Louisiana Morbidity Report

Office of Public Health - Infectious Disease Epidemiology Section P.O. Box 60630, New Orleans, LA 70160 - Phone: (504) 568-8313 www.ldh.louisiana.gov/LMR

Infectious Disease Epidemiology Main Webpage John Bel Edwards Rebekah E. Gee MD MPH GOVERNOR www.infectiousdisease.dhh.louisiana.gov SECRETARY July - August, 2017 Volume 28, Number 4 Rat Lungworm: Louisiana, 2017 Schools and Vaccination Sean Simonson, MPH In the summer of 2017, a Louisiana resident was hospitalized Louisiana, 2017 for eosinophilic meningitis. This is a rare form of meningitis Quan Le, RN; Frank Welch, MD MPH characterized by increased levels of certain white blood cells in Some of history’s greatest public health successes, such as the fluid surrounding the brain and in the cerebrospinal fluid. A childhood vaccination and safer workplaces would not have been sample of the patient’s cerebrospinal fluid tested positive for the possible without laws protecting and promoting health. These parasite, Angiostrongylus cantonensis. laws, which ensure high vaccination coverage, have resulted in While multiple viruses and parasites have been linked significant decreases in -preventable diseases (VPDs). Re- to eosinophilic meningitis, the principle causative agent is ducing the rates of these diseases has curtailed preventable death A.cantonensis, a parasitic nematode commonly known as rat and disability in individual children and decreased the number of lungworm (Figure). VPD outbreaks. Louisiana’s vaccination requirements for school Figure: Angiostongylus cantonensis third stage infective larva re- entry are important tools for maintaining high vaccination cover- covered from a slug. Image Captured under differential interference age rates. Revised Statue 17:170 (http://www.legis.la.gov/Legis/ contrast microscopy. Photo courtesy of the CDC. Law.aspx?d=79952) details the vaccination requirements for day care and school entry, kindergarten through higher education in Louisiana. The Louisiana Department of Health (LDH) Office of Public Health’s (OPH) Immunization Program assesses the immunization rates of non-public and public schools, each school year (SY). This information is reported to the Centers of Disease Control and Prevention (CDC), and shared with LDH, OPH Regions, the Louisiana Department of Education and each parish school board. Working with OPH Health Informatics, parish level data from the (continued on page 6) LINKS school nurse module will be made public for the first time later this year. These results, by parish for kindergarten and sixth-graders are Inside the percentage of children who are up-to-date on immunizations; the ‘Kindergarten Assessment’ includes dosages required for each Tracking Exposures Through Louisiana’s Adult Blood Lead type (DTaP-4, Polio-3, MMR-2, HepB-3, VAR-2); and the ‘Sixth Epidemiology Surveillance (ABLES), 2012-2016 ...... 2 Grade Assessment’ (Tdap-1, MMR-2, VAR-2, HepB-3, MCV4- Save the Date: NHSN/Emerging Infectious Diseases 1*), (Table). Workshops, 2017 ...... 3 Table: Comparison of Immunization Assessments for Kindergarten and Sixth Grade – Louisiana, 2014-2017 Announcements: First Fungal Disease Awareness Week; Updates, IDEpi Webpages ...... 4 Kindergarten Sixth Grade

School Year Non-Public Public Non-Public Public Cyclopora cayetenensis Infection: Louisiana, 2017 ...... 4 SY 2014-2015 93.1% 96.6% 84.1% 89.3% Spotlight: Vibriosis ...... 4 SY 2015-2016 94.4% 96.8% 86.0% 90.3% SY 2016-2017 92.9% 96.2% 87.2% 87.9% Information on Candida auris ...... 5

