Hepatitis C Virus Testing, Infection, and Cases Reported Through Public Health Surveillance During Expanded Screening Recommendations, United States, 2013-2021.

OBJECTIVES: Hepatitis C virus (HCV) infection is the most common bloodborne infection in the United States. We assessed trends in HCV testing, infection, and surveillance cases among US adults. METHODS: We used Quest Diagnostics data from 2013-2021 to assess trends in the numbers tested for HCV antibody and proportion of positivity for HCV antibody and HCV RNA. We also assessed National Notifiable Diseases Surveillance System 2013-2020 data for trends in the number and proportion of hepatitis C cases. We applied joinpoint regression for trends testing. RESULTS: Annual HCV antibody testing increased from 1.7 million to 4.8 million from 2013 to 2021, and the positivity proportion declined (average, 0.2% per year) from 5.5% to 3.7%. The greatest percentage-point increase in HCV antibody testing occurred in hospitals and substance use disorder treatment facilities and among addiction medicine providers. HCV RNA positivity was stable at about 60% in 2013-2015 and declined to 41.0% in 2021 (2015-2021 average, -3.2% per year). Age-specific HCV RNA positivity was highest among people aged 40-59 years during 2013-2015 and among people aged 18-39 years during 2016-2021. The number of reported hepatitis C cases (acute and chronic) declined from 179 341 in 2015 to 105 504 in 2020 (average decline, -13 177 per year). The proportion of hepatitis C cases among those aged 18-39 years increased by an average of 1.4% per year during 2013-2020; among individuals aged 40-59 years, it decreased by an average of 2.3% per year during 2013-2018. CONCLUSIONS: HCV testing increased, suggesting improved universal screening. Various data sources are valuable for monitoring elimination progress.

Hepatitis B Care Continuum Models-Data to Inform Public Health Action.

The application of a care continuum model (CCM) can identify gaps in diagnosis, care, and treatment of populations with a common condition, but challenges are inherent in developing a CCM for chronic hepatitis B. In contrast with treatment for HIV or hepatitis C, treatment is not indicated for all people with chronic hepatitis B, clinical endpoints are not clear for those receiving treatment, and those for whom treatment is not indicated remain at risk for complications. This topical review examines the data elements necessary to develop and apply chronic hepatitis B CCMs at the jurisdictional health department level. We conducted a nonsystematic review of US-based publications in Ovid MEDLINE (1946-present), Ovid Embase (1974-present), and Scopus (not date limited) databases, which yielded 724 publications for review. Jurisdictional health departments, if properly supported, could develop locale-specific focused CCMs using person-level chronic hepatitis B registries, updated longitudinally using electronic laboratory reporting data and case reporting data. These CCMs could be applied to identify disparities and improve rates in testing and access to care and treatment, which are necessary to reduce liver disease and chronic hepatitis B mortality. Investments in public health surveillance infrastructure, including substantial enhancements in electronic laboratory reporting and case reporting and the use of supplementary data sources, could enable jurisdictional health departments to develop modified CCMs for chronic hepatitis B that focus, at least initially, on "early" CCM steps, which emphasize optimization of hepatitis B diagnosis, linkage to care, and ongoing clinical follow-up of diagnosed people, all of which can lead to improved outcomes.

Frequency of Children Diagnosed with Perinatal Hepatitis C, United States, 2018-2020.

We describe hepatitis C testing of 47 (2%) of 2,266 children diagnosed with perinatal hepatitis C who were exposed during 2018-2020 in 7 jurisdictions in the United States. Expected frequency of perinatal transmission is 5.8%, indicating only one third of the cases in this cohort were reported to public health authorities.

Assessing Pathogen Transmission Opportunities: Variation in Nursing Home Staff-Resident Interactions.

