Annual Summary of Infectious Diseases for the City of Cleveland, 2016 Cleveland Department of Public Health Allison LeBorgne, Epidemiology Intern Chenai Milton, Epidemiologist Louisiana Hospital Association. (2017). CDC Update: Prevention of Sexual Transmission of Zika Virus 1
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Published 2017 Complied and Prepared by: Allison LeBorgne, Epidemiology Intern Office of Communicable Disease and Surveillance and Epidemiology Cleveland Department of Public Health 75 Erieview Plaza Cleveland, OH 44114 www.clevelandhealth.org Chenai Milton, Epidemiologist Office of Communicable Disease and Surveillance and Epidemiology Cleveland Department of Public Health 75 Erieview Plaza Cleveland, OH 44114 www.clevelandhealth.org 3
Table of Contents Definitions... 5 Introduction....6 Reportable Diseases for the State of Ohio...7 Reportable Diseases...9 Cleveland Demographics.12 Campylobacteriosis..13 Influenza...15 Legionellosis.17 Meningitis.19 Outbreaks of 2016 22 Methods.....25 Limitations 26 Appendix...27 4
Definitions Acute: a condition or disease with a sudden onset of symptoms Case: an accounted for instance of a health disorder or disease in a population Chronic: condition or disease with a slow onset of symptoms Communicable disease: infectious disease transmitted from someone infected (person, animal or reservoir) to a susceptible host through direct or indirect contact Foodborne Illness: also known as food poisoning and results from consuming an item that has been contaminated with a bacteria, virus or parasite Epidemiology: the study of the distribution and determinants of health and illness in a population Epidemiologist: people who monitor health trends and statistics to identify groups of people who are affected by various diseases. They investigate cases of disease to determine source, mode of transmission and risk factors for disease and use information collected 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 Incubation: the amount of time from a subjects first exposure to an infectious agent until the time of the first visible sign of symptoms Outbreak: occurrence of more cases of a disease than expected in a given area or among a specific group of people over a period of time Recall bias: a systematic error caused by differences in the accuracy or completeness of the information retrieved, or recalled, by study participants regarding information from the past Surveillance: the systematic collection, recording, analysis, interpretation and distribution of data reflecting the current health status of a population 5
Introduction The Cleveland Department of Public Health (CDPH) is the local public health agency for the City of Cleveland residents. Started in 1910, the department improves the quality of life in the city of Cleveland by promoting healthy behavior, protecting the environment, preventing disease, and making the city a healthy place to live. The CDPH has a range of programs providing clinical, environmental, health promotion, and population-based services. CDPH ensures a high quality of resources and services through various partnerships in the community. The Cleveland Department of Public Health have initiated and maintained working relationships with Case Western Reserve University, Metro Health Medical Center, Veterans Affairs Medical Center, Cuyahoga County Board of Health, Lakewood and Shaker Health Departments, the Center for Community Solutions and various others. These partnerships provide successful preventive public health services to meet the needs of the residents for the city of Cleveland communities. The Office of Communicable Disease Surveillance and Epidemiology (OCDSE) is charged with investigating and tracking the spread of communicable and chronic diseases, conduct surveillance and data analysis on public health issues for the city of Cleveland. With the use of the Ohio Disease Reporting System (ODRS) through the Ohio Department of Health (ODH), the epidemiologists are able to report, track and update information of cases reported by healthcare professionals of the city. The state of Ohio has developed a list of infectious diseases based on spread, severity and infectivity have to be reported in certain ways by certain times and are divided into classes A, B and C. 6
