The 2014 Annual Report Is a Project of the Fresno County Department of Public Health (FCDPH)

The 2014

Fresno County Department of Public Health Annual Report Acknowledgements

The 2014 Annual Report is a project of The Fresno County Department of Public Health (FCDPH). This research was supported by funds provided by the State of California for the purpose of public health surveillance.

FCDPH Author: Jared Rutledge, PhD Epidemiologist, Fresno County

FCDPH Advisory Group:

Ken Bird, MD, MPH Health Officer, Fresno County David Pomaville, MBA, REHS Director of Public Health, Fresno County David Luchini, RN, PHN Assistant Director of Public Health, Fresno County Joe Prado Division Manager Community Health, Fresno County

Suggested Citation:

Rutledge, J. T. (2015, November 20). Fresno County Department of Public Health: 2014 annual report. Retrieved from Fresno County Department of Public Health website: http://www.fcdph.org

Fresno County Department of Public Health Page 1 Table of Contents

1 Acknowledgements

2 Table of Contents

3 Executive Summary

4 Activities and Progress

12 Airborne Pathogens

16 Blood–Borne Pathogens

20 Food-Borne Pathogens

25 Sexually Transmitted Diseases

36 Vaccine Preventable Diseases

40 Vector-Borne Diseases

Fresno CountyDepartment Department of Public of Health Public Health Page 2

Executive Summary

Summary of Key Points: 2013 Compared to 2014

In the 2013 Annual Reports there were several trends that were noted. Some of the more interesting trends were the end of year increases in both tuberculosis and pertussis. Significant increases were also observed in syphilis. Rates in HIV/AIDS decreased slightly but were statistically insignificant and rates for gonorrhea and chlamydia stabilized. Lastly, west nile virus had a very low year in all classifications of illness.

In 2014, Fresno County observed significant changes in annual rates in several diseases. 2014 was an epidemic year for pertussis. Pertussis had not occurred at this level since 2010, which is expected for a disease that will behave in a cyclic pattern. Cyclical diseases usually occur in 3 to 5 year intervals. The acellular vaccine that is used to protect the population from this disease is not as protective as previous whole cell vaccines. That being stated, there is still significant protection from severe presentation of illness that would usually require hospitalization of infants and children.

There were several other diseases that observed a reduction in reported cases, which included valley fever, campylobacteriosis, and salmonellosis. Of the observed declines in morbidity only the reductions observed in valley fever were significant.

Focus Areas

Despite the decreases observed in gonorrhea and chlamydia, Fresno County continues to be one of the highest morbidity counties for these two diseases in the entire State of California. Additionally, Fresno Coun- ty observed the highest change in rate of congenital syphilis compared to the state and other counties starting in 2013. For the first time, this report explored the basic descriptive epidemiology of the cases of congenital syphilis.

It is important to note that many of the women who gave birth to babies positive with syphilis had a history of drug use, sex work, survival sex, and low utilization or no access to prenatal care. Fresno County has tak- en the steps to address its congenital syphilis problem through engaging with providers, conducting more timely investigations, and attempting to remove barriers to treatment both with OBGYN providers and patients.

Aside from the investigation and provider engagement regarding syphilis, Fresno County also began ap- proaching health care providers in the community to encourage policies such as expedited partner therapy and accurate, complete, and timely reporting of these diseases to Fresno County Department of Public Health.

Geographic Stability

Many of the diseases observed little to any significant change in the geographic distribution of reported cases throughout 2014. In fact, there appears to be fairly stable patterns from 2011-2014 in terms of where these diseases are present in the community. The Health Department along with community partners should take these factors into consideration when planning for the health of communities.

Fresno CountyDepartment Department of Public of Health Public Health Page 3

Activities and Progress

Disease: Tuberculosis Status 2014:

2011 Recommendations:

 To further improve the County’s ability to detect  The QFT testing equipment and testing LTBI and move in line with CDC guidelines have been adopted and are being recommendations the County should adopt QFT used under the recommendation of the public testing methodology. health physicians.  A policy and procedure should be crafted to  A policy designed to target testing of homeless, target testing of homeless, immigrants from immigrant population from endemic TB areas, endemic TB areas, and HIV positive individuals. and HIV positive individuals is under  The 9 week drug therapy should be utilized by development. providers and the public health department to maximize the likelihood of adherence and  The 9 week drug therapy for latent TB infection is completion of therapy to reduce the risk of explored for use with patients in the 2015 report. antibiotic resistant strains emerging in Fresno  Fresno County continues to recommend against County. universal screening for TB.  Universal screening is no longer recommended in Fresno County. Instead targeted screening of

specific at-risk individuals should be pursued.

Coccidioides (Valley Fever) Status 2014:

Recommendations:

 Providers should utilize targeted screening of  Fresno County Department of Public Health patients who present with pneumonia to the (FCDPH) continues to work with community Central San Joaquin Valley. providers to provide education on Valley Fever  Educational materials should be disseminated to and the populations at risk. schools and other organizations in areas that  Fresno County crafted developed educational experience a disproportionate burden of infec- pamphlets in English and Spanish and tion during: construction, wind storms, or other disseminated them to providers and community activity that might increase the local concentra- members in high risk areas of the county of tion of the Coccidioides immitis in the atmos- Fresno. Fresno County also updated the valley phere. fever website to make it easier to obtain  Air quality alerts for hazardous air days dis- information. pensed through CAHAN when there are natural  Fresno County regularly participates with local environmental conditions that are conducive to universities in regional activities designed to im- high concentrations of fungal spores such as prove surveillance and research of valley fever high wind advisories or warnings. within the community.

