2018 Epidemiology Annual Report
535 South Loop 288 Denton, TX 76205-4502 www.DentonCounty.gov/Health Denton County Public Health
Director Matt Richardson, DrPH, MPH
Epidemiology Division
Chief Epidemiologist Juan Rodriguez, MPH
Epidemiologist Lily Metzler, MPH
Epidemiologist Taylor Keplin, MPH
Epidemiologist Abby Hoffman, M.S. Acknowledgments
This report was prepared by the Epidemiology Division staff. We wish to acknowledge the contribution of our health care providers for reporting notifiable conditions and their cooperation in diseases investigations.
In addition, we wish to thank Denton County Public Health staff and Medical Reserve Corp for their assistance in disease surveillance and investigations along with our colleagues at the Texas Department of State Health Services for providing data used in this report. Methodology
The total population estimates used in this report were collected from the Texas Demographic Center1 and represent the population estimates for Denton County as of July 1, 2018. Population estimates may vary from previous Epidemiology Annual Reports due to changes of these estimates and are not directly associated to population estimates produced by the U.S. Census Bureau.
The Sexually Transmitted Disease (STD) and Human Immunodeficiency Virus (HIV) case numbers and rates for Denton County were obtained from the Texas Department of State Health Services STD Surveillance Program Dashboard2. STD and HIV rates were calculated by the Texas Department of State Health Services based on population projections from the U.S. Census Bureau3.
Data for Denton County notifiable conditions was collected from the Texas Department of State Health Services National Electronic Disease Surveillance System (NEDSS)4. This system delivers public health data to both state and local agencies, allowing data sharing and the ability to conduct disease surveillance. Notifiable condition yearly case counts may fluctuate due to changes in case criteria such as the broadening of case definitions and acceptable testing methods. In addition, some notifiable conditions became newly reportable within this report’s specified 5-year time frame, which may appear as a sudden increase of cases.
1. https://demographics.texas.gov/Data/TPEPP/Estimates/ 2. http://healthdata.dshs.texas.gov/InfectiousDisease/STD 3. https://www.census.gov/data/tables/2017/demo/popproj/2017-summary-tables.html 4. https://www.dshs.texas.gov/nedss/default.shtml Table of Contents
Summary of Notifiable Diseases 2014-2018...... 1
Sexually Transmitted Diseases...... 2 Chlamydia...... 2 Gonorrhea...... 5 HIV...... 8 Syphilis...... 11
Vaccine Preventable Diseases...... 14 Pertussis...... 14 Varicella...... 17
Gastrointestinal Diseases...... 20 Campylobacteriosis...... 20 Cryptosporidiosis...... 23 Cyclosporiasis...... 26 Salmonellosis...... 29 Shiga toxin-producing Escherichia coli (STEC)...... 32 Shigellosis...... 35
Invasive Diseases...... 38 Streptococcus, invasive Group A...... 38 Streptococcus, invasive Group B...... 41 Streptococcus pneumoniae, invasive...... 44 Summary of Notifiable Conditions 2014-2018
Case counts refer to confirmed and probable cases Total Cases in Previous Years Notifiable Condition 2014 2015 2016 2017 2018 Acute Flaccid Myelitis (AFM) 0 0 0 2 0 Amebiasis 5 3 2 4 3 Anaplasma phagocytophilum 0 0 0 0 0 Brucellosis 1 0 3 0 0 Campylobacteriosis 46 84 57 65 59 Carbapenem-resistant Enterobacteriaceae 2 2 3 10 14 Chagas, chronic indeterminate 0 0 0 1 0 Chikungunya virus diseases 8 1 0 1 0 Creutzfeldt-Jakob Disease 0 0 3 1 1 Cryptosporidiosis 7 21 9 24 19 Cyclosporiasis 8 14 11 12 3 Cysticercosis 1 0 1 0 0 Dengue 2 2 1 3 0 Haemophilus influenzae, invasive a 0 1 9 12 10 Hemolytic uremic synd,postdiarrheal 0 1 0 1 0 Hepatitis A, acute 2 10 3 0 5 Hepatitis B, acute 2 6 6 5 7 Hepatitis C, acute 2 1 4 1 0 Hepatitis E, acute 1 1 1 0 1 Influenza-associated pediatric mortality 2 1 0 1 0 Legionellosis 8 5 5 8 11 Leishmaniasis 1 1 1 0 0 Listeriosis 2 0 1 1 0 Lyme disease 1 0 3 3 2 Malaria 1 2 7 2 3 Measles (Rubeola) 0 0 0 0 1 Multidrug-resistant organisms (MDRA) a 3 10 11 9 14 Mumps 0 1 8 12 2 Neisseria meningitidis, invasive (Mening. disease) 0 0 1 0 1 Pertussis 102 78 68 99 55 Q fever, Acute 0 0 0 0 0 Salmonellosis 118 175 142 118 152 Shiga toxin-producing Escherichia coli (STEC) 30 26 27 29 19 Shigellosis 93 58 77 23 29 Spotted Fever Rickettsiosis 1 0 4 0 1 Streptococcus pneumoniae, invasive disease (IPD) 34 38 49 47 53 Streptococcus, invasive Group A 14 13 14 19 22 Streptococcus, invasive Group B 24 26 39 37 40 Typhoid fever (Salmonella typhi) 0 2 1 1 3 Varicella (Chickenpox) 64 51 49 61 30 Vibrio vulnificus infection 0 0 0 0 1 Vibriosis, other or unspecified 1 3 1 1 2 West Nile Virus 4 10 20 12 2 Yersiniosis 0 1 0 0 1 Zikaa 0 0 9 2 0