The National Antimicrobial Resistance Monitoring System ...... 5 * DTap & Tdap- Diphtheria, Tetanus &Pertussis; HepB- Hepatitis B; MMR-Measles Mumps& Rubella; VAR- Varicella; MCV4-Meningo- Blood Products Transmission: Louisiana, 2016 ...... 6 coccal (continued on page 3) LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4 Tracking Exposures Through Louisiana’s Adult Blood Lead Epidemiology Surveillance (ABLES), 2012-2016 Jocelyn Lewis, PhD, MSPH; Rosalind Green, ScD Background painting in Baton Rouge and the Baker Canal Bridge repair in Lead has no beneficial use in the body, and its toxic effects East Baton Rouge and Feliciana parishes. More than 40% of the are well documented. Lead affects many organ systems over a tests were from healthcare providers located in Region 2. LDH wide range of dose levels. Chronic lead exposure in adults may Administrative Region was determined by patient address or by result in adverse effects in neurological, hematological, renal, provider address as a proxy when patient address was unknown. cardiovascular, gastrointestinal, and reproductive systems. There Hispanic ethnicity was approximated by evaluating surnames is wide variability among individuals in the symptoms and re- (Table). sponses to . Table: Average Annual Adult Blood Lead Tests - Louisiana, 2012-2016 Lead poisoning usually occurs from chronic exposure. The degree and severity of effects depend on the dose and dura- Number Percentage 7548 tion of exposure. Symptoms differ among individuals and do Number of Tests not always occur at specific dose levels. Reported symptoms of Number of Patients Tested 6249 lead poisoning in adults include: headache; anorexia; weakness; Patient Demographics Male 5096 82% excessive tiredness; irritability; difficulty concentrating; consti- Female 1153 18% pation; abdominal discomfort; fine tremors; reduced sex drive; Age Group and weakness in fingers, wrists, or ankles. However, lead poison- 16-24 782 13% 25-34 1628 26% ing is often a “silent disease” where symptoms are not observed 35-44 1366 22% until serious damage has occurred. Diagnosis should not rely on 45-54 1177 19% the appearance of symptoms. The only way to determine lead 55-64 775 12% 65+ 520 8% poisoning is by testing for lead levels in blood. Ethnicity The Occupational Safety and Health Administration (OSHA) Hispanic surname 855 14% requires companies to have a biomonitoring and medical surveil- LDH Region Region 1 1196 19% lance program when workers are exposed to airborne inorganic Region 2 2713 43% lead levels greater than the 30 micrograms per cubic meter Region 3 542 9% (time-weighted average) more than 30 days in a year. Exposed Region 4 373 6% Region 5 427 7% workers are to be tested at least every six months, and testing Region 6 127 2% frequency increases to every two months when a worker’s blood Region 7 252 4% lead level is greater than 40 µg/dL. Louisiana law requires that Region 8 207 3% healthcare providers, including clinical laboratories, report all Region 9 314 5% Out-of-State 33 1% laboratory tests for lead, mercury, cadmium, arsenic and carbon Unknown 66 1% monoxide to the Louisiana Department of Health (LDH), Office Blood Lead Level (Highest per Case if Multiple) of Public Health (OPH), Section of Environmental Epidemiol- 0 to < 10 5919 95% 10 to <25 260 4% ogy and Toxicology (SEET). SEET participates in the Centers 25 to < 45 63 1% for Disease Control’s Adult Blood Lead Epidemiology Surveil- >45 8 <1% lance (ABLES) Program, which determines the action threshold (continued on page 3) at which blood lead test results for adults ages 16 years and older are investigated to determine the source of exposure. Although in July 2015, ABLES reduced the lead action threshold from 25 Louisiana Morbidity Report micrograms per deciliter (µg/dL) to 10 µg/dL, an elevated lead Volume 28, Number 4 July-August, 2017 test is still defined as greater or equal to 25 µg/dL for this report. The Louisiana Morbidity Report is published bimonthly by the LDH, OPH Infectious Disease Epidemiology Section to inform physicians, nurses, and Results and Discussion public health professionals about disease trends and patterns in Louisiana. At least 80% of the tests reviewed were for males, and more Address correspondence to Louisiana Morbidity Report, Infectious Disease than 90% of the test results were below 25 µg/dL. A greater pro- Epidemiology Section, Louisiana Department of Health, P.O. Box 60630, New portion of tests were for those from 25 to 34 years old, and 14% Orleans, LA 70160. overall had Hispanic surnames. Region 2*, which reported the Assistant Parham Jaberi, MD, MPH highest numbers of blood tests, includes the following parishes: Secretary OPH East and West Baton Rouge, East and West Feliciana, Ascension, State Epidemiologist Raoult Ratard, MD, MPH Iberville and Pointe Coupee. Associated with these exposures were several bridge renovation projects which occurred dur- Editors Theresa Sokol, MPH ing that time, including the U.S. 190 Mississippi River Bridge Julie Hand, MSPH Rosemarie Robertson, BS, MT(C), CNMT * map of LDH regions on page 7

2 LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4

(Tracking Exposures ... continued from page 2) Common non-work-related sources of exposure were: target Annually, an average of 2% of the total adult patients from shooting as a hobby; casting and reloading ammunition in the 2012 to 2016 had lead levels greater than or equal to 25µg/dL. home; bullets retained in the body after being shot; renovating Most of the elevated tests (98%) were for males, and 28% of older homes and/or furniture and crafting artwork, i.e., stained the patients had Hispanic surnames. Work-related exposures ac- glass making. Healthcare providers can report lead test results by counted for 90% of the elevated tests (Figure). faxing the form to (504) 568-8149. For more information, please contact Dr. Jocelyn Lewis at [email protected]. Figure: Elevated (greater than or equal to 25 µg/dL) Adult Blood Lead Cases by Source of Exposure - Louisiana, 2012-2016 100 (Schools and Vaccination ... continued from page 1) Source of Exposure 90 Unknown OPH continues to work with individual parishes to improve

