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Outbreaks 2009 Annual Summary

Explore the 2009 outbreaks, outbreak investigation steps, common outbreak types, and reporting timeliness. Insights on enteric, respiratory, and vaccine-preventable disease outbreaks. Importance of prompt reporting, laboratory confirmation, and effective control measures.

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Outbreaks 2009 Annual Summary

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  1. Outbreaks 2009 Annual Summary Danae Bixler, MD, MPH Division of Infectious Disease Epidemiology

  2. Objectives • Describe 2009 outbreaks • Lessons learned • Prompt reporting • Laboratory confirmation / diagnosis • Outbreak investigation as problem-solving • Types of common outbreaks • Enteric outbreaks • Rash illness • ‘Other’ • Vaccine preventable disease outbreaks • Respiratory outbreaks • Healthcare associated outbreaks • Relate findings to the 13 steps of outbreak investigation.

  3. Steps of Outbreak Investigation • 1. Prepare for field work • 2. Establish the existence of an outbreak • 3. Verify the diagnosis • 4. Construct a working case definition • 5. Find cases systematically and record information • 6. Perform descriptive epidemiology

  4. Steps of Outbreak Investigation (2) • 7. Develop hypotheses • 8. Evaluate hypotheses epidemiologically • 9. As necessary, reconsider, refine, and re-evaluate hypotheses • 10. Compare and reconcile with laboratory and/or environmental studies • 11. Implement control and prevention measures • 12. Initiate or maintain surveillance • 13. Communicate findings

  5. Summary Data (provisional) • 123 outbreaks reported • 98 (80%) confirmed as outbreaks or clusters • 39 (71 %) counties reported one or more outbreak-related cases • Jurisdiction • 90 (92 %) West Virginia • 3 (3 %) multi-state / West Virginia = lead investigator • 4 (4 %) multi-state / other state = lead investigator

  6. Counties Reporting Outbreak-Related Cases(provisional / includes multi-county outbreaks)

  7. Counties Reporting Outbreak-Related Cases(provisional / includes multi-county outbreaks)

  8. Timeliness of Reporting – Summary Statistics(provisional) • N = 85 observations (87 %) • Mean 42 hours • Median 1 hour • Range = 0 to 662 hours

  9. Timely reporting of outbreaks • Laboratory support • Technical support • Case definitions / diagnosis • Descriptive epidemiology • Cohort or case-control studies • Communications support

  10. Timely reporting of outbreaks • Required under: • Reportable disease rule • Threat preparedness funding stream • Program plan

  11. Timeliness of Reporting(provisional / multi-county outbreaks excluded) Counties that report more than one outbreak reported outbreaks more rapidly:

  12. Reported Outbreaks by Type, West Virginia, 2009 (provisional)

  13. Enteric Outbreaks 2009

  14. Enteric Outbreak Summary(provisional) • N = 29 • Reported by 23 (42%) counties • Jurisdiction: • 24 (83%) West Virginia • 1 (3%) multi-state; West Virginia = lead investigator • 14 cases gastroenteritis • N = 4 (14%) multi-state outbreaks; CDC / other state = lead

  15. West Virginia Enteric Outbreaks(provisional) • 24 (83%) West Virginia enteric outbreaks • 1 (4%)Salmonella enteritidis • 22 (92%) Norovirus or acute gastroenteritis • 18 (82%) in nursing homes / healthcare facilities • 17 (77%) person-to-person transmission • 1 (4%) rotavirus

  16. Acute Gastroenteritis

  17. NorovirusNEJM, 2009; 361:1776 • Acute onset vomiting and/or diarrhea • Reservoir = humans • Highly efficient transmission • 18 – 1000 viral particles • 30% secondary attack rate • Droplets • Fomites • Person-to-person • Environmental contamination

  18. Norovirus (2) NEJM, 2009; 361:1776 • Viral shedding • Precedes onset 30% • After recovery (up to 8 weeks) • Environmental stability • 0° C to 60° C • Surfaces • Recreational and drinking water • Food items such as raw oysters, fruits, vegetables • Lack of long-term immunity • Viral mutation

  19. Norovirus NEJM, 2009; 361:1776 • Prevention and Control • Isolation of ill persons • Enforce personal hygiene • Environmental decontamination • Use of alcohol-based hand sanitizer promising

  20. Acute Gastroenteritis 1. Prepare for field work 2. Establish the existence of an outbreak 3. Verify the diagnosis 4. Construct a working case definition 5. Find cases systematically and record information 6. Perform descriptive epidemiology 7. Develop hypotheses 8. Evaluate hypotheses epidemiologically 9. As necessary, reconsider, refine, and re-evaluate hypotheses 10. Compare and reconcile with laboratory and/or environmental studies 11. Implement control and prevention measures 12. Initiate or maintain surveillance 13. Communicate findings

  21. Acute Gastroenteritis2. Establish the existence of an outbreak3. Verify the diagnosis.4. Construct a working case definition

  22. Acute Gastroenteritis2. Establish the existence of an outbreak3. Verify the diagnosis.4. Construct a working case definition

  23. 6. Perform descriptive epidemiology.