Reportable Diseases for the State of Ohio Class A: Diseases of major public health concern because of the severity of disease or potential for epidemic spread- report immediately via telephone upon recognition that a case, a suspected case, or a positive laboratory result exists. Anthrax Plague Botulism, foodborne Rabies, human Cholera Rubella (not congenital) Diphtheria Severe Acute Respiratory Syndrome Influenza A- novel virus infection (SARS) Measles Smallpox Meningococcal disease Tularemia Middle East Respiratory Syndrome (MERS) Yellow Fever Viral Hemorrhagic fever (VHF), including Ebola Virus disease, Lassa fever, Marburg hemorrhagic fever, and Crimean-Congo hemorrhagic fever Class B: Disease of a public health concern needing timely response because of potential for epidemic spread- report by the end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known. Arboviral neuroinvasive and non-neuroinvasive disease: Chikungunya virus infection Eastern equine encephalitis virus disease LaCrosse virus disease (other California serogroup virus disease) Powassan virus disease St. Louis encephalitis virus disease West Nile virus infection Western Equine encephalitis virus disease Zika virus infection Other arthropod-borne diseases Amebiasis Babesiosis Botulism (infant/wound) Brucellosis Campylobacteriosis Chancroid Chlamydia trachomatis infections Coccidoidomycosis Creutzfeldt-Jakob disease Cryptosporidiosis Cyclosporiasis Dengue 7
Reportable Diseases for the State of Ohio E. Coli O157:H7 and Shiga toxin-producing E. Coli Ehrlichiosis/Anaplasmosis Giardiasis Gonorrhea Haemophilus influenzae (invasive disease) Hantavirus Hemolytic uremic syndrome Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E Influenza-associated hospitalization Influenza-associated pediatric mortality Legionnaires disease Leprosy (Hansen disease) Leptospirosis Listeriosis Lyme disease Malaria Meningitis (Aseptic viral/bacterial) Mumps Pertussis Poliomyelitis (including vaccine-associated cases) Psittacosis Q fever Rubella (congenital) Salmonellosis Shigellosis Spotted fever rickettsiosis, including Rocky Mountain Spotted Fever Staphylococcus aureus, with resistance or intermediate resistance to vancomycin Streptococcal disease, group A, invasive Streptococcal disease, group B, in newborn Streptococcal pneumoniae, invasive disease Syphilis Tetanus Toxic shock syndrome Trichinellosis Tuberculosis, including multi-drug resistant tuberculosis Typhoid fever Varicella Vibriosis Yersiniosis Class C: Report an outbreak, unusual incident or epidemic of other diseases (e.g. histoplasmosis, pediculosis, scabies, staphylococcal infections) by the end of the next business day. Outbreaks: Community Institutional Foodborne Waterborne Healthcare-associated Zoonotic 8
Infectious Disease Cleveland Cases 2016 Reportable Diseases Cleveland Rates 2010 per 100,000 Ohio Cases 2014 Ohio Rates 2014 per 100,000 U.S. Cases 2014 U.S. Rates 2014 per 100,000 Amebiasis 3 0.8 0 0 0 0 Anthrax 0 0 0 0 0 0 Babesiosis 0 0 1 0 1,760 0.6 Botulism, Foodborne 0 0 2 0.02 15 0 Botulism, Infant/Wound 0 0 3 0.03 146 0.05 Brucellosis 0 0 1 0 92 0.03 Campylobacteriosis 77 19.4 8 0.07 N/A N/A Chancroid 0 0 0 0 0 0 Chikungunya virus 0 0 0 0 0 0 Chlamydia trachomatis 6,669 1,681 54,858 473 1,441,789 452 infection Cholera 0 0 0 0 5 0 Coccidioidomycosis 0 0 16 0.1 8,232 2.6 Creutzfeldt-Jakob 0 0 N/A N/A N/A N/A Disease Cryptosporidiosis 9 2.3 324 2.8 8,682 2.7 Cyclosporiasis 0 0 1 0 398 0.1 Dengue 0 0 9 0.8 680 0.2 Diptheria 0 0 1 0 1 0 Eastern Equine 0 0 0 0 8 0 encephalitis E. Coli, Shiga 0 0 204 17.5 6,179 1.9 Toxin-Producing Ehrlichia 0 0 5 0.04 4,275 1.3 Chaffeensis/Anaplasmosis Giardiasis 18 0.5 385 3.3 14,554 4.6 Gonorrhea 2,844 716.7 16,237 140 350,062 109.8 Haemophilus Influenzae 14 3.5 150 1.3 3,541 1.1 (Invasive) Hantavirus 0 0 0 0 32 0.01 Hemolytic Uremic 0 0 9 0.8 250 0.08 Syndrome (HUS) Hepatitis A 0 0 32 0.3 1,239 0.4 Hepatitis B, 117 29.5 387 3.3 15,238 4.8 Acute/Chronic Hepatitis C, 1,034 260.6 15,860 136.8 165,067 51.8 Acute/Chronic Hepatitis D 0 0 N/A N/A N/A N/A 9
