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Tri-County Health Department Serving Adams, Arapahoe and Douglas Counties

Phone 303/220-9200 • Fax 303/741-4173 • www.tchd.org Follow us on Twitter @TCHDHealth and @TCHDEmergency John M. Douglas, Jr., M.D. Executive Director

The pages that follow contain information critical to protecting the health of your patients and the citizens of Colorado.

HAN ADVISORY

Number of pages including cover: 3

Subject: Advisory - () active in Colorado

Message ID: 7/28/2015 5:10:00 PM Recipients: HAN Community Members. From: TRI-COUNTY HEALTH DEPARTMENT Adams, Arapahoe and Douglas County, Colorado

Recipient Instructions: Tri-County Health Department is forwarding you the attached HAN. You may have already received this broadcast if you are on the CDPHE distribution list, however, we wanted to ensure you did not miss this important information. No response is required.

======You have received this message based upon the information contained within our Health Alert Network Notification System. If you have a different or additional e-mail or fax address that you would like us to use, or if you have additional questions, call 720-200-1477.

Categories of Health Alert Network Messages: Health Alert: Conveys the highest level of importance; warrants immediate action or attention. Health Advisory: Provides important information for a specific incident or situation; may not require immediate action. Health Update: Provides updated information regarding an incident or situation; unlikely to require immediate action. Info Service/Public Health Brief: Provides general information that is not necessarily considered to be of an emergent nature.

You may download a copy of this HAN from the TCHD website at http://www.tchd.org/259/Health-Alert-Network

Dedicated to protecting and improving the health and environment of the people of Colorado

HEALTH ALERT NETWORK BROADCAST MESSAGE ID: 07282015 10:35 FROM: CO-CDPHE SUBJECT: HAN Advisory – Plague active in Colorado RECIPIENTS: Local Public Health Agencies / IPs / Clinical Labs / EDs / ID Physicians / Coroners RECIPIENT INSTRUCTIONS: Local Health Public Health Agencies – please forward to healthcare providers

HEALTH ADVISORY Plague (Yersinia pestis) active in Colorado July 28, 2015

****Health care providers: Please distribute widely in your office****

KEY POINTS:

• Plague is currently active in Colorado.

• Colorado has had two cases of human plague in 2015, including one death. In addition, the state health department has received multiple reports of suspected plague die-offs in wildlife from around the state.

• Misidentification of the plague bacterium (Yersinia pestis) by automated laboratory systems can occur and lead to delayed recognition of plague cases.

• Report any suspected case of plague to CDPHE immediately at 303-692-2700.

BACKGROUND INFORMATION:

The state public health laboratory has confirmed two human plague cases in Colorado this season. The first was a case of septicemic plague in a Larimer County resident who died in June. The second was a case of in a Denver County resident who became ill in July and survived. The Denver resident was exposed to plague in Chaffee County.

In addition to the human cases, the state health department has been receiving reports of suspected plague die-offs from around the state. Plague infected wildlife have been found in Baca, El Paso, Fremont, Larimer, Jefferson and Pueblo counties. The most recent of these samples, a tree squirrel from Jefferson County, tested positive on July 24, 2015. The squirrel was found dead at a public park in Golden in the same area where the Buffalo Bill Days Festival was held from July 22-26. Several domestic pets have also been diagnosed with plague, and additional cases are under investigation.

4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe John W. Hickenlooper, Governor | Larry Wolk, MD, MSPH, Executive Director and Chief Medical Officer MIS-IDENTIFICATION CONCERN:

Automated systems used in clinical laboratories can rapidly and accurately identify common bacterial species but are known to misidentify slow-growing, fastidious or rare pathogens such as Yersinia pestis, Francisella tularensis, Burkholderia pseudomallei and Brucella species. In published reports Yersinia pestis (the causative agent for plague) has been misidentified by automated systems as Acinetobacter lwoffii, Pseudomonas luteola and Yersinia pseudotuberculosis. This misidentification leads to delays in diagnosis of what could be a fatal zoonotic pathogen.

RECOMMENDATIONS / GUIDANCE:

Symptoms of plague generally include sudden onset of high fever, muscle pain, malaise, nausea and vomiting, or a general feeling of being ill. Individuals with bubonic plague will develop a large, swollen, painful lymph node (a bubo) in the area of the flea bite. If the patient is not promptly treated with antibiotics, the plague bacterium can enter the bloodstream (septicemic plague) or lungs () causing severe, life-threatening complications. It is also possible for the initial presentation of plague from a flea bite to be primary septicemia without a bubo. In rare instances people can inhale the bacterium and initially present with pneumonic plague. If plague is suspected clinically, the laboratory should be alerted to exercise caution in specimen handling. Specimens should be referred to the State Lab for confirmation. See https://www.colorado.gov/pacific/cdphe/lab.

Suspected cases of human plague should be reported to CDPHE immediately at 303-692-2700, and appropriate diagnostic testing and treatment regimens should be implemented. If the patient has a respiratory component to their illness or there is suspicion of pneumonic plague then droplet precautions should be adopted immediately.

For more specific information about diagnosis and treatment go to CDC’s Plague Resources for Clinicians at: http://www.cdc.gov/plague/healthcare/clinicians.html

APPROVED TREATMENT:

The U.S. Food and Drug Administration approved the use of Avelox (moxifloxacin) to treat patients with pneumonic and septicemic plague on May 8, 2015. In addition to moxifloxacin; levofloxacin, , and are approved for treatment of infection with Yersinia pestis. Alternative agents that can be used (if the preferred agents are not an option) are , ciprofloxacin, and .

FOR MORE INFORMATION:

Contact the Colorado Department of Public Health and Environment at 303-692-2700 or after hours at 303-370-9395.

4300 Cherry Creek Drive S., Denver, CO 80246-1530 P 303-692-2000 www.colorado.gov/cdphe John W. Hickenlooper, Governor | Larry Wolk, MD, MSPH, Executive Director and Chief Medical Officer