Program Program Program Program

CanadianCanadian Consensus Consensus Development Development Conference Conference on on Canadian Consensus Development Conference on SURVEILLANCESURVEILLANCE & & SCREENING SCREENING FOR FOR AROs AROs (Antimicrobial-Resistant(Antimicrobial-ResistantSURVEILLANCE & Organisms) Organisms)SCREENING FOR AROs (Antimicrobial-Resistant Organisms) June 18 - 20, 2014 June 18 - 20, 2014 June 18 - 20,The 2014 Hyatt Regency, Calgary, Alberta TheThe Hyatt Hyatt Regency, Regency, Calgary, Calgary, Alberta Alberta

Jury MembersJury Members ExpertExpert Speakers Speakers Jury Members Expert Speakers Jury Chair – Tom Marrie Liz Bryce Yves Longtin Andrew Simor Jury ChairJury Chair– Tom Tom Marrie Marrie LizLiz Bryce Bryce YvesYves Longtin JimAndrew Talbot Simor Bill AlbrittonBill Albritton BarryBarry Cookson Cookson AllisonAllison McGeer McGeer JimHenri Talbot Verbrugh Bill Albritton Barry Cookson Allison McGeer Jim Talbot Helen BranswellHelen Branswell JulianJulian Davies Davies ScottScott McEwen McEwen HenriBob Weinstein Verbrugh Helen Branswell Julian Davies Scott McEwen Henri Verbrugh Andre CorriveauAndre Corriveau SergeSerge Desnoyers Desnoyers KimKim Neudorf Neudorf Bob Weinstein Andre Corriveau Serge Desnoyers Kim Neudorf Bob Weinstein Barb FarlowBarb Farlow MichaelMichael Edmond Edmond LindsayLindsay Nicolle Nicolle Barb Farlow Michael Edmond Lindsay Nicolle David HeymannDavid Heymann Dan GregsonDan Gregson HowardHoward Njoo Njoo David Heymann Dan Gregson Howard Njoo JurySteven Members LewisSteven Lewis AnthonyExpertAnthony Harris Speakers Harris DavidDavid Patrick Patrick StevenPat Lewis Piaskowski AnthonySusan Huang Harris DavidEli Perencevich Patrick JuryPat Chair Piaskowski – Tom Marrie Susan Huang Eli PerencevichYves Longtin Andrew Simor Pat PiaskowskiJennifer Rodgers LizSusanJohn Bryce Huang Jernigan EliTrish Perencevich Perl Jennifer Rodgers John Jernigan Trish Perl Jim Talbot Bill AlbrittonJenniferJohn Rodgers Spika BarryJohnJoel JerniganCookson Kettner TrishPilarAllison PerlRamon-Pardo McGeer John Spika Joel Kettner Pilar Ramon-Pardo Helen JohnBranswell SpikaHoward Waldner JulianJoelMark Kettner Davies Loeb PilarAndrewScott Ramon-Pardo Simor McEwen Henri Verbrugh Howard Waldner Mark Loeb Andre HowardCorriveau Waldner SergeMark DesnoyersLoeb Kim Neudorf Bob Weinstein Sponsored by Organized by BarbSponsored Farlow by Michael Edmond Organized by Lindsay Nicolle David HeymannSponsored by Dan Gregson Organized by Howard Njoo Steven Lewis Anthony Harris David Patrick Pat Piaskowski Susan Huang Eli Perencevich Jennifer Rodgers John Jernigan Trish Perl John Spika Joel Kettner Pilar Ramon-Pardo Howard Waldner Canadian Consensus DevelopmentMark ConferenceLoeb on Surveillance & Screening for AROs i www.AROsCalgary2014.ca Sponsored by Organized by OVERVIEW OF THE CONFERENCE

The 3-day Canadian Consensus Development Conference on Surveillance & Screening for AROs (Antimicrobial-Resistant Organisms), will be held in Calgary, Alberta from June 18–20, 2014. It is the first event of its kind in Canada to look at issues in the field of AROs.

This conference will be of interest to clinicians, policy-makers, managers, researchers, and students with an interest in AROs. It will address issues in public health, infectious diseases, laboratory medicine, and related fields.

The Consensus Conference model is an exciting format, geared to creating maximum impact on real-world clinical policy and practice. Leading experts from Canada, the US, UK and EU will address a wide range of issues, including:

• Overview – What are AROs? What burden do they impose on patients and the health system? Why does control of AROs vary so much? • Surveillance – Why should we conduct surveillance? What outcomes do we want, and are we achieving them? • Screening – What is appropriate screening for AROs in various settings? Should we screen for AROs – Pro versus Con. • What factors can facilitate or hinder effective ARO control in practice? Organizational and cultural factors; Lab capacity. • Ethical and policy implications – What are the impacts of screening on patients and others? Can screening do harm? What is the economic cost/benefit of screening? What can patients, the public, and health care professionals do to help? • Research/Evidence – What are the most important gaps in our knowledge? How should we evaluate ARO screening in the future? What are the barriers to effective research and what strategies can address them?

On the final day of the conference, an expert Jury chaired by D. Tom Marrie, Dean of Medicine at Dalhousie, will release a Consensus Statement summarizing the evidence and making recommendations for policy and practice in Canada and other countries.

IHE’s Consensus Development Conferences are adapted from the model created by the US National Institutes of Health (NIH) to increase the dissemination and impact of findings from research. Our conferences build on the success of the NIH model in the Canadian context, with a flexible organizational structure and a focus on broad policy issues, as well as clinical and scientific questions.

IHE has held five consensus conferences to date: Self-Monitoring in Diabetes; Low Birthweight; Depression in Adults; FASD Across the Lifespan; and Legal Issues of FASD. Consensus Statements and other documents, along with videotape of the proceedings, can be viewed on the IHE website: http://www.ihe.ca/research/knowledge-transfer-initiatives/--consensus-development-conference-program/

ii ACCREDITATION Accreditation

MAINTENANCE OF CERTIFICATION AttendanceMaintenance at this program entitles certified Canadian of College Certification of Health Leaders members (CHE / Fellow) to 6.5 Category II credits toward their maintenance of certification requirement.

Attendance at this program entitlesLetter from Jim certified Talbot *Coming* Canadian College of Health Leaders members (CHE / Fellow) to 6.5 Category II credits toward their maintenance of certification requirement.

This event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada, and approved by the University of Calgary Office of Continuing Medical Education and Professional Development. Participants can claim up to a maximum of 12 hours study credits.

Message from Alberta’s Chief Medical Officer of Health

On behalf of Alberta Health and the conference organizers, it is my great pleasure to welcome you to the Canadian Consensus Development Conference on

www.AROscalgary2014.caSurveillance and ScreeningCanadian for Consensus AROs Development (Antimicrobial-ResistantConference on surveillance & screening for aros Organisms).

This conference is an important initiative that responds to a critical challenge facing every health system throughout the world. I am proud that Alberta Health is sponsoring this conference, and I am delighted to be taking part.

Alberta Health is funding this conference to inform a new standard for surveillance and screening for AROs. We very consciously chose the conference format so we could share the discussion and findings widely, as this issue is a universal concern.

Most of all, I am grateful to the dozens of colleagues from Alberta and from North America and Europe who have willingly given their time and effort to make this conference happen. We have had tremendous leadership from the Scientific Committee, including colleagues from CDC in the United States and WHO/PAHO, as well as from the four Canadian organizations who offered to be Scientific Sponsors. And, we have been humbled by the response from the senior scientists and health system leaders we invited to serve on the Jury and to be expert presenters. The caliber of the Jury and the presenters speaks to the importance of this topic, and to the collegiality and shared dedication to patients that is at the heart of any health system.

Finally, I would like to thank each and every delegate at the conference - and welcome you to Calgary! I wish you the best and I hope the discussions during these next three days will help you and your colleagues respond to the challenge of AROs.

Sincerely,

James Talbot, PhD, MD, FRCPC Chief Medical Officer of Health Alberta Health

Canadian Consensus Development Conference on Surveillance & Screening for AROs 3 www.AROsCalgary2014.ca WHAT ARE AROs

“Antimicrobial resistant organisms” (AROs) refers to bacteria capable of causing human disease that are resistant to one or more classes of currently available antibiotics. This resistance is associated with treatment failure leading to significant disease, infection complications, prolonged hospital stay, and increased risk of death. In the United States, it is estimated that each year at least 2 million people acquire serious infections caused by AROs, and at least 23,000 people die annually as a direct result of these infections. Of particular concern in Canadian hospitals are AROs such as methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and multidrug-resistant Gram-negative bacteria, especially those with extended-spectrum β-lactamase (ESBL), and carbapenem-resistant Enterobacteriaceae (CRE). Active surveillance screening for MRSA, VRE, and ESBL is receiving greater attention for its potential value in identifying carriers of these pathogens to prevent further transmission. - From the IHE Literature Review completed for the AROs conference.)

“Antimicrobial Resistance (AMR) is a public health problem of increasing magnitude and importance recognized by the United States (US) and the European Union (EU), as well as their partner countries. Resistance occurs naturally, but misuse and overuse is rapidly increasing the prevalence of hard-to- treat infections in both humans and animals. Recognizing that AMR is a growing and dangerous public health issue, the US and EU established a transatlantic taskforce on antimicrobial resistance (TATFAR) in 2009.” - From the 2014 TATFAR Progress Report

AMR is an increasingly serious threat to global public health that requires action across all government sectors and society. AMR is present in all parts of the world. New resistance mechanisms emerge and spread globally threatening our ability to treat common infectious diseases, resulting in death and disability of individuals who until recently could continue a normal course of life. WHO’s 2014 report on global surveillance of antimicrobial resistance reveals that antibiotic resistance is no longer a prediction for the future; it is happening right now, across the world, and is putting at risk the ability to treat common infections in the community and hospitals. Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infections and minor injuries, which have been treatable for decades, can once again kill. - From WHO Fact sheet N°194, updated April 2014

www.AROsCalgary2014.ca 4 Canadian Consensus Development Conference on Surveillance & Screening for AROS JURY CHAIR Jury Chair Questions

Dr. Tom Marrie,1. Overview: Dean of Medicine, a) What are AROs? What is their incidence and prevalence, in health Dalhousie University,care facilities Halifax, and in the NS community? (Global, US, Canadian, and Alberta perspectives.) Why are they a problem, globally and in Canada – what Dr. Tom Marrieburden is ado leading they impose Canadian on patients medical and the healthresearcher, system? professor and b) Where do AROs come from (genetics and evolution)? How big a factor clinician whois returned the use of antimicrobials,to Dalhousie and as what the is Dean the contribution of the Faculty from various of Medicine, September 1,settings 2009. (healthcare, home, agriculture)? c) What is surveillance; what is screening? How are they related? Originally fromd) What Newfoundland, can we learn from Dr. the Marrie experience graduated of other jurisdiction from thes Dalhousie Medical School(International, and joined US, theCanadian, Faculty and of Alberta Medicine perspectives)? in 1977. Why While does at Dalhousie control of AROs vary so much? – e.g., is mandatory public reporting of as a professordata of medicineon AROs helpful? and microbiology, he established the Division of Infectious Diseases. More recently he was the Dean of the Faculty of Medicine 2. Surveillance: and Dentistry at the University of Alberta. Undera) Why his should leadership we conduct in Alberta, surveillance? the What Faculty do we engaged do based onin tahe major capital expansion and developed an alternate fundingresults? What plan outcomes for faculty. do we During want, and this are wetime, achieving he maintained them? an active research program, focusing on community-acquiredb) How shouldpneumonia. we conduct surveillance – what options are available? What are the key areas of focus for surveillance in public health? Among other recognitions, Dr. Marrie has been honoured with a Lifetime Achievement Award by the Dr. Tom Marrie, Dean of Medicine, Dalhousie 3. Screening: Association of Medical Microbiology and Infectiousa) Should Diseases we screen of for Canada; AROs? Pro an versus Excellence Con. in Leadership Award by University, Halifax,the University NS of Alberta; an Eagle Feather awardShould (Aboriginal we rely on horizontal MD Program, measures University only, i.e. general of Alberta);prevention a Master Clinician Lecturer Award by the Department ofmeasures Medicine, with noDalhousie screening? University; and an honourary doctorate by Should we rely on vertical measures, i.e. screen for multiple specific Dr. Tom Marrie is a leadingthe University Canadian of the Mediterranean,medical Marseille,organisms? France. researcher, professor and clinician who returned to If we screen, what options should we use? – e.g., community vs. admission; acute care vs. continuing care; patient selection; methods. Dalhousie as the Dean of the Faculty of Medicine, If we screen, what should we do with the results, and how should we September 1, 2009. evaluate a screening program? QUESTIONS b) Is there a role for decolonization, and if so, when, and how? c) Why do screening practices vary so much between jurisdictions? Originally from1. Overview: Newfoundland, Dr. Marrie graduated b) Lab capacity – what is the burden of ARO testing on labs; is it appropriate/ from the Dalhousiea) What are AROs?Medical What School is their incidence and joined and prevalence, the in health 4. What factorscost-effective can facilitate relative or to hinderother demands effective on labARO resources? Are there changes or care facilities and in the community? (Global, US, Canadian, and Albertacontrol in practice?new options available that could reduce the burden? Faculty of Medicineperspectives.) in Why 1977. are they While a problem, at Dalhousie globally and in as Canada a – what burdena) Organizational and cultural factors (barriers and enablers) professor ofdo medicine they impose onand patients microbiology, and the health system?he established b) Lab capacity5. Ethical– what isand the policy burden implications: of ARO testing on labs; is it b) Where do AROs come from (genetics and evolution)? How big a factorappropriate/cost-effective is a) What is appropriate relative to other screening demands for AROs on lab in resources? various settings? How do we the Division of Infectious Diseases. More recently he Are there changes or new options available that could reduce the the use of antimicrobials, and what is the contribution from various settingsburden? evaluate screening, to determine when it is appropriate? What are the benefits was the Dean(healthcare, of the home, Faculty agriculture)? of Medicine and Dentistry and risks/costs for patients, and for the health system at the Universityc) What ofis surveillance; Alberta. whatUnder is screening? his leadership How are they in related? 5. Ethical andb) What policy are implications: the impacts of screening on patients, and on their family members Alberta, thed) Faculty What can weengaged learn from in the a experience major capitalof other jurisdictions (International,a) What is appropriateand others? screening for AROs in various settings? How do expansion andUS, Canadian, developed and Alberta an alternate perspectives)? funding Why does plancontrol of AROs varywe evaluateso screening,Can screening to determine do harm? when Does it isit appropriate?result in patients Wha receivingt are the reduced care due to much? – e.g., is mandatory public reporting of data on AROs helpful? benefits and “leperization”risks/costs for (stigma)patients, andand forisolation? the health system? for faculty. During this time, he maintained an active b) What are theDoes impacts it impact of screening eligibility/placement on patients, and in home on their care family and continuing care? 2. Surveillance: members andDo others? patients have the right to refuse screening (or should they)? research program, focusing on community -acquired Can screening do harm? Does it result in patients receiving reduced care pneumonia.a) Why should we conduct surveillance? What do we do based on the results?due to “leperization”c) What (stigma) is the economic and isolation? cost/benefit of screening from the point of view of What outcomes do we want, and are we achieving them? Does it impactthe eligibility/placement individual patient; in health home care providers;and continuin andg thecare? funder of the health care b) How should we conduct surveillance – what options are available? WhatDo patients are havesystem? the right How to do refuse we evaluate/measure screening (or should the economicthey)? value of screening? Among otherthe recognitions,key areas of focus for Dr. surveillance Marrie inhas public been health? c) What is thed) economic What can cost/benefit patients, the of public,screening and from health the carepoint professionalsof view do to help? honoured with a Lifetime Achievement Award by the of the individualWould patient; more health education care providers; re: appropriate and the use funder of antibiotics of the help reduce the 3. Screening: health care system?incidence How of do AROs, we evaluate/measure and what would bethe the economic most effective value strategy? Associationa) of Should Medical we screen Microbiology for AROs? Pro versus and Con.Infectious of screening? d) What can patients, the public, and health care professionals do to Diseases ofShould Canada; we rely onan horizontal Excellence measures in only,Leadership i.e. general prevention measureshelp? Would more6. Research/Evidence: education re: appropriate use of antibiotics help Award by thewith University no screening? ofShould Alberta; we rely onan vertical Eagle measures, Feather i.e. screen for multiplereduce the incidencea) What of are AROs, the most and whatimportant would gaps be the in mostour knowledge effective about AROs and specific organisms? If we screen, what options should we use? – e.g., communitystrategy? screening? award (Aboriginalvs. admission; MD acute Program, care vs. continuing University care; patient of Alberta); selection; methods. If b) How should we evaluate ARO screening in practice in the future, and are a Master Clinicianwe screen, whatLecturer should weAward do with by the the results, Department and how should we evaluate6. Research/Evidence: a there new approaches that would enable us to do that better? of Medicine,screening Dalhousie program? University; and an honourary a) What are thec) Whatmost important are the best gaps types in our of studiesknowledge and/or about ongoing AROs monitoringand to help b) Is there a role for decolonization, and if so, when, and how? screening? improve how we identify and manage AROs? Who should commission and doctorate byc) Whythe doUniversity screening practices of the vary Mediterranean, so much between jurisdictions? b) How shouldfund we evaluatethem? ARO screening in practice in the future, and Marseille, France. are there new approaches that would enable us to do that better? c) What are thed) bestWhat types are the of studies barriers and/or to effective ongoing research monitoring and to what help strategies can address 4. What factors can facilitate or hinder effective ARO control in practice?improve how wethem? identify and manage AROs? Who should commission a) Organizational and cultural factors (barriers and enablers) and fund them? d) What are the barriers to effective research and what strategies can address them?

Canadian Consensus Development Conference on Surveillance & Screening for AROs 5 www.AROsCalgary2014.ca

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros PROGRAM

Tuesday, June 17, 2014 (pre-conference day)

5:00 p.m. – 6:00 p.m. Reception for delegates, speakers, and Jury members

6:00 p.m. – 9:00 p.m. Jury dinner (Jury members only)

6:00 p.m. – 9:00 p.m. Speaker dinner (speakers only)

Day 1: Wednesday, June 18, 2014

7:00 a.m. – 8:00 a.m. Continental Breakfast and Registration

8:00 a.m. – 8:15 a.m. Opening Remarks John Conly, Chair, Scientific Committee; Jim Talbot, Chief Medical Officer of Health, Alberta Health, Edmonton

8:15 a.m. – 9:45 a.m. Question 1: Overview

a) What are AROs? What is their incidence and prevalence (in health care facilities and in the community)? (Global, US, Canadian, and Alberta perspectives) Why are they a problem, globally and in Canada – what burden do they impose on patients and the health system? Pilar Ramon-Pardo, WHO/PAHO, Washington Howard Njoo, PHAC, Ottawa

b) Where do AROs come from (genetics and evolution)? How big a factor is the use of antimicrobials, and what is the contribution from various settings (healthcare, home, agriculture)? Julian Davies, University of British Columbia, Vancouver Scott McEwen, University of Guelph

Questions and Answers

9:45 a.m. – 10:00 a.m. Break

10:00 a.m. – 11:15 a.m. Question 1 (continued)

c) What is surveillance; what is screening? How are they related? Joel Kettner, International Centre for Infectious Diseases, Winnipeg

www.AROsCalgary2014.ca 6 Canadian Consensus Development Conference on Surveillance & Screening for AROS PROGRAM

d) What can we learn from the experience of other jurisdictions? (International, US, Canadian, and Alberta perspectives) Why does control of AROs vary so much? – e.g., is mandatory public reporting of data on AROs helpful? Andrew Simor, Sunnybrook, Toronto Robert Weinstein, Cook County, Chicago

Questions and Answers

11:15 a.m. – 12:15 p.m. Lunch

12:15 p.m. – 1:00 p.m. Question 2: Surveillance

a) Why should we conduct surveillance? What do we do based on the results? What outcomes do we want, and are we achieving them? Jim Talbot, Alberta Health, Edmonton

b) How should we conduct surveillance – what options are available? What are the key areas of focus for surveillance in public health? David Patrick, University of British Columbia, Vancouver

Questions and Answers

1:00 p.m. – 2:40 p.m. Question 3: Screening

a) Should we screen for AROs? Pro versus Con. Should we rely on horizontal measures only, ie general prevention? Should we rely on vertical measures, ie screen for multiple specific organisms? If we screen, what options should we use? – eg, community vs admission; acute care vs. continuing care; patient selection; methods. If we screen, what should we do with the results, and how should we evaluate a screening program? Michael Edmond, Virginia Commonwealth University, Richmond Henri Verbrugh, Erasmus University Medical Centre, Rotterdam Allison McGeer, Mount Sinai, Toronto

Questions and answers

2:40 p.m. – 3:00 p.m. Break

3:00 p.m. – 4:00 p.m. Question 3 (Continued)

Canadian Consensus Development Conference on Surveillance & Screening for AROs 7 www.AROsCalgary2014.ca PROGRAM

b) Is there a role for decolonization, and if so, when, and how? Susan Huang, University of California Irvine

c) Why do screening practices vary so much between jurisdictions? John Jernigan, Centers for Disease Control and Prevention, Atlanta

Questions and Answers

4.00 p.m. End of day 1

4:00 p.m. – 5:00 p.m. Reception

Day 2: Thursday, June 19, 2014

8:00 a.m. – 8:45 a.m. Continental Breakfast and Registration

8:45 a.m. – 9:45 a.m. Question 4: What factors can facilitate or hinder effective ARO control in practice?

a) Organizational and cultural factors (barriers and enablers) Liz Bryce

b) Lab capacity – what is the burden of ARO testing on labs; is it appropriate/cost-effective relative to other demands on lab resources? Are there changes or new options available that could reduce the burden? Dan Gregson, Calgary Lab Services

Questions and Answers

9:45 a.m. – 10:00 a.m. Break

10:00 a.m. – 12:00 p.m. Question 5: Ethical and policy implications

a) What is appropriate screening for AROs in various settings? Lindsay Nicolle, University of Manitoba, Winnipeg

www.AROsCalgary2014.ca 8 Canadian Consensus Development Conference on Surveillance & Screening for AROS PROGRAM

b) What are the impacts of screening on patients, and on their family members and others? – eg, can screening do harm? Does it result in patients receiving reduced care due to “leperization” (stigma) and isolation? Does it impact eligibility/placement in home care and continuing care? Do patients have the right to refuse screening (or should they)? Anthony Harris, University of Maryland, Baltimore

c) What is the economic cost/benefit of screening from the point of view of the individual patient; health care providers; and the funder of the health care system? How do we evaluate/measure the economic value of screening? Barry Cookson, London School of Hygiene & Tropical Medicine, London

d) What can patients, the public, and health care providers do to help? Would more education re: appropriate use of antibiotics help reduce the incidence of AROs, and what would be the most effective strategy? What is the appropriate role of health care providers in ensuring responsible stewardship of antimicrobials? Kim Neudorf, Patients for Patient Safety Canada Yves Longtin, Laval University

Questions and Answers

12:00 p.m – 1:00 p.m. Lunch

1:00 p.m – 2:40 p.m. Question 6: Research/evidence

a) Ongoing scientific gaps for facilitating policy in healthcare Trish Perl, Johns Hopkins, Baltimore

b) Outlining a Framework for ARO Screening/Surveillance Studies Eli Perencevich, University of Iowa, Des Moines

c) Designing Interventional Studies for Evaluation of ARO Control Strategies Mark Loeb, McMaster University, Hamilton

d) How CIHR is Addressing Antimicrobial Resistance, Nationally and Internationally Serge Desnoyers, CIHR (III), Quebec City

Questions and Answers

Canadian Consensus Development Conference on Surveillance & Screening for AROs 9 www.AROsCalgary2014.ca PROGRAM

2:40 p.m. – 3:00 p.m. Break

3:00 p.m. – 4:00 p.m. Open Discussion

4:00 p.m. End of Day 2

Day 3: Friday, June 20, 2014

8:00 a.m. – 9:00 a.m. Continental Breakfast and Registration

9:00 a.m. – 9:30 a.m. Reading of the draft Consensus Statement

9:30 a.m. – 10.30 a.m. Open discussion and comments on the statement

10:30 a.m. – 11:00 a.m. Break

11:00 a.m. – 11:15 a.m. Jury Chair Final Comments

11:15 a.m. – 11:30 a.m. Closing Remarks

11:30 a.m. End of the Conference

11:30 a.m. News conference/Media availability

www.AROsCalgary2014.ca 10 Canadian Consensus Development Conference on Surveillance & Screening for AROS The Jury The Jury THE JURY CHAIR - Tom Marrie, MD The Jury Dean, Faculty of Medicine, Dalhousie University Dr. Tom Marrie is a leading Canadian medical researcher, professor and clinician CHAIRCHAIRwho - Tom returned Marrie, - Tom to Dalhousie MDMarrie, as MD the Dean of the Faculty of Medicine, September CHAIR1, 2009. - Tom Originally Marrie, from MD Newfoundland, Dr. Marrie graduated from the Dalhousie Dean, FacultyDean,Dean, of Faculty Medicine, Faculty of Medicine, Dalhousie of Medicine, Dalhousie University University Dalhousie University Medical School and joined the Faculty of Medicine in 1977. While at Dalhousie as Dr. Tom Marrie is a leading Canadian medical researcher, professor and clinician who returned a professor of medicine and microbiology, he established the Division of Infectious to DalhousieDr. Tomas the Marrie Dean ofis athe leading Faculty Canadian of Medicine, medical September researcher, 1, 2009. professor Originally and from clinician Newfoundland,whoDr.Diseases. returnedTom Dr. Marrie MarrieMore to Dalhousie graduated recently is a fromas leadinghe the wasthe Dean Dalhousie the ofCanadian Dean the MedicalFaculty of the Schoolof medicalFaculty Medicin and ofe, joined Septemberresearcher,Medi thecine and Dentistry professor and clinician at the University of Alberta. UnderFaculty his of1,who Medicine leadership 2009. returned Originally in 1977. in Alberta, Whilefrom to DalhousieNewfoundland, at the Dalhousie Faculty as engagedasaDr. professor Marriethe Dean ingraduatedof amedicine major of fromthe capitaland microbiology,theFaculty expansionDalhousie of Medicinwith the e, September construction of two health researchhe established buildings.Medical1, 2009. the DivisionSchool He Originally also and of Infectious developejoined thefrom Diseases. dFaculty an Newfoundland, alternate Moreof Medicine recently funding in he 1977. wasplan Dr. theWhil that DeanMarriee atof feredofDalhousie the graduated Facultya new as method from the Dalhousie to support faculty, enabling greaterof Medicine academica professor and Dentistry activity of medicine at andthe University moreand microbiology, innovative of Alberta. patienthe Under established his care. leadership Duringthe Division in this Alberta, time,of Infectious the he maintained an active research program, Facultyfocusing engagedDiseases.Medical on community-acquired in a Moremajor School recently capital andexpansion he waspneu joined the withmonia. Dean thethe constructionofAmong Facultythe Faculty other of ofof tworecognitions, MediMedicine healthcine research and Dr.Dentistryin Marrie1977. has Whil e at Dalhousie as beenat honouredthe University with of aAlberta. Lifetime Underbuildings. Achievement his Heleadership also developedAward in Alberta, by an the alternate the Association Faculty funding engaged ofplan Medical that in a offered major Microbiology capital a new expansionmethod and to Infectious support with the Diseases construction of two health research buildings.a professor He also developeof medicined an alternate and fundingmicrobiology, plan that offered he aestablished new method the Division of Infectious of Canada; an Excellence in faculty,Leadership enabling Award greater by academic the University activity and of Alberta; more innovative an Eagle patient Feather care. During award this (Aboriginal time, MD to support faculty, enabling greater academicDiseases. activity More and more recently innovative he patient was care. the During Dean this oftime, the he maintainedFaculty of Medicine and Dentistry he maintained an active research program, focusing on community-acquired pneumonia. Among other recognitions, Dr. Program,an active University research ofprogram, Alberta) focusing a Master on community-acquired Clinician Lecturer pneuAwardmonia. by the Among Department other recognitions, of Medicine, Dr. Marrie Dalhousie has University; at the UniversityMarrie hasof beenAlberta. honoured Under with a Lifetime his leadership Achievement Awardin Alberta, by the Association the Faculty of Medical engaged Microbiology in and a majorInfectious capital expansion with the andbeen an honourary honoured with doctorate a Lifetime by Achievementthe University Award of Mediterranean, by the Association Marseille of Medical France. Microbiology and Infectious Diseases constructionofDiseases ofCanada; two of Canada;anhealth Excellence an research Excellence in Leadership in buildings.Leadership Award Award by Hethe by Universityalso the University develope of Alberta; of Alberta; dan an Eagle an alternate Eagle Feather Feather award funding award (Aboriginal (Aboriginal plan MD MDthat offered a new method to support faculty,Program,Program, Universityenabling of Alberta)greaterBill aAlbritton, MasterMaster academic Clinician Clinician MD Lecturer activityLecturer Award Award and by by morethe the Department Department innovative of ofMedicine, Medicine, patient Dalhousie Dalhousie care. University; University; During this time, he maintained andand anan honourary doctorate by by the the University University of of the Mediterranean, Mediterranean, Marseille Marseille France. France. an active research program, focusingProfessor on and community-acquired former Dean of Medicine, pneu Universitymonia. of Among Saskatchewan other recognitions, Dr. Marrie has been honoured with a LifetimeWilliamBill BillAchievement Albritton, Albritton, Albritton MD is MD AwardProfessor by of thePediatrics Association and former of Dean Medical of the MicrobiologyCollege of Medicine and at Infectious Diseases of Canada; an Excellence in LeadershiptheProfessorProfessor University and and Awardformer offormer Saskatchewan. Dean Dean by ofthe of Medicine, Medicine, University He has University University practiced of ofAlberta; ofSaskatchewan pediatric Saskatchewan an infe Eaglectious diseases Feather since award 1976 (Aboriginal MD Program, University of Alberta)andWilliamWilliam a Mastergeneral Albritton Albritton pediatrics Clinician is is Professor Professor since Lecturer of Pediatrics1994. He Awardand andhas former former special by Dean Dean theinterests of of theDepartment the College Collegein frequent of Medicineof Medicine ofinfections, Medicine, at at immune Dalhousie University; deficiency states, including HIV/AIDS. In addition, he has special clinical interests in providing and an honourary doctorate bythethe the UniversityUniversity University of Saskatchewan.Saskatchewan. of Mediterranean, He He has has practiced practiced pediatric Marseille pediatric infectious infe France.ctious diseases diseases since since1976 and 1976 generalandgeneral general pediatrics pediatric pediatrics since continuity since1994. He1994. care has He specialto haschildren interestsspecial with interestsin frequentspecial in infectionsfrequentneeds, developmentinfections, and immune immune delay, and a widedeficiencydeficiency variety states,states, of clinical including including conditions HIV/AIDS.HIV/AIDS. in In Inearly addition,addition, infancy. hehe has hasDr. special speciAlbritton’sal clinical clinical currentinterests interests researchin inproviding providing interests are Billingeneralgeneral Albritton,the evaluation pediatricpediatric carecontinuityMD of tohealthcare children care withto delivery children special systemswithneeds, special development for needs, the underserved delay,development and a wide and delay, variety a varietyand of a of interest inwideclinical medical variety conditions education, of clinical in early conditions including infancy. inDr. admissions early Albritton’s infancy. currentpolicies, Dr. Albritton’s research undergraduate currentinterests research are andin the graduateinterests evaluation are curricula, Professorespeciallyinof thehealthcare evaluation in and delivery areas of former healthcare relatedsystems for to Deandelivery socialthe underserved ofsystemsaccountability Medicine, forand the a variety underservedand University professionalism.of interests and in a medical varietyof Saskatchewan of interest ineducation, medical education,including admissions including admissionspolicies, and policies,undergraduate undergraduate and graduate and curricula, graduate especially curricula, especially in areas related to social accountability and professionalism. Williamin areas Albritton related to social is Professoraccountability and of professionalism.Pediatrics and former Dean of the College of Medicine at the University of Saskatchewan. He has practiced pediatric infectious diseases since 1976 Helen Branswell andHelen general Branswell pediatrics since 1994. He has special interests in frequent infections, immune MedicalHelenMedical Branswell Reporter,Reporter, Canadian Canadian Press Press deficiency Medical Reporter, states, Canadian including Press HIV/AIDS. In addition, he has special clinical interests in providing Helen Branswell is the Medical Reporter for The Canadian Press. In more than 30 years as a Helen Branswell is the Medical Reporter for The Canadian Press, Canada’s news agency. generalHelenjournalist, Branswell pediatric she has is covered the continuity Medical a range Reporter of beatscare forin tobureaus The children Canadian across Canada Press,with andspecialCanada’s in Europe, newsneeds, assuming agency. development delay, and a InCP’s more medical than reporting 30 years job as in a2000. journalist, Based in she Toronto, has shecovered covered a thatrange city’s of SARS beats outbreak in bureaus across wideCanadaIn more variety than and 30inof yearsEurope, clinical as aassuming journalist, conditions CP’sshe has medicalin covered early reporting ainfancy. range ofjob beats Dr.in 2000. inAlbritton’s bureaus Based across in current Toronto, sheresearch interests are in theCanadain 2003, evaluation discoveringand in Europe, inof the assuminghealthcare process an CP’s affinity medical delivery for reportinginfectious systems job diseases in 2000. for reporting. Basedthe underserved inShe Toronto, reports sheon and a variety of interest coveredcovereda range of thatthat health city’s city’s issues, SARS SARS but outbreak specializes outbreak in 2003,in in infectious 2003, discovering discovering diseases in likethe birdprocessin the flu, process anpolio affinity and an the foraffinity newinfectious for infectious in diseasesmedicaldiseasesMiddle Eastern reporting.reporting. education, Respiratory She She reports reportsSyndromeincluding on aon rangevirus, a rangeadmissions orof MERS.health of health Sheissues, is policies,issues,especially but specializes but interested undergraduatespecializes in ininfectious zoonoses, in infectious and graduate curricula, especiallydiseasesdiseasesanimal diseases thingsthings in areas thatlike like spillbird bird relatedoverflu, flu, intopolio polio the toand human socialandthe thenew population. accountabilitynewMiddle Middle EasternShe received Eastern Respiratory aand 2004 Respiratory KnightSyndromeprofessionalism. Public Syndrome virus, virus, ororHealth MERS. Journalism She She is is especially Fellowshipespecially interested at interestedthe Centers in zoonoses, infor zoonoses, Disease animal Control animal disea andses Preventiondisea thatses spill thatin over Atlanta, spill into over the into the humanhumanwhere she population.population. spent three She Shemonths received received working a 2004 a with 2004 Knight scientists Knight Public in Public theHealth hospital Health Jour infectionsnalism Jour Fellowshipnalism and influenza Fellowship at the at the branches. She was a 2011 NiemanCentersCenters Global forfor Disease HealthDisease Fellow Control Control at Harvardand and Prevention PreventionUniversity, in Atlanta, where in Atlanta, her where work where she focused spent she on three poliospent months eradication. three working months working withwithIn scientists August scientists 2013, in inthe Wired the hospital hospital Magazine infectionsinfections named herand and in influenza influenzaits 101 Signals branche branche segments. Shes. onShe was essential wasa 201 a1 blogs, 201Nieman1 Twitter Nieman Global feeds GlobalHealth and Tumblrs FellowHealth atto Fellow Harvard at Harvard University,University,follow. where where her her work work focusedfocused onon polio polio eradication. eradication. In AugustIn August 2013, 2013, Wired Wired Magazine Magazine named namedher in its her 101 in Signals its 101 Signals segment on essential blogs, Twitter feeds and Tumblrs to follow. segment on essential blogs,Helen Twitter Branswell feeds and Tumblrs to follow. Medical Reporter, Canadian Press

