EPIDEMIOLOGY in REVIEW 2005 to 2014 | VOLUME 3 EPIDEMIOLOGY in REVIEW 2005 to 2014 a Review of Surveillance of Notifiable Conditions

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EPIDEMIOLOGY IN REVIEW 2005 TO 2014 | VOLUME 3 EPIDEMIOLOGY IN REVIEW 2005 TO 2014 A Review of Surveillance of Notifiable Conditions

SYLVESTER TURNER Mayor City of Houston

STEPHEN L. WILLIAMS, MPA, M.ED. Director Houston Health Department

RAOUF ARAFAT, MD, MPH Assistant Director Office of Surveillance and Public Health Preparedness

Epidemiology in Review, Volume 3 may be found online at: www.houstontx.gov/health/Epidemiology/EIR3.pdf

HOUSTON HEALTH DEPARTMENT Office of Surveillance and Public Health Preparedness HOUSTONHEALTH.ORG Houston Health Department 8000 North Stadium Drive, Houston, TX 77054 | 713.837.0311 AUTHORS

Epidemiology in Review, 2005 to 2014 was prepared by the Office of Surveillance and Public Health Preparedness, a division of the Houston Health Department, and primarily involved the efforts of the following persons:

RAOUF ARAFAT, MD, MPH Assistant Director Office of Surveillance and Public Health Preparedness

ERIC BAKOTA, MS Biostatistician Office of Surveillance and Public Health Preparedness

BIRU YANG, PHD, MPH Informatics Manager Office of Surveillance and Public Health Preparedness

WESLEY MCNEELY, MS, MPH Biostatistician Informatics and Data Management Program

RYAN ARNOLD, MPH Staff Analyst Office of Surveillance and Public Health Preparedness

NOTE: Affiliated organizations of individuals are listed as they were at the time of writing.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 2 TABLE OF CONTENTS

4 Acronyms 5 Acknowledgements and Contributing Authors 6 Foreward by Stephen L. Williams, Director

INTRODUCTION TO THE OFFICE OF SURVEILLANCE AND PUBLIC HEALTH PREPAREDNESS AND ITS BUREAUS

8 Office of Surveillance and Public Health Preparedness 10 Bureau of Epidemiology 14 Bureau of Laboratory Services 17 Bureau of Jail Health Services 19 Performance Improvement and Accreditation Team (PIAT) 21 Bureau of Public Health Preparedness

DISEASES

24 Amebiasis 76 Hansen’s Disease 132 Poliomyelitis 26 Amebic Meningitis and 78 Hantavirus Infection 134 Q Fever Encephalitis 80 Hemolytic Uremic Syndrome 136 Rabies 29 Anaplasmosis 81 Hepatitis A 138 Rocky Mountain Spotted Fever 31 Anthrax 84 Hepatitis B & D 139 Rubella 34 Arbovirus Infection 87 Hepatitis C 141 Salmonellosis 37 Babesiosis 91 Hepatitis E 144 Severe Acute Respiratory 39 Botulism 93 HIV Syndrome 42 Brucellosis 102 Influenza-associated Pediatric 146 Shiga Toxin E Coli 44 Campylobacteriosis Mortality 149 Shigellosis 47 Chagas 105 Invasive Streptococcal 153 Smallpox 50 Chancroid Infections 155 Syphilis 52 Chikungunya 107 Legionellosis 159 Tetanus 54 Chlamydia 110 Leishmaniasis 160 Trichinosis 57 Creutzfeldt-Jakob Disease 112 Listeriosis 162 Tuberculosis 59 Cryptosporidiosis 114 Lyme Disease 166 Tularemia 61 Cyclosporiasis 116 Malaria 168 Typhus 63 Cysticercosis & Taeniasis 118 Measles 170 Varicella 65 Dengue 120 Meningococcal Infections, Invasive 173 Vibriosis 67 Diphtheria 123 Multi-drug Resistant Organisms 176 Viral Hemorrhagic Fever 69 Ehrlichiosis 125 Mumps 181 Yellow fever 71 Gonorrhea 127 Pertussis 183 Yersiniosis 74 Haemophilus influenzae 130 Plague

SUPPLEMENTARY SUMMARY

186 Drug Overdose Mortalities 189 Heat Related Illness and Mortality 191 Submersion Injury Surveillance

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 3 ACRONYMS

AAP American Academy of Pediatrics HUS Hemolytic uremic syndrome AIDS Acquired immunodeficiency syndrome ICS Incident Command System APHA American Public Health Association MMP Medical Monitoring Project BLS Bureau of Laboratory Services MMR Measles, mumps, and rubella BOE Bureau of Epidemiology MSM Men who have sex with men CD4 Cluster of differentiation 4 NARMS National Antibiotic Resistance Monitoring CDC Centers for Disease Control and Prevention System CJD Creutzfeldt-Jakob disease NBS NEDSS-based system CNS Central nervous system NEDSS National electronic disease surveillance CRS Congenital rubella syndrome NHBS National HIV Behavioral Surveillance CSF Cerebrospinal fluid NNDSS National notifiable diseases surveillance DEET N,N-Diethyl-meta-toluamide NORS National Outbreak Reporting System DFA Direct fluorescent antibody OSPHP Office of Surveillance & Public Health Preparedness DIS Disease intervention specialist PAM Primary amebic meningoencephalitis DNA Deoxyribonucleic acid PHP Public health preparedness DOT Directly observed therapy PFGE Pulse-field gel electrophoresis DSHS Department of State Health Services PCR Polymerase chain reaction DTaP Diphtheria, tetanus, and pertussis PUM Person under monitoring ELISA Enzyme-linked immunosorbent assay Environmental Services QFT QuantiFERON-TB Gold blood test ETU Ebola treatment unit RMSF Rocky Mountain Spotted Fever FDA Food and Drug Administration SARS Severe acute respiratory syndrome GIS Geographic information system STD Sexually transmitted disease E. coli HAV Hepatitis A virus STEC Shiga-toxin producing ; Escheria HBV Hepatitis B virus STI Sexually transmitted infection HCPHES Harris County Public Health & TB Tuberculosis Environmental Services TCID Texas Center for Infectious Disease HCV Hepatitis C virus Tdap Tetanus, diphtheria, and pertussis vaccine HDV Hepatitis D virus VHF Viral hemorrhagic fever HET Heterosexual WHO World Health Organization HPS Hantavirus Pulmonary Syndrome

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 4 ACKNOWLEDGEMENTS

Creating this report has been a vigorous journey involving tremendous efforts and the dedication of many individuals. With gratitude, I acknowledge the Informatics and Data Management Pro- gram and the Bureau of Epidemiology staff members for their contributions (see below).

This report is the third published Epidemiology in Review. The first volume covers the period of 1995 to 1999, and the second volume covers 2000 to 2004. I am committed to producing this report in the hope that it can be a resource to internal and external partners, guiding decisions affecting the health of Houstonians.

RAOUF ARAFAT, MD, MPH Assistant Director, Houston Health Department Office of Surveillance & Public Health Preparedness

CONTRIBUTING AUTHORS

Subject Matter Experts Tristan Broussard Quan Hoang Imran Shaikh Steven Dang Steve Long Kirstin Short John Fleming Zaida Lopez Mamta Singh Hafeez Rehman Yvonne Lu Richard Stancil Camden Hallmark Ted Misselbeck Varsha Vakil Michael Henley Kasimu Muhetaer Nancy Vuong Najmus Abdullah Manuel Perez Nathan Wang Robert Hines Eunice Santos Yufang Zhang

Scientific Writers Reviewers/Editors Maps and Geospatial Analyses Kiley Allred Ryan Arnold Weilin Zhou Abel Assefa Eric Bakota Preston Aycox Salma Khuwaja Layout Design and Formatting Dulan Hailoo Wesley McNeely Althea Lee, Lee Creative Tolulope Olumuyiwa Jeffrey Meyer Avinash Raju Osaro Mgbere Beverly Nichols Brenda Thorne Biru Yang

Note: Names are listed in alphabetical order of last name.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 5 FOREWARD

pidemiology gives vision to Public Health. I like to believe that I have nearly 100 John Snows EWithout the data provided by surveillance at the health department, all of whom gather and investigators and epidemiologists to transform the explore data, which they then use to inform policy data into information, we would be blind to the makers to protect and promote the public’s health conditions afflicting our citizens. Every reader has and well-being. The information, tables, and graphs surely had his or her life positively affected by an you see within this document are evidence that my anonymous epidemiologist. Perhaps it was the mea- belief is well-founded. sles outbreak that was contained in its early stages before you became ill. Or the foodborne illness But just as important as the data, statistics, that never occurred because effective prevention and charts are the stories that describe an measures were in place. Very likely you have never epidemiologist’s work. Throughout this book you had smallpox, an odious disease that killed over will find the personal stories of epidemiology in 300 million individuals last century. The disease has Houston. These narratives provide color and been eradicated, thanks to scientists, including context to the small company of epidemiologists epidemiologists, and a small army of frontline who serve Houstonians. public health workers. These heroes and heroines On a final note, I want to share with you my vision are not household names, though perhaps they for the next 10 years of epidemiology in Houston. should be. Allow me to share the story of one hero The world changes at progressively faster and faster of epidemiology: John Snow. rates and the city must be in step. To accomplish During an outbreak of cholera in London in 1854, this, we need to collect, analyze, and share data he investigated the population to see who was ill faster than ever. Epidemiologists will investigate a and who was not and where each drank his or her disease by automatically pulling information from water. He plotted the data on a map and observed electronic medical records. Currently automated a striking pattern: those who were ill all tended to algorithms can detect disease aberrations by drink from the same water source on Broad Street. analyzing data from a single source; tomorrow’s John Snow and his map convinced the local algorithm needs to look at several data sources at all authorities to remove the pump handle to prevent times to detect unusual health issues. Data should use and shortly thereafter the outbreak passed. be distributed, not stored in a silo. We must share It is impossible to know how much human life our de-identified data on an open platform. By and health were preserved by John Snow’s clever achieving each of these goals, we will better accom- insights. In a similar fashion, I cannot know plish our mission to work in partnership with the how many lives have been helped by our community to promote and protect the health and epidemiologists. social well-being of Houstonians.

STEPHEN L. WILLIAMS, DIRECTOR HOUSTON HEALTH DEPARTMENT

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 6 HOUSTON HEALTH DEPARTMENT

The Office of Surveillance and Public Health Preparedness and its Bureaus

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 7 HOUSTON HEALTH DEPARTMENT

Office of Surveillance and Public Health Preparedness

The Office of Surveillance and Public Health Preparedness (OSPHP) is a division within the Houston Health Department (HHD). It is responsible for assuring the department’s critical roles of detecting and monitoring disease and preparing for and responding to public health emergencies, both natural (such as hurricanes) and unnatural (such as acts of terrorism); and for providing essential medical services at Houston jails. These duties require the division to be vigilant and prepared to respond 24 hours a day, 7 days a week. To fulfill these functions, OSPHP consists of the following four bureaus: Epidemiology, Laboratory Ser- vices, Public Health Preparedness, and Jail Health Services. Additionally, OSPHP houses the Performance Improvement and Accreditation Team, which has been responsible for preparing HHD for Public Health Accreditation (Figure 1).

DIRECTOR

OFFICE OF THE DIRECTOR PUBLIC HEALTH AUTHORITY

Office Of Surveillance Environmental Aging Chronic Community Information Administrative and Public Health Health Disease and Health Technology Services Preparedness Services Injury Prevention Services

Epidemiology

Laboratory Services

Public Health Preparedness

FIGURE 1. Organizational chart for the HHD, simplified to illustrate Jail Health Services components of the OSPHP. The OSPHP works to address 9 out of the 10 essential public health functions.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 8 HOUSTON HEALTH DEPARTMENT

In addition to performing surveillance and public health OSPHP Works To Fulfill 9 Out Of The 10 preparedness, OSPHP acquired a new direction in 2014, when Essential Public Health Functions: the Bureau of Jail Health Services was moved into the division. This bureau broadened the focus of the division to include providing clinical care and care coordination to inmates of the Monitor health status to address and solve municipal jails in the city. community health problems

Diagnose and investigate health problems and health hazards in the community

Inform, educate, and empower people about health issues

Mobilize community partnerships and action to identify and solve health problems

Develop policies and plans that support individual and community health efforts

Enforce laws and regulations that protect health and ensure safety

Link people to needed personal health services and assure the provision of health care when otherwise unavailable

Assure competent public and personal health care workforce

Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Research for new insights and innovative solutions to health problems

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 9 HOUSTON HEALTH DEPARTMENT

Bureau of Epidemiology

The Bureau of Epidemiology (BOE) is responsible for public health surveillance, disease investigation, and response to incidents of disease. Additionally, BOE conducts research on epidemiologic trends in Houston and Harris County. Public health surveillance involves continuous and systematic health data collection, analysis, and interpretation. In order to collect this information, BOE performs 24/7 disease surveillance of notifiable conditions, with epidemiologists on-duty and on-call at all times. Most of these conditions are infectious and require regular, frequent, and timely information to inform prevention and initiate public TABLE 1. Essential Public Health health action. Furthermore, disease surveillance is essential for planning, implement- Services Addressed By BOE. ing, and evaluating public health policies and interventions. The information collected is vital for understanding the landscape of public health in Houston and allocating Monitor health status to identi- resources accordingly. fy and solve community health problems Problems Bureau Addresses Diagnose and investigate health BOE protects Houston from the threat of communicable diseases by conducting problems and health hazards in surveillance, which is used to inform public health action, such as administering the community antibiotics, prophylaxis, and vaccinations, educating the community, and mitigating the risks for future disease transmission. The work of BOE addresses 5 of the 10 es- Inform, educate, and empower sential public health functions (Table 1). Through the Texas Health and Safety Code, people about health issues Chapter 81, certain conditions are required to be reported from healthcare providers, healthcare facilities, laboratories, veterinarians, and others to local health depart- Mobilize community partnerships ments. BOE investigates these cases and submits suspect, probable, and confirmed and action to identify and solve health problems cases to the Texas Department of State Health Services (DSHS), which subsequently submits data to CDC. Develop policies and plans that support individual and community Purpose of Bureau health efforts Conducting public health surveillance and epidemiology underlies the basic mission of the public health system – to ensure conditions in which people can be healthy. Enforce laws and regulations that Surveillance allows for estimating disease burden and health status, measuring the protect health and ensure safety

Link people to needed personal health services and assure the provision of health care when otherwise unavailable

Assure competent public and personal health care workforce

Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Research for new insights and innovative solutions to health problems

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 10 HOUSTON HEALTH DEPARTMENT

FIGURE 1. HHD Health Service Delivery Areas A, B, and C. need for public health action, guiding decision- and policy- Additionally, BOE has spearheaded efforts in protecting makers, and evaluating the effects of interventions. Through Houston from emerging and highly infectious diseases, such as conducting surveillance and epidemiology for the City of the 2009 pandemic H1N1 influenza and the 2014 West Africa Houston, BOE is maintaining situational awareness of these Ebola epidemic. potentially dangerous diseases to public health. In 2013, BOE embarked upon the process of integrating surveillance functions across disease groups. Prior to this, sur- Actions Taken by Bureau veillance was divided for HIV, STDs, and other communicable Methods of routine surveillance include passive and active diseases, in which teams focused on zoonotic, foodborne, and surveillance. Passive surveillance relies upon reporters to submit vaccine-preventable disease; hepatitus; and other conditions. reportable conditions and disease outbreaks to the local health Additionally, these disease-specific groups managed research, department in a timely manner. These reports are received elec- data management, and other functions. Integration shifted the tronically, by mail, by phone, and by fax. Active surveillance focus of groups from conducting all functions for a particular involves a special effort of disease investigators and epidemi- disease or group of diseases to conducting fewer functions, ologists to contact healthcare providers, laboratories, schools, such as disease investigation, data management, or research. or others to identify cases of particular interest. This method Now, disease investigation is conducted by geographically provides more comprehensive data, but requires considerably defined teams (Figure 1). greater resources and is conducted over finite periods of time. One of the most important developments in the past decade In addition to routine surveillance, BOE conducts research has been applying the field of informatics for the department on infectious diseases. The Grants, Research, and Special Proj- and using informatics tools and methods to improve the work ects program manages the National HIV Behavioral Surveil- being done within BOE and HHD. One of these tools is a lance (NHBS) and the Houston Medical Monitoring Project state-of-the-art information management system, Maven, (MMP). Additionally, BOE has conducted several other implemented in 2009. Subsequently, BOE developed auto- research projects in the past. mated, electronic reporting mechanisms with Houston-area hospitals, laboratories, and blood banks. Another tool that has 10-year Trends been continually developed over the past 10 years is syndromic surveillance. Syndromic surveillance is an investigational ap- Over the past 10 years, BOE has undergone important proach where disease indicators are continuously monitored to developments in technology and the practice of surveillance.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 11 HOUSTON HEALTH DEPARTMENT

detect outbreaks earlier than traditional surveillance methods. Currently, the program manages two large projects: the The department adopted this technology in 2004. Since then, Houston Medical Monitoring Project (MMP) and the National BOE has expanded its scope to include over 30 hospitals in the HIV Behavioral Surveillance (NHBS) project. MMP examines Houston-area and several others across the state. HIV medical care in Houston, as part of a consortium of Over the past 10 years, BOE has been on the forefront of jurisdictions nationwide. NHBS conducts behavioral science conducting surveillance and epidemiology for emerging infec- research as part of a national consortium on three specific tious diseases in Houston. Much of this work is highlighted groups of high-risk individuals: men who have sex with men, in this publication’s disease-specific chapters, but two major intravenous drug users, and heterosexuals at increased risk for events included the 2009 H1N1 pandemic and the 2014 Ebola HIV infection. This research supplements surveillance efforts, epidemic in West Africa. In April 2009, BOE identified one of allowing the HHD and others in the Houston area to improve the first cases of H1N1 in the U.S., and was a member of the the health of Houston. nationwide Novel Swine-Origin Influenza A (H1N1) Inves- From 2012 to 2014, BOE conducted the CDC-funded tigation Team. BOE hired and organized additional resources Assessing the Accuracy of Self-Report of HIV Test Behavior for this response, in order to meet the increased surveillance study. This work was designed to inform the accuracy of HIV demands. In 2014, with Ebola incidence on the rise in West incidence and prevalence estimates nationwide. Additional- African countries, BOE initiated a region-wide conversation ly, several smaller studies have been conducted over the past on planning and response months before the threat became a decade. reality in Dallas, Texas. Throughout the epidemic, BOE dedi- cated over 9,000 hours to educate Houston communities and Informatics and Data Management conduct active surveillance for the virus, including daily phone The Informatics and Data Management program, also created or in-person follow-up with the person under monitoring. in 2014, emerged from the need to modernize surveillance, research, and other functions within BOE. In addition to Program-specific Areas improving BOE-specific functions, the Informatics and Data Disease Surveillance Management program has worked department-wide to meet The Office of Surveillance and Public Health Preparedness informatics needs. Informatics also works with external part- conducts surveillance in geographically focused teams. Aligning ners. Examples of this work include collaborating on the Na- with the HHD’s Health Service Delivery Areas, teams con- tional Reportable Conditions Knowledge Management System, ducting surveillance in South/Southeast (A), North/Northeast to enable electronic case reporting, and the Streamlining Hep- (B), and Central-West/Southwest regions of Houston (C) atitis Automatic Reporting Project (SHARP). SHARP aims (Figure 1). Focusing on geographic areas has allowed the teams to automatically capture more comprehensive information on to assess the epidemiology of diseases and co-morbidities (the hepatitis cases in order to improve surveillance of these diseas- presence of two or more diseases in one person) at the commu- es. These advancements can be expanded to other conditions nity level. in the future. Most recently, the program has collaborated with the Public Health Informatics Institute on the EHR Toolkit Grants, Research, and Special Projects Pilot and was awarded NACCHO’s planning grant to increase The Grants, Research, and Special Projects program was created HPV vaccination rates through community planning and data in 2014 to manage communicable disease grants, research, and visualization. The program is also hosting Streaming Health other projects outside of passive and active surveillance. Systems through Interprofessional Education (SHINE) fellows

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 12 HOUSTON HEALTH DEPARTMENT

with the support from CSTE, CDC, NACCHO, ASTHO, and PHII.

10-year Vision for 2015 to 2024 BOE plans to continue protecting the Houston community from the threat of communicable diseases. However, how public health has conducted surveillance for decades is fast- becoming obsolete; BOE recognizes the need to adopt and innovate technologies and methods to meet increasing demands and stay on the cutting edge of public health practice. In order to do this, the role of informatics and data management will be enhanced over the coming decade, especially as public health and BOE move towards automated, electronic case reporting. Part of staying on the cutting edge of public health surveillance is remaining diligent in the surveillance of new and re-emerging infectious diseases. New communicable disease threats, such as the 2009 H1N1 outbreak and the 2014 to 2015 Ebola epidemic, will continue to be an emphasis of the work in BOE. The bureau plans to learn from past experiences, and ensure Houston remains a safe and healthy place to live through partnerships with communities, healthcare, and researchers.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 13 HOUSTON HEALTH DEPARTMENT

Bureau of Laboratory Services

The Bureau of Laboratory Services (BLS) provides a wide range of clinical and environmental testing for the City of Houston, the 17-county Texas Health Service Region 6/5 South, and many medical facilities throughout the region. The public health laboratory conducts infectious disease and environmental testing in monitor to ensure the public’s health. Furthermore, the BLS participates in many federal programs to accomplish this goal.

TABLE 1. Essential Public Health Services Addressed By BLS.

