Zoonotic Disease Updates Epidemiology and Laboratory Capacity Conference

Home , Lyme disease

Zoonotic Disease Updates Epidemiology and Laboratory Capacity Conference – Sept. 2019 DSHS Zoonosis Control Branch Updates and Highlights

• Arboviral diseases . Aedes-transmitted arboviruses . 2018 summary . 2019 updates • Anthrax • Brucellosis • Malaria • Lyme disease

09/25/2019 DSHS ELC Conference 2 Aedes-transmitted Arboviruses

Zika, chikungunya, and dengue • Commonalities: transmission, symptomology, regions of endemicity • Zika & chikungunya: recent emergence followed by sharp downturn • Sporadic, seasonal risk of local vector-borne transmission in South Texas • 2013: dengue outbreak in LRGV & across border • 2015: isolated chikungunya case in Cameron County • 2016 & 2017: sporadic Zika disease cases in Hidalgo, Cameron counties • 2018: isolated dengue case in

Starr County Image Source: https://phil.cdc.gov/phil/details.asp

09/25/2019 DSHS ELC Conference 3 Texas Counties Reporting Arbovirus Activity* in Any Species, 2018

I I I I 11 I ri I I I I I I I j I I I I ii I I I I I oun ty with St lo uis Encephalitis Virus Activity 0 2S 50 '100 150, 200 2SO 1,H e-.s ounty with West N lie Virus Activity

*Indicated by an arbovirus- posit ive bird, mosquito pool, senfnel chicken, horse, or human (disease case or presumptive viremic donor). Excludes imported cases of chikungunya, dengu,e, Zika, and other arbovirnses. Absence of reported activity from counties may be due to absence of a surveil lance program for non-human cases .

09/25/2019 DSHS ELC Conference 4 2018 Human Arbovirus Activity

• Total human arbovirus disease cases: 180

Notably: Zika, 4, • One locally-acquired Chikungunya, 20/o 7, 40/o dengue case in Starr County during outbreak in northern Mexico • Globally decreased Zika activity • Trend of low West Nile disease case totals continues since large 2012 outbreak (with over 1,800 cases)

09/25/2019 DSHS ELC Conference 5 2019 Updates (Provisional)

Dengue: 23 cases (as of 9/20/19) • Acquisition of infection demonstrates widespread global risk • Strong increase in dengue activity in Central America and southern Mexico

Dengue Cases Reported in Texas, 2019, as of 9/20/19, N=23

Image Source: PAHO/WHO, www.reliefweb.int 09/25/2019 DSHS ELC Conference 6 Human West Nile Disease Cases Reported in Texas, by MMWR Week of Onset, 2017-2019*

18 2019 Total*: 17 16

2019 Total*: 14

2017 - 2018 2019 8

0 ~~~~~~~~~~~~~~~~~~~~~~~~~i~~~~~,~,:&~~~ MMWR Week of Onset

09/25/2019 DSHS ELC Conference 7 *2019 data is provisional and as of 9/20/19 2019 Updates (Provisional) Zika Disease: 1 case • Low transmission in Mexico, no current outbreaks worldwide; Texas case acquired in Philippines • 2018 Indian outbreak, South & Southeast Asia and Central Africa spread • US Zika Infant & Pregnancy Registry ended enrollment in March 2018 • Antibody testing and cross-reactivity with dengue continues to cause issues Chikungunya: 6 cases • Similar global risk to dengue

09/25/2019 DSHS ELC Conference 8 Case Definition Updates

Yellow Fever • Specified clinical criteria • Epi-linkage included alongside testing and clinical criteria in probable definition • Brought lab criteria up to date: • Removal of irrelevant diagnostic methods (CF, IFA, HI) • IgM with PRNT confirmation included • Exclusion of those with a history of yellow fever vaccination in the 30 days prior to onset in most cases

Arbovirus (includes West Nile, others) • More nuanced consideration of cross-reactivity in interpretation of PRNT results

