zoonotic disease updates · anthrax • caused by . bacillus anthracis, a spore-forming gram...
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Zoonotic Disease Updates Epidemiology and LaboratoryCapacity Conference – Sept. 2019 DSHS Zoonosis Control Branch
Updates and Highlights
•Arboviral diseases Aedes-transmitted
arboviruses 2018 summary 2019 updates
•Anthrax•Brucellosis•Malaria•Lyme disease
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Aedes-transmitted Arboviruses
Zika, chikungunya, and dengue • Commonalities: transmission, symptomology, regions
of endemicity• Zika & chikungunya: recent emergence followed by
sharp downturn• Sporadic, seasonal risk of local vector-borne
transmission in South Texas
• 2013: dengue outbreak inLRGV & across border
• 2015: isolated chikungunyacase in Cameron County
• 2016 & 2017: sporadic Zikadisease cases in Hidalgo,Cameron counties
• 2018: isolated dengue case inStarr County Image Source: https://phil.cdc.gov/phil/details.asp
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oun ty with St lo uis Encephalitis Virus Activity
ounty with West N lie Virus Activity
I I I I 11 I ri I I I I I I I j I I I I ii I I I I I 0 2S 50 '100 150, 200 2SO 1,H e-.s
*Indicated by an arbovirus- posit ive bird, mosquito pool, senfnel chicken, horse, or human (disease case or presumptive viremic donor). Excludes imported cases of chikungunya, dengu,e, Zika, and other arbovirnses. Absence of reported activity from counties may be due to absence of a surveil lance program for non-human cases ..
Texas Counties Reporting Arbovirus Activity* in Any
Species, 2018
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Chikungunya, 7, 40/o
Zika, 4, 20/o
2018 Human Arbovirus Activity
• Total human arbovirus disease cases: 180Notably: • One locally-acquired
dengue case in StarrCounty duringoutbreak in northernMexico
• Globally decreasedZika activity
• Trend of low WestNile disease casetotals continuessince large 2012outbreak (with over1,800 cases)
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2019 Updates (Provisional)
Dengue: 23 cases (as of 9/20/19) • Acquisition of infection demonstrates widespreadglobal risk
• Strong increase in dengue activity in CentralAmerica and southern Mexico
Image Source: PAHO/WHO, www.reliefweb.int
Dengue Cases Reported in Texas, 2019, as of 9/20/19, N=23
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20
18
16
8
6
4
2
0
2017
- 2018
2019
~~~~~~~~~~~~~~~~~~~~~~~~~i~~~~~,~,:&~~~ MMWR Week of Onset
Human West Nile Disease Cases Reported in Texas, by MMWR Week of Onset, 2017-2019*
2019 Total*: 14
2019 Total*: 17
09/25/2019 DSHS ELC Conference 7 *2019 data is provisional and as of 9/20/19
2019 Updates (Provisional) Zika Disease: 1 case • Low transmission in Mexico, no current outbreaksworldwide; Texas case acquired in Philippines• 2018 Indian outbreak, South & Southeast Asia andCentral Africa spread
• US Zika Infant & Pregnancy Registry endedenrollment in March 2018
• Antibody testing andcross-reactivity withdengue continues tocause issues
Chikungunya: 6 cases • Similar global risk to
dengue
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Case Definition Updates Yellow Fever • Specified clinical criteria• Epi-linkage included alongside testing and clinical
criteria in probable definition• Brought lab criteria up to date:
• Removal of irrelevant diagnostic methods (CF, IFA,HI)
• IgM with PRNT confirmation included• Exclusion of those with a history of yellow fever
vaccination in the 30 days prior to onset in most cases
Arbovirus (includes West Nile, others) • More nuanced consideration of cross-reactivity in
interpretation of PRNT results
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Anthrax • Caused by Bacillus anthracis, a
spore-forming Gram positive rod• B. cereus expressing anthrax
toxins added to case definition• Humans are infected through
skin contact or inhalation• Suspected isolates sent to LRN
• **Labs
Anthrax is reportable upon suspicion** • Clinical diagnosis from
providers• Suspect samples at laboratories
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Updates to Case Definition • Additional confirmatory laboratory testing
• PCR positive from a LRN-validated test • Lethal factor testing (available at CDC)
• Probable case status, clinically compatible illness and • Epidemiological linkage to confirmed case or lab confirmed
exposure • Gram stain positive rods • Positive result from a CLIA-accredited laboratory
• Suspect case status for those with lab tests ordered • Can help LHDs to request records for clinically compatible
