International Travel, Mosquitoes, and Sexual Transmission: Preparing for Zika in the Northern Region of the Grand Canyon State

Transcription

1 International Travel, Mosquitoes, and Sexual Transmission: Preparing for Zika in the Northern Region of the Grand Canyon State Matthew Maurer, MPH, REHS Coconino County Public Health Services District (CCPHSD) International Zika Virus Conference 29-March-2017

2 Overview Characteristics of Coconino County Risks of Zika virus transmission in Coconino County, Arizona Coconino County response plan and actions for Zika virus transmission

3 Where is Coconino County?

4 Where is Coconino County?

5 Where is Coconino County?

6 Coconino County Characteristics Population of 139,097 (½ in Flagstaff) 18,619 square miles (29,964 km) Elevation from 2,500 feet (762 meters) to 12,633 feet (3,850 meters) Most population at 4,000 to 7,000 feet (1,219-2,133 meters) Hispanic population of 14%, Native American 26% Home of Navajo, Hopi, Havasupai, Hualapai, Paiute tribal communities

7 Risks Aedes Mosquito Mosquitoes in Coconino County include Culex and Ochlerotatus Aedes has not yet been identified in Coconino County due to elevation Has been identified in neighboring counties, Southern Arizona counties and Mexico Most favorable elevation are below 6,500 feet (2,000 meters) Some communities below this elevation Seasonal rains in summer called monsoons Mosquitoes can be transported Shipping Human travel

8 Aedes Range in U.S.

9 Aedes aegypti Surveillance in Arizona

10 Risk Factors - Tourism Grand Canyon 6 million visitors in 2016 (5,969,811) Visitors from all over the world Highest visited months are May through October Elevation as low as 2000 feet (610 meters) Sedona 4.5 million visitors each year Elevation around 4000 feet (1,219 meters) Possible sexual transmission from travelers and/or employees from Zika endemic areas

11 Risk Factors - NAU Northern Arizona University (NAU) Enrollment: 20,839 Risks Include Travel to Zika endemic countries (school trips, spring break, home country) Unprotected sex High rate of chlamydia in county compared to state and national

12 Risk Factors Tribal Communities Tribal Communities in Coconino County include: Navajo, Hopi, Havasupai, Hualapai, Paiute Remote populations Access to health care and testing Limited public health capacity Low elevations capable of allowing for survival of Aedes mosquitos

13 Risk Factors Interstate 40/Route 66 through Flagstaff Bring the virus back unknowingly due to high rate of asymptomatic cases No Aedes mosquitoes, but frequent travel to lower elevation areas with Aedes Phoenix, much of Arizona, Las Vegas, etc. Mexico

14 Zika at the Border Coconino County Arizona Source:

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16 Confirmed Confirmed Mexico State Cases Cases Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Guerrero Hidalgo Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo San Luis Potosi Sinaloa Sonora Tabasco Tamaulipas Veracruz Yucatan Zacatecas TOTAL Total Zika in Mexico Mexico State Sonora Nuevo Leon Tamaulipas Coahuila Baja California Confirmed Confirmed Cases Cases Total

17 States in Mexico

18 Human Zika virus in The United States and Territories

19 Zika in Arizona (as of March 2017) 57 confirmed and probable cases, all travel-associated (sexual and mosquito transmission) 1 confirmed case via sexual transmission with infected partner in Arizona Monitoring 15 pregnant women registered to AZ Pregnancy Registry

20 2016 Human Zika Cases Zika Cases by County County Maricopa Pima Total Zika Cases 37 8 Cochise Pinal Yuma Santa Cruz Mohave Coconino 2 1 0

21 Collaboration Response Partners Neighboring counties State Arizona Department of Health Services (ADHS) Federal CDC USFS NPS Tribal Communities Community health partners

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23 Zika Plans - Summary Response Plan Mosquito Surveillance Plan Preparation phase Level 1 Alert Phase Level 2 Planning and Education Planning and Education Surveillance Response Phase Planning and Education Surveillance Recovery Phase No locally-acquired cases, no vector present No locally-acquired cases, vector is present Level 3 Confirmed or probable locally-acquired case, vector is present Level 4 Multiple unrelated locally-acquired cases, vector present in multiple locations

24 Scenario Preparation Phase Matt Schumacher you will want to pause here and explain what you Rachel is 30, living in are doi g. I e reated a s e ario a d so e fi tio al Flagstaff, hara ters Coconino ho li e i Co ocounty, i o Cou ty.arizona, We ll follo U.S.A. their story It was September of 2015 when she and husband were planning to start a family She sees on the news that Zika infections are increasing in South America

25 Discussion Question What should Coconino County be doing to prepare for Zika? What do you think our risks are for transmission of Zika?

