WhenNeglectedTropicalDiseasesKnockonCalifornia’sDoor
AnneKjemtrup,DVM,MPVM,PhDCaliforniaDepartmentofPublicHealth
Vector-BorneDiseaseSecFon
OverviewofToday’sTopics• Neglectedtropicaldiseases:seLngthestageforimpactonCalifornia
• CaliforniaPublicHealthOverview– Surveillance/responsestructure– Vector-BorneDiseaseprogramareas
• Twoexamples:– ArbovirusintroducFon(dengue,chikungunya,zika)– Re-emergenceofRockyMountainspoSedfever(notreallyNTDbutsimilarprincipals)
THEMONSTERRETURNSPeterMcCarty
NeglectedTropicalDiseases
• BuruliUlcer• Chagasdisease• DengueandChikungunya• Dracunculiasis(guinea
wormdisease)• Echinococcosis• Endemictreponematoses
(Yaws)• Foodbornetrematodiases• HumanAfrican
trypanosomiasis(sleepingsickness)
• Leishmaniasis• Leprosy(Hansendisease)• LymphaEcfilariasis• Onchocerciasis(river
blindness)• Rabies• Schistosomiasis• Soil-transmiLed
helminthiases• Taeniasis/CysEcercosis• Trachoma
NeglectedTropicalDiseases• BuruliUlcer• Chagasdisease• DengueandChikungunya• Dracunculiasis(guinea
wormdisease)• Echinococcosis• Endemictreponematoses
(Yaws)• Foodbornetrematodiases• HumanAfrican
trypanosomiasis(sleepingsickness)
• Leishmaniasis• Leprosy(Hansendisease)• LymphaEcfilariasis• Onchocerciasis(river
blindness)• Rabies• Schistosomiasis• Soil-transmiLed
helminthiases• Taeniasis/CysEcercosis• Trachoma
Californiahasvectorand/ordiseaseagent
StateReportableDiseasesCaliforniaDepartmentofPublicHealth!81humandiseasesorcondiEons(includingallthe
naEonaldiseases),2animaldiseases(rabiesandplague)• Vector-Bornediseasesinclude:
• Anaplasma/Ehrlichiosis• Babesiosis• ColoradoTickFever(toberemovednextyear)• Dengue• Hantaviruscardiopulmonarysyndrome• LymeDisease• Malaria• Plague(humanoranimal)• Relapsingfever• RockyMountainspoLedfever• Tularemia• WestNilevirus• YellowFever
7
Notifiable/reportable
Vector control
pathogen control
Vaccination, prophylaxis
Vector-surveillance
pathogen-surveillance
Dise
ase
burd
enIntervention/Response Surveillance
Ri
sk
Reservoir hosts: presence/absence/abundance/distribution
Vector: presence/absence/abundance/distribution
General population: exposure
General pop.: (A)symptomatic infected
General pop.:Symptomatic
Health care provider
hospital
Sero-surveillance, surveys
Public education
(Improved) diagnosis, treatment(s) recommendations
Adapted from Braks et al, Parasites and Vectors 2011, 4: 192
NoEfiableDiseaseSurveillance:RouteofInformaEon
ReporEngmandatedbystatelaw(Title17CCR)
Health care providers, laboratories, others, report to local health department (LHD)
LHD submits reports to CDPH
Reports transmitted to Centers for Disease Control and Prevention (CDC)
NoEfiableDiseaseSurveillance:RouteofInformaEonReporting mandated by state law (Title 17 CCR) Reportable TBD include: anaplasmosis, babesiosis, Lyme disease, relapsing fever (B.
hermsii), spotted fever and non-spotted fever group rickettsia
Local health department (LHD) receives, follows-up, reviews reports
LHD submits reports to CDPH
Reports transmitted to Centers for Disease Control and Prevention (CDC)
Somevector-bornediseasesrequirecomplexsurveillanceeffortstomonitor,intervene,anEcipate,detect,andstudytheirepidemiology(justafewofsurveillancefuncEons)
Urban cycle Rural cycles
??
