Emerging disease, the 10,000 ft data overview CARINA BLACKMORE, DVM, PHD, DIPL ACVPM STATE EPIDEMIOLOGIST DIRECTOR, DIVISION OF DISEASE CONTROL AND HEALTH PROTECTION

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 1 Emerging diseases- Florida

. AIDS (later determined to be caused by HIV) 1981 . Hepatitis C 1989 . West Nile 1999 . SARS 2003 . 2003 . H1N1 2009 . Dengue 2009 . Cholera 2010 . MERS 2012 . 2014 . 2014 . Zika 2017

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 2 Objectives .Driving forces behind emerging/ reemerging diseases .Diseases/ organisms on my radar

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 3 WHO (edited) list of priority diseases

.Crimean Congo .Plague Hemorrhagic .Cholera .Pox (smallpox/ .Corona viruses (MERS, monkeypox) SARS) . .Dengue .Severe fever with .Elizabethkingia .Influenza syndrome . Hendra and .Tularemia . . .Mayaro virus .Meningococcal disease .Zika .

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 4

Emerging Infectious Translocation Diseases Encroachment Human Introduction encroachment “Spill over” & Wildlife EID Ex situ contact “Spill back” Ecological manipulation

Domestic Global travel Animal EID Human EID Agricultural Urbanization Intensification Biomedical manipulation Technology Daszak P. et.al. and Science 2000 287:443 Industry Other risk factors for emerging/ reemerging diseases .Behavior-related disease ◦ Changes in attitudes towards childhood ◦ Anonymous dating ◦ Changes in attitudes about pets .Health-care associated diseases ◦ Advanced medical care ◦ Immune compromised patients ◦ Antibiotic use .Man-made and natural disasters .Coupled with pathogen evolution

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 7 Middle East Respiratory Syndrome .Coronavirus .Severe Acute Respiratory Illness .Not readily transmitted from person-person .Hospital spread .2040 confirmed cases/ 719 deaths (35%) since 2012 .66% male .27 countries .82% of cases in Saudi Arabia Number of Cases 2012 Confirmed global casesof MERS Saudi Arabia Other Republic of Koreaof Republic 2013 - CoV 2014 Week of Onset , June, , June, 2016 Year 2015 2017 2016 2017 6 1 0 2

SARS- the outbreak that came and went .First reported in Asia, February 2003 .8439 total cases-July 2003 ◦ 29 countries ◦ 20% health care workers .812 deaths ◦ 9.6% case fatality rate .May 2004-last case in China 11 people spread SARS across the globe .Hosts?

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Influenza A: rapid evolution through sloppy replication

HA . Orthomyxovirus ◦ Envelope ◦ Surface glycoproteins ◦ Hemagglutinin (HA) (18 types) NA ◦ Neuraminidase (NA) (9 types) ◦ SS(-) RNA ◦ 8 segmented genes

8 5 6 7 1 2 3 4 Cycles of the Asian H5N1 Virus in Animals and Humans

Waterfowl Humans

Domestic birds

Mammals (primarily Waterfowl swine) Cumulative number of confirmed human cases for avian influenza A(H5N1) reported to WHO, 2003-2016 Swine Influenza in North America

1930 International Map Cycles of the Asian H5N1 Virus in Animals and Humans

Waterfowl Humans

Domestic birds

Mammals (primarily Waterfowl swine) Wild bird surveillance contd… Highly Pathogenic Influenza A (HPAI) clade 2.3.4.4. H5 comes to America

.HPAI Eurasian (EA) H5N8 .H5 gene derived from EA clade 2.3.4.4 H5N1 .EA H5N8 in Washington State in Dec 2014 .HPAI North American (NA) H5N2, Dec 2014 .HPAI NA H5N1, Jan 2015 .Detected in 21 states .Outbreaks among domestic poultry in 16 states in 2015 Variant influenza viruses

.Swine viruses causing sporadic infections in humans .H3N2v, H1N1v, H1N2v .+400 cases since 2005 .Several outbreaks associated with agricultural fairs State and County Fairs Exposures

Trock 2012 Influenza A H7N9, China .1548 human cases (36% case fatality rate) since March 2013 .About 50% of cases occurred in 2016-2017 .Poultry contact .14 clusters of limited human to human

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 25 Human Influenza A H7N9 cases, June 2017

Cases Deaths Count

2013 2014 2015 2016 2017 Week and Year

26 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 27 Canine flu (Influenza A H3N8, H3N2)

.It started with 6 dead greyhounds… -borne diseases

Florida Imported and Locally Acquired Chikungunya Cases, 2014 .510 travel- associated cases .12 local cases Travel-Associated Zika Fever Cases, 2016

33 Zika Cases Without Travel, 2016

34 Current Status as of July 28, 2017

2016: 2017: • 285 non-travel related • 6 non-travel related* • 1,122 imported • 88 imported ◦ 49 undetermined ◦ 22 undetermined* • 299 pregnant women • 81 pregnant women • 3 sexual transmission *exposure likely in 2016 • 1 sexual transmission •9 infants with Zika-related birth defects •2 cases of GBS associated with Zika

35 Travel-associated Zika, 2017

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 36 Travel associated Zika, 2017

5

4

3

2 Numer of of Cases Numer

1

0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28

Onset week

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 37 Yellow fever (August 2017)

.907 cases reported from 6 countries since December 2016 .Case fatality rate 37% . campaign .Sylvatic/ urban transmission cycles . aegypti/ .Acute febrile illness .Within 48h ~15% present with more severe symptoms hepatitis, renal failure, coagulopathy and shock

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 38 Mayaro?

