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Health and Wellness for all Arizonans azdhs.gov State of the State APIC Meeting January 25, 2013.

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Presentation on theme: "Health and Wellness for all Arizonans azdhs.gov State of the State APIC Meeting January 25, 2013."— Presentation transcript:

1 Health and Wellness for all Arizonans azdhs.gov State of the State APIC Meeting January 25, 2013

2 Health and Wellness for all Arizonans azdhs.gov Agenda 1:35 – 1:45 pm Introduction and MEDSIS – Shoana/Sara 1:45 – 1:55 pm Vaccine Preventable Disease – Karman Tam 1:55 – 2:05 pm Cocci –Clarisse Tsang 2:05 – 2:15 pm Flu – Shane Brady 2:15 – 2:25 pm HAI – Jason Lempp/Vinita Oberoi 2:25 – 2:40 pm Vector/RMSF – Selam Tecle and Erica Weis 2:40 – 2:50 pm Foodborne – Evan Henke 2:50 – 3:05 pm STD – Roxanne Ereth 3:05 – 3:20 pm HIV – Rick DeStephens 3:20 – 3:35 pm TB – Eric Hawkins 3:35 – 4:00 pm Questions

3 Health and Wellness for all Arizonans azdhs.gov New Year, New MEDSIS Please remember to sign your new user agreement For questions or MEDSIS access, please contact:

4 Health and Wellness for all Arizonans azdhs.gov Meaningful Use Public Health Objectives – Electronic Laboratory Reporting – currently accepting – Immunization Registry – currently accepting – Syndromic Surveillance – will be contacting hospitals shortly

5 Health and Wellness for all Arizonans azdhs.gov Vaccine Preventable Diseases APIC State of the State January 25, 2013 Karman Tam, MPH Office of Infectious Disease Services Arizona Department of Health Services

6 Health and Wellness for all Arizonans azdhs.gov *confirmed and probable cases

7 Health and Wellness for all Arizonans azdhs.gov Pertussis in Arizona 2012 (preliminary) 962 cases 507 confirmed 455 probable cases 160 confirmed 707 probable

8 Health and Wellness for all Arizonans azdhs.gov *confirmed and probable cases

9 Health and Wellness for all Arizonans azdhs.gov Pertussis Testing

10 Health and Wellness for all Arizonans azdhs.gov

11 Health and Wellness for all Arizonans azdhs.gov Mohave County Pertussis Outbreak 92 cases (72 confirmed, 20 probable) to date

12 Health and Wellness for all Arizonans azdhs.gov Calling All Health Care Workers! Get Vaccinated Against Pertussis! Only 20% of HCW’s in the U.S. have received the adult vaccine for pertussis (Tdap) Only ONE dose of Tdap is needed! Protect yourself Protect your patients and their families Protect infants under <1 year old According to the CDC, Tdap vaccination in adults: – Reduces incidence of pertussis in infants – Reduces complications in high-risk individuals

13 Health and Wellness for all Arizonans azdhs.gov Arizona Partners Against Pertussis (APAP) Goal: Achieve 100% pertussis vaccination rate by April 1, 2013 Prize: Certificate of Participation, recognition on the website, and prizes/money

14 Health and Wellness for all Arizonans azdhs.gov H. flu type B (Hib) in children <5 years confirmed cases - 3 year old: fully immunized - 4 month old: not vaccinated confirmed case

15 Health and Wellness for all Arizonans azdhs.gov Meningococcal Invasive Disease confirmed cases 3 serogroup C 1 serogroup Y 1 serogroup W confirmed cases

16 Health and Wellness for all Arizonans azdhs.gov Measles confirmed cases (siblings) 7 year old: PCR positive, not vaccinated 5 year old: IgM positive, not vaccinated confirmed cases

17 Health and Wellness for all Arizonans azdhs.gov Mumps confirmed cases (siblings) 9 year old: IgM and PCR positive, not vaccinated 12 year old: epi-linked, not vaccinated 13 year old: epi-linked, not vaccinated cases

18 Health and Wellness for all Arizonans azdhs.gov Resources 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings Guideline for infection control in health care personnel, 1998

19 Health and Wellness for all Arizonans azdhs.gov Arizona Vaccines For Children (VFC) Program 2012 Arizona Immunization Program Office (AIPO) Arizona Department of Health Services Patty Gast, M.S., Office Chief (602)

20 Health and Wellness for all Arizonans azdhs.gov Vaccines Distributed in 2012 The Arizona VFC Program provided 1,596,867 vaccines ($81,119,566) to more than 850 private and public immunization providers statewide in AZ – VFC vaccine is for children who are on AHCCCS, Native American or uninsured – 317 vaccine is used in AZ for non-VFC eligible children, such as for insured children who present at County Health Departments

21 Health and Wellness for all Arizonans azdhs.gov Vaccine Policy Changes in 2012 Important federal vaccine policies changes were instituted in October 1, 2012, as required by VFC: Federal vaccine may no longer be used for PRIVATELY insured children. – Most county health departments are trying to develop a private stock of vaccine and insurance billing programs in order to continue serving privately insured children. County health departments are encountering significant challenges in developing these programs, and we are concerned about where these children can get immunized in the meantime.