80 Non-work rates less than the performance goal of 95%. (The Louisiana Target Shooting (work) Department of Education reported 13.6% of kindergarteners were 70 Other* in non-public schools and 86.3% in public schools this year; Metal Refining & Smelting 60 sixth-graders were 13.5% in non-public schools and 86.5% in Construction 50 public schools.) Louisiana law allows exemption from immunizations require- 40 ments for medical or religious/philosophical reasons. This year’s 30 school vaccine exemption rate is 0.8% the same as the previous

20 year, with only a slight increase from 0.6% in SY 2014-2015. Louisiana’s exemption rates remain lower than the national Number of Elevated Adult Blood Lead Cases Lead Blood Adult Elevated of Number 10 average, but OPH will continue to monitor these rules closely. 0 National studies have shown that vaccine exemptions tend to 2012 2013 2014 2015 2016 Year cluster geographically, making some communities at greater risk * Other includes Law Enforcement, Oil & Gas Extraction, Transportation and for VPD outbreaks. all other industries not listed In 2017, the Department of Education reported there were 12,792 home study students in Louisiana. It is important to Most major reference laboratories report lead data to SEET. remember that although enforcement of vaccine requirements However, a major data limitation is the lack of reporting by other happens within the school system, vaccine recommendations for labs of adult blood lead tests to SEET. Also, adults who have children are age-related. Having these requirements apply to all non-occupational exposures, i.e., target shooting, may not have school-aged children, including home study students, protects their blood tested for lead. them as well as others in all social environments, not only in Sources of Lead school. Lead exposure often occurs during the construction of build- For more information, please contact Quan Le at quan.le@ ings and commercial structures, particularly while renovating la.gov. houses painted before Environmental Protection Agency’s 1978 ban on the use of lead-based paint on residential buildings and childcare facilities. There is no federal ban on the use of lead- SAVE THE DATE based paint in commercial construction. Routine testing of Healthcare-Associated Infections and Emerging workers in the metal refining and smelting industry drastically declined after a major recycling plant in Louisiana closed in Infectious Diseases Workshops - 2017 2009. Metairie - November 2 Firearms instructors at shooting ranges had a notable increase Lafayette - November 9 in the number of elevated cases in 2016, with the occupation Bossier City - November 16 accounting for at least 12 of the 19 work-related target shooting This is a one-day workshop sponsored by the Department of cases. SEET recently developed a factsheet about how to “Pre- Health’s, Office of Public Health, Infectious Disease Epidemiol- vent Lead Exposure in Indoor Shooting and Firing Ranges” as a ogy Section. It is targeted toward infectious disease preventionists guide for shooting range workers and the general public who are in acute care hospitals that are seeking to reduce the number of exposed to lead dust in these facilities. hospital acquired infections and prepare for emerging infectious Those who work around lead can take the dust home on their disease threats that may present in their facility. clothing and shoes. This puts the most vulnerable population, This workshop is free to attend, but must be registered for young children, pregnant women and nursing mothers, at risk of because of seating limitations and to provide the adequate number lead exposure. Some tips on preventing “take-home exposure” of handouts. Nurse and laboratory education credits have been include: changing clothing before leaving work; washing your applied for. face and hands at the end of the work shift; and washing work Please go to http://new.dhh.louisiana.gov/index.cfm/page/2853 clothing separately from the family’s clothing. for a registration form and more information.

