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Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Clark County Combined Health District 2018 Annual Communicable Disease Report Communicable Disease Summary 2018 In 2018, Clark County experienced a 24.8% increase in the number of communicable disease cases from 2017 to 2018 (1711 cases and 2136 cases, respectively) (Figure 1). The most frequently reported illnesses were (875 cases), gonococcal infection (385 cases), and -associated hospitalizations (312 cases) (Table 1).

Figure 1: Annual Communicable Disease Totals, Clark County, 2014-2018. Case counts include confirmed, probable, and suspect disease case classifications. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019. Reportable Conditions not Reported in Clark County in 2018: Amebiasis Hepatitis E Severe acute respiratory Influenza A – novel virus (SARS) Arboviral neuroinvasive and non- Influenza-associated pediatric Smallpox neuroinvasive disease mortality St. Louis encephalitis virus disease Babesiosis LaCrosse virus disease (other , with , foodborne California serogroup virus disease) resistance or intermediate Botulism, Leprosy (Hansen disease) resistance to Botulism, wound (VRSA, VISA) Streptococcal toxic Malaria syndrome (STSS) Chikungunya Cholera Creutzfeldt-Jakob disease (CJD) MERS Trichinellosis Cyclosporiasis Other arthropod-borne diseases Dengue Typhoid Diptheria Poliomyelitis (including - Varicella Eastern equine encephalitis virus associated cases) Vibrosis disease Powassan virus disease Viral hemorrhagic fever (VHF) /Anaplasmosis Psittacosis Western equine encephalitis virus Hantavirus disease Hemolytic uremic syndrome (HUS) Rabies, human Yellow fever Hepatitis B (Perinatal) Rubella (congenital) Zika virus infection Hepatitis D Rubella (not congenital)

For questions, contact [email protected] 1 Clark County Combined Health District 2018 Annual Communicable Disease Report 1/11/2019

Table 1: Reportable Conditions Reported in Clark County, 2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019. 2018 Reportable Condition Quarter 1 Quarter 2 Quarter 3 Quarter 4 Grand Total Confirmed Total Confirmed Total Confirmed Total Confirmed Total Confirmed Total Enteric Diseases Campylobacteriosis 2 5 4 4 8 11 1 8 15 28 Cryptosporidiosis 6 7 0 0 2 2 3 3 11 12 E. coli, Shiga -Producing (O157:H7, Not O157, Unknown Serotype) 0 0 0 1 2 5 0 0 2 6 Giardiasis 1 1 0 0 0 1 2 4 3 6 Hepatitis A 0 0 3 5 1 2 14 15 18 22 3 4 1 1 4 4 3 3 11 12 0 0 0 0 0 0 0 1 0 1 Yersiniosis 0 1 0 0 0 0 1 1 1 2 Hepatitis B & C Hepatitis B (including delta) - acute 0 0 0 1 0 0 1 2 1 3 Hepatitis B (including delta) - chronic 0 22 1 26 0 23 0 14 1 85 Hepatitis C - acute 0 0 0 2 0 0 0 1 0 3 Hepatitis C - chronic 23 46 24 50 14 44 22 65 83 205 Hepatitis C - Perinatal Infection 0 0 0 0 0 2 0 2 0 4 Sexually Transmitted HIV* 0 0 4 5 5 5 1 3 10 13 Chlamydia infection 195 195 214 214 225 225 241 241 875 875 Gonococcal infection 82 82 93 93 95 95 115 115 385 385 - congenital 0 1 0 1 0 1 0 0 0 3 Syphilis - early 0 7 0 2 0 1 0 0 0 10 Syphilis - primary 0 2 0 3 0 0 0 0 0 5 Syphilis - secondary 0 3 0 3 0 1 0 4 0 11 Syphilis - stage Unknown 0 1 0 0 0 2 0 3 0 6 Syphilis - unknown duration or late 0 3 0 1 0 2 0 2 0 8 Vaccine-Preventable Diseases (invasive disease) 1 2 1 1 1 1 0 0 3 4 Influenza-associated hospitalization 280 284 21 21 0 0 7 7 308 312 Meningitis - aseptic/viral 0 1 1 1 0 0 2 2 3 4 Meningitis - bacterial (Not N. meningitidis) 0 1 0 0 0 0 1 2 1 3 Mumps 0 0 0 0 0 0 0 2 0 2 Pertussis 1 1 0 2 1 4 0 1 2 8 pneumoniae - invasive resistance unknown or non-resistant 6 6 1 1 1 1 4 5 12 13 - invasive antibiotic resistant/intermediate 3 3 1 1 0 0 3 3 7 7

