Public Health. W a k e C o u n t y H u m a n S e r v i c e s P u b l i c H e a l t h Q u a r t e r l y R e p o r t. Prevent. Promote.

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1 Public Health Prevent W a k e C o u n t y H u m a n S e r v i c e s P u b l i c H e a l t h Q u a r t e r l y R e p o r t J a n u a r y M a r c h S p e c i a l E d i t i o n : C o m m u n i c a b l e D i s e a s e s Promote Wake y Human Services Public Health Division 10 Sunnybrook Road P.O. Box Raleigh, NC March 21, 2014 Protect Ramon Rojano, Human Services Director Sue Lynn Ledford, Public Health Division Director Editor-in in chief: Edie Alfano Sobsey, Public Health Epidemiologist Editorial Staff: Carla Piedrahita, Public Health Educator Design and Layout: Michelle Ricci, Public Health Educator

2 Table of Contents Introduction 3 Surveillance for Reportable Communicable Diseases in Wake y 3 General Communicable Diseases 4 Vaccine Preventable Diseases 5 Foodborne Diseases 7 Sexually Transmitted Diseases 8 Tuberculosis 10 Vector-borne Diseases 11 All Reportable Communicable Diseases and Conditions 12 2

3 Introduction Wake y Human Services (WCHS), an accredited health department, continues to strive to perform the three core functions of assessment, policy development and assurance and the 10 public health essential services (Figure 1). This report helps fulfill public health essential services: Number 1: Monitor health status to identify community health problems and Number 3: Inform, educate, and empower people about health issues. Information is provided on a quarterly basis about health and safety trends for Wake y residents to providers, policy makers and the community to better inform decision making. Figure 1 Surveillance for Reportable Communicable Diseases in Wake y Communicable diseases are illnesses caused by infectious agents (bacteria, viruses, parasites, fungi or prions) or their toxins that are transmitted from an infected person, animal, plant or from the environment. Because communicable diseases can have so much impact on populations, they are tracked and the information analyzed (called surveillance) so that measures can be put in place for protecting the public's health. Certain communicable diseases are required by law to be reported to local health departments by physicians, school administrators, child care operators, medical facilities, and operators of restaurants and other food or drink establishments (G.S. 130A-135 through 130A-139). There are 71 reportable diseases specified in the N.C. Administrative Code rule 10A NCAC 41A.0101 ( After initial notification about a case or cases of a communicable disease, an investigation begins to collect details such as demographic, clinical, and epidemiological information. After verifying that a reported case meets the reporting requirements in the standardized case definitions, it is reported electronically to the N.C. Division of Public Health via the North Carolina Electronic Disease Surveillance System (NC EDSS) and then to the Centers for Disease Control and Prevention s (CDC) National Notifiable Diseases Surveillance System. 3

4 This report focuses on all diseases that have been reported in Wake y from 2009 through 2013 by category along with other information about selected communicable diseases of public health significance for Wake y. For a list of all reportable communicable diseases see Table 5 (page 12). General Communicable Diseases Table 1 demonstrates that reports of these diseases remained stable over the last 5 years. In Wake y, as well as worldwide, novel influenza viruses have not been reported since 2009 when the pandemic influenza A H1N1 was first identified and reported. Disease Table 1 Notifiable Communicable Diseases, Wake y Brucellosis * 0 0 Creutzfeldt-Jakob Disease 4 * 1 * 1 * 2 * 2 * Cryptosporidiosis 5 * 2 * * 7 * Dengue * 2 * 1 * 2 * Haemophilus influenzae, invasive disease 12 * 11 * 9 * 12 * 19 * Hemolytic-uremic 2 * 1 * Hepatitis A 6 * 2 * 2 * 2 * 2 * Hepatitis C, acute 1 * 1 * 1 * 3 * 5 * Influenza (NOVEL virus infection) Legionellois 3 * 4 * 8 * 3 * 9 * Meningococal disease * 3 * 1 * 1 * Q Fever * 1 * 0 0 S. aureus with reduced susceptibility to vancomycin * 0 0 Streptococcal infection, 10 * 13 * * 13 * Toxic shock syndrome, streptococcal * 2 * Tuberculosis Vibrio infection, other 1 * 1 * 1 * 2 * 0 0 +s include all cases meeting the suspect, probable, and confirmed North Carolina communicable disease case definitions. *Rates based on fewer than 20 cases are unreliable and not displayed. ** Rate per 100,000 population Data Source: NC Electronic Disease Surveillance System, accessed 2/25/14 Reportable communicable diseases with NO reported cases in the period were not included in the above table. Because cases are routinely updated, case numbers may change. definitions for these diseases are available at: 4