3 LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4 cayetanensis Spotlight: Vibriosis Infections: Louisiana, 2017 Vibrio bacteria naturally live in coastal waters and are present in higher concentrations in the summer months between May and Cyclosporiasis is an intestinal illness caused by the protozoan October when water temperatures are warmer. During this period, parasite (Figure). sickness attributed to Vibrio increases. Figure: Cyclospora cayetanensis. Photo courtesy of the CDC. Approximately a dozen Vibrio species can cause the illness, vibriosis in humans. The most common Vibrio species causing human illness in the U.S. are V. parahaemolyticus, V. vulnificus, and V. alginolyticus. Most people become infected by eating raw or undercooked shellfish, particularly oysters. CertainVibrio species can also cause skin infection when an open wound is exposed to brackish water or saltwater. Out of the 80,000 estimated cases of vibriosis in the U.S. each year, possibly 52,000 of them are caused by eat- ing contaminated . People with compromised immune systems are more likely to get vibriosis. This includes people with: liver disease; cancer; People can become infected with Cyclospora by consuming diabetes; HIV; thalassemia; people who take immune-suppressing food or water contaminated with the parasite; it is not transmit- therapy or medicine to decrease stomach acid levels; and those ted person-to-person. Louisiana, along with many other states, is who have had recent stomach surgery. Reduce your risk of vib- seeing an increase in reported cyclosporiasis cases this summer riosis by following these tips: which is under investigation by the Centers for Disease Control • Don’t eat raw or undercooked oysters or other shellfish. and Prevention (CDC), State and Local Health Departments, and Cook them before eating. the Food and Drug Administration (FDA). The CDC has the fol- • Always wash your hands with soap and water after handing lowing recommendations for Healthcare Providers: raw shellfish. • Consider a diagnosis of cyclosporiasis in patients who have • Avoid contaminating cooked shellfish with raw shellfish prolonged or remitting-relapsing diarrheal illness. and its juices. • If indicated, healthcare providers should specifically order • Stay out of brackish or salt water if you have a wound testing for Cyclospora, whether testing is requested by ova and (including cuts and scrapes), or cover your wound with a parasite (O&P) examination, by molecular methods, or by a gas- waterproof bandage if there’s a possibility it could come trointestinal pathogen panel test. Several stool specimens may be into contact with brackish or salt water, raw seafood, or raw required because Cyclospora oocysts may be shed intermittently seafood juices. and at low levels, even in persons with profuse . • Wash wounds and cuts thoroughly with soap and water if • Report cases to local health departments. Contact the they have been exposed to seawater or raw seafood or its local health department if assistance is needed with reporting juices. or submitting specimens. Cyclosporiasis is a nationally notifi- • If you develop a skin infection, tell your medical provider able disease and is a Class C* disease in Louisiana; reporting is if your skin has come into contact with brackish or salt required within five business days. Healthcare providers should water, raw seafood, or raw seafood juices. report suspect and confirmed cases of infection to the Department If you are in a group more likely to get vibriosis: of Health, Office of Public Health, Infectious Disease Epidemiol- • Wear clothes and shoes that can protect you from cuts and ogy Section at (800)256-2748. scrapes when in brackish or salt water. For more information, please refer to the August 7, 2017 • Wear protective gloves when handling raw seafood. Health Alert Network Health Advisory https://content.govdeliv- For more information go to https://www.cdc.gov/vibrio/pre- ery.com/accounts/USCDC/bulletins/1af73ec. vention.html, or http://new.dhh.louisiana.gov/assets/oph/Center- * Sanitary Code list on page 8 PHCH/Center-CH/infectious-epi/Annuals/Vibrios_LaIDAnnual. pdf.

Arboviral: West Nile Virus Weekly Report Announcements Epidemiology Manual: Candida auris Public Information; First Fungal Disease Awareness Week Cryptococcosis; Histoplasmosis Foodborne/Waterborne: August 14 - 18, 2017 HAI: HAI/AR Advisory Committee Influenza: Monthly Report Updates: Infectious Disease Epidemiology (IDEpi) Webpages Veterinary-Zoonosis: Hospitals That Carry the Rabies Vaccine; www.infectiousdisease.dhh.louisiana.gov Louisiana Bat Removal Companies; Transmitted Infections Annual: Vibrios 4 LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4 Information on Candida auris Candida auris is a pathogenic fungus that can cause serious One in three patients with invasive C. auris (i.e. infection in infections and illness, predominantly in hospitalized patients. blood, brain, heart, etc.) die. The Centers for Disease Control and Prevention (CDC) and the Though C. auris is still rare in the U.S., people who get Louisiana Department of Heath, Office of Public Health, Infec- invasive Candida infections already have underlying conditions tious Disease Epidemiology Section (IDEpi) are working closely that affect the immune system. The most common symptoms are to learn more about C. auris and about how it is spread. C. auris fever and chills that don’t improve after antibiotic treatment for a has only recently appeared in the U.S., and no cases have been suspected bacterial infection. identified in Louisiana. Laboratory staff, healthcare workers, and public health of- Outbreaks have been associated with being spread via contact ficials: with infected patients and contaminated surfaces or instruments/ - Know when to suspect and properly identify C. auris. equipment in healthcare facilities and nursing homes. Similar to - Report cases to IDEpi immediately (800-256-2748) other healthcare-associated and invasive fungal infections, this - Ensure hand cleanliness and use precautions (i.e, wearing disease disproportionately affects patients who require long- gowns and gloves) to prevent spread. term care and those with underlying conditions, such as, (but not - Check the CDC website for the most up-to-date guidance on limited to): identifying and managing C.auris: - patients who experience frequent or extended hospital stays https://www.cdc.gov/fungal/diseases/candidiasis/recommendations.html. - individuals with diabetes or blood cancers - Public health officials should consult all potential cases with - patients who are dependent on medical devices like breath- IDEpi’s Mycotic Disease (Jose Antonio Serrano) and ing/feeding tubes or vein/bladder catheters Healthcare-Associated Infection (Erica Washington) coordi- C. auris is frequently misidentified. Infected patients exhibit nators, as soon as possible. symptoms depending on the part of the body affected; therefore, Family members and close contacts of patients with C. auris symptoms vary widely from case to case. Specialized laboratory infection: equipment is required to correctly isolate the species, in order to - Observe basic hand hygiene by washing your hands with make the correct diagnosis and administer the appropriate treat- soap and water before and after coming into contact with an ment. infected patient or equipment in their room. C. auris is resistant to many types of antifungal medications; - Remind healthcare workers to observe basic hand hygiene. therefore, treatment is difficult. A group of antifungals known as For more information, please contact Jose Antonio Serrano at echinocandins have been effective in treating patients with C. au- (504) 568-8292 or [email protected], or Erica Washington at ris, but antifungal resistance has still been shown in some cases. (504) 568-8319 or [email protected]. Finally, the seriousness of the disease cannot be underplayed.