Helen Branswell is the Medical Reporter for The Canadian Press, Canada’s news agency. In more than 30 years as a journalist, she has covered a range of beats in bureaus across www.AROscalgary2014.caCanada and in Europe,Canadian assuming Consensus CP’s Development medical Conference reporting on surveillance &job screening in 2000. for aros Based in Toronto, she covered that city’s SARS outbreak in 2003, discovering in the process an affinity for infectious www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros diseases reporting. She reports on a range of health issues, but specializes in infectious Canadian Consensus Development Conference on Surveillance & Screening for AROs 11 www.AROsCalgary2014.ca diseases things like bird flu, polio and the new Middle Eastern Respiratory Syndrome virus, or MERS. She is especially interested in zoonoses, animal diseases that spill over into the human population. She received a 2004 Knight Public Health Journalism Fellowship at the Centers for Disease Control and Prevention in Atlanta, where she spent three months working with scientists in the hospital infections and influenza branches. She was a 2011 Nieman Global Health Fellow at Harvard University, where her work focused on polio eradication. In August 2013, Wired Magazine named her in its 101 Signals segment on essential blogs, Twitter feeds and Tumblrs to follow.

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros The Jury THE JURY The Jury The Jury André Corriveau, MD, MBA Chief Public Health Officer, NWT and outgoing Chair, Canadian Public Health Network AndréAndré Corriveau, Corriveau, MD, MBAMD, MBA AndréDr.ChiefChief André Corriveau, Public Public Corriveau Health MD, MBA Officer,Officer,was appointed NWTNWT andasand the outgoingoutgoing Chief PublicChair,Chair, HealthCanadianCanadian Officer PublicPublic for Health theHealth NorthwestNetwork Network ChiefTerritories Public Healthin June Officer, 2012. HisNWT responsibilities and outgoing Chair,include Canadian health promotion,Public Health disease Network surveillance, communicableDr.Dr. André André Corriveau Corriveau disease was appointed control,appointed chronic as as the the Chief disease Chief Public Public prevention, Health Health Officer Officerenvironmental for forthe theNorthwest health,Northwest and aboriginal Dr.health.FromTerritories AndréTerritories Corriveau in in June MarchJune was 2012.2012. 2009appointed His His to responsibilities responsibilitiesJune as the 2012, Chief Dr.include Public include Corriveau Healthhealth health promotion,Officer served promotion, for as thedisease the Northwestdisease Chief surveillance, Medical surveillance, Officer of TerritoriesHealthcommunicablecommunicable (CMOH)in June 2012.disease for theHis control, control,responsibilitiesprovince chronic chronic of Alberta. disease include disease prevention, Dr.health prevention, Corriveau promotion, environmental servedenvironmental disease as health, surveillance, the Provincial/Territorialhealth, and and aboriginal communicableaboriginal health. disease From control, March chronic 2009 diseaseto June 2012,prevention, Dr. Corriveau environmental served health,as the Chief and aboriginal Medical Co-Chairhealth.From of theMarch Pan-Canadian 2009 to June Public 2012, HealthDr. Corriveau Network served from as 2010 the toChief 2013. Medical He is Officer currently of health.FromOfficer Marchof Health 2009 (CMOH) to June for 2012, the Dr.province Corriveau of Alberta. served Dr.as theCorriveau Chief Medicalserved asOfficer the Provincial/ of ChairpersonHealth (CMOH) of thefor theAdvisory province Council of Alberta. of the Dr. Canadian Corriveau Institute served ofas Healththe Provincial/Territorial Information’s Population HealthCo-ChairTerritorial (CMOH) of Co-Chair thefor thePan-Canadian province of the Pan-Canadian of Alberta. Public Dr.Health Public Corriveau Network Health served Network from as 2010 the from Provincial/Territorial to 2010 2013. to 2013.He is He currently is Co-ChairHealth of Initiative, the Pan-Canadian as well as Public a member Health Networkof the Council from 2010 of toChief 2013. Medical He is currently Officers of Health and of Chairpersoncurrently Chairperson of the Advisory of the Advisory Council Councilof the Canadian of the Canadian Institute Institute of Health of Health Information’s Information’s Population Chairpersonthe Advisory of the Board Advisory for theCouncil National of the CollaboratingCanadian Institute Centre of Health for DeterminantsInformation’s Population of Health. From 1998 HealthPopulation Initiative, Health as Initiative, well as aas member well as a memberof the Council of the Council of Chief of Medical Chief Medical Officers Officers of Health of and of Healthto March Initiative, 2009, as wellDr. Corriveauas a member served of the Councilas the Chiefof Chief Medical Medical Officer Officers ofof HealthHealth forand theof Northwest thethe HealthAdvisory Advisory and Board of Board the for Advisory the for Nationalthe BoardNational Collaborating for theCollaborating National Centre Collaborating Centrefor Determinants for DeterminantsCentre of for Health. Determinants of From Health. 1998 of From 1998 Health. From 1998 to MarchTerritories.to 2009, March Dr. 2009, Corriveau Dr. CorriveauDr. Corriveau served receivedas the served Chief his as Medical degree the Chief Officer in Medicalmedicine of Health Officer from for McGill theof HealthNorthwest University for the Territories. inNorthwest 1981 and to completedMarch 2009, a Dr. residency Corriveau in served community as the Chief medicine Medical as Officer well as of a HealthMaster for inthe Business Northwest Administration at Dr. Corriveau received hisTerritories. degreeTerritories. in Dr.medicine Dr.Corriveau Corriveau from received McGill received Universityhis degree his degree in in 1981medicine in and medicine completedfrom McGill from a Universityresidency McGill University inin community1981 and in 1981 and Lavalmedicine University as well as in a 1986. Mastercompleted completedPrior in Business to amoving residency a Administration residency to inthe community inNorthwest community at Laval medicine UniversityTerritories medicine as wellin in 1986.as as1994, well a PriorMaster asDr. toa Corriveau inMastermoving Business toin thealsoBusiness Administration Northwest worked Administration in at Nova Scotia at andLavalTerritories in UniversityNunavikUniversity in 1994, (Northernin in 1986.Dr. 1986. Corriveau Prior PriorQuebec). to moving toalso moving worked to the to in Northwestthe Nova Northwest Scotia Territories and Territories in Nunavikin 1994, in (NorthernDr.1994, Corriveau Dr. Quebec).Corriveau also worked also in worked Nova Scotia in Nova Scotia and inin NunavikNunavik (Northern (Northern Quebec). Quebec). BarbBarb Farlow Farlow BarbPatients Farlow for Patient Safety Canada (Canadian Patient Safety Institute) PatientsBarb Farlow for Patient Safety Canada (Canadian Patient Safety Institute) PatientsPatients for forPatient Patient Safety Safety Canada Canada (Canadian (Canadian Patient Patient Safety Institute)Safety Institute) EducatedEducated as a asmechanical a mechanical engineer, engineer, Barb Farlow Barb has Farlow been advocating has been for advocating improvements for inimprovements in Educatedhealth care as for a mechanical8 years, since engineer, the death Barb of her Farlow daughter has beenAnnie. advocating She is a founding for improvements member of in healthEducatedhealth care care for as 8 for ayears, mechanical 8 years, since thesince engineer, death the of death her Barb daughter of Farlow her daughterAnnie. has been She Annie. isadvocating a founding She is formember a foundingimprovements member in Patients for Patient Safety Canada, and was the first honorary patient perspective board member of Patientshealthof Patients care for Patient for 8Patient years, Safety Safetysince Canada, the Canada, anddeath was ofand the her firstwas daughter thehonorar first Annie.y patient honorar She perspectivey is patient a founding boardperspective member board memberof ofmemberthe Patients International of the of for Internationalthe Patient InternationalSociety Safety forSociety Quality Canada,Society for Qualityin Healthcare. forand inQuality wasHealthcare. Barbthe in first Healthcare.speaks Barb honorar at speaks healthy patientBarb conferences,at health speaks perspective medicalat health board conferences,andmemberconferences, nursing of schoolsmedical the medical International and and has nursing and published nursing Society schools numerous schools forand Quality has papers andpublished in has Healthcare.in peer-reviewed publishednumerous Barb papersnumerous medical speaks in peer- journals. atpapers health She in peer- reviewedis conferences,reviewedpassionate medical aboutmedical medical journals. patient journals. and centredShe nursing is She passionatecare, is schoolsbioethics passionate about and and patient hastransparent about published cen patienttred policy care, numerous cen development. bioethicstred care, papers and bioethics in peer- and transparentreviewedtransparent policy medical policy development. journals. development. She is passionate about patient centred care, bioethics and transparent policy development.

DavidDavid Heymann, Heymann, CBE CBE ProfessorDavid Heymann, of Infectious CBE Disease Epidemiology, London School of Hygiene and Tropical ProfessorDavid Heymann, of Infectious CBE Disease Epidemiology, London School of Hygiene and Tropical Medicine;Professor Head of andInfectious Senior Fellow, Disease Chatham Epidemiology, House Centre London on Global School Health of SecurityHygiene and Tropical Professor of Infectious Disease Epidemiology, London School of Hygiene and Tropical (London)Medicine;Medicine; Head Head and Seniorand Senior Fellow, Fellow, Chatham Chatham House Centre House on Centre Global Healthon Global Security Health Security Medicine; Head and Senior Fellow, Chatham House Centre on Global Health Security (London)(London) Professor(London) David L. Heymann is currently Professor of Infectious Disease Epidemiology, Professor David L. Heymann is currently Professor of Infectious Disease Epidemiology, London London School of Hygiene and Tropical Medicine; Head of the Centre on Global Health SecuritySchoolProfessor of at Hygiene Chatham DavidDavid and L. House,L. TropicalHeymann Heymann London; Medicine; is is currentlyand currently Chairman Head Professor of Professor the of CentrePublic of ofInfectiou Healton Infectiou Globalh England,s HealthDiseases Disease UK. Security Epidemiology Previously Epidemiology at , , heChatham Londonwas the House, SchoolWorldSchool London;Health of of Hygiene Hygiene Organization’s and Chairman and and Tropical Tropical Assistant of Public Medicine; Medicine; Director-General Health Head England, Head of theoffor UK. the HealthCentre Previously Centre Security on Globalon he Globalwasand Healththe Health Environment,WorldSecurity Health atat and Organization’s ChathamChatham Representative House, House, Assistant London;of London; the Director-General Director-General and and Chairman Chairman for for ofHealth pol ofPublicio Public eradication. Security Healt Healt hand England, Fromh Environment, England, 1998 UK. to UK. Previously Previously 2003andhe Representative hewas was thethe Executive WorldWorld of Health theHealth Director Director-General Organization’s Organization’s of the WHO for Communicable Assistant polio Assistant eradication. Director-General Director-General Diseases From Cluster 1998 for to during for2003Health Health hewhich Securitywas Security he and and headedExecutiveEnvironment, the Director global and andresponse of theRepresentative Representative WHO to SARS, Communicable and of of theprior the Director-General to DiseasesDirector-General that was Cluster Director duringfor for forpol the poliowhich eradication.WHOio eradication. he Programme headed From the From 1998 1998 to to onglobal 2003Emerging response hehe waswas and to ExecutiveotherExecutive SARS, Communicable and Director Directorprior to ofthat Diseases.of the thewas WHO WHODirector Earlier Communicable Communicable for experience the WHO sDiseases atProgramme Diseases WHO included Cluster onCluster Emerging Chiefduring during which which he he of Research Activities in the WHO Global Programme on AIDS. Before joining WHO, Prof. and other Communicable Diseases.headed Earlier thethe experiences globalglobal response response at WHO to to includedSARS, SARS, and Chief and prior priorof Research to tothat that was Activities was Dire Director inctor the for WHOforthe theWHO Global WHO Programme Programme Heymann worked for 13 years as a medical epidemiologist in sub-Saharan Africa on assignment from the US Centers Programme on AIDS. Before joiningon Emerging WHO, Prof. and and Heymannother other Communicable Communicable worked for 13 Diseases. years Diseases. as a medical Earlier Earlier epidemiologistexperience experiences at ins WHO atsub-Saharan WHO included included Chief Chief forAfrica Disease on assignment Control and from Prevention the US Centers (CDC) forwhere Disease he participated Control and in Preventionthe first and (CDC) second where outbreaks he participated of Ebola inHemorrhagic the first and Fever, and supported ministriesof of Research health in researchActivities Activities aimed in in the the at WHO betterWHO Global control Global Programmeof Programme malaria, measles, on on AIDS. AIDS. tuberculosis Before Before joining and joining other WHO, WHO, Prof. Prof. second outbreaks of Ebola Hemorrhagic Fever, and supported ministries of health in research aimed at better control of HeymanninfectiousHeymann diseases.worked worked for forPrior 13 to years joining as CDC aa medicalmedical Prof. Heymann epidemiologist epidemiologist worked in in Indiasub- sub- SaharanforSaharan two years Africa Africa as ona medicalon assignment assignment epidemiologist from from the in theUS the USCenters Centers forWHOformalaria, Disease Disease Smallpox measles, ControlControl Eradication tuberculosis andand Prevention Programme. and other (CDC)(CDC) infectious He is where anwhere elected diseases. he he participatedfellow participated Prior of to the joining Institutein in the theCDC first of first Prof.Medicine and andHeymann second secondof the workedoutbreaksNational outbreaks in Academies Indiaof Ebolaof for Ebola two Hemorrhagic Hemorrhagic Fever,(UnitedFever,years as and and States)a medical supported supported and epidemiologist the Academyministries inof ofof theMedical healthhealth WHO Sciencesin in Smallpox research research (United Eradication aimed aimed Kingdom), at at betterProgramme. better and control controlhas Hebeen of is ofmalaria, an awarded malaria, elected measles, severalfellow measles, of public tuberculosisthe tuberculosis Institute health and and other other infectiousawardsinfectiousof Medicine that diseases. diseases. haveof the provided National PriorPrior funding Academiesto joining for theCDC CDC(United establishment Prof.Prof. States) Heymann Heymann and of thean workedon-going Academyworked in mentorship in ofIndia MedicalIndia for for two Sciencesprogramme two years years (United as at asa the medical aKingdom), Internationalmedical epidemiologist epidemiologistand has in the in the WHOAssociationWHObeen awardedSmallpox Smallpox of severalPublic EradicationEradication Healthpublic healthInstitutes Programme. awards (IANPHI). that He He have Inis is 2009an anprovided elected elected Prof. fundingHeymann fellow fellow offor of wasthe the the Instituteappointedestablishment Institute of an ofMedicine honorary ofMedicine an on-going of Commander theof the Nationalmentorship National of theAcademies Academies Most Excellent Order of the British Empire (CBE) for service to global public health. (United(Unitedprogramme States) States) at the andand International thethe Academy Association ofof MedicalMedical of Public Sciences Sciences Health (United Institutes(United Kingdom), Kingdom), (IANPHI). and Inand 2009has has beenProf. been Heymannawarded awarded wasseveral several appointed public public an health health honorary Commander of the Most Excellent Order of the British Empire (CBE) for service to global public health. Canadianawardsawards Consensus that that Development havehave providedprovided Conference funding on surveillance forfor thethe & establishment establishmentscreening for aros of of an an on-going on-going mentorship mentorship programme programmewww.AROscalgary2014.ca at theat theInternational International AssociationAssociation ofof PublicPublic Health Institutes (IANPHI).(IANPHI). In In 2009 2009 Prof. Prof. Heymann Heymann was was appointed appointed an anhonorary honorary Commander Commander of the of the MostMost Excellent Excellent OrderOrder of the British EmpireEmpire (CBE) (CBE) for for service service to to global global public public health. health. Canadian Consensus Development Conference on surveillance & screening for aros Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.cawww.AROscalgary2014.ca www.AROsCalgary2014.ca 12 Canadian Consensus Development Conference on Surveillance & Screening for AROS The Jury

The Jury Steven Lewis, MA HealthTHE Policy Consultant,JURY Saskatoon, Saskatchewan The Jury StevenSteven Lewis, MALewis is a health policy and research consultant based in Saskatoon, and Adjunct Health Policy Consultant, Saskatoon, Saskatchewan Professor of Health Policy at Simon Fraser University. Prior to resuming a full-time StevenStevenSteven Lewis,consulting LewisLewis, MAis a MA health practice policy andhe researchheaded consultant a health based research in Saskatoon, granting and Adjunct agen cy and spent 7 years as HealthHealthProfessor Policy Policy Consultant,of Health Consultant, Policy Saskatoon, at Simon Saskatoon, Saskatchewan Fraser University. Saskatchewan Prior to resuming a full-time consultingCEO practice of the he Healthheaded a Services health research Utilization granting agen andcy Researchand spent 7 years Commission as in Saskatchewan. He StevenCEO Lewis ofhas theis a servedHealthhealth policy Services on and various researchUtilization consultant boards and Research based and in committees,CommissionSaskatoon, and in Adjunct Saskatchewan. including the He Governing Council of the ProfessorSteven of HealthLewis Policy is a athealth Simon policy Fraser University. and research Prior to consultant resuming a full-time based consulting in Saskatoon, and Adjunct has servedCanadian on various Institutes boards and of committees, Health Research, including the Govethe rningSaskatchewan Council of the Health Quality Council, the practiceProfessorCanadian he headed Institutesof aHealth health of research PolicyHealth grantingResearch,at Simon agency theFraser andSaskatchewan spent University. 7 years Healthas CEOPrior Qualityof to the resuming Health Council, athe full-time ServicesconsultingHealth UtilizationHealth Council practice and ofCouncil Canada,Research he headed ofCommissionand Canada, the aeditorial health in Saskatchewan. and boards research the of several editorialHe granting has served journals, boardsagen on various includingcy and of several spentOpen 7 yearsjournals, as including Open boardsCEOMedicine. and ofMedicine. committees, the He Health writes including He frequentlyServices writes the Governingon Utilization frequentlyimproving Council andquality, on ofResearch the equity,improving Canadian and Commission Institutesperformance quality, of Health ininequity, Saskatchewan.health care, and performance He in health care, and is the moderator of the Research,M.A.S.H. the blog Saskatchewan – Meaningful Health Analogies Quality inCouncil, Sports the and Health Health. Council of Canada, and and is the moderator of thehas editorial M.A.S.H. served boards on ofblog variousseveral – journals,Meaningful boards including and committees,Analogies Open Medicine. includingin He Sports writes frequentlythe and Gove Health. onrning Council of the improvingCanadian quality, Institutes equity, and of performance Health Research, in health care, the and Saskatchewan is the moderator ofHealth the M.A.S.H. Quality Council, the blogHealth – Meaningful Council Analogies of Canada, in Sports and and Health.the editorial boards of several journals, including Open Medicine.Pat Piaskowski, He writes RN frequently on improving quality, equity, and performance in health care, Network Coordinator, Public Health Ontario Northwestern Ontario Infection and is the moderator of the M.A.S.H.Pat Piaskowski,Control blogPat –Network Meaningful RNPiaskowski, (NWOICN); Analogies RN in Sports and Health. NetworkEditor-in-Chief, Coordinator,Network Public Canadian Coordinator,Health OntarioJournal Northwestern of InfectionPublic ControlOntarioHealth Infection Ontario Control Northwestern Ontario Infection Network (NWOICN);Control Editor-in-Chief, Network Canadian (NWOICN); Journal of Infection Control Pat PiaskowskiPatPat PiaskowskiPiaskowski, has been the has Network beenRN theCoordinator Network for Coordinator the NWOICN for sincethe NWOICN 2005. Prior since to 2005. assumingPrior this positionto Editor-in-Chief,assuming she was this the position Infection Canadianshe Control was Coordinatorthe Infection Journal at Control Thunder of CoordinatorInfection Bay Regional at ControlThunder NetworkBay Regional Coordinator, Health Sciences Public Centre Health for over Ontario 9 years. Northwestern Her previous roles Ontario include Infection Health SciencesControl Centre Network for over 9(NWOICN); years. Her previous roles include responsibility for quality improvementresponsibility andPat infection Piaskowski for qualitycontrol programsimprovement has in been long and term infectionthe care Network facilities control for programs overCoordinator 10 years. in long She term for the NWOICN since 2005. has maintainedEditor-in-Chief,care facilities certification for over in Canadian infection 10 years. control SheJournal (CIC)has maintained sinceof Infection 1990 andcertificat completed Controlion in an infection Honours control (CIC) since 1990 and completedBachelor an ofHonours SciencePrior inBachelor Nursing to assuming of(HBScN) Science at iLakehead nthis Nursing position University, (HBScN) she Thunder at Lakehead was Bay, the OntarioUniversity Infection in 1993., Thunder Control Coordinator at Thunder Bay, Ontario in 1993. Pat hasPat served has servedPat as Piaskowski asBoard BayBoard member Regionalmember has (1991-1998) (1991-1998) been Health the and andNetwork SciencesPresident President Coordinator (1997) (1997) Centre of Community of Community for for the over and NWOICN Hospitaland 9 years.Hospital since Her 2005. previ ous roles include Infection Control AssociationInfection (CHICA)-CanadaPrior Control to Associationassuming (now Infection (CHICA)-Canada this position Prevention she(now and was Infection Control–Canada). the PreventionInfection and SinceControl Control 2003 Coordinator – she has been at Thunder the Editor in Chief of the Canadian Journalresponsibility of Infection Control for (CJIC). quality She hasimprovement served on numerous and infectionlocal, provincial control and programs in long term Canada). Since 2003 she has been the BayEditor Regional in Chief of Healththe Canadian Sciences Journal ofCentre Infection for Control over 9(CJIC). years. She Her has served previ onous roles include national committees and task forces and iscare a founding facilities member for of overthe previous 10 years. International She Infectionhas maintained Control Council certificat from ion in infection control numerous local, provincial and nationalresponsibility committees and for task quality forces and improvement is a founding member and infection of the previous control International programs in long term (CIC)1998-2008.Infection since Control1990 She has Council and been completed from a long 1998-2008. time member an She Honourshas ofbeen CHICA- a long Bachelor Northwestetime member rnof of Ontario. ScienceCHICA-Northwestern Pat isin co-author Nursing Ontario. of (HBScN)the Pat Infection is co- Controlat Lakehead University, Thunder Toolkitauthor on of theStrategies Infection for Control Pandemics Toolkitcare andon Strategies Disastersfacilities for (2002),for Pandemics over Infection 10 and years. Disasters Control She (2002), Toolkit: has Infection maintained Infection Control Control certificat Toolkit: in Emergencies Infectionion in infection and control (CIC)Bay,Disasters sinceOntarioControl 1990 in (2007), Emergencies in and 1993. ESBL completed and PatToolkit Disasters has (2006) an served(2007),Honours and ESBLGram as Bachelor Toolkit NegativeBoard (2006) of Resistancemember Scienceand Gram ToolkitNegativei(1991-1998)n Nursing (2012) Resistance (HBScN) and Toolkitandother atarticlesPresident (2012) Lakehead andpublished other (1997) University in the of, CommunityThunder and Hospital Bay,Infection OntarioCJIC.articles InControl published2011,in 1993. she inAssociation wasPat the CJIC. namedhas Inserved 2011,CHICA (CHICA)-Canada she as Champion was Board named member ofCHICA Infection Champion (now(1991-1998) Control Infection of and Infection inand 2013 ControlPreventionPresident was andawarded in (1997) 2013 and Honourary was of Control–Canada).awarded Community membership and Hospital Since 2003 she has been Infectionthe EditorinHonourary CHICA-Canada. Control in Chiefmembership Association Sheof the inwas CHICA-Canada. (CHICA)-Canada Canadiana previous member She Journal was of(nowa previous the of infectionInfection Infection member pre Prevention ofvention theControl infection and andcontrol (CJIC).prevention Control–Canada). sub-committee andShe control has sub- of served the Since Provincial 2003on numerous she has been local, provincial and Infectious Diseases Advisory Committee (PIDAC) in Ontario (2004-2013). She has presented at various local, provincial, the Editorcommittee in Chief of the of Provincial the Canadian Infectious Journal Diseases Advisoryof Infection Committee Control (PIDAC) (CJIC). in Ontario She has(2004-2013). served She on has numerous presented local, provincial and nationalnationalat various committees and local, international provincial, and nationalinfection task and controlforces international conferences and infection is a and founding control seminars. conferences member She is and currently seminars. of the a board She previous is currentlymember International afor board the Nursing Infection Control Council from national committees and task forces and is a founding member of the previous International Infection Control Council from 1998-2008.Leadershipmember for She Network the Nursing has (NLN)-Ontario. beenLeadership a longNetwork time (NLN)-Ontario. member of CHICA- Northwestern Ontario. Pat is co-author of the Infection Control 1998-2008. She has been a long time member of CHICA- Northwestern Ontario. Pat is co-author of the Infection Control ToolkitToolkit on on Strategies Strategies for Pandemics for Pandemics and Disasters and Disasters (2002), Infection (2002), Control Infection Toolkit: Control Infection Toolkit: Control Infection in Emergencies Control and in Emergencies and Disasters (2007), ESBLJennifer JenniferToolkit Rodgers, (2006) Rodgers, BSc, and BSc, MSW, Gram MSW, MSc Negative MSc Resistance Toolkit (2012) and other articles published in the Disasters (2007), ESBL ToolkitPatientPatient (2006) SafetySafety and ImprovementImprovement Gram Negative Lead, Lead, Canadian Resistance Canadian Patient Patient Toolkit Safety Safety (2012) Institute Institute and other articles published in the CJIC.CJIC. In In 2011, 2011, she she was was named named CHICA CHICA Champion Champion of Infection of ControlInfection and Control in 2013 wasand awarded in 2013 Honourary was awarded membership Honourary membership Jennifer Rodgers is a Patient Safety Improvement Lead at CPSI with a main focus on providing Jennifer Rodgers is a Patient Safety Improvement Lead at CPSI with a main focus on inin CHICA-Canada.CHICA-Canada. She She was wasprojecta previous amanagement previous member support member of theto the infection National of the Surgical pre infectionvention Safety Strategy. andpre ventioncontrol Jennifer sub-committee hasand over control 20 ofsub-committee the Provincial of the Provincial providing project management support to the National Surgical Safety Strategy. Jennifer has Infectious Diseases Advisoryyears Committee of experience (PIDAC) in healthcare in Ontario with 10 years(2004-2013). of leadership She experience has presented in two large Ontario at various local, provincial, Infectious Diseases Advisoryover 20 yearsCommittee of experience (PIDAC) in healthcare in Ontario with 10 years (2004-2013). of leadership experienceShe has inpresented two large at various local, provincial, national and international infectioncommunity control hospitals conferences in a director roleand with seminars. responsibility She for is patient currently safety, aquality, board risk member for the Nursing Ontario community hospitals in a director role with responsibility for patient safety, quality, national and internationalmanagement infection and control special projects. conferences Jennifer has a andpassion seminars. for patient safety She and isbased currently on a board member for the Nursing Leadership Network (NLN)-Ontario.risk management and special projects. Jennifer has a passion for patient safety and based her education and experience, she understands the challenges and opportunities from all Leadership Network (NLN)-Ontario.on her education and experience, she understands the challenges and opportunities from all perspectives within the healthcare system. Jennifer holds a Masters degree in Social Work from perspectives within the healthcare system. Jennifer holds a Masters degree in Social Work from JenniferWilfrid Laurier Rodgers, University BSc, as wellMSW, as a MastersMSc degree in Health Sciences from the University of Wilfrid Laurier University as well as a Masters degree in Health Sciences from the University of Toronto. PatientToronto.Jennifer Safety ImprovementRodgers, BSc, Lead, MSW, Canadian MSc Patient Safety Institute Patient Safety Improvement Lead, Canadian Patient Safety Institute Jennifer Rodgers is a Patient Safety Improvement Lead at CPSI with a main focus on providing project management support to the National Surgical Safety Strategy. Jennifer has over Jennifer20 years of Rodgers experience is ina Patienthealthcare Safety with 10 Improvement years of leadership Lead experience at CPSI within two a large main focus on www.AROscalgary2014.caOntarioproviding community project hospitals managementCanadian in a director Consensus supportrole Development with responsibilityto Conference the National on surveillance for patient Surgical & screening safety, forS afetyaros quality, Strategy . Jennifer has risk managementover 20 years and ofspecial experience projects. in Jennifer healthcare has a passionwith 10 fo yearsr patient of safety leadership and based experience in two large on herOntario education community and experience, hospitals she understands in a director the role challenges with responsibility and opportunities for patientfrom all safety, quality, Canadian Consensus Development Conference on Surveillance & Screening for AROs 13 www.AROsCalgary2014.ca perspectivesrisk management within the healthcare and special system. projects. Jennifer Jenniferholds a Ma hassters a degreepassion in Socialfor patient Work fromsafety and based Wilfrid Laurier University as well as a Masters degree in Health Sciences from the University of Toronto.on her education and experience, she understands the challenges and opportunities from all perspectives within the healthcare system. Jennifer holds a Masters degree in Social Work from Wilfrid Laurier University as well as a Masters degree in Health Sciences from the University of Toronto. www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros The Jury THE JURY The Jury John Spika, MD Director General, Centre for Immunization and Respiratory Infectious Diseases,Public Health Agency of Canada JohnJohn Spika, Spika, MD MD Director General, Centre for Immunization and Respiratory Infectious Diseases,Public Dr.Director Spika General,is specialist Centre in Paediatricfor Immunization Infectious and Diseases, Respiratory who Infectious has worked Diseases, in public Public health for Health Agency of Canada overHealth 30 Agencyyears, includingof Canada time at the US Centers for Disease Control and Prevention (CDC), Health Canada/ Public Health Agency of Canada, and the World Health Organization Regional Dr.OfficeDr. Spika Spika for isis aEurope. specialist specialist He in in is Paediatric Paediatrica graduate Infectious Infectious of the Diseases,US Diseases, CDC who Epidemic has who worked has Intel workedinligence public inServicehealth public for program.health for He overhasover published 3030 years,years, including overincluding 90 time articles time at the at and theUS bookCentersUS Centers chapters for Disease for on Disease Controlsubjects andControl re Preventionlated and to immunization,Prevention (CDC), (CDC), host HealthdefenceHealth Canada/ and foodborne Public Public Health Health and Agency respiratory Agency of Canada, of diseases. Canada, and the Heand World is the currentl HealthWorldy Organization Healththe Director Organization Regional General, Regional Centre for Office for Europe. He is a graduate of the US CDC Epidemic Intelligence Service program. He OfficeImmunization for Europe. and RespiratoryHe is a graduate Infectious of the Diseases, US CDC PublicEpidemic Health Intel ligenceAgency Service of Canada. program. He hashas published over over 90 90 articles articles and andbook book chapters chapters on subjects on subjects related to re immunization,lated to immunization, host host defencedefence andand foodborne foodborne and and respiratory respiratory diseases. diseases. He is currently He is currentl the Directory the General,Director Centre General, Centre for Immunizationfor Immunization and and Respiratory Respiratory Infectious Infectious Diseases,Diseases, Public Public Health Health Agency Agency of Canada. of Canada.

