1. State of the State
APIC Meeting
January 25, 2013

2. 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. New Year, New MEDSIS Please remember to sign your new user agreement
For questions or MEDSIS access, please contact:

4. Meaningful Use Public Health Objectives
Electronic Laboratory Reporting – currently accepting
Immunization Registry – currently accepting
Syndromic Surveillance – will be contacting hospitals shortly

5. 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. *confirmed and probable cases

7. Pertussis in Arizona 2012 (preliminary) 2011 962 cases 507 confirmed
455 probable
867 cases
160 confirmed
707 probable

8. *confirmed and probable cases

9. Pertussis Testing

11. Mohave County Pertussis Outbreak
92 cases (72 confirmed, 20 probable) to date
~80% unvaccinated
Most cases in those <5 years old

12. 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. 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. H. flu type B (Hib) in children <5 years
2012
2011
2 confirmed cases
- 3 year old: fully immunized
- 4 month old: not vaccinated
1 confirmed case

15. Meningococcal Invasive Disease
2012
2011
5 confirmed cases
3 serogroup C
1 serogroup Y
1 serogroup W135
16 confirmed cases

16. Measles 2012 2011 2 confirmed cases (siblings) 7 year old:
PCR positive, not vaccinated
5 year old:
IgM positive, not vaccinated
2 confirmed cases
rash, fever, cough, coryza, conjunctivitis

17. Mumps 2012 2011 3 confirmed cases (siblings) 9 year old:
IgM and PCR positive, not vaccinated
12 year old:
epi-linked, not vaccinated
13 year old:
0 cases

18. Resources
2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings
Guideline for infection control in health care personnel, 1998

19. 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. 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. 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. 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. 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. 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, 2013.  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. 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 1st hepatitis B vaccine >14 days versus 1st 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. 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. Please contact Karman Tam for more information: karman.tam@azdhs.gov
Thank you!
Please contact Karman Tam for more information:
(602)

28. Coccidioidomycosis in Arizona
Clarisse Tsang, MPH
Acting Program Manager
Infectious Disease Epidemiology
APIC: January 25, 2013

29. Impact of Cocci on Arizonans
60% of all reported US cases are in Arizona
2nd 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. 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 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. Rates of Reported Cocci Cases, Arizona, 1990-2012
Change in EIA Reporting
Lab Reportable

32. Reported Cocci Cases, Age and Gender
Year
Age (median, mean)
Gender (% female)
p-value (Gender)
2007 vs X subgroup
2007
52, 51
45%
n/a
2008
51, 50
48%
2009
47, 47
55%
2010
48, 47
58%
2011*
(2/14-12/31)
p <
EIA alone
46, 46
62%
other positive results
52, 50
43%
p = 0.07
*2011 Numbers are provisional and have not been finalized
n/a = have not analyzed yet

33. Reported Cocci Cases by Age, 2007-2011
Reported cases per 100,000

35. Provider Education
Brochures and posters about cocci testing for providers
CME for the PCP:
Annual Valley Fever Awareness Week in November

37. Public Education Brochures with cocci info for the public Video:
“Valley Fever:
The Impact on Arizonans”

38. 1.

39. Resources ADHS website: www.valleyfeverarizona.org
Valley Fever Center for Excellence:

40. Thank you!
Questions?
Clarisse Tsang

41. Shane Brady, MPH Influenza Epidemiologist

42. 2012-2013 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. Lab-confirmed influenza cases, 2009-2013

44. Age Groups by Flu Type

45. State Lab Data: PCR & cultures, 2012-2013

46. Percentage of Visits for Influenza-like illness at sentinel outpatient providers, 2012-2013

47. 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. 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. Antiviral resistance (national)
Oseltamivir: Resistant Viruses, Number (%)
Zanamivir: Resistant Viruses, Number (%)
Influenza A (H3N2)
None (671* tested)
Influenza B
None (263 tested)
2009 Influenza A (H1N1)
None (85* tested)
None (55 tested)
*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.
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.

