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Inside September-October, 2017 Volume 28, Number 5 Infectious Disease Epidemiology Main Webpage www.infectiousdisease.dhh.louisiana.gov Office of Public Health - Infectious Disease Epidemiology Section P.O. Box 60630, New Orleans, LA 70160 - Phone: (504) 568-8313 www.ldh.louisiana.gov/LMR REBEKAH E. GEE MD MPH SECRETARY JOHN BEL EDWARDS GOVERNOR Louisiana Morbidity Report Candida auris Surveillance: CDC Antibiotic Resistance Laboratory Network .................................................................. 2 Rabies: Answering Physician Questions .........................................3 Rapid Influenza Diagnostic Test Evaluation: Louisiana .................4 Announcements: Updates, IDEpi Webpages ................................. 5 Save the Date: NHSN/Emerging Infectious Diseases Workshops, 2017 .......................................................................5 (continued on page 6) Antibiotic Awareness Week November 13-19, 2017 Andrea Salinas, MPH The annual United States Antibiotic Awareness Week is an observance to raise awareness of antibiotic resistance and the importance of appropriate antibiotic prescribing and use. Antibiot- ics are among the most commonly prescribed drugs used in human medicine and are responsible for saving countless lives since their introduction into healthcare, but use of antibiotics is also the single most important factor leading to antibiotic resistance around the world. Incorrect antibiotic prescribing not only helps fuel the emergence of antibiotic resistance, it is implicated in adverse drug reactions and Clostridium difficile infections. Antibiotic resistance is the ability of bacteria to resist the effects of drugs meant to kill them. While some bacteria are intrinsically resistant to certain antibiotics, they can also become resistant in two ways: by a genetic mutation or by acquiring resistance from another bacteria through the transfer of resistance genes. When antibiotics are not prescribed correctly, or when they are not taken as pre- scribed, non-resistant bacteria may be killed, but resistant bacteria will be left behind and proliferate. These resistant bacteria can then be spread person-to-person, in healthcare settings, in the commu- nity, and across the globe. Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and a growing list of infections - such as pneumonia, tuberculosis, bloodstream infections, and gonorrhea – are becoming harder, and sometimes impossible, to treat as antibiotics are becoming less ef- fective. In Louisiana, approximately 29,000 people become infected with bacteria that are resistant to antibiotics and between 300 and 400 people die as a direct result of these infections each year. Many more people die from other conditions that were complicated by an antibiotic resistant infection. To view the state of antibiotic sensitiv- (continued on page 6) Japanese Encephalitis Julius Tonzel, MPH Japanese encephalitis (JE) is a rare mosquito-borne disease that has potentially severe outcomes, with one case reported annually in the United States. The virus is a member of the family Flaviviri- dae and is closely related to West Nile encephalitis (WNE) and St. Louis encephalitis (SLE). The disease is spread by the bite of an infected mosquito, mainly Culex tritaeniorhynchus, and maintained through a cycle of biting vertebrate hosts. While wading birds and pigs are the primary hosts that continue the transmission in nature, humans serve as dead-end hosts (the bloodstream of an infected human is never concentrated enough to infect a feeding mosquito). JE is found primarily in Southeast Asia and the western Pacific, having peak human cases in the summer and fall seasons. Please visit https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious- diseases-related-to-travel/japanese-encephalitis for an updated list of countries with a JE travel advisory. Less than 1% of humans that are infected with JE develop any signs or symptoms. The incubation period ranges from about five to ten days, with an acute onset of fever, headache, fatigue, nausea or vomiting. The disease can progress to an encephalitis (inflammation of the brain) that can cause neurologic symptoms that include altered mental status, movement disorders or seizures. About 20% to 30% of all patients that develop encephalitis will die; amongst the survivors, about 30% to 50% will continue to have cognitive or psychiatric symptoms long after an acute illness. While there is no specific treatment for JE, supportive care is often required to benefit patients. There is currently a vaccine available for JE. The vaccine is recommended for all travelers that plan to spend at least a month in an area that is known to have local transmission of JE. For more information about the Center for Disease Control and Preven- tion’s (CDC) recommendations for the JE vaccination, please visit https://www.cdc.gov/japaneseencephalitis/vaccine/index.html. General mosquito prevention recommendations should be used to prevent getting bitten by an infected mosquito. In addition to a relevant clinical presentation, there needs to be laboratory confirmation of the virus, either through serum or cerebrospinal fluid. Isolation of the virus and nucleic acid amplifi- cation tests should not be used to rule out JE due to the low levels of viremia found at the time that clinical symptoms appear. Instead, virus-specific antibody tests should be performed to identify the vi- rus. Due to the potential of cross-reactivity with other flaviviruses (i.e. WNE or SLE), confirmatory testing should be performed at the CDC. Magnetic resonance imaging (MRI) could also be used to identify JE-associated abnormalities in the thalamus, basal ganglia, midbrain, pons and medulla.

