OCHD EPI Update 1st Qtr 2014

EPI UPDATE
Published for Healthcare Professionals
1st Quarter 2014
RABIES UPDATE
RICHARD RENAS, MPH
Rabies virus continues to circulate in Oakland County.
During the five year period 2009-2013, infections
were primarily in wildlife (17 bats, 14 skunks, one fox
and one woodchuck) which is consistent with trends
seen in Michigan and the United States. Additionally,
two dogs and two cats tested positive. Skunk rabies
increased significantly from the five cases seen during
2004-2008. Skunk strain spilled over into other wildlife
and domestic cases, including the woodchuck which
was the first ever seen in Michigan. While skunks are a
significant source of rabies, bats are the overwhelming
source of human exposure in Oakland County.
A bite or a scratch is the most common means of becoming
infected with rabies. Particularly with bats, due to their
very small teeth, a bite wound may not be obvious. The
Centers for Disease Control and Prevention (CDC)
suggests post exposure prophylaxis (PEP) where there
is a reasonable probability that contact with a bat may
have occurred (e.g. a deeply sleeping person awakens
to find a bat in the same room, an adult witnesses a bat
in a room with a previously unattended child, mentally
disabled person or intoxicated individual) and when
rabies cannot be ruled out through testing of the bat.
To evaluate animal bites and the need for PEP, refer to
the Rabies Post Exposure Prophylaxis (PEP) Protocol on
page 3 which has been summarized from the Advisory
Committee on Immunization Practices (ACIP)
recommendations for PEP to prevent human rabies.
The Oakland County Health Division Communicable
Disease Unit (OCHD-CDU) has the protocol available
electronically or on laminated, pocket sized cards. To
obtain copies contact the OCHD-CDU at 248-858-1286.
PEP reference documents can also be accessed at:
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm
http://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf
Initiating rabies PEP is an urgent matter, not an
emergency. In most cases it is not necessary to initiate
treatment immediately. PEP can wait 48-72 hours to
(continued on page 2)
In This Issue
Rabies Upate1
OCHD - CDU Rabies Post Exposure Prophylaxis Protocol 3
Influenza 2013-2014 Season Summar4
World TB Day - A Reminder of an Ever-Present Diagnostic Dilemma 5
2013 Active Tuberculosis Cases Summary6
Oakland County Selected Diseasses7
Think TB Poster8
Oakland County Health Division
1200 N. Telegraph Rd., Pontiac, MI 48341
L. Brooks Patterson
Oakland County Executive
Page 1
1st Quarter 2014 - EPI Update
OAKLAND COUNTY
HEALTH DIVISION OFFICES
North Oakland Health Center
1200 North Telegraph 34E
Pontiac, MI 48341-0432
248.858.1280
Toll Free 1.888.350.0900
FAX 248.858.0178
South Oakland Health Center
27725 Greenfield Road
Southfield, MI 48076-3663
248.424.7000
FAX 248.424.7144
Visit us at our website:
oakgov.com/health
Oakland County Health Division will
not deny participation in its programs
based on race, sex, religion, national
origin, age or disability. State and
federal eligibility requirements apply
for certain programs.
RABIES UPDATE (continued from page 1)
receive animal testing results or find and confine the dog, cat, or ferret in order
to avoid unnecessary administration of PEP, which has significant cost, pain
and inconvenience for the patient. Any potential exposure does, however,
need to be evaluated. If it is determined that an exposure did occur, then PEP
should be given. For questions and advice on risk assessment and prophylaxis
call OCHD-CDU at (248) 858-1286. For medical staff questions regarding
evaluation of a patient seen after hours in the emergency department or after
hours clinic, contact the Health Administrator On Call at (248) 858-0931.
With the arrival of spring and summer the number of exposures to bats and
other potentially rabid animals will increase dramatically. In order to minimize
this health problem the following measures will help protect pets, children and
adults:
• Have pets vaccinated and keep up with regular booster shots
• Warn children (and adults) to stay away from wild or stray animals
• Wild-life proof your home
For animal collection call Oakland County Animal Control at (248) 391-4102.