09/25/2019 DSHS ELC Conference 9 Anthrax

• Caused by Bacillus anthracis, a spore-forming Gram positive rod • B. cereus expressing anthrax toxins added to case definition • Humans are infected through skin contact or inhalation • Suspected isolates sent to LRN Labs • **Anthrax is reportable upon suspicion** • Clinical diagnosis from providers • Suspect samples at laboratories

09/25/2019 DSHS ELC Conference 10 Updates to Case Definition

• Additional confirmatory laboratory testing • PCR positive from a LRN-validated test • Lethal factor testing (available at CDC) • Probable case status, clinically compatible illness and • Epidemiological linkage to confirmed case or lab confirmed exposure • Gram stain positive rods • Positive result from a CLIA-accredited laboratory • Suspect case status for those with lab tests ordered • Can help LHDs to request records for clinically compatible cases with no known epidemiological link to anthrax • Addition of B. cereus expressing anthrax toxin to case definition • Historical cases among metal workers in Texas • Request to forward isolates from anthrax-like illness with B. cereus identified • Fully virulent B. cereus biovar anthracis is a Select Agent

09/25/2019 DSHS ELC Conference 11 Texas Counties with r---r Laboratory-Confirmed Anthrax th 2000 - 2019* r1 L

Cases / County

~ 1-2 1111 3 - 5 1111 6-12 County reporting one or more 1111 13 - 16 culture-positive animal or human 1111 17 - 18

*2019 data is provisional, as of 9/23/2019

09/25/2019 DSHS ELC Conference 12 2019 Animal Outbreak

• Anthrax is enzootic in area of Texas between Ozona, Eagle Pass and Uvalde • Recent increase in positives from animals reported by Texas Veterinary Medical Diagnostic Laboratory • As of September 23, 2019: • 25 culture positives from five counties in southwestern Texas • Exotic, domestic, and wild animals positive • Most reported positives since 2001 • Barriers to reporting • Ranchers might be hesitant to test animals due to Texas Animal Health Commission quarantine • Might be clinically diagnosed and not tested • Other positives on same ranch previously reported • Difficulty of getting to animals on large properties

09/25/2019 DSHS ELC Conference 13 Texas Counties with Laboratory-Confirmed Anthrax 2000 - 2019 *

Cases/ County

C:J 2019 Outbreak ~ 1-2 1111 3-5 1111 6-12 County reporting one or more 1111 13 -16 culture-positive animal or human 1111 17 -18 N A *2019 data is provisional, as of 9/23/2019

09/25/2019 DSHS ELC Conference 14 Brucellosis: Worldwide Distribution

,-_:;'.I ~ :Po ((" ,.r---;' \~.;--~~ '-"".._..}",;;__ ""

I . / -_, ,/-f'f ;, "' '/:)/"'' V -..

...,_

Annual 1-n_,,,._...... , nreof , per 1.000 000 brucellosis ~ po;pu lamn - -~500 D 50--500 cas:es • 10-50 D 1.- 10 • <2 D Poosibi ·, em . D Non--eade~ ct': tll;a

Source: Pappas, G., et al. (2006) The new global map of human brucellosis. Lancet Infect Dis, 6, 91- 99.

09/25/2019 DSHS ELC Conference 15 Reported Cases of Brucellosis in Texas, 2010-2019* (n=214)

a, 35 Cl) ,a 30 -cs a, 25 t:: 0 20 C2. I~ 15 10

2019 data is provisional, as o 9/21/20 9

09/25/2019 DSHS ELC Conference 16 TEXAS Heakh and faman I fer.as DepartmHI of Stat@ Reported Cases of Brucellosis in Texas ~rv,ces He11lth Stnlre5 By County of Residence, 2010 - 2019*, N = 214

Species Cases / County

1111 1-9 ;; c=J 10-19 w-+r 1111 >=20 I I l I I I I I I I I I I I I l I I I I I I I I I I 0 25 50 100 150 200 250 Miles *2019 data is provisional, as of 9/21/2019