The National Antimicrobial Resistance Monitoring System

The National Antimicrobial Resistance Monitoring System - Each USDA NARMS agency tests bacteria samples taken Enteric Bacteria (NARMS) is a U.S. public health surveillance from food-producing animals at different stages of production. system that tracks antimicrobial resistance in foodborne and other NARMS monitors antimicrobial resistance among enteric bacte- enteric bacteria. ria from three sources: humans (CDC); retail meats (FDA); and NARMS is an interagency partnership among the U.S. Centers food animals (USDA). for Disease Control and Prevention (CDC), the U.S. Food and Retail meats tested by the FDA from consumer grocery stores Drug Administration (FDA), the U.S. Department of Agriculture include chicken, ground turkey, ground beef, and pork. Bacteria (USDA), and state and local health departments. Human surveil- tested for resistance are , Campylobacter, Escherichia lance began in 14 sites in 1996 and became nationwide in 2003. coli , and Enterococcus. For more information, contact the Infec- Health departments in 15 states and institutions of higher edu- tious Disease Epidemiology Section, Louisiana Department of cation in four states send retail food samples to the FDA. Louisi- Health (504) 568-8313. ana began as one of these in September, 2006.

5 LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4 Babesiosis Blood Products Transmission: Louisiana, 2016 Gary Balsamo, DVM MPH&TM; Michele Pogue, MT (ASCP); Christine Scott-Waldron, MSPH; Sean Simonson, MPH; Calandre Singh, MPH; Julius Tonzel, MPH A case of babesiosis was identified in a Louisiana patient in donations from this individual were identified and destroyed. 2016. Approximately two months after receiving a blood trans- Both donors are now excluded for life from donating blood. fusion in 2015, the patient presented to a primary care provider The fact that the implicated donor had no relevant travel out of with fatigue, weight loss, and anemia. There are several potential state prior to the implicated donation increases the suspicion that causes for these non-specific symptoms, such as . is present and may be sporadically transmitted in Loui- Blood samples were taken to attempt to identify potential siana. There is no current evidence to suggest that transmission infectious agents. A blood smear showed evidence of parasitic occurs frequently. The tick that transmits the disease is present in infection, which was diagnosed as babesiosis at the Centers for nature and Lyme disease has been occasionally locally-acquired Disease Control and Prevention (CDC). The timing and type of as well. This has led to an increase in efforts to isolate the para- infection suggested that the patient likely became infected during site in ticks and identify additional cases in Louisiana in order to the blood transfusions. After tracking the sources of the 105 red confirm its presence. blood cell and platelet products which the patient received, 67 For 2014, the CDC was notified of a total of 1,744 U.S. cases individuals were implicated as potential source donors (this is of babesiosis. Most of the reported cases (94%; n = 1,636/1,744) excluding donations which were previously frozen and preserved, were in residents of seven states in the Northeast and upper Mid- since this process kills the parasite). These donors were contacted west (Connecticut, Massachusetts, Minnesota, New Jersey, New and asked to provide a blood sample for testing in order to find York, Rhode Island, and Wisconsin). Tickborne transmission of the source and prevent any further transmission. About half of the Babesia parasites is well established in these states. Nationally in donors agreed to testing; two had positive tests. 2014, six cases of babesiosis in blood recipients were classified These two donors, also from Louisiana, were contacted and by the reporting state as transfusion-associated. interviewed about their travel and illness history. Donor 1 had For 2014, among the case-patients for whom data were avail- no history of symptoms and no relevant travel during the months able, fever was the most frequently reported clinical manifesta- immediately preceding donation. However, the individual did tion (83%) followed by chills or thrombocytopenia (69%), myal- have frequent travel to northeastern states at other points in time. gia (68%), and anemia (62%). A summary can be found at https:// Also, the only evidence of infection was a positive antibody test, www.cdc.gov/parasites/babesiosis/resources/babesiosis_surveil- which could be indicative of a past infection and not necessarily lance_summary_2016.pdf. an infection at the time of donation. Babesiosis is a Class B* disease in Louisiana and reporting is Donor 2 also had no history of symptoms or relevant travel required within one business day. immediately preceding donation, but did test positive using a test For more information, go to https://www.cdc.gov/parasites/ which detects Babesia DNA, meaning the donor was parasitemic babesiosis/. at the time of the test. This signifies that Donor 2 was more likely * Sanitary Code list on page 8 the source of the infectious blood donation. All remaining blood