Monitor health status to identify and solve community health problems

Diagnose and investigate health problems and health hazards in the community

Inform, educate, and empower people about health issues

Mobilize community partnerships BLS is split into two major functional areas: clinical and environmental laborato- and action to identify and solve ries. The clinical laboratory focuses on infectious disease surveillance testing, while health problems the environmental laboratory focuses on testing water, soil, air, industrial waste, food, and other, non-clinical samples. The clinical laboratory houses a biosafety level (BSL) Develop policies and plans that 3 facility, which conducts testing on highly virulent pathogens, such as Ebola, tuber- support individual and community culosis, and others. health efforts

Enforce laws and regulations that Problems the Bureau Addresses protect health and ensure safety Surveillance is a critical component of public health, fulfilling three essential public health services (Table 1). The laboratory is a critical part of epidemiological surveil- Link people to needed personal health services and assure the lance as it tests for the infectious diseases and environmental hazards that threaten the provision of health care when health of Houstonians and their environment. otherwise unavailable The diseases of public health interest that the laboratory investigates include influenza, HIV, STDs, vaccine-preventable diseases, foodborne diseases, and many others. Assure competent public and The environmental laboratory tests samples for dangerous heavy metals (such as lead), personal health care workforce foodborne pathogens, water contaminants, and hazardous waste. Evaluate effectiveness, accessi- Purpose of Bureau bility, and quality of personal and Conducting public health surveillance and epidemiology underlies the basic mission population-based health services of the public health system – to ensure conditions in which people can be healthy. Surveillance allows for estimating disease burden and health status, measuring the Research for new insights and innovative solutions to health need for public health action, guiding decision- and policy-makers, and evaluating problems the effects of interventions. Through conducting clinical and environmental testing,

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 14 HOUSTON HEALTH DEPARTMENT

BLS supports the Bureau of Epidemiology and others in moni- The previous facility on Braeswood was unable to meet the toring disease burden and health status in several critical areas. electrical demands of new testing equipment and maintain a consistent temperature-controlled environment that is crucial Actions Taken by Bureau to diagnostic testing. Two buildings were purchased on the BLS conducts testing using microbiology, biochemistry, chem- Holcombe campus and remodeled to accommodate the lab- istry, and molecular techniques. Proficiency in these methods oratory’s needs and to provide a safe and controlled environ- is maintained periodically, and BLS is inspected and accredited ment for testing. The new facility allowed for the design and by eight different agencies to ensure that all testing is per- construction of a new BSL-3 facility to accommodate the TB formed in a reliable and accurate manner. and Laboratory Response Network (LRN) testing needs of the laboratory. 10-year Trends Over the past several years, the laboratory has seen a decline in testing volume (Figure 2). This is due primarily to decreased BLS has gone through significant changes over the last decade. patient visits at the HHD clinics and partnering community- BLS tests technology changes quickly and strives to provide based clinics as well as decreased testing needs from the most up-to-date technology for the Houston community. environmental health partners, internally and externally. During the last decade, the clinical laboratory has significantly expanded molecular testing capabilities. Molecular detection TOTAL LAB TESTING CASE COUNT for tuberculosis (TB), Human Immunodeficiency Virus (HIV),

influenza virus, dengue virus, SARS Co-V, MERS Co-V, and 300,000 norovirus are several examples of new molecular tests that have improved the laboratory’s capacity to accurately and efficiently conduct testing. These tests are highly sensitive and specific which provides BLS and the Houston Health Department with high-quality information to act upon. 200,000 The last decade has seen two major events for the laboratory. The first was the 2009 H1N1 influenza pandemic. BLS was inundated with specimens and performed over 10,000 more COUNT tests than in a typical influenza season (Figure 1). The laborato- 100,000 ry staff responded by working overtime and hiring temporary staff to maintain the processing and testing of specimens.

0 INFLUENZA TESTING CASE COUNT 2008 2009 2010 2011 2012 2013 2014 FIGURE 2. Testing volume for the Bureau of Laboratory Services, 2008 to 2014

10000 Program-specific Areas Molecular Diagnostics 7500 The Molecular Diagnostics section is a CDC LRN reference laboratory that provides testing to the 17 surrounding counties with a total population of more than six million. The laboratory is also a member of the Food Emergency Response Network 5000 COUNT (FERN). This section works closely with other laboratories, first responders, the FBI, and others to conduct critical testing for bioterrorism agents, or weapons of mass destruction. 2500 Virology and Serology The Virology and Serology section conducts HIV/STD 0 2008 2009 2010 2011 2012 2013 2014 serology, vaccine-preventable disease serology, diagnostic virology, and rabies testing. The section performs moderate- to FIGURE 1. Influenza testing volume by season (July to June), 2008 to 2014. *2009 season includes testing in April, May, and June after H1N1 was identified in high-complexity procedures for the isolation and identification Houston of various viral pathogens. These pathogens include respiratory viruses, West Nile virus and other encephalitides, and dengue The second major event was relocating to a newer and larger virus. BLS is one of four laboratories in Texas that provides facility in early 2012. The laboratory moved from the heart zoological (animal) testing of rabies. of the Texas Medical Center to the Houston Veterans Affairs Medical Center campus located on Holcombe Boulevard.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 15 HOUSTON HEALTH DEPARTMENT

Microbiology Clean Water Testing The microbiology laboratory serves as a regional reference BLS conducts testing on potable and environmental water laboratory for foodborne outbreak surveillance testing and sources, such as bayous and lakes. The environmental water is nationally recognized as an active PulseNet laboratory, a testing examines ten parameters to assess water safety. For national network of laboratories that perform standardized potable water, the laboratory conducts bacterial testing to molecular subtyping (“fingerprinting”) of foodborne disease- ensure that water is safe to drink for area residents. causing bacteria for the early detection of foodborne disease outbreaks. The laboratory is also an active participant in the Milk and Dairy National Antibiotic Resistance Monitoring System (NARMS). The Milk and Dairy section conducts testing on raw and Finally, BLS provides TB testing for the Bureau of TB Control processed dairy samples to ensure compliance with state and and providers throughout the region. federal regulations. The testing ensures that the dairy supply is free from harmful foodborne pathogens. Health Center Support The Health Center Support section provides clinical testing 10 Year Vision For 2015 to 2025 support to the health centers and conducts pollen and mold The bureau plans to continue improving capacity to meet the spore counts for the greater-Houston area. The tests conducted public health testing needs of the City of Houston and the sur- for the health centers are primarily for HIV and STDs. The rounding counties. In order to do this, BLS plans to continue pollen and mold counts are used to determine allergen levels transitioning from classical diagnostic methods to molecu- for the general public, media, and medical providers. lar-based diagnostic methods. Recently, BLS has adopted the GenMark, MALDI-TOF, and Illumina MiSeq molecular tech- Lead and Heavy Metals nologies. These technologies improve the accuracy of testing The environmental section of BLS provides testing on environ- for respiratory viruses, TB, foodborne bacteria, and many other mental and blood specimens for lead and heavy metals. These harmful bugs. BLS plans to also acquire a Next Generation metals can be very dangerous for human and environmental Sequencing instrument to assist with identifying foodborne health. In children, high lead levels can cause developmental bacteria. and cognitive problems. The laboratory conducts testing for BLS will expand the base of clients in the area that are served the HHD Bureau of Community and Children’s by the Bureau’s clinical and environmental sections. This will Environmental Health. be facilitated with a remote order-entry system, where providers and others will be able to order tests and receive results electronically from BLS. The goal at the Bureau of Laboratory Services is to provide the community and our partners with up-to-date and accurate test results. The bureau will continue to evaluate the needs of the community and plan for future testing needs to serve Houston.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 16 HOUSTON HEALTH DEPARTMENT

Bureau of Jail Health Services

The Bureau of Jail Health Services (JHS) operates two 24-hour minor emergency clinics within the Houston Police Department (HPD) jails. Inmates have distinct medical needs, and their care during incarceration falls on the City of Houston. These clinics triage the inmates, treat minor conditions, conduct medical follow- up, and refer to emergency care, if needed.

Some of the commonly treated medical conditions are: TABLE 1. Essential Public Health • Minor injuries (lacerations, sprains, burns, and other Services Addressed by JHS wounds)

• Drug and alcohol intoxication/detoxification Monitor health status to identify and solve • Diabetes community health problems • Hypertension Diagnose and investigate health problems and health • Seizure disorders hazards in the community • Asthma • Psychiatric disorders Inform, educate, and empower people about health issues • Chronic disability • Coronary heart disease Mobilize community partnerships and action to • Pregnancy monitoring identify and solve health problems The City of Houston jail system dates back to the 1840s, when Develop policies and plans that support individual and the City constructed a two-story jail, which was referred to as community health efforts the “Calaboose,” a common name for a municipal jail at that time. Prior to the construction of the Calaboose, the Houston Enforce laws and regulations that protect health and City Marshals (the forerunner of the current HPD) booked ensure safety prisoners directly into a 24 feet by 24 feet blockhouse, which had neither heat nor ventilation. Link people to needed personal health services and assure the provision of health care when The jail relocated twice more over the next century, until otherwise unavailable HPD opened the Police Administrative Building in 1951 on 61 Reisner Street, which still houses the primary jail. Begin- Assure competent public and personal health care ning in 1978, JHS operated a clinic at the Reisner Street jail, to workforce provide necessary care to inmates. On September 21, 1989, the city entered into a legal consent decree to provide a minimum Evaluate effectiveness, accessibility, and quality of level of care to inmates. The consent decree has since been ter- personal and population-based health services minated, but JHS continues to maintain the 24-hour clinical services at the Reisner and Mykawa jail facilities. Research for new insights and innovative solutions to health problems

Problems Bureau Addresses In addition to psychiatric concerns, JHS provides care for A major issue that JHS addresses is attempted suicide in the all persons in custody. Inmates come with pre-existing condi- inmate population. Historically and into the present, suicide tions (e.g. heart disease, chronic disabilities) and may suffer has been the leading cause of unnatural death in jails (Frank acute conditions (e.g. physical injuries). The clinics work & Aguirre, 2013). The rate has been approximately 47 per closely with hospitals in order to provide emergency care that 100,000, or over four times the rate in the general population cannot be provided in the clinics. These services meet 2 of the (Hanson, 2010; Mumola, 2005). 10 essential public health services (Table 1).

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INMATE CASE COUNT Purpose of Bureau The inmates are in the custody of HPD, so necessary medical care falls on the City to provide. Providing this care reduces morbidity and mortality in this population.

150000 Actions Taken by Bureau Each inmate brought into the jail facility is screened and triaged by clinical assistants and jail medical specialists in order to assess if the inmate has any medical problems or needs. If 100000 the inmate is identified to have a medical need, he is referred to the jail clinic for treatment. If the clinic is able to provide

COUNT the necessary level of care, the patient receives treatment and 50000 medical follow-up as appropriate. If the inmate requires a higher level of care, he is transferred to a local hospital for care, until he is able to be transferred back to the jail. 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 10-year Trends FIGURE 1. Number of inmates screened and treated in HPD jails, 2005 - 2014 The bureau has maintained the clinics at both Houston jail locations over the past 10 years. Currently, the jail staffs

1% 1% 1% 1% 1% two medical doctors, a pharmacist, and over 25 jail medical specialists and clinical assistants. Little has changed in the past 10 years in the operations of the clinics; however, the number 5% of inmates screened and treated has fluctuated throughout the

7% Hanging period. Cutting Wrist The number of inmates screened and treated peaked in Suffocation 2009, with 198,532 screened and 113,273 of those received treatment (Figure 1). Likewise, the number of patients referred 83% Drowning Overdose for outside care also peaked in 2009 at 1,250. Jumping Trends in attempted suicides in the jail have not been Stabbing consistent in the past several years. 2009 saw the second lowest Head Trauma number of attempted suicides (9) and 2013 saw the highest (27). The method of attempted suicide has most commonly been hanging (82.7%) (Figure 2). Approximately 60% of suicide attempts were black inmates (Figure 3), and approximately FIGURE 2. Attempted suicides in HPD jails by method, 2014 80% were male.

Unknown 10-year Vision for 2015 to 2025 1% Municipal jails are quickly disappearing in Texas, in favor of larger county- or state-run facilities. This is because municipal facilities typically only hold prisoners for short periods and Hispanic 12% for low-level crimes. The Houston City Council approved an agreement with Harris County on September 23, 2015 to build a joint inmate processing center. This is the first step in transferring the City’s municipal jail services over to Harris

White Black County, a move that former Mayor Annise Parker said will 30% 57% result in “direct savings from the first day.” The joint processing center is scheduled to open in October 2017, with the City’s facilities closing the following month.

FIGURE 3. Attempted suicides in HPD jails by race/ethnicity, 2014

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 18 HOUSTON HEALTH DEPARTMENT

Performance Improvement and Accreditation Team (PIAT)

The Performance Improvement and Accreditation Team (PIAT) is the coordinating team for Public Health Accreditation and quality improvement initiatives within the Houston Health Department (HHD). Public Health Accreditation is the measurement of a health department’s performance against a set of nationally recognized, practice-focused, and evidence-based standards. It serves as a process that ensures a public health agency is committed to self-study and external reviews by peers, and meets required standards and continuously enhances the quality of services provided. PIAT works strategically with staff to ensure that HHD meets and TABLE 1. Essential Public Health exceeds the standards delineated by the Public Health Accreditation Board (PHAB), Services Addressed By BOE. which ultimately benefit the health and well-being of Houstonians through: • Increased funding opportunities and competitiveness for grant opportunities Monitor health status to identify and solve community health • Improved business processes and efficiency problems • Enhanced collaboration on health improvement initiatives Diagnose and investigate health • Increased community involvement with the department problems and health hazards in • Improved health outcomes for Houstonians the community On December 12, 2014, PIAT succeeded in its primary objective of ensuring HHD Inform, educate, and empower received accreditation. HHD became the first department in Texas and the second people about health issues large city in the nation to be accredited by PHAB. Although the departments’ accreditation lasts five years, the team is already working on improvements and planning for Mobilize community partnerships reaccreditation. and action to identify and solve health problems Problems PIAT Addresses Develop policies and plans that Local health departments serve as the front line of public health across the nation. support individual and community They are tasked with providing the Essential Public Health Services to their juris- health efforts diction and communities. By facilitating performance improvement and obtaining accreditation status, PIAT is improving the delivery of these essential services to the Enforce laws and regulations that City of Houston and directly meeting 2 of the 10 services (Table 1). protect health and ensure safety Link people to needed personal health services and assure the provision of health care when otherwise unavailable

Assure competent public and personal health care workforce

Evaluate effectiveness, accessibility, and quality of personal and population-based health services

Research for new insights and innovative solutions to health problems

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 19 HOUSTON HEALTH DEPARTMENT

3.2012 2012 12.12.2014 Former Accreditation Completed Community Received Accreditation Workgroup Health Assessment

8.2011 12.2012 5.2013 9.2010 Established 2nd Self-Assessment Completed Community Public Health Improvement PIAT Health Improvement 12.2013 - 12.2014 PHAB Application Period Grant Awarded 8.2011 Established PIAT

2010 2011 2012 2013 2014

12.31.2013 Submitted Application 12.2013 - 12.2014 PHAB Application Period

12.31.2013 10.16.2014 12.12.2014 PHAB Site Visit

FIGURE 1. Timeline of PIAT activities and the Accreditation process.

PIAT Responsibilities 10-year Vision for 2015 to 2025 Accreditation efforts at HHD began in September 2011 and PIAT’s 10-year vision is to have a PHAB-accredited department were initially funded by the CDC National Public Health with improved program performance and efficiency through Improvement Initiative grant (Figure 1). The purpose of the continuous quality improvement. Accreditation and quality grant was to assist departments in establishing a culture of improvement will be fully integrated and funded as core func- quality improvement leading to improved efficiency, effective- tions of the department, ensuring HHD continues to operate ness, and health outcomes. at the highest possible standard. All new employees will learn Since 2011, PIAT has taken many steps to prepare the about Public Health Accreditation and the guidelines for department for accreditation, including: proper documentation. The department will continue its role • Training staff on Accreditation, Performance Management as a national leader in public health accreditation, and PIAT (PM), and Quality Improvement (QI) will possess the resources and staff to provide even greater assistance to other health departments across Texas. • Conducting departmental Performance Management and In order to accomplish this, PIAT will be fully staffed, Accreditation Assessments which will allow the team to provide appropriate training and • Creating tools for proper documentation preparation for accreditation activities, and facilitate and lead • Conducting mock site visits important departmental quality improvement projects. The team will continue to develop innovative tools, such as • Developing games and educational materials the Accreditation Documentation Management System and • Coordinating documentation collection and review Good Doc/Bad Doc, to aid other departments pursuing • Providing mentorship and technical assistance for other accreditation. departments pursuing accreditation

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Bureau of Public Health Preparedness

The Bureau of Public Health Preparedness (PHP) is responsible for activities that improve all communities, especially those that are most vulnerable, to help them prepare for and respond to public health emergencies. PHP works within the larger Houston Health Department mission – for families and individuals to be self-sufficient in safe and healthy communities. PHP helps build infrastructure that allows the City of Houston to respond to public health disasters.

When preparing for, responding to, and recovering from a public health emergency, PHP collaborates with the Office of Emergency Management (OEM) in utiliz- TABLE 1. Essential Public Health ing the phases of emergency management: mitigation, preparedness, response and Services Addressed By PHP recovery. The bureau fulfills its role in the Incident Command Structure (ICS) by working with all government agencies to reduce the risk of harm to the public before, Monitor health status to identify during, and after a disaster or emergency, and working to recover and restore normal and solve community health life operations as quickly as possible. PHP searches for ways to reduce the occurrence problems of such emergencies and reduce their impact when they cannot be prevented. Diagnose and investigate health problems and health hazards in Problems Bureau Addresses the community PHP focuses on 15 national disaster planning scenarios that were developed by several federal agencies in collaboration with the Department of Homeland Security. Inform, educate, and empower Those condensed scenarios are: people about health issues Mobilize community partner- 1 Nuclear Detonation 10-Kiloton Improvised Nuclear Device ships and action to identify and solve health problems 2 Biological Attack Aerosol Anthrax

3 Biological Disease Outbreak Pandemic Influenza Develop policies and plans that support individual and commu- 4 Biological Attack Plague nity health efforts

5 Chemical Attack Blister Agent Enforce laws and regulations that 6 Chemical Attack Toxic Industrial Chemicals protect health and ensure safety

7 Chemical Attack Nerve Agent Link people to needed personal health services and assure the 8 Chemical Attack Chlorine Tank Explosion provision of health care when 9 Natural Disaster Major Earthquake otherwise unavailable

10 Natural Disaster Major Hurricane Assure competent public and 11 Radiological Attack Radiological Dispersal Devices personal health care workforce

12 Explosives Attack Bombing Using Improvised Explosive Devices Evaluate effectiveness, accessi- 13 Biological Attack Food Contamination bility, and quality of personal and population-based health services 14 Biological Attack Foreign Animal Disease (Foot & Mouth Disease) Research for new insights and 15 Cyber Attack innovative solutions to health problems The work of PHP addresses four of the essential public health services (Table 1).