Case counts reflective of MMWR year in Texas Department of State Health Services NEDSS database
1 a. Reporting requirements variations during represented time frame Chlamydia STDs Denton County 2014-2018
• Causative Agent: (bacterial) Chlamydia trachomatis • Signs/Symptoms: o Men: Most men do not exhibit symptoms. Symptoms – penile discharge, urethral itching, burning sensation when urinating, pain and swelling in one or both testicles. Complications – rarely infertility. o Women: Up to 70% of infected women do not exhibit symptoms. Symptoms – abnormal vaginal discharge, burning sensation when urinating. Infants born to infected women may develop eye or pneumonic infections. Complications – PID, chronic pelvic pain, infertility, ectopic pregnancy. o Rectal infection – rectal pain, discharge, bleeding. VPDs o Untreated chlamydia may increase the chance of acquiring or transmitting HIV. • Mode(s) of Transmission: Perinatally or sexually transmitted infection • Incubation Period: 7-14 days or longer • Period of Communicability: Infected individuals are assumed to be infectious.
Figure 1. Chlamydia in Denton County and Texas
2500 600
2400 500
2300 400 GI Illness
2200 300 Cases
2100 200 Rate per 100,000
2000 100
1900 0 2014 2015 2016 2017 2018 Year
Denton County Cases Denton County Rate Texas Rate Invasive
Data Source: Texas Department of State Health Services
2 Figure 2. Chlamydia by Gender, Denton County 2014-2018 STDs 450 400 350 300 250 200 150
Rate per 100,000 per Rate 100 50 0
2014 2015 2016 2017 2018 VPDs Male Female
Data Source: Texas Department of State Health Services
Figure 3. Chlamydia by Race/Ethnicity, Denton County New Cases 2018
White 19.7% GI Illness
Unknown Black 50.4% 16.6%
Hispanic 10.9%
Other 2.3% White Black Hispanic Other Unknown
Data Source: Texas Department of State Health Services Invasive
*In 2018, there was a large number of chlamydia and gonorrhea cases for the “unknown” race/ethnicity category. This was due to a delay in updating the race/ethnicity field in the surveillance data. Ongoing data quality improvement will address this for 2019 reporting.*
3 Figure 4. Chlamydia by Race/Ethnicity, Denton County 2014-2018 STDs 700
600
500
400
300
200 Rate per 100,000 per Rate 100
0 VPDs 2014 2015 2016 2017 2018 White Black Hispanic Other
*Graph does not represent unknown or missing Race/Ethnicity Data Source: Texas Department of State Health Services
Figure 5. Chlamydia by Age Group, Denton County 2014-2018
1600 1400 GI Illness 1200 1000 800 600
Rate per 100,000 per Rate 400 200 0 2014 2015 2016 2017 2018 0-14 15-24 25-34 35-44 45+ Invasive
Data Source: Texas Department of State Health Services
4 Gonorrhea STDs Denton County 2014-2018
• Causative Agent: (bacterial) Neisseria gonorrhoeae • Signs & Symptoms: o Men: Many infected men are asymptomatic. Symptoms – burning sensation when urinating, or a white, yellow, or green urethral discharge. Complications – Epididymitis which causes testicular or scrotal pain. In rare cases men may become infertile. o Women: Most infected women are asymptomatic. If a women develops symptoms, they are often so mild and nonspecific that they are mistaken for a bladder or vaginal infection. Symptoms - painful or burning sensation when urinating, increased vaginal discharge, or vaginal bleeding between periods. Regardless of symptom severity, infected women are at risk of developing serious complications. Complications - pelvic inflammatory disease (PID) or infertility. VPDs o Rectal Infections: Can be asymptomatic or cause symptoms in both men and women. Symptoms – discharge, anal itching, soreness, bleeding, painful bowel movements. o Disseminated gonococcal infection: untreated gonorrhea can spread to the blood and cause a life- threatening condition. • Mode(s) of Transmission: perinatally or sexually transmitted infection • Incubation period: 1-14 days • Period of Communicability: months in untreated people
Figure 1. Gonorrhea in Denton County and Texas 900 180 800 160 GI Illness 700 140 600 120 500 100
Cases 400 80 300 60 Rate per 100,000 per Rate 200 40 100 20 0 0 2014 2015 2016 2017 2018
Denton County Cases Denton County Rate Texas Rate Invasive
Data Source: Texas Department of State Health Services
