Annual Summary of Reportable Diseases for the City of Cleveland

Annual Summary of Reportable Diseases for the City of Cleveland 2014 Ebola virus virion: Fredrick A. Murphy, CDC

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2014 Annual Summary of Reportable Diseases for the City of Cleveland Published November 2016 Complied and Prepared by: Paul Zivich, Epidemiology Intern, Office of Communicable Disease Surveillance and Epidemiology, 75 Erieview Plaza Cleveland, OH 44114 www.clevelandhealth.org

Acknowledgements Special thanks to: Alisha Cassady, MPH Candidate Kent State University; College of Public Health Brent Styer, MPH CDPH; Office of Communicable Disease Surveillance and Epidemiology Chenai Milton, MPH CDPH; Office of Communicable Disease Surveillance and Epidemiology Jana Rush, MPH, MA CDPH; Office of Communicable Disease Surveillance and Epidemiology Paul Zivich, MPH Candidate The Ohio State University; College of Public Health Vinothini Sundaram, MPH CDPH; Office of Communicable Disease Surveillance and Epidemiology

Table of Contents Introduction 1 Demographic Profile 2 Reportable Diseases 3 About 3 Reportable Disease Counts & Rates 4 Disease Highlights 7 Cryptosporidiosis 7 Influenza 8 Legionella 9 Shigella 10 Outbreak Highlights 11 Ebola 12 Shigella 13 Scabies 14 Appendix 15 Methods 15 Limitations 16 Definitions 17 Classes of Reportable Diseases 18 References 20

Introduction Infectious and communicable diseases are caused by bacteria, viruses, fungi, parasites, or toxins. They are spread through direct contact (with animals or other people) or indirect contact (through insects, food, water, air, and other routes). Diseases from microorganisms have plagued humanity since our beginning. Infectious diseases still pose a major threat to human health. (CDPH) is the local public health agency for the City of Cleveland. Formally established in 1910, the department is charged with improving the quality of life in the City of Cleveland by promoting healthy behavior, protecting the environment, preventing disease, and making Cleveland a healthy place to live, work, and play. The is made of a range of programs providing clinical, environmental, health promotion, and population-based services. The Office of Communicable Disease Surveillance and Epidemiology (OCDSE) at the Cleveland Department of Public Health conduct communicable disease investigations, surveillance, data analysis and public health action to control the spread of communicable diseases and chronic disease in the City of Cleveland. The OCDSE is responsible for reducing the incidence of communicable disease (not including tuberculosis, sexually transmitted diseases, and HIV/AIDS) in the City of Cleveland through prevention, surveillance, and outbreak control. This report is intended for individuals for whom infectious diseases are of concern. It is also used as a way to provide transparency of disease surveillance and promote awareness. The OCDSE should be contacted to obtain further information on communicable diseases in the City of Cleveland. The OCDSE can be contacted at (216) 664-3747 during normal business hours. For more information regarding CDPH and OCDSE please visit http://www.clevelandhealth.org. Key Findings: In 2014, there were a total of 1871 cases of reportable infectious disease among Cleveland residents (excluding sexually transmitted diseases). The rate of Shigellosis among African Americans is more than 5 times greater than Caucasians. The incidence of Cryptosporidiosis is most common among 20-29 year olds. Of the one positive Ebola case that came through Cleveland, no other infections resulted from exposure to the individual. Proper surveillance and monitoring was used among all individuals who came in contact with the positive individual. 1

Demographic Profile Demographics of Cleveland The 2010 population for Cleveland is 396,815 persons. Cleveland accounts for 3.4% of the population of Ohio. Females account for 52.0% of the population of Cleveland. 56.3% of Cleveland residents are between 18 to 64 years old. African Americans make up 53.3% of the population of Cleveland. White and Hispanic individuals constitute 37.3% and 10.0%, respectively. All of the population data was sourced from the United State Census Bureau. All limitations of census data apply for the following estimates. For additional information, visit www.census.gov Table 1: Age Population Percent < 5 years old 28,174 7.1% < 18 years old 97,616 24.6% 18 64 years old 223,406 56.3% 65+ years old 47,618 12.0% 250000 200000 Population breakdown by Race/Ethnicity Table 2: Gender Population Percent Female 206,344 52.0% Male 190,471 48.0% 150000 100000 Table 3: Race/Ethnicity Percent White 37.3% African American 53.3% American Indian 0.3% Asian 1.8% Two or More Races 2.8% Hispanic/Latino 10.0% 50000 0 2