?? Bird/Mosquito Movement? Aedes, Culiseta Aedes, Culiseta
Culex tarsalis Culex tarsalis
Culex Culex pipiens pipiens stigmat stigmat . . ? ? erythro erythro . .
Dead end hosts
??
Rural cycles
??
?? Bird/Mosquito Movement?
West Nile virus transmission cycles in California
Aedes, Culiseta
Culex tarsalis Culex tarsalis
Culex Culex pipiens pipiens stigmat stigmat . . ? ? erythro erythro . .
Dead end hosts
??
• ExposurepotenEaltohumansfromvectorfleasassessed
• PasthistoryofepizooEcsand/orhumanplaguecasesintheregionreviewed
• RecommendaEonsandacEonstakentoreducevectorsandpublicexposure
Plague Surveillance • CDPH has expanded and refined the
statewide plague surveillance program to include: • investigations of human and domestic
felid plague cases • serologic monitoring of wild carnivores • evaluation of epizootic activity in
rodents
VirusesandTransmission
• ChikungunyaisanalphavirussimilartoWEEandRossRivervirus
• DengueandZikavirusesarebothflavivirusessimilartoyellowfeverandJapaneseencephaliFsvirus
• AllarearbovirusesandtransmiSedprimarilyhumantohumanbyAedesaegyp*andAe.albopictus
AedesalbopictusandAedesaegyp*havearrivedandbecomeestablishedinCA
Aedesalbopictus
AsianFgermosquito2008:Firstintroducedthen
eradicated2011:LosAngelesCounty
Aedesaegyp*Yellowfevermosquito2013:Madera,Fresno,SanMateoCounFes
ImpactofinvasiveAedesintroducEontoCalifornia
• Vector:Dengue,chikungunya,andseveralencephaliFsviruses
• IncreasedriskofintroducFonofexoFcmosquito-borneviruses
• Aggressiveday-biFngmosquitoes• Prefertobitepeople(ratherthanbirdsorotheranimals)
• Difficulttocontrol:Breedincontainers
InvasiveAedesMosquitoesDetecFonSitesinCalifornia,2011-2015
Exeter
Arvin
ClovisFresno
MaderaMaderaRanchosParkwood
MenloParkAtherton
ElMonteArcadiaIrwindaleDuarteMonroviaTempleCityBaldwinParkRosemeadMontereyParkCityofIndustryBradburySouthElMonteAvocadoHeightsWhi_erSanGabrielLaPuente
Aedesaegyp@Aedesalbopictus
EscondidoSanDiegoChulaVista
CommercePicoRivera
CalexicoAndradeAnaheim
Hayward
ClimateChangeandInvasiveAedesMosquitoesinCA
• Tropicalspecies– Warmweatherenhancessurvival,reproducFon,andspread
• Drought:unintendedconsequence– Residentsstorewaterinbackyardbuckets,containers,andrainbarrels
– Donotmaintainswimmingpools
• AedesestablishmentandspaFaldistribuFonmayserveasindictorsofclimatechange
SurveillanceforChikungunya,DengueandZikainCalifornia
• CDPHisworkingcloselywithlocalhealthdepartmentsandvectorcontrolagencies– IdenFfyingviremiccases– Mappingco-locaFonofviremic
casesandinvasiveAedes– PrompFngmosquitosurveillance
nearcaseresidents
• CommunicaFonbetweenlocalVectorControlAgenciesandHealthDepartmentsiscriFcaltoensurerapidresponsetoreduceriskoflocaltransmission
• In2015:561,501confirmedand2,326,829probablecases
• Including10,276deaths
• Highestincidencerate(820/100,000)wasinBrazilwithover1.5millioncases
• Caseswerereportedfrom49countriesorterritoriesintheAmericas
DengueintheAmericas
2015
Confirmed Dengue Cases in Mexico by State January 1, 2015 – December 31, 2015
Sonora
Chihuahua
Coahuila
DurangoNuevoLeón
Tamaulipas
Yucatán
Campeche
OaxacaGuerrero
Chiapas
Colima
Jalisco
TabascoPuebla
Morelos
0confirmedcases
1–100confirmedcases
101–500confirmedcases
501–1000confirmedcases
Morethan1000confirmedcases
Ag.
