Communicable and Environmental Diseases and Emergency Preparedness

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2010-2012 Annual Report

Communicable and Environmental Disease Services Tennessee Department of Health 1st Floor, Cordell Hull Building 425 5th Avenue North Nashville, Tennessee 37243

Phone 615-741-7247 (24 hours a day/7 days a week) Toll-Free 800-404-3006 Fax 615-741-3857

Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Tennessee Department of Health Communicable and Environmental Diseases and Emergency Preparedness

John Dreyzehner, MD, MPH, FACOEM, Commissioner of Health

David Reagan, MD, PhD, Chief Medical Officer

Timothy F. Jones, MD, State Epidemiologist, Director, Communicable and Environmental Diseases and Emergency Preparedness

Available electronically at the Tennessee Department of Health website. In the search box in the top right-hand corner, type “CEDEP Annual Report” and hit Enter. Under Search Results, click on the result entitled “CEDEP Reports”.

http://www.tn.gov/health

This report reflects the contributions of the many committed professionals who are part of the Communicable and Environmental Disease Services Section, Tennessee Department of Health.

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Communicable and Environmental Diseases and Emergency Preparedness Annual Report

TABLE OF CONTENTS

Section I. Introduction ...... 1 A. Purpose of Report ...... 2 B. Notifiable Diseases in Tennessee ...... 2 C. Reporting Notifiable Diseases ...... 3 D. List of Notifiable Diseases ...... 4 E. Isolate Characterization at the State Laboratory ...... 6 F. Referral of Cultures or Positive Specimens to the Department of Health ...... 6 G. Tennessee Department of Health Regions ...... 7 H. Useful Contact Persons, Telephone Numbers, E-Mail and U.S. Addresses ...... 7 I. Emerging Infections and the Emerging Infections Program ...... 8 J. Communicable and Environmental Disease and Emergency Preparedness Website ...... 9 K. Tennessee Population Estimates, 2012...... 10 L. Tennessee’s Department of Health Regions: Counties and Population, 2012 ...... 10 M. Notes on Sources Used in Preparing the Annual Report ...... 12

Section II. Tennessee Reported Cases, 2003-2012 ...... 14 Reported Cases, by Year of Diagnosis, Tennessee, 2003-2012...... 15 Numbers of Reported Cases of Selected Notifiable Diseases with Rates per 100,000 Persons, by Age Group, Tennessee, 2012 ...... 16

Section III. Disease Summaries ...... 18 A. Foodborne and Waterborne Diseases ...... 19 Tennessee FoodNet and FoodCORE Programs...... 20 Campylobacteriosis ...... 21 Listeriosis ...... 23 Salmonellosis ...... 23 Shiga-toxin Producing E. coli and Hemolytic Uremic Syndrome ...... 25 Shigellosis ...... 26 Vibriosis and Cholera ...... 27 Yersiniosis ...... 28 Foodborne and Waterborne Parasitic Diseases ...... 28 Cryptosporidiosis ...... 29 Cyclosporiasis ...... 30 Foodborne Outbreaks ...... 31

Communicable and Environmental Diseases and Emergency Preparedness Annual Report

TABLE OF CONTENTS (CONTINUED)

B. Invasive Diseases ...... 33 Active Bacterial Core Surveillance (ABCs) ...... 34 Other EIP Surveillance Activities ...... 35 Invasive Group A Streptococcal Disease ...... 35 Invasive Group B Streptococcal Disease ...... 37 Meningococcal Disease ...... 38 Methicillin Resistant Staphylococcus aureus Invasive Disease—Passive Surveillance ...... 39 Streptococcus pneumoniae Invasive Disease ...... 40 C. Hepatitis ...... 43 Hepatitis A ...... 44 Perinatal Hepatitis B ...... 45 Acute Hepatitis B Virus Infection ...... 45 Hepatitis C Virus ...... 47 D. Vaccine-Preventable Diseases ...... 49 Pertussis ...... 51 Tetanus ...... 52

Influenza ...... 53 E. Vectorborne and Zoonotic Diseases ...... 55 Arboviral Diseases ...... 56 LaCrosse Encephalitis (LAC) ...... 56 West Nile Fever/Encephalitis ...... 57 Malaria ...... 58 Tickborne Diseases ...... 59 Ehrlichiosis ...... 59 Lyme Disease ...... 60 Spotted Fever Rickettsiosis (including Rocky Mountain Spotted Fever) ...... 60 Zoonotic Diseases ...... 61 Rabies ...... 61 Other Zoonoses: Brucellosis, Q Fever, Tularemia ...... 62 F. Tuberculosis ...... 63 G. Healthcare-Associated Infections (HAI) ...... 67 Catheter-Associated Urinary Tract Infection (CAUTI) ...... 68 Clostridium difficile Infections (CDI) (NHSN) ...... 69 Central Line-Associated Bloodstream Infections (CLABSI) ...... 70

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Communicable and Environmental Diseases and Emergency Preparedness Annual Report

TABLE OF CONTENTS (CONTINUED)

Methicillin Resistant Staphylococcus aureus (MRSA) (NHSN) ...... 72 Invasive Vancomycin-Resistant Enterococcus (VRE) ...... 74 Healthcare-Associated Infections and Antimicrobial Resistance Program Special Projects ...... 75 H. Sexually Transmitted Diseases ...... 79 Chlamydia ...... 80 Gonorrhea ...... 81 Human Immunodeficiency Virus (HIV) Disease ...... 82 Syphilis ...... 83

Section IV. Investigations and Outbreaks ...... 86

Section V. Environmental Health ...... 92

Section VI. Public Health Emergency Preparedness Program ...... 104

Section VII. Surveillance Systems and Informatics Program ...... 108

Section VIII. Epidemic Intelligence Service ...... 112

Section XI. Awards, Honors and Publications ...... 116

SECTION I. INTRODUCTION Communicable and Environmental Diseases and Emergency Preparedness Annual Report

A. Purpose of Report

Communicable and Environmental tors with other variables, including ing descriptive epidemiologic data over Diseases and Emergency Preparedness lifestyle, nutrition and genetics. De- time is the foundation for knowing (CEDEP) is one of the thirteen divi- tecting, preventing and controlling where prevention and control efforts sions/offices within the Tennessee both infectious and environmental need to be focused. One important Department of Health. The twelve disease provides enormous financial goal of this report is to assist providers, other divisions/offices in the depart- and emotional benefits to the citizens laboratorians, and infection control ment include the following: Adminis- of Tennessee. practitioners with reporting of notifia- trative Services; Community Health ble diseases. Health department ad- Services; Family Health and Wellness; dresses, telephone numbers and poli- The CEDEP Annual Report is de- Health Disparities; Health Licensure cies relative to surveillance are present- signed to provide health care organiza- and Regulation; Health Planning; Hu- ed to assist with this important task. tions and providers, government and man Resources; Information Technol- This report is a summary of surveil- regulatory agencies, and other con- ogy Services; Laboratory Services; Pa- lance data from 2003 through 2012 cerned individuals and groups with tient Care Advocacy; Policy, Planning and builds upon the 2000, 2001, important statistical information and Assessment; and Quality Improve- 2002, 2003, 2004-2005, 2006, 2007, about potentially preventable diseases. ment. The seven rural health regions 2008, and 2009 annual reports that The report can serve as one source of also report to the department. were previously published by CEDEP. data for them and can help assure that involved individuals and organizations CEDEP is assigned the responsibility have access to reliable information. We acknowledge, with gratitude, the of detecting, preventing and control- The annual report also provides an efforts of the many committed health ling infectious and environmentally- assessment of the efforts undertaken care professionals throughout Tennes- related illnesses of public health signif- by CEDEP over a period of years. see who contribute to the ongoing icance. A unique attribute of infec- reporting of disease. Surveillance is tious diseases is that they can often be dependent on reporting. This annual Surveillance (i.e., the tracking of infec- prevented, and thus efforts to that end report could not be developed without tious disease incidence and preva- result in lower expenditures for health the assistance of personnel in local lence) is at the heart of the work of care and less personal discomfort and and regional health departments, phy- CEDEP. The reporting and tracking of pain. Environmentally-related illnesses sicians, and infection control practi- cases of illness is essential to knowing are often the result of the interaction tioners and laboratory staff who have who is affected by disease and where of external, physical and chemical fac- reported cases as required by law. the problems are occurring. Examin- B. Notifiable Diseases in Tennessee

A notifiable disease is one for which District of Columbia, and Hawaii; by The list of notifiable diseases is revised regular, frequent, and timely infor- 1928, all states participated in the re- periodically. As new pathogens mation regarding individual cases is porting. In 1961, the Centers for Dis- emerge, new diseases may be added to considered necessary for the preven- ease Control and Prevention (CDC) the list. Public health officials at state tion and control of disease. In 1893, assumed responsibility for the collec- health departments and the CDC col- Congress authorized the weekly report- tion and publication of data concern- laborate in determining which diseases ing and publication of notifiable dis- ing nationally notifiable diseases. As should be notifiable, but laws at the eases, collected from state and munici- world travel becomes increasingly state level govern reporting. In Tennes- pal authorities. The first annual sum- more common, the comparison of see, State Regulations 1200-14-1, sec- mary of “The Notifiable Diseases” was data about infectious diseases across tions .02 through .06, require the re- published in 1912 and included re- states, nations and continents is cru- porting of notifiable diseases by physi- ports of 10 diseases from 19 states, the cial. cians, laboratorians, infection control

2 Communicable and Environmental Diseases and Emergency Preparedness Annual Report personnel, nurses and administrators “List of Notifiable Diseases” was re- Middle East Respiratory Syndrome. in settings where infectious diseases vised annually from 2010-2012. Im- The list is presented in Section D. Sec- are diagnosed. portant additions to the list include a tion E lists those diseases for which number of healthcare associated path- bacterial isolates are to be sent to the ogens, carbon monoxide poisoning, Tennessee Department of Health State The Tennessee Department of Health neonatal abstinence syndrome, and Laboratory. C. Reporting Notifiable Diseases

There are five categories of reporting “Immunizations, Disease Prevention”, number of cases of actual disease. notifiable diseases: (1A & 1B) immedi- click on “List of Reportable Diseases”, There are several reasons for this: a ate telephone reporting, followed with then “Reporting Forms” and “PH- person must seek medical care to re- a written report; (2) written report on- 1600”. CEDEP, as well as regional and ceive a diagnosis, not all cases are con- ly; (3) special confidential reporting of local health departments, welcome firmed with laboratory testing and not HIV/AIDS; (4) laboratory reporting of questions about disease reporting. all confirmed cases are reported. 1 all blood lead test results; and (5) McMillian, et al, utilizing FoodNet monthly reporting via the National data from 2002-2003, estimated that Notifiable disease data are submitted Healthcare Safety Network and the though one in twenty persons reported electronically by the Tennessee Depart- Emerging Infections Program. Reports diarrhea in the previous month, less ment of Health to the Centers for Dis- of infectious diseases are usually sent than one in five sought medical care. ease Control and Prevention on a dai- first to the local (county) health de- Further, less than one in five who ly basis. There they are combined with partment, which is responsible for sought medical care submitted a stool all state data for national analyses and providing basic public health interven- sample which would be needed for are reported in the weekly publication, tion. Regional health departments can laboratory confirmation of the diagno- Morbidity and Mortality Weekly Re- also be called; they submit reports of sis. The study data suggested that well port. Ongoing analyses of this exten- notifiable diseases to the Tennessee over 28 cases of acute diarrheal illness sive database have led to better diagno- Department of Health central office in occur in the population for each stool ses and treatment methods, national Nashville on a daily basis. specimen positive for enteric patho- vaccine schedule recommendations, gens. The data in this annual report changes in vaccine formulation and do not represent all cases of disease; Form PH-1600 is used for written re- the recognition of new or resurgent they track the geographic distribution ports to the health department. It can diseases. of disease, as well as trends over time be obtained by calling your local and serve as the foundation for the health department or CEDEP at 615- The numbers of reportable disease efforts of the Department of Health to 741-7247/800-404-3006. It can also be cases presented in the annual report control communicable diseases. downloaded from the CEDEP website should be considered as the minimum at http://tn.gov/health. Under

1McMillian M, Jones TF, Banerjee A et al. The burden of diarrheal illness in FoodNet, 2002-2003. Poster presented at the International Conference on Emerging Infectious Diseases, Feb 29-March 3, 2004, Atlanta, GA.

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D. List of Notifiable Diseases

The diseases and events listed below are declared to be communicable and/or dangerous to the public and are to be reported to the local health department by all hospitals, physicians, laboratories, and other persons knowing of or suspecting a case in accordance with the provision of the statutes and regulations governing the control of communicable diseases in Tennessee (T.C.A. §68 Rule 1200-14-01-.02). See matrix for additional details. Category 1A: Requires immediate telephonic notification (24 hours a day, 7 days a week), followed by a written report using the PH-1600 within 1 week. [002] Anthrax (Bacillus anthracis)B [516] Novel Influenza A [005] Botulism-Foodborne (Clostridium botulinum)B [032] Pertussis (Whooping Cough) [004] Botulism-Wound (Clostridium botulinum) [037] Rabies: Human [505] Disease Outbreaks (e.g., foodborne, waterborne, [112] Ricin PoisoningB healthcare, etc.) [132] Severe Acute Respiratory Syndrome (SARS) [023] Hantavirus Disease [107] SmallpoxB [096] Measles-Imported [110] Staphylococcal Enterotoxin B (SEB) Pulmonary [026] Measles-Indigenous PoisoningB [095] Meningococcal Disease (Neisseria meningitidis) [111] Viral Hemorrhagic FeverB

Category 1B: Requires immediate telephonic notification (next business day), followed by a written report using the PH-1600 within 1 week. [006] Brucellosis (Brucella species)B [102] Meningitis-Other Bacterial [502] Burkholderia mallei infectionB [031] Mumps [010] Congenital Rubella Syndrome [033] Plague (Yersinia pestis)B [011] Diphtheria (Corynebacterium diphtheriae) [035] Poliomyelitis-Nonparalytic [123] Eastern Equine Encephalitis Virus Infection [034] Poliomyelitis-Paralytic [506] Enterobacteriaceae, Carbapenem-resistant [119] Prion disease-variant Creutzfeldt Jakob Disease [507] Francisella species infection (other than F. tularensis)B [109] Q Fever (Coxiella burnetii)B [053] Group A Streptococcal Invasive Disease (Streptococcus [040] Rubella pyogenes) [041] Salmonellosis: Typhoid Fever (Salmonella Typhi) [047] Group B Streptococcal Invasive Disease (Streptococcus [131] Staphylococcus aureus: Vancomycin non-sensitive – all agalactiae) forms [054] Haemophilus influenzae Invasive Disease [075] Syphilis (Treponema pallidum): Congenital [016] Hepatitis, Viral-Type A acute [519] Tuberculosis, confirmed and suspect cases of active [513] Influenza-associated deaths, age <18 years disease (Mycobacterium tuberculosis complex) [520] Influenza-associated deaths, pregnancy-associated [113] Tularemia (Francisella tularensis)B [515] Melioidosis (Burkholderia pseudomallei) [108] Venezuelan Equine Encephalitis Virus InfectionB Category 2: Requires written report using form PH-1600 within 1 week. [501] Babesiosis [009] Cholera (Vibrio cholerae) [003] Botulism-Infant (Clostridium botulinum) [001] Cryptosporidiosis (Cryptosporidium species) [121] California/LaCrosse Serogroup Virus Infection [106] Cyclosporiasis (Cyclospora species) [007] Campylobacteriosis (including EIA or PCR positive [504] Dengue Fever stools) [522] Ehrlichiosis/Anaplasmosis – Any [503] Chagas Disease [060] Gonorrhea-Genital (Neisseria gonorrhoeae) [069] Chancroid [064] Gonorrhea-Ophthalmic (Neisseria gonorrhoeae) [055] Chlamydia trachomatis-Genital [061] Gonorrhea-Oral (Neisseria gonorrhoeae) [057] Chlamydia trachomatis-Other [062] Gonorrhea-Rectal (Neisseria gonorrhoeae)

BPossible Bioterrorism Indicators

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[133] Guillain-Barré syndrome [130] Staphylococcus aureus: Methicillin resistant Invasive [058] Hemolytic Uremic Syndrome (HUS) Disease [480] Hepatitis, Viral-HbsAg positive infant [518] Streptococcus pneumoniae Invasive Disease (IPD) [048] Hepatitis, Viral-HbsAg positive pregnant female [074] Syphilis (Treponema pallidum): Cardiovascular [017] Hepatitis, Viral-Type B acute [072] Syphilis (Treponema pallidum): Early Latent [018] Hepatitis, Viral-Type C acute [073] Syphilis (Treponema pallidum): Late Latent [021] Legionellosis (Legionella species) [077] Syphilis (Treponema pallidum): Late Other [022] Leprosy [Hansen Disease] (Mycobacterium leprae) [076] Syphilis (Treponema pallidum): Neurological [094] Listeriosis (Listeria species) [070] Syphilis (Treponema pallidum): Primary [024] Lyme Disease (Borrelia burgdorferi) [071] Syphilis (Treponema pallidum): Secondary [025] Malaria (Plasmodium species) [078] Syphilis (Treponema pallidum): Unknown Latent [521] Powassan virus infection [044] Tetanus (Clostridium tetani) [118] Prion disease-Creutzfeldt Jakob Disease [045] Toxic Shock Syndrome: Staphylococcal [036] Psittacosis (Chlamydia psittaci) [097] Toxic Shock Syndrome: Streptococcal [105] Rabies: Animal [046] Trichinosis [122] St. Louis Encephalitis Virus Infection [101] Vancomycin resistant enterococci (VRE) Invasive [042] Salmonellosis: Other than S. Typhi (Salmonella Disease species) [114] Varicella deaths [517] Shiga-toxin producing Escherichia coli (including [104] Vibriosis (Vibrio species) Shiga-like toxin positive stools, E. coli O157 and [125] West Nile virus Infections-Encephalitis E. coli non-O157) [126] West Nile virus Infections-Fever [043] Shigellosis (Shigella species) [124] Western Equine Encephalitis Virus Infection [039] Spotted Fever Rickettsiosis (Rickettsia species [098] Yellow Fever including Rocky Mountain Spotted Fever) [103] Yersiniosis (Yersinia species)

Category 3: Requires special confidential reporting to designated health department personnel within 1 week. [500] Acquired Immunodeficiency Syndrome (AIDS) [525] All CD4+ T-cell and HIV-1 Viral Load testing results [512] Human Immunodeficiency Virus (HIV) from those laboratories performing these tests

Category 4: Laboratories and physicians are required to report all blood lead test results within 1 week. [514] Lead Levels (blood) Category 5: Events will be reported monthly (no later than 30 days following the end of the month) via the National Healthcare Safety Network (NHSN ─ see http://tn.gov/health/topic/hai for more details); Clostridium difficile infections (Davidson County residents only) will also be reported monthly to the Emerging Infections Program (EIP). [523] Healthcare Associated Infections, Catheter [524] Healthcare Associated Infections, Dialysis Events Associated Urinary Tract Infections [510] Healthcare Associated Infections, Methicillin [508] Healthcare Associated Infections, Central Line resistant Staphylococcus aureus positive blood cultures Associated Bloodstream Infections [511] Healthcare Associated Infections, Surgical Site [509] Healthcare Associated Infections, Clostridium difficile Infections

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E. Isolate Characterization at the State Laboratory

Laboratory regulations require all clini- ment of Health State Laboratory in nessee. The list of required isolates is cal laboratories to forward isolates of Nashville. The isolates provide an im- presented in Section F. selected pathogens from Tennessee portant resource for further characteri- residents to the Tennessee Depart- zation and tracking of disease in Ten- F. Referral of Cultures or Positive Specimens to the Department of Health State Laboratory According to Statutory Authority T.C.A. 68-29-107, and General Rules Governing Medical Laboratories, 1200-6-3-.12 Di- rectors of Laboratories are to submit cultures or positive specimens of the following organisms to the Department of Health, Laboratory Services, for confirmation, typing and/or antibiotic sensitivity including, but not limited to:

Salmonella species, including S. Typhi Vibrio species Streptococcus pneumoniae* Shigella species Francisella species Group A Streptococcus* Corynebacterium diphtheria Yersinia pestis Bacillus anthracis Brucella species Shiga-like toxin producing Escherichia Burkholderia mallei Mycobacterium species coli, including E. coli O157 and Burkholderia psuedomallei E. coli non-O157 Legionella species Vancomycin-resistant Staphlyococcus Clostridium botulinum aureus (VRSA) Clostridium tetani Haemophlius influenzae* Vancomycin-intermediate Staphlyococ- Listeria species Neisseria meningitidis* cus aureus (VISA) Plasmodium species

For pathogens marked with an asterisk (*), only isolates from sterile sites are required to be submitted. Sterile sites include blood, cerebral spinal fluid (CSF), pleural fluid, peritoneal fluid, joint fluid, sinus surgical aspirates or bone. Group A Streptococcus will also be considered in isolates from necrotizing fasciitis wound cultures.

Information for Sending Cultures Please include the patient’s full name, address, age, and sex, the physician’s name and address (including county), and the anatomic source of culture.

For UPS and Federal Express Items For U.S. Mail Tennessee Department of Health Tennessee Department of Health Laboratory Services Laboratory Services 630 Hart Lane PO Box 305130 Nashville Tennessee 37216-2006 Nashville Tennessee 37230-5130 Phone 615-262-6300

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G. Tennessee Department of Health Regions

The state of Tennessee is divided up Those metropolitan regions include The non-metropolitan regions are into 13 health regions. Over one-half six counties: Davidson, Hamilton, comprised of the seven clusters of of the state’s population is within the Knox, Madison, Shelby and Sullivan. counties shown in the map. borders of six metropolitan regions.

Tennessee’s Department of Health Regions

Mid-Cumberland Upper Cumberland Sullivan County Nashville/Davidson County East Tennessee West Tennessee

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# Northeast Tennessee # # #

Jackson/Madison County Southeast Knoxville/Knox County South Central Memphis/Shelby County Chattanooga/Hamilton County

H. Useful Contact Persons, Telephone Numbers, E-Mail and U.S. Mail Addresses Tennessee Department of Health Address City Zip Code Phone Communicable and Environmental Disease Services 425 5th Avenue North, 1st Fl. CHB Nashville 37243 615-741-7247 State Laboratory 630 Hart Lane Nashville 37243 615-262-6300 Tennessee Department of Health Regions/Metros Address City Zip Code Phone Chattanooga/Hamilton County (CHR) 921 East Third Street Chattanooga 37403 423-209-8180 East Tennessee Region (ETR) 1522 Cherokee Trail Knoxville 37920 865-546-9221 Jackson/Madison County (JMR) 804 North Parkway Jackson 38305 731-423-3020 Knoxville/Knox County (KKR) 140 Dameron Avenue Knoxville 37917-6413 865-215-5090 Memphis/Shelby County (MSR) 814 Jefferson Avenue Memphis 38105-5099 901-544-7715 Mid-Cumberland Region (MCR) 710 Hart Lane Nashville 37247-0801 615-650-7000 Nashville/Davidson County (NDR) 311 23rd Avenue North Nashville 37203 615-340-5632 Northeast Region (NER) 1233 Southwest Avenue Extension Johnson City 37604-6519 423-979-3200 South-Central Region (SCR) 1216 Trotwood Avenue Columbia 38401-4809 931-380-2527 Southeast Region (SER) 540 McCallie Avenue, Suite 450 Chattanooga 37402 423-634-5798 Sullivan County (SUL) PO Box 630, 154 Blountville Bypass Blountville 37617 423-279-2638 Upper Cumberland Region (UCR) 1100 England Drive Cookeville 38501 931-823-6260 West Tennessee Region (WTR) 295 Summar Street Jackson 38301 731-421-6758

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State Contact’s Name Title E-mail Tim F. Jones, MD State Epidemiologist [email protected] John Dunn, DVM, PhD Deputy State Epidemiologist [email protected] David Smalley, PhD, MSS, BCLD Laboratory Services Director [email protected] Contacts Health Officers Directors of Communicable Disease Control Region Name E-mail Name E-mail CHR Valerie Boaz, MD [email protected] Nettie Gerstle, RN [email protected] ETR Tara Sturdivant, MD [email protected] Cathy Goff, MSN, RN [email protected] JMR Tony Emison, MD [email protected] Connie Robinson, RN [email protected] KKR Martha Buchanan, MD [email protected] Bill Blomenkamp, RN [email protected] MSR Helen Morrow, MD [email protected] Jennifer Kmet, MPH [email protected] (Interim) MCR Lori MacDonald, MD [email protected] Vicki Schwark, RN [email protected] NDR Bill Paul, MD [email protected] Nancy Horner, RN [email protected] NER David Kirschke, MD [email protected] Jamie Swift, RN [email protected] SCR Langdon Smith, MD [email protected] Donna Gibbs, PHR [email protected] SER Jan Beville, MD [email protected] Deborah Walker, RN [email protected] SUL Stephen May, MD [email protected] Jennifer Williams, RN [email protected] UCR Fred Vossel, MD [email protected] Debbie Hoy, RN [email protected] WTR Shavetta Conner, MD [email protected] Susan Porter, RN [email protected] I. Emerging Infections and the Emerging Infections Program

An important emphasis of CEDEP is cies) to assess the public health impact son. In January 2003, the entire state on new and emerging infections. of emerging infections and to evaluate became part of one major program of These include antibiotic resistant in- methods for their prevention and con- the EIP, the Foodborne Diseases fections and emerging foodborne path- trol. Active Surveillance Network ogens, such as Cyclospora cayetanensis, (FoodNet). E.coli O157:H7, Listeria and multi- Currently, the EIP Network consists of drug resistant Salmonella serotype New- ten sites: California, Colorado, Con- The core activity of the EIP is active port. Emerging vector-borne diseases necticut, Georgia, Maryland, Minneso- surveillance of laboratory-confirmed include ehrlichiosis, La Crosse enceph- ta, New Mexico, New York, Oregon cases of reportable pathogens. Labora- alitis and West Nile virus. Avian influ- and Tennessee. tory directors and staff, physicians, enza, meningococcal serogroup Y, nurses, infection control practitioners, monkeypox, adult and adolescent per- and medical records personnel are key tussis, SARS and multi-drug resistant The Tennessee Emerging Infections participants in EIP. Components of tuberculosis are other emerging and re- Program (EIP) is a collaborative effort the EIP in Tennessee investigate food- emerging pathogens. of CEDEP, the Vanderbilt University borne infections [Foodborne Diseases School of Medicine Department of Active Surveillance Network Preventive Medicine, and the Centers The Emerging Infections Program (FoodNet)], invasive bacterial infec- for Disease Control and Prevention. (EIP) is a population-based network of tions [Active Bacterial Core Surveil- From December 1999 until December CDC and state health departments, lance (ABCs)], Clostridium difficile In- 2002, the following eleven counties in working with collaborators fection (CDI), HPV Impact Project, Tennessee were involved in the EIP: (laboratories, academic centers, local and influenza surveillance and vaccine Cheatham, Davidson, Dickson, Hamil- health departments, infection control effectiveness. ton, Knox, Robertson, Rutherford, practitioners, and other federal agen- Shelby, Sumner, Williamson, and Wil-

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J. Communicable and Environmental Diseases and Emergency Preparedness Website Further tabulations of data regarding http://www.tn.gov/health. In the entitled “Communicable and Environ- disease surveillance in Tennessee are search box in the top right-hand cor- mental Diseases and Emergency Pre- available at the CEDEP website. To ner, type “CEDEP” and hit Enter. Un- paredness”. access the web site, go to der Search Results, click on the result

Step 1: Type in the web address http://www.tn.gov/health

Step 2: In the search box, type “CEDEP” and hit Enter

Step 3: Click on Communicable and Environmental Diseases and Emergency Preparedness

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K. Tennessee Population Estimates, 2012

The following statewide population estimates were prepared by the Tennessee Department of Health, Division of Policy, Planning and Assessment, and were used in calculating rates in this report. These population estimates were also utilized in sections, K and M. SEX POPULATION AGE GROUP (years) POPULATION AGE GROUP (years) POPULATION Male 3,108,157 <1 81,018 45-49 454,446 Female 3,252,913 1-4 333,920 50-54 462,838 RACE /SEX POPULATION 5-9 408,066 55-59 421,782 White Male 2.535.288 10-14 410,141 60-64 367,200 White Female 2,616,900 15-19 432,643 65-69 290,055 Black Male 506,318 20-24 427,190 70-74 211,324 Black Female 567,211 25-29 418,113 75-79 153,603 Other Male 66,551 30-34 415,309 80-84 109,299 Other Female 68,802 35-39 421,642 85+ 114,215 TOTAL 6,361,070 40-44 428,266

L. Tennessee’s Department of Health Regions: Counties and Population, 2012

East (Population 755,909) County Population County Population County Population Anderson 74,373 Grainger 23,739 Morgan 20,896 Blount 126,119 Hamblen 63,551 Roane 54,680 Campbell 41,882 Jefferson 53,483 Scott 23,253 Claiborne 32,519 Loudon 47,280 Sevier 88,941 Cocke 36,767 Monroe 47,563 Union 20,863 Mid-Cumberland (Population 1,087,454)

County Population County Population County Population Cheatham 42,222 Montgomery 159,209 Sumner 162,422 Dickson 49,744 Robertson 68,589 Trousdale 8,287 Houston 8,238 Rutherford 256,765 Williamson 184,323 Humphreys 19,067 Stewart 14,151 Wilson 114,437 Northeast (Population 350,502)

County Population County Population County Population Carter 59,965 Hawkins 59,665 Washington 119,361 Greene 68,054 Johnson 18,753 Hancock 6,822 Unicoi 17,882

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South Central (Population 394,681) County Population County Population County Population Bedford 48,083 Lawrence 42,709 Maury 84,148 Coffee 54,707 Lewis 12,208 Moore 6,372 Giles 30,076 Lincoln 34,084 Perry 7,813 Hickman 26,100 Marshall 30,958 Wayne 17,423 Southeast (Population 328,349) County Population County Population County Population Bledsoe 13,565 Marion 54,721 Rhea 31,803 Bradley 99,041 McMinn 28,455 Sequatchie 14,042 Franklin 43,112 Meigs 12,423 Grundy 14,925 Polk 16,262 Upper Cumberland (Population 342,749) County Population County Population County Population Cannon 14,269 Jackson 11,419 Smith 20,104 Clay 8,201 Macon 23,208 Van Buren 5,511 Cumberland 55,798 Overton 21,377 Warren 42,263 DeKalb 19,366 Pickett 5,069 White 25,521 Fentress 18,154 Putnam 72,489 West (Population 546,645) County Population County Population County Population Benton 16,726 Gibson 49,169 Lauderdale 28,360 Carroll 29,843 Hardeman 30,007 McNairy 26,362 Chester 16,893 Hardin 26,955 Obion 32,747 Crockett 15,191 Haywood 19,725 Tipton 62,952 Decatur 11,495 Henderson 27,955 Weakley 33,906 Dyer 39,039 Henry 32,672 Fayette 39,245 Lake 7,403 Metropolitan Regions (Population 2,554,781)

County Population County Population County Population Davidson 602,257 Knox 429,161 Shelby 949,665 Hamilton 318,632 Madison 100,816 Sullivan 154,250

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M. Notes on Sources Utilized in Preparing the Report

Statistics utilized in the various dis- Disease rates for the United States notifiable diseases, United States, ease sections throughout this Annual come from the Centers for Disease 2012, MMWR 2014; 61, No.53. Report present the year the disease Control and Prevention. Summary of was diagnosed.

SECTION II. TENNESSEE REPORTED CASES, 2003-2012 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Reported Cases, by Year of Diagnosis, Tennessee, 2003-2012 DISEASE 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 AIDS 600 694 809 284 582 * * * * * Botulism, Foodborne 0 0 0 0 1 0 0 0 0 0 Botulism, Infant 1 1 0 1 1 1 1 0 3 1 Brucellosis 0 1 0 1 2 1 0 1 2 0 California/LaCrosse Encephalitis 14 13 2 7 14 6 9 11 12 9 Campylobacteriosis 448 438 403 443 448 481 512 391 407 452 Chlamydia 21,034 22,513 23,041 25,303 26,969 28,001 29,710 28,326 31,085 32,531 Cryptosporidiosis 41 55 44 47 137 47 78 54 91 72 E. coli 0157:H7 34 48 45 88 54 54 38 48 59 67 Ehrlichiosis 31 20 24 35 39 91 32 66 69 70 Giardiasis 187 251 225 246 297 215 233 55 0 0 Gonorrhea 8,717 8,475 8,619 9,687 9,584 8,767 7,925 7119 7663 9111 Group A Streptococcus 167 144 152 160 149 154 162 201 182 123 Group B Streptococcus 264 245 368 379 302 319 362 356 402 384 Haemophilus influenzae 58 53 93 72 92 101 114 97 108 101 Hepatitis B Surface Antigen Positive, Pregnant 109 115 191 146 191 184 154 0 0 0 Hepatitis A 202 96 149 69 59 35 13 14 25 22 Hepatitis B, Acute 212 221 153 173 149 155 140 152 216 264 Hepatitis C, Acute 23 35 28 28 38 33 30 51 93 150 Hemolytic Uremic Syndrome 15 25 16 31 23 23 19 19 18 17 HIV 549 586 665 697 792 * * * * * HIV Disease * * * * * 997 923 860 855 869 Legionellosis 37 44 40 50 40 45 66 68 92 58 Listeriosis 9 16 12 14 16 14 15 14 6 7 Lyme Disease 19 25 18 30 42 29 9 33 34 30 Malaria 7 13 14 9 19 17 8 13 21 14 Measles (indigenous) 0 0 1 0 1 0 1 0 0 0 Meningicoccal Disease 30 23 27 25 21 21 15 13 9 7 Meningitis, Other Bacterial 28 28 16 4 3 5 12 18 35 14 Methicillin-Resistant Staphylococcus aureus * 946 1,972 2,005 1,973 1,990 1998 1868 1775 1863 Mumps 5 4 3 11 4 4 3 3 1 2 Penicillin-Resistant Streptococcus pneumoniae 133 153 163 154 199 234 129 57 0 0 Penicillin-Sensitive Streptococcus pneumoniae 493 534 807 837 722 874 953 318 1 0 Pertussis 82 179 213 179 75 120 130 235 106 315 Rocky Mountain Spotted Fever 74 99 139 260 186 233 189 308 262 696 Rubella 0 0 0 0 0 0 0 0 0 0 Salmonellosis, Non-Typhoidal 736 776 820 844 849 905 793 1071 1009 1055 Shigellosis 396 571 507 200 363 968 375 260 202 203 Syphilis, Congenital 2 9 19 8 4 10 14 11 9 2 Syphilis, Early Latent 227 206 205 233 294 310 333 331 256 258 Syphilis, Late Latent 461 400 359 434 442 475 498 492 382 424 Syphilis, Neurological 6 7 8 0 0 0 0 0 0 0 Syphilis, Primary 43 24 62 80 109 123 121 72 72 61 Syphilis, Secondary 93 106 155 169 259 288 282 204 207 207 Tetanus 0 2 0 1 1 0 0 0 0 0 Toxic Shock Staphylococcus 1 2 1 4 0 6 4 4 1 3 Toxic Shock Streptococcus 1 0 0 0 0 0 0 0 0 0 Trichinosis 2 0 1 0 0 0 0 0 0 0 Tuberculosis 285 277 299 277 234 282 219 190 172 170 Tularemia 3 2 7 0 2 2 2 3 3 2 Typhoid Fever 3 4 4 1 1 4 4 8 3 3 Vancomycin Resistant Enterococci 802 406 278 388 287 310 321 294 235 214 Yersiniosis 24 26 18 29 13 21 23 21 24 15

15 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Number of Reported Cases of Selected Notifiable Diseases with Rates per 100,000 Persons, by Age Group, Tennessee, 2012

DISEASE <1Y 1-4 5-14 15-24 25-44 45-64 ≥65 Total population 81,018 333,920 818,207 859,833 1,683,330 1,706,266 878,496 Campylobacteriosis Number 40 69 55 69 133 159 111 Rate 49.4 20.7 6.7 8.0 7.9 9.3 12.6 Chlamydia Number 0 2 341 23719 8020 466 14 Rate 0.0 0.6 41.7 2758.6 476.4 27.3 1.6 Gonorrhea Number 0 2 90 5737 2905 366 18 Rate 0.0 0.6 11.0 667.2 172.6 21.5 2.0 Group A Streptococcus Number 2 5 1 10 22 45 38 Rate 2.5 1.5 0.1 1.2 1.3 2.6 4.3 Hepatitis A Number 0 0 0 6 7 5 5 Rate 0.0 0.0 0.0 0.7 0.4 0.3 0.6 HIV Disease Number 3 0 6 243 411 232 15 Rate 3.7 0.0 0.7 28.3 24.4 13.6 1.7 Meningococcal Disease Number 2 0 2 2 0 1 1 Rate 2.5 0.0 0.2 0.2 0.0 0.1 0.1 Pertussis Number 52 31 50 25 54 77 30 Rate 64.2 9.3 6.1 2.9 3.2 4.5 3.4 Spotted Fever Number 3 9 68 92 300 472 297 Rickettsiosis Rate 3.7 2.7 8.3 10.7 17.8 27.7 33.8 Salmonellosis, Number 114 141 122 74 164 249 204 Non-Typhoid Rate 140.7 42.2 14.9 8.6 9.7 14.6 23.2 Shigellosis Number 5 62 68 19 25 16 8 Rate 6.2 18.6 8.3 2.2 1.5 0.9 0.9 Syphilis, Early Latent Number 0 0 0 77 130 50 1 Rate 0.0 0.0 0.0 9.0 7.7 2.9 0.1 Syphilis, Late Latent Number 0 1 0 62 202 137 23 Rate 0.0 3.0 0.0 72.1 120.0 80.3 26.2 Syphilis, Neurological Number 0 0 0 0 0 0 0 Rate 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Syphilis, Primary Number 0 0 0 24 29 7 1 Rate 0.0 0.0 0.0 2.8 1.7 0.4 0.1 Syphilis, Secondary Number 0 0 1 75 91 40 0 Rate 0.0 0.0 0.1 8.7 5.4 2.3 0.0

SECTION III. DISEASE SUMMARIES Communicable and Environmental Diseases and Emergency Preparedness Annual Report

A. Foodborne and Waterborne Diseases

19 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Tennessee FoodNet and FoodCORE Programs Programmatic Overview The Foodborne Diseases Active Sur- and Cyclospora. In 1995, FoodNet sur- · To disseminate information that can veillance Network (FoodNet) is the veillance began in five locations: Cali- lead to improvements in public principal foodborne disease compo- fornia, Connecticut, Georgia, Minne- health practice and the development nent of the Centers for Disease Con- sota and Oregon. From 1997-2004 the of interventions to reduce the bur- trol and Prevention’s (CDC) Emerging surveillance area, or catchment, ex- den of foodborne illness. Infections Program (EIP). FoodNet is a panded numerous times, with the in- collaborative project amongst CDC, clusion of additional counties or addi- Although CDC had a well-established 10 states (California, Colorado, Con- tional sites (New York and Maryland mechanism through FoodNet to deter- necticut, Georgia, Maryland, Minneso- in 1998, eleven counties in Tennessee mine the burden of foodborne illness, ta, New York, New Mexico, Oregon in 2000 [statewide in 2003], Colorado they did not have such a mechanism and Tennessee), U.S. Department of in 2001, and New Mexico in 2004). for foodborne disease outbreak re- Agriculture’s Food Safety Inspection The total population of the current sponse. In 2009, CDC funded a pilot Service (USDA-FSIS), and the Food catchment is 47.5 million or 15.2% of project to improve state and local re- and Drug Administration (FDA). The the U.S. population. sponses to foodborne disease outbreaks. This project was launched in project consists of active laboratory three centers with support from the surveillance for foodborne diseases FoodNet provides a network for re- USDA-FSIS and the Association of and related studies designed to help sponding to new and emerging food- Public Health Laboratories (APHL). It public health officials better under- borne diseases of national importance, was so successful that in 2010, CDC stand the epidemiology of foodborne monitoring the burden of foodborne expanded the project to additional diseases in the United States (U.S.). illness and identifying the sources of centers. In 2011, the project was re- specific foodborne diseases. The Food- named FoodCORE — Foodborne Foodborne diseases under surveillance Net objectives are: Diseases Centers for Outbreak Re- include infections caused by bacteria · To determine the burden of food- sponse Enhancement. Currently seven such as Salmonella, Shigella, Campylobac- borne illness in the U.S. centers participate (Connecticut, New ter, Shiga toxin-producing Escherichia · To monitor trends in the burden of York City, Ohio, South Carolina, Ten- coli (STEC), Listeria, Yersinia, and Vib- specific foodborne illness over time nessee, Utah, and Wisconsin), cover- rio (including Vibrio species, Grimontia · To attribute the burden of food- ing about 14% of the U.S. population. hollisae and Photobacterium damselae), borne illness to specific foods and and parasites such as Cryptosporidium settings Activities There were four primary activities of mation on laboratory-confirmed tories in the state, including details the FoodNet program during this cases of diarrheal illnesses. Addi- such as test type and brand name. three year period: active laboratory- tionally, active surveillance for he- These surveys focused on the fol- based surveillance, surveys of clinical molytic uremic syndrome (HUS) [a lowing pathogens: Campylobacter, laboratories, epidemiologic studies and serious complication of STEC in- Cryptosporidium, Listeria, Salmonella, FoodNet working group calls. fections] is conducted. The result STEC, Shigella, Vibrio and Yersinia. is a comprehensive and timely da- Surveys will continue to be admin- Active laboratory-based surveillance: tabase of foodborne illness in a istered on, at least, an annual ba- The core of FoodNet is laboratory- well-defined population. sis, if not more frequently, to doc- based active surveillance at over ument testing changes. With the 603 clinical laboratories that test Survey of clinical laboratories: From increase in culture-independent stool samples in the ten participat- 2010-2012, a number of laboratory diagnostic testing (CIDT), this is ing states. In Tennessee, 137 labor- surveys were carried out to deter- becoming very important, as not atories are visited regularly by sur- mine the current testing methods all tests are equal. veillance officers to collect infor- used in each of the clinical labora-

20 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Epidemiologic studies: There were nomics Study for FoodNet. The illnesses caused by different types three epidemiologic studies that goal was to identify potential ge- of non-O157 STEC. Data collec- Tennessee participated in during nomic predictors of developing tion is ongoing. this period in review. In 2006, HUS following infection with Tennessee began enrolling cases to STEC. Tennessee was able to en- FoodNet working group calls: Surveil- participate in the E. coli O157 Co- roll 142 cases over the four year lance officers in central office par- hort Study. The goal was to assess study period. Specimens were be- ticipate on a variety of different risk factors for HUS among pa- ing sequenced at Vanderbilt Uni- national working groups through- tients with E. coli O157 infec- versity. In August 2012, we began out the month. Some of the topics tions, including potential expo- enrolling cases and controls in a have been addressed were attribu- sures to various antibiotics. The study to identify behavioral, envi- tion, case exposure assessment, study concluded in December ronmental, dietary, and medical CIDT, special study analyses, geo- 2010, with 163 cases enrolled. Ad- risk factors for non-O157 STEC spatial analyses, norovirus, STEC/ ditionally in 2006, Tennessee took infection and to describe clinical HUS and outbreaks. the lead on the E. coli O157 Ge- and microbiological features of Impact Foodborne diseases are common; an Current "passive" surveillance systems tions cause diarrheal illness, FoodNet estimated 48 million cases occur each rely upon reporting of foodborne dis- focuses these efforts on persons who year in the U.S. Although most of eases by clinical laboratories to state have a diarrheal illness. these infections cause mild illness, health departments, which in turn severe infections and serious complica- report to CDC. Although foodborne With the addition of the FoodCORE tions do occur. The public health chal- diseases are extremely common, only a program in Tennessee, we have been lenges of foodborne diseases are fraction of these illnesses are routinely able to identify clusters of cases more changing rapidly; in recent years, new reported to CDC via passive surveil- easily as many of the interviews are and emerging foodborne pathogens lance systems. This is because a com- being completed centrally. The hand- plex chain of events must occur before ful of students that complete these have been described and changes in such a case is reported, and a break at interviews are able to pick up on these food production have led to new food any link along the chain will result in a commonalities. safety concerns. Foodborne diseases case not being reported. FoodNet is an have been associated with many differ- "active" surveillance system, meaning John Dunn, Deputy State Epidemiolo- ent foods. Public health officials in the public health officials regularly contact gist, reflected on the approach, “This ten EIP sites are monitoring food- laboratory directors to find new cases model has been successful in Tennes- borne diseases, conducting epidemio- of foodborne diseases and report these see and other states in rapidly respond- logic and laboratory studies of these cases electronically to CDC. In addi- ing to foodborne illness outbreaks. diseases, and responding to new chal- tion, FoodNet is designed to monitor It’s great to work with energetic, re- lenges from these diseases. Infor- each of these events that occur along sourceful students and to give them mation gained through this network the foodborne diseases chain and hands-on experience that ultimately will lead to new interventions and pre- thereby allow more accurate and pre- strengthens our public health work- vention strategies for addressing the cise estimates and interpretation of the force.” public health problem of foodborne burden of foodborne diseases over diseases. time. Because most foodborne infec- Foodborne and Waterborne Bacterial Diseases Campylobacteriosis

Background illnesses, not only in the United bacter jejuni, followed by Campylobacter Campylobacteriosis is one of the most States, but in Tennessee as well. The coli and other less common species. commonly reported gastrointestinal causative agent is primarily Campylo- Most persons infected with the bacte-

21 Communicable and Environmental Diseases and Emergency Preparedness Annual Report rium develop diarrhea, cramping, ab- Figure 1. Incidence of Campylobacteriosis, by Year, dominal pain and fever within two to Tennessee, 2003-2012. five days after exposure. Illness typical- 12 ly lasts one week. Culture-Independent Culture-Confirmed 10 Incidence From 2003-2008, rates (per 100,000 persons) of disease averaged about 7.4 8 cases. However with the ever- increasing adoption of culture- 6 independent diagnostic testing (CIDT) methods (e.g., EIA and PCR) in clini- 4 cal laboratories, the rates of campylobacteriosis have consistently been go- 2 ing up since 2009, with a mean annual rate of 8.5 cases (Figure 1). 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Those at greatest risk of developing Year infection are those under the age of five years. From 2010-2012, the overall Figure 2. Mean Incidence of Campylobacteriosis, rate of disease in this population was by Test Method, Tennessee, 2010-2012. 70.3 cases (culture-confirmed: 52.7 cases; culture-independent: 17.6 cases). However when you look at this age group more closely, the driving force is those children under the age of one (49.2 cases).

