WHAT THE HEALTH DEPARTMENT DOES WITH THOSE REPORTS

AND WHAT’S HAPPENING NOW

Eric McDonald, MD, MPH, FACEP Medical Director, Epidemiology Program

Public Health Services

San Diego County Health & Human Services Agency

AAP Aedes to Zika Webinar

20 June 2018

Title 17, CA Code of Regulations

HOW TO REPORT

To report a communicable disease, you may contact the Epidemiology Program by phone at (619) 692-8499.

For urgent matters on evenings, weekends or holidays, dial (858) 565-5255 and ask for the epidemiologist on-call.

You can also download and print a Confidential Morbidity Report (CMR) form at http://www.sdepi.org and fax it to (858) 715-6458.

The levels of urgency for specific diseases and conditions are listed on the back of the CMR.

REPORT BY PHONE IMMEDIATELY SEE CDPH 110A FOR COMPLETE LIST

Anthrax

Botulism

Brucellosis

Cholera

Ciguatera Fish Poisoning

Dengue

Diphtheria

Domoic Acid Poisoning

STEC & E. coli O:157

Flavivirus, undetermined

Hemolytic Uremic Syndrome

Novel influenza

Measles

Meningococcal Infections

Paralytic Shellfish Poisoning

Plague

Rabies

Scombroid Fish Poisoning

SARS

Shiga toxin

Smallpox

Tularemia

Viral hemorrhagic Fever (Ebola)

Yellow Fever

ZIka

Any Unusual Disease (MERS-CoV)

REPORT WITHIN ONE WORKING DAY SEE CDPH 110A FOR COMPLETE LIST

Ambiasis

Babesiosis

Campylobacteriosis

Chickenpox (outbreak,

hospitalization, death)

Chikungunya

Cryptosporidiosis

Encephalitis

Foodborne disease

Haemophilus influenza, invasive

(under 5 years of age)

Hantavirus

Hepatitis A

Listeriosis

Malaria

Meningitis, specify type

Pertussis

Polio

Psittacosis

Q Fever

Relapsing Fever

Salmonellosis

Shigellosis

Streptococcal infections

(outbreak)

Syphilis

Trichinosis

TB

Typhoid fever

Vibrio infections

West Nile Virus

Yersiniosis

REPORT WITHIN ONE WEEK SEE CDPH 110A FOR COMPLETE LIST

Brucellosis

Cyclosporiasis

Mumps

Rickettsial diseases

Rocky Mountain Spotted Fever

Rubella (German Measles)

Tetanus

But please contact the health department faster!

Sign up for health alerts at CAHAN San Diego

Sign up for monthly reports at EpiDiv.HHSA@sdcounty.ca.gov

WHAT’S UP NOW?

International infectious disease threats

Ebola

MERS

Aedes associated diseases

Vectorborne illnesses in San Diego

West Nile virus

Murine typhus

Others

Vaccine preventable diseases in San Diego

Influenza (!)

Hepatitis A

Pertussis

Mumps

EBOLA

Image Credit: CDC

Zoonotic niche map of Ebola virus disease in Africa

Map source: Pigott, et al. 2016.

https://elifesciences.org/articles/16412

2018 Outbreak

Source: WHO. Downloaded 6/19/18 from: EVD DRC SitRep #11

Epidemic curve for Ebola virus disease outbreak,

Democratic Republic of the Congo, 17 June 2018 (n=52)

Source: WHO. Downloaded 6/19/18 from: EVD DRC SitRep #11

38 confirmed

14 probable

10 suspect

62 total

Source: WHO. Downloaded 6/19/18 from: EVD DRC SitRep #11

Only a plane (or boat) ride away…

EBOLA

WHAT CAN YOU DO?

Obtain a TRAVEL HISTORY whenever patients present for

care with complaints in which a communicable disease is in

differential diagnosis

IDENTIFY ISOLATE INFORM

Be aware of current outbreaks.

Support your friendly neighborhood infection control

professionals

Sign up for updates at: WHO Emergency & Outbreak Bulletins

MERS-COV

Image Credit: CDC

Source: WHO. Downloaded 6/19/18 from:

http://www.emro.who.int/images/stories/csr/MERS-CoV_May_2018.pdf?ua=1

• Since April 2012, 2220 cases reported to WHO, including 790 deaths

• In 2018, KSA has reported 83 lab confirmed cases of MERS-CoV,

including 25 deaths.