5 Figure 2. Gonorrhea by Gender, Denton County 2014-2018 STDs 120
100
80
60
40
Rate per 100,000 per Rate 20
0 2014 2015 2016 2017 2018 VPDs Male Female
Data Source: Texas Department of State Health Services
Figure 3. Gonorrhea by Race/Ethnicity, Denton County New Cases 2018 GI Illness White 23.6% Unknown 36.5%
Black 25.3% Hispanic Other 11.0% 3.6%
White Black Hispanic Other Unknown Invasive
Data Source: Texas Department of State Health Services*
*In 2018, there was a large number of chlamydia and gonorrhea cases for the “unknown” race/ethnicity category. This was due to a delay in updating the race/ethnicity field in the surveillance data. Ongoing data quality improvement will address this for 2019 reporting.* 6 Figure 4. Gonorrhea by Race/Ethnicity, Denton County 2014-2018 STDs 300
250
200
150
100 Rate per 100,000 per Rate 50
0 2014 2015 2016 2017 2018 VPDs White Black Hispanic Other
*Graph does not represent unknown or missing Race/Ethnicity Data Source: Texas Department of State Health Services
Figure 5. Gonorrhea by Age Group, Denton County 2014-2018 GI Illness 400 350 300 250 200 150
Rate per 100,000 per Rate 100 50 0
2014 2015 2016 2017 2018 Invasive 0-14 15-24 25-34 35-44 45+
Data Source: Texas Department of State Health Services
7 HIV STDs Denton County 2014-2018
• Causative Agent: (viral) human immunodeficiency virus • Signs & Symptoms: o Acute infection: Flu-like symptoms. Some people have no symptoms. Large amounts of HIV are produced in the body and the CD4 cell count rapidly falls. Then the immune response stabilizes the virus level. o Clinical latency: HIV reproduces at very low levels. People may not have any symptoms. Toward the middle and end of this period, viral load begins to rise and CD4 cell count begins to drop. As this happens, people may begin to have symptoms of HIV infection because the immune system is too weak to protect them. o AIDS (acquired immunodeficiency syndrome): Immune system is badly damaged so the infected person is vulnerable to infections and infection-related cancers. Medical treatment is VPDs needed to avoid death. • Mode(s) of Transmission: Spread through blood, semen, vaginal secretions, and breast milk. Sexual transmission, perinatal transmission, or sharing needles or syringes. • Incubation period: Variable. Time from HIV infection to AIDS diagnosis ranges from <1 yr to >15 yrs. • Period of Communicability: infected individuals are infectious during all stages of illness
Figure 1. New HIV Diagnoses in Denton County and Texas
100 18 90 16
80 14 GI Illness 70 12 60 10 50
Cases 8 40 6 30 100,000 per Rate 20 4 10 2 0 0 2014 2015 2016 2017 2018 Denton County Cases Denton County Rate Texas Rate Invasive
Data Source: Texas Department of State Health Services
8 Figure 2. New HIV Diagnoses by Gender, Denton County 2014-2018 STDs 20 18 16 14 12 10 8 6
Rate per 100,000 per Rate 4 2 0 2014 2015 2016 2017 2018 VPDs Male Female
Data Source: Texas Department of State Health Services
Figure 3. New HIV Diagnoses by Race/Ethnicity, Denton County New Cases 2018
Unknown Other 5.6% GI Illness 4.5%
White 31.5%
Hispanic 25.8%
Black 32.6%
White Black Hispanic Other Unknown Invasive
Data Source: Texas Department of State Health Services
9 Figure 4. New HIV Diagnoses by Race/Ethnicity, Denton County 2014-2018 STDs 50 45 40 35 30 25 20 15 Rate per 100,000 per Rate 10 5 0 VPDs 2014 2015 2016 2017 2018 White Black Hispanic Other
*Graph does not represent unknown or missing Race/Ethnicity Data Source: Texas Department of State Health Services
Figure 5. New HIV Diagnoses by Age Group, Denton County 2014-2018
40 GI Illness
35
30
25
20
15
Rate per 100,000 per Rate 10
5
0 Invasive 2014 2015 2016 2017 2018 0-14 15-24 25-34 35-44 45+
Data Source: Texas Department of State Health Services
10 Syphilis STDs Denton County 2014-2018
• Causative Agent: (bacterial) Treponema pallidum • Signs & Symptoms: o Primary: Firm, round, painless sore(s). The sore lasts 3 to 6 weeks. o Secondary: Skin rashes and/or sores in the mouth, vagina, or anus. The rash can look like rough, red, or reddish brown spots on the palms of hands and the bottoms of the feet. The rash usually won’t itch and is sometimes so faint that it is not noticed. Other symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue. o Latent & Late Stages: The latent (hidden) stage of syphilis begins when primary and secondary symptoms disappear. Without treatment, the infected person can continue to have syphilis infection in the body without any signs or symptoms. Latent syphilis can last for years. Late stages VPDs of syphilis can develop in about 15% of people who have not been treated for syphilis, and can appear 10–20 years after infection was first acquired. Symptoms of the late stage of syphilis include difficulty coordinating muscle movements, paralysis, numbness, gradual blindness, and dementia. The disease damages internal organs and may be serious enough to cause death. • Mode(s) of Transmission: perinatally or sexually transmitted infection • Incubation period: 10 days to 3 months • Period of Communicability: most contagious during primary and secondary stages
