Public Health Overview and Update

Transcription

1 Public Health Overview and Update Jennifer A. Shuford, MD, MPH Texas Department of State Health Services

2 Public Health Update Zoonoses Foodborne illnesses Influenza MDROs Images courtesy of CDC and APHIS 2

3 Zoonoses in Zika Available at: Accessed on 06/11/

4 Zika in US Primarily spread through Aedes aegypti mosquitoes Texas is at a higher risk for ongoing localized transmission due to its climate and geographic characteristics 4

5 Zika in Texas Since December 2015, 381 Zika disease cases have been reported in Texas Local mosquito transmission in Cameron county (7 cases) and Hidalgo county (4 cases) US case count for 2018 is 34* Year Travel- Associated Locally Transmitted Sexually Transmitted Total Zika Cases * * *Provisional, as of 8/10/2018 US data source: Accessed on 8/10/18. 5

6 Zika Disease Cases by Onset, : US and Texas US data source: 6

7 Locally Acquired Vector-borne Zika Disease in Texas, : 1.November cases 2.December cases 2017 * : 1.August case 2.September case 3.October case 4.December case *Preliminary data as of 7/17/2018. Image Source: 7

8 Changing knowledge, changing guidance Jan 2016: -S. American outbreak underway -Testing recommended for symptomatic travelers only Apr 2016: -CDC concludes Zika is a proven cause of microcephaly and other birth defects Aug 2016: -Local mosquitoborne transmission in Miami, Florida identified Nov 2016: -CDC recommends more PCR testing, updates testing guidance -Local mosquito-borne transmission in Brownsville, Texas identified Apr 2017: -DSHS expands testing criteria to all pregnant women in RGV, regardless of symptoms Feb 2016: -Sexual transmission identified in Texas -Testing recommended for asymptomatic pregnant women with exposure (IgM only) Jul 2016: -Female to male sexual transmission identified -PCR testing recommended for asymptomatic pregnant women (exposures < 2 weeks) Oct 2016: -DSHS expands testing criteria to include symptomatic pregnant women in RGV counties with no known Zika exposure Dec 2016: -CDC Health Alert recommends testing for pregnant women living in or traveling to Brownsville Aug 2017: -DSHS expands testing criteria to more S Texas residents and recommends PCR and IgM -Brownsville cautionary area designation removed US data source: 8

9 Enhanced Surveillance, Texas

10 New Zika Testing Guidance, Texas

11 Zika Testing Recommendations Pregnant Women Test via PCR only if pregnant woman has no symptoms and if: Test concurrently via PCR and IgM if: Statewide Pregnant woman or her sexual partner has traveled to an area with ongoing transmission Pregnant woman exhibits 1 or more Zika symptoms AND she or her sexual partner has traveled to an area with ongoing transmission Pregnant woman has no travel or sexual exposure but exhibits 3 or more Zika symptoms In Enhanced Surveillance Area* All pregnant women residing in these counties should be tested once per trimester, even if no travel or sexual exposure Pregnant woman exhibits 1 or more Zika symptoms at any stage of pregnancy, even if no travel or sexual exposure *Cameron, Hidalgo, Kinney, Maverick, Starr, Val Verde, Webb, Willacy, and Zapata counties 11

12 Zika Testing Recommendations Non-Pregnant Individuals Test concurrently via PCR & IgM if: Statewide Individual or their sexual partner has traveled to an area with ongoing transmission AND has 1 or more Zika symptoms Individual has no travel or sexual exposure but exhibits 3 or more Zika symptoms In Enhanced Surveillance Area* Individual has a rash and at least 1 other Zika symptom *Cameron, Hidalgo, Kinney, Maverick, Starr, Val Verde, Webb, Willacy, and Zapata counties 12

13 CDC Testing Guidance 13 Available at: Accessed 7/17/18.

14 CDC Testing Guidance 14 Available at: Accessed 7/17/18.

15 CDC Testing Guidance Available at: Accessed 7/17/18. 15

16 Zoonoses in Brucellosis Common zoonotic disease worldwide Uncommon in US Brucella abortus, B. melitensis, and B. suis pathogenic to humans B. canis associated with more mild disease Gram negative coccobacillus Incubation from 1 week to several mos Causes non-specific febrile syndrome Image Courtesy of: CDC/ Courtesy of Larry Stauffer, Oregon State Public Health Laboratory 16

