Document Type

Capstone Experience

Graduation Date


Degree Name

Master of Public Health



First Committee Member

Dr. Ishrat Kamal-Ahmed

Second Committee Member

Dr. David Brett-Major

Third Committee Member

Dr. Sharon Meaker-Medcalf


Objectives: Candida auris is an emerging pathogenic yeast that was first identified in Japan in 2009 and detected in the United States in 2015. As of 2020, C. auris has been reported in cases throughout 41 countries, including the United States. The ability of this species of yeast to spread rapidly and survive for long periods of time on surfaces, the high mortality rate of those infected, and its multidrug resistant phenotype, have rendered it a urgent public health threat (the highest threat level) by the United States Centers for Disease Control and Prevention beginning in 2019 (CDC, 2019). Since its emergence in the United states in 2015, 23 states have required the reporting of C. auris. This organism is not yet a mandatory reportable organism within the state of Nebraska. At this time, no analysis has been done in the state of Nebraska to determine the state of surveillance protocols for Candida auris in clinical laboratories. This capstone project seeks to identify the specific processes in which Nebraska microbiology laboratories identify C. auris, and to determine whether specimens they receive are from screening cases or clinical cases alone. This data will inform public health agencies as to the testing capacity of laboratories throughout Nebraska and assist in targeting guidance to individual facilities.

Methods: To assess C. auris laboratory surveillance, a survey constructed in REDCap was sent to thirty-nine clinical microbiology laboratories within the State of Nebraska to determine their identification process and testing capacities. The results of this survey were interpreted via a qualitative analysis to evaluate state laboratory processes. Additionally, Nebraska Public Health Laboratory (NPHL) Candida monthly reports for the year 2022 were analyzed. Descriptive statistics were used to summarize the characteristics of Candida specimens and to determine the types of patients and location the specimens originated from.

Results: 30 sentinel laboratories out of 39 surveyed completed the laboratory surveillance survey from 23 different cities in the state of Nebraska. Results indicated that (40%, n=10) of laboratories refer their Candida specimens elsewhere for identification. Of those surveyed, (40%, n=10) utilize molecular methods that would identify C. auris in blood cultures in-house, and (26.7, n=8) utilize molecular methods capable for C. auris identification for other culture types in-house. Laboratories responded that no facilities are performing colonization testing at this time. Barriers relating to C. auris cited by laboratories included lack of training, lack of material resources, and the need for improved guidance from health agencies. Additionally, 657 cultures were tested at a large Nebraska reference laboratory and reported to NPHL in 2022 from which Candida species were identified, originating from 385 patients in the state. Of the 385 patients, 220 were treated in an outpatient setting at 42 different facilities throughout Nebraska. The most common Candida species identified was Candida albicans, representing 28% of all specimens received. In the year 2022, no Candida auris was identified from these specimens.

Conclusion: This study reveals vulnerabilities in the Nebraska laboratory surveillance system for C. auris. These vulnerabilities include potential for misidentification, potential for non-detection, and need for improved training and accessible guidance for laboratorians. Recommendations include Nebraska DHHS utilizing the results of the survey responses to target individual laboratories in providing valuable assistance and training where it is needed, so that this organism will be detected effectively, should it appear in the state. Recommendations also include the introduction of a screening protocol for patients at high-risk for Candida colonization.

Available for download on Saturday, August 03, 2024