OBJECTIVES: The Centers for Disease Control and Prevention (CDC) recommends implementing Enhanced Barrier Precautions (EBP) for all nursing home (NH) residents known to be colonized with targeted multidrug-resistant organisms (MDROs), wounds, or medical devices. Differences in health care personnel (HCP) and resident interactions between units may affect risk of acquiring and transmitting MDROs, affecting EBP implementation. We studied HCP-resident interactions across a variety of NHs to characterize MDRO transmission opportunities. DESIGN: 2 cross-sectional visits. SETTING AND PARTICIPANTS: Four CDC Epicenter sites and CDC Emerging Infection Program sites in 7 states recruited NHs with a mix of unit care types (≥30 beds or ≥2 units). HCP were observed providing resident care. METHODS: Room-based observations and HCP interviews assessed HCP-resident interactions, care type provided, and equipment use. Observations and interviews were conducted for 7-8 hours in 3-6-month intervals per unit. Chart reviews collected deidentified resident demographics and MDRO risk factors (eg, indwelling devices, pressure injuries, and antibiotic use). RESULTS: We recruited 25 NHs (49 units) with no loss to follow-up, conducted 2540 room-based observations (total duration: 405 hours), and 924 HCP interviews. HCP averaged 2.5 interactions per resident per hour (long-term care units) to 3.4 per resident per hour (ventilator care units). Nurses provided care to more residents (n = 12) than certified nursing assistants (CNAs) and respiratory therapists (RTs) (CNA: 9.8 and RT: 9) but nurses performed significantly fewer task types per interaction compared to CNAs (incidence rate ratio (IRR): 0.61, P < .05). Short-stay (IRR: 0.89) and ventilator-capable (IRR: 0.94) units had less varied care compared with long-term care units (P < .05), although HCP visited residents in these units at similar rates. CONCLUSIONS AND IMPLICATIONS: Resident-HCP interaction rates are similar across NH unit types, differing primarily in types of care provided. Current and future interventions such as EBP, care bundling, or targeted infection prevention education should consider unit-specific HCP-resident interaction patterns.

Risk Factors for SARS-CoV-2 Infection Among US Healthcare Personnel, May-December 2020.

To determine risk factors for coronavirus disease (COVID-19) among US healthcare personnel (HCP), we conducted a case-control analysis. We collected data about activities outside the workplace and COVID-19 patient care activities from HCP with positive severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) test results (cases) and from HCP with negative test results (controls) in healthcare facilities in 5 US states. We used conditional logistic regression to calculate adjusted matched odds ratios and 95% CIs for exposures. Among 345 cases and 622 controls, factors associated with risk were having close contact with persons with COVID-19 outside the workplace, having close contact with COVID-19 patients in the workplace, and assisting COVID-19 patients with activities of daily living. Protecting HCP from COVID-19 may require interventions that reduce their exposures outside the workplace and improve their ability to more safely assist COVID-19 patients with activities of daily living.

Practices and activities among healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection working in different healthcare settings-ten Emerging Infections Program sites, April-November 2020.

Healthcare personnel with severe acute respiratory coronavirus virus 2 (SARS-CoV-2) infection were interviewed to describe activities and practices in and outside the workplace. Among 2,625 healthcare personnel, workplace-related factors that may increase infection risk were more common among nursing-home personnel than hospital personnel, whereas selected factors outside the workplace were more common among hospital personnel.

Antimicrobial Use in a Cohort of US Nursing Homes, 2017.