(Rat Lungworm ... continued from page 1) in Louisiana. The first case was recorded in 1993 when a child A. cantonensis was first detected in rats in China in 1933, presented to the hospital with headache and stiff neck. A case in- and has since been identified mostly in the Indopacific region; vestigation revealed that he had eaten a raw snail on a dare a few however, it has also been found in parts of Africa, the Caribbean, weeks before symptom onset. Australia, Hawaii, and Louisiana. The parasite has a complex The second case was recorded in 2006 when a man was hos- life cycle, initially hatching in the lungs of rats, and subsequently pitalized for suspected meningitis and hypersensitivity to touch. being passed through the feces and infecting intermediate hosts, About a week before symptom onset, the patient had eaten two chiefly slugs and snails. The larvae then mature and reach the raw legs of a green tree frog (also on a dare). infective stage, at which time they are able to infect humans The 2017 case is the third identified case ofA. cantonensis in and other hosts. Humans may become infected by consuming Louisiana. The public health investigation for the 2017 case did uncooked snails or slugs, contaminated vegetables, or other raw not reveal an exposure source. However, the patient did report infected hosts (such as fish, amphibians, reptiles, or crustaceans). frequently consuming boiled shellfish. Roughly two weeks after infection, humans begin to show a A 1987 study found that about 20% of rats trapped in New wide range of symptoms. Over 90% of cases report severe head- Orleans were infected with A. cantonensis. This rat study, along aches; other symptoms include nausea, vomiting, neck stiffness, with the distribution of human cases, and samples of infected and exaggerated sensitivity to touch. Symptoms may last several snails, show evidence that the parasite is present in different parts weeks. Most cases resolve on their own over time, and medica- of Southeastern Louisiana. As a result, there is continued potential tions are commonly discouraged because the brain may have for human infection. However, cases are still extremely rare. detrimental reactions to dead parasites in the meninges. For more information, please contact Sean Simonson at A total of three cases of A. cantonensis have been identified (504) 568-8342 or [email protected]. 6 LA Morbidity Report, Jul - Aug, 2017, Vol. 28, No.4

Table 1: Communicable Disease Surveillance, Incidence by Region and Time Period, May-June, 2017

HEALTH REGION TIME PERIOD Jan-Dec Jan-Dec Jan-Dec DISEASE 1 2 3 4 5 6 7 8 9 May-Jun May-Jun Cum Cum % 2017 2016 2017 2016 Chg* Vaccine-preventable Hepatitis B Cases 1 3 0 0 1 2 1 3 3 14 8 42 27 55.6 Rate1 0.1 0.5 0 0 0.4 0.7 0.2 0.9 0.8 0.3 0.2 1.0 0.6 NA * Measles 0 0 0 0 0 0 0 0 0 0 0 0 0 NA * Mumps 1 4 0 0 0 0 0 0 0 5 0 45 0 4500.0 Rubella 0 0 0 0 0 0 0 0 0 0 0 0 0 NA * Pertussis 2 2 0 0 1 4 0 0 1 10 7 42 24 75.0 Sexually-transmitted HIV /A IDS Cas es 2 73 36 8 26 6 7 26 13 23 218 196 647 576 12.3 Rate1 8.1 5.3 2.0 4.3 2.0 2.3 4.8 3.7 4.0 4.7 4.2 13.9 12.3 NA * Chlamydia Cases1,3 1,404 965 392 583 256 410 859 546 570 5,996 5,254 17,616 15,952 10.4 Rate1 156.5 141.0 96.9 95.7 84.9 134.1 158.1 154.0 98.1 128.1 112.2 376.3 340.7 NA * Gonorrhea Cases1,3 516 313 126 208 84 128 322 177 170 2,044 1,781 5,777 5,261 9.8 Rate1 57.5 45.7 31.2 34.1 27.9 41.9 59.3 49.9 29.2 43.7 38.0 123.4 112.4 NA * Syphilis (P&S) Cases1,3 22 19 11 15 0 7 14 13 1 102 156 316 356 -11.2 Rate1 2.5 2.8 2.7 2.5 0.0 2.3 2.6 3.7 0.2 2.2 3.3 6.7 7.6 NA * En t e r ic Campylobacter Cases 2 12 4 21 7 8 7 7 11 79 62 183 124 47.6 Cases 0 1 0 0 0 0 0 0 0 1 3 4 9 -55.6 Rate1 0 0.2 0 0 0 0 0 0 0 0 0.1 0.1 0.2 NA * Salmonella Cases 17 29 19 33 23 13 18 22 19 193 269 395 525 -24.8 Rate1 1.6 5.1 5.0 6.4 8.6 4.3 3.6 6.3 4.9 4.5 6.2 9.2 12.2 NA * Shigella Cases 3 2 2 1 13 1 10 2 0 34 66 96 194 -50.5 Rate1 0.3 0.4 0.5 0.2 4.9 0.3 2.0 0.6 0.0 0.8 1.5 2.2 4.5 NA * Vibrio, cholera Cases 0 0 0 0 0 0 0 0 0 0 0 0 0 NA * Vibrio, other Cases 2 1 0 3 0 0 0 0 3 9 13 28 21 33.3 Othe r H. influenzae (other) 3 2 0 1 1 1 3 1 1 13 9 36 32 NA * N. Meningitidis 0 0 0 0 0 0 0 0 0 0 1 3 2 NA * 1 = Cases Per 100 000 Population.

