INFECTION PREVENTION NEWS & UPDATES

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1 FEBRUARY 2018 INFECTION PREVENTION NEWS & UPDATES MULTI-COUNTRY OUTBREAK CONTACT + VECTOR NIGERIA, BRAZIL YELLOW FEVER The previously reported outbreak of Yellow Fever in Nigeria has now infected 358 people and caused 45 deaths. The majority of the people affected are under 20 years old. The outbreak was first reported in August Nigeria is applying substantial public health resources to control the outbreak including vaccination and active surveillance (testing of people in the area). Brazil experienced a large Yellow Fever outbreak in , After 6-9 months with virtually no cases, there has been an increase in cases in the last 6 months. There have been 1,080 suspected cases, 213 confirmed cases, and 81 deaths, primarily in the states of Sao Paulo and Minas Gerais. It is not clear at this point what the source of the infection is, but it is believed to be epizootic (animal to human). The Sao Paulo zoo and a number of public parks have been closed until further notice as preventative measures and the Brazil government has started another mass vaccination campaign. The virus that causes Yellow Fever is spread by Aedes mosquitoes, and as with Dengue and Zika, efforts to control Yellow Fever center on mosquito control. The symptoms of Yellow Fever are similar to other mosquitoborne diseases, including fever, chills, headache, back pain, body aches, nausea, and fatigue, but can include jaundice (yellowing of skin color), which is how the infection was named. While most people that get Yellow Fever show no symptoms, about 15% of those that show symptoms develop the more severe form of the disease, which includes the jaundice, high fever, bleeding, and eventually shock and organ failure. For those that develop symptoms, the mortality rate for Yellow Fever is 20-50%. If traveling to the Nigeria, you should discuss with your doctor whether you should have the Yellow Fever vaccination. Anyone planning to travel to areas of high risk for Yellow Fever will typically be advised to be vaccinated in advance.

2 MULTI-COUNTRY OUTBREAK CONTACT USA, EUROPE HEPATITIS A Hepatitis A has been causing outbreaks across many countries in Europe in This trend is expected to continue in 2018, while the peak of the outbreak appears to have occurred in March An estimated 3,813 cases have been reported across 22 European countries that are associated with the outbreak. Additionally, 15,000 Hepatitis A cases were reported in Europe for Jan-Nov 2017, which includes the outbreak cases, which is roughly a 360% increase versus the typical number of cases of Hepatitis A that occur in Europe. Males are 3 times more likely to get Hepatitis A than females in Europe currently. A specific example of the issue of measles in Europe is a recent increase in cases in Leeds in the UK. More than 60 cases have been reported in the last 6 weeks. This is part of a larger trend in the UK where 372 cases have been reported in the 6 weeks before 7 Jan The vast majority of people infected were never immunized, which some were previously immunized, but have not received the recommended boosters later in life. The cases in the UK comes on the heels of the UK being declared measles-free in Sept 2017, which suggests most cases are travel related. A Hepatitis A outbreak in Utah in the United States has infected 152 cases since Jan Genetic testing has linked several of the cases to the outbreak in California and Arizona. As with the other outbreaks, being homeless or an IV drug user increases the chances of contracting Hepatitis A. Hepatitis A is an infection that causes an inflammation of the liver. There are a number of viruses that can cause Hepatitis including Hepatitis A, Hepatitis B, and Hepatitis C, with vaccinations available for Hepatitis A and Hepatitis B. Hepatitis A is passed to other people through contact with infected feces, or if an infected person touches objects after using the toilet and not washing their hands, including contaminating food or drink from contact with contaminated hands, so handwashing and surface disinfection are important interventions to prevent the spread of the virus. It can also be spread by sexual contact. The virus can also be spread through contact with diapers or the stool of an infected child/person. It can take from days to develop symptoms once infected. Preventing Hepatitis A infections involves vaccination of high risk people, hand hygiene, environmental disinfection, and safe sexual practices. The virus causing this illness is hard to kill and AHP hydrogen peroxide disinfectants are the best option to kill it on environmental surfaces as low level disinfectants have minimal effect on Hepatitis A virus. In countries where disinfectants are often not used when cleaning, this is especially concerning because the virus can survive for periods of time in the environment in feces (most likely days to weeks) which allows for time for them to be transmitted from person to person.