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Inside

September-October, 2017 Volume 28, Number 5

Infectious Disease Epidemiology Main Webpage www.infectiousdisease.dhh.louisiana.gov

Office of Public Health - Infectious Disease Epidemiology SectionP.O. Box 60630, New Orleans, LA 70160 - Phone: (504) 568-8313

www.ldh.louisiana.gov/LMR

Rebekah e. Gee MD MPhSeCReTaRY

John bel eDwaRDS GoVeRnoR

Louisiana Morbidity Report

Candida auris Surveillance: CDC Antibiotic Resistance Laboratory Network .................................................................. 2

Rabies: Answering Physician Questions .........................................3

Rapid Influenza Diagnostic Test Evaluation: Louisiana .................4

Announcements: Updates, IDEpi Webpages ................................. 5

Save the Date: NHSN/Emerging Infectious Diseases Workshops, 2017 .......................................................................5

(continued on page 6)

Antibiotic Awareness Week November 13-19, 2017

Andrea Salinas, MPH

The annual United States Antibiotic Awareness Week is an observance to raise awareness of antibiotic resistance and the importance of appropriate antibiotic prescribing and use. Antibiot-ics are among the most commonly prescribed drugs used in human medicine and are responsible for saving countless lives since their introduction into healthcare, but use of antibiotics is also the single most important factor leading to antibiotic resistance around the world. Incorrect antibiotic prescribing not only helps fuel the emergence of antibiotic resistance, it is implicated in adverse drug reactions and Clostridium difficile infections. Antibiotic resistance is the ability of bacteria to resist the effects of drugs meant to kill them. While some bacteria are intrinsically resistant to certain antibiotics, they can also become resistant in two ways: by a genetic mutation or by acquiring resistance from another bacteria through the transfer of resistance genes. When antibiotics are not prescribed correctly, or when they are not taken as pre-scribed, non-resistant bacteria may be killed, but resistant bacteria will be left behind and proliferate. These resistant bacteria can then be spread person-to-person, in healthcare settings, in the commu-nity, and across the globe. Antibiotic resistance is rising to dangerously high levels in all parts of the world. New resistance mechanisms are emerging and a growing list of infections - such as pneumonia, tuberculosis, bloodstream infections, and gonorrhea – are becoming harder, and sometimes impossible, to treat as antibiotics are becoming less ef-fective. In Louisiana, approximately 29,000 people become infected with bacteria that are resistant to antibiotics and between 300 and 400 people die as a direct result of these infections each year. Many more people die from other conditions that were complicated by an antibiotic resistant infection. To view the state of antibiotic sensitiv-

(continued on page 6)

Japanese Encephalitis Julius Tonzel, MPH

Japanese encephalitis (JE) is a rare mosquito-borne disease that has potentially severe outcomes, with one case reported annually in the United States. The virus is a member of the family Flaviviri-dae and is closely related to West Nile encephalitis (WNE) and St. Louis encephalitis (SLE). The disease is spread by the bite of an infected mosquito, mainly Culex tritaeniorhynchus, and maintained through a cycle of biting vertebrate hosts. While wading birds and pigs are the primary hosts that continue the transmission in nature, humans serve as dead-end hosts (the bloodstream of an infected human is never concentrated enough to infect a feeding mosquito). JE is found primarily in Southeast Asia and the western Pacific, having peak human cases in the summer and fall seasons. Please visit https://wwwnc.cdc.gov/travel/yellowbook/2018/infectious-diseases-related-to-travel/japanese-encephalitis for an updated list of countries with a JE travel advisory. Less than 1% of humans that are infected with JE develop any signs or symptoms. The incubation period ranges from about five to ten days, with an acute onset of fever, headache, fatigue, nausea or vomiting. The disease can progress to an encephalitis (inflammation of the brain) that can cause neurologic symptoms that include altered mental status, movement disorders or seizures. About 20% to 30% of all patients that develop encephalitis will die; amongst the survivors, about 30% to 50% will continue to have cognitive or psychiatric symptoms long after an acute illness. While there is no specific treatment for JE, supportive care is often required to benefit patients. There is currently a vaccine available for JE. The vaccine is recommended for all travelers that plan to spend at least a month in an area that is known to have local transmission of JE. For more information about the Center for Disease Control and Preven-tion’s (CDC) recommendations for the JE vaccination, please visit https://www.cdc.gov/japaneseencephalitis/vaccine/index.html. General mosquito prevention recommendations should be used to prevent getting bitten by an infected mosquito. In addition to a relevant clinical presentation, there needs to be laboratory confirmation of the virus, either through serum or cerebrospinal fluid. Isolation of the virus and nucleic acid amplifi-cation tests should not be used to rule out JE due to the low levels of viremia found at the time that clinical symptoms appear. Instead, virus-specific antibody tests should be performed to identify the vi-rus. Due to the potential of cross-reactivity with other flaviviruses (i.e. WNE or SLE), confirmatory testing should be performed at the CDC. Magnetic resonance imaging (MRI) could also be used to identify JE-associated abnormalities in the thalamus, basal ganglia, midbrain, pons and medulla.

