Successful control of 2 simultaneous outbreaks of OXA-48 carbapenemase-producing Enterobacteriaceae and multidrug-resistant Acinetobacter baumannii in an intensive care unit

Healthcare-associated multispecies outbreaks of OXA-48-positive carbapenemase-producing Enterobacteriaceae in a Singapore tertiary-care hospital

OBJECTIVE

To describe OXA-48-like carbapenem-producing Enterobacteriaceae (CPE) outbreaks at Singapore General Hospital between 2018 and 2020 and to determine the risk associated with OXA-48 carriage in the 2020 outbreak.

DESIGN

Outbreak report and case-control study.

SETTING

Singapore General Hospital (SGH) is a tertiary-care academic medical center in Singapore with 1,750 beds.

METHODS

Active surveillance for CPE is conducted for selected high-risk patient cohorts through molecular testing on rectal swabs or stool samples. Patients with CPE are isolated or placed in cohorts under contact precautions. During outbreak investigations, rectal swabs are repeated for culture. For the 2020 outbreak, a retrospective case-control study was conducted in which controls were inpatients who tested negative for OXA-48 and were selected at a 1:3 case-to-control ratio.

RESULTS

Hospital wide, the median number of patients with healthcare-associated OXA-48 was 2 per month. In the 3-year period between 2018 and 2020, 3 OXA-48 outbreaks were investigated and managed, involving 4 patients with Klebsiella pneumoniae in 2018, 55 patients with K. pneumoniae or Escherichia coli in 2019, and 49 patients with multispecies Enterobacterales in 2020. During the 2020 outbreak, independent risk factors for OXA-48 carriage on multivariate analysis (49 patients and 147 controls) were diarrhea within the preceding 2 weeks (OR, 3.3; 95% CI, 1.1-10.7; P = .039), contact with an OXA-48-carrying patient (OR, 8.7; 95% CI, 1.9-39.3; P = .005), and exposure to carbapenems (OR, 17.2; 95% CI, 2.2-136; P = .007) or penicillin (OR, 16.6; 95% CI, 3.8-71.0; P < .001).

CONCLUSIONS

Multispecies OXA-48 outbreaks in our institution are likely related to a favorable ecological condition and selective pressure exerted by antimicrobial use. The integration of molecular surveillance epidemiology of the healthcare environment is important in understanding the risk of healthcare-associated infection to patients.

Contamination of healthcare environment by carbapenem-resistant Acinetobacter baumannii

Acinetobacter baumannii is frequently found on floors, devices, and environmental sites in hospitals and can survive for prolonged periods and accumulate resistance determinants. The infection and presence of carbapenem-resistant A. baumannii (CRAB) in patients is associated with increased mortality, severe clinical outcomes, and longer lengths of stay at hospitals. This review addresses contamination by CRAB in corporal surfaces of patients and healthcare workers and environmental sites at healthcare-related settings. We summarized published data during the last decade on potential reservoirs for CRAB, including contamination frequency and the involved resistance mechanisms, and some measures associated with the elimination of CRAB from hospital surfaces.

Dissemination of a single ST11 clone of OXA-48-producing Klebsiella pneumoniae within a large polyclonal hospital outbreak determined by genomic sequencing

The population structure of a set of OXA-48-producing Klebsiella pneumoniae isolates belonging to sequence type 11 (ST11 Kp-OXA) and obtained from two hospitals in Madrid in the period from 2012 to 2015 was studied by genome sequencing. Overall, 97 ST11 Kp-OXA isolates were sequenced and their population structure and demography were studied by Bayesian phylodynamic analysis using core-genome SNVs. In total, 92 isolates were from Hospital La Paz, 57 of them from two selected units. The remaining five isolates were from different units of Hospital Doce de Octubre. Altogether, 96 out of the 97 ST11 Kp-OXA isolates could be ascribed to a single lineage that evolved into three sublineages. Demographic inference showed an expansion of the ST11 Kp-OXA in the first half of 2013 in agreement with the registered incidences. Dated phylogeny showed transmission clusters within hospital wards, between wards and between hospitals. The ST11 Kp-OXA outbreak in Hospital La Paz was largely due to the expansion of a single clone that was transmitted between different units and to Hospital Doce de Octubre. This clone diverged into three sub-lineages and spread out following a mixed mode of neutral core-genome evolution with some features of antibiotic selection, frequent large deletions and plasmid loss and gain events.