09/25/2019 DSHS ELC Conference 17 I fer.as DepartmHI of Stat@ Confirmed Culture Results for Reported He11lth Stnlre5 Cases of Brucellosis in Texas by County of Residence, 2010 - 2019* , N = 160

Species

[I]]] Bruce/la abortus ~ Bruce/la canis

[=i Bruce/la melitensis ;; ~ Bruce/la suis w-+r l.i RB51 I I l I I I I I I I I I I I I l I I I I I I I I I I 0 25 50 100 150 200 250 Miles *2019 data is provisional, as of 9/21/2019

09/25/2019 DSHS ELC Conference 18 Brucella Species Identified in Confirmed Cases byYear, Texas, 2010-2019* (n=160)

34 35

en enCU 25 23 21 u"' 20 ~ 20 t: 17 0 C. CU 15 13 ~ 12

10 7 7 6

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019*

■ Bruce/lo abortus ■ Bruce/la canis ■ Bruce/lo melitensis ■ Bruce/la suis ■ RB51 •2019 data is provisional, as of 9/21/2019

09/25/2019 DSHS ELC Conference 19 Investigating Laboratory Exposures

. Brucellosis is most common laboratory- associated bacterial infection . Easily aerosolized, low infectious dose . Laboratorians not always aware when Brucella is suspected . Though B. canis is not a Select Agent, still a risk for lab acquisition . Follow up for those with high risk exposure . Fever/symptom watch for 24 weeks . Serologic testing at every six weeks after last exposure for 24 weeks . Serology not available for B. canis or RB51 . Doxycycline and rifampin for three weeks . RB51 resistant to rifampin

09/25/2019 DSHS ELC Conference 20 SAFETY Preventing Aerosolization

AerosoHzallon Examples of Aerosol Producmg Procedures Aerosolization can oocur during any procedure • Opening culture p,late, sniffing p,lates which imparts energy into a microbial suspension,. (Examining colony morphology/growth) producing aerosols or droplets which may contain • Heat fixing a slide infectious organisms. Aerosols are very small • Dispensing pipette tips particles that may remain suspended in the air and • Centrifuge setup/ run/unloading can be inhaled ano retained in the lungs .. Droplets • Vortexing are larger particles which can settle onto surfaces • Spills or splashes of liquid media and gloves due to gravity. Droplets may also come • Subculturing positive blood culture bottles into contact with the mucous membrane•S of the • Inoculation of media (plate or tube} person performing the procedure. • Preparing samples for automated 1D systems • Open flames, sterilizing loops Safety Precautions • Son icati ng Laboratory exposures can be decreased by working • Pipetting in a SSC using BSL-3 practices and appropriate • Catalase test BSL-3 PPE when a biot hreat agent is suspected. • Using automated and manual identification Identified aerosol-generati ng procedure risks systems (e.g., MALDI-TOF, Vitek, API 20 NE, should be mitigated. Bacteo}

Your fa.ci hty may identify additional aerosol generating procedures based on the laboratory's risk assessments.

Source: https://www.aphl.org/aboutAPHL/publications/Documents/2018_BiothreatAgents_SentinelLab_BenchCards_WEB.pdf

09/25/2019 DSHS ELC Conference 21 Investigating Laboratory Exposures

. Collect information on type of exposure: . Manipulation of specimen V,'r:,111:~tl Wlt l'I •.. Did Mt w,1."'i rlc ~ th bl.II Vllr!I.... Unknown O.rl cl · oo,;. ~~flJtNi,: ~Sftih\~' Anlblotic reQ~.'.an,;;» tsbi. '" hoo

. Personal protective equipment ::J ::J D ::J D • ~ anipi.J3ticn chi;roifie:J ;,;;· an ae,osol genua:irg procedure. ::entrifugi-,;i 1. c:-nioidafad sin aeroi;:-I :;o-(•r:.iting OV1Ht -..Jlon porfo•mo:j ,•,thout 6C3 lod ClrriO~. '-13 r i~W:-: m; I~( 3UIOm:J.tod ?h:-:tting of l . ELq>ensior ront:Ji•ing tho org3ni1:-m&, grinding blonding er ::h3king c-o q:>ecimc:n, or procootl'oc ~· Immune status of exposed person s Lspeni::ior i, I cuid to proct.J:r- stan