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

Candida auris Surveillance: CDC Antibiotic Resistance Laboratory Network

Erica Washington, MPH

The proliferation of antimicrobial resistant threats has assumed national attention due to slowed production of developing new antibiotics and emergence of bacteria with unusual and high drug resistant patterns. These novel organisms are commonly referred to as “super bugs” because treatment is generally limited to only a few therapy options. The Centers for Disease Control and Prevention (CDC) has led detection, containment, and response efforts to combat antibiotic threats. In order to equip states with increased resources and support to respond to novel threats, the CDC recently created the Antibiotic Resistance Laboratory Network (ARLN). ARLN supports state health department efforts to detect new resistance threats or outbreaks of highly resistant organism within healthcare settings. ARLN currently consists of seven regional laboratories that serve states in common geographic areas. Louisiana is part of the Southeast ARLN laboratory network for which Tennessee State Public Health Laboratory serves as a reference laboratory for highly resistant organisms. The Louisiana Department of Health, Office of Public Health (OPH) Laboratory, and Tennessee ARLN are working collabora-tively to detect novel threats. Guidance was recently released to acute care hospitals detailing surveillance and response proto-cols for suspected or confirmed cases of Candida auris: a fungal organism that causes invasive infections and severe illness in hospitalized patients. Although U.S. cases of C. auris have been generally contained to the New England region, the Louisiana OPH is increasing collaboration and education for providers to detect and report these threats. The Council of State and Territorial Epidemiologists (CSTE) recently released a standardized case definition for C. auris (Table).

Table. Standardized Council of State and Territorial Epidemiologists Candida auris Case Definition, 2017

C. auris is often misidentified in routine laboratory proce-dures. C. auris should be suspected when an isolate is identified as C. haemulonii because C. auris is most commonly misidenti-fied as this species, including by Vitek-2, BD Phoenix, and some MALDI-TOF databases. DNA sequencing and MALDI-TOF

Louisiana Morbidity ReportVolume 28, Number 5 September - October, 2017

The Louisiana Morbidity Report is published bimonthly by the LDH, OPH Infectious Disease Epidemiology Section to inform physicians, nurses, and public health professionals about disease trends and patterns in Louisiana. Address correspondence to Louisiana Morbidity Report, Infectious Disease Epidemiology Section, Louisiana Department of Health, P.O. Box 60630, New Orleans, LA 70160.

Assistant Parham Jaberi, MD, MPHSecretary OPH

State Epidemiologist Raoult Ratard, MD, MPH Editors Theresa Sokol, MPH Julie Hand, MSPH Rosemarie Robertson, BS, MT(C), CNMT

(continued on page 3)

Figure 1. Candida auris Isolate submission flow to the Tennessee Public Health Laboratory.

Interim infection control containment and response activities will be conducted by the HAI/AR Program to assist the facility with preventing the spread of the contagion (Figure 2).

using certain databases can distinguish C. auris and other related species (e.g., C. duobushaemulonii and C. pseudohaemulonii) from C. haemulonii. Facilities that identify suspect, probable, and confirmed cases of Candida auris should notify the Tennessee ARLN and the Lou-isiana OPH by sending an e-mail to both [email protected] and [email protected] and by phone to the Infectious Disease Epide-miology Section’s 24-hour on call line at 1(800) 256-2748 within 24 hours of receipt of results. The Louisiana Healthcare-Associ-ated Infections and Antibiotic Resistance (HAI/AR) Program will work with facilities to develop a line list of Epi-linked contacts and roommates who are connected to the suspect case. Tennes-see ARLN will respond to the C. auris notification with isolate submission guidelines and a FedEx account number. Suspect C. auris isolates will not be routed through the OPH Laboratory, and submission of isolates come at no cost to the submitting facility (Figure 1).

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

Rabies: Answering Physician Questions

Gary Balsamo, DVM, MPH&TM

Is rabies still a problem in Louisiana?

Louisiana harbors both terrestrial and bat variant rabies within its borders. Bat variant rabies exists throughout the state. Louisiana is home to at least ten different species of bats, and each species is the reservoir for at least one variant type. The southern skunk variant is the only terrestrial variant of rabies circulating in the state. Over the past several decades, there have been two areas of the state where most cases of skunk variant rabies have been identified, northwest Louisiana in an area centered in the Shreveport/Bossier area, and south-central Louisiana in an area centered in Lafayette Parish.

Since skunks and bats are infected with rabies, does that mean that pet species do not get the disease?

Although it is true that very few pets have been infected with rabies over the past decade, the risk remains. Since 2000, four dogs and two cats have been identified with the virus. It is probable that other unrecognized cases have occurred. Due to generally poor rabies vaccine compliance rates in pets, the risk remains fairly constant.

If I practice in an area other than the two geographic foci of skunk rabies listed above, should I worry about rabies as a consequence of dog and cat bites?

Bat variant rabies can be transmitted to dogs and cats. In fact, in 2014 both the dog and cat that were identified with rabies eventually were proven to be infected with bat variants of the virus.Therefore, any bite from a mammal, other than very small rodents, should be evaluated for risk of rabies regardless of the area of the state in which the incident took place.

When a person is bitten by any mammal suspected of being rabid, should that person always be given post-exposure prophylaxis (PEP)?

If the animal that inflicted the bite is available for testing, there is usually no reason to start post-exposure prophylaxis prior to labo-ratory results. Of course, the test result must be available within a reasonable amount of time after the bite, usually five days. Waiting longer periods of time before receiving a test result and initiating PEP may be permissible depending on the anatomical location of the bite. Persons with bites on extremities can wait up to ten days for a test result.

Can serological tests be done on animals that bite humans, to rule in or rule out rabies?

No. The test used by Louisiana’s Office of Public Health and Veterinary Laboratories is the indirect fluorescent antibody test on brain tissue. The animal must be humanely killed or euthanized and the brain must be examined.

Do dogs and cats need to be killed to find out if they have rabies?