Trends There has always been some regional variation in regards to campylobacteriosis in Tennessee. Those persons living in the southern or eastern part of al variation begins to shift (Figure 2). methods versus culture [2011-2012 the state consistently have had higher It wasn’t until 2009 that Tennessee Mean Proportion (CIDT: 23%; Cul- rates of disease, as compared to those began to receive Campylobacter reports ture: 13%)]. living in the north or west. that were tested using CIDT methods.

Cases detected by these methods have Program Activities During this reporting period, the high- increased more than 23-fold from Active laboratory surveillance for Cam- est rates (per 100,000 persons) of dis- 2009 to 2012. The uptake of these pylobacter is carried out statewide by ease were reported in Northeast Re- testing methods has been more spread the FoodNet program. Unlike other gion (22.2 cases), followed by East out across the state. foodborne pathogens, isolates for Cam- Tennessee Region (11.1 cases), South- pylobacter are requested but not re- east Region (10.9 cases) and South In 2010, the largest proportion of cas- quired by state law to be sent in to the Central Region (10.1 cases). Whereas, es reported using CIDT methods was state laboratory. the lowest rates of the state were re- among younger age groups. In fact, ported in Nashville/Davidson County 34% of those CIDT cases were under Typically, interviews for campylobac- metropolitan area with 4.1 cases. the age of 5 years, as compared to 23% teriosis are conducted at the regional

of those culture cases. This trend has or local level. However during this However when you look at rates of since shifted to a much older group time period, FoodNet participated in a disease by testing method, this region- (≥65 years) being tested using CIDT pilot study examining the frequency of

22 Communicable and Environmental Diseases and Emergency Preparedness Annual Report selected exposures among reported CORE program agreed to conduct the  Keep your food preparation areas cases of campylobacteriosis and salmo- interviews centrally. clean nellosis. To insure that cases were in-  Avoid unpasteurized milk terviewed in the same manner and to Preventive Measures  Cook your food to the appropriate reduce the additional burden on the There are five simple prevention temperatures regional and local staff, the Food- measures for campylobacteriosis:  Be careful when dealing with ani-  Wash hands carefully mals Listeriosis

Background Listeria monocytogenes causes listeriosis, Figure. Number of Cases of Listeriosis, Tennessee, 2003-2012. a rare but serious bacterial foodborne disease. It results in only about 2,500 18 of the estimated 76 million foodborne 16 illnesses per year in the United States. 14 However, of that number, listeriosis accounts for 500 deaths and 2,300 12 hospitalizations, the highest rate of 10 hospitalization of any foodborne dis- 8 ease. L monocytogenes can cause menin- 6 gitis, other severe neurological seque- Number of Cases 4 lae, spontaneous abortion, and infection in newborn infants. The primary 2 vehicle is food. 0 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Incidence/Trends The major risk factors for infection Year with L. monocytogenes include consumption of high-risk foods such as That year 6 cases were reported; the in early identification of that outbreak. non-pasteurized dairy products, frank- next year the number jumped to 14. The numbers of cases in Tennessee furters and ready-to-eat deli meats. In 1998, a multistate outbreak of lis- have decreased since 2011. Immunosppressed persons and preg- teriosis resulted from post-processing nant females are most susceptible to contamination in a hot dog manufac- Tennessee reported 14 cases in 2010, infection. In Tennessee, listeriosis be- turing plant in another state. Tennes- 6 cases in 2011, and 7 cases in 2012 came a reportable disease in 1996. see Department of Health staff assisted (Figure). Salmonellosis

Background derly and those with weakened im- cases in 2012 (Figure 1). The average Salmonellosis is a gastrointestinal in- mune systems. In the United States, incidence rate in 2010-2012 was 17.5 fection caused predominately by non- Salmonella causes an estimated 1.2 mil- cases per 100,000 persons, similar to Typhi Salmonella serotypes, gram nega- lion illnesses annually with more than the 2010 national rate of 18 cases per tive enteric bacteria. Salmonellosis 23,000 hospitalizations and 450 100,000 persons. This represents a usually appears 6 to 72 hours after deaths. 30% increase from the 2000-2009 av- eating contaminated food and lasts for erage rate of 13.5 cases per 100,000 in 4 to 7 days. Although the illness is Incidence Tennessee. Both Tennessee and na- regarded as a relatively mild disease, Since 2000, the incidence of salmonel- tional rates are still higher than the severe illness and death can occur in losis has increased in Tennessee and National Health Objective 2020 for some cases particularly in infants, el- the highest number ever was 1,149 incidence of salmonellosis (11.4 per

23 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Figure 1. Rates of Salmonellosis, by Year, As always, Salmonella was isolated in Tennessee, 2003-2012. 2010-2012 most frequently from chil- 20 dren under 5 years of age, who ac- 18 counted for 28% of all salmonellosis cases. During this time period, the

incidence rates of salmonellosis were 14 156 cases per 100,000 infants under 12 the age of one and 57 cases per 100,000 children 1-4 years of age. 10

8 The four most common serotypes of 6

Number of cases Number of Salmonella (S. Typhimurium including

(per 100,00 persons) (per 100,00 4 S. I 4,[5],12:i:-, S. Newport, S. Enter- itidis, and S. Javiana) accounted for 2 70%, 68% and 65% of all Salmonella 0 isolates sent to Tennessee Department 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 of Health State Laboratory in 2010, Year 2011, and 2012, respectively (Figure 2). Fourteen cases of S. Typhi were reported in 2010-2012 including at Figure 2. The Top 5 Serotypes of Salmonella, least nine cases linked to travel to en- Tennessee, 2003-2012. demic areas or were a part of an ex- 30 panded immigrant family. 25 Program Activities 20 CDC is monitoring the emergence of the antimicrobial resistance among 15 Salmonella isolated from humans. Na- 10 tionwide, from 2002-2011, 3% of

Proportion of of Proportion Total Isolates these isolates were resistant to ceftiofur 5 (third generation cephalosporin) and 2% to nalidixic acid (quinolones), 0 both are the main antimicrobials used 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 for treatment of severe salmonellosis. Year In Tennessee, 2 % of the isolates were resistant to these antimicrobials. Re- S. Typhimurium S. Newport S.Enteritidis sistance to ampicillin, chlorampheni- S. Heidelberg S. Javiana col, streptomycin, sulfonamide, and tetracycline (ACSSuT) was reported in 100,000 persons). monellosis (7-13 cases per 100,000 6% of Salmonella isolates nationwide persons) during the same time period. compared with 7% of Tennessee iso- The rates of salmonellosis varied by lates. region in 2010-2012. West Tennessee Trends reported the highest rate of Salmonella From 2010 to 2012, salmonellosis re- Tennessee is also participating in the infections (43 cases per 100,000 per- ports followed a typical seasonal trend Retail Food Study since 2002 in col- sons) followed by two metropolitan with two thirds of cases occurring dur- laboration with FDA, CDC, and nine regions, Jackson/Madison and Mem- ing the summer and fall (69% of cases other state health departments to phis/Shelby Counties, with 24 and 21 were reported during the months of monitor the prevalence and antimicro- cases per 100,000 persons, respective- May through October). In 2012, sal- bial resistance of Salmonella isolated ly. The other four metropolitan re- monellosis peaked in July with 185 from retail meat. The Salmonella isolat- gions reported the lowest rates of sal- (16%) cases. ed from chicken breast and ground

24 Communicable and Environmental Diseases and Emergency Preparedness Annual Report turkey in Tennessee during 2002-2011 of approximately 500 million eggs. crobiology laboratories (S. Typhimuri- were susceptible to nalidixic acid com- Other multistate outbreaks were um). pared to consistent resistance among linked to the consumption of salami 0.4-5% of the isolates submitted from products made with contaminated Preventive Measures other states. On the other hand, the imported black and red pepper (S. To improve surveillance and responses resistance to third generation cephalo- Montevideo), alfalfa sprouts (S. New- to foodborne outbreaks, Tennessee sporines rose in retail chicken (10- port and S. I 4,[5],12:i:-), ground tur- was selected among 5 states since 2010 34%) and ground turkey (8-22%) over- key (S. Heidelberg) and a commercially for the CDC Foodborne Diseases Cen- all in 2002-2011. In Tennessee, this distributed frozen chicken and rice ters for Outbreak Response Enhance- resistance pattern was only seen in entrée (S. Chester). Eighteen states ment (FoodCORE). The FoodCORE 2005 (14% of chicken breast and 11% were affected by the Salmonella Chester team in Tennessee conducts central- of ground turkey) and rose to 38% of outbreak and Tennessee was one of ized rapid interviews to collect demo- chicken breast in 2010 and 22% of only two states that collected food graphic, clinical, risk factors, and other ground turkey in 2011. from ill cases which helped to better information for Salmonella cases in identify the source. Some of the multi- almost all regions. In addition, TN is a Approximately 94% of salmonellosis is state outbreaks during this time period part of the “CDC Case Exposure As- transmitted by food consumed in the were linked to non-food exposures like sessment Working Group” and volun- United States. Tennessee was in- African dwarf frogs (S. Typhimurium), teered to participate in two pilot stud- volved in many multistate outbreaks of frozen rodents used as reptile feed (S I ies in 2011-2012 to develop “standard salmonellosis linked with contaminat- 4,[5], 12:i:-), and chicks and ducklings data elements” that may help to more ed food in 2010-2011. The biggest of (S. Altona and S. Johannesburg) and quickly generate hypotheses in Salmo- these was the national outbreak of S. exposures to clinical and teaching mi- nella clusters and outbreaks. Enteritidis that led to a massive recall Shiga-toxin Producing E. coli and Hemolytic Uremic Syndrome

Background their environment. Entero- thrombocytopenia, and acute renal Escherichia coli are common gram- hemmorhagic E. coli (EHEC) are diar- failure. Several studies have suggested negative bacteria with many subtypes, rheagenic E. coli which are subsets of that the risk of HUS is increased after causing a range of clinical illnesses. Shiga toxin-producing E. coli (STEC). treatment of STEC with antibiotics. If Although most E. coli are non- In the United States and in Tennes- antimicrobial therapy is being consid- pathogenic residents of the colon, vari- see, EHEC are important pathogens ered for an enteric infection, obtaining ous subtypes cause urinary tract infec- causing sporadic illness and outbreaks. a stool culture is important in guiding tions and other extra-intestinal infec- The most commonly isolated EHEC is appropriate treatment. In 2008-2010 tions and are common causes of diar- E. coli O157. Identification is facilitat- Tennessee was involved in conducting rhea worldwide. ed by certain biochemical properties the largest study to date to address the which are distinctive (e.g., the organ- effects of antimicrobial use in persons Shiga toxin-producing E. coli (STEC) is ism does not ferment the sugar sorbi- infected with E. coli O157. a group of E. coli that causes dysentery tol), EHEC, including E. coli O157, (bloody diarrhea). STEC possess sever- can cause watery or bloody diarrhea Although E. coli O157 is most com- al virulence factors, including Shiga and hemorrhagic colitis. Severe ab- monly isolated, over 200 other sero- toxin. Shiga-toxin, also called verotox- dominal cramping or pain is often types of E. coli also produce Shiga- in, is essentially identical to a toxin reported. Nausea, vomiting and fever toxins. Up to half of STEC associated produced by Shigella dysenteriae. Live- are less commonly reported. Of those diarrhea in the U.S. may be due to stock, especially cattle, are thought to infected, 5-10% may develop hemolyt- non-O157 serotypes, though most of be the primary reservoir for STEC. ic uremic syndrome (HUS), which these likely go unreported due to limi- Reservoir species are clinically unaf- disproportionately affects young chil- tations in laboratory testing. The most fected. Transmission has been associat- dren and the elderly and can have a common non-O157 STEC serotypes ed with foods like ground meat, pro- mortality rate of up to 5%. HUS is in the U.S. include O26:H11, O111, duce, and water, as well as direct con- characterized by the clinical triad of O103, O121, and O145. Tennessee is tact with STEC-colonized animals and microangiopathic hemolytic anemia, participating in a multistate case-

25 Communicable and Environmental Diseases and Emergency Preparedness Annual Report control study to identify risk factors Figure. Culture-Confirmed E. coli O157 and HUS, for non-O157 infection, and to de- Tennessee, 2000-2012. scribe clinical and microbiologic fea- 100 E. coli O157 tures of the illness. 90 HUS 80 Most clinical laboratories have the capacity to identify E. coli O157 by 70 culture, isolating sorbitol-negative E. 60 coli. All positive STEC infections in- 50 cluding E. coli O157 are reportable to 40 the Tennessee Department of Health 30 (TDH). Any clinical material [culture Number ofCases 20 material (i.e. broth cultures), or isolates positive for Shiga toxin 10 (including E. coli O157)] must be for- 0 warded to the state public health la- 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 boratory per Tennessee law. This is Year especially important as more labs begin using non-culture based methods. Isolation of the bacteria is im- Incidence age (Figure). Of these, laboratory evi- portant for serotyping and DNA fin- In 2010-2012, 449 cases of STEC were dence of a preceding STEC infection gerprinting by pulsed-field gel electro- reported to the Tennessee Department was obtained in 42 cases (79%). phoresis (PFGE). PFGE helps to iden- of Health. Of these, (Figure) 174 were tify cases with potential epidemiologic culture confirmed E. coli 0157, 128 Program Activities links to other sporadic cases, recog- were culture-confirmed non-O157 As a FoodNet site, Tennessee contin- nized outbreaks, or contaminated STEC, and 6 was culture-confirmed ues to be engaged in studies to better foods. STEC with O antigen undetermined. characterize STEC infections and out- In 2010-12, 53 cases of HUS were re- comes. ported in persons less than 18 years of Shigellosis

Background Figure. Incidence of Shigellosis, by Year, Shigellosis is an infectious disease Tennessee, 1993-2012. caused by a group of bacteria called 20 Shigella. Most persons infected with 18 Shigella develop diarrhea, fever, and 16 stomach cramps within one or two 14 days after they are exposed to the bacterium. The diarrhea is often bloody. 12 However, illness usually resolves in 10 five to seven days. In some persons, 8 especially young children and elderly, 6 diarrhea can be severe requiring hospi- Number of Cases 4 talization. Although some infected (per 100,000 population persons may never show any symptoms 2 at all, they may still pass the Shigella 0 bacteria to others. Transmission occurs primarily person-to-person by the fecal-oral route, with only a few organ- Year isms (10-100) needed to cause infec-

26 Communicable and Environmental Diseases and Emergency Preparedness Annual Report tion. (9.7 cases per 100,000), and 2008 possible, young children with a Shigella (15.8 persons per 100,000 persons) infection who are still in diapers Incidence and are indicative of the four to six should not be in contact with unin- The figure shows the incidence of shi- year cyclical nature of shigellosis in fected children. In daycare settings, gellosis cases from 1993-2012 in Ten- Tennessee (Figure). exclusion of children until they are nessee. symptom free for 48 hours is a mini- Program Activities mum requirement. Local require- Trends Currently, active laboratory surveil- ments may include documentation of Even though the number of cases re- lance is being conducted statewide for negative stool culture. In addition, ported in Tennessee has varied over Shigella by the FoodNet program. people who have shigellosis should not the years, the rate of disease has de- prepare food for others until they have clined overall. However, major in- The spread of Shigella from an infected been symptom free for at least twenty- creases in incidence occurred in 1993 person to other persons can be pre- four hours and educated about basic (18.9 cases per 100,000 persons), 1998 vented by frequent and careful hand- food safety precautions. (15.7 cases per 100,000 persons), 2004 washing with soap and water. When Vibriosis and Cholera

Background 2012, rate of vibriosis nearly doubled. were V. parahaemolyticus and V. vulnifi- Both cholera and vibriosis are gastroin- cus (Table). testinal illnesses caused by bacteria Those at greatest risk of developing found in the Vibrionaceae family. infection are children, immunocom- Program Activities Cholera is specifically caused by two promised persons and persons with Active laboratory surveillance for chol- toxigenic serotypes of Vibrio cholerae chronic liver disease. era and vibriosis is carried out called V. cholerae O1 and V. cholerae statewide by the FoodNet program. O139. Vibriosis is caused by all other Trends Isolates for Vibrio (including Vibrio non-cholera Vibrio species, Grimontia Typically, there are anywhere from species, Grimontia hollisae and Photbac- three to ten cases reported each year in hollisae and Photobacterium damselae. terium damselae) are required by state Tennessee (vibriosis and cholera com- This bacterium is naturally found in law to be sent in to the state laborato- bined). However in 2012, there were marine coastal waters, but is in low ry. numbers as to not pose any health 17 cases reported, which is the most risk. However in the warmer months, ever reported. Of those, there were a these bacteria multiply which cause variety of species identified, as com- In addition to the routine surveillance gross contamination in shellfish and pared to previous years. From 2010- form, a national case report form must water. 2012, the top two species reported be completed and submitted to CDC’s Cholera and Other Vibrio Illness Sur- Most persons infected with the bacte- Table. Reported Species Among Cases of Vibriosis and Cholera, rium develop diarrhea, vomiting, pri- Tennessee, 2010-2012. mary septicemia or wound infections Species 2010 2011 2012 within 5 to 92 hours after exposure. Illness typically lasts two to five days. V. alginolyticus 1 3 2 Treatment is not necessary in most V. cholerae, non-O1/non-O139 0 1 3 cases. However, cases should drink plenty of liquids to replace fluids lost V. cholerae O1/O139 0 0 1 through diarrhea. V. fluvialis 1 0 3

Incidence G. hollisae 0 0 1 From 2003-2011, rates (per 100,000 V. mimicus 0 0 1 persons) of vibriosis averaged about 0.12 cases; whereas, rates of cholera V. parahaemolyticus 3 6 2 averaged about 0.01 cases. However in V. vulnificus 0 1 4

27 Communicable and Environmental Diseases and Emergency Preparedness Annual Report veillance (COVIS) Team. This form tive measures one can take to reduce As for cholera, an oral vaccine was asks for more detailed information their risk of infection with vibriosis. recently developed and is licensed and regarding isolate characteristics, clini-  Seafood should be cooked ade- available in other countries (Dukoral cal presentation, medical history, trav- quately and, if not ingested imme- from SBL Vaccines). The vaccine ap- el history, and food and environmen- diately, should be refrigerated. pears to provide somewhat better im- tal exposures. When shellfish is impli-  Uncooked mollusks and crusta- munity and have fewer adverse effects cated, additional traceback efforts are ceans should be handled with than the previously available vaccine. initiated by Tennessee Department of care. However, CDC does not recommend Agriculture or the Food and Drug Ad-  All children, immunocompro- cholera vaccines for most travelers, nor ministration. mised people, and people with is the vaccine available in the United chronic liver disease should avoid States. Preventive Measures eating raw oysters or clams. There are a number of basic preven- Yersiniosis

Background Figure. Number of Yersioniosis Cases, Yersinia is transmitted via is a gram Tennessee, 2003-2012. negative, rod-shaped bacteria. The 35 common agent for infection is Yersinia enterocolitica. Others include Y. pseudo- 30 tuberculosis and Y. pestis. The main ani- 25 mal reservoir is pigs. Yersinia is often acquired by eating contaminated food. 20 It is often associated with the production and consumption of chitterlings 15 (pork intestines). Symptoms include fever and diarrhea. Most infections 10 Number of Cases are uncomplicated and resolve com- 5 pletely. 0 Incidence 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Based on data from 2003-present, we generally see 10-30 cases annually Year (Figure). Yersinia cases are seen most commonly in the African-American Program Activities Preventive Measures population during Christmas due to The Tennessee Department of Health The Tennessee Department of Health the preparation of chitterlings during has preventive literature available for monitors for outbreaks and provides this time of year. distribution. targeted information. Foodborne and Waterborne Parasitic Diseases

Thousands of people are diagnosed are those who come into contact with see. Only two enteric parasitic diseases with parasitic diseases in the U.S. each or accidentally ingest a parasite that is are reportable in Tennessee, cryptos- year. A portion of those diagnosed are capable of living and reproducing in- poridiosis and cyclosporiasis. These among those who have travelled to or side the human body. two diseases are caused by the inges- lived in areas outside the U.S. where tion of the parasites often from food parasites may exist in greater abun- Many parasitic diseases have tradition- or water contaminated with human or dance. However, many species of para- ally been considered exotic or foreign animal feces. Food may become con- sites are endemic to the U.S. Those at to the U.S. and have not been includ- taminated by poor hygienic behaviors risk for contracting a parasitic illness ed in differential diagnoses in Tennes- of ill foodworkers, failure to properly

28 Communicable and Environmental Diseases and Emergency Preparedness Annual Report wash or cook fruits and vegetables, or ly treated human feces entering water- taminated from a lapse of filtration or failure to properly butcher and cook ways. Groundwater may be contami- chemical treatment at the treatment meats. Surface water may be contaminated by failing onsite septic systems, facility or within the distribution sys- nated when animal feces enters natu- by improper placement of drain field tem through water line breaks or stor- ral waterways or when sewage treat- to water wells or by infiltration of con- age tank breaches. ment facilities have a lapse in treat- taminated surface water to groundwa- ment resulting in untreated or partial- ter. Municipal water can become con- Cryptosporidiosis

Background Cryptosporidiosis is a gastrointestinal Figure 1. Cryptosporidiosis Cases, Tennessee, 1995-2012. illness caused by the protozoal parasite 160 Cryptosporidium affecting both animals and humans. Human infection is 140 commonly associated with person to 120 person transmission, accidental inges- 100 tion, and consumption of contaminated food or water. 80 Often considered a waterborne para- 60 site, Cryptosporidium can exist in soil and water for long periods of time. Number of Cases 40 People enjoying the many streams and 20 lakes of Tennessee may accidentally consume water containing Cryptosporid- 0 ium. This is especially a concern when young children are swimming in natural water bodies. Oocysts encyst when Year in harsh environments making them capable of surviving routine chlorine lasts around 10 days, but can be as were reported statewide representing disinfection in treated recreational short as 1 day and as long as 20 days. an average incidence rate per 100,000 water venues such as swimming pools, population of 1.2. The average nation- splash parks, and hot tubs and are of Incidence al incidence rate during 2000-2010 particular concern in drinking water In Tennessee, cryptosporidiosis is a was 2, with the highest incidence rate treatment systems due to their small Category 2 reportable disease and being 2.9 for 2010. size and chlorine resistivity. The two must be reported in writing within 1 species most commonly found in hu- week of diagnosis. The number of Program Activities mans are C. parvum and C. hominis. C. cryptosporidiosis cases in Tennessee Cryptosporidiosis case reporting facili- parvum has long been recognized in has generally risen during recent years. tated observation of spatial and tem- persons, pets, and ruminant animals During 1995–2012, 821 cases were poral patterns of infection. The east- in agricultural settings. reported, ranging from a minimum of ern third of the state has reported 1 case in 1995 to a maximum of 137 higher incidence of cryptosporidiosis Asymptomatic infections are common cases in 2007. (Figure 1). The cases than the remainder of the state and constitute a source of infection for reported in 2007 included those from (Figure 2). During 2010-2012, under others. The major symptom associated at least 2 recreational water outbreaks. the CDC Environmental Health Spe- with cryptosporidiosis is profuse and There have been no known outbreaks cialist Network grant, a study was un- watery diarrhea, often preceded by since that time. derway to investigate this apparent anorexia and vomiting. The diarrhea is clustering of cryptosporidiosis cases. associated with cramping abdominal Trends Discovered through this investigation pain. In immunocompetent cases, From January 2010 to December was a doubling of cases reported by including children, diarrhea usually 2012, 224 cases of cryptosporidiosis hospitals in the northeast region after

29 Communicable and Environmental Diseases and Emergency Preparedness Annual Report switching to rapid card assays. One Figure 2. Cryptosporidiosis Cases, by Region, pediatric clinic in that region also tests Tennessee, 1995-2012. all children presenting with diarrhea for cryptosporidiosis. This increase in 180 testing rate and increased sensitivity of 160 testing methodologies appear to ac- 140 count for some of this increased re- 120 porting. Another contributing factor, appears to be more frequent contact 100 with cattle or other animals (when 80 compared to case patient exposures in 60 the rest of the state. As a part of this Number of Cases 40 study, stool samples were subjected to polymerase chain reaction (PCR) test- 20 ing. Through this testing, C. parvum 0 was the only species of Cryptosporidium identified in case patients in the northeast region. A subset of stool samples Region was submitted to the CDC’s Parasitic Diseases Laboratory for further genetic card tests have also been associated nessee Department of Environment subtype identification. A unique sub- with false positive results perhaps lead- and Conservation. A drinking water type of cryptosporidium was found in ing to the recent increase in case re- cryptosporidiosis outbreak scenario stool samples from two epi-linked cas- porting from facilities that have recent- was used in breakout sessions. This es. ly switched to these tests. training reinforced the roles of each department and increased collabora- The availability of the anti- Preventive Measures tion between departments at the re- Cryptosporidium drug nitazoxanide, ap- In 2010, waterborne outbreak training gional level. To help prevent cryptos- proved in 2005, is thought to have was conducted in 5 sites across the poridiosis and other waterborne ill- made providers more aware of cryptos- state which included environmental nesses, the Tennessee Department of poridiosis and more likely to pursue health specialists, epidemiologists, Health distributes information on rec- diagnosis. New diagnostic techniques, nurses, medical doctors and veterinari- reational water safety each year. including enzyme immunoassay and ans from the state and regional health rapid card tests, have been document- departments as well as environmental ed to have higher sensitivity. The rapid specialists and managers from the Ten- Cyclosporiasis

Background infective oocysts are shed intermittent- Symptoms of cyclosporiasis begin an Cyclosporiasis is an intestinal infec- ly in stool. The oocysts sporulate in average of 7 days (range 2 days to ≥2 tion caused by the parasite, Cyclospora the environment, making direct per- weeks) after ingestion and may include cayetanens. This disease was first de- son to person infection unlikely. Infec- watery diarrhea, loss of appetite, scribed in humans in New Guinea in tion in humans occurs by ingestion of weight loss, cramping, bloating, nau- 1977 as being caused by “a large fecally contaminated food or water. sea, vomiting, and fatigue. Cyclospora Cyrptosporidium” until taxonomic classi- Oocysts of this organism persist in the infection is diagnosed by examining fication was made in 1993. Cyclospori- environment and may endure after stool specimens; however, diagnosis asis became nationally notifiable in iodine or chlorine disinfection on can be difficult because oocysts maybe 1999 and became reportable in Ten- fresh produce or in drinking water. shed intermittently or in low amounts. nessee in 2002. Inside the gastrointestinal tract, the Cyclospora oocysts are autofluores- sporocysts excyst and migrate to the cent, appearing blue or green against a The only known host of this single lining of the small intestine where they black background under ultraviolet celled parasite is humans. Non- reproduce and form oocysts. light. Alternately, acid-fast staining or

30 Communicable and Environmental Diseases and Emergency Preparedness Annual Report polymerase chain reaction (PCR) is basil; more than 300 individuals were Program Activities used to identify Cyclospora oocysts in sickened in 32 Florida counties. The recommended treatment is a com- stool specimen. bination of two antibiotics, trime- Trends thoprim- sulfamethoxazole. No highly Incidence In Tennessee, cyclosporiasis is a Cate- effective alternative antibiotic regimen Cyclospora is endemic to tropical and gory 2 reportable disease and must be has been identified for patients who subtropical areas. The overall U.S. reported in writing within 1 week of do not respond to the standard treat- incidence of Cyclospora infections is diagnosis. During 2002–2012, a total ment or have a sulfa allergy. Most peo- low with an average incident rate of of 19 cyclosporiasis cases were report- ple with healthy immune systems will 0.08 per 100,000 people during 2000– ed. Regionally, the middle Tennessee recover without treatment, although if 2010 which represents 1,841 cases regions have reported 8 of the 19 cas- not treated symptoms can last for sev- nationwide. During 1995–2000, large es, 5 from the MidCumberland Re- eral weeks. outbreaks of cyclosporiasis in North gion and 3 from Nashville Davidson. America were associated with the con- From January 2010 to December Preventive Measures sumption of fresh raspberries from 2012, 5 cases were reported statewide; As with other foodborne diseases, the Central America. In April 2005, an- 1 from Knox County, 2 from Chatta- department promotes proper cleaning other large outbreak in Florida was nooga/Hamilton Region, and 2 from and cooking of raw vegetables and attributed to consumption of fresh the Nashville/Davidson Region. meats. Foodborne Outbreaks

Programmatic Overview Figure. Reported foodborne disease outbreaks in A foodborne disease outbreak is de- Tennessee, 2003-2012. fined as the occurrence of 2 or more 35 cases of similar illness resulting from the ingestion of a common food. All 30 suspected outbreaks and unusual patterns of gastrointestinal illness should 25 be reported to the local health depart- 20 ment. 15 Activities From 2010-2012, 26, 15, and 21 food- 10 borne outbreaks were reported, respec- Number outbreaks of 5 tively (Figure). The increasing use of pulsed-field gel electrophoresis (PFGE) 0 to determine relatedness of bacterial 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 isolates continues to improve the recognition and investigation of sus- Year pected local and multi-state outbreaks. In 2010, a cluster of Salmonella Enter- the eggs were traced back to a farm in analyses indicated that exposure to itidis with an indistinguishable PFGE the Southeast. Another useful tool in common areas of the hotel tourna- pattern was identified. When cases in outbreak investigations is the polymer- ment attendees stayed at, specifically this cluster were interviewed, epidemi- ase chain reaction (PCR) test. This the pool table room, the swimming ologists discovered that they had all test has markedly improved our ability pool area, and the restaurant areas consumed eggs prepared by the same to confirm norovirus as a common were associated with illness. Given food truck. The environmental health etiology in foodborne disease out- that people were ill prior to arrival at inspection cited violations including breaks. In 2012 over 100 people asso- the hotel, and the evidence of vomit- pooling of eggs. Education was pro- ciated with a hockey tournament being in an open area of the hotel, most vided to the food truck owners and came sick with norovirus. Risk factor likely exposure to contaminated areas

31 Communicable and Environmental Diseases and Emergency Preparedness Annual Report and close contact between team mem- of norovirus gastroenteritis. by public health professionals to pre- bers created the potential for wide- vent additional outbreaks. Also the spread person-to-person transmission Impact use of laboratory tools such as PFGE in this gathering of young people and Several foodborne outbreak investiga- and PCR allow public health staff to their families. It was concluded that tions highlighted the importance of identify and solve outbreaks in a more this was a person to person outbreak these activities and the measures taken timely manner.

32 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

B. Invasive Diseases

33 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Active Bacterial Core Surveillance (ABCs) Programmatic Overview Active Bacterial Core surveillance is a a case report with basic demographic ABCs was initially established in four core component of the Centers for information is completed and bacterial states in 1995. It currently operates Disease Control and Prevention isolates are sent to CDC and other among 10 EIP sites across the United (CDC’s) Emerging Infections Pro- reference laboratories for additional States, representing a population of grams network, a collaboration be- laboratory evaluation. ABCs also pro- approximately 41 million persons. At tween CDC, state health departments, vides an infrastructure for further pub- this time, ABCs conducts surveillance and universities. ABCs is an active lic health research, including special for six pathogens: group A and group laboratory- and population-based sur- studies aiming at identifying risk fac- B Streptococcus (GAS and GBS), Hae- veillance system for invasive bacterial tors for disease, post-licensure evalua- mophilus influenzae, Streptococcus pneu- pathogens of public health im- tion of vaccine efficacy and monitor- moniae, Neisseria meningitidis, and portance. For each case of invasive ing effectiveness of prevention poli- methicillin-resistant Staphylococcus aure- disease in the surveillance population, cies. us.

