June 2019 Florida Department of Health - Hillsborough County EpiNotes Disease Surveillance Newsletter

Director Douglas Holt, MD 813.307.8008 Articles and Attachments Included This Month

Medical Director (HIV/STD/EPI) Health Advisories and Alerts 1 Charurut Somboonwit, MD 813.307.8008 May 2019 Reportable Disease Summary 2

Medical Director (TB/Refugee) Florida Food Recalls 5 Beata Casanas, MD 813.307.8008 CDC Vaccine Schedules App for Healthcare Providers 5

Medical Director (Vaccine Outreach) County Influenza Report 6 Jamie P. Morano, MD, MPH CDC Health Advisory #420 7 813.307.8008 National HIV Testing Day 10 Community Health Director Leslene Gordon, PhD, RD, LD/N Candida auris Update 13 813.307.8015 x7107 Arboviral Clinician Letter and One Pagers 15 Disease Control Director Carlos Mercado, MBA Reportable Diseases/Conditions in Florida, Practitioner List 23 813.307.8015 x6321 FDOH, Practitioner Disease Report Form 24 Environmental Administrator Brian Miller, RS 813.307.8015 x5901 Health Advisories, News, and Alerts Epidemiology Michael Wiese, MPH, CPH 813.307.8010 Fax 813.276.2981 • CDC Health Advisory #420: Nationwide Shortage of Tuberculin Skin Test Antigens: CDC Recommendations for Patient Care and TO REPORT A DISEASE: Public Health Practice Epidemiology 813.307.8010 • CDC Travel Notices:

After Hours Emergency • Global Outbreak Notice - Measles is in many 813.307.8000 countries and outbreaks of the disease are occurring around the world. Before you travel internationally, regardless of HIV/AIDS Surveillance where you are going, make sure you are protected fully Erica Botting against measles. If you are not sure, see your healthcare 813.307.8011 provider at least one month before your scheduled departure. Lead Poisoning • Hajj in Saudi Arabia - The Hajj, or pilgrimage to Mecca, Saudi Cynthia O. Keeton Arabia, is one of the world’s largest mass gatherings. In 2019, 813.307.8015 x7108 Fax 813.272.6915 Hajj will take place August 9–14. Because of the crowds,

Sexually Transmitted Disease mass gatherings such as Hajj are associated with unique Sophia Romeus health risks. Before you go, visit a travel health specialist for 813.307.8045 Fax 813.307.8027 advice, make sure you are up-to-date on all routine and travel-related vaccines, and learn about other health and Tuberculosis safety issues that could affect you during your trip. Irma B. Polster 813.307.8015 x4758 Fax 813.975.2014

Mission: To protect, promote & improve the health of all Ron Desantis people in Florida through integrated state & community 1 Governor efforts. Scott A. Rivkees, MD Vision: To be the Healthiest State in the Nation State Surgeon General

January-May Reportable Disease Summary - Enteric

May YTD 2016-2018 Average 140 May YTD 2019

109.7

84.7 85

38 30.3 34.7 12 24.7 25 10.7 17

Campylobacteriosis Cryptosporidiosis Escherichia coli, Shiga Giardiasis Salmonellosis Shigellosis toxin-producing (STEC)

January-May Reportable Disease Summary - Other Common Reportable Infections

27 May YTD 2016-2018 Average

23.7 23 Two cases of mumps were reported May YTD 2019 related to an increase of cases at the 18.0 University of Florida. Read more here: https://shcc.ufl.edu/2019/06/03/mum ps-prevention-treatment/

6.3 6 5 4 4 1.3 3.7 0.0 1.0 0 2.7 0

Mumps Pertussis Varicella Listeriosis Meningitis Meningococcal Legionellosis Vibriosis (Bacterial, Disease Cryptococcal, Mycotic) These vaccine reportable diseases are summarized monthly in the state Vaccine Preventable Disease Report, which is available online at: http://www.floridahealth.gov/diseases-and-conditions/vaccine-preventable- disease/vaccine-preventable-disease-report-archive.html

2 June 2019

January-May Reportable Disease Summary - Viral Hepatitis

May YTD 2016-2018 Average 634.7 527 May YTD 2019

127.7 143 97

33 23 15.3 10.3 3.7

Hepatitis A Hepatitis B (Acute) Hepatitis C (Acute) Hepatitis B (Chronic) Hepatitis C (Chronic)

Hillsborough County is currently January 2018 to May 2019 Case Summary Total Number of cases 181 experiencing a large increase in Number of cases acquired in Florida or Unknown 169 infections of hepatitis A, which is Age a viral transmitted Mean 40 through the fecal-oral route. Median 38 There is a vaccine available to Min-max 7-71 prevent hepatitis A. Cases by Age Category Number (%) 0-18 1 (1) 19-29 32 (19) Cases Who Report Drug Use 30-39 59 (35) 40-49 49 (29) as a Risk Factor 50-59 21 (12) 60+ 7 (4) Gender Number (%) Female 51 (30) 14% Male 118 (70) Unknown gender 0 Race Number (%) 27% 59% White 143 (85) Black 10 (6) Other 14 (8) Unknown race 2 (1) Ethnicity Number (%) Non-Hispanic 146 (86) Yes No Unknown Hispanic 18 (11) Unknown ethnicity 5 (3)

3 June 2019

January-May Reportable Disease Summary – Arboviral Infections

Cases of any infection are reported based on the county where the person’s home address is. Hillsborough County has reported infections of imported mosquito-borne diseases every year, which means the individual was infected while traveling outside of the county. Hillsborough County has not had any infections of chikungunya, dengue, zika, or malaria acquired through mosquitos in our county in 2018 or 2019. The Florida Department of Health releases a weekly arboviral surveillance report that is available here: http://www.floridahealth.gov/%5C/diseases-and- conditions/mosquito-borne-diseases/surveillance.html

5.7 May YTD 2016-2019 Average May YTD 2019 4

1.3 1 1.0 1 0.7 0 0.7 0 Chikungunya Dengue Lyme Disease Malaria Zika

The data in these charts represent the most common reportable diseases investigated by the Epidemiology Program. All of the state’s reportable disease data is available for the public to search on FL CHARTS here: http://www.flhealthcharts.com/charts/CommunicableDiseases/default.aspx To build your own search, click on the link for “Reportable Diseases Frequency Report”. The case numbers for 2018 and 2019 are provisional and subject to change until the yearly database is closed, usually around April of the following year. Once the numbers are finalized, the state puts together a comprehensive Florida Annual Morbidity Statistics Report that details case trends and notable outbreak investigations. The report for 2017 and previous years are available at: http://www.floridahealth.gov/diseases-and- conditions/disease -reporting-and-management/disease-reporting-and-surveillance/data- and-publications/fl-amsr1.html