22 Health and Wellness for all Arizonans azdhs.gov Vaccine Policy Changes Upcoming mid-year 2013 – our federal vaccine can not be used for underinsured children in private provider offices. – However, a safety net for these children is being established: county health departments and 24 providers statewide are being deputized with authority from a Federally Qualified Health Center (FQHC) to use VFC vaccine on underinsured children. FQHCs and Rural Health Centers (RHCs) already have this authority. – This means that starting in July 2013 (approximately) underinsured children will have to pay out of pocket at their private provider’s office or go to a county, deputized provider, FQHC or RHC to receive free vaccine. – For now, in the first half of 2013, all providers should continue using our vaccine on underinsured children. – As the Affordable Care Act rolls out in 2014, there will hopefully be fewer and fewer underinsured children.

23 Health and Wellness for all Arizonans azdhs.gov Vaccine Policy Changes These policies have affected hospitals’ ability to participate in the Arizona VFC Program, as we previously supplied the Hepatitis B birth dose universally, but now we are not able to do so. Several hospitals have dropped out of the VFC Program, but are offering the birth dose to privately insured children at their own expense. There will always be sufficient vaccine for VFC eligible children.

24 Health and Wellness for all Arizonans azdhs.gov Additional Updates New ADHS manual for preventing perinatal hepatitis B virus infections: with chapters specifically aimed at OBs, hospitals, pediatricians, and health departments. It can be found on the ADHS immunization website under AIPO Program Activities—perinatal hepatitis B prevention. March of Dimes sponsoring coalition of 17 health care organizations entitled Arizona Partners Against Pertussis (APAP): Contest to have employers get staff 100% immunized with Tdap. Deadline April 1, Details on TAPI’s website at AIPO started doing a small pilot project with a rural pharmacy to see if a pharmacy can serve as a VFC vaccine provider in Arizona. FDA has approved Varizig (varicella immune globulin) for prophylaxis in high risk individuals, and has extended use to 10 days (MMWR March 30, 2012).

25 Health and Wellness for all Arizonans azdhs.gov Additional Updates Waiting for MMWR to publish provisional recommendations from ACIP vote on: – Tdap for every pregnant woman during every pregnancy – Measles recommendation changes, including MMR down to 6 months old for international travel and 2 doses of MMR for > 12 months old for international travel ADHS study showed risk factors for having 1 st hepatitis B vaccine >14 days versus 1 st in 3 days. – Babies born to mothers with private insurance were twice as likely to miss the HBV vaccine birth dose – Babies born to mothers with complications during labor or delivery were more than twice as likely to miss the HBV vaccine birth dose than when the mother experienced no complications

26 Health and Wellness for all Arizonans azdhs.gov Additional Updates All influenza vaccines this season are trivalent. – Looking to the future. New influenza vaccines will likely be available next season Live attenuated quadrivalent vaccines: both intranasal and injection. (H1N1, H3N2, and 2 Bs) First influenza vaccine grown with cell culture technology (dog kidney cells). No risk for egg allergic patients.

27 Health and Wellness for all Arizonans azdhs.gov Thank you! Please contact Karman Tam for more information: (602)

28 Health and Wellness for all Arizonans azdhs.gov Clarisse Tsang, MPH Acting Program Manager Infectious Disease Epidemiology APIC: January 25, 2013 Coccidioidomycosis in Arizona

29 Health and Wellness for all Arizonans azdhs.gov Impact of Cocci on Arizonans 60% of all reported US cases are in Arizona 2 nd most commonly reported infectious disease Symptoms last for a median of 4 months In 2007, $83 million was spent on cocci for hospital visits

30 Health and Wellness for all Arizonans azdhs.gov Surveillance: Cocci Case Definition Council for State and Territorial Epidemiologists (CSTE) – Updated in 2007 Clinical case definition Lab criteria* Arizona Department of Health Services (ADHS) – Since 1997 No clinical symptoms required Lab criteria* *Lab criteria for diagnosis includes either detection of IgM by immunodiffusion (ID), enzyme immunoassay (EIA), latex agglutination, or tube precipitin OR IgG by ID, EIA, or complement fixation (CF) OR cultural, histopathologic, or molecular evidence of Cocci species

31 Health and Wellness for all Arizonans azdhs.gov Rates of Reported Cocci Cases, Arizona, Lab Reportable Change in EIA Reporting

32 Health and Wellness for all Arizonans azdhs.gov Reported Cocci Cases, Age and Gender Year Age (median, mean) Gender (% female)p-value (Gender) 2007 vs X subgroup , 5145%n/a , 5048%n/a , 4755%n/a , 4758%n/a 2011* (2/14-12/31) 47, 4758%p < EIA alone46, 4662%p < other positive results52, 5043%p = 0.07 *2011 Numbers are provisional and have not been finalized n/a = have not analyzed yet

