10/12/2015 Public Health Updates Emilio DeBess, DVM, MPH Acute and Communicable Disease Oregon Health Authority Acute Gastroenteritis (AGE) Acute gastroenteritis (AGE), characterized by sudden onset of symptoms such as diarrhea, vomiting, nausea, and abdominal pain and fever is a major cause of morbidity in the United States. Approximately 179 million cases of AGE are estimated to occur annually in the United States, resulting in 600,000 hospitalizations and an estimated 5,000 deaths [1, 2]. 1
Acute Gastroenteritis (AGE) Viruses have been found to be the most common known agents of AGE. Noroviruses specifically are estimated to cause approximately 19-21 million cases of AGE annually, including 56,000-71,000 hospitalizations and 570-800 deaths [3]. With wide diversity of noroviruses in circulation and lack of persistent cross-protective immunity, on average, a U.S. resident experiences five norovirus episodes in his or her lifetime [3]. Kaiser Permanente Study In a recent studythe highest norovirus prevalence was identified among specimens collected from children less than 5 years of age, consistent with previous findings from a similar study [7]. Theprevalence of viral gastroenteritis that causes AGE were highest in the winter and early spring months, consistent with previous descriptions of norovirus and rotavirus seasonality. Person to Person 2
Oregon Norovirus Picture Norovirus Watch includes norovirus outbreak data from the 2014 2015 norovirus season. In July and August 2015, 11 norovirus or norovirus-like outbreaks were reported, of which 4 (36%) were in summer camps, 2 (18%) were in nursing homes or assisted-living facilities, and 1 (9%) was restaurant-associated. (see Fig. 1).. Oregon Norovirus Picture Since August 2014, 66/134 (49%) lab-confirmed and norovirus-like outbreaks occurred in nursing homes or assisted-living facilities. The most common norovirus genotype reported since August 2014 is GII.4 Sydney, identified in 41/76 (54%) lab-confirmed outbreaks 3
Norovirus Strain Replacement New norovirus strain occurs about every three to five years and usually, but not always, results in pandemic spread. Norovirus pandemics occurred with strain replacements in 1995, 2002, and 2006, and in 2009. Genotype II-4 (GII.4 Sydney) norovirus is currently the most commonly detected strain worldwide. In Winter 2014 15, norovirus outbreaks in Guangdong, China, increased with 82% of the outbreaks caused by a norovirus GII.17 variant. Norovirus Strain Replacement The first 2 outbreaks of GII.17 Kawasaki in Oregon were reported in summer camps held in August (see Fig. 2). This particular strain of norovirus has emerged in the last year in Asia and could potentially lead to a global strain replacement. #5 GII 17. outbreaks were reported by CAL in Aug 2015 4
Pertussis Vaccine-preventable diseases Oregon, 2006 2011 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Smallpox 0 0 0 0 0 0 0 0 0 0 Diphtheria 0 0 0 0 0 0 0 0 0 0 Measles 2 2 1* 0 0 3 1 6 5 1 Mumps 19 1 1 2 3 4 6 3 1 2 Pertussis 112 131 174 255 287 328 912 486 406 482 Polio 0 0 0 0 0 0 0 0 0 0 Rubella 0 0 0 0 0 0 0 1 0 0 Tetanus 2 1 0 0 0 0 0 1 0 0 *Dutch citizen 5
Pertussis Contagious respiratory infection Outbreaks first described 16 th century Bordetella pertussis isolated 1906 Estimated >300,000 deaths/year worldwide Pertussis pathogenesis Toxin-mediated disease Bacteria attach to respiratory epithelial cilia Inflammation interferes with clearance of secretions Lymphocytosis promoted but chemotaxis impaired Mandell, Douglas and Bennett s Principles and Practice of Infectious Diseases, 2005 Pertussis: clinical features Incubation period 7 10 (range 4 21) days Upper respiratory infection, insidious onset Fever minimal Catarrhal stage: 1 2 weeks Paroxysmal cough stage: 1 6 weeks Convalescence: weeks to months 6
Pertussis: worse than your usual cough Paroxysms (fits) of coughing Average 15 per 24 hours More at night Post-tussive vomiting Inspiratory whoop in toddlers Apnea, cyanosis in infants Pneumonia 11.8% in infants <6 months of age Pertussis Vaccines DTaP 6 months 6 years of age ~80% effective initially Immunity wanes over a few years Tdap Licensed 2005 based on immunogenicity 11 64 years of age Cases per 100,000 Reported pertussis, by year Oregon, 1915 2012* 200 180 160 140 120 100 80 60 40 20 0 DTP Tetanus and Diphtheria School Tdap Requirements PCR DTaP School Requirement Year *through 10/31/2012 7