 Air quality alerts have not been standardized as of yet. There is insufficient research to support what conditions may put residents most at risk for exposure to the disease.

Fresno CountyDepartment Department of Public of Health Public Health Page 4

Activities and Progress

Disease: Hepatitis C Status 2014:

2011 Recommendations:

 FCDPH needs to engage with community,  FCDPH has participated in local and national academic, and medical partners to raise conferences on correctional health care awareness of HCV and recommend increase describing the epidemic within the county testing among high risk populations. boundaries.  Medical facilities and providers should screen all  FCDPH has worked with local prisons to provide patients with a history of IDU, HIV + status, and/or education and materials regarding hepatitis C blood transfusions prior to 1992. in their population along with trainings.  Providers should consider screening patients who were born between 1945 and 1965, have a  Medical facilities are aware of the new USPSTF confirmed HIV diagnosis, or have been (United States Preventative Services Task Force) incarcerated at any time. through a Hepatitis C conference hosted at Fres-  Implement additional local studies to identify the no State. factors contributing to high rates of HCV in  Local surveillance has been maintained and certain population groups. updates provided annually.  Fresno County needs to consider obtaining addi-  FCDPH has worked with a Community Based tional funding to allow additional in-depth Organization to provide education and research research on the burden of HCV to the County’s to community members, providers, and other at risk population. groups regarding the scope of the epidemic  FCDPH needs to continue to contribute to and the new recommendations put forth by professional and academic publications to CDC and USPSTF. promote awareness of HCV to counter the silent nature of this epidemic.

Food-Borne (Campylobacteriosis and Salmonellosis) Status 2014:

Recommendations:

 FCDPH should conduct population based  Studies have been conducted to determine the studies to enhance the understanding of the scope of campylobacter and their increases impact of campylobacteriosis in the County. annually. Results indicated that safe food handling and practices were needed to reduce  Increase awareness of community partners of these infections. Health Alerts and notifications the observed increase in campylobacteriosis have been periodically sent out to the commu- among residents of the County of Fresno. nity and news media to provide them that guid- ance.

 Investigations should be conducted on a portion  Presentations regarding the prevalence of of the cases of campylobacteriosis that occur in campylobacteriosis as well as other foodborne areas with disproportionate burden of disease. pathogens have been provided to community members at the Emerging Infectious Disease Task Force meetings in Fresno County. Hospitals were made aware and educated through presentations to infection control organizations.

Fresno CountyDepartment Department of Public of Health Public Health Page 5

Activities and Progress

Disease: HIV/AIDS Status 2014:

2011 Recommendations:

 FCDPH has worked with Community Regional  Health care providers and the public health Medical Center to research and evaluate the department should increase HIV testing efforts trends of opportunistic infections among the among 18-25 year old Black/African American county’s HIV/AIDs population. and Hispanic/Latino MSM populations in Fresno County.  FCDPH has continued to hold block parties, and attend events where high risk individuals participate and offer HIV testing.  Health care providers are strongly recommended to utilize the opt-out testing policy for their patients in Fresno County.  FCDPH have used heat maps to determine which communities are disproportionately high for HIV and sent the mobile testing facility to test  Inmates should be offered an HIV test upon be- in these high risk communities. ing admitted to all correctional facilities.

 In 2015, the health officer started a Facebook  FCDPH should utilize social media to provide page to start engaging the community in social outreach to the youth of Fresno County. media. All health related events and messages are also being posted through this media outlet.  The public health department should conduct survey research among the MSM population of  Focus groups and surveys have been attempted Fresno County to assess barriers to testing, per- to assess the needs of the MSM population in ceived societal pressures, adherence to thera- Fresno County. However, these have had histori- py, and other issues pertaining to HIV care. cally low participation and have not provided the health department with information beyond what has already been published on the topic.  The public health department needs to engage

with community partners such as faith-based organizations to disseminate educational materi-  FCDPH continues to work with faith based organizations to promote testing HIV in als. communities.

Fresno CountyDepartment Department of Public of Health Public Health Page 6 Activities and Progress

Disease: STDs Status 2014:

2011 Recommendations:

 The FCDPH should reach out to teenagers with  From 2011-2014 FCDPH sponsored a STD

age appropriate STD education materials to program designed to provide school aged ensure this at risk group is aware of their risk of children with appropriate access to materials STDs. and education regarding sexual health.  The FCDPH should engage with community Information was also disseminated through faith partners including congregations and other based organizations. non-governmental organizations in geographic  Regular site visits, conferences, health alerts, and areas that are most at risk and disproportionate- other notification and education events have ly affected by these organisms. been held from 2012—2014 to educate  Providers and hospitals should follow the new providers on the appropriate use of the new treatment recommendations for these diseases treatment guidelines and expedited partner as put forth by the CDC. therapy.  Providers and hospitals should adopt a policy that embraces Expedited Partner Therapy to  Expedited partner therapy has continued to be reduce the number of infected individuals that promoted in Fresno County. are continuing to spread these pathogens in the  FCDPH along with the State of California have community. two presentations scheduled for 2015 that will  Physicians and healthcare providers should offer an educational series on how to have a engage in a candid discussion with their patients culturally competent discussion regarding STDs, regarding prevention of STDs and/or refer them number of partners, and sexual health with local to programs designed to provide educational providers and hospitals. materials that are culturally sensitive.