. U9e-1he ,n fDIMl!ti on obtairled S1 the inteM~• and the ~Lsboratory Expo~ure Ri~lc .0,gse! ~rre-nt amt Assist with risk classification: Re.o:-0mme-n:ie.ti¢n:," tabl~ b~ to prnl)@ft-/ assi~n"' ri:,k elHsifieMion 1

HIGH RISK . Low Ex_oo,s:ure ~ rio rEP recommend.etio ns Fo l lOW·UP,' moni10, i,1a I 'C"3on ,~h:> rromi:;IJ.)lc:; d "_\XJ.'iJ [1ox~•~~".lir,;,' :,:1ro -:«O'! r: ~1,f:.1~11 1,,11 11 Ii.> , (jlJ'Mle. High UJ ._. lAAl-'~" JI ""· b ~,d·r: r "'W _.~1i.:1k "dlrl. 11 i_1 uli-:,I, ~1 R,;,,-,n, e')"~ F'rd~ =lion: l'.f'! ,'l(W;id'!t o!l'I l.•,o<;.l'tl"l r:.:IWl:'li'!r O'<'lrtP. ~.~cue-ua £a·:•l::gC'31 nu1tonrg AJ I ~'C'·~crr, i:1~e?rrt durI~:r e ag.:in~I f,~r.·,~:rc:1 sivukJ ::i;; gi~,:m ?i1u;:?1~l1r1:1 r.=,·-;., ,=:o. ?1tr:l :i<1 occu··:;cc cto:.·.:~1•g..."l'IC-::1m~ ~·,:;cl(~ ~ 1·CX~C3J·,:, Zltt•: . b:;1 f"rcg, :rt ,,oTI~n ;;.· cu: -cor :;.:.i Itri~ r . lel',l;fl.'o' (~:J Ucl 1lrifu:,1Ir1~ ,·lil t uu. l,tK,.•. ...· 1 i.;x;J~i,;U' i, Provide post-exposure prophylaxis and -.:.t~J,;,,~-~ia· ~,u -1::-( r,~ITi~ ·.o-t:ie-:oh : , N~:t: Ne, -,;,rc,lo~ w m:.nt<>·ir g i~ ~~. 1 Note. P.Ee I ~ llol:iil:t,ml .'J 1l.crn1-1i 111J L',1'w, t.tri~ ~ ii .:¢::;~.:;::ttcs; ,d!h ,;1,1 r') -t~· ;YV,)i)a.;, .;-Rr R~ 1 a l ;1 Nirl trv--:--f.-,~ h :<. -:, fll'll-oilr, n.-.· ~,.. 1...... t··r., 111$1i µ,Jl;jl <.r1 J. ,5,-;.1:,~.,,k.' ~.sllol ~·• :i ('.'t"\.~•-.:r"\-<11~, 1-. t:1,n•r :<. testing recommendations >11 c:=- h-nrh PEP er ll'C.Jti"Ktf oour~~

09/25/2019 DSHS ELC Conference 22 Malaria

eported Cases of Malaria in Texas, 2010 - 2019* {N=l,145) 180 159 158 160 144 140

VI 120 cu 106 VI 102 102 «I 98 99 u 100 "'C 89 cu ~ 0 80 71 C. cu a:: 60

0 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019*

*2019 data is provisional

09/25/2019 DSHS ELC Conference 23 Malaria

D Mallaiir,~ tr,ansm □ Malan1a 1t@1nsm1tss10:n allarJa t@nsmiss&on · ,, I ··j . . i '' . I -., I ' ' oa:::11J1rs,i 1n :some, pa1rts.