Activities In Tennessee, the ABCs Program is presently including all cases that reside analytic agenda, and conducts spatial coordinated through Vanderbilt Uni- throughout the state in Tennessee epidemiologic analyses using geocoded versity. The ABCs surveillance area who met case definition for PCV13 surveillance data linked to census data, comprises the major metropolitan are- and are identifying controls. including measures of poverty, crowd- as of the state (Nashville, Memphis, ing, and access to care, along with oth- Knoxville, Chattanooga, Jackson) and Under the leadership of Dr. er geographic data sources, on behalf 15 surrounding counties. In January Lindegren, we are participating in an of the EIP network. 2010, the ABCs surveillance area was ABCs Group A Strep genomics work- increased for all pathogens from 11 to ing group to design a study to deter- Population-based, active, laboratory the current total of 20 counties; this mine the genetic factors associated surveillance to determine species distri- increased the population under sur- with the development of severe inva- bution and antifungal resistance of veillance from 3.1 million to 3.8 mil- sive Group A streptococcal infection, Candida species causing bloodstream lion. All 59 hospitals in the 20-county specifically necrotizing fasciitis (NF) infections (BSI) is being conducted in surveillance area actively participate. and streptococcal toxic shock syn- nine counties that incorporate Knox- drome (STSS). We will collaborate ville (Knox County) and surrounding A new 13-valent pneumococcal conju- with external partners for genotyping counties. Prospective data and isolate gate vaccine (PCV13, Pfizer) was li- to determine associations between collection began on January 1, 2011. censed in February 2010. Post- genetic variants hypothesized to play a Results of surveillance, including anti- licensure evaluation of PCV13 effec- role in inflammation and immune fungal susceptibility results are being tiveness is important to ensure that regulation with STSS and NF. Identi- communicated to each hospital’s mi- the vaccine performs as expected fying genetic variants will enable fu- crobiology laboratory director and to among children. This project provid- ture targeted prevention efforts using the Infection Preventionist. ed our principal motivation to expand vaccine or other modalities and more our ABCs surveillance area from 11 to aggressive treatment. Vanderbilt ABCs has trained numer- 20 counties, adding eight counties ous MPH students and both pediatric surrounding Knoxville and one county We participate in activities investigat- and adult infectious disease fellows, all between Nashville and Memphis ing population host factors that are of whom have worked on ABCs and which is a semi-urban population cen- potential risks for ABCs infections EIP data. Many of these projects have ter, thus increasing our population such as diabetes, obesity and co- resulted in presentations at scientific under surveillance by 600,000 persons infections. Geocoding for all ABCs meetings and publications. and increasing the power of the study. projects is underway using ArcGIS In another attempt to increase the software. Tennessee provides leader- power of the case control study, we are ship for the geocoding working group

34 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Impact ABCs data have been used to track jugate pneumococcal vaccination. The revised CDC guidelines recommend- disease trends and permitted the dis- emergence of serogroup Y meningo- ing the use of universal screening of covery and quantification of the herd coccal disease also was documented. pregnant women for Group B strepto- effect that accompanied pediatric con- ABCs data have formed the basis of coccal infection. Other EIP Surveillance Activities

Clostridium difficile Infections (CDI) Active Surveillance Emerging Infections Program (EIP) C. from cases with CDI in Davidson identify the proportion of infections difficile Infection (CDI) Surveillance is County and are sent to partner refer- associated with medical care, measure a special ABCs study in Tennessee ence labs for toxigenic culture and trends of disease over time, determine which in addition to nine other states then sent to the Centers for Disease which strains of C. difficile are causing comprise CDC’s Emerging Infections Control and Prevention (CDC) for disease, and in what proportions. In Programs network. Tennessee EIP molecular investigation. Data from addition, the project provides infra- CDI Surveillance is a population- and this project will help inform future structure for further research includ- laboratory-based active surveillance policy and prevention strategies to ing studies to identify risk factors, to system among Davidson County, Ten- reduce C. difficile disease. Specifically, determine population targets for vac- nessee residents. A convenience sam- the goals of EIP C. difficile surveillance cines, and to monitor the efficacy of ple of both community- and healthcare project are to determine the burden of prevention strategies. facility- associated strains are obtained C. difficile disease in the United States, Legionellosis Active Surveillance As a means to evaluate the current participating in the Emerging Infec- ties. Tennessee began active surveil- passive surveillance system and to de- tions Program (EIP) were invited to lance for legionellosis in June 2011. scribe the incidence and epidemiologic add active surveillance for legionellosis characteristics of legionellosis, states to their existing EIP activi- Invasive Group A Streptococcal Disease

Background necrotizing fasciitis (frequently re- observed in 2010. In contrast to the Group A Streptococcal Disease refers ferred to in the lay media as “flesh eat- earlier years’ data that revealed highest to infection with Streptococcus pyogenes ing bacteria”) and streptococcal toxic rate of infection among the African (Group A B-hemolytic streptococcus). shock syndrome (STSS). American population, recent data indi- Group A Streptococcus (GAS) is a cate that there is no major difference bacterium often found in the throat GAS spreads through direct contact in the rate of infection among African and on the skin and may cause no with mucus membrane from nose or American and White populations in symptoms of illness (colonization). throat of persons who are colonized or Tennessee. In 2011, the incidence rate Most infections are relatively mild infected or through contact with in- of invasive GAS infection was 2.3 and such as “strep throat” or impetigo. fected wounds or sores on the skin. 2.4 per 100, 000 among African Amer- Severe GAS diseases may occur when icans and Whites, respectively. bacteria get into parts of the body Incidence where bacteria usually are not found The average incidence of Group A In 2012, the highest incidence rates (e.g., blood, muscle, or the lungs). Invasive Disease in Tennessee ranged were seen in Knox County, Sullivan When bacteria get into normally ster- between 2.4 to 3.2 per 100,000 in the County, East region, Upper Cumber- ile sites and cause infection it is last 8 years with the exception of 2012, land region and Memphis/Shelby termed as “invasive” GAS disease. Two where the lowest incidence (1.9 per County (Figure). of the most severe but less common 100,000) was observed. The highest forms of invasive GAS diseases are incidence rate of 3.2 per 100,000 was

35 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Trends Figure. Incidence Rate of Invasive Group A Streptococcal Infections per 100,000 Invasive Group A Population, Tennessee, 2012. Streptococcal infection occurs more frequently among elderly, young children, the immune compromised and persons with chronic and debilitating diseases. Persons with skin lesions and injecting drug users are other groups at Table. Incidence rate* of Invasive Group A Streptococcal Infections by Age Group, higher risk of the Tennessee, 2010-2012. infection. 2010 2011 2012 Age group Number of Incidence Number of Incidence Number of Incidence (in years) cases Rate cases Rate cases Rate The age adjusted <5 12 2.94 6 1.48 6 1.45 rate of invasive GAS 5 to 9 6 1.46 8 1.95 1 0.25 in Tennessee over 10 to 14 3 0.72 0 0.00 1 0.24 the last three years 15 to 19 4 0.91 6 1.41 5 1.16 revealed that the 20 to 24 2 0.47 7 1.59 6 1.40 incidence rate has 25 to 34 13 1.58 19 2.27 13 1.56 been persistently 35 to 44 25 2.93 23 2.73 7 0.82 higher among those 45 to 54 32 3.45 21 2.28 20 2.18 aged above 45 years 55 to 64 27 3.44 32 3.92 24 3.04 and the rate was low 65+ 76 8.79 65 7.39 38 4.21 among those aged All ages 200 3.15 187 2.92 121 1.90 10 to 14 years of age *Incidence rates are expressed per 100,000 population (Table). Preventive Measures sons exposed to someone with an inva- The rate of invasive GAS disease has The Tennessee Department of Health sive group A strep infection (i.e. ne- been stable for the last seven years, promotes the following to reduce the crotizing fasciitis or strep toxic shock with the exception of 2012 which had spread of all types of GAS infection: syndrome) to receive antibiotic therapy the lowest rate (1.9 per 100,000). Sur- good hand washing, especially after to prevent infection. However, in cer- veillance of invasive GAS will contin- coughing and sneezing and before pre- tain circumstances, antibiotic prophy- ue to determine the distribution of the paring foods or eating. Persons with laxis may be appropriate. disease, emergence and prevalence of sore throats should be seen by a doctor new serotypes, and to identify risk fac- who can perform tests to find out tors for community and health care whether the illness is strep throat. If onset GAS infection. the test result shows strep throat, the person should stay home from work, Program Activities school, or daycare until 24 hours after Surveillance is conducted for invasive taking an antibiotic. All wounds GAS infections. Surveillance data are should be kept clean and watched for used to define trends and look for pos- possible signs of infection such as red- sible outbreaks, particularly in ness, swelling, drainage, and pain at healthcare settings. Case investigations the wound site. A person with signs of are monitored by the Healthcare- an infected wound, especially if fever Associated Infections (HAI) Program. occurs, should immediately seek medical care. It is not necessary for all per-

36 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Invasive Group B Streptococcal Disease

Background Figure 1. Cases and Incidence of Invasive Group B Group B Streptococcal infection Streptococcus Infections, by Year, Tennessee, 2007-2012. (GBS) is caused by the bacteria Strepto- coccus agalactiae. It emerged as the 450 7 leading infectious cause of neonatal 400 morbidity and mortality in the United 6 350 States during the 1970s. Transmission 5 from mother to infant occurs shortly 300 before or during delivery. It can be 250 4 acquired in the nursery from hospital 200 personnel via hand contamination. It 3

150 Incidence Rate also can be acquired in the community 2 Number of Cases from healthy colonized people. Per- 100 (per 100,000 persons) sons at greatest risk of developing in- 50 1 fections are newborns, pregnant wom- 0 0 en and non-pregnant adults who have 2007 2008 2009 2010 2011 2012 underlying medical conditions such as diabetes mellitus, chronic liver or re- Year nal diseases, malignancy or other im- muno-compromising conditions and adults above 65 years of age. Figure 2. Cases and Incidence of Early Onset Invasive Group B Streptococcal Infection by Year, Tennessee, Infection in newborns is classified in 30 2000-2012 0.35 two distinct categories: early onset in 0.3 (0-6 days old) and late onset disease (7- 25 0.25 89 days old). Early onset disease is 20 characterized by signs of systemic in- 0.2 fection, respiratory distress, apnea, 15 shock, pneumonia and less often men- 0.15 10 ingitis. Late onset occurs at 3-4 weeks 0.1 Incidence Rate Incidence of age (7-89 days) and commonly man- Number of Cases 5 ifests with bacteremia or meningitis. 0.05 (per 1,000 livebirths) Preterm infants are more likely to de- 0 0 velop early onset diseases when compared to full term infants. The late onset disease usually occurs in infants Year who have history of prolonged hospi- Number of Cases tal stay. About 4% of infants with early onset infections die from their ill- ure 1. dence of early onset disease. The inci- ness. Trends dence of early-onset GBS disease in The national prevention strategy rec- the United States has declined since Incidence ommends screening of pregnant wom- 1993 by 84% (from 1.7 cases per In Tennessee the number of cases re- en for group B streptococcal coloniza- 1,000 live births in 1993 to 0.26 cases ported among the general population tion at 35 to 37 weeks of gestation and per 1,000 live births in 2011) , coin- appears to be stable at a rate of around providing antibiotic prophylaxis at the ciding with increased prevention activ- 5 to 6 per 100,000 population. Num- time of labor or rupture of membrane ities. However, the incidence rate of ber of cases and incidence rates per when tested positive. This prevention late-onset GBS disease remained stable 100,000 population are shown in Fig- policy was introduced in 1996, result- since 1990 at approximately 0.3 cases ing in a significant impact on the inci- per 1,000 live births despite imple-

37 Communicable and Environmental Diseases and Emergency Preparedness Annual Report mentation of the prevention guide- investigations are monitored by the lines. Program Activities Healthcare-Associated Infections Tennessee Department of Health con- (HAI) Program. In Tennessee, the incidence of early ducts surveillance for Invasive Group onset invasive GBS disease remarkably B Streptococcal infection and pro- Preventive Measures decreased from an incidence rate of motes implementation of CDC’s rec- Prevention of GBS infections includes 0.28 per 1,000 live births in 2003 to ommendations for the prevention of screening pregnant women at 35 to 37 0.19 per 1,000 live births in 2012 co- Perinatal Group B Streptococcal Dis- weeks of gestation providing intrapar- inciding with the implementation of ease http://www.cdc.gov/groupb tum antibiotic prophylaxis at the time CDC’s recommended prevention strat- strep/index.html. The 2010 preven- of labor or rupture of membrane for egies across the State (Figure 2). After tion guidelines recommend screening those who test positive and for others consistently low incidence rates in of pregnant women at 35 to 37 weeks (previous delivery of infant with GBS 2004 to 2008, rates have begun to in- of gestation. Emphasis is given to areas disease, women with GBS bacteriuria crease. This is primarily due to a de- with history of lower screening rates during current pregnancy, unknown crease in screening and antibiotic pre- and high disease incidence. Efforts to GBS status at <37 weeks gestation, ventive therapy in healthcare settings decrease GBS disease in infants are have an intrapartum temperature combined with lack of or no access to consistent with the Tennessee Depart- >100.4°F or rupture of membranes for prenatal care. ment of Health’s goal of lowering in- >18 hours. Penicillin is the preferred fant morbidity and mortality. Case agent. Meningococcal Disease

Background Figure. Number of Cases of invasive Neisseria meningitis Invasive infection usually results in Infections Reported in Tennessee, 1998-2012. meningococcemia, meningitis, or 80 both. Onset often is abrupt in menin- 69 70 gococcemia, with fever, chills, malaise, 61 63 prostration, and a rash that initially 60 56 can be macular, maculopapular, or 50 petechial. The progression of disease 38 often is rapid. The signs and symp- 40 31 toms of meningococcal meningitis are 29 28 30 25 indistinguishable from signs and symp- 23 22 21 toms of acute meningitis caused via 20 13 9 Streptococcus pneumoniae or other me- 10 7 ningeal pathogens. Number of Cases Reported 0 The case fatality rate for invasive meningococcal disease in all ages is be- 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 tween 9-12% even with antibiotic Year treatment; meningococcemia has a case fatality rate of up to 40%. Invasive Neisseria meningitidis is a gram- children under age 5 years, about 60% meningococcal infections can be com- negative diplococcus with at least 13 of cases are caused by serogroup B and plicated by arthritis, myocarditis, peri- serogroups. Strains belonging to are not preventable with vaccine. carditis, and endophthalmitis. Seque- groups A, B, C, Y, and W-135 are im- Transmission occurs from person-to- lae associated with meningococcal dis- plicated most commonly in invasive person through droplets from the res- ease occur in 11%–19% of patients disease worldwide. Approximately piratory tract. The incubation period and include hearing loss, neurologic 73% of cases among adolescents and is 1–10 days and often less than 4 disability, digit or limb amputation, young adults are caused by serogroups days. The peak attack rate occurs in and skin scarring. C, Y, or W135 and potentially are pre- children younger than 1 year of age, ventable with available vaccines. In with a second, smaller peak at about

38 Communicable and Environmental Diseases and Emergency Preparedness Annual Report age 16-21 years and another peak cases in Tennessee has continued to the following: among adults age 65 and older. Fresh- decline. The number and incidence 1. All adolescents 11 through 18 man college students who live in dor- rate of cases (0.2 cases per 100,000 years of age, with a routine dose at mitories have a higher rate of disease persons in 2010, 0.14/100,000 in age 11-12 and a booster dose after compared with individuals who are at 2011, and 0.11/100,000 in 2012) has the 16th birthday the same age and are not attending dropped over the past three years 2. College freshman living in on- college. (Figure). campus housing 3. Microbiologists who are routinely Although about 97% of cases are spo- Program Activities exposed to isolates of N. meningiti- radic and isolated, outbreaks have oc- Surveillance in Tennessee is conduct- dis curred in communities and institu- ed statewide through the National 4. Military recruits tions, including child care centers, Electronic Disease Surveillance System 5. Persons who travel to and U.S. schools, colleges, and military recruit (NEDSS) and the Emerging Infection citizens who reside in countries in camps. Culture or polymerase chain Program’s Active Bacterial Core Sur- which N. meningitidis is hyperen- reaction-based (PCR) can be used as veillance (ABCs). Immediate reporting demic or epidemic (see http:// epidemiologic tools during a suspected via telephone is required in Tennessee www.cdc.gov/travel). outbreak to detect concordance followed by a written report within among strains. The Tennessee Depart- one week. Serogrouping of meningo- 6. Persons with terminal comple- ment of Health Laboratory Services coccal isolates is performed routinely. ment component deficiency has PCR assays that can be used to Case investigations are monitored by 7. Persons with functional or ana- serogroup N. meningitidis in cerebral the Immunizations Program. tomic asplenia spinal fluid (CSF), petechial or purpu- 8. Persons in a defined high-risk ral lesion scrapings, synovial fluid and group during an outbreak of suffi- other usually sterile body fluids. Preventive Measures cient size. Meningococcal vaccine is recommend- Incidence ed for persons at increased risk for Since 1997, the number of reported meningococcal disease which include Methicillin Resistant Staphylococcus aureus Invasive Disease (MRSA) — Passive Surveillance Background Table. Invasive MRSA disease cases and rate (per 100,000 persons) by Methicillin-resistant Staphylococcus aure- year, Tennessee, 2007-2012. us (MRSA) is a bacterium that is re- Year # of Cases Rate sistant to antibiotics such as methicil- 2007 1,985 32.6 lin, oxacillin, penicillin, and amoxicil- lin. Staphylococcal infections, includ- 2008 2,005 32.6 ing MRSA, occur most frequently 2009 1,998 32.2 among persons in hospitals and 2010 1,885 29.7 healthcare facilities (such as nursing homes and dialysis centers) who have 2011 1,782 27.8 weakened immune systems. MRSA in 2012 1,871 29.4 healthcare settings commonly causes serious and potentially life-threatening who have not had a medical procedure occur in otherwise healthy people. CA- infections such as bloodstream infec- (such as dialysis, surgery, catheters) are MRSA infections have been frequently tions. known as community associated (CA- mistaken for “spider-bites”. Incision MRSA) infections. Staphylococcal or and drainage is very important in the MRSA infections that are acquired by MRSA infections in the community management of skin and soft tissue persons who have not been recently are usually manifested as skin infec- infections. (within the past year) hospitalized or tions, such as pimples and boils, and Invasive MRSA disease was made re-

39 Communicable and Environmental Diseases and Emergency Preparedness Annual Report portable in Tennessee in June 2004 Program Activities ing facilities are clean. Additional in- and is defined as isolation of MRSA The Tennessee Department of Health formation may be found at the follow- from a normally sterile site (i.e., speci- monitors the incidence of invasive ing website: www.cdc.gov/mrsa. men source is blood, cerebrospinal MRSA as a measure of effectiveness of fluid [CSF], pleural, pericardial, perito- infection prevention across the spec- General recommendations for caregiv- neal,joint fluid or bone). Skin infec- trum of healthcare. Case investigations ers of MRSA infected people: tions and isolates from sputum, are monitored by the Healthcare-  Caregivers should wash their wound, urine, and catheter tips are Associated Infections (HAI) Program. hands with soap and water after not counted; repeat isolates within 30 physical contact with the infected days are not counted. Preventive Measures or colonized person and before Thorough hand cleansing is the single leaving the home. Trends most important preventative measure  Non-disposable towels used for Incidence of reported invasive MRSA for avoiding the transmission of drying hands after contact should disease has decreased slightly since MRSA, especially when visiting some- be used only once. Disposable 2009, but remained relatively stable one in a hospital or long-term care towels are preferred. around 30 cases per 100,000 popula- facility. Do not share personal items  Disposable gloves should be worn tion (29.7 cases per 100,000 popula- such as towels or razors with another if contact with body fluids is ex- tion in 2010; 27.8 cases per 100,000 person because MRSA can be trans- pected and hands should be population in 2011; 29.4 cases per mitted through contaminated items. washed after removing the gloves. 100,000 population in 2012). The Cover all wounds with a clean band-  Linens should be changed and total number of reported cases has age, and avoid contact with other peo- washed on a routine basis, espe- remained stable during this period as ple’s soiled bandages. If you share cially if they are soiled. well (1,885 cases reported in 2010; sporting equipment, clean the equip-  The patient's environment should 1,782 cases in 2011; 1,871 cases in ment with antiseptic solution before be thoroughly cleaned on a rou- 2012) (Table). using it. Avoid common whirlpools or tine basis, especially when soiled saunas if another participant has an with body fluids. open sore. Make sure that shared bath- Streptococcus pneumoniae Invasive Disease

Background Pneumococcal infections are caused by Streptococcus pneumoniae, a gram- positive, catalase-negative organism commonly referred to as pneumococ- cus. S. pneumoniae is the most common cause of community-acquired pneumonia (CAP), bacterial meningitis, bacteremia, and otitis media, as well as an important cause of sinusitis, septic arthritis, osteomyelitis, peritonitis, and endocarditis and an infrequent cause of other less common diseases.

Pneumococcal infections are most common during winter and early and persons with underlying medical is higher for patients with underlying spring months. Persons at high risk for conditions (e.g., HIV infection and medical conditions and the elderly. the infection are the elderly, children sickle-cell disease). Approximately under 2 years old, blacks, American 10% of all patients with invasive pneu- Reports of drug resistant S. pneumoniae Indians, Alaska Natives, children who mococcal disease die as a result of (DRSP) infection (including strains attend daycare centers, nursing homes, their illness; however, this percentage resistant to penicillin, extended spec-

40 Communicable and Environmental Diseases and Emergency Preparedness Annual Report trum cephalosporins and other drugs) have been increasing in the United States since the 1980s. With the widespread use of antimicrobials, the prevalence of resistance to each new drug class has increased. Recent trends have shown an increasing prevalence of S. pneumoniae with intermediate or high-level resistance to penicillin and other commonly used antibiotics. Many penicillin-resistant strains of S. pneumoniae are also resistant to other antimicrobials such as erythromycin, trimethoprim-sulfamethoxazole, and many of the cephalosporins.

Incidence Invasive Pneumococcal Disease (IPD) is reportable in Tennessee. The incidence rate of IPD (Figure 1) shows a all age groups in Tennessee, a decrease picture of trends in Tennessee and to declining trend in Tennessee coincid- of IPD among high risk groups also provide information for decision making with the introduction of routine has been observed. This includes chil- ers by evaluating the effectiveness of childhood pneumococcal vaccination. dren under five years of age and adults the current pneumococcal vaccine in The incidence rate in 2012 was 10.6 above sixty years of age. As indicated preventing IPD. per 100,000, which is a greater than in Figure 2 below, the rate of infection threefold reduction from 2007. When decreased among these high risk Preventive Measures compared to the national incidence groups from year 2010 through 2012. There are no routine control measures rate of 12.9 cases per 100,000 popula- other than recommended age- tion (based on most recent data availa- Program Activities appropriate immunization. PCV13 ble-2011), the incidence of IPD in Prevention messages and antibiotic (Prevnar) and PPV23 (Pneumovax) Tennessee is slightly lower. stewardship activities are conducted to protect against 90% of invasive dis- inform public health officials, legisla- ease. See CDC’s Immunization Sched- Trends tors, healthcare partners, and the pub- ule (http://www.cdc.gov/vaccines/) In addition to the decline in IPD for lic. Surveillance for IPD is conducted for specific recommendations. and data are used to draw a clearer

41 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

42 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

C. Hepatitis

43 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Hepatitis A

Background Figure. Acute Hepatitis A Cases, 1995-2012, Tennessee. Hepatitis A, caused by infection with the hepatitis A virus (HAV), has an 2500 incubation period of approximately 28 days (range: 15–50 days). HAV repli- 2000 cates in the liver and is shed in high concentrations in feces from 2 weeks before to 1 week after the onset of 1500 clinical illness including fever, malaise, jaundice, loss of appetite and nausea. 1000 HAV infection produces a self-limiting disease that does not result in chronic Number ofCases infection or chronic liver disease. 500

Acute liver failure from hepatitis A is 0 rare (overall case-fatality rate: 0.5%). The risk for symptomatic infection is directly related to age, with >80% of Year adults having symptoms compatible with acute viral hepatitis and the ma- Trends for complete vaccination against hepa- jority of young children having either In Tennessee, an epidemic of acute titis A among all children entering asymptomatic or unrecognized infec- hepatitis A was centered in Shelby kindergarten, beginning in the fall of tion. Antibody produced in response County in 1995 and accounted for 2011. to HAV infection persists for life and three quarters of the nearly 2,000 cases confers protection against reinfection. reported in the state that year (Figure). Preventive Measures In the fall of 2003, approximately 80 Vaccination is the most effective HAV infection is primarily transmit- cases were attributed to a hepatitis A means of preventing HAV transmis- ted by the fecal-oral route, by either outbreak from ingestion of contami- sion among persons at risk for infec- person-to-person contact or consump- nated food from a restaurant located tion. Hepatitis A vaccination is recom- tion of contaminated food or water. in East Tennessee. In general, the mended for all children, for persons Although viremia occurs early in infec- number of cases in Tennessee dramati- who are at increased risk for infection, tion and can persist for several weeks cally dropped over the past 10-15 years for persons who are at increased risk after onset of symptoms, bloodborne and continues to decline over time for complications from hepatitis A, transmission of HAV is uncommon. with the lowest number of cases ever and for any person wishing to obtain reported in the state in 2010. immunity.

In the United States, nearly half of all Program Activities Because transmission of HAV during reported hepatitis A cases have no spe- The Centers for Disease Control and sexual activity probably occurs because cific risk factor identified. Among Prevention (CDC) now routinely rec- of fecal-oral contact, measures typically adults with identified risk factors, the ommends that all children be vaccinat- used to prevent the transmission of majority of cases are among men who ed against hepatitis A between 12 and other STDs (e.g., use of condoms) do have sex with other men, persons who 24 months of age. In 2010, the Ten- not prevent HAV transmission. use illegal drugs, and international nessee Department of Health imple- travelers. mented a requirement for all toddlers

aged 18 months or older to have a Incidence single dose of hepatitis A vaccine in The figure shows the incidence of order to attend a child care facility. Acute Hepatitis A cases from 1995- That rule also phased in a requirement 2012 in Tennessee.

44 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Perinatal Hepatitis B

Background Children born to women actively in- Figure. Reported Number of Infants Born to Hepatitis B Surface Antigen Positive Women, 2006-2012, Tennessee. fected with hepatitis B virus (HBV), as indicated by having a serologic test 250 that indicates they are hepatitis B surface antigen (HBsAg) positive, are at 200 high risk of becoming chronic carriers of hepatitis B virus. 150

Tennessee Code Annotated 68-5-602 100 (a) requires that all women in Tennes-

see be tested for hepatitis B during the Infants of Number prenatal period, and that positive test 50 results be passed on to the delivering hospital and the health department. 0 A pregnant woman with no test results 2006 2007 2008 2009 2010 2011 2012 available at the time of delivery is to be Year tested at that time. The law requires that an infant born to an HBsAg positive mother receive, in a timely man- Trends it has hepatitis B immune globulin ner, the appropriate treatment as rec- Nearly 90% of the global population (HBIG) and vaccine available to ad- ognized by the Centers for Disease lives in areas with high or moderate minister to the infant at delivery. Fol- Control and Prevention (CDC). levels of chronic HBV infection. In lowing delivery, a TDH regional coor- these areas (China, Southeast Asia, dinator follows the infant to ensure it Africa), the lifetime risk of infection receives all three doses of HBV vaccine Incidence The figure shows the number of in- exceeds 60% with most infections ac- on time and that the infant receives fants reported as being born to an quired at birth and are asymptomatic. post-vaccination serologic testing at an HBsAg positive mother from 2006 to In the U.S., Western Europe and Aus- appropriate age, in order to confirm 2012. Over the same time period, tralia, infection rates are low in groups that the infant was not infected and three infants in 2009 and one in 2010 where routine immunization has been that the vaccine has produced protec- born to HBsAg positive mothers even- implemented. tive immunity. tually tested HBsAg positive. Based upon the population of the state, the Program Activities Preventive Measures CDC estimates that approximately The Tennessee Department of Health The risk of perinatal infection of an 300 women actively infected with hep- (TDH) receives the test results and exposed infant is reduced by 90-95% if atitis B virus give birth each year in counsels all pregnant women who are the infant is administered hepatitis B Tennessee. For this reason, the in- reported to the Department as HBsAg immune globulin and hepatitis B vac- crease in infants identified in 2012 is positive. TDH also identifies and vaccine within 12 hours of life, and if that interpreted as an improvement in de- cinates their at-risk contacts, and en- infant then goes on to complete the tection, rather than an increase in the sures that the delivering hospital has a vaccine series on time. actual number of infants at risk. record of the mother’s status and that Acute Hepatitis B Virus Infection

Background cus membrane exposure to infectious is found in highest concentrations in Hepatitis B is caused by an infection blood or body fluids. HBV can be blood and in lower concentrations in with the hepatitis B virus (HBV). HBV transmitted to an infant during child- other body fluids (e.g., semen, vaginal is transmitted by percutaneous or mu- birth by an infected mother. The virus secretions and wound exudates).

45 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Symptoms begin an average of 90 days (60-150 days) after exposure to HBV. Figure 1. Acute Hepatitis B Cases and Incidence, 2007-2012, Tennessee. HBV infection is an established cause 300 4.0 of acute and chronic hepatitis and 3.5 cirrhosis. Acute infection can, but 250 does not always, lead to chronic infec- 3.0 tion. Approximately 90% of infected 200 infants and 25%-50% of infected chil- 2.5 dren aged 1-5 years become chronically 150 2.0 infected in contrast to 5% of adults. 1.5 In 2012, the CDC estimated 2 billion 100 persons worldwide have been infected 1.0 Rate Incidence Number of Cases 50 with HBV, and more than 350 million 0.5 per 100,000 Population persons have chronic, lifelong infec- 0 0.0 tions. 2007 2008 2009 2010 2011 2012

HBV can survive outside the body for Year at least 7 days and is still capable of Number of Cases Incidence Rate per 100,000 Population causing infection. Any blood spills — including dried blood, which can still tion. in unregulated centers and history of be infectious — should be cleaned us- incarceration. Persons with diabetes ing 1:10 dilution of one part house- The incidence of acute viral hepatitis are also at increased risk of HBV infec- hold bleach to 10 parts of water for B is generally higher in rural Tennes- tion. disinfecting the area. Gloves should be see than in metropolitan communities. used when cleaning up any blood During the last three years, highest Program Activities spills. incidence rates were observed in East, Public health authorities in Tennessee North East, and Upper Cumberland conduct surveillance, investigation, In Tennessee, population-based sur- public health regions, as well as Knox and control activities for acute HBV veillance for acute viral hepatitis B is and Shelby Counties (Figure 2). infections. Individuals who are identi- performed statewide. Acute viral hep- fied as at-risk (household and sexual atitis B infection is reportable to the Trends contacts) during public health investi- Tennessee Department of Health Individuals who have not received the gations are offered Hepatitis B vaccina- (TDH) within one week of identifying hepatitis B vaccine are at highest risk tion and counseled on prevention of a case. Surveillance is conducted to for acute hepatitis B virus (HBV) infec- disease transmission. Vaccination and facilitate prevention and control activi- tion. Risk factors identified in Ten- prevention messaging are offered in ties (including identification of per- nessee for the transmission of hepatitis public health clinics across the state. sons who should receive post-exposure B virus infection includes history of Routine screening of all pregnant prophylaxis), detect outbreaks, define sexually transmitted diseases, multiple women for HBsAg and im- disease trends and risk factors, and sexual partners, intravenous drug use munoprophylaxis of infants born to evaluate effectiveness of public health and use of other street drugs, tattooing HBsAg positive mothers is recom- interventions. Figure 2. Incidence Rates of Acute Hepatitis B Infection Incidence (per 100,000 persons), 2012, . In Tennessee, the number of reported acute HBV cases has increased each year since 2010 (Figure 1). In 2011, 192 new cases of acute HBV infection were reported with an incidence rate of 3.00/100,000 population. This is the highest rate for Tennessee since 2005 and the third highest in the na-

46 Communicable and Environmental Diseases and Emergency Preparedness Annual Report mended to prevent perinatal transmis- Preventive Measures  not sharing personal items such as sion. Infants born to infected mothers The best method for prevention is razors, diabetic lancets and glucose are enrolled in the Perinatal Hepatitis vaccination. This includes all children meters; B Prevention Program to ensure ap- under age 19, along with other at-risk  stop drug use or use clean needles propriate follow-up. groups (see CDC’s recommendations and syringes and do not share par- regarding hepatitis B vaccine at aphernalia; In areas with high incidence of HBV http://www.cdc.gov/vaccines/  offer vaccination to at-risk individ- infection, additional efforts are under- vpd-vac/hepb). To prevent perinatal uals identified through public way to decrease the number of new infections, screening of pregnant wom- health investigations (household HBV infections. This includes a HBV en for HBV and, if positive, vaccina- and sexual contacts of an infected vaccination pilot in correctional set- tion and immunoprophylaxis of the person); tings and public health clinics offering infant are necessary.  encourage vaccination of persons STD services. Prevention education at risk for occupational exposure campaigns are underway for at-risk Other preventive measures include: (medical, dental, EMS, police, fire, populations, and correctional facilities,  use of condoms to prevent sexual laboratory professionals, etc.). public health and medical clinic staff. transmission; Hepatitis C Virus

Background Figure 1. Acute Hepatitis C Cases and Incidence, Hepatitis C virus (HCV) infection is 2007-2012, Tennessee. the most common chronic blood- 140 2.0 borne infection in the United States; 1.8 approximately 3.2 million persons are 120 1.6 chronically infected. Sixty to 70% of 100 persons newly infected with HCV typi- 1.4 cally are asymptomatic or have a mild 80 1.2 clinical illness. Chronic HCV infec- 1.0 tion develops in 70%–85% of HCV- 60 0.8 infected persons; 60%–70% of chroni- 0.6

40 Rate Incidence cally infected persons have evidence of 0.4 Number of Cases

20 per 100,000 Population active liver disease. The majority of 0.2 infected persons might not be aware of 0 0.0 their infection because they are not 2007 2008 2009 2010 2011 2012 clinically ill. However, infected per- Year sons serve as a source of transmission to others and are at risk for chronic Number of Cases Incidence Rate per 100,000 Population liver disease or other HCV-related chronic diseases decades after infec- an HCV-infected mother, incarcera- studies reporting a prevalence of 50% tion. tion, intranasal drug use, getting a tat- or more. Hepatitis C–related end-stage too at an unregulated facility, and oth- liver disease is the most common indi- HCV is most efficiently transmitted er percutaneous exposures (such as in cation for liver transplants among U.S. through large or repeated percutane- health care workers or from having adults, accounting for more than 30% ous exposure to infected blood (e.g., surgery before the implementation of of cases. In 2012 the U.S. Preventive through transfusion of blood from universal precautions). Services Task Force (USPSTF) revised unscreened donors or through use of their recommendations to screening injecting drugs). Infrequently, occupa- In the United States HCV is a leading for hepatitis C virus (HCV) infection tional, perinatal, and sexual exposures cause of complications from chronic in persons at high risk for infection also can result in transmission of liver disease. The most important risk and offering 1-time screening for HCV HCV. Additional risk factors include factor for HCV infection is past or infection to adults born between 1945 long-term hemodialysis, being born to current injection drug use, with most and 1965.

47 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

In Tennessee, population-based sur- Figure 2: Acute Hepatitis C Infection Rate veillance for acute viral hepatitis C is (per 100,000 persons), 2012, Tennessee. performed statewide.

Acute hepatitis C infection is reportable as a category 2 disease that requires written reporting within 1 week. Chronic hepatitis C is not reportable. Surveillance is conducted to identify disease trends and risk factors for di- recting and evaluating prevention activities. eastern Tennessee. In 2012, North- viral hepatitis to prevent co-infections. Incidence east, East, and Knox public health re- The incidence rate of acute hepatitis C gions had incidence rates of 8.5, 5.5 Preventive Measures in Tennessee has increased in recent and 3.29 per 100,000 population, re- There is no vaccine available for pre- years. In 2005, the incidence rate of spectively (Figure 2). vention of hepatitis C. Measures to acute hepatitis C was 0.45/100,000 prevent exposure to the virus include: population. In 2011, the rate spiked to Program Activities  use of condoms to prevent sexual 1.3/100,000, which was the second Current viral hepatitis prevention in- transmission; highest in the nation, as well as the frastructures in Tennessee vary greatly  not sharing personal items such as highest incidence rate in the last seven depending on the clinical settings and razors, toothbrushes, diabetic lan- years in Tennessee (Figure 1). geographic areas. The 14 Human Im- cets and glucose meters; munodeficiency Virus/Acquired Im-  stop drug use or use clean needles Trends mune Deficiency Syndrome (HIV/ and syringes and do not share par- In 2012, the most common risk fac- AIDS) Centers of Excellence (COEs) aphernalia; tors identified among the reported across the state provide hepatitis B and  offer vaccination to at-risk individ- cases of acute hepatitis C infection C testing as part of routine care, along uals identified through public includes tattooing (14%), street drug with hepatitis B vaccination, preven- health investigations (household injection (29%) and use of street drugs tion messaging, and referral to care as and sexual contacts of an infected (35%). Persons 21 to 50 years of age appropriate. Public health staff across person); constitute more than 80% of all cases the state document morbidity and risk  encourage vaccination of persons reported in Tennessee in 2012. factors, refer infected patients to the at risk for occupational exposure healthcare system, provide education (medical, dental, EMS, police, fire, Over the last three years, incidence on preventing transmission, and en- laboratory professionals, etc.). rates of acute hepatitis C are highest in courage vaccination for other forms of

48 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

D. Vaccine–Preventable Diseases

49 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Vaccine Preventable Diseases

Programmatic Overview Figure 1. 2012 Immunization Status Survey of 24-Month- One of the most powerful public Old Children - 4:3:1:3:3:1* and 4:3:1:3:3:1:4 Immunization health tools available in the United Level Trends, Tennessee, 2002-2012. States is vaccination, with its ability to 100 4:3:1:3:3:1* eliminate or control vaccine- 4:3:1:3:3:1:4 95 preventable diseases (VPDs). The Ten- nessee Immunization Program (TIP) 90 goal is to achieve a 90% level of com- 85 plete immunization against each of the 80.8* 78.3 80.2 following 10 vaccine- preventable dis- 80 82.4 82.4 82.3 81.2 78.8 eases: diphtheria, tetanus, pertussis, 80.5 75 78.0 75.3 74.7 polio, measles, mumps, rubella, Hae- 75.1 72.3 mophilus influenzae type b (Hib), hep- 70 atitis B, and varicella. In recent years, 65 the incidence of these diseases de- Proportion ImmunizedOn-time 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 clined markedly in Tennessee. This is Year largely due to the widespread use of * 2009 measures series containing only 2 doses of HIB vaccine (4:3:1:2:3:1) vaccines against these diseases and due to vaccine shortage institutional requirements that ensure that children and adolescents attend- (http://health.state.tn.us/ceds/ listed with the exception of PCV ing day care and schools are adequate- reports.htm) is the most valuable be- among children 24 months of age, ly protected. With the exception of cause it assesses on-time immuniza- known as “4:3:1:3:3:1”. Figure 1 com- pertussis, a disease to which neither tion, a marker of optimal protective pares survey results since 2002 to the vaccine nor natural disease results in benefit from vaccination. This survey more detailed results of the 2010-2012 lifelong immunity, and hepatitis B, a not only establishes estimates of im- surveys. disease against which most adults are munization levels in Tennessee, but it not vaccinated, the occurrence of these measures regional differences in those The on-time completion rates of two diseases is very low. levels and identifies certain characteris- doses of hepatitis A vaccine (HAV), at tics of those who do not complete least two doses of rotavirus vaccine Activities their immunization series on time, (RTV) and at least two doses of influ- As these diseases have become increas- thus characterizing a target population enza vaccine (Flu) are also reported in ingly uncommon, progress in the con- on which to focus to further improve the survey of 24-month-old children. trol of vaccine-preventable diseases is immunization levels. not measured by a case count, but ra- The 2012 survey identified certain ther by assessing levels of immunologic For the purposes of the survey of 24- characteristics of children at increased protection against the diseases. To month-old children, complete immun- risk of not completing immunizations. establish estimates of those levels, TIP ization is defined as having received Principally, those are: conducts annual surveys of certain four doses of diphtheria-tetanus- 1. Beginning immunizations at older population sub-groups: children 24 pertussis (DTaP) vaccine, three doses than 120 days of life; months old, children entering kinder- of polio vaccine, one dose of measles- 2. Having two or more living siblings garten, and children enrolled in day- mumps-rubella (MMR) vaccine, three at birth; and care centers that are licensed by the doses of Hib vaccine, three doses of 3. Being identified as black race, spe- Department of Human Services. hepatitis B vaccine (HBV), one dose of cifically for influenza vaccine. School and daycare surveys are con- varicella vaccine (VZV) and 4 doses of ducted to determine compliance with pneumococcal conjugate vaccine The key findings of the 2012 Immun- state school and daycare immunization (PCV). Together, these are known as ization Status Survey of 24 Month Old requirements. the “4:3:1:3:3:1:4” immunization se- Children include: ries. Prior surveys have defined com- 1. In the second year of measure- The survey of 24-month-old children plete immunization of all the vaccines ment, the hepatitis B birth dose

50 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

rate improved significantly from Figure 2. Recommended immunization schedule for persons aged 62.7% to 73.5%, a major step to- 0 through 6 years – United States, 2012, CDC National Center for Immun- ward the Healthy People 2020 ization and Respiratory Diseases. target of 85%. Regional rates vary, but several regions made significant improvements in coverage from 2011 to 2012. This may re- flect the implementation of strict- er birth dose policies in delivery hospitals and wider acceptance of this routine recommendation among caregivers of neonates. 2. Influenza vaccine 2-dose coverage remains low and unchanged from the previous year at 44.2%. Alt- hough the gap between the state average and the public health regions in the western third of the rolled in these programs. For most tect people at every age. Pre-teens and state has narrowed over time, cov- individual vaccines (polio, MMR, older teens should receive a booster erage rates in the three regions in varicella, HBV, and HAV), WIC doses of Tdap to protect them against the western part of the state re- enrollees had a significantly higher tetanus, diphtheria and pertussis. This main significantly lower than the percentage of on-time coverage is also the time to vaccinate them statewide coverage rate. than children who were not en- against meningococcal meningitis and 3. The significant racial disparity in rolled in WIC; however, they had human papillomavirus (HPV). The influenza vaccine coverage be- lower influenza coverage. Those 2012 Immunization Schedule for chil- tween black and white children receiving TennCare benefits also dren ages 0-6 years is presented at the continues (32.3% vs. 46.2%). had lower influenza coverage rates end of this section and, along with There were no significant racial than those not enrolled in immunization schedules for adoles- disparities in the aggregate TennCare. cents and adults, can be accessed at 4:3:1:3:3:1:4 series rates. 6. Rotavirus vaccine coverage contin- http://www.cdc.gov/vaccines/ 4. Completion of the DTaP and ues to exceed the national Healthy schedules/index.html (Figure 2). pneumococcal four-dose series People 2020 goal of 80% coverage continues to be the primary barri- for the second year in a row. This The website of the Centers for Disease er in Tennessee in achieving the is a notable contrast to the influ- Control and Prevention’s National Health People 2020 goal of 80% enza vaccine coverage, which has Center for Immunization and Respira- coverage for the 4:3:1:3:3:1:4 se- been recommended for about the tory Diseases (www.cdc.gov/vaccines) ries for all children. same period of time. contains valuable information for both 5. Children enrolled in TennCare clinicians and the lay public about and/or WIC had immunization Immunizations are not just for infants vaccines and vaccine-preventable dis- rates for the 4:3:1:3:3:1:4 series and toddlers. There are vaccines de- eases. equivalent to children never en- signed and recommended to help pro- Pertussis

Background a subsequent cough, which proceeds Infants are at greatest risk for compli- Pertussis, or whooping cough, is an from moderate to severe spasms with cations or death from pertussis, but acute, infectious, toxin-mediated dis- vomiting often following. Ill persons the disease causes significant illness in ease caused by the bacterium Bordetella are infectious up to 21 days after symp- adolescents and adults, who account pertussis. The bacterium invades the tom onset. Coughing attacks may last for more than half of all reported cases respiratory cilia and produces toxins for several weeks and convalescence and are often the source of illness in that cause inflammation of tissues and may last for months. infants. The most common complica-

51 Communicable and Environmental Diseases and Emergency Preparedness Annual Report tion among those with pertussis, and Figure. Number of Cases of Pertussis Reported, the leading cause of mortality, is sec- Tennessee, 1998-2012. ondary bacterial pneumonia. Seizures 350 and encephalopathy are also complications, most frequently occurring in 300 young children. Pertussis remains one 250 of the most common vaccine- preventable diseases in the United 200 States because neither infection nor vaccination produces long-lasting im- 150 munity to disease. 100

Incidence 50 The figure shows the number of per- Number of Cases Reported tussis cases from 1998 to 2012 in Ten- 0 nessee.