Infectious Disease Reportable Diseases Cleveland Cases 2016 Cleveland Rates 2010 per 100,000 Ohio Cases 2014 Ohio Rates 2014 per 100,000 U.S. Cases 2014 U.S. Rates 2014 per 100,000 Hepatitis E 0 0 0 0 N/A N/A Human N/A N/A 932 8 35,606 11.2 Immunodeficiency Virus Influenza A, Novel 14 3.5 2 0.02 N/A N/A Human Virus Influenza-Associated 325 82 N/A N/A N/A N/A Hospitalization Influenza-Associated 0 0 2 0.02 141 0.04 Pediatric Mortality Invasive Pneumococcal 0 0 981 8.5 15,356 4.8 Disease Lacrosse Virus Disease 0 0 32 0.3 96 0.03 Legionellosis 40 10.1 406 3.5 5,166 1.6 Leprosy (Hansen Disease) 0 0 2 0.02 88 0.03 Leptospirosis 0 0 2 0.02 38 0.01 Listeriosis 0 0 30 0.3 769 0.2 Lyme Disease 0 0 119 1 33,461 0.5 Malaria 6 1.5 38 0.3 1,653 0.5 Measles 0 0 382 3.3 667 0.2 Meningitis, Aseptic 20 5 N/A N/A N/A N/A Meningitis, Bacterial 11 2.8 N/A N/A N/A N/A Meningococcal Disease 0 0 12 0.1 433 0.1 Middle East Respiratory 0 0 0 0 N/A N/A Syndrome Mumps 2 0.5 552 4.8 1,223 0.4 Other Arthropod-borne 0 0 N/A N/A N/A N/A Diseases Pertussis 2 0.5 1,463 12.6 32,971 10.3 Plague 0 0 0 0 10 0 Polioyelitis (including 0 0 0 0 0 0 vaccine-associated cases) Powassan Virus Disease 0 0 0 0 8 0 Psittacosis 0 0 0 0 8 0 Q Fever 0 0 4 0.03 168 0.05 Rabies, human 0 0 0 0 1 0 Rubella (congenital) 0 0 0 0 1 0 Rubella (noncongenital) 0 0 0 0 6 0 10
Infectious Disease Reportable Diseases Cleveland Cases 2016 Cleveland Rates 2010 per 100,000 Ohio Cases 2014 Ohio Rates 2014 per 100,000 U.S. Cases 2014 U.S. Rates 2014 per 100,000 Salmonellosis 51 12.9 1,199 10.3 51,455 16.1 Severe Acute Respiratory 0 0 0 0 0 0 Syndrome (SARS) Shigellosis 15 3.8 606 5.2 20,745 6.5 Smallpox 0 0 0 0 0 0 Spotted Fever 0 0 12 0.1 3,757 1.2 Rickettsiosis St. Louis encephalitis 0 0 0 0 10 0 Staph Aureus, 1 0.2 9 0.08 212 0.07 Vancomycin Intmed Strep Disease (INV), 24 6 N/A N/A N/A N/A Group A Strep Disease, Group B 10 2.5 N/A N/A N/A N/A (Newborn) Strep Toxic Shock 0 0 9 0.08 259 0.08 Syndrome (STSS) Strep Pneumo (INV), 35 8.8 N/A N/A N/A N/A Drug Resistant Syphilis 247 62.2 1,229 10.6 63,450 19.9 Tetanus 0 0 1 0 25 0.01 Toxic Shock Syndrome 0 0 9 0.08 59 0.02 (TSS) Trichinellosis 0 0 1 0 13 0 Tuberculosis (including 0 0 156 1.3 9,421 3 drug resistant) Tularemia 0 0 1 0 180 0.06 Typhoid Fever 0 0 7 0.06 349 0.1 Varicella 13 3.8 535 4.6 10,172 3.2 Vibriosis (Not Cholera) 0 0 12 0.1 1,261 0.4 Viral Hemorrhagic Fever 0 0 0 0 5 0 West Nile Virus 3 0.8 11 0.09 2,205 0.7 Western equine 0 0 N/A N/A N/A N/A encephalitis Yellow Fever 0 0 0 0 0 0 Yersiniosis 2 0.5 N/A N/A N/A N/A Zika Virus 11 2.8 83 0.7 5,102 1.6 --N/A: represents that there is no current information on the incidence of the disease for the specified location. The rates for Cleveland were calculated by using the 2010 census data population of 396,815. The rates for Ohio and the United States were calculated using the Centers for Disease Control and Prevention s 2014 report of infectious disease populations (rounded to the nearest thousandth placement) for Ohio: 11,856,000 and the United States: 11,594,000-- 11
Cleveland Demographics There is an estimated population of Cleveland in 2016 of 385,809 people Out of the estimated population, 51.6 percent of individuals are African Americans The median age of people living in Cleveland, Ohio is 35.9 years old The population of Cleveland has been steadily decreasing for the last 10 years Sex (Estimated) # % Male 186,787 47.8 Female 203,797 52.2 Age Groups (Estimated) # < 5 years old 29,075 5-19 years old 85,214 20-64 years old 255,825 65 or older 51,194 Key Findings: There were 13,322 reports of disease, not accounting HIV cases that were reported for Cleveland in 2016. After confirming addresses, there were 11,617 cases (not accounting for HIV cases) of reportable diseases Sexually transmitted diseases such as chlamydia, gonorrhea and syphilis make up 9,760 of the infectious disease 2016 cases which leaves 1,857 cases of other infectious diseases to observe When observing the 11,617 cases of infection, we find many cases taking place in Wards 5, 7 and 9 with neighborhoods Glenville, Union-Miles and Broadway-Slavic Village with the most cases 12