17 Brucellosis in US In 2010, 115 cases reported in US In 2016, Texas reported 43 cases Sources: and Accessed 7/17/18. 17

18 Brucellosis- Risk Factors Eating undercooked meat Consuming unpasteurized dairy products Exposure of open wounds or mucous membranes to contaminated fluids Inhalation of contaminated dust or aerosols Lab exposures 18 Image courtesy of CDC

19 Brucellosis- Texas 2017 Index patient presents in 7/2017 Symptoms: fever, arthralgia, myalgia, malaise x 8 days No recent travel Consumed raw milk from Texas dairy Gram stain: Gram neg coccobacilli Texas DSHS lab Blood culture positive for Brucella sp. Negative for Brucella antibodies 19

20 Brucellosis- Texas 2017 Isolate sent to CDC for speciation Identified as Brucella abortus strain RB51 by PCR Brucella abortus RB51 Used in live-attenuated vaccine given to cows to prevent brucellosis Previously caused human disease through needle sticks and lab exposures Not detected by serological tests Rifampin-resistant 20

21 Brucellosis- Texas 2017 Raw milk was only known risk factor Bulk milk cultured positive for Brucella sp. Recalled milk Milk isolates sent to CDC for speciation Bruce-Ladder PCR assay used to differentiate Brucella spp. Samples positive for RB51 strain Photo courtesy of CDC 21

22 Brucellosis- Texas 2017 Band Size (bp) Image courtesy of CDC 22

23 Brucellosis- Texas 2017 Milk obtained from each udder quadrant Samples from 2 of 43 cows were culture/pcr + Positive cows were removed from milking herd Repeat milk samples x 2 from remaining herd were negative for Brucella spp. Photo courtesy of APHIS Photo Library 23

24 Brucellosis- Texas households were suspected of being exposed AND had contact information Exposures identified in 10 Texas counties and 7 other states Public Health messaging Health alert for clinicians about potential RB51 exposure Testing recommendations Treatment recommendations No other positive cases identified 24

25 Zoonoses in Murine typhus Caused by Rickettsia typhi Transmitted by rat or cat fleas Endemic in some parts of Texas Reportable disease in Texas Increasing case counts and distribution in Texas 25

26 Murine Typhus in Texas,

27 Murine Typhus in TexasHealth Alert 27

28 Foodborne Illness E. coli O157:H7 Cyclosporiasis 28

29 Foodborne Illnesses in E. coli in Romaine lettuce Multistate outbreak of E. coli O157:H7 210 people infected from 36 states 4 in Texas 96 hospitalized 27 with HUS 5 deaths Illnesses from 3/13/18-6/6/18 Investigation ended on 6/27/18 Source: Accessed 7/17/18. Image courtesy of CDC/Janice Haney Carr 29

30 Foodborne Illnesses in E. coli in Romaine lettuce Outbreak traced back to romaine lettuce from Yuma region 87% reported eating romaine lettuce the week prior to illness1 Genetically similar E. coli found in canal water Ongoing investigation into source of E. coli Concentrated animal feeding operation in the area may be source Accessed 7/17/ eaks/ucm htm. Accessed 8/9/

31 Foodborne Illnesses in Cyclosporiasis Caused by Cyclospora cayetanensis Parasite that causes intestinal illness Transmitted through food or water with fecal contamination containing oocysts Usually through fresh imported produce Symptoms include: nausea, abdominal cramping, watery diarrhea, fatigue 31

32 Cyclosporiasis Diagnosed through microscopy or PCR Oocysts can be identified in stool by using modified acid-fast staining or safranin staining of the stool Treatment options are limited Image courtesy of CDC/ DPDx - Melanie Moser 32

33 Cyclosporiasis in USMcDonald s Salads Available at: Accessed 8/14/

34 Cyclosporiasis in USDel Monte Fresh Produce Trays Available at: Accessed 8/14/

35 Cyclosporiasis in TexasHealth Advisory 35

36 Seasonal Influenza Flu season Flu season Image courtesy of CDC 36

37 Flu Season flu season began in October 2017 H3N2-predominant year Influenza B predominated late in the season High severity season, per CDC Record high numbers of Flu-associated hospitalizations Flu-associated pediatric deaths 37