4 June 2019

Florida Food Recalls (May 25, 2019 – June 25, 2019)

Brand Name Food Date of Health Risk Recall Great Value and Tipton Frozen Blackberries and Frozen 6/20/2019 Norovirus Details Grove Mixed Berries Woodstock Organic Grilled Red Peppers 6/19/2019 Listeria monocytogenes Details

Table 87 Frozen Pork and Beef Pizza Products 6/14/2019 Without Benefit of Inspection Details

King Arthur Flour Unbleached All-Purpose Flour 6/13/2019 E. coli Details

Kroger Frozen Private Selection Berries 6/7/2019 Hepatitis A Details

Table 87 Frozen Pork Pizza Products 6/6/2019 Without Benefit of Inspection Details J Deluca Fish Company Siluriformes Products 5/29/2019 Without Benefit of Inspection Details Inc. Richwell Group, Inc. Siluriformes Products 5/28/2019 Without Benefit of Inspection Details

CDC Vaccine Schedules App for Health Care Providers

Use CDC’s Vaccine Schedules app. to access recommended immunization schedules and footnotes.

This free tool provides the most current version of the • Adult schedule, including recommended vaccines for adults by age group and by medical conditions • Adult contraindications and precautions table • Child and adolescent schedule with vaccine recommendations for patients aged birth – 18 years • Catch-up schedule for patients aged 4 months - 18 years Features of the App • Colors match printed schedules • Hyperlinked vaccine name opens as a pop-up with dose specifics • Related vaccine resources and websites • Any changes in the schedules will be released through app updates

For more information please visit: Immunization Schedules for Health Care Providers.

5 June 2019

Hillsborough County Monthly Influenza Report (Weeks 21-24, 2019)

Flu Level: Recent Flu Activity (May 19 -June 15) Mild • Visits to emergency departments and urgent care centers continues to decline (Figure 1). • The number of positive flu labs reported decreased, and are mostly influenza A. • One ILI outbreak was reported in week 21 in a retirement community. 11 residents were ill with ILI symptoms and one was positive for influenza A. Flu Trend: • No pediatric mortalities were reported in the previous four weeks. Decreasing Flu Activity This Season (September 30 – June 15)

• Total Outbreaks: Twenty outbreaks of influenza or ILI have been reported during the 2018-2019 flu season. • Total Deaths: Hillsborough County has reported no pediatric mortalities in the For statewide data current flu season. see the Florida Flu Review.

Figure 1: In weeks 21-24, the percent of emergency department and urgent care center visits for ILI* in Hillsborough County decreased and are within levels seen in previous seasons.

*Electronic Surveillance System for the Early Notification of Community-based Epidemics (ESSENCE-FL) measures trends in ILI visits from emergency departments (ED) and urgent care clinics (UCC). Participating EDs and UCCs in Hillsborough County (n=21) electronically transmit visit data into ESSENCE-FL daily or hourly. The ESSENCE-FL ILI syndrome captures visits with chief complaints that include the words “influenza” or “flu,” or chief complaints that include the words “fever” and “cough,” or “fever” and “sore throat.”

6 June 2019

This is an official CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network June 6, 2019, 1130 ET (11:30 AM ET) CDCHAN-00420

Nationwide Shortage of Tuberculin Skin Test Antigens: CDC Recommendations for Patient Care and Public Health Practice

Summary The Centers for Disease Control and Prevention (CDC) is expecting a 3 to 10 month nationwide shortage of APLISOL®, a product of Par Pharmaceuticals. APLISOL® is one of two purified-protein derivative (PPD) tuberculin antigens that are licensed by the United States Food and Drug Administration (FDA) for use in performing tuberculin skin tests. The manufacturer notified CDC that they anticipate a supply interruption of APLISOL® 5 mL (50 tests) beginning in June 2019, followed by a supply interruption of APLISOL® 1 mL (10 tests) in November 2019. The expected shortage of APLISOL® 1 mL (10 tests) could occur before November 2019, if demand increases before then. The 3-10 month timeframe for the nationwide shortage is the manufacturer’s current estimate and is subject to change.

To monitor the status of this supply interruption, visit FDA’s “Center for Biologics Evaluation and Research (CBER)-Regulated Products: Current Shortages” webpage: https://www.fda.gov/vaccines- blood-biologics/safety-availability-biologics/cber-regulated-products-current-shortages .

Background Two types of immunological methods are used for detecting Mycobacterium tuberculosis infection: tuberculin skin tests (TSTs) and interferon-gamma release assay (IGRA) blood tests. TSTs and IGRAs are used for diagnosing latent TB infection and may aid in diagnosing TB disease. Additional evaluation and testing is necessary to distinguish between latent TB infection and TB disease, and to determine the correct treatment (1). When findings, such as chest radiography and mycobacterial cultures, are sufficient for confirming or excluding the TB diagnosis, the results from a TST or an IGRA blood test might not be needed (1). Most TB cases in the United States are diagnosed with a set of findings including results from one of these tests.

Two FDA-approved PPD tuberculin antigens are available in the United States for use in performing TSTs: TUBERSOL® and APLISOL®. In controlled studies, the concordance between the two products is high (2).

When TB disease is strongly suspected, specific treatment should be started regardless of results from TST or an IGRA blood test (3,4).

Recommendations CDC recommends three general approaches to prevent a decrease in TB testing capability because of the expected shortage of APLISOL®. • Substitute IGRA blood tests for TSTs. Clinicians who use the IGRA blood tests should be aware that the criteria for test interpretation are different from the criteria for interpreting TSTs (3). • Substitute TUBERSOL® for APLISOL® for skin testing. In cross-sectional studies, the two skin test products give similar results for most patients. • Prioritize allocation of TSTs, in consultation with state and local public health authorities. Prioritization might require the deferment of testing some persons. CDC recommends testing only for persons who are at risk of TB (5-7). High-risk groups for TB infection include: o People who are recent contacts exposed to persons with TB disease; o People born in or who frequently travel to countries where TB disease is common; o People who currently or used to live in large group settings, such as homeless shelters or correctional facilities; o People with weaker immune systems, such as those with certain health conditions or taking certain medications that may alter immunity; and o Children, especially those under age 5, if they are in one of the risk groups noted above.

While overall test concordance is high, switching between PPD skin test products or between TSTs and blood tests in serial testing may cause apparent conversions of results from negative to positive or reversions from positive to negative. This may be due to inherent inter-product or inter-method discordance, rather than change in M. tuberculosis infection status (3,8). Clinicians should assess test results based on the person’s likelihood of infection and risk of progression to TB disease, if infected (1).

In settings with a low likelihood of TB exposure, the deferment of routine serial testing should be considered in consultation with public health and occupational health authorities. Annual TB testing of health care personnel is not recommended unless there is a known exposure or ongoing transmission (8).