1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 Trends Year Recent studies of outbreaks of pertussis have identified older children, ado- probable (e.g. serology-based or clini- Preventive Measures lescents and adults as sources of per- cally compatible) cases of pertussis Childhood immunization against pertussis infection. In the adolescent and identified in Tennessee have fluctuat- tussis has reduced the disease burden adult populations, diagnosis may be ed from year-to-year but overall have in that population; the introduction of more difficult as the symptoms of the trended upward despite high levels of a vaccine to protect older children and disease are milder and not necessarily infant immunization. National data adults aged 11-64 in 2005 (tetanus, recognized as pertussis. An estimated suggests newer vaccines are effective in diphtheria, pertussis, or “Tdap”) helps 800,000 to 3 million B. pertussis infec- the short term but wane more quickly boost waning immunity following tions (many asymptomatic) occur each than older vaccines. With greater childhood immunization. The vaccine year in the United States; most cases awareness of the disease among older is recommended for all children at age among adults and older children are children and adults and better testing, 11 or 12 and as a single dose for all not recognized as pertussis and can be reported cases are likely to continue to adults. Effective July 2010, documen- transmitted to susceptible infants. increase. tation of a Tdap booster dose is required for all children entering 7th The number laboratory-confirmed and grade in Tennessee. Tetanus

Background cattle, dogs, cats, rats, guinea pigs and following: laryngospasms; fractures of Tetanus is an acute, often fatal disease chickens. Tetanus spores usually enter the long bones; hyperactivity of the caused by an exotoxin produced by the the body through a wound. However, autonomic nervous system; secondary bacterium Clostridium tetani. It is char- tetanus is not communicable from one infections, such as sepsis, pneumonia, acterized by generalized rigidity and person to another. Infection is the decubitus ulcers (due to long hospitali- convulsive spasms of skeletal muscles. result of direct inoculation of the body zations, in-dwelling catheters, etc.) and The muscle stiffness usually involves with the spores. Almost all cases of aspiration pneumonias. The fatality the jaw and neck (hence the common tetanus are in persons who were either rate for tetanus is approximately 11%. name “lockjaw”) and then becomes never vaccinated or who had complet- The mortality rate is highest in those generalized. ed a primary series of vaccine, but ≥60 years of age (18%) and unvaccinat- failed to receive a booster in the 10 ed persons (22%). In about 20% of C. tetani produces spores which are years preceding the infection. cases, no other pathology can be iden- widely distributed in soil and in the tified and death is attributed to the intestines and feces of horses, sheep, Complications of tetanus include the direct effect of the toxin.

52 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Incidence Preventive Measures containing vaccine and a booster dose In Tennessee, tetanus is a rare disease; The current general recommendation every 10 years. a total of 4 tetanus cases have been for prophylaxis of tetanus is a primary reported since 2003. series of 3 doses of a tetanus- Influenza

Background Figure. Percentage of Outpatient Visits Reported by the U.S. and Ten- Influenza virus causes seasonal epi- nessee Outpatient Influenza-like Illness Surveillance Network (ILINet) demics of disease annually, usually as Influenza-like Illness, January 2009-December 2012. between October and May. The infection causes an illness characterized by acute onset of fever, muscle aches, sore throat, cough and fatigue. Illness lasts about 5-7 days. It is most often transmitted through respiratory droplets or by self-inoculation after touching surfaces contaminated by infected respiratory secretions, then touching one’s eyes, nose, or mouth. Influenza and its complications result in the deaths of thousands of Americans each year, 90% of whom are aged 65 years and older.

Periodically, new strains of influenza emerge to which humans have little or no immunity. These strains may early February in Tennessee. Pandem- when influenza virus is circulating in emerge directly from an animal strain ic influenza viruses may not follow the community. (e.g., an avian influenza) or may result typical seasonal patterns, and may pro- from the mixing of genetic material duce more than one wave of illness; Since the influenza pandemic in 2009, from human and animal strains. Such the 2009 H1N1 virus was no excep- the Tennessee Emerging Infections strains are capable of causing a world- tion (red arrows in figure). Program has worked with 20 middle wide epidemic, known as a pandemic, Tennessee hospitals to perform ILI Program Activities surveillance among hospitalized pa- and may cause illness in 20-40% of the There are several systems used to track tients. Specimens sent by these facili- world’s population. Influenza pandem- influenza virus activity in Tennessee ties are tested alongside those collected ics also typically result in a greater pro- and nationally. The Sentinel Provider through the SPN and weekly surveil- portion of deaths occurring among Network (SPN) consists of healthcare lance reports are shared with partici- persons younger than 65 years. providers who report the proportion pating providers and posted at of outpatients seen each week with http://health.state.tn.us/TNflu_ Trends influenza-like-illness, defined as fever report_archive.htm. The figure shows the percentage of with cough or sore throat. SPN partici- outpatients with influenza-like illness pants also submit specimens for testing Providers interested in contributing to (ILI) reported weekly from January at the State Public Health Laboratory or learning more about the Sentinel 2009, just prior to the identification of from ILI patients in order to permit Provider Network should contact the the 2009 pandemic A(H1N1) influen- further characterization of circulating Tennessee Immunization Program. za strain, through December 2012. influenza strains as well as for a num- The timing and height of the peak ber of other respiratory viruses. Alt- Preventive Measures week of influenza activity varies; influ- hough non-specific, the number of Annual vaccination each fall is the enza typically peaks in late January or persons with ILI rises predictably best way to prevent seasonal influenza

53 Communicable and Environmental Diseases and Emergency Preparedness Annual Report and is recommended for every person serious illness and the people who care en, persons with chronic illnesses, aged 6 months and older. It is most for them; these groups include the their families and all healthcare pro- important for persons at higher risk of elderly, small children, pregnant wom- viders.

54 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

E. Vectorborne and Zoonotic Diseases

55 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Arboviral Diseases LaCrosse Encephalitis (LAC)

Background Figure. Distribution of La Crosse Encephalitis Cases, La Crosse (LAC) encephalitis virus is by Month of Onset, Tennessee, 1998-2012. the most medically significant of all 70 the California sero-group viruses reported in the US. The virus was ini- 60

tially discovered in 1963 in La Crosse, Wisconsin. The traditional endemic 50 foci of the disease have been in the Great-Lake states, but an increase in 40 case incidence has been detected in 30 the Mid-Atlantic States in recent years. Five of the eight states bordering Ten- 20 nessee typically report La Crosse en- Number of Cases cephalitis cases. These include: Ken- 10 tucky, Virginia, North Carolina, Geor- gia, and Mississippi. La Crosse en- 0 Jan Feb Mar April May June July Aug Sep Oct Nov Dec cephalitis is the leading cause of pediatric arboviral encephalitis and consid- Month of Onset ered an emerging disease in Tennes- see. mained relatively consistent since La Crosse virus can result in mild to 1998 indicating that the disease is en- severe infections with fatalities rare Incidence demic in the state. The incidence of (CFR <1%) and the ratio of inappar- In 2002, 164 cases of La Crosse en- only 2 cases in 2005 may have been ent infection to apparent infections cephalitis were reported from 16 states due to lower abundance of vectors ranges from 26:1 to over 1500:1. The in the United States, representing the during that summer in Tennessee majority of cases (93%) occur in chil- most reported to CDC in any year compared to other years. In Tennes- dren <15 years of age although adult since 1964. Due to the similarity of see, the disease primarily occurs from cases are not uncommon. Although symptoms between LAC and West late May through October with peak deaths are rarely associated with this Nile virus (WNV), this increase in cas- transmission in August (Figure). disease, Tennessee reported a death of es is likely due to improved WNV hu- a child in the 1-4 year old age group in man case surveillance in the United Trends 2003, and a death of a child in the 5- States (MMWR 2003, 51:53). In Ten- Traditionally, Ochlerotatus triseriatus 14 year old age group in 2012. nessee, from 1998-2012, there have (eastern treehole mosquito) is the pri- been 168 cases with a median of 11 mary vector of LAC but in recent years Program Activities cases per year (average: 11; range: 2-19) Aedes albopictus (Asian tiger mosquito) La Crosse infections should be consid- reported per year (Table 1). Incidence have been associated with LAC en- ered in patients (particularly children) rates have ranged from 0.02-0.06 per cephalitis cases in eastern Tennessee. with fever and signs or symptoms of 100,000 population in the United The dramatic increase in LAC cases in central nervous system infection States (1998-2012) and 0.03-0.33 per TN since 1996 has coincided with the (aseptic meningitis or encephalitis) 100,000 population in Tennessee arrival of Ae. albopictus in the eastern presenting during summer months in (1998-2012). Since the disease is en- TN region suggesting that this mosqui- Tennessee. Treatment is supportive. demic in the eastern half of the Unit- to may become an important accessory The diagnosis can be confirmed by ed States, the incidence rates for the vector potentially increasing the num- demonstrating a four-fold or greater TN population will be higher than the ber of human cases in endemic foci or change in serum antibody titer be- incidence rates of the U.S. population. expanding the range of the disease. tween acute and convalescent speci- The incidence rates in TN have re- mens, or enzyme immunoassay anti-

56 Communicable and Environmental Diseases and Emergency Preparedness Annual Report body capture in cerebral spinal fluid creasingly suburban families are relo- are relatively weak flyers and stay near (CSF) or serum. cating to rural areas which may be a the breeding site as adults, reducing factor in changing this trend. stagnant water sources around the Preventive Measures home is critical to reduce disease risk. The primary risk factors for the disease The most effective means of control- Since the primary mosquito vectors are children <16 years old that are ac- ling the disease lies with effective pub- develop in containers as small as tin tive outdoors, reside in woodland hab- lic education of residents in risk- cans and are active during the day, use itats with numerous natural (tree reduction practices which include per- of adulticides by organized community holes) and artificial (tires, gutters etc.) sonal protection and mosquito breed- mosquito control is not effective. Or- containers present capable of supporting site source reduction around the ganized community mosquito control ing a resident Oc. triseriatus and Ae. home. Personal protection includes programs should focus on public edu- albopictus population. Traditionally, the wearing of insect repellents con- cation and homeowner/community the rural poor were the most affected taining DEET. Since the species of source reduction. sector of the population although in- mosquitoes that transmit LAC virus West Nile Virus/Encephalitis

Background the largest outbreak year in TN. Since cases in the U.S. and 33 cases in TN. The natural transmission cycle of West 2002, infection rates in TN have been Cases are found throughout the state Nile virus (WNV) involves birds and going down and have always been low- but are mainly focused in Shelby bird feeding mosquitoes. When the er than the national average infection County with 2 (50%) cases in 2010, 11 viral load builds in the bird popula- rate, with the exception of 2011. In (61%) cases in 2011, and 15 (45%) tion, as the summer progresses there is 2011, TN had an infection rate of cases in 2012. The epidemic curve for an increased risk that bird/ 0.28 compared to 0.23 for the U.S. human cases occurs from late July mammalian (opportunistic mosqui- From 2003 to 20012, the rate of dis- through early October with peaks in toes) feeding mosquitoes will come in ease in various age groups has followed August and September, which coin- contact with the virus and transmit the a pattern of progressively increasing cides with the primary mosquito vec- virus to the human and equine popu- such that the highest rates are usually tor activity (Figure). lation. Humans and horses are re- seen in people 65 years of age and old- ferred to as dead-end hosts because er. About 40% t of the cases in 2004- Program Activities they do not circulate enough infec- 12 were in people over the age of 65. After a thorough review of the 2002 tious units in the blood system to re- About 80 % of cases were in people WN virus human cases, we found that infect a subsequent feeding mosquito. over 40. In 2010, 2 (50%) cases were WN virus infections lead to high rates neuroinvasive compared to 2 (50%) of mortality and substantial persistent Incidence with WN fever. In 2011, 16 cases morbidity. People of advanced age The first West Nile horse case oc- (89%) had neuroinvasive WN virus with preexisting health conditions are curred in 2001 (1 case) and then in and 2(11%) had WN fever. In 2012, particularly susceptible to severe neu- 2002 and 2003 there were 141 and 19 cases (58%) were neuroinvasive rological disease, long-term morbidity, 103 horse cases, respectively. In 2004 compared to 14 (42%) with WN fever. and death from WN virus. Of WN there were 17 horse cases that were In cases from 2004-12, almost 30% of virus meningoencephalitis patients scattered throughout the state. From cases occurred in African Americans over the age of 70 years, 42% had not 2005-2012 there were 3-8 horse cases and the rest in whites. returned to previous functional levels annually. This difference is most likely at least one year after acute illness. due to increase in awareness of the Trends Although WNV fever is considered a need for vaccinating horses rather Tennessee reported 4 human cases in “milder” form of the illness than me- than a reduction of risk in 2004-2012. 2010, 18 cases in 2011, and 33 cases ningoencephalitis, our findings suggest in 2012. Although cases have gone that WNV fever can also be associated The incidence rate of West Nile virus down since 2002 (56 cases) and 2003 with substantial morbidity. in TN (0.97 per 100,000 population) (26 cases), in 2012 there were large and the U.S. (1.06 per 100,000 popu- outbreaks of WNV both nationally Preventive Measures lation) were comparable during 2002, and in Tennessee. There were 5,674 Prevention efforts should be targeted

57 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

to populations at highest risk of severe Figure. Distribution of West Nile Human Cases, by month, Tennessee, 2002-2012. sequelae. Individuals can reduce their chances of acquiring West Nile virus 12 by taking basic precautions which in-

clude personal protective measures 10 such as wearing insect repellents when in mosquito habitats and wearing long 8 pants and sleeves that will provide a physical barrier against mosquitos. 6 Eliminate unwanted containers (tires, trash) or turn containers over as to not 4 collect water (wheelbarrows, kiddie pools) and properly maintain wanted 2 water sources (bird baths, ornamental Number of Human Cases ponds). 0 Jan Feb Mar April May Jun July Aug Sep Oct Nov Dec Month Malaria

Background Nile encephalitis. All age groups re- were responsible for malaria transmis- Malaria is a mosquito-borne disease port malaria in Tennessee and all are sion prior to elimination (Anopheles caused by a parasite. People with ma- susceptible when traveling since, with- quadrimaculatus in the east, An. free- laria often experience fever, chills, and out much exposure in the U.S., we borni in the west, and An. albimanus flu-like illness. Left untreated, they have a very susceptible population. In in the Caribbean) are still widely prev- may develop severe complications and the U.S. there have been 25,552 cases alent; thus there is a constant risk that die. Each year 350-500 million cases of of malaria from 1995-2012, almost 1% malaria could be reintroduced in the malaria occur worldwide, and over one of these from Tennessee. Of the ap- United States. "Airport" malaria refers million people die, most of them proximately 1,300 cases of malaria per to malaria caused by infected mosqui- young children in sub-Saharan Africa. year diagnosed in the U.S., about 73% toes that are transported rapidly by are from U.S. nationals and 27% are aircraft from a malaria-endemic coun- Incidence foreign-born. Almost 70% of all U.S. try to a non-endemic country. If the From 1995 to 2012, there have been reported malaria cases have a travel local conditions allow their survival, 245 cases of malaria reported in Ten- history to continental Africa. Between they can bite local residents who can nessee. None of these cases are 1957 and 2011, in the United States, thus acquire malaria without having thought to have been acquired locally 63 outbreaks of locally transmitted traveled abroad. Even without estab- but rather have been imported cases, mosquito-borne malaria have oc- lished transmission zones of malaria, i.e. United States natives traveling to curred; in such outbreaks, local mos- we still see large numbers of cases an- malaria endemic regions or non- quitoes become infected by biting per- nually. Travelers should take the ap- natives coming from these regions to sons carrying malaria parasites propriate precautions when traveling the U.S. Although 40 counties have (acquired in endemic areas) and then to areas with malaria. reported cases, most of these have transmit malaria to local residents. been from Davidson (27%) and Shelby Program Activities (17%) counties, which have large non- Trends The State of Tennessee requires all native and native populations that are Even though malaria has been eradi- physicians, hospitals, laboratories, more likely to travel abroad. Tennes- cated from the U.S., it continues to be healthcare providers, and other per- see averages about 13 cases of malaria a public health concern due the poten- sons knowing of or suspecting malaria per year (Table 1), which is compara- tial of re-introduction. Of the species to report the case to the health depart- ble to other vector-borne diseases in of Anopheles mosquitoes found in the ment. The Department of Health then the state such as La Crosse and West United States, the three species that investigates further and uses the na-

58 Communicable and Environmental Diseases and Emergency Preparedness Annual Report tional case definition to determine the weeks before foreign travel for mosquito and other insect bites. case classification for notification to any necessary vaccinations, as well Your insect repellent should con- the Centers for Disease Control and as a prescription for an antimalar- tain DEET as its active ingredi- Prevention (CDC). ial drug, if needed. (There are no ent. To prevent malaria, wear vaccines against malaria). insect repellent if out of doors  Take your antimalarial drug exact- between dusk and dawn when the Preventive Measures ly on schedule without missing mosquito that transmits malaria The CDC recommends the following doses. is biting. for preventing malaria:  Wear insect repellent to prevent  Wear long pants and long-sleeved  Visit your health care provider 4-6 clothing. Tickborne Diseases Ehrlichiosis

Background and summer (May through August). repelling ticks and mosquitos. Using Ehrlichiosis and Anaplasmosis are Incidence commercially available permethrin acute febrile illnesses caused by Ehr- Reports of anaplasmosis and ehrlichio- treatment on clothing or buying pre- lichia spp. and Anaplasma phagocytophi- sis have been stable over the past three treated clothing is also effective for lum, respectively. The bacteria are years. The table shows the number of repelling ticks and mosquitos. transmitted to humans through the cases and rate per 100,000 population bites of infected ticks. Ehrlichia for Ehrlichia chaffeensis, Ehrlichia ewing- A thorough check for ticks should be chaffeensis and Ehrlichia ewingii are both ii, Anaplasma phagocytophilum, and in- done after spending time outdoors in spread by lone star ticks (Amblyomma vestigations where the specific agent potential tick habitats. Attached ticks americanum), a commonly found tick could not be determined. One report- should be removed by gripping the in Tennessee. Anaplasma phagocytophi- ed death due to Ehrlichia chaffeensis was head of the tick with tweezers as close lum is spread by the black-legged or confirmed in 2012. to the skin as possible and pulling deer tick (Ixodes scapularis). Prior to steadily upwards in a smooth motion. 2008, ehrlichiosis and anaplasmosis Preventive Measures After removing the tick, the wound were reported collectively as human The best way to prevent any tickborne should then be disinfected. If a fever monocytic ehrlichiosis and human illnesses is to avoid direct contact with begins to develop within two weeks of granulocytic ehrlichiosis. Most cases of ticks by taking preventative measures. being bitten by a tick, see a healthcare ehrlichiosis and anaplasmosis are typi- Repellants with at least 20% or more provider immediately and inform cally reported between the late spring DEET should be used on exposed them of the recent tick bite. skin, and will work for several hours

Table 1. Number of Cases and Incidence Rates (per 100,000 Population) of Ehrlichiosis and Anaplasmosis, Tennessee, 2008-2012.

2008 2009 2010 2011 2012

Cases Rate Cases Rate Cases Rate Cases Rate Cases Rate Anaplasma 0 0.0 1 0.0 11 0.2 10 0.2 13 0.2 phagocytophilum Ehrlichia 72 1.2 71 1.1 58 0.9 54 0.8 61 1.0 chaffeensis Ehrlichia 0 0.0 0 0.0 1 0.0 1 0.0 3 0.0 ewingii Ehrlichiosis/Anplasmosis, 14 0.2 16 0.3 7 0.1 14 0.2 6 0.1 undetermined

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Lyme Disease

Background Figure 1: Incidence Rate of Lyme Disease (per 100,000 Lyme disease is caused by Borrelia Population), Tennessee and U.S., 2003 - 2010. burgdorferi, a spirochetal bacterium. The disease is transmitted to humans 14.0 TN Lyme Rate by the bite of an infected tick. In the 12.0 east, the primary vector of Lyme dis- US Lyme Rate ease is the black-legged or deer tick 10.0 (Ixodes scapularis). Most cases of Lyme disease occur in the New England and 8.0 eastern mid-Atlantic states, although 6.0 northern midwest states such as Wis- consin and Minnesota also report high 4.0 incidences. Early Lyme disease typically involves the appearance of a 2.0 “bullseye” rash (erythema migrans), 0.0 sometimes accompanied by other gen- 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 eralized symptoms. Year Two tiered testing (an EIA/IFA screening test, followed by a western blot test of Lyme disease typically have more A thorough check for ticks should be if the screen is positive) is the recom- confirmed cases. done after spending time outdoors in mended process for Lyme disease test- potential tick habitats. Attached ticks ing. Lyme IgM serologic testing is sus- Preventive Measures should be removed by gripping the ceptible to false positives and should The best way to prevent any tickborne head of the tick with tweezers as close not be relied on for diagnosis more illnesses is to avoid direct contact with to the skin as possible and pulling than 30 days after symptom onset. ticks by taking preventative measures. steadily upwards in a smooth motion. Repellants with at least 20% or more After removing the tick, the wound Incidence DEET should be used on exposed should then be disinfected. If a fever As seen in the figure, the incidence of skin, and will work for several hours begins to develop within two weeks of reported Lyme disease in Tennessee is repelling ticks and mosquitos. Using being bitten by a tick, see a healthcare much lower than the national average. commercially available permethrin provider immediately and inform The majority of cases reported in Ten- treatment on clothing or buying pre- them of the recent tick bite. nessee are probable cases, whereas treated clothing is also effective for states in regions reporting higher rates repelling ticks and mosquitos. Spotted Fever Rickettsiosis (including Rocky Mountain Spotted Fever) Background dog tick (Rhipicephalus sanguineus) are Rickettsiosis” to allow for the official Rocky Mountain spotted fever (RMSF) the three principal tick vectors. The inclusion of all species of pathogenic has been nationally notifiable since treatment of choice for suspected cases spotted fever group rickettsia. In Ten- 1944. The disease is caused by the bac- of RMSF is doxycycline for patients of nessee, most spotted fever reports re- terium Rickettsia rickettsia and is spread all ages. RMSF can cause severe mor- ceived are based on RMSF serologic by the bites of infected ticks. The bidity and mortality if treatment is assays performed at commercial labora- American dog tick (Dermacentor varia- delayed or not given. tories. bilis), the Rocky Mountain wood tick In 2010, the national surveillance defi- (Dermacentor andersoni), and the brown nition was updated to “Spotted Fever

60 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Incidence Figure 1. Rate of Spotted Fever Rickettsiosis, In 2010 – 2012, 316, 262, and 697 Te nnessee and U.S., 2003 - 2012. cases of spotted fever rickettsiosis were 12.0 reported, respectively. Two deaths, TN Spotted Fever Rate

occurring in 2011, were also reported 10.0 US Spotted Fever Rate and confirmed by laboratory testing at the Centers for Disease Control and 8.0 Prevention (CDC). In both instances, the disease was not immediately recog- 6.0 nized and appropriate treatment was not given early on when the symptoms 4.0 were considered mild. The rate of spotted fever reports has been above Number of Cases

(per 100,000 persons) 2.0 historical averages over the past three years. Reports of cases have been high- 0.0 er in males, as seen in Table 1. 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012

Trends Year As seen in Figure 1, the incidence of spotted fever rickettsiosis has increased done at CDC, were followed up, and treated clothing is also effective for in Tennessee over the past decade, had convalescent specimens taken at 2 repelling ticks and mosquitos. while rates nationally have remained weeks, 1 month, and 1 year after the relatively stable. In 2012, an unusually acute specimen. Final follow up and A thorough check for ticks should be high number of spotted fever cases testing was completed in 2012, and done after spending time outdoors in were reported, possibly due to the the findings are published. potential tick habitats. Attached ticks milder winter that occurred that year should be removed by gripping the and changes within the surveillance Preventive Measures head of the tick with tweezers as close system in Tennessee. The best way to prevent any tickborne to the skin as possible and pulling illnesses is to avoid direct contact with steadily upwards in a smooth motion. Program Activities ticks by taking preventative measures. After removing the tick, the wound From 2010 – 2012, a study was done Repellants with at least 20% or more should then be disinfected. If a fever in West Tennessee enrolling patients DEET should be used on exposed begins to develop within two weeks of from participating providers that had a skin, and will work for several hours being bitten by a tick, see a healthcare clinical history suggestive of Rocky repelling ticks and mosquitos. Using provider immediately and inform Mountain Spotted Fever. These pa- commercially available permethrin them of the recent tick bite. tients had acute diagnostic testing treatment on clothing or buying pre- Zoonotic Diseases Rabies

Background Incidence ral cycles of infection. During this peri- The primary host for the rabies virus There were 80 cases of animal rabies od, domestic animal rabies cases were in TN is the skunk. Rabies-positive reported in 2010; 64 cases in 2011; steady at an average of 6 per year. Ra- bats are also occasionally found. The and 49 cases in 2012. bies-positive bats were also steady at an incursion of raccoon-variant rabies average of 10 per year. Few rabies- into eastern TN peaked in 2008 and Trends positive raccoons were reported, with has since declined significantly. The decline in cases reported from 5 in 2010; 1 in 2011; and 2 in 2012. 2010-12 is attributable to fewer cases found in skunks, which reflects natu-

61 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Program Activities Preventive Measures tive at preventing the westward spread The Vectorborne and Zoonosis group The Tennessee Department of Health of raccoon-variant rabies across TN. regularly assists with risk assessments (TDH) continues to support the oral The presence of raccoon rabies is asso- for potential rabies exposures, making rabies vaccination and enhanced sur- ciated with greatly increased cases in recommendations for management of veillance program administered by the domestic animals and other wild ani- biting animals and post-exposure U.S. Department of Agriculture mal species, as well as human expo- prophylaxis for humans. (USDA). This program has been effec- sures and associated costs. Other Zoonoses: Brucellosis, Q fever, Tularemia

Background portant because of their potential for agents. Brucellosis, Q fever, and tularemia are causing naturally-occurring outbreaks diseases caused by bacteria that are as well as for use as a bioweapon. Fran- Incidence maintained in animal hosts (primarily cisella tularensis, the causative agent of Q fever, brucellosis, and tularemia livestock for brucellosis and Q fever; tularemia, has been classified as a Cat- occur sporadically in TN, with only a rabbits and rodents for tularemia). All egory A select agent. Brucella spp. few cases of each reported per year 3 diseases occur naturally in TN. Sur- (brucellosis) and Coxiella burnettii (Q (Table). veillance for these diseases is im- fever) are both classified as Category B

Table. Number of Cases of Brucellosis, Q Fever and Tularemia, Tennessee, 2010-2012.

Year Brucellosis Q fever Tularemia

2010 2 6 3

2011 2 0 3

2012 2 1 2

62 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

F. Tuberculosis

63 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Tuberculosis (TB)

Background Figure . Tube rculosis Ca se s a nd Ra te s*, The Tennessee Department of Health Tennessee, 2000-2012. (TDH) TB Elimination Program, in 450 8 collaboration with local public health departments and health care profes- 400 7 ) 350 s sionals statewide, is engaged in the s 6 s n se e o following activities: (1) collects and a300 s s 5 a r analyzes surveillance data to monitor C C e f 250 f p epidemiologic trends; (2) provides con- o o 0 r 4 r 0 sultation to clinicians and local public e200 e ,0 b b 0 m 3 0 health departments to assure appropri- u150 m 1 N u r ate clinical management and adequate 2 N e therapy for TB patients and persons 100 (p exposed to TB disease. In addition, 50 1 TDH collaborates with community- 0 0 based organizations and voluntary agencies to reach communities affected by TB; facilitates screening of per- Year sons at high risk for TB; provides TB- related education for health care pro- foreign-born has been decreasing  Notify local health departments viders, public health professionals, and whereas the proportion of U.S.-born regarding all newly-reported TB cases the general public; and coordinates persons with TB has increased. Sec- in their jurisdictions and administers a statewide program ondly, the proportion of TB cases of  Analyze, summarize, and distrib- to provide TB medications free of Hispanic origin has decreased while ute data regarding the epidemiology of charge. the proportion of African Americans TB in Tennessee to public health agen- among Tennessee’s TB cases has in- cies statewide and other stakeholders Incidence creased. HIV co-infection among TB  Report surveillance data and pro- During the period of 2010, 2011 and cases has remained steady with an an- grammatic outcomes to the Centers 20012 the incidence of TB in Tennes- nual average of 10.9% of TB cases. for Disease Control and Prevention see was 193, 156 and 164 cases, respec- From 2010-2012, 6.9% of culture- (CDC) tively, and averaged 171 cases annual- confirmed TB cases exhibited re- Conduct or participate in epidemio- ly. The average annual TB case rate for sistance to isoniazid, one of the four logic studies regarding TB in Tennes- 2010-2012 was 2.6, below the national firstline anti-TB medications, and mul- see and nationally; summarize and average of 3.4 cases/100,000 popula- ti-drug resistant cases (resistant to at distribute results to the appropriate tion for the same period. least isoniazid and rifampin) continue audiences to be very rare (<1% annually) in Ten- Trends nessee. 2. Case Management/Contact Investi- As shown in the figure, the reported gation incidence of TB in Tennessee contin- Program Activities ues to follow a generally downward Specific services provided by the TB  Through regular contact with phy- trend, decreasing 57.2% from 2000 Elimination Program include the fol- sicians and public health nurses, moni- through 2012. The TB incidence in lowing: tor the status of individual TB cases to 2011 (156 cases) is the lowest on rec- ensure that appropriate medications ord for Tennessee (Figure). However, are supplied and utilized, that patients there are several significant differences 1. Disease Surveillance/Epidemiology receive regular medical follow-up and in the epidemiology of TB in Tennes- adhere to drug regimens, that clinical see compared to the national epidemi-  Compile standardized case reports response to therapy is documented ological trends for this period (Table). for all TB cases reported in Tennessee according to national guidelines First, in Tennessee the proportion of

64 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Table. Select Characteristics of Tuberculosis Cases, Tennessee, 2010-2012. 2010 2011 2012 2010-2012 Characteristic N=193 N=156 N=164 Mean=171.0 Freq. (%) Freq. (%) Freq. (%) Freq. (%) Sex Female 57 (29.5) 58 (37.2) 54 (32.9) 56.3 (32.9) Male 136 (70.5) 98 (62.8) 110 (67.1) 114.7 (67.1) Age (years) ≤4 11 (5.7) 2 (1.3) 5 (3.0) 6.0 (3.5) 5-15 6 (3.1) 7 (4.5) 6 (3.7) 6.3 (3.7) 16-17 0 (0.0) 3 (1.9) 2 (1.2) 1.7 (1.0) 18-24 12 (6.2) 14 (9.0) 12 (7.3) 12.7 (7.4) 25-44 64 (33.2) 48 (30.8) 51 (31.1) 54.3 (31.8) 45-64 61 (31.6) 48 (30.8) 59 (36.0) 56.0 (32.7) 65+ 39 (20.2) 34 (21.8) 29 (17.7) 34.0 (19.9) Race/Ethnicity Asian 25 (13.0) 19 (12.2) 21 (12.8) 21.7 (12.7) Black/AA 62 (32.1) 54 (34.6) 68 (41.5) 61.3 (35.9) Hispanic (any race) 37 (19.2) 27 (17.3) 17 (10.4) 27.0 (15.8) Multi-race 1 (0.5) 1 (0.6) 0 (0.0) 0.7 (0.4) Native Hawaiian/PI 0 (0.0) 0 (0.0) 2 (1.2) 0.7 (0.4) White 68 (35.2) 55 (35.3) 56 (34.1) 59.7 (34.9) Birth Status Foreign-born 70 (36.3) 55 (35.3) 52 (31.7) 59.0 (34.5) U.S.-born 123 (63.7) 101 (64.7) 112 (68.3) 112.0 (65.5) Status at Diagnosis Dead 8 (4.1) 7 (4.5) 3 (1.8) 6.0 (3.5) Alive 185 (95.9) 149 (95.5) 161 (98.2) 165.0 (96.5) Site of Disease Pulmonary 129 (66.8) 109 (69.9) 111 (67.7) 116.3 (68.0) Extrapulmonary 37 (19.2) 32 (20.5) 36 (22.0) 35.0 (20.5) Both 27 (14.0) 15 (9.6) 17 (10.4) 19.7 (11.5) HIV Status Positive 18 (9.3) 20 (12.8) 18 (11.0) 18.7 (10.9) Negative 167 (86.5) 129 (82.7) 143 (87.2) 146.3 (85.6) Status Not Known 8 (4.1) 7 (4.5) 3 (1.8) 6.0 (3.5) Homeless Yes 11 (5.7) 11 (7.1) 6 (3.7) 9.3 (5.5) Drug-Susceptibility* N=135 N=107 N=113 Ave.=118.3 INH-monoresistant 11 (8.1) 5 (4.7) 7 (6.2) 7.6 (6.5) Multi-drug resistant** 3 (2.2) 0 (0.0) 0 (0.0) 1.0 (0.8) * Drug susceptibility testing is only performed on isolates that are culture-positive ** Resistant to at least Isoniazid (INH) and Rifampin

65 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

 Work with local health depart- and other provider and patient educa- arriving in Tennessee ments to ensure that complete and tion materials  Track TB screening results and timely contact investigations are con-  Develop state-specific guidelines outcome of treatment of TB disease or ducted surrounding infectious TB cas- and recommendations, as indicated TB infection among newly arrived ref- es in Tennessee; analyze and summa-  Ensure that TB-related training ugees and immigrants with TB class rize the findings of TB contact investi- and education resources are available conditions gations; provide feedback to local and disseminated to local health de- Report programmatic outcomes to agencies partments, health care professionals CDC  Receive and send interstate refer- and others rals for TB patients who move be- Provide telephone consultation regard- 5. TB Medications Service tween jurisdictions during the course ing a variety of TB-related issues to of TB treatment health care providers, local public Provide free medications statewide for  Administer grant funding to met- health agencies, long term care facili- persons receiving treatment for TB ropolitan public health departments ties, correctional facilities, workplaces, disease or TB infection Facilitate the provision of culturally- the general public, and others appropriate TB outreach services in Preventive Measures the community 4. Screening and Follow-up of Immi- 1. Early detection and treatment of grants and Refugees at Risk for TB persons with active TB disease 3. Consultation/Education 2. Through timely contact investiga-  Upon notification from the CDC tion, identifying and treating per-  Medical and public health practice Division of Quarantine and Global sons who are infected with M. consultation with health care provid- Migration, facilitate the evaluation of tuberculosis to prevent the progres- ers and local health departments re- primary refugees and immigrants iden- sion from TB infection to active garding diagnostic procedures, treat- tified overseas with TB-related medical TB disease. ment regimens, clinical monitoring, findings; review records for TB follow- 3. Implementation of effective TB management of complications, and TB up needs and assist in referring indi- control programs in health care contact investigations viduals to local public health agencies facilities, homeless shelters and  Disseminate national guidelines for follow-up medical evaluation after correctional facilities.

66 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

G. Healthcare-Associated Infections (HAI)

67 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Catheter-Associated Urinary Tract Infection (CAUTI)

Table. Key Percentiles and 95% Confidence Intervals for Facility-Specific Catheter-Associated Urinary Tract Infection (CAUTI) Standardized Infection Ratios (SIRs) in Intensive Care Units (ICUs) by Reporting Year, Tennessee, 01/01/2012-12/31/2012. UNIT TYPE YEAR No. SIR LOWER UPPER 10% 25% 50% 75% 90% LIMIT LIMIT

Adult/Pediatric ICUs 2012 94 1.46* 1.37 1.56 0.00 0.00 1.12 1.65 2.43 Data reported as of May, 2013. No.= number of facilities with reporting units; SIR= standardized infection ratio (observed/predicted number of CAUTI); *= SIR for reporting period is significantly higher than national 2009 SIR of 1.0.

Background Incidence Catheter-associated urinary tract infec- The standardized infection ratio (SIR) Trends tions (CAUTI) are among the most is used as a summary measure to com- Figure. Catheter-Associated Urinary common healthcare-associated infec- pare CAUTI data in adult and pediat- Tract Infection (CAUTI) Standard- tions reported to National Healthcare ric ICUs in Tennessee to published ized Infection Ratios (SIRs) for Inten- Safety Network (NHSN). In the state national (NHSN) data for 2009 for sive Care Units (ICUs) by Quarter, of Tennessee, CAUTIs have been re- each location type. The SIR -- identical Tennessee, 01/01/2012–12/31/2012 portable since January 2012. All hospi- in concept to a standardized mortality [Reference standard: National tals, excluding critical access facilities, ratio -- is an indirect standardization Healthcare Safety Network (NHSN), must report CAUTIs from adult and method for summarizing the HAI ex- 2009] pediatric intensive care units (ICUs). perience across any number of strati- As of October 2012, all inpatient reha- fied groups of data, and is a ratio of Program Activities bilitation facilities and long-term acute the number of infections observed Tennessee’s Report on Healthcare- care hospitals (LTACs) are required to divided by the number predicted Associated Infections (https:// report CAUTIs from inpatient loca- (Table). health.state.tn.us/Ceds/HAI/) is pub- tions. Monthly reporting of numerator and denominator data is ongoing in Figure. Catheter-Associated Urinary Tract Infection (CAUTI) Standard- each location type unless otherwise ized Infection Ratios (SIRs) for Intensive Care Units (ICUs) by Quarter, specified. Tennessee, 01/01/2012–12/31/2012 [Reference standard: National Healthcare Safety Network (NHSN), 2009]. More details on Tennessee’s reporting requirements can be found at: https://health.state.tn.us/Ceds/HAI/ PDFs/CAUTI_Factsheet_TN.pdf, and the complete NHSN protocol for CAUTI reporting can be found at: http://www.cdc.gov/nhsn/pdfs/ pscmanual/7psccauticurrent.pdf

Tennessee’s Healthcare-Associated Infections (HAI) reporting requirements are guided by the TN Multi- Disciplinary Advisory Group (MDAG) on HAI. Currently, TN requirements align closely with federal mandates set forth by the Centers for Medicare & Medicaid Services (CMS).