No. Dogs, cats, and even ferrets can be held under observation for ten days. If no signs of rabies develop in the animal within ten days

of the bite, the animal could not have been shedding rabies virus in saliva at the time of the bite. There would be no reason to start PEP in humans. In adult victims where the bite is below the neck, the victim can wait the full ten days before PEP should be started. For incidents involving small children or bites to the neck or above, it is suggested to check with the Infectious Disease Epidemiology Section (IDEpi), or the State Public Health Veterinarian for recommenda-tions.

Can we do a ten-day observation on other species, besides dogs, cats and ferrets?

No. Not enough is known about the behavior of the virus in species other than dogs, cats or ferrets. The relationship of salivary shedding to onset of clinical signs has not been adequately studied in other species.

The administration of which medications constitute PEP?

In persons that have never before completed a full course of either pre-exposure prophylaxis or PEP, PEP consists of an injection of human rabies immunoglobulin (HRIG) and a series of four rabies vaccinations given on days 0, 3, 7, and 14. In immunosuppressed patients the series of vaccines is increased to five, given on days 0, 3, 7, 14, and 28.

All acute care hospitals are asked to participate in this reporting because timely detection and response is necessary for the contain-ment of any infectious disease. The HAI/AR Program is increasing provider awareness and competency with dealing with emerging threats by providing the annual Healthcare-Associated Infections and Emerging Infectious Diseases Workshops (information on page 5). Current national case counts of C. auris are accessible at https://www.cdc.gov/drugresistance/c-auris.html. Questions about submitting suspect C. auris isolates should be directed to Erica Washington at [email protected] or (504) 568-8319.

(Candida auris Surveillance ... continued from page 2)Figure 2. Provider reporting scheme for suspect, probable, and confirmed cases of Candida auris.

(continued on page 6)

Identify a patient with confirmed or suspected Candida auris

Identify Epi-linked contacts and roommates or inpatient location

TN ARLN will share results within 1 day of isolate receipt with the submitting facility as well as the Louisiana HAI-AR Program. Interim and follow up infection control guidance

will be provided to the facility.

Follow submission guidelines and ship using FedEx account provided by TN ARLN.

Call Infectious Disease Epidemiology within 24 hours of receipt of results

Send an email to [email protected] and cc [email protected] isolate submission guidelines

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

(continued on page 5)

The Louisiana Office of Public Health (LA OPH) Infectious Disease Epidemiology (IDEpi) Section conducts influenza surveil-lance for the state utilizing a three-pronged, voluntary approach. Taken together, these components provide a comprehensive view of influenza in the state including: the beginning and end of influenza season; intensity of influenza activity; the age groups most affected by influenza each season; when and where influenza viruses are circulating; and finally to identify changes in the circulating viruses. The main component of the program is outpatient influenza-like illness (ILI) surveillance from sentinel sites including physicians, hospitals and urgent care facilities. Sites report data each week on number of patient visits for ILI in five age groups (0-4 years, 5-24 years, 25-49 years, 50-64 years, older than 64 years) and the total number of patient visits for any reason. The ILI case definition is fever over 100°F (37.8°C), oral or equivalent, AND cough and/or sore throat (without a known cause other than influenza). There is no requirement for a positive influenza test. Data is submitted to the Centers for Disease Control and Preven-tion (CDC) U.S. Outpatient Influenza-Like Illness Surveillance Network (ILINet), an online reporting system that is designed to collect information on ILI for national surveillance. The other two components of influenza surveillance in Louisiana revolve around laboratory testing. Participating providers report rapid test results weekly and the total number of tests done. The last component of the system is active virologic surveil-lance. Beginning with the 2013-2014 influenza season, IDEpi and the Louisiana State Public Health Laboratory implemented a strategy to increase samples to meet requirements in the Association of Public Health Laboratories (APHL) Influenza Virologic Surveil-lance Right Size Roadmap. Influenza testing at the state laboratory is done by Real Time Reverse Transcription Polymerase Chain Reaction (rRT-PCR). During the first year, the state laboratory tested 2,352 samples representing a five-fold increase over samples tested the previous season. During the 2016-2017 season, over 1,700 samples were tested (data described here from the 2016-2017 is only through Sep-

Julie Hand, MSPH; Olivia Dominguez, MPH; Errin C. Rider, PhD, D(ABMM); Danielle Haydel, MT; Ha Tran, MT(ASCP)

Table: Breakdown of Discrepant Results by Season, RIDT vs. rRT-PCR – Louisiana, 2013-2017

Interpretation of RIDT results is usually thought to be correlated with influenza activity: poor sensitivity when activity is high (false negative results more common), and poor specificity when activity is low (false positives results more common). While false negatives were more common when ILI activity was high, false negative and false positives occurred throughout the season. Discrepant results are those that were RIDT positive, but incorrect for virus type. There were five discrepants during the 2016-2017 season: two influenza B that were actually Influenza A/H3 and three influenza A & B that were confirmed to be Influenza A/H1N1, Influenza A/H3, and Influenza B/Yam (Figure 1).