Vaccine Preventable Diseases Status 2014:

2011 Recommendations:

The Health Officer should issue an order suggesting  The health officer provided incremental medical facilities mandate seasonal influenza vac- changes to mandate flu vaccination among cine for healthcare workers to be in compliance employees that work in a acute care setting, with the health and safety code (CA Health & Safe- clinic, and other health care environment. ty Code 1288.7 effective January 1, 2007 and 5199  Regular updates and recommendations from Aerosol Transmissible Diseases standard of Cal ACIP have been provided to local providers OSHA, effective September 1, 2010). through educational presentations , e-mail, or fax correspondence. Providers should follow the immunization schedule  Research on pertussis was conducted to put forth by the CDC and ACIP determine the vaccine coverage in those who

were positive in the pertussis epidemic year and All ACIP and Immunization policies should be pro-  provided within this report. vided to local providers as updates occur to ensure the population is sufficiently vaccinated.

Fresno CountyDepartment Department of Public of Health Public Health Page 7 Airborne Pathogens Coccidioidomycosis

Summary of the Results:

In 2014, Fresno County continued to Figure 1: Annual trend of reported cases of coccidioidomycosis observe significant decreases in cases in Fresno County from 2007-2014. of reported coccidioidomycosis (Valley Fever) since 2010. Total cases include community cases, which were defined as residents of Fresno County, and institutional cases, which were defined as cases from inmates at Pleasant Valley State Prison (PVSP) or Coalinga State Hospital. Reported institutional cases represented only 7.6% of total cases, which was the lowest contribution to total cases in the last five years.

Pleasant Valley State Prison began active control measures, which involved spraying soil sealants and providing masks to inmates and employees during time spent outdoors*. Also a skin test is being Table 1: Annual trend of reported cases of coccidioidomycosis in offered to inmates to prevent Fresno County from 2007-2014, stratified by community and

susceptible inmates from being institutional rate. assigned to PVSP. All case definitions Year Community Institutional Total remained consistent with the 2011 Rate* Rate* Annual Report. 2007 13 4,342 49

2008 11 2,724 33 The annual rate for institutional cases 2009 21 4,237 55 a n d c o m m u n i t y c a s e s b o t h 2010 42 4,284 75 decreased in 2014. The institutional rate 2011 38 4,500 73 dropped significantly (82%) compared 2012 35 3,270 53 to the previous year’s rate. The 2013 26 1,967 32 community observed a 42.3% 2014 15 389 16 decrease from the previous calendar *Rate per 100,000 population year 2013, overall the community rate of reported valley fever has decreased 53.7% over a 5 year baseline.

*personal communicaon with PVSP nursing staﬀ Fresno CountyDepartment Department of Public of Health Public Health Page 8 Airborne Pathogens Coccidioidomycosis

The most significant drop in cases was Table 2: Annual trend of reported cases of coccidioidomycosis in observed among the age group of Fresno County from 2007-2014, stratified by age group. under 15 years old. In 2014, the total number of cases of 14 years old and Age <15 15 – 24 25 – 44 45 – 64 65+ Total** younger dropped 85.71% from the Groups previous year. All age groups observed 2007 18 42 240 125 25 450 drops in the number of cases. It is 2008 14 39 150 94 12 309

currently being investigated as to 2009 22 73 258 141 24 518 whether the drought has had any 2010 56 108 319 197 43 723 impact on the number of Valley Fever 2011 78 75 222 125 44 544 cases. 2012 42 49 179 162 42 474

2013 14 29 108 103 40 294 Calendar year 2014 observed a 2014 2 14 46 64 20 146 decrease in the rate of reported Valley *Includes both institutional and community cases. Fever among Black/African Americans, **May not add up to annual totals due to incomplete data Whites, and Hispanic/Latinos. The annual incidence rate decreased among Black/African Americans, Whites, and Hispanic/Latinos by 7 8 .4 3 % , 2 6 .6 7 % , a n d 4 6 .1 5 % , respectively. Nationally, Black/African Americans continued to have significantly higher rates of Valley Figure 2: Annual trend of reported cases of coccidioidomycosis Fever. Fresno County has observed a in Fresno County from 2007-2014, stratified by race/ethnicity. drop among the Black/ African American population

Fresno CountyDepartment Department of Public of Health Public Health Page 9

Airborne Pathogens Coccidioidomycosis

Figure 3: Valley Fever cases by Zip Code in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 10 Airborne Pathogens Coccidioidomycosis

The western region of Fresno County has traditionally been disproportionately affected by Valley Fever. This has to do with a myriad of reasons which include soil type, low population density, and climate. Lower population density in a given region increases the likelihood of open fields with no vegetation, asphalt, or other constructs that have been shown to reduce the risk of acquiring the causative agent of Valley Fever. There were several regions that had similar case counts to the traditionally endemic regions of the County of Fresno. While it does appear that zip codes close to metropolitan Fresno and Clovis are experiencing a burden of Valley Fever, it should be emphasized that these areas are more densely populated, which would result in a much lower rate than these same color shaded regions in the western region of Fresno County.

