Reportable Disease Section Update Local Health Department Nurses Meeting August 15, 2013 T.J. Sugg, MPH

1. Reportable Disease Section Update Local Health Department Nurses Meeting August 15, 2013 T.J. Sugg, MPH

2. Objectives • Introduce new regional epidemiologists • Staffing changes on the Reportable Diseases Section • Highlight changes to MERS-CoV guidance (*denotes changes) • Provide an update on Campylobacter, Cryptosporidium, Salmonella, STEC (Shiga toxin-producing E. coli), and pertussis activity. • Discuss FDA recall of contaminated calcium gluconate infusions • Important Points • Brief Updates

3. New Regional Epidemiologists • Amanda England – Lake Cumberland • Molly Jernigan – Buffalo Trace • Big Sandy – Vacant • Lesia Smith is now the regional epidemiologist in the Capital Region (Northern Bluegrass ADD)

4. RDS Staffing Updates • Kristy Royalty has accepted a position in Family Planning and Women’s Health. • The following KDPH staff have been assigned the diseases/conditions for which Kristy was responsible. • Haemophilusinfluenzae – Melissa Eastman • Pertussis – Leslie Minch • Hepatitis B – Jim Britton • Legionella – Stacy Davidson • Meningococcal disease – Sandy Kelly • Streptococcus pneumoniae, invasive– Peggy Ellis • Q fever – Peggy Ellis • Streptococcal, toxic shock syndrome – T. J. Sugg • Staphylococcal, toxic shock syndrome – T.J. Sugg

5. Middle East Respiratory Syndrome Coronavirus (MERS-CoV) • Novel coronavirus that emerged in 2012 • Causes severe acute respiratory illness • First cluster of 2 cases occurred near Amman, Jordan April 2012

6. MERS-CoV Symptoms • Severe acute respiratory illness: • Fever • Cough • Shortness of breath • Illness onsets were from April 2012 through July 2013 • Some cases have had atypical presentations: • Initially presented with abdominal pain and diarrhea and later developed respiratory complications

7. MERS-CoV Transmission • Airborne • Incubation period is 10-14 days • The following have been observed: • Transmission between close contacts • Transmission from infected patients to healthcare personnel • Eight clusters of illnesses have been reported by six countries • So far, all cases have a direct or indirect link to one of four countries: Saudi Arabia, Qatar, Jordan, and the United Arab Emirates

8. MERS-CoV Cases*

9. Patient Under Investigation (PUI)* • Any PUI should be reported to state and local health departments immediately • PUI Criteria: • Fever (≥38°C, 100.4°F) and pneumonia or acute respiratory distress syndrome (based on clinical or radiological evidence); AND EITHER • History of travel from countries in or near the Arabian Peninsula within 14 days before symptom onset; OR • Close contact with a symptomatic traveler who developed fever and acute respiratory illness (not necessarily pneumonia) within 14 days after traveling from countries in or near the Arabian Peninsula; OR • Is a member of a cluster of patients with severe acute respiratory illness (e.g. fever and pneumonia requiring hospitalization) of unknown etiology in which MERS-CoV is being evaluated, in consultation with state and local health department.

10. Close Contact • Any person who provided care for the patient, including a healthcare worker or family member, or had similarly close physical contact • Any person who stayed at the same place (lived with, visited) as the patient while the patient was ill

11. Recommendations for PUI • All clusters of severe acute respiratory illness (SARI) should be investigated. If no obvious etiology is identified, local public health officials should be notified and testing for MERS-CoV conducted if indicated • Local health departments should notify DPH immediately of SARI clusters and PUIs • Local health departments should collect data on the PUI using the form available at: http://www.cdc.gov/coronavirus/mers/guidance.html and fax to RDS secure fax 502-696-3803

12. Probable Case Definition* • A PUI with absent or inconclusive** laboratory results for MERS-CoV infection who is a close contact of a laboratory-confirmed MERS-CoVcase. **Examples of laboratory results that may be considered inconclusive include a positive test on a single PCR target, a positive test with an assay that has limited performance data available, or a negative test on an inadequate specimen. Identification of another etiology does not exclude someone from being classified as a probable case.