33 Health and Wellness for all Arizonans azdhs.gov Reported Cocci Cases by Age, Reported cases per 100,000

34 Health and Wellness for all Arizonans azdhs.gov

35 Health and Wellness for all Arizonans azdhs.gov Provider Education Brochures and posters about cocci testing for providers CME for the PCP: https://www.vfce.arizona.edu/clinicians/Free OnineCME.aspx https://www.vfce.arizona.edu/clinicians/Free OnineCME.aspx Annual Valley Fever Awareness Week in November

36 Health and Wellness for all Arizonans azdhs.gov

37 Health and Wellness for all Arizonans azdhs.gov Public Education Brochures with cocci info for the public Video: “Valley Fever: The Impact on Arizonans”

38 Health and Wellness for all Arizonans azdhs.gov 1.

39 Health and Wellness for all Arizonans azdhs.gov Resources ADHS website: Valley Fever Center for Excellence:

40 Health and Wellness for all Arizonans azdhs.gov Thank you! Questions? Clarisse Tsang

41 Health and Wellness for all Arizonans azdhs.gov Influenza: Shane Brady, MPH Influenza Epidemiologist

42 Health and Wellness for all Arizonans azdhs.gov Season Early flu season around the country First case confirmed on October 30th, 2012 with activity intensifying in the last few weeks Vaccine is a good match to all three circulating strains – an A/California/7/2009 (H1N1)pdm09-like virus – an A/Victoria/361/2011 (H3N2)-like virus – a B/Wisconsin/1/2010-like virus (from the B/Yamagata lineage of viruses)

43 Health and Wellness for all Arizonans azdhs.gov Lab-confirmed influenza cases,

44 Health and Wellness for all Arizonans azdhs.gov Age Groups by Flu Type

45 Health and Wellness for all Arizonans azdhs.gov State Lab Data: PCR & cultures,

46 Health and Wellness for all Arizonans azdhs.gov Percentage of Visits for Influenza-like illness at sentinel outpatient providers,

47 Health and Wellness for all Arizonans azdhs.gov School surveillance Approx. 300 schools around the state participate in an automated surveillance program that pulls data from the school nurses’ database – Analyzed weekly for influenza-like illness visits to school nurses’ office – Seeing a small increase in activity now Some counties have additional school surveillance: – Maricopa: Has web-based system to collect information from participating schools on student absences due to ILI, respiratory diseases, GI diseases and other reasons. Plans to expand system.

48 Health and Wellness for all Arizonans azdhs.gov Pediatric Flu-Associated Mortality One case this season: – Yavapai County child 5 years old – PCR confirmed influenza A (H3) and RSV – Underlying conditions – Not vaccinated

49 Health and Wellness for all Arizonans azdhs.gov Antiviral resistance (national) Oseltamivir: Resistant Viruses, Number (%) Zanamivir: Resistant Viruses, Number (%) Influenza A (H3N2)None (671* tested) Influenza BNone (263 tested) 2009 Influenza A (H1N1) None (85* tested)None (55 tested) Neuraminidase inhibitors continue to show very little resistance (e.g., Tamiflu). Adamantanes are not useful as high levels of resistance persist among 2009 influenza A (H1N1) and A (H3N2) viruses. *Includes specimens tested in national surveillance and additional specimens tested at public health laboratories in four states (AZ, MD, NY, and PA) who share testing results with CDC.

50 Health and Wellness for all Arizonans azdhs.gov Antiviral Treatment Clinical trials and observational data show that early antiviral treatment may do the following: shorten the duration of fever and illness symptoms reduce the risk of complications from influenza (e.g., otitis media in young children, pneumonia, respiratory failure) and death shorten the duration of hospitalization

51 Health and Wellness for all Arizonans azdhs.gov CDC Recommendations for Influenza Antiviral Medications for the Season Clinical benefit is greatest when antiviral treatment is administered early – ideally within 48 hours of symptom onset However, antiviral treatment might still be beneficial in patients with severe, complicated, or progressive illness and in hospitalized patients when started after 48 hours of illness onset

52 Health and Wellness for all Arizonans azdhs.gov CDC Recommendations (cont’d) Antiviral treatment is recommended as early as possible for any patient with confirmed or suspected influenza who is hospitalized; has severe, complicated, or progressive illness; or is at higher risk for influenza complications. This list includes:

53 Health and Wellness for all Arizonans azdhs.gov children younger than 2 years; [ii] adults aged 65 years and older; [ii] persons with immunosuppression, including that caused by medications or by HIV infection; women who are pregnant or postpartum (within 2 weeks after delivery); persons aged younger than 19 years who are receiving long-term aspirin therapy; American Indians/Alaska Natives; persons who are morbidly obese (i.e., body-mass index is equal to or greater than 40);