2 = These totals reflect people w ith HIV infection w hose status w as first detected during the specified time period. This includes people w ho w ere diagnosed w ith AIDS at the time HIV first w as detected. Because of delays in reporting HIV/AIDS cases, the number of persons reported is a minimal estimate. Data should be considered provisional.

3 = Prelminary data. Figure: Department of Health Regional Map

* = Percent change not calculated for rates or count differences less than 5.

Table 2: Diseases of Low Frequency, January-December, 2017 Disease Total to Date Legionellosis 18 Lyme Disease 1 Malaria 6 Rabies, animal 10 Varicella 35

Table 3: Animal Rabies, May - June , 2017 Par is h No. Cases Species DeSoto 7 Skunk

7 Sanitary Code - State of Louisiana Part II - The Control of Disease LAC 51:II.105: The following diseases/conditions are hereby declared reportable with reporting requirements by Class:

Class A Diseases/Conditions - Reporting Required Within 24 Hours Diseases of major public health concern because of the severity of disease and potential for epidemic spread-report by telephone immediately upon recognition that a case, a suspected case, or a positive laboratory result is known; [in addition, all cases of rare or exotic communicable diseases, unexplained death, unusual cluster of disease and all outbreaks shall be reported.

Acute Flaccid Paralysis Fish/ (domoic acid, neurotoxic Plague (Yersinia pestis) Smallpox Anthrax shellfish poisoning, ciguatera, paralytic shellfish Poliomyelitis (paralytic & non-paralytic) Staphylococcus aureus, Vancomycin Avian or Novel Strain Influenza A poisoning, scombroid) Q Fever Coxiella( burnetii) Intermediate or Resistant (VISA/VRSA) (initial detection) Foodborne Infection Rabies (animal and human) Staphylococcal Enterotoxin B (SEB) Pulmonary Haemophilus influenzae (invasive infection) Ricin Poisoning Poisoning Brucellosis Influenza-associated Mortality Rubella (congenital syndrome) Tularemia (Francisella tularensis) Cholera Measles (Rubeola imported or indigenous) Rubella (German Measles) Viral Hemorrhagic Fever (Ebola, Lassa, Marburg, Clostridium perfringens Neisseria meningitidis (invasive infection) Severe Acute Respiratory Syndrome- Crimean Congo, etc.) (foodborne infection) Outbreaks of Any Infectious Disease associated Coronavirus (SARS-CoV) Yellow Fever Diphtheria Pertussis

Class B Diseases/Conditions - Reporting Required Within 1 Business Day Diseases of public health concern needing timely response because of potential of epidemic spread-report by the end of the next business day after the existence of a case, a suspected case, or a positive laboratory result is known.

Amoeba (free living infection: Acanthamoeba, Chagas Disease Hepatitis B (perinatal infection) Mumps Naegleria, Balamuthia, others) Chancroid Salmonellosis Anaplasmosis Escherichia coli, Shiga-toxin producing Herpes (neonatal) Shigellosis Arthropod-Borne Viral Infections (West Nile, (STEC), including E. coli O157:H7 Human Immunodeficiency Virus2 [(HIV), Syphilis¹ Dengue, St, Louis, California, Eastern Granuloma Inguinale infection in pregnancy] Tetanus Equine, Western Equine, Chikungunya, Hantavirus (infection or Pulmonary Syndrome) Human Immunodeficiency Virus2 [(HIV), Tuberculosis3 (due to M. tuberculosis, Usutu, and others) Hemolytic-Uremic Syndrome perinatal exposure] M. bovis, or M. africanum) Aseptic Meningitis Hepatitis A (acute illness) Legionellosis Typhoid Fever Babesiosis Hepatitis B (acute illness and carriage in pregnancy) Malaria

Class C Diseases/Conditions - Reporting Required Within 5 Business Days Diseases of significant public health concern-report by the end of the workweek after the existence of a case, suspected case, or a positive laboratory result is known.

