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The Implications and Impact of CIDTs at Public Health Laboratories
Dave Boxrud| Enterics Unit Supervisor
Minnesota Department of Health
November 7, 2017
Outline
• Background
• Status of CIDTs at MDH and other public health labs
• Effect of CIDTs on foodborne disease surveillance
• Opportunities
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Current Foodborne Disease Surveillance in the US
• Outbreak detection-REQUIRES ISOLATES
• Antibiotic Susceptibility Testing-REQUIRES ISOLATES
• Case counts-ACCURACY/CONSISTENCY REQUIRES ISOLATES
• Developed early 1990s• Rapid (hours)• Urine specimen (vs urethral swab)• Includes Chlamydia trachomatis• High sensitivity/specificity
•Specimen incompatible with culture•No susceptibility data
Demise of GC culture
Implications of reduced culture-GC
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Preparing for CIDTs
• John Besser (MN/CDC)
• Workgroups
• APHL guidance documents, factsheets
• Working with industry
• Working with regulators
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CIDT Questions
• Are we seeing a decrease in the number of isolates?
• Do CIDTs slow down surveillance?
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Molecular CIDT Specimens Received at MDH
0
100
200
300
400
500
600
Mar Apr May Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct
2015 2016 2017
BioFire Verigene
Large Metropolitan Hospital In Minnesota
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20
40
60
80
100
120
140
160
Isolates Submitted to MDH
Specimens submitted to MDH
Confirmation Rate of CIDT Positive-MDH
74.2%
95.9%
85.7%
75.0%
57.1%
59.0%
47.3%
87.8%
71.9%
45.9%
0.0%
65.4%
0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0%
Campylobacter
Cryptosporidium
Cyclospora
EAEC
EIEC/Shigella
EPEC
ETEC
Salmonella
STEC
Vibrio
Vibrio cholerae
Yersinia
**
*
Percent Salmonella Confirmed for Days to Receipt at MDH
0
20
40
60
80
100
120
0 1 2 3 4 5 6 7 8 9 10
Percent Campylobacter Confirmed for Days to Receipt at MDH
0
10
20
30
40
50
60
70
80
90
0 1 2 3 4 5 6 7 8 9 10
Confirmation Rates of Biofire and Verigene
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
CampyBiofire
EIEC/ShigBiofire
SalmBiofire
STECBiofire
VibrioBiofire
YersiniaBiofire
CampyVerigene
EIEC/ShigVerigene
SalmVerigene
STECVerigene
VibrioVerigene
YersiniaVerigene
Number specimens received by days from collection to received date
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0
200
400
600
800
1000
1200
1400
1600
1800
2000
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 18 19 23 29 32 33 35 42 92
Salmonella Trends Since CIDTs Were Introduced
• Important foodborne pathogen
• Before CIDTs, culture was main detection assay
• STEC-rapid antigen assays, PCR
• Campy-rapid antigen assays, not required submission in all states
• WARNING-IMPERFECT DATA AHEAD!!!!