54 Health and Wellness for all Arizonans azdhs.gov residents of nursing homes and other chronic-care facilities. persons with the following conditions: o chronic pulmonary (including asthma) o cardiovascular (except hypertension alone) o renal, hepatic, hematological (including sickle cell disease), metabolic disorders (including diabetes mellitus) o neurologic and neurodevelopment conditions (including disorders of the brain, spinal cord, peripheral nerve, and muscle such as cerebral palsy, epilepsy [seizure disorders], stroke, intellectual disability [mental retardation], moderate to severe developmental delay, muscular dystrophy, or spinal cord injury);

55 Health and Wellness for all Arizonans azdhs.gov Additional Updates All influenza vaccines this season are trivalent. – Looking to the future. New influenza vaccines will likely be available next season Live attenuated quadrivalent vaccines: both intranasal and injection. (H1N1, H3N2, and 2 Bs) First influenza vaccine grown with cell culture technology (dog kidney cells). No risk for egg allergic patients.

56 Health and Wellness for all Arizonans azdhs.gov Resources ADHS Weekly Activity Reports: m CDC Website:

57 Health and Wellness for all Arizonans azdhs.gov Thank you! Shane Brady

58 Health and Wellness for all Arizonans azdhs.gov Healthcare Associated Infections Program: Selected 2012 Investigations January 25 th, 2013 APIC Grand Canyon “State of the State” Health Services Advisory Group Jason Matthew Lempp, MPH CDC/CSTE Applied Epidemiology Fellow Healthcare Associated Infections Epidemiologist Arizona Department of Health Services (ADHS) Office of Infectious Disease Services 58 Jason Matthew Lempp, MPH CDC/CSTE Applied Epidemiology Fellow Outbreak Capacity Epidemiologist Office of Infectious Disease Services Arizona Department of Health Services

59 Health and Wellness for all Arizonans azdhs.gov ADHS & Healthcare Associated Infection (HAI) Program Facilitate State HAI Advisory Committee Provide infection prevention technical assistance – Education on best practices – Counties & facilities Assist outbreak and exposure investigations Monitor AZ public HAI data & reportable disease surveillance Build partnerships and capacity to prevent HAIs

60 Health and Wellness for all Arizonans azdhs.gov Arizona HAI Advisory Committee 2008 AZ Legislature – Infection Prevention and Control Advisory Committee (IPCAC) Expanded to HAI Advisory Committee (2010) – Infection preventionists, Nurses, Doctors, Pharmacists, Epidemiologists, Medical industry reps, YOU? – Quarterly Meetings: March 18 th, 2013 State HAI Coordinator – Vinita Oberoi 60 – (602)

61 Health and Wellness for all Arizonans azdhs.gov 61 HAIs Training & EducationPreventionSurveillance Antimicrobial Stewardship Long Term Care Dialysis

62 Health and Wellness for all Arizonans azdhs.gov HAI & Exposures Investigations 62

63 Health and Wellness for all Arizonans azdhs.gov 2012 HAI Investigations ~80 “outbreak” investigations initiated in HCFs ~75% GI related (typically Norovirus) Primarily handled by county health depts ~10% Lice & Mite related (scabies) ~10% Vaccine Preventable or Respiratory Influenza, Pertussis – Disease Specific Epis These are some of the “Others”… HAI “exposure investigations” ≠ “outbreaks” 63

64 Health and Wellness for all Arizonans azdhs.gov MRSA – Pain Management Clinic Severe methicillin-resistant Staphylococcus aureus (MRSA) case led to concern of HAI by treating MD 4 MRSA cases investigated at hospital, similar onsets 3 received recent procedure at same outpatient clinic – sites of infection align with pain treatment injection sites County and ADHS found infection control breaches Single-dose vial of contrast media (radiologic imaging reagent) vial associated with cases seen at clinic 64

65 Health and Wellness for all Arizonans azdhs.gov 1)Dilution of reagents: not manufacturer’s recommendations 2) “Single-dose” vials used for more than one patient Solution: Pharmaceutical Compounding – Sterile preparation by licensed pharmacy or reagent laboratory 3)Insufficient PPE (respirators) during spinal injections Infection Control Issues 65 Contrast Media Reagent Saline

66 Health and Wellness for all Arizonans azdhs.gov Quick 2x2 Statistical Tests Patient 1 Patient 2 Patient 3 Patient 4 Patient 5 Patient 6 Patient 7 Patient 8 Patient 9 Patient 10 Patient 11 Patient 12 Patient 13 Patient 14 Patient 15 Patient 16 Patient 17 Patient 18 Patient 19 Patient 20 Patient 21 Patient 22 Patient 23 Patient 24 Patient 25 Patient 26 Patient 27 Patient Patients seen at clinic on same DOS as 3 cases Patient 15 Patient 21 Patient Patients received contrast media injections ( * ) * * * * * * * * * * Culture Confirmed MRSA Any Contrast ( + )( - ) Yes3710 No Fisher exact: “Morning” versus “Afternoon” Contrast separation MorningMorning AfternoonAfternoon Culture Confirmed MRSA After- noon Contrast ( + )( - ) Yes314 No Fisher exact: *