As the drought continues and fields lay fallow there is reduced risk of increasing cases of Valley Fever in the western region of Fresno County. Any activities that will disturb the dust will put people at risk for Valley Fever. Fresno County residents are encouraged to educate themselves on how to prevent Valley Fever by visiting: www.fcdph.org/valleyfever

Fresno County Department of Public Health Activities:

 Fresno County Department of Public Health disseminated pamphlets on Valley Fever education and conducted several radio interviews to get the information out to residents.

 Fresno County Department of Public Health continues to collaborate with regional health departments and academic institutions to perform research, engage the population, and bring about awareness of Valley Fever in the Central San Joaquin Valley.

 Fresno County Department of Public Health has collaborated with University of California, San Francisco to evaluate the different individual risk factors that could predispose a resident to disseminated Valley Fever infection, which is the most severe form of the disease.  Fresno County Department of Public Health is currently researching the potential for valley fever cases to increase once agricultural activity increases again in the central valley.

Fresno CountyDepartment Department of Public of Health Public Health Page 11 Airborne Pathogens Tuberculosis (TB)

Summary of the Results:

FCDPH observed a slight increase in the annual incidence rate in active TB cases in 2014 compared to previous Figure 4: Annual trend of reported cases of active TB in Fresno years. There was a 4.55% increase in County from 2004-2014. the annual rate of disease reported compared to a 5 year baseline.

In total, there were 51 cases of TB reported to FCDPH in 2014. The months of June, August, October, and November observed the highest number of cases of reported active TB. An in-depth discussion of latent TB infection and its effect on active TB disease rates can be found in the 2011 Annual Report.

Figure 5: Monthly trend of reported cases of active TB in Fresno In figure 5, there is a clear depiction County from 2014. that cases of active TB do not have any strong seasonal trends in Fresno County for 2014, but the risk profile which will be described in the demographics section match the national trend among the Fresno County population groups.

This resurgence highlights the importance of targeted testing of high risk residents, follow up, and treatment of LTBI cases.

Fresno CountyDepartment Department of Public of Health Public Health Page 12 Airborne Pathogens Tuberculosis (TB)

People of Hispanic or Latino ethnicity comprise 45.09% of cases of active TB identified in 2014. Fresno County consisted of more than 50% Hispanic or Table 3: Active TB cases and annual incidence rates* stratified by Latino residents in 2014, according to Ethnicity/Race in Fresno County, 2014. the American Community Survey. While Asian/Pacific Islanders constitute Ethnicity/Race Cases Annual Incidence Rate* Asian/Pacific Islander 26 26.70 less than 10% of the County’s Hispanic/Latino population they accounted for 51% of 23 4.62 cases. Black/African American 2 4.23 Total: 51 5.29

*per 100,000 population

While there is a disproportionate rate among Asian/Pacific Islanders in Fresno County, there is no statistically significant difference in the age Table 4: Active TB cases age distribution stratified by highest risk

distribution when comparing Asian/ racial groups.. Pacific Islanders to non-Asian/Pacific Islanders. There was also a slight Ethnicity Mean Count Std. Deviation Median increase in the rate among Asian/ Asian/Pacific 55 26 24 59 Islander Pacific Islanders compared to 2013. All Other Race 54 25 19 55 Categories

Active TB in Fresno County is still present disproportionately among

non-native born residents. Only 29.41% (n=15) of cases identified with active TB Table 5: Active TB cases stratified by region of origin. in 2014 were born in the US, which is an Country of Origin Cases Percent increase from 2013. The remaining Asia 22 43.13% residents (70.59%; n=36) were born Mexico 14 27.45% outside of the United States. Cases United States 15 29.41% were distributed across Asia (43.13%, Total 51 100%* n=22) and Mexico (27.45%; n=14). Discussions and research regarding *Does not meet 100% due to rounding these finding were presented in the 2011 Annual Report.

Fresno CountyDepartment Department of Public of Health Public Health Page 13 Airborne Pathogens Tuberculosis (TB)

In 2014, 72.55% (n=37) of TB specimens analyzed exhibited no resistance to antibiotic therapies. In total, 13.73% (n=7) presented some type of drug resistance. Only 7.04% (n=5) of total cases reported were not able to be assessed for antibiotic resistance.

Fresno County Department of Public Health Activities:

The 2011 report made r e c o m m e n d a t i o n s b a s e d o n Figure 6: TB susceptibility tests for specimens isolated in 2014. peer-reviewed journals and data regarding Fresno County’s TB data.

 Fresno County is now implementing testing of TB infection among jail inmates who will be in the facility longer than 2 weeks with a TST.

 Fresno County purchased the Interferon-Gamma Release Assay * equipment. This was purchased to aid in the evaluation of TB infection and TB disease in situations where this is more appropriate than the use of TST. *No Culture

 Fresno County continues to advocate against universal screening for TB infection. Data and best practice indicate there are specific groups that are at disproportionate risk for disease. In 2014 Fresno County will work on identifying these groups that may be unique to Fresno County.

Fresno CountyDepartment Department of Public of Health Public Health Page 14 Airborne Pathogens Tuberculosis (TB)

Figure 7: Active TB cases by Zip Code in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 15 Blood-Borne Pathogens Hepatitis C Virus (HCV)

Summary of the Results: Since HCV lab reporting became mandated in 2008, reported cases of chronic HCV have been fairly Figure 8: Annual trend of reported cases of chronic hepatitis C in stable with very little fluctuation. Fresno County from 2004-2014. Figure 8 displays the change in cases and rate from 2004-2014. A drop in cases was observed in 2013. However, this is likely due to the efforts that the California Department of Public Health has made to de-duplicate cases across county boundaries.