Helpful websites for rabies prevention and control information are:
• OCHD Rabies Fact Sheet
www.oakgov.com/health/Documents/Facts%20Sheets/fs_rabies.pdf
OAKLAND COUNTY
HEALTH DIVISION - CD UNIT
248.858.1286
Pamela Hackert, MD, JD, MPH
Chief of Medical Services
Nicole Parker, MPH
Epidemiologist
Richard Renas, MPH
Epidemiologist
Suzanne Brunette, RN, BSN
Communicable Disease Nurse
Anne Hocking, RN, BSN
Communicable Disease Nurse
Carolyn Padro, RN, BSN
Communicable Disease Nurse
After hours urgent calls:
248.858.0931, ask for the
health administrator on call.
• MI Rabies Maps, PEP Protocols, On line PEP course – CE credits
www.michigan.gov/rabies
• ACIP Guidelines, physician info
www.cdc.gov/rabies
• CDC Safe Bat Capture Guidelines
www.cdc.gov/rabies/bats/contact/index.html
OAKLAND COUNTY HEALTH DIVISION
RABIES PRESENTATION
The Oakland County Health
Division (OCHD) Public Health
Speakers Team offers rabies
educational presentations for
professionals or for community
groups. If you are interested in
scheduling a presentation visit the
OCHD Public Health Speakers
Team web site at:
www.oakgov.com/health/Pages/Public-Health-Speakers-Team.aspx
Page 2
NO
Do Not
Administer PEP
YES
MICHIGAN LAW REQUIRES ANIMAL BITES
BE IMMEDIATELY REPORTED TO THE
LOCAL HEALTH DEPARTMENT
Contact OCHD-CDU
at 248-858-1286
or 248-858-0931
after hours
YES
Rabies PEP is a medical urgency, NOT an emergency. Treatment
does not usually need to begin immediately if animal is available for
testing or observation.
NOTE:
evaluation.
** Rabies PEP is not generally recommended for a provoked bite/
scratch from a healthy cat or dog in the USA (e.g. bite/scratch occurs
while petting or feeding). Each incident needs to be evaluated
individually.
* Any mammal exhibiting unusual behavior, contact OCHD for
Administer
PEP
NO
Do Not
Animal available for
YES Administer PEP*
testing?
YES
NO
NO
Exposure To:
Exposure To:
Exposure To:
bat (see other side),
squirrel, hamster,
dog, cat or ferret?**
skunk, raccoon, fox,
mouse, rabbit, rat,
coyote, or opossum?
or woodchuck?*
YES
Was person bitten or scratched,
in contact with saliva or brain tissue
of a mammal, or exposed to a bat?
The Oakland County Health Division will not deny participation in its programs based on race, sex, religion, national origin, age or disability. State and federal eligibility requirements apply for some programs.
I:\Health\CHPIS\HealthEd\Smith\EPI\Rabies\ERFlipChart2011\RabiesQuickRef2011.indd (ModifiedJune2011)
After hours call Health Administrator on Call @ 248-858-0931
An Epidemiologist will return your call 24 hours a day.
OCHD CDU, Monday-Friday 8:30 AM - 5:00 PM @ 248-858-1286
Immunosuppressed and Previously Vaccinated Patient: No HRIG,
and only two (2) doses of vaccine on days 0 and 3. Submit serum for rapid
fluorescent focus inhabition test (RFFIT) 1-2 weeks following final dose.
3
Immunosuppressed and Unvaccinated Patient: HRIG and a five (5) dose
series of vaccine on days 0, 3, 7, 14, 28. Submit serum for rapid fluorescent
focus inhabition test (RFFIT) 1-2 weeks following final dose.
2
Previously Vaccinated Patient: No HRIG, and only two (2) doses of vaccine
on days 0 and 3.
1
anyone, including pregnant women.
NOTE: There are no contraindications for rabies prophylaxis for
administered on Day 0. Dosage (20 IU/kg) should be infiltrated
into and around bite wound as much as possible. The rest must
be given IM at a site(s) distant from vaccine administration site.