67 Health and Wellness for all Arizonans azdhs.gov Investigations 67 OUTCOMES Single-dose vials & HAI education campaigns Medication shortage of appropriate doses/concentrations National picture:

68 Health and Wellness for all Arizonans azdhs.gov Hepatitis B – Dialysis Ward Hepatitis B virus (HBV) infected, dialysis patient – out of state visitor to AZ, no medical records Admitted at hospital, received 9 sessions of dialysis – Initial unknown HBV status = received testing – Upon blood borne pathogen (BBP) lab results, HBV+ not communicated – no dedicated machine/HCW 13 dialysis patients used shared dialysis machine 68

69 Health and Wellness for all Arizonans azdhs.gov Infection Control Issues Unknown BBP status should (ideally) receive lab results prior to receipt of hemodialysis Unknown hepatitis status requiring dialysis should have dedicated station, machine and HCW Increased terminal cleaning for unknown & HBV+ BBP results not communicated to nursing staff 69 ? !

70 Health and Wellness for all Arizonans azdhs.gov Outcomes ADHS Infection Control Technical Assistance Visit: Division of Licensing Services Surveyors with Office of Infectious Disease Services Epidemiologists Improved practices with facility No resultant seroconversions 70 Collaboration

71 Health and Wellness for all Arizonans azdhs.gov Hepatitis C – Multi-State Investigation National investigation of hepatitis C virus (HCV) infected traveling HCW, alleged drug diverter 8 states affected, with 17 facilities (AZ = 2) Thousands of patients since 2005 notified Over 30 patients with linked genotypes (NH, KS) 71

72 Health and Wellness for all Arizonans azdhs.gov Infection Control Issues Protocols/systems to monitor narcotics – Automated dispensing cabinets – Limited access to non-essential staff Other issues brought to light: – Employee screening? – Background checks? – National registry for HCWs? 72

73 Health and Wellness for all Arizonans azdhs.gov Outcomes 73 Facility Facility Patient Counts Tested Negative (%); Positive (%) Excluded Deceased; Prior + Contacted** Phone Confirm Letter LTF ALL Total (38.5) 110 (38.2) 1 (0.3)* 18 (6.2) 12 (4.2) 5 (2.1) 54 (18.8) 10 (3.5) 44 (15.3) 105 (36.4) *Positive patient not same genotype as HCW – not linked to NH cluster ** 132 patients calls made by ADHS and LHD – many disconnected #’s No evidence to support that HCV transmission occurred due to traveling HCW exposure Results of HCV testing of two Arizona facilities for patients with exposure to injectable narcotics and cardiac cathiterization lab or other high-risk units National investigation is still ongoing

74 Health and Wellness for all Arizonans azdhs.gov Blood Borne Pathogen Exposure & Laryngoscope Processing LHD contacted ADHS about a outpatient clinic identified by “parent” HCF of gap in infection control Laryngoscopes are semicritical items, requiring “high-level” disinfection – this scope was reportedly cleaned with alcohol but did not routinely receive this level of cleaning. Procedural gap 2008 – patients exposed 74 info/ /Fiber-Optic-Flexible-Ent- Endoscope.html

75 Health and Wellness for all Arizonans azdhs.gov High Level Disinfection High-level disinfection: complete elimination of all microorganisms in or on an instrument, except for small numbers of bacterial spores. The FDA definition: a sterilant used for a shorter contact time to achieve a 6-log10 kill of an appropriate Mycobacterium species. Cleaning followed by high-level disinfection should eliminate enough pathogens to prevent transmission of infection. 75

76 Health and Wellness for all Arizonans azdhs.gov Why BBP Testing? Last DOS 7/12 – most bacterial infections would present by now, leaving primary BBPs – Hepatitis B, Hepatitis C, and HIV Over 200 patients have been tested to date. A small number of patients (< 1%) have been identified with HCV antibody positive results – indicating past or current HCV infection. Investigation ongoing to identify presence or absence of HCV prior to DOS 76

77 Health and Wellness for all Arizonans azdhs.gov HCV 77 m/HepTestingRecsGraphics2012.html Media/ButtonsBadges.htm ~3.25% of birth cohort are anti-HCV (+) = 2.74 million ~75% of which have chronic HCV infection = 2.0 million

78 Health and Wellness for all Arizonans azdhs.gov Contaminated MPA x 2 National Recall: New England Compounding Center Contaminated methylprednisolone (MPA) – None distributed or “used” in AZ Patients receiving injections in other states (n = 4) 2 “cases”; 2 “non-cases” with similar Sx Regional Recall: Nevada compounding center “Contaminated” methyprednisolone – AZ MDs contacted 0 infections; NV investigation = lab contaminant? 78