HowardHoward Waldner, Waldner, CHE, CHE, MBA, MBA, ICD.D ICD.D Principal, Caledonia Solutions; Principal, Caledonia Solutions Former CEO, Vancouver Island Health Authority (also former COO, Calgary Health HowardHowardRegion) Waldner Waldner, is the CHE, Principal MBA, of CaledoniaICD.D Solutions, Canada, Inc., a B.C. based strategic consultingPrincipal, company Caledonia formed Solutions; in 2013. He has had a distinguished career in senior health leadership,FormerHoward CEO,Waldner spanning Vancouver is over the 35 Principal years, Island working of Health Caledonia in both Authority Canada Solutions, (alsoand the Canada, former UK. Most COO,Inc. recently, a CalgaryB.C. he based Health Strategic spentRegion)Consulting almost aCompany decade as Presidentformed in and 2013. Chief He Executive has had Officer a distinguished of Vancouver career Island in HealthSenior Health AuthorityLeadership, in British spanning Columbia, over Canada.35 years, VIHA working is Canada’s in both 4th Canada largest health and carethe UK.region, Most with recently , he anHowardspent annual almost Waldneroperating a decade, isbudget the Principal inas excess President ofof $2 Caledonia billion.and Chief VIHA Solutions, Executive was recognized Canada, Officer as ofoneInc. V ancouverof a Canada’sB.C. based Island Strategic Health topConsultingAuthority 100 employers in Company British for Columbia,5 successive formed in Canada.years 2013. from He VIHA 2008 has tois had 2013.Canada’s a Howarddistinguished 4th was largest Adjunct career Health Professor in SeniorCare in Region, Health with theLeadership,an Facultyannual of operating Medicinespanning atbudget overthe University 35 in years,excess of working British of $2 billionColumbia in both dollars. Canadafrom 2006VIH andA to was 2013, the recognized UK. and priorMost to recently as one, ofhe that,spentCanada’s Adjunct almost top Associate a100 decade, employers Professor as President withfor 5 the successive Facultyand Chief of Medicine years Executive from at the 2008Officer University to of2013. V ancouverof Calgary Howard fromIsland was AdjunctHealth 1999 to 2005. Howard was recentlyAuthorityProfessor recognized in in British the by Faculty the Columbia, Canadian of Medicine Canada.College atof VIHAtheHealth University is Leaders Canada’s by of receivingBriti 4thsh largest Columbia the 2013 Health Canadian from Care 2006 Region, to 2013, with Nationaland prior Award to that, for AdjunctInnovation Associatean in annual Health-Care Professoroperating Leadership withbudget thein Canada. inFaculty excess Prior of of Medicine to$2 joining billion atVIHA, dollars. the University he VIHwas Athe was Executiveof Calgaryrecognized Vice- from as 1999 one toof 2005. President and Chief Operating Officer for the former Calgary Health Region from 1999 until 2004. Before moving to Calgary Howard was recently recognizedCanada’s by top the 100 Canadian employers College for 5 of successive Health Leaders years byfrom receiving 2008 to the 2013. 2013 Howard Canadian was National Adjunct in 1999, he held a number of senior leadership roles within the Scottish National Health Service, most recently as CEO of Award for Innovation in Health-CareProfessor in Leadership the Faculty in of Canada. Medicine Prior at the to joiningUniversity VIHA, of Britihe wassh Columbia the Executive from 2006Vice-President to 2013, Dundee University Teaching Hospitals NHS Trust. He received his Executive MBA from the University of Glasgow, Scotland, and priorChief to Operating that, Adjunct Officer Associate for the Professorformer Calgary with the Health Faculty Region of Medicine from 1999 at untilthe University 2004. Before of Calgary moving from to Calgary 1999 to in 2005. 1999, andHoward is an activewas recently member ofrecognized the Canadian by Collegethe Canadian of Health College Service Executives,of Health Leadersand a Fellow by receivingof the United the Kingdom 2013 Canadian Institute National he held a number of senior leadership roles within the Scottish National Health Service, most recently as CEO of Dundee ofAward Health for Care Innovation Managers. in He Health-Care is also a Certified Leadership Member in ofCanada. the Canadian Prior Institute to joining of VIHA,Corporate he wasDirectors. the ExecutiveHe has served Vice-President University Teaching Hospitals NHS Trust. He received his Executive MBA from the University of Glasgow, Scotland, and onand several Chief “for-profit” Operating and Officer “non-profit” for the formerBoards includingCalgary theHealth British Region Columbia from Academic1999 until Health 2004. Council, Before the moving Canadian to Calgary in 1999, is an active member of the Canadian College of Health Service Executives, a Fellow of the United Kingdom Institute of Institutehe held fora number Health Information, of senior leadership the United Wayroles Campaign within the Cabinet, Scottish Carewest, National and Health the Greater Service, Victoria most Coalition recently to asend CEO of Dundee Health Care Managers. He is also a Certified Member of the Canadian Institute of Corporate Directors. He has served Homelessness.University Teaching Currently Hospitals he serves NHSas an independentTrust. He received Director hisof the Executive board of StrataMBA Health,from the a successful University Calgary of Glasgow, based Scotland, and on several “for-profit” and “non-profit” Boards including the British Columbia Academic Health Council, the Canadian healthis an activetechnology member company, of the and Canadian is a Partner College with Prioritize of Health Software, Service a dynamicExecutives, Vancouver a Fellow based of information the United Kingdommanagement Institute of Institute for Health Information, the United Way Campaign Cabinet, Carewest, and the Greater Victoria Coalition to end solutionsHealth Care company. Managers. He is also a Certified Member of the Canadian Institute of Corporate Directors. He has served Homelessness. Currently he serves as an independent Director of the board of Strata Health, a successful Calgary on several “for-profit” and “non-profit” Boards including the British Columbia Academic Health Council, the Canadian based health technology company, and is a Partner with Prioritize Software, a dynamic Vancouver based information Institute for Health Information, the United Way Campaign Cabinet, Carewest, and the Greater Victoria Coalition to end management solutions company. Homelessness. Currently he serves as an independent Director of the board of Strata Health, a successful Calgary based health technology company, and is a Partner with Prioritize Software, a dynamic Vancouver based information management solutions company.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca

Canadianwww.AROsCalgary2014.ca Consensus Development Conference on14 surveillanceCanadian & screening Consensus for aros Development Conference on Surveillance & Screeningwww.AROscalgary2014.ca for AROS THE MODERATOR

Moderator

Fred Keating Keating - Moderator - Moderator

In September September 2013 2013Fred Keating Fred servedKeating as Master served of Ceremonies as Master at theof CeremoniesIHE International at Symposium the IHE for International Symposiumthe Prevention of for FASD. the While Prevention Fred is not ofa health FASD. care While worker, scientistFred is or not economist a health himself, care his worker, knack scientist or for making complex information accessible to audiences and guiding the progress and process of national economistand international himself, conferences his compelled knack for IHE making to bring him complex on to this currentinformation professional accessible gathering. Heto hasaudiences and guidinghosted special the events progress involving and Olympic process champions, of national world-class and scientists international and technologists, conferences and various compelled IHE to MCcombinations this conference of North America’s as well. most He influential has hosted politicians, special sports events heroes, academicsinvolving and Olympicperforming champions, world- artists. class scientists and technologists, and various combinations of North America’s most influential politicians,Fred’s Edmonton-based sports highheroes, definition academics video production and performing company (Lindisfarne artists. Productions) has produced many award-winning programs for clients such as the Discovery Channel, PBS, National Geographic, BBC, Fred’sCBC, the Edmonton-based History Channel and others. high As definition a performer, Fredvideo has hadproduction recurring roles company in TV series (Lindisfarne such as Jake Productions) hasand the produced Kid, DaVinci’s many Inquest, award-winning The Killing, and theprograms soon-to-be-released for clients Fox TVsuch series as Gracepointthe Discovery as well as Channel, PBS, APTN’s Blackstone. National Geographic, BBC, CBC, the History Channel and others. As a performer, Fred has had recurring roles in TV series such as Jake and the Kid, DaVinci’s Inquest, The Killing, and the soon-to-be-released Fox TV series Gracepoint as well as APTN’s Blackstone.

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 15 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

Dr.Dr. Elizabeth Elizabeth Bryce Bryce, BSc, MD, BSc, FRCPC MD, FRCPC RegionalRegional Medical Medical Director Director for Infection for Infection Control, Control, Vancouver Vancouver Coastal Health; Coastal Health; Clinical Clinical Professor, University of British Columbia (UBC) Professor, University of British Columbia (UBC) Dr.Dr. Elizabeth Elizabeth Bryce Bryce is the isRegional the Regional Medical DirectorMedical for Director Infection forControl Infection at Vancouver Control Coastal at Vancouver Health Acute Coastal and has been involved in the field of infection prevention and control for the last 20 years. She is dually qualified inHealth Medical AcuteMicrobiology and has and been Internal involved Medicine in and the is field a Clinical of infection Professor atprevention the University and of Britishcontrol Columbia. for the Shelast is 20a past years. co-chair She of is the dually Canadian qualified Nosocomial in infectionMedical surveillanceMicrobiology Program and andInternal the current Medicine co-chair and of is a theClinical Provincial Professor Infection atControl the University Network of Britishof British Columbia Columbia.. Dr. Bryce She is isone a pastof the co-chair founding membersof the Canadian of the UBCNosocomial Certificate infectionin Infection surveillance Control as well Program as several andon-line the educational current modulesco-chair on of this the topic. Provincial Dr. Bryce Infection is the RegionalControl Medical Network Director of British for Infection Columbia. Control atDr. Vancouver Bryce is Coastal one of Health the founding Acute. Elizabeth members is a member of the ofUBC the Pandemic Influenza Guidelines Committee for Respiratory Protection for the Public Health Agency of Canada and a reviewerCertificate for Infection in Infection Control GuidelinesControl asfor thiswell sameas several organization. on-line She educational is a co-chair ofmodules the Canadian on this Nosocomial topic. InfectionD. Bryce Surveillance is the Regional Program Medicalas well as Directora co-chair forfor the Infection Provincial Control Infection at Control Vancouver Network Coastal of British Health Acute. Elizabeth is a memberColumbia. of the Pandemic Dr. Bryce is Influenzaone of the founding Guidelines members Committee of the UBC for Certificate Respiratory in Infection Protection Control forprogram. the Public She and Health Agency of Canada andcolleagues a reviewer have alsofor Infectiondeveloped an Control on-line basicGuidelines infection for control this module same organization.for healthcare professionals She is a co-chair that has been of the Canadian Nosocomial Infectionused province-wide Surveillance as Program well as being as welladopted as aby co-chair the Pan-America for then ProvincialHealth Organization Infection for useControl in South Network America. of British Columbia. Dr. Bryce is one of the founding members of the UBC Certificate in Infection Control program. She and Abstract colleagues have also developed an on-line basic infection control module for healthcare professionals that has been used province-wideWhat factors can as facilitate well as being or hinder adopted effective by theARO Pan-American control in practice? Health Organization for use in South America.

Abstract:a) Organizational What and factors cultural can factors facilitate (barriers orand hinder enablers) effective ARO control in practice? a) Organizational and cultural factors (barriers and enablers) Background: Healthcare is a complex ecosystem and implementing any large-scale change must consider the pattern of complex relations between Background:the organization, Healthcarethe environment, is a and complex the individuals ecosystem within and the system.implementing This is true any for large-scale successful ARO change control must which consider involves thetimely pattern a) ofidentification complex relationsof high risk between patients; b)the performance organization, of appropri the ateenvironment, screening cultures; and thec) receipt individuals of results; within and d) theappropria system.te application This is oftrue Contact for successfulPrecautions. AROIndividual control factors which affecting involves ARO control timely include a) identification perception/beliefs/knowledge of high risk regardingpatients; the b) importanceperformance of ARO of control,appropriate workload, screening and internal prioritization of tasks. These factors affect compliance with asking the relevant screening questions consistently of patients, completing the cultures;necessary forms c) receipt (paper of or results;electronic) and which d) appropriatesignal the need application for screening ofcultures; Contact taking Precautions. the appropriate Individual cultures correctl factorsy and affecting expeditiously ARO and control - includeupon receiving perception/beliefs/knowledge results - taking the initiative to regardinginstitute Contact the importancePrecautions and of isolation/cohorting. ARO control, workload, Organizational and factors internal influencing prioritization compliance of tasks.with effective These ARO factors control affect include compliance bed capacity andwith bed asking flow, theinstitutional relevant priorities, screening staffing questions allocation, consistently the workplace of setting,patients, conflicting completing theprocedures/policies, necessary forms and (paperbudgetary or constraints. electronic) Environmental which signal factors the afneedfecting for ability screening to comply cultures; with ARO taking control the include appropriate the availability cultures or correctlyrobustness ofand information expeditiously technology and (e.g. - upon electronic receiving risk asse resultsssment - tools,taking reminders, the initiative checklists, to institutetoolkits, training Contact modules Precautions), internal communicationand isolation/ systems (particularly with housekeeping) and importantly, the number and availability of isolation rooms. Unfortunately ARO control measures cohorting.currently rely Organizational primarily on individual factors compliance influencing by healthcare compliance workers ratherwith effective than on the moreARO reliablecontrol environmental include bed or capacity organizational and controls.bed flow, institutional priorities, staffing allocation, the workplace setting, conflicting procedures/policies, and budgetary constraints. EnvironmentalResults: A major environmental factors affecting barrier toability compliance to comply with ARO with control ARO is control the lack includeof isolation the beds availability with Canadian or robustnesshospitals operating of information routinely at technologyor above 100% (e.g. capacity electronic in facilities risk with assessment limited single tools, rooms reminders,. Priorities forchecklists, bed flow toolkits,and patient training access (or ganizationalmodules), factors) internal that communication often conflict with infection prevention goals compound the situation. Robust Information Technology systems (environmental factors) to support control efforts do systemsexist but competing (particularly priorities with and housekeeping) funding constraints and have importantly, curtailed their the use. number Inability and to link availability the various of information isolation s ystemsrooms. further Unfortunately compromises AROthe ability control to integrate measures communications. currently relyThe lastprimarily few years on has individual seen recognition compliance of the importance by healthcare of patient workers safety both rather by society than andon thehealthcare. more reliableThis has resultedenvironmental in many positive or organizational organizational changescontrols. such as raising the profile of infection prevention and the need for accountability at all organizational levels. Sustainment and continued positive change will require embedding environmental, organizational, and individual factors so Results:they become A themajor culture environmental norm. barrier to compliance with ARO control is the lack of isolation beds with Canadian hospitals operating routinely at or above 100% capacity in facilities with limited single rooms. Priorities for bed flow and patientConclusions: access The (oganizational current Canadian factors) situation thatwith strainsoften on conflict bed capacity, with increasing infection workload, prevention and inadequate goals compound Information the Technology situation. resources Robust are Informationsignificant barriers Technology to ARO control. systems Measures (environmental that focus or relyfactors) primarily to supporton individual control behaviour efforts for compliancedo exist but require competing a high level priorities of institutional and effort and are difficult to sustain. Policies that focus on improved environmental controls and organizational safety climate require a long-term fundinginvestment constraints but have the greatesthave curtailed opportunity their for success.use. Inability to link the various information systems further compromises the ability to integrate communications. The last few years has seen recognition of the importance of patient safety both by society and healthcare. This has resulted in many positive organizational changes such as raising the profile of infection prevention and the need for accountability at all organizational levels. Sustainment and continued positive change will require embedding environmental, organizational, and individual factors so they become the culture norm. Conclusions: The current Canadian situation with strains on bed capacity, increasing workload, and inadequate Information Technology resources are significant barriers to ARO control. Measures that focus or rely primarily on individual behaviour for compliance require a high level of institutional effort and are difficult to sustain. Policies that focus on improved environmental controls and oganizational safety climate require a long-term investment but have the greatest opportunity for Canadiansuccess. Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca

www.AROsCalgary2014.ca 16 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

Barry Cookson, BDS, MBBS, MSc, HonDipHIC, FRSPH, FRCP, Barry Cookson, BDS, MBBS, MSc, HonDipHIC, FRSPH, FRCP, FFPH, FRCPath FFPH,Professor, FRCPathUniversity College and London School of Hygiene and Tropical Medicine; Professor,Consultant, University World Health College Organization and London (WHO) andSchool European of Hygiene Centre forand Disease Tropical Control Medicine; (ECDC) Consultant, World Health Organization (WHO) and European Centre for Disease Barry Cookson is medically and dentally qualified, a medical microbiologist and was Director of the Laboratory Controlof Healthcare (ECDC) Associated Infection (HCAI) in the Microbiological Services Colindale of the Health Protection BarryAgency Cookson for over 22 is years medically and retired and in dentally June 2012 qualified, to become a aProfessorship medical microbiologist at University College and waswhere Director he teaches and holds research grants. He also holds a professorship at the London School of Hygiene and Tropical ofMedicine. the Laboratory He is Chair of of Healthcare the Diploma Associatedin Hospital Infection Infection Control (HCAI) Examination in the Committee Microbiological and organised Services the ColindaleHCAI Foundation of the Course Health at ColindaleProtection since Agency 1990. He for is overa Care 22 Quality years. Commission He retired Associate in June and 2012 very to active become anationally Professor and at internationally University Collegein related whereresearch he and teaches multi-disciplinary and holds approaches research togrants. improving He alsoinfection holds acontrol professorship and antibiotic at theprescribing London practices, School He of hasHygiene over 300 and publications Tropical and Medicine. attracted grantsHe is toChair the value of the of over £15m. He was until 2012 an advisor to the Department of Health Committee on antimicrobial resistance Diploma in Hospital Infectionand Control HCAI and Examination has chaired their Committee sub-groups and on occupational organised healththe HCAI issues Foundationwith MRSA in Course veterinary at workers Colindale since 1990. He is a Care Qualityand Commissionanother on competencies Associate required and very for antimicrobial active nationally prescribing. and Heinternationally is an ECDC and in WHO related consultant research and, untiland 2011,multi-disciplinary was a member of approaches the UK Veterinary to improving Products Committee. infection His control current and projects antibiotic and interests prescribing include European practices. Performance He has over Indicators 300 in Longpublications Term Care and Facilities attracted (“HALT grants 1 and to 2”), the Clostridium value of overdifficile £15m. in England He was (community until 2012 and an hospital advisor costings), to the isolation Department ward strategies, of Health cost- effectivenessCommittee of on MRSA antimicrobial screening in resistance England, Training and HCAI of ICTs and in Europehas chaired (TRICE their 1 and sub-groups Implementation on Strategy occupational projects), health ESCMID issues Antibiotic- with resistant Gram negative rod guidelines and an ECDC MRSA systematic review. He is also the external consultant to an EU project writing an infectionMRSA in control veterinary manual workersfor Kazakhstan and anotherand has advised on competencies their Ministry ofrequired health on for HCAI antimicrobial and Antimicrobial prescribing. Stewardship. He is an ECDC and WHO consultant and, until 2011, was a member of the UK Veterinary Products Committee. His current projects and interests Abstractinclude European Performance Indicators in Long Term Care Facilities (“HALT 1 and 2”), Clostridium difficile in England (community and hospital costings), isolation ward strategies, costeffectiveness of MRSA screening in England, Training of WhatICTs inis theEurope economic (TRICE cost/benefit 1 and Implementation of screening from Strategy the point projects), of view ofESCMID the individual Antibiotic-resistant patient; health Gramcare providers; negative androd theguidelines funderand an ofECDC the health MRSA care systematic system? Howreview. do Hewe evaluate/measureis also the external the consultant economic valueto an ofEU screeni projectng? writing an infection control manual for Kazakhstan and has advised their Ministry of health on HCAI and Antimicrobial Stewardship. Backgrounds WHO and ECDC mentioned healthcare associated infections (HAI) in strategies to reduce the global burden of antimicrobial resistance (AMR) and Abstract:important roles What for antimicrobial is the economic stewardship cost/benefit and infection of prescreeningvention and from control. the Apoint recent ofGlobal view burden of the of individual disease assessment patient; highlighted health a carelack of a standardised/harmonised methodology. This is particularly evident for the HAI/AMR burden, making advice on the economic costs/benefits providers;problematic. and the funder of the health care system? How do we evaluate/measure the economic value of screening? Backgrounds: WHO and ECDC mentioned healthcare associated infections (HAI) in strategies to reduce the global Methods burdenMixed methods of antimicrobial including; reflections resistance on (AMR)our own studies and important and the literature roles reviewed for antimicrobial with others e.g. stewardship in various guideline and infection groups, modelling,prevention the and control.context of healthcareA recent delivery,Global burdenways in which of disease national assessment costs/benefits highlighted are assessed. a lackHow relevantof a standardised/harmonised is culture when one addresses methodology. cost benefit and This utility? is particularlyWhat other countries evident have for a similarthe HAI/AMR culture to Canada: burden, are making their experiences advice on and the costings economic more relevant? costs/benefits problematic.

Methods:Results/Discussion Mixed methods including; reflections on our own studies and the literature reviewed with others e.g. in various guidelineOthers at the groups, meeting modelling,will present the the evidence context for of screening healthcare and howdelivery, it informs ways the in interventions which national used (e.g. costs/benefits isolation measur arees, decolonisation/assessed. How relevantsuppression) is cultureand also thewhen laboratory one addresses costings approaches cost benefit to scr eening.and utility? Few have What attempted other tocountries approach HAIs/AMRhave a similar from culturethe point to of viewCanada: of the are theirindividual experiences patient. In andsome costings countries patientmore relevant?advocacy groups are very influential.The major costs of HAI/AMR are in extending the length of hospital stay and these are of major concern to providers/ funders of healthcare systems, as they impact on their ability to reduce waiting times for Results/Discussion:treatment, often a “hot” political Others issue. at the Review meeting of the will literat presenture shows the a evidencelack of a joined-up for screening approach and regarding how itassessing informs the the costings interventions of HAI and usedrelated (e.g. issues isolation of AMR e.g.measures, methods decolonisation/suppression)differ, detail of costs vectors gathered and are also lacking. the laboratory The context ofcostings healthcare approaches delivery also to can screening. vary between Few countries (e.g. private and/or public funding, the hospitals/units involved, patient case mix, MRSA type and prevalence). Canada would need to haveanalyse attempted its own situation to approach and reflect HAIs/AMR carefully. from the point of view of the individual patient. In some countries patient advocacy groupsI will present are verythe most influential. detailed approach The yetmajor progressed costs of for anHAI/AMRalysing the are cost-ef in extendingfectiveness ofthe screening length forof MRSA,hospital which stay weand have these just arecomplete of majord concernin England. to Mandatory providers/ universal funders screening of healthcare had been systems,introduced as and they we wereimpact funded on totheir assess ability it. The to approach reduce wewaiting used included times for an audittreatment, of oftenEnglish hospitalsa “hot” politicaland entering issue. their Reviewdata into ofa sophisticatethe literatured model shows which a lackwe had of developed.a joined-up We approachhave analysed regarding six screening assessing strategies the including costings no ofscreening, HAI and universal, related risk issues factor-based, of AMR and e.g. screening methods of high-risk differ, specialtiesdetail of andcosts explored vectors a rangegathered of MRSA are lacking.prevalence. TheThe currentcontext strategy of healthcare is not cost effective using the NICE recommendations for Cost/QALY (£30K/QALY). A consultation is underway to help agree the best way forward. There deliveryare issues, alsofor example, can vary with between the practicalities countries of risk (e.g. base privated screening and/or and publicthe pressures funding, for a zero-tolerancethe hospitals/units approach involved, to HAI. patient case mix, MRSA type and prevalence). Canada would need to analyse its own situation and reflect carefully. Conclusions/Policy IThere will arepresent many issuesthe most relating detailed to the way approach in which yet cost/benefits progressed of screening for analysing have been the performed. cost-effectiveness It has been mostof screening studied for for MRSA MRSA, and I presentwhich wean approach have just that completed the jury could in consider.England. The Mandatory model the jury universal uses to determine screening policy had also been needs introduced to be considered. and we were funded to assess it. The approachRecommendations we used included an audit of English hospitals and entering their data into a sophisticated model which we had developed.In view of the We many have deficiencies analysed in sixthe screeningcurrent literature, strategies the jury including should ensure no thatscreening, an approach universal, to costings risk is includedfactor-based, in the research and screening of high-risk specialties and explored a range of MRSA prevalence. The current strategy is not cost effective using the NICE www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 17 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS

recommendations for Cost/QALY (£30K/QALY). A consultation is underway to help agree the best way forward. There are issues, for example, with the practicalities of risk based screening and the pressures for a zero-tolerance approach to HAI. Conclusions/Policy: There are many issues relating to the way in which cost/benefits of screening have been performed. It has been most studied for MRS and I present an approach that the jury could consider. The model the jury uses to determine policy also needs to be considered. Recommendations: In view of the many deficiencies in the current literature, the jury should ensure that an approach to costingsSpeakers is included in& the Abstracts research

JulianJulian Davies, Davies, BSc, BSc, PhD, PhD, FRS FRS ProfessorProfessor Emeritus, Emeritus, Research Research Team Team Leader, Leader, Department Department of ofMicrobiology Microbiology and and Immunology, Immunology,UBC UBC

Julian DaviesJulian Davies (JD) obtained (JD) obtained his BSc his BSc(1953) (1953) and and PhD PhD (1956) (1956) in in Chemistry Chemistry atat Nottingham Nottingham University . University.After After three yearsthree of years postdoctoral of postdoctoral training at training Columbia at UniversiColumbiaty (NY) University and the (NY)University and of Wisconsin, the Universityhe accepted of Wisconsin, a Lecturership he inaccepted Chemistry a Lecturership at the University in Chemistryof Manchester at Institutethe University of Technology in 1959. of ManchesterIn 1962 JDInstitute quit chemistry of Technology and joined in the1959. laboratory In 1962 of JD Bernar quitd chemistry Davis (Harvard and joinedMedical School) to the laboratorystudy the of mode Bernard of action Davis of streptomycin(Harvard Medical and then School) teamed toup studywith Luigi the mode Gorini of and action Walter Gilbert to of streptomycinidentify aminoglycoside-induced and then teamed up withmiscoding. Luigi Later,Gorini he and went Walter to work Gilbert with H. to Gobind identify Khorana to study the molecular nature of antibiotic-induced mistranslation. In 1965, an NIH fellowship permitted him to aminoglycoside-inducedwork with Francois Jacobmiscoding. (Pasteur Later, Institute) he went to genetically to work mawithp the H. regulatory Gobind Khorana genes of the to E.colistudy lac the molecularoperon. Innature 1967 ofhe antibiotic-inducedwas appointed to the mistranslation.Biochemistry faculty In 1965, at the an University NIH fellowship of Wisconsin permitted and worked on antibiotichim to work mode with of action, Francois the origins Jacob and(Pasteur evolution Institute) of antibiotic to genetically resistance mapand the the use regulatory of resistance genes genes of asthe selective E.coli lac markers operon. in transformation. In 1967 Takinghe wasa sabbatical appointed in Geneva to the inBiochemistry 1975 he co-discovered faculty at transposable the University antibiotic of Wisconsin resistance. and Later, worked he developed on antibiotic gene transfer mode processes of action, between the bacteriaorigins and andeukaryotic evolution cells. of In antibiotic 1980, JD left resistance academia and to Bi theogen use as of Research resistance Director genes, eventually as selective becoming markers President. in transformation. He left in 1985 Taking to become a a laboratorysabbatical director in Geneva at the Institut in 1975 Pasteur he co-discovered (Paris), studyi transposableng a variety of antibiotictopics including resistance. antibiotic Later, resistance, he developed antibiotic gene production, transfer mechanisms processes of bacterialbetween and fungalbacteria pathogenicity, and eukaryotic and horizontal cells. In gene1980, transfer JD left in academiamicrobes. JDto becameBiogen Professoras Research and HeadDirector, of the eventually Department becoming of Microbiology and ImmunologyPresident. at Hethe Universityleft in 1985 of Britishto become Columbia a laboratory in 1992. Hedirector founded at TerraGenthe Institut Diversity, Pasteur one (Paris), of the firststudying environmental a variety ofDNA topics metagenome-based including Biotech companies in 1996 (subsequently acquired by Cubist Pharmaceuticals). JD served as the President of the American Society of Microbiology fromantibiotic 1999-2000 resistance, and President antibiotic of the International production, Union mechanisms of Microbiological of bacterial Societies and fungal in 2003. pathogenicity, He is a Fellow and of the horizontal Royal Soci geneeties transferof London and Canada,in microbes. and has received JD became several Professor other awards, and Headincluding of the the DepartmentLifetime Achievement of Microbiology Award from and the Immunology American Society at the of UniversityMicrobiology. of He chaired the ExternalBritish ColumbiaScientific inBoard 1992. of the He foundedNIH Human TerraGen Microbiome Diversity, Project from one 2009-2012.of the first As environmental a Professor Emeritus DN metagenome-basedat UBC he maintains aBiotech research lab and companiesteaches in assorted in 1996 courses. (subsequently His research acquired focuses by on Cubist studies Pharmaceuticals).of antibiotic mode of JD action, served bacterial as the cell President signaling, of antibioticthe American resistance Society mechanisms of and Microbiologytheir suppression, from antibiotic 1999-2000 discovery and andPresident the biology of the of lichens.International Union of Microbiological Societies in 2003. He is a Fellow of the Royal Societies of London and Canada, and has received several other awards, including the Lifetime Achievement Award from the American Society of Microbiology. He chaired the External Scientific Board of the NIH Human Microbiome Abstract Project from 2009-2012. As a Professor Emeritus at UBC he maintains a research lab and teaches in assorted courses. His research focuses on studies of antibiotic mode of action, bacterial cell signaling, antibiotic resistance mechanisms and their Cansuppression, anything be antibiotic done to prevent discovery antibiotic and the resistance biology of developme lichens. nt?