Reportable Diseases About Disease reporting is when physicians and other health care providers report diseases of public health concern (communicable/infectious diseases) to the local public health department. The Ohio Administrative Code (3701-3-02 & 3701-3-03) mandates disease reporting to the local health department. Investigations of these listed diseases are done daily. Reportable diseases are divided into three categories; A, B, and C. Class A diseases must be reported immediately by phone upon recognition of a case, suspected case, or positive laboratory result exists. Class B diseases must be reported by the end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known. Class C diseases are outbreak, unusual incidence, or epidemics that are reported by the end of the next business day. A list of the diseases that are required by the State of Ohio to be reported is available in the Classes of Reportable Diseases section. Timeliness of reporting is an important part of disease surveillance. A quick exchange of information to the health department allows for a rapid response. This can lessen the impact of infectious diseases on the public. If information is delayed, it can lead to larger outbreaks and increased strain on the healthcare system. The Ohio Disease Reporting System The Ohio Disease Reporting System (ODRS) provides real-time secured access for state and local public health practitioners to report infectious diseases. ODRS allows local health departments with jurisdictional responsibility and relevant ODH program staff to have immediate access to infectious disease reports on a 24/7/365 basis for disease control and disease surveillance purposes. This assures cases of significant public health importance receive immediate attention and public health response. Morbidity and Mortality Weekly Report MMWR is a national disease reporting systems. Data is collected and released on a weekly basis by the National Notifiable Diseases Surveillance System (NNDSS). Values are reported to NNDSS by local and state health departments. The purpose of MMWR is to support public health reporting and collect information that will be aggregated into the annual Summary of Notifiable Diseases, United States. The 2014 MMWR weeks were broken down into 53 weeks, beginning on December 29, 2013 and ending on January 3, 2015. 3

Reportable Diseases Reportable Diseases for Cleveland, OH: Annual Case Count & Rates Disease Cases Rate Ohio Rate 2012 US Rate 2012 Amebiasis 0 0.0 0.1 - Anthrax 0 0.0 - - Babesiosis 0 0.0-0.3 Botulism(foodborne) 0 0.0 0.0 0.0 Botulism (infant/wound) 0 0.0 0.0 0.0 Brucellosis 0 0.0 0.0 0.0 Campylobacteriosis 13 3.3 9.8 - Chancroid 0 0.0-0.0 Chlamydia trachomatis infections 6893 1737.1-456.7 Cholera 0 0.0 0.0 0.0 Coccidioidomycosis 0 0.0 0.1 5.7 Creutzfeldt-Jakob Disease 1 0.3 0.1 - Cryptosporidiosis 18 4.5 4.8 2.6 Cyclosporiasis 0 0.0 0.0 0.0 Dengue 1 0.3 0.1 0.2 Diptheria 0 0.0-0.0 Eastern equine encephalitis 0 0.0-0.0 E coli O157:H7 and other Shiga-toxin producing E. coli 0 0.0 2.1 2.1 Ehrlichiosis / anaplasmosis 0 0.0 0.1 1.2 Giardiasis 16 4.0 4.9 4.9 Gonorrhea 2593 653.5-107.5 Haemophilus influenzae 5 1.3 1.3 1.1 Hantavirus 0 0.0-0.0 Hemolytic uremic syndrome 0 0.0 0.1 0.1 Hepatitis A 0 0.0 0.4 * Hepatitis B (including chronic) 35 8.8 1.5 * Hepatitis C (acute & chronic) 703 177.2 - * Hepatitis D 0 0.0 - - Hepatitis E 0 0.0 0.0 - Influenza A - novel virus 0 0.0 0.9 0.1 Influenza -associated hospitalization 709 178.7~ 25.6~ - Influenza-associated pediatric mortality 0 0.0-0.0 LaCross virus disease 0 0.0 0.1 0.0 Legionnaires' disease 33 8.3 2.5 1.2 Leprosy (Hansen Disease) 0 0.0 0.0 0.0 4