References 1. Lewinsohn, David M., et al. "Official American Thoracic Society/Infectious Diseases Society of America/Centers for Disease Control and Prevention clinical practice guidelines: diagnosis of tuberculosis in adults and children." Clinical Infectious Diseases 64.2 (2017): e1-e33. https://academic.oup.com/cid/article/64/2/e1/2629583

2. Villarino ME, Burman W, Wang Y, et al. Comparable specificity of 2 commercial tuberculin reagents in persons at low risk for tuberculous infection. JAMA. 1999;281(2):169–171. http://dx.doi.org/10.1001/jama.281.2.169

3. Centers for Disease Control and Prevention. Updated guidelines for using interferon gamma release assays to detect Mycobacterium tuberculosis infection — United States, 2010. MMWR 2010;59(RR- 5): 1-25. https://www.cdc.gov/mmwr/PDF/rr/rr5905.pdf

4. Nahid, Payam, et al. "Official American Thoracic Society/Centers for Disease Control and Prevention/Infectious Diseases Society of America clinical practice guidelines: treatment of drug- susceptible tuberculosis." Clinical Infectious Diseases 63.7 (2016): e147-e195. https://academic.oup.com/cid/article/63/7/e147/2196792

5. Centers for Disease Control and Prevention. Targeted tuberculin testing and treatment of latent tuberculosis infection. MMWR 2000;49(RR-6): 1-51. https://www.cdc.gov/mmwr/PDF/rr/rr4906.pdf

6. Centers for Disease Control and Prevention. Guidelines for the investigation of contacts of persons with infectious tuberculosis; recommendations from the National Tuberculosis Controllers Association and CDC, and Guidelines for using the QuantiFERON®-TB Gold test for detecting Mycobacterium tuberculosis infection, United States. MMWR 2005;54(No. RR-15): 1-47. https://www.cdc.gov/mmwr/pdf/rr/rr5415.pdf

7. US Preventive Services Task Force. Screening for latent tuberculosis infection in adults: US Preventive Services Task Force recommendation statement. JAMA. 2016;316(9):962–969. DOI: http://dx.doi.org/10.1001/jama.2016.11046

8. Sosa LE, Njie GJ, Lobato MN, et al. Tuberculosis screening, testing, and treatment of U.S. health care personnel: recommendations from the National Tuberculosis Controllers Association and CDC, 2019. MMWR Morb Mortal Wkly Rep 2019;68:439–443. DOI: http://dx.doi.org/10.15585/mmwr.mm6819a3

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national, and international organizations. ______

Categories of Health Alert Network messages: Health Alert Requires immediate action or attention; highest level of importance Health Advisory May not require immediate action; provides important information for a specific incident or situation Health Update Unlikely to require immediate action; provides updated information regarding an incident or situation HAN Info Service Does not require immediate action; provides general public health information

##This message was distributed to state and local health officers, state and local epidemiologists, state and local laboratory directors, public information officers, HAN coordinators, and clinician organizations##

June 25, 2019

NO-COST HIV TESTING AND MORE TO HIGHLIGHT HIV TESTING DAY IN TAMPA BAY

CONTACT: Kevin Watler [email protected] o: (813) 307-8044 c: (813) 298-2024

Tampa Bay, FL — National HIV Testing Day, June 27, has been observed since 1995 to raise awareness about the importance of HIV testing and early diagnosis of HIV. This year’s theme, “Doing It My Way,” highlights how and why people make testing a part of their lives.

To encourage people to know their HIV status within minutes, the Florida Department of Health in Citrus, Hernando, Hillsborough, Manatee, Pasco, Pinellas and Polk counties are teaming up to provide numerous opportunities in the Tampa Bay area for no-cost HIV testing on Thursday, June 27, at the following locations and times.

• Citrus County HIV testing from 1 to 4 p.m. at: o Citrus Health Department: 3700 W. Sovereign Path in Lecanto • Hernando County HIV testing available by appointment. Call 352-540-6800. • Hillsborough County HIV testing (includes no-cost testing for chlamydia, gonorrhea and , and no-cost hepatitis A and HPV vaccines) from 7:30 a.m. to 2 p.m. at: o University Area Health Center: 13601 N. 22nd St. in Tampa o Specialty Care Center: 1105 E. Kennedy Blvd in Tampa • Manatee County HIV testing (includes no-cost hepatitis A vaccines) from 9 a.m. to 5 p.m. at: o Manatee Health Department: 410 6th Ave. E. in Bradenton • Pasco County HIV testing (includes no-cost testing for hepatitis C and no-cost hepatitis A vaccines) from 3 to 9 p.m. at: o The Asylum Nightclub: 6153 Massachusetts Ave. in New Port Richey • Pinellas County HIV testing from 8 a.m. to 5 p.m. at: o St. Petersburg Health Department: 205 Dr. Martin Luther King Jr. St. N. o Pinellas Park Health Department: 6350 76th Ave. N. o Mid-County (Largo) Health Department: 8751 Ulmerton Rd. o Clearwater Health Department: 310 N. Myrtle Ave. o Tarpon Springs Health Department: 301 S. Disston Ave. • Polk County HIV testing from 10 a.m. to 3 p.m. at: o Auburndale Health Department: 1805 Hobbs Rd. o Bartow Specialty Care Clinic: 1255 Brice Blvd. o Haines City Health Department: 1700 Baker Ave. E. o Lakeland Health Department: 3241 Lakeland Hills Blvd. o Walgreens: 311 E. Memorial Blvd. in Lakeland In 2017, 116,944 Floridians were confirmed to be living with HIV. An estimated 18,000 more were living with HIV but unaware of it. “To see these numbers come down in our state, we need to recognize the role of stigma as a barrier to getting tested,” said department HIV/AIDS Section Administrator Laura Reeves. “Normalizing HIV testing and making sure there’s a testing option that works for everyone is one way to reduce stigma. This is important, because knowing your HIV status gives you the power to make informed decisions about your health. Our goal is to work with our partners to make sure every Floridian has that power.”

For more information, please call 1-800-FLA-AIDS or visit KnowYourHIVStatus.com.

About the Florida Department of Health The department, nationally accredited by the Public Health Accreditation Board, works to protect, promote and improve the health of all people in Florida through integrated state, county and community efforts.

Follow us on Facebook, Instagram and Twitter at @HealthyFla. For more information about the Florida Department of Health please visit www.FloridaHealth.gov.

