Annual Outbreak Report West Virginia, 2010

1. Annual Outbreak Report West Virginia, 2010 Sherif Ibrahim, MD, MPH Division of Infectious Disease Epidemiology May, 2011

2. Objectives • Describe 2010 Outbreaks • Discuss types of outbreak reported in 2010 • Describe healthcare-associated outbreaks (HAOs) • Conclusions and lessons learned • Recommendations

3. Background • In WV, outbreaks are reportable immediately to local health departments(LHDs) • LHDs are required to report outbreaks to Bureau for Public Health (BPH) within 60 minutes • LHDs report and investigate outbreaks with assistance from regional epidemiologists & BPH • There was a 13-fold increase in reported outbreaks from 2001 to 2010

5. Summary Outbreak Data - 2010 • 124 outbreaks were reported • 96 (77.4%) were confirmed • 28 (51%) counties reported outbreaks • Jurisdictions • 95 (99%) were limited to WV residents • 1 (1%) involved residents of other states

9. Types of Confirmed Outbreaks, West Virginia, 2010

10. Enteric Disease Outbreaks • Total: 35 • 16 (29%) counties • 1 reported multi-state outbreak (CDC: Lead) • Norovirus and acute gastroenteritis: 28 (80%) • Acute gastroenteritis outbreaks were defined as “outbreaks of illness with short duration (2-3 or fewer days) and characterized by acute onset of vomiting and /or diarrhea and no laboratory confirmation”.

11. Outbreaks of Enteric Disease by Transmission Settings, West Virginia, 2010

12. Outbreaks of Enteric Disease by Etiologic Agent, West Virginia, 2010

14. Foodborne Outbreaks – Salmonellosis • Salmonella serotype Enteritidis: • Family of 10 from 3 households • 6 cases (3 confirmed and 3 probable) • Salmonella serotype Montevideo: • One WV resident among 272 US residents • Traced to salami products containing contaminated imported black and red pepper.

15. Foodborne Outbreaks – Salmonellosis • Salmonella serotype Enteritidis • 18 confirmed and 4 probable cases. • Case control study  illness associated with eating at multiple locations of a single chain restaurant • Lab (PFGL &MLVA) 11 isolates were identical • Identical to a 2009 outbreak strain associated with multiple locations of the same chain restaurant • Recommendations to the corporate

16. Foodborne Outbreak – Hepatitis A • First Hepatitis A Outbreak • Two family members • Epi-link to a hepatitis A outbreak in a daycare in KY • Hepatitis A is asymptomatic in children < 6 years in 70% of cases

17. Foodborne Outbreak – Hepatitis A • Second  Hepatitis A Outbreak • 11 cases • Delayed reporting (2 months) • Retrospective identification of several cases • Transmissionperson-to-person among friends and secondary spread to households • LHD press releases, education, outreach and community-wide vaccination

18. FoodBorne: Bacilluscereus • The outbreak • 10 family members  acute gastroenteritis • Pizza from a local restaurant • Laboratory testing of the patients was negative • Testing of the remaining pizza at OLS revealed contamination with Bacilluscereus • Bacillus cereus: • B. cereus is an aerobic, spore-forming, gram-positive rods • Food-poisoning can result from two types of toxins • Diarrheal syndrome : (incubation period of 10-12 hrs) associated with heat-labile (meat, stews, gravies) • Emetic syndrome: (incubation period of 1-6 hrs) associated with a heat-stable toxin (fried rice, meat, improper refrigeration)

19. Rash Illness Outbreaks by Etiologic Agent/Clinical Syndrome, West Virginia, 2010

20. Rash Illness Outbreaks – Varicella • A ten-fold increase from 2009. • Varicella Vaccine Effectiveness Project: • Hired two full-time staff • Offered free laboratory testing • Active surveillance in WV public schools • Education campaign • Change in varicella outbreak definition for schools • 19 from schools and 1 from a community. • Lab testing • 7 laboratory confirmed • 3 negative or non-contributory • 10 did not have laboratory testing.