68 Communicable and Environmental Diseases and Emergency Preparedness Annual Report lished publicly two times per year, and laborative. In addition, the HAI pro- Preventive Measures includes facility-specific and state ag- gram works closely with collaborative Guidelines for the Prevention of Catheter- gregate data on NHSN-reportable partners, such as the Tennessee Hospi- Associated Urinary Tract Infections were HAIs. tal Association and QSource, Tennes- published by the Healthcare Infection see Quality Improvement Organiza- Control Practices Advisory Committee TDH provides NHSN reporting assis- tion (QIO) to align prevention activi- (HICPAC) in 2009 and can be found tance to the 89 acute care hospitals ties and coordinate data feedback to at: http://www.cdc.gov/hicpac/pdf/ involved in the TN Center for Patient reporting facilities. CAUTI/CAUTIguideline2009 Safety (TCPS) CAUTI prevention col- final.pdf Clostridium difficile Infections (CDI) (NHSN)

Background current.pdf from 1.98 events per 1,000 hospital Clostridium difficile or Clostridium dif- admissions in 2010 to 2.35 events per ficile infections (CDI) have been in- Tennessee’s Healthcare-Associated 1,000 hospital admissions in 2011 and creasing in the community and Infections (HAI) reporting require- 2.76 events per 1,000 admissions in healthcare facilities in recent years. ments are guided by the TN Multi- 2012. The prevalence of community- Complications of CDI include uncom- Disciplinary Advisory Group (MDAG) onset healthcare-facility associated plicated diarrhea, pseudomembranous on HAI. Currently, TN requirements (CO-HCFA) CDI, defined as a patient colitis, and toxic megacolon which align closely with federal mandates set with CO CDI who has been dis- can, in some instances, lead to sepsis- forth by the Centers for Medicare & charged from a healthcare facility in like syndrome and death. Treatment Medicaid Services (CMS). the 4 weeks prior to specimen collec- of patients with CDI can be challeng- tion, has remained relatively stable, ing, and infections can be severe and Incidence close to 1 event per 1,000 hospital life-threatening. Since July 1, 2010, See the Table. admissions from 2010-2012. The Tennessee Department of Health (TDH) has required certain facilities to Trends report all positive C. difficile laboratory Incidence of healthcare-onset (HO) Program Activities assays for inpatients facility-wide (with CDI has increased from 4.71 events Tennessee’s Report on Healthcare- some exclusions) and for emergency per 10,000 patient days in 2010 to Associated Infections (https:// departments to the National 5.36 and 5.49 events per 10,000 pa- health.state.tn.us/Ceds/HAI/) is pub- Healthcare Safety Network (NHSN). tient days in 2011 and 2012, respec- lished publicly two times per year, and tively (Figure). Part of this increase is includes facility-specific data on central More details on Tennessee’s reporting due to changes to more sensitive test- line-associated bloodstream infections requirements can be found at: ing methodologies such as PCR and (CLABSIs) from intensive care units https://health.state.tn.us/Ceds/HAI/ other nucleic acid amplification test- (ICUs) and neonatal ICUs, excluding PDFs/CDIFF_Factsheet_TN.pdf, and ing (NAAT). The prevalence of com- burn and trauma ICUs, as well as state the complete NHSN protocol for CDI munity-onset (CO) CDI, defined as a aggregate HAI data. reporting can be found at: http:// positive specimen collected within 3 www.cdc.gov/nhsn/PDFs/ days of hospital admission, has also The Nashville/Davidson County Clos- pscManal/12pscMDRO_CDAD increased over the same time period, tridium difficile Infection Prevention

Table. CDI Incidence and Prevalence, Tennessee, 07/01/2010-12/31/2012. Year No. of No. of No. of CO2 CO-HFA3 No. of Patient HO4 CO2 CO-HFA3 admissions prevalence prevalence HO4 days incidence events events rate^ rate^ events rate* 20101 740 383 374,365 1.98 1.02 845 1,793,207 4.71 2011 1,818 901 774,502 2.35 1.16 1,955 3,650,574 5.36 2012 2,193 922 795,606 2.76 1.16 2,029 3,697,894 5.49 1CDI events reported from July-December 2010; 2Community-onset C. difficile infections; 3Community-onset healthcare -facility associated C. difficile infections; 4Healthcare-onset C. difficile infections; ^Per 1,000 admissions; *Per 10,000 patients days.

69 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

monthly webinars.

Preventive Measures Transfer of the pathogen to the patient via the hands of health-care workers is thought to be the most likely mechanism of exposure. Standard isolation techniques intended to minimize enteric contamination of patients, health-care–workers’ hands, patient-care items, and environmental surfaces have been published. Hand- washing remains the most effective means of reducing hand contamination. Proper use of gloves is an ancil- lary measure that helps to further minimize transfer of these pathogens from one surface to another. ( CDC. Sehul- ster L, Chinn RYW. Guidelines for environmental infection control in healthcare facilities. MMWR 2003;52 (RR10);1–42.) Figure. CDI Incidence and Prevalence by Half Year, Tennessee, 07/01/2010-12/31/2012. The Healthcare Infection Control Practices Advisory Committee Collaborative (CDI-PC) is an ongoing healthcare within Davidson County. (HICPAC) published Management of collaborative led by staff from the TN Key focus areas include hand hygiene, Multidrug Resistant Organisms in Department of Health (TDH) and contact precautions, laboratory testing, Healthcare Settings in 2006, which can QSource, TN's quality improvement environmental cleaning, and transi- be found at: http://www.cdc.gov/ organization, which involves a core tions of care. TDH and Qsource pro- hicpac/pdf/MDRO/MDROGuideline group of 10 representatives from 7 vide educational support to CDI-PC 2006.pdf. facilities across the spectrum of participants through site visits and Central Line-Associated Bloodstream Infections (CLABSI)

Background and denominator data is ongoing in on HAI. Currently, TN requirements Central line-associated bloodstream each location type unless otherwise align closely with federal mandates set infections (CLABSI) are believed to specified. More details on Tennessee’s forth by the Centers for Medicare & account for a large proportion of reporting requirements can be found Medicaid Services (CMS). bloodstream infections (BSIs) occur- at: https://health.state.tn.us/Ceds/ ring in U.S. hospitals. In the state of HAI/PDFs/CLABSI_Factsheet_ Incidence Tennessee, CLABSIs have been report- TN.pdf, and the complete NHSN pro- The standardized infection ratio (SIR) able to the Tennessee Department of tocol for CLABSI reporting can be is used as a summary measure to com- Health (TDH) via the National found: http://www.cdc.gov/nhsn/ pare CLABSI data in adult, pediatric, Healthcare Safety Network (NHSN) pdfs/pscmanual/4psc_clabscurrent. and neonatal ICUs in Tennessee to since January 2008 from adult and pdf. published national (NHSN) data for pediatric intensive care units (ICUs), 2006-8 for each location type. The SIR since July 2008 from neonatal inten- Tennessee’s Healthcare-Associated -- identical in concept to a standard- sive care units (NICUs), and from long Infections (HAI) reporting require- ized mortality ratio -- is an indirect -term acute care hospitals since July ments are guided by the TN Multi- standardization method for summariz- 2010. Monthly reporting of numerator Disciplinary Advisory Group (MDAG) ing the HAI experience across any

70 Communicable and Environmental Diseases and Emergency Preparedness Annual Report number of stratified groups of data, and is a ratio of the number of infections observed divided by the number predicted (Table).

Program Activities Tennessee’s Report on Healthcare- Associated Infections (https:// health.state.tn.us/Ceds/HAI/) is published publicly two times per year, and includes facility-specific data on CLABSIs from intensive care units (ICUs) and neonatal ICUs, excluding burn and trauma ICUs, as well as state aggregate HAI data.

TDH provides NHSN reporting assistance to the 87 acute care hospitals, 24 NICUs, and 2 long term acute care Figure. Central Line-Associated Bloodstream Infection (CLABSI) Stand- (LTACs) involved in the TN Center ardized Infection Ratios (SIRs) for Intensive Care Units (ICUs) by Quarter, for Patient Safety (TCPS) CLABSI Tennessee, 01/01/2008–12/31/2012 [Reference standard: National prevention collaborative. In addition, Healthcare Safety Network (NHSN), 2006-8]. the HAI program works closely with collaborative partners, such as the Ten- site targeted validation of CLABSI published by the Healthcare Infection nessee Hospital Association and data in 26 adult and pediatric ICUs Control Practices Advisory Committee QSource, Tennessee Quality Improve- and 14 NICUs. (HICPAC) in 2011 and can be found ment Organization (QIO) to align pre- at: http://www.cdc.gov/hicpac/pdf/ vention activities and coordinate data Preventive Measures guidelines/bsi-guidelines-2011.pdf . feedback to reporting facilities. In Guidelines for the Prevention of Intravas- 2010, the HAI program performed on- cular Catheter-Related Infections were

Table. Key Percentiles and 95% Confidence Intervals for Facility-Specific Central Line-Associated Bloodstream Infection (CLABSI) Standardized Infection Ratios (SIRs) in Intensive Care Units (ICUs) by Reporting Year, Excluding Burn and Trauma ICUs, Tennessee, 01/01/2008–12/31/2012 . UNIT TYPE YEAR No. SIR LOWER UPPER 10% 25% 50% 75% 90% LIMIT LIMIT 2012 94 0.56^ 0.50^ 0.63^ 0.00 0.00 0.19 0.82 1.87 2011 92 0.72^ 0.64^ 0.81^ 0.00 0.00 0.25 0.90 1.71 Adult/ 2010 83 0.79^ 0.71^ 0.88^ 0.00 0.00 0.45 0.88 1.67 Pediatric ICUs 2009 79 1.16* 1.06* 1.27* 0.00 0.00 0.70 1.38 2.40 2008 79 1.20* 1.10* 1.31* 0.00 0.00 0.87 1.45 2.48 2012 24 0.54^ 0.41^ 0.70^ 0.00 0.00 0.08 0.68 1.51 2011 24 0.62^ 0.48^ 0.79^ 0.00 0.00 0.21 0.74 0.94 Neonatal ICUs 2010 24 0.69^ 0.54^ 0.86^ 0.00 0.00 0.39 0.93 1.24 2009 25 1.01 0.84 1.21 0.00 0.00 0.00 0.85 2.20 2008* 25 1.51* 1.22* 1.85* 0.00 0.00 0.69 1.68 2.49 Data reported as of May, 2013 No.= number of facilities with reporting units; SIR = standardized infection ratio (observed/predicted number of CLABSI); *= SIR for reporting period is significantly higher than national 2006-2008 SIR of 1.0; ^= SIR for reporting period is significantly lower than national 2006-2008 SIR of 1.0.

71 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Methicillin Resistant Staphylococcus aureus (MRSA) — National Healthcare Safety Network (NHSN) Background MRSA reporting through NHSN be- Program Activities Methicillin-resistant Staphylococcus aure- gan in Tennessee in 2010 (1.14 events Tennessee’s Report on Healthcare- us (MRSA) infections are costly and per 10,000 patient days in 2010; 1.19 Associated Infections (https:// can be severe and life threatening. In events per 10,000 patient days in health.state.tn.us/Ceds/HAI/) is pub- the state of Tennessee, cases of inva- 2011; 1.13 events per 10,000 patient lished publicly two times per year, and sive MRSA have been reportable to days in 2012) (Table). The prevalence includes facility-specific and state ag- the Tennessee Department of Health of community-onset MRSA, defined as gregate data on NHSN-reportable (TDH) since July 2004. Beginning July a positive blood specimen collected HAIs. 1, 2010, certain facilities were asked to within 3 days of hospital admission, also report MRSA-positive blood cul- has also remained steady during this TDH provides reporting assistance to tures for inpatients facility-wide and period, at 1.6 events per 1,000 admis- the 113 acute care facilities and 9 long- for emergency departments. As of July sions (Figure). term acute care facilities which report 2012, all hospitals (with the exception MRSA to TDH through NHSN, in- of critical access hospitals), regardless Figure 1. MRSA Incidence and Prevalence by Half Year, Tennessee of average daily census, were asked to (07/01/2010-12/31/2012). report these events.

More details on Tennessee’s reporting requirements can be found at: http:// health.state.tn.us/Ceds/HAI/PDFs/ MRSA_Factsheet_TN.pdf, and the complete NHSN protocol for MRSA reporting can be found at: http:// www.cdc.gov/nhsn/PDFs/pscManual/ 12pscMDRO_CDADcurrent.pdf.

Trends Incidence of healthcare-onset (HO) MRSA has remained steady since Table. MRSA Incidence and Prevalence, Tennessee (07/01/2010-12/31/2012). Year No. of No. CO2 No. of Patient HO3 CO2 of prevalence rate HO3 days incidence rate events admissions (per 1,000 admissions) events (per 10,000 patient days) 20101 675 412,587 1.64 224 1,964,459 1.14 2011 1417 861,108 1.65 471 3,965,483 1.19 2012 1443 878,655 1.64 453 4,014,185 1.13 No.= number of facilities with reporting units; SIR= Standardized infection ratio (observed/predicted number of SSI) Red highlighting indicates for SIR for reporting period is significantly higher than national 2006-2008 SIR of 1.0 Blue highlighting indicates for SIR for reporting period is significantly lower than national 2006-2008 SIR of 1.0

72 Communicable and Environmental Diseases and Emergency Preparedness Annual Report cluding the 56 acute care facilities (CDI and MRSA) is planned for 2013- (HICPAC) published Management of which were involved in the Tennessee 2014. Multidrug Resistant Organisms in Center for Patient Safety (TCPS) infec- Healthcare Settings in 2006, which tion prevention initiative targeting Preventive Measures can be found at: http://www.cdc.gov/ MRSA in 2010 and 2011. Statewide The Healthcare Infection Control hicpac/pdf/MDRO/ validation of NHSN LabID event data Practices Advisory Committee MDROGuideline2006.pdf. Surgical Site Infections (SSI)

Background Table 1. Key Percentiles for Facility-Specific Surgical Site Infection (SSI) Complex A/R Infections following surgi- Standardized Infection Ratios (SIRs) by Reporting Year, Tennessee 01/01/2010- cal procedures are called 12/31/2012. surgical site infections SIR, 95% CONFIDENCE INTERVAL, AND KEY PERCENTILES (SSI). In the state of Ten- LOWER UPPER PROCEDURE YEAR No. SIR 10% 25% 50% 75% 90% nessee, infections follow- LIMIT LIMIT ing coronary artery bypass 2012 26 0.72 0.55 0.93 0.00 0.00 0.61 1.19 1.48 graft (CABG) surgeries 1 have been reportable CABG 2011 26 0.91 0.72 1.13 0.00 0.00 0.6 1.36 1.91 since January 2008. Infec- 2010 26 0.71 0.55 0.90 0.00 0.18 0.74 1.28 2.23 tions following abdominal hysterectomy procedures 2011 74 0.84 0.67 1.03 0.00 0.45 0.68 1.13 1.92 (HYST) and those follow- HPRO2 ing colon surgery (COLO) 2010* 66 0.51 0.32 0.75 0.00 0.00 0.16 0.74 1.66 have been reportable CARD2 2011* 25 0.40 0.11 1.02 0.73 0.73 0.73 0.73 0.73 since January 2012. Infec- tions following hip pros- COLO1 2012 88 0.93 0.81 1.08 0.00 0.00 0.00 0.93 1.71 thesis surgeries (HPRO) 1 were reportable from July HYST 2012 88 0.88 0.67 1.13 0.00 0.00 0.00 0.89 3.57 2010 through January 2012, and those following cardiac sur- forth by the Centers for Medicare & lished publicly two times per year, and gery were reportable from July 2011 Medicaid Services (CMS). includes facility-specific and state ag- through January 2012. Monthly re- gregate data on NHSN-reportable porting of numerator and denomina- Incidence HAIs. tor data is ongoing for each surgical The standardized infection ratio (SIR) procedure unless otherwise specified. is used as a summary measure to com- TDH provides NHSN reporting assis- pare SSI data for surgical procedures tance to the 96 acute care hospitals More details on Tennessee’s reporting performed in Tennessee to published involved in the TN Center for Patient requirements can be found at: national (NHSN) data for 2006-8. The Safety (TCPS) SSI prevention collabo- https://health.state.tn.us/Ceds/HAI/ SIR -- identical in concept to a stand- rative. In addition, the HAI program PDFs/SSI_Factsheet_TN.pdf, and the ardized mortality ratio -- is an indirect works closely with collaborative part- complete NHSN protocol for SSI re- standardization method for summariz- ners, such as the Tennessee Hospital porting can be found at: http:// ing the HAI experience across any Association and QSource, Tennessee www.cdc.gov/nhsn/pdfs/ number of stratified groups of data, Quality Improvement Organization pscmanual/9pscssicurrent.pdf and is a ratio of the number of infec- (QIO) to align prevention activities tions observed divided by the number and coordinate data feedback to re- Tennessee’s Healthcare-Associated predicted. porting facilities. Infections (HAI) reporting requirements are guided by the TN Multi- Program Activities Preventive Measures Disciplinary Advisory Group (MDAG) Tennessee’s Report on Healthcare- Guideline for the Prevention of Surgical on HAI. Currently, TN requirements Associated Infections (https:// Site Infections was published by the align closely with federal mandates set health.state.tn.us/Ceds/HAI/) is pub- Healthcare Infection Control Practices

73 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Advisory Committee (HICPAC) in www.cdc.gov/hicpac/pdf/guidelines/ 1999 and can be found at: http:// SSI_1999.pdf . Invasive Vancomycin-Resistant Enterococcus (VRE)

Background Figure 1. Invasive VRE cases and rate per 100,000 population by year, Enterococci are bacteria that live in the 2007-2012. digestive and genital tracts (colonization). They normally do not cause infection in healthy people. Van- comycin is an antibiotic that is often used to treat infections caused by enterococci. In some cases, enterococci have become resistant to vancomycin and are called vancomycin-resistant enterococci or VRE. VRE infection can occur throughout the body, with the most common body sites being the urinary tract, surgical wounds, and/or bloodstream. Enterococcus faecalis and Enterococcus faecium are the most commonly isolated enterococcus species causing human infection. Resistance is caused by plasmids (e.g., Van A, Van Figure 2. Incidence Rates of VRE per 100,000 populations, by Age Group, B). These plasmids can be transferred Tennessee, 2010-2012. to other organisms such as Staphylococ- cus aureus, resulting in vancomycin- resistant Staphylococcus aureus (VRSA). Control of VRE is critical to reduce the chances of emerging VRSA.

Persons at higher risk of becoming infected with VRE include those who have previously been treated with vancomycin, persons hospitalized for longer periods, persons with weakened immunity, persons who have under- gone surgery and those with medical devices that stay in for some time such between 2007 and 2009, with over 300 Trends as urinary catheters or central intrave- cases reported each year and a rate of There has been a steady drop in the nous devices. Mainly older adults who over 5 cases per 100,000 population. incidence of invasive VRE in Tennes- are over the age of 60 years are more Since 2009, when there were 333 re- see since 2009 (see Figure 1). likely to have risk factors that put them ported cases, the number of cases has at higher risk of contracting VRE and been decreasing (295 cases in 2010; Program Activities hence we observe higher incidence 235 cases in 2011; 214 cases 2012). By The Tennessee Department of Health rates among older adult populations as 2012, the incidence had dropped to monitors the incidence of invasive shown in Figure 2. 3.4 cases per 100,000 population VRE as a measure of effectiveness of (Figure 1). The incidence of invasive infection prevention and antimicrobial Incidence VRE increases with increasing age stewardship. Control of VRE is im- The number of reported VRE cases in (Figure 2). portant to prevent emergence of Tennessee remained relatively stable VRSA.

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Preventive Measures wash their hands thoroughly after  Wear gloves if hands may come in Antimicrobial stewardship and infec- using the bathroom and before contact with body fluids that may tion control measures are important in preparing food. Clean their hands contain VRE, such as stool or the control of VRE. Additional details after contact with persons who bandages from infected wounds. can be found at: http://www.cdc.gov/ have VRE. Wash with soap and Always wash their hands after re- hicpac/mdro/mdro_0.html. water (particularly when visibly moving gloves. soiled) or use alcohol-based hand  If someone has VRE, be sure to  If a patient or someone in their rubs. tell healthcare providers so that household has VRE, the following  Frequently clean areas of the they are aware of the infection. are some things they can do to home, such as bathrooms, that Healthcare facilities use special prevent the spread of VRE: may become contaminated with precautions to help prevent the  Keep their hands clean. Always VRE. spread of VRE to others. Healthcare-Associated Infections and Antimicrobial Resistance Program Special Projects Programmatic Overview The Tennessee Department of Health (TDH) Healthcare-Associated Infec- tions (HAI) and Antimicrobial Re- sistance Program participate in a number of projects through the Emerging Infections Program Healthcare Associ- ated Infections and Community Inter- face (HAIC) component. The aim of this component is to engage state health departments and their academic medical center partners to help an- swer critical questions about emerging HAI threats, advanced infection tracking methods, and antibiotic resistance in the United States. Infor- mation gathered through these projects plays a key role in shaping policy and recommendations for HAI surveillance and prevention. Sample of TN results from Phase 3 of HAI and Antimicrobial Use Prevalance Survey. Source: TDH. 2011. Activities objectives of the survey were: 1) to esti- In 2010, TDH completed data collec- Healthcare-Associated Infections and mate the prevalence of HAIs and the tion and entry for Phase 2. During this Antimicrobial Use Prevalence Survey distribution of HAIs by pathogen and phase, 149 charts were reviewed at 3 The Healthcare-Associated Infections major infection site, and 2) to estimate hospitals. Over 63% of all surveyed and Antimicrobial Use Prevalence the prevalence and rationale for anti- patients were found to be on antibiot- Survey was conducted by the Centers microbial use among inpatients in ics within these facilities, with preva- for Disease Control and Prevention acute healthcare facilities. The Tennes- lence rate at each hospital ranging (CDC) and the Emerging Infections see Department of Health (TDH) par- from 47% to 69%. Checklists were Program (EIP) as a point prevalence ticipated in developing and conduct- designed for each major HAI event survey for HAIs and antimicrobial use ing both Phase 2 (limited roll-out) and and were used to determine whether in a sample of U.S. acute care general Phase 3 (full-scale survey). each potential HAI met the appropri- and general children’s hospitals. The ate National Healthcare Safety Net-

75 Communicable and Environmental Diseases and Emergency Preparedness Annual Report work (NHSN) case definition. After completing Phase 2, TDH worked with CDC and other EIP sites to develop the protocol for Phase 3.

TDH completed Phase 3 of the survey in 2011. A stratified random sample of hospitals within each of 3 bed size stra- ta (small, medium, and large) were selected to participate. During this phase, 1486 charts were reviewed at 25 hospitals. Over 56% of all surveyed patients were found to be on antibiotics. TDH worked with CDC and other EIP states to analyze the survey data and help prepare a manuscript presenting the results.

Surveillance of Bloodstream Infections in Dialysis (SuBSID) Study Central Office epidemiologist Ashley Moore demonstrated proper hang hygiene for Tennessee worked with CDC through chlorhexidine study field staff in training video developed by TDH. the Emerging Infections Program be- Source: TDH, 2011 tween 2010 and 2012 to develop and carry out a study evaluating the use of nization Among Patients in Long- to obtain structured feedback from electronic data capture for surveillance Term Care Facilities long-term care facilities (LTCFs) re- of bloodstream infections (BSI) in a TDH collaborated with CDC to con- garding 1) comprehensibility and usa- large dialysis organization (LDO) in duct a research study evaluating the bility of HAI surveillance tools, 2) clar- the Nashville and Chattanooga areas. benefits of bathing with chlorhexidine ity and usefulness of HAI surveillance The primary objectives of this study gluconate (CHG) in order to reduce instructions and training materials, 3) were: 1) to demonstrate feasibility of the colonization of multidrug-resistant burden of data collection, and 4) feasi- creating a uniform surveillance dataset organisms (MDRO) among residents bility of conducting HAI surveillance from existing electronic medical rec- of LTCFs. The specific MDROs stud- using the provided tools. Three LTCFs ord data provided by an LDO; 2) to ied included methicillin-resistant in Tennessee provided TDH and implement an enhanced measure of Staphylococcus aureus (MRSA), vanco- CDC with feedback and data related BSI incidence for patients at partici- mycin-resistant enterococcus (VRE), to Clostridium difficile infection surveil- pating hemodialysis centers (HDCs) by extended-spectrum beta-lactamase pro- lance and/or urinary tract infection identifying BSIs diagnosed within and ducing gram-negative bacteria (ESBL), surveillance. PISToL gave TDH the outside the HDC; 3) to validate the and carbapenem-resistant enterobacte- opportunity to establish relationships quality of outpatient hemodialysis pa- riaceae (CRE). Two LTCFs in Blount with these LTCFs and to introduce tient-day denominator data recorded County participated in this study in these settings to HAI surveillance in LDO electronic medical record sys- 2012; final results are currently pend- through NHSN. tems; and 4) to evaluate the perfor- ing. mance characteristics of several proxy Impact BSI and denominator metrics cap- PISToL Project tured electronically through existing In 2012, the TDH HAI Program par- HAI and Antimicrobial Use Preva- data provided by the LDO. Publica- ticipated in the Piloting Infection Sur- lence Survey tion of final results is expected in late veillance Tools in Long-Term Care The results from the HAI and Antimi- 2013. (PISToL) project, an EIP project de- crobial Use Prevalence Survey provid- signed to inform CDC’s development ed important information regarding Chlorhexidine Bathing to Reduce of a long-term care component for the burden and types of HAIs in acute Multi-Drug Resistant Organism Colo- NHSN. The goals of the project were care facilities, in addition to antimicro-

76 Communicable and Environmental Diseases and Emergency Preparedness Annual Report bial drug use in Tennessee and other Results of this study will inform im- ally, TDH staff gained experience EIP states. Based on findings of higher provement in data capture and collec- working in the long-term care setting, -than-expected antimicrobial use in tion methods for surveillance of HAIs which is a growing area of interest in Tennessee, TDH has initiated an anti- in dialysis facilities. TDH mandated HAI prevention. microbial stewardship collaborative to reporting of NHSN-defined Dialysis improve the judicious use of antimi- Events beginning in 2012, and the PISToL Project crobials across the healthcare spec- results of this study will be critical for In addition to providing CDC with trum. The prevalence survey will be future validation of surveillance data valuable feedback on its new LTCF repeated at regular intervals to assess collected through this mechanism. module, the PISToL study gave TDH HAI and antimicrobial use trends, the opportunity to establish relation- with the next phase (Phase 4) planned Chlorhexidine Bathing Study ships with participating LTCFs and to in 2014. The results of this study may be im- introduce these settings to HAI surveil- portant for informing standard of care lance through NHSN. Surveillance of Bloodstream Infections in LTCFs, a setting which often faces a in Dialysis (SuBSID) Study high prevalence of MDROs. Addition-

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78 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

H. Sexually Transmitted Diseases

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Chlamydia

Background Figure 1. Reported Cases of Chlamydia, Chlamydia is a common sexually trans- Tennessee, 2010-2012. mitted disease (STD) caused by the 33,000 bacterium, Chlamydia trachomatis, 32,570 which can damage a woman's repro- 32,000 ductive organs. It is the most frequently reported bacterial sexually 31,000 31,085 transmitted disease in the United 30,000 States. Chlamydia affects both males and females, although it is most preva- 29,000 lent among young women. 28,311

Reported Cases 28,000 Chlamydia can be transmitted during vaginal, anal, or oral sex. It can also 27,000 be passed from an infected mother to 26,000 her baby during vaginal childbirth. 2010 2011 2012 The majority of people infected with chlamydia have no symptoms. If Year symptoms do occur, they usually appear with 1-3 weeks after exposure. Women who have symptoms of chla- Figure 2. Reported Cases of Chlamydia, by Race, 2012. mydia might have an abnormal vaginal discharge or a burning sensation when 5% urinating. Men with symptoms may also have a burning sensation when urinating or a discharge from the penis, as well as burning or itching 40% around the opening of the penis. For- tunately, chlamydia can be easily treated and cured with antibiotics. If untreated, it can progress to serious re- productive and other health problems, 55% such as pelvic inflammatory disease in women and epididymis in men.

Incidence In 2012, there were 32,569 cases of White African-American Other/Unknown Chlamydial infection reported to the Tennessee Department of Health. Of Americans and 9,563 (41%) were iden- 2012. these cases, 22,763 (70%) were identi- tified among Whites (Figure 1) fied among women, and among 15-24 Among the 9,767 male cases reported Trends year olds (73%), which is a direct re- in 2012, 5,749 (59%) were identified From 2010-2012, reported Chlamydia sult of focused STD testing efforts among Black/African-Americans and cases have increased 15% in volume. among women being seen within Fam- 3,595 (37%) were identified among (Figure 2) While cases among Blacks ily Planning and Maternal Child Whites. Among both females and have increased a modest 5.6% over Health clinics. males, cases from Asian, Hawaiian/ this 3-year period, cases among Whites Pacific Islanders, Native Americans, have increased 30%. These increases Among female cases, 12,244 (55%) and Multi-race persons composed only have been attributed to aggressive test- were identified among Black/African- 3 percent of the overall morbidity for ing efforts aimed at identifying new

80 Communicable and Environmental Diseases and Emergency Preparedness Annual Report cases throughout Tennessee. Addi- disease, verification of diagnosis and who have sexual contact with more tionally, there have been no apprecia- treatment of all reportable STDs from than one partner should be tested reg- ble changes by age category during this public and private providers, partner ularly for the disease. Constant aware- period as the majority of our pro- referral services which provides notifi- ness and protection are necessary be- gram’s funded testing efforts are cation, screening and treatment to cause a person who has once contract- among 15-24 year olds in Family Plan- sexual partners, and educational and ed the disease does not become im- ning and Maternal Child Health clin- counseling services to those at risk for mune, and many people acquire Chla- ics. sexually transmitted diseases as well as mydia more than once. the community in general. Program Activities If a person has been diagnosed and Within our state health department Preventive Measures treated for gonorrhea, he or she system, all clients who test positive for Abstaining from sexual intercourse is should notify all recent sex partners so a sexually transmitted disease are of- the best protection against Chlamydia they can see a health care provider and fered a variety of services to reduce and other STDs; however, the use of be treated. This will reduce the risk their risks of acquiring sexually trans- latex condoms during sexual inter- that the sex partner will develop seri- mitted diseases in the future. These course when always and correctly used ous complications from gonorrhea and services include: confidential counsel- can reduce the risk of transmission of will also reduce the person’s risk of ing, testing, and treatment of those Chlamydia. Because Chlamydia is becoming re-infected. persons who are infected or who have highly contagious and yet may cause been exposed to a sexually transmitted no symptoms, all men and women Gonorrhea

Background Figure. Reported Cases of Gonorrhea, Gonorrhea is caused by the bacterium Tennessee, 2010-2012. Neisseria gonorrhoeae. It is a very common infectious disease and is 10,000 spread through contact with the penis, vagina, mouth, or anus. It can also be 8,000 9,120 spread from mother to baby during 7,663 delivery. Most men and women with 7,120 gonorrhea have no symptoms at all. 6,000 When men have signs or symptoms, they may appear one to fourteen days 4,000

after infection, and could include a Reported Cases burning sensation when urinating, or 2,000 a white, yellow, or green discharge from the penis. When a woman has symptoms they are often mild, and 0 may include a painful or burning sen- 2010 2011 2012 sation when urinating, increased vagi- Year nal discharge, or vaginal bleeding between periods. Antibiotics can suc- Incidence (6,917, or 75% of total cases reported). cessfully cure gonorrhea in adolescents In 2012, there were 9,120 cases of White cases represented 20% of the and adults. As with chlamydia, un- Gonorrhea reported to the Tennessee total cases reported, and other races, treated gonorrhea can cause serious Department of Health. Similar pro- such as Native Americans, Asians, and and permanent health problems in portions of cases were identified Hawaiian/Pacific Islanders comprised both men and women, such as pelvic among men and women (48% and the remaining 5%. inflammatory disease and epididymis. 51%, respectively). In terms of race, the majority of cases were reported Trends among Black/African-Americans Following declines in overall morbidi-

81 Communicable and Environmental Diseases and Emergency Preparedness Annual Report ty from 2008-2009, the past three years their risks of acquiring sexually trans- the best protection against Gonorrhea have seen reported cases of Gonorrhea mitted diseases in the future. These and other STDs; however, the use of increase 28% (Figure) services include: confidential counsel- latex condoms during sexual inter- ing, testing, and treatment of those course when always and correctly used In 2012, reported cases of Gonorrhea persons who are infected or who have can reduce the risk of transmission of were highest within our largest metro- been exposed to a sexually transmitted Gonorrhea. Because Gonorrhea is politan areas, including Memphis, disease, verification of diagnosis and highly contagious and yet may cause Nashville, Hamilton, and Knox coun- treatment of all reportable STDs from no symptoms, all men and women ties. This historical trend holds true public and private providers, partner who have sexual contact with more for all sexually transmitted disease cas- referral services which provides notifi- than one partner should be tested reg- es in Tennessee, including HIV dis- cation, screening and treatment to ularly for the disease. Constant aware- ease. sexual partners, and educational and ness and protection are necessary be- counseling services to those at risk for cause a person who has once contract- Program Activities sexually transmitted diseases as well as ed the disease does not become im- Within our state health department the community in general. mune, and many people acquire Gon- system, all clients who test positive for orrhea more than once. a sexually transmitted disease are of- Preventive Measures fered a variety of services to reduce Abstaining from sexual intercourse is Human Immunodeficiency Virus (HIV) Disease

Background Figure 1. HIV Exposure among Males, Tennessee 2012. HIV Disease is a collective term for the total population of persons infect- 1% ed with the Human Immunodeficien- cy Virus. It is comprised of persons who are infected with HIV, but have not been diagnosed with AIDS (Acquired Immune Deficiency Syn- drome), as well as persons who have 43% 50% been diagnosed sometime in the past with AIDS.

To date, 25,658 Tennesseans have been diagnosed with HIV Disease 4% since 1980, and of these persons, 8,280 (32%) have died. As of 1/1/13, 2% there are 19,083 persons living with MSM IDU Hetero Other/Unk MSM/IDU HIV in Tennessee.

Incidence regardless of where they were initially Trends In 2012, there were 923 newly diag- diagnosed with the disease. After gradual declines in HIV morbidi- nosed HIV infections (with or without ty from 2008-2011, reported HIV cas- AIDS) among Tennessee residents. Among the 713 males reported with es increased 7.4% from 2011-2012 The majority (77%) of persons newly an initial HIV diagnosis in 2012, 355 (Figure 2), which was the result of a diagnosed with HIV infection was (50%) acquired their infection 10.1% increase in reported cases male, was African-American (62%), through sexual contact with other among males, combined with a slight and was between 15-34 years of age at males (MSM), 4.2% through hetero- decrease in cases among females. time of diagnosis (54%). As of sexual contact with infected female 12/31/12, there were 19,083 persons partners, and 14 (2%) through injec- Program Activities living with HIV Disease in Tennessee, tion drug use (IDU) (Figure 1). Our current CDC grant supports a

82 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Figure 2. Reported Cases of HIV Disease, als (HIV-IP), public information pro- Tennessee, 2010-2012. grams (PIP), a toll-free HIV/STD hot- line, capacity building programs, and a 940 quality assurance and evaluation component. 920 923 900 Preventive Measures To avoid infection through sex, a per- 880 son should not have anal, vaginal or oral sexual intercourse. An individual should only have sex with someone 860 868

Reported Cases who is not infected and who has sex 859 840 only with that individual. A person should use latex condoms always and 820 correctly each time s/he has vaginal, 2010 2011 2012 anal or oral sex to greatly lower the risk of infection. An individual should Year never share needles or injection equipment to inject drugs or steroids, as the range of activities that include: HIV services (PS), HIV health education HIV in blood from an infected person counseling, testing and referral (CTR), and risk reduction programs (HERR), can be transferred directly into the HIV partner counseling and referral HIV prevention for positive individu- bloodstream of the next user. Syphilis

Background Figure. Reported Cases of Early Syphilis, Syphilis is caused by the bacterium Tennessee, 2010-2012. Treponema pallidum, and is spread 660 through direct contact with a syphilis sore. These sores occur mainly on the 640 external genitals, vagina, anus, or in 620 641 the rectum. However, they can also occur in the lips and in the mouth. 600 Syphilis is transmitted during vaginal, 580 anal, or oral sex, and pregnant women 560 with syphilis can pass it on to the ba- bies they are carrying. The course of Reported Cases 540 546 syphilis is divided into different stages 520 537 (Primary, Secondary, Latent,) each with their own signs and symptoms. 500 480 A single intramuscular injection of 2010 2011 2012 penicillin, an antibiotic, will cure a Year person who has had syphilis for less than a year. Additional doses (up to Syphilis (< 1 year duration) reported in three doses, given over a three week Tennessee. Black/African Americans Trends period) are needed for someone who represented the majority of cases (377, Cases reported in 2012 represented a has had Syphilis for longer than a year. or 69% of total cases reported). There 9.7% decrease from cases reported in were 158 (29%) of cases among 2010 (Figure) This can be attributed Incidence Whites, while the remaining 11 cases primarily to the 12.6% decrease in In 2012, there were 546 cases of Early were comprised by other races. cases among Black/African Americans

83 Communicable and Environmental Diseases and Emergency Preparedness Annual Report from 2010 to 2012, which represent cal settings, expanded laboratory ser- of the disease. Latex condoms, when the majority of early syphilis cases in vices, strengthened community in- always and correctly used, can reduce Tennessee. volvement and agency partnerships, the risk of syphilis and other STDs but and enhanced health promotion. only when the infected areas are cov- Program Activities ered or protected by the condom. (The The epidemiology of syphilis repre- Syphilis prevention and control activi- open sores may occur in genital areas sents a dynamic interaction between ties predominantly take place within that can be covered or protected by a behavior, biology, and the effective- the context of health services that in- condom, but they also may occur in ness of public health interventions. clude STD, Infectious Disease, HIV areas that cannot be covered or pro- Syphilis elimination is possible be- Outreach and other services. tected by a condom.) cause the disease is easy to cure once diagnosed, and because the syphilis Preventive Measures Testing and treatment early in preg- epidemic is concentrated in a small Abstaining from sexual intercourse is nancy is the best way to prevent syphi- number of geographic areas. the best protection against Syphilis lis in infants and should be a routine and other STDs. part of prenatal care. All women re- Key strategies in place throughout ceiving prenatal care should be tested Tennessee for the successful preven- The open sores associated with syphilis for syphilis during their first prenatal tion and elimination of syphilis in- may be visible and are infectious dur- exam and during their last three clude: expanded surveillance and out- ing the active stages of the disease. Any months of pregnancy. break response activities, rapid screen- contact with these contagious sores ing and treatment in and out of medi- must be avoided to prevent the spread

84 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

85 SECTION IV. INVESTIGATIONS AND OUTBREAKS Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Multistate Outbreak of Human Salmonella Chester Infections

CDC collaborated with public health officials in many states, the U.S. De- partment of Agriculture's Food Safety and Inspection Service (USDA/FSIS), and the U.S. Food and Drug Admin- istration (FDA) to investigate a multistate outbreak of Salmonella serotype Chester infections. Investigators used DNA analysis of Salmonella bacteria obtained through diagnostic testing to identify cases of illness that were part of this outbreak.

A total of 44 individuals infected with a matching strain of Salmonella Ches- ter were reported from 18 states since April 11, 2010 (Figure). Among those for whom information is available about when symptoms started, illnesses began between April 4, 2010 and Marie Callender’s Cheesy Chicken & meal. There was insufficient data from June 16, 2010. Case-patients ranged in Rice single-serve frozen entrées. Dur- this study to implicate a specific frozen age from <1 to 88 years old, and the ing June 14-18, 2010, CDC and public meal type. However, many of the ill median age was 36 years. Fifty-four health officials in multiple states con- persons reported eating a Marie percent of patients were female. ducted an epidemiologic study by com- Callender's Cheesy Chicken & Rice Among the 43 patients with available paring foods eaten by 19 ill and 22 frozen entrée in the week before be- hospitalization information, 16 (37%) well persons. Analysis of this study coming ill. Additionally, two uno- were hospitalized. No deaths were re- suggested that eating a Marie Callen- pened packages of Marie Callender’s ported. Tennessee reported one case der's frozen meal was a source of ill- Cheesy Chicken & Rice single-serve in this multi-state outbreak. This case ness. Ill persons (89%) were signifi- frozen entrées collected from two pa- was female, between the ages of 20-49 cantly more likely than well persons tients’ homes (one collected in Minne- and visited the emergency room. (14%) to report eating a frozen meal. sota on June 18, and one in Tennessee All ill persons (100%) who ate frozen on July 19) yielded Salmonella Chester Collaborative investigative efforts of meals reported eating a Marie Callen- isolates with a genetic fingerprint in- officials in many local, state, and feder- der's frozen meal. None of the well distinguishable from the outbreak pat- al public health, agriculture, and regu- persons who ate a frozen meal report- tern. latory agencies linked this outbreak to ed eating a Marie Callender's frozen Outbreak of an Unidentified GI Illness at a Lodge, June 2010

Background the National Park Service and Lodge single night at the site after completing On Monday, June 21, 2010, the East A’s Concessioner indicated that ap- the 5+ mile hike to the Lodge on one Tennessee Regional Office of the Ten- proximately 7 visitors had become ill of four trails. Set meals are served at 6 nessee Department of Health (ETRO) in the early hours of Monday morn- pm and 8 am; each consists of multi- received a report of multiple coming. No administrative staff or food ple canned/packaged items that are plaints of gastrointestinal symptoms service workers were reported to be ill. prepared daily. Following the morn- among visitors to a Lodge in the Great Lodge A, which is accessible only on ing meal, most visitors to the Lodge Smoky Mountains National Park foot, serves two meals a day and visi- begin the return hike, although a lim- (Lodge A). Initial consultation with tors to the Lodge generally spend a ited number of visitors stay for two

87 Communicable and Environmental Diseases and Emergency Preparedness Annual Report nights. The Lodge is a popu- Table 1. Total Interviews and Attack Rates by Date of Overnight Visit (N=82). lar vacation destination; cab- Date Total interviewed Well Ill Attack Rate ins remain booked throughout the season and reserva- June 18 4 4 0 0% tions are made as far as a year June 19 38 12 26 68% in advance. Due to the inac- June 20 36 8 28 78% cessibility of the site, provi- sions for the entire season are ordered in advance and 27 dropped by helicopter one June 21 (23 stayed 06/20 as well; 4 27 0 0% time in the spring. Given the stayed only 06/21) difficulties that would result if alteration to the menu were made, careful investigation was re- terial toxin ingested as a point-source and this analysis is limited to these quired to determine whether existing item. The rapid onset of illness ap- individuals. Among the visitors inter- inventory items were safe and ensure peared to rule out person-to-person viewed, 53 individuals reported be- that no foods were discarded unneces- transmission or a traditional food- coming ill during their trip to Lodge A sarily. borne enteric illness such as Campylo- and one additional individual report- bacter. Anecdotal reports from visitors ed becoming ill the day before arrival A food- or water-borne pathogen was suggested that no vegetarians had be- at the Lodge (Table 1). suspected as a probable cause based on come ill and appeared to implicate a the symptoms initially reported. Ac- canned beef product served as the Reports of illness yielded unanimous cordingly, the interview tool included main entree. None of the visitors in- lower gastrointestinal symptoms, alt- questions regarding food history, recre- terviewed on-site were currently symp- hough most of the cases interviewed ational water exposure, and animal tomatic and stool specimens could not also reported multiple other symptoms contact. Two ETRO staff members be collected. such as cramps, nausea, and headache. and one Sevier County staff member Onset times ranged from 3 - 91 hours were dispatched to the National Park A total of 115 cabin spaces were re- after the evening meal served both on Tuesday, June 22, to interview and served for the nights of June 19 and nights (range excludes the ill visitor collect specimens from ill visitors, who 20. Reservations are made in the whose symptoms began before arrival). had been requested to present at the name of the head of party and these An epidemic curve generated from the Park Headquarters following their de- individuals were contacted to provide interviews indicates that the largest scent from the Lodge. a complete list of visitors in each cab- proportion developed symptoms early in. The precise number of individuals in the morning hours of June 20 and Staff at Lodge A were also able to pro- lodged on-site each night could not be June 21. This is consistent with the vide contact information for individu- conclusively determined since spaces working hypothesis that a food item als who made a reservation at the in rented cabins may go unused and (or items) was the source of intoxica- lodge from June 18 through June 21. not all heads of party could be tion. Staff from ETRO and the Tennessee reached. There were a total of 94 indi- Department of Health in Nashville viduals identified who stayed at the The mean incubation period among ill contacted these individuals and inter- Lodge at least one of the two nights in visitors was13.6 hours; this varied sig- viewed them with the outbreak ques- question: 48 on June 19 and 46 on nificantly when stratified by date of tionnaire to assess illness, exposures June 20. lodging (17.1 vs. 10.4 hours on June and to receive contact information for 19 and June 20, respectively). The others who visited Lodge A. Interviews with visitors to the site on decrease in mean incubation period June 18 and June 21 revealed no ill- may signify that visitors to the Lodge ness, so the event period has been re- on the second night of the event peri- Results stricted to visitors lodging the nights od received a greater dose of the causa- Initial interviews revealed a consistent of June 19 and June 20. A total of 74 tive agent. This is also consistent with set of symptoms with a tight onset pe- interviews were completed with visi- the increased attack rate noted among riod, consistent with a pre-formed bac- tors to the site during the event period visitors on June 20.