Preventing infections caused by carbapenemase-producing bacteria in the intensive care unit - Think about the sink

OBJECTIVE

Outbreaks caused by carbapenemase-producing bacteria (CPB) are challenging to manage in critical care settings and can be protracted due to inadvertent and ubiquitous ecological niches within the built unit environment, such as handwashing sinks. We discuss evidence from a narrative review on transmission pathways and interventions for critical care practitioners.

METHODS

A literature review was undertaken using Pubmed, CINAHL and Embase and included outbreaks of CPB, and equivalent bacteria in critical care units, between 1998 and May 2020. Intervention studies targeting elements of sinks that were employed in response to outbreaks in critical care units were included (n = 30).

FINDINGS

We found control measures included sink removal, use of physical barriers or design modification to protect patients from sinks, engineering controls to mitigate bacterial dispersal and administrative controls. A multi-disciplinary approach involving practitioners from critical care, infection prevention and control, engineering and other staff, should be involved in ongoing measures and in outbreak control activities. Ascertaining the optimal method to end CPB outbreaks in critical care is challenging due to the lack of prospective studies available. However, the literature suggests that sinks can and do serve as reservoirs of CPB near critically ill patients, and should be considered hazardous, especially when sub-optimally designed or used.

A novel source of hospital microorganisms in healthcare settings

Background. Most healthcare-associated infections (HAI) develop due to a colonization of patients and healthcare workers by hospital strains of pathogens. The aim to study was to assess whether the dust within the health facilities can harbor microorganisms acting as a reservoir of HAIs.

Materials and methods. Dust samples collected in the air ducts and ventilation grilles of health facilities underwent a detailed physicochemical analysis by means of scanning electron microscopy, dynamic light scattering, energy-dispersive X-ray spectroscopy, and high-temperature catalytic oxidation. Bacterial and viral diversity was investigated using an automated biochemical analyzer and polymerase chain reaction, respectively. Investigation of the microenvironment included detection of biofilms using a catalase indicator and quantification of viable microorganisms per 1 m3 air.

Results. Dust from the hospital ventilation grilles and air ducts was contaminated with microorganisms in 71.13% of cases. Strikingly, multidrug-resistant and biofilm-forming strains have been found in 69.4% and 48.0% of samples, respectively. The total viable count before and after opening doors and windows was 276 and 462 colony-forming units/m3 respectively (p = 0.046). Biodiversity was represented by 21 genera of microorganisms which were consistently detected upon 6 months of follow-up. All samples contained a nanosized particulate matter. Chemical elements comprising dust were carbon (16.26–50.69%), oxygen (20.02–37.50%), nitrogen (1.59–25.03%), hydrogen (2.03–6.67%), sulfur (0.15–2.38%), calcium (0.19–7.49%), silicon (0.21–4.64%), chlorine (0.05–2.83%), sodium (0.07–1.86%), aluminum (0.36–1.78%), iron (0.08–1.61%), magnesium (0.11–1.40%), potassium (0.04–0.85%), and phosphorus (0.04–0.81%).

Discussion. A wide range of multidrug-resistant strains of bacteria, detected in a hospital particulate matter with a diverse chemical composition, indicates the persistence of HAI-causing pathogens in the hospital environment.

Conclusion. Dust from the ventilation grilles and adjacent air ducts should be considered as an additional reservoir of multidrug-resistant strains of bacteria in the healthcare settings.

Systematic review on use, cost and clinical efficacy of automated decontamination devices

BACKGROUND

More evidence is emerging on the role of surface decontamination for reducing hospital-acquired infection (HAI). Timely and adequate removal of environmental pathogens leads to measurable clinical benefit in both routine and outbreak situations.