50. 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. CDC Recommendations for Influenza Antiviral Medications for the 2012-2013 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. 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. children younger than 2 years;[ii]adults aged 65 years and older;
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. residents of nursing homes and other chronic-care facilities.
persons with the following conditions:
chronic pulmonary (including asthma)
cardiovascular (except hypertension alone)
renal, hepatic, hematological (including sickle cell disease), metabolic disorders (including diabetes mellitus)
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. 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. Resources ADHS Weekly Activity Reports:
CDC Website:

57. Shane Brady Shane.brady@azdhs.gov 602-364-3523
Thank you!
Shane Brady

58. Healthcare Associated Infections Program: Selected 2012 Investigations
January 25th, 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
Jason Matthew Lempp, MPH
CDC/CSTE Applied Epidemiology Fellow
Outbreak Capacity Epidemiologist
Office of Infectious Disease Services
Arizona Department of Health Services

59. ADHS & Healthcare Associated Infection (HAI) Program1
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 2

60. 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 18th, 2013
State HAI Coordinator – Vinita Oberoi
– (602)

61. Training & Education
Prevention
Surveillance
HAIs
Dialysis
Antimicrobial Stewardship
Long Term Care

62. HAI & Exposures Investigations
MRSA

63. 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”

64. 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

65. Infection Control Issues
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
Saline
Contrast Media Reagent

66. 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 28
Quick 2x2 Statistical Tests *
Morning
28 Patients seen at clinic on same DOS as 3 cases *
10 Patients received contrast media injections (*) * *
“Morning” versus “Afternoon” Contrast separation * *
Afternoon
Culture Confirmed MRSA
After-noon
Contrast
( + )
( - )
Yes 3 1 4 No 24 25 28
Culture Confirmed MRSA
Any
Contrast
( + )
( - )
Yes 3 7 10 No 18 25 28
Patient 15 *
Patient 21
Fisher exact: *
Fisher exact: 0.073 *
Patient 26 *

67. OUTCOMES Investigations National picture:
Single-dose vials & HAI education campaigns
Medication shortage of appropriate doses/concentrations

68. 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

69. 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 ! ?

70. Outcomes
Collaboration
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
Epidemiology
Counties
Facilities
Licensing

71. 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)

72. 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?

73. Outcomes No evidence to support that HCV transmission
Results of HCV testing of two Arizona facilities for patients with exposure to injectable narcotics and cardiac cathiterization lab or other high-risk units
Facility
Facility Patient
Counts
Tested
Negative (%);
Positive (%)
Excluded
Deceased; Prior +
Contacted**
Phone
Confirm Letter
LTF
ALL
Total
288
111 (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
National investigation is still ongoing

74. 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 – 2012
+500 patients exposed

75. 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.

76. 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

77. HCV ~3.25% of birth cohort 1945-1965 are anti-HCV (+) = 2.74 million
~75% of which have chronic HCV infection = 2.0 million

78. 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?

79. 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

80. Questions? Jason Matthew Lempp Jason.Lempp@AZDHS.gov (602) 364-0780
MRSA
Jason Matthew Lempp
(602)

81. 2012 Arizona Vector/Zoonotic Diseases Update
Selam Tecle, MPH
VBZD Epidemiologist
Office of Infectious Disease Services
Arizona Department of Health Services

82. 2012 Brucellosis Cases 6 cases reported Demographics
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. 2012 Hantavirus Cases Demographics 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. 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. 2012 Q Fever Update 4 cases reported Demographics
2 Maricopa County
2 Pima County
Demographics
All male
Age range: 32-70; median age: 34
No local high risk exposures reported

86. 2012 Rabid Animals

87. 2012 Rabies Update Exposure to Lab Confirmed Rabid Animals:
7 Humans
25 Domestic Animals
0 Human cases
0 Domestic animal cases

88. Rocky Mountain Spotted Fever Update
43 cases (3 deaths) reported in 2012
287 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. 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. Questions??
Contact Information: Selam Tecle, VBDZ-Epi o: (602)

91. Foodborne Disease Outbreaks: What We Do with Your Reports
Evan Henke, PhD, MPH
Arizona Department of Health Services
APIC 2013
January 25, 2013

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

93. 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. What we do with your hard work
Healthcare Providers/Labs Or
ADHS Epidemiology
ADHS State Lab

95. Counties Interview Cases You See
ADHS Epidemiology
County Health Dept.

96. State Lab Fingerprints the Pathogen
ADHS State Lab
Pattern: JEGX
PFGE Lab
Salmonella
Shiga-toxin producing E. coli
Listeria
ADHS Epidemiology

97. Clusters of Illness are Defined
Salmonella Enteriditis JEGX01.004
Summer 2010

98. Clusters of Illness are Defined
Salmonella Saintpaul JN6X
Summer 2008

99. Clusters of Illness are Defined
Salmonella Poona JL6X
Fall 2012

100. Clusters of Illness are Defined
Salmonella Poona JL6X

101. Epidemiology Investigates Clusters
ADHS Epidemiology
Case 1:
JEGX
Case 2:
JEGX
Case 3:
JEGX

102. Product Supply Chain Traceback

103. Outbreak Investigations

104. Our Challenges Goals: Capture all cases PFGE all specimens
Interview all individuals
BIG Challenges:
Non-culture methods
Staffing
Complex Food Supply Chain

