Sherif Ibrahim, MD, MPHDivision of Infectious Disease Epidemiology

May, 2011

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Describe 2010 Outbreaks Discuss types of outbreak reported in

2010 Describe healthcare-associated

outbreaks (HAOs) Conclusions and lessons learned Recommendations

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In WV, outbreaks are reportable immediately to local health departments(LHDs)

LHDs are required to report outbreaks to Bureau for Public Health (BPH) within 60 minutes

LHDs report and investigate outbreaks with assistance from regional epidemiologists & BPH

There was a 13-fold increase in reported outbreaks

from 2001 to 2010

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124 outbreaks were reported 96 (77.4%) were confirmed 28 (51%) counties reported outbreaks Jurisdictions

95 (99%) were limited to WV residents 1 (1%) involved residents of other states

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Type of Outbreaks

Number of Outbreaks Percent

Enteric 35 36.5%

Rash 33 34.4%

Respiratory 26 27%

Other 2 2.1%

Total 96 100%

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Total: 35 16 (29%) counties 1 reported multi-state outbreak (CDC: Lead) Norovirus and acute gastroenteritis: 28 (80%) Acute gastroenteritis outbreaks were defined as

“outbreaks of illness with short duration (2-3 or fewer days) and characterized by acute onset of vomiting and /or diarrhea and no laboratory confirmation”.

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Transmission SettingsNumber of Outbreaks Percent

Healthcare Facilities 22 62.8%Schools 4 11.4%Communities 3 8.6%Households 2 5.6%Banquet 1 2.9%Basketball tournament 1 2.9%Restaurant 1 2.9%Schools / Community 1 2.9%Total 35 100%

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Etiologic AgentNumber of Outbreaks Percent

Norovirus 16 45.7%

Acute Gastroenteritis (Undetermined etiology) 12 34.3%

Salmonella Species 3 8.6%

Hepatitis A 2 5.7%

Bacillus cereus 1 2.9%

Shigella sonnei 1 5.7%

Total 35 100%

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Salmonella serotype Enteritidis: Family of 10 from 3 households 6 cases (3 confirmed and 3 probable)

  Salmonella serotype Montevideo:

One WV resident among 272 US residents Traced to salami products containing contaminated

imported black and red pepper.

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Salmonella serotype Enteritidis 18 confirmed and 4 probable cases. Case control study illness associated with

eating at multiple locations of a single chain restaurant

Lab (PFGL &MLVA) 11 isolates were identical Identical to a 2009 outbreak strain associated

with multiple locations of the same chain restaurant

Recommendations to the corporate

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First Hepatitis A OutbreakTwo family membersEpi-link to a hepatitis A outbreak in a

daycare in KYHepatitis A is asymptomatic in children < 6 years in 70% of cases

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Second  Hepatitis A Outbreak  

11 casesDelayed reporting (2 months) Retrospective identification of several casesTransmissionperson-to-person among

friends and secondary spread to households

LHD press releases, education, outreach and community-wide vaccination

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The outbreak 10 family members acute gastroenteritis Pizza from a local restaurant Laboratory testing of the patients was negative Testing of the remaining pizza at OLS revealed

contamination with Bacillus cereus Bacillus cereus:

B. cereus is an aerobic, spore-forming, gram-positive rods Food-poisoning can result from two types of toxins Diarrheal syndrome : (incubation period of 10-12 hrs)

associated with heat-labile (meat, stews, gravies) Emetic syndrome: (incubation period of 1-6 hrs) associated

with a heat-stable toxin (fried rice, meat, improper refrigeration)

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Clinical Diagnosis Number of outbreaks Percent

Varicella (Chickenpox) 20 60.6%

Scabies 8 24.2%

Hand, Foot and Mouth Disease 2 6.1%

Skin infection - MRSA 2 6.1%

Rash / Folliculitis 1 3.0%

Total 33 100%

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A ten-fold increase from 2009. Varicella Vaccine Effectiveness Project:

Hired two full-time staff Offered free laboratory testing Active surveillance in WV public schools Education campaign Change in varicella outbreak definition for schools

19 from schools and 1 from a community. Lab testing

7 laboratory confirmed 3 negative or non-contributory 10 did not have laboratory testing.