Tl.
Ag.=AguascalientesQuer.=QuerétaroDF=DistritoFederalTl.=Tlaxcala
DataformapavailablefromhSp://www.epidemiologia.salud.gob.mx/dgae/panodengue/intd_dengue.html
Confirmed Chikungunya Cases in Mexico by State January 1, 2015 – December 31, 2015
Sonora
Chihuahua
Coahuila
DurangoNuevoLeón
Tamaulipas
Yucatán
OaxacaGuerrero
Chiapas
Colima
Jalisco
Nayarit
TabascoPuebla
Morelos
0confirmedcases
1–100confirmedcases
101–500confirmedcases
501–1000confirmedcases
Morethan1000confirmedcases
Ag.=AguascalientesQuer.=QuerétaroDF=DistritoFederalTl.=Tlaxcala
Ag.
Tl.
DataformapavailablefromhSp://www.epidemiologia.salud.gob.mx/doctos/avisos/2016/chik/DGE_CHIK_CASOSYDEF_SEM05_2016.pdf
Confirmed Zika Cases in Mexico by State January 1, 2016 – February 19, 2016
Sonora
Chihuahua
Coahuila
DurangoNuevoLeón
Tamaulipas
Yucatán
OaxacaGuerrero
Chiapas
Colima
Jalisco
Nayarit
TabascoPuebla
Morelos
0confirmedcases
1–25confirmedcases
26–50confirmedcases
51–100confirmedcases
Morethan100confirmedcases
Ag.=AguascalientesQuer.=QuerétaroDF=DistritoFederalTl.=Tlaxcala
Ag.
Tl.
DataprovidedbytheMexicanMinistryofHealthhSp://www.epidemiologia.salud.gob.mx/doctos/avisos/2016/zika/DGE_ZIKA_CASOS_SEM06_2016.pdf
75
42
76
119109
89
1
1
10
823
25
0
20
40
60
80
100
120
140
2010 2011 2012 2013 2014 2015
Num
bero
frep
ortedden
guecases
Year
ImportedHumanDengueCasesinCalifornia2010-2015*
*AsofFebruary17,2016
n=581
ConfirmedProbable
ImportedDengueinCalifornia,2015• 114casesreportedin2015*
– From22counFes,10withinvasiveAedes– 62casesreturnedtocounFeswithinvasiveAedes
• Ofthose76%werelikelyviremicwhileinCalifornia
• 54%ofcaseswerefemale• 32%ofcasesrequiredhospitalizaFon• 45%ofcaseshadtraveltoLaFnAmerica
– Mexico17%,ElSalvador12%
*EsFmatedFebruary2016
ChikungunyaintheUnitedStates2014
2015
2014:2,811importedcasesreportedinUS,12locallyacquiredcasesinFlorida2015:679importedcasesreportedinUS,nolocallyacquiredcases
ImportedChikungunyaCasesinCalifornia,2015
• 233casesreportedin2015*(140casesin2014)– From30counFes,10withinvasiveAedes– 152casesreturnedtocounFeswithinvasiveAedes
• Ofthose53%werelikelyviremicwhileinCalifornia
• 67%ofcaseswerefemale• Only8%ofcasesrequiredhospitalizaFon• 91%ofcaseshadtraveltoLaFnAmerica
– Mexico40%,ElSalvador16%,Guatemala13%*EsFmatedasofFebruary2016
2015 Human dengue and/or chikungunya cases
Aedes aegypti
Aedes albopictus
San Diego
Los Angeles
Kern
Tulare
Fresno Madera
San Mateo
Imperial
California, USA
No reported cases 1-10 reported cases 11-20 reported cases >21 reported cases
Orange
Alameda
San Bernardino
Riverside
DengueandChikungunyaCasesinCaliforniaandLocaFonofInvasiveAedes
ImportedZikaintheUnitedStates,2015-2016
Noreportedcases
1-4reportedcases
5-9reportedcases
10-15reportedcases
>15reportedcases
DistrictofColumbia
N=107
ImportedZikainCalifornia2013-2016Year CDCFinal
ConfirmedCases*CDCPreliminaryPosiEveCases*
2013 1 NA
2014 3 NA
2015 4 0
2016 6 0