21. Scabies Outbreaks By transmission Settings, West Virginia , 2010

22. Scabies Outbreak • Incubation period: 2-6 weeks • Outbreak definition: 2 or more cases of scabies among residents/staff within 4-6 week • Confirm the diagnosis consult a dermatologist • Isolation /exclusion of ills  a day after effective treatment • Offer treatment to contacts /families • Provide education • Environmental measures

23. Respiratory Disease Outbreaks • Total 26 (27%) • Reported by 14 (25%) counties. • In 2009 53 respiratory disease outbreaks • No influenza outbreaks in 2010

24. Respiratory Outbreaks by Clinical Syndrome, West Virginia, 2010

25. Upper Respiratory Illness (URI) • 16 outbreaks • 15 from LTCFs and one from a school • Case definition: new onset of at least two of the following symptoms: • Runny nose or sneezing • Stuffy nose / congestion • Sore throat / hoarseness • Difficulty swallowing • Dry cough, and/or cervical lymphadenopathy • Rule out allergy • Rule out influenza  fever of 100 or more

26. Pertussis Outbreaks • Total # 5 • Reported by 4 Counties • 4 Communities and 1 daycare • No pertussis-related deaths • All outbreaks were PCR confirmed • Cyclical pattern every 3-5 years • Vaccine is not 100% effective

28. “Other” Outbreaks • 2 outbreaks of conjunctivitis (pink eye) • Reported from schools • Laboratory testing • 1 was not done • 1 negative or non-contributory • Testing can be done for these outbreaks • Hand washing and environmental cleaning

29. Vaccine Preventable Diseases by Etiologic Agent or Clinical Syndrome, West Virginia, 2010

30. Healthcare-Associated Outbreaks(HAOs) • Outbreaks where exposure / transmission is associated with healthcare facility(ies) • 43 (45%) • 16 Counties (29%) • 41 (95%) from LTCFs and 2 (5%) from hospitals. • 33 in 2009 • 55 in the first 3 months, 2011(90% from LTCFs)

31. Healthcare-Associated Outbreaks by Type of Outbreak, West Virginia, 2010

34. Outbreak of Human Metapneumovirus • URI outbreak in a LTCF complicated by pneumonia • AR: 47% and Death rate 1% • HMPV: • Identified in 2001 • RNA virus related to RSV and PIV • Transmission: droplet and contact • Seasonality: winter and spring • IP: 2-8 days • At-risk populations: infants, children, elderly and LTCFs • Clinical presentation: URI, pharyngitis, pneumonia, bronchiolitis • CXR findings: diffuse interstitial infiltrates, hyperinflation • Precautions: standard and contact (droplet if indicated)

36. Timeliness of Outbreak Reporting Summary • 81 (81.4%) outbreaks with complete data on date and time of reporting • Mean= 35.8 hours • Median= 1 hours • Range= 0 to 864 hours • 71 (88%)  same day notification •  15 (15.6%) outbreaks were missing info on date and/or time of reporting

38. Timely Reporting of Outbreaks • LHD is required to report outbreaks within 60 minutes under • Reportable disease rules • Threat preparedness funding • Program plan

39. Timely Reporting of Outbreaks • Scientific and technical support • Case definition • Diagnosis and prevention measures • Descriptive epidemiology • Special studies if needed • Laboratory support • Resources support • Communication support

40. Conclusions • Marked improvement in reporting and management of outbreaks in WV • Outbreak investigation requires: • Problem-solving skills, training and experience • Collaboration between epidemiology, laboratory and environmental • Collaboration between local, regional, healthcare providers, state, and CDC • Most HAOs are reported from LTCFs

41. Recommendations • Report outbreaks to DIDE within 60 minutes • Use DIDE’s guidelines for outbreak investigation • Consult and get assistance from your regional epidemiologist (Field investigation, Training) • Training and education • Plan to improve your communication with LTCFs • Feedback information on outbreaks to reporting sources and other partners • Outbreaks = opportunities for improvements

42. Outbreak Report, West Virginia, 2010 http://www.wvidep.org/Portals/31/PDFs/IDEP/Outbreaks/2010_Final_%20Outbreak%20Report.pdf Contact Information: 304-558-5358 OR 800-423-1271 (24/7) Office:304-356-4074 Cell: 304-553-9165 sherif.m.ibrahim@wv.gov

43. Questions