Figure 1: Discrepant RIDTs by Month with ILI Activity – Louisiana, 2016-2017 Season

tember 2017). Virologic surveillance sites collect influenza swabs on patients each week and submit them for subtyping at the state public health laboratory. Sample collection is designed to be random based on the site preference, most sites choose one day a week for sampling and collect a swab for submission from any patient who presents with ILI. If a rapid test was done, sites record those results on the laboratory test request form to allow for comparison with the state laboratory rRT-PCR results. This data has given us the opportunity to evaluate the perfor-mance of rapid influenza diagnostic tests (RIDT) in clinical settings throughout the state. Over the last four influenza seasons a total of 6,697 unscreened specimens have been submitted for active viro-logic surveillance, of which 6,073 (90.7%) had a comparison RIDT result. Of these 6,073, there was a discrepancy between RIDT and rRT-PCR on 820 (13.5%) samples (Table).

Rapid Influenza Diagnostic Test Evaluation: Louisiana

SEASON 2013-2014 2014-2015 2015-2016 2016-2017

Total Unscreened Samples 1,953 2,362 915 1,467

Number With RIDT Result 1,692 2,054 860 1,310

Number / Percentage Discrepant 319 (18.9%) 263 (12.8%) 70 (8.1%) 168 (12.8%)

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

There are four different RIDTs used by virologic surveillance sites in Louisiana, Figures 2 and 3 illustrate how they perform when compared with the manufacturers’ expectations. For specificity, the tests perform closely to the manufacturer guidelines; however, for sen-sitivity, three of the tests perform sub-optimally. One test performs below manufacturer expectations for both influenza A and influenza B.

Figures 4 and 5 are comparisons between the percentages of discrepant results by each manufacturer based on submitted samples. Two of the RIDTs are responsible for a similar percentage of samples and discrepant results. One RIDT is responsible for 10% greater discrepant results while another is responsible for 11% less discrepant results than samples.

This data illustrates the importance of interpretation of RIDTs particularly if patients have clinical symptoms consistent with influenza. If the patient is at risk for complications of influenza or critically ill, antiviral treatment should not be delayed until rRT-PCR testing can be completed. For more information, please contact Julie Hand at (504) 568-8298 or [email protected].

Figure 2: Influenza A, All Sites with Manufacturer Expectation Louisiana, 2016-2017 Season

Figure 3: Influenza B, All Sites with Manufacturer Expectation Louisiana, 2016-2017 Season

60.0

65.0

70.0

75.0

80.0

85.0

90.0

95.0

100.0

Sensitivity Specificity

Perc

enta

ge

Influenza B - all sites

RIDT #1

RIDT #2

RIDT #3

RIDT #4

Manufacturer Avg

60.0

65.0

70.0

75.0

80.0

85.0

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Perc

enta

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Influenza A - all sites

RIDT #1

RIDT #2

RIDT #3

RIDT #4

Manufacturer Avg

Figure 4: Percentage of Samples by Manufacturer - Louisiana, 2016-2017 Season

Figure 5: Percentage of Discrepant Results by Manufacturer - Louisiana, 2016-2017 Season

RIDT #125%

RIDT #29%

RIDT #328%

RIDT #438%

% SamplesRIDT #1

RIDT #2

RIDT #3

RIDT #4 RIDT #124%

RIDT #29%

RIDT #319%

RIDT #448%

% DiscrepantRIDT #1

RIDT #2

RIDT #3

RIDT #4

Metairie - November 2 Lafayette - November 9 Bossier City - November 16

This is a free, one-day workshop sponsored by the Department of Health’s, Office of Public Health, Infectious Disease Epidemiol-ogy Section. It is targeted toward infectious disease preventionists in acute care hospitals that are seeking to reduce the number of hospital acquired infections and prepare for emerging infectious disease threats that may present in their facility. This workshop must be registered for because of seating limita-tions and to provide the adequate number of handouts. Nurse and laboratory education credits have been applied for. Please go to http://new.dhh.louisiana.gov/index.cfm/page/2853 for a registration form and more information.

Healthcare-Associated Infections and Emerging Infectious Diseases Workshops - 2017

SAVE THE DATE

(Rapid Influenza ... continued from page 4 )

Updates: Infectious Disease Epidemiology (IDEpi) Webpageswww.infectiousdisease.dhh.louisiana.gov

Annual: Campylobacter; Cryptococcosis; Cyclospora; Legionella; Listeria; Measles; Pertussis; Plague; Poliomyelitis; Psittacosis; Rubella; Salmonella

Epidemiology Manual: Clostridium difficile Public Information;Hantavirus Brochure (CDC); Hantavirus Fact Sheet (CDC); Legionella Prevention (VHA Directive)

HAI: August 2017 Newsletter: September 2017 Nursing Home EditionInfluenza: Influenza Specimen Collection LA Public Health Laboratory

September 2017; Monthly Report; Prevention and Control of Seasonal Influenza with Vaccines: Recommendations of the Advisory Committee on Immunization Practices - United States, 2017-18 Influenza Season (MMWR-CDC); Summary of ACIP Recommendations - U.S., 2017-18 (MMWR-CDC)

Veterinary-Rabies: Head Removal Instruction; Rabies Specimen Submission

Announcements

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

Figure: Antibiotic Prescriptions Dispensed in Community Pharmacies per 1000 Population - United States, 2014

To fight unnecessary and incorrect prescribing, the Centers for

(Antibiotic Awareness ... continued from page 1)ity/resistance as identified by hospital microbiology laboratories in Louisiana, please reference the Antibiogram Report at http://ldh.louisiana.gov/index.cfm/page/534. Most unnecessary prescribing occurs for respiratory infections commonly caused by viruses (common cold, influenza, viral sore throat) which do not respond to antibiotics, or for bacterial infec-tions that do not always need antibiotics (e.g. many sinus and ear infections). Efforts to reduce the unnecessary or incorrect use of antibiotics are especially necessary in Louisiana, where the outpa-tient prescription dispensing rate is approximately 35% higher than the national average of 835 antibiotic prescriptions dispensed per 1000 population (Figure).