Pertussis Incidence U.S. and Oregon, 1995 2012* Cases per 100,000 25 20 15 10 5 0 Oregon U.S. 95 97 99 01 03 05 07 09 11 U.S. Year of onset *through 10/31/2012 Artifactual? Advent of PCR: more sensitive Physician and patient awareness Real increase? Cyclical population immunity Acellular vaccines less effective? Why the epidemic? 8
Source of pertussis in infants Adults transmit pertussis to infants Among 264 known source-cases: 49% were parents, most often mothers 51% were adults >19 years of age BisgardKM, et al. Infant pertussis: who was the source? PediatrInfect DisJ 2004; 23(11):985-989. WendelboeAM, et al. Transmission of Bordetella pertussis to young infants. Pediatr Infect Dis J 2007; 26(4):293-299. degreeffsc et al. Pertussis disease burden in the household: how to protect young infants. Clinical Infectious Diseases 2010; 50(10):1339 1345. Source of Pertussis in Infants, Oregon, 2010 2013 Mother Father Unknown Siblings Other Day care Grandparents *As of 10/01/2012 9
Pertussis Incidence, by Age and Year Oregon, 2000 2013* 250.0 200.0 150.0 100.0 50.0 <1 1 4 5 9 10 14 15 19 20 0.0 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 *through 9/23/2013 20 Incidence of pertussis by year and sex, Oregon, 1991 2007 Cases/100,000 15 10 5 0 Female Male Year Influenza Update 10
Influenza Vaccine Efficacy Early returns, 2014 2015 season U.S. Influenza Vaccine Effectiveness Network MI, PA, TX, WA, WI Patients 6 months of age Seeking outpatient medical care for ARI Adjusted for place, age, sex, race, ethnicity, self-rated health, enrollment lags 2,321 enrolled Nov 10, 2014 Jan 2, 2015 CDC. MMWR 2015; 64:10 5. Influenza Vaccine Efficacy Early returns, 2014 2015 season Influenza + Influenza - Adjusted VE Age Total %Vax Total %Vax VE 95% CI 6 mos 17 years 410 39% 583 49% 24% 0% 43% 18 49 years 268 43% 400 48% 16% -18% 41% 50 years 272 71% 388 76% 23% -14% 41% Overall 950 49% 1371 56% 23% 8% 36% MMWR, June 5, 2015: Updated VE against A(H3N2): 18% CDC. MMWR 2015; 64:10 5; 583 90. Antigenic Shift Switch in entire genetic segments Reassortment between human and animal strain Pandemic requirement Earthquake fault, New Zeeland Health Emergency Management, NZ 11
Small changes from RNA mutations Antibodies generated by vaccines have less affinity for virus Many people newly susceptible every few years Reason for annual changes in seasonal vaccine strains Antigenic Drift Circulating Influenza Strains 2014 2015 Season* 14 30 A(H3) 42 A(H3): 92.7% B(Yamagata) B(Victoria) A(H3) B(Yamagata) B(Victoria) A(H1) Vaccine strains: 34.9% *Through 5 Feb 2015. Data extrapolated from CDC. MMWR 2015; 64:206 12. 150 2014-2015 Influenza Season, Age distribution 140 130 120 110 Reported Cases 100 90 80 70 60 50 40 30 20 10 0 age 0-4 age 5-17 age 18-49 age 50-64 age 65 MMWR Week 12
Antivirals High-risk groups include people 65 years of age, young children, pregnant women, and people with underlying medical conditions. There is negligible viral resistance to neuraminidase inhibitors (such as Tamiflu ), and these drugs can shorten the duration of fever and other symptoms, and probably reduces the risk of complications from flu. CDC recommends beginning antiviral treatment as soon as possible in all severely ill patients; ideally, treatment should begin within 48 hours of symptom onset. Forget about adamantanes they are not active against influenza B viruses, and there almost all influenza A viruses isolated in recent years have been resistant.. www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm#table2. Influenza Vaccine Strains Northern Hemisphere, 2015 2016 Season A/California/7/2009 (H1N1)pdm09-like A/Switzerland/9715293/2013 (H3N2)-like B/Phuket/3073/2013-like Bird Flu Also notable during the 2014 2015 flu season was the detection of highly pathogenic avian influenza (HPAI), first seen in Oregon in wild birds and a back yard flock in December 2014 and 2015. These illnesses were caused by H5N8 and H5N2 virus strains. Since then, millions of infected birds have been detected across the U.S., including huge commercial poultry flocks in the Midwest. According to the U.S. Department of Agriculture (USDA), poultry is a $48.3 billion industry, so controlling HPAI in such flocks has become a national priority to reduce the impact on international trade.. www.usda.gov/wps/portal/usda/usdahome?contentidonly=true&contentid=avian_influenz a.html 13
