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Public Health Updates - oregonpa.org Presentations...10/12/2015 1 Public Health Updates Emilio...
Transcript of Public Health Updates - oregonpa.org Presentations...10/12/2015 1 Public Health Updates Emilio...
10/12/2015
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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].
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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 study the 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].
The prevalence 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
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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
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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
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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
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Pertussis
• Contagious respiratory infection
• Outbreaks first described 16th 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
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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
Reported pertussis, by yearOregon, 1915–2012*
0
20
40
60
80
100
120
140
160
180
200
Year
Cases per 100,000
*through 10/31/2012
DTP
Tetanus and Diphtheria
School
Requirements
DTaP
Tdap
PCR
School
Requirement
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Pertussis Incidence U.S. and
Oregon, 1995–2012*
*through 10/31/2012
Why the epidemic?
• Artifactual?
• Advent of PCR: more sensitive
• Physician and patient awareness
• Real increase?
• Cyclical population immunity
• Acellular vaccines less effective?
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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
Bisgard KM, et al. Infant pertussis: who was the source? Pediatr Infect Dis J 2004; 23(11):985-989.
Wendelboe AM, et al. Transmission of Bordetella pertussis to young infants. PediatrInfect Dis J 2007; 26(4):293-299.
deGreeff SC 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
*As of 10/01/2012
Mother
Father
Siblings
Day care
GrandparentsOther
Unknown
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Pertussis Incidence, by Age and Year
Oregon, 2000–2013*
0.0
50.0
100.0
150.0
200.0
250.0
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
<1
1–4
5–9
10–14
15–19
≥20
*through 9/23/2013
Incidence of pertussis by year and sex,
Oregon, 1991–2007
0
5
10
15
20
Cases/1
00,0
00
Year
Female
Male
Influenza Update
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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%
CDC. MMWR 2015; 64:10–5; 583–90.
MMWR, June 5, 2015:Updated VE against A(H3N2): 18%
Antigenic Shift
• Switch in entire genetic segments
• Reassortment between human and animal strain
• Pandemic requirement
Earthquake fault, New Zeeland
Health Emergency Management, NZ
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Antigenic Drift
• 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
Circulating Influenza Strains2014–2015 Season*
A(H3)
A(H3) 42
3014
B(Yamagata)B(Victoria)A(H1)
B(Yamagata)B(Victoria)
A(H3): 92.7%
Vaccine strains: 34.9%
*Through 5 Feb 2015. Data extrapolated from CDC. MMWR 2015; 64:206–12.
2014-2015 Influenza Season, Age distribution
0
10
20
30
40
50
60
70
80
90
100
110
120
130
140
150
Re
po
rte
d C
as
es
MMWR Week
age 0-4
age 5-17
age 18-49
age 50-64
age ≥65
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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_influenza.html
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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.
Leptospirosis 1.2 42
Coyote
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Rabies-positive animals
Oregon, 2014
GILLIAM
MAN
WASCO
CLATSOP
BAKER
CROOK
DESCHUTES
DOUGLAS
GRANT
LAKE
MALHEUR
MORROW
UMATILLA
UNION
WALLOWA
WHEELER
SHER-
COLUMBIA
CURRY
POLK
TILLAMOOK
LINCOLN
WASHINGTON
CLACKAMAS
JACKSON
LANE
BENTON
JOSEPHINE
HARNEY
JEFFERSON
MULTNOMAH
MARION
KLAMATH
LINN
HOOD
RIVER
COOS
YAMHILL
Fox
As of September 23, 2014
Bat
Month County Species
July Lane 1 Fox
July Yamhill 1 Bat
August Lake 1 Bat
August Benton 2 Bats
September Multnomah Marion
Josephine
1 Bat1 Bat
1 Fox
Reported Animal Bites
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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.
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Common aerobic and anaerobic bacterial genera
isolated from 50 infected dog bite wounds
Bacterial genus Frequency (%)
Aerobic organisms
Pasteurella 50
Streptococcus 46
Staphylococcus 46
Neisseriab 32
Corynebacterium 12
Moraxella 10
Enterococcus 10
Bacillus 8
Anaerobic organisms
Fusobacterium 32
Porphyromonas 28
Prevotella 28
Propionibacterium 20
Bacteroidesb 18
Peptostreptococcus 16
A majority of the infections
were purulent wounds without
abscess formation (58%),
followed by nonpurulentwounds with cellulitis,
lymphangitis, or both (30%) and
abscesses (12%).
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
Neisseriab 35
Moraxella 35
Corynebacterium 28
Enterococcus 12
Bacillus 11
Anaerobic organisms
Fusobacterium 33
Porphyromonas 30
Bacteroides 28
Prevotella 19
Propionibacterium 18
Common aerobic and anaerobic bacterial genera
isolated from 50 infected cat bite wounds
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 trimethoprim-sulfamethoxazole
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DOG, 1236
CAT , 480
BAT, 53
RACCOON , 15
RODENT, 7
SQUIRREL, 6
Species
DOG
CAT
BAT
RACCOON
RODENT
SQUIRREL
0 200 400 600 800 1000 1200 1400
Animal Species biting Oregonians, 2013
0
50
100
150
200
250
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec
Number of Reports
Month
Animal Bites Reported, Oregon 2013
Animal Bites by Species by Month, Oregon, 2013
0
20
40
60
80
100
120
140
160
Jan Feb Mar April May Jun Jul Aug Sep Oct Nov Dec
Cat
Dog
Bat
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19
0%
57%
43%
Animal Bites by Sex, Oregon 2013n=1879
F M
Animal Bites, by species in Male Oregonians , Oregon 2013
79%
18%
3%
Male
Dog
Cat
Bat
Animal Bites by Species in Female Oregonians,
Oregon 2013
63%
34%
3%
Female
Dog
Cat
Bat
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Dog bites by Sex , Oregon 2013
619
598
Female
Male
Cat bites by Sex, Oregon 2013
344
134
Female
Male
284
200235
213 222246
205
110
39
0 -9 1 9 2 9 3 9 4 9 5 9 6 9 7 9 8 0 +
NU
MB
ER
RE
PO
RT
ED
AGE GROUPS
ANIMAL BITE REPORT BY AGE GROUPS, OREGON, 2013
(N=1754)