OBJECTIVES

This systematic review aimed to evaluate published studies describing the effect of automated technologies delivering hydrogen peroxide (H202) or ultra-violet (UV) light on HAI rates.

METHODS

A systematic review was performed using relevant search terms. Databases were scanned from January 2005 to March 2020 for studies reporting clinical outcome after use of automated devices on healthcare surfaces. Information collected included device type, overall findings; hospital and ward data; study location, length and size; antimicrobial consumption; domestic monitoring; and infection control interventions. Study sponsorship and duplicate publications were also noted.

RESULTS

While there are clear benefits from non-touch devices in vitro, we found insufficient objective assessment of patient outcome due to the before-and-after nature of 36 of 43 (84%) studies. Of 43 studies, 20 (47%) used hydrogen peroxide (14 for outbreaks) and 23 (53%) used UV technology (none for outbreaks). The most popular pathogen targeted, either alone or in combination with others, was Clostridium difficile (27 of 43 studies: 63%), followed by methicillin-resistant Staphylococcus aureus (MRSA) (16 of 43: 37%). Many owed funding and/or personnel to industry sponsorship (28 of 43: 65%) and most were confounded by concurrent infection control, antimicrobial stewardship and/or cleaning audit initiatives. Few contained data on device costs and rarely on comparable costs (1 of 43: 2%). There were expected relationships between the country hosting the study and location of device companies. None mentioned the potential for environmental damage, including effects on microbial survivors.

CONCLUSION

There were mixed results for patient benefit from this review of automated devices using H202 or UV for surface decontamination. Most non-outbreak studies lacked an appropriate control group and were potentially compromised by industry sponsorship. Concern over HAI encourages delivery of powerful disinfectants for eliminating pathogens without appreciating toxicity or cost benefit. Routine use of these devices requires justification from standardized and controlled studies to understand how best to manage contaminated healthcare environments.

Investigation of Acinetobacter baumannii Activity in Vascular Surgery Units through Epidemiological Management Based on the Analysis of Antimicrobial Resistance, Biofilm Formation and Genotyping

Background/Objectives: The genus Acinetobacter demonstrates resistance to antibiotics and has been shown to spread in the hospital environment causing epidemic outbreaks among hospitalized patients. The objectives of the present study was to investigate the antibiotic resistance, biofilm formation, and clonality among Acinetobacter baumannii strains. Materials and Methods: The study involved 6 (I Outbreak) and 3 (II Outbreak) A. baumannii strains isolated from patients hospitalized in vascular surgery unit. Results: All tested A. baumannii strains were extensively drug resistant (XDR) and all the isolates were carbapenem-resistant and among them, all carried the bla_OXA-51 gene, the bla_OXA-24 gene, as well as the bla_OXA-23 gene. All of the investigated strains had the ability to form a biofilm, but all of them produced less biofilm than the reference strain. Multi-locus sequence typing (MLST) showed that all strains belonged to the ST2 clone. Pulsed-field gel electrophoresis (PFGE) divided the tested outbreak strains into two clones (A and B). Conclusion: This study shows a nosocomial spread of XDR A. baumannii ST2 having the bla_OXA-51 gene, the bla_OXA-24 gene, as well as the bla_OXA-23 gene, low biofilm formers, that was prevalent in the vascular surgery unit. To identify the current situation of vascular surgery departments targeted epidemiological investigation was needed. Effective implementation of infection control prevented the spread of the epidemic outbreaks.

OXA-48 Carbapenemase-Producing Enterobacterales in Spanish Hospitals: An Updated Comprehensive Review on a Rising Antimicrobial Resistance

Carbapenemase-producing Enterobacterales (CPE) are significant contributors to the global public health threat of antimicrobial resistance. OXA-48-like enzymes and their variants are unique carbapenemases with low or null hydrolytic activity toward carbapenems but no intrinsic activity against expanded-spectrum cephalosporins. CPEs have been classified by the WHO as high-priority pathogens given their association with morbidity and mortality and the scarce number of effective antibiotic treatments. In Spain, the frequency of OXA-48 CPE outbreaks is higher than in other European countries, representing the major resistance mechanism of CPEs. Horizontal transfer of plasmids and poor effective antibiotic treatment are additional threats to the correct prevention and control of these hospital outbreaks. One of the most important risk factors is antibiotic pressure, specifically carbapenem overuse. We explored the use of these antibiotics in Spain and analyzed the frequency, characteristics and prevention of CPE outbreaks. Future antibiotic stewardship programs along with specific preventive measures in hospitalized patients must be reinforced and updated in Spain.