For questions, contact [email protected] 2 Clark County Combined Health District 2018 Annual Communicable Disease Report 1/11/2019

2018 Reportable Condition, continued Quarter 1 Quarter 2 Quarter 3 Quarter 4 Grand Total Confirmed Total Confirmed Total Confirmed Total Confirmed Total Confirmed Total Varicella 1 3 0 2 1 2 3 4 5 11 Vector-borne and Zoonotic Diseases 0 3 0 2 2 5 0 1 2 11 Spotted Fever Rickettsiosis,including Rocky Mountain spotted fever (RMSF) 0 0 0 0 0 0 0 1 0 1 West Nile virus disease (also current infection) 0 0 0 0 0 2 0 0 0 2 Other Reportable Infectious Diseases Coccidioidomycosis 0 1 0 1 0 2 0 0 0 4 CP-CRE 0 0 0 0 3 3 2 7 5 10 Immigrant Investigation 0 1 0 0 0 0 0 0 0 1 Influenza - ODH Lab Results 0 2 0 0 0 0 0 7 0 9 Legionellosis - Legionnaires' Disease 2 2 4 4 5 5 2 3 13 14 Streptococcal - Group A -invasive 6 6 4 5 1 1 0 0 11 12 Streptococcal - Group B - in newborn 0 1 1 1 0 0 0 0 1 2 Tuberculosis 0 0 0 0 0 1 0 0 0 1 Total 2630 697 378 454 371 453 428 532 1789 2136 *HIV data were collected from ODRS and not from ODH HIV Surveillance.

For questions, contact [email protected] 3 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Disease Trends Chlamydia Infection Chlamydia infection has been the most frequently reported condition in Clark County since 2011, and has increased by 18.6% over the last year (Figure 2). In the state of Ohio, Chlamydia cases have also been steadily increasing. Gonococcal Infection The number of cases of gonococcal infection in Clark County has been increasing over time (19.2% increase in 2018) (Figure 2). This disease trend has been seen in the state of Ohio as well.

Figure 2: Chlamydia Infection and Gonococcal Infection cases in Clark County, 2014-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019.

Influenza-associated Hospitalizations In 2018, the total number of confirmed influenza-associated hospitalizations increased by 121.6% from 2017 (Figure 3). This number has been increasing since 2016.

Figure 3: Influenza-associated Hospitalizations, Clark County, 2014-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019. Influenza data represents calendar year and not influenza season.

For questions, contact [email protected] 4 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Hepatitis C – Chronic Infection The total number of Hepatitis C – Chronic cases in Clark County has been slowly increasing over time. This is partially due to a change in 2016, which broadened the case definition for Hepatitis C – Chronic infection, resulting in more cases being classified as “Probable” and fewer cases being classified as “Confirmed.” This is evidenced by the increase in total number of cases and a decrease in confirmed cases (Figure 4).

Figure 4: Hepatitis C - Chronic cases by case classification status, Clark County, 2014-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019.

Total Syphilis Total syphilis includes syphilis, congenital; syphilis, early; syphilis, late latent (>1 year) asymptomatic; syphilis, primary; syphilis, secondary; syphilis, stage unknown; syphilis, unknown duration or late. Total syphilis in Clark County decreased from 2015-20117, but slightly increased in 2018 (Figure 5).

Figure 5: Total syphilis cases by case classification status, Clark County, 2014-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019.

For questions, contact [email protected] 5 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Hepatitis A There was a dramatic increase (214.3%) in the number of hepatitis A cases reported to the Clark County Combined Health District (CCCHD) in 2018 (Figure 6). In 2018, there were 22 total cases of hepatitis A reported in Clark County (18 confirmed, 4 suspect) (Table 2). Prior to 2018, the most recent confirmed case of hepatitis A occurred in 2011 (Table 2).

Figure 6: Hepatitis A, Clark County, 2014-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/10/2019.

Table 2: Hepatitis A in Clark County, Ohio, 2018-2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/10/2019.

Year Case Classification Status 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Confirmed 0 2 0 1 0 0 0 0 0 0 18 Suspected 1 1 1 5 0 5 4 1 2 7 4

The Ohio Department of Health (ODH) has declared a statewide community outbreak of hepatitis A after observing an increase in cases linked to certain risk factors since the beginning of 2018. Clark County has 17 cases associated with the statewide community outbreak. For further case statistics relating to Clark County’s statewide community outbreak cases, please see attached Hepatitis A Report. 2018 Clark County Outbreaks Clark County Combined Health District investigated 21 outbreaks in 2018 (Table 3). Six investigations involved a long-term care facility and 11 involved a school or day care facility.

For questions, contact [email protected] 6 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Table 3: Outbreak Investigations in Clark County, 2018.

Date Investigation Date Investigation Outbreak Agent Outbreak Type Reported Completed 1 Influenza virus Healthcare-Associated 1/5/2018 1/19/2018 2 perfringens Healthcare-Associated 1/9/2018 5/4/2018 3 Pink eye Community 1/19/2018 1/30/2018 4 Influenza virus Institutional 1/26/2018 4/9/2018 5 Streptococcus Community 2/2/2018 3/2/2018 6 Norovirus Institutional 2/6/2018 3/2/2018 7 Influenza virus Healthcare-Associated 2/6/2018 3/22/2018 8 Influenza virus Institutional 2/9/2018 2/26/2018 Cryptosporidium & 9 Zoonotic 2/15/2018 5/24/2018 Campylobacter 10 Influenza virus Healthcare-Associated 3/6/2018 3/30/2018 11 Fifth disease Community 4/17/2018 6/8/2018 12 Rotavirus Community 4/30/2018 6/12/2018 13 Hand, foot, mouth disease Community 6/11/2018 6/26/2018 14 Hand, foot, mouth disease Institutional 9/11/2018 12/10/2018 15 Hand, foot, mouth disease Institutional 9/12/2018 12/11/2018 16 Hand, foot, mouth disease Community 10/2/2018 12/21/2018 17 Hand, foot, mouth disease Institutional 10/15/2018 12/11/2018 18 Institutional 10/29/2018 12/11/2018 19 Norovirus Unusual Incidence 10/30/2018 11/27/2018 20 Hand, foot, mouth disease Community 11/14/2018 12/21/2018 Report outstanding 21 Campylobacter Cluster 12/10/2018 (90-day window not closed)

For questions, contact [email protected] 7 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Timeliness of Disease Reporting Timely reporting of infectious diseases is important in identifying potential outbreaks and reducing disease burden. Public health relies on health care providers and laboratories for identification and prompt reporting of these communicable diseases. The Ohio Administrative Code identifies two quality indicators related to completeness and timeliness for nine reportable diseases (OAC 3701-36-05(B) (2)): • Meeting the median number of days between date of diagnosis and report to the health department in ODRS. • Increasing the percent completeness for reportable infectious diseases in ODRS by age, race, ethnicity, and sex. The following reportable diseases were identified by the advisory committee as having the most value and opportunity to impact public health related to improved timeliness and completeness of reporting: Camplyobacteriosis, Cryptosporidiosis, E. Coli O157:H7 and Shiga toxin-producing E. Coli (STEC), Giardiasis, Influenza-associated hospitalization, Legionnaires’ disease, Pertussis, Salmonella, and Shigellosis. The reporting lag is the difference in days between the date of diagnosis and the date the case was reported to Clark County Combined Health District (CCCHD). Weekends were removed in the median lag calculation and only confirmed and probable cases were included in the analysis. All diseases included are Class B reportable diseases with an expectation that they be reported to ODH by the next business day. Given this established standard, an appropriate proxy that should also be monitored to see continuous improvement is the percentage of reports (locally and aggregated at the state level) that meet or exceed the established standard (Ohio Department of Health, 2018).

Table 4: Percent Completeness of Report and Median Days Reporting Lag for Selected Diseases* in Clark County, 2018. All data queried from Ohio Disease Reporting System (ODRS) data extract on 1/9/2019. Reported Age Sex Race Ethnicity Within 1 Reporting Lag** Total Number Reportable Condition Business Day of Cases Percent Percent Percent Percent Percent Reported Median Days Completed Completed Completed Completed Reported Campylobacteriosis 100% 100% 50% 100% 60.7% 1 28 Cryptosporidiosis 100% 100% 92% 92% 66.7% 1 12 Giardiasis 100% 100% 100% 100% 66.7% 0 3 Influenza-associated hospitalization 100% 100% 98% 99% 61.4% 1 308 Legionellosis - Legionnaires' Disease 100% 100% 100% 100% 100% 0 13 Pertussis 100% 100% 100% 100% 100% 0 4 Salmonellosis 100% 100% 100% 100% 41.7% 2 12 Shigellosis 100% 100% 100% 100% 100% 1 1 * Diseases included confirmed and probable cases of: Campylobacteriosis, Cryptosporidiosis, E. coli O157:H7 and Shiga toxin-producing E. coli (STEC), Giardiasis, Influenza-associated hospitalization, Legionnaires; disease, Pertussis, Salmonellosis and Shigellosis. ** Reporting Lag is the difference in business days between the date of diagnosis and the date of report. If blank, date of diagnosis defaulted to lab specimen collection date, then date of illness onset.

For questions, contact [email protected] 8 Clark County Combined Health District 2018 Annual Communicable Disease Report rev. 1/16/2019 Notes Reportable Disease Changes in Ohio in 2018 The following changes took effect on March 21, 2018:

Additions: Carbapenemase producing (CP) – carbapenem resistant Enterobacteriaceae (CRE); Hepatitis C, Perinatal Infection References Ohio Department of Health. (2018). Public Health Quality Indicators: Annual Report, July 2018. https://odh.ohio.gov/wps/wcm/connect/gov/d19078a3-4144-4bb4-94f5-32d92d700f7d/Quality-Indicators- Report-2018.pdf?MOD=AJPERES&CONVERT_TO=url&CACHEID=ROOTWORKSPACE.Z18_M1HGGIK0N0JO00QO9 DDDDM3000-d19078a3-4144-4bb4-94f5-32d92d700f7d-mqNAxBh Record of Change Date Revision(s) By Whom Anna Jean 1/10/2019 Report created Petroff Hepatitis A 2018 confirmed and suspect numbers updated in “Disease Anna Jean 1/16/2018 Trends” Petroff

For questions, contact [email protected] 9 Clark County Combined Health District Hepatitis A Report rev. 1/16/2019 2018 Hepatitis A Update The Ohio Department of Health (ODH) has declared a statewide community outbreak of hepatitis A after observing an increase in cases linked to certain risk factors since the beginning of 2018. Outbreaks of hepatitis A are occurring in several states across the U.S., including neighboring states of Indiana, Kentucky, Michigan and West Virginia.

Hepatitis A is a vaccine-preventable disease that usually spreads when a person ingests fecal matter - even in microscopic amounts - from contact with objects, food or drinks contaminated by the stool of an infected person. Hepatitis A can also be spread from close personal contact with an infected person, such as through sex.

People at increased risk for hepatitis A in this outbreak include:

• People with direct contact with individuals infected with the virus • Men who have sex with men • People who use street drugs whether they are injected or not • People who are incarcerated • People experiencing homelessness • People who have traveled to other areas of the U.S. currently experiencing outbreaks Symptoms of hepatitis A include fatigue, low appetite, stomach pain, nausea, clay-colored stools and jaundice. People with hepatitis A can experience mild illness lasting a few weeks to severe illness lasting several months.

As of January 7, 2019, ODH reported 1,370 outbreak cases of Hepatitis A across 66 (75%) counties in Ohio (Table 1).

Table 1: Hepatitis A Statewide Community Outbreak Case Statistics, Ohio, 2018. Data obtained from ODH, last updated 1/7/2019.

Hepatitis A Statewide Community Outbreak, Ohio Case Statistics Number of cases 1370 Illness onset range 1/5/2018 - 12/29/2018 Number of hospitalizations 856 (63%) Age range 2-81 years Sex 59% male Number of 4 Number of counties with cases 66 (75%)

Hepatitis A in Clark County There was a dramatic increase (214.3%) in the number of hepatitis A cases reported to the Clark County Combined Health District (CCCHD) in 2018 (Figure 1). In 2018, there were 22 total cases of hepatitis A reported in Clark County (18 confirmed, 4 suspect) (Table 2). Prior to 2018, the most recent confirmed case of hepatitis A occurred in 2011 (Table 2).

Table 2: Hepatitis A in Clark County, Ohio, 2008-2018. Data queried from Ohio Disease Reporting System (ODRS) Data Extract on 1/10/2019.

Year Case Classification Status 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 Confirmed 0 2 0 1 0 0 0 0 0 0 18 Suspected 1 1 1 5 0 5 4 1 2 7 4

Contact [email protected] with questions 1 Clark County Combined Health District Hepatitis A Report rev. 1/16/2019

Figure 1: Annual hepatitis A cases in Clark County, 2008-2018. Data queried from Ohio Disease Reporting System (ODRS) Data Extract on 1/10/2019.

Hepatitis A Statewide Community Outbreak Case Statistics for Clark County Clark County has 17 cases associated with the statewide community outbreak. Of these cases, 70.6% are male, 94.1% are white, and 88.2% are non-Hispanic (Table 3). Ages are distributed evenly, ranging from 23-54 years with an average age of 38.4 and a median age of 37 (Table 3). Approximately 59% of cases are 30-39 years old (Figure 2). The hospitalization rate of outbreak-related hepatitis A cases in Clark County is 47% (Table 3). While this rate is lower than the state hospitalization rate (63%), it is still higher than expected. The majority of Clark County cases were reported in November and December 2018, but there was an initial peak in May 2018 (Figure 3).

Table 3:Hepatitis A Statewide Community Outbreak Case Statistics, Clark County, 2018. Data queried from Ohio Disease Reporting System (ODRS) Data Extract on 1/10/2019.

Hepatitis A Statewide Community Outbreak, Clark County Case Statistics Number of cases 17 Illness onset range 5/13/2018 - 12/19/2018 Number of hospitalizations 8 (47%) Age range 23-54 years Average age 38.4 Median age 37 Sex 70.6% Male Race 94.1% White Ethnicity 88.2% Non-Hispanic

Contact [email protected] with questions 2 Clark County Combined Health District Hepatitis A Report rev. 1/16/2019

Figure 2: Hepatitis A statewide community outbreak cases by age group, Clark County, 2018. Data queried from Ohio Disease Reporting System (ODRS) Data Extract on 1/10/2019.

Figure 3: Hepatitis A statewide community outbreak cases by month, Clark County, 2018. Data queried from Ohio Disease Reporting System (ODRS) Data Extract on 1/10/2019.

Community Response Community response includes:

• Ongoing surveillance • Case investigation • Post-exposure prophylaxis for contacts of hepatitis A cases • Vaccine outreach to high risk populations • Education and awareness to high risk populations

Contact [email protected] with questions 3 Clark County Combined Health District Hepatitis A Report rev. 1/16/2019 Record of Change Date Revision(s) By Whom 1/10/2019 Report created Anna Jean Petroff 1/16/2018 Hepatitis A 2018 confirmed and suspect numbers updated Anna Jean Petroff

Contact [email protected] with questions 4