PORCUPINE HEALTH UNIT INFECTIOUS DISEASE STATUS REPORT

Transcription

1 PORCUPINE HEALTH UNIT INFECTIOUS DISEASE STATUS REPORT JUNE 2014 i

2 MESSAGE FROM THE MEDICAL OFFICER OF HEALTH Public health units in Ontario are mandated to prevent or reduce the burden of infectious diseases of public health importance, as regulated by the Health Promotion and Protection Act (HPPA). These diseases are important since they have the ability to cause serious illness and/or be transmitted to large numbers of individuals. Public Health s disease-related programs are guided by the Ontario Public Health Standards (OPHS) and local needs. In order to fulfill this mandate, Porcupine Health Unit monitors the occurrence of these diseases, their associated risk factors and emerging trends. The Health Unit is also committed to providing the public with timely and accurate information on the local status of infectious diseases. As a result, I am pleased to release this report Porcupine Health Unit Infectious Disease Status Report: This report not only presents local disease trends over a seven-year period, but also provides a provincial comparison of rates. I hope you find the information contained in this report both interesting and useful in your day-to-day work. As always, Porcupine Health Unit continually strives to improve its programs, services and reporting related to infectious diseases in an effort to build healthy and supportive communities. Dr. Rosemarie Ramsingh Medical Officer of Health Porcupine Health Unit ii Porcupine Health Unit Infectious Disease Status Report:

3 ACKNOWLEDGEMENTS This report was produced under the direction of Porcupine Health Unit staff, who contributed to the collection, entry and validation of infectious disease data. Program staff also reviewed and approved the final report. The Health Unit would also like to thank the staff at Public Health Ontario, Surveillance Services and Analytic Services, for providing the Ontario data for this report. Author Asma Razzaq Editors and Contributors Dr. Rosemarie Ramsingh, Lynn Leggett, Chantal Porter, Sandra Lapajne, Robert Bell, Julie Lapointe, Gary Schelling Suggested Citation Porcupine Health Unit (2014). Porcupine Health Unit Infectious Disease Status Report: Timmins, ON: Author. For more information please contact: Gary Schelling Communications Specialist Porcupine Health Unit 169 Pine Street South Timmins, Ontario P4N 8B7 Phone: Porcupine Health Unit Infectious Disease Status Report: iii

4 TABLE OF CONTENTS MESSAGE FROM THE MEDICAL OFFICER OF HEALTH... ii ACKNOWLEDGEMENTS... iii TABLE OF CONTENTS... iv EXECUTIVE SUMMARY... 1 LIST OF TABLES... 6 LIST OF FIGURES... 7 ABBREVIATIONS... 9 INTRODUCTION FOOD, WATER-BORNE AND PARASITIC DISEASES AMEBIASIS CAMPYLOBACTERIOSIS CRYPTOSPORIDIOSIS GIARDIASIS SALMONELLOSIS VECTOR-BORNE AND ZOONOTIC DISEASES SEXUALLY TRANSMITTED AND BLOOD-BORNE DISEASES FOCUS ON: CHLAMYDIA FOCUS ON: GONORRHEA HEPATITIS B (Acute) FOCUS ON: HEPATITIS C HIV SYPHILIS VACCINE PREVENTABLE DISEASES INFLUENZA INVASIVE PNEUMOCOCCAL DISEASE (IPD) PERTUSSIS (WHOOPING COUGH) OTHER INFECTIOUS DISEASES INVASIVE GROUP A STREPTOCOCCAL DISEASE (igas) TUBERCULOSIS (TB) OUTBREAKS REFERENCES iv Porcupine Health Unit Infectious Disease Status Report:

5 APPENDIX A: RARE DISEASES, PORCUPINE HEALTH UNIT, COMBINED APPENDIX B: LIST OF REPORTABLE DISEASES APPENDIX C: GLOSSARY OF TERMS APPENDIX D: DATA SOURCES AND METHODOLOGY Porcupine Health Unit Infectious Disease Status Report: v

6

7 EXECUTIVE SUMMARY Infectious diseases, also known as transmissible or communicable diseases, are illnesses caused by a specific infectious agent such as a virus or bacteria, or its toxic products. Public health units across Ontario monitor these diseases since they have the potential to cause serious illness and can be transmitted to large numbers of individuals. As such, under provincial law, all cases of reportable diseases as designated in Ontario s Health Protection and Promotion Act (HPPA) (1), must be reported to local public health authorities (see Appendix B). This is the first comprehensive infectious disease report for the Porcupine Health Unit (PHU). The report presents rates of reportable diseases between 2006 and 2012 for the Porcupine Health Unit area, provides a provincial comparison of rates, and includes a brief interpretation of the trends in disease rates. The Porcupine Health Unit uses this information to further guide disease prevention and control efforts as well as health promotion, resource allocation and policy decisions. Diseases are categorized into five main sections of the report, aligning with a specific mode of disease transmission. Within each of these sections, disease summaries are organized in alphabetical order and follow a standard format. Data was summarized for diseases which had seven or more reported cases cumulatively during the seven-year study period. Diseases for which there were fewer than seven reported cases in the Porcupine Health Unit area during the study period are not included in the disease summaries, but are listed in the Rare Diseases Table of Appendix A. Between 2006 and 2012, there were a total of 3,761 reported cases of infectious disease in the Porcupine Health Unit area. The top three diseases - chlamydia, influenza, and gonorrhea accounted for 85.7% of all cases. Chlamydia, by far, accounted for the largest proportion of cases (63.4%), followed by influenza at 12.4% of cases, and gonorrhea at 9.9% of cases. Locally, disease rates increased by 58.5% between 2006 and 2012; however, some of this increase was due to the fact that First Nations on reserve cases under Federal Jurisdiction in the PHU area began to be counted for the first time in The change in rate between 2009 and 2012 is therefore, a more appropriate comparison and during this time, the overall rate of disease locally decreased by 21.2%. Provincially, the rate of infectious diseases increased by 40.7% between 2006 and 2012 and by 20.7% between 2009 and Table 1 on the next page lists the number and proportion of all reportable diseases, for which there were one or more cases, in the PHU area during the seven-year study period between 2006 and Porcupine Health Unit Infectious Disease Status Report:

8 Table 1. Number and proportion of all reportable diseases (with one or more cases), by rank, Porcupine Health Unit, combined Rank Disease # of Cases Proportion (%) of Cases 1 Chlamydia 2, Influenza* Gonorrhea Hepatitis C Salmonellosis Camylobacteriosis Giardiasis Invasive Pneumococcal Disease (IPD) Invasive, Group A Streptococcal Disease (igas) 10 Pertussis Cryptosporidiosis Tuberculosis Syphilis^ Human Immunodeficiency Virus (HIV) Amebiasis Hepatitis B Cyclosporiasis Hepatitis A Legionellosis Malaria Shigellosis Verotoxin producing E.coli (VTEC) Yersiniosis Encephalitis/meningitis Invasive Meningococcal Disease (IMD) Mumps Cytomegalovirus, congenital 1 < Group B streptococcal disease, neonatal 1 < Heamophilus influenzae B (HiB) 1 < Herpes, neonatal 1 < Listeriosis 1 < Lyme disease 1 <0.1 Total 3, * Influenza data is seasonal from 2005/06 to 2012/13 ^Syphilis includes infectious, non-infectious and unspecified cases Source: iphis , MOHLTC, extracted November 7, Porcupine Health Unit Infectious Disease Status Report:

9 Food, Water-Borne and Parasitic Diseases A total of 239 enteric illnesses (6.4% of all cases) were reported in the PHU area between 2006 and Salmonellosis, campylobacteriosis, and giardiasis accounted for 82% of these cases. This is similar to the ranking and proportion of enteric illnesses provincially. Cyclosporiasis, hepatitis A, shigellosis, verotoxin producing E. coli, yersiniosis, listeriosis, and typhoid/paratyphoid fever each had less than seven reported cases cumulatively between 2006 and For all enteric illnesses considered in this report, average local rates of disease were lower than average provincial rates of disease over the seven-year study period. Males accounted for slightly more than half of cases locally. Between 2006 and 2012, there were 52 enteric outbreaks (average of 8.7 per year) reported in the PHU area. This includes an outbreak of 13 cases of Clostridium Difficile Infection (CDI), which is rare, but occurred in a local hospital in Outbreaks occurred seasonally with the highest number happening between January and March of any given year, peaking at an average of 2.0 outbreaks in March. The majority of these outbreaks occurred in long-term care homes and hospitals. Community outbreaks (which represented 9.6% of all reported outbreaks) are likely underestimated since they are not required to be reported to Public Health authorities and can be difficult for health care providers to recognize. Vector-Borne and Zoonotic Diseases Between 2006 and 2012, there were only 4 reported cases of vector-borne and zoonotic diseases (0.1% of all cases) in the PHU area. Three of these cases were of malaria and 1 of Lyme disease. Zero cases of rabies or West Nile Virus were reported. Provincially, malaria also represented the majority of these cases. Sexually Transmitted and Blood-Borne Diseases Locally, there were 2,962 reported cases of sexually transmitted and blood-borne infections (78.8% of all cases) in the PHU area between 2006 and Chlamydia, gonorrhea, and hepatitis C accounted for 99.2% of all cases locally. Provincially, the ranking and proportion of these diseases was similar. Local average incidence rates for chlamydia and gonorrhea were greater than the provincial average rates over the seven-year study period. Although this difference increased after 2009 when First Nations on reserve cases under Federal Jurisdiction began to be counted locally, rates from 2009 onwards represent a more accurate local picture. For hepatitis B and C, local average rates were similar to provincial average rates of disease. Finally, local average rates for HIV and syphilis (both infectious and non-infectious) were lower than provincial average rates. There were no cases of AIDS reported in the PHU area during the study period. Porcupine Health Unit Infectious Disease Status Report:

10 By their nature, sexually transmitted and blood-borne illnesses occur most frequently amongst adults. Males and females 15 to 24 years of age accounted for the largest proportion of these cases. Within this age group, females accounted for the majority of cases with rates two to three times the male rate. Vaccine Preventable Diseases Between 2006 and 2012, there were 514 reported cases of vaccine preventable disease (13.7% of all cases) in the PHU area. Influenza, invasive pneumococcal disease, and pertussis accounted for almost all of the cases both locally and provincially. Of these, influenza accounted for approximated 90% of cases locally. There were no locally reported cases of measles and less than seven cases each of invasive meningococcal disease mumps during the study period. While average local incidence rates for influenza were higher than average provincial rates during the study period, local average rates for invasive pneumococcal disease and pertussis were lower than average provincial rates. Females accounted for slightly more than half of the vaccine preventable disease cases locally. By age group, older adults over the age of 65 and children less than 5 years of age had the highest rates of disease. These two populations are at higher risk for complications related to influenza and therefore, may be tested more often. During the seven-year study period, there were 53 respiratory outbreaks in the PHU area. Eighteen of these outbreaks (34%) were influenza-related. These outbreaks were seasonal in nature and had the highest rates between January and April, peaking in February and March. The vast majority of respiratory outbreaks occurred in long-term care homes, followed by hospitals and retirement homes. Other Infectious Diseases Locally, there were 39 reported cases of other infectious diseases (1.0% of all cases) in the PHU area between 2006 and The top three diseases locally were invasive Group A streptococcal disease, tuberculosis, and legionellosis. Provincially, the top three diseases were tuberculosis, invasive Group A streptococcal disease, and encephalitis/meningitis. During the study period, there were less than seven reported cases each of encephalitis/meningitis, legionellosis, and group B streptococcal disease (neonatal) in the PHU area. The local average incidence rate for invasive Group A streptococcal disease was similar to the provincial average rate during the study period, while the local average rate for tuberculosis was lower than the provincial average rate. Males accounted for slightly more than half of the cases locally, while older adults over the age of 65 had the highest rate of disease, by age group. Conclusion The Porcupine Health Unit Infectious Disease Status Report: helps to fulfill the Porcupine Health Unit s mandate under the Ontario Public Health Standards (2), to 4 Porcupine Health Unit Infectious Disease Status Report:

11 conduct disease surveillance and publicly report on findings. This report will be the first in a series of regular reports to the public to contribute to ongoing infectious disease surveillance and timely updates to the community on the local status of infectious disease. The Porcupine Health Unit will use the findings from this report to inform public health programming for the community it serves. It is hoped that this report will be useful for community agencies in the work that they do to support and enhance community health. Porcupine Health Unit Infectious Disease Status Report:

12 LIST OF TABLES Table 1. Number and proportion of all reportable diseases (with one or more cases), by rank, Porcupine Health Unit, combined...2 Table 2. Number and proportion of enteric cases, Porcupine Health Unit & Ontario, combined 11 Table 3. Number and proportion of vector-borne and zoonotic diseases, Porcupine Health Unit & Ontario, combined...19 Table 4. Number and proportion of sexually transmitted and blood-borne infections, Porcupine Health Unit & Ontario, combined.20 Table 5. Number and proportion of vaccine preventable diseases, Porcupine Health Unit & Ontario, combined.33 Table 6. Number and proportion of other infectious diseases, Porcupine Health Unit & Ontario, combined.40 6 Porcupine Health Unit Infectious Disease Status Report:

13 LIST OF FIGURES Figure 1. Age-standardized Amebiasis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 2. Age-standardized Campylobacteriosis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 3. Age-standardized Cryptosporidiosis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 4. Age-standardized Giardiasis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 5. Age-standardized Salmonellosis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 6. Salmonellosis incidence rates, by age group and sex, Porcupine Health Unit, combined 18 Figure 7. Age-standardized Chlamydia incidence rates, by year, Porcupine Health Unit & Ontario, Figure 8. Age-standardized Chlamydia incidence rates, by sex and year, Porcupine Health Unit & Ontario, Figure 9. Chlamydia incidence rates, by age group and sex, Porcupine Health Unit, combined 23 Figure 10. Age-standardized Gonorrhea incidence rates, by year, Porcupine Health Unit & Ontario, Figure 11. Age-standardized Gonorrhea incidence rates, by sex and year, Porcupine Health Unit & Ontario, Figure 12. Gonorrhea incidence rates, by age group and sex, Porcupine Health Unit, combined 26 Figure 13. Age-standardized Hepatitis B incidence rates, by year, Porcupine Health Unit & Ontario, Figure 14. Age-standardized Hepatitis C incidence rates, by year, Porcupine Health Unit & Ontario, Figure 15. Age-standardized Hepatitis C incidence rates, by sex and year, Porcupine Health Unit & Ontario, Figure 16. Hepatitis C incidence rates, by age group and sex, Porcupine Health Unit, combined 30 Figure 17. Age-standardized HIV incidence rates, by year, Porcupine Health Unit & Ontario, Porcupine Health Unit Infectious Disease Status Report:

14 Figure 18. Age-standardized Syphilis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 19. Age-standardized Influenza incidence rates, by year, Porcupine Health Unit & Ontario, 2005/ / Figure 20. Influenza incidence rates, by age group and sex, Porcupine Health Unit, 2005/ /13 combined...35 Figure 21. Age-standardized Invasive Pneumococcal Disease incidence rates, by year, Porcupine Health Unit & Ontario, Figure 22. Invasive Pneumococcal Disease incidence rates, by age group and sex, Porcupine Health Unit, combined...37 Figure 23. Age-standardized Pertussis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 24. Pertussis incidence rates, by age group and sex, Porcupine Health Unit, combined 39 Figure 25. Age-standardized Invasive Group A Streptococcal disease incidence rates, by year, Porcupine Health Unit & Ontario, Figure 26. Invasive Group A Streptococcal disease incidence rates, by age group and sex, Porcupine Health Unit, combined..42 Figure 27. Age-standardized Tuberculosis incidence rates, by year, Porcupine Health Unit & Ontario, Figure 28. Number of enteric outbreaks, by month and seasonal year, Porcupine Health Unit, 2006/ / Figure 29. Proportion of enteric outbreaks, by risk setting, Porcupine Health Unit, 2006/ /12.45 Figure 30. Number of respiratory outbreaks, by month and seasonal year, Porcupine Health Unit, 2006/ / Figure 31. Proportion of respiratory outbreaks, by risk setting, Porcupine Health Unit, 2006/ / Porcupine Health Unit Infectious Disease Status Report:

15 ABBREVIATIONS ACRONYM AIDS Flu igas HiB HIV HPPA IMD IPD iphis MOHLTC OPHS PHU STI TB VTEC WNV NAME Acquired immunodeficiency syndrome Influenza Invasive, Group A streptococcus Haemophilus influenzae b Human immunodeficiency virus Health Protection and Promotion Act Invasive meningococcal disease Invasive pneumococcal disease integrated Public Health Information System Ministry of Health and Long-Term Care Ontario Public Health Standards Porcupine Health Unit Sexually Transmitted Infection Tuberculosis Verotoxin producing Escherichia coli West Nile virus Porcupine Health Unit Infectious Disease Status Report:

16 INTRODUCTION Infectious diseases, also known as transmissible or communicable diseases, are illnesses caused by a specific infectious agent such as a virus or bacteria, or its toxic products. Because these diseases have the potential to cause serious illness and can be transmitted to large numbers of individuals, they are reportable to public health authorities under the Ontario Health Protection and Promotion Act (HPPA). The Porcupine Health Unit Infectious Disease Status Report: , is the first comprehensive report that describes infectious disease trends over a seven-year period for the Porcupine Health Unit area. It presents summaries of infectious diseases reportable under the HPPA (see Appendix B). Cases of disease are included in this report for individuals who lived within the Porcupine Health Unit area at the time of their illness. The diseases presented in this report are organized into the following five sections: Food, water-borne and parasitic diseases Vector-borne and zoonotic diseases Sexually transmitted and blood-borne infections Vaccine preventable diseases Other infectious diseases Disease summaries are organized in alphabetical order within each section of the report and follow a standard format. Data was summarized for diseases which had seven or more reported cases cumulatively during the seven-year study period from 2006 to Diseases for which there were fewer than seven reported cases in the Porcupine Health Unit area during the study period are not included in the disease summaries, but are listed in the Rare Diseases Table of Appendix A. Further, in-depth analysis was conducted for select diseases, and these are highlighted in the Focus On sections of the report. These diseases - chlamydia, gonorrhea, and hepatitis C were highlighted for a variety of reasons including: local rates were significantly different than provincial rates, there are emerging issues related to the disease either locally or provincially, or because the Porcupine Health Unit has taken or would like to take measures for the prevention or containment of the disease. 10 Porcupine Health Unit Infectious Disease Status Report:

17 FOOD, WATER-BORNE AND PARASITIC DISEASES The following food, water-borne and parasitic diseases, also known as enteric illnesses, are included in this report: Amebiasis Listeriosis Campylobacteriosis Salmonellosis Cryptosporidiosis Shigellosis Cyclosporiasis Typhoid/Paratyphoid fever Giardiasis Verotoxin producing E. coli (VTEC) Hepatitis A Yersiniosis Since a number of the diseases within this grouping (cyclosporiasis, hepatitis A, shigellosis, VTEC, yersiniosis, listeriosis, and typhoid/paratyphoid fever) had less than seven cases cumulatively between 2006 and 2012, these diseases are listed in the Rare Diseases Table of Appendix A. Key Messages Table 2. Number and proportion of enteric cases, Porcupine Health Unit & Ontario, combined Porcupine Health Unit Ontario Proportion (%) of cases # of cases Disease Rank Disease # of cases Proportion (%) of cases Salmonellosis 1 Campylobacteriosis 25, Campylobacteriosis 2 Salmonellosis 18, Giardiasis 3 Giardiasis Cryptosporidiosis 4 Amebiasis 5, Amebiasis 5 Cryptosporidiosis 2, Cyclosporiasis 6 Yersiniosis 1, Hepatitis A 7 Shigellosis 1, Shigellosis 8 VTEC 1, VTEC 9 Typhoid/paratyphoid fever Yersiniosis 10 Hepatitis A Listeriosis 11 Cyclosporiasis Typhoid/Paratyphoid 12 Listeriosis fever Total 70, Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013 Porcupine Health Unit Infectious Disease Status Report:

18 A total of 239 cases of enteric illness were reported in the PHU area between 2006 and 2012 (see Table 2 above). Locally, salmonellosis was the most commonly reported enteric illness (43.5%), while provincially, campylobacteriosis was the most commonly reported (36.5%). The top 5 enteric illnesses both locally and provincially were salmonellosis, campylobacteriosis, giardiasis, cryptosporidiosis, and amebiasis. These diseases accounted for 91.2% of cases locally and 88.3% of cases provincially. Males accounted for the majority of cases locally (53.1%). There were no age trends related to enteric diseases locally as all age groups were represented amongst the cases. 12 Porcupine Health Unit Infectious Disease Status Report:

19 AMEBIASIS Figure 1. Age-standardized Amebiasis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were a total of 9 reported cases of amebiasis in the Porcupine Health Unit (PHU) area (average rate of 1.5 cases per 100,000 population). The majority of these cases (77.8%) occurred in Three of these cases were among one family but the others were unrelated. In all years of the study, the amebiasis rate in the PHU area has remained below the provincial rate, which was at an average of 5.9 cases per 100,000. Due to the small number of cases and resulting instability in rates, caution should be used in interpreting this data. Porcupine Health Unit Infectious Disease Status Report:

20 CAMPYLOBACTERIOSIS Figure 2. Age-standardized Campylobacteriosis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were a total of 59 cases of campylobacteriosis in the PHU area (average rate of 9.0 cases per 100,000). The local rate of disease has fluctuated between a low of 2.3 cases per 100,000 in 2011 to a high of 15.8 cases per 100,000 in In the most recent year of the study, the rate was 12.7 cases per 100,000. In every year of the study, the local rate has been lower than the provincial rate, which averaged 28.4 cases per 100,000. Local rates were highest amongst those 65 years of age and older (15.2 cases per 100,000) and lowest amongst those less than 25 years of age (data not shown). 14 Porcupine Health Unit Infectious Disease Status Report:

21 CRYPTOSPORIDIOSIS Figure 3. Age-standardized Cryptosporidiosis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were a total of 13 cases of cryptosporidiosis in the PHU area between 2006 and 2012 (average rate of 2.6 cases per 100,000). The local rate fluctuated between 1.1 and 6.2 cases per 100,000. The average local rate of 2.6 cases per 100,000 was slightly lower than the average provincial rate of 3.0 cases per 100,000 over the study period. Due to the small number of cases and resulting instability in rates, caution should be used in interpreting this data. Porcupine Health Unit Infectious Disease Status Report:

22 GIARDIASIS Figure 4. Age-standardized Giardiasis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were a total of 33 cases of giardiasis in the PHU area (average rate of 6.2 cases per 100,000). The local rate has steadily decreased from a high of 9.8 cases per 100,000 in 2007 to 3.4 cases per 100,000 in In each year of the study, the local rate has remained below the provincial rate, which averaged 12.0 cases per 100,000. The majority of local cases were amongst males (60.6%) and the highest rates of disease were amongst children less than four years of age and amongst those 25 to 34 years of age (data not shown). 16 Porcupine Health Unit Infectious Disease Status Report:

23 SALMONELLOSIS Figure 5. Age-standardized Salmonellosis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were a total of 104 cases of salmonellosis in the PHU area between 2006 and 2012 (average rate of 16.3 cases per 100,000). The local rate fluctuated between a low of 8.0 cases per 100,000 in 2009 to a high of 25.1 cases per 100,000 in In 2010, a notable increase of Salmonella was identified in the PHU area within a short period of time. Between August and October, 8 cases of Salmonella were reported, of which 7 resided in one community and the 8th had history of travel through the community prior to illness. In 2011, 13 cases of Salmonella Heidelberg were identified as part of a community outbreak. Except for 2011, the local rate remained lower than the provincial rate, which averaged 21.1 cases per 100,000 over the study period. Porcupine Health Unit Infectious Disease Status Report:

24 Figure 6. Salmonellosis incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, Male rate Female rate Overall rate Age Group Males and females accounted for an equal proportion of cases. The highest rates were amongst adults 55 years of age and older, although cases occurred amongst all age groups. 18 Porcupine Health Unit Infectious Disease Status Report:

25 VECTOR-BORNE AND ZOONOTIC DISEASES For the purposes of this report, diseases transmitted by vectors and animals include: Lyme Disease Malaria Rabies West Nile Virus During the seven-year study period between 2006 and 2012, there were 3 cases of malaria, 1 of Lyme disease, and zero cases each of rabies and West Nile Virus in the PHU area. As such, these diseases are listed in the Rare Diseases Table of Appendix A. Provincial comparisons for these diseases are provided in Table 3 below. Table 3. Number and proportion of vector-borne and zoonotic diseases, Porcupine Health Unit & Ontario, combined Porcupine Health Unit Ontario Proportion (%) of cases # of cases Disease Rank Disease # of cases Proportion (%) of cases Malaria 1 Malaria 1, Lyme disease 2 Lyme disease Rabies 3 West Nile Virus West Nile Virus 4 Rabies 1 < Total 2, Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013 There were a total of 4 reported cases of vector-borne and zoonotic diseases in the PHU area between 2006 and 2012, 75% of which were malaria cases occurring in All of the malaria cases were travel-related. Provincially, malaria also accounted for the majority of these cases (54.8%). Porcupine Health Unit Infectious Disease Status Report:

26 SEXUALLY TRANSMITTED AND BLOOD-BORNE DISEASES For the purposes of this report, sexually transmitted and blood-borne infections include: Chlamydia Gonorrhea Hepatitis B (acute) Hepatitis C HIV and AIDS Syphilis Since there were zero reported cases of AIDS during the study period between 2006 and 2012, this disease is listed in the Rare Diseases Table of Appendix A. Key Messages Table 4. Number and proportion of sexually transmitted and blood-borne infections, Porcupine Health Unit & Ontario, combined Porcupine Health Unit Ontario Proportion (%) of cases # of cases Disease Rank Disease # of cases Proportion (%) of cases ,383 Chlamydia 1 Chlamydia 206, Gonorrhea 2 Hepatitis C 30, Hepatitis C 3 Gonorrhea 27, Syphilis* 4 Syphilis* 12, HIV 5 HIV 6, Hepatitis B 6 Hepatitis B AIDS 7 AIDS ,962 Total 285, * Includes infectious, non-infectious and unspecified cases of syphilis Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013 Locally, there were 2,962 reported cases of sexually transmitted and blood-borne infections in the PHU area between 2006 and Chlamydia, by far, accounted for the largest proportion of cases both locally (80.5%) and provincially (72.5%). The top three diseases, chlamydia, gonorrhea, and hepatitis C accounted for 99.2% of all cases locally. Provincially, the ranking and proportion of these diseases was similar (92.9%). Females (66.8%) and those between 15 and 24 years of age (66.3%) each accounted for about two-thirds of all cases locally. 20 Porcupine Health Unit Infectious Disease Status Report:

27 FOCUS ON: CHLAMYDIA Figure 7. Age-standardized Chlamydia incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were 2,383 cases of chlamydia in the PHU area (average rate of cases per 100,000). The local chlamdyia rate overall increased by 82.9% between 2006 and 2012, however, much of this increase was due to the fact that First Nations on reserve cases under Federal Jurisdiction began to be counted for the first time in The change in rate between 2009 and 2012 is therefore, a more appropriate comparison and during this time, the overall rate increased by only 3.2%, while the Ontario rate increased by 23.4%. Prior to the inclusion of these cases, the local rate was being underestimated. With the inclusion of these cases, the local rate is a more accurate depiction of the rate of chlamydia in the community. Porcupine Health Unit Infectious Disease Status Report:

28 Figure 8. Age-standardized Chlamydia incidence rates, by sex and year, Porcupine Health Unit & Ontario, Rate per 100, Porcupine Male Rate Porcupine Female Rate Ontario Male Rate Ontario Female Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 As Figure 8 shows, females both locally and provincially have higher rates of chlamydia than do males. Locally, the female rate is at least twice the male rate year-over-year. Provincially, the difference is not as great, with the female rate being about 1.5 times greater than the male rate. Between 2009 and 2012, Porcupine Health Unit s male rates were significantly higher than Ontario s male rates, but prior to 2009, the rates were not significantly different. 22 Porcupine Health Unit Infectious Disease Status Report:

29 Figure 9. Chlamydia incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Males and females 15 to 24 years of age accounted for the largest proportion, 72.2%, of all chlamydia cases in the PHU area over the seven-year study period. Within this age group, females accounted for the majority of cases, 73.9%, with a rate almost twice the male rate during most years of the study. Porcupine Health Unit Infectious Disease Status Report:

30 FOCUS ON: GONORRHEA Figure 10. Age-standardized Gonorrhea incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Locally, there were 372 reported cases of gonorrhea in the PHU area (average rate of 44.1 cases per 100,000) between 2006 and The local rate increased by 126.2% during this time period; however, much of this increase was due to the fact that First Nations on reserve cases under Federal Jurisdiction began to be counted in The change in rate between 2009 and 2012 is therefore, a more appropriate comparison. During this time, the PHU overall rate decreased by 69.1%, while the Ontario rate increased by 12.6%. 24 Porcupine Health Unit Infectious Disease Status Report:

31 Figure 11. Age-standardized Gonorrhea incidence rates, by sex and year, Porcupine Health Unit & Ontario, Rate per 100, Porcupine Male Rate Porcupine Female Rate Ontario Male Rate Ontario Female Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Locally, the gonorrhea rate for females has been higher than the rate for males; however, provincially, it is the opposite trend with the male rates being consistently higher than the female rates. Between 2009 and 2011, local rates were significantly higher than provincial rates, however, in 2012, there was no significant difference. Porcupine Health Unit Infectious Disease Status Report:

32 Figure 12. Gonorrhea incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Males and females 15 to 24 years of age accounted for more than half of the total number of local gonorrhea cases (59.7%) over the seven-year study period. Within this age group, females accounted for the majority of cases (68.9%), with a rate almost 1.5 times the male rate in most years of the study period. 26 Porcupine Health Unit Infectious Disease Status Report:

33 HEPATITIS B (Acute) Figure 13. Age-standardized Hepatitis B incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were a total of 7 cases of hepatitis B in the PHU area between 2006 and 2012 (average rate of 1.0 cases per 100,000). The local rate fluctuated between 0.0 cases and 2.5 cases per 100,000, but remained lower than the provincial rate (average of 1.0 cases per 100,000) in most years of the study. Due to small numbers and the resulting instability in rates, caution should be used in interpreting this data. Porcupine Health Unit Infectious Disease Status Report:

34 FOCUS ON: HEPATITIS C Figure 14. Age-standardized Hepatitis C incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were a total of 181 cases of hepatitis C in the PHU area (average rate of 30.8 cases per 100,000). During this time, the PHU rate increased by 31.1%, however, much of this increase was due to the fact that First Nations on reserve cases under Federal Jurisdiction began to be counted in The change in rate between 2009 and 2012 is therefore, a more appropriate comparison. During this time, the PHU rate decreased by 3.8%, while the provincial rate decreased by 12.0%. Prior to 2009, the local rate was generally lower than the provincial rate. However, since 2009, the local and provincial rates have been similar. 28 Porcupine Health Unit Infectious Disease Status Report:

35 Figure 15. Age-standardized Hepatitis C incidence rates, by sex and year, Porcupine Health Unit & Ontario, Rate per 100, Porcupine Male Rate Porcupine Female Rate Ontario Male Rate Ontario Female Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 The local male rate for hepatitis C has remained consistently higher than the local female rate year-over-year, but in the last two years of the study, these rates have converged. Similarly, in the province overall, male rates of disease have remained consistently higher than female rates. The provincial male rate has remained consistently higher than the local male rate. The same is true of the female rates between 2006 and 2009; however, since 2010 the local females rates of disease have surpassed the provincial female rates. Porcupine Health Unit Infectious Disease Status Report:

36 Figure 16. Hepatitis C incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 The highest rates of disease were amongst males 45 to 59 years of age, with rates ranging from 84.8 to 87.3 cases per 100,000. This age group of males accounted for more than a third of the total cases (36.5%). Amongst females, the highest rates of disease were amongst those 40 to 44 years of age (63.4 cases per 100,000), followed by those 20 to 24 years of age (52.1 cases per 100,000). 30 Porcupine Health Unit Infectious Disease Status Report:

37 HIV Figure 17. Age-standardized HIV incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were 9 cases of HIV in the PHU area between 2006 and 2012 (average rate of 1.6 cases per 100,000). Two-thirds of these cases occurred in 2008 and 2009 and in the most recent year of the study, there were no reported cases of HIV locally. The local rate has remained below the provincial rate (average of 7.4 cases per 100,000) in every year of the study. Due to small numbers and resulting instability in rates, caution should be used in interpreting the data. Porcupine Health Unit Infectious Disease Status Report:

38 SYPHILIS Figure 18. Age-standardized Syphilis* incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 * Syphilis includes infectious, non-infectious and unspecified cases Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were 10 reported cases of infectious and noninfectious syphilis in the PHU area (average rate of 1.2 cases per 100,000). Of these, 4 cases were infectious and 6 were non-infectious. The local rate was highest in 2006 with 4.8 cases per 100,000 and in the most recent two years has been 1.2 cases per 100,000. The local rate has remained below the provincial rate (average of 11.4 cases per 100,000) during each year of the study period. Due to small numbers and the resulting instability in rates, caution should be used in interpreting the data. 32 Porcupine Health Unit Infectious Disease Status Report:

39 VACCINE PREVENTABLE DISEASES For purposes of this report, vaccine preventable diseases include: Influenza Invasive Meningococcal Disease (IMD) Invasive Pneumococcal Disease (IPD) Measles (Red Measles) Mumps Pertussis (Whooping Cough) There were less than seven reported cases of IMD, measles and mumps in the PHU area between 2006 and As such, these diseases are not further elaborated in this section, but are presented in the Rare Diseases Table of Appendix A. Key Messages Table 5. Number and proportion of vaccine preventable diseases, Porcupine Health Unit & Ontario, combined Porcupine Health Unit Ontario Proportion (%) of cases # of cases Disease Rank Disease # of cases Proportion (%) of cases Influenza* 1 Influenza* 45, IPD 2 IPD 7, Pertussis 3 Pertussis 4, IMD 4 Mumps Mumps 5 IMD Measles 6 Measles Total 59, * Influenza data is by seasonal year from 2005/06 to 2012/13 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013 Between 2006 and 2012, there were 514 reported cases of vaccine preventable disease in the PHU area. Influenza, by far, accounted for the largest proportion of cases both locally (90.9%) and provincially (76.4%). The top three diseases, influenza, IPD and pertussis accounted for 99.3% of all cases locally. Provincially, the ranking and proportion of these diseases was similar (98.0%). Females accounted for the majority of cases (54.7%), while older adults over the age of 65 (22.8%) and children less than 5 years of age (17.3%) had the highest rates of disease, by age group. Porcupine Health Unit Infectious Disease Status Report:

40 INFLUENZA Figure 19. Age-standardized Influenza incidence rates, by seasonal year, Porcupine Health Unit & Ontario, 2005/ / Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7 and 20, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Over the 8-year period between 2005/06 and 2012/13, there were 467 reported cases of influenza in the PHU area (average rate of 68.1 cases per 100,000). The local rate was highest during the 2009/10 influenza season, which marked the year of the H1N1 pandemic. Although the local rate has been higher than the provincial rate (average of 43.4 cases per 100,000) in most years, in the latest two years of the study, the rates have been similar. 34 Porcupine Health Unit Infectious Disease Status Report:

41 Figure 20. Influenza incidence rates, by age group and sex, Porcupine Health Unit, 2005/ /13 combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7 and 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Females accounted for the majority of influenza cases (55.7%) locally. The highest rates of disease were amongst children under the age of 5 (232.4 cases per 100,00), followed by children between 5 and 9 years of age (136.9 cases per 100,000), and finally amongst seniors 65 years of age and older (124.0 cases per 100,000). Porcupine Health Unit Infectious Disease Status Report:

42 INVASIVE PNEUMOCOCCAL DISEASE (IPD) Figure 21. Age-standardized Invasive Pneumococcal Disease incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were 26 reported cases of IPD in the PHU area between 2006 and 2012 (average rate of 3.8 cases per 100,000). The local rate was highest in 2010 at 6.6 cases per 100,000, but in the most recent year of the study has decreased to 4.4 cases per 100,000. In all years of the study, the local rate has remained below the provincial rate (average of 7.6 cases per 100,000). Due to small numbers and the resulting instability in rates, caution should be used in interpreting the data. 36 Porcupine Health Unit Infectious Disease Status Report:

43 Figure 22. Invasive Pneumococcal Disease incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, Male rate Female rate Overall rate Age Group The majority of IPD cases were amongst males (57.7%) locally. Cases of IPD were reported most frequently amongst older individuals, aged 60 years of age and older (between 11.2 and 11.7 cases per 100,000). Porcupine Health Unit Infectious Disease Status Report:

44 PERTUSSIS (WHOOPING COUGH) Figure 23. Age-standardized Pertussis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, Between 2006 and 2012, there were 17 reported cases of pertussis in the PHU area (average rate of 3.4 cases per 100,000). The local rate has fluctuated significantly over this time period, with a peak rate of 10.8 cases per 100,000 in Four of the 7 cases of pertussis that year were part of a community outbreak. Due to small numbers and resulting instability in rates, caution should be used in interpreting this data. 38 Porcupine Health Unit Infectious Disease Status Report:

45 Figure 24. Pertussis incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Pertussis cases were equally distributed between males and females in the PHU area. The highest rates of diseases were amongst children less than 5 years of age (23.2 cases per 100,000). Porcupine Health Unit Infectious Disease Status Report:

46 OTHER INFECTIOUS DISEASES There are some reportable diseases that are not easily categorized into one of the previous sections. These include: Encephalitis/Meningitis Invasive Group A Streptococcal Disease (igas) Group B Streptococcal Disease (Neonatal) Legionellosis Tuberculosis (TB) Between 2006 and 2012, there were less than seven reported cases of each of encephalitis/meningitis, legionellosis, and group B streptococcal disease (neonatal) in the PHU area. As such, these diseases are not further elaborated in this section, but are included in the Rare Diseases Table of Appendix A. Key Messages Table 6. Number and proportion of other infectious diseases, Porcupine Health Unit & Ontario, combined Porcupine Health Unit Ontario Proportion (%) of cases # of cases Disease Rank Disease # of cases Proportion (%) of cases igas 1 Tuberculosis 4, Tuberculosis 2 igas 3, Legionellosis 3 Encephalitis 1, meningitis Encephalitis 4 Legionellosis meningitis Group B streptococcal 5 Group B disease (neonatal) streptococcal disease (neonatal) Total 10, Source: iphis , MOHLTC, extracted November 7, 2013; Ontario data, MOHLTC, iphis, extracted by PHO on November 20, 2013 Locally, there were a total of 39 reported cases of other infectious diseases in the PHU area between 2006 and The top three diseases locally were igas, tuberculosis, and legionellosis, accounting for 92.3% of all cases. Provincially, the top three diseases were tuberculosis, igas, and encephalitis/meningitis, accounting for 89.5% of all cases., In the PHU area, males accounted for the majority of cases (53.8%), while older adults over the age of 65 (28.2%) had the highest rate of disease, by age group. 40 Porcupine Health Unit Infectious Disease Status Report:

47 INVASIVE GROUP A STREPTOCOCCAL DISEASE (igas) Figure 25. Age-standardized Invasive Group A Streptococcal disease incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 Between 2006 and 2012, there were 22 reported cases of igas in the PHU area (average rate of 3.4 cases per 100,000). The local rate fluctuated between a low of 0.7 cases per 100,000 in 2006 and a high of 7.9 cases per 100,000 in Overall, the local rate has remained below the provincial rate (average of 3.9 cases per 100,000). Due to small numbers and resulting instability in rates, caution should be used in interpreting the data. Porcupine Health Unit Infectious Disease Status Report:

48 Figure 26. Invasive Group A Streptococcal disease incidence rates, by age group and sex, Porcupine Health Unit, combined Rate per 100, Male rate Female rate Overall rate Age Group Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 The local cases of igas were fairly equally distributed amongst males and females. The highest rates were amongst adults 65 years of age and older (7.0 cases per 100,000), while the lowest rates were amongst those 5 to 14 years of age. 42 Porcupine Health Unit Infectious Disease Status Report:

49 TUBERCULOSIS (TB) Figure 27. Age-standardized Tuberculosis incidence rates, by year, Porcupine Health Unit & Ontario, Number of Cases Rate per 100, Porcupine Cases Porcupine Rate Ontario Rate Year 0.0 Source: iphis , MOHLTC, extracted November 7, 2013; Population estimates, IntelliHealth, MOHLTC, extracted September 19, 2013 There were a total of 11 reported cases of tuberculosis in the PHU area between 2006 and 2012 (average rate of 1.6 cases per 100,000). The local rate of TB peaked in 2009 with 5.1 cases per 100,000, but has since decreased to 2.7 cases per 100,000 in The local rate of disease has remained below the provincial rate (average 4.8 cases per 100,000) during the seven-year study period. Due to small numbers and resulting instability in rates, caution should be used in interpreting this data. Porcupine Health Unit Infectious Disease Status Report:

50 OUTBREAKS Figure 28. Number of enteric outbreaks, by month and seasonal year, Porcupine Health Unit, 2006/7-2011/12* Number of Outbreaks Sep Oct Nov Dec Jan Feb Mar Apr May June July Aug 2006/ / / / / / year average Month * Outbreaks are presented by seasonal year (September to August of any given year) from 2006/07 to 2011/12. Source: iphis , MOHLTC, extracted November 7, Porcupine Health Unit Infectious Disease Status Report:

51 Figure 29. Proportion of enteric outbreaks, by risk setting, Porcupine Health Unit, 2006/ /12* Community 9.6% Long-Term Care 53.8% Hospital 34.6% Retirement home 1.9% * Outbreaks are presented by seasonal year (September to August of any given year) from 2006/07 to 2011/12. Source: iphis , MOHLTC, extracted November 7, 2013 There were a total of 52 enteric outbreaks (average of 8.7 per year) reported in the PHU area between 2006 and The annual number of outbreaks fluctuated between one outbreak in 2007/08 to 13 outbreaks in 2010/11. This data includes an outbreak of 13 cases of Clostridium Difficile Infection (CDI), which is rare, but occurred in a local hospital in Enteric outbreaks showed a seasonal trend with the highest number occurring between January and March of any given year, peaking at an average of 2.0 outbreaks in March. The majority of outbreaks occurred in long-term care homes (53.8%), followed by hospitals (34.6%), and the community (9.6%). Porcupine Health Unit Infectious Disease Status Report:

52 Figure 30. Number of respiratory outbreaks, by month and seasonal year, Porcupine Health Unit, 2006/ /12* Number of Outbreaks Sep Oct Nov Dec Jan Feb Mar Apr May June July Aug 2006/ / / / / / year average Month * Outbreaks are presented by seasonal year (September to August of any given year) from 2006/07 to 2011/12. Source: iphis , MOHLTC, extracted November 7, Porcupine Health Unit Infectious Disease Status Report:

53 Figure 31. Proportion of respiratory outbreaks, by risk setting, Porcupine Health Unit, 2006/ /12* Hospital 7.5% Retirement home 1.9% Long-Term Care 90.6% * Outbreaks are presented by seasonal year (September to August of any given year) from 2006/07 to 2011/12. Source: iphis , MOHLTC, extracted November 7, 2013 Between 2006 and 2012, there were a total of 53 respiratory outbreaks in the PHU area (average of 8.8 per year). Thirty-four percent of these outbreaks, or 18, were influenza-related. Respiratory outbreaks were also seasonal in nature and had the highest rates between January and April, peaking in February and March at a rate of 1.5 outbreaks per month. The vast majority of respiratory outbreaks occurred in long-term care homes (90.6%), with 7.5% occurring in hospitals and the remainder (1.9%) in retirement homes. Porcupine Health Unit Infectious Disease Status Report:

54 REFERENCES 1. Health Protection and Promotion Act, 2011, Ontario Ministry of Health and Long- Term Care. Toronto: Queen s Printer for Ontario; Retrieved November 25, 2013 from 2. Ontario Ministry of Health and Long-Term Care, 2009, Ontario Public Health Standards, Toronto: Queen s Printer for Ontario; Retrieved November 28, 2013 from 3. Association of Public Health Epidemiologists in Ontario ( Population estimates. Retrieved December 18, 2013 from 4. Ontario Ministry of Health and Long-Term Care, 2013, Infectious Diseases Protocol, Toronto: Queen s Printer for Ontario; Retrieved November 5, 2013 from x 5. Doyle TJ, Glynn MK, and Groseclose SL. Completeness of notifiable infectious disease reporting in the United States: an analytical literature review. American Journal of Epidemiology. 2002;155(9); Majowicz SE, Edge VL, Fazil A, McNab WB, Dore KA, Sockett PN, et al. Estimating the under-reporting rate for infectious gastrointestinal illness in Ontario. Can J Public Health. 2005;96(3); Heymann DL, editor. Control of communicable diseases manual. 19 th edition. Washington, DC: American Public Health Association; Kwong JC, Crowcroft NS, Campitelli MA, Ratnasingham S, Daneman N, Deeks SL, Manuel DG. Ontario Burden of Infectious Disease Study Advisory Group; Ontario Burden of Infectious Disease Study (ONBOIDS): An OAHPP/ICES Report. Toronto: Ontario Agency for Health Protection and Promotion, Institute for Clinical Evaluative Sciences; Available from 9. Ontario Agency for Health Protection and Promotion (Public Health Ontario). Reportable disease trends in Ontario, Toronto, ON: Queen s Printer for Ontario; Available from ario_2011.pdf 48 Porcupine Health Unit Infectious Disease Status Report:

55 10. Region of Waterloo Public Health (2011). Waterloo Region Infectious Disease Status Report: Waterloo, ON: Asma Razzaq. Available from ctiousdiseasereport_2011.pdf 11. Region of Waterloo Public Health (2012). Infectious Diseases in Waterloo Region: Surveillance Report Waterloo, ON: Asma Razzaq. Available from ctiousdiseasereport_2012.pdf 12. Toronto Public Health (2013). Communicable Diseases in Toronto City of Toronto: Toronto, Canada. December Available from cable%20disease%20control/communicable%20disease%20surveillance/annual%20 Reports/Files/pdf/2/0%20-%202012%20Annual%20Report.pdf Porcupine Health Unit Infectious Disease Status Report:

56 APPENDIX A: RARE DISEASES, PORCUPINE HEALTH UNIT, COMBINED Disease Number of Cases Disease Anthrax 0 Measles 0 Invasive Meningococcal Botulism 0 Disease (IMD) 2 Number of Cases Brucellosis 0 Mumps 2 Chancroid 0 Ophthalmia neonatorum 0 Cholera 0 Plague 0 Creutzfeldt-Jakob disease 0 Polio 0 Cyclosporiasis 6 Q fever 0 Cytomegalovirus, congenital 1 Rabies 0 Diptheria 0 Rubella 0 Rubella, congenital syndrome 0 Severe Acute Respiratory Syndrome (SARS) 0 Encephalitis/meningitis 2 Group B streptococcal disease, neonatal 1 Haemophilus influenzae B (Hib) 1 Shigellosis 3 Hantavirus 0 Smallpox 0 Hepatitis A 5 Tetanus 0 Hepatitis D 0 Trichinosis 0 Hemorrhagic fever 0 Tularemia 0 Herpes, neonatal 1 Typhoid/paratyphoid fever 0 Lassa fever 0 Viral hemorrhagic fevers 0 Verotoxin producing E.coli (VTEC) 3 Legionellosis 3 Leprosy 0 West Nile Virus 0 Listeriosis 1 Yellow fever 0 Lyme disease 1 Yersiniosis 3 Malaria 3 Total 38 Source: iphis , MOHLTC, extracted November 7, Porcupine Health Unit Infectious Disease Status Report:

57 APPENDIX B: LIST OF REPORTABLE DISEASES Porcupine Health Unit Infectious Disease Status Report:

58 `APPENDIX C: GLOSSARY OF TERMS Active Transmission: The spread of an infectious agent from one person to another. Age Standardization: A method of adjusting rates to minimize the effects that different age compositions have on populations. This method is used when comparing two or more populations. For example, an older population would be more likely to have higher rates of chronic diseases compared to a younger population. Standardizing controls for these differences. Agent of Disease: A factor whether microorganism, chemical substance, radiation or nutrient whose presence or absence is essential for the onset of disease. A disease may require more than one agent to develop. Average: See Mean. Case: A case is an individual with an episode of a reportable disease. For each reportable disease there is a case definition which outlines the criteria to confirm that episode of disease. Case definitions are determined by the Ministry of Health and Long-Term Care. Carrier: A person or animal without evident clinical disease (signs or symptoms) who harbours an infectious agent and is able to transmit the agent to others. Contact: A person who may have acquired an infection from a case. Incidence: The number of new events (such as new cases of a disease) among a population within a specific point in time. Incidence Rate: The rate at which new events, or new cases, occur in a specified time in a defined population that is at risk of experiencing the condition or event. Infectious Disease: An illness that results from the transmission of an infectious agent or its toxins from an infected person, animal, or reservoir to a susceptible host, either directly or indirectly through an intermediate plant or animal host, vector or inanimate objects. Mean: The mean or average is the sum of all the individual values in a set of measurements divided by the total number of values in the set of measurements. Outbreak: When the occurrence of cases of a disease or condition is in excess of the expected number of cases in a localized area over a given period of time. There is no set number of cases required to declare an outbreak as it varies by disease and local conditions. 52 Porcupine Health Unit Infectious Disease Status Report:

59 Proportion: A proportion is a type of ratio in which the numerator is included in the denominator. A proportion is calculated be dividing the number of people with a common characteristic at a given time period by the total population that shares the same event in the same time period. Reportable Disease: A human disease that is required to be reported to public health authorities in Ontario according to Regulation 559/91 (Specification of Reportable Diseases) made under the Health Protection and Promotion Act (HPPA) (available at Under this legislation, physicians, laboratories, hospital administrators, principals of schools and superintendents of institutions must notify local health units about the occurrence or suspected occurrence of these diseases. Risk Factor: An aspect of someone s behaviour or lifestyle, a characteristic that a person was born with, or an event that s/he has been exposed to that is associated with acquiring a disease. Risk Setting: The place or environment where the case may have acquired the infection. Risk settings reported by cases include: hospital, long-term care home, residential facility, retirement home, child care facility and community setting. Sporadic: When a disease occurs infrequently and irregularly. This term is also used to refer to non-outbreak associated cases of disease. Surveillance: The ongoing, systematic collection, collation, analysis and interpretation of data with prompt dissemination of the results to those who need to know, particularly those who are in a position to take action. Trends: Trends are changes in frequencies, proportions or rates of a disease, or an event observed over time. Trends may be irregular, flat or move in one direction. Trends can be expressed in many forms, including tables, graphs and pie charts. Vector-borne disease: A class of miscellaneous diseases which are transmitted to humans by vectors, predominately insects (e.g. mosquito-borne diseases caused by viruses, bacteria, etc.). Vector: A living creature, typically an animal, which carries an infectious pathogen to a susceptible host. It is an intermediary without evident clinical disease who harbours an infectious agent and is able to transmit the agent to others. Porcupine Health Unit Infectious Disease Status Report:

60 APPENDIX D: DATA SOURCES AND METHODOLOGY Data Sources All information related to cases of infectious disease for Porcupine Health Unit (PHU) included in this report was collected by PHU under the authority of the Health Protection and Promotion Act (HPPA), which mandates health care practitioners to notify the Medical Officer of Health (MOH) of all confirmed and, in some cases, probable cases of reportable disease. Case reports are investigated by Public Health staff as part of their routine activities. Cases are entered into a provincially-mandated information and surveillance system, the integrated Public Health Information System (iphis), maintained by the Ontario Ministry of Health and Long-term Care (MOHLTC). In 2005, the iphis database replaced the previous provincial reporting system (the Reportable Disease Information System RDIS), which had been operational since Population Data Incidence rates were calculated using population estimates and projections obtained from the Ontario MOHLTC, Public Health Planning Data Base (PHPDB). The PHPDB is an information resource provided by the Health Data Branch of the Ontario MOHLTC. Queries on PHPDB are completed via an online portal called IntelliHealth. Public health unit population data in IntelliHealth are based on census subdivision (CSD) populations provided by Statistics Canada. Population estimates for 2006 onwards are post-censal estimates based on the 2006 census counts adjusted for net undercoverage and changes in the population between Census Day and July 1st (3). The population estimates in this report may differ from those presented elsewhere due to differences in methodology, or updating of population data by the MOHLTC. Population data used in this report was downloaded from IntelliHealth on September 19, 2013 by PHO and reflects the latest population estimates and projections at the time of this report. These data were stratified by age and sex to provide the appropriate denominators to calculate overall, age, sex, and health unit specific incidence rates. Methodology Sporadic Cases Local cases of infectious disease reported to PHU with an episode accurate (onset) date between January 1, 2006 and December 31, 2012 were extracted from iphis between November 7 and November 20, Tuberculosis and AIDS data was extracted by diagnosis date, which is the date of a case s diagnosis; while, HIV data was extracted by encounter date, or the date the case became known to public health. Influenza case counts and rates as well as outbreak data were analyzed by seasonal 54 Porcupine Health Unit Infectious Disease Status Report:

61 year (September 1 st of any given year to August 31 st of the following year). Influenza data is from the 2005/06 to the 2012/13 season while outbreak data is from the 2006/07 season to the 2011/12 season. Cases that resided in the PHU area, had Porcupine Health Unit as the Diagnosing Health Unit, and met the provincial surveillance case definition were included. All data sets were reviewed by PHU staff to ensure that final case counts were accurate. For TB, only active cases were included in the reporting of confirmed cases (i.e., latent TB infections are not included). Similarly, for hepatitis B, only acute cases are included in the reporting of confirmed cases. Unless otherwise stated, case counts included only confirmed case classifications. Probable cases were included in the total counts for Lyme disease, mumps, pertussis, amebiasis, and WNV (since 2006) due to case definition changes in The latest case classifications for all diseases were used from the Ontario MOHLTC 2013 Infectious Diseases Protocol (4). Provincial case summaries are compiled by Public Health Ontario (PHO), which provided the Ontario data for this report. Provincial data was extracted on November 20, 2013 and includes all infectious diseases reported in the province of Ontario between January 1, 2006 and December 31, Information on past episodes of disease can be added or updated to the provincial reporting system at any time. The information summarized in this report represents what was known to PHU and the PHO at the time of data extraction (Fall 2013) with the stipulation that these data are provisional and subject to change. Analysis For each reportable infectious disease, data on the number of cases and incidence rates were presented. Where possible, disease case counts and rates were further broken down by: Year (2006, 2007, 2008, 2009, 2010, 2011, and 2012) Sex (male and female) Age group (0-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, and 65+ years) Seasonality (month) As age can be a factor in whether a person acquires a disease and how the disease progresses, it is necessary to control for differences in age distribution when comparing two populations. Age-standardization is a technique that minimizes the effect of differences in age between populations so that findings can be attributed to factors other than age. For this report, when comparisons between PHU and Ontario were Porcupine Health Unit Infectious Disease Status Report:

62 made, rates were directly age-standardized using the 1991 Canadian Standard population from Statistics Canada. For each disease, age-standardized incidence rates were presented for PHU and Ontario on a yearly basis and refer to the number of new cases of disease per 100,000 population. The 20 age groups (in years) used for direct age-standardization were: <1, 1-4, 5-9, 10-14, 15-19, 20-24, 25-29, 30-34, 35-39, 40-44, 45-49, 50-54, 55-59, 60-64, 65-69, 70-74, 75-79, 80-84, 85-89, 90+. Proportions and rates were rounded to one decimal place. As much as possible, data were presented in a consistent format with a figure highlighting the age-standardized overall rates for PHU and Ontario, allowing a provincial comparison. Select diseases were highlighted with further in-depth analysis (e.g., by age group or sex). These diseases were selected for a variety of reasons including: local rates were significantly different than provincial rates, there are emerging issues related to the disease such as a provincial or local campaign, or because PHU has undertaken specific measures related to the prevention or containment of the disease. Infectious diseases for which there were less than seven cases cumulatively between 2006 and 2012 were considered rare and not further analyzed. Identified differences in rates and counts from one period to another or between Porcupine Health Unit and Ontario, are absolute and do not imply statistical significance. Data Limitations The published literature reveals variation in infectious disease reporting completeness. According to a review of the literature by Doyle (5), reporting completeness was significantly greater for TB, AIDS and sexually transmitted diseases as a group than for all other reportable diseases combined. Other studies estimate that for each reported case of enteric illness, there are at least several hundred undiagnosed or unreported cases in the community (6). Individuals that experience less severe manifestations of a disease may not experience symptoms, or only mild symptoms and may not seek medical assistance or be tested for the presence of a disease. Disease reports rely on a passive surveillance system, wherein laboratories, physicians, other health care providers and institution administrators are entrusted to know the regulations, recognize a disease that is on the reportable disease list and inform public health. Since iphis is a dynamic disease reporting system which allows ongoing updates to previously entered data, the data extracted from iphis represents a snapshot at the time of extraction and may differ from previous or subsequent reports. Discrepancies in the data may arise from periodic data quality assurance checks and corrections that result in the reclassification of cases. In addition, there may be a lag in reporting of some cases due to the time required to collect a specimen, carry out a diagnostic test and inform the local public health department and Ontario MOHLTC which could lead to future changes in the number of reported cases. 56 Porcupine Health Unit Infectious Disease Status Report:

63 For some diseases, case definitions have changed over time. As of April 28, 2009, new provincial case definitions for reportable diseases came into effect, and some of these have been further updated since in the Infectious Disease Protocol 2013 (4). Ontario's new case definitions were updated to reflect the changing epidemiology of infectious diseases and the use of newer laboratory technologies. These updates impacted the classification of cases for several diseases and may influence the incidence of some diseases during the year As such, an observed increase or decrease in disease incidence during this period may not reflect a true change in incidence. While the provincial case summaries allowed for local data comparisons with Ontario rates, comparisons with other health units can be problematic due to inconsistencies in data collection and reporting across health units. Also, some cases may be doublecounted among people who move to other health units. This double-counting is not an issue with the provincial data due to regular efforts to resolve inter-health unit duplicate records. For some diseases, the observed variability in incidence rates should be interpreted with caution due to small case counts. In such cases, population-specific rates or agestandardization are not appropriate statistical measures. Instead, either counts over the seven-year time period were combined and average rates were calculated, or the diseases were presented in the Rare Diseases Table of Appendix A. Finally, the data presented in this report only relate to data collected on cases residing in PHU area. Therefore, caution should be used when attempting to generalize these results beyond this area. Porcupine Health Unit Infectious Disease Status Report:

64

65 MAIN OFFICE: 169 Pine Street South Timmins, ON P4N 8B7 (705)