Don’t miss this free event! When: Thursday, June 27, 2019 from 7:30 a.m. to 2 p.m. Testing Locations: University Area Health Center 13601 North 22nd Street, Tampa, FL 33613

Specialty Care Center 1105 E. Kennedy Blvd., Tampa, FL 33602 Free Testing for Teens and Adults • HIV, Chlamydia, Gonorrhea, Syphilis

Free Vaccines for Teens and Adults • Hepatitis A and HPV

The documentary CHOICES will play at noon. This is an inspiring story of a family living with HIV. Candida auris Update: Information for Clinicians and Laboratorians Version 5.0 June 20, 2019 CDC: www.cdc.gov/fungal/candida-auris www.cdc.gov/fungal/candida-auris/health-professionals.html

Contact the state and county health department if Candida auris infection or colonization is suspected. This is a nationally notifiable disease of public health concern. State points of contact: Nychie Dotson, MPH, CIC [email protected]; CAPT Greg Eckert-Raczniak, MD, PhD [email protected]

This is an update to Florida Department of Health (FDOH) detection and reporting guidance for multidrug- resistant Candida auris (C. auris). We are actively identifying cases in Miami-Dade and Broward counties. This important emerging fungal pathogen causes invasive infections, can be misidentified using standard laboratory methods, persists in the environment, and is transmitted in health care settings. The spread of C. auris may be particularly high in nursing homes and other long-term care facilities which provide ventilator care. The Centers for Disease Control and Prevention (CDC) reports 54% of C. auris infections are identified in blood. C. auris bloodstream infections have a 30-day mortality rate of 39% and a 90-day rate of 58%.1 Globally, 93% of isolates show resistance to fluconazole and 41% have resistance to at least two antifungal drug classes. As of April 30, 2019, the CDC reported 654 confirmed cases of C. auris infection in 12 states. Since 2017, FDOH has identified 20 clinical cases of C. auris and 30 colonizations in Florida (including four clinical cases) for a total of 41 confirmed cases. FDOH is responding to the spread of C. auris by implementing a CDC containment strategy. Working with county health departments and facilities, FDOH provides ongoing technical assistance for conducting surveillance, working with laboratories to use proper methods to detect C. auris, guidance to facilities for hand hygiene, environmental cleaning, and contact precaution strategies. These are essential elements for containment. Without urgent action for containment, it is likely Florida will follow the trend of other U.S. and international locations and C. auris will become endemic.

Recommendations: 1. Test and identify all Candida isolates obtained from the bloodstream and other normally sterile invasive body sites (e.g., cerebrospinal fluid). • C. auris is commonly misidentified as Candida haemulonii and other Candida species, as conventional biochemical identification is not reliable for speciation. More information can be found at CDC: www.cdc.gov/fungal/candida-auris/recommendations.html

2. Test Candida isolates from non-sterile, non-invasive sites to determine species when: • Clinically indicated in the care of a patient. • A case of C. auris infection or colonization has been detected in your facility or unit. • An increase in unidentified Candida species infections in a patient care unit is identified. • The patient has had inpatient health care at a facility outside the United States in the previous one year, especially if in a country with documented C. auris transmission: www.cdc.gov/fungal/candida-auris/tracking-c-auris.html#world. Note: Colonization for longer than one year has been identified among some C. auris patients; consider determining the Candida species isolated from patients with remote exposure to health care abroad.

3. Screen patients who are at high risk of C. auris, including:

1 https://wwwnc.cdc.gov/eid/article/24/10/18-0649_article

03/01/2019

• Close health care contacts of patients with newly identified C. auris infection or colonization. • Patients who have had inpatient health care exposures outside the United States. • Patients who have infection or colonization with carbapenemase-producing gram-negative bacteria. C. auris co-colonization with these organisms has been observed regularly.

Please contact FDOH for assistance. Screening is available at no cost.

Infection Prevention Measures:  Place patients with C. auris infection or colonization in a single patient room on contact precautions.  Enforce good hand hygiene practices.  Clean and disinfect rooms of patients with C. auris infection or colonization (daily and terminal) using an Environmental Protection Agency-registered hospital-grade disinfectant effective against Clostridioides difficile spores (i.e., List K: www.epa.gov/pesticide-registration/list-k-epas-registered- antimicrobial-products-effective-against-clostridium agents).  Communicate the patient’s C. auris status when transferring them to other facilities.

Reporting: Immediately notify the state and county health department at 813-307-8010 if C. auris is suspected or identified to arrange confirmatory testing and conduct surveillance screening.

Ron DeSantis Mission: Governor To protect, promote & improve the health of all people in Florida through integrated state, county & community efforts.

Vision: To be the Healthiest State in the Nation

June 12, 2019

Dear Health Care Provider,

The Florida Department of Health (FDOH) would like to remind health care providers of the importance of reporting suspect non-endemic mosquito-borne disease cases to your county health department immediately upon suspicion () or immediately upon suspicion during business hours (Zika, dengue, chikungunya). Other mosquito-borne diseases endemic to Florida, such as West Nile virus illness, Eastern equine encephalitis, and St. Louis encephalitis are reportable by the next business day. For more information on these endemic diseases, please visit: www.floridahealth.gov/diseases-and-conditions/mosquito-borne- diseases/index.html.

Local introduction of one or more non-endemic viruses has occurred annually since 2009, when infected travelers were bitten by mosquitoes while in Florida, leading to vector-borne transmission to other people. Prompt reporting of suspect cases helps ensure county health department and local mosquito control officials are able to rapidly implement appropriate control measures.

Zika, dengue, chikungunya, and yellow fever viruses circulate in many of the same areas of the world. The diseases they cause are often difficult to differentiate clinically and co-infections are possible. Providers should consider all relevant mosquito-borne diseases when evaluating, testing, and managing ill individuals with recent travel. The Centers for Disease Control and Prevention (CDC) Yellow Book is an on-line, open access travel health reference that includes the geographic distribution of many diseases associated with international travel: wwwnc.cdc.gov/travel/page/yellowbook-home. Laboratory testing for Zika, dengue and chikungunya is available commercially. In addition, testing for Zika, dengue, and chikungunya can be requested through your county health department for suspect local cases or for uninsured patients meeting clinical criteria. Yellow fever testing is available through your county health department for patients meeting clinical criteria. Additional information on these criteria are enclosed.

Florida Department of Health Division of Disease Control and Health Protection 4052 Bald Cypress Way, Bin A-09 • Tallahassee, FL 32399 PHONE: 850/245-4732 • FAX: 850/922-8743

FloridaHealth.gov

Page Two June 12, 2019

Please educate patients on precautions that should be taken to avoid mosquito bites while traveling and at home, including:  Use EPA-registered insect repellent with any of the following active ingredients: o DEET o Oil of lemon eucalyptus o Picaridin o IR3535

It is safe for pregnant or nursing women to use EPA-approved repellents if applied according to package label instructions.