Figure 1. Syphilis in Denton County and Texas
200 50 GI Illness 180 45 160 40 140 35 120 30 100 25
Cases 80 20
60 15 100,000 per Rate 40 10 20 5 0 0 2014 2015 2016 2017 2018 Invasive Denton County Cases Denton County Rate Texas Rate
Data Source: Texas Department of State Health Services
11 Figure 2. Syphilis by Gender, Denton County 2014-2018
45 STDs 40 35 30 25 20 15 Rate per 100,000 per Rate 10 5 0 2014 2015 2016 2017 2018 VPDs Male Female
Data Source: Texas Department of State Health Services
Figure 3. Syphilis by Race/Ethnicity, Denton County New Cases 2018
Other Unknown 3.3% 1.1% GI Illness
Hispanic White 22.4% 37.2%
Black 36.1%
White Black Hispanic Other Unknown Invasive
Data Source: Texas Department of State Health Services
12 Figure 4. Syphilis by Race/Ethnicity, Denton County 2014-2018 STDs 80.0 70.0 60.0 50.0 40.0 30.0 20.0 Rate per 100,000 per Rate 10.0
0.0 VPDs 2014 2015 2016 2017 2018 White Black Hispanic Other
*Graph does not represent unknown or missing Race/Ethnicity Data Source: Texas Department of State Health Services
Figure 5. Syphilis by Age Group, Denton County 2014-2018
70 GI Illness
60
50
40
30
20
Rate per 100,000 per Rate 10
0 2014 2015 2016 2017 2018 Invasive 0-14 15-24 25-34 35-44 45+
Data Source: Texas Department of State Health Services
13 Pertussis STDs Denton County 2014-2018
• Causative Agent: (bacterial) Bordetella pertussis • Signs & Symptoms: o Catarrhal Stage: Runny nose, sneezing, low-grade fever, and slight cough. The cough gradually becomes more severe and after 1-2 weeks, the next stage develops. o Paroxysmal Stage: Coughing fits (paroxysms), which may be followed by inspiratory whooping sound, vomiting, or apnea. Usually lasts 1-6 weeks, but may continue for 10 weeks. o Convalescent Stage: Gradual resolution of paroxysmal coughing. The coughing may last a few weeks or continue for months o Pertussis in infants may be atypical with a short catarrhal stage, followed by gagging, gasping, bradycardia, or apnea as early symptoms and ab absence of whoop. Older children, VPDs adolescents, and adults usually experience milder pertussis symptoms. o Complications: . Infants – About half of infants with pertussis are hospitalized. Complications include apnea, pneumonia, pulmonary hypertension, seizures, encephalopathy, and death. . Adults – fainting, weight loss, sleep disturbance, incontinence, rib fractures, and pneumonia. • Mode(s) of Transmission: person-to-person through direct contact with respiratory secretions, most commonly airborne droplets from infectious individuals • Incubation period: 4-21 days; average 7-10 days • Period of Communicability: Most infectious during catarrhal period and for 21 days after cough onset. GI Illness
Figure 1. Pertussis in Denton County
120 18
100 15
80 12
60 9 Rate Cases 40 6
20 3 Invasive
0 0 2014 2015 2016 2017 2018 Cases Rate/100,000
14 Figure 2. Pertussis by Sex, Denton County New Cases 2018 STDs
40 8
35 7
30 6
25 5
20 4 Rate Cases 15 3
10 2
5 1
0 0 Female Male VPDs Cases Rate/100,000
Figure 3. Pertussis by Race/Ethnicity, Denton County New Cases 2018
50 10
40 8 GI Illness
30 6 Rate Cases 20 4
10 2
0 0 White Non Black Non Other Hispanic Hispanic Hispanic
Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
15 Figure 4. Pertussis by Age Group, Denton County New Cases 2018 STDs
15 25
12 20
9 15 Rate Cases 6 10
3 5 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
16 Varicella STDs Denton County 2014-2018
• Causative Agent: (viral) Huma (alpha) herpesvirus 3 (varicella-zoster virus, VZV) • Signs & Symptoms: o Fever and generalized, itchy maculopapulovesicular rash with lesions in various stages of development. The lesions are maculopapular for a few hours, vesicular and pustular for 3-4 days, then crust, leaving scabs. Lesions commonly occur in successive crops for 3-7 days. Lesions tend to be more abundant on the trunk. Mild, atypical, and unapparent infections also occur. Vaccinated individuals with varicella may only have a few lesions and no fever. Complications – dehydration, pneumonia, bleeding problems, infection or inflammation of the brain, bacterial infections of the skin and soft tissues in children, blood stream infections, toxic