cases with no known epidemiological link to anthrax • Addition of B. cereus expressing anthrax toxin to case
definition • Historical cases among metal workers in Texas • Request to forward isolates from anthrax-like illness with
B. cereus identified • Fully virulent B. cereus biovar anthracis is a Select Agent
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Cases / County
~ 1-2
1111 3 - 5
1111 6-12
1111 13 - 16
1111 17 - 18
r---r
th r1 L
County reporting one or more culture-positive animal or human
Texas Counties with Laboratory-Confirmed Anthrax
2000 - 2019
*
*2019 data is provisional, as of 9/23/2019
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2019 Animal Outbreak • Anthrax is enzootic in area of Texas between Ozona,
Eagle Pass and Uvalde • Recent increase in positives from animals reported by
Texas Veterinary Medical Diagnostic Laboratory • As of September 23, 2019:
• 25 culture positives from five counties in southwestern Texas
• Exotic, domestic, and wild animals positive • Most reported positives since 2001 • Barriers to reporting
• Ranchers might be hesitant to test animals due to Texas Animal Health Commission quarantine
• Might be clinically diagnosed and not tested • Other positives on same ranch previously reported • Difficulty of getting to animals on large properties
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Cases/ County
C:J 2019 Outbreak
~ 1-2
1111 3-5
1111 6-12
1111 13 -1 6
1111 17 -1 8
County reporting one or more culture-positive animal or human
Texas Counties with Laboratory-Confirmed Anthrax
2000 - 2019
N
A
*
*2019 data is provisional, as of 9/23/2019
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-
Annual 1-n_,,,._ , ........,nreof per 1.000 000 brucellosis
-
~ po;pulamn -~500
D 50--500 cas:es • 10-50 D 1.- 10 • <2 D Poosibi ·, em . D Non--eade~ ct': tll;a
,-_:;'.I ~ :Po ((" ,.r---;'
\ ~.;--~~ '-"".._..",;;__ ""
I . / -_, ,/-f'f ;, "' ' V - ..
'/:)/"'
...,_
Brucellosis: Worldwide Distribution
Source: Pappas, G., et al. (2006) The new global map of human brucellosis. Lancet Infect Dis, 6, 91 99.
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50
45
40
a, 35 Cl) ,a 30
-cs a, 25 t:: 0 20 C2.
I~ 15
10
5
0
2019 data is provisional, as o 9/21/20 9
<o S1
Iv
Reported Cases of Brucellosis in Texas, 2010-2019* (n=214)
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TEXAS Heakh and faman I fer.as DepartmHI of Stat@ ~rv,ces He11lth Stnlre5
Species
Cases / County 1111 1-9 c=J 10-19
1111 >=20
Reported Cases of Brucellosis in Texas By County of Residence, 2010 - 2019*, N = 214
;;
w-+r I I l I I I I I I I I I I I I l I I I I I I I I I I
0 25 50 100 150 200 250 Miles
*2019 data is provisional, as of 9/21/2019
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Species
I fer.as DepartmHI of Stat@ He11lth Stnlre5
[I]]] Bruce/la abortus
~ Bruce/la canis
[=i Bruce/la melitensis
~ Bruce/la suis
l.i RB51
Confirmed Culture Results for Reported Cases of Brucellosis in Texas by County
of Residence, 2010 - 2019* , N = 160
;;
w-+r I I l I I I I I I I I I I I I l I I I I I I I I I I
0 25 50 100 150 200 250 Miles
*2019 data is provisional, as of 9/21/2019
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35
30
en CU 25 en
"' u ~ 20 t: 0 C. CU 15 ~
10
5
0
17
7
2010 2011
34
23
20
13
6 7
2012 2013 2014 2015 2016 2017
Bruce/lo abortus Bruce/la canis Bruce/lo melitensis Bruce/la suis RB51
• 2019 data is provisional, as of 9/21/2019
21
12
2018 2019*
Brucella Species Identified in Confirmed Cases byYear, Texas, 2010-2019* (n=160)
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Investigating Laboratory Exposures Brucellosis is most common laboratory-
associated bacterial infection Easily aerosolized, low infectious dose Laboratorians not always aware when
Brucella is suspected Though B. canis is not a Select Agent, still
a risk for lab acquisition Follow up for those with high risk exposure Fever/symptom watch for 24 weeks Serologic testing at every six weeks after
last exposure for 24 weeks Serology not available for B. canis or
RB51 Doxycycline and rifampin for three weeks RB51 resistant to rifampin
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SAFETY
Preventing Aerosolization
AerosoHzallon Aerosolization can oocur during any procedure
which imparts energy into a microbial suspension,. producing aerosols or droplets which may contain
infectious organisms. Aerosols are very small
particles that may remain suspended in the air and
can be inhaled ano retained in the lungs .. Droplets
are larger particles which can settle onto surfaces and gloves due to gravity. Droplets may also come
into contact with the mucous membrane•S of the
person performing the procedure.