• All14ZikacasesreportedtodatehavetraveledtoaregionwithaknownZikaoutbreakatFmeoftravel
• Travelcountriesinclude:FrenchPolynesia,CookIslands,EasterIsland,KiribaF,ElSalvador,HaiF,Colombia,MexicoandHonduras
• Ofthe10casesin2015-2016,5wereresidentsofcounFeswithinvasiveAedes
• 8werepotenFallyviremicwhileinCalifornia
*CDPHhasreceivedthefinalwriSenlabreportfromCDC**CDPHhasreceivedpreliminarynoFficaFonofaposiFvecasefromCDC
FactorsMiFgaFngDengue,ChikungunyaandZikaTransmissioninCalifornia
• RelaFvelyshortviremia(average5-7days)• HousingcondiFonsandlifestylesminimizevector-humancontact• VectordistribuFonandlongevityisvariableanduneven• Vectordensityneededfortransmissionmaynotbehighenough• ComprehensivemosquitocontrolprogramsinCalifornia
• Riskoflocaldengue,chikungunyaorZikatransmissionislow
• NolocallyacquiredinfecFonshavebeendocumentedinCalifornia
• ThedetecFonofAedesaegyp*andAedesalbopictusandviremictravelersinthesameareaisapublichealthconcern
– Climatechange/DroughtmayimpactdistribuFon/abundanceofvectorbasedonhumanresponse
• EnhancedsurveillanceofbothmosquitoesandcasepaFentsisnecessarytoreduceriskofautochthonoustransmission
Conclusion
CaliforniaDepartmentofPublicHealth(CDPH)hSps://www.cdph.ca.gov/HealthInfo/discond/Pages/Zika.aspx
CentersforDiseaseControlandPrevenFon(CDC)hSp://www.cdc.gov/zika/index.html
PanAmericanHealthOrganizaFon(PAHO)hSp://www.paho.org/hq/index.php?opFon=com_topics&view=arFcle&id=427&Itemid=41484&lang=en#
CharseyColePorse,PhD,MPHCaliforniaDepartmentofPublicHealth,Vector-BorneDiseaseSecFon
MoreInformaFon
CaliforniahasseveralendemicFck-bornepathogensinRickeSsialesorder
RickeSsialdiseasescalled,“spoSedfevergroup”becauserashesaretypicallyseenwithinfecFonswiththesebacteria
• Clinical:– Nonspecific(canbedifficulttodiagnose)– Fever,headache,nausea,muscleaches2-14daysa}erFckbite– Rashdevelops3-5daysa}erfever– DecreasedcloLngcellsleadingtoseverecomplicaFons:Acute
respiratorydistresssyndrome(ARDS),abdominalpain(leadingtosurgery),neurologicorbleedingdisorders,lossofcirculaFon(gangrene)
– Casefatalityreportsrangingfrom5-90%
48
RMSFinHumans
• Diagnosis:– Serology:RisinganFbodyFters(4Xchangeinacuteandconvalescent
samples).IFAorELISAtests.– PCR,immunohistochemicalstainingofFssue,culture:(Fssuesdifficultto
obtain)
• Treatment:Doxycycline– adultsandchildren– Cannotwaitfordiagnosis–musttreatonsuspicion
49
RMSFinHumans
LifecycleofRickeCsiarickeCsii
RockyMountainwoodEckDermacentorandersoni
AmericanDogTickDermacentorvariabilis
• Mammalreservoirbut…
• Tickmaybebothreservoirandvector
• RarelyfindagentintheFck
RockyMountainSpoSedFever,Arizona
• 2002-2004:11confirmedcasesofRMSFidenFfiedinclosegeographicareainArizona
• NoDermacentorsppFcksfoundinarea• HomesandareasaroundhomesinfestedwithbrowndogFcks;many
free-roamingdogsinarea• R.ricke9siadetectedmolecularlyandculturedfromareaFcks• FirstEmebrowndogEckimplicatedasvectorforRMSFinN.