13. Confirmed Case Definition • A confirmed case is any person with laboratory confirmation of infection with MERS-CoV (PCR)

14. Infection Control Recommendations • Standard, contact, and airborne precautions are recommended for management of hospitalized patients with known or suspected MERS-CoV infection. • Airborne Infection Isolation Room (AIIR) • If unavailable, transport to another facility • Place facemask on patient and isolate in a single-patient room with door closed. Air should not recirculate without HEPA filtration

15. Collection of Laboratory Specimens • Determine if patient meets PUI criteria • CDC recommends collecting multiple specimens from different sites at different times after symptom onset. • Collect: • An upper respiratory specimen: • Nasopharyngeal ANDoropharyngeal swab • A lower respiratory specimen: • Broncheoalveolar lavage, OR • Tracheal aspirate, OR • Pleural fluid, OR • Sputum • Serum for eventual antibody testing (tiger top tube) • Should be collected during acute phase during first week after onset, and again during convalescence ≥ 3 weeks later

16. MERS Resources • MERS overview:http://www.cdc.gov/coronavirus/mers/index.html • Case definitions and guidance: http://www.cdc.gov/coronavirus/mers/case-def.html • Additional MERS resources: http://www.cdc.gov/coronavirus/mers/related-materials.html

17. Campylobacteriosis

19. Campylobacter Investigation • Complete the Enteric Disease Investigation Form for each case of Campylobacteriosis • Enter the data into NEDSS for all suspect, probable, and confirmed cases • Work with local laboratories to ensure isolates are sent to DLS

20. Cryptosporidiosis

22. Salmonellosis

25. Shiga toxin-producing E. coli(STEC)

27. Pertussis

30. Calcium Gluconate Recall

31. FDA Recall – Specialty Compounding, Cedar Park, TX • FDA is alerting health care professionals not to use any sterile products supplied by Specialty Compounding, Cedar Park, TX • Bacterial infections have been associated with contaminated sodium gluconate infusions. • Fifteen patients in two TX hospitals developed bacterial bloodstream infections caused by Rhodococcusequi. • Cultures from intact samples of calcium gluconate compounded by Specialty Compounding show growth of bacteria consistent with Rhodococcus species • Healthcare professions should report any adverse reactions to FDA’s MedWatch program

32. Important Points • Begin the investigation of Salmonellosis and STEC cases upon receipt of preliminary or presumptive positive Salmonellaspecies or and EIA screen for shiga-like E. coli results. • STEC is an illness that can be complicated by hemolytic uremic syndrome (HUS) or thrombocytopenic purpura (TTP). • Ensure that isolates are sent to DLS for confirmatory testing. • Remember to click “Create Notification” when you enter additional lab reports. Do not create another investigation.

33. Important Points Cont’ • If preliminary results are reported for Campylobacter, the case is “suspect”. Since the bacterium was detected, even though the results may be preliminary, the case is considered “suspect” and should be investigated and entered into NEDSS just as it would if it were “confirmed”. If DLS is unable to confirm the bacterium, the case is still considered a“suspect” case and should still be investigated and reported. Campylobacter is a fragile organism and often the bacterium dies during transport to DLS. Lack of confirmation from DLS does not negate the original lab result (preliminary). If DLS is able to isolate the bacterium, the case status will then change to “confirmed”. • Treat all reports of Campylobacter the same. All cases (whether suspect, confirmed or probable) should be investigated and the lab reports and enteric questionnaire responses entered into NEDSS.

34. Brief Updates • FB/WB Outbreak Investigation Manual is under revision. Updated version will be released in December 2013. • Reportable Disease Annual Summaries were released last week. Two 5-year summaries (2003-2007 and 2008-2012) and one 10-year summary (2003-2012). A more detailed report will be released later this year. • Please include the name of the reporting laboratory in NEDSS in the “Text Results” box in the lab report section. This is valuable information for RDS and DLS. • Please monitor Outreach regularly and enter final lab results for your cases.

35. Brief Updates Cont’ • Clinician guidance for harmful algal blooms (HAB) is undergoing review and approval. Once approved, KDPH will release it to LHDs and health care providers. • Please complete the food and beverage form of the Enteric Disease Investigation Form in NEDSS. • RDS will be working with IT to develop online NEDSS training modules. • Kentucky Infection Prevention Boot Camp: • September 11-14, Somerset, KY

36. Questions?Thank you!!