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Purpose of Bureau departments, and other jurisdictions. Ensuring the safety of Houston is important not only for the Finally, the West Africa Ebola epidemic presented a new health of the population, but also the economic and social threat to Houston and the rest of the United States. As a wellbeing of the city and region. Preparing Houston to con- culturally diverse region with high levels of international travel front these potential emergencies is a pivotal step that the PHP and commerce, Houston was at a relatively higher risk than takes in order to mitigate potential effects of these emergencies. many other areas of the United States. PHP worked with epidemiology partners, medical providers, community-based organizations, academic institutions, and others to educate and Actions Taken by Bureau prepare the city for a potential case of Ebola. PHP actively participates in national, regional, and local preparedness responses that include exercises and drills. PHP Program-specific Areas facilitates customized trainings and presentations on various All-hazards plans can provide a basic framework for responding disaster preparedness topics to different organizations and to a wide variety disasters, but planners typically address the provides community liaisons at community and organizational kinds of disasters that might be expected to occur and their as- functions, and health fairs and expos to present and educate sociated response actions, such as coordination of medical care the population at-large on emergency preparedness. PHP (including treatment, transport, and tracking of the injured), provides leadership and management roles to the following disposition of the deceased, sanitation, vector control, mental response actions: health, and other coordination roles, as necessary. • Non-pharmaceutical interventions including social distanc- Emergency planning normally begins with the identification ing, isolation, and quarantine—with the complement of of the disasters that have occurred in a community in the re- wrap-around services required for day-to-day living. cent past. These are the known and generally the most probable • Administration or dispensing of life-saving medications (pills hazards. Planners may then focus on the disasters that have or injected vaccines) to a variety of threats ranging from occurred in the distant past by reviewing newspaper archives, hurricanes to pandemics to bioterrorism. history books, and other documents and by interviewing • Disease monitoring in multiple settings including the long-time residents. Other hazards may be added to the list if community at-large, emergency departments, hospitals and it is determined that there is some probability of them posing clinics, congregate settings. significant risk to life, property, or to the environment. For example, new highways and rail lines may increase the • Mass fatality management and the coordination services for potential for hazardous materials accidents. victim identification and survivor care and case management PHP works with numerous partners including healthcare through the operation of Family Reception Centers and colleagues, mental health partners, medical examiner partners Family Assistance Centers. at Harris County Institute of Forensic Science, the broad base • Coordination of mass care in sheltering scenarios, when the of community partners who provide a complement of human Red Cross is not available. services, and the over 20,000 member workforce at the City of • Coordination and consultation for threats where continua- Houston. Together, PHP and its partners provide the foundation of operations and response overlap. tion for a public health preparedness system that can respond to any potential disaster that would threaten Houston. 10-year Trends 10-year Vision for 2015 to 2025 In the past 10 years, the PHP has confronted many challeng- ing scenarios and conducted many activities to better prepare The bureau of PHP will continue to serve the citizens of for future scenarios. Since 2005, PHP has over 300 classes on Houston in preparation for and response to public health weapons of mass destruction to educate citizens, employees, emergencies. In this vein, PHP will continue to provide cur- and others on preparing for such an attack on the city. rent services, but with a focus on finding and implementing In 2006 and 2008, PHP played major roles in the responses innovative, efficient means of improving the preparedness of to Hurricanes Katrina, Rita, and Ike. While the majority of Houston. the effects of Hurricane Katrina were experienced in Louisiana, In order to build on the foundation that has been estab- Houston became a major hub for relocation and shelter for lished, the PHP will need to create new partnerships, leverage victims of the hurricane. For all hurricanes, the city must pro- existing partnerships for expanded capacity, and provide more vide emergency shelter during the storm, work with external direct information to the public. partners to provide shelter after the storm, and resume normal Following the hurricanes, infectious disease, and terrorism operations of the city as quickly as possible following the threats in recent years, PHP has continually updated plans for storm. addressing these threats. PHP’s goal is to have plans that are Pandemic influenza struck in 2009, causing significantly -in robust enough to be applied to situations but realistic in creased disease and economic burden on the city. PHP played situation-specific needs. a vital role in coordinating the response efforts internally and with external partners, such as healthcare providers, other

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 22 HOUSTON HEALTH DEPARTMENT

Disease Articles

he rest of the Epidemiology in Review will potential to spread rapidly in a community (e.g., Tprovide insight into each condition that HHD measles), high mortality (e.g., Ebola and other viral is mandated by law to surveil. The articles will hemorrhagic fevers), or have the potential to be be broken into at least 4 sections: Introduction, used as an agent of bioterrorism (e.g., anthrax). Transmission, Epidemiology, Public Health In the past 10 years, more hospitals and Action. Some articles will have additional sections laboratories have used electronic records to store as needed. These analyses are meant to give readers and transmit data. This has greatly enhanced the a snapshot into understanding how diseases affect a capacity and efficiency of public health surveillance. community and how HHD has responded. While some records are still relayed to HHD via Reportable conditions are those conditions fax or telephone, most records come electronically set forth by law in the Texas Administrative Code. and are automatically deposited into our electronic Hospitals and laboratories are required to send the surveillance information system. This change has local public health authority records of patients allowed HHD and other public health agencies to with diseases enumerated in the Administrative increase surveillance capacity even during a time of Code. These diseases are usually those with high shrinking budgets and staff.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 23 HOUSTON HEALTH DEPARTMENT

Amebiasis

INTRODUCTION Amebiasis is a parasitic disease caused by the organism Entamoeba histolytica. In 2013, amebiasis was the fourth leading cause of death from parasitic diseases worldwide (Hotez, 2015). While there are other Entamoeba species that inhabit humans, none are as pathogenic as E. histolytica.

Up to 90% of infected persons do not expe- disease is mainly observed in immigrants from SURVEILLANCE rience symptoms (Haque, Huston, Hughes, such countries, travelers to tropical areas, in- SUMMARY Houpt, & Petri, 2003). Symptoms can be stitutionalized persons, immunocompromised Surveillance History mild (infrequent diarrhea) to severe (fulmi- persons, and people who have contact with Reportable condition since nant colitis or liver abscesses). Symptoms fecal matter during sex (Centers for Disease 1986 include fever, weight loss, dehydration, ab- Control and Prevention, 2015). Amebiasis has dominal cramps, and diarrhea. Symptoms can also been observed in men who have sex with Population at Higher Risk persist for months without proper treatment. men worldwide (Shelton, 2004). Travelers to endemic countries In rare cases, the infection can spread to other Healthcare providers have to report suspect organs, causing liver abscesses or skin lesions. or confirmed cases of amebiasis within one Notable Outbreaks Individuals can carry the parasite for weeks to week to the health department. A confirmed None years without experiencing any symptoms. case of amebiasis requires a valid laboratory Reports Investigated Amebiasis is common in countries with diagnosis. 1,030 poor sanitation. In the United States, the Seasonality Summer Disease Transmission shows, the number of cases increased during Average Cases Per Year The incubation period is generally 2 to 4 the years 2006 to 2008 and the case count 39 weeks, with a range of a few days to several months or years. The disease is transmitted via the fecal-oral route, similar to other gastrointestinal infections. The parasite is shed in the AMEBIASIS CASE COUNT feces of infected persons, and subsequently spread to others via several ways. Consumption of contaminated food 150 and water are the most common sources of infection. People who care for infants can get infected after changing diapers. Certain sexual practices, such as anal and oral-anal sex, carry 100 an increased risk for amebiasis and other gastrointestinal infections. Even small amounts COUNT of the parasite are known to cause disease. Since the disease is often asymptomatic, an 50 infected person can unknowingly transmit the infection to others (Shelton, 2004).

Epidemiology in Houston 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 From 2005 to 2014, there were 387 cases of amebiasis reported in Houston. As Figure 1 FIGURE 1. Amebiases case count.

A Report of the Office of Surveillance and Public Health Preparedness Epidemiology in Review 2005 to 2014 24 HOUSTON HEALTH DEPARTMENT

peaked in 2007, with 174 cases. Higher number of cases reported may be because of the higher number of refugee screenings for amebiasis done during this period. Refugees may get the infection because of the unsanitary conditions at the refugee camps or in their home country. Since 2009 the number of cases reported annually are less than 20.

Public Health Action The best practices to prevent amebiasis are avoiding cross-contamination of food and water, and practicing proper hand hygiene. It is important to thoroughly wash hands prior to eating or handling food, and after using the toilet or changing diapers. Fruits and vegetables need to be washed adequately with clean water. Travelers to developing countries should avoid consuming uncooked foods and contaminated water. Travelers are advised to drink water boiled for at least one minute, only boiled or filtered water, and avoid drinks that have ice (DSHS, 2015). Patients with symptomatic amebiasis can be treated with anti-parasitic drugs, including metronizadole or tinidazole.

WORKS CITED Centers for Disease Control and Prevention. (2015, July 20). Entamoeba histolytica Infection. Retrieved from www.cdc.gov/parasites/amebiasis/general-info.html. DSHS. (2015, August 17). Amebiasis. Retrieved from www.dshs.state.tx.us/idcu/disease/ amebiasis/faqs/. Haque, R., Huston, C., Hughes, M., Houpt, E., & Petri, W. A. (2003). Amebiasis. The New England Journal of Medicine, pp. 1565 - 1573. Hotez, P. (2015, January 16). One Million Deaths by Parasites. Retrieved from: blogs.plos. org/speakingofmedicine/2015/01/16/one-million-deaths-parasites/. Shelton, A. A. (2004). Sexually Transmitted Parasitic Diseases. Clin Colon Rectal Surg, pp. 231 - 234. Retrieved from www.ncbi.nlm.nih.gov/pmc/articles/PMC2780057/.

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Amebic Meningitis and Encephalitis

INTRODUCTION Several types of amoebas, including Balamuthia spp., Naegleria fowleri, and Acanthamoeba spp., have rarely been known to cause human central nervous system (CNS) infection, including encephalitis, meningitis, and meningoencephalitis. Meningitis is the inflammation of the meninges, a thin, membranous tissue progresses, additional symptoms might SURVEILLANCE covering the brain and the spinal cord, while develop, including photophobia, mental-state SUMMARY encephalitis is the inflammation of the brain. abnormalities, hallucinations, delirium, Surveillance History Meningoencephalitis is a combination of the seizures, and coma. After the onset of Reportable condition since two conditions with inflammation of the symptoms, the disease progresses rapidly and 2013 brain and its membranous tissues (Heymann, usually results in death within 3 to 7 days 2008; Texas Department of States Health Ser- (Heymann, 2008); (Texas Department of Population at Higher Risk vices, Amebic Central Nervous System (CNS) States Health Services, Primary Amebic Outdoor swimmers Infections, 2015). Meningoencephalitis (PAM), 2015). Notable Outbreaks Primary amebic meningoencephalitis The principal causes for amebic meningi- None (PAM) occurs when meningoencephalitis is tis and encephalitis are Balamuthia spp. and Reports Investigated caused by an ameba. The main cause for PAM Acanthamoeba spp. The free-living form of 0 is the free-living form of the ameba Naegleria these 2 amebas species reaches the central ner- fowleri. Human exposure to Naegleria fowleri vous system though the blood. Those infected Seasonality occurs when water containing ameba enters are frequently chronically ill or immunosup- Summer for cetain types the nose. Transmission occurs when the pressed patients with no history of swim- Average Cases Per Year free-living form of the ameba, a trophozoite, ming or no known source of infection. The 0 penetrates the nasal tissue and migrates to the symptoms include seizures, partial paralysis, brain via the olfactory nerves causing PAM mental status changes, fever, muscular weak- (Heymann, 2008; Texas Department of States ness, double vision, sensitivity to light, and Health Services, Primary Amebic Meningoen- other neurologic problems (Heymann, 2008; cephalitis (PAM), 2015). Centers for Disease Control and Prevention, The incubation period for PAM is 3 to 15 Acanthamoeba – Granulomatous Amebic days. Initial signs and symptoms consist of Encephalitis (GAE); Keratitis, 2013; Centers sudden onset of headache, fever, nausea for Disease Control and Prevention, 2011). and vomiting, and stiff neck. As the disease

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Disease Transmission brain that is fatal in over 95% of cases. inhaled into the lungs. Most people will Naegleria fowleri is found in warm fresh- It can take weeks to months to develop be exposed to Acanthamoeba during water such as rivers, lakes, and ponds. the first symptoms ofBalamuthia GAE their lifetime, but very few will become Amoebas are thought to be introduced after initial exposure to amoebas (CDC, sick from this exposure (CDC, 2013). to the brain by forced entry of water up 2011). While Naegleria fowleri infection usu- the nose during freshwater recreational Balamuthia amoebas live freely in soil ally occurs in young healthy individuals, activities, such as diving. The organism around the world. Gardening, playing Acanthamoeba and Balamuthia infec- has also been found in tap water and with dirt, or breathing in soil carried tions typically appear in the immune can be introduced to the brain when by the wind might increase the risk for compromised (Heymann, 2008; Texas tap water is used for nasal irrigation or infection. Balamuthia might also be Department of States Health Services, sinus flushes. However, people do not present in fresh water. There have been Primary Amebic Meningoencephalitis become infected from drinking con- reports of Balamuthia GAE infection (PAM), 2015). taminated water (Texas Department of in dogs that swam in ponds. However, States Health Services, Primary Amebic there have been no reported human Epidemiology in Houston Meningoencephalitis (PAM), 2015). cases where the only potential exposure There were no cases of amebic meningi- Balamuthia amoebas are thought to was swimming (CDC, 2011). tis or encephalitis reported in Houston enter the body when soil containing Acanthamoeba is a microscopic, from 2005 to 2014. the amoeba comes in contact with skin free-living ameba that can cause rare, Acanthamoeba and Balamuthia wounds and cuts, or when dust contain- but severe infections of the eye, skin, meningitis and encephalitis cases have ing Balamuthia is breathed in or gets in and central nervous system. The ameba occurred in Texas. From 2009 to 2014, the mouth. Once inside the body, the is found worldwide in the environment there were 2 Texas cases of Balamuthia amoebas can then travel to the brain and in water and soil. The amoebas can be (2010 and 2014) and 1 Texas case of cause granulomatous amebic encephali- spread to the eyes through contact lens Acanthamoeba (2012). From 2005 to tis (GAE). GAE is a severe disease of the use, cuts or skin wounds, or by being 2014, there were 9 cases of amebic

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meningoencephalitis cases reported in water-related activities in shallow, the state of Texas (Texas Department of warm, freshwater areas. States Health Services, Amebic Central • Use only sterile, distilled, or luke- Nervous System (CNS) Infections, warm previously boiled water for 2015; Texas Department of States nasal irrigation or sinus flushes (Texas Health Services, Primary Amebic Department of States Health Services, Meningoencephalitis, 2015). Primary Amebic Meningoencephalitis (PAM), 2015). Public Health Action The only way to preventNaegleria fowleri Currently, there are no known ways infections is to refrain from water-related to prevent infection with Balamuthia activities in stagnant waters. If you do or Acanthamoeba since it is unclear how plan to take part in water-related activi- and why some people become infect- ties, here are some measures that might ed while others do not (CDC, 2013); reduce risk: (CDC, 2011). • Avoid water-related activities in bodies of warm stagnant freshwater during periods of high water temperature and low water levels. • Hold the nose shut or use nose clips when taking part in water-related activities in bodies of warm freshwater such as lakes, rivers, or hot springs. • Avoid digging in or stirring up the sediment while taking part in

WORKS CITED Centers for Disease Control and Prevention. (2011). Balamuthia mandrillaris – Granulomatous Amebic Encephalitis (GAE). Retrieved from www.cdc.gov/parasites/ balamuthia/. Centers for Disease Control and Prevention. (2013). Acanthamoeba – Granulomatous Amebic Encephalitis (GAE); Keratitis. Retrieved from www.cdc.gov/parasites/ acanthamoeba/. Heymann, D. L. (2008). Naegleriasis, Acanthamebiasis, and Balamuthiasis. In D. L. Heymann, Control of Communicable Diseases Manual, Washington, DC: American Public Health Association. pp. 438 - 44. Texas Department of States Health Services. (2015). Amebic Central Nervous System (CNS) Infections. Retrieved from dshs.state.tx/IDCU/disease/ Amebic-Central-Nervous-System-(CNS)-Infections.doc. Texas Department of States Health Services. (2015). Primary Amebic Meningoencephalitis (PAM). Retrieved from www.dshs.state.tx.us/idcu/disease/ primary_amebic_meningoencephalitis/.

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Anaplasmosis

INTRODUCTION Anaplasmosis is a rare bacterial disease caused by Anaplasma phagocytophilium. The disease is transmitted by ticks. Symptoms typically develop 1 to 2 weeks after being bitten by an infected tick and include fever, headache, muscle pain, and confusion. In rare cases, a rash develops. The majority of infections occur during the summer include labored breathing, hemorrhage, renal SURVEILLANCE months, when people and ticks are most ac- failure, or neurological problems. Less than SUMMARY tive. Cases can occur year-round, however. 1% of cases are fatal (Center for Disease Control and Prevention, 2013). Surveillance History Severe complications from the illness Nationally condition since 1999 Disease Transmission Public Health Action Population at Higher Risk A. phagocytophilium is endemic to several The City of Houston promotes general • Hikers species of ticks, including the American dog awareness about tick-borne diseases such as • Travelers tick (Dermacentor variabilis), blacklegged Lyme, erlichiosis, and anaplasmosis. When tick (Ixodes scapularis), and the Western traveling in dense foliage, hiking on trails, or • The elderly blacklegged tick (Ixodes pacificus). Both the walking through a field, it is important to be Notable Outbreaks American dog tick and blacklegged tick can vigilant for tick bites. This is especially true None be found in eastern Texas. When an infected during the summer months when ticks are Reports Investigated tick bites a human, there is a potential for the more likely to bite humans. 8 bacteria to then infect the human. The disease Prevention methods include: is more common in the northern Midwest Seasonality and Northeastern States, including Wisconsin, • Avoid areas with ticks when possible June and July Minnesota, and Maine. Incidence in Texas • Wear light-colored clothing so that ticks Average Cases Per Year is relatively low. Recent analysis indicates can be easily seen and be removed prior to 0 that the geographic range of anaplasmosis is biting increasing over time (Dahlgren, Heitman, • Wear long-sleeved shirts and tuck pants into Drexler, Massung, & Behravesh, 2015). socks or boots • Apply permethrin to clothes or insect repel- Epidemiology in Houston lents containing DEET; DEET can be used Given that ticks are uncommon in densely safely on children and adults (EPA, 2007) populated areas, cities such as Houston • Check regularly for ticks when in their have a low rate of incidence. In the past habitat 10 years, Houston did not have any cases of anaplasmosis. • Protect pets with approved tick repellents According to the CDC, annual reported after discussing the best options with a veterinarian cases have increased since the disease became reportable in 1999. Over 90% of all report- Ticks that have already bitten can be removed ed cases in the US come from just six states: with tweezers. Remove the entire tick and New York, Connecticut, New Jersey, Rhode not just the body. A detached head can still Island, Minnesota, and Wisconsin (CDC, transmit disease causing bacteria. After remov- 2013). While any person can become ill with al, wash the bite area with rubbing alcohol, the disease, the elderly see the highest rate of iodine, or soap and water. reported illness.

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WORKS CITED CDC. (2013, July). Anaplasmosis. Retrieved from www.cdc.gov/anaplasmosis/symptoms/. Dahlgren, F., Heitman, K., Drexler, N., Massung, R., & Behravesh, C. (2015). Human Granulocytic Anaplasmosis in the United States from 2008 to 2012: A summary of National Surveillance Data. American Journal of Tropical Medicine and Hygiene. Environmental Protection Agency. (2007). Diethyltoluamide (DEET). EPA.

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Anthrax

INTRODUCTION Bacillus anthracis is a spore-forming bacterium that causes the acute infectious disease anthrax. Anthrax has three major clinical forms classified by the route of entry of the bacteria into the body: • Inhalation: a disease resembling a viral respiratory illness, followed by distress from tissues not receiving enough SURVEILLANCE oxygen. This is the most dangerous form. SUMMARY

• Cutaneous: an infection of a wound that produces a lesion Surveillance History Reportable condition since on the skin, generally considered the least dangerous. 1944 Intestinal Population at Higher Risk • : severe abdominal distress followed by fever and Animal handlers signs of septicemia. This form is very rare. Notable Outbreaks None Inhalation infections result when the bacteria Small cuts or open wounds are often the point Reports Investigated spores are inhaled. This is especially a concern of entry of the bacteria into the host. 15 with weaponized anthrax. Intestinal infection Anthrax is a notifiable condition in Texas results when a person ingests spores into the and the United States. It should be reported Seasonality gut via food or drink. Cutaneous infections within an hour of suspicion by a physician, June, July, August and occur when B. anthracis bacteria are able to by- laboratory, or other caregiver in order to September pass the protective skin and cause an infection. initiate public health action. Average Cases Per Year 0 Disease Transmission and Eastern Europe. Occasionally, travelers to Anthrax usually affects livestock (e.g., cattle, parts of the world where anthrax is endemic sheep, goats) as well as wild herbivores. Hu- have contracted the disease. mans rarely become infected except as a result of occupational exposure to infected animals Epidemiology in Houston or contaminated animal products, such as No case of anthrax has been reported in tissues, hides, or wool. Typically, anthrax in- Houston since 1922. Available data suggests fections are more prevalent in agricultural and that as early as 1903, anthrax was not consid- impoverished regions with inadequate disease ered a pubblic health concern in the Houston control systems. Person-to-person anthrax is area. Dr. F. J. Slataper, the City Pathologist rare and has only been observed in the cuta- and Chemist reported that one “culture [was] neous form when a person has direct contact examined for anthrax” in 1912 (Slataper, with a skin lesion (Center for Disease Control 1913). and Prevention, 2013). In the early 1900s the number of anthrax A special type of cutaneous anthrax is cases reported nationally was approximately injection anthrax. It has been observed in 130 per year. The current incidence of natural- Europe among heroin users. Injection anthrax ly occurring anthrax infections in humans is 1 is especially severe and requires immediate to 2 per year (CDC, 2013). medical attention (Grunow, et al., 2012). The cutaneous form of anthrax is more Anthrax is endemic in Central and South common than the other forms. During the America, sub-Saharan Africa, parts of Asia, whole of the 20th century, at least 71 cases

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of inhalation anthrax were reported in the United States (Holty, et al., 2006). White Powder Runs The overall case fatality rate exceeded 75%. Following the bioterrorist attacks in October 2001 in which anthrax was introduced through the postal system, isease progression after exposure to the case-fatality rate among patients with Danthrax can be very rapid and the case inhalation disease was 45%. Though fatality rate can be very high, especially there were suspected cases reported in if there are delays in diagnosis and treat- Houston in 2001, none were confirmed. ment; therefore, preparing for these potential threats is important for the safe- Certain professions, such as laboratory ty of Houston. Factors that determine the scale of the public health response workers and persons working directly include how the anthrax was detected and the risk to those exposed. The public with animals or animal products, are at health response has four goals: (1) remove the source of the anthrax spores; increased risk of exposure to anthrax. (2) remove people from the affected area and decontaminate the people and However, the risk is still very low. the site; (3) provide prophylaxis to people exposed with no symptoms; and (4) diagnose and treat people who develop signs or symptoms of anthrax. Laboratory Testing Beginning with the “Amerithrax” incident in 2001, when letters laced with Current testing in HHD laboratory anthrax were sent to congressmen and media offices, preparedness exercises includes real-time PCR and conventional known as “white powder runs” have become common practice. In Houston, culture methods for clinical or environ- these “white powder runs” exercise protocols and procedures developed for the mental isolates. Testing by PCR is based FBI, Houston Police Department, Houston Fire Department (HFD) Hazardous on three markers specific to the bacteri- Materials (HazMat) team, and the Houston Health Department (HHD). In July of um. PCR from a direct clinical patient 2014, the Houston Health Department was invited along with our HFD HazMat sample culture or from an isolate can be partners to participate in a drill at an oil and gas office with a complex mail-han- reported as confirmatory. Confirmatory dling process. testing includes tests for capsule produc- The exercise began with the identification of a suspicious package in the tion and gamma phage lysis, along with mail-handling process and proceeded to initiate a response by the HFD HazMat, characteristic culture morphology and HHD, FBI, and law enforcement. The HFD HazMat secured the suspicious biochemistry. Antimicrobial susceptibili- package and conducted field testing while the risk to employees was assessed ty for B. anthracis can also be performed following decontamination. The drill ended with the confirmatory testing of the in the laboratory. Advances in geno- sample at the HHD Laboratory, theoretical public health control measures, and typing methods have led to improved initiation of a criminal investigation. analysis of the genetic variation and The public health response and control measure to an anthrax exposure can relatedness of B. anthracis. vary widely depending on the situation, from a confined area with few people to an open-air setting with a large gathering of people. For example, a public health response to a United States Postal Service (USPS) Biohazard Detection System (BDS) alarm would be confined to the immediate building and people who had been inside the affected area when the release may have occurred. Bacillus Anthracis Tests Houston tested such a response with the USPS on June 28, 2011. The response Conducted at HHD Laboratory involved securing the building, calmly evacuating workers, getting them through decontamination, and providing them with treatment to prevent anthrax infec- 2006 22 tion. Once the immediate public health threat is addressed, law enforcement 2007 16 partners at the United States Postal Inspection Service (USPIS) and Federal Bureau of Investigations (FBI) would continue with a criminal investigation. 2008 16 A substantially wider response would be needed for an open-air setting with 2009 15 aerosolized anthrax. Additionally, exposed individuals would need to be treated within 48 hours. In Houston, the plan is to issue medication via 50 public Points 2010 20 of Dispensing (POD) sites for the general public as well as at specific sites (called 2011 45 “closed PODs”) for certain personnel. Rapid throughput of 1,000 medications per hour per site would be achieved to individuals for their families. These 2012 33 POD sites would be coordinated through the Houston Health Department 2013 27 Operations Center and the Houston’s Emergency Operations Center. HHD and other regional local health department partners tested this mass dispensing 2014 28 plan on November 2, 2013 as part of the Regional Allocation Distribution and 2015 19 Dispensing (RADD) full-scale exercise. This included a demonstration of our ability to mobilize POD sites and meet Houston’s needs within the 48-hour window.

