11/2/2015

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Incidence of Infectious Disease in Florida: Perspectives from the Division of Disease

Control and Health Protection

Anna M. Likos, MD, MPHState Epidemiologist and Director

Division of Disease Control and Health ProtectionFlorida Department of Health

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Objectives

A little bit about the DivisionDisease Control and Health Protection

Review Infectious Disease Threats in FloridaNew Bugs

Old “Friends”A couple of commercialsGlobal Health News Report

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

NEW BUGS

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

EbolaSept 30, 2014

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Florida’s Response

Oct 6, 2014 Incident Management TeamTwice-daily calls, state and local partners

Daily calls with County Health DepartmentsFielded lots of calls

Technical assistance for testingFlorida-specific guidance

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

CDC Response

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EPIXUpdate@cdc.govImportant: DGMQ Enhanced Ebola Entry Screening: Contact List for Flight UAL 0951 on 08/15/2015 for FL

EPIXUpdate@cdc.govImportant: Interstate Movement Notification-Active Monitoring for Ebola -- NYC to FL, Transfer Depart Date: 08/16/2015

Airport Monitoring

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Florida’s Response

Oct 25, 2015: Executive Order 2014-280Establishes Ebola Virus Disease Response Protocol

Twice a day, face to face, monitoring of travelers

As of Oct 27:Total of 747 travelers have been monitoredCurrently monitoring: 17

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Florida’s ResponseLaboratory Testing

Miami Laboratory: 1 of first 11 labs nationally with EVD testing capability

Now all 3 BPHL labs can test

Tested total of 4 individuals 2 prior to monitoring: Negative

2 after monitoring began: Negative

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

West Africa Today

Week Oct 11-18: 3 cases reported3 in Guinea, 0 in Sierra Leone

5th consecutive week with 0 cases in Sierra Leone

Total of 28,476 cases

11,298 Deaths

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Chikungunya and Dengue

Chikungunya: “Man who walks stooped over”“All bent up”

NOT: An illness of chickens

BUT: “Chicken gumbo” is close enoughAND: It could be worse:

O’nyong nyong virus

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Patient StoryPatient Story� 68-year-old Puerto Rican general surgeon and medical school

professor� History of mosquito bites� 5 days later developed 102°F fever � High fever for 3 days � Fever subsided 1-2 days� High fever recurred along with severe, migratory joint pain –

hands, wrists, shoulder, feet, hips � Disrupted sleep: awakened by fever and stabbing joint pains � Severe symptoms: Trouble walking due to swollen feet –

couldn’t wear shoes and couldn’t work. Cancelled vacation. � Lasting symptoms: 10 weeks later still had joint pain

� 6 months later – still mildly symptomatic

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Arthritis – swollen joints

What does it look like?

Rash covering torso and extremities Blistering rash

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Chikungunya Virus Disease“That which bends over”

• Mosquito-borne viral disease characterized by acute onset of fever and severe pain in multiple joints

• Mortality low but extremely debilitating • Most infected persons become symptomatic• No antiviral therapy

• Treatment is symptomatic

• Lifelong immunity following infection• No licensed vaccines• Prevention relies on avoidance of mosquito bites and

mosquito control

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Diagnostic TestingPCR and Serology

• Florida DOH BPHL• Tampa and Jacksonville

• CA, NY State Labs • CDC Arboviral Diseases Branch • Single commercial laboratory

• Focus Diagnostics

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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2014: 510 Imported Cases12 Locally Transmitted Cases (2.3% of total cases in 2014)

4 Counties: Broward (1), Miami-Dade (2), Palm Beach (5), St Lucie (4)2015: 65 as of Oct 24, 2015

0 Locally Transmitted Cases so far

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Chikungunya virus Disease Cases Reported by Territory — United States, 2014

(as of February 10, 2015)

*30,983 suspected cases also reported to Puerto Rico Dept of Health†1,321 suspected cases also reported to U.S.VI Dept of Health

Note: 99.2% of Puerto Rican and 94.7% of U.S.VI cases are locally-transmitted cases

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Why the Difference?

• Air Conditioning• Screened Windows and Doors

• ? Due to vector differences• Aedes albopictus is less efficient at

transmission

• Close working relationship with Mosquito Control at the county level

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Chikungunya and Dengue

Dual testing indicated

2014: 17 cases of co-infection 2015: 3 cases of co-infection so far

80% found by BPHL labsNo dual infections were local transmissions

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Dengue

2014: 83 imported cases7 local transmissions

3 in a single householdsplit into 3 living units

2015: 47 imported cases0 local transmission so far

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Old Bugs

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Measles

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Measles in Florida2014: No Cases

2015: 5 imported cases in non-resident travelers

5 local cases:3 households in 2 counties

Temporally linked

Identical genotypeNo epidemiological linkage

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Value of ESSENCEIn outbreak setting:

Use broader search terms

Identify additional casesInform County Health Departments

Calls made to rule in/out cases

Measles: No additional cases detected

Chikungunya: Two additional cases found

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Rubella2014: None

2015: 1 case (first case since 2008)Imported from Phillipines

1,338 Contacts identified620 reached in person

All received notification

No additional cases found

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Meningococcal Disease

2014: 50 Cases~ 7 Deaths

2015: 16 cases

~ 5 DeathsChild in Detention HomeNeed for vaccination in group settings

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Neisseria meningitidis W135

Florida: Different from rest of USPredominant serogroup is W135

Mostly in south-east FloridaSeen sporadically throughout state

Most isolates share PFGE patternWorking with UF for whole genome sequencingIsolates very closely related