Source: GHK CHP. Downloaded 6/19/18 from:

http://www.chp.gov.hk/files/pdf/distribution_of_mers_cases_en.pdf

MERS-COV

WHAT CAN YOU DO?

IDENTIFY ISOLATE INFORM

OBTAIN A TRAVEL HISTORY EARLY IN EVALUATION

Travel to affected area in last 2 weeks

Camel contact, healthcare contact

Be aware of the clinical spectrum of reported illness

Inform Epidemiology Program to facilitate testing

Three specimens needed (upper tract, lower tract, serum)

Specimens go to CDPH lab – 24 hour turn around

Counsel patients prior to travel to take precautions

AEDES DISEASES

Zika

Dengue

Chikungunya

Yellow Fever

Select Vectorborne Infections by Month

San Diego County, June 2017 – May 2018

Source: CDC. Downloaded 3/22/17 from

https://wwwnc.cdc.gov/travel/page/world-map-areas-with-zika

Where is Zika now?

Africa: Angola, Benin, Burkina-Faso, Burundi,

Cameroon, Cape Verde, Central African Republic,

Chad, Congo Congo-Brazzaville), Côte d’Ivoire,

Democratic Republic of the Congo (Congo-Kinshasa),

Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya,

Liberia, Mali, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan,

Sudan, Tanzania, Togo, Uganda

Asia: Bangladesh, Burma (Myanmar), Cambodia, India, Indonesia, Laos,

Malaysia, Maldives, Philippines, Singapore, Thailand, Vietnam

Caribbean: Anguilla, Antigua and Barbuda, Aruba, Barbados, Bonaire, British

Virgin Islands, Cuba, Curaçao, Dominica, Dominican Republic, Grenada, Haiti,

Jamaica, Martinique, Montserrat, Puerto Rico, Saba, Saint Kitts and Nevis, Saint

Lucia, Saint Martin, Saint Vincent and the Grenadines, Sint Eustatius, Sint

Maarten, Trinidad and Tobago, Turks and Caicos Islands, US Virgin Islands

North/Central/South America: Argentina, Belize, Bolivia, Brazil, Colombia,

Costa Rica, Ecuador, El Salvador, French Guiana, Guatemala, Guyana,

Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Venezuela

Pacific Islands: Fiji, Papua New Guinea, Samoa, Solomon Islands, Tonga

AREAS WITH

ZIKA RISK

American Samoa (4/17)

Bahamas (2/18)

Cayman Islands (7/17)

Cook Islands (3/17)

Guadeloupe (6/17)

French Polynesia (3/17)

Ilsa de Pascua, Chile (3/17)

AREAS WITH

INTERRUPTED

TRANSMISSION

Travelers’ Health

Marshall Islands (1/18)

Martinique (6/17)

Micronesia (11/17)

New Caledonia (3/17)

Palau (11/17)

Saint Barthelemy (5/17)

Vanuata (3/17)

2015 Total : US States = 62 + 0 , US Territories = 10 + 0

Source: CDC. Downloaded 6/4/18 from:

https://www.cdc.gov/zika/reporting/2015-case-counts.html

13

2016 Total : US States = 5,168 + 38 , US Territories = 36,512 + 325

Source: CDC. Downloaded 6/4/18 from:

https://www.cdc.gov/zika/reporting/2016-case-counts.html

496

Source: CDC. Downloaded 6/20/18 from:

https://www.cdc.gov/zika/reporting/2017-case-counts.html

2017 Total as of 5/2/18: US States = 451 + 31 , US Territories = 666 + 6

126

Source: CDC. Downloaded 6/20/18 from:

https://www.cdc.gov/zika/reporting/2018-case-counts.html

2018 Total as of 6/6/18: US States = 20 + 1 , US Territories = 62 + 0

21

Map prepared on 6/20/18 using data from:

https://www.gob.mx/salud/acciones-y-programas/zika-informacion-relevante

and software on: http://diymaps.net/

Mexican States with Confirmed Local Transmission of Zika, 2015-2018

Total Confirmed

Autochthonous

Cases = 11,992

as of 6/11/18

1

Confirmed local transmission

No local transmission

Case count

3

55

84

182

336 950

2

684

1 801

1

459

297

502

27

68

528

17 285

225 2,101

514

375

821

94

388

1,299

887

5

Map prepared on 6/20/18 using data from:

https://www.gob.mx/salud/acciones-y-programas/zika-informacion-relevante

and software on: http://diymaps.net/

No local transmission

Case count

345

Mexican States with Confirmed Local Transmission of Zika, 2017

Case count 1

No local transmission

Confirmed local transmission

Total Confirmed

Autochthonous

Cases = 3,292

as of 6/11/18

3

60

22 107

274 108

2 1 653

493 614 15

8

2 15

4

134

6

106

78 18

27

22

5 3

196

415

Map prepared on 6/20/18 using data from:

https://www.gob.mx/salud/acciones-y-programas/zika-informacion-relevante

and software on: http://diymaps.net/

No local transmission

Case count

Mexican States with Confirmed Local Transmission of Zika, 2018

1

Total Confirmed

Autochthonous

Cases = 75

as of 6/11/18

4 5

6

27

4

8

1

1

2

1 8

Case count 1

No local transmission

Confirmed local transmission

5

1

Mexican States with Confirmed/Probable Cases of Dengue, 2017

Source: Secretaría de Salud. Map downloaded on 1/29/18:

https://www.gob.mx/cms/uploads/attachment/file/285237/Pano_dengue_sem_52_2017.pdf

Total Cases with

symptom onset in 2017

Confirmed= 14,138

Probable = 89,893

Total = 104,031

as of 1/2/18

Incidence per 100,000

of confirmed cases

Baja California

11 confirmed

161 probable

Mexican States with Confirmed/Probable Cases of Dengue, 2018

Source: Secretaría de Salud. Map downloaded on 6/20/18:

https://www.gob.mx/cms/uploads/attachment/file/335795/Pano_dengue_sem_23_2018.pdf

Incidence per 100,000

of confirmed cases

Baja California

0 confirmed

30 probable

Total Cases with

symptom onset in 2018

Confirmed= 886

Probable = 10,645

Total = 11,531

as of 6/11/18

Source: Secretaría de Salud. Map downloaded on 6/20/18:

https://www.gob.mx/cms/uploads/attachment/file/335795/Pano_dengue_sem_23_2018.pdf

Confirmed and Probable Dengue Cases in Mexico 2017, 2018

Epidemiology Curve by Week

Total Zika referrals: 4,191

Confirmed/Probable Zika cases: 108

103 travel, 2 sexual, 3 congenital

Confirmed cases in pregnant women: 15

Cases ruled out for Zika: 3,982

Cases pending lab results or submission: 69

Cases pending lab results in pregnant women: 37

Cases referred to Vector Control: 449

ZIKA REFERRALS

IN SAN DIEGO 2015-18

Prevent – no standing water, dump once a week

Protect – use repellants with DEET, IR3535, oil of lemon

eucalytus, picaridin (permethrin in clothes)

Report - dead birds, mosquito breeding sites, green

pools, and day biting mosquitoes

www.sdvector.com

Meningococcal Disease

Overall, 2,002 cases of

WNV disease in people

were reported to CDC.

1,339 (67%) were classified

as WNND and 663 (33%)

were non-WNND.

WEST NILE VIRUS – US 2017

Downloaded 5/25/18 from http://diseasemaps.usgs.gov/mapviewer/

554 human cases from 27

counties have tested

positive for WNV in 2017.

44 WNV-related fatalities

were reported

2 confirmed WNV cases in

San Diego, 0 deaths

WEST NILE VIRUS – CA 2017

Source: CDPH http://www.westnile.ca.gov/

4 human cases from 3

counties have tested

positive for WNV in 2018.

0 WNV-related fatalities

have been reported

0 confirmed WNV cases in

San Diego this year,

0 deaths, 0 cases pending

WEST NILE VIRUS – CA 2018

Source: CDPH http://www.westnile.ca.gov/

Downloaded 6/20/18

www.sdvector.com

May 4, 2018

https://www.countynewscenter.com/county-set-to-conduct-first-larvicide-drop-of-2018-mosquito-season/

WHAT CAN YOU DO?