shock syndrome, bone infections, joint infections. Some people with serious complications have VPDs to be hospitalized. Chickenpox can also cause death. o Pregnant women who get varicella have increased risk of developing pneumonia. Fetal infection may result in the baby being born with congenital varicella syndrome or fetal death. Neonatal varicella can result in infants whose mothers develop varicella 5 days before to 2 days after delivery. • Mode(s) of Transmission: direct contact with patient with varicella (chickenpox) or zoster (shingles); droplet or airborne spread of vesicle fluid or secretions of the respiratory tract; indirectly by contaminated inanimate objects. • Incubation period: 10-21 days; usually 14-16 days. May be prolonged to 28 days after receipt of Varicella-Zoster Immune Globulin and shorter in immunocompromised patients. • Period of Communicability: 5 days before rash onset (especially 1-2 days before rash onset) and up to 5 days after onset of lesions (until crusting). GI Illness
Figure 1. Varicella in Denton County
70 14
60 12
50 10
40 8 Rate Cases 30 6
20 4 Invasive 10 2
0 0 2014 2015 2016 2017 2018 Cases Rate/100,000
17 Figure 2. Varicella by Sex, Denton County New Cases 2018 STDs
20 5
18
16 4
14
12 3
10 Rate Cases 8 2
6
4 1 VPDs 2
0 0 Female Male Cases Rate/100,000
Figure 3. Varicella by Race/Ethnicity, Denton County New Cases 2018
15 5 GI Illness 12 4
9 3 Rate Cases 6 2
3 1
0 0 White Non Black Non Other Hispanic
Hispanic Hispanic Invasive Cases Rate/100,000
*Graph does not represent unknown or missing Race/Ethnicity
18 Figure 4. Varicella by Age Group, Denton County New Cases 2018 STDs
12 30
10 25
8 20
6 15 Rate Cases
4 10 VPDs 2 5
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
19 Campylobacteriosis Denton County 2014-2018 STDs
• Causative Agent: (bacterial) Campylobacter species, mostly C. jejuni, and fewer C. coli • Signs & Symptoms: Diarrhea, abdominal pain, malaise, and fever. The diarrhea may be bloody and the patient may also experience nausea and vomiting. Bacteremia is uncommon. Symptoms usually last less than one week. Complications post infection – reactive arthritis, Guillain-Barre Syndrome, and irritable bowel syndrome. • Mode(s) of Transmission: Fecal-oral • Incubation period: 1-10 days; usually 2-5 days • Period of Communicability: infected persons may excrete the organism for 2-7 weeks, but person-to- person transmission is uncommon. VPDs
Figure 1. Campylobacteriosis in Denton County
100 12
75 9
50 6 Rate Cases GI Illness
25 3
0 0 2014 2015 2016 2017 2018 Cases Rate/100,000 Invasive
20 Figure 2. Campylobacteriosis by Sex, Denton County New Cases 2018
40 8 STDs
35 7
30 6
25 5
20 4 Rate Cases 15 3
10 2
5 1
0 0
Female Male VPDs
Cases Rate/100,000
Figure 3. Campylobacteriosis by Race/Ethnicity, Denton County New Cases 2018
40 8
35 7
30 6
25 5 GI Illness
20 4 Rate Cases
15 3
10 2
5 1
0 0 White Non Black Non Other Hispanic Hispanic Hispanic Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
21 Figure 4. Campylobacteriosis by Age Group, Denton County New Cases 2018 STDs
14 14
12 12
10 10
8 8 Rate Cases 6 6
4 4 VPDs
2 2
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
22 Cryptosporidiosis Denton County 2014-2018 STDs
• Causative Agent: (protozoan parasite) Cryptosporidium species. Most commonly C. hominus and C. parvum • Signs & Symptoms: Frequent, non-bloody, watery diarrhea is the most common symptom. Other symptoms include fever, abdominal cramps, fatigue, nausea, vomiting, anorexia, and weight loss. Illness usually lasts 1-2 weeks (less than 30 days). Some infected people have no symptoms. Complications – Immunocompromised individuals may have chronic diarrhea with malnutrition and significant weight loss, which can contribute to death. Rare instances of disseminated infection may occur in immunocompromised individuals. • Mode(s) of Transmission: Fecal-oral through ingestion of sporulated oocysts. • Incubation period: Variable; usually 1-12 days, with an average of 7 days • Period of Communicability: Oocysts shed while symptomatic and for up to 2 weeks after symptoms VPDs resolve. Immunocompromised individuals may shed oocysts for months.