26 Meanwhile at CCPHSD Preparation Phase Getting information about Zika from: The Centers for Disease Control (CDC) World Health Organization (WHO) Arizona Department of Health Services (ADHS) Preparing for media and social media communications public education Educating staff on current guidelines and protocols Giving presentations to hospitals, healthcare providers, first responders Including current protocols for testing, availability of testing, identification of atrisk patients, etc.

27 Preparing for Zika in Coconino County Preparation Phase Assessing risks Conducting human surveillance Talking to residents concerned that they may have been exposed/infected with Zika while traveling Arranging testing with Arizona Department of Health Services (ADHS) Isolating cases during testing phase Conducting mosquito surveillance Watching for Aedes mosquitos Creating plan for Zika surveillance and response (pre and post Aedes ID)

28 Scenario Alert Phase Ra hel s hus a d, Albo Rodriguez, is preparing for a marathon in Brazil Zika travel associated and locally acquired cases increase in Latin America, Mexico, U.S. Only cases in Arizona are people who travelled to Zika areas, such as Brazil

29 Discussion Question Has anything changed to the response plan?

30 Meanwhile at CCPHSD Alert Phase (EH Level 1) Providing education about Zika virus Continuing healthcare and public information Investigating probable, suspect, or confirmed Zika cases among CCPHSD residents Environmental Health Stars monitor mosquitoes Routine mosquito surveillance Identify problem areas for mosquito breeding Respond to public nuisance complaints.

31 Scenario Response Phase (No Aedes) Ra hel s hus a d, Albo Rodriguez, returns from his trip to Brazil One week after getting back, experiences fever, joint pain, conjunctivitis, and a rash on his arm Goes to the doctor doctor calls health department Health department contacts the state to facilitate Zika testing While testing is taking place, surveillance expert contacts Albo to talk about Zika and prevent transmission to local mosquitos Test comes back positive!

32 Zika testing algorithm in Arizona

33 Meanwhile at CCPHSD Response Phase Epidemiology Hero interviews case to determine possible source and provide education for preventing transmission of Zika virus Records and documents all relevant information about case(s) Communicates with provider about risks and disease control Informs staff, including protocols and guidelines Public Information Officer assists with notifying the public Monitors mosquito activity and species present in Coconino County

34 Scenario Response Phase (Aedes Identified) Monsoon storms pick up heavily during the month of July Rachel Schumacher calls Health District due to abundance of mosquitoes around her home Environmental Health stars set up mosquito traps around her home and surrounding area Aedes mosquitos are identified within the collected mosquitos

35 Meanwhile at CCPHSD Response Phase (EH Level 2) Notify public of Aedes mosquitoes found in Coconino County Adult mosquito trapping and identification Identify at risk populations due to presence of vector Aedes mosquitoes will be sent to ADHS for testing of diseases Conduct public mosquito education campaigns focused on eliminating mosquito breeding grounds Respond to mosquito complaints and control measures implemented

36 Scenario Response Phase (Local Case?) Rachel Schumacher becomes pregnant and is concerned with both her husband having been infected and now the presence if Aedes mosquitoes around their house Visits healthcare provider who contacts the Health District to approve testing Specimen is sent to lab at ADHS Zika test result is positive!