The number of cases in 2014 appears stable. The guidelines for screening baby boomers from the United States Preventative Services Task Force has not appeared to impact the rate of reported cases.

Deaths attributed to HCV as a Figure 9: Annual trend of reported deaths associated with primary or contributing cause have chronic hepatitis C in Fresno County from 2005-2014. been declining since 2008. These data are based on Automated Vital Statistics System (AVSS) for Fresno County. To be included in this graph, a physician must list HCV as a primary or contributing cause on the death certificate. Patients that died as a result of complications associated with HCV, but whose HCV status was omitted or not determined, were not included in this analysis. It is possible that this artifact of the data could result in the downward curve observed for Fresno County.

Fresno CountyDepartment Department of Public of Health Public Health Page 16 Blood-Borne Pathogens Hepatitis C Virus (HCV)

Table 6: Chronic HCV cases and rates Fresno County 2014, stratified by incarceration status. Population 95% Confidence Ethnicity/Race Mean Age STD Cases Rate* Estimate Interval (CI)Ω

Incarcerated Populations ¥ Hispanic/Latino 38.5 10.83 59 1,941 3,040 2,335 – 3,894 White 44.3 13.46 58 921 6,298 4,826 – 8,084 Black/African American 44.4 10.14 5 53 9,434 3,457 – 20,910 Asian/Pacific Islander -- -- 1 162 61.73 30.89 – 3,044 American Indian/Alaskan Native 0 0 0 0 -- -- Other 0 0 0 0 -- --

Unknown 42.37 12.07 83 0 -- -- Total: 41.74 12.30 206 3,077 6,695 5,826 – 7,657

Non-Incarcerated Populations €

Hispanic/Latino 51.96 12.79 255 501,705 50.8 44.9 – 57.4 White 51.50 13.62 307 304,329 100.9 90 – 113 Black/African American 57.55 8.90 76 47,643 159.5 126.6 – 198.6 Asian/Pacific Islander 56.33 16.97 27 98,202 27.49 18.49 – 39.45 American Indian/Alaskan Native 54.57 6.78 7 3,889 180 78.72 – 356 Other 36 30.51 6 ------Unknown 52.92 12.29 348 ------Total: 52.65 12.93 1,026 972,297 105.5 99.22 – 112.1 *Non-incidence rate per 100,000 population ¥ Population figures procured from the California Department of Corrections & Rehabilitation. Figures on Asian/Pacific Is- landers, AI/AN, were all provided as other. € The general population of Fresno County as reported by State of California Department of Finance Table 1: E-4 Population Estimates for Counties and State Ω Mid-P Exact Test -- Suppressed values to protect privacy or not available The mean age at diagnosis of chronic HCV skewed significantly younger among incarcerated populations when compared to non-incarcerated Figure 10: Gender distribution of chronic HCV cases in Fresno populations across racial and ethnic categories. In County for 2014, non-incarcerated. total, there were 206 incarcerated cases and 1,026 non-incarcerated cases of chronic HCV reported in 2014. The younger age at diagnosis among the incarcerated population is concerning because this is a deviation from the traditional epidemiological distribution in terms of age alone. Incarceration has always been a significant risk factor when an individual’s HCV risk profile is assessed.

Among non-incarcerated populations the gender distribution was expected. Female cases constituted 37% (n=381) and male cases constituted 63% (n=645). Previous reports provided research to support why this disparity exists.

Fresno CountyDepartment Department of Public of Health Public Health Page 17 Blood-Borne Pathogens Hepatitis C Virus (HCV)

Table 7: Top 6 Chronic HCV zip codes: Cases and rates Fresno County 2014, stratified by incarceration status.

Non- 95% Zip Percent of Total HCV Non-Incarcerated Cases Incarcerated Confidence Code Positive 2014 Population of Zip Code* Rate ¥ Interval (CI)Ω Incarcerated Non-Incarcerated 93210 206 14 18.26% 21,846 64.08 36.48—105 93722 0 73 6.06% 79,727 91.56 72.29—114.5 93706 0 70 5.81% 38,963 179.7 141.1—225.6 93727 0 64 5.31% 70,774 90.43 70.22—114.7 93705 0 54 5.23% 38,600 139.9 106.1—181.2 93721 0 60 4.98% 6,445 931 716.7—1,190 *American Community Survey 2013 (5 year estimate) ¥ Non-incidence rate per 100,000 population Ω Mid-P Exact Test Fresno County has several zip codes which carry a disproportionate burden of reported HCV cases. The top 6 zip codes are listed in table 7. The six zip codes listed in the aforementioned table account for over 25% of the total newly reported cases in Fresno County. The population size estimates from the American Community Survey were included along with the Confidence Interval at 95%. This impact mapping can help guide testing activities as well as assist the County in prioritizing resources to address the epidemic (which is a widespread occurrence of an infectious disease) of HCV in Fresno County.

Fresno County Department of Public Health Activities:

 FCDPH representatives attended a conference and presented findings from the 2013 annual report to a national representative sample of correctional health care personnel.