Safety Precautions Laboratory exposures can be decreased by working
in a SSC using BSL-3 practices and appropriate
BSL-3 PPE when a biot hreat agent is suspected.
Identified aerosol-generating procedure risks
should be mitigated.
Examples of Aerosol Producmg Procedures • Opening culture p,late, sniffing p,lates
(Examining colony morphology/growth) • Heat fixing a slide
• Dispensing pipette tips
• Centrifuge setup/ run/unloading
• Vortexing • Spi lls or splashes of liquid media
• Subculturing positive blood culture bottles
• Inoculation of media (plate or tube
• Preparing samples for automated 1D systems
• Open flames, sterilizing loops
• Son icati ng
• Pipetting
• Catalase test
• Using automated and manual identification systems (e.g., MALDI-TOF, Vitek, API 20 NE, Bacteo
Your fa.cihty may identify additional aerosol generating procedures based on the laboratory's risk assessments.
Source: https://www.aphl.org/aboutAPHL/publications/Documents/2018_BiothreatAgents_SentinelLab_BenchCards_WEB.pdf
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Investigating Laboratory Exposures
Collect information on type of exposure: Manipulation of specimenWhat was done with the isolate Proximity to isolate being
manipulated Safety precautions Biosafety cabinet Personal protective equipment Immune status of exposed person Assist with risk classification: Minimal Low High Provide post-exposure prophylaxis and
testing recommendations 09/25/2019 DSHS ELC Conference 22
eported Cases of Malaria in Texas, 2010 - 2019* N=l,145)
180
159 158 160
144
140
VI 120 106 cu 102 102 VI
98 99 «I u 100 89 "'C cu ~ 80 0 71 C. cu a::
60
40
20
0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019*
*2019 data is provisional
Malaria
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D Mallaiir,~ tr,ansm I -., I ' '
Malan1a 1t@1nsm1tss10:n oa:::11J1rs, i1n :some, pa1rts.
allarJa t@nsmiss&on · ,, I ··j . . i '' .
Malaria
Approximation of the parts of the world where malaria transmission occurs
https://www.cdc.gov/malaria/about/distribution.html
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• Zaire ebolavirus
• Sudan ebolavorus
• Tao Forest ebolavirus
0
Nigeria South
~ dan
• fl O • ~ . • • Uganda
Ga?c;n o!ifcratic Republie Congo , f. e Congo
Number of Cases 0 1 - 10
11 • 1()0
101 • 425
Greater than 425
0 250 500 I I I I I
1,000 Moles t I
Ebola Virus Outbreaks by Species and Size, Since 1976
https://www.cdc.gov/vhf/ebola/history/distribution-map.html 09/25/2019 DSHS ELC Conference 25
Malaria Reporting Guidelines Texas Residents For malaria cases who reside in Texas, but are diagnosed in another Texas jurisdiction, please report by the case patient’s residence.
Out of Country Residents For malaria cases who reside in another country, but are diagnosed in Texas, please report by the location where the patient was diagnosed.
Out of State Residents For malaria cases who reside in another state, but are diagnosed in Texas, please communicate with the Regional ZC office so we can work with the other state to determine which state will count it as a case to prevent dual reporting.
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Malaria • Treatment changes – April 2019 Quinidine no longer available in the U.S. Intravenous artesunate for treatment of severe
malaria available through CDC Quarantine Stations Clinicians must call CDC’s Malaria Hotline
(770-488-7788) • Guidelines for treatment in United States https://www.cdc.gov/malaria/diagnosis_treatment/
treatment.html • Malaria travel information and prophylaxis https://www.cdc.gov/malaria/travelers/
country_table/a.html • General information https://www.cdc.gov/parasites/malaria/index.html
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Lyme Disease Erythema Migrans (EM) Confirmed: A case with physician-diagnosed EM ≥ 5 cm in size with an exposure in a high-incidence state or country*, OR a case of physician-diagnosed EM ≥ 5 cm in size with laboratory confirmation with an exposure in a low-incidence state or country*, OR a case with at least one late manifestation that has laboratory confirmation.
Classic EM rash EM rash: • Occurs in approximately 70 to 80 percent
of infected persons • Begins at the site of a tick bite after a
delay of 3 to 30 days (ave. ~7 days) • Expands gradually over several days • May reach 12” (30 cm) or more across • May feel warm to the touch but is rarely
itchy or painful • Sometimes clears as it enlarges, resulting
in a target or “bull’s-eye” appearance • May appear on any area of the body
Allergic reaction
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Lyme Disease High & Low Incidence Areas Confirmed: A case with physician-diagnosed EM ≥5 cm in size with an exposure in a high-incidence state or country*, OR a case of physician-diagnosed EM ≥5 cm in size with laboratory confirmation with an exposure in a low-incidence state or country*, OR a case with at least one late manifestation that has laboratory confirmation. *Exposure is defined as having been (≤ 30 days before onset of EM) in wooded, brushy, or grassy areas (i.e., potential tick habitats).