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Public Health Action Cases of anthrax are rare, sporadic, and generally confined to persons who have traveled to countries where the disease is endemic or who have had contact with an infected animal. Because it is so rare, if someone were to become ill without a history of travel or interaction with diseased animals, bioterrorism activity would be suspected and would prompt immediate notification by HHD to the appropriate authorities, including the FBI and CDC. A coordinated investigation would ensue to determine the source of the illness. CDC has classified anthrax as a Category A bioterrorism agent. Category A agents are those that pose the greatest possible threat to public health, may spread across a large area, and need public awareness as well as a great deal of planning to protect the public’s health. The ability of anthrax to be used as a biological weapon was demonstrated in the United States in October 2001. Individu- als in Florida, New York City, and Washington, D.C. received letters sent through the postal system containing cultivated anthrax spores. Five letters were sent from (Trenton, New Jersey) and caused 22 cases of anthrax infection. Following the anthrax attacks, the United States Postal Srevice (USPS) implemented a screening system to detect anthrax distributed in the mail system. Persons potentially exposed to anthrax should seek medical attention immediately. Treatment with antibiotics is administered for 60 days. In an emergency situation, the anthrax vaccine may be administered to prevent infection, though the efficacy of post-exposure vaccination has not been documented (CDC, 2015). The vaccine is not routinely administered except to military personnel and livestock.

WORKS CITED CDC. (2013, August). CDC Anthrax. Retrieved from www.cdc.gov/anthrax/basics/ transmission.html. CDC. (2015, September 1). Prevention. Retrieved from www.cdc.gov/anthrax/ medical-care/prevention.html Grunow, R., Verbeek, L., Jacob, D., Holzmann, T., Birkenfeld, G., Wiens, D., . . . Reischl, U. (2012). Injection anthrax — a new outbreak in heroin users. Deutsches Arzteblatt International. Holty, J., Bravata, D., Liu, H., Olshen, R., McDonald, K., & Owens, D. (2006). Systematic Review: A Century of Inhalational Anthrax Cases from 1900 to 2005. Annals of Internal Medicine. Slataper, F. J. (1913). Annual Report of City Pathologist and Chemist for the Year Ending February 28, 1912. Houston: Houston, Texas: W. H. Coyle.

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Arbovirus Infection

INTRODUCTION Arboviruses are vector-borne diseases transmitted by arthropods, usually mosquitoes, and are known to cause illnesses in humans and animals. Illnesses can range in severity from acute fevers of short duration to mild aseptic meningitis to encephalitis with coma and death. Arboviral activity in Texas is usually represented by five distinct appeared in the eastern United States in the SURVEILLANCE illnesses: California encephalitis (CE), St. summer of 1999. The virus is closely related SUMMARY Louis encephalitis (SLE), Eastern equine to the St. Louis Encephalitis virus found in Surveillance History encephalomyelitis (EEE), Western equine the early 1930s in the United States. West WNV: Reportable condition encephalomyelitis (WEE), West Nile virus Nile virus can infect humans, birds, mosqui- since 2001 (WNV); and dengue fever (Texas Department toes, horses, and some other animals. Up to SLE: Reportable in Texas of State Health Services, 2013). 80 percent of people infected with West Nile since 1964 Arboviral diseases can be difficult to prevent virus will have no symptoms; however, some and control. The pattern of outbreaks is infections can result in serious illness or death. Population at Higher Risk generally unpredictable and the lifecycle of the People over 50 years of age and those Those with outdoor occupations or hobbies virus can involve avian, equine, and the canine with weakened immune systems are at higher population in addition to humans. risk of becoming seriously ill if infected. Notable Outbreaks West Nile virus is currently the most (Heymann, 2008). All 5 arboviruses previous- WNV: 2002, 2012 common mosquito-borne illness in Texas. ly listed have similar signs and symptoms but Other: None Historically, the virus was commonly found vary in severity. Reports Investigated in Africa, West Asia, and the Middle East but 1,851 Seasonality Late summer and early fall

Average Cases Per Year WNV: 41 Other: 3

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WNV is a reportable condition in WEST NILE VIRUS CASE COUNT Texas and must be reported within 7 days according to the Texas Health and Safety Code.

Disease Transmission Most arboviruses are transmitted by 100 mosquitoes but can be transmitted by ticks and sandflies. The incubation period of West Nile virus in humans is 3 to 14 days. While there is no evidence that West COUNT Nile virus is spread from person to 50 person or from animal to person through normal exposures, in rare cases transmission has occurred through organ transplant and blood transfusion (Heymann, 2008).

Epidemiology in Houston 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Cases of West Nile disease usually occur in the late summer or early fall; how- Figure 1. West Nile Virus case count in Houston. ever, due to the moderate temperatures in Texas, West Nile virus can be found year-round. West Nile disease is well situated to thrive in Houston. Outbreaks occur when seasonal changes and weather conditions affect avian populations. Houston’s bayous and riparian environs make the city a ready environment for outbreaks when weather conditions permit. The City of Houston identified its first case of West Nile Virus and outbreak in 2002, with 70 cases and four fatalities reported. In the last 10 years in Houston, 411 cases of West Nile virus were reported. Two large outbreaks occurred in 2012 and 2014, as reflected in Figure 1. In 2012 and 2014, Houston experienced unusually large WNV caseloads. These two years account for over half of the cases reported during the 10-year period from 2005 to 2014. Many factors about the epidemiology of WNV are not well understood. However, Houston’s Figure 2. West Nile Virus cases by zip code, 2010 to 2014 (n = 165). humid, wet, and hot climate is known to contribute to the unusually high number of cases. Many of the cases occurred in the northern half of Houston, as seen in Figure 2. Arboviral infections other than WNV are rare in Houston, as seen in Figure 3.

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The 2012 WNV season was the worst ARBOVIRUS – OTHER CASE COUNT on record for Texas and the United States. Texas alone accounted for one- third of the 5,674 WNV cases and 10 one-third of the 286 WNV deaths reported in the US. 8 Public Health Action The Arbovirus Surveillance Program at 5 the Texas Department of State Health COUNT Services was created to detect arboviral activity in mosquitoes prior to the beginning of outbreaks. 3 Mosquito control activities in Houston are conducted by the Harris County Public Health and Environmental 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Services (HCPHES) Mosquito Control Division. The division was established Figure 3. Arbovirus case accounts for Flavivirus, Japonese Encephalitis, La Crosse, St. Louis Encephalitis. in 1965 in response to the outbreak of SLE. Details of the demographic and clinical information of patients in Houston are shared with HCPHES THE BEST FORMS OF PREVENTION Mosquito Control so mosquito control INCLUDE THE FOLLOWING: activities can be targeted to specific locations where transmission likely occurred. In 2014, positive mosquito pools in 1. Use of insect repellents when outside. Harris County accounted for about 33% of the state positive pools. 2. Regularly drain standing water, including The Mosquito Control Division at water that collects in empty cans, tires, Harris County conducts surveillance, buckets, clogged rain gutters and saucers mosquito control, education, and research to prevent and control mos- under potted plants because mosquitoes quito-borne diseases. The division also breed in stagnant water. monitors the Culex mosquito population, the primary transmitter of SLE 3. Wear long sleeves and pants outside at and WNV, conducts laboratory analysis dawn and dusk when mosquitoes are most of mosquito samples to detect SLE and active. WNV, monitors and tests live and dead birds for SLE and WNV, and conducts 4. Ensure there are screens on all ground and aerial spraying activities in areas with confirmed SLE and WNV exterior doors and windows to (Harris County Public Health and keep mosquitoes from entering Environmental Services, 2014). the home. Currently there is no vaccine for West Nile virus or other arboviruses.

WORKS CITED Harris County Public Health and Environmental Services. (2014). Mosquito Control Retrieved from www.hcphes.org/divisions_and_offices/mosquito_control. L.Heymann, D. (2008). Control of Communicable Diseases Manual. Washington, DC: American Public Health Association. Texas Department of State Health Services. (2013, September 20). Arboencephalitis overview retrieved from www.dshs.state.tx.us/idcu/disease/arboviral/arboviral_en- cephalitides/overview/.

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Babesiosis

INTRODUCTION Babesiosis is a tick-borne emerging illness caused by Babesia parasites that infect and destroy red blood cells. Babesia microti is the most common Babesia parasite that causes babesiosis in humans. It is endemic in the Northeast and Midwest regions of the United States (U.S. Department of Health and Human Services, 2015). Gener- who do not have other predisposing illnesses. SURVEILLANCE al signs and symptoms of babesiosis are similar Half of children and a quarter of previously SUMMARY to that of influenza, which can result in mis- healthy adults who are infected with B. microti Surveillance History diagnosis. Common symptoms include fever, have no symptoms (Vannier & Krause, 2012). Reportable condition since chills, sweats, fatigue, and headache along Babesiosis became reportable in Texas in 2013 with less common symptoms of cough and 2013. All confirmed and suspect cases are sore throat. Clinical presentation of babesiosis to be reported within 1 week. No cases have Population at Higher Risk varies depending on the status of an indi- been reported by HHD since the disease • Older adults vidual’s immune system. Asymptomatic and became reportable. • Those at risk for renal moderate infections generally occur in people disease, lung disease, or an organ transplant • Those with compro- Disease Transmission infection are advised to refrain from donat- mised immune systems Babesiosis is transmitted by ticks that carry ing blood (U.S. Department of Health and Notable Outbreaks Babesia parasites; B. microti being the most Human Services, 2009). None common. B. microti is spread by Ixodes Reports Investigated Epidemiology in Houston scapularis ticks, which are most commonly 1 found in wooded, brushy, or grassy areas in Babesiosis is rare in Houston and in Texas. Seasonality certain regions and seasons. When a tick bites Since becoming a reportable condition in June, July, and August an individual, the parasite enters the body and 2013, there have been no cases in Houston; has the potential of infecting and destroying Texas had 2 reported cases. In the United Average Cases Per Year red blood cells. The incubation period for the States, the condition is reportable in 27 states, 0 illness can range from 7 days to more than 9 mostly in the Northeast and Midwest where it weeks. Seroprevalence studies show that most is endemic. infections are asymptomatic. In some cases, During 2013, 1,762 cases were reported infected persons without symptoms may have to the Centers for Disease Control and low-level parasitemia for months, possibly for Prevention (CDC). A large majority (95%) longer than a year, making transmission via of the reported cases were from seven states: blood transfusion an issue (Heymann, 2014). Connecticut, Massachusetts, Minnesota, Cases are most often reported in the Midwest New Jersey, New York, Rhode Island, and and Northeast during warm weather months Wisconsin (U.S. Department of Health and when tick bites are most common (U.S. Human Services, 2015). Individuals traveling Department of Health and Human Services, to these states should take precautionary 2015). measures to decrease their likelihood of Transmission of the parasites through blood contracting a tick-borne disease. transfusions has occurred and can happen anywhere and during anytime of the year. Public Health Action There are currently no licensedBabesia tests Public health agencies are responsible for available for screening prospective blood educating the public on the risk of and how to donors. Persons who test positive for Babesia

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prevent tick bites. Public health agencies • Wear light-colored clothing when transmit the bacteria that causes must continue passive surveillance going into areas with ticks so that tick-borne diseases programs to monitor incidence among ticks can be seen on the clothes more • Reduce tick habitats around homes by residents in order to effectively target readily and be removed before attach- removing leaves, brush, and woodpiles prevention campaigns. Investigations ing to the skin around buildings and at the edges of detailing the geographic location where • Wear long-sleeved shirts and tuck yards. Discourage animals that may a tick exposure most likely occurred pants into socks or boot tops carry ticks, such as deer and rodents, provides important information to state • Apply permethrin (which kills ticks from entering backyards by reducing and regional organizations for informing hiding places the public and for posting disease warn- on contact) to clothes or insect repel- ings. No vaccine is available to protect lents containing DEET to clothes and people against babesiosis. People who exposed skin to provide protection; live, work, or travel in tick-infested areas DEET can be used safely on children can take simple steps to help protect and adults, but should be applied ac- themselves against tick bites and cording to Environmental Protection tick-borne infections: Agency (EPA) guidelines to lower the risk of toxicity • Avoid areas that are likely to have ticks, particularly in spring and sum- • Perform a tick check and remove mer when ticks and tick nymphs feed attached ticks. It generally takes a tick 36 hours of attachment to successfully

WORKS CITED Heymann, D. (2014). Control of Communicable Diseases Manual. American Public Health Association. US Department of Health and Human Services. (2009). Babesiosis and the US Blood Supply. Atlanta: Centers for Disease Control and Prevention. US Department of Health and Human Services. (2015). Tickborne Disease of the United States. Atlanta: Centers for Disease Control and Prevention. Vannier, E., & Krause, P. J. (2012). Human Babesiosis. The New England Journal of Medicine, pp. 2397 - 2407.

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Botulism

INTRODUCTION Botulism is a rare but potentially fatal disease caused by the bacterium Clostridium botulinum. The spores of these bacteria, which are present in soil, untreated water, and air, produce toxins in that can cause severe harmful effects when ingested. There are 7 types of botulism toxin (A-G).

Types A, B, E, and rarely F can cause human law, any suspected case of botulism is to be SURVEILLANCE botulism, while the other types cause ani- reported immediately to the health department SUMMARY mal botulism. The most recognized forms of by phone. Since botulism is a rare condition, Surveillance History human botulism are wound, foodborne, and one case of botulism is considered an outbreak Reportable condition since infant (World Health Organization, 2013). situation. 1947 Symptoms of botulism include double Botulism symptoms are similar to those or blurred vision, drooping eyelids, slurred of other neurological diseases, such as Population at Higher Risk speech, difficulty swallowing, dry mouth, and Guillain-Barré syndrome, stroke, chemical Everyone, especially infants and injection drug users muscle weakness. The most common type intoxication, or myasthenia gravis (Arnon, et is infant botulism, which is characterized by al., 2001). Clinicians should immediately treat Notable Outbreaks symptoms like constipation, drooling, weak- patients with suspected botulism and not wait None ness, respiratory distress, and lack of appetite. for laboratory confirmation, which may take Reports Investigated If botulism is not treated immediately, it can days. The laboratory criteria for diagnosis are 9 lead to severe muscle paralysis (WHO, 2013). the detection of toxin in serum, stool, or con- Seasonality Botulinum toxin, the most potent naturally taminated food or the isolation of the bacteria None occurring toxin, is among the top five from stool (Center for Disease Control and potential bioterrorism agents. Per Texas state Prevention, 2006). Average Cases Per Year 0 Disease Transmission caused by contaminated food, often The transmission routes, common sources, home-canned foods with low acid content, and incubation periods of the different types improperly canned foods, foil-wrapped of botulism are described below in Table 1 baked potatoes, and fermented seafood. (WHO, 2013). In wound botulism, the bacteria spores Botulism is not spread person-to-person. enter an open wound and produce toxin. C. botulinum spores are common in soil and Wound botulism is common among injection elsewhere in the environment, including on drug users. Inhalation botulism is caused by vegetables. Botulism is primarily acquired breathing in botulism toxins in the air. These by eating spore-contaminated food. The toxins can be introduced into the air acci- consumption of honey, corn syrup, and dentally or deliberately by terrorists (WHO, home-canned vegetables are common causes 2013). of infant botulism. Foodborne botulism is

TYPE OF BOTULISM COMMON SOURCES OF INFECTION PERCENTAGE OF TOTAL BOTULISM CASES INCUBATION PERIOD Infant Honey, corn syrup, home-canned vegetables 65% 3 to 30 days Wound Black-tar heroin; open wounds 20% 14+ days Foodborne Home-canned foods (low acid content), fermented seafood 15% 1 to 3 days Inhalation Accidental laboratory exposure; bioterrorism Rare 1 to 3 days

TABLE 1. Botulism by type, common source of infection, prevalence, and incubation period.

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Epidemiology in Houston pressure canner for low-acid vegetables, meat, fish, and poultry. From 2005 to 2014, Houston had only one case of Boiling water canners cannot eliminate the spores. The United botulism; in 2008, an infant contracted the disease. The case States Department of Agriculture has detailed, step-by-step investigation was unable to find the source of infection. In the instructions to properly can foods (National Center for Home same time frame, Texas reported 65 cases, 49 of which were Food Preservation, 2009). infant botulism. The Texas cases were reported throughout the CDC advises consumers to discard any suspicious home- state, though a considerable amount (20%) was reported in canned foods. Home-canned food, even if it looks, smells, or El Paso County (Texas Department of State Health Services, tastes normal, may have C. botulinum. Containers that are 2015). In the United States, an average of 145 cases are report- damaged or altered should be thrown away. The same guide- ed annually to CDC, 65% of which are infant botulism, 20% line applies to canned foods that are moldy, foul-smelling, or are wound, and 15% are foodborne (CDC, 2015). discolored (CDC, 2015). In the United States, home-canned vegetables are the most To prevent infant botulism, parents and caregivers should common source in botulism outbreaks. From 1996 to 2008, avoid feeding infants honey, including honey-coated pacifiers, there were 116 outbreaks caused by foodborne botulism. as the honey can be contaminated with C. botulinum spores. Home-prepared foods were the cause in 48 outbreaks, of which For wound botulism, the primary prevention is to avoid inject- 18 were traced to home-canned vegetables (CDC, 2012). ing drugs and get immediate treatment for infected wounds (Texas Department of State Health Services, 2015). Public Health Action Botulism is treated by supportive care and antitoxin. Antitoxin for non-infant botulism is available through the While C. botulinum spores are heat-resistant (WHO, 2013), CDC’s Strategic National Stockpile at 20 CDC quarantine the harmful toxin released by the spores can be destroyed by stations around the nation, including Houston. Antitoxin for heating contaminated food or water to an internal tempera- infant botulism is available through the California Department ture of 185°F (85°C) for at least five minutes. People who eat of Health (CDC, 2015). Antitoxin is not readily available home-canned foods (e.g. low acidic, non-pickled foods) should to the general public. Clinicians who suspect botulism in a boil the food before eating it. The bacteria do not grow in patient must request the antitoxin immediately. When taken acidic environments, so toxins will not be generated in acidic early, antitoxin can speed up recovery and reduce severity of foods. However, a low pH cannot destroy pre-formed toxin. symptoms (National Institutes of Health, 2014). Pickling, sugar syrup, or sufficient brining should prevent the growth of C. botulinum. CDC recommends always using a

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WORKS CITED Arnon, S. S., Schechter, R., Inglesby, T., Henderson, D. A., Bartlett, J. G., Ascher, M. S., et al. (2001). Botulinum Toxin as a Biological Weapon: Medical and Public Health Management. JAMA, pp. 1059 - 1070. CDC. (2006, October 6). Botulism: Diagnosis & Laboratory Guidance for Clinicians. Emergency Preparedness and Response: Retrieved from www.emergency.cdc.gov/ agent/Botulism/clinicians/diagnosis.asp. CDC. (2012, July 26). Consumer Information and Resources. National Center for Emerging and Zoonotic Infectious Diseases. Retrieved from www.cdc.gov/nczved/ divisions/dfbmd/diseases/botulism/consumers.html. CDC. (2015, July 30). Home Canning and Botulism. Retrieved from www.cdc.gov/ features/homecanning/. CDC. (2015, August 11). National Botulism Surveillance. National Surveillance of Bacterial Foodborne Illnesses (Enteric Diseases). Retrieved from www.cdc.gov/ nationalsurveillance/botulism-surveillance.html. CDC. (2015, October 2). Our Formulary. CDC Drug Service. Retrieved from www.cdc.gov/laboratory/drugservice/formulary.html. DSHS. (2015, December 11). Botulism Cases and Incidence Rates in Texas, 2001-2014. Infectious Disease Control. Retrieved from www.dshs.state.tx.us/ IDCU/disease/botulism/Data.doc. FoodSafety.gov. (n.d.). Botulism. Retrieved from www.foodsafety.gov/poisoning/ causes/bacteriaviruses/botulism/. NCHFP. (2009, December). USDA Complete Guide to Home Canning, 2009. USDA Publications. Retrieved from www:/nchfp.uga.edu/publications/publications_ usda.html. NIH. (2014, April 25). Facts about Botulism. National Institute of Allergy and Infectious Diseases. Retrieved from www.niaid.nih.gov/topics/botulism/pages/ default.aspx. Passaro, D. J., Werner, B., McGee, J., MacKenzie, W. R., & Vugia, D. J. (1998). Wound Botulism Associated With Black Tar Heroin Among Injecting Drug Users. JAMA, pp. 859 - 863. Texas Department of State Health Services. (2015, April 14). Botulism. Infectious Disease Control. Retrieved from www.dshs.state.tx.us/idcu/disease/botulism/. WHO. (2013, August). Fact sheets. Retrieved from www.who.int/mediacentre/factsheets/fs270/en/.