Campylobacteriosis Transmission: found on raw meat and un-cleaned food surfaces; Highest rate of infection takes place in the summer months because bacteria grows rapidly in warm weathers Prevention: Food preparers should make sure foods are cooked to right temperature, cleaned and prepared properly before serving/consuming Agent: Caused by the bacteria Campylobacter; One of the most common causes of diarrheal illness in the US Symptoms: diarrhea, cramping, abdominal pain, and fever within two to five days after exposure to the organism for the most common symptoms Incubation/Duration: illness lasts on average one week; some individuals do not have any symptoms What we find about Cleveland: There were 77 cases of Campylobacteriosis in the City of Cleveland in 2016. Over 50 percent of the cases that occurred were in Caucasians even when considering that the city s population is greatly African American. The average age for individuals who were diagnosed with the infection was approximately 40 years old. Also a majority of the cases took place in the months of January and May. Ward 15 and 16 had the most cases which consist of neighborhoods such as Detroit Shoreway, Edgewater, Bellaire-Puritas and Jefferson. 13
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Influenza Agent: contagious respiratory illness that spreads easily through communities Symptoms: fever, cough, sore throat, runny nose, muscle or body aches, headache, fatigue and sometimes vomiting and diarrhea which is more common in children Incubation/Duration: infection takes about1 to 4 days to show symptoms in the body and the infection lasts on average for the same amount of time Transmission: most people are infected from coming into contact with someone who is already infected. Hospitalized-acquired influenza cases are individuals who go into the hospital with another complication and due to their immunocompromised state, they contracted influenza. The biggest chance of infection is when the climate switches from cold to hot and bacteria replicates. What we find about Cleveland: There were 339 cases of influenza in Cleveland that were reported to the Cleveland Department of Public Health in 2016. The majority of the cases (325) were individuals who were found with positive flu results during hospitalization while the rest (14) were other positive lab results. Half of the cases were reported in the month of March with the average age at approximately 46 years old. A large amount of the cases took place in Wards 1 and 7 which consists of neighborhoods such as Lee-Harvard, Lee-Seville, Hough and Central.. 15
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Legionellosis Agent: Legionella or Legionnaries disease is a bacterium that s naturally found in freshwater environments Symptoms: fever, cough, chills and muscle aches Incubation: may take 2 to 10 days after exposure before you experience symptoms Transmission: the bacteria can grow in man-made water systems like showers, faucets, air-conditioning units, hot tubs, public swimming areas, fountains, hot water tanks, etc. Prevention: to reduce disease spread, regularly clean and disinfect any water systems that you, your family or members of your community may come into contact with Most healthy people exposed to the bacteria will not become ill but smokers, individuals 50 years or older, people with chronic lung disease, with weak immune systems or are immunocompromised have a greater risk of having complications What we find about Cleveland: There were 40 cases of Legionnaires disease in the city of Cleveland in 2016. Most of the cases took place in the summer months and the average age of cases was approximately 57 years old. Considering older populations are at a higher risk for contracting this disease, it is expected that the average age would be higher than the average age for other diseases. Most of the cases took place in Wards 1 and 14 which consists of neighborhoods such as Lee-Harvard, Lee-Seville, the Stockyards and Clark-Fulton. 17
