Emerging Infections in Washington Disease of Public Health Interest

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1 Emerging Infections in Washington Disease of Public Health Interest SCOTT LINDQUIST MD MPH WASHINGTON STATE COMMUNICABLE DISEASE EPIDEMIOLOGIST Disclosure: Dr. Lindquist has no financial interest in any of the products or manufacturers mentioned.

2 One Health Concept

3 Overview Ebola Avian Influenza West Nile Virus Coccidioidomycosis E. coli Salmonella I-4,5,12 i-

4 Ebola

5 Ebola Virus Disease Symptoms Symptoms Typically Include fever (>101.5 F) headache, muscle pain weakness diarrhea, vomiting abdominal pain lack of appetite Symptoms Can Include rash red eyes cough, hiccoughs sore throat, chest pain difficulty breathing or swallowing, unexplained bleeding inside and outside of the body

6 Transmission of EVD Spread through direct contact--through broken skin or mucous membranes- - with: a sick person's blood or body fluids: urine, saliva, feces, vomit, and semen objects--such as needles that have been contaminated with infected body fluids infected animals

7 Overview The Outbreak

8 Case Counts* Country Suspect and Confirmed Case Counts Guinea Sierra Leone Liberia Total 28,055 11,288 Suspected Case Deaths Case-fatality rate = ~40% * As of August 28, 2015

9 Stopping the Outbreak in Africa (and Washington)

10 CDC Travel Notices Level 3 Warning: Avoid Nonessential Travel Guinea and Sierra Leone Level 2 Alert: Practice Enhanced Precautions Nigeria Liberia

11 Travel Screening In Washington State Exit screening in Ebola-affected countries Entry screening in 5 US airports Travelers need to enter US via these airports Completion of declaration form & temperature screen Distribution of CARE kits Contact information electronically transmitted to DOH Monitoring of travelers in Washington by LHJs

12 WA State Monitoring of Travelers Travelers Monitored since September (3 from Benton County) Travelers currently being monitored 12 Total tested for Ebola 2

14 Avian Influenza

Avian Influenza: Background Signs of Infection Can vary from inapparent to rapidly fatal Decreased food consumption, huddling, depression, closed eyes Respiratory signs (coughing

15 Avian Influenza: Background Signs of Infection Can vary from inapparent to rapidly fatal Decreased food consumption, huddling, depression, closed eyes Respiratory signs (coughing and sneezing) Decreased egg production, watery greenish diarrhea, excessive thirst Swollen wattles and combs Bruising under the skin and on the organs High death rate and sudden death

16 Avian Influenza: Background H s and N s Tell us the strain of the virus Can tell us some about the human health risk High and Low Pathogenic Tell us the severity of disease in domesticated poultry

17 Role of Wild Waterfowl Where could Washington wild birds get bird flu? Main Possibilities: Alaska / NE Asian breeding areas British Columbia domestic poultry

18 Highly Pathogenic Avian Influenza (HPAI) Situation in Washington State Whatcom County Four Captive Gyrfalcons in Lynden (Dec 10 th ) Benton County Two Backyard poultry premises in Benton City (Dec 31 st ) Clallam County Backyard poultry farm in Port Angeles (Jan 16 th ) Okanogan County Backyard poultry (game bird) farm in Riverside, WA (Jan 29th) Backyard poultry farm in Oroville, WA (Feb 3rd) *All dates given as confirmation from USDA National Veterinary Services Laboratory

19 Highly Pathogenic Avian Influenza (HPAI) in the U.S.

20 From Avian Virus to Human Virus Concerns exist that avian flu viruses could infect a person, and potentially spread from one person to another Source:

21 How do we prevent this? Protection of birds (biosecurity) Knowing the signs Not handling Sick and Dead Birds REPORT SICK AND DEAD DOMESTIC POULTRY: WSDA Avian Health Program: Such reports will be responded to by WSDA veterinarians

22 Human Health Implications These reports are the first infections with HPAI H5N8, H5N2, and reassortant H5N1 in US wild or domestic birds These viruses generally do not cause illness in humans Infections that do occur almost always involve direct contact with birds or their environment Generally do not spread easily from person to person However, human infection with other avian influenza viruses has been associated with severe disease

23 Human Avian Flu Infections Worldwide Avian influenza H5N1 virus infections Since 2003, 784 cases (429 deaths) in 16 countries No evidence of sustained human-to-human spread Avian influenza H7N9 virus infections Since March 2013, 571 cases (212 deaths); nearly all in China No evidence of sustained human-to-human spread; more transmissible among people than H5N1 2 cases in Canada associated with travel to China Source: World Health Organization

24 WSDA/USDA/Fish and Wildlife notifies WA DOH of AI positive birds WA DOH notifies Local Health Jurisdiction (LHJ) LHJ contacts bird contacts Monitor for ILI for 10 days from last exposure Determine if anyone exposed in past 10 days If ILI develops, test for influenza & begin treatment. Isolate until results received. Consider Oseltamivir prophylaxis

25 West Nile Virus

26 Mosquito-Borne Disease: West Nile Virus (WNV) Vector: Culex Mosquitos Reservoir host: Birds Dead-end hosts: Humans, horses (incidental infections)

27 WNV Human Infection Iceberg

28 Reported In-state Acquired WNV Cases by Year, Washington, ** 2015: provisional data as of 8/21/

29 Human WNV cases by county of likely exposure, 2015 ** 2015: provisional data as of 8/21/2015

30 Vector-Borne Disease: Primary Prevention = Bite Prevention Know times, seasons, and habitats of risk Use effective repellent E.g., DEET, permethrin, picaridin Wear long pants and long sleeves at dawn and dusk when mosquitos are most active Bug-proof screens on doors and windows Reduce mosquito habitat around your home