79 Health and Wellness for all Arizonans azdhs.gov Thank You HAI Advisory Committee and Subcommittee Members Counties helping our prevention and education campaigns Counties and facilities who worked with us on these investigations (you know who you are!) CDC – Division of Healthcare Quality Promotion Division of Viral Hepatitis ADHS – Office of Infectious Disease Services 79

80 Health and Wellness for all Arizonans azdhs.gov Questions? 80 Jason Matthew Lempp (602)

81 Health and Wellness for all Arizonans azdhs.gov 2012 Arizona Vector/Zoonotic Diseases Update Selam Tecle, MPH VBZD Epidemiologist Office of Infectious Disease Services Arizona Department of Health Services

82 Health and Wellness for all Arizonans azdhs.gov 2012 Brucellosis Cases 6 cases reported – 5 Maricopa County, 1 Pinal County Demographics – 4 female, 2 male – Age range: 30 – 69 years; mean: 51 years 4 cases reported consumption of unpasteurized cheese produced out of the country – One case had past exposure to livestock in Guatemala No local high risk exposures reported

83 Health and Wellness for all Arizonans azdhs.gov 2012 Hantavirus Cases 1 case (fatal) reported  Apache County resident Demographics  Male  62 years old Reported exposure to mouse droppings at different locations all within the county Important to remind residents to take precautions when cleaning rodent infested areas

84 Health and Wellness for all Arizonans azdhs.gov 2012 Lyme Disease Cases 13 cases of Lyme Disease were reported in Arizona by following counties: 2 Cochise 1 Coconino 2 Maricopa 1 Mohave 1 Navajo 3 Pima 3 Yavapai All cases had travel history to one of the following endemic areas: Minnesota New York California Maine Rhode Island Massachusetts Pennsylvania Germany Canada *Lyme Disease is not endemic to Arizona. Evidence of the vector (Ixodes pacificus) has only been found in Mohave County at the top of the Hualapai Mountains.

85 Health and Wellness for all Arizonans azdhs.gov 2012 Q Fever Update 4 cases reported – 2 Maricopa County – 2 Pima County Demographics – All male – Age range: 32-70; median age: 34 No local high risk exposures reported

86 Health and Wellness for all Arizonans azdhs.gov 2012 Rabid Animals

87 Health and Wellness for all Arizonans azdhs.gov 2012 Rabies Update Exposure to Lab Confirmed Rabid Animals: 7 Humans 25 Domestic Animals 0 Human cases 0 Domestic animal cases

88 Health and Wellness for all Arizonans azdhs.gov Rocky Mountain Spotted Fever Update 43 cases (3 deaths) reported in suspect cases still under investigation Statewide plan CDC best practices for prevention and spread In-service training at hospitals Ensure continuity of care for transfer cases from tribal health facilities

89 Health and Wellness for all Arizonans azdhs.gov 2012 West Nile Virus Update 132 human cases (7 deaths) reported in Arizona – La Paz, Maricopa, Mohave, Pima, Pinal, Yuma – 82 (62%) reported were neuroinvasive 5,387 cases reported nationally (243 deaths) 189 positive mosquito pools – Apache, La Paz, Maricopa, Pima, Pinal, Yavapai, Yuma

90 Health and Wellness for all Arizonans azdhs.gov Questions?? Contact Information: Selam Tecle, VBDZ-Epi o: (602)

91 Health and Wellness for all Arizonans azdhs.gov Foodborne Disease Outbreaks: What We Do with Your Reports Evan Henke, PhD, MPH Arizona Department of Health Services APIC 2013 January 25, 2013

92 Health and Wellness for all Arizonans azdhs.gov Reportable Food and Waterborne Diseases Amebiasis Botulism Campylobacteriosis Cholera Cryptosporidiosis Cysticercosis Encephalitis, parasitic Enterohemorrhagic E. coli Enterotoxigenic E. coli Giardiasis Hemolytic Uremic Syndrome Hepatitis A Hepatitis E Listeriosis Salmonellosis Taeniasis Trichinosis Typhoid Fever Vibrio infection Yersiniosis

93 Health and Wellness for all Arizonans azdhs.gov Why we collect disease reports To study trends, measure success, and identify opportunities To detect and stop outbreaks To prevent future food safety failures

94 Health and Wellness for all Arizonans azdhs.gov What we do with your hard work ADHS EpidemiologyADHS State Lab Or Healthcare Providers/Labs

95 Health and Wellness for all Arizonans azdhs.gov Counties Interview Cases You See ADHS Epidemiology County Health Dept.