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Meningitis (Aseptic/Viral and Bacterial) Agent: - Meningitis: causes an inflammation of tissues that cover the brain and spinal cord - Viral: there are many different types of viruses that can cause viral meningitis but the most common is non-polio enteroviruses. Viral meningitis is the most common meningitis but usually not as severe as bacterial - Bacterial: the bacteria that cause the most infections of bacterial meningitis in the United States are Streptococcus pneumoniae, Group B Streptococcus, Neisseria meningitides, Haemophilus influenza and Listeria monocytogenes (although for these reported cases, it is not including infections from Neisseria meningitides) - Aseptic: can be a result from the bacteria in bacterial meningitis; sepsis is the body s overwhelming and life-threatening response to infection that can cause tissue damage, organ failure, and death Symptoms: for all types of meningitis people may experience fever, headache, stiff neck, sensitivity to bright light, sleepiness or trouble waking up from sleep, nausea, vomiting, lack of appetite, lethargy (a lack of energy) and altered mental status Transmission: viral meningitis may be passed to another person but it is not likely that they will become ill from the virus, infected persons may have received it as a secondary infection if their immune system is compromised. Bacterial meningitis may replicate in someone who naturally carries the bacteria in their body which is also how they would be able to pass it to other individuals 19
Meningitis (Aseptic/Viral and Bacterial) Duration: In viral meningitis, the infection can clear up on its own in 7 to 10 days but for bacterial, it depends on when treatment is started and how intense the infection is Treatment: if viral, healthy individuals can wait for the virus to clear up but if patient is immunocompromised they may want to seek medical attention to avoid secondary infections. If patient has bacterial meningitis, doctors will use multiple different antibiotics and patients need to be treated as soon as possible because it s more dangerous Prevention: many types of bacterial meningitis have vaccinations that are suggested for children and while viral meningitis does not have a vaccine, following through with good hygiene and avoiding infected individuals is a good way to reduce chances of contracting the disease What we find about Cleveland: There were 31 cases of all types of meningitis reported in the city of Cleveland in 2016. Viral and aseptic meningitis made up 20 of these cases while bacterial meningitis made up the remaining 11 cases. Women made up about 65 percent of the cases and the largest amount of cases was reported for the month of October. A large amount of cases look place in Wards 12 and 14 which consist of neighborhoods such as Cuyahoga Valley, Broadway-Slavic Village, Brooklyn Centre, Stockyards and Clark-Fulton. 20
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Outbreaks of 2016 Foodborne Illness at a Restaurant The event gathered at the location January 9, 2017 and the outbreak was reported January 12, 2016. Two of the symptomatic individuals from the event submitted stool samples to find what they had and fortunately, the host of the party worked for the Cleveland Clinic and reported promptly after finding many were ill. The illness of concern was Norovirus 2. From the 80 people who were interviewed, 56 of them reported symptoms following the event including stomach cramps, nausea, vomiting, diarrhea, headache, body aches, joint pain, fever, chills and fatigue. This makes up 70 percent of the individuals who attended the event. The individual who notified the health department of the outbreak also reported that about 40 guests had called off work days after the event with these symptoms. Two guests went for laboratory testing and had positive viral agent of Norovirus 2. Looking at the epidemiologic curve, it was found that 39 out of the 56 people who were ill became ill on the 11 th of January which is two days after the event. Like prevention for the foodborne illness Campylobacteriosis, it is best to suggest better hand hygiene and proper washing of produce to avoid cross contamination. Making sure that foods, especially poultry, are looked to the right temperature is also important in preventing foodborne illnesses. --Photo was created by an organization called Fight Bac who s a partnership for food and safety education, 2016-- 22