• A high-incidence state is a state with an average Lyme disease incidence of at least 10 confirmed cases/100,000 persons for the previous three reporting years.
• A low-incidence state is defined as a state with disease incidence of <10 confirmed cases/100,000 persons for the previous three reporting years.
www.cdc.gov/lyme/stats/tables.html
Texas is considered a low-incidence state for Lyme disease!
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Lyme Disease High Incidence Areas
• Most commonly reportedvector-borne illness in theUnited States
• Does not occur nationwideand is concentrated heavily inthe northeast and upperMidwest
High Incidence States: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont, Virginia, Wisconsin
Outside of the US, Lyme disease is common in some forested areas in Europe. Countries with highest reported incidence include Germany, Austria, Slovenia, and Sweden. Infectious Disease Clinics of North America, Vol. 22/Ed. 2, Fish AE, Pride YB, Pinto DS, Lyme carditis, 275-288
www.cdc.gov/lyme/stats/index.html
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Lyme Disease Late Manifestation Confirmed: A case with physician-diagnosed EM ≥ 5 cm in size with an exposure in a high-incidence state or country, OR a case of physician-diagnosed EM ≥ 5 cm in size with laboratory confirmation with an exposure in a low-incidence state or country, OR a case with at least one late manifestation* that has laboratory confirmation.
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Lyme Disease Late Manifestations: Alternate Explanations * For purposes of surveillance, late manifestations include any of the
following when an alternate explanation is not found: • Musculoskeletal system: recurrent, brief attacks (weeks or
months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. • NOT: chronic progressive arthritis not preceded by brief
attacks; chronic symmetrical polyarthritis or arthralgia, myalgia, or fibromyalgia syndromes alone
• Nervous system: any of the following, alone or in combination: lymphocytic meningitis; cranial neuritis, particularly facial palsy (can be bilateral); radiculoneuropathy; or, rarely, encephalomyelitis. • NOT: headache, fatigue, paresthesia, or mildly stiff neck alone
• Cardiovascular system: acute onset of high-grade (2nd or 3rd-degree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. • NOT: palpitations, bradycardia, bundle branch block, or
myocarditis alone wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/
09/25/2019 DSHS ELC Conference 32
Lyme Disease Probable & Suspect Cases Probable: Any other clinically compatible* case of physician-diagnosed Lyme disease that has laboratory confirmation and absence of a more likely clinical explanation
*fever, chills, headache, fatigue, muscle & joint aches, swollen lymph nodes, EM rash
Suspect: A case of EM with no known exposure and no laboratory evidence of infection, OR a case with laboratory evidence of infection but no clinical information available
Note: Lyme disease reports will not be considered cases if the medical provider specifically states this is not a case of Lyme disease, or the only symptom listed is “tick bite” or “insect bite.”
09/25/2019 DSHS ELC Conference 33
More on Zoonoses
• Thursday Breakout Session Zoonotic Disease Investigations
10:15 am
• Regional Zoonosis Control Officeshttp://www.dshs.texas.gov/idcu/health/zoonosis/contact/
09/25/2019 DSHS ELC Conference 34
https://www.dshs.texas.gov/idcu/health/zoonosis/contact/ Public Health Region 1 Public Health Region 2 Kimberly Hencken, DVM Nick Ferguson Lubbock, TX Abilene, TX Public Health Region 2/3
Amarillo Sub-Office Tonya Finch
Public Health Region 9 Amanda Kammen, MPH Midland, TX
Public Health Region 9/10 Kenneth Waldrup, DVM, PhD El Paso, TX
San Antonio, TX
Public Health Region 1
Public Health Region 8 Amanda Kieffer, DVM, MPH, DACVPM
Shelley Stonecipher, DVM, MPH Arlington, TX
Houston, TX
Public Health Region 11 Ronald Tyler, DVM, MS Harlingen, TX
11
43
7 5N
6 8
10
2
1
9
Public Health Region 4/5N Samantha Puttick Tyler, TX
Public Health Region 7
5S David Smonko, DVM Temple, TX
Public Health Region 6/5S Caitlin Cotter, DVM, MPH
Department of State Health Services Zoonosis Control Branch
Austin, TX 78756 (512) 776-7255
www.TexasZoonosis.org E-mail:[email protected]
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Thank you Kelly Broussard, MPH
Briana O’Sullivan, MPH Laura E. Robinson, DVM, MS
Zoonosis Control Branch 09/25/2019 DSHS ELC Conference 36