 FCDPH continues to work with Wings for Life and California State University, Fresno to build an educational intervention designed to target low socioeconomic groups and educate them regarding the risk factors and dangers of HCV.  FCDPH continues to offer HCV testing in addition to HIV testing in the community through its mobile testing van.

The next page contains the map of Fresno County and the distribution of HCV cases in the county. Please review the map for details. The map displays number of cases. The number of cases in any individual zip code are so small that they could lead to drastic fluctuations in rate. While it can be helpful to compare two zip codes in terms of rates, rates are most helpful when comparing counties as opposed to zip codes.

Fresno CountyDepartment Department of Public of Health Public Health Page 18 Blood-Borne Pathogens Hepatitis C Virus (HCV)

Figure 11: Chronic HCV cases by Zip Code in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 19 Food-Borne Pathogens Campylobacteriosis and Salmonellosis

Summary of the Results:

S a l m o n e l l o s i s a n d campylobacteriosis are Figure 12: Annual trend of reported cases of Salmonellosis and foodborne pathogens. Both Campylobacteriosis in Fresno County from 2004-2014. diseases can originate from c r o s s - c o n t a m i n a t i o n , inadequately cooked foods, inappropriate handling of pet waste, and many other risk f a c t o r s . R a t e s o f c a m p y l o b a c t e r i o s i s decreased for the first time since 2004, while cases of Salmonellosis are remaining

The annual incidence rate decrease of salmonellosis observed in 2014 is not significant with a p-value of 0.93 The decrease in rate observed in 2014 for campylobacteriosis might and a rate ratio of 1, and be a result of people not seeking medical care as a result of campylobacteriosis observed infection. Traditionally, the population under 5-years of age has been a non-significant decrease in disproportionately reported with this illness. This population is more 2014 compared to a 5 year likely to require hospital intervention as a result of infection. The age baseline with a p-value of distribution among cases 5-years of age and younger remained 0.67 and a rate ratio of 1.28. stable, while the cases in adults decreased. This is highly suggestive that the adults are simply not seeking medical care, which would result in a diagnostic test and a report to the health department.

Table 8: Rate difference among Campylobacteriosis and Salmonellosis rates in 2014 compared to a 5 year baseline.

Confidence Test Statistic: Disease Rate Comparison* Rate Ratio Limits 95% z-score** Lower, Upper 5 Year Base Line Campylobacteriosis 1.28 0.70, 1.82 P = 0.6706 to 2013 5 Year Base Line Salmonellosis 1 .50, 1.98 P = 0.9384 to 2013 *Includes data from 2009-2013 ** Two tail test

Fresno Department of Public Health Page 20 Food-Borne Pathogens Campylobacteriosis and Salmonellosis

Figure 13: Monthly trend of reported cases of Salmonellosis and Campylobacteriosis in Fresno County in 2014.

Figure 13 contains a break down of the number of cases reported each month of S a l m o n e l l o s i s a n d C a m p y l o b a c t e r i o s i s . Traditionally, foodborne pathogens are reported in higher numbers in the summer months. This can be due to increased outdoor cooking, family events, or dining outside the home more often. As is displayed in Figure 13, summer months Figure 14: Age group trend of reported cases of Salmonellosis were reported as having the and Campylobacteriosis in Fresno County from 2014. greatest case counts for salmonellosis.

Campylobacteriosis appears to be relatively active throughout the year, but Salmonellosis retains the more characteristic distribution of foodborne illness. Fresno County first documented the irregular distribution of Campylobacteriosis in the 2011 Annual Report. Further i n v e s t i g a t i o n i n t o The age distribution for Salmonellosis was characteristic of national and environmental and individual regional trends. Children are more likely to require hospitalization or care level characteristics did not as the result of foodborne illness and they are often over represented in result in an explanation for surveillance data such as displayed in Figure 14. With regards to Fresno County’s unusual Campylobacteriosis, the 65+ age group appeared to be the only group Campylobacteriosis cases. that appeared to not follow the trend. However, this difference was not statistically significant.

Fresno CountyDepartment Department of Public of Health Public Health Page 21 Food-Borne Pathogens Campylobacteriosis and Salmonellosis

Table 9: Cases and Rates of Salmonellosis and Campylobacteriosis stratified by Ethnicity and Race for 2014. *Rates are per 100,000 population

Salmonellosis Ethnicity/Race Campylobacteriosis Rate* Rate* (excluding S. typhi)

Hispanic/Latino 188 37.47 87 17.34

White 77 25.30 46 15.12

Black/African American 9 18.89 6 12.59

Asian/Pacific Islander 13 13.24 19 19.35

Other 3 — 1 —

Unknown 59 — 5 —

Total 350 36 164 16.87

Hispanic/Latino and White residents displayed the highest rates of Campylobacteriosis, while the Asian/ Pacific Islanders and Black/African Americans appeared to experience a significantly lower rate. Salmonellosis appears to be evenly distributed among Hispanic/Latino, Black/African American, White residents, and Asian/Pacific Islander population. In 2013, there were several outbreaks among families that were responsible for significant rate disparities for Salmonellosis. Regardless of the source of the infection, common food safety practices can eliminate the observed disparity among these population groups.

