The Topic of This Month Vol. 32, No. 1 (No. 371)

Japan Nosocomial Infections Surveillance (JANIS), a program of Ministry of Health Labour and Welfare
(IASR 32: 1-2, January 2011)

Japan Nosocomial Infections Surveillance (JANIS) was launched as a program of Ministry of Health Labour and Welfare (MHLW) to provide information on isolation of drug-resistant bacteria and clinical cases caused by such bacteria.  The data are collected from about 1,000 hospitals (as of January 2011) with more than 200 beds in Japan, which agreed to collaborate with this project.  The surveillance data after completion of analysis are fed back to the member hospitals and are made accessible on the internet.

JANIS consists of 5 divisions, Clinical Laboratory (CL) division reporting prevalence of drug-resistant bacteria among the isolates, Antimicrobial Resistant Bacterial Infections (ARBI) division reporting the incidence and prevalence of antimicrobial resistant bacterial infections (patients base), Surgical Site Infections (SSI) division and Intensive Care Unit (ICU) division, and Neonatal Intensive Care Unit (NICU) division reporting incidence of nosocomial infections in its own unit irrespective of drug-resistance of the causative agents.

Background and start of JANIS: The problem of drug resistance in clinical setting was first recognized in 1980's in Japan as widespread methicillin-resistant Staphylococcus aureus (MRSA) infection in hospitals.  In 1990's, IMP-1 type metallo-β-lactamase-producing Gram-negative bacteria and vancomycin-resistant enterococci (VRE) were isolated one after another in Japanese medical facilities.  The situation prompted a national surveillance system for monitoring drug-resistant bacteria to be established.

JANIS was launched under such circumstances.  Its basic design and structure were made by two MHLW-supported projects, “Research on the construction of surveillance system of infectious diseases caused by drug-resistant bacteria (Chief Investigator: Yoshichika Arakawa)” and “Research on the construction of network of information on drug-resistant bacterial infection cases (Chief Investigator: Nobuhiko Okabe)”.  JANIS was started as a program of MHLW in July 2000.  Initially the program was designed to make surveillance of clinical cases associated with drug-resistant bacteria only.  However, it was soon recognized that the measures against infection with drug-resistant bacteria and those against nosocomial infection were inseparable, so it was decided that JANIS covers the both drug-resistant bacteria and nosocomial infections.  At its start, JANIS consisted of 3 divisions, CL (see p. 4&6 of this issue), ARBI (see p. 10 of this issue) and ICU (see p. 13 of this issue) divisions, but in 2002 it established two new divisions, SSI (see p. 12 of this issue) and NICU (see p. 15 of this issue) divisions.

Renewal of the system: Participation to JANIS is entirely on voluntary basis, and there is no legal obligation or financial support for the participation.  Therefore, to maintain sufficient number of participant medical facilities that periodically submit surveillance data of high quality, it was imperative to lessen the burden associated with the data submission and, simultaneously, to increase the benefit gained through participation.  Accordingly, through activities of “Research on the network of surveillance system of infectious diseases caused by drug-resistant bacteria (Chief Investigator: Yoshichika Arakawa)”, the system was modified so that JANIS requests the participant hospitals the data that are essential for distribution and feedback of information, and it discontinued collection of data are rather unreliable, difficult to interpret or less useful for monitoring of the trends.  At the same time, so as to increase the utility of the feedback data, JANIS started to provide information that may facilitate comparison of a participant hospital with other participant hospitals, such as on isolation frequencies of the drug-resistant bacteria, or trend information, such as, monthly data of hospital infection.  Such data were presented graphically so as to be used readily in the hospital infection committee meetings (see p. 7 of this issue).  JANIS enriched its homepage and it provided a mechanism of answering questions related to the surveillance through e-mail, which invited new participants into this activity and strengthened the ongoing activity.

Three years after the renewal of JANIS in July 2007, through the recruitment once a year, the participant increased to 30-40% of all the eligible hospitals in Japan, and 80-90% of the participant hospitals report regularly.  Now, JANIS is gaining a stable position in nationwide surveillance of drug-resistant bacteria and nosocomial infection.

Administrative organization of JANIS: The enforcing body of JANIS is MHLW, i.e., Japanese government.  In practice, it is run by the JANIS Secretariat in Department of Bacteriology II, National Institute of Infectious Diseases (NIID); the JANIS database is maintained and managed by the Secretariat and a company to which IT service is consigned.  A research team supported by MHLW [currently, “Research on new type drug-resistant bacteria (Chief investigator: Yoshichika Arakawa) ”] regularly reviews the content of JANIS with the JANIS Secretariat, and drafts summary of the information to be placed on the web site and revise the different criteria of surveillance when necessary.  For appropriate operation of JANIS, Hospital Infection Surveillance Committee (HISC) consisting of experts on hospital infection control is organized by Professions, Health Policy Bureau, MHLW and meets once or twice a year, and gives advice on the operation of JANIS and checks the information to be released.  HISC's advice is considered by the research team and the JANIS Secretariat to be reflected in JANIS operation and the web site information.

Information provided by JANIS: JANIS releases two kinds of information, information open to the public and information for feedback.  The former aims at providing the general public including public health workers with the data on incidence of hospital infections and isolation of drug-resistant bacteria in Japan (available on JANIS homepage and p. 3 of this issue).  The latter aims at feedback of the information to the participant hospitals so that they can use their own data processed in the standard format and the analysis made by JANIS for their own evaluation of the infection control practice.  The participant hospitals are accessible to their own data and other information appearing the specific site of the homepage.  The schedule of data release is shown in Table 1.

Challenge: Efficient quality management of the submitted data is crucial for providing reliable information in timely manner (see p. 16 of this issue).  JANIS currently targets the medical institutions with more than 200 beds, but about 70% of the medical institutions in Japan have less than 200 beds.  To assess the overall situation of hospital infection in Japan, it may be required to include such smaller institutions under the surveillance.

Health centers (HCs) and prefectural and municipal public health institutes (PMPHIs) that play important role in infectious disease control in Japan are excluded from JANIS, as JANIS started as contract between MHLW and individual medical institutes concerning the whole process of data submission to information feedback.  A mechanism of sharing the data with HCs and PMPHIs may have to be developed.

The drug-resistant bacteria, such as NDM-1 type metallo-β-lactamase-producing bacteria that appeared in 2010, cannot be diagnosed with drug susceptibility pattern only but need PCR detection of the resistance gene.  The current JANIS activity cannot cope with such needs.  It is important for JANIS to include molecular epidemiological data in its database.  For this, a mechanism of collecting such data and integrating them into JANIS is required.

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