Importance: Controlling antimicrobial resistance in health care is a public health priority, although data describing antimicrobial use in US nursing homes are limited. Objective: To measure the prevalence of antimicrobial use and describe antimicrobial classes and common indications among nursing home residents. Design, Setting, and Participants: Cross-sectional, 1-day point-prevalence surveys of antimicrobial use performed between April 2017 and October 2017, last survey date October 31, 2017, and including 15 276 residents present on the survey date in 161 randomly selected nursing homes from selected counties of 10 Emerging Infections Program (EIP) states. EIP staff reviewed nursing home records to collect data on characteristics of residents and antimicrobials administered at the time of the survey. Nursing home characteristics were obtained from nursing home staff and the Nursing Home Compare website. Exposures: Residence in one of the participating nursing homes at the time of the survey. Main Outcomes and Measures: Prevalence of antimicrobial use per 100 residents, defined as the number of residents receiving antimicrobial drugs at the time of the survey divided by the total number of surveyed residents. Multivariable logistic regression modeling of antimicrobial use and percentages of drugs within various classifications. Results: Among 15 276 nursing home residents included in the study (mean [SD] age, 77.6 [13.7] years; 9475 [62%] women), complete prevalence data were available for 96.8%. The overall antimicrobial use prevalence was 8.2 per 100 residents (95% CI, 7.8-8.8). Antimicrobial use was more prevalent in residents admitted to the nursing home within 30 days before the survey date (18.8 per 100 residents; 95% CI, 17.4-20.3), with central venous catheters (62.8 per 100 residents; 95% CI, 56.9-68.3) or with indwelling urinary catheters (19.1 per 100 residents; 95% CI, 16.4-22.0). Antimicrobials were most often used to treat active infections (77% [95% CI, 74.8%-79.2%]) and primarily for urinary tract infections (28.1% [95% CI, 15.5%-30.7%]). While 18.2% (95% CI, 16.1%-20.1%) were for medical prophylaxis, most often use was for the urinary tract (40.8% [95% CI, 34.8%-47.1%]). Fluoroquinolones were the most common antimicrobial class (12.9% [95% CI, 11.3%-14.8%]), and 33.1% (95% CI, 30.7%-35.6%) of antimicrobials used were broad-spectrum antibiotics. Conclusions and Relevance: In this cross-sectional survey of a cohort of US nursing homes in 2017, prevalence of antimicrobial use was 8.2 per 100 residents. This study provides information on the patterns of antimicrobial use among these nursing home residents.

International comparison of pressure ulcer measures in long-term care facilities: Assessing the methodological robustness of 4 approaches to point prevalence measurement.

INTRODUCTION: Pressure ulcer indicators are among the most frequently used performance measures in long-term care settings. However, measurement systems vary and there is limited knowledge about the international comparability of different measurement systems. The aim of this analysis was to identify possible avenues for international comparisons of data on pressure ulcer prevalence among residents of long-term care facilities. MATERIAL AND METHODS: A descriptive analysis of the four point prevalence measurement systems programs used in 28 countries on three continents was performed. The criteria for the description and analysis were based on the scientific literature on criteria for indicator selection, on issues in international comparisons of data and on specific challenges of pressure ulcer measurements. RESULTS: The four measurement systems use a prevalence measure based on very similar numerator and denominator definitions. All four measurement systems also collect data on patient mobility. They differ in the pressure ulcer classifications used and the requirements for a head-to-toe resident examination. The regional or country representativeness of long-term care facilities also varies among the four measurement systems. CONCLUSIONS: Methodological differences among the point prevalence measurement systems are an important barrier to reliable comparisons of pressure ulcer prevalence data. The alignment of the methodologies may be improved by implementing changes to the study protocols, such as aligning the classification of pressure ulcers and requirements for a head-to-toe resident skin assessment. The effort required for each change varies. All these elements need to be considered by any initiative to facilitate international comparison and learning.

Antibiotic-resistant pathogens associated with urinary tract infections in nursing homes: Summary of data reported to the National Healthcare Safety Network Long-Term Care Facility Component, 2013-2017.