88 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

A food history was collected from all tive agent since the symptoms and in- appear to have been transmitted per- interviewed visitors utilizing the dining cubation periods experienced by ill son-to-person in this instance, because hall menu provided by Lodge A. Visi- visitors were consistent with C. of the potential for spread and the tors were also questioned regarding perfringens intoxication. Additionally, difficulties that would be faced if a exposure to creek water and contact the anaerobic bacterium C. perfringens different pathogen were to establish with animals. No visitors reported is often associated with canned prod- itself at the site, ETRO staff discussed having contact with animals while en ucts and meat products, which were with the Concessioner disinfection route to or at the Lodge. Consump- among foods consumed that had the procedures that should be implement- tion of food items was consistent be- highest odds ratios on both a per-day ed and also provided Lodge A’s staff tween both ill and well visitors. Odds and absolute exposure basis. with Parapaks and instructions regard- ratios were calculated by day of expo- ing collection of stool if a future out- sure for those food items with the Discussion break should occur. highest attack rates. As described above, despite an implicated food item, a lab-confirmed food Only two items had significantly high source could not be determined. Recommendations odds ratios for both days in which ill- Lodge policy and practice require that To reduce the potential for additional ness occurred: beef in gravy and leftover food be immediately disposed outbreaks at Lodge A, ETRO staff also mashed potatoes. Because these items of and all food containers well washed made the following recommendations were almost universally consumed to- to minimize the attraction of bears for the Concessioner and Lodge staff, gether and quantity of each food item and smaller nuisance animals to the especially food services workers: consumed was not collected, it is diffi- Lodge. Given these practices, food cult to tease apart their individual con- samples could not be collected. How- tributions. However, when odds ratios ever, the Concessioner also described  Frequently review and ensure ad- were calculated for absolute consump- occasional storage of unprepared lefto- herence to food handling practices tion of food items (that is, combining ver foods; upon interview, food service that minimize the likelihood of both days and assessing consumption), workers were able to confirm that ap- both food and surface contamina- the beef was clearly implicated, pro- proximately half a can of additional tion ducing an odds ratio of 17.667 (95% beef was used on June 19, the remain-  Frequently review and ensure ad- CI: 1.914, 163.027). der of which was stored in a sealed, herence to routine disinfection refrigerated container and added to practices with cleaning products ETRO/Sevier County staff worked the cans of beef prepared on June 20. effective against persistent patho- closely with the TDOH Central Office The storage of the unused beef gens in order to minimize the like- to respond quickly and arrive at the (although apparently properly han- lihood of surface contamination National Park before visitors returned dled), subsequent increase in attack to their locations of origin. Most of rate and decrease in incubation period  Enforce exclusion policies for ill the ill visitors’ symptoms had already provide multiple points of evidence staff, especially food handlers resolved at the time of interview and that further increase the index of sus-  Ensure that handwashing facilities no stool specimens were collected at picion with regard to the beef. are properly supplied and alcohol- the time of ETRO staff’s visit to the based hand sanitizers are readily Park. The Central Office coordinated The individual that provided the stool available in areas where handwash- with both the National Park Service specimen was notified of the results by ing facilities do not exist and with other states’ departments of phone. The Lodge Concessioner was  Monitor visitor health and collect health to achieve collection of stool notified that S. aureus and C. stool specimens if more than 3 specimens from visitors that reported perfringens had been isolated from a visitors become ill with diarrheal ongoing illness. A single stool speci- specimen and he was encouraged to illness in a 24 hour period men was collected and submitted for contact the Sevier County Health De- culture; results revealed a quick- partment or ETRO if he had any fur- growing Staphylococcus aureus and a ther questions regarding outbreak pre- Although no visitors to Lodge A pre- more slow-growing Clostridium vention or facility disinfection. sented to a hospital for their illness, perfringens. The latter pathogen has been identified as a more likely causa- Although the causative agent does not the large numbers of out-of-state visi-

89 Communicable and Environmental Diseases and Emergency Preparedness Annual Report tors to the National Park and the is unique to the East Tennessee Re- creased surveillance for enteric illness closely associated tourist attractions in gion. In light of this and following an originating in Blount and Sevier Pigeon Forge/Gatlinburg each year earlier outbreak in 2010 associated Counties, especially associated with signify a local area of increased risk for with another Great Smoky Mountains out-of-state patients presenting to local initiation of a multi-state outbreak that National Park facility, ETRO has in- hospitals. Fungal Infections Associated with Contaminated Methylprednisolone Acetate Injections in Tennessee, Fall 2012- 2013

Background TDH and the Tennessee clinical com- TDH partnered with the Poison Con- Starting in September 2012, the Ten- munity through Epi-X and Tennessee trol Center to help handle the call nessee Department of Health (TDH) Health Alert Network (THAN) mes- volume from the public and con- investigated an outbreak of fungal in- sages helped to identify new potential cerned patients regarding the fungal fections among recipients of epidural cases; these were evaluated and started infection outbreak. TDH was able to glucocorticoid injections at three out- on antifungal therapy. In the first contact and track all exposed patients patient clinics in Tennessee, which week of October, the TDH State (thought to be over 1,100 at the time) was part of a larger national outbreak Health Operations Center (SHOC) for any new disease through the end of involving 20 states. Contaminated was activated, along with Regional November. The extensive amount of preservative free methylprednisolone Health Operation Centers (RHOCs) information from these efforts was acetate (MPA) from one compounding across the state to manage every aspect coordinated through the use of the pharmacy was implicated as the source of the investigation which included, Tennessee Countermeasure Response of fungal exposure. Cases were identi- but was not limited to: identification Network (TNCRN). fied as individuals that had received a of all exposed patients; exposed pa- potentially-contaminated MPA injec- tient notification and tracking (from Due to the large amount of clinical tion with subsequent development of TDH staff) through phone calls, home and procedure information that was meningitis, spinal or paraspinal ab- visits and certified mail; finding of being provided to TDH as well, an scess, peripheral joint infection, or cases; case treatment and exposure information management system was posterior circulation stroke in the ab- analysis; communication to the public established to track patient follow-up, sence of any lumbar puncture result. and key stakeholders; and coordina- clinical, and procedure information tion between TDH and CDC, FDA and to coordinate with the TNCRN Investigation and other state entities. Also in Octo- system on a daily basis. Information In the early stages of the investigation ber, TDH gained assistance from CDC collected was used so that all exposed in mid-September, TDH efforts were to help in the process of case data col- patients were referred to the focused on identification of the causa- lection and analysis in the form of an healthcare system and received appro- tive exposure, identification of new EPI-AID (on-site assistance from priate follow-up and treatment based cases, and the determination of the CDC’s Epidemic Intelligence Service on CDC’s guidelines. The infor- best course of treatment for ill pa- officers). This effort was further assist- mation collected in Tennessee was also tients. TDH also encouraged the af- ed when 14 hospitals were able to pro- used to help inform national diagnos- fected clinics to begin notifying all vide TDH with remote access to their tic and treatment guidelines. potentially exposed patients. By the electronic medical record (EMR) sys- end of September, TDH had identi- tem. A second Epi-AIDepi-aid would Procedure and exposure data were fied the most likely source of exposure be called for in November to help as- analyzed on a daily basis to help better (MPA from the New England Com- sist with data collection in response to describe the risk factors for disease to pounding Center [NECC]) which an increase of patients presenting with help prioritize communication and helped push for a recall of all poten- infections at the location where injec- outreach. Analysis was also completed tially contaminated MPA lots. Coop- tions were administered (e.g. spinal on available clinical and treatment eration and communication between and paraspinal abscesses). data to help better understand the

90 Communicable and Environmental Diseases and Emergency Preparedness Annual Report course of illness and the most effective tration was 46 mg per deciliter (range, 12 respectively). Risk factors for meningitis or treatment strategies for all patients. to 194). A total of 31 patients had labora- localized infection were similar to the re- Results are described in the following tory confirmation of Exserohilum rostratum sults for all cases, though receiving an injec- two paragraphs. infection (30 patients) or Aspergillus fu- tion at Clinic A was a risk factor for men- migatus infection (1 patient). Fifteen pa- ingitis (aOR: 3.02; 95% CI: 1.29, 7.04). Of the 153 case patients, 22 had meningi- tients died (9.8%). tis alone (14.4%), 69 had spinal or Summary paraspinal infection alone (45.1%), 57 In Tennessee, 1021 patients received MPA The relationship between the state had meningitis and spinal or paraspinal injections. As of April 30, 2013, 152 health department and Tennessee’s infection (37.3%), 3 had posterior circula- patients (14.9%) met the case definition; clinical community were essential to tion stroke without LP (2.0%), and 2 had 126 had localized infection, 79 had menin- timely identification of the first cases peripheral joint infection (1.3%). The me- gitis, 3 had stroke (with no lumbar punc- linked to epidural steroid injections. dian age was 68 years (range, 23 to 91). ture), and 2 had joint infection. Univari- Existing emergency preparedness infra- The median time from the last epidural ate risk factors for fungal infection includ- structure was key to patient notifica- glucocorticoid injection to symptom onset ed: age >60 years, female sex, injection tion and follow-up. Ease of communi- was 36 days (range, 0 to 198). Symptoms received at Clinic B, exposure to multiple cation between clinicians and TDH and signs included headache (in 60% of procedures, exposure to MPA lot staff (including remote EMR access) the patients), new or worsening back, neck 06292012@26, and exposure only to vials helped to identify the causative expo- or leg pain (in 71%), neurologic symptoms >50 days old (compared to exposure to sure and describe the spectrum of ill- (in 47%), nausea or vomiting (in 35%), newer vials only). In multivariate analysis, ness among the exposed. Real time and stiff neck (in 24%). The median cere- risk factors for infection included age >60 review of case medical records was in- brospinal fluid white-cell count on the first years (adjusted odds ratio (aOR): 3.15; strumental in the development of in- lumbar puncture among patients who pre- 95% CI: 1.99, 4.99); undergoing ≥1 terim treatment guidelines throughout sented with meningitis, with or without translaminar procedure (aOR: 1.81; 95% the course of the outbreak. Invest- stroke or focal infection, was 460 per cubic CI: 1.15, 2.83); and cumulative dose of ments in public health infrastructure millimeter (range, 6 to 12,745), with 72% lot 06292012@26 injected 46-60 days from the state and federal levels were granulocytes (range, 0 to 94); the median and >60 days after production, in 40-mg critical for an effective response. protein level was 121.5 mg per deciliter increments (aOR: 1.40; 95% CI: 1.18, (range, 29 to 893); and the glucose concen- 1.65; aOR: 1.85; 95% CI: 1.55, 2.21,

91 SECTION V. ENVIRONMENTAL HEALTH Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Partnership to Promote Localized Efforts to Reduce Environmental Exposure Programmatic Overview Agreement Program, EEP prepares ATSDR provides funding and tech- Tennessee Department of Health Public Health Assessments (PHAs), nical assistance to identify and evalu- (TDH) Environmental Epidemiology Health Consultations (HCs), and ate environmental health threats to Program ( EEP) is an active participant Technical Assists (TAs). PHAs, HCs, communities. These resources enable in Agency for Toxic Substances and and TAs provide a response to an envi- state health departments and other Disease Registry (ATSDR’s) Partner- ronmental public health question. grantees to further investigate environ- ship to Promote Localized Efforts to These reports provide a viewpoint on a mental health concerns and to educate Reduce Environmental Exposure public health issue related to human communities. From 2010 to 2012, (APPLETREE) Program. Based on exposure to a hazardous substance. If TDH EEP released 23 reports (Table). environmental data, EEP performs a health hazard is identified, EEP Our public health assessments, consul- public health assessments, health con- makes specific recommendations to tations, fact sheets, and other reports sultations, exposure investigations, eliminate the hazard. Examples of are available on the TDH Website at community involvement activities, and public health actions may be providing http://health.tn.gov/environmental. technical assistance. These reports emergency water supply, restricting site Tennessee is consistently listed as one present conclusions, make recommen- access, or taking other necessary of the top users and generators of haz- dations, and plan corrective actions. measures to stop the exposure. To- ardous materials in the United States. gether, EEP and ATSDR use the best In 2012, Tennessee had 16 active sites Activities science, take responsive public health on the federal National Priorities List actions, and provide trusted health (NPL) of Superfund sites. The NPL Site-Specific Investigations and Re- information to prevent exposure and consists of the hazardous waste sites in sponse disease related to toxic substances. most need of cleanup. When a site is As a partner in ATSDR’s Cooperative proposed for the NPL, federal rules

Table. Completed Environmental Public Health Reports, Tennessee, 2010-2012. Name of Site City and County Name of Site City and County of Site of Site Former 36th Street Chattanooga, Hamilton Tiger Cleaners Memphis, Shelby Landfill Davis Mill Creek Copperhill, Polk Lawson’s Cleaners Memphis, Shelby Ponds, Copper Basin TVA Kingston Fossil Harriman, Roane Kraus Model Memphis, Shelby Plant Coal Ash Spill Cleaners ISS Oxford Site Memphis, Shelby Pyramid Site Memphis, Shelby Restaurant Vapor Memphis, Shelby Rental Uniform Kingsport, Sullivan Intrusion Investigation Company Egyptian Lacquer Franklin, Williamson Park Place Cleaners Memphis, Shelby Manufacturing Company Vapor Intrusion Investigation Security Signals Oakland, Fayette Bruce Spring Dickson, Dickson IGI Adhesives Vapor Nashville, Davidson Tokheim Update Jasper, Marion Intrusion Investigation Quad Industries Bradford, Gibson Wright Medical Arlington, Shelby Technology Johnson Controls Lexington, Henderson 9053 Middlebrook Knoxville, Knox Vapor Intrusion Pike Investigation Smokey Mountain Knoxville, Knox Goodrich Landing Tullahoma, Coffee Smelters Gear Tokheim Site Jasper, Marion

93 Communicable and Environmental Diseases and Emergency Preparedness Annual Report mandate an assessment of health. The U.S. EPA proposed the Clinch mining wastes at Copper Basin. River Corporation (CRC) Site on Sep- New National Priorities List Super- tember 14, 2012. From 1929 to 2002, In December 2008, over a billion gal- fund Sites a pulp and paper mill operated on the lons of coal ash spilled at the TVA On September 22, 2010, the Smokey CRC Site in Roane County. By- Kingston Fossil Plant in Roane Coun- Mountain Smelters Site in Knox products of the pulp and paper mill ty. Our previous Annual Report de- County was added to the federal NPL manufacturing process included black tailed the spill and the resultant public of Superfund sites. Smelting opera- liquor (spent processing waste) and health response. In 2010, following a tions took place from 1922 until 1944. coal tar constituents. Black liquor can public comment period, EEP and The site had a history of uncontrolled be composed of phenols, sodium hy- ATSDR published the final PHA Ten- hazardous waste management. Soil, droxide, sodium oxide, and sulfur as nessee Valley Authority (TVA) Kingston groundwater, and surface water were well as metals, such as calcium and Fossil Plant Coal Ash Release. The final impacted by contamination including magnesium. Coal tar consists of poly- report has been of great interest as the metal slag, aluminum dross, and am- nuclear aromatic hydrocarbons, phe- safety of other coal ash impoundments monia. Additional construction, dem- nols, and heterocyclic oxygen, sulfur, and the hazard disposal classification olition, trash, and potentially hazard- and nitrogen compounds. Surface of coal ash were both under review by ous materials were dug up during site operations. The U.S. Environmental Protection Agency (EPA) did a full- scale cleanup of the site.

The Alamo Contaminated Groundwa- ter Site became an NPL site in Septem- ber 2011. In 1988, volatile organic compounds (VOCs) were discovered in the groundwater used for the Town of Alamo’s public water supply in Crockett County. An air stripping system has been used to purify the drinking water for consumer use. So far the air stripper has been able to remove the VOCs. The site consists of a VOC-contaminated groundwater plume that extends approximately ⅓- mile northeast to southwest in the area of the Alamo municipal well field. The Alamo water department estimates 300,000 gallons of water is A polluted leachate pond with leftover salt cake and barrels stain the Smokey pumped from their four municipal Mountain Smelters Site in Knoxville, Knox County. groundwater wells per day. Various studies have found multiple possible water, groundwater, soil, sediment, the U.S. EPA. sources of VOCs in the vicinity of the and fish have been impacted by con- plume. Due to the likelihood that the tamination from this site. When this There are hundreds of other hazard- pollution is the result of multiple re- Annual Report was written, our envi- ous waste sites in Tennessee. Most leases, the groundwater contamination ronmental public health investigation sites are cleaned up and overseen by cannot be attributed to any particular of the CRC Site was just beginning. Tennessee Department of Environ- source. During our investigation, EEP ment and Conservation (TDEC) Divi- met with local government officials. In addition to these new NPL sites, sion of Remediation or Division EEP anticipates the completed PHA EEP worked on older, active NPL sites (DoR) or the Division of Solid and will be published in 2013. investigating carbon tetrachloride at Hazardous Waste Management the Hardeman County Landfill and (DSWM).

94 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

There were several important advance- ments in health risk assessment from 2010 to 2012. Vapor intrusion continues to be discussed and re- searched. Vapor intrusion is the migration of volatile chemicals from contaminated groundwater or soil into an overlying building. At the IGI Adhe- sives Site in Nashville, Davidson County, chemicals from a former manufacturing plant leaked into the ground. TDEC wanted to know if homes or businesses in the area were affected by vapor intrusion. EEP and TDEC measured levels of chemicals in the indoor air in 3 homes and 2 businesses. Levels of site-related chemicals in the indoor air at all locations were within accepted health risk limits. EEP informed the residents and business owners of the results. EEP A pit full of dirty water creates a physical hazard at the Clinch River Corpora- and TDEC also sampled indoor air in tion Site in Harriman, Roane County. homes near the ELMCO Site in Franklin, Williamson County. The dential yards. EEP assisted with data es in the vicinity of daycare facilities. chemicals, benzene, acetone, and tolu- evaluation and health education in the EEP communicated the results of our ene, were found seeping into a nearby neighborhood. The joint efforts of evaluations to individual homeowners creek. Several homes were situated EEP, TDEC, and EPA improved the and daycare operators through individ- between the creek and the ELMCO health of the community through edu- ual meetings and correspondence. plant. Indoor air was sampled in 3 cation and remediation of the lead Community meetings were held in homes. Results of the sampling hazard in the soils of their neighbor- Chattanooga to report results for three showed levels of these chemicals in hood. separate sites relating to redevelop- indoor air were within accepted health ment of two former school sites, clo- risk limits. Impact sure and remediation of a former From 2010 to 2012, the EEP worked chemical company site, and for a New research suggested the heavy met- on 35 environmental sites as part of its neighborhood having elevated lead in al lead could have harmful effects on a APPLETREE Cooperative Agreement. lawn soils. The meetings informed the developing child at levels lower than As a result, many HCs, TAs, and a communities of findings and provided previously thought. The CDC low- PHA were prepared that evaluated the a forum for citizen’s questions to be ered their childhood blood lead potential for exposure to site-related answered. EEP educates individuals screening guidance from 10 μg/dL to chemicals in the soil, groundwater, and community members on chemical 5 μg/dL. In a south Chattanooga surface water, or air. Much of our site- exposure and environmental impacts neighborhood, high levels of lead con- specific work involved evaluating fu- through these interactions. tamination were discovered in residen- ture exposure to those that would oc- tial soils. Although the source of the cupy commercial buildings that were lead was unknown, TDEC speculated to be re-purposed as new businesses. it may have come from foundry sand EEP evaluated potential exposures in or bag house dust from Chattanooga’s single family homes near manufactur- industrial past. TDEC screened many ing plants that had some type of his- yards to determine the extent of the toric chemical release to the soil, lead contamination. The EPA re- groundwater, or air. Further work moved contaminated soil from 68 resi- included evaluation of chemical releas-

95 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Healthy Places

Programmatic Overview Environmental Epidemiology Program (EEP) promotes Healthy Homes. A healthy home reassures health and wellness by preventing illness and injury. Through our Healthy Homes Web- site, EEP addresses issues like mold, radon, lead, carbon monoxide, mercu- ry, pesticides, and unintentional injuries.

Activities

Healthy Homes Environmental hazards in the home harm millions of people each year. A ries occur in the home. Falls are the Nashville. Then in February 2011 in healthy home can prevent illness and most frequent cause of residential inju- East Tennessee, flash flood over- injuries. A healthy home is designed, ries to children, followed by injuries whelmed parts of Knoxville. The rains built, and maintained to support from objects in the home, burns and of April and May 2011 along the Mis- health. Centers for Disease Control poisonings. sissippi River were among the largest and Prevention (CDC’s) Healthy and most damaging recorded in the Homes Program is a coordinated, com- Contaminant-Free: Chemical exposures past century. Officials ordered over prehensive, and holistic approach to include lead, radon, carbon monoxide, 1,300 homes to be evacuated near preventing diseases and injuries that pesticides, asbestos and environmental Memphis. Heavy rainfall and flooding result from housing-related hazards tobacco smoke. Exposures are often can ruin a home, increase the risk of and deficiencies. Following these sev- higher indoors than outdoors. waterborne disease, lead to groundwa- en Healthy Homes principles will pro- ter contamination, cause a septic sys- mote good health and wellness. Ventilated: Studies have shown that tem to fail, create massive trash piles, increasing the fresh air in a home im- wreck farms and livestock, result in Keep your home: proves respiratory health. hazardous materials release, or destroy infrastructure.For residents and busi- Dry: Damp houses provide a good en- Maintained: Poorly-maintained homes nesses, quickly cleaning up and drying vironment for mites, roaches, rodents, are at risk for moisture and pest prob- out after a flood is important to main- and molds. lems. Deteriorated lead-based paint in tain good health. Tennessee Depart- homes built before 1978 is the primary ment of Health (TDH) distributed Clean: Clean homes help reduce pest cause of lead poisoning in children. factsheets about Reentering Your Flooded infestations and exposure to contami- Home, Make Water Safe, Protect Yourself nants. Flooding from Mold, and Drink Safe Water to Many parts of Tennessee experienced help residents get back into their Pest-Free: Studies have shown exposure flooding. In May 2010, flash flooding homes safely. Some county health to mice and cockroaches can increase displaced thousands of residents. In departments had to close due to infra- asthma attacks in children. Improper some counties, flooding reached a structure damage. Boil water advisries pesticide treatments for pest infesta- 1,000-year flood event as recorded by were announced for many communi- tions can worsen health problems, the National Weather Service. In ties. since pesticide residues in homes can West Tennessee, a levee on the Wolf pose health risks. River broke flooding Millington. In Our Environmental Health Specialists Middle Tennessee, the Cumberland Network (EHS-Net) and CDC’s Na- Safe: The majority of children’s inju- River overflowed its banks spilling into tional Center for Environmental

96 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Health (NCEH) compared contaminants in flood water to contaminants in river water and domestic well water. All ten surface water samples collected after the flood were positive for fecal coliforms, E. coli, enterococcus, and Salmonella. Some of the samples were positive for Cryptosporidium, Campylo- bacter, and adenovirus. In general, water sampling done a month later at the same locations showed much less or no contamination. After the heavy rainfall, some groundwater wells tested positive for fecal coliforms, Salmonella, and Campylobacter. Residents were ad- vised to stop using their well or to shock-disinfect their well.

As residents and businesses cleaned Ellen Yard, PhD, tests for contaminants in flood water near downtown up, tons of trash was produced. It was Nashville, Davidson County. difficult for maintenance crews to keep up with the garbage, water-logged ronmental Protection Agency (EPA) weather, Environmental Public Health debris, white goods, and household assessed oil and hazardous material has a vital role in ensuring health and hazardous materials being discarded. releases. EPA performed recon and safety is reestablished after severe A dead animal disposal advisory was pickup of flood-related hazmat materi- weather. shared with farmers. The U.S. Envi- als. While we cannot control the National Toxic Substance Incidents Program (NTSIP)

Programmatic Overview EEP is planning to correlate environ- chemical suicides in automobiles and Tennessee Department of Health mental exposures to hazardous sub- from industrial chemical releases to (TDH) Environmental Epidemiology stances with adverse health effects in transportation accidents. Such events Program (EEP) performs acute chemi- populations as a part of Centers For frequently require public health pro- cal exposure surveillance through the Disease Control and Prevention tective actions such as evacuations, in- National Toxic Substance Incidents (CDC’s) Environmental Public Health place sheltering, or decontaminations. Program (NTSIP). Tennessee was one Tracking (EPHT) Network. Ultimate- of only seven states to be awarded a ly, Environmental Public Health Tennessee was one of only seven states cooperative agreement with Agency for Tracking will be able to provide cur- to be awarded a grant from ATSDR Toxic Substances and Disease Registry rent, relevant, and accurate infor- for the National Toxic Substance Inci- (ATSDR) for NTSIP. Program staff mation about environmental expo- dents Program. NTSIP collects and collect information on harmful materi- sures and health outcomes. combines information from many re- als also known as toxic substances. sources to protect people from harm These materials include chemicals, Activities caused by spills and leaks of toxic sub- radiation, and naturally-occurring mat- National Toxic Substance Incidents stances. Data is gathered through our ter that could cause harm to people or Program partnerships with the National Re- the environment. The information is Approximately 2,400 out of 15,000 sponse Center (NRC), Tennessee uploaded into the NTSIP database annual toxic substance incidents in Emergency Management Agency within 48 hours of an incident. the United States result in death, ill- (TEMA), and Department of Trans- NTSIP staff create educational materi- ness, or injury. Acute toxic incidents portation (DOT) as well as from news als about hazards commonly recorded may range from illicit methampheta- media reports. NTSIP surveillance in their database. mine lab explosions in homes to data is used to prepare prevention

97 Communicable and Environmental Diseases and Emergency Preparedness Annual Report messages to protect the general public from chemical exposure.

From 2010 to 2012, NTSIP reported 1,095 acute toxic substance incidents eligible for surveillance with 281 vic- tims and 29 fatalities. NTSIP tracks methamphetamine incidents that result in acute chemical exposure to any- one or in injury to a first responder. NTSIP has prepared web-based fact sheets on chemicals commonly show- ing up in surveillance data. Infor- mation about carbon monoxide, pesticides, ammonia, sodium hydroxide, and natural gas safety are available at http://health.state.tn.us/ environmental/NTSIP.htm.

Impact TDH NTSIP has developed excellent A tanker leaking nitrogen creates a potentially hazardous situation in Johnson working relationships with TEMA, City, Washington County. NRC, TN Meth Task Force, and local health agencies. Program staff investigated incidents and alerted others about the incidents on a regular basis. Based on surveillance data, success stories and fact sheets were prepared. A Community Assessment for Public Health Emergency Response (CASPER) questionnaire was also developed. It included specific survey questions about carbon monoxide awareness and preparedness. The CASPER questionnaire was used during a training exercise as staff went door-to-door asking questions and sharing a carbon monoxide factsheet. NTSIP staff directly engaged the general public by answering their carbon monoxide poisoning questions.

The U.S. Environmental Protection Agency cleaned up 68 yards contaminated with lead in Chattanooga, Hamilton County.

Environmental Health Specialist Network (EHS Net): Food Safety

Programmatic Overview local agencies to develop a better un- is to help reduce the incidence of Tennessee’s EHS-Net staff works in derstanding of the environmental foodborne illness through our partici- collaboration with federal, state, and causes to foodborne illness. Our goal pation in local and national research,

98 Communicable and Environmental Diseases and Emergency Preparedness Annual Report focused in key areas of food safety and outbreak prevention. Outcomes of our work provide generalizable knowledge that facilitates a better understanding of foodborne diseases, their causes and exposure routes, and illness prevention through education. In addition, our research provides supportive data for longstanding, effective policy development and/or change in public and private communities of food safety.

Activities Tennessee Projects:  Grocery Store Survey (Risk Analy- sis)  Outbreak Investigation Training  Evaluation of Self-Analysis for Danny Ripley, Environmental Health Specialist, Metro Public Health Depart- Food Excellence (SAFE) program ment, Nashville, Tennessee, teaching a basic food handlers class.  Foodborne Illness Compliant Form Public Health Service organized a food flow and contributing factors  Analysis of Statewide Restaurant risk assessment exercise targeting to promote use of the EHS-Net Data grocery stores within Nashville/ Outbreak Study investigation tool Davidson County, Tennessee. In by environmentalists statewide. Multisite Projects: 2012, additional steps were taken  The EHS-Net specialist working in  Leafy Green Handling Study to conduct analysis between store the Davidson County catchment  Ill Food Handler Study characteristics and risk to find any area has been involved since 2003  Cooling Study association. A final report of the in developing and administering a initial work was produced, and a remedial food safety training pro- Impact manuscript that includes all work gram for poorly performing restau- The following are examples of project is in progress. rants (that score <70 on inspec- accomplishments and impacts that  Environmental specialists in Ten- tions), their management, and have been made: nessee gained valuable experience staff. During this time 388 restau- by participating in the EHS-Net rants and 686 foodworkers have  In June 2010, data was collected Outbreak Study and Epi-Ready participated in Self-Analysis for for the Grocery Store Survey in Training. An EHS-Net specialist, Food Excellence training, which the Nashville area. The goal was the state’s foodborne outbreak includes classroom review and to create a grocery store database coordinator, and the assistant di- onsite evaluation of each restau- to describe the retail grocery and rector of Tennessee’s State Public rant’s facilities. During 2010, it market sector in Nashville with Health Laboratory participated in included 46 establishments and the purpose of facilitating in- an Epi-Ready Train-the-Trainer 77 individuals. Training was con- formed discussion locally and course. This environmentalist- ducted in the field at these poor- among EHS-Net partners regard- epidemiologist team planned and performing restaurants; the focus ing future studies and interven- facilitated 4 regional outbreak was on critical violations, risk fac- tions within grocery store environ- training exercises throughout the tor violations (3, 12, and 20), and ments. The objectives were to as- state in 2010. More than 215 En- monitoring logs and procedures sess and categorize risk by estab- vironmental and Epi staff were (no score was given). The EHS-Net lishing a risk assessment protocol trained. Additional outbreak train- specialist also held classroom for grocery stores and markets. ing was conducted in 2011, which training on basic food safety with EHS-Net in collaboration with the emphasized the evaluation of emphasis on temperature control,

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hygienic practices, cleaning and best-practices, CIFOR guidelines, strategies. sanitizing, and monitoring proce- and past EHS-Net projects are be-  EHS-Net staff designed the survey, dures. While participating restau- ing implemented. The form may pilot tested, and data is currently rants consistently demonstrated be viewed at the CDC website: being collected in 50 establish- marked improvement in the regu- http://www.cdc.gov/nceh/ehs/ ments for the Cooling study, larly scheduled follow-up inspec- EHSNet/resources/index.htm. which is aimed to better under- tion, evaluation of long-term per-  Tennessee EHS-Net staff has con- stand potentially hazardous food formance is lacking. Violations tributed substantially to the design cooling procedures among restau- associated with risk factors for of three multistate and five local rants within the EHS-Net capture foodborne illness reduced 62%, studies, have contributed partici- areas. critical violations reduced 85%, pant interviews in all EHS-Net  In October 2011, Tennessee’s and a total of 694 establishments multistate studies, frequently ex- EHS-Net staff collaborated with have been trained thru 2003-2010. ceeding the required sample size CDC, FDA, and eight other local Such analysis will help us describe by 100%, and have led results health departments in an effort to the importance of EHS-Net and through ≥20 publications and ≥13 better understand the contributing the effectiveness of government scientific presentations by EHS- factors that lead to foodborne ill- food safety programs. Net staff. This EHS-Net teamwork ness, by examining the relation-  An EHS-Net multi-state project has contributed to the effective- ship between kitchen managers’ resulted in the development of a ness and stability of EHS-Net as a knowledge and attitudes, and their Foodborne Illness Complaint meaningful national project and food safety practices through the Form available for use by public has encouraged discussion and “Kitchen Managers Certification health agencies that receive com- awareness of EHS-Net in the pub- Study”. Within our catchment plaints from residents/consumers lic health community. areas, 50 restaurants were visited regarding possible foodborne ill-  Leadership was provided by Ten- for the study to compare food safe- nesses. This complaint form will nessee to the data analysis ty knowledge levels and attitudes be used to evaluate trends of dif- workgroup in the Leafy Green of certified kitchen manager/ ferent complaints, achieve evalua- Handling study and Ill Food Han- person in charge (KM/PIC) and tion and follow-up, and transfer of dler study. An abstract of the Ill non-certified KM/PIC, and food- information between environmen- Food Handler study submitted by borne illness outbreak risk factors. tal and epidemiologist staff. Ten- Tennessee was presented at the Data has suggested that food safety nessee is installing a new infor- 2010 USDA Food Safety Educa- certification is related to food safe- mation system to be used by envi- tion Conference. The finding of ty knowledge, and receiving certifi- ronmentalists statewide. Tennes- this study would encourage work- cation from an accredited organi- see was selected as an awardee for ers to stay at home when ill and zation is important. Additional a 2010-2015 EHS-Net Food prac- could help public health agencies analysis is ongoing for this study. tice grant. Interventions based on create more focused intervention Environmental Health Specialist Network (EHS Net): Water

Programmatic Overview departments and among other agen- and outbreaks, and by working on lo- The Tennessee Department of Health cies such as the Tennessee Department cal and national levels to understand (TDH) has been a participant in the of Environment and Conservation how environmental factors allow these Environmental Health Specialist Net- (TDEC) and the Tennessee Depart- outbreaks to occur. work (EHS-Net) Water since its incep- ment of Agriculture. Additionally, we tion in 2005. Our involvement in are concerned with preventing water- Activities EHS-Net Water has increased our ca- borne outbreaks by promoting healthy pacity to conduct waterborne outbreak swimming and swimming pool mainte- Tennessee Projects: response, increased our understanding nance practices, by working with water  Purchased field and laboratory of antecedents to water related illness- regulatory agencies to promote safe equipment for water sampling and es, and improved communication drinking water supplies, by fully inves- analysis within the state and regional health tigating potential waterborne illnesses  Conducted waterborne disease

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outbreak training at 5 sites  Evaluated public water system complaint logs under the Public Health Surveillance System Frame- work  Hosted 2 U.S. Public Health Ser- vice Applied Public Health Team (APHT) Training events in 3 counties  Conducted a computer assisted telephone drinking water survey  Completing a multiyear study to understand the geographic disproportionality of cryptosporidiosis in Northeast Tennessee  Building a Geographic Infor- mation System (GIS) of public water distribution systems and private water well locations

Multisite Projects: U.S. Public Health Service, Applied Public Health Team interviewing a water  Conducted a review of 35 years of well owner. waterborne outbreak reporting  Created an integrated food and used to evaluate radon levels from tection of waterborne illness and waterborne illness complaint form groundwater samples provided by drinking water contamination public water systems in support of under the guidelines of the Public Impact a study the TDEC Division of Wa- Health Surveillance System Frame-  Prior to our involvement with ter Resources is currently conduct- work. The results of this evalua- EHS-Net Water, species of Cryptos- ing and may be useful for private tion reveal that the complaint log poridium causing illness were not well samples in the future. system does not allow use of this being identified. With the equip-  During 2011, waterborne out- information as a standalone sur- ment made possible through EHS- break training was conducted in 5 veillance tool. However, with ad- Net, TDH Laboratory Services sites and included state and re- justment, the complaints could be now has capacity to identify Cryp- gional environmental staff from useful as an early indicator of fac- tosporidium from stool and envi- the TDH and TDEC, and epide- tors leading to possible water- ronmental samples and conduct miologic and laboratory staff from borne disease. A written summary polymerase chain reaction (PCR) TDH. The purpose of these work- of the project was completed and analysis to determine species. In shops was to elaborate on ways shared with the TDEC including addition, with EHS-Net funds, we that the TDEC and TDH could recommendations to improve have purchased equipment to col- collaborate during waterborne complaint log usefulness in this lect, filter, and analyze water sam- outbreaks. Having local and re- regard. ples. In 2011, we purchased a gional staff at the workshops, and  During 2010 and 2011, APHTs hand held water quality meter, hosting them at local venues, gave conducted over 1,200 door to peristaltic pump, photoionization everyone involved the opportunity door surveys to help delineate the detector and other supplies to col- to meet and better understand sources of drinking water used by lect water samples in the field. For their roles. households. Geolocated were the Nashville laboratory, a new  During 2010, public water system 400+ wells and maps of public liquid scintillation counter was complaint logs from 32 public water distribution systems. purchased to detect radiologic water systems in middle Tennessee  During 2010, a computer assisted contaminants from water samples. were reviewed as a public health telephone drinking water survey The scintillation counter is being surveillance tool for the early de- entitled Knowledge, Attitudes, and

101 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

sented at the March 2013 Tennes- see Environmental Conference.  Building a GIS of public water distribution systems and private water well locations involves combining disparate sources of drinking water data into one geographic information system. Community water systems in the middle Ten- nessee area have been contacted by phone and e-mail to obtain digital or paper maps of public water distribution systems. Private water well data are being obtained from the TDEC water well database and mapped in the GIS. Having these data in a central location will provide additional re- Sampling water from Bee Spring for Cryptosporidium. sources to investigate illness related to contaminated drinking wa- Behaviors Regarding the Water We nessee. Supplemental case forms ter and provide a means to priori- Consume was administered to were developed, laboratory equip- tize outreach to private well users. 2,000 Tennessee residents. Ques- ment was purchased and stool  During 2010, Tennessee led the tions covered 4 broad categories: samples from case patients were EHS-Net workgroup calls to com- 1) drinking water sources; 2) home collected in support of this study. plete an integrated food and wa- water treatment; 3) water safety A geographic information system terborne illness complaint form. concerns; and 4) demographics. of cases in the northeast region This form provides an instrument Results from this survey demon- was created to analyze ecologic for standardizing an initial inter- strate that the majority of Tennes- and environmental data based on view with a person believed to see residents (90%) consume wa- proximity of case patient address have a food or waterborne illness. ter from public water systems with- to each other and to potential en- The form was shared with EHS- out further treatment, dispelling vironmental reservoirs. Leveraging Net sites and the TDEC during the thought that bottled water is results from a FoodNet laboratory 2011. the most popular drinking water survey with the enhanced cryptos-  As a multisite project, we conduct- of choice. Additionally, these sur- poridiosis surveillance data indi- ed a review of 34 years of water- vey results indicate that individu- cated that the reported number of borne outbreak reporting during als using private well or spring cases doubled after laboratories which we identified 30 waterborne water are unlikely to treat their switched to rapid card assays. Pre- disease outbreaks, 17 of which water prior to drinking and be- liminary results of this investiga- were previously unreported to lieve it safe to drink. These results tion indicate that beef cattle densi- CDC. The results of this retro- may be beneficial in targeting pub- ty and animal contact are generally spective study have been compiled lic health messaging in the future. greater in the northeast region of and are being incorporated into a  In 2010, we began a multiyear Tennessee. Preliminary findings manuscript by our EHS-Net Water study to investigate the geographic were disseminated during a De- partners in Minnesota. disproportionality of cryptosporid- cember 2012 NORS WASH iosis reporting in Northeast Ten- Webinar Series and will be pre-

102 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

103 SECTION VI. PUBLIC HEALTH EMERGENCY PREPAREDNESS PROGRAM Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Emergency Preparedness (EP)

Programmatic Overview The mission of EP is “to prepare for, respond to and recover from health emergencies affecting the State of Tennessee”. Our vision is “to be the top accredited public health preparedness program in the nation.” EP mission critical activities are supported by an annual budget of ~$18M and ~110 staff statewide who pursue core values of Innovation, Re- sponsiveness, Excellence and Integrity.