AntibioticAbstract: resistance Can anythingpredates the be therapeutic done to prevent use of antibioti antibioticcs by millionsresistance of years. development? The conclusion is that antibiotics will never escape the development of resistance development. However, strictly-controlled, rational and prudent use of antibiotics could delay this process and intelligent chemistryAntibiotic combined resistance with the predates genomic the manipulation therapeutic of producinguse of antibiotics strains should by millions furnish ofan years.unlimited The source conclusion of novel is antimicrobia that antibioticsl agents. will Unfortunatelynever escape the costthe willdevelopment be high. of resistance development. However, strictly-controlled, rational and prudent use of antibiotics could delay this process and intelligent chemistry combined with the genomic manipulation of producing strains should furnish an unlimited source of novel antimicrobial agents. Unfortunately the cost will be high.

www.AROsCalgary2014.ca 18 Canadian Consensus Development Conference on Surveillance & Screening for AROS

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

Serge Desnoyers, PhD SergeAssistant Director,Desnoyers, Canadian Institutes PhD of Health Research-Institute of Infection and Immunity Assistant Director, Canadian Institutes of Health Research-Institute of Infection andDr. Serge Immunity Desnoyers completed his post-secondary education in Canada, where he obtained a B.Sc. and an M. Sc. in Biology from Université de Sherbrooke, and a PhD in Endocrinology-Physiology from Université Dr.Laval Serge (Québec). Desnoyers Following a completed four-year postdoctoral his post-secondary position at Cold Spring education Harbor Laboratory in Canada, (New York,where he obtained a USA) in molecular genetics, Dr. Desnoyers moved back to Canada for a position at the CHUL Research B.Sc.Centre inand Quebec an M.City. Sc. After in a Biologysuccessful careerfrom as Université an independent de investigator Sherbrooke, for over and 10 years, a PhD he in Endocrinology- Physiologyjoined CIHR in fromFebruary Université 2010 and is currently Laval (Québec).the Assistant Director Following for CIHR a four-year Institute of Infection postdoctoral and position at Immunity where he manages the host Institute, and participates in the elaboration of research initiatives. ColdThe Institute Spring of Infection Harbor and Laboratory Immunity (III) (Newsupports York, researc hUSA) and helps in tomolecular build research genetics, capacity in Dr. the Desnoyers moved backareas of to infectious Canada disease for anda position the body’s atimmune the CHULsystem. Through Research the Institute’s Centre programs, in Quebec researchers City. After a successful careeraddress a as wide an range independent of health concerns investigator related to infection for over and immunity10 years, including he joined disease CIHR mechanisms, in February 2010 disease prevention and treatment, and health promotion through public policy. Antibiotic resistance (AMR) andhas been is currentlya strategic research the Assistant priority for IIIDirector since the begifornning, CIHR appearing Institute in three of consecutiveInfection Strategic and Immunity where hePlans, manages including the most host recent Institute, 2013-18 Plan.and Since participates 2001, III has in led the a number elaboration of initiatives of withresearch a focus initiatives. The on AMR, such as the Safe Food and Water Initiative, and the Novel Alternatives to Antibiotics Initiative. IIIInstitute also partnered of Infection in 2010 with andthe UK Immunity MRC in the joint(III) support supports of two researchlarge consortia and focused helps on to the build translation research and implementation capacity inof AMR the areas of infectious researchdisease into and clinically the body’srelevant interventions.immune system. More recentl Throughy Canada, throughthe Institute’s CIHR-III, becameprograms, the co-lead researchers of the Joint Praddressogramming a Initiativewide range on of health concerns Antimicrobialrelated to Resistanceinfection (JPIAMR). and immunity including disease mechanisms, disease prevention and treatment, and health promotion through public policy. Antibiotic resistance (AMR) has been a strategic research priority for III since the beginning, Abstract appearing in three consecutive Strategic Plans, including the most recent 2013-18 Plan. Since 2001, III has led a number Howof initiatives CIHR is Addressing with a focus Antimicrobial on AMR, Resistance, such as Nationally the Safe andFood Internationally? and Water Initiative, and the Novel Alternatives to Antibiotics

Background:Initiative. Antimicrobial III also partnered resistance (AMR) in 2010 is recognized with the internationally UK MRC as inan emergingthe joint health support crisis that of threatens two large to undermine consortia our ability focused to on the translation controland implementationbacterial infections. The of complacency AMR research generated into by the clinically success of antibioticsrelevant has interventions. led to their widespread More overuse recently and misuse, Canada, accelerating through the CIHR-III, generationbecame of the multi-drug co-lead resistance. of the Once Joint known Programming mainly to resea rchers,Initiative resistant on microbes Antimicrobial like methicillin-resistant Resistance staphyloc (JPIAMR).occus aureus (MRSA), vancomycin-resistant Enterococcus (VRE), and Clostridium difficile have entered the public consciousness, and pose a serious health threat. If the spread of antimicrobial resistance is not checked, and if new methods for treating bacterial infections are not found, we face returning to a pre- antibiotic-likeAbstract: era.How CIHR is Addressing Antimicrobial Resistance, Nationally and Internationally? Results/KeyBackground: Data: When Antimicrobial the Science Ministers resistance of the G8 (AMR) countries is met recognized in London in Juneinternationally 2013, they had to as deal an with emerging their top global health challenge, crisis that threatens to namelyundermine AMR in medicine.our ability They tohave control committed bacterial to a series infections.of statements regarding: The complacency the efficacy of existinggenerated antimicrobial by the agents, success preventing of antibiotics the has led to their emergence of AMR through the development of rapid diagnostics; supporting the development of new diagnostics to improve the early and accurate identificationwidespread of antimicrobialoveruse and resistant misuse, infections accelerating to improve treatment the generation efficacy; and of supporting multi-drug theoretical resistance. and applied Onceresearch knownto better understand mainly to researchers, theresistant origin, spread, microbes evolution, like and methicillin-resistantdevelopment of resistance in staphylococcus microorganism.Antimicrobial aureus resistance(MRSA), has vancomycin-resistantbeen a research priority of the EnterococcusCIHR (VRE), and Institute of Infection and Immunity (III) since its inception, and a number of strategic research initiatives have been launched to address this global healthClostridium problem by promotingdifficile and havesupporting entered research the related public to mechanisms consciousness, and processes and that pose impact a serious the emergence health and spreadthreat. of Ifresistance. the spread For of antimicrobial example,resistance CIHR-III is not spearheaded checked, the Safeand Food if new and Water methods initiative, for which treating lead to bacterialthe creation ofinfections the Canadian are Research not found, Coalition we for Safeface Food returning and to a pre- Water.antibiotic-like The goal of this era. coalition was to build a national, coordinated research agenda in the area of microbial contamination of food and water and antimicrobial resistance in the food chain. The Novel Alternatives to Antibiotics (NAA) initiative, which included a focus on areas such as phage therapyResults/Key and probiotics Data: in which When Canada the had Science little or no Ministers research capacity of the, was G8 designed countries to augment met the in existing London research in Junefunding 2013, availa blethey through had to deal with their the CIHR open competitions by attracting applications focused on novel approaches to antibiotic resistance. Lastly, the Canada/UK Joint Health Researchtop global Program challenge, on Antibiotic namely Resistance AMR was created in medicine. to promote theThey development have committed of multi-national to basica series and translational of statements research regarding:collaborations the efficacy of inexisting the area of antimicrobial AMR. As many countries agents, are preventing now ramping up theemergence their strategies to combatof AMR antibiotic through resistance the and development international partnerships of rapid are diagnostics; supporting emerging to promote value-added collaborations in a multifaceted, multidisciplinary approach to the problem, this joint program is a perfect example. Recently,the development CIHR-III established of new a partnership diagnostics with the to European improve Joint the Programming early and Initiative accurate on AMR identification (JPIAMR), which of will antimicrobial enhance the impact resistant of infections to researchimprove by aligning treatment and building efficacy; upon existing and nationalsupporting progra mstheoretical and identifying and common applied goals researchthat would benefitto better from jointunderstanthe action. origin, spread, evolution, and development of resistance in microorganism. Antimicrobial resistance has been a research priority of the CIHR Institute Conclusions/Recommendations: Several aspects of AMR need to be addressed. Lack of awareness would benefit from educational outreach to the media,of Infection public and andgovernment. Immunity The need (III) to better since utilize its publicinception, and private and sector a number partnerships of (PPPs), strategic which research could be accomplished initiatives by have building been launched to onaddress successful this PPPs, global and by healthintensifying problem collaboration by promotingwith industry. There and shouldsupporting also be an research increase in relatedfinancial investmentto mechanisms for new research and processes into that impact fundamental mechanisms of AMR, to monitor the impact of AMR on the health care system, to assess health services readiness to respond, and to acceleratethe emergence through research and thespread development of resistance. of new drugs, For new example, vaccines, and CIHR-III new technologies. spearheaded the Safe Food and Water initiative, which lead to the creation of the Canadian Research Coalition for Safe Food and Water. The goal of this coalition was to build a national, coordinated research agenda in the area of microbial contamination of food and water and antimicrobial resistance in the food chain. The Novel Alternatives to Antibiotics (NAA) initiative, which included a focus on areas such as phage therapy and probiotics in which Canada had little or no research capacity, was designed to augment the existing research www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros funding available through the CIHR open competitions by attracting applications focused on novel approaches to antibiotic resistance. Lastly, the Canada/UK Joint Health Research Program on Antibiotic Resistance was created to promote the development of multi-national basic and translational research collaborations in the area of AMR. As many countries are now ramping up their strategies to combat antibiotic resistance and international partnerships are emerging to promote value- added collaborations in a multifaceted, multidisciplinary approach to the problem, this joint program is a perfect example. Recently, CIHR-III established a partnership with the European Joint Programming Initiative on AMR (JPIAMR), which will enhance the impact of research by aligning and building upon existing national programs and identifying common goals that would benefit from joint action.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 19 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS

Conclusions/Recommendations: Several aspects of AMR need to be addressed. Lack of awareness would benefit from educational outreach to the media, public and government. The need to better utilize public and private sector partnerships (PPPs), which could be accomplished by building on successful PPPs, and by intensifying collaboration with industry. There should also be an increase in financial investment for new research into fundamental mechanisms of AMR, to monitor the impact of AMR on the health care system, to assess health services readiness to respond, and to accelerate through research the development of new drugs, new vaccines, and new technologies. Speakers & Abstracts

MichaelMichael B. Edmond, B. Edmond, MD, MPH, MD, MPA MPH, MPA Professor, Virginia Commonwealth University; HospitalProfessor, Epidemiologist, Virginia VirginiaCommonwealth Commonwealth University; University HospitalHealth System Epidemiologist, Virginia Commonwealth University Health System Dr. Edmond is the Richard P. Wenzel Professor of Internal Medicine in the Division of Infectious Diseases at VirginiaDr. Edmond Commonwealth is the University. Richard He P. alsoWenzel holds Professora faculty appointment of Internal in the Medicine Department in of theEpidemiology Division and of CommunityInfectious Health Diseases and serves at Virginiaas the Hospital Commonwealth Epidemiologist for University. the VCU Health He System. also holds a faculty appointment He is a graduate of the West Virginia University School of Medicine (MD), the University of Pittsburgh Graduate Schoolin the of DepartmentPublic Health (MPH), of Epidemiology and the Virginia andCommonwealth Community University Health School and of servesGovernment as the and Hospital Public AffairsEpidemiologist (MPA). He was for a resident the VCU and chief Health resident System. in Internal He Medicine is a graduate at West Virginiaof the WestUniversity Virginia Hospitals. University HeSchool then completed of Medicine a fellowship (MD), in Infectious the University Diseases at of the Pittsburgh University of Graduate Pittsburgh Medical School Center of Public and a Health fellowship(MPH), in and Hospital the EpidemiologyVirginia Commonwealth at the University of University Iowa College Schoolof Medicine. of Government Dr. Edmond’s areas and of Public Affairs research focus on the epidemiology of healthcare-associated infections and the public policy implications (MPA). He was a resident andof infection chief resident control. He in has Internal published Medicine 350 papers, at abstracts West aVirginiand book chapters, University and co-writes Hospitals. a blog He entitled then completed a fellowship in Infectious DiseasesControversies at the in HospitalUniversity Infection of Pittsburgh Prevention. Over Medical the past Center few years, and Dr. aEdmond fellowship has been in named Hospital to Epidemiology at the University of Iowa CollegeRichmond of Medicine.Magazine’s Top Dr. Doctors, Edmond’s America’s areas Top of Doctors, research US Newsfocus and on World the epidemiologyReport’s Top Doctors, of healthcare- Our Health Richmond Magazine’s Best Bedside Manner Award, and Health Leaders Magazine’s 20 People Who associated infections and theMake public Healthcare policy Better. implications of infection control. He has published 350 papers, abstracts and book chapters, and co-writes a blog entitled Controversies in Hospital Infection Prevention. Over the past few years, Dr. Edmond Abstracthas been named to Richmond Magazine’s Top Doctors, America’s Top Doctors, US News and World Report’s Top Doctors, Our Health Richmond Magazine’s Best Bedside Manner Award, and Health Leaders Magazine’s 20 People Who Make ShouldHealthcare We Screen Better. for AROs? Background: OptimalAbstract: methods Should for the We control Screen of AROs for remain AROs? inconclusive. Over the past decade, there has been a push for active detection and isolation (ADI) to control AROs in the hospital setting. However, most studies supporting this approach are single-center, observational, nonrandomized, before-and- afterBackground: evaluations that Optimal cannot establish methods causality. for the control of AROs remain inconclusive. Over the past decade, there has been a push for active detection and isolation (ADI) to control AROs in the hospital setting. However, most studies supporting this approach Policyare single-center, Recommendations: observational, nonrandomized, before-and-after evaluations that cannot establish causality. Active detection and isolation for the control of endemic pathogens should not be pursued. Rather, hospitals should primarily focus on population- based,Policy horizontal Recommendations: infection prevention Active strategies detection which have and the isolationcapacity to reducefor the infections control due of to endemic all organisms pathogens transmitted should via direct not or indirect be pursued. contact. Rather, hospitals should primarily focus on population-based, horizontal infection prevention strategies which have the Rationale:capacity to reduce infections due to all organisms transmitted via direct or indirect contact. 1. There are no convincing experimental data that the ADI approach is effective for organisms that are highly endemic in hospitals. Cluster randomizedRationale: controlled trials in the ICU setting have shown no advantage of ADI to comparator approaches. 2.1. ScreeningThere programs are no incur convincing high resource experimental utilization. The datacost ofthat an ADIthe programADI approach includes the is direct effective costs (laboratory for organisms costs, disposable that are personal highly endemic protectivein hospitals. equipment), Clusteropportunity randomized cost (tracking ofcontrolled patients and trials ensuring in isolation),the ICU as setting well as othershave (disposalshown noof consuma advantageble plastics of ADI and theirto comparator impact on the environment). 3. Evenapproaches. if ADI programs could demonstrate perfect results (i.e., no nosocomial transmission of the targeted pathogens), they have no impact on organisms2. Screening not included programs in the screening incur program high resource (i.e., they areutilization. unipotent and The lack costa future of orientation).an ADI program includes the direct costs (laboratory 4. Contactcosts, precautions disposable impede personal patient care. protective They have equipment),been demonstrated opportunity to reduce visits cost by doctors(tracking and nurses, of patients impose existentialand ensuring burden isolation),on as well patients (increased anxiety and depression, reduced satisfaction), and are associated with supportive care failures. Moreover, contact precautions reduceas patient others throughput. (disposal of consumable plastics and their impact on the environment). 5.3. ContactEven precautions if ADI programspose a unique could ethical demonstrateissue in that the benefitperfect of resultsthe intervention (i.e., no does nosocomial not accrue to thetransmission patients who bear of theits burden. targeted pathogens), they have no impact on organisms not included in the screening program (i.e., they are unipotent and lack a future orientation). 4. Contact precautions impede patient care. They have been demonstrated to reduce visits by doctors and nurses, impose existential burden on patients (increased anxiety and depression, reduced satisfaction), and are associated with supportive care failures. Moreover, contact precautions reduce patient throughput. 5. Contact precautions pose a unique ethical issue in that the benefit of the intervention does not accrue to the patients who bear its burden.

www.AROsCalgary2014.ca 20 Canadian Consensus Development Conference on Surveillance & Screening for AROS Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

DanDan Gregson,Gregson, MD, MD,FRCPC; FRCPC Associate Professor, University of Calgary; Clinical Section Chief, Medical Microbiology, Calgary Laboratory Services; Infectious Diseases AssociateConsultant, Professor,Calgary, Alberta University Health Services of Calgary; Clinical Section Chief, Medical Microbiology, Calgary Laboratory Services; Infectious Diseases Consultant, Calgary, Alberta Health ServicesDr. Gregson trained in Medicine at the University of Toronto, graduating in 1983 after which he did specialty training in Internal Medicine and Medical Microbiology and Sub-specialty training Dr.in Infectious Gregson Disease trained in Toronto. in Medicine Subsequently, at the Dr. UniversityGregson worked of in Toronto, Medical Microbiology graduating and in 1983 after which he didInfectious specialty Diseases training in London, in InternalOntario for Medicine10 years before and movi Medicalng to Calgary Microbiology in 2000. He has and been Sub-specialty training inClinical Infectious Section DiseaseChief in Medical in Toronto. Microbiology Subsequently, in Calgary for Dr. 7 years. Gregson worked in Medical Microbiology and Infectious Diseases in London, Ontario for 10 years before moving to Calgary in 2000. He has been Clinical Section Chief in Medical Microbiology in Calgary for 7 years.

AbstractAbstract: What factors can facilitate or hinder effective ARO control in practice? WhatLaboratory factors can Factors facilitate Affectingor hinder effective ARO AROControl. control in practice? LaboratoryBackground: Factors Affecting Infection ARO Control.Control Programs generally request screening cultures as part of the bundle to prevent Healthcare transmission of antibiotic resistant organisms. The laboratory costs and the sensitivity of the method are generally not Background:considered Infection when Control strategies Programs are generally implemented. request scree Aning review cultures of as the part relative of the bundle sensitivities to prevent Healthcare of various trans AROmission screening methods was of antibiotic resistant organisms. The laboratory costs and the sensitivity of the method are generally not considered when strategies are implemented.done using A review literature of the relativereview sensitivities and program of various costs ARO were screening calculated methods was based done onusing current literature Alberta review and reagent program andcosts laborwere prices. calculated based on current Alberta reagent and labor prices. Results: The sensitivity of laboratory screening for ARO’s varies with the number of patient sites sampled, the use of broth Results:enrichment The sensitivity prior of tolaboratory culture, screening the culture for ARO’s medium varies with used, the number and theof patient ARO sites being sampled, screened the use offor. broth Organisms enrichment priorsuch to as vancomycin- culture,resistant the culture enterococci, medium used, have and thedetection ARO being rates screened as lowfor. a Organisms 50% on such a single as vancomycin-resistant rectal sample. enterococci, Single site have sampling detection rates for methicillin- as low a 50% on a single rectal sample. Single site sampling for methicillin-resistant Staphylococcus aureus has a sensitivity of 80%. Sampling multipleresistant sites with Staphylococcus broth enrichment aureusis required has for amethicilli sensitivityn-resistant of 80%. Staphylococcus Sampling aureus multiple to reach sitesa detection with rate broth of 95%. enrichment Detection rates is required for for methicillin-resistantCRE vary according to the geneticStaphylococcus mechanism of aureus producti on.to reachUse of commerciala detection nucleic rate acid of amplification95%. Detection methods rates cost 5 for – 10 CRE the cost vary of according to the culture-basedgenetic mechanism methods and have of notproduction. been consistently Use shown of commercial to reduce transmission nucleic events. acid amplification The cost of a screening methods program cost will vary5 –10 with the the cost of culture-based required sensitivity of the method implemented in addition to the number of patients being screened. Decision tree analysis of all of the options is requiredmethods to make and rational have decisions not been and these consistently need to be re-eva shownluated to as reduce the prevalence transmission of the ARO events. changes. The cost of a screening program will vary with the required sensitivity of the method implemented in addition to the number of patients being screened. Decision tree Conclusions:analysis ofCosts all per of case the identified options increase is required incrementally to make as methods rational to increase decisions sensitivity and of these detection need are implementeto be re-evaluatedd, and increase as the prevalence of the logarithmically as the prevalence of ARO colonization decreases. Screening programs need to alter their strategy based on these factors. InfectionARO control changes. programs need to set lower limits on the prevalence at which screening should be implemented, and the upper limit at which screening no longer cost effective. More expensive, rapid methods have generally not been shown to improve outcomes. Budgeting for Conclusions: Costs per case identified increase incrementally as methods to increase sensitivity of detection are laboratory screening for ARO’s should be tied directly to Infection Control programs to ensure optimal utilization of health care resources. implemented, and increase logarithmically as the prevalence of ARO colonization decreases. Screening programs need to alter their strategy based on these factors. Infection control programs need to set lower limits on the prevalence at which screening should be implemented, and the upper limit at which screening no longer cost effective. More expensive, rapid methods have generally not been shown to improve outcomes. Budgeting for laboratory screening for ARO’s should be tied directly to Infection Control programs to ensure optimal utilization of health care resources.

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 21 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

AnthonyAnthony Harris, Harris, MD, MPH MD, MPH Professor, Epidemiology and Public Health, University of Maryland; ActingProfessor, Medical Epidemiology Director of Infection and ControlPublic University Health, Universityof Maryland Medicalof Maryland; Center Acting Medical Director of Infection Control University of Maryland Medical Center Dr.Dr. Harris Harris is an isinfectious an infectious disease physician disease and physician epidemiologist and whoseepidemiologist research interests whose include research emerging interests include pathogens, antimicrobial-resistant bacteria, hospital epidemiology/infection control, epidemiologic methods in infectiousemerging diseases pathogens, and medical antimicrobial-resistant informatics. He has publishe bacteria,d over 135 hospital papers. He epidemiology/infection has current or has had funding control, fromepidemiologic the NIH, CDC andmethods AHRQ toin study infectious antibiotic diseases resistance and and hospitalmedical epidemiology. informatics. He hasHe numeroushas published publicationsover 135 involving papers. theHe pros has and current cons of oractive has surveillance had funding and contact from precautions.the NIH, CDC and AHRQ to study antibiotic resistance and hospital epidemiology. He has numerous publications involving the pros and cons of active surveillance and contact precautions.

Abstract Background: Contact Precautions are a recommended method for preventing patient-to-patient transmission of multiple Abstract drug-resistant organisms. However, in the last decade, concerns have arisen about the possible adverse events associated with Background:contact precautions. Contact Precautions In my are presentation, a recommended I methodwill review for preventing the literature patient-to-patient on the transmissionpotential adverse of multiple events drug-resis of tantcontact organisms. precautions However,with a focus in the onlast thedecade, acute concerns care havehospital arisen setting.about the Ipossible will also adverse address events patientassociated choice with contact regarding precautions. active In surveillancemy presentation, culturing. I will review the literature on the potential adverse events of contact precautions with a focus on the acute care hospital setting . I will also address patient choiceResults: regarding Initial active studies surveillance led to culturing public .health concerns that contact precautions lead to decreased healthcare worker visits, increased anxiety, increased depression and an increase in other adverse events. More recent higher quality observational Results: Initial studies led to public health concerns that contact precautions lead to decreased healthcare worker visits, increased anxiety, increased depressionstudies demonstrate and an increase thatin other patients adverse whoevents. are More on rececontactnt higher precautions quality observational have more studies pre-existing demonstrate thatconditions patients who that are lead on contact to this anxiety precautionsand depression have more and pre-existing that contact conditions precautions that lead to themselves this anxiety and do depression not increase and that anxiety contact precautionsor depression. themselves A recent do not largeincrease randomized anxiety ortrial depression. showed A thatrecent adverse large randomized events weretrial showed not increased that adverse for events patients were not on increased universal for patients contact on precautions.universal contact This precautions. same randomizedThis trial samedid confirmrandomized that trial didpatients confirm on that universal patients on contactuniversal precautionscontact precautions are areseen seen less less oftenoften by byhealthcare healthcare workers. workers. The literature The literature is sub- is sub- optimal to assess the impact of contact precautions on family members. Patients being placed on contact precautions have been demonstrated to have aoptimal negative impactto assess on bed the flow impact into long-term of contact care precautionsfacilities and rehabilitation on family facilities members. but this Patients could be being improved. placed on contact precautions have been demonstrated to have a negative impact on bed flow into long-term care facilities and rehabilitation facilities but this Conclusions:could be improved. My personal opinions based on my review of the literature are that: Patients should have the right to refuse active surveillance culturing (as with any test). The potential adverse events associated with contact precautions have been dramatically overstated. The science indicates that contactConclusions: precautions My do notpersonal cause increased opinions anxiety based or depressi on myon. review Contact of precautions the literature do not clearlyare that: lead Patients to an increase should in adverse have events. the right They to refuse doactive lead tosurveillance a decrease in healthcareculturing worker (as with visits anythe effect test). of The which, potential at this point adverse in time is events not clear. associated I believe that with any contactnegative effectsprecautions of contact have been precautions can be overcome with more thoughtful implementation that includes patient education about need for contact precautions. dramatically overstated. The science indicates that contact precautions do not cause increased anxiety or depression. Contact precautions do not clearly lead to an increase in adverse events. They do lead to a decrease in healthcare worker visits the effect of which, at this point in time is not clear. I believe that any negative effects of contact precautions can be overcome with more thoughtful implementation that includes patient education about need for contact precautions.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca

www.AROsCalgary2014.ca 22 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

SusanSusan Huang Huang,, MD, MPHMD, ; MPH AssociateAssociate Professor, Professor, University University of California; of California; Medical Medical Director ofDirector Epidemiology of Epidemiology and Infection andPrevention at UC Irvine Health Infection Prevention at UC Irvine Health SusanSusan Huang, Huang, MD MPHMD MPHis an Associate is an Associate Professor inProfessor the Division in theof Infectious Division Diseases of Infectious and Health Diseases Policy Research and Institute at the University of California Irvine School of Medicine, and the Medical Director of Epidemiology and InfectionHealth Prevention Policy Research at UC Irvine Institute Health. at She the received University her MD of degree California from Johns Irvine Hopkins School University of Medicine, School of Medicineand the and Medical her MPH Director degree from of Epidemiology Harvard School ofand Public Infection Health. HerPrevention clinical epidemiologic at UC Irvine research Health. has focused onShe healthcare-associated received her MD infections degree - fromidentifying Johns the Hopkins population University burden, risk School factors for of acquisitionMedicine and and disease her sequelae, andMPH preventative degree strategies from Harvard for containment. School Dr.of PublicHuang isHealth. currently Her the clinicallead investigator epidemiologic of three randomized research clinicalhas trials on MRSA disease prevention. She also serves as a member of the Healthcare Infection Control Practices Advisory Committeefocused (HICPAC),on healthcare-associated a 14-member federal infections advisory committee – identifying that develops the population guidelines burden,on infection risk control factors and preventionfor acquisition in healthcare and settings.disease sequelae, and preventative strategies for containment. Dr. Huang is currently the lead investigator of three randomized clinical trials on MRSA disease prevention. She also serves as a member of the Healthcare Infection Control Practices Advisory Committee (HICPAC), a 14-member federal advisory committee that develops guidelines on infection control and prevention in healthcare settings. Abstract Abstract: Is there a role for decolonization, and if so, when, and how? IsBackground: there a role for Measures decolonization, for preventing and if so, AROs when, have and largely how? focused on reducing new acquisition by preventing transmission. However, these measures do not prevent the high risk of infection among the rising number of patients who already carry Background: Measures for preventing AROs have largely focused on reducing new acquisition by preventing transmission. However, these measures doAROs. not prevent Decolonization the high risk ofhas infection the benefit among theof bothrising reducingnumber of transmissionpatients who already from carry current AROs. carriers Decolonization and preventing has the benefit later of infection. both reducing transmissionResults: Several from current quasi-experimental carriers and preventing studies later over infecti theon. past decade have demonstrated the safety and effectiveness of Results:decolonization Several quasi-experimental strategies to reduce studies ARO over the transmission past decade have and demonstrated environmental the safety contamination and effectiveness in the of decolonization ICU setting, strategies particularly to reduce AROdue totransmission MRSA and and VRE.environmental Recently, contamination several large in the cluster-randomized ICU setting, particularly ICU due trials to MRSA have and shown VRE. Recently,significant several reductions large cluster-randomized in ARO ICUtransmission trials have shown and central significant line reductions associated in ARObloodstream transmission infections and central with line associateddaily chlorhexidine bloodstream infections bathing, withand daily large chlorhexidine reductions bathing, andin MRSA large reductions clinical in cultures MRSA clinical and all-pathogen cultures and all-pathogen bloodstream bloodstream infections infections with withdaily daily chlorhexidine chlorhexidine bathing bathing plus plus short short course course mupirocin tomupirocin reduce both to total reduce body surfaceboth total burden body and thesurface nasal burdenreservoir andof S. theaureus nasal (both reservoir MRSA and of MSSA). S. aureus Attention (both to MRSA the nasal and reservoir MSSA). of S. Attention aureus is important as it has been found to be the #1 pathogen for healthcare-associated infections due to devices and surgeries. In addition, other randomized clinicalto the trialsnasal have reservoir demonstrated of S. aureussignificant is important reductions in as S. it aureus has beensurgical found site infections to be the when #1 similarpathogen chlorhexidine for healthcare-associated and mupirocin regimens infections are used todue decolonize to devices inpatient and carrierssurgeries. prior In to addition,surgery or outpatientother randomized carriers prior clinical to cardiac trials and possiblyhave demonstrated orthopedic surgery. significant reductions in S. aureus surgical site infections when similar chlorhexidine and mupirocin regimens are used to decolonize inpatient carriers Discussion:prior to surgery Body surface or outpatient and nasal decolonizationcarriers prior is toa simple cardiac and and highly possibly effective orthopedic strategy to reduce surgery. the risk of infection in high risk settings and among high risk patients. Targeted decolonization has been shown to reduce the risk of later infection in S. aureus carriers under select settings, suchDiscussion: as before surgery. Body surfaceIn contrast, and universal nasal decolonization decolonization has is been a simple shown andto be highly more effective effective than strategytargeted decolonization to reduce the in riskadult ofICUs infection and in universalhigh risk decolonization settings and in among both adult high and riskpediatric patients. ICUs reduc Targetedes AROs decolonization and bloodstream has infections. been shown Clinical to trials reduce are needed the risk to understand of later infection whether decolonizationin S. aureus carriersis beneficial under in other select high settings, risk settings such such as asbefore the neonatal surgery. ICU, In bone contrast, marrow universaltransplant/oncology decolonization units, and haspost-acute been showncare settings. to Conclusions/be more effective Policy Recommendations: than targeted decolonizationUniversal decolonization in adult w ithICUs both and chlorhexidine universal and decolonization mupirocin should in beboth adopted adult in ICUand settingspediatric to reduce ICUs allreduces cause bloodstream AROs and infection, bloodstream and to reduceinfections. MRSA Clinical clinical cultures. trials are Alternatively, needed to universal understand decolonization whether with decolonization chlorhexidine alone is beneficial could be in adoptedother high to reduce risk centralsettings line such associated as the bloodstream neonatal infectiICU, onbone and marrowARO transmission, transplant/oncology but may not be units,as effective and againstpost-acute MRSA/MSSA care settings. compared to decolonization with chlorhexidine plus mupirocin to address the nasal reservoir. Decolonization with both chlorhexidine and mupirocin in high risk inpatientConclusions/ S. aureus Policy carriers Recommendations: select outpatient S. aureus Universal carriers prior decolonization to surgery should with be adoptedboth chlorhexidine to reduce surgical and site mupirocin infections. should be adopted in ICU settings to reduce all cause bloodstream infection, and to reduce MRSA clinical cultures. Alternatively, universal decolonization with chlorhexidine alone could be adopted to reduce central line associated bloodstream infection and ARO transmission, but may not be as effective against MRSA/MSSA compared to decolonization with chlorhexidine plus mupirocin to address the nasal reservoir. Decolonization with both chlorhexidine and mupirocin in high risk inpatient S. aureus carriers select outpatient S. aureus carriers prior to surgery should be adopted to reduce surgical site infections.