America
RMSFResponse:2004-2005SHORTTERM
• EducaFonforresidents&clinicians• Tickcontrolondogs• Pestcontrolaroundhomes• Communityclean-upLONGTERM
• Animalcontrolprogram• Sustainedvectorcontrol• Structuralchangestohomes–skirFng• Clean-upcampaign:TribalMembersandothersTeam:CDC,HIS,Tribes,ADHS,ORKIN®,WATSONIANS,USDA,Army–Ft.Huachuca
53
TickControlforDogs:AnimalServicesAgencyCoordinaFon
• USDA,Army,CDC,IHS&ADHS
• Zodiak®Eckcollars–(propoxur–3monthresidual)wereplacedon1,000’sofdogs(est.70%+coverage)
• Also,spot-ontreatments&sprays
54
RockyMountainSpoSedFever,Mexico
• UrbanoutbreakofRMSFinMexicali,Mexico,2009
• BrowndogFck-associated• >1200suspectcases,217confirmed
• 6deaths(2.3%)amongconfirmedcases
56
BrowndogFckhabitat,Mexico
hSps://www.epa.gov/sites/producFon/files/2016-02/documents/rmsf_on_the_border_where_children_contagion_and_climate_converge.pdf
AredogsinCaliforniaAffected?
• DogsareacommonFckhostforR.ricke9siiFck-vectors.Theycangetill-evendie-frominfecFonswithR.ricke9sii.
• ReportsintheliteratureofconcomitantinfecFonofownersandtheirdogs,suggesFngacommonexposure
• AnecdotalreportsofRMSFinCAdogs
Findings• OnJuly26,2005,morethan200Rh.sanguineusFckswerecollectedatthesiteinRiverside
• R.ricke9siiDNAwasdetectedin1of62(1.6%)adultRh.sanguineusFcksbyCDC(differentfromthoseisolatedfromMontanaandArizona.)
Results
• 338completedresponses• PredominatelysmallanimalpracFcesthoughafewmixedandexoFc-mixedpracFcesalsoresponded.
• PracFcesizerangedfrom5-50,000dogvisitsperyear(median2500dogvisits).
1
2-10
11-20 21-41
Number of responses (n=338)
County # Reported RMSF Cases
Orange 6
San Diego 5
Contra Costa 3
San Mateo 3
Alameda 2
Calaveras 1
Kern 1
Los Angeles 1
Riverside 1
Sacramento 1
Santa Barbara 1
Total 25
64
RMSF diagnosed in Californian dogs, CDPH Survey, 2007
ClinicalPresentaFon
Clinical Sign Number (percentage) n=25
Fever 17 (68%)
Other* 11 (44%)
Multiple painful joints 11 (44%)
tiny hemorrhages on gums, mucous membranes
4 (16%)
Abdominal Pain 3 (12%)
Edema (swelling) 2 (8%)
*Tiredness most common “other” sign
Small number of clinical cases precludes statistical comparison, however, note that a large percentage of clinics with RMSF dogs reported high exposure in their general practice to the brown dog tick, followed by the American dog tick and the western black-legged tick when compared to all practices.
