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Home , Chlamydia, Gonorrhea

D R A F T • 4/5/2018 Infectious Disease • Sexually Transmitted Vermonters Diagnosed with Sexually Transmitted Infections Vermont Reportable Disease Surveillance / Vermont Enhanced HIV/AIDS Reporting System • 2010–2016 n Female n Male • Infectious Disease Surveillance New Diagnoses 2010–2016 n White n People of Color The incidence of infectious disease in Vermont is sex 72 % 28 % less common than chronic disease. Still, we must HIV Chlamydia race 86 % 14 % keep a close watch as new risks emerge due to age: <19 3,354 83 2 5 drug resistance, novel infections and zoonotic 20–39 8,650 520 49 47 sex 45% 55% Gonorrhea agents. And generations of Vermonters who have race 83 % 17 % never experienced outbreaks of life-threatening 40–69 340 68 44 44 69+ 3 0 0 0 sex 7 % 93 % infectious diseases may not understand the risks Syphilis of an under-vaccinated population. Total 12,347 671 95 96 race 89 % 11 % median annual 1,727 97 9 13 sex 20 % 80 % diagnoses HIV Disease reporting enables officials to race 72 % 24 % collect, analyze and distribute data about illness and death. Reporting helps to describe disease trends, identify outbreaks, and control the sources of infection. The information helps us find and treat people who may have been exposed, plan Chlamydia Cases Gonorrhea Cases disease prevention campaigns, and educate the Vermont Reportable Disease Surveillance • 2006–2016 Vermont Reportable Disease Surveillance • 2006–2016 health care community and residents. # of Vermonters diagnosed each year with chlamydia # of Vermonters diagnosed each year with gonorrhea • Sexually Transmitted Infections Chlamydia, gonorrhea, syphilis and HIV are sexually transmitted infections that must be reported by health care providers to the Health Department. 100 Most people who have a sexually transmitted infection do not have immediately recognizable 1800 80 symptoms, and this delays treatment. Early treat- Female 1400 60 Female/Other 59 ment can mean a longer and better quality of life. 1,354 This is why it’s important for sexually active people 1000 897 40 36 to have appropriate and comprehensive testing 22 31 600 21 based on their personal sexual risks. Having an un- Male 550 20 294 11 Non-MSM treated sexually transmitted infection also increas- 200 Men having Sex with Men es a person’s risk for acquiring HIV. In Vermont, 2006 | 2008 | 2010 | 2012 | 2014 | 2016 2006 | 2008 | 2010 | 2012 | 2014 | 2016 men who have sex with men are disproportion- ately affected by gonorrhea and HIV.

8 • State Health Assessment 2018 HIV Testing, by Population HIV Viral Suppression • Chlamydia Vermont Behavioral Risk Factor Surveillance System • 2016 Vermont Enhanced HIV/AIDS Reporting System • 2016 Chlamydia is the most commonly reported Vermont Youth Risk Behavior Survey • 2015 % of people with viral suppression among Vermonters living infectious disease in the U.S and Vermont. It is % of adults age 18–64 tested in the past 12 months with diagnosed HIV infection in 2016 preventable, but cases continued to rise since 2004, especially among younger people. Females usually have no symptoms, but infection can result Asian/Pacific Islander 7% of HIV infections in Vermonters in pelvic inflammatory disease–a major cause of 94% have been virally suppressed Black 21% , ectopic and chronic pelvic Hispanic 8% pain. Females are diagnosed more than twice as Native American 11% often as males, often when seeking reproductive Female 93 % White, non-Hispanic 8% health services. This may account for the greater Male 94 % number diagnosed between age 15 and 24. Males Multi-racial 14% rarely have health problems linked to chlamydia. Other/unknown 8% Transgender 100 % • Gonorrhea Adolescents (grades 9 to12) Vermont’s overall rates of gonorrhea are well below who have ever been tested 10% age < 20 91 % the national average. Males and females have been almost equally affected in past years, but in age 20–39 88 % 2016 most cases were among men who have sex HIV Testing, by Gender with men. Between 2014 and 2015 there was a Vermont Behavioral Risk Factor Surveillance System • 2016 age 40–69 95 % steep increase in cases among females for reasons age 70+ 95 % that are unclear. Untreated gonorrhea can cause n n LGBT Heterosexual serious and permanent health problems in both Ever been tested– males and females. The emergence of multi-drug 65% resistant gonorrhea in other states makes early 52% Asian/Pacific Islander 92 % diagnosis and treatment a pressing health priority. 36% 35% Black 90 % • Suppressing the HIV Hispanic 100 % Compared to most of the U.S., Vermont has a relatively small number of people living with HIV. White, non-Hispanic 94 % Male Female Most Vermonters living with HIV are in medical Other 92 % care, take , and are virally suppressed. Tested in last 12 months– A person who is virally suppressed has very low race unknown 85 % 26% levels of virus in their body. Viral suppression 21% lowers a person’s infectiousness, and the risk of 7% 5% to others. Testing is recommended Male Female for nearly everyone who is sexually active.