Approximation of the parts of the world where malaria transmission occurs https://www.cdc.gov/malaria/about/distribution.html

09/25/2019 DSHS ELC Conference 24 Ebola Virus Outbreaks by Species and Size, Since 1976

Nigeria South ~ dan • fl O • ~ . • • Uganda Ga?c;n o!ifcratic Republie Congo , f. e Congo

Number of Cases

• Zaire ebolavirus 0 1 - 10

11 • 1()0 • Sudan ebolavorus 0 250 500 1,000 Moles 101 • 425 I I I I I t I • Tao Forest ebolavirus 0 Greater than 425 https://www.cdc.gov/vhf/ebola/history/distribution-map.html

09/25/2019 DSHS ELC Conference 25 Malaria Reporting Guidelines Texas Residents For malaria cases who reside in Texas, but are diagnosed in another Texas jurisdiction, please report by the case patient’s residence. Out of Country Residents For malaria cases who reside in another country, but are diagnosed in Texas, please report by the location where the patient was diagnosed. Out of State Residents For malaria cases who reside in another state, but are diagnosed in Texas, please communicate with the Regional ZC office so we can work with the other state to determine which state will count it as a case to prevent dual reporting. 09/25/2019 DSHS ELC Conference 26 Malaria • Treatment changes – April 2019 Quinidine no longer available in the U.S. Intravenous artesunate for treatment of severe malaria available through CDC Quarantine Stations Clinicians must call CDC’s Malaria Hotline (770-488-7788) • Guidelines for treatment in United States https://www.cdc.gov/malaria/diagnosis_treatment/ treatment.html • Malaria travel information and prophylaxis https://www.cdc.gov/malaria/travelers/ country_table/a.html • General information https://www.cdc.gov/parasites/malaria/index.html

09/25/2019 DSHS ELC Conference 27 Lyme Disease Erythema Migrans (EM)

Confirmed: A case with physician-diagnosed EM ≥ 5 cm in size with an exposure in a high-incidence state or country*, OR a case of physician-diagnosed EM ≥ 5 cm in size with laboratory confirmation with an exposure in a low- incidence state or country*, OR a case with at least one late manifestation that has laboratory confirmation. Classic EM rash EM rash: • Occurs in approximately 70 to 80 percent of infected persons • Begins at the site of a tick bite after a delay of 3 to 30 days (ave. ~7 days) • Expands gradually over several days • May reach 12” (30 cm) or more across • May feel warm to the touch but is rarely Allergic reaction itchy or painful • Sometimes clears as it enlarges, resulting in a target or “bull’s-eye” appearance • May appear on any area of the body

09/25/2019 DSHS ELC Conference 28 Lyme Disease High & Low Incidence Areas

Confirmed: A case with physician-diagnosed EM ≥5 cm in size with an exposure in a high-incidence state or country*, OR a case of physician-diagnosed EM ≥5 cm in size with laboratory confirmation with an exposure in a low- incidence state or country*, OR a case with at least one late manifestation that has laboratory confirmation. *Exposure is defined as having been (≤ 30 days before onset of EM) in wooded, brushy, or grassy areas (i.e., potential tick habitats). • A high-incidence state is a state with an average Lyme disease incidence of at least 10 confirmed cases/100,000 persons for the previous three reporting years. • A low-incidence state is defined as a state with disease incidence of <10 Texas is considered a confirmed cases/100,000 persons for low-incidence state for the previous three reporting years. Lyme disease! www.cdc.gov/lyme/stats/tables.html

09/25/2019 DSHS ELC Conference 29 Lyme Disease High Incidence Areas

• Most commonly reported vector-borne illness in the United States • Does not occur nationwide and is concentrated heavily in the northeast and upper Midwest

High Incidence States: Connecticut, Delaware, Maine, Maryland, Massachusetts, Minnesota, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island,

Vermont, Virginia, Wisconsin www.cdc.gov/lyme/stats/index.html

Outside of the US, Lyme disease is common in some forested areas in Europe. Countries with highest reported incidence include Germany, Austria, Slovenia, and Sweden. Infectious Disease Clinics of North America, Vol. 22/Ed. 2, Fish AE, Pride YB, Pinto DS, Lyme carditis, 275-288 09/25/2019 DSHS ELC Conference 30 Lyme Disease Late Manifestation Confirmed: A case with physician-diagnosed EM ≥ 5 cm in size with an exposure in a high-incidence state or country, OR a case of physician-diagnosed EM ≥ 5 cm in size with laboratory confirmation with an exposure in a low- incidence state or country, OR a case with at least one late manifestation* that has laboratory confirmation.