OBJECTIVE: Antibiotic resistance (AR) is a growing and highly prevalent problem in nursing homes. We describe selected AR phenotypes from pathogens causing urinary tract infections (UTIs) reported by nursing homes to the National Healthcare Safety Network (NHSN). DESIGN: Pathogens and antibiotic susceptibility testing results for UTI events in nursing homes between January 2013 and December 2017 were analyzed. The pathogen distribution and pooled mean proportion of isolates that tested resistant to select antibiotic agents are reported. SETTING AND PARTICIPANTS: US nursing homes voluntarily participating in the Long-Term Care Facility component of the NHSN. RESULTS: Overall, 243 nursing homes reported 1 or more UTIs: 121 (50%) were nonprofit facilities, median bed size was 91 (range: 9-801), and average occupancy was 87%. In total, 6,157 pathogens were reported for 5,485 UTI events. Moreover, 9 pathogens accounted for 90% of all reported UTIs; the 3 most frequently identified were Escherichia coli (41%), Proteus species (14%), and Klebsiella pneumoniae/oxytoca (13%). Among E. coli, fluoroquinolone, and extended-spectrum cephalosporin resistance were most prevalent (50% and 20%, respectively). Although Staphylococcus aureus and Enterococcus faecium represented <5% of pathogens reported, they had the highest rates of resistance (67% methicillin resistant and 60% vancomycin resistant, respectively). Multidrug resistance was most common in Pseudomonas aeruginosa (11%). For the resistant phenotypes we assessed, 36% of all UTIs reported were associated with a resistant pathogen. CONCLUSIONS: This is the first summary of AR among common pathogens causing UTIs reported to NHSN by nursing homes. Improved understanding of the resistance burden among common infections helps inform facility infection prevention and antibiotic stewardship efforts.

Facility-Wide Testing for SARS-CoV-2 in Nursing Homes - Seven U.S. Jurisdictions, March-June 2020.

Undetected infection with SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) contributes to transmission in nursing homes, settings where large outbreaks with high resident mortality have occurred (1,2). Facility-wide testing of residents and health care personnel (HCP) can identify asymptomatic and presymptomatic infections and facilitate infection prevention and control interventions (3-5). Seven state or local health departments conducted initial facility-wide testing of residents and staff members in 288 nursing homes during March 24-June 14, 2020. Two of the seven health departments conducted testing in 195 nursing homes as part of facility-wide testing all nursing homes in their state, which were in low-incidence areas (i.e., the median preceding 14-day cumulative incidence in the surrounding county for each jurisdiction was 19 and 38 cases per 100,000 persons); 125 of the 195 nursing homes had not reported any COVID-19 cases before the testing. Ninety-five of 22,977 (0.4%) persons tested in 29 (23%) of these 125 facilities had positive SARS-CoV-2 test results. The other five health departments targeted facility-wide testing to 93 nursing homes, where 13,443 persons were tested, and 1,619 (12%) had positive SARS-CoV-2 test results. In regression analyses among 88 of these nursing homes with a documented case before facility-wide testing occurred, each additional day between identification of the first case and completion of facility-wide testing was associated with identification of 1.3 additional cases. Among 62 facilities that could differentiate results by resident and HCP status, an estimated 1.3 HCP cases were identified for every three resident cases. Performing facility-wide testing immediately after identification of a case commonly identifies additional unrecognized cases and, therefore, might maximize the benefits of infection prevention and control interventions. In contrast, facility-wide testing in low-incidence areas without a case has a lower proportion of test positivity; strategies are needed to further optimize testing in these settings.

Documentation of acute change in mental status in nursing homes highlights opportunity to augment infection surveillance criteria.

Acute change in mental status (ACMS), defined by the Confusion Assessment Method, is used to identify infections in nursing home residents. A medical record review revealed that none of 15,276 residents had an ACMS documented. Using the revised McGeer criteria with a possible ACMS definition, we identified 296 residents and 21 additional infections. The use of a possible ACMS definition should be considered for retrospective nursing home infection surveillance.

Epidemiology of Antibiotic Use for Urinary Tract Infection in Nursing Home Residents.