Vermont Department of Health • 9 D R A F T • 4/5/2018 Birth Dose of Infectious Disease • Immunization National Immunization Survey • 2006–2016 % of children 19–35 months old who have received a dose of hepatitis B vaccine at birth • Vaccinate for a Healthy Life have repeatedly been shown to be safe and effective in preventing infectious diseases. 100% A person who is immunized is protected against 90% vaccine-preventable diseases or severe illness, and 80% helps prevent disease outbreaks in the community. 70% 71% 60% U.S. The overall immunization rate for children young- 50% 50% 49% 40% er than 3 years is improving. In 2016, 77% were 30% Vermont immunized with the full series of recommended 20% 20% vaccines, higher than the national average of 71%. 10% Still, one in four children in this age group have not received the full series of these vaccines. 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Early Childhood Immunizations National Immunization Survey • 2006–2016 Varicella Vaccination & Disease Rates Vermont Reportable Disease Surveillance • 2006–2016 MMR Vermont 95% measles, mumps, rubella New England 96% % of Vermont children age 19–35 months who are vaccinated, and the # of varicella cases in the Vermont population each year U.S. 91% 92% 92% DTaP Vermont 87% 85% 86% 87% diptheria, tetanus, pertussis New England 91% 81% 83% 83% 80% U.S. 83% 78% 77% % of Vermont children vaccinated Hep A Vermont 57% hepatitis A New England 66% Year: 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 U.S. 61%

Hep B (birth dose) Vermont 49% 33 hepatitis B New England 74% 50 U.S. 71% 112 117 100 118 130 145 Rotavirus Vermont 81% New England 82% U.S. 74% 323 # of varicella cases each year in Vermont Combined Vermont 77% 380 vaccine series New England 80% U.S. 71% 789

10 • State Health Assessment 2018 Pertussis Cycles • Hepatitis B Vaccine at Birth Vermont Reportable Disease Surveillance • 2007–2016 Hepatitis B is a life-threatening liver infection 149 caused by a virus. All should receive a dose # cases of pertussis per 100,000 people spike year of hepatitis B vaccine at birth. This is important because 90% of infants who contract the disease become chronic carriers and are at risk for liver cancer. Yet of all the states, Vermont has the lowest 46.3 rate of hepatitis B vaccine dose given at birth.

27.1 • Varicella (Chickenpox) 28.5 18.0 Higher rates of varicella vaccination correlate with 9.6 6.6 7.8 lower numbers of cases of the disease. A second 3.9 4.2 dose of vaccine at 4 to 6 years is recommended. In 2016, 5- to 9-year-olds accounted for 22% of all 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 cases of varicella, down from 58% in 2006. # of cases = 112 24 26 41 170 933 176 60 49 290 • Pertussis (Whooping ) Pertussis outbreaks tend to occur in waves, with peaks every three to five years. Vaccination rates Vaccination Exemptions in Kindergarten Vaccination Among Adults Age 65+ in Vermont are high: 94% of Kindergarteners and Vermont Annual Immunization Report • 2013–2017 Vermont Behavioral Risk Factor Surveillance System • 2007–2016 93% of 7th graders are appropriately vaccinated. % of incoming Kindergarteners in Vermont who have exemptions % of Vermonters age 65+ receiving the annual flu shot and the from required vaccinations, by school year one-time pneumococcal vaccine • Vaccines for Kindergarten Entry Since the 2013-14 school year, non-medical n Philosophical exemption n Religious exemption exemptions from vaccines for school entry have decreased, and vaccination rates have increased 6.3% 6.1% 100 5.6% to 94% for all students in grades K through 12. The 80 Adults age 65+ receiving annual flu shot philsophical exemption was eliminated in 2016. 77% 5.9% 5.8% 4.6% 3.9% 60 59% • Vaccines for Older Adults 40 Older adults are at high risk for serious illness and death from flu and pneumococcal , 20 shaded area = Those who have ever received the pneumococcal vaccine but vaccination rates are low. Vermonters age 65+ .9% 3.7% .2% – .1% – who have a college degree are more likely to get Medical Exemptions: .2% .2% .1% .2% | 2008 | 2010 | 2012 | 2014 | 2016 the flu vaccine than those with less education. 2013-14 2014-15 2015-16 2016-17 School Year