09/25/2019 DSHS ELC Conference 31 Lyme Disease Late Manifestations: Alternate Explanations

* For purposes of surveillance, late manifestations include any of the following when an alternate explanation is not found: • Musculoskeletal system: recurrent, brief attacks (weeks or months) of objective joint swelling in one or a few joints, sometimes followed by chronic arthritis in one or a few joints. • NOT: chronic progressive arthritis not preceded by brief attacks; chronic symmetrical polyarthritis or arthralgia, myalgia, or fibromyalgia syndromes alone • Nervous system: any of the following, alone or in combination: lymphocytic meningitis; cranial neuritis, particularly facial palsy (can be bilateral); radiculoneuropathy; or, rarely, encephalomyelitis. • NOT: headache, fatigue, paresthesia, or mildly stiff neck alone • Cardiovascular system: acute onset of high-grade (2nd or 3rd- degree) atrioventricular conduction defects that resolve in days to weeks and are sometimes associated with myocarditis. • NOT: palpitations, bradycardia, bundle branch block, or myocarditis alone wwwn.cdc.gov/nndss/conditions/lyme-disease/case-definition/2017/

09/25/2019 DSHS ELC Conference 32 Lyme Disease Probable & Suspect Cases

Probable: Any other clinically compatible* case of physician- diagnosed Lyme disease that has laboratory confirmation and absence of a more likely clinical explanation *fever, chills, headache, fatigue, muscle & joint aches, swollen lymph nodes, EM rash

Suspect: A case of EM with no known exposure and no laboratory evidence of infection, OR a case with laboratory evidence of infection but no clinical information available

Note: Lyme disease reports will not be considered cases if the medical provider specifically states this is not a case of Lyme disease, or the only symptom listed is “tick bite” or “insect bite.”

09/25/2019 DSHS ELC Conference 33 More on Zoonoses

• Thursday Breakout Session  Zoonotic Disease Investigations 10:15 am

• Regional Zoonosis Control Offices http://www.dshs.texas.gov/idcu/ health/zoonosis/contact/

09/25/2019 DSHS ELC Conference 34 https://www.dshs.texas.gov/idcu/health/zoonosis/contact/

Public Health Region 1 Public Health Region 2 Kimberly Hencken, DVM Nick Ferguson Lubbock, TX Abilene, TX Public Health Region 2/3 Public Health Region 1 Shelley Stonecipher, DVM, MPH Amarillo Sub-Office Arlington, TX Tonya Finch 1 Public Health Region 4/5N Public Health Region 9 Samantha Puttick Amanda Kammen, MPH 3 2 4 Tyler, TX Midland, TX 10 9 Public Health Region 9/10 7 5N Public Health Region 7 Kenneth Waldrup, DVM, PhD 5S David Smonko, DVM El Paso, TX 6 8 Temple, TX

Public Health Region 8 Public Health Region 6/5S Amanda Kieffer, DVM, MPH, DACVPM 11 Caitlin Cotter, DVM, MPH San Antonio, TX Houston, TX Public Health Region 11 Ronald Tyler, DVM, MS Department of State Health Services Harlingen, TX Zoonosis Control Branch Austin, TX 78756 (512) 776-7255 www.TexasZoonosis.org E-mail:[email protected] 09/25/2019 DSHS ELC Conference 35 Thank you

Kelly Broussard, MPH Briana O’Sullivan, MPH Laura E. Robinson, DVM, MS Zoonosis Control Branch

09/25/2019 DSHS ELC Conference 36