1. Reportable Disease Update Local Health Department Nurses Meeting June 20, 2013 T.J. Sugg, MPH

2. Objectives Discuss Middle East Respiratory Syndrome Coronavirus (MERS CoV) Describe current clusters of Salmonella and explain investigation and reporting criteria Describe current cases of STEC (Shiga toxin-producing E. coli) and explain investigation and reporting criteria Discuss Campylobacter activity and laboratory testing Discuss enteric disease investigation guidelines

3. 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

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

5. 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

6. MERS-CoV Cases MERS Cases and Deaths, April 2012 - Present CountriesCases (Deaths) France2 (1) Italy3 (0) Jordan2 (2) Qatar2 (0) Saudi Arabia49 (32) Tunisia2 (0) United Kingdom (UK)3 (2) United Arab Emirates (UAE)1 (1) Total64 (38) = 59% MR Median Age = 56 All patients were aged ≥ 24 yrs except for a 2yo and a 14yo

7. Number of confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (N = 55) reported as of June 7, 2013, to the World Health Organization, by month of illness onset — worldwide, 2012–2013 MMWR. June 14, 2013 / 62(23);480-483

8. Confirmed cases of Middle East Respiratory Syndrome Coronavirus (MERS-CoV) (N =55) reported as of June 7, 2013, to the World Health Organization, and history of travel from the Arabian Peninsula or neighboring countries within 14 days of illness onset — worldwide, 2012–2013 MMWR. June 14, 2013 / 62(23);480-483

9. Patient Under Investigation (PUI) Any PUI should be reported to state and local health departments immediately PUI Criteria: 1. Acute respiratory infection, may include fever ≥ 100.4°F and cough 2. Suspicion of pneumonia or acute respiratory distress syndrome based on clinical or radiological evidence 3. History of travel to the Arabian Peninsula or neighboring countries within 14 days 4. Symptoms not already explained by any other infection or etiology

10. Patient Under Investigation (PUI) The following persons may be considered for evaluation of MERS-CoV: Persons who develop severe acute lower respiratory illness of known etiology within 14 days after traveling from the Arabian Peninsula or neighboring countries, but who do not respond to appropriate therapy OR Persons who develop severe acute lower respiratory illness who are close contacts of a symptomatic traveler who developed fever and acute respiratory illness within 14 days of traveling from the Arabian Peninsula or neighboring countries

11. 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

12. 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 http://www.cdc.gov/coronavirus/mers/guidance.html

13. Probable Case Definition A probable case is any person who: Meets PUI criteria and has clinical, radiological, or histopathological evidence of pneumonia or ARDS, but no possibility of lab confirmation exists, either because patient or samples are unavailable or no testing available for other respiratory infections, AND Is a close contact with a laboratory confirmed case, AND Has illness not already explained by any other infection or etiology, including all clinically indicated tests for community-acquired pneumonia OR any person with: SARI with no known etiology, AND An epidemiologic link to a confirmed MERS case

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

15. 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

16. Collection of Laboratory Specimens Determine if patient meets PUI criteria Collect: An upper respiratory specimen: Nasopharyngeal AND oropharyngeal 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

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

18. Salmonellosis Clusters

19. Salmonellosis Epi Curve

20. Salmonellosis Investigation Complete the Enteric Disease Investigation Form for each case of Salmonella, regardless of specimen type. Enter the data into NEDSS Food and beverage form will be added to NEDSS production soon. Currently investigating 2 major clusters: S. enteritidis JEGX01.0004 (24 KY cases) S. enteritidis JEGX01.0005 (10 KY cases) Until the food and beverage form is in NEDSS, DPH will request a faxed copy if, and only if, a Salmonellosis case is identified as being from one of these clusters.

21. Shiga Toxin-Producing E. coli Investigation

22. STEC Epi Curve

23. STEC Investigation Complete the Enteric Disease Investigation Form for each case of STEC, regardless of specimen type. Enter the data into NEDSS Food and beverage form will be added to NEDSS production soon. Notify DPH immediately of any case of HUS

24. Campylobacter Investigation

25. Campylobacter Epi Curve

26. 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 Food and beverage form will be added to NEDSS production soon. Work with local laboratories to ensure isolates are sent to DLS

27. Enteric Disease Investigation Guidelines

28. Enteric season has begun See email distributed by Stacy Davidson, DPH Nurse Consultant, regarding: Investigation and reporting of all enteric pathogens Community mitigation guidelines.

29. Questions? Thank you!!