37 Zika testing algorithm in Arizona

38 Meanwhile at CCPHSD Response Phase (EH Level 3) Epidemiology Hero investigates cause of Zika virus Difficult to determine if sexually transmitted from husband or mosquito-acquired Notifies state and CDC of possible local transmission Establishes active and cautionary Zika transmission areas Rachel is placed in Pregnancy Registry Environmental Health Stars emphasize reducing and eliminating mosquito breeding areas Increase trapping and testing of mosquitoes in the area surrounding the suspect case Approval to use adulticide and larvicidal treatments

39 Scenario Response Phase (Multiple local transmission) In August, four unrelated cases test positive for Zika All have residences within one square mile of each other Aedes testing in that area comes back positive for Zika virus

40 Meanwhile at CCPHSD Response Phase (EH Level 4) Outbreak is declared, Incident Command is established and Emergency Operations Center (EOC) is set up Continue notification of public Epidemiology Hero continues interviewing/documenting cases to identify cause(s) of Zika virus transmission Revise active and cautionary Zika transmission areas Environmental Health Stars continue trapping, testing, pesticide application, if approved

41 Scenario Recovery Phase Recovery Phase By the beginning of October (end of mosquito season) no more cases Complete after-action reports County, state, CDC all work together Educate staff, other agencies, and the public Campaign to prevent mosquito breeding Identify public areas that need to be modified or treated to eliminate mosquito breeding

42 Discussion/Questions What are some of the risks for acquiring Zika virus in your area? Does your area have a plan in place for: Human surveillance Mosquito surveillance Response to human infection Do you have any barriers when it comes to surveillance and treatment? How does Coconino County compare to your area?

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44 Roles and Responsibilities Public Health Emergency Preparedness: Communicate and coordinate with local healthcare providers on Zika virus and its presence within Coconino County and Arizona Prepare communications for release to the public in Coconino County, including mosquito prevention and guidance for individuals infected with Zika such as safe sex practices, abstaining from donating blood, and isolation from mosquitos. Implement local and regional Zika surveillance Refer healthcare providers and healthcare clinics to Zika virus protocols and guidance Conduct suspected, probable, and confirmed Zika patient investigations, including obtaining travel history, sexual history, and blood donations. Report birth defects to the ADHS Birth Defects Monitoring Program and following-up with CDC

45 Roles and Responsibilities Clinic and Women, Infant, Children (WIC) Zika virus awareness/educational materials to pregnant mothers and patrons of sexual education classes or consultations Following CDC and/or ADHS Zika virus protocols and guidelines for patient care Environmental Health Monitoring Coconino County for Aedes mosquitos Provide resources for mosquito intervention

46 Scenario - Tra Albo Rodriguez attends NAU and goes to Costa Rica for Spring Break One week after getting back, experiences fever, joint pain, conjunctivitis, and a rash on his arm Goes to the doctor doctor calls health department Health department contacts the state to facilitate Zika testing While testing is taking place, surveillance expert contacts Albo to talk about Zika and prevent transmission to local mosquitos Test comes back positive!

47 Travel-Associated Case in Coconino County Epi Wiz enters Response Phase Investigates possible source and work to prevent the spread Communicates with provider about risks and disease control Send out press release Informs staff, including protocols and guidelines Monitors surveillance reports Monitors mosquito activity and species present in Coconino County

48 No Mosquito, No local Transmission Vector Surveillance is at Response Level 1 Environmental Health Star conducts routine surveillance (AprilSeptember) Aedes aegypti trapping and testing Adult and larval identification Identify problem areas for mosquito breeding Staff involved in zoonotic disease meetings with state Mosquito education campaigns to reduce and eliminate breeding. Respond to public nuisance complaints.

49 Travel-Associated Case in Coconino County Environmental Health Pro continues Response Level 1 Aedes aegypti trapping and testing. Surveys to determine abundance, distribution, and types of containers existing in the county. Surveillance Trapping of adult mosquitoes and dipping for larvae in known problem areas. Surveillance sites recorded via GPS. Response to all mosquito complaints received.

50 Later that summer Aedes aegypti mosquito is found in Coconino County Epi Wiz continues in Response Phase Investigates possible cases and works to prevent the transmission Communicate with providers about risks and disease control Assist with campaign to educate public about minimizing mosquito breeding Send out press release about mosquito present in Coconino county Inform staff, including protocols and guidelines Monitor surveillance reports Monitor mosquito activity and species present in Coconino County

51 Later that summer Aedes aegypti mosquito is found in Coconino County Environmental Health Pro enters Response Level 2 Routine surveillance (April-September) still conducted. Identification of at risk populations due to presence of vector Adult mosquito trapping and identification. Aedes mosquitoes will be sent to ADHS for testing of diseases. Conduct public mosquito education campaigns focused on eliminating mosquito breeding grounds. Respond to mosquito complaints and control measures implemented. Provide educational materials to public and participate in vector meetings with ADHS

