State of the State January 25, 2019 Presenting to APIC Grand Canyon | Phoenix AZ Arizona Department of Health Services Update on the Syphilis Outbreak Rebecca Scranton, MPH Program Manager ADHS STD Control A Brief History of Syphilis in Arizona How does syphilis compare?
STDs in Arizona Syphilis represents 4% of STDs
Only 1:4 syphilis cases are women
2007 2018 Outbreak declared!
Directors Blog, September 25, 2018 Why syphilis?
STDs in Arizona Syphilis in Arizona
Status TBD Case
2007 2018 2007 2018 Outbreaks can last for years
Syphilis Timeline
6.5 mo
Exposure >1 mo 1.5 mo 1.5 mo
• 2 Infectious periods, last > 1 month • Up to 6.5 months between exposure and start of 2nd infectious period • Some cases can relapse into a 3rd infectious period at any time • Pregnant women can pass the disease to their developing baby at any time What about the babies?
Congenital syphilis started to increase in 2017
Status TBD Survived Died 2014 2015 2016 2017 2018 Statewide increase of CS
Congenital Syphilis in Arizona 1 2 3 4 5+ Number of congenital cases
2014 2015 2016 2017 2018 What are we doing about it? Statewide actionAction Planplan
Awareness Partnerships Screening Why screening?
Syphilis Timeline
Exposure Primary Secondary CDC Screening Recommendations
Pregnant At first prenatal visit, retest women at third trimester and at delivery if at high risk MSM Annually HIV+ Annually Effective Jan 1, 2018; A healthcare provider for a pregnant syphilis case shall order serologic testing for syphilis at 28 to 32 weeks gestation and at delivery
A.R.S. § R9-6-381 A-2 Missed opportunities
77% of moms saw a provider > 30 days 77% prior to delivery
1/3 of CS cases could have been prevented 36% through third trimester testing Risk factors included meth, heroin, cocaine, and/or opiates. IV drug 12% 46% use was also reported. ADHS CDC Screening Recommendations
Pregnant At first prenatal visit, retest women at third trimester and at delivery if at high risk - Create electronic reminder systems MSM Annually HIV+ Annually Drug Opt out screening for men & users women that use drugs AHCCCS Covers 3 Screenings! Summary Action Plan
Syphilis is [still] Screening is increasing important
2007 2018 Coming Soon!
Annual HIV/STD/TB Clinical Update
2nd Annual Tribal STD/HIV Conference
[email protected] azdhs.gov/std Thanks!
Rebecca Scranton STD Control Program Manager [email protected] Rabies Post-Exposure Prophylaxis
APIC State of the State
Hayley D. Yaglom, MS, MPH 1/25/2019 Senior Epidemiologist Vector-borne & Zoonotic Diseases Program What is Rabies?
RNA virus in the family Rhabdoviridae.
Rabies virus infects the central nervous system.
Disease is progressive and rapidly fatal. How is Rabies Spread?
The bite of an infected animal.
Mucous membrane, scratch, abrasion, or open wound contact with saliva or other potentially infectious material.
Inhalation of aerosolized rabies virus is also a possibility.
Petting a rabid animal or contact with the blood, urine or feces does not constitute an exposure. Rabies in Arizona
Arizona is home to three rabies reservoirs: bats, gray foxes, and skunks. Rabies in Arizona
In 2018, we had 159 positive rabid animals.
51 domestic animals exposed to rabid animals.
29 humans exposed to rabid animals. What is Rabies Post-Exposure Prophylaxis?
Rabies post-exposure prophylaxis (PEP) involves wound cleansing, administration of human rabies immune globulin (HRIG) and a series of vaccinations. Human Rabies Immune Globulin Recommended dose is 20 IU/kg body weight (all age groups).
Infiltrate one time into wound and surrounding area.
Remaining volume should be injected intramuscularly (IM). Human Rabies Immune Globulin
If there is no wound, the entire dose of HRIG should be administered IM. Human Rabies Immune Globulin
Provides immediate antibodies until the body can respond to the vaccine.
Can be administered up to 7 days after the first dose of vaccine.
Not recommended beyond day 7 since an antibody response to the vaccine is presumed to have occurred.
Rabies Post-Exposure Prophylaxis Vaccines
RabAvert (PCECV) and Imovax (HDCV) are considered interchangeable in terms of indications for use, immunogenicity, efficacy and safety.