5 Vaccine Preventable Diseases Chronic hepatitis B and pertussis were the most commonly reported vaccine preventable diseases during (Table 2). The pertussis rate per 100,000 Wake y decreased during 2013, likely a result of the vaccination campaign to increase immunization of those at risk and those who care for infants since the 2012 nationwide outbreak. Vaccination is an effective way to prevent communicable diseases. One of the Wake y Human Services health indicators is to monitor the % of children 24 months of age who receive the recommended vaccines [Dtap (4), Hepatitis B (3), HIB (3), Polio (3), Pneumococcal (4) MMR (1) and Varicella]. The NC Immunization Program y target is for 73% and the Wake y Human Service target is for 89% of children to receive these vaccinations by age 24 months. As of , 67% of clients residing in Wake y and 85% of clients associated with Wake y Human Services received all the recommended vaccinations. Disease Table 2 Vaccine Preventable, Wake y Rate ** Hepatitis B, acute 7 * 4 * 4 * 4 * 5 * Hepatitis B-chronic Rate* * Influenza, pediatric death (< 18 years of age) Influenza, adult death ( = 18 years of age) 1 * * * 3 * 2 * Mumps * Pertussis (Whooping Cough) 10 * 19 * 6 * s include all cases meeting the suspect, probable, and confirmed North Carolina communicable disease case definitions. *Rates based on fewer than 20 cases are unreliable and not displayed. ** Rate per 100,000 population Data Source: NC Electronic Disease Surveillance System, accessed 2/25/14 Influenza In North Carolina, the current flu season ( ) peaked during the holiday week in December and the predominant circulating strain was influenza A (H1N1). Fewer cases were reported (Figure 2, page 6) but more deaths occurred from influenza complications as compared to the previous flu season. As of 3/8/14, 86 flu deaths were reported in North Carolina compared to 59 reported last flu season. Most of these deaths (71 %)occurred among those 25 to 64 years of age. Among those cases for whom vaccination status (73) and risk factors (75) were known, 81% were unvaccinated and most (88%) had underlying high risk conditions. 5

6 Figure 2 Data Source: NC Department of Health and Human Services Figure 3 represents the number of flu immunizations provided at Wake y Human Services by age of patient. All clinics, program areas, and locations are represented. Flu immunizations provided by WCHS to people ages 25 to 64 years were 4277 doses for the 2012/13 season and, as of 2/20/14, 2794 doses for the 2013/14 season*. Figure 3 * The 2013/14 Flu immunization season totals are through February 17, Data Source: North Carolina Immunization Registry (NCIR) 6