3 CONTACT + DROPLET + VECTOR LASSA VIRUS/LASSA FEVER The outbreak of Lassa Fever in Nigeria from Q1-Q was believed to have ended, but 107 suspected cases were reported in the last month, triggering concerns that another outbreak may be starting. In a country where Lassa Virus infections are endemic, there are always a small number of cases, but sudden increases such as this often signal the start of an outbreak. The government of Nigeria has activated outbreak control procedures across the country. The Lassa virus is transmitted primarily via rats which are believed to be the primary host for the virus. Infected rats secrete the virus in urine and feces, so cleaning areas where rats are prevalent can spread the virus as can food preparation with dead rats and eating infected rats. NIGERIA Lassa Fever is a viral hemorrhagic fever with a high mortality rate and outbreaks of Lassa Fever in Africa are not unusual, but are always of a concern because of the ease with which the virus can be carried to other countries by infected people.

4 CONTACT + VECTOR CHOLERA Yemen s outbreak of cholera in 2017 totaled 1,029,717 cases with 2,241 deaths (0.22%). Children under 5 years old were 28.6% of all cases. The outbreak has finally slowed, but smaller numbers of cases continue to be reported daily in the largest cholera outbreak ever recorded in modern history. Cholera is an infection caused by a bacterium, Vibrio cholera. Cholera outbreaks usually occur due to contaminated water supplies especially where sewage contaminates the water supply. Cholera infections are an indication of the fragility of the water supply and waste treatment systems. YEMEN Cholera infections can be prevented by vaccination, access to clean water and proper sanitation for wastes. In countries without access to clean drinking water and proper sewage treatment, risks of a Cholera outbreak are usually significantly increased.

5 VECTOR MALARIA In addition to the widespread cholera outbreak in Yemen, the rates of malaria have increased as well. In 2017 there were 433,000 cases versus the 336,000 cases in 2016, which is roughly a 30% increase. Malaria is caused by the Plasmodium parasite that infects Anopheles mosquitoes, which in turn infects people. There are more than 100 species of Plasmodium that can infect animals and people. There are an estimated 214 million cases of malaria each year in people resulting in 438,000 deaths, mostly children in Africa. YEMEN As Malaria is transmitted via mosquitos, control of mosquitoes is an important part of combatting Malaria infections, including use of mosquito repellants and eliminating breeding grounds for mosquitoes. If traveling to an area with high levels of Malaria, recommended precautions include the use of Malaria pills, insect repellant, long-sleeved clothing, bed nets, and the use of door and window screens or air conditioning (to reduce the potential for mosquitoes to enter buildings).

6 CONTACT + VECTOR DENGUE FEVER VIRUS Sri Lanka has experienced a high number of cases of Dengue Fever in 2017 with 184,442 cases reported with 320 deaths. This is 3 times higher than in previous years, indicating that the current control practices are not achieving the desired effect. Dengue Fever is a viral infection caused by the Dengue virus and transmitted primarily by the Aedes mosquito. Annually, up to 400 million people are believed to become infected with Dengue virus each year with only 100 million (25%) showing symptoms. This makes Dengue infections routine, especially in Southeast Asia. SRI LANKA As Dengue is transmitted via the same mosquito as Zika, control of mosquitoes is an important part of combatting Dengue infections. Countries should have and aggressively enforce mosquito suppression programs to reduce the risk of Dengue infections. Testing for Dengue can help rule out other infections which may present with similar symptoms, but not all countries can afford routine testing.