Other types of tissue culture and avian culture vaccines are available in other countries and are considered interchangeable. rPEP Vaccine Administration Reminders
First vaccine dose should never be administered in the same syringe or in the same anatomical site as HRIG.
Subsequent doses of vaccine in the series can be administered in the location where HRIG dose was given.
Pregnancy is not a contraindication to PEP. Rabies Post-Exposure Prophylaxis Schedule
Immunocompetent Individual HRIG and first vaccination are given on the first day of treatment (day 0), and three additional vaccinations are given on days 3, 7, and 14.
Immunocompromised Individual Receive a 5th vaccination on day 28 and tested for seroconversion 7-14 days following completion of PEP.
Previously Vaccinated Individual (either pre or post-exposure) Receive only two rabies vaccine boosters on days 0 and 3, and NO HRIG. Rabies PEP: Immunocompetent People (including pregnant women) Rabies PEP: Immunocompromised and Previously Vaccinated People Deviations from Recommended Schedule After day 3 of the regimen, deviations of a few days are acceptable.
For most minor delays or interruptions, the vaccination schedule can be shifted and resumed as though the patient were on schedule. Special Considerations
602-364-3676 Resources
CDC Rabies Webpage www.cdc.gov/rabies https://www.cdc.gov/rabies/medical_care/index.html https://www.cdc.gov/rabies/medical_care/vaccine.html https://www.cdc.gov/rabies/resources/acip_recommendations.html https://www.cdc.gov/rabies/resources/availability.html
Use of a Reduced (4-Dose) Vaccine Schedule for Post-exposure Prophylaxis to Prevent Human Rabies: Recommendations of the Advisory Committee on Immunization Practices https://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm
Human Rabies Prevention —United States, 2008 Recommendations of the Advisory Committee on Immunization Practices https://www.cdc.gov/mmwr/PDF/rr/rr5703.pdf
http://www.who.int/vaccine_safety/initiative/tools/Rabies_Vaccine_rates_information_sheet.pdf
https://azdhs.gov/documents/preparedness/epidemiology-disease-control/rabies/rabies-post-exposure-management.pdf Questions
[email protected] | 602-542-2521 | [email protected] | 602-364-3676 Tuberculosis + HIV Testing
TB Control Program TB Surveillance Epidemiologist Evan Timme
APIC – State of the State Friday, January 25th, 2019 Disclosures:
• No known conflicts of interest TB: By the Numbers
Today vs 1975 TB: By the Numbers
Today vs 1975
<200 >400 TB: By the Numbers
Today vs 1975
<200 >400
<3/100,000 19/100,000 TB: By the Numbers
2 0 1 8 ?
2012 2017 TB: By the Numbers
2012 2017 TB & HIV
Surveillance Review TB & HIV
Surveillance Review
• 1993 2016 TB HIV TB & HIV
ID Week 2018: Poster #2263 p < 0.0001 TB & HIV
Site of Dz
ID Week 2018: Poster #2263 p < 0.0001 TB & HIV
ID Week 2018: Poster #2263 TB & HIV
ID Week 2018: Poster #2263 TB & HIV
Outcome
ID Week 2018: Poster #2263 p < 0.0001 TB & HIV
HIV Dx Years Date
ID Week 2018: Poster #2263 TB & HIV
More than 93% of persons Dx with TB & HIV were Dx with HIV BEFORE Tuberculosis Dx.
HIV Dx Years Date
ID Week 2018: Poster #2263 TB & HIV
Without treatment, on average 1 in 10 people with latent TB infection will get sick with TB disease in the future.
The risk is higher for persons living with HIV.
HIV Dx Years Date
ID Week 2018: Poster #2263 https://www.cdc.gov/tb/topic/treatment/decideltbi.htm Know your TB Program TB: In the Works
2019: New Healthcare Personnel TB Screening Guidelines Thanks for the opportunity to share some work.