  24. 6. Perform descriptive epidemiology. 7. Develop hypotheses.

  25. Multi-state Salmonella outbreaks

  26. Salmonella • Bacterial cause of diarrhea, fever, abdominal cramps • Most persons recover without treatment. • Severe illness: • Elderly • Infants and young children • Immunocompromised persons • Multi-state outbreaks • Widely distributed • Commercial food products • Produce • Detection by pulse-net

  27. Multi-state Salmonella Outbreaks • Pulsenet • Send isolates to OLS for PFGE • 2008 Salmonella typhimurium / peanut butter • National update • 2009 • March: Salmonella typhimurium / Virginia • April: Salmonella St. Paul / multistate • June: Salmonella enteritidis / Virginia • June: Salmonella oranienburg / Louisiana

  28. Salmonella typhimuriumoutbreakMMWR, 2009; 58:85-90. • Nov 25, 2008 investigation started. • Multiple institutional outbreaks … traceback demonstrated one common food: King Nut peanut butter • Step 7: Develop hypotheses • Case-control implicated peanut butter • Step 8: Evaluate hypotheses epidemiologically. • Jan 9, 2009, Minnesota Department of Agriculture isolated the outbreak strain from King Nut Peanut Butter. • Step 10: Compare and reconcile with laboratory and/or environmental studies.

  29. Ongoing investigationMMWR, 2009; 58:85-90. • Multiple institutional outbreaks … King Nut peanut butter was distributed to institutions. • Many ill persons did not eat peanut butter in institutions. • Step 9. As necessary, reconsider, refine and re-evaluate hypotheses. • Second series of case-control studies: pre-packaged peanut butter crackers. • Step 8: Evaluate hypotheses epidemiologically. • Intact packages of crackers yielded the outbreak strain • Step 10: Compare and reconcile with laboratory and/or environmental studies.

  30. MMWR, 2009; 58:85-90.

  31. MMWR, 2009; 58:85-90.

  32. Number of infections (N = 226*) with the outbreak strain of Salmonella Saintpaulassociated with eating alfalfa sprouts, by date of illness onset --- United States, February--April 2009*as of May 1, 2009 MMWR, 2009; 58:500-503

  33. Number of infections (N = 228*) with the outbreak strain of Salmonella Saintpaul, associated with eating alfalfa sprouts, by state --- United States, February--April 2009*as May 1, 2009 MMWR, 2009; 58:500-503

  34. Rash Illness 2009

  35. Rash Illness Outbreaks(provisional) • 4 Human parvovirus B-19 (“Fifth Disease”) • schools • 3 scabies • Nursing home • Detention center • Homeless shelter • 2 varicella • schools

  36. ErythemaInfectiosum (Parvovirus B-19) (“Fifth Disease”) • Mild prodrome • Fever 15-30% • ‘Slapped face’ rash • Rash • Symmetric, maculopapular, reticular, often pruritic • Trunk • Moves peripherally to arms, buttocks, thighs • Fluctuates / recurs

  37. Parvovirus B-19 (“Fifth Disease”)

  38. Parvovirus B-19 (“Fifth Disease”)Hardin MD/University of Iowa and CDC http://www.lib.uiowa.edu/hardin/Md/cdc/fifthdisease/4507.html

  39. Parvovirus B-19adapted from 2009 Redbook

  40. Parvovirus B-19ErythemaInfectiosum • Transmission: contact with respiratory tract secretions • Secondary spread • 50% in household contacts • 20% in school and daycare • Infectious period • Prior to rash onset • No exclusion of children with rash

  41. Parvovirus B-19ErythemaInfectiosum • Control • Hand hygiene • Dispose of tissues • Counsel pregnant women • Low risk • Exclusion not recommended • Evaluation per OB/GYN

  42. Parvovirus B-19 Outbreaks 1. Prepare for field work 2. Establish the existence of an outbreak 3. Verify the diagnosis 4. Construct a working case definition 5. Find cases systematically and record information 6. Perform descriptive epidemiology 7. Develop hypotheses 8. Evaluate hypotheses epidemiologically 9. As necessary, reconsider, refine, and re-evaluate hypotheses 10. Compare and reconcile with laboratory and/or environmental studies 11. Implement control and prevention measures 12. Initiate or maintain surveillance 13. Communicate findings

  43. Scabies Cleaveland Clinic J Med, 2008; 75:474-478. • Papules • Excoriations • Burrows • Nodules

  44. Atypical ScabiesN Engl J Med, 2006; 345:1718-27.

  45. Management of Scabies Outbreaks • Nosocomial / institutional outbreaks: • Contact precautions • 24 hours after treatment • 10 days after treatment of crusted scabies • Make a secure diagnosis • Consider dermatology consultation • Identify infested persons • Treat infested persons and contacts • Patients and staff • Environmental control measures

  46. Environmental Management of Scabies Infestation(CDC) • Insecticide sprays and fumigants NOT recommended • Mites do not survive more than 3 days away from human skin

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