105. Foodborne Disease Epidemiologist
THANK YOU!
Evan Henke, PhD, MPH
Foodborne Disease Epidemiologist
Arizona case definitions and exclusion rules

106. Arizona Department of Health Services STD Control Program
2013 APIC State of the State
January 25, 2013

107. STD Reporting Requirements
Reportable sexually transmitted diseases to local health department/ADHS (within 5 working days):
Chlamydia (genital)
Gonorrhea
Syphilis
Herpes genitalis
Chancroid
Updated Administrative Rules for Provider Reporting (R )
New Communicable Disease Reports

108. 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. Program Targets Adolescents and Young Adults Men Who have Sex With Men
Multi-Drug Resistant Gonorrhea
Congenital Syphilis

110. Chlamydia Anita Betancourt, Epidemiologist/IPP Coordinator/Chlamydia Surveillance

111. 5% increase over 2011
14% increase over 2010
AZ rates slightly lower than 2011 national rate of 457 and ranked 18th.
Maricopa ranked 8th for number of cases, nationally in 2011

114. Awareness of recommendation to screen women under 26.
Women more likely to pursue care.
Infertility Prevention Project
Although undiagnosed, the effective use of expedited therapy for partners will prevent additional transmission

115. 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. Joe Mireles, Epidemiologist/Syphilis Surveillance

117. Arizona 18th in 2011 by rate.
National rate: 4.5
Maricopa ranked 13th by number of cases.

119. Of 720 cases, 81 were black

120. Maricopa County
Total for 2011: 354

121. 2011: 461 cases
2012: 339 cases
Nearly 27% decrease

122. Ranked 6th by rate.

124. Kunuwo Fokong, Epidemiologist/Gonorrhea Surveillance

125. In 2011, increased by 4% nationally.
40% increase in 2011
28% increase in 2012
Overall 80% increase since 2010
Arizona ranked 32nd nationally by rate during 2011 (nat’l rate: )
Maricopa 15th by case in 2011

133. 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. Questions? Roxanne Ereth, Manager Melanie Taylor, MD
Melanie Taylor, MD
Kerry Kenney, CDC Senior PHA/Syphilis Coordinator

135. Questions? Arshad Aziz, Epidemiologist/Data Manager
Anita Betancourt, Epidemiologist/IPP Coordinator/Chlamydia Surveillance
Joe Mireles, Epidemiologist/Syphilis Surveillance
Kunuwo Fokong, Epidemiologist/Gonorrhea Surveillance

136. Thanks!
To the incredible staff in the ADHS STD Control Program.
QUESTIONS?

137. Arizona HIV/AIDS Data January 2013
Rick DeStephens
HIV Epidemiology

138. HIV/AIDS Events Per Year Arizona, 1981-2011
Whats important in this slide are the blue and green lines… HIV and deaths. This shows what an HIV epi curve looks like or epidemic stages. Incidence being new cases red and blue lines peaked REPORTING.
Because at the beginning of the epidemic in the 80s and 90s people weren’t getting diagnosed and reported diagnosis’ until it was possibly too late and there were already sick.

139. Arizona 5-Year Emergent HIV/AIDS Case Rate Trend
Emergenct cases- are incident cases which are based upon the sum of new HIV cases, and new AIDS cases not diagnosed as HIV infections in any prior calendar year.
Rates are Frequency with which an event occurs in a defined population.
These annualized 5-year rates may be regarded as the average annual rate across the 5 years in the reporting timeframe.
The State of Arizona is has experienced significant population growth over the last decade. Most of that growth is taking place in the Phoenix Metropolitan area. Recent trends show the 5-year HIV/AIDS emergence case rate has been declining. Steady decline throughout the 90s, leveling off from the period and beginning to decline lightly again starting with the time period. The rate of emergent HIV infection in AZ was per 100,000 per year during the time period. According to the most recent estimates of CDC, the 2010 estimated HIV/AIDS diagnosis rate for AZ was under the national rate.

140. Arizona Prevalent HIV, AIDS Cases
December 2004 – June 2012
Important slide to look at.
prevalence rates continue to rise in Arizona. Prevalence of reported HIV infection is cases per 100,000 persons (up from in 2010). Currently, there are about 15,000 persons living with HIV/AIDS in Arizona, a rise of nearly 30% in 5 years. The increase in prevalence rates appears to be due to the efficacy of multi-drug treatments for HIV infection, which have sharply reduced HIV-related death. Additionally, Arizona’s increased population growth may be contributing to an increase in prevalence; 23% of prevalent cases were diagnosed in another state, while only 11% of cases present in Arizona five years ago have left the state.
In June 2009, the number of persons living with AIDS in Arizona surpassed the number of persons with HIV infection who have not been diagnosed with AIDS. Because the burden of HIV-related disease is greater among persons with AIDS, treatment, utilization, and continuity of care will become increasingly critical issues.