Human Rabies Immune Globulin (HRIG) – One (1) dose
in the deltoid region on days 0, 3, 7, 14. Never administer vaccine
in gluteal area.
Rabies Vaccine – Four (4) doses (1.0 ml each) administered IM
(If ever received rabies PEP1 or Immunosupressed2 or both3 see below)
RABIES POST-EXPOSURE PROTOCOL:
The Centers for Disease Control & Prevention (CDC) suggests PEP where a
reasonable probability that contact with a bat may have occurred (e.g. a deeply
sleeping person awakens to find a bat in the same room, an adult witnesses a
bat in a room with a previously unattended child, mentally disabled person, or
intoxicated individual) and when rabies cannot be ruled out by testing of the bat.
NOTE: A bite from a bat MAY NOT leave a noticeable wound.
(OCHD-CDU)
Rabies Post-Exposure Prophylaxis (PEP) Protocol
BAT EXPOSURES:
OAKLAND COUNTY HEALTH DIVISION COMMUNICABLE DISEASE UNIT
1st Quarter 2014- EPI Update
Page 3
1st Quarter 2014 - EPI Update
INFLUENZA 2013-2014 SEASON SUMMARY
NICOLE PARKER, MPH
The 2013-14 influenza season has been similar to the 2012-13
influenza season. Figure 1 shows that the 2013-14 season did not
have a mid-February peak that is typically seen in Oakland County
and nationwide. Instead the peak of the 2013-14 influenza season
occurred during late December – early January, similar to the peak
of 2012-13 season, and consistent with what occurred nationwide.
The 2013-14 season quickly declined after its peak during the
first week of January; whereas, the 2012-13 season was sustained
throughout the month of February. In contrast to the 2012-13
season, this season started around the same time as in years past,
with the first cases of influenza being reported in late November
and early December.
In terms of strains seen, this season was atypical, 97.2%, of
laboratory confirmed and probable cases of influenza reported to the Oakland County Health Division (OCHD) were influenza A
positive (Figure 2).
Sixty-four of the 419 influenza A cases were subtyped by
MDCH-BOL. Of those, 96.9% were confirmed as being positive
for influenza A H1N1 2009. Throughout Michigan and the
United States influenza A H1N1 2009 was observed to be the
predominant circulating strain.
The statewide surveillance system identified a majority, 92.1%,
of specimens positive for influenza A 2009 H1N1, as of April 17,
2014. Of the 366 influenza specimens tested at the state level,
3.5% were positive for influenza A/H3 and 3.8% were positive
for influenza B. This is unique to this season within the state and
nationwide because despite the influenza A H1N1 2009 strain
being a good match to the vaccine, the strain was still able to
circulate and infect the population.
During the 2013-14 season, Oakland County hospitals reported 191 inpatient cases to OCHD. This diligent reporting and continued
participation in reporting hospitalized influenza patients is much appreciated. As part of their reporting, these facilities provide
additional information about the patient’s stay in the hospital and pre-existing risk factors that may lead to complications with
influenza. This season 169 hospitalized patients had additional stay and risk factor information reported.
Of the hospitalized patients reporting risk factors for complications with influenza:
• 59.2% were taking an immunosuppressive drug
• 42.0% had a chronic underlying heart disease
• 37.2% were obese based upon their body mass index
• 29.0% had a chronic underlying metabolic disease including diabetes
• 27.2% had a chronic underlying lung disease
• 21.3% had asthma
• 11.2% had been diagnosed with cancer in the last 12 months
• 10.7% had another immunosuppressive condition
• 8.3% had a chronic underlying renal disease
• 7.7% had a chronic underlying neurologic disease
• 1.9% of the 105 females were pregnant
*Figure 1 and 2 reported as of end of MMWR Week 14-2014
(continued on page 5)
Page 4
1st Quarter 2014 - EPI Update
INFLUENZA SUMMARY (continued from page 4)
Tragically, two pediatric deaths were associated with laboratory confirmed influenza in Michigan during the 2013-14 season. No
pediatric deaths were recorded in Oakland County. However, consistent with the predominance of the influenza A H1N1 2009
strain, three deaths of 20-30 year olds were attributed to complications related to influenza A H1N1 2009 infection. All three
individuals were unvaccinated.
