Evaluating the Surveillance Capabilities for Selected Multidrug-Resistant Organisms in Hawaii, 2012-2013

BACKGROUND:   Antibiotic resistance has been identified as one of the world’s most pressing public health issues. Vancomycin-intermediate and -resistant Staphylococcus aureus (VISA/VRSA) and invasive pneumococcal disease (IPD), which includes drug-resistant Streptococcus pneumoniae (DRSP), are reportable conditions in Hawaii and are typically received via electronic laboratory reports (ELR). Although not reportable, carbapenem-resistant Enterobacteriaceae (CRE) results are identified through requests to send isolates for confirmatory testing. We evaluated Hawaii’s disease surveillance to assess the quality of CRE, VISA, VRSA, and DRSP reporting from 2012−2013.

METHODS:   We reviewed any cases in 2012 and 2013 of suspect and confirmed CRE, VISA, and VRSA, and identified DRSP through review of IPD records with susceptibility results. We analyzed records for predictive value positive (PVP), data quality, and timeliness. Specifically, we calculated PVP as the proportion of confirmed cases within all cases reported to Hawaii Department of Health. We assessed data quality through review of case demographic and laboratory field completeness. Timeliness was defined as time from symptom onset to reporting date. 

RESULTS:   During 2012–2013, we identified one case each of CRE and VISA, no cases of VRSA, and 29 cases of DRSP. We determined that ELRs did not include susceptibility results; we were only able to classify DRSP when investigators had actively collected those results (68% [n=111] of IPD cases). We discovered that laboratories lacked the capacity to report VISA through ELRs; the single VISA was reported via ELR as another condition and subsequently corrected manually. ELR capacity to report VISAs was implemented; no other VISAs were identified retrospectively. The PVPs for CRE, VISA, VRSA, and DRSP were 3.2%, 100%, 0% and 12.3%, respectively. Twelve fields were analyzed for completeness; only race/ethnicity was missing for CRE and VISA. The percentage of DRSP cases with missing fields ranged from 3% (gender) to 31% (ethnicity). Timeliness was 277 days for CRE, 4 days for VISA, and ranged from 3−16 days (median 6 days) for DRSP.

CONCLUSIONS:   Our evaluation found that Hawaii’s surveillance system can detect multidrug-resistant organisms (MDROs) of interest, even for conditions that were not reportable. Electronic reporting and timeliness issues were observed, but quality information was available for the majority of cases. Although only a small number of MDROs were identified, the threat of antibiotic resistance clearly exists in Hawaii. Vigilant monitoring of national and local trends and ongoing assessment of MDRO reporting will determine whether specific system enhancements are necessary in the future.