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Brucellosis

INTRODUCTION Brucellosis is a bacterial illness characterized by an acute onset of fever, night sweats, fatigue, anorexia, weight loss, headache, and painful joints. Severe infections of the central nervous system (CNS) or lining of the heart may occur. It is also called undulant fever since the fever is intermittent or irregular. Brucellosis is found worldwide but is bacteria, including B. arbortus, B. melitensis, SURVEILLANCE more prominent in Mediterranean countries, and B. suis, are pathogenic to humans. SUMMARY the Middle East, Africa, Central and South Brucella reservoirs include cattle, goats, sheep, Surveillance History America, and Central Asia (Centers for pigs, horses, bison, elk, caribou, some deer, Reportable condition since Disease Control and Prevention, 2012) and dogs (CDC, 2012; Heymann, 2008). 1944 (Heymann, 2008). Six species of Brucella Population at Higher Risk • Animal handlers Disease Transmission Epidemiology in Houston • Persons who consume Humans become infected with brucellosis by Human brucellosis is a rare disease in the unpasteurized milk coming into contact with animals or animal United States, with only 100 to 200 cases Notable Outbreaks products that are contaminated with Brucella per year. From 2005 to 2014, there were 157 None bacteria. Brucellosis is most commonly ac- brucellosis cases reported in the state of Texas quired by ingesting contaminated dairy prod- (CDC, 2012, Texas Department of States Reports Investigated ucts, such as unpasteurized milk or cheese. Health Services, 2015). 44 Contact with infected animal tissues and Brucella infections are rarely reported in Seasonality bodily fluids, such as blood, urine, discharge, Houston. Between 2005 and 2014, a total of Summer and spring and placentas, is another mode of transmis- 12 cases of brucellosis were reported in Average Cases Per Year sion. Breathing in bacteria present in the 1 environment, usually within slaughterhouses, may also lead to infection. No reports of person-to-person transmission of the bacteria have been documented. It typically takes one BRUCELLOSIS CASE COUNT to two months for brucellosis to develop after 4 exposure (CDC, 2012; Heymann, 2008). Brucella is considered a Class B bioterrorism agent by CDC. Category B includes the second highest priority agents that pose a risk to 3 national security due to the following features: being moderately easy to disseminate, causing moderate morbidity and low mortality, and 2 requiring specific enhancement of laboratory COUNT diagnostic capacity and enhanced disease surveillance. It can be spread for bioterrorism activities by contaminating foods or used as 1 an aerosol for inhalation (Texas Department of States Health Services, 2015; Yagupsky

& Baron, 2005; Southern Illinois School of 0 Medicine, 2010). 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

FIGURE 1. Brucellosis case count in Houston.

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Houston residents, as seen in Figure tested for Brucella at HHD laboratory; involve Public Health Preparedness and 1. Of the 12 cases, 11 were persons of none were positive for the organism. law enforcement, including the FBI and Hispanic ethnicity. Homeland Security. Most of the infections (75%) were Public Health Action Fortunately, treatment of brucellosis due to B. melitensis, while the remaining Public health action consists of passive does exist, consisting of six weeks cases were not typed (17%) or due to B. surveillance, in which hospitals, clinics, of 600 to 900 mg of rifampicin daily canis (8%). Five of the brucellosis cases and laboratories report positive cases combined with doxycycline 200 mg reported travel history, three reported to HHD, and the infected persons are (Heymann, 2008). consuming unpasteurized food products, interviewed. If there were an outbreak Prevention strategies for brucellosis and two reported contact with animal of brucellosis, HHD would enhance include: bodily fluids. surveillance, notifying doctors and hos- • Avoiding unpasteurized dairy products pitals of an unusual incidence of disease, Laboratory Testing (raw goat milk, unpasteurized milk requesting them to consider brucellosis or cheese made from unpasteurized While many laboratory tests are avail- as part of the differential diagnosis milk). able, such as standard agglutination tests of febrile patients, and to report in a and ELISA, PCR has been shown to timely manner all suspected cases. HHD • Wearing appropriate protective gear have superior specificity and sensitivity. would pursue confirmation of the source when handling feral swine and animal Houston has the ability to conduct PCR of infection in a given case and close carcasses. testing on Brucella as well as traditional contacts through follow-up interviews • Providing adequate ventilation in culturing. A positive PCR result gives a for exposure history. Epidemiologists slaughterhouses, butcher shops, and presumptive identification but does not would then assess the extent of disease meat processing plants. determine the species. Culture testing is transmission through possible serological • Disinfecting areas contaminated with required for confirmatory results and is screening of the household occupants animal body fluids. based on the results for hydrogen sulfide and other close contacts of the case. production, urease, gel formation, lysis BOE would also assess if the infection • Tracing the source of infection to by Tbilisi phage and PCR results. Each was naturally occurring or intentionally prevent additional exposures. species has distinct results for these tests. introduced into the environment. If • Testing and immunizing suspected Table 1 shows the number of specimens bioterrorism were suspected, HHD will animals (Heymann, 2008).

TABLE 1. BRUCELLA TESTING AT HHD LABORATORY To prevent brucellosis cases from 2006 2007 2008 2009 2010 2011 2012 2013 2014 occurring, public education about the health risks of contact with animals and 6 5 1 4 8 4 5 4 2 animal products is vital. Education is especially important among persons who are more likely to consume unpas- WORKS CITED teurized food products, such as special Centers for Disease Control and Prevention. (2012, November 12). Brucellosis. ethnic foods. BOE has received reports Centers for Disease Control and Prevention, Retrieved from www.cdc.gov/ of unlicensed street vendors who have brucellosis/. sold unpasteurized dairy products imported from other countries, unwittingly Heymann, D. L. (2008). Brucellosis. Control of Communicable Diseases Manual. spreading disease to households and Washington, D.C.: American Public Health Association, pp. 87 - 90. communities in Houston. BOE works Southern Illinois School of Medicine. (2010). Overview of Potential Agents of closely with the Bureau of Consumer Biological Terrorism. Southern Illinois School of Medicine, Department of Internal Health in the investigation when such Medicine, Division of Infectious Disease. Retrieved from www.siumed.edu/ situations occur to find and eliminate medicine/id/bioterrorism.htm#b. sources of infection (Heymann, 2008). Texas Department of States Health Services. (2015, June 29). Zoonotic Disease- Human Cases for the Last Ten Years. Texas Department of States Health Services, Retrieved from www.dshs.state.tx.us/idcu/health/zoonosis/disease/Cases/. Yagupsky, P., & Baron, E. J. (2005). Laboratory Exposures to Brucellae and Implications for Bioterrorism. Emerging Infectious Diseases, pp. 1180 - 1185.

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Campylobacteriosis

INTRODUCTION Campylobacteriosis is caused by Campylobacter, a bacterium found in the gastrointestinal tracts of animals, including chickens, cows, and dogs. The disease causes a broad range of symptoms, from self-limited gastroenteritis to septicemia, or infection of the blood. It is possible but rare for campylobacteriosis to cause death. Asymp- and chronic infections. Campylobacter SURVEILLANCE tomatic cases can also occur. CDC estimates occasionally spreads to the bloodstream and SUMMARY that approximately 100 Americans die from causes a serious life-threating infection. Surveillance History campylobacteriosis each year (Mead, et al., Campylobacteriosis has been reportable in Reportable condition since 1999). Texas since 1985. Confirmed cases should be 1985 Campylobacteriosis is an acute zoonotic reported to the state or local health department disease that varies in severity. The disease is within one week of laboratory confirmation. Population at Higher Risk characterized by diarrhea (occasionally watery A presumptive test for campylobacteriosis • Persons with poor food handling practices and bloody), abdominal pain, malaise, fever, consists of visualization of spiral-shaped bacte- nausea, and vomiting. The symptoms usually ria in specimens. A confirmation test consists • Persons who consumed resolve in 2 to 5 days, but can last as long as of isolation of Campylobacter from stool or contamined food or drink 10 days. Adults are more susceptible to relapse blood specimens. Notable Outbreaks None Disease Transmission cases of campylobacteriosis in Houston Reports Investigated Campylobacteriosis is commonly transmitted (Figure 1). Cases frequently go undiagnosed 1,345 when contaminated food or drink is ingested. or unreported due to several factors, including The bacteria are commonly found on chickens persons who are ill who do not seek medical Seasonality that often do not show any signs of illness. attention, and providers who do not submit Summer and spring required reports to the health department. Approximately half of all raw chicken found Average Cases Per Year Electronic lab reporting has alleviated much in grocery stores are contaminated with the 106 bacteria (Center for Disease Control, 2014). of the concern with the latter issue, as the lab Poor handwashing and improper kitchen hygiene are frequently involved in the transmission of the disease. Mishandling of raw poultry and consumption of undercooked poultry are major risk factors for human campylobacteriosis. Contamination occurs when poultry and raw meats are handled or processed without subsequent careful washing of hands, cutting boards, utensils, or counter tops that have come into contact with the bacteria. Sick animals such as dogs, cats, and farm animals can also be sources of infection. However, Campylobacter is not usually transmitted from person to person.

Epidemiology in Houston From 2005 to 2014, there were 1,067 reported

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CAMPYLOBACTERIOSIS CASE COUNT CAMPYLOBACTERIOSIS DISTRIBUTION BY AGE

160

120

80 COUNT DENSITY

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 25 50 75 AGE FIGURE 1. Campylobacteriosis case count in Houston. FIGURE 2. Campylobacteriosis case count by age.

results are now automatically transmitted to HHD. Still, recent Children aged 5 and under are at the highest risk of estimates suggest that the true burden of the disease is under- contracting the disease (Figure 2) due to less developed im- reported by a factor of 30, which suggests that approximately mune systems when compared to healthy adults. In addition, 30,000 cases occurred within the City of Houston (Scallan, et children are more likely to practice unhygienic behaviors. al., 2011). Campylobacteriosis afflicts all sections of Houston, as seen in Campylobacteriosis is seasonal in Houston with the highest Figure 3. Large outbreaks in a small area are relatively uncom- number of cases in the spring and summer. The incidence mon. Generally, Campylobacter is contracted when consuming generally begins to increase in April, peaks in July, and tapers undercooked poultry or food contaminated by raw chicken. off in the fall and winter months. The geographic spread of campylobacteriosis suggests that the

FIGURE 3. Campylobacteriosis counts by zip for 2010 to 2014.

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more rural parts of Houston are disproportionately affected.

WORKS CITED CDC. (2014, June 3). Campylobacter. Retrieved from www.cdc.gov/nczved/divisions/ dfbmd/diseases/campylobacter/. Mead, P., Slutsker, L., Dietz, V., McCaig, L., Bresee, J., & Shapiro, C. (1999). Food-Related Illness and Death in the United States. Emerging Infectious Disease. Scallan, E., Hoekstra, R. M., Angulo, F. J., Tauxe, R. V., Widdowson, M.-A., Roy, S. L., . . . Griffin, P. M. (2011). Foodborne Illness Acquired in the United States–Ma- jor Pathogens. Emerging Infectious Diseases, pp. 7 - 15.

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Chagas Disease

INTRODUCTION Chagas disease is a potentially life-threatening disease caused by the parasite Trypanosoma cruzi, which is transmitted to animals and people by insects, (Figure 1) that are found mainly in rural areas of Latin America where poverty is widespread (Bern, 2015). Chagas an emerging disease in

SURVEILLANCE SUMMARY

Surveillance History Reportable condition since 2013

Population at Higher Risk Originate in endemic foreign countries

Notable Outbreaks None FIGURE 1. Rhodnius prolixus in the nymph stages through to adult (Wikipedia, 2015). Reports Investigated 19 the United States (Nunes, Dones, Morillo, This phase is also characterized by undetect- Encina, & Ribero) and became reportable in able parasites in the blood. Individuals in this Seasonality Texas in 2013. Chagas disease has two phases phase will develop debilitating and sometimes Summer and spring (World Health Organization, 2015). The first life-threatening medical problems over the Average Cases Per Year phase is acute and lasts for about two months course of their lives. These medical problems 1 after infection (WHO, 2015). The hallmark may include: heart rhythm abnormalities that of the acute phase is detectable parasites in the can cause sudden death, a dilated heart that blood (Bern, 2015). Though a high number of does not pump blood well, and/or a dilated parasites circulate in the blood, in most cases esophagus or colon, leading to difficulties with symptoms are absent or mild. Characteristic eating or passing stool (Texas Department of first visible signs can be a skin lesion or a State Health Services, 2015). purplish swelling of the lids of one eye, fever, Diagnosis of acute infection is based on the headache, enlarged lymph glands, pallor, mus- microscopic detection of the parasite in blood. cle pain, difficulty in breathing, swelling and During the chronic phase, because parasitemia abdominal or chest pain (WHO, 2015). is scarce, diagnosis requires the detection of Following the acute phase, most infected IgG antibodies against T. cruzi antigens by at people enter the indeterminate (asymptomat- least two different serological methods (Rassi ic) form of the chronic phase (called “chronic Jr, 2010). indeterminate”) during which few or no para- The most important consequence of chronic sites are found in the blood. During this time, T. cruzi infection is dilated cardiomyopathy most people are unaware of their infection. (Nunes, Dones, Morillo, Encina, & Ribeiro, Many people remain asymptomatic for life 2013), which occurs in 20 to 30% of infected and never develop chronic symptoms (Texas persons (Bern, 2015) (Garcia, et al., 2015). Department of State Health Services, 2015). Cardiologists in the US should consider Among those with the indeterminate Chagas disease in their differential diagnoses chronic form, about 20 to 30% of patients for patients who may have clinically progress to the chronic symptomatic phase.

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compatible EKG changes or nonischemic cardiomyopathy, the United States (Albajar-Vinas & Dias, 2014). Rising immi- even if the patients have no histories of residing in Chagas- gration from Latin American countries (Albajar-Vinas & Dias, endemic countries (Garcia, et al., 2015). 2014) and climate changes that make the United States more The World Health Organization (WHO) estimates that 8 hospitable to its insect vectors are making Chagas disease a to 10 million people are infected worldwide, mostly in Latin significant threat to public health (Kuehn, 2015). America where the disease is endemic (CDC, 2013; Nunes, Since national blood donor screening began in 2007, Dones, Morillo, Encina, & Ribeiro, 2013; Manne-Goehler, approximately 2,000 infected donors have been identified in Ramsey, Salgado, Wirtz, & Reich, 2014). the U.S. (Garcia, et al., 2015). The majority of infected US As many as 8 million people in Latin America have Chagas residents are Latin American immigrants who were infected in disease, most of whom do not know they are infected. If un- their home countries (Bern, 2015). CDC estimates that treated, infection is lifelong and can be life threatening (CDC, Chagas disease affects 300,000 US residents who have emigrat- 2013). ed from Latin American countries (Bern, 2015) and contributes Chagas disease is a serious health problem in Latin America to about 30,000 to 45,000 cases of cardiomyopathy in the and is an emerging disease in non-endemic countries, including United States each year (Kuehn, 2015).

Disease Transmission or childbirth, organ transplants using organs from infected In Latin AmericaT. cruzi parasites are mainly transmitted by donors, and laboratory accidents (WHO, 2015). contact with triatomine bugs. These bugs typically live in the Up to 10% of infected mothers transmit the parasite to cracks of poorly-constructed homes in rural or suburban areas. their infants (Yadon & Schmunis, 2009). They usually bite an exposed area of skin such as the face, and the bug defecates close to the bite. The parasites enter the Epidemiology in Houston body when the person inadvertently smears the bug feces into CDC recently reported rare cases of domestically acquired the bite, the eyes, the mouth, or into any skin break (WHO, infection from a large nationwide follow-up study of infected 2015). blood donors. In addition to those cases, a study by Garcia et In addition to triatomine bugs, al. of blood donors in the Houston area found 35% (6 of 17) T. cruzi can also be transmitted by consumption of food con- with evidence of locally, within the United States, acquired in- taminated with T. cruzi through contact with infected triatom- fection. Their findings suggest an unrecognized risk of human ine bug feces, blood transfusion from infected donors, passage vector-borne transmission in southeast Texas. The authors con- from an infected mother to her newborn during pregnancy cluded that education of physicians and public health officials

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is crucial for identifying the true disease WORKS CITED burden and source of infection in Texas Albajar-Vinas, P., & Dias, J. C. (2014, May 15). Advancing the Treatment for (Garcia, et al., 2014). This study sug- Chagas’ Disease. The New England Journal of Medicine, pp. 1942 - 1943. gests that the true prevalence of Chagas disease is much higher than reported. Bern, C. (2015, July 30). Chagas’ Disease. The New England Journal of Medicine, In Houston, from 2005 to 2014, 5 pp. 456 - 466. cases of chronic indeterminate disease, and 3 cases of chronic symptomatic dis- CDC - Chagas Disease. (2013, July 13). Retrieved from www.cdc.gov/parasites/ ease were reported to HHD. All 8 cases chagas/. occurred during 2013 and 2014 and in Garcia, M. N., Aguilar, D., Gorchakov, R., Rossmann, S. N., Montgomery, S. P., adults aged 40 and above. This number Rivera, H., . . . Murray, K. (2014, November 4). Case Report: Evidence of is likely to be an underestimation due Autochthonous Chagas Disease in Southeastern Texas. American Journal of Tropical to disease underreporting and minimal Medicine and Hygiene. physician awareness about the disease. Garcia, M., Murray, K., Hotez, P., Rossmann, S., Gorchakov, R., Ontiveros, A.,... Public Health Action Agular, D. (2015). Development of Chagas Cardiac Manifestations Among Texas In endemic areas, improved housing and Blood Donors. The American Journal of Cardiology,. pp. 113 - 117. spraying insecticide inside housing to eliminate triatomine bugs has signifi- Kuehn, B. (2015, March). Putting Chagas Disease on the US Radar Screen. JAMA, cantly decreased the spread of Chagas pp. 1195 - 1197. disease. Further, screening of blood do- Manne, J., Snively, C., Ramsey, J., Salgado, M., Barnighausen, T., & Reich, M. nations for Chagas is another important (2013, October). Barriers to Treatment Access for Chagas Disease in Mexico. PLoS public health tool in helping to prevent Neglected Tropical Diseases, pp. 1 - 10. transfusion-acquired disease. Early detection and treatment of new cases, Manne-Goehler, J., Ramsey, J. M., Salgado, M. O., Wirtz, V. J., & Reich, M. R. including mother-to-baby (congenital) (2014, September 29). Short Report: Increasing Access to Treatment for Chagas cases, will also help reduce the burden of Disease: The Case of Morelos, Mexico.American Journal of Tropical Medicine and disease (CDC, 2013). Hygiene, pp. 1125 - 1127. The currently available drugs for Chagas disease are benznidazole and ni- Nunes, M. C., Dones, W., Morillo, C. A., Encina, J. J., & Ribeiro, A. L. (2013, furtimox, which are effective in the acute November 9). Chagas Disease. Journal of the American College of Cardiology, phase but have shown mixed results in pp. 767 - 776. individuals with chronic infection, and are associated with adverse reactions in Rassi Jr, A. M.-N. (2010, April 17). Chagas disease. Lancet, pp. 1388 - 1402. 20 to 40% of patients. Thus, new drugs Sasagawa, E., Aiga, H., Soriano, E., Marroquin, B., Ramirez, M., Aguilar, A.,... or treatment strategies are needed Kita, K. (2015). Mother-to-Child Transmission of Chagas Disease in El Salvador. (Albajar-Vinas & Dias, 2014; Bern, American Journal of Tropical Medicin and Hygiene, pp. 326 - 333. 2015). Texas Department of State Health Services. (2015). Epi Case Criteria Guide, 2015. Austin.

World Health Organization. Chagas disease. (2015). Retrieved from www.who.int/ topics/chagas_disease/en/.

Yadon, Z., & Schmunis, G. (2009). Congenital Chagas Disease: Estimating thePo- tential Risk in the United States. The American Journal of Tropical Medicine and Hygiene, pp. 927 - 933.