Acquired Immune Deficiency Giardiasis Listeriosis Staphylococcal Toxic Shock Syndrome Syndrome3 (AIDS) Glanders (Burkholderia mallei) Lyme Disease Streptococcal Disease, Group A (invasive Anaplasma Phagocytophilum Gonorrhea¹ (genital, oral, ophthalmic, pelvic Lymphogranuloma Venereum1 disease) Blastomycosis inflammatory disease, rectal) Melioidosis (Burkholderia pseudomallei) Streptococcal Disease, Group B (invasive Campylobacteriosis Hansen’s Disease (leprosy) Meningitis, Eosinophilic (including disease) Chlamydial infection¹ Hepatitis C (acute illness) those due to Angiostrongylus infection) Streptococcal Toxic Shock Syndrome Coccidioidomycosis Histoplasmosis Nipah Virus Infection Streptococcus pneumoniae, invasive disease Cryptococcosis (C. neoformans and C. gattii) Human Immunodeficiency Virus2 (HIV Non-gonococcal Urethritis Transmissible Spongiform Encephalopathies (infection other than as in Class B) Ophthalmia neonatorum (Creutzfeldt-Jacob Disease & variants) Cyclosporiasis Human T Lymphocyte Virus (HTLV Psittacosis Ehrlichiosis (human granulocytic, human I and II infection) Spotted Fevers [Rickettsia species including Varicella (chickenpox) monocytic, E. chaffeensis and E. ewingii) Leptospirosis Rocky Mountain Spotted Fever (RMSF)] Vibrio Infections (other than cholera) Enterococcus, Vancomycin Resistant Staphylococcus aureus (MRSA), invasive infection Yersiniosis [(VRE), invasive disease]

Class D Diseases/Conditions - Reporting Required Within 5 Business Days

Cancer Heavy Metal (arsenic, cadmium, mercury) Phenylketonuria4 Severe Traumatic Head Injury Carbon Monoxide Exposure and/or Poisoning5 Exposure and/or Poisoning (all ages)5 Pneumoconiosis (asbestosis, berylliosis, silicosis, Severe Undernutrition (severe anemia, failure to Complications of Abortion Hemophilia4 byssinosis, etc.) thrive) Congenital Hypothyroidism4 Lead Exposure and/or Poisoning (all ages)4, 5 Radiation Exposure, Over Normal Limits Sickle Cell Disease4 (newborns) Galactosemia4 Pesticide-Related Illness or Injury (all ages)5 Reye’s Syndrome Spinal Cord Injury Sudden Infant Death Syndrome (SIDS)

Case reports not requiring special reporting instructions (see below) can be reported by mail or facsimile on Confidential Disease Report forms (2430), fascimile (504) 568-8290, telephone (504) 568-8313, or (800) 256-2748 for forms and instructions. ¹Report on STD-43 form. Report cases of syphilis with active lesions by telephone, within one business day, to (504) 568-8374. ²Report to the Louisiana HIV/AIDS Program: Visit www.hiv.dhh.louisiana.gov or call 504-568-7474 for regional contact information. 3Report on form TB 2431 (8/94). Mail form to TB Control Program, DHH-OPH, P.O. Box 60630, New Orleans, LA. 70160-0630 or fax both sides of the form to (504) 568-5016 4Report to the Louisiana Genetic Diseases Program and Louisiana Childhood Lead Poisoning Prevention Programs: www.genetics.dhh.louisiana.gov or fascimile (504) 568-8253, telephone (504) 568-8254, or (800) 242-3112 5Report to the Section of Environmental Epidemiology and Toxicology: www.seet.dhh.louisiana.gov or call (225) 342-7136 or (888) 293-7020

All laboratory facilities shall, in addition to reporting tests indicative of conditions found in §105, report positive or suggestive results for additional conditions of public health interest. The following findings shall be reported as detected by laboratory facilities: 1. adenoviruses; 2. coronaviruses; 3 .enteroviruses; 4. hepatitis B (carriage other than in pregnancy); 5. hepatitis C (past or present infection ); 6. human metapneumovirus; 7. parainfluenza viruses; 8. respiratory syncytial virus; and 9. rhinoviruses.

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