Comparison of reported tick species between veterinary practices with and without RMSF K9 cases
0
10
20
30
40
50
60
70
80
90
Brow n dogtick
Unknow nspp.
Americandog tick
None torare tick
Westernblack-
legged tick
Pacif icCoast tick
Rocky MtnWood tick
Lone Startick
Winter tick
Tick Species
Perc
enta
ge o
f pra
ctic
es Practices with NO RMSF (n=321)
Practices with RMSF (n=17)
“DoesSpotgetSpots?”Conclusions
• RMSFisrareindogsinCalifornia• Largenumberofcasesreportedfromurbanareasandwithno
travelhistorysupportsideathatRMSFecologyhaschangedoverthepast50years.
• Spotdoesgetspots,thoughrarityofdiseasebothinhumansanddogsandcomplexityofsurveillanceprecludesusingcaninesasregular“senFnel”forhumandisease.
CoulddogsinSouthernCaliforniabeinfectedwithR.rickeCsiiand/orinfestedwithinfectedbrowndogEcks?(CDC,CDPHandImperialCo.DOHstudy)EstablishedTwoSitesforDogSurveillance
• CityAnimalShelterinCalexico
• CountyAnimalShelterinEl
Centro
Results
• 116dogsexamined(45inCalexicoand71inElCentro)March-April2009
• Ticksfoundon35(30%)dogs(16inCalexicoand19inElCentro)
• Overall,200Fckswerecollected(111females,87males,and2nymphs)andallwereidenFfiedasRh.sanguineus
• PCRtesFngresultsshowedthatonefemaleFckwaspresumpFvelyposiFveforrickeSsialDNAbutspecies(orstrain)wasnotconfirmed
Conclusions
• Rh.sanguineusinfestaFonondogsinImperialCo.ismoreheavierthaniniFallythoughtandtheFckscanbepotenFallyrelocatedintoneighboringareas
• LackofR.ricke9siidetecFoninFckssuggestedthattheriskofRMSFintheareaisminimalattheFme
• AcFveFcksurveillanceandcontroloffree-roamingdogsareimportantaspectsforkeepingtheriskofRMSFbelowepidemicthresholds
2013• Resident,Fresnocounty• PresentedlateDecember2012tolocalEDwithfever,headache,muscleaches,rashonwrist,leg,andtorso.
• PaFentsuccumbedtoillness• OrganFssuestestedposiFvebyimmuno-histochemistryandPCRatCDC
• PaFenthadhistoryofvisiFnglocalruralCaliforniaareasoneweekprecedingdiseaseonset
• 36Dermacentorspp.FcksrecoveredfromoneareapaFentvisited;alltestednegaFve
2014• Resident,ImperialCounty• PresentedMaytolocalEDwithfever,nausea,vomiFng
• Duringcourseofillness,RMSFserologictestsshowedrisingFter(confirmedcase)
• PaFentcouldnotrecoveranddiedlateJune• PaFent’smothertraveledwithdogsacrossMexicanborder
• BrowndogFckspresentinandaroundhome;1/95posiFveforR.ricke9sii
• NewsreleaseissuedbyImperialCountya}erpaFent’sdeathtoincreaseawarenessofdisease,importanceoftreaFngFckinfestaFons
LifecycleofRickeCsiarickeCsiiTickVectorsinCalifornia
RockyMountainwoodEckDermacentorandersoni
NaturalareasnortheasternCalifornia
PacificCoastEck,CADermacentoroccidentalis
Humid,naturalareasthroughoutCalifornia
BrownDogTickRipicephalussanguineus
UrbanareasandnaturalareasthroughoutCalifornia
AmericanDogTickDermacentorvariabilis
NaturalareasthroughoutCalifornia
• Mammalreservoirbut…
• Tickmaybebothreservoirandvector
• RarelyfindagentintheFck
AnotherTicktoA
ddto
theStory…….