Figure 1. Cryptosporidiosis in Denton County
30 6
25 5 GI Illness 20 4
15 3 Rate Cases
10 2
5 1
0 0 2014 2015 2016 2017 2018 Cases Rate/100,000 Invasive
23 Figure 2. Cryptosporidiosis by Sex, Denton County New Cases 2018
14 5 STDs
12 4 10
3 8 Rate Cases 6 2
4 1 2
0 0 VPDs Female Male Cases Rate/100,000
Figure 3. Cryptosporidiosis by Race/Ethnicity, Denton County New Cases 2018
14 7
12 6 GI Illness 10 5
8 4 Rate Cases 6 3
4 2
2 1
0 0 White Non Black Non Other Hispanic Hispanic Hispanic Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
24 Figure 4. Cryptosporidiosis by Age Group, Denton County New Cases 2018
8 8 STDs
6 6
4 4 Rate Cases
2 2 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
25 Cyclosporiasis Denton County 2014-2018 STDs
• Causative Agent: (protozoan parasite) Cyclospora cayetanensis • Signs & Symptoms: Watery diarrhea is the most common symptom. Other symptoms are low-grade fever, anorexia, weight loss, nausea, vomiting, prolonged fatigue, abdominal cramps, flatulence, and myalgia. Asymptomatic infections can occur, especially where cyclosporiasis is endemic. Untreated people may have remitting, relapsing symptoms for weeks to months. • Mode(s) of Transmission: Ingestion of oocysts in contaminated food or water • Incubation period: 2-14 days; usually 7 days • Period of Communicability: Direct person-to-person transmission is unlikely because the oocysts are not infectious in freshly excreted stool. Indirect transmission can occur if the oocysts contaminate the environment and sufficient time/conditions allow them to become infectious (sporulate). VPDs
Figure 1. Cyclosporiasis in Denton County
16 2.0 14 12 1.5 10 GI Illness 8 1.0 Rate Cases 6 4 0.5 2 0 0.0 2014 2015 2016 2017 2018 Cases Rate/100,000 Invasive
26 Figure 2. Cyclosporiasis by Sex, Denton County New Cases 2018
3 1.5 STDs
2 1.0 Rate Cases
1 0.5
0 0.0 VPDs Female Male
Cases Rate/100,000
Figure 3. Cyclosporiasis by Race/Ethnicity, Denton County New Cases 2018
5 2.5
4 2.0 GI Illness
3 1.5 Rate Cases 2 1.0
1 0.5
0 0.0 White Non Black Non Other Hispanic Hispanic Hispanic Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
27 Figure 4. Cyclosporiasis by Age Group, Denton County New Cases 2018 STDs 2 2
1 1 Rate Cases VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
28 Salmonellosis Denton County 2014-2018 STDs
• Causative Agent: (bacterial) Salmonella species • Signs & Symptoms: Diarrhea, nausea, headache, abdominal cramps/pain, fever, and sometimes vomiting. Bloody diarrhea and invasive disease may occur. A carrier state may develop. Infections caused by S. Paratyphi can cause a systemic illness with symptoms of fever, loss of appetite, lethargy, and/or malaise. • Mode(s) of Transmission: Fecal-oral • Incubation period: 6-72 hours; usually 12-36 hours. For S. Paratyphi, usually 1-10 days but may be as long as 2-3 weeks. • Period of Communicability: People are infectious as long as bacteria is shed in their stool. Bacteria are can be shed through the course of infection, usually several days to several weeks. A small percentage of cases shed the organism for many months. Antibiotic use can prolong the duration of fecal shedding. VPDs
Figure 1. Salmonellosis in Denton County
200 40
175 35
150 30 GI Illness 125 25
100 20 Rate Cases 75 15
50 10
25 5
0 0 2014 2015 2016 2017 2018 Cases Rate/100,000 Invasive
29 Figure 2. Salmonellosis by Sex, Denton County New Cases 2018
100 25 STDs
80 20
60 15 Rate Cases 40 10
20 5 VPDs
0 0 Female Male Cases Rate/100,000
Figure 3. Salmonellosis by Race/Ethnicity, Denton County New Cases 2018
100 20
90 18 GI Illness 80 16
70 14
60 12
50 10 Rate Cases 40 8
30 6
20 4
10 2
0 0 White Non Black Non Other Hispanic Hispanic Hispanic Invasive Cases Rate/100,000
*Graph does not represent unknown or missing Race/Ethnicity
30 Figure 4. Salmonellosis by Age Group, Denton County New Cases 2018
40 80 STDs
35 70
30 60
25 50
20 40 Rate Cases
15 30
10 20 VPDs 5 10
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
31 Shiga toxin-producing STDs Escherichia coli (STEC) Denton County 2014-2018
• Causative Agent: (bacterial) Shiga-toxin producing Escherichia coli • Signs & Symptoms: Symptoms vary but predominant symptoms are severe abdominal pain and non- bloody diarrhea which can become bloody after 3-4 days. Complications – Hemolytic uremic syndrome (HUS). Patients with HUS can develop neurologic complications. • Mode(s) of Transmission: Fecal-oral. Person-to-person spread is common within households and daycare centers. • Incubation period: 1-10 days; E. coli O157:H7 is usually 3-4 days, with 6% of infections developing
hemolytic uremic syndrome (HUS) within 3 weeks of infection. VPDs • Period of Communicability: Duration of pathogen excretion - 1 week or less in adults. 3 weeks in 1/3 of children. Prolonged carriage is uncommon.