Prevalence of antibiotic-resistant organisms among hospitalized patients at a tertiary care center in Lebanon, 2010-2018

BACKGROUND

Infections due to antibiotic resistant organisms (ARO) among hospitalized patients are associated with increased morbidity, mortality, and healthcare costs. Longitudinal data about antimicrobial resistance are scarce in Lebanon and the region. The objective of this study is to describe the temporal trends of resistance of selected pathogens among hospitalized patients at a tertiary care center in Lebanon.

METHODS

We conducted a retrospective review of surveillance data from 2010 until 2018. Six target organisms isolated from hospitalized patients were included: carbapenem-resistant Escherichia coli (CREC), carbapenem-resistant Klebsiella spp. (CRKP), multi-drug resistant Pseudomonas aeruginosa (MDRPA), carbapenem-resistant Acinetobacter baumannii (CRAB), methicillin-resistant Staphylococcus aureus (MRSA), and vancomycin-resistant Enterococcus spp. (VRE). Correlation analysis was performed to evaluate for temporal trends.

RESULTS

A total of 15,901 isolates were examined, most of which were obtained from urinary specimens. Among Gram-negative organisms, the highest resistance was found among CRAB (81.7%), followed by CRKP (6.5%) and CREC (3.3%). MDRPA overall prevalence was 0.8%. Among Gram-positive organisms, the prevalence of MRSA and VRE was 26.2% and 2.6%, respectively. CREC, MRSA, and VRE showed statistically significant increasing temporal trends, while CRAB decreased significantly from 2013 to 2018.

CONCLUSION

These data are helpful in characterizing the epidemiology of antimicrobial resistance in Lebanon and show that controlling emerging resistance is achievable with concerted infection control and antimicrobial stewardship efforts. Caution should be exercised to contain early on the spread of CREC and of resistant Gram-positive pathogens.

Clinical Relevance of Antibiotic Susceptibility Profiles for Screening Gram-negative Microorganisms Resistant to Beta-Lactam Antibiotics

The increasing resistance to antibiotics is compromising the empirical treatment of infections caused by resistant bacteria. Rapid, efficient, and clinically applicable phenotypic methods are needed for their detection. This study examines the phenotypic behavior of β-lactam-resistant Gram-negative bacteria grown on ChromID ESBL medium with ertapenem, cefoxitin, and cefepime disks, reports on the coloration of colonies, and establishes a halo diameter breakpoint for the detection of carbapenemase-producing bacteria. We studied 186 β-lactam-resistant Gram-negative microorganisms (77 with extended spectrum beta lactamase (ESBL), 97 with carbapenemases, and 12 with AmpC β-lactamases (AmpC)). Susceptibility profiles of Gram-negative bacteria that produced ESBL, AmpC, and carbapenemases were similar to the expected profiles, with some differences in the response to cefepime of ESBL-producing microorganisms. Coloration values did not differ from those described by the manufacturer of ChromID ESBL medium. In the screening of carbapenemase production, inhibition halo diameter breakpoints for antibiotic resistance were 18 mm for Enterobacterales and ertapenem, 18 mm for Pseudomonas and cefepime, and 16 mm for Acinetobacter baumannii and cefepime. This innovative phenotypic approach is highly relevant to clinical laboratories, combining susceptibility profiles with detection by coloration of high-priority resistant microorganisms such as carbapenemase-producing A. baumannii, carbapenemase-producing Pseudomonas spp., and ESBL and/or carbapenemase-producing Enterobacterales.