141. Arizona Emergent HIV/AIDS Rate by County 2006-2010
State Emergence Rate = 10.96
Correctional Dx:
*68% of Pinal County
**36% of Graham County

142. Arizona Emergent HIV/AIDS Cases, by County 2006-2010
Correctional Dx:
*68% of Pinal County
**36% of Graham County

143. Arizona Emergent HIV/AIDS by Gender: 1999-2011
Rate per 100,000
As we already know higher rates in males. 86% of total cases in AZ are males, for both prevalenace and incidence/emergent cases.

144. Arizona 5-Year New HIV/AIDS Rate by Race/Ethnicity, 1990-2011
Rates of HIV/AIDS prevalence and emergence differ sharply between African Americans and other race/ethnicity groups. African Americans are the only race/ethnicity group in Arizona that experiences such a severe disparity of HIV/AIDS impact. Currently, the emergent HIV/AIDS rate among African Americans in Arizona is nearly three times that of the state average. The disparity observed in Arizona among African Americans is also seen elsewhere in the country. The CDC estimates that, in 2009, blacks were 14% of the total population in states with established confidential HIV reporting, and 44% of new HIV diagnoses.
*Non-Hispanic, A/PI/H=Asian/Pacific Islander/Native Hawaiian, AI/AN=American Indian/Alaska Native

145. HIV Incidence by Race 2000 to 2011

146. Risk -- New HIV/AIDS DX
Men who have sex with men (MSM) account for the largest proportion of emergent HIV/AIDS cases in Arizona. The proprtion of emergent cases that are MSM-related hover right around 60%. This proportion had been rising over time, but has declined in recent years. The downward trend in rates among MSM has been mirrored by a similar upward trend among persons with no reported risk. It had reached a high of 26% in In recent years, increased efforts to ascertain risk has decreased NRR to 13%.

147. Transmission Category, Estimates of New HIV Infection, United States and Arizona, 2006
In Arizona, we show what is ACTUALLY being reported. we have a no reported risk/other category.
The United States estimate does not include an NRR category. We don’t know exactly what they do but They assign a value based on an algorithm that looks at proportions in order to assign each NRR/other person to a particular category.

148. Female United States and Arizona Estimates of New HIV Infections, By Transmission Category
The United States estimate does not include an NRR category.
US statistics found at
IDU = Injection Drug User NRR =No Risk Reported

150. AZ HIV Epi On the Web

151. How you can help: Race Risk Earliest positive HIV test dates
Latest negative test date

152. This data brought to you by…
Your friendly state disease investigators.
Julia (Capacity)
Mersija (Core)
Jillian(Incidence)

153. Tuberculosis in Arizona
Tuberculosis Control Program
Arizona Department of Health Services

154. TB Case Rates per 100,000 population, Arizona & U.S., 2000 - 2011

155. TB Cases by Race & Ethnicity, Arizona, 2007 -2011

156. TB Case Rates by Race & Ethnicity, Arizona, 2007-2011

157. TB Cases by Age Groups, Arizona, 2007 - 2011

158. Risk Factors for TB Cases, Arizona, 2011
% of Cases in AZ
% of Cases in US
Foreign-born
170
66.6
61.8
Correctional Facility Cases 64
24.6
4.2
HIV Positive 10
4.3
7.7
Contact of Infectious TB Case, <2 years 15
5.9
Diabetes Mellitus 31
12.2
Excess Alcohol 34
13.3
12.4
Non-injecting Drug Use 25
9.8
7.6
Injecting Drug Use 8
3.1
1.5
Homeless
5.8
Long-term Care Facility
2.3

159. U.S. –born & Foreign-born TB Cases, Arizona, 2007 - 2011

160. % of TB Cases with HIV Co-infection & % of HIV Results Known, Arizona, 2007 - 2011

161. Primary Resistance to Anti-TB Drugs, Arizona, 2007 – 2011

162. 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. 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. 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. 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. New LTBI Treatment 3HP Once weekly dose for 12 weeks
Combination of Isoniazid & Rifapentine
Once weekly dose for 12 weeks
Must be given by DOT
Healthy patients ≥ 12 years of age

167. 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