• Mosquito-borne • Tropical Americas • potential vector • Acute febrile illness with severe • Reported in Haiti 2015…

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 39 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 40 Vibriosis – Florida Data

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 41 Vibrio

.Gram-negative, rod-shaped .Occur naturally in estuarine and marine environments .V. vulnificus is ingested by filter-feeding mollusks such as oysters, mussels, clams, and scallops ◦ Areas where the temperature exceeds 18°C ◦ Brackish water ◦ Warmer months

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 42 Vibriosis

.Human exposure routes ◦ Consumption of raw or undercooked seafood ◦ Exposure to seawater or marine life (open wounds, soft tissues) .Clinical presentation associated with exposures ◦ Gastrointestinal: watery diarrhea, abdominal cramps, nausea, vomiting, fever and bloody diarrhea ◦ Septicemia ◦ Bullae, cellulitis, necrosis ◦ Rapid/dramatic progression

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 43 Florida Data 2004-2016 .Cases ◦ 71.7% male ◦ 81.2% white ◦ 83.1% non-Hispanic .Case pre-existing conditions

2008-2016 Pre-Existing Conditions (%) Species Alcoholism Liver disease Heart disease Diabetes Renal disease

V. vulnificus 95 (32) 88 (29) 87 (29) 67 (22) 45(15)

V. parahaemolyticus 22 (7) 18 (5) 42 (13) 44 (13) 19(6)

V. alginolyticus 26 (6) 14 (3) 31(7) 36 (8) 12 (3)

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 44 Legionellosis – National Data

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 45 Legionellosis Outbreaks

16 2012-2016

14

12

10

8

6 Number ofNumber Outbreaks 4

2

0 2012 2013 2014 2015 2016 2017 Year Total Legionella Outbreaks Health Care Acquired Outbreaks

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 46 Policy to Reduce Legionella in Health Care Facilities Water Systems . June 2, 2017 . Centers for Medicare and Medicaid Services

DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 47 48 National Incidence Rates per 100,000 (Excluding Florida) vs. Florida Measles Incidence Rates per 100,000 by Year 2010-2016 0.25 National Rate Excluding Florida Florida Rate

0.20

0.15

0.10 Incidence Rate Incidence 0.05

0.00 2010 2011 2012 2013 2014 2015 2016* Report Year *National Rate as of December 31, 2016. Case count is preliminary and subject to change. National Mumps Incidence Rates per 100,000 (Excluding Florida) vs. Florida Mumps Incidence Rates per 100,000 by Year 2010-2016 2.00 National Rate Excluding Florida 1.80 1.60 1.40 1.20 1.00 0.80 0.60

0.40 Rate Incidence 0.20 0.00 2010 2011 2012 2013 2014 2015 2016* Report Year *National Rate as of December 31, 2016. Case count is preliminary and subject to change. 51 National Pertussis Incidence Rates per 100,000 (Excluding Florida) vs. Florida Pertussis Incidence Rates per 100,000 by Year 2010-2016

18.00 National Rate Excluding Florida Florida Rate 16.00 14.00 12.00 10.00 8.00 6.00

Incidence Rate Incidence 4.00 2.00 0.00 2010 2011 2012 2013 2014 2015 2016* Report Year 53 HIV Cases by Year of Diagnosis, Florida, 2007–2016 7,000 6,498 6,066 3 year % change (2014–2016) = 8% 6,000 5,195 4,972 5,000 4,721 4,667 4,708 4,507 4,599 4,370

4,000

3,000 Number of of Number Cases 2,000

1,000

0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 Year of Diagnosis

54 U.S. FL N= 39,513 4,972 Sex HIV, Male 81% 78% Female 19% 22% 2016 Race/Ethnicity White 27% 24% Black 45% 42% Hispanic 23% 32% Age at Diagnosis Age <13 <1% <1% Age 13–29 41% 34% Age 30–49 41% 45% Age 50+ 17% 21% Method of Transmission MSM 67% 60% IDU 6% 4% MSM/IDU 3% 2% Heterosexual 24% 33% 55 Ten Year Trend Lines

9000

8000 Total 7000 Syphilis Cases 6000

5000

4000

3000 Infectious 2000 Syphilis Cases 1000

0 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 DIVISION OF DISEASE CONTROL & HEALTH PROTECTION 57