Outbreaks of 2016 Hand, Foot and Mouth Disease (HFMD) at a Daycare On March 31, 2016, the Office of Communicable Disease Surveillance and Epidemiology (OCDSE) received a phone call about ten possible cases of hand, foot and mouth disease in children at the daycare in question with two confirmed cases. When the facility learned of the outbreak the location was sanitized immediately. By April 13, 2016, the learning center reported there were seven confirmed cases out of 16 possible cases. When a Cleveland Department of Public Health daycare inspector visited and inspected the daycare, they did not find any problematic areas in the center that would suspect an outbreak. HFMD spreads the same way the flu does, so if someone comes into contact with an individual who has the disease or touches an object they have previously touched, there is a chance you may get it as well. This is why it tends to spread through populations with children because they do not wash their hands as often. The disease does not have a definitive treatment and usually clears up on its own. Persons infected can use over the counter medication such as aspirin (for adults only) for pain and antiseptic mouth washes and sprays to numb the mouth pain. --These two photos are from the CDC website on HFMD-- 23
Outbreaks of 2016 Zika Virus as a new Reportable Infectious Disease finding its way into our community In late 2016, Zika virus was added to the Ohio s ABC Reportable Disease List. In 2016, there were 11 confirmed cases of Zika virus in the City of Cleveland. All cases of Zika virus in Cleveland either traveled internationally or originally came from countries where the disease is common and they brought the disease unknowingly with them. All but one of the cases of Zika were women, which means there s a larger chance for the virus to spread to unborn children if women of child-bearing age were pregnant when bitten or became ill before the pregnancy. Pregnant women reported are followed throughout their pregnancy and through the first year of the child s life to observe any effects the disease may have on the child. Many studies have shown that children born to mothers, who have the Zika virus during pregnancy or up to two years before pregnancy, may have a child with microcephaly. Microcephaly is --The photo above is from an article written in homeland security global news about the possibility of Zika Virus being sexually transmitted, 2016-- when an infant is born with a head that s much smaller than expected. Babies suffering from microcephaly may experience symptoms such as seizures, developmental delays such as problems with speech or other developmental milestones (like sitting, standing, and walking), intellectual disability (decreased ability to learn and function in daily life), problems with movement and balance, feeding problems such as difficulty swallowing and hearing loss or vision problems. Health professionals predict that due to the increase in climate change, the United States will have higher incidences of Zika virus because of the movement of aedes aegypti and aedes albopictus mosquitoes into the states. These mosquitoes prefer warm climates and, in fact in 2016, southern states such as Florida and Texas already have about 224 cases that are presumably confirmed cases of Zika virus from the local mosquito population. 24
Methods All data used in this summary report was reported to the Cleveland Department of Public Health which was later reported to the Ohio Department of Health as well as the Centers for Disease Control and Prevention. The populations that were used to calculate incidence rates were 396,815 for Cleveland, 11,594,000 for the state of Ohio and 318,856,000 for the United States. For each disease the local, state and national incidence rates were calculated using the following: With this formula we would calculate, for example, a rate of 260.6 per 100,000 people in the city of Cleveland in 2016 that had a reported case of either chronic or acute Hepatitis C. This means that for every 100,000 people in Cleveland, approximately 260 people had Hepatitis C at some point during the year. All data collected was analyzed in SPSS statistical software. The maps that were shown throughout this report were mapped and analyzed with the use of GIS (Geographic Information Systems) software to help identify areas in the city that specific disease showed to be more problematic than others. There are 17 wards for Cleveland and 34 neighborhoods, respectively. Each neighborhood falls into a ward but can also be included in more