OBJECTIVES: Describe antibiotic use for urinary tract infection (UTI) among a large cohort of US nursing home residents. DESIGN: Analysis of data from a multistate, 1-day point prevalence survey of antimicrobial use performed between April and October 2017. SETTING AND PARTICIPANTS: Residents of 161 nursing homes in 10 US states of the Emerging Infections Program (EIP). METHODS: EIP staff reviewed nursing home medical records to collect data on systemic antimicrobial drugs received by residents, including therapeutic site, rationale for use, and planned duration. For drugs with the therapeutic site documented as urinary tract, pooled mean and nursing home-specific prevalence rates were calculated per 100 nursing home residents, and proportion of drugs by selected characteristics were reported. Data were analyzed in SAS, version 9.4. RESULTS: Among 15,276 residents, 407 received 424 antibiotics for UTI. The pooled mean prevalence rate of antibiotic use for UTI was 2.66 per 100 residents; nursing home-specific rates ranged from 0 to 13.6. One-quarter of antibiotics were prescribed for UTI prophylaxis, with a median planned duration of 111 days compared with 7 days when prescribed for UTI treatment (P < .001). Fluoroquinolones were the most common (18%) drug class used. CONCLUSIONS AND IMPLICATIONS: One in 38 residents was receiving an antibiotic for UTI on a given day, and nursing home-specific prevalence rates varied by more than 10-fold. UTI prophylaxis was common with a long planned duration, despite limited evidence to support this practice among older persons in nursing homes. The planned duration was ≥7 days for half of antibiotics prescribed for treatment of a UTI. Fluoroquinolones were the most commonly used antibiotics, despite their association with significant adverse events, particularly in a frail and older adult population. These findings help to identify priority practices for nursing home antibiotic stewardship.

The National Healthcare Safety Network Long-term Care Facility Component early reporting experience: January 2013-December 2015.

BACKGROUND: In 2012, the Centers for Disease Control and Prevention launched the Long-term Care Facility (LTCF) Component of the National Healthcare Safety Network (NHSN) designed for LTCFs to monitor Clostridium difficile infections (CDIs), urinary tract infections (UTIs), infections due to multidrug-resistant organisms, including methicillin-resistant Staphylococcus aureus (MRSA), and infection prevention process measures. METHODS: We describe characteristics and reporting patterns of facilities enrolled in the first 3 years of the surveillance system and rate estimates for CDI, UTI, and MRSA data submitted between 2013 and 2015. RESULTS: From 2013-2015, 279 LTCFs were enrolled and eligible to report to the NHSN with variability in reporting from year to year. Crude rate estimates pooled over these 3 years from reporting facilities were 0.98 incident LTCF-onset CDI cases per 10,000 resident days, 0.59 UTI cases per 1,000 resident days, and 0.10 LTCF-onset MRSA cases per 1,000 resident days. CONCLUSIONS: These initial data demonstrate the capability of the NHSN LTCF Component as a national surveillance system for monitoring infections in LTCFs. Further investigation is needed to understand factors associated with successful enrollment and reporting. As participation increases, data from a larger group of LTCFs will be used to establish national baselines and track prevention goals.

Measuring Antibiotic Appropriateness for Urinary Tract Infections in Nursing Home Residents.

We assessed the appropriateness of initiating antibiotics in 49 nursing home (NH) residents receiving antibiotics for urinary tract infection (UTI) using 3 published algorithms. Overall, 16 residents (32%) received prophylaxis, and among the 33 receiving treatment, the percentage of appropriate use ranged from 15% to 45%. Opportunities exist for improving UTI antibiotic prescribing in NH. Infect Control Hosp Epidemiol 2017;38:998-1001.

Impact of removing mucosal barrier injury laboratory-confirmed bloodstream infections from central line-associated bloodstream infection rates in the National Healthcare Safety Network, 2014.

Central line-associated bloodstream infection (CLABSI) event data reported to the National Healthcare Safety Network from 2014, the first year of required use of the mucosal barrier injury laboratory-confirmed bloodstream infection (MBI-LCBI) definition, were analyzed to assess the impact of removing MBI-LCBI events from CLABSI rates. CLABSI rates decreased significantly in some location types after removing MBI-LCBI events, and MBI-LCBI events will be removed from publicly reported CLABSI rates.