Reportable Diseases Disease Cases Rate Ohio Rate 2012 US Rate 2012 Leptospirosis 0 0.0 0.0 - Listeriosis 1 0.3 0.2 0.3 Lyme Disease 0 0.0 0.5 9.9 Malaria 5 1.3 0.3 0.5 Measles 0 0.0 0.0 0.0 Meningitis: aseptic (viral) 37 9.3 - - Meningitis: bacterial 9 2.3 - - Meningococcal disease 1 0.3 0.2 0.2 Mumps 0 0.0 0.1 0.1 Mycobacterial disease, other than tuberculosis 0 0.0 - - Other arthropod-borne disease 10 2.5 - - Pertussis 7 1.8 7.8 15.5 Plague 0 0.0-0.0 Poliomyelitis (including vaccine-associated cases) 0 0.0-0.0 Powassan virus disease 0 0.0-0.0 Psittacosis 0 0.0 0.0 0.0 Q Fever 1 0.3 0.0 0.0 Rabies, human 0 0.0-0.0 Rubella (congenital) 0 0.0-0.0 Rubella (non-congenital) 0 0.0-0.0 Salmonellosis 46 11.6 11.0 17.3 Severe Acute Respiratory Syndrome 0 0.0-0.0 Shigellosis 141 35.5 15.7 4.9 Smallpox 0 0.0-0.0 Spotted Fever Rickettsiosis 0 0.0-1.4 St. Louis encephalitis 0 0.0-0.0 Staphylococcus aureus, with resistance or 1 0.3 0.1 0.0 intermediate resistance to vancomycin Streptococcal disease, Group A, invasive (IGAS) 14 3.5 2.5 - Streptococcal disease, Group B, in newborn 8 - - Streptococcal toxic shock syndrome 0 0.0 0.1 0.1 Streptococcus pneumoniae, invasive disease 44 11.1 10.3 - Syphilis 151 38.1-16.0 Tetanus 1 0.3 0.0 0.0 Toxic shock syndrome 0 0.0 0.0 0.0 Trichinellosis 0 0.0-0.0 5

Reportable Diseases Disease Cases Rate Ohio Rate 2012 US Rate 2012 Tuberculosis, including multi-drug resistant 0 0.0-3.2 tuberculosis Tularemia 0 0.0 0.0 0.0 Typhoid fever 1 0.3 0.1 0.1 Typhus fever 0 0.0 0.0 - Varicella 5 1.3 7.0 4.3 Vibriosis 0 0.0 0.1 0.4 Viral hemorrhagic fever 0 0.0-0.0 West Nile virus infection 3 0.8 1.1 1.8 Western equine encephalitis 0 0.0 - - Yellow fever 0 0.0-0.0 Yersiniosis 2 0.5 0.4 - - : no data available * : CDC data only includes acute cases ~: May not be correct to compare rates due to large yearly variations in the disease US rate calculated from MMWR report using population estimate of 311,591,917 6

Disease Highlights Cryptosporidiosis Summary Case: 18 Rate: 4.5 per 100,000 Epidemiology Infectious agent: Cryptosporidium Mode of transmission: Waterborne, fecal-oral route, contaminated food Incubation period: 2-10 days Common symptoms: Watery diarrhea, stomach pain, dehydration, nausea, vomiting, fever, weight loss Prevention: Wash hands frequently (alcohol-based hand sanitizers do not effectively kill Cryptosporidium), exclude children with diarrhea from daycares until symptoms stop, avoid swallowing pool water, prevent fecal contact during sex through barriers (e.g. condoms, dental dams, etc) 12 10 8 6 4 2 0 Cryptosporidiosis Cases by Age 0-19 20-29 30-39 40-49 50+ 5 4 3 2 1 0 Image: CDC / Alexander J. da Silva, PhD / Melanie Moser Cases of Cryptosporidiosis by Month 7