Vermont Department of Health • 11 D R A F T • 4/5/2018 Infectious Disease • Ticks & Mosquitoes Tickborne Disease Cases Cases Vermont Reportable Disease Surveillance • 2016 Vermont Reportable Disease Surveillance • 2008–2016 # of cases reported, per 10,000 people # of cases of Lyme disease in Vermont, per 100,000 people • The Emergence of Tickborne Diseases Vermont is home to Lyme disease and at least Grand Isle Franklin Orleans four other tickborne diseases, several of which are 17.5 4.7 1.5 Essex 1.6 becoming increasingly common in the state. Lamoille female male Vermont has one of the highest rates of Lyme Chittenden 5.5 Caledonia age 6.5 4.9 disease in the U.S., and other tickborne diseases Washington 30.3 0–4 43.6 such as and babesiosis are emerging. 6.0 Addison 70.6 5–9 92.0 These diseases cause a range of health outcomes, 15.9 Orange 15.9 from self-limiting to death. 39.8 10–14 74.1 higher rate Rutland 30.8 Windsor 22.2 15–19 39.6 Tickborne diseases are both preventable and 30.1 treatable. A timely diagnosis can help patients 21.9 20–24 33.9 avoid further health complications. All cases that Bennington lower rate 25.0 25–29 44.0 are diagnosed in Vermont must be reported to the 55.6 Windham 26.5 Health Department. 30.7 30–34 38.4 32.1 35–39 49.2 • Lyme Disease, Anaplasmosis, Babesiosis Tickborne Disease Reports Vermont Reportable Disease Surveillance • 2008–2016 There is geographic variation in the incidence of 33.2 40–44 51.8 tickborne diseases. Southern counties have the # of cases of Lyme Disease, Anaplasmosis & other tickborne 44.8 45–49 58.8 highest rate of tickborne disease reporting. diseases (Babesiosis & ) Bennington County has by far the highest rate of 61.7 50–54 75.7 763 tickborne diseases cases in the state. 70.0 55–59 78.7 60–64 • Who is most affected by ticks? Lyme Disease 76.5 89.0 All Vermonters are at risk, but some groups are 81.2 65–69 84.8 more at risk than others. People who spend time 83.0 70–74 61.6 outdoors for work or recreation are more likely to 67.3 75–79 75.6 encounter ticks that can spread these diseases. 404 32.5 80–84 72.1 Children and older adults have the highest num- 201 bers of confirmed cases of Lyme disease. Older 19.8 85+ 24.4 Anaplasmosis adults and males have the highest numbers of cases of anaplasmosis. 3 Other 21 2008 | 2010 | 2012 | 2014 | 2016

12 • State Health Assessment 2018 Anaplasmosis Cases West Nile Virus & EEE in Mosquito Pools • Mosquito-borne Disease Monitoring Vermont Reportable Disease Surveillance • 2008–2016 Vermont Arbovirus Surveillance • 2013–2017 During the summer months, mosquitoes are # of cases of anaplasmosis in Vermont, per 100,00 people Towns where one or more mosquito pools have been found to monitored for mosquito-borne diseases. Each contain West Nile virus, Eastern Equine Encephalitis (EEE), or both week, mosquitoes are collected at various locations around the state by the Vermont Agency of Agriculture, Food & Markets. These collections female male of mosquitoes are tested by the Health Depart- age ment Laboratory for diseases that affect 0 0–4 .7 humans, such as West Nile virus and Eastern equine encephalitis (EEE). 2.7 5–9 .6