Rabies and Animal bites Distribution of major rabies virus variants among carnivore reservoirs in the United States and Puerto Rico, 2008 to 2012. *Potential host shift event. Month County Species Rabies-positive animals Oregon, 2013 CLATSOP TILLAMOOK YAMHILL POLK COLUMBIA MARION WASHINGTON MULTNOMAH CLACKAMAS HOOD RIVER WASCO SHER- MAN GILLIAM MORROW UMATILLA UNION February Josephine 2 Foxes May Jackson 1 Bat Grant 1 Bat June Grant 1Bat July Clackamas 1Bat Josephine 1Bat August Tillamook 1 Bat September Baker 1 Coyote LINCOLN WHEELER BAKER BENTON LINN JEFFERSON GRANT Coyote CROOK LANE DESCHUTES Fox COOS Bat DOUGLAS MALHEUR LAKE HARNEY JOSEPHINE JACKSON KLAMATH Leptospirosis 1.2 42 CURRY As of August 7, 2013 14
10/12/2015 Rabies-positive animals Oregon, 2014 COLUMBIA County Species July Lane 1 Fox July Yamhill Month CLATSOP WASHINGTON HOOD RIVER MULTNOMAH TILLAMOOK UMATILLA SHERMAN GILLIAM YAMHILL WALLOWA MORROW UNION CLACKAMAS WASCO POLK 1 Bat August Lake 1 Bat August Benton 2 Bats September Multnomah Marion Josephine 1 Bat 1 Bat 1 Fox MARION LINCOLN BAKER WHEELER LINN JEFFERSON GRANT BENTON CROOK LANE Fox DESCHUTES Bat COOS MALHEUR DOUGLAS LAKE JOSEPHINE HARNEY JACKSON KLAMATH CURRY As of September 23, 2014 Reported Animal Bites 15
Animal bites -US An estimated 4.7 million dog bites occur annually in the US. An estimated 368,245 persons are treated in emergency departments for nonfatal dog bites annually. Approximately 42% of dog bites occurred in children aged less than 14 years. Dog bite rates were significantly higher for boys (293.2 per 100,000) than for girls (216.7 per 100,000). Animal bite Statistics US 42% of dog bites occurred in children aged less than 14 years, with injury rates highest for children aged 5-9 years. Dog bite rates were significantly higher for boys (293.2 per 100,000) than for girls (216.7 per 100,000) Overall number of cases increased slightly from April through September, with a peak occurring in July (11.1%). Animal bite hospitalization In the U.S. about 1% of dog bites require hospitalization 5 10% of cat bites require hospitalization. 16
Common aerobic and anaerobic bacterial genera isolated from 50 infected dog bite wounds A majority of the infections were purulent wounds without abscess formation (58%), followed by nonpurulent wounds with cellulitis, lymphangitis, or both (30%) and abscesses (12%). Bacterial genus Frequency (%) Aerobic organisms Pasteurella 50 Streptococcus 46 Staphylococcus 46 Neisseria b 32 Corynebacterium 12 Moraxella 10 Enterococcus 10 Bacillus 8 Anaerobic organisms Fusobacterium 32 Porphyromonas 28 Prevotella 28 Propionibacterium 20 Bacteroides b 18 Peptostreptococcus 16 Common aerobic and anaerobic bacterial genera isolated from 50 infected cat bite wounds Out of 57 clinically infected human cat bite wounds, 63% of the wounds were a mix of aerobic and anaerobic organisms. Bacterial genus Frequency (%) Aerobic organisms Pasteurella 75 Streptococcus 46 Staphylococcus 35 Neisseria b 35 Moraxella 35 Corynebacterium 28 Enterococcus 12 Bacillus 11 Anaerobic organisms Fusobacterium 33 Porphyromonas 30 Bacteroides 28 Prevotella 19 Propionibacterium 18 Animal bites -Prophylaxis Prophylactic antibiotic treatment for bite wounds ranges between 3 and 7 days, depending on the risk of infection and depth of the wound. The regimen of choice for treating dog and cat wounds in adults is amoxicillin- clavulanate (Augmentin ) 875/125 mg orally twice a day or 500/125 mg orally three times daily. Children should be dosed at 25 50 mg/kg orally per day divided into three doses. For adults who are allergic to penicillin, prescribe clindamycin, 300 mg orally four times daily, plus a fluoroquinolone after a dog bite. Children who are allergic to penicillin can take clindamycin and trimethoprimsulfamethoxazole 17
Animal Species biting Oregonians, 2013 SQUIRREL SQUIRREL, 6 RODENT RODENT, 7 RACCOON RACCOON, 15 BAT BAT, 53 CAT CAT, 480 DOG DOG, 1236 Species 0 200 400 600 800 1000 1200 1400 Animal Bites Reported, Oregon 2013 250 200 Number of Reports 150 100 50 0 Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month Animal Bites by Species by Month, Oregon, 2013 160 140 120 100 80 60 Cat Dog Bat 40 20 0 Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec 18
Animal Bites by Sex, Oregon 2013 n=1879 0% 43% 57% F M Animal Bites, by species in Male Oregonians, Oregon 2013 18% 3% Male Dog Cat Bat 79% Animal Bites by Species in Female Oregonians, Oregon 2013 3% Female 34% Dog Cat Bat 63% 19
Dog bites by Sex, Oregon 2013 598 619 Female Male Cat bites by Sex, Oregon 2013 134 Female Male 344 ANIMAL BITE REPORT BY AGE GROUPS, OREGON, 2013 (N=1754) NUMBER REPORTED 284 200 235 213 222 246 205 110 39 0-9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 0 + AGE GROUPS 20
Animal bites by Species and Age group 250 affected, Oregon, 2013 200 150 100 50 0 0-9 10's 20's 30's 40's 50's 60's 70's 80's Dog Cat Bat End 21