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 23 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

John Jernigan,John Jernigan MD, MS, MD, MS ; Director,Director, Office of Office Prevention of PreventionResearch and ResearchEvaluation, and Centers Evaluation, for Disease Centers Control forand Disease PreventionControl (CDC); and Clinical Prevention Associate (CDC); Professor, Clinical Emory UniversityAssociate School Professor, of Medicine, Emory University DivisionSchool of Infectious of Medicine, Diseases Division of Infectious Diseases John A. Jernigan, M.D., M.S. is currently Director of the Office of Prevention Research and Evaluation,John Division A. Jernigan, of Healthcare M.D., M.S. Quality is currently Promotion, Director Centers of the Officefor Disease of Prevention Control andResearch and Evaluation, PreventionDivision (CDC), of andHealthcare Clinical Quality Associate Promotion, Professor Centers of Medicine for Disease at the Control Emory and University Prevention(CDC), and Clinical School ofAssociate Medicine, Professor Division of of Medicine Infectious at Diseases.the Emory He University attended School medical of schoolMedicine, at Vanderbilt Division of Infectious University,Diseases. where heHe also attended completed medical his school internship at Vanderbilt and residency University, in Internal where he Medicine, also completed and his internship and residency in Internal Medicine, and served as Chief Medical Resident. Following his residency, he spent a year served as Chief Medical Resident. Following his residency, he spent a year practicing medicine practicing medicine in East Africa, then returned to the United States to complete his fellowship in Infectious in East Africa, then returned to the United States to complete his fellowship in Infectious Diseases at the University of Virginia, where he also earned a Masters Degree in Epidemiology. He joined the faculty Diseasesof Emory atUniversity the University in 1994, of andVirginia, became where Hospital he also Epidem earnediologist a Masters at Emory Degree University in Epidemiology. Hospital in He1995. joined In Spri theng faculty 2000, heof joined the Division of HealthcareEmory Quality University Promotion in 1994, at the and CDC, became but maintains Hospital his Epidemiologist faculty appointment at Emory in the University Emory Division Hospital of inInfectious 1995. In Diseases Spring 2000,. He has served on the Board of Directorshe for joined both the the DivisionAssociation of Healthcarefor Professionals Quality in InfectionPromotion Control at the and CDC, Epidemiology but maintains (APIC) his facultyand the appointment Society for Healthcare in the Emory Epidemiology of America (SHEA),Division was named of Infectious the SHEA Diseases. Investigator He hasawardee served in on2005, the and Board served of Directors as president for of both SHEA the in Association 2013. His editorial for Professionals activities havein included service on the EditorialInfection Board Control of Infection and Epidemiology Control and Hospital (APIC) Epidemiol and the Societyogy and for Hospital Healthcare Epidemiology Epidemiology Section of EditorAmerica for (SHEA),Current Infec was tiousnamed Disease Reports. He has authored/coauthoredthe SHEA Investigator numerous awardee peer-reviewed in 2005, andpublications served as and president textbook of chapters SHEA in dealing 2013. withHis editorialthe epidemiology activities of have healthcare-associated included infections and antimicrobialservice resistance, on the Editorial and has Board a particular of Infection interest Controlin the epidemiology and Hospital of Epidemiology drug-resistant Staphylococcusand Hospital Epidemiology aureus. Section Editor for Current Infectious Disease Reports. He has authored/coauthored numerous peer-reviewed publications and textbook Abstractchapters dealing with the epidemiology of healthcare-associated infections and antimicrobial resistance, and has a particular interest in the epidemiology of drug-resistant Staphylococcus aureus. Why Do Screening Practices Vary Across Jurisdictions? Abstract: Why Do Screening Practices Vary Across Jurisdictions? An oftenAn used often component used component of antimicrobial of antimicrobial resistance controlresistance strategies control is strategiesscreening ispatients screening for carriagepatients of for multi-drug carriage resistof multi-drugant organisms (MDROs) to guide targetedresistant interventions. organisms This approach(MDROs) is toutilized guide with targeted great interventions. heterogeneity acrossThis approachhealth jurisdictions is utilized at withthe local,great regional,heterogeneity national, across and healthinternational levels. Factors jurisdictionscontributing toat thethe variability local, regional, include national, debate aboutand international the effectiveness levels. of screening-basedFactors contributing strategies, to the their variability resource include intensity debate, and a range of contextual factors thatabout influence the effectiveness decisions regardingof screening-based their use. strategies, their resource intensity, and a range of contextual factors that influence There aredecisions two major regarding approaches their to use. preventing infections caused by antimicrobial resistant organisms in the healthcare setting: 1) interventions designed to prevent infections caused by any organism (whether an MDRO or not) already carried by the patient, and 2) preventing transmission of MDROs from carriers to non-carriersThere arewho two may majorbe at approachesrisk for infection. to preventing Most healthca infectionsre epidemiologists caused by antimicrobial agree that both resistant are important, organisms but in there the ishealthcare widespread disagreement on the optimalsetting: strategy 1) for interventions preventing transmission designed to of prevent MDROs. infections Epidemi causedologic evidence by any organism clearly suggests (whether that an direct MDRO or indirect or not) transm alreadyission carried of MDROs in healthcare settingsby is commonthe patient, in settings and 2) preventingthat employ transmission Standard Precautions of MDROs (e.g. from standard carriers hand to hygiene non-carriers practice, who etc.). may This be suggestsat risk for that infection. either standard IC practice is not sufficientMost healthcare to completely epidemiologists interrupt transmission, agree that both or that are standard important, practices but thereare insufficiently is widespread implemented disagreement in onmost the sett optimalings. Some feel strongly that the responsestrategy should forbe topreventing improve implementation transmission of of MDROs. standard Epidemiologicprecautions and evidence focus on clearlyinfection-specific suggests that interventions direct or indirect (e.g. inter transmissionventions designed to prevent central line-associatedof MDROs in healthcarebloodstream settings infections is common caused by in any settings organism, that employnot just StandardMDROs), Precautionswhile others (e.g.suggest standard additional hand precautions hygiene are necessary to reliably interruptpractice, MDRO etc.).transmission. This suggests For those that favoring either standard taking additi IC practiceonal precautions is not sufficient to prevent to transmission, completely theinterrupt choices transmission, include: 1) applying or that extra measures to all patientsstandard (or to practicesdefined arepopulations insufficiently of patients implemented that are easy in to definemost settings. and identify Some feelwithout strongly laboratory-based that the response screening) should , or 2) be applying to improve extra measures to only thoseimplementation patients who are of standard MDRO carriers. precautions The latterand focus approach on infection-specific most often requires interventions laboratory-based (e.g. screening, interventions and triggers designed the to use prevent of additional infection control centralsupplies, line-associated person time, hospital bloodstream space, wasteinfections producti causedon, andby any other organism, logistical not requirements. just MDROs), Hence, while screening-based others suggest approaches additional can be very resource intensive.precautions are necessary to reliably interrupt MDRO transmission. For those favoring taking additional precautions to Given theprevent resource transmission, intensity of thescreening-based choices include: approaches, 1) applying there extra has beenmeasures a demand to all to patients clearly quantify(or to defined effectiveness populations in order of thatpatients clear cut cost-benefit-based decisionsthat can are be easy made. to Whiledefine circumstantial and identify evidencewithout laboratory-based and a strong theoretical screening), case can or be2) madeapplying that extraoptimal measures MDRO to control only thoserequires patients more than the use of standard precautions, at least in certain settings, clear-cut evidence of cost-benefit from rigorously controlled studies has been difficult to produce. (It should who are MDRO carriers. The latter approach most often requires laboratory-based screening, and triggers the use of be noted that the same can be said of strategies relying on standard precautions alone). There are a myriad of reasons for this, in part due to methodological additional infection control supplies, person time, hospital space, waste production, and other logistical requirements. Hence, limitations of the existing studies that stem from the major logistical complexities of controlled studies of population-based interventions and outcomes in the healthcarescreening-based setting. approaches can be very resource intensive. In presenceGiven of thesuch resource uncertainty, intensity those ofresponsible screening-based for controlling approaches, antimicrobial there has resistance been a demand in healthcare to clearly facilities quantify must effectivenessweigh the theoretical/circumstantial in evidenceorder for benefit that clear against cut cost-benefit-based certain contextual factors. decisions For canexample, be made.the prevalence While circumstantial of the MDRO evidence in question and may a strong be important theoretical. In settingscase where prevalence is high, canit may be madebe more that practical optimal and MDRO effective control to use requires screening-based more than strategies the use in of comparison standard precautions, to settings where at least the in targeted certain MDROsettings, is highly endemic either in healthcareclear-cut facilities evidence or in of the cost-benefit community. from The clinicalrigorously consequences controlled ofstudies the MDRO has been in question difficult is also to produce.important (It to shouldconsider; be if noted effective that treatment options are limitedthe forsame a certain can be MDRO said of andstrategies infection relying results on instandard high morbidity/mortality precautions alone)., more There aggressive are a myriadaction mayof reasons be warranted. for this, Thein part characteristics due of the patient population needs to be considered as well; some populations may be particularly susceptible to morbidity/mortality to MDROS (e.g. ICU or oncology patients) and warrant additional efforts to prevent MDRO transmission. Differences in the context account for much of the variability in use of screening- based prevention practices. Summary: Decisions on whether or not to use screening-based practice for MDRO control are complex, and must take into account multiple contextual factors such as resource availability, prevalence of the pathogen, consequence of infection by the pathogen, population at risk, and weighing the theoretical rationale for screening-basedwww.AROsCalgary2014.ca approaches against limitations24 in the existCanadianing evidence Consensus base. Development Such complexity Conference does on not Surveillance lend itself &to Screening a “one size for fits AROS all” approach, and therefore there is wide variability of practice across jurisdictions.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca SPEAKERS & ABSTRACTS

to methodological limitations of the existing studies that stem from the major logistical complexities of controlled studies of population-based interventions and outcomes in the healthcare setting. In presence of such uncertainty, those responsible for controlling antimicrobial resistance in healthcare facilities must weigh the theoretical/circumstantial evidence for benefit against certain contextual factors. For example, the prevalence of the MDRO in question may be important. In settings where prevalenceis high, it may be more practical and effective to use screening-based strategies in comparison to settings where the targeted MDRO is highly endemic either in healthcare facilities or in the community. The clinical consequences of the MDRO in question is also important to consider; if effective treatment options are limited for a certain MDRO and infection results in high morbidity/mortality, more aggressive action may be warranted. The characteristics of the patient population needs to be considered as well; some populations may be particularly susceptible to morbidity/mortality to MDROS (e.g. ICU or oncology patients) and warrant additional efforts to prevent MDRO transmission. Differences in the context account for much of the variability in use of screening-based prevention practices. Summary: Decisions on whether or not to use screening-based practice for MDRO control are complex, and must take into account multiple contextual factors such as resource availability, prevalence of the pathogen, consequence of infection by the pathogen, population at risk, and weighing the theoretical rationale for screening-based approaches against limitations in the existing evidence base. Such complexity does not lend itself to a “one size fits all” approach, and therefore there is wide variability of practice across jurisdictions.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 25 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

JoelJoel Kettner, Kettner, MD, MD, MSc, FRCSC, FRCSC, FRCPC; FRCPC Scientific Lead, National Collaborating Centre for Infectious Diseases, International Centre Scientificfor Infectious Lead, DiseasesNational Collaborating Centre for Infectious Diseases, International Centre for Infectious Diseases Dr. Dr.Kettner Kettner was was raised raised in in the northnorth end end of ofWinnipeg Winnipeg and obtainedand obtained his medical his medical degree at degree the University at the of Manitoba, graduating in 1976. He obtained his general surgery specialty certificate in 1984 (University Universityof Manitoba), of Manitoba, his Masters graduating of Science in Epidemiology1976. He obtained at the Uni hisversity general of Londonsurgery School specialty of Hygiene certificate in 1984and Topical (University Medicine of Manitoba),in 1986, and his CommunityMasters of MedicineScience in(now Epidemiology called Public Healthat the andUniversity Preventive of LondonMedicine) School specialty of Hygienecertificate and in 1991 Topical (University Medicine of Manitoba)in 1986,. For and the his next Community two decades, Medicine Kettner worked (nowat thecalled University Public of Health Manitoba’s and PreventiveFaculty of Medicine Medicine) and specialtyfor the Province certificate of Manitoba, in 1991 where (University he first served of Manitoba).as a Regional For Medical the next Officer two ofdecades, Health in he northern, worked rural at the and Universityurban settings, of followedManitoba’s by twelve Faculty years of Medicineas Manitoba’s and for Chief the MedicalProvince Officer of Manitoba, of Health where and, after he thefirst new served Public asHealth a Regional Act, Chief Medical Public HealthOfficer Officer until 2012. In November, 2012, Kettner joined the International Centre for Infectious Diseases as of Healthits medical in northern, director and rural scientific and urban lead for settings, the National followed Collaborating by twelve Centre years for asInfectious Manitoba’s Diseases. Chief In addition,Medical he is Officer director of of the Health Master and,of Public after Health the programnew Public at the Health University Act, of Chief Manitoba, Public a visitingHealth professor Officer of until the Uni 2012.versity In of November,Winnipeg 2012, Master’sKettner in Development joined the International Practice program, Centre and a forfreelance Infectious consultant. Diseases He is as president its medical of the director Public Health and scientificPhysicians oflead Canada for the and aNational director of the CollaboratingCanadian Public CentreHealth Association. for Infectious Diseases. In addition, he is director of the Master of Public Health program at the University of Manitoba, a visiting professor of the University of Winnipeg Master’s in Development Practice program, and a Abstractfreelance consultant. He is president of the Public Health Physicians of Canada and a director of the Canadian Public Health Association. What is surveillance; what is screening? How are they related? Abstract: What is surveillance; what is screening? How are they related? Background: The terms surveillance and screening have distinct meanings, but are often used interchangeably, resulting in confusion. Background: The terms surveillance and screening have distinct meanings, but are often used interchangeably, resulting in Methods:confusion. A non-systematic review of the etymology and definitions of surveillance and screening, as well as the components of such programs, was used to prepare this presentation. Methods: A non-systematic review of the etymology and definitions of surveillance and screening, as well as the components Results:of such Surveillance programs, is the was systematic used to observationprepare this and presentation. monitoring of current events and trends for the purpose of estimating burden of illness in the present and future and can be used to guide short-term and long-term decision-making about interventions and to guide evaluation. Screening is systematicResults: testingSurveillance of individuals is the tosystematic detect the presenceobservation of a conditionand monitoring before it isof manifested current events by symptoms and trends in the forbelief the that purpose earlier detectionof estimating and subsequentburden intervention of illness in is theof net present benefit and for thefuture individual and can patient be usedand/or to others. guide short-term and long-term decision-making about interventions and to guide evaluation. Screening is systematic testing of individuals to detect the presence of a condition Discussion:before it Surveillance is manifested and screeningby symptoms programs in the share belief some that comm earlieron goals detection and methods; and subsequent however, they intervention have different is objectives of net benefit and processes. for the In consideringindividual and patientevaluating and/or the implementation others. of surveillance and/or screening, therefore, it seems important to be clear about their similarities and differences. Discussion: Surveillance and screening programs share some common goals and methods; however, they have different Conclusions/Policyobjectives and Recommendations:processes. In considering Clear, standard and evaluatingdefinitions andthe frameworksimplementation should ofbe surveillanceused for surveillance and/or and screening, screening therefore,in general -it and moreseems specifically important for programs to be clear such about as those their for thesimilarities prevention andand controldifferences. of antimicrobial resistant organisms. Consistent use of such standardized terms and frameworks should improve communication and facilitate knowledge translation with respect to the effectiveness, efficiency, and equity of surveillanceConclusions/Policy and screening programsRecommendations: and activities. Clear, standard definitions and frameworks should be used for surveillance and screening in general - and more specifically for programs such as those for the prevention and control of antimicrobial resistant organisms. Consistent use of such standardized terms and frameworks should improve communication and facilitate knowledge translation with respect to the effectiveness, efficiency, and equity of surveillance and screening programs and activities.

www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

www.AROsCalgary2014.ca 26 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

Mark Loeb, BSc, MSc, MD, FRCPC; Mark Professor, Loeb, Department BSc, of MSc, Pathology MD, and FRCPC Molecular Medicine; Professor,Joint Member, Department Department of of Pathology Clinical Epidemiology and Molecular and Biostatistics; Medicine; Joint Medical Member, Director, Department Infection ofControl, Clinical Hamilton Epidemiology Health Sciences, and Biostatistics; McMaster University Medical Director, Infection Control, Hamilton Health Sciences, McMaster University Dr. Loeb is a Professor in the Departments of Pathology and Molecular Medicine and Clinical Epidemiology and Dr.Biostatistics Loeb is ata McMasterProfessor University. in the Departments He graduated of from Pathology McGill Medical and Molecular School then Medicine completed and fellowships Clinical in EpidemiologyInternal Medicine, and Infectious Biostatistics Diseases at and McMaster Medical MicrobiolUniversity.ogy He at the graduated University from of Toronto McGill and Medical McMaster SchoolUniversity, and and completed an MSc in Clinicalfellowships Epidemiology in Internal at McMaster. Medicine, He Infectious holds the Michael Diseases G DeGroote and Medical Chair in Infectious Diseases Research. Dr. Loeb has published 220 peer reviewed papers and 12 book chapters. He has been MicrobiologyPI on CIHR funded at the epidemiological University ofstudies Toronto and clinical and McMaster trials on antibiotic University, use and and antimicrobial an MSc in resistance Clinical in Epidemiology at McMaster. He holds the Michael G. DeGroote Chair in Infectious Diseases residents of long-term care facilities. Research. Dr. Loeb has published 220 peer reviewed papers and 12 book chapters. He has been PI on CIHR funded epidemiological studies and clinical trials on antibiotic use and antimicrobial resistance in residents of long-term care facilities.

AbstractAbstract Various types of interventions that have been assessed for reducing the spread of antimicrobial resistance. Limitations Various types of interventions that have been assessed for reducing the spread of antimicrobial resistance. Limitations of observational studies will of observational studies will be briefly discussed followed by a focus on cluster randomized controlled trials. A strong be briefly discussed followed by a focus on cluster randomized controlled trials. A strong justification for these trials as the interventional studies of choicejustification will be made. for these The presentationtrials as the will interventional review design andstudies analysis of choice aspects ofwill cluster be made. randomized The trialspresentation and will outline will review strengths design and limitations and ofanalysis this design. aspects of cluster randomized trials and will outline strengths and limitations of this design.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca

Canadian Consensus Development Conference on Surveillance & Screening for AROs 27 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

Yves Longtin, MD, FRCPC; Chair,Yves Infection Longtin, Prevention MD, andFRCPC Control Unit, Montreal Jewish General Hospital – SMBD; Associate ProfessorChair, Infection of Medicine, Prevention McGill University and Control Unit, Montreal Jewish General Hospital – SMBD; Associate Professor of Medicine, McGill University Dr. Yves Longtin obtained his MD from Sherbrooke University and completed his training in Infectious Diseases and Dr. Yves Longtin obtained his MD from Sherbrooke University and completed his training Microbiology at Laval University in 2005. Thereafter, Dr. Longtin pursued a fellowship in Infection Control at the Genevain Infectious University Diseases Hospitals and (HUG), Microbiology Switzerland, at Lavalfrom 2006 University to 2009. in Dr 2005.. Longtin Thereafter, practiced Infectious Dr. Longtin Diseases / Microbiologypursued a fellowship with a special in Infectioninterest in InfectionControl Controlat the Geneva at Centre University Hospitalier Hospitals Universitaire (HUG), de Québec (CHUL) and theSwitzerland, Institut Universitaire from 2006 de Cardiologieto 2009. Dr. et Longtinde Pneumologie practiced de QuébecInfectious (IUCPQ) Diseases from /2009 Microbiology to 2013. He with is the chair ofa thespecial Infection interest Prevention in Infection and Control Control Unit at of Centre the Jewish Hospitalier General Hospital Universitaire in Montreal de Québec since April (CHUL) 2013. He is also a andconsultant the Institut to the WorldUniversitaire Health Organization de Cardiologie for the et Saves de Pneumologie Lives: Clean Yourde Québec Hands Global (IUCPQ) Initiative. from Dr. 2009 Longtin’s researchto 2013. interests He is theinclude chair patient of the involvement Infection Preventionin quality impr andovement, Control hand Unit hygiene of the and Jewish Clostridium General difficile infections.Hospital in Montreal since April 2013. He is also a consultant to the World Health Organization for the Save Lives: Clean Your Hands Global Initiative. Dr. Longtin’s research interests include patient involvement in quality improvement, hand hygiene and Clostridium difficile infections.

Abstract:Abstract (1)What can patients, the public, and health care professionals do to help? (2)Would more education of the public and patients re: appropriate use of antibiotics help reduce the incidence of AROs,(1)What and can what patients, would the be public, the most and effective health care strategy? professionals do to help? (2)Would more education of the public and patients re: appropriate use of antibiotics help reduce the incidence of AROs, and what Background:would be the mostEvidence effective suggests strategy? that the spread of antibiotic resistant organisms (ARO) can be reduced by judicious use of antimicrobials. Some experts argue that patients and the public can help control the spread of ARO. Background Methods:Evidence suggests Review that the of spread the scientific of antibiotic literatureresistant organisms (pubmed, (ARO) canOvid, be reduced CINHAL) by judicious and usereview of antimicrobials. of the grey Some literature experts argue for that relevant patients andstudies the public can andhelp controlinformation the spread of ARO. Results:Methods Review of the scientific literature (pubmed, Ovid, CINHAL) and review of the grey literature for relevant studies and information. Question 5d (1): Patients and the public could help prevent the spread of ARO in numerous ways. They could help prevent theResults spread of ARO by promoting good hygiene practices in the community and in hospitals (such as cough etiquette andQuestion hand 5d (1).hygiene).[1, 2] In addition, patients could be invited to mention any recent hospitalization abroad. They can Patients and the public could help prevent the spread of ARO in numerous ways. They could help prevent the spread of ARO by promoting good hygiene practices in the alsocommunity be involved and in hospitals in the (such auditing as cough of etiquette the quality and hand of hygiene).[1, care (such 2] In as addition, auditing patients hand could hygiene be invited practicesto mention any of recenthealthcare hospitalization workers) abroad. They can also thatbe involved will ultimately in the auditing help of the decrease quality of care the (such spread as auditing of ARO.[3] hand hygiene Also, practices as numerous of healthcare patient-related workers) that will ultimately factors helprepresent decrease barriersthe spread ofto ARO.[3] Also, as numerous patient-related factors represent barriers to implementation of guidelines on antibiotic use, patients should be involved in the creation of such documents. This will help implementationforesee potential lapses of before guidelines their publication, on antibiotic and will li use,kely improve patients uptake should and dissemination.[4] be involved in the creation of such documents. This will help foresee potential lapses before their publication, and will likely improve uptake and dissemination.[4]

QuestionQuestion 5d (2).5d (2): There is widespread misunderstanding from the public on how to use antimicrobials responsibly. This may leadThere tois widespreadpatients misunderstandingpressuring physicians from the public to beon howprescribed to use antimicrobials antimicrobials responsibly even. This when may lead they to patients are not pressuring indicated.[5] physicians toImproving be prescribed patient antimicrobials even when they are not indicated.[5] Improving patient and public education regarding proper antibiotic use and ARO is thus likely to be essential to the control of the spread andof these public pathogens. education There is moderateregarding evidence proper that patientantibiotic and public use education and ARO programs is thus can decreaselikely to antibiotic be essential use and theto spreadthe control of ARO. Thereof the is spreadevidence thatof education thesecampaigns pathogens. can induce moreThere prudent is usemoderate of antimicrobials,[6] evidence athatnd can patient lead to a andsignificant public decrease education in antimicrobial programs use.[7] canA systematic decrease review antibiotic concludes usethat massand mediathe can be spreadeffective ofto improve ARO. health-servicesThere is evidence utilization.[8] that However, education the optimal campaigns method remains can induce to be identified, more prudentas no study usehas comparedof antimicrobials,[6] different initiatives andin terms can of lead effectiveness or cost-effectiveness. Many publications are quasi-experimental single-center studies with a small number of study subjects.[4, 9] to a significant decrease in antimicrobial use.[7] A systematic review concludes that mass media can be effective to improve health-servicesContent of education utilization.[8] programs However, the optimal method remains to be identified, as no study has compared different initiativesThe learning objectivesin terms of of educational effectiveness campaigns or are cost-effectiveness. numerous. Educating about Many prudent publications antimicrobial useare and quasi-experimental the need to avoid overuse single-center of antimicrobials studies is important, with as is the need to correct misunderstandings about the need for antimicrobials in some clinical settings. It is also essential to highlight the correlation between antimicrobial use and aemergence small number and spread of of studyresistance,[4] subjects.[4, and to reinforce 9] the notion that antimicrobials can have harmful effects such as C. difficile infections and candidiasis.[4]

ContentEducation channels of education programs: The learning objectives of educational campaigns are numerous. Educating about prudent antimicrobialNumerous channels use can andbe used the to neededucate to patients avoid and overuse the publi cof including antimicrobials mass media, isweb-based important, professional as is educationthe need and to te achingcorrect by keymisunderstandings stakeholders. As individuals have higher awareness when exposed to more than one intervention, use of a combination of interventions using multiple channels may be required to obtain a maximum impact.[6, 10] aboutHealthcare the professionals need for mayantimicrobials need to be trained in tosome become clinical good teachers. settings. This mayIt is require also essentialmodification to of highlight medical training the correlationcurriculum and production between of toolkits to help them antimicrobialmanage public demand use forand antibiotics.[11, emergence 12] and However, spread there of is resistance,[4]limited evidence regarding and to thereinforce cost-effectiveness the notion of such that program. antimicrobials can have harmful effects such as C. difficile infections and candidiasis.[4] Conclusions/ Policy recommendations Education channels: Numerous channels can be used to educate patients and the public including mass media, web-based • Despite its strong theoretical basis, few studies have assessed the effectiveness of public education programs to decrease inappropriate antibiotic use and limit the spread of ARO; professional• Patient involvement education in preventing and the teaching spread of byARO key could stakeholders. be useful, but the As effect individuals is not fully documented; have higher awareness when exposed to more than one• Public intervention, and patient education use of could a combination be useful to change of interventionsthe social norms, which using are multiple important determinants channels ofmay behavior; be required to obtain a maximum impact.[6,• Successful interventions 10] Healthcare will likely professionals require targeting may both theneed public, to patientsbe trained and healthcare to become workers good through teachers. numerous Thisconcomitant may channelsrequire and modificationmedia; of • Involving the public, patients and healthcare workers will require additional resources, and cost-effectiveness studies have never been performed; www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

www.AROsCalgary2014.ca 28 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS

medical training curriculum and production of toolkits to help them manage public demand for antibiotics.[11, 12] However, there is limited evidence regarding the cost-effectiveness of such program.