3.1 10–14 1.8 Like tickborne diseases, every human case of West Nile virus and EEE diagnosed in Vermont must be 15–19 .5 1.9 reported to the Health Department. 2.6 20–24 1.4 • Mosquitoes & West Nile Virus 3.8 25–29 2.5 Based on years of monitoring, risk for West Nile 1.9 30–34 2.6 virus appears to be widespread across the state. 3.1 35–39 8.8 West Nile virus activity has been detected in all counties in birds, mosquitoes, people or animals. 1.1 40–44 4.5 However, during the 2017 season, only 89 of 4,288 4.7 45–49 8.9 mosquito pools tested positive for West Nile virus.

4.3 50–54 17.1 In 2017, human infections with West Nile virus 13.7 55–59 14.2 were identified in Chittenden, Addison and Grand Isle counties. 11.2 60–64 25.5 12.5 65–69 23.2 • Mosquitoes & EEE No human cases of Eastern equine encephalitis 20.3 70–74 31.4 (EEE) have been reported in Vermont since 2012. 18.3 75–79 35.4

23.8 80–84 31.4 Two areas of the state are considered to be at low risk based on detections of EEE virus in mosquito 12.3 85+ 27.8 pools in the past 10 years: western Franklin county, and northern Rutland/southern Addison counties.

Vermont Department of Health • 13 D R A F T • 4/5/2018 Infectious Disease • Other Conditions Vermont Department of Health

• Diseases Reportable to Public Health Reportable Diseases The Health Department depends on health care Reportable: professionals to identify and report certain diseases. Any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other illness of major public health concern, because of the severity of illness or potential for epidemic spread, which may indicate a newly recognized infectious agent, an This enables public health officials to investigate outbreak, epidemic, related public health hazard or act of bioterrorism. and act quickly to control the spread of disease. ◼ Anaplasmosis ◼ Hepatitis C ◼ Rubella (German Measles) ◼ AIDS ◼ Hepatitis E ◼ Rubella, Congenital Rubella ◼ Anthrax ◼ Human immunodeficiency virus Syndrome Hepatitis C, tuberculosis and are three ◼ Arboviral disease (HIV) ◼ Salmonellosis examples of infectious diseases of public health ◼ Babesiosis ◼ Influenza: Report only ◼ Severe Acute Respiratory Syndrome (SARS) ◼ Blood lead levels – Individual cases of influenza due to a novel ◼ Shiga toxin-producing E. coli (STEC) significance that affect some groups of people ◼ Botulism strain of Influenza A ◼ more than others. ◼ – Pediatric influenza-related deaths ◼ Smallpox ◼ – Institutional outbreaks ◼ Streptococcal disease, Group A, ◼ infection ◼ Legionellosis invasive ◼ • Health Care-Associated Infections (HAIs) ◼ ◼ Streptococcal disease, Group B, ◼ Creutzfeldt-Jakob disease/transmissible ◼ invasive (infants less than 1 month Health care-associated infections are infections spongiform encephalopathies of age) ◼ Lyme Disease ◼ Cryptosporidiosis ◼ pneumoniae disease, that patients can acquire while receiving medical ◼ Malaria ◼ Cyclosporiasis invasive ◼ Measles (Rubeola) treatment in a health care facility. HAIs are a major, ◼ Dengue ◼ Syphilis ◼ , bacterial ◼ Diphtheria ◼ Tetanus yet often preventable, threat to patient safety. ◼ ◼ Eastern Equine Encephalitis ◼ ◼ Middle East Respiratory Syndrome ◼ Ehrlichiosis ◼ Sepsis is a potentially life-threatening (MERS) Trichinosis ◼ Encephalitis ◼ Tuberculosis of infection, and may occur in health care settings. ◼ Mumps ◼ Gonorrhea ◼ ◼ Pertussis () ◼ Guillain-Barré Syndrome ◼ ◼ ◼ influenzae disease, ◼ ◼ Varicella (Chickenpox only) Some HAIs are caused by , or fungi invasive Poliovirus infection, including poliomyelitis ◼ Viral hemorrhagic fever ◼ Hantavirus disease that are resistant to one or more antimicrobials ◼ ◼ Vibriosis ◼ Hemolytic Uremic Syndrome (HUS) ◼ ◼ West Nile Virus used to treat these infections. This makes HAIs ◼ Hepatitis A ◼ Rabies, human and animal cases ◼ Yellow Fever ◼ Hepatitis B dangerous for all people, but especially for those ◼ Reye Syndrome ◼ ◼ Hepatitis B, positive surface antigen ◼ who are immunocompromised. difficile in a pregnant woman