38 ILI- Flu Season Available at: m6722a4_w. Accessed: 7/19/

39 Texas ILI- Flu Season Available at: Accessed: 7/19/

40 Hospitalizations- Flu Season Available at: _cid=mm6722a4_w. Accessed: 7/19/

41 Hospitalizations- Flu Season Available at: _cid=mm6722a4_w. Accessed: 7/19/

42 Flu Vaccine Available at: Accessed on 7/19/

43 Flu Season season begins October 2018 LAIV4 is back on the ACIP list of recommended vaccines Questions: Which flu virus will predominate? Will it be as severe as last season? How well will the vaccine match? LAIV4 has a new H1N1 component Inactivated quadrivalent vaccines will have new H3N2 and Influenza B-Victoria lineage viruses 43

44 MDROs Reportable MDROs ARLN Carbapenem-resistant organisms Candida auris Images courtesy of CDC 44

45 MDR-Acinetobacter N=978 (3.53 cases per 100,000 persons) 45

46 MDR-Acinetobacter N=1,006 (3.6 cases per 100,000 persons) 46

47 MDR-Acinetobacter *N=1,144 (3.97 cases per 100,000 persons) *preliminary data 47

48 CRE N=875 (3.16 cases per 100,000 persons) 48

49 CRE N=1,243 (4.4 cases per 100,000 persons) 49

50 CRE *N=1,138 (3.95 cases per 100,000 persons) *preliminary data 50

51 CDC Antibiotic Resistance Laboratory Network (ARLN) Purpose: Establish 7 regional laboratories with comprehensive testing capacity for CDC s urgent or serious threats. Goal #1: Enhance outbreak detection and response support Goal #2: Create a surveillance system to detect resistance mechanisms Goal #3: Produce real-time, actionable data to prevent and combat current and future antimicrobial resistance threats 51

52 Antibiotic Resistance Lab Network (ARLN) 52

53 Testing in the ARLN Identification and antibiotic susceptibility confirmation Carbapenemase-producing Test for resistance genes 53

54 ARLN alerts 54

55 Mountain Region ARLN Laboratory Texas DSHS Laboratory capacity is 2,000 colonization swabs and 2,000 isolates per year. Testing results: Tested 1616 samples in total through April 2018 Next testing to implement: Candida C. auris identification available now 55

56 Isolates Tested (as of March 2018) Texas ARLN Isolate Counts Carbapenem-Resistant Enterobacteriaceae Jun 17-Jul 17-Aug 17-Sep 17-Oct 17-Nov 17-Dec 18-Jan 18-Feb 18-Mar Carbapenem-resistant Enterobacteriaceae Carbapenemase-producing Carbapenem-resistant Enterobacteriaceae 56

57 Isolates Tested (as of March 2018) Texas ARLN Isolate Counts Carbapenem-Resistant Pseudomonas aeruginosa Jun 17-Jul 17-Aug 17-Sep 17-Oct 17-Nov 17-Dec 18-Jan 18-Feb 18-Mar Carbapenem-resistant Pseudomonas aeruginosa Carbapenemase-producing Carbapenem-resistant Pseudomonas aeruginosa 57

58 Isolates Tested (as of March 2018) Texas ARLN Isolate Counts Carbapenem-resistant Acinetobacter baumannii Jun 17-Jul 17-Aug 17-Sep 17-Oct 17-Nov 17-Dec 18-Jan 18-Feb 18-Mar Carbapenem-resistant Acinetobacter baumannii Carbapenemase-producing Carbapenem-resistant Acinetobacter baumannii 58

59 Surveillance Findings * All mechanisms of resistance we have the capability of testing for have been identified in Texas MCR-1 in E.coli VIM in P. aeruginosa IMP in P. aeruginosa NDM in E. coli OXA-48 in E. coli KPC in K. pneumonia (pan-resistant) 59

60 Summary & Future Directions Increased testing contributes to enhanced detection and containment efforts Focus now turns to: Increasing awareness for the benefits of CP organism colonization screening Recruiting and testing for targeted surveillance (CRAB and mcr) Building and improving partnerships between: Laboratory and Epidemiologists Mountain Region States ARLN Regions 60

61 Thank you Jennifer A. Shuford, MD, MPH 61