• May include outbreak isolates, duplicates
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Salmonella Isolates-Minnesota, 2008-2014 (pre-CIDT)
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0
100
200
300
400
500
600
700
800
900
1000
2008 2009 2010 2011 2012 2013 2014
Yearly average=804
Salmonella isolates recd at PHL
Isolates recovered at PHL from stools
Salmonella Isolates-Minnesota, 2008-2017
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Yearly average (2008-2014)=804
0
200
400
600
800
1000
1200
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017(through Sept
30)
Salmonella isolates recd at PHL
Isolates recovered at PHL from stools
Predicted isolates for remaining 2017
Molecular GI CIDTs introduced January 2015
Salmonella Isolates-South Dakota, Iowa, Wisconsin, Kansas
18
0
50
100
150
200
250
300
350
400
2013 2014 2015 2016 2017 (throughSept 30)
Kansas
0
50
100
150
200
250
300
2013 2014 2015 2016 2017 (throughSept 30)
South Dakota
0
100
200
300
400
500
600
700
800
2013 2014 2015 2016 2017 (throughSept 30)
Iowa
0
200
400
600
800
1000
1200
2013 2014 2015 2016 2017 (throughSept 30)
Wisconsin
Salmonella Isolates-Missouri
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0
200
400
600
800
1000
1200
1400
1600
2013 2014 2015 2016 2017 (through Sept 30)
Salmonella isolates recd at PHL
Isolates recovered at PHL from stools
Predicted isolates for remaining 2017The Gladbach Effect
Steve Gladbach (MO Dept Health)-tracks all clinical labs as they go to CIDTs-requests that they continue culture
Minnesota Isolations-2016
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0
100
200
300
400
500
600
700
800
900
1000
2016
N=873
CIDT positive Salmonella
CIDT positive STEC
CIDT positive Campy
Minnesota Isolations-2016 and 2017 (includes projected)
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0
200
400
600
800
1000
1200
1400
1600
2016 2017
N=873
N=1428 (includes estimate for remainder of 2017)
CIDT positive Salmonella
CIDT positive STEC
CIDT positive Campy
ETEC
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• Cause profuse, watery diarrheae
• One of the leading causes of diarrheae in the developing world
• As common as Salmonella*
• Need for additional investigation
*Medus et. al. Open Forum Infect Dis. 2016 Jan 18;3(1)
ETEC Co-Detections
Co-detected w/ETEC # % ETEC confirmed
Campylobacter + EAEC + Salmonella 1 0
Campylobacter + EAEC + EPEC 1 100
Campylobacter + EPEC 2 0
Campylobacter + rotavirus 1 100
Campylobacter 2 50
Campylobacter + STEC non-O157 2 0
Campylobacter + STEC O157 1 0
EAEC + EIEC/Shigella + EPEC 1 0
EAEC + EIEC/Shigella 1 100
EAEC + EPEC 16 69
EAEC + EPEC + norovirus 1 100
EAEC 3 100
EAEC + norovirus 2 0
EAEC + STEC nonO157 2 50
EIEC/Shigella 2 100
EPEC 14 64
EPEC + sapovirus 1 0
EPEC + Salmonella 2 50
EPEC + Salmonella + Plesiomonas 1 0
ETEC only 32 56
ETEC + adenovirus 1 0
ETEC + norovirus 2 50
Salmonella 1 0
STEC nonO157 5 60
STEC nonO157 + norovirus 1 0
STEC O157 2 0
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ETEC
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PFGE-XbaI
100
90
80
70
PFGE-XbaI
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ETEC-WGS Characterization
Specimen Serotype MLST Virulence factors Antibiotic resistance*
I2017000684-1 O159:H4 ST-10 ltcA Te
I2017000818-2 O15:H18 ST-69 eatA A, Q, Tr
M2017000963-1 O169:H41 ST-182 sta1 A, B, S, Te, Tr
M2017000965-6 Onovel31:H18 ST-69 Te, Tr
I2017001980-2 O153var1:H12 ST-155
I2017002797-3 O6:H16 ST-4 ltcA, eatA
I2017002816-2 O169:H41 ST-182 sta1 A, B, Q, S, Te, Tr
I2017002942-ET2 O6:H16 ST-4 ltcA, eatA
I2017003794-ET1 O64:H5 ST-3857 ltcA, eatA A, B, S, Te
I2017003985-ET3 O6:H16 ST-4 ltcA, eatA
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A= Aminoglycoside
B=Beta-lactam
Q=Quinolone
S=Sulphonamide
Te=Tetracycline
Tr=Trimethoprim
Cases of Cylosporiasis, Minnesota, 2008-2017
0
5
10
15
20
25
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017*
Cyclosporiasis Cases
Year of Specimen Collection
No
. of
Cas
es
*2017 data through 10/31/17
Conclusions
• Preliminary evidence shows that CIDTs are not having a negative impact on foodborne disease surveillance
• Isolate numbers are stable or rising since CIDTs
• Burden on PHLs
• PHLs will need more resources for the future to maintain culture
• CIDTs are having a tremendous impact on resources at PHLs
• CIDTs may allow us to better identify and understand other pathogens
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Acknowledgements
• Steve Gladbach-Missouri
• Tim Monson-Wisconsin
• Chris Carlson-South Dakota
• Ryan Jepson-Iowa
• Carissa Robertson-Kansas
• Elizabeth Cebelinski-Minnesota
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