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Chancroid

INTRODUCTION Chancroid is a sexually transmitted disease caused by the bacterium Haemophilus ducreyi. Chancroid is more common in developing countries, such as Asia, Africa, and the Caribbean. Though it is rare in industrialized countries, outbreaks occur sporadically (Center for Disease Control, and Prevention, 2015). The incubation period herpes and syphilis, clinicians not familiar SURVEILLANCE for chancroid is 4 to 14 days. A fluid-filled with the disease may misdiagnose chancroid SUMMARY bump (pustule) forms on the genitals, which patients. While a culture test can confirm the Surveillance History turns into an ulcer (open sore). The ulcer, presence of H. ducreyi, the test is not widely Reportable condition since called chancre, is soft-edged and painful, available in commercial labs. CDC indicates a 1944 which is a characteristic sign of the disease. probable diagnosis of chancroid can be made This is contrast to ulcers seen in syphilis if the following criteria are met: a) the patient Population at Higher Risk patients, which are generally hard-edged and has one or more painful ulcers; b) the clinical • Sex workers painless. When left untreated, the lymph symptoms are typical of chancroid; c) the • Clients of sex workers nodes in the groin may swell, causing adenitis. patient does not have syphilis (T. pallidum) as Notable Outbreaks Other symptoms include vaginal discharge, confirmed by a serologic test done after seven None rectal bleeding, and pain while urinating, def- days of onset of the ulcers; and d) a herpes Reports Investigated ecating, or having sex. Chancroid is treatable test done on the ulcer exudate is negative. 2 with antibiotics (CDC, 2014). Chancroid is to be reported to the health Since the ulcers are similar to those of department within one week (CDC, 2015). Seasonality None

Disease Transmission transmitted infections, chancroid has a lower Average Cases Per Year 2 Most people in the United States who contract infectivity rate (WHO, 2001). chancroid have a history of recent travel to a country where the infection is prevalent. Epidemiology in Houston Chancroid is generally transmitted by sexual Chancroid is rare in Houston, which recorded contact, including oral, vaginal, and anal. an average of 2 cases per year during 2005 Nonsexual transmission occurs when the to 2014. In the same time frame, Texas had pus from the ulcer comes into contact with an average of 5 cases per year (CDC, 2014) another person. and the United State had approximately 19 Uncircumcised males have a higher risk cases per year (CDC, 2014). Since reliable lab of contracting chancroid and other sexually tests are not widely available for H. ducreyi, transmitted infections. The warm, moist envi- the disease is likely under-diagnosed. Hence, ronment under the foreskin may play a role in the actual case counts may be higher (CDC, increasing the growth of pathogens. Moreover, 2015). a person with chancroid has a higher risk of While rates are at historic lows, Houston contracting HIV. Genital ulcers can bleed continues to have disproportionately higher during sex, and when the blood comes into numbers relative to other major cities. The contact with the mouth or genitals, it can lead reason for this is unclear, but has been consis- to HIV transmission (Weiss, Thomas, tent since the 1990s when Houston, Dallas, Munabi, & Hayes, 2006). New Orleans, and New York City accounted In other countries, chancroid has been for 62% of all US cases (Borchardt, Kenneth, commonly observed in sex workers and & Noble, 1997). their clients. Compared to other sexually

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In the late 1980s, Houston recorded a time, with a partner who has been tested sexual contact in the 10 days prior to chancroid outbreak of 35 cases. All cases and known to be uninfected. Individuals the onset of the patient’s symptoms were diagnosed in black men. Eighteen who have multiple sexual partners have a (CDC, 2015). cases were confirmed through medi- higher risk of contracting STDs. STD testing is recommended prior cal record abstraction and laboratory Chancroid is treatable with the appro- to having sex with a new partner. The confirmation. The patients were treated priate antibiotic regimen (azithromycin, Houston Health Department offers using antibiotics, and were cured within ceftriaxone, ciprofloxacin, or erythromy- confidential HIV/STD testing at 2 to 3 weeks (Jones, Rosen, Clarridge, & cin). Symptoms usually resolve within a its Northside, Sharpstown, and Collins, 1990). week while on antibiotic therapy. Sunnyside Health Centers. The depart- Patients who do not respond to treatment’s mobile clinic also offers testing Public Health Action ment include those who have coinfec- and education at select sites in the Male latex condoms, when used tions, those who do not follow the Houston area. consistently and correctly, can reduce the recommended dosage, or those whose risk of contracting chancroid. CDC also who have an antibiotic-resistant recommends mutual monogamy, or the infection. Sexual contacts of a chancroid practice of having one sexual partner at a patient should be treated if they had

WORKS CITED Borchardt, Kenneth, & Noble, M. (1997). Sexually Transmitted Diseases: Epidemiology Pathology, Diagnosis, and Treatment. CRC Press. CDC. (2014, December 16). 2013 Sexually Transmitted Diseases Surveillance. Retrieved from www.cdc.gov/std/stats13/tables/1.htm. CDC. (2014, May 29). Chancroid. Retrieved from www.cdc.gov/immigrantrefugee- health/guidelines/domestic/sexually-transmitted-diseases/chancroid.html. CDC. (2014, December 16). Sexually Transmitted Diseases (STDs). Retrieved from www.cdc.gov/std/stats/archive.htm. CDC. (2015, November 17). 2014 Sexually Transmitted Diseases Surveillance. Retrieved from www.cdc.gov/std/stats14/other.htm#chancroid. CDC. (2015, June 4). Chancroid. 2015 Sexually Transmitted Diseases Treatment Guidelines, Retrieved from http://www.cdc.gov/std/tg2015/chancroid.htm. Jones, C., Rosen, T., Clarridge, J., & Collins, S. (1990). Chancroid: Results from an Outbreak in Houston, Texas. Southern Medical Journal, 83(12), pp. 1384 - 1389. Weiss, H. A., Thomas, S. L., Munabi, S. K., & Hayes, R. J. (2006). Male circumcision and risk of syphilis, chancroid, and genital herpes: a systematic review and meta‐analysis. Sexually Transmitted Infections, pp. 101 - 110. WHO. (2001). Eradicating chancroid. Public Health Reviews, 79(9), Retrieved from www.who.int/bulletin/archives/79(9)818.pdf, pp. 818 - 826.

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Chickungunya

INTRODUCTION Chikungunya is a virus spread by mosquitoes (Murray, 2014). It was first identified in Tanzania in 1952. Chikungunya means “that which bends up” in a local Tanzanian language, referring to the bent over posture as a result of the joint pain (Center for Disease Control and

Prevention, 2014). In the United States, it weeks to years in some patients. For public SURVEILLANCE is usually acquired by travelers to countries health surveillance purposes, a chikungunya SUMMARY where the virus is endemic. Symptoms include case is considered confirmed if it meets clini- Surveillance History fever, joint pain, headache, muscle pain, joint cal and laboratory criteria (CDC, 2015). Reportable condition since swelling, and rash. Fever and joint pain are Persons at risk for more severe disease 2015 the most common symptoms. Dengue has include infants, the elderly, and immuno- similar symptoms, and in some cases, patients compromised persons. There is no treat- Population at Higher Risk with chikungunya may be misdiagnosed as ment for the virus, other than supportive Persons traveling to tropical and subtropical having dengue. The disease is rarely fatal. An care. Chikungunya is to be reported to the areas individual generally recovers within a week health department within one week of and is immune to the virus for life, (CDC, diagnosis. Notable Outbreaks 2015). However, the joint pain can persist for None Reports Investigated 20 Disease Transmission the time of disease onset was 46 years, with a range of 8 to 69 years. Of the 14 patients, 4 Seasonality Chikungunya has been reported in over 60 None countries worldwide. The incubation period were hospitalized, 7 did not require hospi- is 4 to 7 days. Aedes aegypti and Aedes aegypti talization, and 3 did not have hospitalization Average Cases Per Year mosquitoes — which can also carry dengue information. 2 — commonly spread the virus to humans. Before 2006, the virus was rarely reported These mosquitoes generally bite humans in U.S. travelers. From 2006 to 2013, there during the daytime, but can also bite at night. was an average of 28 people per year in the Mosquitoes can acquire the virus after biting U.S. who were infected with the virus, all of an infected person, and can subsequently whom were travelers to endemic countries. transmit the virus to other people (Vega-Rua, The first local transmission of the virus in the et al., 2015). In rare cases, chikungunya can be transmitted from mother-to-child at the time of birth. It can theoretically spread via blood transfusions, though no documented cases exist to verify this mechanism (CDC, 2015). 14 PATIENTS WITH CHIKUNGUNYA

Epidemiology in Houston 8 Acquired in El Salvador

No cases of chikungunya had been reported in 2 Acquired in South America Houston until 2014, when Houston recorded 14 cases. All 14 patients acquired the virus 4 Acquired in the Caribbean outside the country; 8 acquired the virus in El Salvador, 2 in South America, and 4 in the Caribbean. The average age of the patients at

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Western Hemisphere occurred in Public Health Action and insect repellant, the sunscreen must December 2013 in the Caribbean. Mosquito bite prevention is the best be applied first (CDC, 2015). The 2013 virus spread throughout the strategy to protect oneself from chi- Individuals traveling to tropical areas Caribbean, causing an outbreak. kungunya. There is no vaccine for should wear long-sleeve shirts and In 2014, Texas had 114 travel- the disease. CDC recommends using long pants or consider wearing perme- associated cases of chikungunya and EPA-registered insect repellants that thrin-treated clothing. Homes should be the U.S. had 2,788. The first local trans- contain one of the following ingredients: protected against mosquito habitation. mission of the virus occurred in the DEET, Picaridin (KBR 3023, Bayrepel, CDC recommends using window/door United States in July 2014 in Florida, or icaridin), IR3535, oil of lemon eu- screens and to seal off any points of which had 11 locally-acquired cases in calyptus (OLE), or para-menthane-diol entry into the home. Since mosquitoes 2014 (CDC, 2015). (PMD). Natural insect repellants such as thrive in humid environments, it is also essential oils have not been tested for ef- recommended to use air conditioning fectiveness. When using both sunscreen (CDC, 2015).

WORKS CITED CDC. (2014, December 31). Chikungunya: A new mosquito-borne disease hits the Western Hemisphere, including the United States. Global Health Stories. Retrieved from www.cdc.gov/globalhealth/stories/chikungunya.htm. CDC. (2015, July 30). Arboviral diseases, neuroinvasive and non-neuroinvasive. Na- tional Notifiable Diseases Surveillance System (NNDSS). Retrieved from www. cdc.gov/nndss/conditions/arboviral-diseases-neuroinvasive-and-non-neuroinvasive/ case-definition/2015/. CDC. (2015, August 3). Chikungunya Virus. Chikungunya virus in the United States, Retrieved from www.cdc.gov/chikungunya/geo/united-states.html. CDC. (2015, November 27). Fact Sheets and Posters. Chikungunya Virus. Retrieved from www.cdc.gov/chikungunya/fact/index.html. CDC. (2015, August 3). Prevention. Chikungunya virus, Retrieved from www.cdc.gov/chikungunya/prevention/index.html. CDC. (2015, August 3). Symptoms, Diagnosis, & Treatment. Chikungunya Virus, Retrieved from www.cdc.gov/chikungunya/symptoms/. CDC. (2015, August 3). Transmission. Chikungunya Virus. Retrieved from www.cdc.gov/chikungunya/transmission/index.html. Murray, K. (2014, June 11). Texas Children’s Blog, Chikun—What? A Closer Look at the Chikungunya Virus. Retrieved from texaschildrensblog.org/2014/06/chikun- what-a-closer-look-at-the-chikungunya-virus/. Vega-Rua, A., Lourenco-de-Oliveira, R., Mousson, L., Vazeille, M., Fuchs, S., Yebakima, A., et al. (2015). Chikungunya Virus Transmission Potential by Local Aedes Mosquitos in the Americas and Europe. PLoS Neglected Tropical Diseases. WHO. (2015, May). Chikungunya. Retrieved from www.who.int/mediacentre/ factsheets/fs327/en/. World Health Organization. (n.d.). Dengue control. Chikungunya. Retrieved from www.who.int/denguecontrol/arbo-viral/other_arboviral_chikungunya/en/.

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Chlamydia

INTRODUCTION Chlamydia is caused by the bacterium Chlamydia trachomatis. Chlamydia is the most commonly reported sexually transmitted disease seen in the United States today. According to the Centers for Disease Control and Prevention, an estimated 2.9 million Americans suffer from a new chlamydia infection each year. Chlamydia not experience any symptoms. However, when SURVEILLANCE cases are believed to be grossly underreported symptoms do occur, they usually include SUMMARY due to several factors: asymptomatic cases discharge from the genitals and a burning Surveillance History are often undiagnosed and not reported, sensation when urinating. Infected persons Reportable condition since chlamydia may co-exist with gonorrhea and can experience conjunctivitis (red eyes) and 1987 infections may be reported only as gonorrhea, an infection of the lymph nodes due to or the provider does not report the case or do chlamydia. Infants born to infected mothers Population at Higher Risk laboratory tests for chlamydia. Confirmed are also known to experience conjunctivitis, as • Men who have sex with men cases of chlamydia are identified through well as pneumonia (CDC, Chlamydia, 2015). isolation of the serology tests or organism Complications are uncommon in men. • Sexually active women 25 and older (Centers for Disease Control and Prevention, If complications do occur they may include 2015). epididymitis, characterized by pain and • Pregnant women under 25 Men, women, and infants are affected, but swelling in the testicles, and a syndrome called women bear a disproportionate burden due Reactive Arthritis (CDC, 2015). Notable Outbreaks to their increased risk for adverse reproductive Men and women can also get infected with None consequences, such as pelvic inflammatory chlamydia in their rectum, either by having Reports Investigated disease, ectopic pregnancy, and transmission receptive anal sex, or by spread from another 11,441 to neonates during pregnancy and delivery infected site. Often an infection at this site Seasonality (Texas Department of States Health Services, also has no symptoms, though the most com- None 2014). mon symptoms include rectal pain, discharge, Most people infected with chlamydia have and bleeding (CDC, 2015). Average Cases Per Year no symptoms. CDC estimates as many as 19,515 90% of males and 70% to 95% of females will

Disease Transmission Certain risk factors associated with Chlamydia can infect anyone who is sexually chlamydia transmission include new or active. Exposure to chlamydia can occur multiple sex partners, adolescence, being a through vaginal, anal, or oral sex or congen- young woman, presence of another STD, itally from an infected mother to her child history of STD infection, and lack of barrier during a vaginal birth. After exposure to the contraception. People who have been success- bacteria there is a 7- to 21-day incubation fully treated for chlamydia may become re- period preceding symptoms. Transmission infected if they engage in sexual contact with from an infected mother to her child results in an infected person. Chlamydia infection can neonatal conjunctivitis in 30% to 50% of facilitate the transmission of HIV (CDC, exposed babes and pneumonia in 3% to 16% 2015). of exposed babies (CDC, 2015).

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CHLAMYDIA CASE COUNT Epidemiology in Houston 25000 Chlamydia trachomatis infection is the most commonly reported notifiable disease in Houston and the United States. It is among the most prevalent of all STDs, and since 1994, 20000 has comprised the largest proportion of all STDs reported to CDC. In 2014, a total of 1,441,789 chlamydial infections were 15000 reported to CDC in 50 states and the District of Columbia. This case count corresponds to a rate of 456 cases per 100,000 COUNT persons. During 1993 to 2011, the rate of reported chlamydial 10000 infection increased from 178 to 453 cases per 100,000 persons. From 2011 to 2013, the national rate of reported cases decreased from 453 to 444 cases per 100,000. From 2013 to 5000 2014, the rate cases increased 2.8% to 456 cases per 100,000 persons (CDC, 2015). The majority of cases were among the Hispanic population 0 (44%), followed by the black population (32%), and the white population (24%) (Texas Department of States Health Ser- FIGURE 1. Chlamydia case count in Houston/Harris County. vices, 2014; Texas Department of States Health Services, 2014 Annual Report: Texas STD Surveillance Report, 2015; Texas CHLAMYDIA CASE COUNT BY SEX Department of States Health Services, 2011 Annual Report: Texas STD Surveillance Report, 2012). From 2007 to 2014, the majority of reported cases in Texas SEX were in the age group 20 to 24 years (37.7%), followed by 15 Female Male to 19 years (32.2%), 25 to 29 years (16.1%), and 30 to 34 15000 years (6.9%) (Texas Department of States Health Services, 2015). HHD received an average of 19,515 cases per year from 2005 to 2014 (range from10,929 to 25,000). A steady increase in the number of reported cases was observed each year as can 10000 be seen in Figure 1.

As seen in Figure 2, the majority of reported Houston/Harris COUNT County cases were female. This is consistent with national and 5000 state data and likely results from the fact that females are more susceptible to the disease as well as more likely to be tested for the presence of the disease. 0 The majority of the reported chlamydia cases were black, 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 followed by Hispanic, and white, (Figure 3). From 2005 to FIGURE 2. Chlamydia case count by sex in Houston/Harris County.. 2014, Figure 4 shows that the majority of reported cases within Houston were within the age group of 20 to 29 years, followed by 10 to 19 years. CHLAMYDIA CASE COUNT BY RACE Chlamydia is more common in densely populated or low socioeconomic status areas, as seen in Figure 5. Many of cases RACE/ETH are concentrated in areas in north or south Houston; though Asian all residential ZIP codes in Houston have large numbers of cas- Black es. Chlamydia is the most commonly diagnosed STD in Texas. 7500 Hispanic

Texas also saw a similar trend as the rest of the U.S. with steady Other increases of chlamydia case counts. From 2005 to 2014, Texas Unknown had an average of 106,862 yearly reported cases (range: 71,621 White to 128,932). From 2007 to 2014, 76.6% of the reported Texas 5000 cases were female and 23.4% were male. From 2007 to 2014,

Texas had at least twice as many reported female cases as male COUNT cases. 2500

Public Health Action

Preventive measures that can be taken to reduce the spread of 0 Chlamydia trachomatis infections include providing early health 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 FIGURE 3. Chlamydia case count by race in Houston/Harris County..

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and sex education for high-risk groups. Because chlamydia is CHLAMYDIA CASE COUNT BY AGE usually asymptomatic, screening is necessary to identify most AGE GROUP infections. CDC recommends yearly chlamydia screening of 0 all sexually active women age 25 or younger and older women 01 to 04 with risk factors for infection. Men who have sex with men 10000 05 to 09 (MSM) engaging in receptive anal sex should be screened for rectal infection at least annually. Likewise, MSM engaging in 10 to 19 insertive sex should be screened for urethral infection at least 20 to 29 annually. Pregnant women should be screened at their first 30 to 39 prenatal care visit. Pregnant women under 25 are at increased 40 to 49 risk for chlamydia and should be screened again in their third COUNT 5000 50 to 59 trimester. Routine screening is not recommended for men. 60+ Screening of sexually active young men should be considered Unknown in clinical settings with a high prevalence of chlamydia (e.g., correctional facilities) when resources permit and do not hinder screening efforts in women (Texas Department of States Health 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Services, 2013 Texas STD and HIV Epidemiologic Profile, 2014). FIGURE 4. Chlamydia case count by age in Houston/Harris County.. Chlamydia can be easily cured with antibiotics. Latex male condoms, used consistently and correctly, can reduce the risk of contracting chlamydia. The CDC also recommends mutual monogamy, or the practice of having one sexual partner at a time, with a partner who has been tested and known to be uninfected (Centers for Disease Control and Prevention, 2015).

FIGURE 5. Reported Chlamydia cases in Houston/Harris County 2005 to 2014 (n = 183,360).

WORKS CITED Centers for Disease Control and Prevention. (2015, November 17). Chlamydia. Retrieved from www.cdc.gov/std/stats14/chlamydia.htm. Texas Department of States Health Services. (2012). 2011 Annual Report: Texas STD Surveillance Report. Retrieved from www.dshs.state.tx.us/hivstd/reports/. Texas Department of States Health Services. (2014, December 1). 2013 Texas STD and HIV Epidemiologic Profile. Retrieved from www.dshs.state.tx.us/hivstd/ reports/. Texas Department of States Health Services. (2015). 2014 Annual Report: Texas STD Surveillance Report. Retrieved from www.dshs.state.tx.us/hivstd/reports/.

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Creutzfeldt-Jakob Disease

INTRODUCTION Creutzfeldt-Jakob disease (CJD) is a very rare degenerative neurological disorder, which is incurable and always fatal. Like bovine spongiform encephalopathy (BSE), or mad cow disease, CJD is caused by prions, which are virus-like, misfolded proteins.