than one. Since it can be difficult to determine from looking at one map, each of the diseases that were discussed previously in the report have two maps to see the differences between ward and neighborhood. Any data that was provided and the case had an address from outside of the city of Cleveland was removed. While sexually transmitted diseases are shown to have the most significant results in this study, they are not discussed in depth in this report because they are annually reported separately, but are included because they are reportable infectious diseases. Data for HIV/AIDS for 2016 for the city of Cleveland has not been finalized and as of June 2017 there is not a confirmed frequency of cases. 25
Limitations Unfortunately, there is missing data in this report. In fact as mentioned earlier, there were 13,322 cases reported in 2016, and only 11,617 cases were analyzed because they included complete Cleveland address information that can be utilized through GIS (not including HIV/AIDS). There is also an issue of misclassification in this data. For example, time of infection that is reported by the patient could be inaccurate and can be reported differently by the researcher for each disease. Some disease incidence cases reported in ODRS have an event date as the first day of symptom onset while other diseases and/or cases go by the date of positive result from a lab from a patient s biological sample. This means the information of date and/or month of event could be skewed per disease. Underreporting continues to be an issue all over the country due to public health and healthcare professionals not fully understanding protocols. Since each state has different policies and still has to follow the national protocols, reports slip through the cracks. This is also an issue with diseases who have similar, common symptoms where individuals would not seek out medical assistance in diagnoses. Many outbreaks reported do not have a confirmed disease that caused the outbreak especially in the cases of foodborne illnesses because of the multitude of different diseases that could be the culprit. This point goes to the possibility that many diseases reported annually are underreported for the city, state and country. 26
Appendix 1. Centers for Disease Control and Prevention. (2015, August 18). About Hand, Foot, and Mouth Disease (HFMD). In CDC, from https://www.cdc.gov/hand-foot-mouth/about/index.html 2. Centers for Disease Control and Prevention. (2017, January 25). Bacterial Meningitis. In CDC, from https://www.cdc.gov/meningitis/bacterial.html 3. Centers for Disease Control and Prevention. (2014, June 3). Campylobacter. In CDC, from https://www.cdc.gov/foodsafety/diseases/campylobacter/index.html 4. Centers for Disease Control and Prevention. (2016, December 7). Facts about Microcephaly. In CDC, from https://www.cdc.gov/ncbddd/birthdefects/microcephaly.html 5. Centers for disease Control and Prevention. (2017, March 24). Influenza (Flu). In CDC, from https://www.cdc.gov/flu/index.htm 6. Centers for Disease Control and Prevention. (2016, July 7). Legionella (Legionnaires Disease and Pontiac Fever). In CDC, fromhttps://www.cdc.gov/legionella/index.html 7. Centers for Disease Control and Prevention. (2016, October 14). Summary of Notifiable Infectious Diseases and Condition United States, 2014. In CDC, from https://www.cdc.gov/mmwr/volumes/63/wr/mm6354a1.htm 8. Centers for Disease Control and Prevention. (2016, June 15). Viral Meningitis. In CDC, from https://www.cdc.gov/meningitis/viral.html 9. Centers for Disease Control and Prevention. (2017, May 25). 2016 Case Counts in the US. In CDC, from https://www.cdc.gov/zika/reporting/2016-case-counts.html 10. Cleveland Department of Public Health. (2017). About the Cleveland Department of Public Health. In Cleveland Health, from http://clevelandhealth.org/about.php 11. United States Census Bureau. (2015). Cleveland Sex by Age Population Estimate for 2015. In American Fact Finder, from https://factfinder.census.gov/faces/tableservices/jsf/pages/productview.xhtml?pid=acs_15_5 YR_B01001B&prodType=table 12. United States Census Bureau. (2015). U.S. Department of Commerce: Tables for Cleveland, Ohio. In Census, from https://www.census.gov/quickfacts/table/pst045215/3916000 27