Table 1 shows a comparison of 2012-13 and 2013-14 hospitalized patients with information available:
Table 1 – 2012- 2013 and 2013-2014 Inpatient Demographics
2012-2013
2013-2014
<65 Years
40.6
64.4
Average Age
48.6
53.3
Age Range
1 month - 102 years
1 month - 90 years
Reported Being Vaccinated
32.3
37.2
Average Days Hospitalized
4.5
5.2
Admitted to ICU
11.8
24.6
Ventilator
1.3
15.2
ECMO
2.2
3.1
Pneumonia
24.9
42.4
ARDS
1.3
14.1
More detailed and up to date information on influenza surveillance is available online at:
• Michigan.gov (http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_22779_40563-143382--,00.html )
• Centers for Disease Control and Prevention (http://www.cdc.gov/flu/weekly/fluactivitysurv.htm )
WORLD TB DAY – A REMINDER OF AN EVER-PRESENT DIAGNOSTIC DILEMMA
PAMELA B HACKERT, MD, JD, MPH
World TB Day, March 24, serves as an annual reminder of just how
devastating a burden tuberculosis (TB) is to most of the world and
how much of an impact it still has in Michigan. This annual event
commemorates the date in 1882, when Dr. Robert Koch announced his
discovery of Mycobacterium tuberculosis, the bacillus that causes TB.
Although Michigan is a low incidence state, TB is still a significant health
issue, not only for individuals, but for anyone who breathes that same air.
This year, the Centers for Disease Control and Prevention (CDC) selected the theme “Find TB. Treat TB. Working
together to eliminate TB.” Even with the declining number of TB cases in the United States, our current efforts
to find and treat latent TB infection and TB disease are not sufficient. Misdiagnosis of TB still exists and health
care professionals often do not “Think TB,” until several rounds of antibiotics have been given without curing that
persistent “pneumonia.” Also, we are seeing rarer manifestations of TB. Even while our overall numbers indicate
low incidence, the complexity of cases is seemingly higher, with some recent examples such as central nervous
system TB, drug resistant TB or multiple types of mycobacterium in a patient.
On March 26, I had the opportunity to present at Michigan’s commemorative event for World TB Day in Lansing.
It was a full day of up to the minute information about TB, including topics such as the epidemiology of TB, the
dilemmas of diagnosis, the particular concerns of patients with TB/HIV co-infection, etc., but the most moving
and inspiring part of the day was when a patient shared her story of how her life changed when she was diagnosed
with multi-drug resistant TB. Through the sharing of these stories we can bring attention to this critical public
health problem and ensure that resources continue to be available to eradicate this disease because, “Everyone has
a role in ensuring that one day TB will be eliminated.”
Conference resources are available at: https://mphi-web.ungerboeck.com/wri/wri_p1_display.aspx?oc=10&cc=WORLDTB
CDC TB information is located at: www.cdc.gov/tb
Page 5
1st Quarter 2014 - EPI Update
2013 ACTIVE TUBERCULOSIS CASES SUMMARY, NICOLE PARKER, MPH
• 57% were male
• Average age 48.7 years, ranging from 17 to 88 years
Figure 1: 2009 - 2013 TB Case Rate per 100,000 population
2.5
2
Rate per 100,000
During 2013, twenty-six cases of active Tuberculosis (TB)
disease were reported to the Oakland County Health Division TB Unit (OCHD TB Unit). The case rate per 100,000 population
is 2.2 (Figure 1), this case rate is slightly higher than previous
years but is well below the national case rate for the United
States. Of the 26 cases:
1.5
Rate per 100,000
1
0.5
0
Active TB disease can present in three different forms:
Pulmonary, Extra-pulmonary, or a combination of both.