Keep WNV in the differential when patients present with:

Encephalitis

Aseptic meningitis

Acute flaccid paralysis

Atypical Guillain-Barré Syndrome (GBS)

Transverse myelitis

Promote prevention messages Stay indoors at dawn and dusk

Avoid mosquito bites; wear long sleeves, long pants, and socks

when outdoors

Use mosquito repellent

Keep screens on windows and doors in good repair

Identify and eliminate standing water sources that can be mosquito-

breeding areas around the home

WEST NILE VIRUS

MURINE TYPHUS

Photo: CDC

MURINE TYPHUS

Acute febrile illness caused by Rickettsia typhi, is distributed worldwide.

Mainly transmitted by fleas of rodents, associated with cities and ports

where urban rats (Rattus rattus and Rattus norvegicus) are abundant.

In the US, cases are concentrated in TX and CA.

Contrary to the classic rat-flea-rat cycle,

most important reservoirs of infection

in these areas are opossums and cats.

Cat flea, Ctenocephalides felis,

has been identified as principal vector.

Photo: CDC

MURINE TYPHUS

TX: murine typhus cases occur in spring and summer.

CA: cases have been documented in summer and fall.

Most patients present with fever, and many have rash

and headache.

Studies reporting clinical findings

associated with murine typhus.

Rachel Civen, and Van Ngo Clin Infect Dis. 2008;46:913-918

© 2008 by the Infectious Diseases Society of America

MURINE TYPHUS

Serologic testing with the indirect immuno-

fluorescence assay is the preferred diagnostic method.

(Do this through PHL!)

Doxycycline is the antibiotic of choice and has been

shown to shorten the course of illness.

June 1, 2018

MURINE TYPHUS

In addition to using flea-control products on pets, the

public can also protect themselves and their pets by

keeping rodents and animals away from their homes,

workplaces and recreational areas.

Remove brush, rock piles, junk, cluttered firewood and

food supplies — especially pet food.

Use Environmental Protection Agency (EPA)-registered insect

repellent labeled for use against fleas if they think they

could be exposed to fleas during activities such as

camping, hiking, or working outdoors.

Permethrin can be used to treat clothing and outdoor

gear, but it should not be used on skin

WHAT CAN YOU DO?

Keep murine typhus in the differential in patients with

persistent fever of unknown etiology

Ask about animal exposure and flea bites

Promote prevention messages

Flea control for pets

Remove food sources for opossums, rats around

the home

MURINE TYPHUS

TULAREMIA

Photo credit: CDC

Photos: COSD DEH

HANTAVIRUS

(Sin nombre virus)

Most recent find

June 12, 2017

near

Warner Springs

VACCINE PREVENTABLE ILLNESSES

Photo credit: San Diego Union Tribune

20,757

341 300 ICU CASES

DEATHS

TOTAL REPORTED

INFLUENZA CASES

INFLUENZA 2017/18

117 OUTBREAKS

Preliminary Results as of 4/30/18

Data Source: Reported Influenza Case Reports

Prepared by County of San Diego, Health & Human Services Agency,

Public Health Services, Epidemiology and Immunization Services Branch

63.2%

0.3%

2.9%

32.5%

0.2%0.1% 0.9%

Influenza A

Influenza A (H1N1)pdm09

Influenza A (H3) Seasonal

Influenza B

Influenza B/Yamagata

Influenza B/Victoria

Influenza A/B

2016 – 6

2017 – 571

2018 – 12

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 6/12/18

Outbreak-associated Hepatitis A Cases by Onset Week

11/1/2016 – 6/4/2018, N = 589*

PHE Declared

CAHAN PHE Ended

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology & Immunization Services, 6/12/18

For more information contact:

Eric C. McDonald, MD, MPH, FACEP Medical Director, Epidemiology and Immunizations Services

Public Health Services

County of San Diego Health and Human Services Agency

3851 Rosecrans Street (MS-P578)

San Diego, CA 92110

Phone: (619) 692-8436

Fax: (858) 715-6458