 Cover skin with long-sleeved shirts and long pants. o Apply a permethrin repellent directly to clothing or purchase pre-treated clothing. Follow the manufacturer’s directions and do not apply directly to skin.  Keep mosquitoes out of homes and other buildings. o Use air conditioning and maintain intact screens on windows and doors.  Travelers can protect family members and prevent infection of local mosquitoes by avoiding mosquito bites for at least three weeks following return home.  Protect family members by draining standing water near residences and businesses at least weekly to keep local mosquito populations low and prevent local introductions.

Additional virus-specific precautions include:

 Zika virus o Zika virus infection during pregnancy can cause certain birth defects, including microcephaly. Pregnant women in any trimester should consider postponing travel to areas where Zika virus transmission is ongoing. Pregnant women who must travel to these areas should talk to their doctors or other health care providers first, and strictly follow steps to avoid mosquito bites during the trip. o There is a risk of sexual transmission of Zika virus. Pregnant women and their sexual partners should consistently and correctly use condoms or other barrier precautions, or abstain from sex for the duration of the pregnancy if the partner travels to an area with Zika virus activity. o Women and men trying to become pregnant should consult with their health care providers before traveling to areas with Zika virus activity and strictly follow steps to prevent mosquito bites during the trip. Couples should consider delaying attempts to become pregnant for two months following the female partner’s travel to Zika-active areas. Couples should consider delaying attempts to become pregnant for three months if male partners traveled to Zika-active areas.

 Yellow fever virus o An FDA-approved yellow fever vaccine is recommended for travelers visiting endemic countries. Additional information on clinics offering the vaccine as well as vaccine recommendations for specific countries are available on the CDC’s website: www.cdc.gov/yellowfever/vaccine/index.html.

Page Three June 12, 2019

Mosquito-borne disease-related resources:  CDC Yellow Book health information for providers consulting with international travelers: wwwnc.cdc.gov/travel/page/yellowbook-home  CDC Health Alert Network (HAN) travel-related disease alerts: emergency.cdc.gov/han/index.asp  FDOH mosquito-borne disease information, including current Florida surveillance data: www.floridahealth.gov/diseases-and-conditions/mosquito-borne-diseases/index.html  CDC mosquito-borne disease prevention information: www.cdc.gov/westnile/prevention/index.html  FDOH county health department contact information: www.floridahealth.gov/diseases-and-conditions/disease-reporting-and-management/index.html

Thank you for supporting public health!

Sincerely,

Carina Blackmore, DVM, PhD, Dipl ACVPM State Epidemiologist Director Division of Disease Control & Health Protection

Enclosed 5 pages

Zika Fever – Information for Clinicians Version 5 5/10/2019

Please contact your county health department immediately during business hours if you suspect a patient has Zika fever to ensure prompt mosquito control efforts.

While Zika virus transmission throughout the Americas has decreased since its introduction in 2015, the current risk of exposure in these countries and territories is unknown. In addition to the Americas and Caribbean, cases have been documented in Africa, Southeast Asia, the Indian subcontinent, and islands in the Pacific Ocean: wwwnc.cdc.gov/travel/page/zika-travel-information. Zika virus infection during pregnancy can cause certain birth defects, including microcephaly. Fetuses and infants of women infected with Zika virus during pregnancy should be evaluated for possible congenital infection and neurologic abnormalities. Zika virus infection has also been linked to Guillain-Barré syndrome (GBS).

Transmission occurs through the bite of an infected mosquito. Perinatal, in utero, sexual, transfusion and bodily fluid transmissions have also been reported. Potentially infected men or women with pregnant partners should either abstain from sex or use condoms consistently and correctly during intercourse for the duration of the pregnancy. Suspected Zika fever cases should be advised to avoid mosquito bites while ill to prevent infection of local mosquitoes.

Incubation period is approximately 3 to 14 days.

Clinical Presentation: Only about one in five people infected with Zika virus are symptomatic. Zika fever is a mild illness with symptoms similar to those of mild dengue fever or influenza. Symptoms can be treated; however, there is no medication to treat the disease and illness typically resolves within one week. Co- infections with dengue or chikungunya are possible and should be considered. Aspirin and other non-steroidal anti-inflammatory drugs are not advised in case of co-infection with dengue. Pregnant women with fever should be treated with acetaminophen.

Zika fever may include: • Acute fever (often low grade) • Conjunctivitis • Vomiting • Rash (may be pruritic) • Myalgia • Cough or sore throat in some • Arthralgia • Headache cases

Laboratory Testing: Polymerase chain reaction (PCR) can detect viral RNA in serum during the first week of illness and in urine for samples collected within two weeks of illness onset. Serum antibody tests are recommended for samples collected four or more days after illness onset. Dengue IgM antibody testing should be run on samples from patients with positive Zika IgM antibody tests due to cross-reactivity. Both Zika virus PCR and antibody testing are commercially available. Zika virus testing is available at the Florida Department of Health (FDOH) for symptomatic patients who are uninsured, potentially exposed uninsured asymptomatic pregnant women through the end of the first post-natal week, infants of potentially exposed pregnant women, suspected GBS cases with recent potential exposure to Zika, and suspected local cases meeting the criteria below.

Please contact your county health department to report on the same business day suspect Zika infections including:

• All persons with two or more of the following signs/symptoms: fever, maculopapular rash, arthralgia or conjunctivitis (GBS could follow) and a history of travel to an area reporting Zika virus activity in the two weeks prior to illness onset. • Suspect local cases in a county/area with no reported local Zika virus infections and three or more of the following signs/symptoms: fever, maculopapular rash, arthralgia and conjunctivitis. • Infant or fetus with microcephaly, intracranial calcifications, or abnormalities, or poor fetal outcome diagnosed after the first trimester and with history of travel to an area with Zika virus activity during pregnancy. Testing of both mother and infant is recommended; testing of the infant is still recommended even if the mother previously tested negative.

Resources: Hillsborough County Health Department: 813-307-8010 FDOH: www.zikafreefl.org CDC: www.cdc.gov/Zika

Yellow Fever – Information for Clinicians Version 2 5/10/2019

Please contact your county health department immediately if you suspect a patient has yellow fever.

Yellow fever (YF) is a mosquito-borne flavivirus that is endemic to tropical and subtropical areas of Trinidad and Tobago, Panama, South America and Sub-Saharan Africa. In 2017–2018, the Ministry of Health of Brazil reported an outbreak in several states, including areas near large cities and popular tourist destinations, resulting in several unvaccinated travelers becoming infected. While fewer cases have been identified in 2019, activity in Brazil continues and expansion into urban settings may increase the risk of infection in travelers to/from those areas.

Transmission occurs through the bite of an infected Aedes aegypti mosquito, which is present in Florida.

Incubation period is approximately three to six days.