7 Foodborne Diseases The Centers for Disease Control and Prevention (CDC) estimates that each year roughly 1 in 6 Americans (or 48 million people) get sick, 128,000 are hospitalized, and 3,000 die of foodborne diseases. In the U.S. during , most (58%) illnesses were caused by norovirus, followed by non-typhoidal Salmonella spp. (11%), Clostridium perfringens (10%), and Campylobacter spp. (9%). Leading causes of hospitalization were non-typhoidal Salmonella spp. (35%), norovirus (26%), Campylobacter spp. (15%), and Toxoplasma gondii (8%) and leading causes of death were non-typhoidal Salmonella spp. (28%), T. gondii (24%), Listeria monocytogenes (19%), and norovirus (11%). Estimating the number, trend and foods responsible for foodborne illness is complex and more detailed information about these illnesses is available from the CDC at: In Wake y, during 2009 through 2013, the three most commonly reported food-borne illnesses were caused by Salmonella spp (63%), non-typhoidal, Campylobacter spp (24%), and E. coli (5%) (Figure 4). Laboratory testing to confirm the cause of some reportable diseases, for example Clostridium perfringens food poisoning, is not routinely available except under special circumstance during outbreaks; therefore these numbers are likely underreported. Figure 4 Reported Foodborne Illness (%), Wake y Poisoning (1) Other (2) Shigella (4) Campylobacter spp. (24) Salmonella, nontyphoidal, (63) E coli ( 5) Hepatitis A, (1) Data Source: North Carolina Electronic Disease Surveillance System Data accessed 2/25/14 In addition, cases of some food-borne diseases caused by other microorganisms are not required to be reported under NC communicable disease law. However, all foodborne outbreaks are required to be reported to local health departments and the NC Division of Public Health. During 2013, three outbreaks associated with food consumption were investigated in Wake y. In March, 27 patrons became ill with gastrointestinal illness from infection with norovirus after eating at a restaurant. On June 8, a party of 9 reported nausea, vomiting and diarrhea after eating at another restaurant. The cause of this outbreak could not be confirmed. After eating a Thanksgiving meal at yet another restaurant, members of four separate parties reported illness. Seven were confirmed by interview to be ill with symptoms of diarrhea and abdominal cramps. Patrons refused to provide stool samples so the cause of this outbreak could not be confirmed. Control measures to prevent further spread were communicated and implemented for all outbreaks. 7

8 Sexually Transmitted Diseases In Wake y, the most commonly reported sexually transmitted diseases are chlamydia and gonorrhea followed by non-gonococcal urethritis and pelvic inflammatory disease ( PID) (Table 3). According to the Centers for Disease Control and Prevention (CDC), the 2012 national rates for chlamydia increased 0.7% to 456.7/100,000 population and 4.1% for gonorrhea to 107.5/100,000 population. While rates increased in all regions of the United States, both the chlamydia rate (496.9 per 100,000) and gonorrhea rate (131.9 cases per 100,000 population) were highest in the southern part of the US. Additionally, surveillance data continues to show that numbers and rates of reported chlamydia and gonorrhea cases are highest in Americans between the ages of 15 and 24. The rates for both chlamydia and gonorrhea in Wake y have increased steadily from 2009 through They have declined since then but still remain high (Figure 5, page 9). During 2013, Wake y chlamydia rates (497/100,000) were higher than NC chlamydia rates (442/100,000) while Wake y gonorrhea rates (127/100,000) were lower than NC gonorrhea rates (140/100,000). During , among those tested positive for chlamydia or gonorrhea 8.0% (1626 clients) were co-infected with chlamydia and gonorrhea and 18% ( 3655 clients) were infected with either chlamydia and gonorrhea or both, treated and later re-infected (after 21 days or more) with either chlamydia and gonorrhea or both. Disease Table 3 STDs, Wake y ** ** ** AIDS Chancroid * Chlamydia 2, , , , , Gonorrhea , , , HIV Non-gonococcal urethritis PID Syphilis, primary 14 * 3 * 13 * 7 * 18 * Syphilis, secondary Syphilis, early latent Syphilis, latent, unknown duration 18 * 17 * 8 * 14 * 12 * Syphilis, late latent Syphilis, late with symptoms 1 * Syphilis, neurosyphilis 3 * s include all cases meeting the suspect, probable, and confirmed North Carolina communicable disease case definitions. * Rates based on fewer than 20 cases are unreliable and not displayed. ** Rate per 100,000 population Data Source: NC Electronic Disease Surveillance System Data accessed 2/25/14 8