Conclusions/ Policy recommendations: • Despite its strong theoretical basis, few studies have assessed the effectiveness of public education programs to decrease inappropriate antibiotic use and limit the spread of ARO; • Patient involvement in preventing the spread of ARO could be useful, but the effect is not fully documented; • Public and patient education could be useful to change the social norms, which are important determinants of behavior; • Successful interventions will likely require targeting both the public, patients and healthcare workers through numerous concomitant channels and media; • Involving the public, patients and healthcare workers will require additional resources, and cost-effectiveness studieshave Speakersnever been performed; & Abstracts

Scott McEwen, DVM, DVSc, Dip ACVP; Professor, Ontario Veterinary College, University of Guelph Scott McEwen, DVM, DVSc, Dip ACVP Dr.Professor, Scott McEwen Ontario obtained Veterinary his DVM and College, Doctor of University Veterinary Science of Guelph degrees from the University of Guelph. He is currently a Professor in the Department of Population Medicine, Ontario Veterinary College. His research focuses on the epidemiologyDr. Scott McEwen of foodborne obtained infections his in DVM food animal and Doctor populations of Veterinary, particularly E.Science coli and degrees antibiotic from resistant the or ganisms, but alsoUniversity Salmonella of and Guelph. other pathogens. He is currently He has extensive a Professor experienc in thee in Department conducting epidemiological of Population studies Medicine, in cattle, poultry, swineOntario and other Veterinary food animal College. species His and researchhas also participated focuses on in athe number epidemiology of studies of of zoonotic foodborne infections infections in companion animals and in humans, including antimicrobial resistance in commensal and pathogenic bacteria. His research on antimicrobialin food animal resistant populations, bacteria, Salmonella particularly and E. E.coli coli O157:H and7 antibiotic and related resistantorganisms organisms,focuses on the but distribution also of fecal sheddingSalmonella in animals, and otherand risk pathogens. factors for infection He has inextensive animals and experience humans. He in also conducting studies the determinantsepidemiological of selection and assessmentstudies in of cattle, human poultry,health risks swine from andantimicrobial other food use in animal animals. species Since 1986 and he has has also supervised participated over 50 MScin a and PhD students.number He of is studiesauthor or of co-author zoonotic of overinfections 200 publications in companion in refereed animals scientific and journals in humans, and has includingdelivered invited research presentationsantimicrobial in eleven resistance countries. in Hecommensal consults on andfood pathogenicsafety, antibiotic bacteria. resistance, His epidemiology research on and antimicrobial other veterinary public health matters with a number of governmental and non-governmental organizations at the provincial, national andresistant international bacteria, levels, Salmonella notably various and food E. colianimal O157:H7 industry groups, and related the Canadian organisms Committee focuses on Antibiotic on the Resistance distribution of fecal shedding(CCAR) in animals, the Alliance and forrisk the factors Prudent for Use infection of Antibiotics in animals (APUA), andthe Public humans. Health He Agency also studiesof Canada, the Health Canada, the determinants of selection andUnited assessment States Food of andhuman Drug healthAdministration, risks from the Centers antimicrobial for Disease use Control in animals. and the World Since Health 1986 Organization he has (WHO). supervised over 50 MSc andHe PhD chaired students. Health Canada’sHe is author Advisory or co-authorCommittee onof Animal over 200 Uses publications of Antimicrobials in refereed and Impact scientific on Resistance and Human Health. He also chaired numerous international antibiotic resistance committees, including the World Health Organization’s evaluation of the termination ofjournals the use of and antimicrobial has delivered growth invited promoters research in Denmark, presentations the FAO/OIE/WHO in eleven Expert countries. Workshop He on consults Non-human on Antimicrobialfood safety, Usageantibiotic and Antimicrobial Resistance:resistance, Scientific epidemiology Assessment and and other the Jointveterinary FAO/WHO/OIE public healthExpert mattersMeeting on with Critically a number Important of governmentalAntimicrobials. Heand is currentlynon-governmental a member of theorganizations WHO Advisory at Groupthe provincial, on Integrated national Surveillance and of international Antimicrobial Resistancelevels, notably Surveillance various (AGISAR) food animal and chairs industry its antibiotic groups, usage the monitoring Canadian subcommittee.Committee on Antibiotic Resistance (CCAR) the Alliance for the Prudent Use of Antibiotics (APUA), the Public Health Agency of Canada, Health Canada, the United States Food and Drug Administration, the Centers for Disease Control and the AbstractWorld Health Organization (WHO). He chaired Health Canada’s Advisory Committee on Animal Uses of Antimicrobials and Impact on Resistance and Human Health. He also chaired numerous international antibiotic resistance committees, including Antimicrobial Drug Use in Animals as a Driver of Resistance the World Health Organization’s evaluation of the termination of the use of antimicrobial growth promoters in Denmark, Antimicrobialsthe FAO/OIE/WHO are used widely Expert in veterinary Workshop medicine, on Non-humanfood animal production Antimicrobial and aquaculture. Usage Most and drug Antimicrobial classes used in huma Resistance:ns are also Scientificused in animals. Some are administeredAssessment on andan individual the Joint animal FAO/WHO/OIE basis, but administrati Experton to Meetingentire groups, on herds Critically or flocks Important of animals is Antimicrobials. common. General indications He is currently for group treatmenta member include therapy,of the WHOdisease prophylaxis Advisory and Group growth on promotion Integrated / feed Surveillance efficiency. Antimicrobial of Antimicrobial use is a major Resistance driver of resistance, Surveillance but animal (AGISAR) production andpractices chairs also itscontribute to spread of resistant bacteria and their genes between animals, herds and countries. Animals are a source of resistance for humans, either directly from animals, or much moreantibiotic importantly, usage through monitoring indirect transmission subcommittee. by various environmental routes, especially food. Available evidence suggests that the most important contribution of antimicrobial use in animals to resistance problems in humans is selection and spread of resistance in enteric pathogens, such as Salmonella spp, Campylobacter jejuniAbstract: and Escherichia Antimicrobial coli. Resistance Drug is alsoUse a in problem Animals in some as important a Driver bacterial of Resistance infections of animals (e.g. E. coli in pigs and poultry, Staphylococcus intermedius in pets), however, resistance is not perceived to be as big a threat to animal health as it is to human health. In the veterinary and animal production communities, antimicrobialAntimicrobials resistance are is used thought widely to be mainlyin veterinary a public healt medicine,h problem. food Consequently animal, ARO production screening isand rare aquaculture. to non-existent inMost animals drug and classes efforts to used control in resistancehumans in are animals also areused mainly in animals.focused on Somehuman healthare administered protection. Scientists on an have individual for decades animal been trying basis, to better but charact administrationerize the human to healthentire implications groups, of antimicrobial use in animals, but major progress is made difficult by the diverse and complex ecological nature of bacteria / animal / environment / human interactions. Directherds measurement or flocks ofof humananimals health is riskcommon. has not been General possible indications, so indirect risk for assessment group treatment methods have include been adapted therapy, from ediseasenvironmental prophylaxis health and usedand to map andgrowth quantify promotion risk pathways / feed and health efficiency. consequences Antimicrobial in humans. These use efforts is a have major been driver seriously of hamperedresistance, by limitedbut animal understanding production of the dynamics practices of resistance also selectioncontribute and spread to spread through of the resistant varied and bacteria complex andenvironment their genesal pathways between from animals animals, to humans herds (e.g. and food, countries. water, soil, Animals pets). Targeted are aresearch source can of address specific knowledge gaps, but improved surveillance is the most efficient and useful way of advancing knowledge on resistance selection and spread at regional and nationalresistance levels, for and humans, surveillance either is needed directly to support from better animals, antimicrobial or much use policy more, and importantly, assess effectiveness through of interventions. indirect transmissionAntimicrobial resistance, by various particularly fromenvironmental non-human sources, routes, is an especially ecological phenomenon,food. Available requiri evidenceng ecological suggests approaches that to research,the most risk important assessment and contribution risk management. of antimicrobial Underpinning each use of these approaches is surveillance of antimicrobial use and antimicrobial resistance at the local, regional, national and international levels. The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) is vital for assessing and addressing enteric bacteria resistance concerns at the animal / food / human interface, and should be strengthened and expanded in order to more comprehensively monitor antimicrobial use in animals, and address resistance in a wider range of bacteria and environmental settings. Conclusions/Policy Recommendations: Integrated surveillance of antimicrobial use and resistance in animals, food, environment and humans is essential and should be enhanced and strengthened in Canada at Canadianprovincial and Consensus national levels Development and coordinated Conference with internati on Surveillanceonal partners. & Screening for AROs 29 www.AROsCalgary2014.ca Survelliance of resistance in veterinary pathogens is needed to better understand the impact of resistance on animal health in the expectation that this will provide more motivation in the veterinary and farming community to reduce antimicrobial use. ARO screening is rarely if ever used in animals. Containing the spread of enteric pathogens to humans through food and water is already the focus of intensive efforts, some of which involve types of screening (e.g. E. coli testing to monitor effectiveness of food safety and water disinfection measures). Given the experience of controlling these enteric other important infections in animals and their subsequent spread to humans, ARO-specific screening would in future likely only be warranted if vital international trade implications and / or potentially catastrophic animal or human health consequences were at stake. This possibility should be incorporated into contingency planning.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca SPEAKERS & ABSTRACTS

in animals to resistance problems in humans is selection and spread of resistance in enteric pathogens, such as Salmonella spp, Campylobacter jejuni and Escherichia coli. Resistance is also a problem in some important bacterial infections of animals (e.g. E. coli in pigs and poultry, Staphylococcus intermedius in pets), however, resistance is not perceived to be as big a threat to animal health as it is to human health. In the veterinary and animal production communities, antimicrobial resistance is thought to be mainly a public health problem. Consequently, ARO screening is rare to non-existent in animals and efforts to control resistance in animals are mainly focused on human health protection. Scientists have for decades been trying to better characterize the human health implications of antimicrobial use in animals, but major progress is made difficult by the diverse and complex ecological nature of bacteria / animal / environment / human interactions. Direct measurement of human health risk has not been possible, so indirect risk assessment methods have been adapted from environmental health and used to map and quantify risk pathways and health consequences in humans. These efforts have been seriously hampered by limited understanding of the dynamics of resistance selection and spread through the varied and complex environmental pathways from animals to humans (e.g. food, water, soil, pets). Targeted research can address specific knowledge gaps, but improved surveillance is the most efficient and useful way of advancingknowledge on resistance selection and spread at regional and national levels, and surveillance is needed to support better antimicrobial use policy, and assess effectiveness of interventions. Antimicrobial resistance, particularly from non-human sources, is an ecological phenomenon, requiring ecological approaches to research, risk assessment and risk management. Underpinning each of these approaches is surveillance of antimicrobial use and antimicrobial resistance at the local, regional, national and international levels. The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) is vital for assessing and addressing enteric bacteria resistance concerns at the animal / food / human interface, and should be strengthened and expanded in order to more comprehensively monitor antimicrobial use in animals, and address resistance in a wider range of bacteria and environmental settings. Conclusions/Policy Recommendations: Integrated surveillance of antimicrobial use and resistance in animals, food, environment and humans is essential and should be enhanced and strengthened in Canada at provincial and national levels and coordinated with international partners. Surveillance of resistance in veterinary pathogens is needed to better understand the impact of resistance on animal health in the expectation that this will provide more motivation in the veterinary and farming community to reduce antimicrobial use. ARO screening is rarely if ever used in animals. Containing the spread of enteric pathogens to humans through food and water is already the focus of intensive efforts, some of which involve types of screening (e.g. E. coli testing to monitor effectiveness of food safety and water disinfection measures). Given the experience of controlling these enteric other important infections in animals and their subsequent spread to humans, ARO-specific screening would in future likely only be warranted if vital international trade implications and / or potentially catastrophic animal or human health consequences were at stake. This possibility should be incorporated into contingency planning.

www.AROsCalgary2014.ca 30 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

AllisonAllison McGeer, McGeer, MD, FRCPCMD, FRCPC MicrobiologistMicrobiologist & Infectious & Infectious Disease Disease Consultant; Consultant; Director Director of Infection of InfectionControl; Control; Director, Director, Infectious Diseases Epidemiology Research Program, Mount Sinai Hospital and Professor,Infectious Laboratory Diseases Medicine Epidemiology and Pathobiology Research and Program, Public Health Mount Sciences, Sinai Hospital University and of TorontoProfessor, Laboratory Medicine and Pathobiology and Public Health Sciences, University of Toronto Dr. McGeer trained in internal medicine and infectious diseases at the University of Toronto, then completed a fellowshipDr. McGeer in hospital trained epidemiology in internal at Yale medicine New Haven and Hospital infectious in 1989/90 diseases before at thereturning University to Mount of Sinai Toronto, Hospital.then completed Her research a interestsfellowship are in in the hospital prevention epidemiology of infection in athealth Yale care New institutions Haven andHospital control inof 1989/90 antimicrobialbefore returning resistance. to Mount Sinai Hospital. Her research interests are in the prevention of infection in health care institutions and control of antimicrobial resistance.

Abstract AbstractBackground: Antibiotic resistance imposes a significant and increasing burden in Canada, both in terms of patient morbidity and mortality, and medical care costs. Hospitals are a particular focus for antibiotic resistance because of the highly Background: Antibiotic resistance imposes a significant and increasing burden in Canada, both in terms of patient morbidity and mortality, and medicalsusceptible care costs. populations Hospitals they are a serve,particular the focus infection for anti bioticrisk associated resistance because with medical/surgicalof the highly susceptible interventions, populations they the serve,frequent the infection need for riskantibiotic associated use, with and medical/surgical the potential interventions, for person-to-person the frequent need spread for antibiotic of bacteria. use, and All the Canadian potential forhospitals person-to-person have multi-faceted spread of bacteria. programs Allfor Canadianthe prevention hospitals ofhave infection multi-faceted which programs include for measures the prevention to preventof infection transmission which include of measures microbes to prevent from transmissiperson toon person of microbes within the fromhospital. person Despite to person our within infection the hospital. control Despite programs, our infecti iton is control clear programs,that person-to-person it is clear that person-to-person spread of antimicrobial spread of antimicrobial resistant resistant organisms organisms (AROs) continues in all hospitals in Canada. (AROs) continues in all hospitals in Canada. The recognition recognition of the of burden the burden of illness of associated illness associated with AROs andwith the AROsfailure andof general the failure infection of preventiongeneral infection programs toprevention prevent transmission programs of to these organisms has led hospitals to create specific ARO transmission control programs. All hospitals in Canada have at least one of these programs. prevent transmission of these organisms has led hospitals to create specific ARO transmission control programs. All hospitals Inin anCanada ideal world, have all at medical least one interventions, of these programs.including prevention programs, would be assessed for their cost-effectiveness in extending patient survival/quality of life, and implemented based on WHO recommendations for cost-effectiveness (expressed as $/QALY or DALY). In addition, we wouldIn an haveideal specific world, evidenceall medical to inform interventions, us about the relativeincluding cost-ef preventionfectiveness of programs, general and would organisms be specificassessed infection for their prevention cost-effectiveness programs. Our continuingin extending disagreement patient onsurvival/quality the relative value of of life,specific and implementedARO control programs based stems on WHOlargely fromrecommendations an absence of data for regarding cost-effectiveness cost-effectiveness. This(expressed absence ofas data$/QALY occurs orbecause DALY). hospitals In addition, are part of we regio wouldnal healthcare have specific systems, whichevidence are theto bestinform unit ofus analysis about ithen studies relative comparing cost- controleffectiveness programs, of because general control and programsorganisms are multifacetedspecific infection themselves prevention and thus difficult programs. to standardize Our continuing and compare, disagreement because general andon the specific relative programsvalue of overlap,specific and ARO because control being multifacetedprograms stems (or “bundled”) largely isfrom essential: an absence the value ofof eachdata individualregarding component cost-effectiveness. is small, but the Thiscombination absence of may be highly effective. data occurs because hospitals are part of regional healthcare systems, which are the best unit of analysis in studies comparing Thecontrol components programs, of ARO because transmission control control programs programs are comprise: multifaceted hand hygiene, themselves education, and screening thus difficult patients, screeningto standardize staff, use andof additional compare, precautions,because general use of privateand specific rooms, environmental programs overlap,and equipment and becausedecontamination, being patientmultifaceted and staf (orf cohorting, “bundled”) antimicrobial is essential: stewardship, the value and of each programindividual evaluation. component In this iscontext small, “screening” but the combination refers to laboratory may testingbe highly that iseffective. done to identify patients (or, less commonly, workers) who are colonized but not infected with an ARO. The components of ARO transmission control programs comprise: hand hygiene, education, screening patients, screening Screeningstaff, use patients of additional for AROs precautions,might be considered use of for private one of tworooms, purposes: environmental to evaluate a transmissionand equipment control decontamination, program, or to reduce patient transmission and staffas part of an ARO control program. This presentation will focus only on the latter goal. cohorting, antimicrobial stewardship, and program evaluation. In this context “screening” refers to laboratory testing that is Methods/Resultsdone to identify patients (or, less commonly, workers) who are colonized but not infected with an ARO. This talk will consider the conditions in which screening may be of value in ARO control programs. Screening patients for AROs might be considered for one of two purposes: to evaluate a transmission control program, or to Potentiallyreduce transmission relevant conditions as part include: of an theARO proportion control of program.the hospital Thisorganism presentation reservoir which will colonized focus only patients on thecomprise, latter the goal. relati ve risk of transmissionMethods/Results: from colonized This astalk compared will consider to infected the patients, conditions the relative in whicheffectiveness screening of standard may andbe ofadditional value in precautions ARO control or standar programs.d and private accommodation in preventing transmission from colonized patients, the performance characteristics of available screening programs, and the costs, benefitsPotentially and adverserelevant consequences conditions of include: the identification the proportion of colonized of patients. the hospital organism reservoir which colonized patients comprise, the relative risk of transmission from colonized as compared to infected patients, the relative effectiveness of standard Conclusions/Policy Recommendations Screeningand additional to identify precautions patients colonized or standard by an ARO and is private one common accommodation component of ARO in preventing transmission transmission control programs. from In some colonized circumstances, patients, screeningthe performance appears to characteristicshave been essential of to available the success screening of transmission programs, control programs.and the costs,However benefits, it is often and difficult adverse to separateconsequences the relative of valuethe of differentidentification components of colonizedof control programs, patients. and most are measured against imperfect standard programs. Conclusions/Policy Recommendations: Screening to identify patients colonized by an ARO is one common component of ARO transmission control programs. In some circumstances, screening appears to have been essential to the success of www.AROscalgary2014.catransmission control programs. However, it is often difficultCanadian to Consensusseparate Developmentthe relative Conference value of ondifferent surveillance components & screening forof aroscontrol programs, and most are measured against imperfect standard programs.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 31 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

KimKim Neudorf, Neudorf, RN, BSN, RN, MEd; BSN, MEd Patients for Patient Safety Champion (PFPS), Canadian Patient Safety Institute Patients for Patient Safety Champion (PFPS), Canadian Patient Safety Institute Kim has been a member of Patients for Patient Safety Canada since 2009. She became a Patient for Patient KimSafety has Champion been aafter member her mother of Patientswas harmed for by Patientthe health Safety care system. Canada She believessince 2009. in the importanceShe became of the a Patient forpatient Patient voice Safetyto help shape Champion safer health after care systemsher mother and is interestedwas harmed in seeing by the highest health standard care system.possible She believespracticed atin the the patient’s importance bedside. Kimof the was patient a nurse educatorvoice to in helpSaskatchewan shape safer for 25 health years and care maintains systems her and is designation as a registered nurse. She has published and presented papers that focus on students and patient interestedsafety, and co-presented in seeing severalthe highest times with standard her mother possible describing practiced their health at care the experience. patient’s bedside. Kim was a nurse educator in Saskatchewan for 25 years and maintains her designation as a registered nurse. She has published and presented papers that focus on students and patient safety, and co- presented several times with her mother describing their health care experience.

Abstract Abstract Background: The public is at the heart of the deliberations on antimicrobial resistant organisms (AROs). They can contribute toBackground: the joint effortThe public to isreduce at the heart the ofprevalence the deliberations of AROson antimicrobial and improve resistant the organisms patient (AROs). experience. They can contribute to the joint effort to reduce the prevalence of AROs and improve the patient experience. Methods: Evidence has been drawn from the literature, review of infection control policies, consumer websites, patients’ Methods: Evidence has been drawn from the literature, review of infection control policies, consumer websites, patients’ anecdotal stories and opin- anecdotalions, and correspondence stories and with opinions, patient advocates. and correspondence with patient advocates. Results: There is conflicting evidence describing the definitive benefits of active screening and isolation to reduce healthcare Results: There is conflicting evidence describing the definitive benefits of active screening and isolation to reduce healthcare associated infections. associatedHowever, several infection. best practice However, guidelines several and the best patient practice advocacy guidelines groups recommend and the this patient approach. advocacy groups recommend this approach. There is a dearth of research that investigates the acceptability of screening to the patient. Patients are largely tolerant of screening and surveillance Thereprotocols is and a acceptdearth that of carrierresearch identification that investigates may be beneficia the l acceptabilityfor their personal of healthcare screening and tothe the safety patient. of others. Patients However ,are communication largely tolerant of screeningabout their carriage and surveillance status and explanations protocols of the and causes accept and consequencesthat carrier is identification not made clear to themay patient. be beneficial for their personal healthcare and theThrough safety the ofeyes others. of patients However, and families, communication inconsistencies in about infection their control carriage practices status are noticed. and explanationsThese inconsistencies of the are causes evident andfrom consequencesresearch is notto point made of care. clear to the patient. The public is aware of “superbugs,” but lack depth in understanding the relationship between antibiotic use and the development AROs, and are Throughgenerally unaware the eyes of the of impact patients antibiotic and resistancefamilies, may inconsistencies have on them personally in infection or on society control. The practicespublic holds are varying noticed. beliefs aboutThese health inconsistencies and are illness--interested primarily in cure and relief of symptoms, but also wanting more information and more involvement in their health care. They have evidentvarying beliefs from about research when an to antibiotic point of is care.required and the associated responsibilities with its use. ThePatient public engagement is aware in healthcare of “superbugs,” leads to safer but care lack and betterdepth outcomes. in understanding Shared decision the making relationship processes, inclusivebetween of antibioticdecision aids, use help and to the increase confidence and assist patients and caregivers to self-manage common illnesses and use antibiotics appropriately. Involving patients in quality developmentimprovement initiatives AROs, contributes and are togenerally improved careunaware processes of andthe patient impact satisfaction. antibiotic resistance may have on them personally or on society. The public holds varying beliefs about health and illness--interested primarily in cure and relief of symptoms, but also wantingDiscussion: more Screening information is a commonly and practiced, more involvement albeit inconsistent, in theirsecondary health prevention care. measure.They haveThere varyingis inconsistency beliefs in aboutresearch whenresults, an policy, antibiotic is and practice leaving the public vulnerable. When infection prevention measures are substandard, the value of screening becomes questionable. Pri- requiredmary prevention and thestrategies associated that engage responsibilities the public in the withcautious its use use. of antibiotics have the potential to circumvent the prevalence of AROs. Patient engagement in healthcare leads to safer care and better outcomes. Shared decision making processes, inclusive Conclusions/Policy Recommendations: Screening and isolation are common practices adopted to protect the public. Patient engagement and shared ofdecision decision making aids, are ethicalhelp to imperatives increase at confidence the center of managi and ngassist this growingpatients public and health caregivers problem. to To self-manage improve patient common safety and illnessesthe patient expeand- use antibioticsrience and help appropriately. control AROs in Involvinghospitals and patients communities in qualitythe following improvement recommended initiatives interventions contributes are offered: to improved care processes and patient1) Improve satisfaction. patient-provider communication •Shared decision making-Involve, Inform. Discussion:•Develop health Screening literacy for self-management is a commonly of commonpracticed, viral albeit illnesses. inconsistent, secondary prevention measure. There is inconsistency in2) Involveresearch the results,public/patient policy, from and research practice to point leaving of care in the public vulnerable. When infection prevention measures are substandard, • primary prevention strategies using a community-based multimodal approach to encourage appropriate antibiotic use. the• quality value improvement of screening initiatives becomes to reconcile questionable. inconsistencies Primary in infection prevention control and strategies improve the that patient engage experience the andpublic make in it easythe forcautious people touse of antibioticsdo things right. have the potential to circumvent the prevalence of AROs. Conclusions/Policy Recommendations: Screening and isolation are common practices adopted to protect the public. Patient engagement and shared decision making are ethical imperatives at the center of managing this growing public health problem. To improve patient safety and the patient experience and help control AROs in hospitals and communities the following recommended interventions are offered: 1) Improve patient-provider communication Canadian• ConsensusShared Developmentdecision making-Involve, Conference on surveillance Inform. & screening for aros www.AROscalgary2014.ca • Develop health literacy for self-management of common viral illnesses. 2) Involve the public/patient from research to point of care in • primary prevention strategies using a community-based multimodal approach to encourage appropriate antibiotic use. • quality improvement initiatives to reconcile inconsistencies in infection control and improve the patient experience and make it easy for people to do things right.

www.AROsCalgary2014.ca 32 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

LindsayLindsay Nicolle,Nicolle, BSc, BSc, BSc(med), BSc(med), MD, FRCPC MD, FRCPC Professor, Department of Internal Medicine and Medical Microbiology, University of Manitoba Professor, Department of Internal Medicine and Medical Microbiology, University ofDr. Manitoba Lindsay Nicolle is Professor of Internal Medicine and Medical Microbiology at the University of Manitoba and a Consultant in Adult Infectious Diseases at the Health Sciences Centre and Winnipeg Dr.Regional Lindsay Health Nicolle Authority. is Professor She is a past of ChairInternal of the Medicine Department and of Internal Medical Medicine Microbiology at the University at the Universityof Manitoba of and Manitoba has contributed and toa Consultantmany national in and Adult international Infectious committees Diseases including at the past Health chair Sciences Centreof the Health and Winnipeg Canada Nosocomial Regional Infections Health Steering Authority. Committee She isfrom a past 1994 Chair to 2005, of past the President Department of Internalof the Canadian Medicine Infectious at the Diseases University Society, of member Manitoba of the and Board has for contributed the Community to andmany Hospital national and Infection Control Association and the Canadian Society for Clinical Investigation, chair of the Long internationalTerm Care Committee committees and Annual including Meeting past Planning chair Committee of the Health and secretary Canada of the Nosocomial Society of Health Infections SteeringCare Epidemiology Committee of America, from 1994 and member to 2005, of pastthe American President Society of the of Microbiology Canadian InfectiousICAAC Program Diseases Society,Planning member Committee. of Shethe presentlyBoard for chairs the the Community Expert Advisory and Committee Hospital on Infection Blood Regulation Control of Association andHealth the Canada, Canadian and is Society a member for of Clinical the Canadian Investigation, Drug Expert Commchairittee. of the She Long was the Term Editor Care-in-chief Committee of the Canadian Journal of Infectious Diseases and Medical Microbiology for 20 years. and Annual Meeting Planning Committee and secretary of the Society of Health Care Epidemiology of America, and member of the American SocietyDr. Nicolle’sof Microbiology research interests ICAAC have Program been in urinary Planning tract infection, Committee. hospital She acquired presently infections, chairs the Expert antimicrobialAdvisory Committee resistance, and on infections Blood Regulationin the elderly ofand Health she has publishedCanada, extensively and is a member in these fields. of the She Canadian has contribute Drugd to Expertthe development Committee. She ofwas many the national Editor-in-chief and international of the consensus Canadian documents Journal and of prac Infectioustice guidelines Diseases addressing and aspects Medical of infectious Microbiology diseases forand 20infection years. control. Dr. Nicolle’s research interests have been in urinary tract infection, hospital acquired infections, antimicrobial resistance, Abstract and infections in the elderly and she has published extensively in these fields. She has contributed to the development of Whatmany Is national Appropriate and Screeninginternational For consensusAro’s In Various documents Settings? and practice guidelines addressing aspects of infectious diseases and infection control. ARO screening policies in acute care settings need to address varying circumstances, as well as substantial differences in patient populations. OutbreaksAbstract: may What occur Is with Appropriate strains which Screening are more effectively For AROs transmitted In Various or have Settings?greater morbidity. In the context of an ARO outbreak investigation, screening of potentially colonized or infected patients is an essential component of the response at several levels, including describingARO screening the extent policies of the outbreak, in acute clarifying care settings risk associat needions, to and address monitoring varying the ef circumstances,fectiveness of control as wellinterventions. as substantial differences in patient populations. Outbreaks may occur with strains which are more effectively transmitted or have greater morbidity. ARO screening and the interventions prompted by a positive screening test may interfere with patient care while providing no benefits. For psychiatricIn the context in-patient of anpopulations ARO outbreak the prevalence investigation, of AROs appears screening low and of attributable potentially morbidity colonized has not or been infected described patients in this setting. is an essential Barrier interventionscomponent may of theobstruct response patient atcare several goals through levels, restricti includingng socialization describing and the limiting extent participation of the outbreak, in group therapy clarifying. As behavioral risk associations, and managementmonitoring is theproblematic effectiveness for many ofof controlthese patients, interventions. implementation of patient restrictions is disruptive to patient and staff. Patients on rehabilitation units may have a high prevalence of AROs, but new acquisition of AROs by patients on these wards has been reported to be infrequentARO screening in limited and studies. the AROinterventions restrictions promptedmay interfere by with a positiverehabilitation screening goals of care.test may Rehabilitation interfere patients with patientat risk of careARO whileinfection providing areno readilybenefits. identified Forpsychiatric by characteristics in-patient including populations the presence of the invasive prevalence devices, ofbeing AROs bedbound, appears and low having and pressure attributable ulcers. Practicesmorbidity to has limitnot beenARO infectiondescribed can inlikely this be setting. targeted toBarrier identifiable interventions high risk patients. may obstruct Observations patient from thecare VA goals MRSA through initiative restrictingreport decreased socialization MRSA infections, but not transmission, in acute care spinal cord injury units, but the contribution of ARO screening to outcomes in this program and limiting participation in group therapy. As behavioral management is problematic for many of these patients, remains unclear. implementation of patient restrictions is disruptive to patient and staff. Patients on rehabilitation units may have a high Longprevalence term acute of careAROs, units but provide new care acquisition to patients whoof AROs require by extended patients hospitalization on these wardsfollowing has acute been illness. reported In the toUS be, these infrequent are often in limited free-standingstudies. ARO facilities restrictions while in Canadamay interfere patients may with be rehabilitationresident on dedicated goals wards of care. of acute Rehabilitation or long term care patients facilities. at Therisk use of ofARO invasive infection are devicesreadily and identified device-associated by characteristics infection rates includingin these patients the approachpresence those of invasive observed indevices, ICU populations, being bedbound, and the ARO and prevalence having exceeds pressure ulcers. that observed for most acute care populations. Optimal screening approaches need to consider admission to these facilities, facility stay, and readmissionsPractices to to limit an acute ARO care infection facility. However, can likely the intensity be targeted of exposure to identifiable and high prevalence high risk of riskpatients. suggests approachesObservations similar from to ICUthe VA MRSA patientsinitiative are reportappropriate decreased to evaluate. MRSA infections, but not transmission, in acute care spinal cord injury units, but the contribution of ARO screening to outcomes in this program remains unclear. Screening programs should be feasible and beneficial. ARO restrictions in some populations may interfere with patient care leading to a more prolongedLong term length acute of stay care and, units potentially, provide increasing care to overall patients prevalence who require of AROs extended in a facility. hospitalization A high standard offollowing routine practices acute inillness. all acute In the US, carethese facilities, are often together free-standing with continued facilities documentation while of in evide Canadance of harmpatients (i.e. infections)may be resident and effective on antimicrobialdedicated wardsstewardship of acute should or belong term care goalsfacilities. for management. The use of invasive devices and device-associated infection rates in these patients approach those observed in ICU populations, and the ARO prevalence exceeds that observed for most acute care populations. Optimal screening approaches need to consider admission to these facilities, facility stay, and readmissions to an acute care facility. However, the intensity of exposure and high prevalence of risk suggests approaches similar to ICU patients are appropriate to evaluate. Screening programs should be feasible and beneficial. ARO restrictions in some populations may interfere with patient care leading to a more prolonged length of stay and, potentially, increasing overall prevalence of AROs in a facility. A high standard of routine practices in all acute care facilities, together with continued documentation of evidence of harm (i.e. www.AROscalgary2014.cainfections) and effective antimicrobial stewardship shouldCanadian be goals Consensus for management.Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 33 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS Speakers & Abstracts