In the central nervous system, these prions CJD is divided into four categories based SURVEILLANCE rapidly cause brain degeneration by con- upon how the disease is acquired: SUMMARY verting properly folded proteins to the same • Sporadic (sCJD) – caused by sporadic Surveillance History misfolded proteins of the prion. The newly refolding of normal proteins in an otherwise Reportable condition since converted proteins then cause more damage healthy central nervous system 1988 to properly folded proteins, leading to an exponential increase in the numbert of prions. • Familial (fCJD) – caused by an inherited Population at Higher Risk The brain quickly takes on a spongiform ap- mutation in the genes coding for the nor- • Those genetically predisposed pearance, or resembles a sponge in structure. mal protein, resulting in the prions About one in four people with CJD initially • Iatrogenic (iCJD) – caused by contam- • Persons undergoing medical procedures that show relatively mild symptoms of the disease, ination from an infected person’s tissue contaminate a person’s including progressive dementia, generalized during a medical procedure, such as blood tissue weakness, changes in sleep pattern, loss of ap- transfusions, human-derived pituitary • Persons consuming petite, weight loss, and/or decreased sex drive. growth hormones, gonadotropin hormones, food contaminated with Vision problems and physical symptoms, or corneal transplants prions such as muscle spasms, jerking movements, • Variant (vCJD) – caused by consuming Notable Outbreaks and muscle stiffness, are also common. Most food that is contaminated with the prions None patients die within six months of symptom that cause BSE, or mad cow disease. onset. Reports Investigated 16

Disease Transmission transmission period less than 10 years (Brown, Seasonality None The protease-resistant protein (PrP) can be et al., 2012). transmitted during certain medical proce- The vCJD form is transmitted through Average Cases Per Year dures, where a patient is exposed to infected consuming beef that contains the prions caus- 1 tissues. The iCJD form is increasingly rare, ing BSE. These prions are transmitted among with only occasional cases that have very long cattle when healthy animals are exposed to incubation periods (Brown, et al., 2012). As diseased tissue from other animals. Theories of 2012, 226 cases were documented to be of how the disease began in cattle include a caused by contaminated growth hormones sporadic change in the PrP gene or transmis- worldwide, and 228 were caused by dura sion of the disease scrapie from sheep to cattle. mater (the outermost membrane of the brain Furthermore, historical accounts describe sim- and spinal cord) grafts (Brown, et al., 2012). ilar diseases in cattle (and sheep) as far back as Very few had other sources of transmission, the fifth century BCE (McAlister, 2005). including blood transfusions (3), instrument contamination (6), other types of human- Epidemiology in Houston derived hormones (4), and corneal grafts (2) Excluding variant CJD, approximately 85% (Brown, et al., 2012). Incubation periods of cases worldwide are the classic sporadic for all iCJD cases ranged from 1 to 42 years; form; 5 to 15% are the familial form; and however, most transmission types had a mean less than 5% are the iatrogenic form (World

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Health Organization, 2012). The sCJD population; in the past 5 years, this rate inclusion of prion-reducing steps during form most commonly occurs in peo- increased to 0.85 cases per million due instrument sterilization. Additionally, ple over 60 and there is no apparent to increased surveillance efforts (Texas despite the diminishing risk, embargoes exposure event. The fCJD is an inher- Department of State Health Services, on biological products from the United ited genetic mutation, and it has been 2015). However, CJD is often under-re- Kingdom remain in effect as of January shown to be more common in certain ported and misdiagnosed, due to lack 2015 due to fears of BSE. ethnic groups, including Jewish people of pre-mortem diagnostic testing (Texas In 2005, the US Department of of Italian, Libyan, and Israeli descent Department of State Health Services, Agriculture confirmed BSE results in (Finkelstein, 1998). These forms are 2015). Nationally, the rate of CJD has a cow from Texas, making it the first caused by the PRNP gene, which en- been approximately 1.0 to 1.5 cases endemic case of BSE in the US (Rogers codes for the protease-resistant protein per million, resulting in approximately & Jones, 2005). Ongoing prevention (PrP) (Gambetti, Kong, Zou, Parchi, & 9,630 deaths through 2013 (Centers for efforts include identifying BSE in im- Chen, 2003). Disease Control and Prevention, 2015). ported and domestically raised livestock. From 2005 to 2014, a total of 14 Furthermore, the WHO recommends cases of CJD were reported in Houston. Public Health Action that ruminant tissues should not be Of these cases, 12 occurred in individ- The long incubation periods, often used in feed, as this could spread BSE uals over 50 years of age (Table 1). This years to decades, present a problem for throughout livestock (World Health suggests that these cases are the sporadic public health, as public health actions Organization, 2012). form, the risk for which increases with may prevent new cases, but do not There is no cure for CJD. There is also age. Despite decreases worldwide, address people who have the disease in no treatment that will slow the pro- Houston experienced higher rates in the pre-clinical (undiagnosed) phase. gression of the disease, once acquired. 2011 and 2014 (Table 1). Current strategies include restrictions Supportive therapy can be used to treat In the past 10 years, the rate of CJD on tissue donation from persons with a some of the symptoms of the disease; in Texas was 0.77 cases per million higher than normal risk for CJD, and however, in most cases, there are few months to provide this treatment before the disease becomes fatal. TABLE 1: NUMBER OF CREUTZFELDT-JAKOB DISEASE CASES BY AGE GROUP, 2005-2014 Autopsy and post-mortem brain AGE 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 GRAND biopsy are the only methods of con- GROUP TOTAL firming a case of CJD. Following the 0-9 0 0 0 0 0 0 0 0 0 0 0 death of a person suspected of having 10-19 0 0 0 0 0 0 0 0 0 0 0 CJD, autopsy or postmortem biopsy are 20-29 0 0 0 0 0 0 0 0 0 0 0 strongly encouraged. The National Prion 30-39 1 0 0 0 0 0 0 0 0 0 1 Disease Surveillance Center provides 40-49 0 0 0 0 0 1 0 0 0 0 1 autopsy services and support for the 50-59 0 1 0 0 0 0 1 1 1 1 5 families of individuals suspected of 60+ 1 0 1 0 0 1 2 0 0 2 7 dying from CJD. TOTAL 2 1 1 0 0 2 3 1 1 3 14

WORKS CITED Brown, P., Brandel, J., Sato, T., Nakamura, Y., MacKenzie, McAlister, V. F. (2005). Sacred disease of our times: failure of J., Will, R. G., et al. (2012). Iatrogenic Creutzfeldt-Jakob the infectious disease model of spongiform encephalopathy. disease, final assessment.Emerging Infectious Diseases, 18(6), Clincal & Investigative Medicine, 28(3), pp. 101 - 104. pp. 901 - 907. Rogers, J., & Jones, R. (2005). Investigation results of Texas Centers for Disease Control and Prevention. (2015, February cow that tested positive for bovine spongiform encephalopathy 6). Creutzfeldt-Jakob Disease, Classic (CJD). Centers for Dis- (BSE). Washington: United States Department of Agricul- ease Control and Prevention, Retrieved from www.cdc.gov/ ture; Food and Drug Administration. prions/cjd/index.html. Texas Department of State Health Services. (2015, July 1). Finkelstein, L. E. (1998). Creutzfeldt-Jakob disease. American Creutzfeldt-Jakob Disease. Retrieved from www.dshs.state. Journal of Nursing, 98(9), pp. 66 - 67. tx.us/idcu/disease/creutzfeldt-jakob/. Gambetti, P., Kong, Q., Zou, W., Parchi, P., & Chen, S. G. World Health Organization. (2012, February). Variant (2003). Sporadic and familial CJD: classification and Creutzfeldt-Jakob disease. Retrieved from www.who.int/ characterization. British Medical Bulletin, 66(1), mediacentre/factsheets/fs180/en/. pp. 213 - 239.

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Cryptosporidiosis

INTRODUCTION Cryptosporidiosis is an intestinal infection caused by the parasite, Cryptosporidium parvu. The parasite is found in the feces of infected people and animals. Cryptosporidium has been identified as one of the most common causes of water- borne disease in humans in the United States (Centers

for Disease Control and Prevention, 2010). their feces and pass on the disease. SURVEILLANCE The parasite is found across the United States Individuals that have HIV/AIDS are at a SUMMARY and throughout the world. Cryptosporidium is higher risk of contracting cryptosporidiosis Surveillance History a leading cause of persistent diarrhea in those and are more likely to face severe adverse Reportable condition since under one year of age in developing countries effects from the infection. Individuals infected 1996 (World Health Organization, 2006). with HIV have difficulty overcoming the Cryptosporidiosis is characterized by watery infection and may be unable to recover from Population at Higher Risk diarrhea. Other symptoms that may pres- cryptosporidiosis, leading to prolonged illness • Immunocompromised persons ent after infection are: stomach cramps or and possible death. pain, dehydration, nausea, vomiting, fever, Cryptosporidiosis was added to the • Young children and elderly and weight-loss. In healthy individuals, the Nationally Notifiable Diseases List in 1995 infection may be asymptomatic or present for probable and confirmed cases. According • Animal handlers with mild symptoms. Most healthy people to Texas state law, confirmed symptomatic or • Travelers recover from the illness in less than two weeks. asymptomatic cryptosporidiosis cases must • Men who have sex with In severely immunocompromised patients, the be reported within one week. In 2014, the men disease can be prolonged and life-threatening. Houston Health Department (HHD) received Notable Outbreaks Persons with the infection, whether or not 35 reports of cryptosporidiosis. None they show symptoms, can shed the parasites in Reports Investigated 192

Disease Transmission in contaminated pools, drinking untreated Seasonality Cryptosporidiosis is contracted and spread water from contaminated lakes/rivers, eating Summer through the fecal-oral route. An individual has uncooked C. parvu contaminated foods, and touching your mouth with hands that have Average Cases Per Year to come into contact with C. parvu contam- 18 inated human or animal feces in water, food, come into contact with C. parvu contaminat- or on objects and surfaces. Ingesting as few as ed surfaces like toys, bathroom fixtures, and 10 C. parvu oocysts, the parasitic stage shed diapers (CDC, 2010). Transmission of cryp- by infected individuals, can result in infec- tosporidiosis is also possible during oral-anal tion. An infected person can shed 10,000,000 sexual contact where there might be exposure to 100,000,000 oocysts in a single bowel to an infected person’s feces. movement (Centers for Disease Control and Cryptosporidiosis has been identified in Prevention, 2010). The parasites shed in the all parts of the world, making all individuals feces can survive in a moist environment for susceptible. In North America, approximate- 2 to 6 months. The incubation period for the ly 2% of the population is infected at any disease ranges from 1 to 12 days, with 7 days given time and about 80% have been exposed being the typical duration (Center for Food (Center for Food Security & Public Health, Security & Public Health, 2005). 2005). While all people are at risk, the disease The most common methods of transmis- has different outcomes depending on health sion of the disease are: swallowing water status. Healthy individuals can fight off the

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TABLE 1: NUMBER OF CRYPTOSPORIDIOSIS CASES BY SEX, 2005 TO 2014 SEX 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 TOTAL FEMALE 0 0 7 12 7 7 8 9 8 5 63 MALE 0 0 12 6 11 19 9 7 22 30 116 UNKNOWN 1 0 1 0 0 0 0 0 0 0 2 TOTAL 1 0 20 18 18 26 17 16 30 35 181

infection in 7 to 14 days, but immuno-compromised individu- Public Health Action als (especially those with AIDS) can face lifelong symptomatic There is no vaccine available for preventing cryptosporidiosis. infections which may contribute to mortality (CDC, 2010). The infectious oocysts that are found in the feces of infected animals and people are poorly inactivated by chlorine or Epidemiology in Houston iodine, making chemical disinfection difficult (CDC, 2010). From 2005 to 2014, 181 cases of Cryptosporidiosis were Washing hands is the most effective means of preventing reported by the Bureau of Epidemiology (Figure 1). Men cryptosporidiosis transmission. Immunocompromised people accounted for 116 (69%) of all reported cases (Table 1). should practice safe sex and wash their hands thoroughly after High risk groups for cryptosporidiosis are young children, any contact with animals, stool, or the living areas of ani- the elderly, the immunocompromised, and men who have sex mals. Immunocompromised persons may also take additional with men (MSM). Young children and older adults comprise precautions by washing, peeling, or cooking all vegetables to the majority of the cases of cryptosporidiosis. This can be seen ensure safety. in Figure 2, which shows the distribution of ages for persons afflicted with the disease. The distribution is bimodal, or having two peaks; one peak is seen for children under the age of 5 and another peak for adults around 45 years of age.

CRYPTOSPORIDIOSIS CASE COUNT CRYPTOSPORIDIOSIS DISTRIBUTION BY AGE

150

100 DENSITY COUNT

0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 0 25 50 75 AGE

FIGURE 1. Cryptosporidiosis case count FIGURE 2. Cryptosporidiosis distribution by age

WORKS CITED Center for Food Security & Public Health. (2005). Cryptosporidiosis. Ames: Iowa State University. Centers for Disease Control and Prevention. (2010, November 2). Parasites, Cryptosporidium. Retrieved from www.cdc.gov/parasites/crypto/gen_info/ infect.html. World Health Organization. (2006). Cryptosporidium. WHO.

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Cyclosporiasis

INTRODUCTION Cyclosporiasis is an intestinal disease caused by the parasite Cyclospora cayetanensis. Symptoms of the disease include watery diarrhea, anorexia, fatigue, weight loss, nausea, vomiting, and abdominal cramping (Herwaldt, 2000). The symptoms typically last for a few days, but if the infection is left untreated, symptoms can can last for nosis, which entails detection of Cyclospora in SURVEILLANCE months. It is possible for the infection to the infected person’s stool. Specimens are not SUMMARY occur without any symptoms (Ortega & usually tested for Cyclospora unless specifi- Surveillance History Sanchez, 2010). Trimethoprim/sulfamethox- cally requested by physicians (CDC, 2014). Reportable condition since azole (TMP/SMX), also known as Bactrim, is In Texas, any suspect or confirmed case of 2000 used to treat the infection (Center for Disease cyclosporiasis is to be reported to the health Control and Prevention, 2013). department within one week. Population at Higher Risk Confirmed cases require a laboratory diag- None Notable Outbreaks One Disease Transmission in reporting since 2012 likely resulted from the large outbreaks observed in 2013 & 2014. Reports Investigated Cyclospora is transmitted through the con- 52 sumption of contaminated food or water While Houston did not have many cases (Abanyie, Harvey, Harris, Wiegand, Gaul, & linked to the outbreak, there likely was an Seasonality Desvignes-Kendrick, 2015). increased awareness among physicians to test Summer There have been several foods linked to for the disease during that time period. Average Cases Per Year Cyclospora. In 2014, cilantro imported from 3 Mexico was linked to an outbreak of 304 cases, with 133 in Texas. Since the 1990s, Cyclospora outbreaks in the US have been linked to imported raspberries, basil, mesclun CYCLOSPORIASIS CASE COUNT lettuce, and snow peas (CDC, 2013). The incubation period of the disease is 2 to 14 days, with a mean of 7 days. The disease peaks during summer months in the United States.

10 Epidemiology in Houston Houston recorded 30 confirmed cases of cyclosporiasis from 2005 to 2014, and all

occurred between 2012 and 2014. Figure 1 COUNT illustrates this trend. In the same time period, the state of Texas recorded 638 cases, 595 of 5 which occurred between 2012 and 2014. In 2013 and 2014, the incidence of Texas cases was higher among individuals aged 40 years and above. (Texas Department of State Health Services, 2015). Part of the dramatic increase 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

FIGURE 1. Cyclosporiasis case count in Houston.

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Public Health Action The most effective prevention is to avoid contaminated food and water, especially food from unknown sources and untreated water. Fresh produce must be adequately washed with clean water prior to consumption. Travelers to countries with inadequate sanitation are advised to drink only purified water (Schneider, Silverberg, Richardson, & Schneider, 2015). Since the disease is not directly transmitted from person to person, emphasis of disease control has been placed on rapid identification and accurate contact tracing of impli- cated foods through food distribution networks.

WORKS CITED Abanyie, F., Harvey, R., Harris, J., Wiegand, R., Gaul, L., & Desvignes-Kendrick, M. (2015). 2013 Multistate Outbreaks of Cyclospora cayetanesis infections associated with fresh produce: Focus on the Texas investigations. Epidemiology and Infection, pp. 1 - 8. CDC. (2013, January 10). Epidemiology & Risk Factors. Cyclosporiasis (Cyclospora Infection). Retrieved from www.cdc.gov/parasites/cyclosporiasis/epi.html. CDC. (2013, January 10). Treatment. Parasites - Cyclosporiasis (Cyclospora Infetion). Retrieved from www.cdc.gov/parasites/cyclosporiasis/treatment.html. CDC. (2014, June 13). Cyclosporiasis FAQs for Health Professionals. Parasites — Cyclosporiasis (Cyclospora Infection). Retrieved from www.cdc.gov/parasites/ cyclosporiasis/health_professionals/hp-faqs.html. Schneider, K. R., Silverberg, R., Richardson, S., & Schneider, R. (2015, March). Preventing Foodborne Illness: Cyclospora cayetanensis. University of Florida IFAS Extension. Retrieved from www.edis.ifas.ufl.edu/pdffiles/FS/FS13000.pdf. Texas Department of State Health Services. (2015, August 27). Cyclospora Data. Infectious Disease Control. Retrieved from www.dshs.state.tx.us/IDCU/ disease/cyclospora/data/.

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Cysticercosis & Taeniasis

INTRODUCTION Cysticercosis & taeniasis are an emerging food-borne illnesses caused by eating Taenia-contaminated beef or pork products. Taenia is a genus of parasitic tapeworms. Whether the disease is classified as cysticercosis or taeniasis depends on the life-cycle stage of the tapeworm when it infects the host.

Consumption of tapeworm eggs results in Infection can develop into the more serious SURVEILLANCE cysticercosis, whereas consumption of adult disease, cysticercosis. Larva enter the blood- SUMMARY tapeworms results in taeniasis. The implemen- stream and move throughout the body with Surveillance History tation of laws regarding feeding practices and the potential of infecting any organ within the Reportable condition since inspection of animals has largely eliminated body, which results in the formation of cysts. 2007 tapeworm within the United States; however, Nuerocysticercosis, the infection of the central the parasite still impacts 50 million individ- nervous system with T. solium, is the major Population at Higher Risk uals worldwide (World Health Organization, cause of acquired epilepsy in the world (Texas • Travelers to endemic areas 2015). Department of State Health Services, 2011). Infection with the taeniasis-causing tape- Cysticercosis and taeniasis became • Individuals who eat raw meat or other contami- worm species is often entirely asymptomatic reportable conditions in 2007. Reporting of nated products or mild in its clinical presentation. If symp- confirmed or suspected taeniasis cases are toms do develop, individuals may experience required within a week. While there have been Notable Outbreaks digestive issues such as abdominal pain, loss no cases reported by the Houston Health None of appetite, weight loss, and upset stomach. Department (HHD), the Texas Department Reports Investigated Tapeworm segments being expelled by the of State Health Services has reported a total of Cysticercosis: 34 body through the anus and in feces are visual 6 cases since 2007 (Texas Department of State Taeniasis: 12 indicators of taeniasis. Health Services, 2011). Seasonality None

Average Cases Per Year Disease Transmission For a person to get cysticercosis, he or she Cysticercosis: 1 must consume the taeniasis eggs from an in- Taeniasis occurs after eating beef or pork Taeniasis: 0 products contaminated with adult tapeworms. fected person. This may happen directly, such While rare in the US, the disease has high as a person having eggs on his or her hands prevalence in Latin America, Africa, and and touching their mouth. It can also happen South and Southeast Asia (Centers for Disease indirectly, such as eating food or drinking Control and Prevention, 2016). Eating raw water that has had contact with human feces or uncooked beef or pork products is the pri- containing the eggs (CDC, Parasites-Cystic- mary risk factor for acquiring taeniasis (Texas ercosis, 2014) (Texas Department of State Department of State Health Services, 2011). Health Services, 2002). The incubation period for the disease varies depending on the tapeworm species that has infected the individual and generally ranges from 8 to 14 weeks (CDC, 2016).

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Symptoms of cysticercosis may appear from weeks to 10 years after the infection (Centers for Disease Control and Prevention, Parasites-Cysticercosis, 2014; Heymann, 2008).

Epidemiology in Houston Taeniasis is a rare condition within Houston and within the US. Since it became a reportable condition in 2007, no cases have been reported in Houston. Only 6 cases have been reported in Texas. Nationally, less than 1,000 cases have been reported. Cysticercosis is also rare. Since 2007, there have been 5 cases in Houston and 65 cases reported in Texas (Texas Department of States Health Services, 2015). While rare in the United States, the disease has high prevalence in Latin America, Africa, and South and Southeast Asia. Cysticercosis seen in developed countries is mostly a result of WORKS CITED migration from endemic countries and Centers for Disease Control and Prevention. (2014, April). Parasites-Cysticercosis. less frequently due to travel (Centers for Retrieved from www.cdc.gov/parasites/cysticercosis/. Disease Control and Prevention, 2015) Centers for Disease Control and Prevention. (2015). Taeniasis. In P. T. Cantey, & J. (Garcia, 2012). L. Jones, The Yellow Book. New York City: Oxford University Press. Public Health Action Centers for Disease Control and Prevention. (2016). Taeniasis. Yellow Book. HHD interviews both taeniasis and Garcia, H. H. (2012). Neurocysticercosis in Immigrant Populations. Journal of Travel cysticercosis cases to identify the sources Medicine, pp. 73 - 75. of those infections to prevent further spread. Heymann, D. L. (2008). Taeniasis. In D. L. Heymann, Control of Communicable The risk of contracting taeniasis Diseases Manual. American Public Health, Washington, D.C.., pp. 598 - 601. within the U.S. is limited. Improved Texas Department of State Health Services. (2002, May). Cysticercosis & Taeniasis. agriculture and health standards have Texas, United States: Texas Department of State Health Services. limited the chances of contracting tapeworm. Cooking, freezing or irradiating Texas Department of State Health Services. (2011, March 10). Infectious Disease meat destroys tapeworm larva and Control. Retrieved from www.dshs.state.tx.us/idcu/disease/taeniasis/faqs/. prevents both cysticercosis and taeniasis. Texas Department of States Health Services. (2015, June). Zoonotic Disease—Human Maintaining good hygiene and prac- Cases for the Last Ten Years. Retrieved from www.dshs.state.tx.us/idcu/health/zoo- ticing good hand-washing techniques nosis/disease/Cases/. also reduces transmission. Infection in animals is prevented by protection of the World Health Organization. (2015, May). Taeniasis, Cysticercosis. Retrieved from animal feed or grazing areas. www.who.int/mediacentre/factsheets/fs376/en/.