Please visit the following website for Food Safety Tips: hp://www.cdc.gov/foodsafety/cdc‐and‐food‐safety.html

Table 10: Top 5 Zip Codes for Cases of Salmonellosis and Campylobacteriosis for 2014. Zip

Zip Code Campylobacteriosis Percent Code Salmonellosis Percent

93706 27 7.78% 93722 17 10.37% 93702 25 7.20% 93727 14 8.54% 93722 22 6.34% 93706 13 7.93% 93703 22 6.34% 93726 12 7.32% 93727 20 5.76% 93657 10 6.10% Total 116 33.14% Total 66 40.24%

Table 10 displays the top five zip codes with the highest case counts. Several zip codes displayed higher case counts than surrounding areas. These populations were selected to determine if there was a rate difference and if the higher case counts could be explained by crowding and increased population density. As is observed in the figure above, several zip codes are co-morbid for both diseases, which is not surprising considering the similarities among risk factors. There appears to be persistence of high rates in several of these zip code. Previous annual reports have identified a disproportionate burden among these specific zip codes. Five zip codes of the 61 total zip codes in Fresno County account for 33.14% of campylobacteriosis and 40% of salmonellosis.

Fresno CountyDepartment Department of Public of Health Public Health Page 22 Food-Borne Pathogens Campylobacteriosis and Salmonellosis

Figure 15: Salmonellosis and Campylobacteriosis cases by Zip Code in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 23 Food-Borne Pathogens Campylobacteriosis and Salmonellosis

Salmonellosis and Campylobacteriosis cases are Through standard surveillance practices and displayed in a map of the County of Fresno investigations Fresno County assisted with the (Figure 15). Salmonellosis cases are depicted investigation of several cases of salmonellosis that with the diagonal lines, whereas were linked to larger national or state wide Campylobacteriosis cases are represented by outbreaks. the color shading. The darker the red shading t h e h i g h e r t h e c a s e c o u n t o f Campylobacteriosis, and the more diagonal FCDPH Participated in National Outbreak lines the higher case count of Salmonellosis. Investigation in the Following Outbreak:

West and South East Fresno City (93706, 93722, Salmonella Infantis, Newport, or Hadar, 93702, & 93727) appears to experience a higher number of both Salmonellosis and Campylobacteriosis.

Fresno County Department of Public Health Activities:

 FCDPH worked closely with the California Department of Public Health and several other Available from CDC at: regional health departments to investigate several outbreaks of Salmonellosis that were hp://t.cdc.gov/ecards/message.aspx?cardid=561 discovered t hrough epidemiological investigation this year.

 FCDPH has conducted several health alerts and educational presentations to increase awareness of food safety in the home.  Creation of an enhanced investigation protocol for campylobacteriosis cases continues being pursued.

Fresno CountyDepartment Department of Public of Health Public Health Page 24 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Summary of the Results:

There are several limitations to the Figure 16: Treatment cascade for all HIV positive resident of Fresno treatment cascade presented in County January 1, 2014—December 31, 2014. this document. The limitations are clearly noted below the figure and discussed in great detail in the 2011 Annual Report. As the 2014 treatment cascade is evaluated, the concerning figure is that only 314 cases out of a total of 1,777 cases have controlled HIV. Approximately 17% of cases are effectively controlling their HIV

through a combination of drug ∞ € * therapy and regular office visits. € Patients had a viral load reported for 2013 that was defined as non- This is a reduction from 33% with detected. controlled HIV in 2013. Fewer HIV ∞ Ordered some type of HIV viral load, CD4, or other lab in 2014. *Start ART at some point positive patients are effectively controlling their HIV.

Figure 17, displays the current age Figure 17: Residents of Fresno County who are living with HIV and AIDS by age group from January 1, 2014—December 31, 2014. distribution of those living with HIV in Fresno County. These are not new cases, but are cases that were actively seeking treatment while residing in the County of Fresno for calendar year 2014. Approximately 39.7% of the patients living with HIV (regardless of AIDS status) are under 45. Of those under 45, 22.2% (n=391) were diagnosed as HIV positive only and have not progressed to AIDS. When the remaining HIV p o s i t i v e i n d i v i d u a l s w e r e evaluated, 17.7% (n=316) of the total had progressed to AIDS. *Age ranges are broad to protect privacy

Fresno CountyDepartment Department of Public of Health Public Health Page 25 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Table 11: HIV and AIDS cases and prevalence figures for residents of Fresno County from January 1, 2014—December 31, 2014, stratified by Ethnicity/Race.

Ethnicity/Race HIV Prevalence** AIDS Prevalence** Hispanic/Latino 339 67.57 513 102.25 White 213 69.99 327 107.45 Black/African American 110 230.89 187 392.5 Asian/Pacific Islander 19 19.34 27 27.5

American Indian/Alaskan Native 9 231.42 4 102.9 Multi-Race 7 — 8 — Unknown 0 — — — Total 701 72.1 1076 110.67 *Some cases were censored to protect privacy **Per 100,000 population

The health disparity in Fresno County clearly resides among Black/African American (230.89 per 100,000 population) and American Indian/Alaskan Natives (231.42 per 100,000 population) for those who are classified as HIV positive only and have not progressed to AIDS. Among those who have progressed to AIDS, the Black/ African Americans remain disproportionately affected at 392.5 per 100,000 population.

In Figure 18, there is a stratification of risk factors for the acquisition of HIV. These risk factors are self reported. In Fresno County, 72% (n=67) of new cases of HIV were attributed to a history of MSM Figure 18: Risk factors for acquisition of the virus that causes AIDS activity as the only risk factor. All for residents of Fresno County, new cases from January 1, 2014— new female cases of HIV were December 31, 2014. attributed to IDU, Heterosexual sex, or multiple risk factors.