Howard Njoo Njoo,, MD, MHSc MD, MHSc Director General, Centre for Communicable Diseases & Infection Control, Public Health Agency ofDirector Canada (PHAC) General, Centre for Communicable Diseases & Infection Control, Public Health Agency of Canada (PHAC) Dr. Howard Njoo is the Director General of the Centre for Communicable Diseases and Infection Control at theDr. Public Howard Health NjooAgency is of the Canada. Director In his career General as a public of the health Centre physician, for Dr. Communicable Njoo has worked in Diseasesall and three levels of government. Previously, he worked at the Public Health Branch of the Ontario Ministry of HealthInfection and as Controlthe Associate at Medicalthe Public Officer Health of Health Agency for the City of Canada.of Toronto DepartmentIn his career of Public as aHealth. public health Dr.physician, Njoo joined Dr. the federalNjoo governmenthas worked in 1996 in allas the three Director levels of Tuberculosis of government. Prevention Previously, and Control at he worked at the HealthPublic Canada Health and subsequentlyBranch of worked the Ontario in a variety Ministry of positions of, in Health both chronic and and as infectiousthe Associate diseases asMedical Officer well as emergency preparedness and response. Dr. Njoo earned his medical degree and a Masters in Health Science,of Health specializing for the in Citycommunity of Toronto health and Department epidemiology, from of Publicthe University Health. of Toronto, Dr. Njoo and has joined a the federal fellowshipgovernment in the Royalin 1996 College as theof Physicians Director and of Surgeons Tuberculosis of Canada inPrevention community medicine. and Control Dr. Njoo at Health Canada is a Consultant Physician at the Ottawa Hospital Tuberculosis Clinic, is an Assistant Professor, Department ofand Medicine, subsequently Division of workedInfectious Diseases,in a variety and has of an positions, adjunct appointment in both in chronicthe Department and of infectious diseases Epidemiologyas well as emergency and Community preparedness Medicine at the Universityand response. of Ottawa Dr.. Njoo earned his medical degree and a Masters in Health Science, specializing in community health and epidemiology, from the University of Toronto, and has Abstracta fellowship in the Royal College of Physicians and Surgeons of Canada in community medicine. Dr. Njoo is a Consultant Pan-CanadianPhysician at theResponse Ottawa Required Hospital to Address Tuberculosis Antimicrobial Clinic, Resistance is an Assistant Professor, Department of Medicine, Division of Infectious Diseases, and has an adjunct appointment in the Department of Epidemiology and Community Medicine at the AntimicrobialUniversity resistanceof Ottawa. (AMR) is considered a serious and growing global public health threat as it undermines our collective ability to fight infectious diseases. The issue is complex and cuts across a range of jurisdictions, sectors and stakeholders — e.g. all levels of government, the health and agricultural sectors, private industry and the general public. Therefore, in both Canada and around the world, addressing AMR is seen as a shared responsibility.Abstract: Pan-Canadian Response Required to Address Antimicrobial Resistance Under the direction of the federal Minister of Health, the Public Health Agency of Canada, Health Canada, the Canadian Food Inspection Agency (CFIA)Antimicrobial and the Canadian resistance Institutes (AMR) of Health isResearch considered undertake a variousserious activities and growing which contribute global to thepublic overall health goal of prethreatventing, as limiting it undermines and our controllingcollective the ability emergence to fightand spread infectious of antimicrobial diseases. resistance The in humans,issue isanimals complex and food. and cuts across a range of jurisdictions, sectors and The Public Health Agency of Canada (the Agency) provides national leadership on the public health aspects of antimicrobial resistance. It works withstakeholders both domestic — and e.g. international all levels partners of government, in the areas of s theurveillance, health laboratory and agricultural reference services, sectors, management private of industryinfectious disease and outbreaks,the general public. publicTherefore, awareness in and both the developmentCanada and of public around health the guidance world,. The addressingAgency works withAMR its ispublic seen health as counterpartsa shared responsibility. in the provinces and territories through the Public Health Network Council and its Communicable and Infectious Diseases Steering Committee for coherent action to addressUnder AMR. the direction of the federal Minister of Health, the Public Health Agency of Canada, Health Canada, the Canadian The Agency, supported by CFIA, leads two national surveillance systems to monitor trends in antimicrobial resistance and antimicrobial use in Canada:Food Inspection the Canadian Nosocomial Agency (CFIA) Infection Surveillanceand the Canadian Program (CNISP) Institutes and the ofCanadian Health Integrated Research Program undertake for Antimicrobial various Resistance activities which Surveillancecontribute (CIPARS). to the overall These systems goal monitor of preventing, resistance in limiting common hospital and controlling infections; community-related the emergence foodborne and spreadinfections; of and antimicrobial antibiotic resistance in usehumans, among humans animals as well and as food.food-producing animals. Surveillance products assist in identifying trends and assessing the impact of policies and programs. These surveillance data also support decision making at provincial, territorial, and local levels and are valuable for front line practitioners toThe assist Public them in limitingHealth the Agency development of Canadaand spread (the of antimi Agency)crobial-resistant provides organisms national in their leadership day to day practice. on the public health aspects of antimicrobial Recognizingresistance. that It publicworks health with is aboth shared domestic responsibility, and the internationalAgency actively collaborates partners with in theits provincial areas of and surveillance, territorial counterparts laboratory as well reference services, as other key stakeholders to enhance its AMR surveillance activities, increasing access to integrated, timely and reliable surveillance data and informationmanagement and providing of infectious up-to-date disease reference outbreaks, and analytical publicservices thatawareness supports health and authorities the development dealing with infectiousof public disease health and foodborneguidance. The Agency outbreaks.works with its public health counterparts in the provinces and territories through the Public Health Network Council and its WorkingCommunicable with its partners, and the Infectious Agency’s future Diseases efforts to Steering address AMR Committee will be aimed for at further coherent strengthening action surveillance, to address increasing AMR. the use and uptake of continuously updated guidance, building on previous public awareness campaigns to increase knowledge and behaviour change, and developingThe Agency, new diagnostic supported tools. by CFIA, leads two national surveillance systems to monitor trends in antimicrobial resistance and antimicrobial use in Canada: the Canadian Nosocomial Infection Surveillance Program (CNISP) and the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS). These systems monitor resistance in common hospital infections; community-related foodborne infections; and antibiotic use among humans as well as food-producing animals. Surveillance products assist in identifying trends and assessing the impact of policies and programs. These surveillance data also support decision making at provincial, territorial, and local levels and are valuable for front line practitioners to assist them in limiting the development and spread of antimicrobial-resistant organisms in their day to day practice. Recognizing that public health is a shared responsibility, the Agency actively collaborates with its provincial and territorial counterparts as well as other key stakeholders to enhance its AMR surveillance activities, increasing access to integrated, Canadiantimely Consensus and Developmentreliable surveillance Conference on surveillancedata and & information screening for aros and providing up-to-date referencewww.AROscalgary2014.ca and analytical services that supports health authorities dealing with infectious disease and foodborne outbreaks. Working with its partners, the Agency’s future efforts to address AMR will be aimed at further strengthening surveillance, increasing the use and uptake of continuously updated guidance, building on previous public awareness campaigns to increase knowledge and behaviour change, and developing new diagnostic tools.

www.AROsCalgary2014.ca 34 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

DavidDavid Patrick, Patrick, MD, MD, FRCPC, FRCPC, MHSc MHSc ProfessorProfessor and and Director, Director, School School of Population of Population & Public & Public Health, Health, UBC; UBC; Medical Medical Epidemiology Lead for AMR and the Do Bugs Need Drugs Project, British Columbia Centre for Epidemiology Lead for AMR and the Do Bugs Need Drugs Project, British Columbia Disease Control (BCCDC) Centre for Disease Control (BCCDC) Dr.Dr. David David Patrick Patrick is an Infectious is an Infectious Disease Physician Disease and Physician Epidemiologist and with Epidemiologist posts as Professor with and Director posts as of Professorthe UBC School of Population and Public Health and as Medical Epidemiology Lead for Antimicrobial Resistance and the Do Bugs Need Drugs Projectand Directorat the British of Columbia the UBC Centre School for Disease of Population Control. His and interest Public is in Healthfostering andinterdisciplinary as Medical approaches Epidemiology to the control of infectiousLead for diseases Antimicrobial in populations. Resistance Current expressions and the of Do this Bugsare found Need in ef Drugsforts to trackProject and controlat the antimicrobialBritish Columbia resistance and theCentre establishment for Disease of efforts Control. to understand His the interest emergence is in and fostering cause of new interdisciplinary infectious diseases. approaches to the control of infectious diseases in populations. Current expressions of this are found in efforts to track and control antimicrobial resistance and the establishment of efforts to understand the emergence and cause of new infectious diseases.

Abstract: How do we decide where to focus surveillance? Abstract Background: Surveillance of antimicrobial resistance (AMR) and antibiotic use (AMU) are addressed to varying degrees internationally.How do we decide Canada where is to now focus taking surveillance? a fresh look at its own efforts.

Methods:Background: We reviewed previous reports on surveillance, conducted a formal literature review, surveyed Canadian experts andSurveillance produced of antimicrobial a criterion-based resistance (AMR) evaluation and antibiotic of available use (AMU) systems. are addressed We report to varying on degreesexisting internationally gaps and .provide Canada is a now number taking ofa fresh look at its own recommendationsefforts. about the way forward. Results:Methods: The most comprehensive systems (e.g. EARS-Net) combine the following: We reviewed previous reports on surveillance, conducted a formal literature review, surveyed Canadian experts and produced a criterion-based evaluation of available systems.• Population-based We report on existing human gaps and AMU provide use a metricsnumber of from recommendations communities about andthe way hospitals forward. • AMU metrics by commodity from animal agriculture Results:• AMR trends from a list of indicator organisms from community and hospital settings; The most comprehensive systems (e.g. EARS-Net) combine the following: • • Population-basedTrends in rates human of AMU key nosocomialuse metrics from infections communities and hospitals • AMU• AMR metrics trends by commodity from sampling from animal within agriculture agriculture and retail food settings; • AMR• Reference trends from microbiology a list of indicator capabilities organisms from to communitycharacterize and hospital new strains; settings; • Trends in rates of key nosocomial infections In• AMR Canada trends wefrom find sampling some within elements agriculture in andplace retail but food many settings; largely missing: • • ReferenceAMU microbiologysurveillance capabilities is improving to characterize thanks new to straiCIPARS/IMSns; collaboration. Data on population based antibiotic use (over time,

In Canadaby province we find someand elementsby drug in class) place butare manybecoming largely missing:available. • AMU• Similar surveillance data isfrom improving the hospital thanks to CIPARS/IMSsector has beencollaboration. largely Datamissing, on population though based efforts antibiotic by useCIPARS (over time, and by CNISP province mayand byhelp drug to class) fill arethis becominggap overavailable. the next yea. • • SimilarThere data arefrom comparatively the hospital sector few has beendata largelyavailable missing, on thoughAMU efforts in agriculture by CIPARS andor companionCNISP may help animal to fill thispractice. gap over the next year. • There are comparatively few data available on AMU in agriculture or companion animal practice. • AMR• AMR surveillance surveillance from hospitals from benefitshospitals from benefits CNISP output. from TheCNIS focus output. has been onThe illness focus or colonizationhas been eventon illness surveillance or colonization for a discrete listevent of strains (e.g. MRSA,surveillance VRE, C. difficile, for a discreteESBLs). list of strains (e.g. MRSA, VRE, C. difficile, ESBLs). • • ThereThere are ongoing are ongoing discussions discussions about the potential about for the broader potential isolate-based for broader surveillance isolate-based that would track surveillance trends in resistance that wouldfor a large track list oftrends organisms. in • There is a fairly large gap in representative, population-based data on trends in resistance in community based infections. The data exist at laboratory level and there is muchresistance potential in forthe analysisa large of list aggregated of organisms. laboratory data. • AMR• There surveillance is a fairly in agriculture large gap and incompanion representative, animal practice population-based has limited coverage. data Exceptions on trends include in resistance focused surveillance in community on a few entericbased organisms. infections. The data exist at laboratory level and there is much potential in the analysis of aggregated laboratory data. Discussion• AMR surveillance in agriculture and companion animal practice has limited coverage. Exceptions include focused Lead recommendations from our report include: 1) Establishingsurveillance a nationally on a few coordinated enteric program organisms. of surveillanc e. PHAC cannot do this alone but can provide conceptual oversight, surveillance standardization and work toward a comprehensive national annual report. Discussion2) Make sure that Lead our recommendationsstrongest assets (CNISP/CIPARS,NML) from our report have include: secure funding as the nucleus of future federal activity 3)1. Work Establishing with individual a nationally lab networks coordinated toward a system program of susceptibility of surveillance. data warehousing PHAC or reporting cannot that do allows this alonefor much but broader can provideinference aboutconceptual the burden of illness at populationoversight, level. surveillance standardization and work toward a comprehensive national annual report. 4)2. Work Make at hospital, sure that health our authority, strongest provincial assets and (CNISP/CIPARS, national levels toward NML) better hospital have secure utilization funding data directly as the linked nucleus to stewardship of future programs federal activity 5) Integrate annual reports of findings in the human and agricultural sectors. 6)3. Close Work the withloop by individual funding research lab networks through CIHR toward and fundi a systemng public of and susceptibility professional education data warehousing programs to support or reporting more logical that use ofallows antibiotics. for much broader inference about the burden of illness at population level. Conclusions:4. Work at hospital, health authority, provincial and national levels toward better hospital utilization data directly linked to Surveillance reports should be seen as information for action that must be produced and disseminated in a timely fashion. We will not fare well in reducing the burden stewardship programs of5. antimicrobial Integrate resistanceannual reports if we cannot of findingsmeasure where in thewe are.human and agricultural sectors www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 35 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS

6. Close the loop by funding research through CIHR and funding public and professional education programs to support more logical use of antibiotics. Conclusions: Surveillance reports should be seen as information for action that must be produced and disseminated in a timelySpeakers fashion. We will ¬ Abstractsfare well in reducing the burden of antimicrobial resistance if we cannot measure where we are.

EliEli PerencevichPerencevich,, MD, MD, MS MS Professor,Professor, Internal Internal Medicine Medicine – General – General Internal Internal Medicine Medicine and Epidemiology, and Epidemiology, University of University Iowa Carver College of Medicine of Iowa Carver College of Medicine Dr.Dr. EliEli Perencevich Perencevich is a istenured a tenured Professor Professor of Internal of MedicineInternal andMedicine Epidemiology and Epidemiology at the University at of theIowa Carver College of Medicine as well as the Director of the Center for Comprehensive Access & Delivery Research Universityand Evaluation of (CADRE)Iowa Carver at the College Iowa City of VA Medicine Medical Center. as well He as was the recently Director named of theSenior Center Associate for for ComprehensiveInfection Control Studies Access for & VA’s Delivery Office Researchof Public Health’s and Evaluation National Center (CADRE) for Occupational at the Iowa Health City and VA MedicalInfection ControlCenter. (COHIC). He was Dr.recently Perencevich named is an Senior infectious Associate disease physicianfor Infection and epidemiologist Control Studies with over for 15the VAyears Office experience of studyingPublic theHealth epidemiology National and Center outcomes for of Occupational hospital-acquired Health infections and usingInfection mathematical Control models, large administrative databases and multicenter clinical trials. He has significant experience studying (COHIC).the comparative Dr. effectivenessPerencevich of isinfectious an infectious disease treatmentdisease physicianand prevention and strategies epidemiologist and has received with over 15continuous years experience funding through studying VA HSR&D the epidemiology since 2002. Recent and funding outcomes includes of hospital-acquireda VA IIR studying the infections comparative usingeffectiveness mathematical of methods models, for controlling large MRSAadministrative and a VA IIR databases assessing andoptimal multicenter methods for clinical tracking trials.hand- He has significant experience studyinghygiene thecompliance comparative and feeding effectiveness back hand-hygiene of infectious compliance disease to healthcare treatment workers. and Currently prevention Dr. Perencevich strategies and has received continuous fundingis the Project through Director VA and HSR&D PI of a 10-site, since VA-funded2002. Recent CREATE funding grant. includes He oversees a VA all fourIIR projectsstudying under the this grant, which each aim to examine a number of approaches to MRSA prevention and eradication within VA. comparative effectiveness of methods for controlling MRSA and a VA IIR assessing optimal methods for tracking hand- hygieneAbstract compliance and feeding back hand-hygiene compliance to healthcare workers. Currently Dr. Perencevich is the Project Director and PI of a 10-site, VA-funded CREATE grant. He oversees all four projects under this grant, which each aimOutlining to examine a Framework a number of Antimicrobialof approaches Resistant to MRSA Bacterial prevention Surveillance and eradication Studies within VA.

Abstract:Antimicrobial Outlining resistant bacterial a Framework infections of have Antimicrobial recently received Resistant significant Bacterial attention. SurveillanceDespite work focused Studies on elucidating the epidemiology and poor outcomes associated with such infections, success in hindering their emergence remains elusive. Importantly, the evidence base on which Antimicrobialpotential infection-prevention resistant bacterial surveillance infections systems and have programs recently must received be built issignificant limited because attention. few of the Despite necessary work clinical focused studies on have elucidating been thecompleted. epidemiology Conducting and such poor studies outcomes is constrained associated by the percei withved such difficulty infections, of completing success the in hinderingnecessary studies their and emergence limited funding remains available elusive. for Importantly,assessing prevention the evidence interventions. base on which potential infection-prevention surveillance systems and programs must be built isTo limited effectively because protect fewpatients, of the rigorous necessary studies clinical must determine studies the have comparative been completed. effectiveness Conducting of competing suchsurveillance studies and is prevention constrained interventions. by the perceivedThus, scientists difficulty and public of health completing officials theneed tonecessary recognize studies the strengths and limitedand limitations funding of the available epidemiological for assessing study desi preventiongns that could interventions. be used to answer these critical questions. Additionally, initial investments must be made to establish the infrastructure necessary to complete such studies Toefficiently effectively and cost-effectively. protect patients, This talkrigorous will (a) studies outline themust infrastructure determine necessary the comparative to complete studieseffectiveness seeking to of detect competing and prevent surveillance antimicrobial andresistant prevention bacterial infectionsinterventions. and (b) Thus,discuss threescientists complement and arypublic methods health for comparativeofficials needeffectiveness to recognize research the in infectionstrengths prevention: and limitations cluster of therandomized epidemiological trials, quasi-experimental study designs studies, that andcould mathematical be used to models. answer Attention these willcritical be focused questions. primarily Additionally, on designing initialand supporti investmentsng high- mustquality be quasi-experimental made to establish studies. the infrastructure necessary to complete such studies efficiently and cost-effectively. This talk will (a) outline the infrastructure necessary to complete studies seeking to detect and prevent antimicrobial resistant bacterial infections and (b) discuss three complementary methods for comparative effectiveness research in infection prevention: cluster randomized trials, quasi-experimental studies, and mathematical models. Attention will be focused primarily on designing and supporting high-quality quasi-experimental studies.

www.AROsCalgary2014.ca 36 Canadian Consensus Development Conference on Surveillance & Screening for AROS Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca Speakers &SPEAKERS Abstracts & ABSTRACTS

Trish Perl, MD, MSc TrishSenior Perl, Epidemiologist, MD, MSc John Hopkins Health System; Senior Epidemiologist, John Hopkins Health System; Professor of Medicine, Johns Professor of Medicine, Johns Hopkins University Hopkins University

Dr. PerlDr. is Perl a Professor is a Professor in the in Departments the Departments of Medicine of Medicine (Infectious (Infectious Diseases) Diseases) and and Pathology Pathology at at Johns Hop- Johnskins Hopkins University University School School of Medicine of Medicine in Baltimore, in Baltimore, Maryland, Maryland, and in the and Department in the Department of Epidemiology at the of EpidemiologyJohns Hopkins at theBloomberg Johns Hopkins School ofBloomberg Public Health. School She of is Public Senior Health. Epidemiologist She is Senior for The Johns Hopkins EpidemiologistMedicine. Dr.for PerlThe receivedJohns Hopkins her Bachelor Medicine. of Arts Dr. and Perl medical received degree her fromBachelor the Universityof Arts and of North Carolina medicalat Chapel degree Hill from and the a UniversityMaster of Science of North degree Carolina from atMcGill Chapel Unive Hillrsity and ina Master Montreal, of ScienceCanada. She completed degreea residencyfrom McGill in internal University medicine in Montreal, and a fellowship Canada. inShe infectious completed diseases a residency and clinical in internal epidemiology at the medicineUniversity and a fellowshipof Iowa in Iowain infectious City, Iowa. diseases She has and extensive clinical practicalepidemiology and research at the University experience in the field of of Iowahealthcare in Iowa associatedCity, Iowa. infections She has extensive and resistant practical and epidemiologi and researchcally experience significant in theorganisms field and is world renownedof healthcare for her innovation associated and infections research and in the resistant field and the epidemiologically use of research knowledge significant in theorganisms healthcare and setting. is world Dr renowned. Perl is the for former President of theher Society innovation of Hospital and research Epidemiologists in the field of America and the (SHEA) use of research and has servedknowledge on advisory in the healthcarepanels for thesetting. IOM, Dr.the Perl CDC is theand formerWHO and been a consultantPresident to the of NIH the Societyand ARHQ. of Hospital She was Epidemiologists the Courage Fund of AmericaVisiting Professor (SHEA) andin 2008-10. has served An activeon advisory researcher, panels Dr. for Perl the has IOM, been the a principal and co-principalCDC and investigator WHO and multiple been a studiesconsultant funded to theby theNIH CDC, and tARHQ.he Veteran’s She Affairswas the Administration Courage Fund over Visiting the years. Professor She in has 2008-10. authored or coauthored over An200 active peer-reviewed researcher, articles. Dr. Perl In addition,has been shea principal has written and multiple co-principal chapters investigator and contributed multiple to guidelinesstudies funded and policies by the CDC,relevant the to healthcare associatedVeteran’s infections Affairs at theAdministration institutional, overstate the and years. federal She level. has authored or coauthored over 200 peer-reviewed articles. In addition, she has written multiple chapters and contributed to guidelines and policies relevant to healthcare associated infections at the institutional, state and federal level.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 37 www.AROsCalgary2014.ca www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros SPEAKERS & ABSTRACTS Speakers & Abstracts

PilarPilar Ramon-Pardo Ramon-Pardo,, MD, PhDMD, PhD RegionalRegional Advisor, Advisor, PAHO/WHO, PAHO/WHO, Washington Washington DC DC

PilarPilar Ramon-Pardo Ramon-Pardo is the is Regional the Regional Advisor Advisor on Clinical on Management Clinical Management of Infectious of Diseases Infectious and Antimicrobial Diseases Resistanceand Antimicrobial Surveillance Resistanceat the Pan American Surveillance Health at Organization the Pan American (PAHO), WHO’sHealth RegionalOrganization Office (PAHO),for the Americas. SheWHO’s holds aRegional Ph.D. in Medicine Office fromfor thethe UniversityAmericas. Complutense She holds a, Madrid.Ph.D. in She Medicine worked asfrom clinical the practitioner Universidad in a tertiary hospital for almost ten years. After, she moved to the public health arena working for HIV and TB programs in Africa,Complutense, Asia and Latin Madrid. America. She Currently, worked asshe clinical is responsible practitioner for planning, in a tertiary programming hospital and forimplementing almost regional strategiesten years. to support After, countriesshe moved to carry to the out publicand scale-up health nati arenaonal responses,working forspecifically HIV and in TBantimicrobial programs resistance in surveillanceAfrica, Asia and and infection Latin control. America. Currently, she is responsible for planning, programming and implementing regional strategies to support countries to carry out and scale-up national responses, specifically in antimicrobial resistance surveillance and infection control.

Abstract: AROs, from a global perspective. Background:Abstract Trends in antibiotic resistance and their consequences for health, welfare and the economy are rapidly changing. The foreseen decline in antibiotic effectiveness explains the needs for data to inform the global public health agendaAROs, fromabout a theglobal magnitude perspective. and evolution of antibiotic resistance as a serious threat to human health and development. Opportunistic bacterial pathogens are the cause of the majority of community and hospital-acquired infections worldwide. ThisBackground global report responds at the urgent need for data on the present situation and burden of antimicrobial resistance, Trends in antibiotic resistance and their consequences for health, welfare and the economy are rapidly changing. The foreseen decline in antibiotic particularlyeffectiveness explainsfor bacteria the needs causing for data common to inform infections. the global public health agenda about the magnitude and evolution of antibiotic resistance as a Methods:serious threat The to human report health describes and development. antibacterial Opportunistic resistance bacterial(ABR) surveillancepathogens are fromthe cause a global of the majorityperspective, of communit presentsy and national hospital-acquired orinfections published worldwide. data on This resistance global report in seven responds defined at the urgentbacteria need of forpublic data onhealth the present importance, situation includes and burden systematic of antimicrobial reviews resistance, of the particularly for bacteria causing common infections. evidence of the burden of resistance in five bacteria resistance combinations, and addresses where the gaps in knowledge and surveillanceMethods are. These seven bacteria (E. coli, K. pneumoniae, S. aureus, S pneumoniae, nontyphoidal Salmonella, Shigella speciesThe report and describes N. gonorrhoeae antibacterial ) wereresistance chosen (ABR) on thesurveilla basisnce that from they a global have greatperspective, public presents health impact.national or published data on resistance Results:in seven defined 129 countries bacteria respondedof public health of which importance, 114 returned includes systematic at least some reviews data of theon evidenceat least oneof the of burden the 9 requestedof resistanc bacteria–e in five bacteria/ resistance combinations, and addresses where the gaps in knowledge and surveillance are. These seven bacteria (E. coli, K. pneumoniae, S. aureus, S antibacterialpneumoniae, nontyphoidal drug combinations. Salmonella, E. Shigella coli and species K.pneumoniae and N. gonorrhoeae have high ) were levels chosen of resistance on the basis to that 3rd they generation have great cephalosporins.public health impact High resistance to fluoroquionolones in E. coli is also reported from most parts of the world. Carbapenem resistance in K. pneumoniaeResults has already spread to all parts of the world. S. aureus is a common colonizer of the skin. MRSA was initially a129 major countries concern responded in hospital-acquired of which 114 returned infections, at least some but is data now on alsoat least of onegrowing of the concern9 requested in bacteria–antibacterial the community. In drug the community,combinations. reducedE. coli and susceptibility K.pneumoniae to have penicillin high levels in S.of pneumoniaresistance to 3r isd reported generation from cephalosporins. all parts of High the resistanceworld. Older to fluoroquionolone and cheaper santibacterial in E. coli is also medicinesreported from are most no partslonger of theeffective world. Carbapenemin treatment resistance of gonorrhoea in K. pneumoniae and 3rd hasgeneration already spread cephalosporins to all parts of are the the world. last Sresort. aureus for is a common colonizer of the skin. MRSA was initially a major concern in hospital-acquired infections, but is now also of growing concern in the community. In treatment.the community, reduced susceptibility to penicillin in S. pneumonia is reported from all parts of the world. Older and cheaper antibacterial medicines Discussion:are no longer effectiveThere inwas treatment a statistically of gonorrhoea significant and 3rd increased generation risk cephalosporins for patients are infected the last resort with afor resistant treatment. strain to die from the infection in all but two combinations where there was not enough data. The additional risk to die was about 2-fold for Discussion infectionsThere was a with statistically the resistant significant Gram-negative increased risk bacteria, for patients and infected more with than a resistant50% higher strain for to die MRSA from theinfections. infection Forin all infections but two combinations caused bywhere E. coli there resistant was not enoughto fluoroquionolones, data. The additional K.risk pneumoniae to die was about resistant 2-fold tofor 3rdinfections generation with the cephalosporins resistant Gram-negative and S. aureus bacteria, resistant and more tothan methicillin, 50% higher therefor MRSA was alsoinfections. an increased For infections risk for caused progresstion by E. coli toresistant septic to shock fluoroquionolones, and/or admission K. pneumoniae to intensive resistant care tounit. 3rd generation Excesscephalosporins costs were and higherS. aureus for resistant infections to methicillin, caused by there resistant was also strains. an increased For E. risk coli, for hospital progresstion costs to were septic about shock 1.6-3and/or times admission higher to intensivein infectionscare unit.Excess caused costs by were strains higher resistant, for infections as opposed caused byto ressensitive,istant strains.For to 3rd generation E. coli, hospital cephalosporins. costs were about 1.6-3 times higher in infections caused by strains resistant, as opposed to sensitive, to 3rd generation cephalosporins. Conclusions/Policy Recommendations: Conclusions/Policy• High proportions Recommendations of ABR to common treatments were reported in bacteria causing common infections in both healthcare • Highsettings proportions and in of theABR community to common treatmentsin all parts were of thereported world in bacteria causing common infections in both healthcare settings and in the community• Antibacterial in all parts resistance of the world has a negative effect on patient outcomes and increases health expenditures • Antibacterial resistance has a negative effect on patient outcomes and increases health expenditures • • TreatmentTreatment options options for common for common infections infections are running are out running out • Despite limitations, the report demonstrates worldwide magnitude of ABR and gaps in surveillance • Despite limitations, the report demonstrates worldwide magnitude of ABR and gaps in surveillance

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca

www.AROsCalgary2014.ca 38 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

AndrewAndrew Simor, Simor, MD, FRCPC MD, FRCPC Chief, Department of Microbiology; Chief, Division of Infectious Diseases Sunnybrook Health SciencesChief, DepartmentCentre; Senior Scientist,of Microbiology; Sunnybrook Chief,Research Division Institute; of Infectious Diseases, Sunnybrook Professor,Health Sciences Departments Centre; of Laboratory Senior Medicine Scientist, & Pathobiology,Sunnybrook and Research Medicine, Institute; University Professor,of TorontoDepartments of Laboratory Medicine & Pathobiology and Medicine, University of