Disease Control and Prevention (CDC) in collaboration with federal, state, and local partners, are focusing on antibiotic stewardship activities to improve antibiotic prescribing. Facilities in Louisiana can begin working toward better antibiotic prescribing practices by referencing the core elements of antibiotic stewardship and imple-mentation strategies created by the CDC for the following healthcare settings: • Acute-Care Hospitals: https://www.cdc.gov/getsmart/health-care/implementation/core-elements.html • Nursing Homes: https://www.cdc.gov/longtermcare/prevention/antibiotic-stewardship.html • Outpatient Settings: https://www.cdc.gov/getsmart/community/improving-prescribing/core-elements/core-outpatient-stewardship.html • Small and Critical-Access Hospitals: https://www.cdc.gov/getsmart/healthcare/implementation/core-elements-small-critical.html. Beginning November 28, 2017, nursing homes will be required by the Centers for Medicare and Medicaid Services (CMS) to have antibiotic stewardship programs that meet all core elements and a similar CMS regulation is expected for acute-care hospitals. Cur-rently, only 30% of acute care hospitals in Louisiana have antibiotic stewardship programs that meet all core elements. Hospitals can also choose to participate in the National Health-care Safety Network’s (NHSN) Antibiotic Use and Resistance (AUR) Module (https://www.cdc.gov/nhsn/acute-care-hospital/aur/index.html) to track and analyze antibiotic use and resistance patterns in their facilities in order to better direct their stewardship programs. For more information about antibiotic resistance, stewardship, or participation in the NHSN AUR Module, please contact Andrea Salinas at (504) 568-8317 or [email protected].

(Japanese Encephalitis ... continued from page 1) Louisiana identified its first imported case of JE in a person that extensively traveled to Guam and the Philippines in the summer of 2016. The patient first experienced nausea and vomiting on the last few days of travel, followed by extreme weakness and difficulty walking. Upon return to the U.S., the patient became confused and experienced changes in mental status. Upon hospitalization in a Louisiana facility, a fever was also noted. The cerebrospinal fluid findings showed the presence of elevated protein and white blood cells; an MRI was performed and identified some hyperintensity within the left thalamus. Based on these findings and along with the clinical presentation, the physician began to suspect aseptic encephalitis as a diagnosis. Serologic testing was positive for antibodies against JE and

WNE viruses. The serum was not able to be forwarded to the CDC for confirmatory testing. At the time of infection, JE virus was en-demic to the Philippines, whereas WNE virus was not found in that country. This information, in addition to the clinical presentation and the remarkable MRI results, suggest JE as a more probable diagnosis for this infection. With assistance from the Mississippi State Department of Health, the Louisiana Department of Health’s Infectious Disease Epidemiol-ogy Section was able to interview the patient after two weeks of hos-pitalization. At the time of interview, the patient had fully resolved the symptoms and did not have any cognitive or psychiatric deficits that are sometimes seen after an infection. For more information, please contact Julius Tonzel at (504) 568-8296 or [email protected].

Administration of a booster dose of tetanus vaccine should also be considered. HRIG should be infiltrated into, and around the wounds. Any excess volume of HRIG or HRIG used when the exposure is other than a localized wound (e.g. unknown type of bat exposure) should be injected intramuscularly at a site distant from vaccine administration. The suggested schedule of vaccinations should be strictly followed. Questions about deviations from this protocol should be addressed to the LDH IDEpi Section or the State Public Health Veterinarian.

What are the preferred sites for rabies vaccine administration?

The preferred sites are the deltoid muscle in adults or the antero-lateral thigh for small children and infants. The gluteal area should never be used for either HRIG or rabies vaccine administration.

What if my patient had been previously vaccinated for rabies?

Previously vaccinated persons should receive two intramuscular doses of vaccine, one immediately and one 72 hours or three days later. HRIG is not indicated. For more information please contact Dr. Balsamo, State Public Health Veterinarian, at (504) 568-8315 or [email protected].

(Rabies ... continued from page 3)

Rate (Antibiotic RX per1,000 Population)

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LA Morbidity Report, Sep - Oct, 2017, Vol. 28, No.5

Figure: Department of Health Regional Map

Table 1: Communicable Disease Surveillance, Incidence by Region and Time Period, July-August, 2017

TIME PERIOD Jan-Dec Jan-Dec Jan-Dec

DISEASE 1 2 3 4 5 6 7 8 9 Jul-Aug Jul-Aug Cum Cum %2017 2016 2017 2016 Chg*

Vaccine-preventable Hepatitis B Cases 0 3 0 0 0 0 0 1 6 10 10 54 37 45.9

Rate1 0 0.5 0 0 0 0 0 0.3 1.6 0.2 0.2 1.3 0.9 NA* Measles 0 0 0 0 0 0 0 0 0 0 0 0 0 NA* Mumps 0 4 1 2 0 0 0 0 0 7 0 52 0 5200Rubella 0 0 0 0 0 0 0 0 0 0 0 0 0 NA* Pertussis 3 0 0 0 1 0 1 0 1 6 12 51 37 37.8