Clinical Presentation: Yellow fever virus infections are generally asymptomatic or cause a mild, self-limited illness. If symptomatic, the patient is usually viremic during the initial symptomatic period, which lasts for approximately three days. Three clinical stages have been identified: infection, remission, and in approximately 15% of infected persons, progression to the toxic stage. The toxic stage is characterized by jaundice, hemorrhage, and multiorgan dysfunction or failure, including renal insufficiency, cardiovascular instability, organ ischemia, and death (20–50% fatality rate). YF signs and symptoms may include: • Acute fever • Backache • Jaundice • Chills • Myalgia • Hemorrhagic diathesis • Severe headache • Bradycardia with fever • Mucosal bleeding • Nausea (Faget’s sign) • Elevated serum transaminase • Vomiting • Scleral icterus

Laboratory Testing: For patients who meet the testing criteria below, polymerase chain reaction (PCR) at the Florida Department of Health (FDOH) is recommended for serum samples collected within three days after illness onset. Serum antibody tests are available for serum samples collected four or more days after illness onset. Commercial testing for YF is currently not available.

Prevention: An FDA-approved yellow fever vaccine from Sanofi Pasteur (YF-Vax) is recommended for travelers to endemic countries. However, due to recent manufacturing limitations, the YF-Vax will be unavailable until the end of 2019. The FDA has granted an expanded access investigational new drug (eIND) protocol for use of the yellow fever vaccine Stamaril, which has been used in more than 70 countries with comparable safety and efficacy to the currently available YF-Vax in the U.S. A listing of clinics approved to provide the Stamaril vaccine is posted at wwwnc.cdc.gov/travel/page/search-for-stamaril-clinics. Because other mosquito-borne diseases such as dengue and Zika circulate in the same areas, travelers should also use general precautions to avoid mosquito bites, including use of EPA-approved insect repellent such as DEET.

Please contact your county health department to report suspected YF cases and to request laboratory testing for patients meeting the following criteria: • All persons, including pregnant women, with two or more of the following signs/symptoms: acute fever, headache, backache, myalgia, Faget’s sign, jaundice/scleral icterus, mucosal bleeding, and history of travel to an area reporting YF activity in the week prior to illness onset. • Immediately report suspect local case (no recent travel) with three or more of the following signs/symptoms: acute fever, headache, backache, myalgia, nausea and vomiting, Faget’s sign, jaundice/scleral icterus, mucosal bleeding and no other identified cause.

Resources: Hillsborough County Health Department: 813-307-8010 FDOH: www.floridahealth.gov/diseases-and-conditions/yellow-fever/index.html CDC: www.cdc.gov/yellowfever/healthcareproviders/index.html West Nile Fever and Neuroinvasive Disease – Information for Clinicians

Please contact Hillsborough county health department (CHD) by the next business day if you suspect West Nile virus infection to ensure prompt mosquito control efforts.

Transmission: West Nile virus (WNV) is transmitted to humans primarily through the bites of infected mosquitoes. Other modes of transmission include blood transfusion and organ transplantation.

Incubation Period: 2 to 14 days.

Clinical Presentation: The clinical spectrum for WNV infection includes asymptomatic infection or mild illness (fever and headache), aseptic meningitis, and encephalitis that can progress to coma and death. West Nile virus infection cases are often categorized into two primary groups: neuroinvasive disease and non-neuroinvasive disease. Approximately 80% of those infected show no clinical symptoms. Twenty percent have mild symptoms, and less than 1% experience the neuroinvasive form of illness.

Neuroinvasive disease such as aseptic meningitis, encephalitis, or acute flaccid paralysis (AFP). Symptoms include: ▪ Fever ▪ Stiff neck ▪ Altered mental status ▪ Seizures ▪ Limb weakness ▪ Cerebrospinal fluid (CSF) pleocytosis ▪ Abnormal neuroimaging Non-neuroinvasive disease (e.g., West Nile fever). Symptoms include: ▪ Fever ▪ Headache ▪ Myalgias ▪ Arthralgias ▪ Rash ▪ Gastrointestinal symptoms

Patients at risk for severe disease: Individuals over 60 years of age Immunosuppressed patients

Laboratory Testing: Testing for WNV-specific IgM antibodies should be requested for serum specimens or CSF. XXX CHD can provide guidance on how and when to submit samples to the Florida Department of Health (FDOH) Bureau of Public Health Laboratories.

Resources: Hillsborough County Health Department phone number: 813-307-8010 FDOH: www.floridahealth.gov/diseases-and-conditions/mosquito-borne-diseases/index.html CDC: www.cdc.gov/westnile/index.html

Dengue Fever – Information for Clinicians Version 2.1 5/10/2019

Please contact your county health department (CHD) immediately during business hours if you suspect a patient has dengue to ensure prompt mosquito control efforts.

Dengue infection is caused by any of four distinct but closely related dengue virus (DENV) serotypes (called DENV-1, -2, -3, and -4). Dengue is currently the most frequent cause of acute febrile illness among returning U.S. travelers from the Caribbean, Central and South America, and Asia.

Transmission occurs through the bite of an infected mosquito. Dengue may also be transmitted from mother to fetus in utero or to neonate at parturition. An infected person should avoid mosquito bites while ill to prevent infection of local mosquitoes.

Incubation period is 3 to 14 days.

Clinical Presentation: Dengue fever can range from a mild non-specific febrile syndrome to classic dengue fever or “break-bone fever,” or in the most severe forms of the disease (2–4% of cases), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS). More than 20% of cases may be asymptomatic. Dengue should be considered when locally acquired infection is suspected or in persons who live in or have traveled to a dengue endemic area in the two weeks prior to symptom onset and have fever.

Dengue fever signs and symptoms may include: • Headache or retro-orbital pain • Anorexia and • Thrombocytopenia • Myalgia, bone pain, or nausea • Leukopenia arthralgia • Rash

Hemorrhagic fever or shock symptoms may appear after the febrile phase and include abdominal pain or tenderness, persistent vomiting, mucosal bleeding, liver enlargement, clinical fluid accumulation, or laboratory results indicating an increase in hematocrit concurrent with a rapid decrease in platelets.

Patients at risk for severe disease: • Previously infected with another • Infants • Chronic renal failure dengue virus • Sickle cell anemia • Elderly • Diabetes mellitus

Patients with suspected dengue fever also should be evaluated, tested and managed for possible Zika or chikungunya virus infection if travel was to areas where these viruses are present, as co-infection is possible.

