Infectious Disease

1. Infectious Disease Portraits of the Past; Vision of the Future Puja Mehta, MPH Maine CDC Oct 13, 2009

2. Infectious Disease Today Newly emerging and re-emerging infectious disease An emerging disease is one that has appeared in a population for the first time, or that may have existed previously but is rapidly increasing in incidence or geographic range. �In an oft-quoted statement, the Surgeon General of the United States of America, William Stewart, said in 1967: �The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.� �In an oft-quoted statement, the Surgeon General of the United States of America, William Stewart, said in 1967: �The time has come to close the book on infectious diseases. We have basically wiped out infection in the United States.�

3. �As the human immunodeficiency virus (HIV) epidemic surely should have taught us, in the context of infectious diseases, there is nowhere in the world from which we are remote and no one from whom we are disconnected.� Institute of Medicine, 1992

4. Emerging Infectious Diseases Which infectious disease are emerging Who are they affecting Why are they emerging What can be done to control them

5. Target Areas Antimicrobial resistance Foodborne and waterborne diseases Vectorborne and zoonotic diseases Chronic diseases caused by infectious agents Diseases of persons with impaired host defenses Diseases of pregnant women and newborns Diseases of travelers, immigrants, and refugees Vaccine development and use

6. Select infectious disease Maine 2008 highlights Chlamydia TB Lyme Rabies EEE H1N1 Of 400 LTBI reports, 77% were foreign born. All cases are evaluated by a TB consultant physician and are placed on directly observed therapy (DOT) dministered by Public Health Nurses.Of 400 LTBI reports, 77% were foreign born. All cases are evaluated by a TB consultant physician and are placed on directly observed therapy (DOT) dministered by Public Health Nurses.

7. Chlamydia and TB Chlamydia remained the most commonly reported infectious disease in the state with 2,594 cases. The number of cases of tuberculosis fell to only 9 cases, all but one of whom were foreign-borne. Case total of 9 represents a 53% decrease from 2007 Seventy-two percent of reported infections of chlamydia were in persons 15-24 years of age. Seventy-two percent of reported infections of chlamydia were in persons 15-24 years of age.

8. Lyme Disease Lyme disease numbers continued to increase with 908 cases reported. Part of the increase was attributed to a new case definition for the disease. Case total of 908 represents a 72% increase over 2007. Most cases occurred during summer months (67% in June-August) � Cases were greatest in York (32%) and Cumberland (25%) counties The case definition for classifying cases changed starting January 1, 2008 that included a probable case definition which led to a higher case count than previous years. Burden of LD disease increasing while resources remain unchanged �Change in LD case definition had small effect on confirmed cases although non-cases dropped substantiallyCase total of 908 represents a 72% increase over 2007. Most cases occurred during summer months (67% in June-August) � Cases were greatest in York (32%) and Cumberland (25%) counties The case definition for classifying cases changed starting January 1, 2008 that included a probable case definition which led to a higher case count than previous years. Burden of LD disease increasing while resources remain unchanged �Change in LD case definition had small effect on confirmed cases although non-cases dropped substantially

9. Lyme Disease

10. Animal Rabies

11. Eastern Equine Encephalitis Virus (EEEV) Arthropod-borne virus (Arbovirus) Rare disease transmitted by mosquitoes Belongs to genus Alphavirus � other diseases in this category include Western equine encephalitis virus (WEEV) and Venezuelan equine encephalitis virus (VEEV).

12. EEE in Humans ~5 cases per year in U.S. since 1964 Most severe domestic arboviral infection 30% case-mortality rate Most cases occur June thru October Neurological attack rate based upon a serological prevalence study performed during an outbreak in New Jersey in 1959. The ratio represents apparent infections = neurological infection (EEE) to inapparent infections = all other infections, including subclinical infections, and milder systemic illnesses.Neurological attack rate based upon a serological prevalence study performed during an outbreak in New Jersey in 1959. The ratio represents apparent infections = neurological infection (EEE) to inapparent infections = all other infections, including subclinical infections, and milder systemic illnesses.