Disease Highlights Influenza Summary Number of cases of influenza-associated hospitalizations: 709 Rate of influenza-associated hospitalizations: 178.7 per 100,000 Rates by gender: Female: 191.7 per 100,000 Male: 160.8 per 100,000 Epidemiology Infectious agent: Influenza virus type A or influenza virus type B Mode of transmission: Direct person-to-person spread through droplets or indirect through objects Incubation period: 1-4 days Common symptoms: Fever, chills, body aches, cough, runny nose, sore throat, headache Prevention: Receive yearly flu vaccine and wash hands frequently 450 400 350 300 250 200 150 100 50 0 Image: Erskine Palmer, PhD / CDC; M.L. Martin Influenza-associated Hospitalizations by Gender Male Female Influenza-associated Hospitalizations by Month 20 15 10 5 0 Dec-13 Jan-14 Feb-14 Mar-14 Apr-14 May-14 Jun-14 Jul-14 Aug-14 Sep-14 Oct-14 Nov-14 Dec-14 8

Disease Highlights Legionella Summary Number of cases: 33 Rate: 8.3 per 100,000 Rates by gender: Female: 5.3 per 100,000 Male: 11.6 per 100,000 Epidemiology Infectious agent: Legionella bacteria Mode of transmission: Inhalation of contaminated mist or vapor; contaminated warm water generally found in hot tubs, hot water tanks, large plumbing systems, and air-conditioning systems of large buildings Incubation period: 2-14 days Common symptoms: High fever, cough, headache, muscle aches, pneumonia Prevention: Improvements in plumbing and cooling system design, avoid high-risk exposures (e.g. hot tubs, humidifiers) 20 15 10 5 0 Image: CDC / Margaret Williams, PhD; Claressa Lucas, PhD; Tatiana Travis, BS Legionella Cases by Race White Black Other 8 7 6 5 4 3 2 1 0 Cases of Legionella by Month 10 8 6 4 2 0 Legionella Rates by Race White Black Other 9

Disease Highlights Shigella Summary Number of cases: 141 Rate: 35.5 per 100,000 Rates by race: Black: 51.5 per 100,000 White: 8.8 per 100,000 Epidemiology Infectious agent: Shigella bacteria Mode of transmission: fecal-oral route, contaminated food, infected water Incubation period: 1-2 days Common symptoms: Fever, abdominal pain, diarrhea (sometimes bloody) Prevention: Wash hands frequently, exclude children with diarrhea from daycares until symptoms stop, avoid swallowing recreational water, prevent fecal contact during sex through barriers (e.g. condoms, dental dams, etc.) 100 80 60 40 20 0 120 100 80 60 40 20 0 Cases of Shigella by Gender Female Male Cases of Shigella by Race White Black Other Unknown 40 35 30 25 20 15 10 5 0 Cases of Shigella by Month Jan Feb Mar Apr May June July Aug Sept Oct Nov Dec 10

Outbreak Highlights Summary of Outbreaks Outbreaks are divided into six different categories: foodborne, waterborne, zoonotic, institutional, healthcare-associated, and community. Foodborne outbreaks are defined as two or more cases of a similar illness resulting from ingestion of a common food. Waterborne outbreaks are cases associated with a common water exposure. Zoonotic disease outbreaks are defined as when two or more cases experience a similar illness after exposure to the same or a similar animal. Institutional outbreaks are two or more cases of similar illness with a common exposure at an institution that is not a foodborne or waterborne disease outbreak. Examples of institutional facilities are correctional facilities, daycares, group homes, schools, and assisted-living facilities. Healthcare-associated outbreaks are occurrences of cases of a disease above the expected level (baseline) as a result of being in a healthcare facility or receiving healthcare. Community outbreaks are two or more cases of a similar illness with a common exposure in the community and not considered a foodborne, waterborne, zoonotic, healthcareassociated, or institutional disease outbreak. All outbreak definitions were provided by the Ohio Department of Health (ODH). During 2014, the investigated seventeen outbreaks. Most of the outbreaks (76.4%) were institutional outbreaks. Ten of the institutional outbreaks were in either schools or daycare centers. There were two foodborne outbreak investigations. There were no investigations of waterborne or zoonotic outbreak types. The most outbreak investigations (6) took place during the third quarter (July-September). Four investigations took place during the second quarter (April-June) and five during January to March. Only two investigations occurred during the fourth quarter (October-December). 5 Outbreak Investigations by Causitive Agent 4 3 2 1 0 11