Laboratory Testing: Polymerase chain reaction (PCR) can be used to detect viral RNA in serum samples collected during the first seven days post-symptom onset. Testing for DENV-specific IgM antibodies should be requested for serum specimens taken six or more days after onset. Approximately 20% of dengue patients who have been previously exposed to another dengue serotype may show elevated IgG titers and have transient or no elevated dengue IgM titers, making identification of such cases difficult without PCR testing on the acute sample. PCR testing is available commercially and is the only way to definitively diagnose acute cases. In 2018 alone, over 75 individuals tested PCR-positive for dengue virus after travel to affected areas. More than one third of these would not have been identified without complete dengue testing, including PCR. Your CHD can provide guidance on how and when to submit samples to the Florida Department of Health (FDOH) Bureau of Public Health Laboratories.

Resources: Hillsborough County Health Department: 813-307-8010 FDOH: www.floridahealth.gov/diseases-and-conditions/dengue/index.html CDC: www.cdc.gov/dengue/clinicallab/clinical.html

Chikungunya – Information for Clinicians Version 1.1 3/28/2018

Please contact your county health department (CHD) immediately during business hours if you suspect a patient has a chikungunya infection to ensure prompt mosquito control efforts.

Chikungunya, a dengue-like illness, has been identified in the Caribbean, Central America, and South America. Outbreaks have been documented in Africa, Southern Europe, Southeast Asia, the Indian subcontinent, and islands in the Indian and Pacific Oceans prior to the introduction into the Caribbean in December 2013. An infected person should avoid mosquito bites while ill to prevent infection of local mosquitoes.

Transmission occurs through the bite of an infected mosquito. Chikungunya infection can also occur in neonates (aged <1 month) via transmission from infected mothers during the intrapartum period.

Incubation period is 1 to 12 days.

Clinical Presentation: A majority of people infected with chikungunya virus become symptomatic. Relapse of joint pain and fatigue may occur within three months after acute illness. Chronic joint pain and fatigue of several weeks to years duration is seen in some patients, especially those >45 years of age or with preexisting joint disease. Persons at risk for more severe acute disease include neonates exposed intrapartum, adults >65 years of age, and persons with underlying medical conditions (e.g., hypertension, diabetes, or cardiovascular disease). Chikungunya fever signs and symptoms may include: • Acute fever • Myalgia • Polyarthralgia • Arthritis • Headaches • Rash

Patients with suspected chikungunya fever also should be evaluated, tested and managed for possible dengue virus infection if travel was to areas where both are present, as co-infection is possible. Aspirin is not advised in case of co-infection with dengue.

Laboratory Testing: Polymerase chain reaction (PCR) can be used to detect viral RNA in serum samples collected during the first week post-symptom onset. Virus-specific IgM and neutralizing antibody testing should be requested for serum specimens taken more than one week post-onset. Both acute less than one week post- onset) and convalescent (more than one week post-onset) sera should be collected. Your CHD can provide guidance on how and when to submit samples to the Florida Department of Health (FDOH) Bureau of Public Health Laboratories.

Please contact your county health department if you have a patient who has: • Acute onset of high fever and polyarthralgia with or without recent (two weeks prior to onset) travel to an endemic area including the Caribbean, and Central and South America.

Resources: Hillsborough County Health Department: 813-307-8010 FDOH: www.floridahealth.gov/diseases-and-conditions/chikungunya/index.html CDC: www.cdc.gov/chikungunya/hc/clinicalevaluation.html

Reportable Diseases/Conditions in Florida Practitioner List (Laboratory Requirements Differ) Per Rule 64D-3.029, Florida Administrative Code, promulgated October 20, 2016 Florida Department of Health

! Report immediately 24/7 by phone upon initial suspicion or laboratory test order www.FloridaHealth.gov/DiseaseReporting Report immediately 24/7 by phone  Report next business day www.FloridaHealth.gov/CHDEpiContact + Other reporting timeframe

! Outbreaks of any disease, any case, ! Haemophilus influenzae invasive  Pesticide -related illness and injury, cluster of cases, or exposure to an disease in children <5 years old acute infectious or non-infectious disease,  Hansen ’s disease (leprosy) ! Plague condition, or agent found in the general Hantavirus infection Poliomyelitis community or any defined setting (e.g., ! hospital, school, other institution) not Hemolytic uremic syndrome (HUS)  Psittacosis (ornithosis) listed that is of urgent public health Hepatitis A  Q Fever significance  Hepatitis B, C, D, E, and G Rabies, animal or human Acquired immune + Hepatitis B surface antigen in pregnant deficiency syndrome (AIDS)  ! Rabies, possible exposure women and children <2 years old Amebic encephalitis ! Ricin toxin poisoning Herpes B virus, possible exposure ! Anthrax  Rocky Mountain spotted fever and other  Herpes simplex virus (HSV) in infants spotted fever rickettsioses  Arsenic poisoning <60 days old with disseminated ! Rubella ! Arboviral diseases not otherwise listed infection and liver involvement; encephalitis; and infections limited to  St. Louis encephalitis  Babesiosis skin, eyes, and mouth; anogenital HSV  Salmonellosis Botulism, foodborne, wound, and ! in children <12 years old Saxitoxin poisoning (paralytic shellfish unspecified  + Human immunodeficiency virus (HIV) poisoning)  Botulism, infant infection ! Severe acute respiratory disease !  HIV-exposed infants <18 months old syndrome associated with coronavirus  California serogroup virus disease born to an HIV-infected woman infection  Human papillomavirus (HPV)-  Shigellosis  Campylobacteriosis associated laryngeal papillomas or + Cancer, excluding non-melanoma recurrent respiratory papillomatosis in ! Smallpox skin cancer and including benign and children <6 years old; anogenital Staphylococcal enterotoxin B poisoning borderline intracranial and CNS papillomas in children ≤12 years old Staphylococcus aureus infection, tumors ! Influenza A, novel or pandemic strains intermediate or full resistance to  Carbon monoxide poisoning vancomycin (VISA, VRSA) Influenza-associated pediatric mortality  Chancroid in children <18 years old  Streptococcus pneumoniae invasive disease in children <6 years old  Chikungunya fever  Lead poisoning (blood lead level ≥5 µg/dL)  Syphilis Chikungunya fever, locally acquired  Legionellosis Syphilis in pregnant women and  Chlamydia  Leptospirosis neonates ! Cholera (Vibrio cholerae type O1)  Tetanus Listeriosis  Ciguatera fish poisoning  Trichinellosis (trichinosis)  Lyme disease + Congenital anomalies  Tuberculosis (TB)  Lymphogranuloma venereum (LGV)  Conjunctivitis in neonates <14 days old Tularemia  Malaria !  Creutzfeldt -Jakob disease (CJD) (Salmonella serotype ! Measles (rubeola)  Cryptosporidiosis Typhi) ! Melioidosis  Cyclosporiasis ! Typhus fever, epidemic  Meningitis, bacterial or mycotic Vaccinia disease ! Dengue fever ! ! Meningococcal disease  Varicella (chickenpox) ! Diphtheria  Mercury poisoning  Eastern equine encephalitis ! Venezuelan equine encephalitis  Mumps  Vibriosis (infections of Vibrio species  Ehrlichiosis/anaplasmosis + Neonatal abstinence syndrome (NAS) and closely related organisms,  Escherichia coli infection, Shiga toxin- excluding Vibrio cholerae type O1) producing Neurotoxic shellfish poisoning ! Viral hemorrhagic  Giardiasis, acute Paratyphoid fever (Salmonella serotypes Paratyphi A, Paratyphi B, and  West Nile virus disease ! Glanders Paratyphi C) ! Yellow fever  Gonorrhea Pertussis ! Zika fever  Granuloma inguinale

