No extra burdens of reporting for the laboratories or health-
care-workers

SURVEILLANCE OF HOSPITAL-ACQUIRED INFECTIONS

INFECTIONS INCLUDED IN HAIBA
Hospital-acquired bacteremia
Hospital-acquired urinary tract infections
Hospital-acquired Clostridium difficile infections
Infections following surgery
- Primary total hip arthroplasty
- Primary total knee arthroplasty
Validated by comparison to Point-prevalence-
surveys

TYPICAL CASE DEFINITION IN HAIBA
Numerator: infections occuring after 48 hours of
hospital stay (positive microbiological sample(s))
Denominator: the total of patients-day
Algorithms of the course of stay for each patient is
created (due to data from the National Patient
Registry)

EVERYONE CAN ACCESS DATA FROM HAIBA
Type of infection Hospital/department Time-spanData-type?

OUTPUT DELIVERY FROM HAIBA
Aggreated data, updated daily, access for all
Homepage/
online
Hospital
management
systems
Userface -
aggregated
Userface -
Patient-ID
National quality
model
Just bacteremias and C. difficile, published annually
Aggreated data, updated daily, incorporated regionally
Like homepage, but adjusted to the given department
Line-list of patient, addidtional informations

USE OF HAIBA: REGIONAL LEVEL
Regional Task Force
Increased focus on C. diff and MDRO
Regional Task Force

MEDIA ON DATA FROM HAIBA

BUT IT CAN BE DIFFICULT OT USE DATA FROM HAIBA
The ”Public Accounts Committee ”
concludes:
Hospitals should be better to use
data from HAIBA
- Set specific goals for reduction of
infections
- Follow trends of infection over time
Improve and monitor adherence to
guidelines
Improve use of antibiotics

SURVEILLANCE OF HAI AND AMR IN DENMARK
Some AMR are mandatory notifiable
- Methicillin-resistent Staphylococcus aureus
- Carbapenem resistent organisms (CPO, CPE)
HAI are becoming mandatory notifiable
Strains of MRSA and CPO are sent to National
Reference Laboratory
Information on the patient are sent separately

AMR SURVEILLANCE: NOTIFIED AMR, E.G. MRSA
Each case of MRSA must be notified
Data included in a national database
- Demographic data (e.g. Gender, age, work)
- Exposure data (e.g. foreign hospital, travel)
- Risk data (e.g. comorbidity)
- Clinical (e.g. infection, asymptomatic)
Combined with national data on typing
- Clonality, virulence-factors
Updated reports on occurence and prevalence on
SSI-website (”tal og grafer”)
Annually report on MRSA (Epi-news)

SURVEILLANCE OF OUTBREAK
Local:
- the microbiological laboratory
- The infections Disease Specialists
National
- Mandatory notifications
- National reference laboratory
International
- WHO, IHR
- ECDC, others
Denmark: Problem with transfer of patients between hospitals and regions

AMR: OUTBREAKS MATTERS
Worsening epidemiological situation of carbapenemase-producing Enterobacteriaceae in Europe, assessment by national experts from 37 countries, July
2018. EurosurveillanceVolume 24, Issue 9, 28/Feb/2019
CPE outbreak in
Europe 2018

TYPING DO NOT SOLVE ALL PROBLEMS
Available information
• Possible WGS link (cgMLST)
• Submitting KMA
• Submitting department
• Travel?
Needed for (timely) national
outbreak detection
• Fast typing information
• Updated patient movement
information (local/HAIBA)
• Ability to process data
ST410
Epidemiological Linking is
needed

MANUAL TRACKING OF POSSIBLE NETWORKS
Patient 1  Patient 4
Summery: - Patient 1 was the main source of the outbreak
- All patients are linked in a common network (5 out of 5 patients)
- The most predominant department was A1 (4 out of 5 patients)
- The most predominant hospitals were A (4 out of 5 patients) and B (3 out of 5 patients)
Building transmission network manually

EPILINX – A TOOL FOR TRACKING PATIENT NETWORKS
Anna Emilie Henius
Statens Serum Institut
Generic “base R” software tool (“Shiny” tool package)
(Under development)
Input:
• WGS-based data (MLST/cgMLST)
• patient location information (National or local)
• Other epidemiological data (sample date, death ect..)

EPILINX – TOOL FOR TRACKING EPIDEMIOLOGICAL
LINKS
1
2
3
4
5
EpiLinx v1.0

ST18 C. FREUNDII – DIRECT LINKS

ST18 C. FREUNDII – ALL LINKS

OUTBREAK SURVEILLANCE
Starting a national collaboration with all Department
of Clinical Microbiology and
Infection Control Unit/specialists
To conclude on each outbreak (starting with CPO)

HOW TO TARGET YOUR SURVEILLANCE
Importance, i.e. the consequences are potentially life-
threatening for the patient
Common, i.e. the infection is regularly seen and is present in
most if not all centres/countries
Recognizable, i.e. there is no doubt what the infection is and
where it causes disease
Definable, i.e. there are criteria or definitions for deciding
when and if the infection is present
Accessible, i.e. data on the infection can be accessed in
many local, national and international datasets
Standardized, i.e. the more standardized the diagnostic and
treatment practices, the more suitable the infection is for
automation.

CONCLUSION ON SURVEILLANCE
Focus on what you want to monitor
Work together with other specialists
You have to use your laboratories
You have to use your clinicians
Better to take small steps and reach your goal than
to jump into the Darkness

IMPORTANT ISSUES FOR ICP AND AMR
Establishing a national action plan
The laboratory capacity
Data management and infrastructure
Sales of antibiotics without prescription
Public awareness

QUESTIONS ?

QUESTION FOR NW RUSSIA
Do you have local surveillance
Do you have national surveillance
Do you have mandatory surveillance
Who is doing the surveillance
- Hospitals
- Government
- Independent organisations

A journey towards electronic surveillance

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