Activities Mission critical activities include:  planning, exercising, and responding to all-hazard events in coordination with local, state, and federal partners;  maintaining capacity for rapid, mass distribution of medicine and medical supplies;  increasing hospital preparedness, response and surge capacity; The State Health Operations Center (SHOC) was activated to coordinate the  providing emergency health infor- public health response to Tennesseans at risk of life-threatening fungal infec- mation quickly and effectively to tions following contaminated steroid injection. Standing at the front are all Tennesseans; Commissioner John Dreyzehner and Governor Bill Haslam.  coordinating Medical Reserve Corps (MRC) volunteer units; macy was identified. On October pensing of medical countermeas-  building epidemiologic surveil- 5, the State Health Operations ures to the public. From 2010 lance and investigation capacity; Center (SHOC) was activated to through 2012 the local and state  supporting a comprehensive exer- support active surveillance, case scores have continued to improve cise program to test emergency investigation and provide at-risk demonstrating maturity of local response capacity; communication and monitoring planning and operational readi-  developing risk communication for ~1,100 Tennessee residents ness. Statewide averages have im- and dissemination strategies; who received contaminated MPA. proved from a score of 85 in 2010  improving fiscal and administra- The SHOC was operational for to 90 in 2012. tive readiness; and more than three months to pro-  Tennessee Department of Health vide state-wide coordination of (TDH) can monitor medical mate- Impact approximately 170 practitioners riel levels through the use of the The following are examples of pro- participating in this historical pub- Tennessee Countermeasure Re- gram accomplishments and impacts on lic health response. sponse Network (TNCRN). The public health readiness:  Statewide infrastructure was system has an inventory manage- strengthened and readiness im- ment module for tracking and  Late in September 2012, a cluster proved through procurement of managing inventory of disaster of life-threatening infections fol- three Mobile Emergency Opera- resources. This includes personal lowing epidural injection of tions Centers and upgrades to Re- protective equipment, antiviral methylprednisolone acetate (MPA) gional Health Operations Centers. medications, other pharmaceuti- from a single compounding phar-  Technical Assistance Reviews are a cals, and medical material from a measure of local readiness for dis- variety of sources. Full deploy-

105 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

ment of the TNCRN Inventory cises, outbreaks, natural disasters, essary maps and assessment tools Management system to Knox staff assembly, and response tests. ready for quick team deployment, County Health Department has  In 2010, EP increased its multi- and trained more than 200 profes- occurred. It includes 21 depart- sionals to conduct post-disaster state alerting capability by achiev- ments and over 90 daily users. needs assessments.  In 2011 and 2012, EP partnered ing Public Health Information  In October 2011, EP teamed with with the U.S. Marshals Service to Network Certification for Cascade local, state and federal partners to provide convoy Security Training alerting and conducted tests with rapidly investigate potential Stron- for local law enforcement person- both State and CDC partners. In tium overexposure among Tennes- nel. This unique training 2012, TNHAN moved to a virtual- see residents who previously re- strengthened partnerships and based platform which greatly en- ceived Cardiogen-82 Positron increased understanding of the Emission Tomography. Infor- hanced network security and sta- procedures used during a public mation gained helped determine health emergency requiring de- bility. During 2010–2012, EP that improper usage of the Cardio- ployment of the Strategic National worked with first responder agen- Gen-82 generator contributed to Stockpile. cies to improve redundant excess radiation in patients from  An EP evaluation team participat- 800MHz radio communications. two states, rather than a generator ed in Flulapalooza held at Vander- This successfully provided the 13 defect affecting patients nation- bilt University Medical Center in public health regions direct con- wide. The investigation team ac- 2012. Flulapalooza was designed complished the unprecedented tact to the Tennessee Emergency to test the Medical Center’s emer- task of rapid radiation screening gency mass vaccination plan and Management Agency, State Emer- on a large number of TN resi- was awarded the Guinness World gency Operations Center in Nash- dents. Experience gained en- Record for the most vaccinations ville. hanced our ability to respond to given in eight hours. Free flu vac-  In May 2010, EP hired a dedicated future radiologic events. cines were given to 12,850 Univer- coordinator for the Emergency  Training and planning are critical sity and Medical Center faculty, Services for the Advance Registra- elements of the EP program. The staff, volunteers and students dur- tion of Volunteer Health Profes- TNCAT exercise series, estab- ing the daylong event. Nurses, 44 sionals (ESAR-VHP). In late lished in 2007, is an ongoing local at a time from a labor pool of 138, 2011, ESAR-VHP was integrated and state government collabora- worked simultaneously at individ- with MRC to support public tive effort of planning, exercise ual stations in the Flulapalooza health initiatives in health, safety, and training. The TNCAT2k12 tent with a separate group of vol- and resiliency of local communi- Full Scale Exercise was implement- unteers maintaining patient flow ties within Tennessee. MRC had a ed to evaluate the Middle Tennes- and logistics. face lift in 2012—the volunteer see Region’s Communications,  EP continually works to improve web page was redesigned (http:// Emergency Operations Center and expand stakeholder infor- health.state.tn.us/volunteer/ Management, Hospital Surge, Tri- mation sharing and rapid alerting. index.shtml), outreach materials age and Treatment, and Logistics Operations capabilities. The full In 2010, the Tennessee Health such as posters and information cards developed and distributed, scale exercise involved numerous Alert Network (TNHAN) was used and a system upgrade initialized. and diverse agencies including to generate 373 alerts at the state,  The Rapid Assessment of Popula- seven local emergency manage- regional and local levels. In 2011, tions Impacted by Disasters ment agencies, 11 hospitals, and the number of alerts increased to (RAPID) Team was formed to im- five state agencies. 400 and in 2012 they totaled 584 prove state disaster surveillance  EP collaborated with the Universi- alerts. This increasing trend capabilities and build a cache of ty of North Carolina’s CDC- sponsored Preparedness and demonstrates success towards im- disaster surveillance tools. The team conducted four full-scale Emergency Response Learning proving communications among exercises in Knox, Cheatham and Center to develop the Tennessee stakeholders. Alerts involved mul- Davidson Counties , created a Disaster Support Network (TDSN) ti-agency and multi-regional exer- RAPID Toolkit with all of the nec- (http://health.state.tn.us/Ceds/

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TNDisSup/index.htm) designed  During 2010–2012, EP enhanced Disaster Medical System (NDMS) to assist Tennessee communities administrative preparedness and and Memphis Emergency Manag- in meeting their needs before, dur- improved efficiency by providing ers. EP demonstrated the ability ing, and after a disaster. While technical assistance to Regional to track patient status and location TDH is working to ensure that all Health Departments for effective in real time, using common data Tennessee residents and visitors management of their respective exchange specifications and across are prepared to respond to a wide budgets, resulting in an 80% re- multiple jurisdictions. Patient range of emergencies, individuals duction of unspent regional funds data was successfully transmitted with functional needs may be dis- and implementing electronic in- throughout the continuum of care proportionately affected by a disas- voices to reduce reimbursement from the originating state, through ter. To close this gap, the TDSN times and cut administrative costs patient reception areas to Mem- website was designed to connect in half. phis NDMS hospitals using four populations that have unique  In 2012, the TNCRN patient disparate information technology needs with the agencies that serve management module was tested in systems, including TNCRN. them. collaboration with the National

107 SECTION VII. SURVEILLANCE SYSTEMS AND INFORMATICS PROGRAM Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Surveillance Systems and Informatics Program

Programmatic Overview reporting (ELR), implementation of The Surveillance Systems and Infor- decision support functionality, and matics Program (SSIP) supports inte- STD surveillance system integration. grated disease surveillance activities for SSIP also works closely with the both reportable and non-reportable CDC’s NBS User Group, or NUG, conditions and events across programs consisting of 19 jurisdictions which in the Communicable and Environ- utilize the NBS for integrated disease mental Diseases & Emergency Prepar- surveillance, to document system and edness (CEDEP) section of the Ten- integration requirements, oversee ap- nessee Department of Health (TDH). plication development governance, SSIP was formed in 2011, and pro- perform application testing, and dis- motes interoperability by facilitating cuss and support integrated disease the accurate and timely receipt and surveillance and electronic reporting transfer of public health information practices across the NBS jurisdictions. to surveillance systems via accepted standards and vocabulary while main- Informatics Support to CEDEP taining data security. Currently com- SSIP provides support to program are- prised of epidemiologists and an ad- as for other surveillance systems, in- ministrative assistant, SSIP works SSIP brought in the New Year and cluding PRISM for STD surveillance closely with information technology recognized the Systematized Nomen- and case management, eHARS for partners, including surveillance system clature of Medicine with SNOMED HIV/AIDS surveillance, and works and EDI (Electronic Data Interchange) the Snowman. closely with other informatics inten- administrators and the Health Systems sive projects such as Immunization Architect. This collaboration allows Electronic Disease Surveillance System Registry messaging, public health lab TDH to provide public health investi- (NEDSS) Base System (NBS), supplied report messaging, and syndromic sur- gators with the information needed for by the Centers for Disease Control veillance messaging. SSIP staff also surveillance of ongoing and emerging and Prevention (CDC). It allows inves- work with program areas to analyze public health threats through investi- tigators to look at a patient (not a dis- and document public health business gations and public health interven- ease) across time and condition or processes. The program provides HL7 tions. SSIP recognizes successful in- CEDEP program area. Currently this education and resources to other pub- teroperability in TN as involving three system is used for surveillance of gen- lic health staff to support CEDEP ac- primary aspects of effective communi- eral communicable diseases, including tivities. SSIP team members also cation across information systems and but not limited to tuberculosis, Food- work with internal and external part- business uses: semantic understanding Net activities, arboviral diseases in sup- ners toward implementation of stand- (vocabulary), syntactic agreement port of ArboNet, carbon monoxide ards-based messaging, including: elec- (communication structure), and busi- poisoning, as well as non-reportable tronic laboratory reporting, immuniza- ness process understanding and work- conditions such as latent tuberculosis tion registry queries, responses and flow integration. infection. SSIP provides NBS support updates, case notifications to CDC for to both CEDEP program area staff nationally notifiable diseases, and elec- Activities and field staff throughout TN. SSIP tronic data interchange and interoper- aids in data management, builds data ability with other health department Integrated Disease Surveillance System extracts, builds condition-specific NBS systems, including blood lead surveil- SSIP is responsible for the implemen- investigation pages using information lance and cancer reporting. Addition- tation and maintenance of TN’s inte- standards, and creates and maintains ally, SSIP is working on the develop- grated disease surveillance system for training materials. Other integrated ment of syndromic surveillance mes- communicable disease surveillance. disease surveillance activities include saging and laying the groundwork to The integrated surveillance solution electronic case reporting, refining and receive, process, and send electronic used in TN is known as the National further adopting electronic laboratory case and morbidity reports. Program

109 Communicable and Environmental Diseases and Emergency Preparedness Annual Report staff members continue to work with Tennessee Department of Health La- boratory Services toward implementation of electronic exchange of information, which includes sending and receiving of test orders and results (TOR) from our patient health record system and the lab’s Laboratory Infor- mation Management System, as well as electronic laboratory results reports (ELR) for reportable lab events. Fu- ture work will include additional integrated disease surveillance activities particularly in regard to STD surveillance as well as working closely with CEDEP program experts to develop and utilize decision support capabilities in our integrated disease surveillance. SSIP works with TDH’s Infor- mation Technology Services Division and external partners at the TN Office of eHealth Initiatives to increase electronic data transport by adopting and offering secure transport methodologies such as DIRECT transport and SOAP/web services to the state HISP (Health Information Service Provid- TN Department of Health is long standing and active member of the ANSI ac- ers). credited standards development organization Health Level Seven International (HL7). Meaningful Use SSIP provides support for and coordi- and syndromic surveillance infor- costs, and ensure the public’s health. nation of the public health aspects of mation with public health agencies. CMS (Centers for Medicare and Medi- TDH accepts immunization registry Electronic Laboratory Reporting caid Services) Meaningful Use Incen- data and ELR in order for eligible pro- (ELR) tive Program using ONC (Office of viders and hospitals to meet Meaning- As of June 2013, TDH has worked the National Coordinator for Health ful Use objectives. TDH’s active par- with 21 health systems representing 57 Information Technology) Certified ticipation in the Meaningful Use In- hospital laboratories to facilitate ELR Electronic Health Record (EHR) tech- centive program allows public health for Stage 1 of Meaningful Use follow- nology (CEHRT). This initiative calls to develop more collaborative relation- ing the HL7 2.5.1 Implementation for the use of certified electronic ships with trading partners, provides Guide for ELR. To date, 42 hospitals health records to exchange electronic opportunity for electronic data receipt have successfully completed Meaning- health information in a meaningful and exchange, and encourages public ful Use testing for ELR. Although no manner in order to improve the quali- health to improve efficient use of lim- hospitals are in production sending ty of health care and promote public ited resources. Meaningful Use is an ELR to TDH, there are 14 hospitals health. Meaningful Use is an on-going ambitious and fast-moving incentive that are working on final details and initiative staged in cycles. Currently in program working toward implementa- are close to full production submis- Stage 1, eligible healthcare providers tion of EHR while encouraging in- sion. Two national laboratories, Lab must choose one of three Public teroperability among information sys- Corp and Mayo, have been sending Health objectives, which focus on shar- tems in order to share meaningful in- ELR data to the Department of Health ing immunization registry data, elec- formation to improve individual following CDC’s Health Level 7 Inter- tronic laboratory results reports (ELR), health care, reduce overall healthcare national (HL7) based 2.3.1 Implemen-

110 Communicable and Environmental Diseases and Emergency Preparedness Annual Report tation guide for ELR since 2005. A consumed by a TDH communicable ty through standardization and auto- third national laboratory, ARUP, be- disease surveillance system are received mation. It also promotes responsible gan sending ELR data to TDH follow- via ELR. use of limited personnel and financial ing the same specification for ELR in resources by providing opportunities June 2012. Currently TDH is testing Impact for eliminating unnecessary duplicate with Quest Diagnostics Atlanta and it The Surveillance Systems and Infor- data entry across health record systems is anticipated that Quest be moved to matics Program works to provide pub- and public health systems. Further- production by the end of 2013. In lic health with the information needed more, it improves decision making addition, TDH continues to work with to conduct investigations and public capabilities for patient health with the TN State Public Health Lab to health interventions, allowing for sur- increased validity and reliability of implement ELR following the HL7 veillance of ongoing and emerging information used for the key public 2.5.1 ELR Implementation Guide and public health threats. TDH’s readiness health activities of case detection, sur- will continue testing for production and willingness to be a meaningful veillance, disease investigation, and implementation during 2013-2014. participant in electronic health infor- public health intervention. Currently, roughly 33% of lab reports mation exchange improves data quali-

111 SECTION VIII. EPIDEMIC INTELLIGENCE SERVICE Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Epidemic Intelligence Service

A critical function of the Centers for 3000 EIS officers who have played out professional experience. CDC po- Disease Control and Prevention pivotal roles in investigating and con- sitions in Atlanta, Fort Collins, Mor- (CDC) is to investigate outbreaks and trolling major epidemics. EIS has been gantown or Cincinnati are available, train Epidemiologists to serve our na- central in many high profile public or positions may be based at state tion. Since 1951, the Epidemic Intelli- health activities, including traveling to health departments like the Tennessee gence Service (EIS) has trained “shoe- the farthest reaches of the world to Department of Health. In both CDC leather” Epidemiologists to respond to achieve disease eradication, describe and state-based positions, EIS officers the most urgent and serious public disease transmission during outbreaks, gain experience and provide important health threats in the world. The CDC and implement preventive measures to support for a variety of applied epide- EIS program was established following stop diseases. Many of the nation's miologic studies and investigations. the start of the Korean War as an early medical and public health leaders, in- The Tennessee Department of Health warning system against biological war- cluding CDC directors and deans of has been hosting EIS officers since fare and man-made epidemics. The the country's top schools of public 1970. During the period covered in program was primarily made up of health, are EIS alumni. Approximately this report, Rendi Murphree, PhD medical doctors but has grown to en- 70% of alumni pursue careers in pub- completed her assignment, and Jane compass a more representative and lic health following their EIS training. Baumblatt joined the EIS in Tennes- diverse set of researchers and scientists see. who serve in the two-year EIS assign- EIS officers typically include persons ments. Additionally, the EIS program with advanced degrees and some train- Examples of recent EIS investigations of today has expanded into a surveil- ing or interest in public health. Offic- in Tennessee include: lance and response unit for all types of ers are assigned to positions either at  Surveillance for Guillain-Barré epidemics, including chronic disease the CDC. Some EIS officers have ex- Syndrome during the National and injuries. tensive clinical medicine training Influenza A (H1N1) 2009 Vac- while others have strong biostatistics cination Campaign: U. S. Emerg- Since the first cold war EIS classes of backgrounds. The program offers ap- ing Infections Program Sites the 1950’s, CDC has trained nearly plied Epidemiology training to round  Adverse events associated with

Epidemic Intelligence Service Officers, 1970-2009 Tennessee Department of Health

Years Name Years Name 1970-1971 G. Doty Murphy, MD 1990-1992 Peter A. Briss, MD 1971-1972 David L. Freeman, MD 1992-1994 Steven M. Standaert, MD 1972-1974 Bernard Guyer, MD 1995-1997 Allen S. Craig, MD 1974-1976 David S. Folland, MD 1997-1999 Timothy F. Jones, MD 1976-1977 R. Campbell McIntyre, MD 1999-2001 Joseph F. Perz, DrPH 1977-1979 Timothy J. Dondero, MD 2001-2003 David L. Kirschke MD 1980-1982 Tracy L. Gustafson, MD 2003-2005 Rose Devasia, MD 1982-1984 Michael D. Decker, MD, MPH 2005-2007 L. Rand Carpenter, DVM Jennifer MacFarquhar, RN, 1984-1986 William T. Brinton, MD 2007-2009 MPH, CIC 1986-1988 Melinda Wharton, MD 2009-2011 Rendi Murphree, PhD, MS 1988-1990 Ban Mishu, MD 2011- Jane Baumblatt, MD

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intravitreal inoculation of bevaci- Related Well Water Contamina-  Shigella flexneri Infection among zumab in three patients with mac- tion via Ultra-filtration Men Who Have Sex with Men ular degeneration  Acute Gastroenteritis among Stu-  Outbreak of Fungal Meningitis  Outbreak of Tuberculin Skin Test dents of Indian Lake Elementary Associated with Spinal Injections Conversion among Employees of School - Hendersonville, TN,  Evaluation and Data Analysis of an Elephant Sanctuary 2010 the Tennessee Controlled Sub-  Surveillance for a Possible Increase  Cluster of Acute Hepatitis C cases stances Monitoring Program of Legionnaire's Disease Following Among Inmates of a Federal Pris-  Attitudes of Tennessee Residents Record Flooding on to Organic and GM Foods  NCEH Health Studies Branch  Acute Gastroenteritis among Pilot Study to Assess Flood- NACCHO Conference Attendees

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115 SECTION IX. AWARDS, HONORS AND PUBLICATIONS Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Awards and Honors

Dr. John Dunn: standing Service, Tennessee De- Academy of Pediatrics “Friend of  National Association of State Pub- partment of Health, 2012 Children” Award, 2010 lic Health Veterinarians  Distinguished Leadership Award, (NASPHV), Treasurer, 2012 Council of State and Territorial Dr. Rendi Murphree: Epidemiologists, 2012  CDC, H1N1 Incident Manager, Brenda Eggert:  Tennessee and New York tied for Certificate and Honor Coin, 2012  Tennessee Public Health Associa- first place for “Most Collaborative  Outstanding Unit Citation, 2010, tion (TPHA) Public Health Work- Healthcare-Associated Infections 2011, 2012 er of the Year, 2012 State Program”, Division of  Unit Commendation, 2010, 2011, Healthcare Quality and Promo- 2012 Katie Garman: tion, 2011  Achievement Medal, 2011  FoodNet Star Award, 2012  Woman of Influence Award for  CDC, National Center for Emerg- Public Policy, Nashville Business ing and Zoonotic Infectious Dis- Carter Garner: Journal, 2011 eases, Honor Award, 2010  Lynn B. Hearn Award, 2012-2013  HICPAC Liaison, 2010, 2011, Environmentalist of the Year, Ten- 2012 Dr. Paul Petersen: nessee Environmental Health As-  Bull’s Eye Award for Innovation  CDC Region IV SNS Leadership sociation and Excellence for the Tennessee Award, 2012 Web Immunization System H1N1  Federal Computer Week Top Fed- Dr. Samir Hanna: Provider Pre-Registration System, eral 100 Award, 2011  FDA Award for participation in Association of Immunization the National Antimicrobial Re- Managers (along with Dr. Kelly CDR Jay Roth: sistance Monitoring System Moore), 2010  CDC, H1N1 Incident Manager, (NARMS), 10 years  Immunization Excellence Award: Certificate and Honor Coin, 2012  FDA Award for Outstanding Ef- Honorable Mention for Overall  Achievement Medal, 2010 forts in Record Maintenance and Season Activities, National Influ-  Outstanding Unit Citation, 2010 Data Sharing, 2012 enza Vaccine Summit (along with  Unit Commendation, 2010 Dr. Kelly Moore), 2010 Erin Holt: Thom Shavor  HL7® V2.7 Control Specialist Lori LeMaster:  Secretary of AIDS Coalition Certification, 2012  National Conference for Food Protection, Chairman, 2012-2013 Craig Shepherd: Dr. Marion Kainer:  Walter S. Mangold Award, 2011  One of the 10 Best Physicians of Dr. Kelly L. Moore:  Davis Calvin Wagner Sanitarian the year, Medscape, 2012  Association of Immunization Award, 2011  Tennessean of the Year (together Managers (AIM) Natalie J. Smith with Dr. April Pettit), The Tennes- Memorial Award for Outstanding Dr. Jon Warkentin: sean, 2012 Program Management, 2012  National Tuberculosis Controllers  Testified in front of the US Senate  AIM’s liaison member of the Fed- Association (NTCA), President, Health, Education, Labor and eral Advisory Committee on Im- 2012-2013 Pensions Committee, 2012 munization Practices (ACIP), 2011  Commissioner’s Award for Out-  TN Chapter of the American Publications, Posters, and Presentations

Active Bacterial Core Surveillance KA, Bennett NM, Reingold A, Thom- Team. An assessment of the screening (ABCs): as A, Baumbach J, Harrison LH, Petit method to evaluate vaccine effective- Cohen AL, Taylor T, Farley MM, S, Beall B, Zell E, Moore M and the ness: The case of 7-valent pneumococ- Schaffner W, Lesher LJ, Gershman Active Bacterial Core Surveillance cal conjugate vaccine in the United

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States. 2012; PLoS ONE 7 Bennett NM, Craig AS, Schaffner, W, necol 2010; 115:1217-1224. (8):e47185.doi:10.137/journal Thomas A, Lewis MM, Scallan E, pone.0041785. Schuchat A for the Emerging Infec- MacFarquhar JK, Jones TF, Woron tions Program Network. Bacterial AM, Kainer MA, Whitney CG, Beall De Serres G, Pilishvili T, Link-Gelles meningitis in the United States, 1998- B, Schrag SJ, Schaffner W. Outbreak R, Reingold A, Gershman K, Petit S, 2007. N Engl J Med 2011; 364:2016- of late-onset Group B streptococcus in Farley MM, Harrison LH, Lynfield R, 2025. a neonatal intensive care unit. Am J Bennett NM, Baumbach J, Thomas A, Infect Cont 2010; 38:283-288. Schaffner W, Beall B, Whitney C, Burton DC, Flannery B, Bennett NM, Moore M. Use of surveillance data to Farley MM, Gershman K, Harrison Pilishvili T, Lexau C, Farley MM, Had- estimate the effectiveness of the 7- LH, Lynfield R, Petit S, Reingold AL, ler J, Harrison LH, Bennett NM, valent conjugate pneumococcal vac- Schaffner W, Thomas A, Plikaytis BD, Reingold A, Thomas A, Schaffner W, cine in children less than 5 years of Rose CE, Whitney CG, Schuchat A Craig AS, Smith PJ, Beall BW, Whit- age over a 9 year period. Vaccine for the Active Bacterial Core Surveil- ney CG, Moore MR for the Active 2012; 30:4067-4072. lance/Emerging Infections Program Bacterial Core Surveillance/Emerging Network. Socioeconomic and racial/ Infections Program Network. Sus- Hampton, LM, Farley MM, Schaffner ethnic disparities in the incidence of tained reductions in invasive pneumo- W, Thomas A, Reingold A, Harrison bacteremic pneumonia among U.S. coccal disease in the era of conjugate LH, Lynfield R, Bennett NM, Petit S, adults. Am J Pub Health 2010; vaccine. J Infect Dis 2010; 201:32-41. Gershman K, Baumbach, J, Beall B, 100:1904-1911. Jorgensen J, Glennen A, Zell E, Moore Pilishvili T, Zell ER, Farley MM, M. Prevention of antibiotic – nonsus- Cohn AC, MacNeil JR, Harrison LH, Schaffner W, Lynfield R, Nyquist A, ceptible Streptococcus pneumoniae with Hatcher C, Jordan T, Schmidt M, Vazquez M, Bennett NM, Reingold A, conjugate vaccines. J Infect Dis 2012; Pondo T, Arnold KE, Baumbach J, Thomas A, Jackson D, Schuchat A, 205:401-411. Bennett N, Craig AS, Farley M, Whitney CG. Risk factors for invasive Gershman K, Petit S, Lynfield R, pneumococcal disease in children in MacNeil JR, Cohn AC, Farley M, Reingold A, Schaffner W, Shutt KA, the era of widespread conjugate vac- Mair R, Baumbach J, Bennett N, Zell ER, Mayer LW, Clark T, Stephens cine use. Pediatrics 2010; 126:e6-e17. Gershman K, Harrison LH, Lynfield D, Messonnier NE. Changes in Poehling KA, Light LS, Rhodes M, R, Petit S, Reingold A, Schaffner W, Neisseria meningitidis disease Snively BM, Halasa NB, Mitchel E, Thomas A, Coronado F, Zell ER, May- epidemiology in the United States, Schaffner W, Craig AS, Griffin MR. er LW, Clark TA, Messonnier NE. 1998-2007: implications for Sickle cell trait, hemoglobin C trait, Current epidemiology and trends in prevention of meningococcal disease. and invasive pneumococcal disease. invasive Haemophilus influenza disease – Clin Infect Dis 2010; 50: 184-191. Epidemiology 2010; 21:340-346. United States, 1989-2008. Clin Infect Dis 2011; 53:1230-1236. Cohen AL, Harrison LH, Farley MM, Foodborne Diseases Active Surveil- Reingold AL, Hadler J, Schaffner W, lance Network (FoodNet): Rosen, JB, Thomas AR, Lexau CA, Lynfield R, Thomas AR, Campsmith Clogher P, Hurd S, Hoefer D, Hadler Reingold A, Hadler JL, Harrison LH, M, Li J, Schuchat A, Moore MR and JL, Pasutti L, Cosgrove S, Segler S, Bennett NM, Schaffner W, Farley the Active Bacterial core surveillance Tobin-D’Angelo M, Nicholson C, MM, Beall BW, Moore MR, CDC team. Prevention of invasive pneumo- Booth H, Garman K, Mody R, Gould Emerging Infections Program Net- coccal disease among HIV-infected LH. Assessment of physician work. Geographic variation in inva- adults in the era of childhood pneu- knowledge and practices concerning sive pneumococcal disease following mococcal immunization. AIDS 2010; STEC infection and enteric illness, pneumococcal conjugate vaccine intro- 24:2253-2262. 2009, FoodNet. Clin Inf Dis 2012; 54 duction in the United States. Clin (suppl 5): S446-S452 doi:10.193/cid/ Infec Dis 2011; 53:137-143. Goins WP, Talbot TR, Schaffner W, cis246. Edwards KM, Craig AS, Schrag SJ, Thigpen MC, Whitney CG, Messonier VanDyke MK, Griffin MR. Adher- Cronquist AB, Mody RK, Atkinson R, NE, Zell ER, Lynfield R, Hadler JL, ence to perinatal Group B streptococ- Besser J, D’Angelo MT, Hurd S, Rob- Harrison LH, Farley MM, Reingold A, cal prevention guidelines. Obstet Gy- inson T, Nicholson C, Mahon BE.

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Impacts of culture-independent diag- Kendall ME, Crim S, Fullerton K, Boothe E, Gould LH. Strategies for nostic practices on public health sur- Han PV, Cronqist AB, Shiferaw B, surveillance of pediatric hemolytic ure- veillance for bacterial enteric patho- Ingram A, Rounds J, Mintz ED, Ma- mic syndrome: Foodborne Diseases gens. Clin Infect Dis 2012; (Suppl 5): hon B. Travel-associated enteric infec- Active Surveillance Network, 2000- S432-S439 doi:10.1093/cid/cis267. tions diagnosed after return to the 2007. Clin Infect Dis 2012; 54 United States, Foodborne Diseases (Suppl. 5):S424-S431 doi:10.1093/ Gould C, Edwards J, Cohen J, Active Surveillance Network cid/cis208. McDonald L, Farley M, Johnston H, (FoodNet), 2004-2009. Clin Infec Dis Wilson L, Hanna S, Winston L, 2012; 54 (Suppl 5): S480-S487 Silk BJ, Date KA, Jackson KA, Poullot Holzbauer S, Lyons C, Phipps E, Hol- doi:10.1093/cid/cis052. R, Holt KG, Graves LM, Ong L, Hurd lick G, Beldavs Z, Gerding D, MD, S, Meyer R, Marcus R, Shiferaw B, Lessa F, and CDC's Clostridium difficile Manikonda K, Palmer A, Wymore K, Norton DM, Medus C, Zansky SM, Infection Surveillance Investigators. McMillian M, Nicholson C, Hurd S, Cronquist A, Henao OL, Jones TF, Effect of nucleic acid amplification Hoefer D, Tobin-D’Angleo M, Cos- Vugia DJ, Farley MM, Mahon BE. testing on population-based incident gove S, Lyons C, Lathrop S, Hedican Invasive listeriosis in Foodborne Dis- rates of Clostridium difficile Infection E, Patrick M. Validating deaths re- eases Active Surveillance Network, (CDI). Abstract #35403, IDSA, Octo- ported in the Foodborne Diseases Ac- 2004-2009: further targeted preven- ber 2012 San Diego, CA. tive Surveillance Network: are all tion needed for higher- risk groups. deaths being captured: Clin Infect Dis Clin Infect Dis 2012; Suppl 5:S396- Hale CR, Scallan E, Dunn J, Smith K, 2012; 54 (Suppl 5): S421-S423 404. Robinson T, Lathrop S, Tobin- doi:10.1093/cid/cis266. D’Angleo M, Clogher P. Estimates of Behravesh CB, Jones TF, Vugia DJ, enteric illness attributable to contact Mody RK, Luna-Gierke RE, Jones TF, Long C, Marcus R, Smith K, Thomas with animals and their environments Comstock N, Hurd S, Scheftel J, Lath- SM, Zansky S, Fullerton KF, Henao in the United States. Clin Infect Dis rop S., Smith G, Palmer A, Strockbine OL, Scallan E. Deaths associated with 2012; 54 (Suppl 5): S472-S479 N, Talkington D, Mahon BE, Hoeks- bacterial pathogens commonly trans- doi:10.1093/cid/cis051. tra RM, Griffin PM. Infections in mitted through food -- Foodborne Dis- pediatric hemolytic uremic syndrome: eases Active Surveillance Network Hurd S, Patrick M, Hatch J, Clogher factors associated with identifying Shi- (FoodNet) 1996-2005. J Infect Dis P, Wymore K, Cronquist AB, Segler S, ga-toxin-producing Eschericia coli. Arch 2011;204:263-7. Robinson T, Hanna S, Smith G, Fitz- Ped Adolesc Med 2012. gerald C. Clinical laboratory practices Hoefer D, Hurd S, Medus C, for the isolation and identification of Murphree R, Garman K, Phan Q, Cronquist A, Hanna S, Hatch J, Hayes Campylobacter in foodborne diseases, Everstine K, Gould LH, Jones TF. T, Larson K, Nicholson C, Wymore K, Active Surveillance Network Characteristics of foodborne disease Tobin-D'Angelo M, Strockbine N, (FoodNet) Sites: Baseline information outbreak investigations conducted by Snippes P, Atkinson R, Griffin PM, for understanding changes in surveil- FoodNet Sites, 2003-2008. Clin Infect Gould LH; Laboratory practices for lance data. Clin Infect Dis. 2012: 54 Dis 2012; Suppl 5:S498-503. the identification of Shiga toxin- (suppl 5): S440-S445 doi:10.1093/ producing Escherichia coli in the cid/cis245. Ong KL, Gould LH, Chen DL, Jones United States, FoodNet Sites, 2007. TF, Lyons C, Scheftel J, Hayes T, Mo- Emerging Infections Program Foodnet Jones, TF. How useful are stool stud- dy RK, Mahon BE. Changing epide- Working Group. Foodborne Pathog ies for acute gastroenteritis? (Editorial). miology of Yersinia enterocolitica infec- Dis. 2011 Apr; 8(4):555-60. J Infect Dis. 2012;205:1334-5. tions: overall declines and markedly decreased rates in young black chil- Jones TF, Grimm K. Public knowledge Jones, TF, Gerner-Smidt P. Non- dren, FoodNet, 1996-2009. Clin In- and beliefs about diarrheal disease. culture diagnostics for acute gastroen- fect Dis 2012; Suppl 5:S385-09. Foodborne Path Dis 2011:8:165-167. teritis: new challenges, new opportunities. (Editorial). Emerg Infect Dis Ong KL, Apostal M, Comstock N, Nelson JM, Griffin PM, Jones TF, 2012:18:513-514. Hurd S, Webb T, Mickelson S, Smith KE, Scallan E. Antimotility and Scheftel J, Smith G, Shiferaw B, antimicrobial use in persons with shiga

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-toxin producing E. coli O157 infec- tuberculosis infections in Foodborne confirmed influenza virus infections: tion in FoodNet sites. Clin Infect Dis Diseases Active Surveillance Network a multi-state study. J Infect Dis 2012; 2011:52;1130-32. sites and comparison with Y. enterocolit- 205:13-19. ica infections, 1996-2007. Emerg In- Sumner S, Brown LG, Frick R, Stone fect Dis 2010;16:566-567. Wise M, Viray M, Sejvar J, Lewis P, C, Carpenter LR, Bushnell L, Nicho- Baughman A, Connor W, Danila R, las D, Mack J, Blade H, Tobin- Majowicz SE, Musto J, Scallan E, An- Giambrone G, Hale C, Hogan B, D'Angelo M, Everstine K; Environ- gulo FJ, Kirk M, O’Brien SJ, Jones TF, Meek J, Murphree R, Oh J, Reingold mental Health Specialists Network Fazil F, Hoekstra RM. The global bur- A, Tellman N, Conner S, Singleton J, Working Group. J Food Prot. 2011 den of non-typhoidal Salmonella gastro- Lu P, DeStefano F, Fridkin S, Vellozzi Feb;74(2):215-20. PMID: 21333140 enteritis. Clin Infect Dis 2010;50:882- C, Morgan O. 2012. Guillain-Barré [PubMed - indexed for MEDLINE]. 889. Syndrome during the 2009-2010 H1N1 influenza vaccination cam- Clarkson LS, Tobin-D'Angelo M, Influenza: paign: population-based surveillance Shuler C, Hanna S, Benson J, Voetsch Jain S, Benoit SR, Bramley AM, Finelli among 45 million Americans. Am J AC. Sporadic Salmonella enterica L. 2009 Pandemic Influenza A Epidemiol. 2012 Jun 1;175(11):1110- serotype Javiana infections in Georgia (H1N1) Virus Hospitalizations Investi- 9. and Tennessee: a hypothesis- gation Team (member). Influenza- generating study. Epidemiol Infect. associated pneumonia in hospitalized Creanga AA, Kamimoto L, Newsome 2010 Mar;138(3):340-6. patients with 2009 H1N1 influenza K, D’Mello T, Jamieson DJ, Zotti ME, virus in the United States, April – Arnold KE, Baumbach J, Bennett NM, Haley CC, Hedberg K, Cieslak PR, June 2009. Clin Infect Dis 2012. Farley MM, Gershman K, Kirschke D, Scallan E, Ong KL, Marcus R, Shin S, Lynfield R, Meek J, Morin C, Cronquist AB, Gillespie J, Jones TF, Jules A, Grijalva CG, Zhu Y, Talbot Reingold A, Ryan P, Schaffner W, Shiferaw B, Fuller C, Edge K, Ander- HK, Williams JV, Dupont WD, Ed- Thomas A, Zansky S, Finelli L, son BJ, Ryan PA, Mintz ED. Risk fac- wards KM, Schaffner W, Shay DK, Honein MA. Seasonal and 2009 pan- tors for sporadic shigellosis: FoodNet, Griffin MR. Estimating age-specific demic influenza A (H1N1) virus infec- 2005. Foodborne Path Dis 2010; influenza-related hospitalization rates tion during pregnancy: a population- 7:741-7. during the pandemic (H1N1) 2009 in based study of hospitalized cases. Am Davidson Co, TN. Influenza and Oth- J Obstet Gynecol 2011; 2004 9suppl Hanna S, Atkinson R, Dunn J, Jones er Respiratory Viruses 2012. DOI: 1): S38-S45. TF. Health department reporting of 10.1111/j.1750-2659.2012.00343.x. shiga-toxin producing Escherichia coli Dawood FS, Kamimoto L, Newsome (STEC) in Tennessee: Surveillance and Luckhaupt SE, Sweeney MH, Funk R, K, D’Mello TA, Reingold A, Gersh- current clinical laboratory practices. Calvert GM, Nowell M, D’Mello T, man K, Meek J, Arnold KE, Farley M, Tenn Med 2010;103:39-43. Reingold A, Meek J, Yousey-Hindes K, Ryan P, Lynfield R, Morin C, Arnold KE, Ryan P, Lynfield R, Morin Baumbach J, Zansky S, Bennett N, Jones TF. When diarrhea gets deadly: C, Baumbach J, Zansky S, Bennett Thomas A, Schaffner W, Kirschke D, A look at nursing home gastroenteritis NM, Thomas A, Schaffner W, Jones, Finelli L and the Emerging Infections outbreaks. Clin Infect Dis T. Influenza-associated hospitaliza- Program Network. Children with 2010;51:915-916. tions by industry, 2009-10 influenza asthma hospitalized with seasonal or season, United States. Emerging Infec pandemic influenza, 2003-2009. Pedi- Kozlica J, Claudet AL, Solomon D, Dis 2012; 18:556-562. atrics 2011;125:e27-e32. Dunn JR, Carpenter LR. Waterborne outbreak of Salmonella I4,[5],12:i-. Vandermeer ML, Thomas AR, Ka- Doshi S, Kamimoto L, Finelli L, Perez Foodborne Pathog Dis. 2010 Nov;7 mimoto L, Reingold A, Gershman K, A, Reingold A, Gershman K, Yousey- (11):1431-3. Epub 2010 Jul 9. Meek J, Farley MM, Ryan P, Lynfield Hindes K, Arnold K, Ryan P, Lynfield R, Baumbach J, Schaffner W, Bennett R, Morin C, Baumbach J, Hancock Long C, Jones TF, Vugia DJ, Scheftel N, Zanskey S. Association between EB, Bennett NM, Zansky S, Thomas J, Strockbine N, Ryan P, Shiferaw B, use of statins and mortality among A, Schaffner W, Fry AM. Description Tauxe RV, Gould LH. Yersinia pseudo- patients hospitalized with laboratory- of antiviral treatment among adults