Dr.Toronto Simor graduated with a medical degree from the University of Toronto in 1976, and completed Royal College fellowship training in internal medicine, infectious diseases, and medical microbiology. He has worked atDr. Sunnybrook Simor graduated Health Sciences with Centre a medical since 1993. degree Dr. Simor from is recognizedthe University nationally of andToronto internationally in 1976, and ascompleted a leader in the Royal field Collegeof hospital fellowship epidemiology. training He has received in internal research medicine, funding from infectious peer-reviewed diseases, and and industry-basedmedical microbiology. granting agencies. He Hehas has worked published at a Sunnybrooklarge number of Healthpapers in Sciencesscientific journals, Centre andsince he is 1993. onDr. the Simor Editorial is Boardrecognized of the journal, nationally Infection and Control internationally and Hospital Epidemiology as a leader, and in isthe an fieldAssociate of Editorhospital for the Canadian Journal of Infectious Diseases and Medical Microbiology. His primary research interests include:epidemiology. antimicrobial He resistance, has received hospital-acquired research infectionsfunding, andfrom the peer-reviewedapplication of molecular and industry-basedtechnologies togranting the diagnosis agencies. and management He has ofpublished infectious diseases.Dr.a large number Simor has of received papers several in scientific teaching awardjournals, from and he theis on university, the Editorial and in 2005 Board was selected of the tojournal, receive the Infection Distinguished Control Service and Award Hospital from the Epidemiology, university’s Department and is of anLaboratory Associate Medicine Editor & for the Pathobiology. He has also received a CHICA-Canada Award of Merit for service in the advancement of infection prevention and control. Canadian Journal of Infectious Diseases and Medical Microbiology. His primary research interests include: antimicrobial Abstractresistance, hospital-acquired infections, and the application of molecular technologies to the diagnosis and management of infectious diseases. Dr. Simor has received several teaching award from the university, and in 2005 was selected to receive the SurveillanceDistinguished for ServiceAntibiotic Award Resistant from Organisms the university’s in Canadian Department Hospitals of Laboratory Medicine & Pathobiology. He has also received a CHICA-Canada Award of Merit for service in the advancement of infection prevention and control. Background: Surveillance for antibiotic resistant organisms (AROs) in Canada may be done at the regional, provincial, or national level. This presentation reviews provincial and national surveillance initiatives that are in place for AROs in hospitalized patients in Canada. Abstract: Surveillance for Antibiotic Resistant Organisms in Canadian Hospitals Methods: Provincial and national surveillance programs for human AROs were reviewed. Background: Surveillance for antibiotic resistant organisms (AROs) in Canada may be done at the regional, provincial, Results:or national All provinces level. This conduct presentation surveillance for reviews AROs, but provincial the surveillance and objectives,national methods,surveillance protocols, initiatives and requirements that are for in public place reporting for AROs in arehospitalized highly variable. patients The data in received Canada. by the provinces are generally not audited for accuracy, and the results are not risk-adjusted. There are a few national surveillance systems in place. The Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) focuses on surveillanceMethods: in Provincial the agri-food and sector, national but also surveillanceconducts surveillance programs of antibiotic for human resistance AROs in human were Salmonella reviewed. isolates. The Canadian Antimicrobial Resistance Alliance (CARA) determines antimicrobial resistance profiles in human clinical isolates obtained from a limited convenience sample ofResults: participating All hospitals,provinces but conducthas no corresponding surveillance clinical for or AROs, epidemiologic but the information. surveillance The only objectives, national surveillance methods, system protocols, that includes and arequirements largefor public and fairly reporting representative are samplehighly of variable. hospitals, andThe is abledata to receivedprovide clinical/epidemiologic by the provinces data are corresponding generally notto ARO audited isolates for is theaccuracy, Canadian and the Nosocomial Infection Surveillance Program (CNISP). This program has been conducting surveillance for methicillin-resistant Staphylococcus aureusresults (MRSA), are not vancomycin-resistant risk-adjusted. There Enterococcus are a few(VRE), national C. difficile surveillance infection, and systemscarbapenem-resistant in place. EnterobacteriaceaeThe Canadian (CRIntegratedE) in Program hospitalizedfor Antimicrobial patients since Resistance 1995. In 2012, Surveillance the incidence (CIPARS) of MRSA, VRE,focuses and CREon surveillance per 1,000 admissions in the was agri-food 8.8, 7.5, and sector, 0.2 respect but ivelyalso. conductsMost of thesesurveillance patients were of antibioticcolonized with resistance these AROs; in only human a small Salmonella proportion was isolates. infected. The The healthcare-associatedCanadian Antimicrobial C. difficile infectionResistance rate inAlliance 2012 (CARA) wasdetermines 4.8/1,000 admissions.antimicrobial Changes resistance over time profilesand regional in varia humantions in clinical these ARO isolates rates were obtained observed. from a limited convenience sample of participating hospitals, but has no corresponding clinical or epidemiologic information. The only national surveillance Discussion/Conclusions: Provincial surveillance for AROs in Canada is currently fragmented, uncoordinated, and unable to provide results that can besystem aggregated that or includes compared. a CNISPlarge andis a collaborative fairly representative network of hospitals, sample with of goodhospitals, geographic and representation is able to provide across the clinical/epidemiologic country, working with the data Publiccorresponding Health Agency to ofARO Canada isolates (PHAC) is and the the Canadian National Microbiology Nosocomial Laboratory Infection (NML) Surveillance to provide accurate Program and comprehensive (CNISP). This national program ARO has surveillancebeen conducting data, as well surveillance as regional surveillance for methicillin-resistant results. CNISP also Staphylococcushas the unique ability aureus to link epidemiologic(MRSA), vancomycin-resistant and laboratory databases. EnterococcusIn the past(VRE), decade, C. CNISPdifficile results infection, have been used and to carbapenem-resistant “benchmark” hospital ARO rates,Enterobacteriaceae to alert healthcare facilities(CRE) andin governmenthospitalized agencies patients about since emerging 1995. In 2012, ARO trends, and to influence changes in infection prevention and control practices. the incidence of MRSA, VRE, and CRE per 1,000 admissions was 8.8, 7.5, and 0.2 respectively. Most of these patients were colonized with these AROs; only a small proportion was infected. The healthcare-associated C. difficile infection rate in 2012 was 4.8/1,000 admissions. Changes over time and regional variations in these ARO rates were observed. Discussion/Conclusions: Provincial surveillance for AROs in Canada is currently fragmented, uncoordinated, and unable to provide results that can be aggregated or compared. CNISP is a collaborative network of hospitals, with good geographic representation across the country, working with the Public Health Agency of Canada (PHAC) and the National Microbiology Laboratory (NML) to provide accurate and comprehensive national ARO surveillance data, as well as regional surveillance results. CNISP also has the unique ability to link epidemiologic and laboratory databases. In the past decade, CNISP results have been used to “benchmark” hospital ARO rates, to alert healthcare facilities and government agencies about emerging ARO trends, and to influence changes in infection prevention and control practices. www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros

Canadian Consensus Development Conference on Surveillance & Screening for AROs 39 www.AROsCalgary2014.ca SPEAKERS & ABSTRACTS

James Talbot, PhD, MD, FRCPC Chief Medical Officer of Health, Alberta Health, Edmonton On June 18, 2012, Dr. James Talbot was appointed Chief Medical Officer of Health (CMOH) for the province of Alberta. The CMOH acts on behalf of the Minister of Health to monitor the health of Albertans and to make recommendations to the Minister and Alberta Health Services on measures to protect and promote the health of the public and to prevent disease and injury. The CMOH plays a key role in advising on the need for legislation, policies and practices affecting public health. Prior to this appointment, Dr. Talbot served as Senior Provincial Medical Officer of Health for Alberta where his main responsibilities were in strategic planning and development of surveillance, health assessment and special projects. Dr. Talbot has a B.Sc. degree, PhD in biochemistry and an M.D. from the University of Toronto. He is a Royal College of Physicians and Surgeons specialist in medical microbiology, for which he received additional training at the University of California in San Diego. He has worked in public health since 1991, with posts as Director of the Provincial Laboratory for Northern Alberta, Chief Medical Officer for Nunavut and Associate Medical Officer of Health for Capital Health and Alberta Health Services since 2004. Dr. Talbot has most recently served as Medical Director for the Alberta Real-Time Surveillance Syndromic Surveillance Net, a surveillance system he helped create to monitor and act on emerging infections and injuries. Dr. Talbot is also an Associate Professor in the School of Public Health and the Faculty of Medicine at the University of Alberta.

Abstract: Why should we conduct surveillance Background: Surveillance of antimicrobial resistance and antibiotic use is primarily of importance to Ministries of Health for planning and policy purposes. As antibiotic resistant organisms evolve surveillance is essential to; guide provincial strategies and operations of the health care system, increase prevention activities, minimize risk to citizens, and efficiently use health care resources. Methods: A review of ministry of health activities, briefing notes and strategies relevant to antimicrobial resistance and use was conducted. We report on why we conduct surveillance, what we do with the results, and whether we are meeting our objectives. Results: Surveillance main purpose is to guide actions. With antibiotic resistance, these actions include, detection and identification of antibiotic resistant organisms residing or being introduced into the province, detection of clusters or ongoing transmission, evaluating the success of prevention or control measures, determining conditions that may stimulate or decrease the development of antimicrobial resistance, providing quantitative estimates of the magnitude and impact of ARO’s. Discussion: Surveillance information is necessary to guide numerous provincial policies. These can and have included; hospital design and construction (how many hand washing sinks, where etc.), professional competence (adherence to infection control protocols), veterinary and physician standard of practice (overprescribing of antibiotics), emergency department and hospital screening (NDM-1 screening in patients who have been in or are being transferred from hospitals in countries known to be high incidence.) provincial and federal legislation and regulations (allowing antibiotics to be imported for personal use.), patient safety (increased length of stay, poorer outcomes), agricultural standards, regulations and practices, (international agreements forbidding antibiotic in products, use of antibiotics to prevent disease in intensive livestock operations, organic practices ) and many others. Conclusions: The surveillance conducted relative to infection prevention and control in acute care and continuing care settings (patient safety, reducing health care costs) is relatively comprehensive and responsive but would still benefit from increased standardization and innovation. However that related to reducing the creation of antibiotic resistance due to human and animal use of antibiotics (antibiotic stewardship) is still complicated, fragmented and conducted with fewer resources.

www.AROsCalgary2014.ca 40 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS Speakers & Abstracts

Henri A. Verbrugh, MD, PhD, FIDSA ProfessorHenri and A. Chair Verbrugh, Department ofMD, Medical PhD, Microbiology FIDSA and Infectious Diseases, ErasmusProfessor University and Chair, Medical Department Center, Rotterdam, of Medical The Netherlands Microbiology and Infectious Diseases, Erasmus University Medical Center, Rotterdam, The Netherlands Following his MD degree from Erasmus University, Dr. Henri Alexander Verbrugh was trained as a ClinicalFollowing Microbiologist his MD at degree and received from his Erasmus PhD degree University, from the University Dr. Henri of Utrecht, Alexander The Netherlands. Verbrugh was trained Heas subsequentlya Clinical spentMicrobiologist two years as a atNIH and Fogarty received International his PhD Fellow degree at the University from the of UniversityMinnesota, of Utrecht, The Minneapolis, USA, where he collaborated with Professor Paul Quie and Dr. Phil Peterson on the pathogenesis ofNetherlands. Staphylococcus Heaureus subsequently infection. In 1993, spent he was two appointed years as in hisa NIH current Fogarty position atInternational the Erasmus University Fellow at the MedicalUniversity Center, of Rotterdam, Minnesota, The Netherlands, where he where collaborated he also became with director Professor of the fellowshipPaul Quie program and forDr. Phil Peterson medicalon the microbiology. pathogenesis He has of remainedStaphylococcus involved in aureusresearch regardinginfection. staphylococci In 1993, and he staphylococcalwas appointed to his infections with an emphasis on nosocomial infections and antimicrobial resistance. He (co)authored over 425 peercurrent reviewed position papers, contributedat the Erasmus to books Universityand supervised Medical 50 PhD fellows Center, during Rotterdam, his tenure. In The 1989, heNetherlands, where instigatedhe also thebecame Dutch nationaldirector surveillance of the fellowship system for hospital- programacquired for infection medical (PREZIES). microbiology. He was cofounder He has remained ofinvolved the Dutch innational research Working regarding Party on Infection staphylococci Prevention and (WIP) staphylococcal and the Dutch national infections Working withParty an emphasis on on Antibiotic Policies (SWAB). For this work he received the 2008 Leadership Award from the Alliance for nosocomialPrudent Use of Antibiotics infections (APUA). and antimicrobial He also served as resistance.the first president He (co)authoredof the Dutch Society over of 425Medical peer Microbiology reviewed and papers, represented contributed the society to books andat the supervisedEuropean level 50 (ESCMID PhD fellows and UEMS). during He currently his tenure. is a mem Inber 1989, of the he Presidium instigated of the theDutch Dutch Health nationalCouncil that surveillance provides science-based system for hospital- acquiredadvice to the infection Government (PREZIES). on all major issues He inwas health cofounder and health care,of the including Dutch issues national pertaining Working to antimicrobial Party resistancon Infectione emergence. Prevention (WIP) and the Dutch national Working Party on Antibiotic Policies (SWAB). For this work he received the 2008 Leadership Award from Abstractthe Alliance for Prudent Use of Antibiotics (APUA). He also served as the first president of the Dutch Society of Medical ShouldMicrobiology we screen and for representedAROs? Pro versus the societyCon. at the European level (ESCMID and UEMS). He currently is a member of the Presidium of the Dutch Health Council that provides science-based advice to the Government on all major issues in health Backgrounds:and health AROscare, areincluding moving targets issues that pertaining originate from to a wideantimicrobial range of sources resistance among human emergence. and animal populations and from environmental niches. AROs are transmitted world wide through various routes including food chains and business class air travel. Local expansion of clones of AROs is due to selection by exposure to antimicrobial agents under epidemic-permissive conditions. General preventive measures, including handAbstract: hygiene, Should alone are wenot sufficient.screen for They AROs? clearly failedPro toversus prevent, Con. let alone redress, the MRSA pandemic, active screening of populations and environments was needed for effective MRSA control (search & destroy policy). Without ARO screening most ARO trafficking in and out of the hospitalsBackgrounds: will remain AROs undetected, are movingonly by clinical targets infection that sooriginateme AROs willfrom show a widein diagnostic range cultures. of sources among human and animal populations Recommendations:and from environmental ARO control shouldniches. be AROsconceptually are transmitteddynamic and include world general wide preventive through action various (classical routes hygiene) including as well as food targeted chains and business interventions, including screening. Screening for AROs is indicated to uncover and monitor sources and transmission routes not made evident by routineclass air diagnostic travel. cultures Local in expansion human health, of animal clones health of AROsor environmental is due to care selection settings. ARO by exposurescreening is alsoto antimicrobial indicated to prevent agents unnoticed under epidemic- introductionpermissive of conditions.AROs in settings General in need to preventive remain free of measures, ARO because including they may cause hand serious hygiene, infection alone in that are setting not (e.g. sufficient. hospitals). ARO They clearly failed to screening,prevent, eitherlet alone by phenotypic redress, or theby genotypic MRSA means, pandemic, is rathe ractive costly and screening should yield of actionable populations information, and environments directly or indirectly was. The needed (cost)- for effective efficacy of ARO screening strategies critically depends on the effectiveness of the preventive measures taken when a carrier or niche of an ARO isMRSA detected. control Currently, (search many countries, & destroy including policy). the Netherlands, Without recommendARO screening selective mostscreening ARO of patients trafficking for MRSA, in VRE, and PNSP, out MDR-of the hospitals will Enterobacteriaceae,remain undetected, -Pseudomonas only by aeruginosa, clinical infection-Acinetobacter some baumanii AROs and will-Mycobacterium show in diagnostic tuberculosis on cultures. the basis of patient risk profiling at the time of their admission to hospitals. ARO-suspected and ARO- positive patients are isolated. Profiling is based on locally identified risk factors. E.g., refugeesRecommendations: immigrating into the ARO Netherlands control are should screened be for conceptuallyM.tuberculosis, a dynamicpublic health and measure include that has general prevented preventive (MDR-)tuberculosis action (classicalfrom (re) hygiene) gainingas well a asfoothold targeted in the interventions, Netherlands. Risk profilesincluding are updatescreening.d as new Screeninginformation about for AROsARO sources is indicated and transmission to uncover routes becomes and monitor available. sources and Recently,transmission employment routes as merchant not made fleet evident sailor has bybeen routine added to diagnostic the list of risk culturesfactors for inMRSA human carriage. health, Likely, animal recent international health or travel environmental to care certain geographical areas of the world, including the Middle East and the Far East will be added to the risk list. Up to 80% of healthy travelers to thatsettings. region ofARO the world screening carry ESBL is also positive indicated Gram-negative to prevent bacilli in unnoticed their gut when introduction they return home. of Usually AROs they in settingsreport no exposure in need to tomedical remain free of facilitiesARO because in the country they they may visited. cause Spontaneous serious infectionloss of intestinal in that ESBL setting positive (e.g.strains hospitals). does occur but ARO may take screening, many months. either Over by 1 billionphenotypic or by personsgenotypic engage means, in international is rather leisure costly travel and each should year, thus yield a sizable actionable proportion information,of those admitted directlyto hospital or will indirectly. have a history The of international (cost)-efficacy of ARO travel in the preceding year. In ARO outbreaks screening is also crucial for control, and usually needs to include patients, health care workers and environmentalscreening strategies niches in contact critically with the depends index case. on the effectiveness of the preventive measures taken when a carrier or niche of an ARO is detected. Currently, many countries, including the Netherlands, recommend selective screening of patients for MRSA, VRE, PNSP, MDR-Enterobacteriaceae, -Pseudomonas aeruginosa, -Acinetobacter baumanii and -Mycobacterium tuberculosis on the basis of patient risk profiling at the time of their admission to hospitals. ARO-suspected and ARO- positive patients are isolated. Profiling is based on locally identified risk factors. E.g., refugees immigrating into the Netherlands are screened for M.tuberculosis, a public health measure that has prevented (MDR-)tuberculosis from (re) gaining a foothold in the Netherlands. Risk profiles are updated as new information about ARO sources and transmission routes becomes available. Recently, employment as merchant fleet sailor has been added to the list of risk factors for MRS carriage. Likely, recent international travel to certain geographical areas of the world, including the Middle East and the Far East will be added to the risk list. Up to 80% of healthy travelers to that region of the world carry ESBL positive Gram- Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.canegative bacilli in their gut when they return home. Usually they report no exposure to medical facilities in the country they visited. Spontaneous loss of intestinal ESBL positive strains does occur but may take many months. Over 1 billion persons engage in international leisure travel each year, thus a sizable proportion of those admitted to hospital will have a history of international travel in the preceding year. In ARO outbreaks screening is also crucial for control, and usually needs to include patients, health care workers and environmental niches in contact with the index case.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 41 www.AROsCalgary2014.ca Speakers SPEAKERS& Abstracts & ABSTRACTS

Bob Weinstein, MD Chairman,Bob Weinstein, Department MD of Medicine, Cook County Health and Hospitals System; ChiefChairman, Operating Department Officer, theof Medicine, outpatient CookRuth CountyM. Rothstein Health CORE and HospitalsCenter for theSystem; Prevention, Care, and ResearchChief Operating of Infectious Officer, Diseases; Ruth M. Rothstein CORE Center for the Prevention, Care, C.and Anderson Research Hedberg of Infectious MD Professor Diseases; of C. Internal Anderson Medicine, Hedberg Rush MD University Professor Medical of Internal Center, Chicago Medicine, Rush University Medical Center, Chicago Dr. Weinstein is Chairman, Department of Medicine, Cook County Health and Hospitals System (formerly Cook CountyDr. Weinstein Hospital); is Chairman,Chief Operating Department Officer, ofthe Medicine, outpatient CookRuth CountyM. Rothstein Health CORE and CenterHospitals for the Prevention, Care,System and (formerly Research Cookof Infectious County Diseases; Hospital); and Chief the C. Operating Anderson HedbergOfficer, MD Ruth Professor M. Rothstein of Internal CORE Medicine, RushCenter University for the Prevention, Medical Center Care, – alland in ResearchChicago IL of USA. Infectious Dr. Weinstein Diseases; attended and the Cornell C. Anderson University and Cornell UniversityHedberg MD Medical Professor College; of Internalwas a medical Medicine, house Rush officer University at Barnes MedicalHospital; Centerand trained – all in in Infectious Chicago Diseases and EpidemiologyIL USA. Dr. Weinstein in the CDC’s attended EIS Program Cornell and University at the University and Cornell of Chicago. University Dr. Weinstein’s Medical College; clinical andwas research interestsa medical focus house on healthcare-acquiredofficer at Barnes infectionsHospital; (particularland trainedy thein Infectiousepidemiology Diseases, costs, andmicrobiome, Epidemiology and prevention of in the CDC’s EIS Program andantimicrobial at the University resistance of Chicago. and infections Dr. Weinstein’s in intensive clinical care units and), rapidresearch HIV interests testing, and focus healthcare on costs and outcomes healthcare-acquired infectionsfor (particularly patients with the HIV/AIDS. epidemiology, Dr. Weinstein costs, microbiome, is a past-president and preventionof the Society of forantimicrobial Healthcare Epidemiologyresistance of America (SHEA), a past-chair of the CDC’s Healthcare Infection Control Practices Advisory Committee (HICPAC), and a and infections in intensive care units), rapid HIV testing, and healthcare costs and outcomes for patients with HIV/AIDS. past member of the IDSA Board of Directors. Dr. Weinstein currently serves on the CDC’s National Center for Infectious Disease Board of Scientific Dr.Counselors Weinstein and is as a Chairpast-president of that Board’s of the Antimicrobial Society for HealthcareResistance Working Epidemiology Group. ofHe America was a recipient (SHEA), of thea past-chair National Association of the CDC’s of Public Hospitals Healthcareand Health SystemsInfection 1999 Control Clinical Practices Research Advisory Award, theCommittee 2005 recipient (HICPAC), of the SHEA and a Lectureship past member Award, of the and IDSA the 2008 Board recipient of Directors. of the SHEA Mentor Dr.Award, Weinstein and was currently honored withserves a Lifetime on the CDC’s Achievement National Award Center from for the Infectious CDC in 2010, Disease the Infectious Board of DiseaseScientific Society Counselors of America and Walter as Stamm ChairMentor of Award that Board’s in 2012, Antimicrobial and the IDSA JosephResistance Smadel Working Named Group. Lecture He in 2014.was a Dr.recipient Weinstein of the has National published Association over 300 peer-reviewed of Public scientific articles, Hospitalsover 50 book and chapters, Health Systems2 books, 1999and over Clinical 25 CDs Research and internet Award, educational the 2005 materials.And recipient of thehe is SHEA mostly Lectureship a nice guy. Award, and the 2008 recipient of the SHEA Mentor Award, and was honored with a Lifetime Achievement Award from the CDC in 2010, the InfectiousAbstract Disease Society of America Walter Stamm Mentor Award in 2012, and the IDSA Joseph Smadel Named Lecture in 2014. Dr. Weinstein has published over 300 peer-reviewed scientific articles, over 50 book chapters, 2 books, and over 25 CDs andWhat internet can we educational learn from materials. other jurisdictions? And he is mostly a nice guy.

Abstract:Background: What can we learn from other jurisdictions? The impact of public reporting on control of antibiotic resistant organisms (AROs) is key in light of dwindling antibiotic pipelines and increasing Background: The impact of public reporting on control of antibiotic resistant organisms (AROs) is key in light of dwindling global ARO rates. Lessons to be learned from other jurisdictions include varying focus on AROs, types/uses of reporting, and practical experience antibioticwith ARO-reporting. pipelines and increasing global ARO rates. Lessons to be learned from other jurisdictions include varying focus on AROs,AROs oftypes/uses concern vary of reporting, over time and space. practical For experience two-plus decades with ARO-reporting., gram positive bacteria AROs – of methicillin-resistant concern vary over Staphylococcus time and space. aureus (MRSA), Forvancomycin-resistant two-plus decades, Enterococci gram positive (VRE) bacteria and increasingly – methicillin-resistant Clostridium difficile Staphylococcus – have been aureus great (MRSA),concerns. vancomycin-resistant More recently, ARO gram-negative Enterococcibacilli, including (VRE) producers and increasingly of extended-spectrum Clostridium beta-lactamas difficile –es have(ESBLs), been metallo-beta-lactamases,great concerns. More recently, and carbapenem-modifying ARO gram-negative e nzymes, have bacilli,become including concerns. producers of extended-spectrum beta-lactamases (ESBLs), metallo-beta-lactamases, and carbapenem- modifyingResults/Key enzymes, Data: have become concerns. Like politics, all resistance is local; however, the globe is shrinking. In addition, there is a marked “resistance iceberg”; for every patient recognized Results/Keyto be ARO-colonized Data: Like or infected, politics, there all resistance are 3-10+ isunrecognized local; however, carriers. the globe The early is shrinking. spread of AROsIn addition, often involves there is long-terma marked care facilities, which “resistancein the 1990s iceberg”; were foci for for everyspread patient of ESBL-containing recognized to Klebsiella be ARO-colonized and E. coli andor infected, in the 2000s there for are spread 3-10+ of unrecognizedVRE. Now, carbapenem-resistant carriers. TheEnterobacteriaceae early spread of(CRE) AROs are often spreading involves in long-term long-term acute care care facilities, hospitals which(LTACHs), in the the 1990s nursing were home foci equivalentsfor spread ofof ICUs.ESBL-containing In Chicago, surveys Klebsiellashowed a nine-fold and E. coli higher and prevalence in the 2000s of CREfor spread in LTACHs of VRE. compared Now, carbapenem-resistant to acute care hospital ICUs. Enterobacteriaceae In LTACHs, CRE (CRE) “colonization are spreading pressure” (number inof long-termpatients colonized acute care and hospitalssources of (LTACHs), ARO transmission) the nursing has become home equivalents a major variable of ICUs. affecting In Chicago, spread. surveys showed a nine- foldPublic higher reporting prevalence can focus of onCRE healthcare-associated in LTACHs compared infections to acute (HAIs), care e.g., hospital bloodstream ICUs. In infections, LTACHs, AROs CRE from“colonization clinical isolates, pressure” or AROs from active (numbersurveillance of patientstesting (AST). colonized Reports and can sources be used of forARO trending transmission) rates (usually has becomeeffective), a majorfor directing variable and affecting evaluating spread. interventions Public (usually effective), or reportingfor inter-facility can focus comparisons on healthcare-associated (problematic/not recommended). infections (HAIs), e.g., bloodstream infections, AROs from clinical isolates, orIn AROsthe USA, from state-mandated active surveillance reporting testing of HAIs (AST). has prompted Reports imprcan beovements used for in trendinglocal rates rates and provides(usually nationaleffective), data for for directingtracking HAIsand and AROs. evaluatingReporting of interventions MRSA is required (usually in ~15 effective), states; some or for of inter-facilitywhich have mandatory comparisons MRSA (problematic/not AST. A regional recommended). evaluation of the Ineffectiveness the USA, of VRE AST and reporting almost two decades ago showed that when VRE colonization pressure was very low, rates could be further lowered by AST, reporting, state-mandated reporting of HAIs has prompted improvements in local rates and provides national data for tracking HAIs and interventions. However, experience with regional mandates for MRSA AST has been less successful. Currently, ~18 states require CRE andreporting AROs. to improveReporting control; of MRSA however, is required CRE resistance in ~15 states;icebergs some and ofcolonization which have pressure mandatory may make MRSA reporting AST. A alone regional insufficient, evaluation and CRE control ofmay the require effectiveness active interventions, of VRE AST such and as reporting chlorhexidine almost patient two bathing.decades ago showed that when VRE colonization pressure was very low,In considering rates could public be further reporting, lowered information by AST, needs reporting, vary by and stakeholder interventions., e.g., clinicians However, need experience phenotype with data regional (antimicrobial mandates susceptib for ilities) while MRSAinfection AST control has andbeen public less successful. health also Currently,need genotype ~18 (resista states ncerequire mechanism) CRE reporting data. In toIllinois, improve an XDRO control; (extremely however, ARO) CRE registryresistance was created to icebergsallow hospitals and colonization to electronically pressure report may and makequery reportingpatient-leve alonel CRE insufficient, resistance. and CRE controlmay require active interventions, suchConclusions/Recommendations: as chlorhexidine patient bathing. In considering public reporting, information needs vary by stakeholder, e.g., clinicians needAll resistance phenotype is local data but (antimicrobial not for long. susceptibilities)Public reporting ofwhile HAIs infection provides control trending and data public and drives health hospital-level also need genotype improvem (resistanceent. Reporting surveil- lance culture data may be useful when directed at emerging pathogens, e.g., CRE in some locales, and is particularly useful depending on the ARO epidemiology, e.g., directed at long-term care epicenters. To be effective, reporting must be used in conjunction with interventions.

Canadian Consensus Development Conference on surveillance & screening for aros www.AROscalgary2014.ca www.AROsCalgary2014.ca 42 Canadian Consensus Development Conference on Surveillance & Screening for AROS SPEAKERS & ABSTRACTS

mechanism) data. In Illinois, an XDRO (extremely ARO) registry was created to allow hospitals to electronically report and query patient-level CRE resistance. Conclusions/Recommendations: All resistance is local but not for long. Public reporting of HAIs provides trending data and drives hospital-level improvement. Reporting surveillance culture data may be useful when directed at emerging pathogens, e.g., CRE in some locales, and is particularly useful depending on the ARO epidemiology, e.g., directed at long-term care epicenters. To be effective, reporting must be used in conjunction with interventions.

Canadian Consensus Development Conference on Surveillance & Screening for AROs 43 www.AROsCalgary2014.ca COMMITTEES

SCIENTIFIC COMMITTEE

Chair and Co-Chairs: Dr. John Conly, Professor & Co-Director, Snyder Institute, University of Calgary – Chair Dr. Mark Joffe, Professor, University of Alberta; Senior Medical Director, Infection Prevention & Control, Alberta Health Services – Co-Chair Dr. Geoff Taylor, Professor & Director, Infectious Diseases, University of Alberta – Co-chair

Organizing Committee Co-Chairs: Dr. Martin Lavoie, Deputy Chief Medical Officer of Health, Alberta Health Steve Buick, Director, Policy & Communications, IHE

Scientific Sponsor Representative: Dr. Howard Njoo, Director General, Centre for Communicable Diseases & Infection Control - Public Health Agency of Canada Anne MacLaurin, Patient Safety Improvement Lead - Canadian Patient Safety Institute Heather Howley, Health Services Research Specialist - Accreditation Canada Dr. Marc Ouellette, Scientific Director - Canadian Institutes of Health Research, Institute of Infection & Immunity Nancy Alfieri, Executive Director, Infection Prevention & Control, Calgary, South & Central Zones, Alberta Health Services Dr. John Jernigan, Director, Office of Prevention Research and Evaluation, U.S. Centres for Disease Control & Prevention (NCEZID) Dr. Joel Kettner, Scientific lead, National Collaborating Centre for Infectious Diseases, International Centre for Infectious Diseases, Winnipeg

ORGANIZING COMMITTEE

Dr. Martin Lavoie, Deputy Chief Medical Officer of Health, Alberta Health - Co-Chair Steve Buick, Director, Policy & Communications, IHE - Co-Chair Dr. Mark Joffe, Professor, University of Alberta; Senior Medical Director, Infection Prevention & Control, Alberta Health Services Dawn Friesen, Executive Director, Health Protection, Alberta Health Melinda Connolly, Director, Infection Prevention & Control, Alberta Health Samuel Hester, Project Manager, Infection Prevention & Control, Alberta Health John Sproule, Senior Director, Health Policy, IHE Dr. Lorne Tyrrell, Board Chair, IHE

www.AROsCalgary2014.ca 44 Canadian Consensus Development Conference on Surveillance & Screening for AROS Scientific SponsorsSCIENTIFIC SPONSORS

Canadian Consensus Development Conference on Surveillance & Screening for AROs 45 www.AROsCalgary2014.ca www.AROscalgary2014.ca Canadian Consensus Development Conference on surveillance & screening for aros www.AROsCalgary2014.ca 46 Canadian Consensus Development Conference on Surveillance & Screening for AROS Canadian Consensus Development Conference on Surveillance & Screening for AROs 47 www.AROsCalgary2014.ca Institute of Health Economics #1200, 10405 Jasper Avenue Edmonton, AB T5J 3N4 Tel. 780.448.4881 Fax. 780.448.0018 [email protected] www.ihe.ca