9 Wake y Chlamydia and Gonorrhea Rates* for All Ages from Figure Chlamydia Gonorrhea *per 100,000 population Data Source: NC Division of Public Health, Communicable Disease Branch Similar to national and state trends, chlamydia and gonorrhea rates are highest among years of age in Wake y (Figure 6 ). For more information about STDs in NC and the US visit: and default.htm. Figure 6 Reported Chlamydia and Gonorrhea s by Age Group in Wake y % Chlamydia Gonorrhea < >35 Age Group Data Source: NC Division of Public Health, Communicable Disease Branch Data accessed 2/25/14 9

10 Number Tuberculosis Overall, the number of clients diagnosed with TB decreased from a high of 54 in 2007 to 16 in 2012 with spikes in 2010 and 2013 (Figure 7). Of the 108 clients with TB from , 41% are in the year age group. There is no significant difference in gender from as 52% are male and 49% female. Number of s of Tuberculosis (TB) Reported to the Center for Disease (CDC) Wake y Calendar Years Figure Source: Wake y Human Services Tuberculosis Control Annual Report The percentage of foreign born clients compared to US-born increased significantly from 2010 to 2013 (Figure 8). Asians disproportionately account for the highest number of TB cases cared for by Wake y Human Services TB Control Program. In 2012, 56% of the cases were found in the Asian population while they represented only 5.8% of Wake y s population. Similarly, blacks accounted for 31% of the cases representing 21.4 % of the population. Hispanics, with 13% of the cases, represented 10% of the county s population. Figure 8 100% 80% 60% 40% 20% 0% Tuberculosis (TB) s Foreign Born Compared to Persons Born in the United States Wake y Human Services TB Control Program Calendar Years % 46% 66% 34% 75% 25% % 15% Foreign Born US-born Data Source: Wake y Human Services TB Control Program 10

11 To treat and prevent further spread of disease, clients need to take all of one or more prescribed medications for up to a year. If the medication is not taken as prescribed, drug-resistant TB can occur. This in turn requires longer treatment for clients. Nurses conduct TB screening, directly observe clients with TB disease take their medication, monitor medications and assess for side effects. In 2013, 3,634 TB related home visits were made (Figure 9). Figure Tuberculosis (TB) Related Home Visits TB Control Program Wake y Human Services Wake y Calendar Years Data Source: Wake y Human Services AS-400 Patient Care Management System Total Vector-borne Diseases Vector-borne diseases are caused by microbes that are spread to people by arthropods like ticks and mosquitoes that feed on human blood. The vector-borne diseases that occur most often in Wake y are caused by ticks. Table 4 (page 12) shows confirmed as well as suspect and probable cases of tick-borne disease. For the tick-borne diseases (ehrlichiosis, Lyme disease and Rocky Mountain spotted fever), many more cases are suspected and investigated than can be confirmed. This is due to the difficulty in getting clinical and/or laboratory information needed to meet the confirmed case definition. 11

12 Table 4 Vectorborne, Wake y Disease * Confirmed Confirmed Confirmed Confirmed Confirmed Ehrlichiosis, HGA (human granulocytic anaplasmosis) Ehrlichiosis, HME (human monocytic or E. chaffeensis) Ehrlichiosis, Lyme disease Rocky Mountain *s include all cases meeting the suspect, probable, and confirmed North Carolina communicable disease case definitions. Data Source: NC Electronic Data Surveillance System Data accessed 2/26/14 All Reportable Communicable Diseases and Conditions Table 5 Notifiable Communicable Diseases , Wake y Disease AIDS Anthrax Botulism, Foodborne Botulism, Intestinal (Infant) Botulism, Wound Brucellosis * 0 0 Campylobacter infection Chancroid * Table 5 continued on next page 12