Outbreak Highlights Ebola Ebola was first discovered in the Democratic Republic of Congo in 1976. It has been the cause of several outbreaks; the largest is the 2014 West Africa Outbreak. Ebola is a viral disease, from the Filoviridae family. Common symptoms of Ebola are fever, severe headache, muscle pain, weakness, vomiting, and unexplained bleeding. Four cases have been reported in the US. The following paragraph outlines the s (CDPH) response and surveillance from a case that traveled through Cleveland and later tested positive for Ebola. On October 15, 2014, the Center for Disease Control and Prevention (CDC) confirmed that one of the nurses who had cared for the first confirmed Ebola patient in the United States had tested positive for Ebola. The nurse had traveled by plane to Cleveland, traveled to her hometown of Akron, and traveled back to Texas. In response, CDPH activated their Emergency Operations Center (EOC) to begin contact tracing of all individuals who may have come into contact with the nurse and to field any questions or concerns. CDC created and provided questionnaires to administer to the contacts to determine their level of exposure. Based on their responses, the contacts were placed into a tier that would define the level of monitoring they would undergo. Contacts were notified and provided instructions pertaining to their monitoring. At the conclusion of the 21-day monitoring period, all contacts were notified that their monitoring was over. The Epidemiology Strike Team completed contact tracing for 24 total contacts that required monitoring in the City of Cleveland. These contacts included airline passengers, airline staff, airline cleaning staff, and customers who were at the bridal shop at the same time as the Ebola-infected nurse. The last day of monitoring for the final contact was November 3rd, 2014. 18 16 14 12 10 8 6 4 2 0 Number of Persons at Monitoring Tiers Tier 1 Tier 2A Tier 2B Tier 3 Tier 4 Exposure Intervention Tier 1 Any direct contact Quarantine Tier 2A No direct contact, within risk zone: Within a 3ft radius of infected individual for greater Active monitoring Tier 2B Tier 3 Tier 4 than 1 hour No direct contact, not in risk zone: In the same enclosed space as infected individual for more than 1 hour No direct contact, not in risk zone: Same enclosed space for less than 1 hour No direct exposure, but within broad vicinity Verified selfmonitoring Self-monitoring Education 12

Outbreak Highlights Shigella Shigella is a bacterium that causes shigellosis. It is a very contagious disease that is spread through the fecal-oral route. The most common ways to be exposed to Shigella are contaminated hands touching your food or mouth, eating contaminated food, swallowing recreational water, or exposure to feces through sexual contact. Symptoms of shigellosis include diarrhea (sometimes bloody), fever, abdominal pain, and tenesmus. Tenesmus is the feeling of needing to use the bathroom even when the bowels are empty. Symptoms generally begin 1-2 days after exposure and last for 5-7 days. Shigella can be treated with antibiotics but there are strains that are resistant. Those who are at the highest risk are young children, travelers going to developing countries, men who have sex with men, and HIV-infected persons. To protect yourself from shigellosis, follow these steps: practice proper hand washing techniques, avoid swallowing recreational water, and avoid sexual activity with individuals who have recently had diarrhea. Image: James Archer, CDC Four of the outbreak investigations by the involved Shigella. Two occurred during May, one during June, and one during December. Three of the shigellosis outbreaks were centered on daycares and one was centered on an elementary school. The most cases were related to the elementary school cluster. In May 2014, OCDSE was notified of a case of Shigellosis through the Ohio Disease Reporting System (ODRS). Later in the same day, OCDSE received a notification from Cuyahoga County Board of Health that they had a shigellosis case who also attended the same school. A line-list and shigellosis information was provided to the school principal for documentation of symptomatic cases during the remaining days of the school year. It was determined that there were a total of fourteen cases in the outbreak. Of the fourteen cases, four were primary cases, seven were probable primary cases (symptomatic), and three were secondary cases. All of the secondary cases were family members of a student who attended the school. The school took necessary precautions in regards to cleaning/disinfecting and conducted proper notification of exposure to parents of students. One of the key ways to lessen exposure to Shigella is to have all symptomatic cases stay home from school. For daycares, the Ohio Administrative Code mandates that infected persons may return to the daycare if diarrhea has ceased and after two consecutive follow-up stool specimens are negative for Shigella. 13

