10/12/2015

1

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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2

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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3

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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5

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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8

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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9

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

10/12/2015

11

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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18

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

10/12/2015

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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20

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)

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Animal bites by Species and Age group

affected, Oregon, 2013

0

50

100

150

200

250

0-9 10's 20's 30's 40's 50's 60's 70's 80's

Dog Cat Bat

End