7 CONTACT + DROPLET JAPAN HAND, FOOT AND MOUTH DISEASE Japan experienced about 70,000 cases of Hand, Foot, and Mouth (HF&M) disease in However in 2017 they experienced a significant increase in cases, with 358,764 cases reported, which is similar to 2015 when 380,000 cases were reported. The wide variation between years shows the impact of outbreaks on case totals as localized outbreaks can infect hundreds or more and the importance of infection prevention precautions as a part of daily hygiene. Hand, Foot, and Mouth (HF&M) disease is caused by several different enteroviruses, including Enterovirus 71 (EV-A71) and Coxsackievirus A16. HF&M causes painful sore/blisters in the mouth, on the palms of the hands, on the buttocks, and on the feet. In rare cases, severe side effects can be life threatening and cause death. The fluid from the blisters can be contagious and control measures should be used to prevent the spread of the virus. Outbreaks of HF&M are common globally, with cases being routinely reported in many countries. Summer months in Southeast Asia historically show the most activity. Preventing Hand, Foot, and Mouth disease involves hand hygiene, environmental disinfection, and respiratory hygiene practices. The virus causing this illness is hard to kill and AHP disinfectants are the best option to kill it as low level disinfectants have minimal effect on enteroviruses. Because the virus can be present in feces, changing the diaper of a baby with HF&M should be followed by thorough hand washing.

8 MULTI-COUNTRY OUTBREAK CONTACT + DROPLET USA, NEW ZEALAND WHOOPING COUGH/PERTUSSIS Clusters of Pertussis cases have been occurring across the US, with notable clusters in Colorado, Minnesota (800 cases), and North Carolina. New Zealand has reported 24 probably and confirmed cases and an increasing case total. While outbreaks of Pertussis tend to be small and to primarily affect unvaccinated people, the severity of the infection is always cause for concern, especially in children. Pertussis (Whooping Cough) is caused by the bacteria Bordetella pertussis, which attaches itself to the lining of the lungs producing inflammation and coughing fits that include a characteristic whooping sound. The bacteria can be transmitted from person to person by respiratory secretions from coughing and sneezing which can be inhaled or indirectly contacted. Outbreaks of Pertussis are usually related to a lack of vaccination. It is important that all people receive immunization to ensure a high degree of immunity. The best defense is for all staff to be immunized. Facilities should have immunization requirements to protect staff and customers. The bacteria can be transmitted via environmental surfaces and hands, so good hand hygiene and proper surface cleaning and disinfection are also important parts of preventing the spread of Pertussis.

At Diversey, we reduce the risk of infection to make your facility safer Across our customers facilities, our comprehensive cleaning, disinfection, and hand hygiene programs provide the solutions and

Diversey provides resources to help our customers manage outbreaks including providing education and training for our customers regarding best practices for cleaning, disinfection, and hand hygiene

9 At Diversey, we reduce the risk of infection to make your facility safer Across our customers facilities, our comprehensive cleaning, disinfection, and hand hygiene programs provide the solutions and expertise needed to reduce the risk of infection while increasing operational efficiency. Diversey provides resources to help our customers manage outbreaks including providing education and training for our customers regarding best practices for cleaning, disinfection, and hand hygiene in healthcare and public environments. INFLUENZA 3-5 MILLION people infected globally each year 250, ,000 deaths Our best in class solutions include the following: AHP Hydrogen Peroxide Disinfectants Realistic contact times that kill pathogens before surfaces dry Excellent staff safety profile - can be used without personal protective equipment Strong cleaning ability to reduce environmental bioburden Excellent sustainability profile to reduce environmental impact Available in a range of formats including prewetted disposable wipers IntelliCare Hand Hygiene Program Innovative dispenser including patented hybrid manual/touchless Full product range and formats from a single dispenser Electronic compliance monitoring program to increase efficiency Trusted brands, such as Lux, for a more home-like experience Our experts frequently consult with our customers on environmental hygiene practices for facilities in a wide range of industries including healthcare, hospitality, education, offices, and public buildings such as retail stores, shopping malls, and airports. Not all outbreaks are environmentally transmitted, but even for those with minimal environmental routes of transmission, we still help customers with other aspects of prevention to create safer facilities Diversey 21 million people infected in the US alone each year with deaths. NOROVIRUS PERTUSSIS WHOOPING COUGH 16 million people infected globally each year, 200,000 deaths. 20 million infected globally each year, 146,000 deaths MEASLES DENGUE 400 million people infected globally each year, 12,500 deaths

INFECTION PREVENTION NEWS & UPDATES

INFECTION PREVENTION NEWS & UPDATES CONTACT + DROPLET EBOLA INFECTION While the Ebola outbreak from the Democratic Republic of the Congo from earlier this year is over, a new outbreak of Ebola has been identified that has infected at least