Outbreak Highlights Scabies Scabies is caused by an infestation of the human itch mite in the skin. The mite lives and lays its eggs in the upper layer of the skin. Symptoms commonly include intense itching sensations and a pimple-like rash. In persons who have never had scabies before, it can take up to 4-6 weeks to develop symptoms. The individual can still spread scabies during this time, even if they do not have symptoms. Individuals who have been previously infested generally exhibit symptoms 1-4 days after exposure. Scabies is spread through direct and prolonged skin contact with an infested person. Crusted scabies, a more easily spread infestation; can be spread through direct contact or through contaminated items (clothing, bedding, furniture, etc.). It is important that individuals with crusted scabies be treated immediately to prevent large outbreaks. Scabies can be treated with a doctor-prescribed scabicide. There were four outbreaks of scabies investigated by CDPH. Two outbreaks were located in medical centers, one in a rehabilitation center and one in a workplace. In July, OCDSE received a report of a potential scabies cluster at a hospital. The report noted that six cases at the facility had to be treated for scabies. During the six weeks of monitoring by OCDSE, six cases were reported. The first case had an onset date of symptoms in February. Two of the cases were patients and the remaining four were staff members. According to the infection control preventionist (ICP), all patients received treatment after they were diagnosed with scabies. All of the patients were in the same ward of the hospital. All six cases experienced itching and rash symptoms. The two cases that were patients also experienced crusting; these two patients also required hospitalization. None of the four staff members were hospitalized. Identical cleaning measures were taken by the facility regarding each case. After the six week period, no other cases were reported to the OCDSE. All potentially exposed persons should be treated at the same time as the infested person to prevent possible re-exposure and re-infestation. Bedding and clothing worn or used next to the skin anytime during the 3 days before treatment should be machine washed and dried using the hot Symptoms exhibited water and hot dryer cycles or be dry-cleaned. 7 Items that cannot be dry-cleaned or laundered can be disinfested by storing in a 6 closed plastic bag for several days to a week. 5 Children and adults usually can return to child 4 Staff care, school, or work the day after treatment. 3 Rooms used by a patient with crusted scabies 2 Patient should be thoroughly cleaned and vacuumed 1 after use. Environmental disinfestation using 0 pesticide sprays or fogs generally is itching rash fever crusting unnecessary and is discouraged. 14

Appendix Methods Data in this report was collected from healthcare, laboratory, and other reports of the listed conditions were reported to the and occurred within the jurisdiction. The occurrences were then reported to ODH and the Centers for Disease Control and Prevention (CDC). Annual summaries are taken from the National Notifiable Disease Surveillance System (NNDSS). Cleveland is part of Cuyahoga County in Ohio. A map of the neighborhoods and wards within Cleveland are shown in the maps. The top map shows the various neighborhoods that make up the City of Cleveland. The second map shows the seventeen wards that Cleveland is subdivided into. Race and ethnic designations are based off the CDC s categories. The CDC based their categories off of the US Bureau of the Census and the US Office of Management and Budget. To determine the rate of diseases, the total number of cases was divided by the total population then multiplied by 100,000. The total population for Cleveland used in the calculations is 396,815. This is based of US Census estimates for 2013. Gender, race, or ethnicity specific rates were based off relative population 15