120 Communicable and Environmental Diseases and Emergency Preparedness Annual Report hospitalized with influenza before and Moore, BK, Ingram A, Moore KL, KG, Lynfield R, Openo KP, Kirley PD, during the 2009 pandemic: United H1N1 Vaccine Distribution Team. Pasutti LE, Barnes BG, Schaffner W, States, 2005-09. J Infect Dis 2011; Brother, Can You Spare a Dose (of Kamimoto L. Influenza testing and 204:1848-1856. H1N1 Vaccine)? Flexibility is Key to antiviral prescribing practices among Efficient Distribution. 44th National emergency department clinicians in 9 Fowlkes AL, Arguin P, Biggerstaff MS, Immunization Conference, Atlanta, states during the 2006 to 2007 influ- Gindler J, Blau D, Jain S, Dhara R, GA, April 19-22, 2010 (oral presenta- enza season. Ann Emerg Med 2010; McLaughlin J, Turnipseed E, Meyer JJ, tion). 55:32-39. Louie JK, Siniscalchi A, Hamilton JJ, Reeves A, Park SY, Richter D, Ritchey Frost BA, Kainer MA, Thiantai T, Healthcare Associated Infections- MD, Cocoros NM, Blythe D, Peters S, Green AL, Kranz MK, MacFarquhar J, Community Interface (HAIC): Lynfield R, Peterson L, Anderson J, Moore, BK, Ingram A, Moore KL, Berger BE, Kainer MA. A Rising Tide Moore Z, Williams R, McHugh L, H1N1 Vaccine Distribution Team. Doesn’t Lift All Boats: Different Rates Cruz C, Waters CL, Page SL, McDon- Brother, Can You Spare a Dose (of of Change in the Central Line- ald CK, Vandermeer M, Waller K, H1N1 Vaccine)? Flexibility is Key to Associated Bloodstream Infection Bandy U, Jones TF, Bullion L, Vernon Efficient Distribution. Council of Standardized Infection Ratio Among V, Lofy KH, Haupt T, Finelli L. Epi- State and Territorial Epidemiologists Intensive Care Units. Council of State demiology of 2009 pandemic influenza Annual Conference, Portland, OR, and Territorial Epidemiologists A (H1N1) deaths in the United States, June 6-10, 2010 (oral presentation). (CSTE) annual conference, Omaha, April-July, 2009. Clin Ifect Dis 2011; NE, June 3-7, 2012 (poster presenta- 52:S60-S68. Frost BA, Kainer MA, Kirschke DL, tion). Jones TF. Compliance of H1N1 Speci- Dao CN, Kamimoto L, Nowell M, men Submissions to the State Public Berger BE, Kainer MA. Using Nation- Reingold A, Gershman K, Meek J, Health Laboratory by Facilities Partici- al Healthcare Safety Network (NHSN) Arnold KE, Farley M, Ryan P, Lynfield pating in the Emerging Infections Pro- Data to Guide Tennessee’s Multidisci- R, Morin C, Baumbach J, Hancock E, gram [EIP] in Tennessee. Council of plinary Advisory Group. Council of Zansky S, Bennett NM, Thomas A, State and Territorial Epidemiologists State and Territorial Epidemiologists Vandermeer M, Kirschke DL, Annual Conference, Portland, OR, (CSTE) annual conference, Omaha, Schaffner W, Finelli L. for the Emerg- June 6-10, 2010 (poster presentation). NE, June 3-7, 2012 (oral presentation- ing Infections Program Net- break out session). work. Adult hospitalizations for labor- Hopkins RH, Schaffner W, Nichol atory-positive influenza during the KL. Perspective: add pneumococcal Berger BE, Crist M, Kainer MA. Tar- 2005-06 through 2007-08 seasons in vaccination. The Lancet online. Dec geted Validation of Central Line- the United States. J Infect Dis 2010; 2009. Also published as: Maximize Associated Bloodstream Infection Da- 202:881-888. protection this flu season in Family ta Reported to the National Practice News, Dec 2009 and in Inter- Healthcare Safety Network. Council of Dawood FS, Fiore A, Kamimoto L, nal Medicine News, Jan 2010, pg 14. State and Territorial Epidemiologists Nowell M, , Reingold A, Gershman K, (CSTE) annual conference, Omaha Meek J, Hadler J, Arnold KE, Ryan P, Jones, Timothy F, Marcy McMillian, NE, June 3-7, 2012 (oral presentation- Lynfield R, Morin C, Baumbach J, Effie Boothe, Samir Hanna, and L. break out session). Zansky S, Bennett NM, Thomas A, Amanda Ingram. Hospital discharge Schaffner W, Kirschke D, Finelli L for data for Guillain-Barre Syndrome and Birnbaum D, Kainer MA Healthcare the Emerging Infections Program (EIP) Influenza A (H1N1) vaccine adverse Associated Infection (HAI) Reporting, Network. Influenza-associated pneu- events. Emerging Infectious Diseases Meaningful Use, and the Standards monia in children hospitalized with (EID), Vol. 16, No. 9, September and Interoperability Framework Initia- laboratory-confirmed influenza, 2003- 2010. tive. Health and Human Services 2008. Pediatr Infect Dis J 2010; (HHS) Data Summit Kansas City, 29:585-590. Mueller MR, Smith PJ, Baumbach JP, MO, May 30-31, 2012 (poster presen- Palumbo JP, Meek JI, Gershman K, tation). Frost BA, Kainer MA, Thiantai T, Vandermeer M, Thomas AR, Long Green AL, Kranz MK, MacFarquhar J, CE, Belflower R, Spina NL, Martin Borchers E, Kainer M. Collaboration:

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The key to reducing the burden for field R, Melchreit R, Nadle J, Ray SM, 2011 Annual Scientific Meeting, Dal- healthcare facilities in reporting and Thompson D, Wilson L, Fridkin S. las, TX, April 1-4, 2011 (poster presen- preventing healthcare-associated infec- Point Prevalence Survey of Antimicro- tation). tions. Council of State and Territorial bial Use in U.S. Acute Care Hospitals, Epidemiologists (CSTE) annual con- ID Week, San Diego, CA Oct 17-21, Berger BE, Crist M, Kainer M, Ten- ference, Omaha, NE, June 3-7, 2012 2012 (oral presentation). nessee’s Tools and Trainings for (poster). Healthcare-Associated Infection Re- Pollock D, Kainer M. Healthcare Asso- porting, Society for Healthcare Epide- Edwards AE, Crist M, Kainer MA. ciated Infections and Reportable Com- miology of America (SHEA) 2011 An- Epidemiology of the Newly Reportable municable Diseases: Birds of a Feath- nual Scientific Meeting, Dallas, TX, Carbapenem-Resistant Enterobacteri- er, or Horses of a Different Color? April 1-4, 2011 (poster presentation). aceae (CRE) in Tennessee, Interna- Council of State and Territorial Epide- tional Conference on Emerging Infec- miologists (CSTE) annual conference, CDC. Transplant-transmitted hepatits tious Diseases (ICEID), Atlanta, GA, Omaha, NE, June 3-7, 2012 (oral B virus – United States, 2010 March 11-14, 2012 (poster presenta- presentation- roundtable discussion). MMWR, 2011 August; 60(32):1087 tion). (co-author). See I, Iwamoto M, Allen-Bridson K, Edwards AE, McNish EL, Kainer M. Horan T, Magill SS, Fridkin SK, Crist MB, Berger BB, Ward J, Johnson Easier Said Than Done: Challenges of Thomspon ND, MBI-LCBI Field Test -Brockman C, Borchers EL, Kainer Carbapenem-Resistant Enterobacteri- Working Group. Piloting a Modifica- MA “Facebook for Healthcare- aceae Surveillance in Tennessee. tion to the National Healthcare Safety Associated Infections” – an Infection Council of State and Territorial Epide- Network (NHSN) Bloodstream Infec- Prevention Tool Implemented by the miologists (CSTE) annual conference, tion Definition: Mucosal Barrier Inju- Tennessee Department of Health So- Omaha, NE, June 3-7, 2012 (poster ry-Laboratory Confirmed Bloodstream ciety for Healthcare Epidemiology of presentation). Infection (MBI-LCBI), ID Week, San America (SHEA) 2011 Annual Scien- Diego, CA Oct 17-21, 2012 (oral tific Meeting, Dallas, TX, April 1-4, Kainer M, Wiese AD, Benedict K et al. presentation). 2011 (poster presentation). Multistate Outbreak of Fungal Infec- tion Associated with Injection of See I, Bamberg W, Beldavs ZG, Duran Duffy J, Sievert D, Rebmann C, Methylprednisolone Acetate Solution J, Kainer MA, Maloney M, Thompson Kainer M, Lynfield R, Smith P, Frid- from a Single Compounding Pharma- D, Thompson N D. Evaluation of kin S. Elements of effective state- cy — United States, 2012, MMWR Sampling Denominator Data to Esti- based surveillance for multidrug- 2012 61(41);839-842. mate Urinary Catheter- and Ventilator resistant organisms related to -Days for the National Healthcare Safe- healthcare-associated infections: sum- Kainer MA, Reagan DR, Nguyen DB ty Network (NHSN), ID Week, San mary of discussions from a Council of et al. Fungal infections associated with Diego, CA Oct 17-21, 2012 (oral State and Territorial Epidemiologists contaminated methylprednisolone in presentation). and Centers for Disease Control and Tennessee. N Engl J Med 2012; Prevention Experts Meeting. Public 367:2194-2203. Smith RS, Schaefer MK, Kainer MA et Health Reports 2011 March-April 126 al. Fungal infections associated with (2):176-85. Kainer M, Wiese AD, Benedict K et al. contaminated methylprednisolone Multistate outbreak of fungal infection injections—preliminary report, N Engl Frost BA, Kainer MA. Safe prepara- associated with injection of J Med December 19, 2012;DOI: tion and administration of intravitreal methylprednisolone acetate solution 10.1056/NEJMoa1213978. bevacizumab injections. N Engl J Med. from a single compounding pharmacy 2011;365(23):2238. — United States, 2012 . JAMA Berger BE, Soe MM, Kainer M, Utili- 2012,308(22):2328. zation of the Standardized Infection Frost BA, Soe MM, Rabi W, Kainer Ratio for Summarizing Neonatal Cen- MA, Prioritization of Surveillance and Magill S, McAllister L, Neuhauser M, tral Line-Associated Bloodstream In- Infection Prevention Activities to Re- Zintars G. Beldavs ZG, Dumyati G, fection Data, Society for Healthcare duce Healthcare Associated Infections Duran J, Edwards J, Kainer MA, Lyn- Epidemiology of America (SHEA) [HAI] in Tennessee, Society for

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Healthcare Epidemiology of America tific Meeting, Dallas, TX, April 1-4, [CLABSI] in a Neonatal Intensive (SHEA) 2011 Annual Scientific Meet- 2011 (oral presentation- late breaker). Care unit [NICU]: A 13 Year Experi- ing, Dallas, TX, April 1-4, 2011 (poster ence. 5th Decennial International presentation). MacCannell T, Umscheid CA, Conference on Healthcare-Associated Agarwal RK, Lee I, Kuntz G, Steven- Infections, Atlanta, GA, March 18-22, Frost BA, Kainer MA, Eye-Opening: son KB; Healthcare Infection Control 2010 (poster presentation). Are Compounded Drugs Causing Practices Advisory Committee- Harm? Society for Healthcare Epide- HICPAC. Guideline for the preven- Cardo D, Dennehy PH, Halverson P, miology of America (SHEA) 2011 An- tion and control of norovirus gastroen- Fishman N, Kohn M, Murphy CL, nual Scientific Meeting, Dallas, TX, teritis outbreaks in healthcare settings. Whitley RJ, HAI Elimination White April 1-4, 2011 (poster presentation). Infect Control Hosp Epidemiol. 2011 Paper Writing Group, Brennan PJ, Hellinger WC, Rosser BG, Keaven Oct;32(10):939-69. Epub 2011 Sep 1. Bright J, Curry C, Graham D, Haerum AP, Alcantara R, Zaheer S, Robyn Kay B, Kainer M, Kaye K, Lundstrom T, R, Pringle S, Stump K, Schlessinger S, O'Grady NP, Alexander M, Burns LA, Richards C, Tomlinson L, Skillen EL, Richardson D, Anderson J, Byers P, Dellinger EP, Garland J, Heard SO, Streed S, Young M, Septimus E. Mov- Frost BA, Kainer MA, Killackey MT, Lipsett PA, Masur H, Mermel LA, ing toward elimination of healthcare- Caruso AM, Balart LA, Hachem R, Pearson ML, Raad II, Randolph AG, associated infections: A call to action. Turabelidze G, Carrie F. Nielsen CF, Rupp ME, Saint S; the Healthcare Infect Control Hosp Epidemiol Notes from the Field: Transplant- Infection Control Practices Advisory 2010,31(11):1101-5. transmitted hepatitis B virus—United Committee (HICPAC). Summary of States, 2010, MMWR 2011 60(32); recommendations: guidelines for the Cardo D, Dennehy PH, Halverson P, 1087 (co-author). prevention of intravascular catheter- Fishman N, Kohn M, Murphy CL, related infections. Clin Infect Dis. Whitley RJ, HAI Elimination White Kainer MA, Pollock D, Healthcare- 2011 May;52(9):1087-1099. Paper Writing Group, Brennan PJ, Associated Infection (HAI) Reporting Bright J, Curry C, Graham D, Haerum and State-Federal Working Relation- O'Grady NP, Alexander M, Burns LA, B, Kainer M, Kaye K, Lundstrom T, ships, Council of State and Territorial Dellinger EP, Garland J, Heard SO, Richards C, Tomlinson L, Skillen EL, Epidemiologists Annual Conference, Lipsett PA, Masur H, Mermel LA, Streed S, Young M, Septimus E. Mov- Pittsburgh, PA, June 12-16, 2011 Pearson ML, Raad II, Randolph AG, ing toward elimination of healthcare- (oral/breakout presentation). Rupp ME, Saint S; the Healthcare associated infections: A call to action. Infection Control Practices Advisory Am. J Infect Control 2010 Nov, 38 Klevens M, Iqbal K, Rizzo E, Gerard Committee (HICPAC). Guidelines for (9):671-5. K, Vonderwahl C, Sweet K, Bornschle- the prevention of intravascular cathe- gel K, Thomas A, Bryant T, Kainer M, ter-related infections. Clin Infect Dis. Gould CV, Umscheid CA, Agarwal Jiles R. Incidence of Acute, Sympto- 2011 May;52(9):e162-e193. Epub RK, Kuntz G, Pegues DA, and the matic Hepatitis B in the United States, 2011 Apr 1. Healthcare Infection Control Practices 2005–2010. From Outbreak Investiga- Advisory Committee (HICPAC). tion to Policy Changes, European Sci- O'Grady NP, Alexander M, Burns LA, Guideline for prevention of catheter- entific Conference on Applied Infec- Dellinger EP, Garland J, Heard SO, associated urinary tract infections, tious Disease Epidemiology Lipsett PA, Masur H, Mermel LA, 2009. Infect Control Hosp Epidemiol (ESCAIDE). Stockholm, Sweden, Nov Pearson ML, Raad II, Randolph AG, 2010 Apr;31(4):319-26. 6-8, 2011 (oral presentation). Rupp ME, Saint S; Healthcare Infec- tion Control Practices Advisory Com- Hellinger WC, Rosser BG, Keaven Magill SS, McAllister LM, Allen- mittee. Guidelines for the prevention AP, Alcantara R, Zaheer S, Robyn Kay Bridson K, Bamberg W, Kainer MA, of intravascular catheter-related infec- R, Pringle S, Stump K, Schlessinger S, Fridkin S. Preliminary Results of a tions. Am J Infect Control. 2011 Richardson D, Anderson J, Byers P, Healthcare Associated Infection and May;39 (4 Suppl 1):S1-34. Frost BA, Kainer MA, Killackey MT, Antimicrobial Use Prevalence Survey Caruso AM, Balart LA, Hachem R, in 22 U.S. Acute Care Hospitals, Soci- Berry SB, Soe MM, Frost BA, Yeoman Turabelidze G, Carrie F. Nielsen CF, ety for Healthcare Epidemiology of CA, Kainer MA. Reduction in central Notes from the Field: Transplant- America (SHEA) 2011 Annual Scien- Line Associated Bloodstream Infection

123 Communicable and Environmental Diseases and Emergency Preparedness Annual Report transmitted hepatitis B virus—United [NHSN]. 5th Decennial International 2011; 49:1583-1587. States, 2010, JAMA 306(15) 1648. Conference on Healthcare-Associated Infections, Atlanta, GA, March 18-22, Creech CB, Litzner B, Talbot TR, Hellinger WC, Rosser BG, Keaven 2010 (oral presentation). Schaffner W. Frequency of detection AP, Alcantara R, Zaheer S, Robyn Kay of methicillin-resistant Staphylococcus R, Pringle S, Stump K, Schlessinger S, Soe MM, Swart D, Clarke C, Lee L, aureus from rectovaginal swabs in preg- Richardson D, Anderson J, Byers P, Kainer M. Participation in a Central nant women. Am J Infect Cont 2010; Frost BA, Kainer MA, Killackey MT, Line Associated Bloodstream Infection 38: 72-74. Caruso AM, Balart LA, Hachem R, [CLABSI] Prevention Collaborative Turabelidze G, Carrie F. Nielsen CF, and CLABSI Rates- Tennessee, 2008. Kallen AJ, Mu Y, Bulens, Reingold A, Notes from the Field: Transplant- 5th Decennial International Confer- Petit S, Gershman K, Ray, SM, Harri- transmitted hepatitis B virus—United ence on Healthcare-Associated Infec- son LH, Lynfield R, Dumyati G, States, 2010, JAMA 306(15) 1648. tions, Atlanta, GA, March 18-22, 2010 Townes JM, Schaffner W, Patel PR, (poster presentation). Fridkin SK. for the Active Bacterial Kainer MA, Mitchell J, Frost BA, Soe Core surveillance (ABCs) MRSA inves- MM. Validation of Central Line Asso- Umscheid CA, Agarwal RK, Brennan tigators of the Emerging Infections ciated Bloodstream Infection PJ; Healthcare Infection Control Prac- Program. Healthcare-associated inva- [CLABSI] Data Submitted to the Na- tices Advisory Committee (HICPAC). sive MRSA infections 2005-2007. JA- tional Healthcare Safety Network Updating the guideline development MA 2010: 304:641-648. [NHSN]—A Pilot Study by the Tennes- methodology of the Healthcare Infec- see Department of Health [TDH]. 5th tion Control Practices Advisory Com- Tickborne Diseases: Decennial International Conference mittee (HICPAC). Am J Infec Control Fritzen C, Huang J, Westby K, Freye on Healthcare-Associated Infections, 2010 May;38(4)264-73. JD, Dunlap B, Yabsley M, Dunn J, Atlanta, GA, March 18-22, 2010 Jones, TF, Moncayo A. Infection prev- (poster presentation). Methicillin-resistant Staphylococcus alences of common tickborne patho- aureus (MRSA): gens in adult Lone Star ticks Kainer MA, Frost BA, Thiantai T, Lessa FC, Mu Y, Ray SM, Dumyati G, (Amblyomma americanum) and Ameri- Green AL, Kranz MK, MacFarquhar J, Bulens S, Gorwitz RJ, Fosheim G, can Dog ticks (Dermacentor variabilis) Moore, BK, Ingram A, Moore KL, DeVries AS, Schaffner W, Nadle J, from Kentucky. Am J Trop Med Hyg H1N1 Vaccine Distribution Team. Gershman K, Fridkin SK for the Ac- 2011;85:718-723. Brother, Can You Spare a Dose (of tive Bacterial Core sureveillance H1N1 Vaccine)? Flexibility is Key to (ABCs) MRSA Investigators of the Cohen SB, Freye JD, Dunlap BG, th Efficient Distribution. 5 Decennial Emerging Infections Program. Impact Dunn JR, Jones TF, Moncayo AC. International Conference on of USA 300 methicillin-resistant Staph- Host associations of Dermacentor, Am- Healthcare-Associated Infections, At- ylococcus aureus on clinical outcomes of blyomma, and Ixodes (Acari: Ixodidae) lanta, GA, March 18-22, 2010 (poster patients with pneumonia or central ticks in Tennessee. J Med Entomol presentation). line-associated bloodstream infections. 2010;47:415-20.

Clin Infect Dis 2012; 55:232-241. Kainer MA, Assessment of Infection Cohen SB, Yabsley MJ, Freye JD, Dun- Risk Among Recipients of Recalled Satola SW, Lessa FC, Ray SM, Bulens lap BG, Rowland ME, Huang J, Dunn Human Tissue for Transplantation. SN, Lynfield R, Schaffner W, Dumyati JR, Jones TF, Moncayo AC. Preva- 5th Decennial International Confer- G, Nadle J, Patell JB for the Active lence of Ehrlichia chaffeensis and Ehr- ence on Healthcare-Associated Infec- Bacterial Core surveillance (ABCs) lichia ewingii in Ticks from Tennessee. tions, Atlanta, GA, March 18-22, 2010 MRSA investigators. Clinical and la- Vector Borne Zoonotic Dis. 2010; 10 (poster presentation). boratory characteristics of invasive in- (5):435-40. fections due to methicillin-resistant

Soe MM, Kainer MA. Sustainable, Staphylococcus aureus isolates demon- Moncayo A, Cohen S, Fritzen C, Cost-Effective Internal Data Valida- strating a vancomycin MIC of 2 mi- Huang E, Yabsley M, Freye J, Dunlap tion of Healthcare Associated Infec- crograms per milliliter:lack of effect of B, Huang J, Mead D, Jones TF, Dunn tions Surveillance Reported to the heteroresistant vancomycin – interme- J. Absence of Rickettsia rickettsii and National Healthcare Safety Network diate S.aureus phenotype. J Clin Micro occurrence of other spotted fever

124 Communicable and Environmental Diseases and Emergency Preparedness Annual Report group Rickettsiae in ticks from Ten- Tuberculosis: Schaffner W, Jones TF. 2011. Ele- nessee. Am J Trop Med Hyg Blackman A, May S, Devasia RA, Ma- phant-to-human transmission of tuber- 2010;83:653-7. ruri F, Stratton C, Sterling TR. Micro- culosis. Emerg Infect Dis 17(3):366– colonies in fluoroquinolone agar pro- 71. Arbovirus: portion susceptibility testing of Myco- Murphree R, Dunn JR, Schaffner W, bacterium tuberculosis: an indicator of Pettit AC, Kaltenbach LA, Maruri F, Jones TF. 2011. La Crosse Encephali- drug resistance. Eur J Clin Microbiol Cummins J, Smith TR, Warkentin JV, tis surveillance using single versus Infect Dis. 2012 Feb 10. [Epub ahead Griffin MR, Sterling TR. Chronic paired serologic testing. Zoonoses and of print]. PMID: 22322359. lung disease and HIV infection are Public Health 59:181–183. risk factors for recurrent tuberculosis Cain KP, Garman KN, Laserson KF, in a low-incidence setting. Int J Tuberc Other: Ferrousler-Davis OP, Miranda AG, Lung Dis. 2011 Jul;15(7):906- Reilly M, Schillie S, Smith E, Poissant Wells CD, Haley CA. Moving toward 11. PMID:21682963. PMCID: T, Vonderwahl C, Gerard K, Baum- tuberculosis elimination implementa- PMC3172045. gartner J, Mercedes L, Sweet K, Muleta tion of statewide targeted tuberculin D, Zaccaro D, Klevens M, Murphy T. testing in Tennessee. AJRCCM Environmental Epidemiology: Increased risk of acute hepatitis B 2012:186:273-279. George J. Indoor Air Investigation at among adults with diagnosed diabetes a Day Care, Memphis, Shelby County, mellitus. J Diabetes Science and Tech- Maruri F, Sterling TR, Kaiga AW, Tennessee. Tennessee Department of nology 2012:6:858-866. Blackman A, van der Heijden YF, Health, Nashville, TN, January 26, Mayer C, Cambau E, Aubry A. A sys- 2012 (report). Levi J, Schaffner W, Cimous M, tematic review of gyrase mutations Guidos R, Segal LM. Adult associated with fluoroquinolone- George J. Air Investigation, Bruce Immunization: shots to save lives. An resistant Mycobacterium tuberculosis and Road, Dickson, Dickson County, Ten- issue brief from Trust for America’s a proposed gyrase numbering system. J nessee. Tennessee Department of Health and the Infectious Diseases Antimicrob Chemother. 2012 Apr;67 Health, Nashville, TN, April 9, 2012 Society of America. Feb 2010, pp 1- (4):819-31. Epub 2012 Jan 25. PMID: (report). 28. 22279180. PMCID: PMC3299416. George J. Updated Evaluation of Air MacFarquhar JK, Melstrom P, Van der Heijden YF, Maruri F, Black- Sampling Results for the Tokheim Hutchison R, Broussard D, Wolkin A, man A, Holt E, Warkentin JW, Shep- Site, Jasper, Marion County, Tennes- Martin C, Burk RF, Dunn JR, Green herd BE, Sterling TR. Fluoroquino- see. Tennessee Department of Health, AL, Hammond R, Schaffner W, Jones lone exposure prior to tuberculosis Nashville, TN, June 6, 2012 (report). TF. Acute selenium toxicity associated diagnosis is associated with an in- with a dietary supplement. Arch Int creased risk of death. Int J Tuberc George J. Wright Medical Technology Med 2010;170:256-261. Lung Dis. 2012 July 12. Inc., Air Sampling Results Evaluation, Arlington, Shelby County, Tennessee. Maloney J, Newsome A, Huang J, Kir- Devasia R, Blackman A, Eden S, Li H, Tennessee Department of Health, by J, Kranz M, Dunlap B, Yabsley M, Maruri F, Shintani A, Alexander C, Nashville, TN, August 8, 2012 Dunn JR, Jones TF, Moncayo AC. Kaiga A, Stratton CW, Warkentin J, (report). Seroprevalence of Trypanosoma cruzi in Tang YW, Sterling TR. High propor- raccoons from Tennessee. J Parasitol tion of fluoroquinolone-resistant Myco- George J. 9053 Middlebrook Pike Air 2010;96:353-358. bacterium tuberculosis isolates with novel Sampling Results Evaluation, Knox- gyrase polymorphisms and a gyrA re- ville, Knox County, Tennessee. Ten- Rowland ME, Maloney J, Cohen S, gion associated with fluoroquinolone nessee Department of Health, Nash- Yabsley MJ, Huang J, Kranz M, susceptibility. J Clin Microbiol. 2012 ville, TN, October 3, 2012 (report). Wateska A, Dunn JR, Carpenter LR, Apr;50(4):1390-6. Epub 2011 Dec 21. Jones TF, Moncayo AC. Factors associ- PMID: 22189117. PMCID: Gorham R., George J. CDC’s Updat- ated with exposure to Trypanosoma PMC3318526. ed Recommendations on Children’s cruzi among domestic canines in Ten- Blood Lead Levels. Emerging Infection nessee. J Parasitol 2010;96:547-51. Murphree R, Warkentin JV, Dunn JR, Program Annual Day, Nashville, TN,

125 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

October, 2012 (poster presentation). 2011 (report). Gorham R. Tiger Cleaners, Memphis, Shelby County, Tennessee. Tennessee Mukhopadhyay, S. Tennessee’s Na- George J. Former Lawson’s Cleaners Department of Health, Nashville, TN, tional Toxic Substance Incidents Pro- Update, Memphis, Shelby County, May 5, 2011 (report). gram: an Ongoing Journey. Tennessee Tennessee. Tennessee Department of Environmental Conference, King- Health, Nashville, TN, March 18, Kranz, M. Music TOXICity, USA Pre- sport, TN, March, 2012 (poster 2011 (report). liminary Results from First Year of presentation). Data Collection (2010) for the Nation- George J. Quad Industries Indoor Air al Toxic Substance Incidents Program Mukhopadhyay, S. Memphis: The Investigation, Bradford, Gibson Coun- (NTSIP). Presentation to the Regional Number One City of Chemical Relat- ty, Tennessee. Tennessee Department Epidemiology Meeting, Spencer, TN, ed Incidents in Tennessee. Council of of Health, Nashville, TN, April 2, April, 2011 (oral presentation). State and Territorial Epidemiologists 2011 (report). Annual Conference, Omaha, NE, Kranz, M. Music TOXICity, USA Ten- June, 2012 (poster presentation). George J. Kraus Model Cleaners In- nessee’s Implementation of the Na- door Air Evaluation, Memphis, Shelby tional Toxic Substance Incidents Pro- Mukhopadhyay S, Bottomley M. Un- County, Tennessee. Tennessee Depart- gram. Tennessee Environmental Con- derestimating Carbon Monoxide Poi- ment of Health, Nashville, TN, April ference, Kingsport, TN, March, 2011 soning Prevalence: Data from Tennes- 26 2011 (report). (oral presentation). see’s National Toxic Substance Inci- dents Program. Emerging Infection George J. Evaluation of the Vapor Kranz, M. Identifying Chemical Trans- Program Annual Day, Nashville, TN, Intrusion Investigation for the John- portation Routes and Prioritizing Vul- October, 2012 (poster presentation). son Controls Facility, Lexington, Hen- nerable Communities in East Tennes- derson County, Tennessee. Tennessee see through Mapping and Analysis of Borowski D. Fact Sheet for the Public Department of Health, Nashville, TN, Chemical Spill Incidents, 2010. Ten- Health Assessment for Smokey Moun- May 2, 2011 (report). nessee Geographic Information Coun- tain Smelters, Knoxville, Knox Coun- cil, Gatlinburg, TN, April, 2011 ty, Tennessee. Agency for Toxic Sub- George J. Evaluation of the Vapor (poster presentation). stances and Disease Registry, Atlanta, Intrusion Investigation for the Tok- GA, July 25, 2011 (report). heim Site, Jasper, Marion County, Mukhopadhyay, S. National Toxic Tennessee. Tennessee Department of Substance Incidents Program (NTSIP). Borowski, D. TN Dept of Health/ Health, Nashville, TN, May 27, 2011 Presentation to Methamphetamine PHA and ORAU Health Screening (report). Task Force, Nashville, TN, October, Results. Tennessee Environmental 2011 (presentation). Conference, Kingsport, TN, March, George J. Indoor Air Investigation, 2011 (oral presentation). IGI Adhesives and Vicinity, Nashville, Bashor B. Final Release of the Public Davidson County, Tennessee. Tennes- Health Assessment for the TVA King- Borowski, D. “The Day the Dam see Department of Health, Nashville, ston Fossil Plant Coal Ash Release, Broke…” TVA Coal Ash Release in TN, September 16, 2011 (report). Roane County, Tennessee. Agency for Tennessee. Kentucky Association of Toxic Substances and Disease Registry, Milk, Food, Environmental Sanitari- Gorham R. Security Signals, Inc., Atlanta, GA, September 7, 2010 ans / Kentucky Onsite Waste Water Oakland, Fayette County, Tennessee. (report). Association 41st Annual Educational Tennessee Department of Health, Conference, Louisville, KY, February Nashville, TN, February 25, 2011 Borowski, D. TVA Coal Ash Release… 2011 (oral presentation). (report). the TN Dept. of Health Story. ATSDR DHAC Site Rounds, Atlanta, GA, George J. Review of Receptor and Soil Gorham R. Rental Uniform Compa- June, 2010 (presentation). Gas Survey Report for the Memphis ny, Kingsport, Sullivan County, Ten- Pyramid Site, Memphis, Shelby Coun- nessee. Tennessee Department of Borowski, D. TVA/Kingston panel ty, Tennessee. Tennessee Department Health, Nashville, TN, April 18, 2011 discussion. Tennessee Environmental of Health, Nashville, TN, March 17, (report).

126 Communicable and Environmental Diseases and Emergency Preparedness Annual Report

Conference, Kingsport, TN, March, Manners, J. Pilot Study to Assess CRI Summit, Louisville, KY, 2012 2010 (presentation). Flood Related Well Water Contamina- (poster presentation). tion Via Ultrafiltration,Tennessee George J. Evaluation of Vapor Intru- American Water Resources Confer- Petersen P. Strategic National Stock- sion at a Restaurant, Memphis, Shelby ence, (AWRA), Montgomery Bell State pile CHEMPACK Chain of Custody County, Tennessee. Agency for Toxic Park, Dickson TN April 2011 (oral Form Quality Improvement Project, Substances and Disease Registry, At- presentation). 2012 Multi-State SNS-CRI Summit, lanta, GA, March 16, 2010 (report). Louisville, KY, 2012 (poster presenta- Manners J, Green, A, Carpenter, LR. tion). George J. ISS Oxford Building Ser- Public Perception and Possible Health vices Site, Memphis, Shelby County, Effects of a Large Water Utility Cross Petersen P. Strategic National Stock- Tennessee. Agency for Toxic Sub- Connection Event,Tennessee Ameri- pile Multi-Hospital Allocation Quality stances and Disease Registry, Atlanta, can Water Resources Conference, Improvement Project, 2012 Multi- GA, March 18, 2010 (report). (AWRA), Montgomery Bell State Park, State SNS-CRI Summit, Louisville, Dickson TN April 2010 (oral presenta- KY, 2012 (poster presentation). George J. Davis Mill Surface Water tion). SUB OU 1-D Gypsum Pond Area, Petersen P. Emergency Preparedness Copper Basin Mining District, Cop- Emergency Preparedness: Partnerships with Pharmacists, Lip- perhill, Polk County, Tennessee, EPA Choudhary E, Chen TH, Martin C, scomb University College of Pharma- Facility ID: TN0001890839. Agency Vagi S, Roth J Jr, Keim M, Noe R, cy, Nashville, TN, 2012 (oral presenta- for Toxic Substances and Disease Reg- Ponausuia SE, Lemusu S, Bayleyegn T, tion). istry, Atlanta, GA, April 22, 2010 Wolkin A. 2012. Public health needs (report). assessments of Tutuila Island, Ameri- Roth J. Rapid Assessment of Popula- can Samoa, after the 2009 tsunami. tions Impacted by Disasters (RAPID) George J. Alton Park Site #1, South Disaster Medicine and Public Health Toolkit, Career Epidemiology Field Side Health Department/Former Preparedness. 2012 Oct;6(3):209-16. Officer Annual Meeting, Atlanta, GA, Franklin Middle School/Former 36th doi: 10.1001/dmp.2012.40. August 2012 (oral presentation). Street Landfill Properties, Chattanoo- ga, Hamilton County, Tennessee. Petersen P. Catastrophic Earthquake Roth J. The Diverse and Integral Roles Agency for Toxic Substances and Dis- Medical Countermeasure Formulary of the HSO Epidemiologist., USPHS ease Registry, Atlanta, GA, May 3, Project, Lipscomb University College Scientific and Training Symposium, 2010 (report). of Pharmacy Scientific Presentation College Park, MD, May 2012 (oral Day, Nashville, TN, 2012 (poster presentation). George J. Residential Indoor Air In- presentation). vestigation, Egyptian Lacquer Manu- Roth J. Community Assessment of facturing Company, Inc. Franklin, Petersen P. Methadone and Evacuee Disaster-Associated Mental Health Williamson County, Tennessee, EPA Planning Data Sharing for Optimal Issues One Year Following 2010 Facility ID: TND093148682. Agency Patient Care, Integrated Medical, Pub- Flooding in Tennessee, Public Health for Toxic Substances and Disease Reg- lic Health, Preparedness and Response Preparedness Summit, Anaheim, CA, istry, Atlanta, GA, November 22, 2010 Training Summit, Nashville, TN, 2012 February 2012 (poster presentation). (report). (poster presentation). Roth J. Community Assessment One Environmental Health Specialists Petersen P. ESF-8 Patient Tracking Year Post-Flood – Davidson County, Network (EHS-Net): Force Multipliers, Integrated Medical, Tennessee, May 24 – 26, 2011, Public Luffman, IE, Manners, J, Environmen- Public Health, Preparedness and Re- Health Preparedness Summit, Ana- tal Risk Factors for Cryptosporidiosis sponse Training Summit, Nashville, heim, CA, February 2012 (poster in East Tennessee: 2000-2010,CDC TN, 2012. presentation). Water Sanitation, and Hygiene (WASH) Webinar, December 2012 Petersen P. CHEMPACK Optimiza- Brown KC, Horner N, Fankhauser M, (webinar presentation). tion: Historical Perspective and Future Roth J, Victoroff T. 2012. Assess- Best Practices, 2012 Multi-State SNS- ment of household preparedness

127 Communicable and Environmental Diseases and Emergency Preparedness Annual Report through training exercises — two met- mation systems (GIS) in Public Health ropolitan counties, Tennessee, 2011. and Medical Disaster Response, 10th Petersen P. Emergency Preparedness Morbidity and Mortality Weekly Re- Annual Middle TN Forum On Geo- and Response, Belmont School of port, 61(36);720-722, 201. graphical Information Systems, Ruth- Pharmacy: State Public Health Policy erford Co., TN, November 2011 (oral Course, Nashville, TN, 2010. Casey-Lockyer M, Donald CM, presentation). Moulder J, Aderhold D, Harris D, Petersen P. Emergency Preparedness Woodall G, Young D, MacAloney B, Roth, J. Prevalence of Wuchereria and Response, University of Tennes- Carbin G, Morrison M, Chester T, bancrofti Infection in American Sa- see College of Pharmacy: State Public Roth J, Noe R, Schnall A, Wolkin A, moa After Seven Years of Mass Drug Health Policy, Nashville, TN, 2010. Vagi S, Mertzlufft CE, Sugerman D, Administration with Diethylcarbamaz- Chiu C. 2012. Tornado-related fatali- ine and Albendazole, American Socie- Petersen P. Pandemic Medical Coun- ties — five states, southeastern United ty of Tropical Medicine and Hygiene termeasures, Chattanooga State Com- States, April 25–28, 2011. Morbidity (ASTMH) 60th Annual Meeting, Phil- munity College Pandemic Pharmacy and Mortality Weekly Report, 61(28); adelphia, PA, December 2011 (poster Workshop, Chattanooga, TN, 2010. 529-533. presentation). Roth J. Community Needs Assess- Petersen P. Strategic National Stock- Roth J. Applying Epidemiology Dur- ment for Public Health Emergency pile: CHEMPACK Overview, Home- ing Officer Deployments: Disaster Response (CASPER) in Tennessee, land Security District #4 Chemical Epidemiology Following an Earth- TN Regional Epidemiology Meeting, Nerve Agent Workshop, Cookeville, quake and Tsunami in American Sa- Nashville, TN, April 2010 (oral presen- TN,2011. moa in 2009, Epidemiology Interest tation). Group Session, USPHS Scientific and Petersen P. SNS Warehouse Opera- Training Symposium, New Orleans, Roth J. Community Needs Assess- tions Workshop, Warehouse Task- LA, June 2011 (oral presentation). ment for Public Health Emergency force Briefing, Nashville, TN, 2011. Response Following the Earthquake Petersen P. Strategic National Stock- and Tsunami in American Samoa, Peterson P. Interstate/Cross-Border pile: Medical Countermeasure Man- 59th Annual Epidemic Intelligence CHEMPACK Planning, 2011 Multi- agement, U.S. Public Health Service Service (EIS) Conference, Atlanta, State SNS-CRI Summit: The Road to Commission Corps Applied Public GA, April 2010 (oral presentation). Readiness, Chattanooga, TN, 2011. Health Team Deployment, Nashville, TN, 2010. Peterson P. Prepositioned Medical Countermeasures: TN Perspective, Petersen P. Responding to the H1N1 Tennessee Department of Health Pandemic: A Project Management Per- Commissioner Level Briefing, Nash- spective, Project Management Insti- ville, TN, 2011. tute, Nashville, TN, 2010.

Petersen P. Strategic National Stock- Peterson P. Tennessee Department of pile: Medical Countermeasure Man- Health H1N1 Influenza Response in agement, University of Tennessee Col- Review, May 2010 Severe Weather lege of Pharmacy: State Public Health and Flooding: TN Perspective Pa- Policy, Nashville, TN, 2011. tient Tracking Interoperability Systems and Exercises, 2010 Multi-State SNS- Petersen P. SNS Warehouse Opera- CRI Summit, Biloxi, MS, 2010. tions Medical Countermeasure Man- agement and Distribution, Warehouse Peterson P. CHEMPACK Medical Taskforce Enlistment Briefing, Nash- Assets, Tennessee National Guard ville, TN, 2011. 45th Civil Support Team: Medical Countermeasure Briefing, Smyrna, Roth J. The Role of Geographic Infor- TN, 2010.

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