Pulmonary TB is the most infectious form of active TB disease. Of the active cases in Oakland County, 57% had the
pulmonary form and 7.6% had evidence of both pulmonary and extra-pulmonary TB infection.
2009
2010
2011
2012
2013
Year
Table 1 - 2013 Case Risk Factors for active TB disease
Risk Factors
Foreign Born
Unemployed
Diabetes
Contact to an Active Case
Homeless
Immunosuppressive Condition, not HIV/AIDS
HIV Positive
No Risk Factors
%
73.1
34.6
19.2
3.8
3.8
3.8
0.0
3.8
There are a variety of risk factors associated with
active TB disease (Table 1), these risk factors range
from underlying medical conditions to socioeconomic factors. The three most common risk factors
amongst Oakland County’s 2013 TB cases were:
birth in a foreign country (73.1%); unemployment
(34.6%);, and diabetes (19.2%). Other known risk
factors such as homelessness, immunosuppressive
conditions, and being a contact to a known case
were also present.
OCHD TB Unit’s two case managers, under the direction of OCHD’s Medical Director, Dr Pamela Hackert, work
tirelessly to ensure that all identified cases receive directly observed therapy (DOT). The standard of care set by the
Centers for Disease Control and Prevention (CDC) is that all cases, both pulmonary and extrupulmonary, receive
DOT. This ensures that the needed four drugs for successful treatment are administered appropriately and that
any side effects from the therapy are caught early. For the 15 cases that completed treatment in 2013, the OCHD
TB Unit case managers administered DOT for 26.5 weeks on average, with some cases continuing for as long as 40
weeks. Treatment for the remaining 11 cases is ongoing into 2014.
In addition, these case managers work to ensure that all case contacts: family members, friends, co-workers, are
appropriately assessed at OCHD clinics or in their home, and follow-up treatment is conducted as indicated. During
2013 these case managers also directed the assessment of a large school based case contact investigation in which
280 case contacts were assessed. (See Second Quarter 2013 Epi Update for the full report on that investigation).
The efforts of the TB case managers and the OCHD TB Unit work toward preventing further TB disease within
Oakland County and help move Public Health closer to the goal of eliminating TB disease worldwide.
For additional information regarding TB data in Michigan visit the Michigan Department of Community Health’s
(MDCH) TB Control Program page at: www.michigan.gov/mdch/0,1607,7-132-2945_5104_5281_46528---,00.html
For additional information regarding national TB data visit the Centers for Disease Control and Prevention’s
(CDC) TB information page at: www.cdc.gov/tb/
Page 6
1st Quarter 2014 - EPI Update
OAKLAND COUNTY SELECTED DISEASE DATA
DISEASE
HIV (all stages)1
AIDS (HIV infection stage 3)2
Campylobacter
Chickenpox
Chlamydia
Giardiasis
Gonorrhea
Hepatitis A
Hepatitis B Acute
Hepatitis C Chronic
Legionellosis
Listeriosis
Measles
Meningitis, viral (aseptic)
Meningococcal Disease
Pertussis
Salmonellosis
Shiga-toxin producing E. coli (STEC)
Shigella
Syphilis (primary&secondary)
Strep pneumonia, invasive
Tuberculosis-Pulmonary
Tuberculosis-Extrapulmonary
Typhoid Fever
Jan-March
2012
20
16
22
33
816
14
202
1
3
150
3
0
1
22
0
22
24
5
6
6
13
2
2
0
Jan-March
2013
27
19
16
11
837
11
237
5
4
123
2
0
0
17
0
16
16
3
0
12
18
3
1
0
Jan-March
2014
26
8
26
20
820
13
159
0
1
124
4
0
0
15
0
32
18
3
5
4
15
1
1
2
Note: Data may change slightly as new information becomes available.
1
Includes all newly diagnosed HIV cases, including those diagnosed with Stage 3 (AIDS) at the same time as their HIV diagnosis, based on date of HIV diagnosis
2
Includes all newly diagnosed Stage 3 (AIDS) cases, including those diagnosed with HIV at the same time as their Stage 3 diagnosis, based on date of Stage 3 diagnosis
Page 7

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