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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
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
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
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