Figure 1. STEC in Denton County
35 7
30 6 GI Illness
25 5
20 4 Rate Cases 15 3
10 2
5 1
0 0 2014 2015 2016 2017 2018 Invasive Cases Rate/100,000
32 Figure 2. STEC by Sex, Denton County New Cases 2018
12 6 STDs
10 5
8 4
6 3 Rate Cases
4 2
2 1 VPDs
0 0 Female Male Cases Rate/100,000
Figure 3. STEC by Race/Ethnicity, Denton County New Cases 2018
16 8
14 7 GI Illness 12 6
10 5
8 4 Rate Cases
6 3
4 2
2 1
0 0 White Non Black Non Other Hispanic Hispanic Hispanic Invasive Cases Rate/100,000
*Graph does not represent unknown or missing Race/Ethnicity 33 Figure 4. STEC by Age Group, Denton County New Cases 2018 STDs 5 5
4 4
3 3 Rate Cases 2 2
1 1 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
34 Shigellosis Denton County 2014-2018 STDs
• Causative Agent: (bacterial) Shigella species – S. dysenteriae, S. flexneri, S. boydii, and S. sonnei. • Signs & Symptoms: Acute onset of diarrhea, usually accompanied by moderate to high fever, abdominal pain, cramping, nausea, and a painful sensation of needing to pass stools even when bowels are empty. Diarrhea is often watery, but may be mucoid or bloody. Mild and asymptomatic infections also occur. Complications – post-infectious arthritis, blood stream infections, seizures, hemolytic uremic syndrome (HUS). • Mode(s) of Transmission: Mainly by direct or indirect fecal-oral transmission from a symptomatic patient or asymptomatic carrier. Transmission can also occur from sexual contact, including oral-anal contact. Person-to-person transmission is common within households and childcare facilities or other close contacts, especially when handwashing is inadequate. Infectious dose is as low as 10-100 organisms. VPDs • Incubation period: 12-96 hours; usually 1-3 days • Period of Communicability: Infectious as long as bacteria are shed in the stool. Shedding may last 1-4 weeks after illness onset. Individuals may rarely remain carriers for many months.
Figure 1. Shigellosis in Denton County
100 12 90 80 10 GI Illness 70 8 60 50 6 Rate Cases 40 30 4 20 2 10 0 0 2014 2015 2016 2017 2018 Cases Rate/100,000 Invasive
35 Figure 2. Shigellosis by Sex, Denton County New Cases 2018 STDs 18 9
16 8
14 7
12 6
10 5 Rate Cases 8 4
6 3
4 2
2 1 VPDs 0 0 Female Male Cases Rate/100,000
Figure 3. Shigellosis by Race/Ethnicity, Denton County New Cases 2018
14 7
12 6 GI Illness 10 5
8 4 Rate Cases 6 3
4 2
2 1
0 0 White Non Black Non Other Hispanic Hispanic Hispanic
Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
36 Figure 4. Shigellosis by Age Group, Denton County New Cases 2018
8 16 STDs
7 14
6 12
5 10
4 8 Rate Cases
3 6
2 4
1 2 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
37 Streptococcus, STDs Invasive Group A Denton County 2014-2018
• Causative Agent: (bacterial) Streptococcus pyogenes (Group A Streptococcus) • Signs & Symptoms: Non-invasive illnesses include strep throat, scarlet fever, impetigo, cellulitis, otitis media, and wound infections. Invasive manifestations include meningitis, septicemia, septic arthritis, necrotizing fasciitis, peritonitis, osteomyelitis, and toxic-shock syndrome. Severity varies by clinical presentation. • Mode(s) of Transmission: contact with large respiratory droplets and direct contact • Incubation period: 1-5 days • Period of Communicability: Untreated cases may be infectious for 10-21 days, and longer if purulent VPDs discharges are present. No longer infectious 24 hours after appropriate treatment. A person can be an asymptomatic carrier.