*Subsection 381.0031(2), Florida Statutes, provides that “Any practitioner licensed in this state to practice medicine, osteopathic medicine, chiropractic medicine, naturopathy, or veterinary medicine; any hospital licensed under part I of chapter 395; or any laboratory licensed under chapter 483 that diagnoses or suspects the existence of a disease of public health significance shall immediately report the fact to the Department of Health.” Florida’s county health departments serve as the Department’s representative in this reporting requirement. Furthermore, subsection 381.0031(4), Florida Statutes, provides that “The Department shall periodically issue a list of infectious or noninfectious diseases determined by it to be a threat to public health and therefore of significance to public health and shall furnish a copy of the list to the practitioners…”

Practitioner Disease Report Form

Complete the following information to notify the Florida Department of Health of a reportable disease or condition. This9 can be filled in electronically.

Per Rule 64D-3.029, Florida Administrative Code, promulgated October 20, 2016 (laboratory reporting requirements differ).

Patient Information Medical Information SSN: MRN: Last name: Date onset: Date diagnosis: First name: Died: Yes No Unknown Middle: Hospitalized: Yes No Unknown Parent name: Hospital name:

Gender: Male If female, Yes Date admitted: Date discharged: Female pregnant: No Unknown Unknown Insurance:

Birth date: Death date: Treated: Yes No Unknown

Race: American Indian/Alaska native White Specify Asian/Pacific islander Other treatment: Black Unknown Laboratory Ethnicity: Hispanic Yes No Unknown Attach laboratory Non-Hispanic testing: result(s) if available Unknown Address: Provider Information ZIP: County: Physician: City: State: Address: Home phone: City: State: ZIP: Other phone: Phone: Emergency phone: Fax: Email: Email: To obtain local county health department contact information, see www.FloridaHealth.gov/CHDEpiContact. See www.FloridaHealth.gov/DiseaseReporting for other reporting questions. HIV/AIDS and HIV-exposed newborn notification should be made using the Adult HIV/AIDS Confidential Case Report Form, CDC 50.42A (revised March 2013) for cases in people ≥13 years old or the Pediatric HIV/AIDS Confidential Case Report, CDC 50.42B (revised March 2003) for cases in people <13 years old. Please contact your county health department for these forms (visit www.FloridaHealth.gov/CHDEpiContact to obtain contact information). Congenital anomalies and neonatal abstinence syndrome notification occurs when these conditions are reported to the Agency for Health Care Administration in its inpatient discharge data report pursuant to Chapter 59E-7 FAC. Cancer notification should be directly to the Florida Cancer Data System (http://fcds.med.miami.edu). All other notifications should be to the CHD where the patient resides. Reportable Diseases and Conditions in Florida Notify upon suspicion 24/7 by phone Notify upon diagnosis 24/7 by phone

Amebic encephalitis Gonorrhea Melioidosis Staphylococcus aureus infection, intermediate or full resistance to Anthrax Granuloma inguinale Meningitis, bacterial or mycotic vancomycin (VISA, VRSA) Arsenic poisoning Haemophilus influenzae invasive Meningococcal disease Streptococcus pneumoniae invasive disease in children <5 years old disease in children <6 years old Arboviral diseases not otherwise listed Mercury poisoning Hansen’s disease (leprosy) Syphilis Babesiosis Mumps Hantavirus infection Syphilis in pregnant women and Botulism, foodborne, wound, and neonates Neurotoxic shellfish poisoning unspecified Hemolytic uremic syndrome (HUS) Paratyphoid fever (Salmonella Tetanus

Botulism, infant Hepatitis A serotypes Paratyphi A, Paratyphi B, Trichinellosis (trichinosis) and Paratyphi C) Brucellosis Hepatitis B, C, D, E, and G Tuberculosis (TB) Pertussis California serogroup virus disease Hepatitis B surface antigen in pregnant women and children <2 years old Pesticide-related illness and injury, Campylobacteriosis Herpes B virus, possible exposure acute Typhoid fever (Salmonella serotype Typhi) Carbon monoxide poisoning Herpes simplex virus (HSV) in infants Plague Typhus fever, epidemic Chancroid <60 days old with disseminated Poliomyelitis infection and liver involvement; Vaccinia disease Chikungunya fever encephalitis; and infections limited to Psittacosis (ornithosis) Varicella (chickenpox) Chikungunya fever, locally acquired skin, eyes, and mouth; anogenital HSV Q Fever in children <12 years old Venezuelan equine encephalitis Chlamydia Human papillomavirus (HPV)- Rabies, animal or human Vibriosis (infections of Vibrio species associated laryngeal papillomas or Cholera (Vibrio cholerae type O1) Rabies, possible exposure and closely related organisms, recurrent respiratory papillomatosis in excluding Vibrio cholerae type O1) Ciguatera fish poisoning children <6 years old; anogenital Ricin toxin poisoning papillomas in children ≤12 years old Viral hemorrhagic fevers Conjunctivitis in neonates <14 days old Rocky Mountain spotted fever and Influenza A, novel or pandemic strains other spotted fever rickettsioses West Nile virus disease Creutzfeldt-Jakob disease (CJD) Influenza-associated pediatric mortality Rubella Yellow fever in children <18 years old Cryptosporidiosis St. Louis encephalitis Lead poisoning (blood lead level Zika fever Cyclosporiasis ≥5 ug/dL) Salmonellosis Outbreaks of any disease, any case, Dengue fever Legionellosis Saxitoxin poisoning (paralytic shellfish cluster of cases, or exposure to an poisoning) infectious or non-infectious disease, Diphtheria Leptospirosis Severe acute respiratory disease condition, or agent found in the Eastern equine encephalitis Listeriosis syndrome associated with coronavirus general community or any defined infection setting (e.g., hospital, school, other Ehrlichiosis/anaplasmosis Lyme disease Shigellosis institution) not listed above that is of Escherichia coli infection, Shiga toxin- Lymphogranuloma venereum (LGV) urgent public health significance. producing Smallpox Specify in comments below. Malaria Giardiasis, acute Staphylococcal enterotoxin B poisoning

Glanders Measles (rubeola) Comments: