9/14/ VECTORBORNE DISEASE UPDATE OVERVIEW. Vectorborne disease overview. NJ surveillance trends and updates

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1 218 VECTORBORNE DISEASE UPDATE KAREN WORTHINGTON, MS, RN VECTOR-BORNE DISEASE PROGRAM OVERVIEW Vectorborne disease overview NJ surveillance trends and updates Arboviral disease presentations and testing Disease cases from mosquito, tick and flea bites tripled in the US from 24 to new germs spread by mosquitoes and ticks discovered or introduced since 24 8% of vector control agencies lack critical prevention and control capacities 1

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3 VB DISEASE BASICS Vector mosquito, tick, flea that transmits the pathogen Animal hosts birds, small or large mammals that vectors must feed upon to grow to adulthood Some enable the pathogen to replicate and be passed to uninfected vectors Others are dead-end hosts pathogen level doesn t get high enough to transmit Pathogen parasite, bacteria or virus causing infection and sometimes disease. Parasite: Plasmodium, Babesia Bacteria: Borrelia burgdorferi, Ehrlichia, Anaplasma, Rickettsia rickettsia, Arbovirus: WNV, EEE, Zika, Dengue, Chikungunya, Powassan PREVENTION OF VECTORBORNE DISEASE Individual Vaccination only 2 licensed in US Immune globulin some lab exposures Reduce ticks / mosquitoes / animal hosts at home Use tick or mosquito repellant Showers / tick checks after possible tick exposure After return from travel, avoid getting mosquito bites for 3 weeks to prevent introduction of new diseases to NJ mosquitoes. Public Health NJ State Mosquito Control Commission Mosquito control agencies in all NJ counties Mosquito trapping / testing at PHEL Targeted mosquito control activities in community Visits to homes of positive cases to reduce mosquito habitat No equivalent tick control activities yet. NJ interagency Vectorborne Disease Working Group VECTORBORNE DISEASE PREVENTION RESOURCES Under revision 3

4 MOST RELEVANT VECTORBORNE DISEASES IN NEW JERSEY TICK MOSQUITO Locally acquired Lyme (517) Babesiosis (193) Anaplasmosis (154) Spotted Fever Group Rickettsiosis (137) Ehrlichiosis (12) Powassan (4) Locally acquired West Nile Virus (8) Eastern Equine Encephalitis () Travel-related Malaria (125) Zika (37) Dengue (25) Chikungunya (12) UNCOMMON AND EMERGING VECTORBORNE DISEASES OF POSSIBLE CONCERN Could be acquired within the U.S. International travel-related Tick Heartland Virus Midwest, South Bourbon Virus Midwest, South Powassan Northeast, Great Lakes Mosquito Eastern Equine Encephalitis East coast, Great Lakes, Mississippi LaCrosse Virus Upper Midwest, mid-atlantic, SE states Jamestown Canyon Virus New York, Connecticut Mosquito Usutu virus Austria, Europe Yellow fever Africa, S. America All are arboviruses, many of which can be neuroinvasive. NEW TICK OF POSSIBLE CONCERN ASIAN LONGHORNED TICK (Haemaphysalis longicornis) First U.S. identification - Hunterdon County, 217 Now in Hunterdon, Union, Bergen, Middlesex, Mercer Other states: NC, WV, VA, AR, NY, PA, MD Collected from: sheep, deer, cow, raccoon, opossum, horse, goat, dog, cat NJ Department of Agriculture Information Line: 833-NEW TICK or Impact on human health unknown Testing of the tick for human pathogens so far negative In Asia, Australia associated with Powassan, a viral hemmorhagic fever and Japanese Spotted Fever. Surveillance is ongoing 4

5 REPORTABLE TICKBORNE DISEASES IN NEW JERSEY, # CASES DEER TICK (Ixodes scapularis or blacklegged tick) 6 Lyme Disease Cases by Year, New Jersey,

6 DEER TICK (Ixodes scapularis or blacklegged tick) Select Tickborne Diseases Transmitted by Deer Ticks, NJ, by Year Babesiosis Anaplasmosis Powassan LYME DISEASE, BABESIOSIS and ANAPLASMOSIS 5-year incidence rates by county, (per 1, population) DEER TICK -UPDATES FIRST REPORTED B. Miyamotoi infections TRANSFUSION-TRANSMITTED BABESIOSIS Borellia miyamotoi identified in ticks in Japan 211 found to be a pathogen in humans in Russia 213- first cases in U.S., including Hunterdon Co. Not a reportable disease; reporting encouraged September cases identified in Cape May and Warren Counties Symptoms range from flu-like illness to meningoencephalitis Most common transfusion-transmitted pathogen Leading cause of mortality in transfusion recipients Timely investigations needed to identify h/o blood transfusion/donation or organ transplant Expect more LHD inquiries re: transfusion dates, blood products and sources New NJDOH Babesiosis Investigation Worksheet includes questions about transfusion/donation 6

7 AMERICAN DOG TICK (Dermacentor variabilis) NJ Spotted Fever Group Rickettsiosis Cases, by Year Spotted Fever Group Rickettsiosis (SFGR) Rocky Mountain Spotted Fever Other less common diseases: Tularemia SPOTTED FEVER GROUP RICKETTSIOSIS 5-year incidence rates by county, (per 1, population) AMERICAN DOG TICK - UPDATE SPOTTED FEVER GROUP RICKETTSIOSIS PCR testing on whole blood, rash/eschar biopsies now available at NJ PHEL/CDC Indications: 3 to 8 days after symptom onset or in severely ill patients Specimen: Before or within 24 hours of antibiotics 3 ml of whole blood in a lavender top tube Biopsy tissue or eschar swab specimens in dry, sterile container Forms: Complete SFGR Investigation worksheet Approval: to NJDOH Vectorborne Disease Team: CDSVectorTeam@doh.nj.gov Don t delay initiation of antibiotic therapy! Send acute and convalescent serology specimens to commercial lab 7

8 LONE STAR TICK (Ambylomma americanum) 12 1 NJ Ehrlichiosis Cases, by Year Ehrlichiosis: E. chaffensis, E. ewingii Less common diseases: Tularemia Heartland Virus Bourbon virus STARI Red meat allergy EHRLICHIOSIS 5-year incidence rates by county, (per 1, population) GULF COAST TICK HAS IT ARRIVED IN NJ? Rickettsia parkeri Less severe illness that Rocky Mountain Spotted Fever so probably not hospitalized Almost always associated with an inoculation eschar at site of tick attachment PCR testing and convalescent serologies can help to differentiate from the more serious Rocky Mountain Spotted Fever PCR specimens before or within 24 hours of antibiotics (PHEL/CDC) 3 ml of whole blood in a lavender top tube Swab of eschar in dry, sterile container Convalescent specimens 2-4 weeks after acute (commercial lab) 8

9 MOSQUITO-BORNE DISEASE IN NJ RESIDENTS Travel-related Malaria (125) Zika (37) Dengue (25) Chikungunya(12) Locally acquired West Nile Virus (8) Eastern Equine Encephalitis () REPORTABLE MOSQUITO-BORNE DISEASES, NEW JERSEY, (travel-associated and locally-acquired) # CASES % Travel-related 7% Locally-acquired MOSQUITO-BORNE DISEASE CASES (TRAVEL-ASSOCIATED) 25 Malaria, Dengue, Chikungunya, Zika, New Jersey, Malaria Dengue Chikungunya Zika 9

10 MALARIA DISTRIBUTION MAP Rückert, C. et al. Impact of simultaneous exposure to arboviruses on infection and transmission by Aedes aegyptimosquitoes. Nat. Commun. 8, doi: 1.138/ncomms15412 (217 MALARIA 5-YR INCIDENCE BY NJ COUNTY, (PER 1,) All NJ cases are travel-associated CHIK/DENV/ZIKA DISTRIBUTION MAP Rückert, C. et al. Impact of simultaneous exposure to arboviruses on infection and transmission by Aedes aegyptimosquitoes. Nat. Commun. 8, doi: 1.138/ncomms15412 (217). 1

11 CHIKUNGUNYA, DENGUE, ZIKA 3-YR INCIDENCE BY NJ COUNTY, (PER 1,) All NJ cases are travel-associated ZIKA - PERSONS TESTED AND CASES IDENTIFIED, Persons approved for testing at PHEL, n = 5411 # of Zika cases identified, n = # of persons # of cases Early in the outbreak, PCR, serology and confirmatory PRNT testing were only available at CDC, then regional public health laboratories and finally at commercial labs. Confirmatory testing is not yet available commercially. No. of cases Jan Mar May Jul Sep Nov Jan Mar May Jul Sep Nov Jan Mar May Jul ZIKA monitoring zika positive pregnant women and their infants in NJ Jamaica, 3 Puerto Rico, 6 Guatemala, 6 El Salvador, 4 NJ Maternal Travel Locations, N= 86 Unknown, Cameroon, 1 Guyana, 1 Colombia, 1 Nicaragua, 1 Mexico, 3 Ecuador, 3 Honduras, 5 Haiti, 1 N/A, Dominican Republic, 41 Maternal County of Residence PASSAIC UNION 14 ESSEX 1 MERCER 1 HUDSON 7 CAMDEN 6 MONMOUTH 4 BERGEN 2 MIDDLESEX 2 CUMBERLA 2 BURLINGTON 1 SOMERSET 1 WARREN 1 SUSSEX 1 ATLANTIC CAPE MAY GLOUCESTER HUNTERDON MORRIS OCEAN SALEM UNKNOWN 25 Hospitals with 2 or > deliveries: St. Joseph s (25), Trinitas (12), Capital Health Hopewell (9), Clara Maas (5), Cooper (5), Hackensack (3), Newark BI (3), St. Peter s (3), University, Newark (3), Monmouth (3), Inspira, Vineland (2) 11

12 ZIKA - KEY UPDATES AT YEAR 3 1 in 7 infants evaluated in U.S. territories with local Zika transmission had a Zika-related conditions. Careful monitoring of infants born to infected mothers is essential for early detection of developmental abnormalities. Continue to screen pregnant women for travel/ Zika exposure. Men with possible Zika exposure should wait 3 months before unprotected sex. All NJ cases are travel-associated MOSQUITO-BORNE DISEASE CASES (LOCALLY-ACQUIRED) 6 West Nile Virus and Eastern Equine Encephalitis Virus, New Jersey, West Nile Virus Eastern Equine Encephalitis WEST NILE VIRUS 1-YEAR INCIDENCE RATES BY NJ COUNTY, data is preliminary 12

13 WEST NILE VIRUS NEUROINVASIVE DISEASE INCIDENCE TRENDS Incidence by year, , U.S. Incidence by state, 217, US 5 cases WEST NILE VIRUS CASES, human cases 4 male, 4 female Mean age 64 years (41-8 yrs) 6/8 neuroinvasive presentation 15d average hospitalization 2 deaths WEST NILE VIRUS CASES, human cases 1 male, 9 female Mean age 65 years (24-8 yrs) 15 cases neuroinvasive 7 day average hospitalization deaths 13

14 EASTERN EQUINE ENCEPHALITIS NEUROINVASIVE DISEASE # of U.S. cases, States where cases reported, data is preliminary EASTERN EQUINE ENCEPHALITIS data is preliminary ARBOVIRUSES THAT CAN CAUSE NEUROINVASIVE DISEASE Documented in NJ Within the U.S. International West Nile Eastern equine encephalitis Powassan (tick) In states near/similar to NJ La Crosse Heartland Bourbon Jamestown Canyon West Nile Eastern equine encephalitis Western equine encephalitis St. Louis encephalitis California encephalitis La Crosse Jamestown Canyon Colorado tick fever (tick) Powassan (tick) Bourbon virus (tick) West Nile Eastern equine encephalitis Western equine encephalitis St. Louis encephalitis Venezuelan equine encephalitis Japanese encephalitis Tickborne encephalitis Murray Valley encephalitis Rift Valley fever Toscana virus (sandfly) Zika Dengue Chikungunya Powassan (tick) Usutu Sinbis TRAVEL HISTORY IS IMPORTANT! 14

15 Found in states near / similar to NJ Midwest & South Heartland Virus La Crosse Virus Bourbon Virus Found in other areas of the U.S. St. Louis Encephalitis Virus Jamestown Canyon Virus Colorado Tick Fever ARBOVIRAL SYSTEMIC ILLNESS VS NEUROINVASIVE DISEASE Systemic lllness Febrile illness Fever/rash/arthalgias, myalgias Flu-like illness Flu-like illness with arthralgias, conjunctivitis Flu-like illness with N&V Flu-like illness with N&V, hepatitis, rash, hemmorhagic fever Neuroinvasive Diseases Meningitis Encephalitis Myelitis Encephalomyelitis Neuritis Myositis Frequent forerunners of neuroinvasive disease: altered mental status, muscle weakness/paralysis ARBOVIRAL TESTING Testing options Commercial Available for many arboviruses: WNV, Zika, Dengue, Chikungunya Public health or specialty laboratories: Rare or emerging diseases: EEE, Jamestown Canyon, Powassan, Yellow Fever NOTE: Currently limited at NJ PHEL Testing at NJ PHEL or CDC Case-by-case consultation Focus Hospitalized patients Clinically compatible illness Neuroinvasive presentation Suspected arboviral disease Risk factors e.g., known outdoor exposures / travel history Absence of another known etiology 15

16 REQUESTING ARBOVIRAL TESTING FOR HOSPITALIZED PATIENTS WITH NEUROINVASIVE DISEASE 1. Complete the NJDOH Arboviral Testing Request Worksheet 2. to NJDOH at: (preferred) or fax to If approved, CDS Vector Team sends SRD-1 form for completion along with specimen collection and shipping instructions. 4. When specimen collection date/time and submitting laboratory information is completed, or fax the completed form to the CDS Vector Team as above. 5. Testing can take up to 3 weeks from time specimen is received at CDC (via PHEL). Results will be faxed to HCP and hospital listed on SRD-1form. NJDOH Arboviral Testing Request Worksheet INFORMATION TO GATHER ARBOVIRAL WORKSHEET Signs & Symptoms Fever Headache Myalgia Rash Altered mental status Stiff neck / meningeal signs Seizures Lab Information / Test Results CBC - WBC CSF glu, prot, WBC Brain imaging Current Diagnosis: Encephalitis Meningitis Other Testing to R/O other causes: Cytomegalovirus Enteroviruses Epstein Barr virus Herpes Simplex virus La Crosse virus St. Louis Encephalitis Varicella Zoster West Nile virus Travel / exposure risk factors Vaccination history Japanese Enceph., Yellow Fever, Dengue Transfusion / transplants IN CONCLUSION Tick and mosquito-borne disease cases in NJ are increasing Travelers and ticks are on the move Human AND vector surveillance are needed to identify new pathogens and monitor ones we know about Diagnosis of rare or emerging diseases (B. miyamotoi, Powassan, Bourbon virus, Heartland virus) rely on clinician awareness and specialized testing 16

17 Karen Worthington, MS, RN Vector-borne Disease Team Communicable Disease Service NJDOH Tel: NJDOH VBD Team Colin Campbell, DVM, CPM Kristin Garafalo, MPH, CHES Lindsay Lowe Moji Ojo, MPH Krista Reale, MA, CHES Kim Cervantes, MA, MPH, CIC 17