Assessment of National Reporting of Drug-Resistant Streptococcus pneumoniae -- United States, 1995-1996

Because of the rapidly emerging resistance of Streptococcus pneumoniae (SP) infections to penicillin and other antimicrobial agents, the Drug-Resistant Streptococcus pneumoniae Working Group (DRSPWG) was established in 1993 to develop a strategy to minimize the impact of drug-resistant SP (DRSP) (1). Based on a recommendation from the DRSPWG, in 1994 the Council of State and Territorial Epidemiologists (CSTE) resolved that each state should designate as reportable to state and federal officials all invasive infections caused by DRSP (2). In 1995, health departments in 14 jurisdictions (Arkansas, Colorado, Connecticut, Georgia, Michigan, Minnesota, Missouri, New Hampshire, New Jersey, New York, North Carolina, Ohio, South Carolina, and New York City) instituted regulations requiring laboratories to report the isolation of DRSP from specimens obtained from normally sterile sites (e.g., cerebrospinal fluid and blood). To determine the impact of the CSTE resolution on nationwide reporting of DRSP, in May 1996 CDC conducted a telephone survey of public health officials in all states, New York City, and the District of Columbia. This report summarizes the survey findings, which indicate an increase in the proportion of jurisdictions that conduct surveillance for DRSP.

CDC contacted by telephone the state/territorial epidemiologist or their designee in each of the 50 states and the District of Columbia and the Commissioner of Health for New York City. The response rate was 100%. Respondents were asked whether DRSP was designated as reportable in their jurisdiction and about their methods of collecting, analyzing, and disseminating information regarding DRSP and barriers to DRSP surveillance. Respondents from jurisdictions in which DRSP was not reportable were asked whether any other organization or program in the jurisdiction conducted DRSP surveillance.

Of the 52 participating jurisdictions, 16 (31%) had designated DRSP reportable by initiating surveillance, and 12 (23%) were planning to require DRSP reporting by June 1997. Of the 13 jurisdictions for which data were available, six collected information about invasive pneumococcal isolates, and seven collected information about both invasive and noninvasive isolates. Information about infections caused by intermediate and resistant (i.e., nonsusceptible) SP isolates is or will be collected by 19 (68%) of the 28 states that have initiated or plan to initiate DRSP surveillance. Seven (25%) jurisdictions collected or plan to collect information about all invasive pneumococcal infections (i.e., susceptible and nonsusceptible) to enable estimation of the proportion of invasive SP isolates that were not susceptible to antimicrobials.

All 28 jurisdictions that have initiated or plan to initiate DRSP surveillance reported disseminating or planning to disseminate surveillance findings to the health-care workers and organizations in their respective jurisdictions through one or more methods, including the state epidemiology/public health bulletin (83%), presentations at medical society meetings (17%), and broadcast electronic messages (e.g., e-mail and World Wide Web pages) (17%).

Of the 52 respondents, 39 (75%) reported having encountered barriers to implementation of DRSP surveillance within their state, including lack of awareness among laboratory personnel and physicians about requirements to report DRSP (42%), lack of standardization of susceptibility-testing methods among laboratories (25%), and lack of resources from state health departments (SHDs) for surveillance (17%). Responses to an open-ended question identified lack of a specified federal mechanism for reporting DRSP to CDC as a barrier to national DRSP surveillance.

Reported by: Childhood and Respiratory Diseases Br, Div of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC.

Editorial Note

Editorial Note: SP is a leading cause of morbidity and mortality in the United States, resulting each year in an estimated 3000 cases of meningitis, 50,000 cases of bacteremia, 500,000 cases of pneumonia, and 7,000,000 cases of otitis media (3-5). Case-fatality rates vary by age and underlying illnesses of patients: among elderly persons with pneumococcal bacteremia, 40% of cases are fatal, and among children and adults with meningitis, 6% and 30% of cases, respectively, are fatal despite appropriate antimicrobial therapy (6). The emergence of DRSP further complicates management and treatment of these common infections; however, the lack of a systematic surveillance system for DRSP constrains calculation of accurate estimates of the prevalence of DRSP.

The findings in this report indicate that many jurisdictions either have implemented (16 jurisdictions) or are planning to implement (12 jurisdictions) DRSP surveillance to characterize the public health impact of DRSP; however, mechanisms for reporting data to CDC are present in only a few jurisdictions. Population-based laboratory surveillance enables the accurate assessment of geographic and temporal trends in DRSP. States that conducted such surveillance in 1995 included those participating in CDC's Emerging Infections Program (California, Connecticut, Minnesota, and Oregon) and those participating in the Active Laboratory-Based Surveillance System (Georgia, Maryland, Tennessee, and Texas). State-based surveillance systems should especially collect data from clinical laboratories about the antimicrobial susceptibility of invasive pneumococcal isolates. Data should be aggregated, analyzed, and reported to local health-care providers in a timely manner. Clinical health-care providers can use information specific to their communities to select appropriate antimicrobial agents when initiating empiric treatment for persons with presumptive pneumococcal infections, and public health officials can use such information to develop interventions for specific communities or regions (1).

The two options for state and local health officials to report information about DRSP to CDC are completion and submission of case-report forms and electronic transmission of case information. Electronic laboratory reporting is the preferred method of reporting because it facilitates rapid feedback of information to laboratories, state and local health departments, CDC, and health-care professionals. Through electronic reporting, SHDs can report to CDC all cases of invasive pneumococcal infections and the antimicrobial susceptibility patterns of the pneumococcal isolates to enable calculation of the prevalence of DRSP. The Public Health Laboratory Information System (PHLIS), available in all SHD laboratories, can be used for electronic reporting of DRSP. PHLIS is a personal computer-based reporting system for local, county, or state organizations and can be used to enter, edit, and analyze data on-site and then transmit that information to other state or federal offices. Data in PHLIS is maintained in a format that can be made compatible with data in the state epidemiologist's office and can be easily shared between the laboratory and the epidemiology office on a local area network (7). In the future, it is anticipated that electronic reporting of information from clinical laboratories to public health officials will be possible using a standardized message format (e.g., Health Level Seven).

Additional information about DRSP reporting or training in PHLIS-based electronic reporting is available from CDC's Childhood and Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, by telephone ({404} 639-2215} or e-mail (drsp@ciddbd1.em.cdc.gov).

References

1. CDC. Defining the public health impact of drug-resistant Streptococcus pneumoniae: report of a working group. MMWR 1996;45(no. RR-1).

2. CDC. National surveillance for infectious diseases, 1995. MMWR 1995;44:737-9.

3. Breiman RF, Butler JC, Tenover FC, Elliott JA, Facklam RR. Emergence of drug-resistant pneumococcal infections in the United States. JAMA 1994;271:1831-5.

4. Reichler MR, Allphin AA, Breiman RF, et al. The spread of multiply-resistant Streptococcus pneumoniae at a day care center in Ohio. J Infect Dis 1992;166:1346-53.

5. Stool SE, Field MJ. The impact of otitis media. Pediatr Infect Dis J 1989;8:S11-S14.

6. Wenger JD, Hightower AW, Facklam RR, Gaventa S, Broome CV, the Bacterial Meningitis Study Group. Bacterial meningitis in the United States, 1986: report of a multistate surveillance study. J Infect Dis 1990;162:1316-23.

7. Martin SM, Bean NH. Data management issues for emerging diseases and new tools for managing surveillance and laboratory data. Emerging Infectious Diseases 1995;1:124-8.

   
   

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