April 2018 Communicable Disease Forum Webinar April 26, :00 3:00 PM NJ Department of Health Communicable Disease Service

Transcription

1 April 2018 Communicable Disease Forum Webinar April 26, :00 3:00 PM NJ Department of Health Communicable Disease Service Welcome to the webinar Today s webinar is being recorded and archived. It will be posted to the NJ Department of Health website. Continuing Education Credits Credits offered for this webinar: 2.0 Public Health and Nursing Credits provided to those who attend the webinar live Must also be registered on Go To Webinar and NJLMN to be eligible for credits NOTE: Those viewing the webinar in the archived version are not eligible to receive continuing education credits. 1

2 Questions during the webinar? All attendee lines are muted. Please use the Question box to ask a question. Questions will be answered at the end of the webinar, time permitting. Webinar handouts Handouts (slides and resources) may be accessed in the Handouts box. Handouts on Go To Webinar are only available during live webinars Handouts also posted to NJLMN in Practice Exchange After the You will receive a link to the evaluation after the webinar. The evaluation link will be sent to your NJLMN address Those seeking continuing education credits MUST complete the evaluation within 5 days after receiving link Evaluation link closes after 5 days After the evaluation closes, certificates are ed to the address listed in NJLMN (for nurses); and attendance is verified in NJLMN (for PH) Those who do not complete the evaluation will not receive credits 2

3 Reminder You must be registered on both Go to Webinar and NJLMN Link to evaluation ed to NJLMN address only. If you are not registered on NJLMN, you will not receive the link. Complete evaluation for continuing education credits Certificates for RNs ed after evaluation closes; Attendance verified for licensed PH professionals Once webinar is posted to the NJDOH website, we will notify via NJLMN Upcoming trainings, webinars, and conferences May 2, :30 11:30am NJ Public Recreation and Bathing: New Regs (Webinar). FREE. No credits. Register at Go To Webinar. Webinar ID: May 22, am 11am Tick borne Diseases: What NJ Public Health Professionals Need to Know (Webinar). FREE. Public Health credits. Register online via NJLMN: and Go to Webinar : Webinar ID: June 12, :30 3:30 4 th Annual NJ Drug Diversion Conference, Responding to Drug Diversion in Health Care Settings at Rutgers University. CME, CNE, CPE, CHES credits. $50/pp. Link to register: July 12, :30 11:30 Communicable Disease Forum (Webinar). FREE. Nursing and Public Health credits. Register on NJLMN and Go To Webinar. Webinar ID: Stay tuned this coming fall In person CD Forum LTCF in person training Communicable Disease Forum Webinar Agenda 1 1:20 pm Welcome, Housekeeping, and Program Updates Sherif Ibrahim, MD, MPH, Regional Epidemiology Program Manager 1:20-1:50 pm Itching for a Mosquito Update Kim Cervantes, MA, MPH, CIC, Vectorborne Disease Program Coordinator 1:50-2:15 pm CDRSS 2.0: What You Need to Know Dela Darji, MPH, CDRSS Coordinator Jennifer Lawall, MPH, Health Data Analyst 2:15-2:45 pm Case Study: A Case of Brucella abortus RB51 Associated with Raw Milk Consumption Kristen Garafalo, MPH, CHES, Zoonotic Disease Epidemiologist 2:45-3 pm Questions & Answers Type questions into the chat box during the webinar 3

4 NJDOH Communicable Disease Service Program Updates Regional Epidemiology Program New Regional Epidemiologist, Brett Nance, MPH, for the Southern Region covering (Camden, Gloucester, Cumberland, and Salem) REP is on the process of hiring two more regional epidemiologists Influenza Season (as of 4/7/18) Peak occurred in mid February Influenza AH3 was predominant virus 51 severe pediatric influenza case reported and 3 influenza associated pediatric deaths reported 183 respiratory outbreaks reported on long term care facilities ED visits and admission were higher than both and seasons which were the last 2 significant AH3 seasons As seasonal influenza declines, the summer tends to be when novel viruses circulate so it s important to continue to be vigilant for unusual respiratory illness in the coming months. 4

5 Infection Control Assessment and Response (ICAR) ICAR activities have been extended for an additional year, ending March 2019 The ICAR team will continue to recruit facilities for assessments, focusing on longterm care facilities Any interested facilities can contact the ICAR team at or at (609) More information can be found on the ICAR website, here: ml RESOURCES: Keeping Legionella out of water systems in buildings is key to preventing infection Water management programs have been established as an industry bestpractice for building water systems, including healthcare facilities, in the United States. For more information about water management programs, visit Centers for Medicare and Medicaid Services (CMS) released a memorandum that mandates CMS certified healthcare facilities to have water management policies and procedures to reduce the risk of growth and spread of Legionella and other opportunistic pathogens in building water systems. For more information, visit Enrollment and Certification/SurveyCertificationGenInfo/Downloads/Survey and Cert Letter pdf REMINDER: The peak season for legionellosis is approaching (summer and early fall) All legionellosis case patients should be interviewed to determine exposures during their incubation periods. A hypothesis generating questionnaire can be used when investigating single cases of legionellosis to collect additional epidemiologic data, visit generatingquestionnaire.pdf Information should be entered into each CDRSS case. This information helps detect both local and travel related clusters and outbreaks. 5

6 Hepatitis C Surveillance Reminders Any new cases involving dialysis are high risk for seroconversion. These require investigation to determine if the case was already HCV positive prior to starting dialysis. If you receive a verbal report or CDS 17 that states that the case has a Negative HCV Nat or a prior Negative HCV AB please request a hard copy of that lab report for confirmation. Signs and Symptoms, Notification and Education, and Risk Factors do not get picked up from the comment tab. Those need to be placed in the drop down boxes to be counted. Always start with a person search for potential prior cases; no duplicates! This is the link to the guidance document and webinar slides for reference: Multidrug resistant organism (MDRO) updates The NJDOH is seeking labs to submit the following isolates for antimicrobial resistance mechanism testing: Carbapenem resistant Klebsiella pneumoniae Carbapenem resistant Pseudomonas aeruginosa Contact patricia.barrett@doh.nj.gov to submit isolates Antibiotic stewardship training opportunity The CDC has released the first of four training modules on antibiotic stewardship All four modules provide free continuing education credits for: CME, CNE, CEU, CECH, and CPE, and CPH Register at: 30/ 6

7 VPDP Update: Measles 1 confirmed measles case in NJ in measles cases reported/investigated; 4 reports were ruled out Measles exposures occurring at many locations throughout the United States, including exposures of NJ residents NJLINCS Messages: 1/12 (Newark Airport), 3/14 (Newark Airport), 3/27 (KS, MO, MI, NJ, TN), 4/3 (NYS), 4/24 (NYS) Multiple measles flight notifications: 7 flights; 57 passengers exposed 13 additional NJ residents identified as exposed in other jurisdictions Remain vigilant for cases of measles (consider measles in persons who present with fever and rash), and stress the importance of receiving up to date immunizations, especially prior to international travel Measles resources: Multistate Outbreak of E. coli O157:H7 Infections Linked to Romaine Lettuce DEEPAM THOMAS FOODBORNE DISEASE SURVEILLANCE COORDINATOR Background U.S and N.J Case Counts Appx. 265,000 cases nationally Appx. 254 cases in NJ STEC serotypes Over 200 different recognized serotypes Distinguished by their major surface antigens O & H E.Coli O157:H7 vs Non O157 Outbreaks usually caused by O157 Other STEC serogroups include O145, O26, O111 & O103 7

8 Transmission, Incubation and Clinical Features Modes of transmission Contaminated food Contaminated water Exposure to animals or their environment Person to person Risky food (unpasteurized milk/juice, inadequately cooked meat) Incubation period 3 4 days after exposure (Range: 1 10 days) Clinical Features Abdominal pain Bloody diarrhea HUS Testing, Case Definitions and Investigation Lab testing Culture, Enrichment broths Confirmed by NJPHEL Matched by PFGE Case Definition Confirmed Probable Possible Case Investigation STEC Case Report Form (CDS 40) Checklist 8

9 The beginning Increase in STEC cases compared to last year 6 STEC cases; 3 separate Panera locations (3/29/18 4/3/18) Informed CDC of increase (4/2/18) Prioritized interviews, Expedited testing at NJPHEL Inspection/invoices/testing/traceback (4/4/18) 2 PA cases with similar exposures, CDC assigned a cluster code CDS CC with LHDs on 4/6/18, LINCS message sent on 4/7/18 CDC/FDA/Multistate call on 4/9/18 (19 cases from 9 states, with 6 in NJ) April 10, 2018 (n=17) April 13, 2018 (n=35) April 18, 2018 (n= 53) Multistate Cluster Summary of confirmed NJ cases Total number of confirmed cases in NJ: 7 Counties Involved: Hunterdon (4), Monmouth, Somerset, Sussex Age range: yrs., Median 46 yrs. Illness onset range: 3/15/18 3/26/18 6/7 cases are White & Female 6/7 cases were Hospitalized; 6/6 have been discharged, 1/6 cases HUS, and discharged 7/7 cases reported romaine lettuce in the week before illness onset 9

10 and the outbreak continues. Itching for a Mosquito Update? Communicable Disease Forum, April 2018 Kim Cervantes, MA, MPH, CIC Vector-borne Disease Coordinator Overview VBD surveillance partners & resources Arboviral diseases impacting NJ Key investigation data Arboviral testing resources 10

11 NJDOH NJMCA Lab Assoc Execs LHD Mosquito-borne Disease Surveillance NJDA SMCC Surveillance Partners Rutgers CMCA NJDEP What s going on during the season? NJDOH Vector-borne Disease Surveillance Report: atistics/arboviral-stats/ Rutgers University vector and adult mosquito population surveillance reports: rveillance.php 11

12 Arboviral diseases affecting NJ Endemic West Nile virus (WNV) Eastern Equine encephalitis (EEE) Travel-associated Chikungunya Dengue Emerging/Possible Concerns Powassan Jamestown Canyon La Crosse virus Yellow fever Usuto virus Zika All 2017 data is preliminary and subject to change West Nile Virus (WNV) West Nile virus (WNV) 1 in 5 persons infected develop symptoms Fever, headache, body aches, joint pains, vomiting, diarrhea, rash Average annual incidence of West Nile virus neuroinvasive disease reported to CDC by age group, in 150 persons infected develop severe, sometimes fatal illness Encephalitis, meningitis, limb weakness, paralysis 1 in 10 persons with severe illness die 12

13 WNV Incidence National & by State West Nile virus neuroinvasive disease incidence reported to CDC by year, ,000 cases West Nile virus neuroinvasive disease incidence by state US, 2017 (as of January 9, 2018) WNV 10-Year Incidence Rates by NJ County, data is preliminary NJ WNV Cases, human cases 4 male, 4 female Mean age 64 years (41-80 yrs) 6/8 neuroinvasive presentation 15d average hospitalization 2 deaths 13

14 Eastern Equine Encephalitis (EEE) Alphavirus transmitted by an infected mosquito What is Eastern Equine Encephalitis? Enzootic cycle Ornithophilic mosquitoes (Culiseta melanura) & passerine birds in freshwater swamps Other species implicated as bridge vectors Human illness is rare Horses are susceptible EEE neuroinvasive disease cases reported by state, Human illness/cases 2016 Most infections asymptomatic (severe illness 4-5%) Symptoms: fever, headache, chills, vomiting, disorientation, seizures, coma cases / 5 states 6/7 (86%) encephalitis Median age 63 yrs (57% >60 yrs) 6/7 (86%) male Illness onset July October All hospitalized 3/7 (43%) died Human cases underestimated EEE cases reported by state,

15 NJ EEE Activity 2016 Mosquito pools Middlesex County: 3+ EEE pools Passaic Morris Middlesex Horses Morris County: 2 that were <5 miles from each other (onsets Aug 9, Aug 23) Ocean County: 1 (onset Aug 26) Passaic County: 1 (onset Sept 5) Human case Passaic County: 1 (onset Sept 30) EEE Positive Mosquito Pools County Salem 5 Burlington 3 1 Cape May 3 2 Atlantic 3 1 Camden 1 2 Cumberland 1 Gloucester 1 1 Monmouth 1 1 Middlesex 3 Total EEE activity ,745 Cs. Melanura mosquitoes (742 pools) from 15 counties tested 18 EEE + pools 18,491 specimens / 21 other species tested, 0 positive 6 EEE+ horses 5-yr avg = 4 / yr All in south jersey 0 human cases Travel-associated arboviruses Chikungunya Dengue Zika 15

16 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: /ncomms15412 (2017). Chikungunya, Dengue, Zika 3-yr incidence by NJ County, (per 100,000) All NJ cases are travel-associated 4 virus serotypes Up to 75% infections asymptomatic High fever, severe headache, muscle and joint pain, rash, mild bleeding manifestations Dengue Travel-associated and locally-acquired dengue cases, 2017 (preliminary as of 2/28/18) 5% severe disease fever resolves, increase in capillary permeability hemorrhage, shock Untreated, severe dengue mortality rate 20% - properly managed <1% Infection confers lifelong immunity to 1 serotype BUT increases risk of severe disease if infected with 2 nd serotype 598 total cases, 21 NJ 9 severe dengue cases, 0 NJ mid-july early Nov 16

17 Up to 80% infections asymptomatic Mild illness fever, rash, conjunctivitis, joint pain, headache, muscle pain Rare cases of Guillain-Barré syndrome Transmitted sexually Zika Associated with birth defects, including microcephaly Pregnant women should avoid travel to areas of risk 433 symptomatic cases in US States * 12 symptomatic cases in NJ 5 locally acquired cases (2-FL, 3-TX) 7 sexual transmission cases 25 asymptomatic infections in NJ Zika in NJ, cases 37 cases 3,020 persons tested 2,157 persons tested Chikungunya 75% infections are symptomatic Sudden onset high fever, severe/debilitating joint pain, muscle pain, headache, rash Neurologic complications and mortality are rare Severe joint pain may persist months or years Infection thought to confer lifetime immunity Reported Cases, 2017 (preliminary as of 1/9/18) 114 cases, US States, 10 NJ NJ 4 th highest number No locally acquired cases 17

18 Emerging and/or Potential Arboviruses Tickborne disease blacklegged tick Powassan Cases may be asymptomatic or mild Testing available via public health labs Symptoms: fever, headache, vomiting, muscle weakness Severe illness: encephalitis, meningitis, altered mental status, seizures, speech and movement disorders ½ permanent neurological disorders 10% mortality 31 cases, 4 NJ NJ 3 rd highest number cases NJ test requests: 33 NJ cases: Essex, Morris Sussex (2) Jamestown Canyon Virus & La Crosse Jamestown Canyon La Crosse virus 2017: 67 cases 2015: 1 NJ case, Sussex : median age 48yrs 2017: 44 cases : median age 8yrs 18

19 Usutu & Yellow Fever Usutu virus Emerging flavivirus in Europe 2001 WNV similarities Culex species (Cx. pipiens) High avian mortality, blackbirds 1 st human cases in Europe 2009 Fever, rash, jaundice, headache, stiff neck, hand tremor, and hyperreflexia Yellow fever Transmitted by Aedes mosquitos in Africa and South America Febrile illness to severe liver disease and hemorrhage Vaccine preventable Very rare cause of illness in US travelers Recent outbreaks in Brazil and Nigeria Key Investigation Data Signs/Symptoms (ex. WNV/EEE) Arthralgia/joint pain Stiff Neck Asymptomatic Vomiting Diarrhea Altered mental status Fever Encephalitis Headache Meningitis Myalgia Paralysis/weakness Neurological disorders Seizure Rash Clinical Presentation / Severity Other Clinical Information Hospitalization and dates Disposition Rehab Death CSF studies: CSF WBCs/µL CSF Protein (mg/dl) CSF Glucose (mg/dl) 19

20 Risk Factors (ex. Dengue) In the 30 days before illness onset or diagnosis, did the patient travel outside the country? In the 30 days before illness onset or diagnosis, did the patient travel outside NJ (within the U.S.)? In the 30 days prior to illness onset or diagnosis, did the patient relocate to the US from a country with known disease transmission? In the 30 days before illness onset or diagnosis, did the patient receive a blood transfusion? In the 30 days before illness onset or diagnosis, did the patient receive an organ transplant? Was the patient exposed in a healthcare setting? Was the patient exposed in a laboratory setting? Did the patient have close contact with a confirmed/probable case? CDRSS 2.0 Disease-Specific Questions Arboviral Testing Testing options Commercial testing available for many arboviruses (WNV, Zika, Dengue, Chikungunya, Malaria) For some, testing only available at public health laboratories or specialty laboratories (EEE, Jamestown Canyon virus, Powassan, Yellow Fever) Arboviral testing is limited at PHEL Public health testing Case-by-case consultation Focus Hospitalized patients Clinically compatible illness Neuroinvasive presentation Suspected arboviral disease Risk factors e.g., known outdoor exposures / travel history 20

21 Final thoughts Routine but flexible surveillance Improved diagnostics/clinician outreach Partnership & collaboration Mobile population Other VBD Updates Mosquito-borne Disease Brochure online ( printed copies coming soon SFGR Chapter and investigation form posted online Messaging to be sent to clinicians Emphasis on convalescent specimens VBD Vital Signs May May Tick Blitz Tickborne Disease Webinar (May 22) Kim Cervantes Vector-borne Disease Coordinator 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 Karen Worthington, MS, RN 21

22 CDRSS 2.0 UPDATES NEW JERSEY DEPARTMENT OF HEALTH APRIL 26, 2018 TOPICS CDRSS 2.0 SYSTEM UPDATE TRAINING UPDATES LESSONS LEARNED FROM TRAINING QUESTIONS CDRSS 2.0 SYSTEM UPDATE CDRSS has been undergoing a system update including new enhancements, functionalities, and design to improve your workflow The new version of CDRSS (CDRSS 2.0) includes improved security and technology updates including heightened password requirements and expanded device capabilities 22

23 TRAINING OPTIONS Users must attend/complete one training session to ensure access to CDRSS 2.0. Training is offered via webinar or in-person: 1. WEBINAR One hour pre-recorded with live Q&A Started in March, ongoing through June Additional webinar dates for June will be posted on the CDRSS main page 2. IN-PERSON Two-three hour interactive session at Regional Medical Coordination Centers (MCC) Ongoing in April Additional in-person trainings can be scheduled upon request at NJDOH (Trenton) IF YOU HAVE NOT ATTENDED OR REGISTERED FOR EITHER THE WEBINAR OR IN-PERSON TRAINING, PLEASE SIGN UP FROM THE CDRSS MAIN PAGE. REMAINING TRAININGS WEBINARS All scheduled webinars are currently full *ADDITIONAL DATES TO BE AVAILABLE FOR MAY/JUNE * Continue to check the main CDRSS page for these additional dates IN-PERSON Northeast Region: University Hospital of New Jersey - Newark Training dates: April 27, 2018; April 30, 2018; May 1, 2018 *ADDITIONAL IN-PERSON TO BE AVAILABLE UPON REQUEST AT NJDOH (TRENTON)* 23

24 NEW USER TRAINING For new users needing access to CDRSS: Complete Training Request and User Agreement from main CDRSS page. Receive training (method will be verified by CDRSS Admins after receiving training request form). LESSONS LEARNED FROM TRAINING GENERAL FEEDBACK New design is visually appealing Streamlined functions Too many clicks Will take time to adjust to new interface Workplace limitations to access Google Chrome Intuitive design FAVORED FUNCTIONALITIES Toggle Tool Panel Provider Search Person and Case Merge Section-Based Saving Recently Viewed Cases Reports QUESTIONS TRAINING: HELP DESK: 24

25 Human Case of Brucella abortus RB51 Associated with Raw Milk Consumption New Jersey, 2017 Kristin Garafalo, MPH, CHES Zoonotic Disease Epidemiologist Brucellosis: Background Systemic disease from Brucella species Human infections are most often associated with B. melitensis *, B. suis*, B. abortus* High risk regions: Mediterranean Basin, South and Central America, Eastern Europe, Asia, Africa, the Caribbean and the Middle East Rare in U.S. largely due to cattle vaccination practices; U.S. cases usually imported or result from accidental laboratory exposures *designated as select agents, i.e., potential to be developed as bioterrorism agents due to ability to undergo aerosolization Source: species.html Brucella abortus RB51: Background Brucella abortus is causative agent for brucellosis in cattle Brucella abortus RB51 is a vaccine strain Conditionally approved for use in cattle in 1996 Safe for cattle over 3 months of age Should not cause clinical signs of disease in cattle Usually clears from the blood stream within 3 days but in rare cases, vaccinated cows can shed Brucella abortus RB51 in their milk Human exposure to RB51 Accidental contact with and injection of Brucella abortus RB51 vaccine can cause infection in humans Ingestion of raw (unpasteurized) milk or raw milk products from vaccinated cows Inhalation of organism in laboratory setting Source: 25

26 Brucellosis: Transmission Transmission of Brucella spp. to humans: eating undercooked meat or raw dairy products direct contact with infected animals (e.g., hunting) inhalation exposure through skin wounds and mucous membranes person to person transmission is rare Source: Clinical presentation in humans Incubation period: usually 2 4 weeks after exposure (range: 5 days to several months) Initial symptoms: Fever Sweats Malaise Anorexia Headache Muscle/joint pain Fatigue Persisting symptoms: Recurrent fevers Arthritis Swelling of testicle and scrotum area Swelling of heart (endocarditis) Neurological symptoms Chronic fatigue Depression Swelling of liver and/or spleen Source: Identifying Risk Factors for Brucellosis Questions about risk factors may include: Do you work in a slaughterhouse or meat packing environment? Have you recently traveled overseas? If so, where and when? Did you consume any raw or undercooked meat or unpasteurized dairy products? Of so, which products? How much? Do you hunt? If so, have you come into contact with moose, elk, caribou, bison or wild hogs? Have you had recent contact with animals? If so, which species? Did you assist the animal while giving birth? Do you work in a laboratory? If so, does the lab handle Brucella specimens? 26

27 Laboratory Testing NON RB51 For case definition, a Brucella microagglutination test or standard tube agglutination test is required if using serologic testing PCR Culture BRUCELLA ABORTUS RB51 No serologic assay available to detect Brucella abortus RB51 Diagnosis by culture or PCR only Case Investigation: Brucella abortus RB51 Late September 2017 NJDOH was notified by the Minnesota Department of Health of a laboratory report of a presumptive positive Brucella abortus isolate from a NJ resident. Notification and first steps NJDOH: entered the laboratory result into CDRSS and notified the local health department where the patient resides and the hospital where the patient was receiving care. Hospital laboratory: developed a line list of all employees in the lab when the specimen was manipulated Local health department: conducted patient interview to identify risk factors for brucellosis using the NJDOH Brucellosis Investigation Worksheet 27

28 Timeline of Isolate Confirmation 9/28: Presumptive positive for Brucella spp. at commercial laboratory (located in MN); forwarded to MNDOH Case summary: diagnostics 10/13: Presumptive positive for Brucella abortus RB51 at MNDOH 10/23: Culture confirmed positive for Brucella abortus RB51 at CDC Other findings: resistance to rifampin; PFGE showed isolate was 10 SNPs different than agent in Texas outbreak earlier in 2017 Added to the NJDOH Brucellosis webpage in June 2017 NJDOH Brucellosis Investigation Worksheet 28

29 Local Health Department Response: Epidemiologic Investigation SIGNS AND SYMPTOMS Onset: mid September Non specific symptoms were consistent with brucellosis: Fever (Tmax 102.3F) Chills Neck pain Headache RISK FACTORS Patient consumed 4.5% milk fat raw cow s milk from Udder Milk, home delivery company that has illegally sold unpasteurized milk in New Jersey Consumed small quantities (e.g., uses in coffee); other family members are primary consumers Case Investigation: Laboratory Exposures NJDOH Response: Laboratory Exposures The original specimen was collected at a New Jersey hospital. NJDOH notified the hospital laboratory of the presumptive positive Brucella isolate Brucellosis is most commonly reported laboratory associated bacterial infection lack of experience working with Brucella work performed on Brucella isolate on an open bench, not under BSL 3 conditions inadequate personal protective equipment unknown or unidentified samples that arrive for analysis Certain characteristics of bacterium, such as its low infectious dose and ease of aerosolization also contribute to risk of infection by organism in laboratory setting Source: 29

30 Assessing laboratory exposure risk RISK LEVEL = HIGH Persons at Risk Exposure Activities Person performing Worked with a Brucella isolate activity and any person Sniffed or opened culture plate within a 5 ft. radius Mouth pipetted specimen material Worked in Class II biosafety cabinet or on open bench without using BSL 3 precautions RISK LEVEL = LOW Persons at Risk Exposure Activities All person present in laboratory Present in the lab at the time of room at distance greater than 5 manipulation of Brucella isolate ft. from activity on an open bench, but who do not have high risk exposures All persons present in laboratory room Occurrence of widespread aerosol generating procedures* 17 high risk exposures were identified in New Jersey Source: level.html Risk Level High Risk Post exposure prophylaxis (PEP) and monitoring BRUCELLA SPP. (NON RB51) PEP Recommendations Doxycycline 100mg twice daily and rifampin 600mg once daily for 3 weeks Follow up/ Monitoring Sequential serologic testing at 0, 6, 12, 18 and 24 weeks post exposure Symptom watch (e.g. weekly) and daily self fever check for 24 weeks Risk Level High Risk BRUCELLA ABORTUS RB51 PEP Recommendations Doxycycline and trimethoprim and sulfamethoxazole (Bactrim) for 3 weeks Follow up/ Monitoring Symptom watch (e.g. weekly) and daily self fever check for 24 weeks Low Risk Discuss with HCP May consider PEP if immunocompromised or pregnant Sequential serologic testing at 0, 6, 12, 18 and 24 weeks post exposure Symptom watch (e.g. weekly) and daily self fever check for 24 weeks Low Risk Discuss with HCP May consider if immunocompromised or pregnant Symptom watch (e.g. weekly) and daily self fever check for 24 weeks Source: raw milk.html Case Investigation: Udder Milk 30

31 Investigation of Raw Milk Distribution Udder Milk Co op on wheels Distributes raw milk to multiple states Raw milk is illegal to be sold across state lines Sale or distribution of raw milk is illegal in NJ Members only Need to be approved before you can order Provides drop offs in public locations and home delivery Where is the milk coming from? No physical address on website (only a cell phone number and e mail address) Actions: NJDOH issued a Cease and Desist order to Udder Milk on 11/10/2017 After the issuance of the Cease and Desist, Udder Milk moved their regular pick up sites to unannounced members addresses and seem be delivering direct to the customer s home Public notification Surveillance To date, two additional families that consumed raw milk from Udder Milk started PEP and symptom monitoring. Family 1: Child who consumed Udder Milk s raw milk presented to healthcare provider with mild headache Physician ended up ordering serology for both children and placed them both on antibiotics. Serology is negative (RB51 cannot be detected through serology) Family 2: 4 family members who consumed raw milk/milk products from Udder Milk had symptoms were consistent with brucellosis Blood specimens were tested by PCR at the NJDOH BioThreat Response Laboratory were negative for Brucella spp. Specimens were forward to CDC for repeat PCR and culture. All were negative for Brucella spp. 31

32 The future INFORM THE PUBLIC OF THE RISK OF RAW MILK OR RAW MILK PRODUCT CONSUMPTION Thank you! Kristin Garafalo, MPH, CHES Zoonotic Disease Epidemiologist QUESTIONS AND ANSWERS 32