Vision A recognized and trusted leader, partnering and engaging to make Tennessee one of the nation s 10 healthiest states

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1 Vision A recognized and trusted leader, partnering and engaging to make Tennessee one of the nation s 10 healthiest states John Dreyzehner, MD, MPH ASTHO Annual Meeting September 20, 2013

2 The astute clinician with a vital relationship September 18, 2012

3 Partners Engaged Clinicians Laboratory staff Infection control professionals Affected clinics and staff Tennessee Dept of Health (TDH) colleagues at all levels Tennessee Poison Control Center Professional associations (esp. THA, TMA, TPA) Centers for Disease Control and Prevention (CDC) Food and Drug Administration (FDA) Massachusetts Department of Health (MADOH) ASTHO and other State Health Depts. (esp. IN, MI, VA, NC, NJ) Governor Haslam, Administration Colleagues and Legislators

4 Within 48 hours Confirmed exposure of index patient Contacted CDC Identified 2 additional cases in TN Clinic voluntarily closed Identified the suspect medication (MPA) Traced the MPA to NECC Sequestered supplies of MPA at the clinic

5 Within 72 hours On site evaluation of clinic processes and environment of care Identified additional potential cases TN Medical community notified via THAN 1 st THAN 21 Sept 12 CDC: no cases identified from other States

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7 Within Eight Days Worked with clinic to begin contacting patients possibly exposed to contaminated medication Conference call with: Massachusetts Department of Health Massachusetts Board of Pharmacy CDC NECC Nationwide recall of three lots of MPA by NECC The only lots of MPA ever linked to the outbreak

8 23 Affected states

9 Within 10 Days First preliminary results from cohort study implicates MPA and no clinic related factors Epi-X call for cases A second state, North Carolina, reports potential case

10 Contemporaneous Background: Unrelated Meningitis Concerns in Tennessee 10 September, 18 y/o MTSU student dies of N. Meningitides; students propylaxed 20 September, letter to parents at a Williamson County elementary school, 4 cases of viral meningitis at school 28 September, 9y/o student death reported as pneumococcal meningitis.

11 Within 14 days October 1, st press conference called at TDH (Day 14) Alerts and updates given frequently Active Outreach to exposed patients Completion of first epidemiologic studies Multi-state investigation underway Many partner agencies involved Hospitals and EDs VERY busy

12 Media Coverage

13 Extensive local coverage

14 National & Scientific Interest

15 October 4 (Day 17) FDA: sealed vial had fungal contaminant on microscopic examination CEASE use of all NECC medications/products

16 Active Case Finding and Investigation 3 clinics in TN, 1009 patients exposed to 3 lots of MPA from NECC Two resource-intensive outreach efforts to all exposed individuals Initial outreach for case finding & follow-up and second effort to identify additional local infections Joint effort between public health and clinics Engaged local and regional public health nurses

17 Extensive and Constant Emphasis on Communication Essential to Partnerships Internal : TDH and Metro Partners at multiple levels, Sister Agencies, Governor and staff, Legislators, Public HealthPartners (CDC, FDA, Other States) External ; Patients and Families, Impacted Clinicians, Professional Associations and Broader Medical and Scientific Community, Media and Public

18 Daily Briefs, SHOC Activated, Partners & Leaders Kept Current

19 Lessons Communicate, communicate, communicate Robust public health infrastructure critical, including authority to act quickly Preexisting capacity, plans and trusting relationships key. Takes time to and effort to create them Lean forward Don t let the perfect be the enemy of the good Always have a crack team of experienced and well-led healthcare associated infection epidemiologists at the ready

20 Healthcare Associated Infections (HAI) Team Marion Kainer Loretta Moore-Moravian Jennifer Ward Daniel Muleta Andrew Wiese Susan Massey Jea-Young Min Brynn Berger Meredith Kanago Dana Jackson

21 A part of the Tennessee Fungal Investigation Team (Only Central Office Branch!)

22 Lessons Public health is a team sport Regulation is important but will never assure right action by itself. Incentives must be aligned to achieve the result we wish to achieve. This is hard. Regulation that is part of a thoughtful system that incentivizes high reliability and is applied consistently across a sector is a good model. Respect and acknowledge the known unknowns, Beware of the unknown unknowns

23 Meningitis Cases and 30-Day Case-Fatality Rate by Week of Diagnosis Each 30-day case-fatality rate is calculated for patients diagnosed during the corresponding week. TDOH indicates Tennessee Department of Health; NECC, New England Compounding Center; CDC, Centers for Disease Control and Prevention; FDA, US Food and Drug Administration. JAMA. 2013;():1-2. doi: /jama

24 Partnering and Engaging Infrastructure Shared concerns about HAIs, work on HAIs, shared success on HAIs Safe Sleep Campaign Joint Breastfeeding Support and Promotion ( ) Early Elective Delivery Hard Stop (Joint letter ) Health Joint Information Center Partnership (Product of after action meeting at THA) Whatever we think of next

25 Joint TDH/THA Breastfeeding Letter

26 Memorandum of Understanding with other Tennessee Associations: Tennessee Dental Association Tennessee Funeral Directors Association Tennessee Health Care Association Tennessee Medical Association Tennessee Nurses Association Tennessee Pharmacists Association Tennessee Primary Care Association Tennessee Veterinary Medical Association

27 THE TENNESSEE HEALTH JOINT INFORMATION CENTER

28 Standardized Infection Ratios (SIR) for Central Line-Associated Bloodstream Infections (CLABSIs) in Adult and Pediatric ICUs by Quarter, Tennessee, January December 2012 Tennessee SIR NHSN Baseline SIR HHS 5-Year Goal SIR Q Q Q Q Q Q Q Q Q Q Quarter Reference standard: National Healthcare Safety Network (NHSN), ; Data Source: NHSN 08/15/2013

29 SIR Standardized Infection Ratios (SIR) for Surgical Site Infections (SSIs) Following Abdominal Hysterectomy (HYST) Procedures by Quarter, Tennessee 2012 Tennessee All SSI SIR Tennessee Complex A/R SIR NHSN Baseline SIR HHS 5-Year Goal Q Q Quarter Q Q Reference standard: National Healthcare Safety Network (NHSN), ; Data Source: NHSN 08/15/2013

30 When the best leaders work is done the people say, We did it ourselves -Lau Tzu, B.C.