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Transmission Settings

Number of outbreaks Percent

LTCFs 5 62.5%

Jail 1 12.5%

School 1 12.5%

Women Shelter 1 12.5%

Total 8 100%

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Incubation period: 2-6 weeks Outbreak definition: 2 or more cases of scabies

among residents/staff within 4-6 week Confirm the diagnosis consult a dermatologist Isolation /exclusion of ills a day after effective

treatment Offer treatment to contacts /families Provide education Environmental measures

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Total 26 (27%) Reported by 14 (25%) counties. In 2009 53 respiratory disease

outbreaks No influenza outbreaks in 2010

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Clinical SyndromeNumber of Outbreaks Percent

Upper Respiratory Illness 16 61.6%Pertussis (Whooping Cough) 5 19.2%

Streptococcal Pharyngitis 3 11.6%

Influenza-Like Illness 1 3.8%

Upper Respiratory Illness / Pneumonia 1 3.8%Total 26 100%

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16 outbreaks 15 from LTCFs and one from a school Case definition: new onset of at least two of the

following symptoms: Runny nose or sneezing Stuffy nose / congestion Sore throat / hoarseness Difficulty swallowing Dry cough, and/or cervical lymphadenopathy

Rule out allergy Rule out influenza fever of 100 or more

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Total # 5 Reported by 4 Counties 4 Communities and 1 daycare No pertussis-related deaths All outbreaks were PCR confirmed Cyclical pattern every 3-5 years Vaccine is not 100% effective

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2 outbreaks of conjunctivitis (pink eye) Reported from schools Laboratory testing1 was not done1 negative or non-contributory

Testing can be done for these outbreaks Hand washing and environmental cleaning

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Clinical Diagnosis Number of Outbreaks Percent

Varicella (Chickenpox) 20 74.1%

Pertussis (Whooping Cough) 5 18.5%

Hepatitis A 2 7.4%

Total 27 100%

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Outbreaks where exposure / transmission is associated with healthcare facility(ies)

43 (45%) 16 Counties (29%) 41 (95%) from LTCFs and 2 (5%) from

hospitals. 33 in 2009 55 in the first 3 months, 2011(90% from

LTCFs)

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Type of outbreak

Number of Outbreaks Percent

Enteric 22 51.2%

Respiratory 16 37.2%

Rash 5 11.6%

Total 43 100%

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URI outbreak in a LTCF complicated by pneumonia AR: 47% and Death rate 1% HMPV:

Identified in 2001 RNA virus related to RSV and PIV Transmission: droplet and contact Seasonality: winter and spring IP: 2-8 days At-risk populations: infants, children, elderly and LTCFs Clinical presentation: URI, pharyngitis, pneumonia,

bronchiolitis CXR findings: diffuse interstitial infiltrates, hyperinflation Precautions: standard and contact (droplet if indicated)

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81 (81.4%) outbreaks with complete data on date and time of reporting Mean= 35.8 hours Median= 1 hours Range= 0 to 864 hours 71 (88%) same day notification

 15 (15.6%) outbreaks were missing info on date and/or time of reporting

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LHD is required to report outbreaks within 60 minutes under Reportable disease rules Threat preparedness funding Program plan

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Scientific and technical support Case definition Diagnosis and prevention measures Descriptive epidemiology Special studies if needed

Laboratory support Resources support Communication support

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Marked improvement in reporting and management of outbreaks in WV

Outbreak investigation requires: Problem-solving skills, training and experience Collaboration between epidemiology, laboratory

and environmental Collaboration between local, regional, healthcare

providers, state, and CDC Most HAOs are reported from LTCFs

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Report outbreaks to DIDE within 60 minutes Use DIDE’s guidelines for outbreak investigation Consult and get assistance from your regional

epidemiologist (Field investigation, Training) Training and education Plan to improve your communication with LTCFs Feedback information on outbreaks to reporting

sources and other partners Outbreaks = opportunities for improvements

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Outbreak Report, West Virginia, 2010

http://www.wvidep.org/Portals/31/PDFs/IDEP/Outbreaks/2010_Final_%20Outbreak%20Report.pdf

Contact Information:304-558-5358 OR 800-423-1271 (24/7)

Office:304-356-4074 Cell: 304-553-9165

sherif.m.ibrahim@wv.gov

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Questions

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