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Vibrio vulnificus

2014: 32 Cases7 Deaths

2015: 40 cases

16 DeathsMajority are wound relatedImmunocompromised individuals

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

The Vibrios2004-2013: Vibrio vulnificus

~25% were foodborne

~50% were wound associated~25% either multiple causes or unknown

2004-2013: All VibriosFoodborne associated with less fatal infections

(V. mimicus, V. hollisae, V. fluvialis)

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Primary Amoebic Meningo-encephalitis

2014: 1 case Naegleria fowleri1 death

June 19-27: Costa Rican resort

June 27: Onset symptoms June 29: Hospitalized

July 2: Request for MiltefosineExpired

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Primary Amoebic Meningo-encephalitis

2015: 1 case Acanthomoeba66 year old male, multiple co-morbidities14 year hx ulcerative colitis; recent dx of HIV

6/22-6/25: Hospitalized in ChicagoAseptic Meningitis

6/28: Presented to Shands with HA, fever7/3: ExpiredSource is unknown

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Carbapenem-Resistant Enterococcus

March, 2015: CRE linked to duodenoscopes

Data from historical outbreak in Florida

Today’s Emerging Pathogens:Antimicrobial Resistant Organisms

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Salmonella

2014: 6,019 confirmed and probable cases37 multi-state investigations

2015: 4,723 cases28 multi-state investigations

Forward specimens to BPHL for PFGE and serotyping

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Legionella

2014: 280 confirmed cases4 outbreaks

2015: 253 confirmed cases

5 outbreaksFlorida non-residents are not included in

these numbers

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Food and WaterborneComplaints and Cases

2014: 2,165 complaints

104 outbreaks identified1,311 cases associated with outbreaks

2015: 1,936 complaints

70 outbreaks587 cases

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Rabies

2014: 2201 Animals tested 91 Positive

895 Cats572 Dogs

Cats: more frequent vectors of rabies than dogs– Lack of vaccination– Cat food left outside attracts raccoons

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

2015: >1712 Animals tested60 Positive

29 Racoons

14 Bats7 Foxes6 Cats

2 Goats (frirst time in 57 years)

1 Dog

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Rabies

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

ArbovirusesSt Louis Encephalitis2014: 2 cases (first since 2003)

2015: 0 cases West Nile Virus2014: 16 cases (11 neuroinvasive)

4 asymptomatic blood donors2015: 9 human cases (9 neuroinvasive)

1 asymptomatic blood donors

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Brucellosis2014: 3 Cases in pig hunters

– Brucella suis

2015: 8 cases (confirmed or probable)1. 7/8 have links to swine

2. Positive Blood Donor– Symptomatic– Spouse of a pig hunter

3. 2 members of same household positive– 1 year apart

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Bugs and Tatoos

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Tattoos

Early May, 2015:– Rash-like illness in 3 recipients of tattoos

from Studio X in Miami, same artist– Rash associated with grey color – Investigation initiated

394 clients contacted

38 cases found3 artists

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Tattoos

Collaborative investigation with FDA & DoH

FDA:– Opened and unopened bottles of ink– Tap water

DoH:– Clinical specimens– Provided treatment

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Non-tuberculous Mycobacteria

Culture Results:– Variety of Mycobacteria

• Opened ink bottles: M. abscessus• Unopened bottles: M. chaeloni (unopened)• Other bacteria found as well

– Tap water: M. abscessus

Labs are doing PFGE

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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Further Actions

Manufacturer not producing ink

Follow up investigation to characterize clinical course

Additional case finding (clients from last May)

Genotyping

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

HIV Infection Cases and Rates*,by Year of Report, 2005-2014, Florida

Year Rate05 38.706 36.507 37.008 41.909 29.510 2611 26.412 23.713 28.314 31.4

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

HIV

2014: 6019 Cases diagnosedMiami-Dade: 23.44%

Broward: 16.5%4 Counties: Between 5 and 8.36%

13 Counties: Between 1 and 5%43 Counties: Less than 1%5 Counties: No identified cases

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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My Personal Leadership Vision

Integrated Public HealthMeans

Working Together

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Healthiest Weight

65% Floridians at unhealthy weight1 out of 3 kids considered obese

Chronic Disease due to obesity costs– $34 billion over next 17 years

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

Healthiest Weight Strategies

1. Increase opportunities for physical activity2. Make healthy food available everywhere

3. Promote health in the worksite4. Strengthen schools as the heart of health

5. Market what matters for a healthy life

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

When Everything is Crashing Around You

Stay CalmAnd

Get a Flu Shot

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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Global Health News

To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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To Cure DiseaseIs Glory

To Prevent DiseaseIs Victory

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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.

Division of Disease Control and Health Protection

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Contact Information:

Anna M. Likos, MD, MPHState Epidemiologist and Director

Division of Disease Control and Health ProtectionEmail: Anna.Likos@FLHealth.gov

Phone: 850-245-4411