96 Health and Wellness for all Arizonans azdhs.gov State Lab Fingerprints the Pathogen ADHS State Lab Pattern: JEGX ADHS Epidemiology PFGE Lab Salmonella Shiga-toxin producing E. coli Listeria

97 Health and Wellness for all Arizonans azdhs.gov Clusters of Illness are Defined Salmonella Enteriditis JEGX Summer 2010

98 Health and Wellness for all Arizonans azdhs.gov Summer 2008 Clusters of Illness are Defined Salmonella Saintpaul JN6X

99 Health and Wellness for all Arizonans azdhs.gov Clusters of Illness are Defined Fall 2012 Salmonella Poona JL6X

100 Health and Wellness for all Arizonans azdhs.gov Salmonella Poona JL6X Clusters of Illness are Defined

101 Health and Wellness for all Arizonans azdhs.gov Epidemiology Investigates Clusters Case 1: JEGX ADHS Epidemiology Case 2: JEGX Case 3: JEGX

102 Health and Wellness for all Arizonans azdhs.gov Product Supply Chain Traceback

103 Health and Wellness for all Arizonans azdhs.gov Outbreak Investigations

104 Health and Wellness for all Arizonans azdhs.gov Our Challenges Goals: Capture all cases PFGE all specimens Interview all individuals BIG Challenges: Non-culture methods Staffing Complex Food Supply Chain

105 Health and Wellness for all Arizonans azdhs.gov Arizona case definitions and exclusion rules Evan Henke, PhD, MPH Foodborne Disease Epidemiologist THANK YOU!

106 Health and Wellness for all Arizonans azdhs.gov Arizona Department of Health Services STD Control Program 2013 APIC State of the State January 25, 2013

107 Health and Wellness for all Arizonans azdhs.gov STD Reporting Requirements Reportable sexually transmitted diseases to local health department/ADHS (within 5 working days) : – Chlamydia (genital) – Gonorrhea – Syphilis – Herpes genitalis – Chancroid

108 Health and Wellness for all Arizonans azdhs.gov Program Responsibilities Monitor, control, and prevent sexually transmitted diseases through education of those at risk. Detect asymptomatic and symptomatic infected individuals. Diagnosis and treat those who are infected. Evaluate, treat and counsel sex partners of persons who have a sexually transmitted disease.

109 Health and Wellness for all Arizonans azdhs.gov Program Targets Adolescents and Young Adults Men Who have Sex With Men Multi-Drug Resistant Gonorrhea Congenital Syphilis

110 Health and Wellness for all Arizonans azdhs.gov Chlamydia Anita Betancourt, Epidemiologist/IPP Coordinator/Chlamydia Surveillance

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115 Health and Wellness for all Arizonans azdhs.gov CDC Recommendation CDC recommends annual screening of chlamydia for all sexually active females 25 and under and for women older than 25 with risk factors such as a new sex partner or multiple partners.

116 Health and Wellness for all Arizonans azdhs.gov Syphilis Joe Mireles, Epidemiologist/Syphilis Surveillance

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124 Health and Wellness for all Arizonans azdhs.gov Gonorrhea Kunuwo Fokong, Epidemiologist/Gonorrhea Surveillance

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131 Health and Wellness for all Arizonans azdhs.gov

132 Health and Wellness for all Arizonans azdhs.gov

133 Health and Wellness for all Arizonans azdhs.gov Treatment of Suspected Resistance The Centers for Disease Control and Prevention (CDC) and the Arizona STD Control Program recommend the following in cases of suspected cephalosporin treatment – If the patient has not already been treated with ceftriaxone 250 mg, then treat with ceftriaxone 250 mg IM x 1 AND azithromycin 1 gram orally in a single dose. – Perform a test of cure with culture and antibiotic susceptibility testing (before re- treating). – Inform your local health department. – For clinical consultation call the STD Program's Medical Epidemiologist at (602) – In patients who have already been treated with the recommended ceftriaxone regimen whose symptoms do not resolve after treatment, please call (602) for clinical consultation. Emphasize that patients should abstain from oral, vaginal, or anal sex until one week after the patient and all of his/her partners are treated.

134 Health and Wellness for all Arizonans azdhs.gov Questions? Roxanne Ereth, Manager – – Melanie Taylor, MD – – Kerry Kenney, CDC Senior PHA/Syphilis Coordinator – –

135 Health and Wellness for all Arizonans azdhs.gov Questions? Arshad Aziz, Epidemiologist/Data Manager – – Anita Betancourt, Epidemiologist/IPP Coordinator/Chlamydia Surveillance – – Joe Mireles, Epidemiologist/Syphilis Surveillance – – Kunuwo Fokong, Epidemiologist/Gonorrhea Surveillance – –

136 Health and Wellness for all Arizonans azdhs.gov Thanks! To the incredible staff in the ADHS STD Control Program. QUESTIONS?