Appendix counts from US Census data as well. All rates included in the report are per 100,000 persons and were rounded to one decimal place. All calculations were performed in Microsoft Excel (Redmond, Washington; 2010). Graphs were generated using Microsoft Excel. Maps of Cleveland were generated using ArcGIS (Version 10.1; Redlands, California; 2011). Formula1: Rate = cases incidences of disease 100,000 = total population 100,000 persons The diseases selected to be reportable vary from state to state. Ohio s reportable diseases are listed in the Classes of Reportable Diseases section. These diseases were chosen by ODH and Ohio legislature, based off recommendations from the Council of State and Territorial Epidemiologists (CSTE). To ensure uniformity, CSTE and CDC set specific definitions for cases of each disease. This allows for accurate local, state, and national disease summaries. These definitions are published in MMWR [1997; 46(RR-10)]. Limitations The estimates of disease rates in this report are likely lower than the actual rates. This is due to a multitude of reasons. Some cases exhibit no symptoms (asymptomatic) or mild symptoms. These cases do not pursue medical care and will not be reported. Other cases might not be reported by medical professionals. Diseases might also take long periods of time before persons begin to exhibit symptoms (latency period). These and other factors limit the accuracy of the reported rates of disease. Furthermore, this report only includes cases of disease defined by CDC. For most diseases, probable and suspected cases are not included in this report. Other diseases may include probable cases in the total count. Cases also may be missing demographic information. This limits analysis of the burden of disease among subpopulations. This report only includes information on the diseases listed in the section. Sexually transmitted diseases are not included in this report. Information regarding chlamydia, gonorrhea, and other sexual transmitted infections can be found at http://www.clevelandhealth.org/network/health/cleveland_health_statistics.php. Some disease rates are not available for Ohio and US to compare to Cleveland. This is due to differences in what diseases were listed as reportable for 2012 and 2014. The rates listed for Ohio and US are 2012. At the time of this report s creation, these were the most recent yearly rates available. Caution should be taken when interpreting differences in the rates across years. For example, flu severity depends on the strain that is circulating that year. Differences in rates may be due to flu strain differences All limitations of ODRS, MMWR, and the US Census are included as limitations of this report. Limitations of Ohio rates and US rates are outlined in their respective reports. 16

Appendix Definitions Acute: a condition or disease with a sudden onset of symptoms Agent: a factor whose presence, excessive presence, or absence is essential for the occurrence of a specific disease Case: countable instance of a health disorder or disease in a population Chronic: a condition or disease with a gradual onset of symptoms Communicable disease: infectious disease transmitted from an infected person, animal, or reservoir to a susceptible host through an intermediate plant, animal, or the inanimate environment. Food-borne illness: commonly known as food poisoning resulting from eating or drinking something that has been contaminated with bacteria, parasites or viruses. Epidemiology: study of the distribution and determinants of health and illness in a population. Epidemiologists: monitor health trends and statistics to identify groups of people who are affected by various diseases. Epidemiologists investigate cases of disease to determine the source, modes of transmission, and risk factors for disease. This information is then used to implement control measures to prevent the spread of disease. Incidence: rate of new cases of a specific disease, over a defined period of time Outbreak: occurrence of more cases of a disease than expected in a given area or among a specific group of people over a defined period of time. Also can referred to as epidemics Pandemic: an epidemic occurring over a very wide area (several countries or continents) and usually affecting a large proportion of the population. Prevalence: rate of cases (new and old) of a specific disease, over a defined period of time Surveillance: ongoing systematic collection, recording, analysis, interpretation, and distribution of data reflecting the current health status of a community or population. Syndromic surveillance: applies to surveillance using health-related data that precede diagnosis and signal a sufficient probability of a case or an outbreak to warrant further public health response. Vector-borne diseases: infections transmitted to humans by vectors (i.e. flies, mites, fleas, ticks, rats, and dogs). 17

Appendix Classes of Reportable Diseases Ohio Department of Health (January 1, 2014): Class A (immediate report by phone): Anthrax Botulism, foodborne Cholera Meningococcal disease Plague Severe acute respiratory syndrome (SARS) Diphtheria Rabies, human Smallpox Influenza A novel virus Measles Rubella (not congenital) Tularemia Viral hemorrhagic fever(vhf) Yellow fever Class B (end of next business day) Amebiasis Arboviral neuroinvasive and non-neuroinvasive disease: [Eastern equine encephalitis virus disease, LaCrosse virus, Powassan virus disease, St. Louis encephalitis virus disease, West Nile virus infection, Western equine encephalitis virus disease, Other arthropod-borne diseases] Babesiosis Botulism, infant, wound Brucellosis Campylobacteriosis Chancroid Chlamydia trachomatis infections Coccidioidomycosis Creutzfeldt-Jakob disease (CJD) Cryptosporidiosis Cyclosporiasis Dengue E. coli O157:H7 and Shiga toxinproducing E. coli (STEC) Ehrlichiosis / anaplasmosis Giardiasis Gonorrhea (Neisseria gonorrhoeae) Haemophilus influenzae (invasive disease) Hantavirus Hemolytic uremic syndrome (HUS) Hepatitis A Hepatitis B, (nonperinatal, perinatal) Hepatitis C Hepatitis D (delta hepatitis) Hepatitis E Influenza-associated Hospitalization Influenza-associated pediatric mortality Legionnaires disease Leprosy (Hansen disease) Leptospirosis Listeriosis Lyme disease Malaria Meningitis: Aseptic (viral), Bacterial 18