RockyMountainSpoLedFeverinHumansin
California2002-2014
CountyofresidenceofconfirmedRMSFhumancases
aTravelhistoryoutofcountybFatality
Since2002therehavebeen13confirmedcasesofRMSFreportedinCalifornia
2002,2014a,b
2004
2003
2002
2010
2011
2012a
2013a,b
2014a2014b
2012a
2011
Demographics,RMSFConfirmedandProbableReportedCases,1997–2014
Frequency Percent 95%CILower 95%CIUpper
Female 24 43.6% 30.3% 57.7%
Male 31 56.3% 42.3% 69.7%
TOTAL 55
North/SouthDistribuFonCountyofResidence,RMSFCasePaFents
ProporEonofcase-paEents(confirmedandprobable)whosecountyofresidenceisinNorth/SouthCA,byyearofsymptomonset,p<0.05.
Southern California Northern California
FrequencyofHispanic/LaEnoethnicityselfreported,byyear
-Trend(notsignificant)towardgreaterfrequencyofHispanic/LaFnoethnicity,(N=39)ChiSquared(MxN)p>0.05
NonHispanic/NonLatino Hispanic/Latino
ImpactonMessagingForbothFckvectors:
• AwarenessofDisease• AvoidFckbites
– RemoveFckspromptlyandcorrectly– InspectpetsandremoveFcks
• Seephysicianifdevelopfever,headacheorrasha}erFckbite
• Takepettoveterinarianifitdevelopsfever,lethargya}erFck-bite
ImpactonMessaging:Dermacentorspp
• AwarenessofRMSFDisease– Moregeneralapproach– Targetaudience(California):outdoor
enthusiasts,ruralresidents• AvoidFckbites
– Stayinmiddleoftrails– WheninFckhabitat:wearrepellents
containingDEETorclothingtreatedwithpermethrin
– RemoveFckspromptlyandcorrectly• Seephysicianifdevelopfever,headache
orrasha}erFckbite• Takepettoveterinarianifitdevelops
fever,lethargya}erFck-bite
ImpactonMessagingBrownDogTick(Rhipicephalussanguineus)
• AwarenessofDisease– Mayneedcommunityapproach
• Localresident/physicianawareness• AvoidFckbites
– Hostandenvironmentalissue• KeepdogsonFckprevenFon(collars,vet-
approvedproduct)• Environmentaltreatmentmayberequired
bylicensedpest-controloperator(mulFpletreatmentssomeFmesnecessary)
• CleanupyardtoremovedebriswhereFckscanhide
– RemoveFckspromptlyandsafely– InspectpetsandremoveFcks
• Seephysicianifdevelopfever,headacheorrasha}erFckbite
• Takepettoveterinarianifitdevelopsfever,lethargya}erFck-bite
Source:Az.Dept.ofHealthServices
Conclusions:re-emergingRicke9sia
• NewlyidenFfiedFckvectorforCaliforniademonstrated
• PotenFalsouthtonorthintroducFon• ImpactshealtheducaFonmessaging• Onehealthapproach(canine/human)usefulforsurveillanceandcontrol– Sustainedsurveillance/controleffortneededforbrowndogFck-transmiSedRMSF
FinalThoughtsonDiseasesatCalifornia’sDoor
THEMONSTERRETURNSPeterMcCarty
• Morepandemicslikelytobeseen“knocking”atthedoor
• Airtravel/massiverapidmovementofpeople• Increasedincomedisparitywillcontributetoemergence
• ClimatechangemayinfluencevectorsaswellassocialstructurethatwillencouragemoremigraFon
• PublichealthinfrastructureallowsforearlydetecFonandplanningforintroduceddisease
• Ongoing,systemaFcsurveillance• Buildonpreviousexperience(e.g.WestNilevirus)andmulF-agency(One-Health)collaboraFon
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