137 Health and Wellness for all Arizonans azdhs.gov Arizona HIV/AIDS Data January 2013 Rick DeStephens HIV Epidemiology 137

138 Health and Wellness for all Arizonans azdhs.gov HIV/AIDS Events Per Year Arizona,

139 Health and Wellness for all Arizonans azdhs.gov Arizona 5-Year Emergent HIV/AIDS Case Rate Trend 139

140 Health and Wellness for all Arizonans azdhs.gov Arizona Prevalent HIV, AIDS Cases December 2004 – June

141 Health and Wellness for all Arizonans azdhs.gov Arizona Emergent HIV/AIDS Rate by County State Emergence Rate = Correctional Dx: *68% of Pinal County **36% of Graham County 141

142 Health and Wellness for all Arizonans azdhs.gov Arizona Emergent HIV/AIDS Cases, by County Correctional Dx: *68% of Pinal County **36% of Graham County 142

143 Health and Wellness for all Arizonans azdhs.gov Arizona Emergent HIV/AIDS by Gender: Rate per 100,

144 Health and Wellness for all Arizonans azdhs.gov Arizona 5-Year New HIV/AIDS Rate by Race/Ethnicity, *Non-Hispanic, A/PI/H=Asian/Pacific Islander/Native Hawaiian, AI/AN=American Indian/Alaska Native 144

145 Health and Wellness for all Arizonans azdhs.gov HIV Incidence by Race 2000 to

146 Health and Wellness for all Arizonans azdhs.gov Risk -- New HIV/AIDS DX

147 Health and Wellness for all Arizonans azdhs.gov Transmission Category, Estimates of New HIV Infection, United States and Arizona,

148 Health and Wellness for all Arizonans azdhs.gov Female United States and Arizona Estimates of New HIV Infections, By Transmission Category IDU = Injection Drug User NRR =No Risk Reported 148

149 Health and Wellness for all Arizonans azdhs.gov 149

150 Health and Wellness for all Arizonans azdhs.gov AZ HIV Epi On the Web

151 Health and Wellness for all Arizonans azdhs.gov How you can help: Race Risk Earliest positive HIV test dates Latest negative test date

152 Health and Wellness for all Arizonans azdhs.gov This data brought to you by… Your friendly state disease investigators. Julia (Capacity)Mersija (Core)Jillian(Incidence) 152

153 Health and Wellness for all Arizonans azdhs.gov Tuberculosis in Arizona Tuberculosis Control Program Arizona Department of Health Services

154 Health and Wellness for all Arizonans azdhs.gov TB Case Rates per 100,000 population, Arizona & U.S.,

155 Health and Wellness for all Arizonans azdhs.gov TB Cases by Race & Ethnicity, Arizona,

156 Health and Wellness for all Arizonans azdhs.gov TB Case Rates by Race & Ethnicity, Arizona,

157 Health and Wellness for all Arizonans azdhs.gov TB Cases by Age Groups, Arizona,

158 Health and Wellness for all Arizonans azdhs.gov Risk Factors for TB Cases, Arizona, 2011 Risk Factor #Cases % of Cases in AZ % of Cases in US Foreign-born Correctional Facility Cases HIV Positive Contact of Infectious TB Case, <2 years Diabetes Mellitus Excess Alcohol Non-injecting Drug Use Injecting Drug Use Homeless Long-term Care Facility

159 Health and Wellness for all Arizonans azdhs.gov U.S. –born & Foreign-born TB Cases, Arizona,

160 Health and Wellness for all Arizonans azdhs.gov % of TB Cases with HIV Co-infection & % of HIV Results Known, Arizona,

161 Health and Wellness for all Arizonans azdhs.gov Primary Resistance to Anti-TB Drugs, Arizona, 2007 – 2011

162 Health and Wellness for all Arizonans azdhs.gov Interferon-Gamma Release Assays Two IGRAs available and FDA approved – QuantiFERON-TB Gold In-Tube test (QFT-GIT) – T-SPOT.TB (T-Spot) Each of the tests measure different aspects of the immune response – Results might not be interchangeable – Different tests can yield different results

163 Health and Wellness for all Arizonans azdhs.gov General Recommendations for Use of IGRAs Used as aids in diagnosing infection with M. tuberculosis Should not be used for testing those at low risk for both infection and progression – Same recommendation for TST IGRA lab testing availability should be determined prior to testing

164 Health and Wellness for all Arizonans azdhs.gov Test Selection An IGRA may be used in place of (but not in addition to) a TST in all situation in which CDC recommends a TST Even in special circumstances, either test is considered acceptable medical and public health practice

165 Health and Wellness for all Arizonans azdhs.gov Either TST or IGRA Contacts to an active case Periodic screenings for occupation exposures – Healthcare workers – Two-step testing not needed with IGRA IGRAs do not have booster effect – IGRAs may produce more conversions

166 Health and Wellness for all Arizonans azdhs.gov New LTBI Treatment 3HP – Combination of Isoniazid & Rifapentine Once weekly dose for 12 weeks – Must be given by DOT – Healthy patients ≥ 12 years of age

167 Health and Wellness for all Arizonans azdhs.gov TB Program Contacts Cara Christ, MD TB Control Officer/Medical Director Carla Chee, MHS Office Chief Eric Hawkins, MS Program Manager Larissa Anderson Special Projects Epidemiologist Cherie Fulk, RN, MPH TB Nurse Coordinator Mary Gullion Program Project Specialist


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