Zoonotic Disease Updates - Texas Department of State ...€¦ · Zoonotic Disease Updates Epidemiology and Laboratory Capacity Conference – Sept. 2019 ... skin contact or inhalation

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

09/25/2019 DSHS ELC Conference 2

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


https://phil.cdc.gov/phil/details.asp

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


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)


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


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


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


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


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


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


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


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

*



-

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.


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)


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



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



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)


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


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


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


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


https://www.cdc.gov/malaria/about/distribution.html

• 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

https://www.cdc.gov/vhf/ebola/history/distribution-map.html

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.


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


https://https://www.cdc.gov/parasites/malaria/index.html

https://https://www.cdc.gov/malaria/travelers

https://https://www.cdc.gov/malaria/diagnosis_treatment

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


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!


www.cdc.gov/lyme/stats/tables.html

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


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.


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/


https://wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017

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.”


More on Zoonoses

• Thursday Breakout Session Zoonotic Disease Investigations

10:15 am

• Regional Zoonosis Control Officeshttp://www.dshs.texas.gov/idcu/health/zoonosis/contact/


http://www.dshs.texas.gov/idcu

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]


mailto:E-mail:[email protected]

www.TexasZoonosis.org

https://www.dshs.texas.gov/idcu/health/zoonosis/contact

Thank you Kelly Broussard, MPH

Briana O’Sullivan, MPH Laura E. Robinson, DVM, MS

Zoonosis Control Branch 09/25/2019 DSHS ELC Conference 36