Figure 1. Streptococcus, invasive Group A in Denton County
25 5 GI Illness 20 4
15 3 Rate Cases 10 2
5 1
0 0 2014 2015 2016 2017 2018 Invasive Cases Rate/100,000
38 Figure 2. Streptococcus, invasive Group A by Sex, Denton County New Cases 2018 STDs 16 4
14
12 3
10
8 2 Rate Cases
6
4 1
2 VPDs
0 0 Female Male Cases Rate/100,000
Figure 3. Streptococcus, invasive Group A by Race/Ethnicity, Denton County New Cases 2018
16 4
14 GI Illness
12 3
10
8 2 Rate Cases
6
4 1
2
0 0 White Non Black Non Other Hispanic Hispanic Hispanic Invasive Cases Rate/100,000
*Graph does not represent unknown or missing Race/Ethnicity 39 Figure 4. Streptococcus, invasive Group A by Age Group, Denton County New Cases 2018 STDs 12 12
10 10
8 8
6 6 Rate Cases
4 4
2 2 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
40 Streptococcus, STDs Invasive Group B Denton County 2014-2018
• Causative Agent: (bacterial) Streptococcus agalactiae (Group B Streptococcus) • Signs & Symptoms: o Neonates: Early onset disease (<7 days old) and late-onset disease (7-90 days old) – both syndromes include sepsis, pneumonia, and meningitis. o Pregnancy-related infections: sepsis, amnionitis, urinary tract infection, and stillbirth. o Adults: pneumonia, bacteremia, meningitis, joint infections, or soft tissue infections • Mode(s) of Transmission: from mother to infant during delivery. After delivery, infants occasionally infected via person-to-person transmission in the nursery. In adults, GBS can be acquired from person- VPDs to-person transmission from healthy carriers in the community. • Incubation period: Incubation period for early onset GBS disease in neonates is <7 days. Incubation period is unknown for late onset GBS disease in infants, children, and adults. • Period of Communicability: 10%-30% of women are carriers. GBS colonization is primarily in the gastrointestinal and genital tracts. About half of infants born to colonized mothers are also colonized on the skin and mucosal surfaces after passage through the birth canal or from GBS ascending into the amniotic fluid. The majority of colonized infants are asymptomatic.
Figure 1. Streptococcus, invasive Group B in Denton County GI Illness
50 5
40 4
30 3 Rate Cases 20 2
10 1
0 0 Invasive 2014 2015 2016 2017 2018
Cases Rate/100,000
41 Figure 2. Streptococcus, invasive Group B by Sex, Denton County New Cases 2018 STDs 40 8
30 6
20 4 Rate Cases
10 2 VPDs 0 0 Female Male Cases Rate/100,000
Figure 3. Streptococcus, invasive Group B by Race/Ethnicity, Denton County New Cases 2018
30 6
25 5 GI Illness
20 4
15 3 Rate Cases
10 2
5 1
0 0 White Non Black Non Other Hispanic
Hispanic Hispanic Invasive Cases Rate/100,000
*Graph does not represent unknown or missing Race/Ethnicity
42 Figure 4. Streptococcus, invasive Group B by Age Group, Denton County New Cases 2018 STDs 25 25
20 20
15 15 Rate Cases 10 10
5 5 VPDs
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
43 Streptococcus pneumoniae, Invasive Disease (IPD) STDs Denton County 2014-2018
• Causative Agent: (bacterial) Streptococcus pneumoniae • Signs & Symptoms: Major clinical manifestations of invasive disease are bacteremia and meningitis. Bacteremia without a known site of infection is the most common invasive presentation in children 2 years of age and younger. Pneumonia is the most common clinical presentation in adults. Symptoms include abrupt onset of fever and chills or rigors. Other common symptoms are pleuritic chest pain, productive cough, shortness of breath, rapid breathing, hypoxia, rapid heart rate, malaise, and weakness. • Mode(s) of Transmission: Person-to-person contact via respiratory droplets and by autoinoculation in
persons carrying the bacteria in their upper respiratory tract. VPDs • Incubation period: Varies by type of infection but can be as short as 1-3 days • Period of Communicability: Unknown. Maybe as long as organism is present in respiratory tract secretions but is probably less than 24 hours after effective antimicrobial therapy is started.
Figure 1. Streptococcus pneumoniae in Denton County
60 8
7 GI Illness 50 6 40 5
30 4 Rate Cases 3 20 2 10 1
0 0 2014 2015 2016 2017 2018 Invasive Cases Rate/100,000
44 Figure 2. Streptococcus pneumoniae by Sex, Denton County New Cases 2018 STDs 35 7
30 6
25 5
20 4 Rate Cases 15 3
10 2
5 1 VPDs
0 0 Female Male Cases Rate/100,000
Figure 3. Streptococcus pneumoniae by Race/Ethnicity, Denton County New Cases 2018
40 8
35 7 GI Illness 30 6
25 5
20 4 Rate Cases 15 3
10 2
5 1
0 0 White Non Black Non Other Hispanic Hispanic Hispanic
Cases Rate/100,000 Invasive
*Graph does not represent unknown or missing Race/Ethnicity
45 Figure 4. Streptococcus pneumoniae by Age Group, Denton County New Cases 2018 STDs 35 35
30 30
25 25
20 20 Rate Cases 15 15
10 10 VPDs 5 5
0 0 0-4 5-9 10-14 15-19 20-24 25-34 35-44 45-54 55-64 65+ Cases Rate/100,000 GI Illness Invasive
46