Sexually-transmittedHIV/AIDS Cases2 72 46 5 23 6 8 21 15 7 203 203 844 776 8.8

Rate1 8.0 6.7 1.2 3.8 2.0 2.6 3.9 4.2 1.2 4.3 4.3 18.0 16.6 NA*Chlamydia Cases1,3 1255 881 430 575 205 301 868 585 490 5610 5474 23197 21417 8.3

Rate1 139.9 128.7 106.3 94.4 68.0 98.4 159.7 165.0 84.3 119.8 116.9 495.5 457.5 NA*Gonorrhea Cases1,3 578 301 153 217 69 90 329 199 116 2052 2031 7870 7309 7.7

Rate1 64.4 44.0 37.8 35.6 22.9 29.4 60.5 56.1 20.0 43.8 43.4 168.1 156.1 NA*Syphilis (P&S) Cases1,3 26 24 6 8 6 2 16 19 3 110 166 434 504 -13.9

Rate1 2.9 3.5 1.5 1.3 2.0 0.7 2.9 5.4 0.5 2.3 3.5 9.3 10.8 NA*EntericCampylobacter Cases 5 7 1 18 3 5 8 9 11 67 51 254 177 43.5Hepatitis A Cases 0 0 0 1 0 0 0 0 1 2 0 6 9 -33.3

Rate1 0 0 0 0.2 0 0 0 0 0.3 0 0 0.1 0.2 NA*Salmonella Cases 16 21 18 37 19 15 11 21 36 194 318 602 846 -28.8

Rate1 1.5 3.7 4.8 7.2 7.1 4.9 2.2 6.0 9.4 4.5 7.4 14.0 19.6 NA*Shigella Cases 4 4 1 1 7 1 2 3 3 26 61 124 255 -51.4

Rate1 0.4 0.7 0.3 0.2 2.6 0.3 0.4 0.9 0.8 0.6 1.4 2.9 5.9 NA*Vibrio, cholera Cases 0 0 0 0 0 0 0 0 0 0 0 0 0 NA*Vibrio, other Cases 2 3 0 2 1 0 1 0 4 13 14 42 35 20.0OtherH. influenzae (other) 1 1 1 3 0 0 1 0 0 7 6 43 38 13.2N. Meningitidis 0 0 0 0 0 0 0 0 0 0 0 3 2 NA*1 = Cases Per 100 000 Population.

2 = These totals reflect people w ith HIV infection w hose status w as f irst detected during the specif ied time period. This includes people w ho w ere diagnosed w ith AIDS at the time HIV f irst w as detected. Because of delays in reporting HIV/AIDS cases, the number of persons reported is a minimal estimate. Data should be considered provisional.

3 = Prelminary data.

* = Percent change not calculated for rates or count differences less than 5.

Table 2: Diseases of Low Frequency, January-December, 2017Disease Total to DateLegionellosis 26Lyme Disease 3Malaria 7Rabies, animal 13 Varicella 43

Table 3: Animal Rabies, July - August , 2017Parish No. Cases Desoto

Species

HEALTH REGION

Skunk3

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Sanitary Code - State of Louisiana Part II - The Control of Disease

LAC 51:II.105: The following diseases/conditions are hereby declared reportable with reporting requirements by Class:

Class A Diseases/Conditions - Reporting Required Within 24 HoursDiseases of major public health concern because of the severity of disease and potential for epidemic spread-report by telephone immediately upon recognition that a case, a suspected case, or a positive laboratory result is known; [in addition, all cases of rare or exotic communicable diseases, unexplained death, unusual cluster of disease and all outbreaks shall be reported.

Acute Flaccid Paralysis Fish/Shellfish Poisoning (domoic acid, neurotoxic Plague (Yersinia pestis) Smallpox Anthrax shellfish poisoning, ciguatera, paralytic shellfish Poliomyelitis (paralytic & non-paralytic) Staphylococcus aureus, Vancomycin Avian or Novel Strain Influenza A poisoning, scombroid) Q Fever (Coxiella burnetii) Intermediate or Resistant (VISA/VRSA) (initial detection) Foodborne Infection Rabies (animal and human) Staphylococcal Enterotoxin B (SEB) Pulmonary Botulism Haemophilus influenzae (invasive infection) Ricin Poisoning Poisoning Brucellosis Influenza-associated Mortality Rubella (congenital syndrome) Tularemia (Francisella tularensis) Cholera Measles (Rubeola imported or indigenous) Rubella (German Measles) Viral Hemorrhagic Fever (Ebola, Lassa, Marburg, Clostridium perfringens Neisseria meningitidis (invasive infection) Severe Acute Respiratory Syndrome- Crimean Congo, etc.) (foodborne infection) Outbreaks of Any Infectious Disease associated Coronavirus (SARS-CoV) Yellow Fever Diphtheria Pertussis Class B Diseases/Conditions - Reporting Required Within 1 Business DayDiseases of public health concern needing timely response because of potential of epidemic spread-report by the end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known.