13 Notifiable Communicable Diseases , Wake y Disease Chlamydia 2, , , , , Cholera Creutzfeldt-Jakob Disease 4 * 1 * 1 * 2 * 2 * Cryptosporidiosis 5 * 2 * * 7 * Cyclosporiasis 1 * Dengue * 2 * 1 * 2 * Diphtheria E. coli -shiga toxin producing 13 * 11 * * 17 * Ehrlichiosis, HGA (human granulocytic anaplasmosis) Ehrlichiosis, HME (human monocytic or E. chaffeensis) 0 * 5 * 14 * 10 * 11 * 18 * * Ehrlichiosis, unspecified * 0 0 Encephalitis, arboviral, LaCrosse * 0 0 Encephalitis, arboviral,eastern equine encephalitis Encephalitis, arboviral, West Nile Virus * 7 * 0 0 Encephalitis, arboviral, other Foodborne disease: Clostridium perfringens Foodborne: staphylococcal * 2 * Foodborne disease: other/unknown Foodborne poisoning (ciguatera, mushroom, scrombroid fish) 13 * * 0 0 Gonorrhea , , , Granuloma inguinale Haemophilus influenzae, invasive disease 12 * 11 * 9 * 12 * 19 * Hantavirus infection Hemolytic-uremic syndrome (HUS) 2 * 1 * Hemorrhagic fever virus infection Hepatitis A 6 * 2 * 2 * 2 * 2 * Table 5 continued on next page 13

14 Notifiable Communicable Diseases , Wake y Disease Hepatitis B, acute 7 * 4 * 4 * 4 * 5 * Hepatitis B-chronic Hepatitis B, perinatally acquired Hepatitis C, acute 1 * 1 * 1 * 3 * 5 * HIV Influenza, pediatric death (< 18 years of age) 1 * * Influenza, Adult death ( 18 years of age) 4 * * 3 * 2 * Legionellois 3 * 4 * 8 * 3 * 9 * Leprosy (Hansen's Disease) Leptospirosis Listeriosis 3 * 1 * 1 * * Lyme disease Lymphogranuloma venereum Malaria 3 * 15 * 10 * 5 * 8 * Measles (rubeola) Meningococal disease, * 3 * 1 * 1 * Monkeypox Mumps * Non-gonococcal urethritis Novel influenza virus infection Opthalmia neonatorum Pertussis (Whooping Cough) 11 * 19 * 6 * PID Plague Poliomyelitis, paralytic Psittacosis Q Fever * 1 * 0 0 Rabies, human Rocky Mountain Spotted Fever Rubella Rubella, congenital syndrome Table 5 continued on next page 14

15 Notifiable Communicable Diseases , Wake y Disease Salmonellosis S. aureus with reduced susceptibility to vancomycin * 0 0 SARS (coronavirus infection) Shigellosis 10 * 14 * 11 * 14 * Smallpox Streptococcal infection, Group A, invasive 10 * 13 * * 13 * Syphilis, primary 14 * 3 * 13 * 7 * 18 * Syphilis, secondary Syphilis, early latent Syphilis, latent, unknown duration 18 * 17 * 8 * 14 * 12 * Syphilis, late latent Syphilis, late with symptoms 1 * Syphilis, neurosyphilis 3 * Syphilis, congenital * 1 * Tetanus Toxic shock syndrome, non-streptococcal Toxic shock syndrome, streptococcal * 2 * Trichinosis Tuberculosis Tularemia Typhoid Fever - acute 2 * 3 * 1 * 1 * 0 0 Typhoid carriage (Salmonella typhi) Typhus Vaccinia Vibrio infection, other than cholera and vulnificus 1 * 1 * 1 * 2 * 4 * Vibrio vulnificus * 0 0 Yellow Fever Data Source: NC Electronic Data Surveillance System Data accessed 2/25/24 15

16 Acknowledgements For contributions to this Quarterly Report: Roxanne Deter Joann Douglas Ramsay Hoke Sherry Leonard 16