ADHS TB Control [email protected]
APIC-SotS: Friday, January 25th, 2019 Acute Flaccid Myelitis
Susan Robinson, MPH Vaccine Preventable Disease Epidemiologist
What is AFM? Acute Flaccid Myelitis
Acute onset of Limb weakness Inflammation of the symptoms *Can also include facial droop* spinal cord Acute Flaccid Myelitis
Acute onset of Limb weakness Inflammation of the symptoms *Can also include facial droop* spinal cord
One limb or all four limbs may be affected How is it diagnosed? MRI imaging Pleocytosis
o White blood cell count > 5 cells/mm3
JAMA. 2015;314(24):2663-2671. doi:10.1001/jama.2015.17275 How is it treated? No current targeted therapies or interventions currently available No current targeted therapies or interventions currently available o Supportive care o Physical therapy and rehabilitation early Are there lab tests? Short answer: Short answer: no
Specific pathogens to consider: Specific pathogens to consider:
oEnteroviruses (polio and non-polio) Specific pathogens to consider:
oEnteroviruses (polio and non-polio)
oWNV Specific pathogens to consider:
oEnteroviruses (polio and non-polio)
oWNV
oAdenoviruses Current AFM surveillance?
4
2
1 1 1 1 1 1 1 4
2
1 1 1 1 1 1 1
First year of surveillance in the US 4
2
1 1 1 1 1 1 1
A cluster was seen at PCH 14 cases reported over 5 years of surveillance 14 cases reported over 5 years of surveillance
Mean age: 9.5 years old Range: 17 months to 23 years 14 cases reported over 5 years of surveillance
Mean age: 9.5 years old Range: 17 months to 23 years 14 cases reported over 5 years of surveillance
Mean age: 9.5 years old Range: 17 months to 23 years
Over 50% of AZ cases had 4 limbs involved. Considerations for EVD68? Bradford Hill criteria: Bradford Hill criteria:
Strength of association Strength of association Bradford Hill criteria:
Strength of association
Consistency Consistency Bradford Hill criteria:
Strength of association
Consistency
Specificity Specificity
Not supported Bradford Hill criteria:
Strength of association
Consistency
Specificity
Temporality Temporality
o Generally febrile respiratory or GI prodrome precedes onset of neurological symptoms
o Respiratory specimens collected in that prodrome timeframe are positive prior to onset of neurological symptoms Bradford Hill criteria:
Strength of association
Consistency
Specificity
Temporality
Biological gradient Biological gradient
Not supported Bradford Hill criteria:
Strength of association
Plausibility
Consistency
Specificity
Temporality
Biological gradient Plausibility Bradford Hill criteria:
Strength of association
Plausibility
Consistency
Coherence
Specificity
Temporality
Biological gradient Coherence
o Viremia detected early in the course of enterovirus D68 infection and neuron-specific receptors for EV-D68 provide potential mechanism for neuroinvasion Bradford Hill criteria:
Strength of association
Plausibility
Consistency
Coherence
Specificity
Experiment
Temporality
Biological gradient Experiment
o Recent EV-D68 mice studies o EV-D68 causes loss of motor neurons in anterior horn of spinal cord in mice
o EV-D68 isolated from the spinal cord of paralyzed mice transmits paralytic disease to naïve mice
o EV-D68 antibodies protect against paralytic disease in mice Bradford Hill criteria:
Strength of association
Plausibility
Consistency
Coherence
Specificity
Experiment
Temporality
Analogy
Biological gradient Analogy
o Recent EV-D68 mice studies o EV-D68 causes loss of motor neurons in anterior horn of spinal cord in mice
o EV-D68 isolated from the spinal cord of paralyzed mice transmits paralytic disease to naïve mice
o EV-D68 antibodies protect against paralytic disease in mice Bradford Hill criteria:
Strength of association
Plausibility
Consistency 7 out of 9 criteriaCoherence met! Specificity
Experiment
Temporality
Analogy
Biological gradient THANK YOU
Susan Robinson, MPH | Vaccine Preventable Disease Epidemiologist [email protected] | 480-435-3929
azhealth.gov @azdhs facebook.com/azdhs Would you like some E.coli with your salad?
Kaitlyn Snyder Foodborne Disease Epidemiologist Arizona Department of Health Services March 2018
October 2018
MEDSIS Update January 25th, 2019
Presenting To APIC State of the State | Maricopa County Department of Public Health Teresa Jue | EDC Systems Manager What happened in 2018?
Four MEDSIS Production releases
Secure Messaging Resources Other enhancements & bug fixes Cloud Migration Health Services Portal https://connect.azdhs.gov What’s next?