13. EEEV Transmission Cycle

14. EEE in US

15. EEE in Maine 13 horses have died from confirmed or suspected EEE since August 1, 2009 Location of cases include York, Cumberland, Waldo, Penobscot & Kennebec 3 flocks of pheasants confirmed with EEE 2 mosquito pools confirmed with EEE From 2005�2008, 3 horses diagnosed with EEE , in 2008 one mosquito pool tested positive for EEE. All located in southern Maine No reported human infections in Maine Fatal case in MA resident who visited ME (2008) Previous human cases in NH and MA

16. Prevention and Treatment No commercial vaccine for humans Mosquito control programs Personal protective measures No specific antivirals Supportive care

17. H1N1 Worldwide March/April, 2009 � first detected in Mexico and southern US August, 2009 � detected in over 200 countries. Nation By April 23, 7 cases in US (California & Texas) By August 27, 8842 hospitalized cases and 555 deaths in US.

18. H1N1 As of 4 October 2009, worldwide there have been more than 375,000 laboratory confirmed cases of pandemic influenza H1N1 2009 and over 4500 deaths reported to WHO.

20. H1N1 The 2009 novel H1N1 influenza virus is the predominant influenza virus in circulation in most countries worldwide. More than half of the country is seeing widespread influenza, with nearly all of it being the 2009 novel H1N1 influenza strain. Very little seasonal flu strains are being detected at this time.

21. H1N1 in Maine 399 confirmed and probable cases of H1N1 total to date 243 in Maine residents 15 Maine residents have been hospitalized 156 in out of state residents tested in Maine 5 Out of state residents have been hospitalized in Maine 1 death reported to date 91% of lab confirmed H1N1 cases in Maine residents and out of state visitors are under the age of 50 (range 0-81 years, mean of 22 years)

22. H1N1 in Maine

23. Lab confirmed H1N1 counts as of 10/08/09

24. Characteristics of Lab Confirmed H1N1 cases �Maine, 2009

25. Prevention Cover coughs and sneezes with a tissue or sleeve. Wash hands frequently. Stay home if ill with a fever. Consider getting both seasonal (regular) flu and H1N1 (�Swine flu�) shots this year.

26. Overall Priority groups for vaccination The overall 5 priority groups with Maine estimates of numbers for fall, 2009 are: Pregnant women (8,500); Persons who live with or provide care for infants aged <6 months (e.g. parents, siblings, and daycare providers) (18,500); Children and young adults aged 6 months through 24 years (390,000); Persons aged 25 through 64 years who have medical conditions* that put them at higher risk for influenza-related complications (155,000); Health care and emergency medical services personnel (122,000). Medical conditions that confer a higher risk for influenza-related complications include chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematologic, or metabolic disorders (including diabetes mellitus) and immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus).Medical conditions that confer a higher risk for influenza-related complications include chronic pulmonary (including asthma), cardiovascular (except hypertension), renal, hepatic, cognitive, neurologic/neuromuscular, hematologic, or metabolic disorders (including diabetes mellitus) and immunosuppression (including immunosuppression caused by medications or by human immunodeficiency virus).

27. Priority Groups for Antivirals Hospitalized patients Those at high risk of severe disease Children younger than 2 years old* Adults 65 years and older Pregnant women and women up to 2 weeks from end of pregnancy People with certain chronic medical conditions (such as asthma, heart failure, chronic lung disease) and people with a weak immune system (such as diabetes, HIV) People younger than 19 years of age who are receiving long-term aspirin therapy

28. Additional Information Maine www.mainepublichealth.gov Centers for Disease Control (CDC) www.cdc.gov World Health Organization (WHO) www.who.int

29. Summary Increased surveillance Develop and promote strategies to change behavior that encourages disease transmission Promote disease control internationally Research

30. Conclusion �The future of humanity and microbes likely will unfold as episodes of a suspense thriller that could be titled Our Wits Versus Their Genes.