Amoeba (free living infection: Acanthamoeba, Chagas Disease Hepatitis B (perinatal infection) Mumps Naegleria, Balamuthia, others) Chancroid Hepatitis E Salmonellosis Anaplasmosis Escherichia coli, Shiga-toxin producing Herpes (neonatal) Shigellosis Arthropod-Borne Viral Infections (West Nile, (STEC), including E. coli O157:H7 Human Immunodeficiency Virus2 [(HIV), Syphilis¹ Dengue, St, Louis, California, Eastern Granuloma Inguinale infection in pregnancy] Tetanus Equine, Western Equine, Chikungunya, Hantavirus (infection or Pulmonary Syndrome) Human Immunodeficiency Virus2 [(HIV), Tuberculosis3 (due to M. tuberculosis, Usutu, and others) Hemolytic-Uremic Syndrome perinatal exposure] M. bovis, or M. africanum) Aseptic Meningitis Hepatitis A (acute illness) Legionellosis Typhoid Fever Babesiosis Hepatitis B (acute illness and carriage in pregnancy) Malaria Class C Diseases/Conditions - Reporting Required Within 5 Business DaysDiseases of significant public health concern-report by the end of the workweek after the existence of a case, suspected case, or a positive laboratory result is known.

Acquired Immune Deficiency Giardiasis Listeriosis Staphylococcal Toxic Shock Syndrome Syndrome3 (AIDS) Glanders (Burkholderia mallei) Lyme Disease Streptococcal Disease, Group A (invasive Anaplasma Phagocytophilum Gonorrhea¹ (genital, oral, ophthalmic, pelvic Lymphogranuloma Venereum1 disease) Blastomycosis inflammatory disease, rectal) Melioidosis (Burkholderia pseudomallei) Streptococcal Disease, Group B (invasive Campylobacteriosis Hansen’s Disease (leprosy) Meningitis, Eosinophilic (including disease) Chlamydial infection¹ Hepatitis C (acute illness) those due to Angiostrongylus infection) Streptococcal Toxic Shock Syndrome Coccidioidomycosis Histoplasmosis Nipah Virus Infection Streptococcus pneumoniae, invasive disease Cryptococcosis (C. neoformans and C. gattii) Human Immunodeficiency Virus2 (HIV Non-gonococcal Urethritis Transmissible Spongiform Encephalopathies Cryptosporidiosis (infection other than as in Class B) Ophthalmia neonatorum (Creutzfeldt-Jacob Disease & variants) Cyclosporiasis Human T Lymphocyte Virus (HTLV Psittacosis Trichinosis Ehrlichiosis (human granulocytic, human I and II infection) Spotted Fevers [Rickettsia species including Varicella (chickenpox) monocytic, E. chaffeensis and E. ewingii) Leptospirosis Rocky Mountain Spotted Fever (RMSF)] Vibrio Infections (other than cholera) Enterococcus, Vancomycin Resistant Staphylococcus aureus (MRSA), invasive infection Yersiniosis [(VRE), invasive disease]

Class D Diseases/Conditions - Reporting Required Within 5 Business Days

Cancer Heavy Metal (arsenic, cadmium, mercury) Phenylketonuria4 Severe Traumatic Head Injury Carbon Monoxide Exposure and/or Poisoning5 Exposure and/or Poisoning (all ages)5 Pneumoconiosis (asbestosis, berylliosis, silicosis, Severe Undernutrition (severe anemia, failure to Complications of Abortion Hemophilia4 byssinosis, etc.) thrive) Congenital Hypothyroidism4 Lead Exposure and/or Poisoning (all ages)4, 5 Radiation Exposure, Over Normal Limits Sickle Cell Disease4 (newborns) Galactosemia4 Pesticide-Related Illness or Injury (all ages)5 Reye’s Syndrome Spinal Cord Injury Sudden Infant Death Syndrome (SIDS) Case reports not requiring special reporting instructions (see below) can be reported by mail or facsimile on Confidential Disease Report forms (2430), fascimile (504) 568-8290, telephone (504) 568-8313, or (800) 256-2748 for forms and instructions.¹Report on STD-43 form. Report cases of syphilis with active lesions by telephone, within one business day, to (504) 568-8374.²Report to the Louisiana HIV/AIDS Program: Visit www.hiv.dhh.louisiana.gov or call 504-568-7474 for regional contact information.3Report on form TB 2431 (8/94). Mail form to TB Control Program, DHH-OPH, P.O. Box 60630, New Orleans, LA. 70160-0630 or fax both sides of the form to (504) 568-5016 4Report to the Louisiana Genetic Diseases Program and Louisiana Childhood Lead Poisoning Prevention Programs: www.genetics.dhh.louisiana.gov or fascimile (504) 568-8253, telephone (504) 568-8254, or (800) 242-31125Report to the Section of Environmental Epidemiology and Toxicology: www.seet.dhh.louisiana.gov or call (225) 342-7136 or (888) 293-7020

All laboratory facilities shall, in addition to reporting tests indicative of conditions found in §105, report positive or suggestive results for additional conditions of public health interest. The following findings shall be reported as detected by laboratory facilities: 1. adenoviruses; 2. coronaviruses; 3 .enteroviruses; 4. hepatitis B (carriage other than in pregnancy); 5. hepatitis C (past or present infection ); 6. human metapneumovirus; 7. parainfluenza viruses; 8. respiratory syncytial virus; and 9. rhinoviruses.