Cloud Optimization
2019 Prioritization How do I submit feedback?
MEDSIS Infection Preventionist Quarterly Workgroup Meetings
MEDSIS Help Desk [email protected] THANK YOU
Teresa Jue | EDC Systems Manager [email protected] | 602-364-0151
azhealth.gov/medsis @azdhs facebook.com/azdhs APIC January 25, 2019 Creating Arizona Statewide Antimicrobial Stewardship Initiatives
Leadership Commitment
Accountability
Drug Expertise
Action AS Initial Project Description
(Arizona LTCF’s)
(Pharmacies) (Microbiology Labs) AS Future Directions
• Expand into additional Tracking facilities
• Provide targeted AS Reporting interventions
• Develop LTCF AS Toolkits Education Questions?
Juan E. Villanueva, PharmD, BCPS Assistant Professor Email: [email protected] Office: 520.626.5764 ADHS HAI Quarterly TAPS Report Trends Facility Outreach
Identify facilities that Provide these facilities consistently aren’t meeting with CDC TAPS 2020 HHS Target Goals Assessment Tools Facility consistently above the 2020 target SIR goals
ADHS is targeting high infection rates from recent quarters 2018 Quarter 1 NHSN Data Observed Predicted Quarterly CAD* Infections Infections SIR 3 4.614 0.7 1 Number of infections that need to be 2018 Quarter 2 NHSN Data prevented to Observed Predicted Quarterly reach 2020 HHS CAD* Infections Infections SIR target goals 4 3.197 1.2 3 1. Let facilities know about high HAI rates at their hospital 2. Share HAI specific CDC TAPS Assessment Tool 3. Explain how to perform this assessment 4. Encourage facilities to reach out to the state and local health departments TAPS Facility Instructions for Assessment Tool Administration: This Facility Assessment Tool should be administered to a variety of staff and healthcare personnel at different levels of the organization and/or unit (i.e., frontline providers, mid-level staff, and senior leadership). This assessment captures healthcare personnel’s knowledge, attitudes, and perceptions of infection prevention practices. The greater number of assessments collected, the greater the ability to identify gaps and target prevention.
Thank You! Questions?
[email protected] Arizona Influenza Update January 25, 2019
Presenting To APIC Grand Canyon’s State of the State Phoenix, AZ
Xandy Peterson, MPH
Vaccine-Preventable Disease Epidemiologist 2017-2018 Influenza Season In 2017-2018, there were 35,520 laboratory confirmed cases.
5 Season Average 2015–2016 2016–2017 2017–2018 6,000
5,000
4,000
3,000
2,000 Number Number Cases of 1,000
0
Week of Report 2018-2019 Influenza Season In the past week, there were 863 laboratory confirmed cases for a season total of 6,603.
5 Season Average (2013–2017) 2016–2017 2017–2018 2018–2019 6,000
5,000
4,000
3,000
Number of Cases Cases of Number 2,000
1,000
0
Week of Report
For the season, 90% are type A, 8% are type B, and 2% are unknown. 2018-2019 Season 2017-2018 Season
0 to 4 years 15% 24%
5 to 18 years 19% 29%
19 to 49 years 24% 25%
50 to 64 years 12% 14%
65 years or older 11% 28%
0% 5% 10% 15% 20% 25% 30% 35% Influenza-like Illness (ILI) Surveillance
Fever and Cough or Sore Throat Influenza-Like Illness (ILI) Surveillance from Sentinel Outpatient Providers ILI percent was above threshold at 3.9% in week 2.
ILI % ILI% Baseline Threshold (AZ) Number of Sites Reporting
9.0 60
8.0 50 7.0
6.0 40
5.0 30 4.0
% of Visits for ILI for Visits of % 3.0 20
2.0 Reporting Sites of Number 10 1.0
0.0 0
Week Ending Date
Percentage of Visits for ILI at Sentinel Providers, 2018–2019, Arizona 5% of Emergency Room visits are ILI in the past week compared to 8% for the same week in the 2017–2018 season.
18
16
14
12
10 % ILI % 8
6
4
2
0
Week 2% of hospitalizations (inpatient admissions) are ILI in the past week compared to 5% for the same week in the 2017–2018 season. 14
12
10
8 % ILI % 6
4
2
0
Week In Arizona, 4% of visits in the past week were ILI, compared to 3% nationally.
7
6
5
4 % ILI % 3
2
1
0
Week
Please see the new interactive influenza dashboard for more details on current and past seasons in Arizona. 2018-2019 Influenza Season
Visit azhealth.gov/flu to sign up for our weekly influenza reports! THANK YOU
Xandy Peterson | VPD Epi [email protected] | 480-202-0145
azhealth.gov @azdhs facebook.com/azdhs