Cohorting for preventing the nosocomial spread of Carbapenemase-Producing Enterobacterales, in non-epidemic settings: is it mandatory?

BACKGROUND

Worldwide dissemination of Carbapenemase-Producing Enterobacterales (CPE) has led to national and international guidance recommending the implementation of cohorting in healthcare settings (HS). However, in view of recent data regarding the spread of Extended-spectrum Beta-lactamase-producing Enterobacterales, we may wonder about the usefulness of this measure in a non-outbreak settings; here, individual contact isolation may be sufficient to control the risk of dissemination.

AIM/METHODS

We conducted a narrative review of the literature and discussed the role of cohorting.

FINDINGS

CPE are responsible for outbreaks in HS, which are considered the epicentre of spread of resistance strains. CPE are responsible for adverse effects such as increases in hospital stay and costs, less therapeutic options and thus higher risk of clinical failures and mortality. Environment and materials have also been described contaminated with CPE and can be the source of outbreak. Even if guidelines and publications have supported implementation of cohorting, there are no randomized studies demonstrating the mandatory nature of this measure. Most studies are descriptive and cohorting is usually one of several other measures to control outbreaks. Cohorting is not adapted to all HS, which requires human and material resources. Other measures must be strengthened such as compliance of hand hygiene, antibiotic stewardship and surveillance of contact patients. Individual risk factors of acquisition should also be evaluated.

CONCLUSION

Local epidemiology and resources must be assessed before implementing cohorting.

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

The role of hospital environment in transmissions of multidrug-resistant gram-negative organisms

Infections by multidrug-resistant (MDR) Gram-negative organisms (GN) are associated with a high mortality rate and present an increasing challenge to the healthcare system worldwide. In recent years, increasing evidence supports the association between the healthcare environment and transmission of MDRGN to patients and healthcare workers. To better understand the role of the environment in transmission and acquisition of MDRGN, we conducted a utilitarian review based on literature published from 2014 until 2019.

The Global Ascendency of OXA-48-Type Carbapenemases

Surveillance studies have shown that OXA-48-like carbapenemases are the most common carbapenemases in Enterobacterales in certain regions of the world and are being introduced on a regular basis into regions of nonendemicity, where they are responsible for nosocomial outbreaks. OXA-48, OXA-181, OXA-232, OXA-204, OXA-162, and OXA-244, in that order, are the most common enzymes identified among the OXA-48-like carbapenemase group. OXA-48 is associated with different Tn1999 variants on IncL plasmids and is endemic in North Africa and the Middle East. OXA-162 and OXA-244 are derivatives of OXA-48 and are present in Europe. OXA-181 and OXA-232 are associated with ISEcp1, Tn2013 on ColE2, and IncX3 types of plasmids and are endemic in the Indian subcontinent (e.g., India, Bangladesh, Pakistan, and Sri Lanka) and certain sub-Saharan African countries. Overall, clonal dissemination plays a minor role in the spread of OXA-48-like carbapenemases, but certain high-risk clones (e.g., Klebsiella pneumoniae sequence type 147 [ST147], ST307, ST15, and ST14 and Escherichia coli ST38 and ST410) have been associated with the global dispersion of OXA-48, OXA-181, OXA-232, and OXA-204. Chromosomal integration of bla _OXA-48 within Tn6237 occurred among E. coli ST38 isolates, especially in the United Kingdom. The detection of Enterobacterales with OXA-48-like enzymes using phenotypic methods has improved recently but remains challenging for clinical laboratories in regions of nonendemicity. Identification of the specific type of OXA-48-like enzyme requires sequencing of the corresponding genes. Bacteria (especially K. pneumoniae and E. coli) with bla _OXA-48, bla _OXA-181, and bla _OXA-232 are emerging in different parts of the world and are most likely underreported due to problems with the laboratory detection of these enzymes. The medical community should be aware of the looming threat that is posed by bacteria with OXA-48-like carbapenemases.