(C. diff) is one example of an -resistant Treatment: Human rabies postexposure treatment (HRPET) is reportable even when no evidence of rabies has been found. bacteria that causes serious diarrheal illness, and Reporting of Diseases can be picked up from contaminated surfaces or The law requires that health care providers report diseases of public health importance. Persons who are required to report: health care providers, infection preventionists, laboratory directors, nurse practitioners, nurses, physician assistants, physicians, school spread from the hands of a health care worker. health officials and administrators of long-term care and assisted living facilities. Cases of reportable diseases should be reported to the Health Department within 24 hours. Immediate notification is essential for diseases marked by a telephone symbol ( ).

Older people are most affected by sepsis and C. Consultation and Inquiries 24/7: difficile, likely because they tend to interact more 802-863-7240 or 1-800-640-4374 (VT only) often with the health care system.

HealthVermont.gov DEPARTMENT OF HEALTH effective 3/26/15

14 • State Health Assessment 2018 Hepatitis C Cases Tuberculosis Cases • Hepatitis C is a life-threatening viral infection Vermont Reportable Disease Surveillance • 2006–2016 Vermont Reportable Disease Surveillance • 2004–2016 of the liver. Since 2014, 800 to 900 cases of hepatitis # of Vermonters diagnosed with hepatitis C, per 100,000 people # of Vermonters diagnosed with tuberculosis, per 100,000 people C have been reported in Vermont residents each year, most commonly among (born 1945-1965) and injection drug users. 278.6 268.4 • Active Tuberculosis disease is rare in Vermont, age 20–29 5.1 233.7 but still affects a few people each year. From 2003 221.8 U.S. to 2016, 82 cases were reported. Foreign-born and people of color are disproportionately affected. 2.9 age 30–59 • Salmonellosis. Vermont Reportable Disease 90.8 Surveillance data shows that while children under age 10 make up just 11% of the population, they age 60+ 1.3 Vermont 1.0 23.4 accounted for 41% of salmonellosis due to contact 17.7 <19 9.3 with live poultry. 2006 | 2008 | 2010 | 2012 | 2014 | 2016 | 2004 | 2006 | 2008 | 2010 | 2012 | 2014 | 2016 625 Salmonella cases 2011–2015 age <10 : — all others — 112 total 513 88 24 Clostridium Difficile Cases Sepsis Cases 59 Vermont Uniform Hospital Discharge Data Set • 2007–2016 Vermont Uniform Hospital Discharge Data Set • 2009-2016 were contracted through contact with live poultry # of Vermonters diagnosed with C. diff, per 10,000 people # of Vermonters diagnosed with sepsis, per 10,000 people 41% of live poultry-related cases of salmonellosis are among children under 10 7.9 13.1 • Clostridium Difficile is the #1 cause of age 65+ infectious diarrhea in hospitalized patients in the U.S. The rate of C. difficile is increasing in Vermont. Older adults with current or previous antibiotic use and receiving medical care are at highest risk 8.6 for infection.

2.9 • Sepsis cases in Vermont appear to have sharply decreased over the past decade. This may reflect age 18–64 1.5 1.1 better recognition of sepsis in hospitalized 0 <18 0.2 patients. In 2016, sepsis was the cause of 217 | 2008 | 2010 | 2012 | 2014 | 2016 2009 2010 2011 2012 2013 2014 2015 2016 deaths among Vermonters.

Vermont Department of Health • 15