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Dengue

INTRODUCTION Dengue is a viral disease caused by any one of four dengue viruses (DEN-1, DEN-2, DEN-3, and DEN-4). It is spread by two species of infected mosquitoes, Aedes aegypti and Aedes albopictus. The disease is thought to have originated in either Africa or Southeast Asia between 100 and 800 years

ago (Centers for Disease Control and The symptoms of both conditions are similar, SURVEILLANCE Prevention, 2014). The movement of troops with DHF presenting with more aggressive SUMMARY during World War II and the rise of air travel variations of dengue fever symptoms. Surveillance History resulted in the introduction of the disease to DHF presents with fever that lasts from 2 Reportable condition since new areas of the world (Gubler, 2002). The to 7 days with persistent vomiting and severe 1931 first dengue epidemic was identified during abdominal pain. Difficulty breathing may the 1950s in the Philippines and Thailand. develop. Once symptoms present, there is a Population at Higher Risk The disease is not an issue in most parts of 24- to 48-hour period when the small blood Travelers to endemic countries the United States; most cases reported within vessels within the infected individual allow the US were acquired in other countries by fluid to escape. DHF can be fatal if unrec- Notifiable Outbreaks: travelers or immigrants. Globally, there are ognized. With timely medical care, however, None an estimated 390 million dengue infections risk of death due to DHF can be less than 1% Reports Investigated yearly, with over 3 billion people at risk of (CDC, 2014). 139 infection from the dengue viruses (Brady, et Dengue fever has been a reportable Seasonality al., 2012). condition in Texas since 1931. Suspected None Infection with dengue virus can result in or confirmed dengue fever cases are to be either dengue fever or dengue hemorrhagic reported to the local health department Average Cases Per Year fever (DHF). Dengue hemorrhagic fever within one week. The Houston Health 1 is a more severe form of dengue infection. Department (HHD) reported 8 cases of Dengue fever is characterized by a high fever, dengue fever in 2014. severe headache, severe pain behind the eyes, joint and bone pain, rash, and mild bleeding.

Disease Transmission Dengue is transmitted to humans by mosquitoes. Human to human transmission occurs rarely and has been identified in some instances as a result of organ transplants, blood transfusions, or transmission from infected mother to fetus. The most common transmitter in the western hemisphere is the Aedes aegypti mosquito, but Aedes albopictus can also carry the dengue virus. It is specu- lated that the A. albopictus mosquito species was introduced into Houston through used truck tires imported from Southeast Asia from recapping in 1985 (Nelson, 2004). The spare tires collected rain water and served as

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Epidemiology In Houston Dengue is rare in Houston. From 2005 to 2014, there were a total of 12 cases reported by HHD. There were no reported cases prior to 2012.

Public Health Action There is no vaccine for preventing dengue. The best preventive measure for residents living in areas infested with Aedes aegypti is to eliminate the places where the mosquito lays its eggs, primarily artificial containers that hold water (CDC, 2014). Items that collect rainwater or are used to store water, such as plastic containers, 55-gallon drums, buckets, or used automobile tires, should be covered or properly discarded. Pet and animal watering containers and vases with fresh breeding places for the mosquitoes. infected for the remainder of its life flowers should be emptied and scoured After an infected mosquito bites an (CDC, 2014). at least once a week. This will eliminate individual, the individual does not show Travelers to tropical/sub-tropical the mosquito eggs and larvae and reduce symptoms for a period of 3 to 14 days; countries are most at risk for contracting the number of mosquitoes present in commonly 3 to 7 days. Once symptoms dengue. Dengue is endemic in many these areas. do present, they usually last 3 to 10 tropical countries across Africa, Asia, the For travelers to areas with dengue, days. The mosquitoes become carriers Americas, the Pacific, and the Caribbean. as well as for people living in areas with of the dengue virus after feeding on an Residents of the United States most dengue, the risk of being bitten by mos- infected individual. For the mosquito to likely to contract the disease are those quitoes indoors is reduced by utilization become infected, it must feed during a that live in Puerto Rico, the U.S. Virgin of air conditioning or windows and 5-day period when large amounts of vi- Islands, Samoa, and Guam. A year- doors that are screened. Proper applica- rus are in the individuals’ blood (CDC, round population of abundant Aedes tion of mosquito repellent containing 2014). This usually occurs shortly before aegypti makes Puerto Rico susceptible at least 20 to 30% DEET as the active symptoms develop. Infected individuals to outbreaks of dengue. Since the late ingredient on exposed skin and clothing who do not present with significant 1960s, island-wide epidemics have oc- decreases the risk of being bitten by symptoms are still capable of passing on curred; the most recent outbreak being mosquitoes. The risk of dengue infection the dengue virus to mosquitoes. Once a in 2007 where more than 1,000 cases for international travelers appears to be mosquito has been infected, it remains were diagnosed (CDC, 2014). small, unless an epidemic is in progress.

WORKS CITED Brady, O. J., Gething, P. W., Bhatt, S., Messina, J. P., Brownstein, J. S., Hoen, A. G., et al. (2012). Refining the Global Spatial Limits of Dengue Virus Transmission by Evidence-Based Consensus. PLoS Neglected Tropical Diseases. Centers for Disease Control and Prevention. (2014, June 9). Dengue. Dengue. Retrieved from www.cdc.gov/dengue/. Gubler, D. J. (2002). Epidemic dengue/dengue hemorrhagic fever as a public health, social and economic problem in the 21st century. Trends in Microbiology, pp. 100 - 103. Nelson, K. (2004). Emerging and New Infectious Diseases. In K. Nelson, Infectious Diseases Epidemiologu: Theory and Practice. London: Jones and Bartlett Publishers Inc.

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Diphtheria

INTRODUCTION Diphtheria is an uncommon, vaccine-preventable disease in the United States. It is caused by the toxins released by the gram-positive bacilli bacteria Corynebacterium diphtheria. There are two types of diphtheria: respiratory diphtheria and cutaneous diphtheria. Respiratory diphtheria develops two

to five days after exposure and is characterized theria, left untreated, has been fatal due to the SURVEILLANCE by a sore throat, difficulty swallowing, a low- membrane restricting airways and compli- SUMMARY grade fever, and a temporary grayish-white cations involving the heart, nervous system, Surveillance History membrane forming inside the throat. In and kidneys. Cutaneous diphtheria is usually Reportable condition since moderate to severe cases swelling of the lymph mild and consists of sores or shallow ulcers on 1944 nodes and tissues of the neck may give rise to the skin (Texas Department of States Health a “bull-neck” appearance. Respiratory diph- Services, 2013; Tiwari, 2011). Population at Higher Risk Unvaccinated individuals Notifiable Outbreaks: Disease Transmission diphtheria antitoxin immediately after bacte- None Diphtheria is transmitted from person to per- riologic specimens are taken without waiting son by respiratory droplets or direct contact for lab results. The most effective diphtheria Reports Investigated with respiratory secretions, discharge from the prevention method is through vaccination. 4 skin lesions, or, rarely, contact with contami- Children should receive a dose at 2 months, 4 Seasonality nated objects. Untreated patients are usually months, and 6 months of age. A fourth dose Fall should be given between 15 and 18 months infectious for up to two weeks. However, Average Cases Per Year of age and the fifth dose between 4 to 6 years. some individuals can carry the bacteria with- 0 out signs of the disease and may be infectious An additional booster is recommended for for six months or more. Diphtheria is only children 11 to 12 years of age. Adults should known to infect humans (Heymann D. L., also receive a tetanus-diphtheria booster every Diphtheria, 2008; Tiwari, 2011). 10 years (CDC, 2015).

Epidemiology In Houston No cases of diphtheria have been reported in the City of Houston, or even Texas, in over 30 years. Diphteria was the most common causes of illness and death among children in early 1900s. Since the introduction and widespread use of diphtheria vaccines in the 1920’s and 1930’s and universal childhood immuniza- tion in the late 1940’s, diphtheria has been continually decreasing in the United States. There have only been two cases recorded in the United States in the past decade (CDC, 2013; CDC, 2015; Texas Department of States Health Services, 2013).

Public Health Action Suspect cases of diphtheria should receive

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WORKS CITED Centers for Disease Control and Prevention. (2013, May 13). Diphtheria: Surveillance. Retrieved from www.cdc.gov/diphtheria/surveillance.html. Centers for Disease Control and Prevention. (2015, October 27). Diphtheria, Tetanus, and Pertussis vaccine safety. Retrieved from www.cdc.gov/vaccinesafety/ vaccines/dtap-tdap-vaccine.html. Centers of Disease Control and Prevention. (2015), November 20). Morbidity and Mortality Weekly Report. Retrieved from www.cdc.gov/mmwr/preview/mmwrhtml/ mm6445md.htm?s_cid=mm6445md_w. Heymann, D. L. (2008). Diphtheria. In D. L. Heymann, Control of Communicable Disease Manual (pp. 195 - 200). Washington, D.C.: American Public Health Association. Texas Department of States Health Services. (2013, May 29). Diphtheria. Retrieved from: www.dshs.state.tx.us/idcu/disease/diphtheria/. Tiwari, T. S. (2011). Chapter 1: Diphtheria. In Centers for Disease Control and Prevention, Manual for the Surveillance of Vaccine-Preventable Diseases. Atlanta, GA: Centers of Disease Control and Prevention.

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Ehrlichiosis

INTRODUCTION Ehrlichiosis refers to infection with the Ehrlichia bacteria. It was first recognized in the United States in 1986 and is found in areas where lone star ticks are common. The lone star tick generally transmits Ehrlichia in the southeastern and south-central United States. In 2009, a new strain of ehrlichiosis was detected in the Midwest. Symptoms caused by infection from the SURVEILLANCE Symptoms of the disease include fever, Ehrlichia species usually develop 1 to 2 weeks SUMMARY headache, chills, malaise, and muscle pain. after a person is bitten by an infected tick. Surveillance History The severity of symptoms varies person to Tick bites are usually painless and about half Reportable condition since person, and some patients may not experience of those who develop ehrlichiosis do not know 1999 any symptoms at all. Any suspected case of if they were bitten. Ehrlichiosis became a ehrlichiosis is to be reported to HHD within reportable disease in 1999 (www.cdc.gov, Population at Higher Risk one week. Ehrlichiosis is diagnosed based on 2013). Older individuals the clinical presentation and laboratory test Notable Outbreaks: confirmation. None Reports Investigated Disease Transmission Public Health Action 3 The pathogen is an intracellular organism that Ehrlichiosis can be prevented by avoiding tick Seasonality survives and reproduces in the white blood bites. Prevention strategies include: Summer and spring cells of an infected individual. Major animal • Avoid areas that are likely to have ticks, Average Cases Per Year reservoirs include white-tailed deer, dogs, and when possible, particularly in spring and 0 rodents. summer when ticks and tick nymphs feed. A history of tick bite or exposure to tick- infested habitats is reported in 50% to 90% • Wear light-colored clothing when going of cases. Most patients with ehrlichiosis are into areas with ticks so that ticks can be infected in the spring and summer, the season seen on the clothes more readily and be for adult ticks. Unlike other tick-transmitted removed before attaching to the skin diseases, reported rates of ehrlichiosis increase with age and most patients with the disease are older adults greater than 40 years of age (CDC, 2013).

Epidemiology in Houston From 2005 to 2014, no cases of Ehrlichiosis were reported to HHD. It is a rare disease with fewer than 10 cases reported each year in Texas. However, since many people with ehrlichiosis have no symptoms, it is difficult to estimate its true prevalence.

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• Apply permethrin (which kills ticks on contact) to clothes or insect repellents containing DEET to clothes and exposed skin to provide protection. DEET can be used safely on children and adults but should be applied according to Environmen- tal Protection Agency guidelines to lower the risk of toxicity. • Perform a tick check and remove attached ticks. • Reduce habitats around homes by removing leaves, brush and woodpiles around buildings and at the edges of yards. Discourage animals that may carry ticks such as deer and rodents from entering backyards by reducing hiding places. • Protect pets with approved tick repellents.

WORKS CITED Centers for Disease Control and Prevention. (2013, September 9). Ehrlichiosis. Retrieved from: www.cdc.gov/ehrlichiosis/stats/index.html.

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Gonorrhea

INTRODUCTION Gonorrhea is a sexually transmitted disease caused by the bacterial agent Neisseria gonorrhoeae. This infection is characterized by symptoms including discharge and inflammation at the urethra, cervix, pharynx and anus. Gonorrhea is the second most commonly reported sexually transmitted disease within the United States. penis, and painful, swollen testicles. Antimi- SURVEILLANCE The United States alone detects and reports crobial resistance is a growing concern in the SUMMARY over 350,000 cases annually. treatment of gonorrhea, and the Centers for Surveillance History An infection can present as a single Disease Control and Prevention (CDC) now Reportable condition since symptom or as a combination of symptoms. recommends using 2 drugs for treatment. 1941 Symptoms vary among men and women. Prompt identification and treatment of this Women often have no symptoms. Some wom- disease is the key to controlling the spread of Population at Higher Risk en, however, present with painful sensation this condition and assisting in the contain- • Teenagers to young adults during urination, increased vaginal discharge, ment of bacterial drug resistance. and irregular vaginal bleeding. Men tend Gonorrhea is a mandatory reportable dis- • African American to be asymptomatic, but when symptoms ease in all states, including Texas. Confirmed Notable Outbreaks occur they include burning sensation while and suspected cases of gonorrhea are report- None urinating, white or yellow discharge from the able to HHD within a week of diagnosis. Reports Investigated 6,107 Disease Transmission rates of infection were seen among teenagers Seasonality Transmission of gonorrhea is primarily and young adults. In 2014, Houston/Harris None through sexual contact with an infected County ranked 3rd overall in reported Average Cases Per Year individual. Gonorrhea transmission may be gonorrhea cases, preceded only by Cook 6,504 through oral, vaginal or anal contact routes. County (Illinois) and Los Angeles County Gonorrhea can be transmitted from mother to (California) (CDC, 2014). infant at the time of vaginal birth. The incubation period for this infection is 2 to 5 days but symptoms may not develop for up to 30 days (Healthwise, 2014). Risk factors include sexual contact without a latex condom, multiple sex partners, sexually active young adult, sex for money or drugs, lower socioeconomic status, and previous gonorrhea diagnosis.

Epidemiology in Houston From 2005 to 2015, over 60,000 cases of gonorrhea were reported in Houston/Harris County (Figure 1). Approximately, 50% of the reported cases were persons between the ages of 20 to 29 (Figure 2). Data reflects that during the reporting period, the number of cases reported in women were similar to the number of cases reported in men. The highest

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GONORRHEA CASE COUNT GONORRHEA CASE COUNT BY AGE

6000 3000 AGE GROUP

01 to 04

05 to 09 4000 2000 10 to 19

20 to 29

COUNT 30 to 39 COUNT 40 to 49 2000 1000 50 to 59

60+

0 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 FIGURE 1: Gonorrhea case count in Houston. FIGURE 2: Gonorrhea case count by age in Houston.

Nationally, the black population makes up the largest Drug Resistance proportion of gonorrhea cases and has the highest rates of all Drug resistance is a public concern because those treated with racial/ethnic groups. Similarly, between 2005 to 2014, the the standard single dose therapy may continue to exhibit black population experienced a disproportionate burden of symptoms of the infection and transmit the infection to others. gonorrhea in Houston/Harris County (Figure 3). Untreated patients may have increased incidence of pelvic Between 2005 to 2014, blacks accounted for 38,907 cases, inflammatory disease, epididymitis, and increased transmission approximately 64% of all cases within Houston/Harris County. of HIV. This translates into increased hospital time, compli- Gonorrhea is endemic to all residential parts of Houston, cations involving advanced therapies and increased in overall (Figure 4). Areas with lower socioeconomic status or high healthcare cost. In order to manage this public threat, it is vital density are disproportionately affected. There is also higher that providers consistently provide the most current disease disease presence along the north and south corridors of management therapies. Houston. Neisseria gonorrhoeae is a steadily evolving bacterium. Nationally, the overall incidence of gonorrhea has steadily Traditional single drug therapies have shown to be ineffective declined over the past 10 years due to increased awareness and for a small percentage of the bacteria. Neisseria gonorrhoeae public health interventions. Currently, CDC reports that the has shown some degree of resistance to cefixime, ceftrixaone, national gonorrhea rate is 106 cases per 100,000 population. azithromycin and tetracycline. According to data provided Unfortunately, many cases of gonorrhea infections remain by CDC, approximately 1% of cases identified in 2011 were unreported. It is estimated that there are over 800,000 cases resistant to the primary therapy treatment option of ceftriax- of gonorrhea within the United States. According to 2013 one (CDC, 2014). Ceftriaxone has been the gold standard for statistics only 40% of cases have actually been reported (CDC, the treatment of Neisseria gonorrhoeae for many years. Recently, 2014). due to the possibility of enhanced resistance, CDC has released new therapeutic guidelines that recommend first line treatment GONORRHEA CASE COUNT BY RACE with dual therapy medications. The latest recommendations are

RACE/ETH to treat Neisseria gonorrhoeae with both Ceftriaxone plus either 4000 Asian Azithromycin or Doxycycline (CDC, 2014).

Black Public Health Action Hispanic 3000 Other To contain gonorrhea, it is essential that rapid detection and

Unknown early treatment are at the forefront of local and national efforts.

White Working closely with CDC to enhance surveillance and preven- 2000 tion efforts is a priority that Houston/Harris County has taken COUNT in order to contain the spread of this condition. The Houston Health Department recommends utilizing the most updated

1000 treatment options to care for infected populations. It is the responsibility of healthcare professionals to stay current with evolving treatment recommendations. The Houston Health Department recommends risk reduction 0 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 measures such as correct and consistent use of condoms, regular FIGURE 3: Gonorrhea count by race. testing and community education and awareness. Specialized

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FIGURE 4. Gonorrhea cases in Houston/Harris County 2005 to 2014. oversight of pregnant mothers infected with gonorrhea is vital to limiting the spread of disease to newborn infants.

WORKS CITED CDC. (2014, December 16). 2013 Sexually Transmitted Diseases Surveillance. pp. 1941 - 2013. Retrieved from www.cdc.gov/std/stats13/tables/1.htm. Center for Disease Control and Prevention. (2014, July 17). Antibiotic Resistance Threats in the United States. Retrieved from www.cdc.gov/drugresistance/threat- report-2013/. Healthwise. (2014, June 04). WebMD. Retrieved from www.webmd.com/sexual- conditions/tc/gonorrhea-topic-overview.

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Haemophilus Influenzae, Type B

INTRODUCTION Haemophilus influenzae is a gram-negative bacterium. Six different types exist (A to F). Historically, Haemophilus influenzaetype B (Hib) has been the predominant strain to infect humans (Puig, et al., 2014). Since the introduction of the Hib vaccine to protect against type B, the other types have posed a growing risk (Adam, Richardson, compatible, culture confirmed, and identi- SURVEILLANCE Jamieson, Rawte, Low, & Fisman, 2010). fied specifically asH. influenzaetype B. The SUMMARY Hib may produce several types of infections, specimen used for isolation must be obtained Surveillance History with the most common being meningitis from a normally sterile site within the body. Reportable condition since and bacteremia (Heymann D. , 2008). These A case is regarded as probable if it is clinically 1991 clinical manifestations are of public health compatible and Hib antigen is detected in the importance. cerebrospinal fluid. Antigen testing of urine or Population at Higher Risk The disease became nationally reportable serum samples is unreliable for diagnosis. Elderly in 1991. A case is confirmed if it is clinically Notable Outbreaks None Disease Transmission (Briere, Rubin, Moro, Cohn, Clark, & Reports Investigated H. influenzaeis transmitted from person to Messonnier, 2014). However, Hib remains a 267 person though inhalation or direct contact major cause of lower respiratory tract infec- Seasonality with droplets of respiratory tract secretions. tions in infants and children in developing • March to May The bacteria enter the body through the naso- countries where the vaccine is not widely used • September to December pharynx where they feed and grow for several (Zar, Madhi, Aston, & Gordon, 2013). Average Cases Per Year months before symptoms develop. During 1 this stage, a person is considered an asymptomatic carrier. Risk factors for contracting the disease include certain medical conditions INVASIVE HAEMOPHILUS INFLUENZAE IN CHILDREN AGED ≤ 5 YEARS such as sickle cell disease, being HIV positive, receiving chemotherapy, or anything that 30 First polysaccaride Hib vaccine licensed reduces the immune system’s ability to fight for use in children aged ≥ 18 months an infection (CDC, 2014). Other risk factors 25 First conjugate Hib vaccine licensed for include prolonged exposure to infected use in children aged ≥ 18 months persons in places such as daycares or large First Hib vaccines licensed for use in 20 infants aged ≥ 2 months foster homes (Heymann D., 2008). Before 1985, Hib was the most common cause of bacterial meningitis and other severe 15 infections among U.S. children aged less than INCIDENCE 5 years (Wenger, Hightower, Facklam, Gaven- 10 ta, & Broome, 1990). Figure 1, Hib vaccines were introduced in the United States in 1985, 5 1987, and 1989 (Briere, Rubin, Moro, Cohn,

Clark, & Messonnier, 2014). During 1989 0 to 2000, the annual incidence of invasive 1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 Hib disease in children aged less than 5 years FIGURE 1. Estimated annual incidence (per 100,000 population) of invasive Haemophilus influenzae type decreased by 99%, to less than one case per b (Hib) disease in children aged ≤ 5 years—United States, 1980 to 2012 (Adapted from Briere, Rubin, 100,000 children as shown in Figure 1 Moro, Cohn, Clark, & Messonnier, 2014)

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