52 Scenario Rachel Schumacher makes a complaint into CCPHSD about the large quantity of mosquitoes around their property EH team investigates and identifies Aedes aegypti mosquitoes She is four months pregnant and has been bit several times over the last couple of weeks while outside during the day She is advised to see her doctor who contacts the Health District and works with the state to approve testing Zika test comes back positive

53 First Locally-Acquired Case EPI Wiz continues Response Phase Follows established guidelines for investigating locally-acquired case. Notifies state and CDC of local transmission Establishes active and cautionary Zika transmission areas Inform public about the risk of locally acquired Zika Analyze human and mosquito surveillance data through mapping Describe epidemiology of affected individual(s) Pregnant case is placed in Pregnancy Resgistry

54 First Locally-Acquired Case Environmental Health Pro enters Response Level 3 Community partners (other counties, state, and CDC) notified Emphasis on prevention to the public and use existing resources to educate the public on prevention and mosquito abatement. Door hangers and educational handouts provided for home owners in affected areas. Initiate community source reduction Increase trapping and testing of mosquitoes in the area surrounding the suspect case. All Aedes mosquitoes sent to ADHS for testing (ZikV, ChikV, DenV) Determine ability to use aldulticide and larvicidal treatments

55 In August, Four unrelated cases test positive for Zika EPI Wiz continues Response Phase Outbreak is declared, Incident Command is established and Emergency Operations Center (EOC) is set up Identifies likely locations for Zika transmission Active Zika Transmission area is determined Public is advised not to travel to the area, particularly pregnant women or couples planning on getting pregnant Zika cautionary area is also established

56 In August, Four unrelated cases test positive for Zika Environmental Health Pro enters Response Level 4 Extensive mosquito trapping and testing. Sample at least 100 meter radius surrounding the suspected location of transmission for suspect/probable/confirmed human cases. Neighborhood adulticide and larvicide treatment Identify and treat mosquito breeding areas. Continuation of education campaigns. Press release disseminated to the public. Properties found to be breeding mosquitoes will be given NOV to abate breeding sites if found

57 Recovery Planning and Education Conduct an After Action Review (AAR) of the response Review and update any Zika protocols Update public education and awareness activities Update CCPHSD staff education and awareness activities Update CCPHSD staff and local healthcare providers on current guidelines and protocols

58 Recovery/Post Mosquito Season Complete Action Report/Improvement Plan (AAR/IP) Training all departments Planning updates Education Determine abundance, distribution, and type of containers in high risk areas. Cover, dump modify, or treat large water-holding containers with long-lasting larvicide. Identify areas with vegetation that could become adult mosquito resting sites and trim vegetation accordingly.

59 Zika cases increase in Latin America, Mexico, U.S. Alert Phase Provide education about Zika virus Provide information on risks, severity, symptoms of disease, updated case counts, etc. Offer guidelines for protection from the vectors reported to carrying Zika virus (e.g. mosquito repellent) and other modes of transmission (e.g., sexual) Supply timely situational awareness to partners and general public, as needed Update CCPHSD staff on current guidelines and protocols Educate local health providers on Zika virus symptoms, guidelines, protocols, etc. Conduct human surveillance Monitor weekly/daily surveillance reports from local, national, and state sources Investigate any probable, suspect, or confirmed Zika cases among Coconino County residents, including travel history, contact tracing, and blood donation Conduct routine mosquito surveillance

60 Proximity to Mexico Nearly 14 percent of the population in Coconino County is Hispanic Many travel back and forth to Mexico where Zika has local transmission Mexico is destination for nonhispanic residents as well

61 Zika in Mexico 2017 Zika in Mexico

62 Confirmed Confirmed Mexico State Cases Cases Aguascalientes Baja California Baja California Sur Campeche Coahuila Colima Chiapas Guerrero Hidalgo Jalisco Michoacan Morelos Nayarit Nuevo Leon Oaxaca Puebla Quintana Roo San Luis Potosi Sinaloa Sonora Tabasco Tamaulipas Veracruz Yucatan Zacatecas TOTAL Total Zika in Mexico Mexico State Sonora Nuevo Leon Tamaulipas Coahuila Baja California Confirmed Cases Confirmed Cases 2017 Total