Appendix Mumps Mycobacterial disease, other than tuberculosis (MOTT) Pertussis Poliomyelitis (including vaccineassociated cases) Psittacosis Q fever Rubella (congenital) Salmonellosis Shigellosis Spotted Fever Rickettsiosis, including Rocky Mountain spotted fever (RMSF) Staphylococcus aureus, with resistance or intermediate resistance to vancomycin (VRSA, VISA) Streptococcal disease, group A, invasive (IGAS) Streptococcal disease, group B, in newborn Streptococcal toxic shock syndrome (STSS) Streptococcus pneumoniae, invasive disease (ISP) Syphilis Tetanus Toxic shock syndrome (TSS) Trichinellosis Tuberculosis (TB), including multi-drug resistant tuberculosis (MDR-TB) Typhoid fever Typhus fever Varicella Vibriosis Yersiniosis Class C (end of next business day) Outbreaks: Community Healthcare-associated Waterborne Foodborne Institutional Zoonotic 19

Appendix References ODRS: Ohio Department of Health. (2015). Ohio Disease Reporting System. Retrieved from https://www.odh.ohio.gov/healthstats/elr/odrs1.aspx MMWR: Centers for Disease Control and Prevention. (2015). Morbidity and Mortality Weekly Report. Retrieved from http://wwwn.cdc.gov/mmwr/ NNDSS: Centers for Disease Control and Prevention. (2015). National Notifiable Disease Surveillance System. Retrieved from http://wwwn.cdc.gov/nndss/ 2012 Ohio Rate: Ohio Department of Health. (2014). 2012 Annual Summary of Infectious Diseases, Ohio. Retrieved from https://www.odh.ohio.gov/healthstats/disease/idann/idsum12/12idsum.aspx 2012 US Rate: Centers for Disease Control and Prevention. (2015). Summary of Notifiable Diseases- United States 2012. Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6153a1.htm Cryptosporidiosis: Centers for Disease Control and Prevention. (2015). Parasites Cryptosporidium. Retrieved from http://www.cdc.gov/parasites/crypto/ Influenza: Centers for Disease Control and Prevention. (2015). Influenza (Flu). Retrieved from http://wwwn.cdc.gov/flu/ Legionella: Centers for Disease Control and Prevention. (2013). Legionella: About the Disease. Retrieved from http://www.cdc.gov/legionella/about/index.html Shigella: Centers for Disease Control and Prevention. (2015). Shigella - Shigellosis. Retrieved from http://www.cdc.gov/shigella/ Outbreak Definition, Foodborne: Ohio Department of Health. (2014). Foodborne Disease Outbreaks. Retrieved from http://www.odh.ohio.gov/pdf/idcm/fdbrn.pdf 20

Appendix Outbreak Definition, Waterborne: Ohio Department of Health. (2014). Waterborne Disease Outbreaks. Retrieved from http://www.odh.ohio.gov/pdf/idcm/wtrbrne.pdf Outbreak Definition, Zoonotic: Ohio Department of Health. (2014). Zoonotic Disease Outbreaks. Retrieved from http://www.odh.ohio.gov/pdf/idcm/zoooutbrk.pdf Outbreak Definition, Institutional: Ohio Department of Health. (2014). Institutional Outbreaks. Retrieved from http://www.odh.ohio.gov/pdf/idcm/istitut.pdf Outbreak Definition, Healthcare-associated: Ohio Department of Health. (2014). Healthcare-Associated Outbreaks Retrieved from http://www.odh.ohio.gov/pdf/idcm/hlthcare.pdf Outbreak Definition, Community: Ohio Department of Health. (2014). Community Outbreaks. Retrieved from http://www.odh.ohio.gov/pdf/idcm/comoutbrk.pdf Ebola: Centers for Disease Control and Prevention. (2015). Ebola (Ebola Virus Disease). Retrieved from http://www.cdc.gov/vhf/ebola/ Scabies: Centers for Disease Control and Prevention. (2015). Parasites Scabies. Retrieved from http://www.cdc.gov/parasites/scabies/ 21