Carbapenem-Resistant Enterobacteriaceae Outbreak in a Medical Ward in Spain: Epidemiology, Control Strategy, and Importance of Environmental Disinfection

Introduction: Carbapenem-resistant Enterobacteriaceae (CRE) are a growing public health problem. We describe an outbreak by CRE and the measures to control it in a hospitalization unit in Spain. Methods: In June 2015, the system of prevention and control of CRE implemented in the hospital detected an increase in the incidence of patients with CRE in a mixed hospitalization facility (geriatrics, internal medicine, and pneumology), with the appearance of four related patients in 2 weeks, three of them being nosocomial cases. A multidisciplinary group was created and carried out: weekly screenings, general cleaning, four training sessions for personnel, two hand hygiene observation studies and environmental sampling. A higher incidence of new cases was detected in three adjoining rooms, in which environmental decontamination was performed with vaporized hydrogen peroxide. Results: In 5 months, a total of 18 cases were detected, 14 of them were nosocomial. Four different clones of Klebsiella pneumoniae OXA-48 were responsible for 83.3% of the cases. Adherence to hand hygiene increased from 36% to 85% after the training sessions. Seven percent of the environmental samples were positive for CRE in rooms with high incidence, moving to 0% after decontamination with hydrogen peroxide. Three patients died, one of them possibly associated with clinical infection due to CRE. Conclusions: Multidisciplinary information strategies, personnel training, and control of environmental reservoirs are effective to address outbreaks of CRE.

Effect of chlorhexidine bathing on colonization or infection with Acinetobacter baumannii: a systematic review and meta-analysis

Healthcare-associated infections (HAIs) caused by multi-drug-resistant Gram-negative bacteria (MDRGNB) have increased prevalence in intensive care units (ICUs). A common strategy to prevent HAIs is bathing patients with chlorhexidine gluconate (CHG). However, the effectiveness of CHG bathing against multidrug-resistant Acinetobacter baumannii (MDRAB) is still controversial. The aim of this study was to perform a systematic review and meta-analysis of the effectiveness of CHG bathing on Acinetobacter baumannii colonization and infection in the ICU setting. A systematic literature search of PubMed, EMBASE, Web of Science and CINAHL was performed from inception through to June 2018. Randomized controlled trials (RCTs), pre-post studies, or interrupted time series (ITS) studies were included. The numbers of patients with/without colonization or infection of A. baumannii in the experimental or control groups were extracted from each study. Quality assessment was performed by the related instruments of National Institute of Health. Pooled risk ratios (RRs) were calculated using the random-effects model. One RCT and 12 pre-post or ITS studies comprising 18,217 patients were included, of which 8069 were in the CHG bathing arm and 9051 in the control arm. CHG bathing was associated with a reduced colonization of A. baumannii (RR, 0.66; 95% confidence interval: 0.57-0.77; P<0.001). Chlorhexidine at 4% showed a better effect than 2% chlorhexidine (meta-regression P=0.044). CHG bathing was associated with a non-significant reduction of infection (pooled RR 0.41, 95% CI: 0.13-1.25). This study suggests that CHG bathing significantly reduces colonization of A. baumannii in the ICU setting. However, more trials are needed to confirm whether CHG bathing can reduce infections with A. baumannii.

Wastewater drains: epidemiology and interventions in 23 carbapenem-resistant organism outbreaks

For many years, patient-area wastewater drains (ie, sink and shower drains) have been considered a potential source of bacterial pathogens that can be transmitted to patients. Recently, evolving genomic epidemiology tools combined with new insights into the ecology of wastewater drain (WWD) biofilm have provided new perspectives on the clinical relevance and hospital-associated infection (HAI) transmission risks related to these fixtures. To further clarify the clinical relevance of WWD-associated pathogen transmission, reports of outbreaks attributed to WWDs were selected for review that (1) investigated the outbreak epidemiology of WWD-associated transmission of bacterial pathogens, (2) utilized advanced microbiologic methods to establish clonality of outbreak pathogens and/or resistance genes, or (3) described interventions implemented to mitigate transmission of the outbreak pathogens from WWDs. These reports were collated, compared, and analyzed, and the results are presented here.