31 Coccidioidomycosis

immitis Commonly referred to as Cocci or Valley Fever Infection generally caused by inhaling

32 Coccidioides CDC Fungus in soil of warm, arid regions with low rainfall Two species cause disease (coccidioidomycosis): C. posadasii C. immitis Commonly referred to as Cocci or Valley Fever Infection generally caused by inhaling spores from the environment Both humans and animals can be infected Most infected people are asymptomatic Disease can be self-limiting or severe

33 33

34 Joint Efforts in Disease Surveillance/Control WA DOH received reports of 3 acute cases among Benton, Franklin, and Walla Walla residents without any recent travel Case #1: digging and building forts in dirt Case #2: ATV crash on dirt track Case #3: Soil excavator Geographically and temporally clustered Area has favorable growth parameters Rain shadow, semi-arid, low elevation Previous animal cases without travel identified

for 2 of 3 cases Soil specimens collected from 2

35 Joint Efforts in Disease Surveillance/Control Interviews with case-patients identified suspected exposure sites for 2 of 3 cases Soil specimens collected from 2 locations in Benton County Soil tested positive for C. immitis at CDC

Joint Efforts in Disease Surveillance/ Control Cocci reportable as a rare disease (2014) Interview all reported cases to determine whether WA exposure possible If WA exposure, determine location for

36 Joint Efforts in Disease Surveillance/ Control Cocci reportable as a rare disease (2014) Interview all reported cases to determine whether WA exposure possible If WA exposure, determine location for soil sampling Question about pets on case report form Continued soil sampling to determine the physical, chemical, biological and temporal factors that influence the presence or growth of Coccidioides

37 Number of Cases 5 Cases of Locally Acquired Coccidioidomycosis, WA State, Onset Date Report Date Jan Feb March April May June July Aug Sept Oct Nov Dec

38 Conclusions Human, animal, and environmental testing data used to identify an emerging pathogen in WA Need to increase awareness among healthcare providers and veterinarians Need to increase understanding of environmental niche and geographic ranges Joint office project planning ongoing: Human prevalence studies Canine prevalence studies Ongoing soil sampling Collaboration with providers

39 E. coli

40 E. coli 0157 Bacteria, heathy cattle are main animal reservoir Fecal-oral transmission Contaminated food, water, environment Contact with animal or persons Very low infectious dose Can survive >42 weeks in environment 1 Incubation period: 1-10 days Symptoms include abdominal cramps, diarrhea (often bloody), and vomiting 5-10% develop potentially life-threatening hemolytic uremic syndrome (HUS) 1 Varma, JAMA.

41 Milk Makers Fest

42 North Beef sho w Dair y sho w Manu re bunk Whatcom County Youth Fair Dairy & Beef Cattle Shows in Dairy Barn April 10-11, 2015 Bleachers Positioned near dairy and beef shows

43 No. of ill persons Illness Onset Dates by Participation in Milk Makers Fest (n=50) Milk Makers Fest April Primary (attended MMF) Series2 Secondary (did not attend Series1 Date of Illness Onset, 2015

source = Multiple Locus VNTR Analysis (MLVA) Variable number tandem repeats (VNTR) Discrimination

44 Laboratory Methods: Molecular Subtyping Pulsed Field Gel Electrophoresis (PFGE) PFGE pattern = unique molecular fingerprint Isolates with indistinguishable PFGE patterns are more likely to share a common source = Multiple Locus VNTR Analysis (MLVA) Variable number tandem repeats (VNTR) Discrimination through highly variable target sequences Provides additional data regarding relatedness of outbreak isolates

45 Conclusions Barns, farms, and areas where cattle have been kept should be approached as if they were contaminated with E. coli Standard procedures for cleaning and facility design should be adopted to minimize risk of exposure *** Shared responsibility to promote and adopt measures to prevent transmission Educate public, staff, and attendees about risk of disease transmission from animals and animal environments Promote hand washing with soap, running water, and disposable towels Ensure adequate access to hand washing facilities Prepare/serve/consume food and beverages only in nonanimal areas

46 Recommendations: Attendees and Public Promote awareness: public settings and events which include and involve animals can pose health risks to the public if certain prevention measures are not taken. Hands should always be washed immediately when exiting animal areas, after removing soiled clothing or shoes, and before eating or drinking. Closely supervise children and be aware that objects such as clothing and shoes can become soiled and serve as a source of germs after leaving an animal area If someone in the household is ill with vomiting or diarrhea, hand washing is essential to prevent transmission to other household members.

47 Salmonella I-4/5/12 i-

48 Salmonella One million illnesses in the US each year 19,000 hospitalizations 380 deaths Most develop diarrhea, fever and abdominal cramps hours after infection Illness lasts 4-7 days Most recover without treatment with antibiotics

Salmonella 2014-15 Outbreaks include: Pork Chicken Tuna Pet Crested Gecko s

49 Salmonella Outbreaks include: Pork Chicken Tuna Pet Crested Gecko s Cucumbers Bean Sprouts Nut Butter Chia powder Lab exposures Pet bearded dragons

50 Current Statewide Pork Outbreak

51 Current Statewide Pork Outbreak

Questions and Answers on Ebola

Questions and Answers on Ebola Updated: August 26, 2014 The 2014 Ebola outbreak is the largest Ebola outbreak in history and the first in West Africa. The current outbreak is affecting four countries in West Africa: Guinea, Liberia,