Prevalence of Antimicrobial Use and Opportunities to Improve Prescribing Practices in U.S. Nursing Homes.

OBJECTIVES: To describe the prevalence and epidemiology of antimicrobial use (AU) in nursing home residents. DESIGN: One-day point prevalence survey. SETTING AND PARTICIPANTS: Nine nursing homes in four states; 1,272 eligible residents. MEASUREMENT: Frequency of antimicrobials prescribed, drug name, start date, duration, route, rationale, and treatment site. AU prevalence per 100 residents overall and by resident characteristic. RESULTS: AU prevalence was 11.1% (95% confidence interval, 9.4%-12.9%) and varied by resident characteristics. Most (32%) antimicrobials were given for urinary tract infection. For 38% of AU, key prescribing information was not documented. CONCLUSION: Opportunities to improve AU documentation and prescribing exist in nursing homes.

Evaluation of Manual and Automated Bloodstream Infection Surveillance in Outpatient Dialysis Centers.

Outpatient hemodialysis bloodstream infection rates, now used for performance measurement and were significantly higher for manual compared with automated surveillance (P<.001), largely owing to the absence of blood culture data in the dialysis electronic health record. Improvement in data sharing between hospitals and outpatient dialysis centers is necessary.

Mucosal Barrier Injury Laboratory-Confirmed Bloodstream Infections (MBI-LCBI): Descriptive Analysis of Data Reported to National Healthcare Safety Network (NHSN), 2013.

OBJECTIVES To determine the impact of mucosal barrier injury laboratory-confirmed bloodstream infections (MBI-LCBIs) on central-line-associated bloodstream infection (CLABSI) rates during the first year of MBI-LCBI reporting to the National Healthcare Safety Network (NHSN) DESIGN Descriptive analysis of 2013 NHSN data SETTING Selected inpatient locations in acute care hospitals METHODS A descriptive analysis of MBI-LCBI cases was performed. CLABSI rates per 1,000 central-line days were calculated with and without the inclusion of MBI-LCBIs in the subset of locations reporting ≥1 MBI-LCBI, and in all locations (regardless of MBI-LCBI reporting) to determine rate differences overall and by location type. RESULTS From 418 locations in 252 acute care hospitals reporting ≥1 MBI-LCBIs, 3,162 CLABSIs were reported; 1,415 (44.7%) met the MBI-LCBI definition. Among these locations, removing MBI-LCBI from the CLABSI rate determination produced the greatest CLABSI rate decreases in oncology (49%) and ward locations (45%). Among all locations reporting CLABSI data, including those reporting no MBI-LCBIs, removing MBI-LCBI reduced rates by 8%. Here, the greatest decrease was in oncology locations (38% decrease); decreases in other locations ranged from 1.2% to 4.2%. CONCLUSIONS An understanding of the potential impact of removing MBI-LCBIs from CLABSI data is needed to accurately interpret CLABSI trends over time and to inform changes to state and federal reporting programs. Whereas the MBI-LCBI definition may have a large impact on CLABSI rates in locations where patients with certain clinical conditions are cared for, the impact of MBI-LCBIs on overall CLABSI rates across inpatient locations appears to be more modest. Infect. Control Hosp. Epidemiol. 2015;37(1):2-7.

Completeness of Methicillin-Resistant Staphylococcus aureus Bloodstream Infection Reporting From Outpatient Hemodialysis Facilities to the National Healthcare Safety Network, 2013.

Reports of bloodstream infections caused by methicillin-resistant Staphylococcus aureus among chronic hemodialysis patients to 2 Centers for Disease Control and Prevention surveillance systems (National Healthcare Safety Network Dialysis Event and Emerging Infections Program) were compared to evaluate completeness of reporting. Many methicillin-resistant S. aureus bloodstream infections identified in hospitals were not reported to National Healthcare Safety Network Dialysis Event.