According to the epidemiological data, most of the new transmission of HIV in the County of Fresno is due to MSM activity. Targeted testing and outreach here are essential activities to control the continued growth of this disease., which the county regularly engages in looking at high risk populations and geographies.

Fresno CountyDepartment Department of Public of Health Public Health Page 26 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Table 12: Fresno County new cases of HIV/AIDS for 2014 by disease category.

Disease Cases Percent Incidence* HIV only 72 76.60% 7.41 HIV and later AIDS ∞ 3 3.19% 0.31 HIV and AIDS diagnosed simultaneously 19 20.21% 1.95 Total 93 100.00% 9.66 *Per 100,000 population ∞ Within the calendar year

20.21% (n=19) of the new cases of HIV/AID in 2014 received their AIDS diagnoses within a calendar year of being informed that he or she was HIV positive. This suggests the patient was not getting tested regularly. Either the patient did not want to know his or her status or they were not able to access or were not aware of the testing services in their community. Figure 19: Ethnic/Race distribution of new cases of HIV/AIDS in In 2014, 55% (n=52) of the new HIV/AIDS Fresno County, 2014. cases were Hispanic/Latino. While this is a large number, it is important to note that Hispanic/Latinos constitute 51.2% of the population in Fresno County. Approximately

14% (n=13) of the new cases of HIV/AIDS were Black/African American, which is a concern because they only constitute 5% of the total population.

Figure 20: Age distribution of the cases of HIV/AIDS diagnosed in Fresno County, 2014.

In 2014, patients that received a diagnosis of HIV only skewed younger when compared to those in the County that received a diagnosis of AIDS at the same time or within that calendar year. In previous years there was little to no difference between these two groups. This year the department observed a shift. Increased testing of young adults may be showing an impact.

*Data were censored due to cell sizes being to small.

Fresno CountyDepartment Department of Public of Health Public Health Page 27 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Figure 21: HIV/AIDS annual incidence rate trend data 2004-2014.

Fresno County observed a slight increase in the new cases of HIV/

AIDS reported to the Department in 2014. In 2014, the County found that the rate has slightly increased.

Uncontrolled HIV/AIDS infection Figure 22: Diagnosis of AIDS at the same time or within that same calendar year, trending data 2004-2014. continues to be a concern. Displayed in Figure 22 is the rate of people who were diagnosed late in Fresno County. Although, there appears to be a drop in those that are late diagnosed. It is imperative to get patients linked into care and on anti-viral therapy early in the disease to decrease the risk of converting to AIDS, which can be more costly to treat and increase the risk of mortality.

Fresno CountyDepartment Department of Public of Health Public Health Page 28 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Figure 23: HIV annual incidence rate by female gender and ethnicity for residents of Fresno County, 2014.

Fresno County observed a drop in new cases of HIV among Black/

African American women for the f o u r t h c o n s e c u t i v e y e a r . No increases were observed. To protect residents who are HIV positive from being identified numbers are zeroed out if the number in that category is too small and there is potential for that person to be identified. This is a requirement from the State of California.

The rate of new cases of HIV Figure 24: HIV annual incidence rate by male gender and ethnicity for among Black/African American residents of Fresno County, 2014. males increased from the previous year, and appears to be fluctuating. Rates among White and Hispanic/Latino males decreased and remained stable compared to 2013. Data had to be suppressed for confidentiality issues, which is excellent. This shows the rates are dropping a c r o s s r a c e a n d e t h n i c categories.

*Two-hundred and thirty seven cases were incomplete regarding age or were censored to ensure confidentiality.

Fresno CountyDepartment Department of Public of Health Public Health Page 29 Sexually Transmitted Diseases Human Immunodeficiency Virus (HIV)

Figure 25: Distribution of people living with HIV/AIDS in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 30 Sexually Transmitted Diseases Chlamydia, Gonorrhea, & Syphilis

Summary of the Results:

Figure 26: Chlamydia and Gonorrhea case counts and annual incidence rate for residents of Fresno County, 2014. Fresno County has had a persistently high rate of Chlamydia and Gonorrhea for several years. The California Department of Public Health (2012, [CDPH]) found that Fresno County ranked 52 out of 58 counties for male, and 56 out of 58 for female GC infection rates from 2009-2011. In 2014, Fresno County is ranked 57 out of 58 counties for rates of Chlamydia infection among males and females.

Figure 26 shows there was a 14% decrease in Gonorrhea from 2013 to 2014. There was a 22.84% increase in 2014 compared to a 5 year average (spanning 2009-2013). Chlamydia experienced a 7.9% decrease in 2014 as compared to 2013. Figure 27: Chlamydia and Gonorrhea case counts stratified by age group for residents of Fresno County, 2014. Traditionally, Chlamydia and Gonorrhea cases appeared disproportionately among 15—24 year olds. Figure 27 provides a breakdown of Gonorrhea and Chlamydia by age group. In 2014, 91.6% (n=5,189) of Chlamydia and 82.77% (n=1,235) of Gonorrhea occurred in patients younger than 34 years old.

1. California Department of Public Health. (2012, September 22). State of California, Department of Finance, race/Hispanics population with age and gender detail, 2000-2010.

Fresno CountyDepartment Department of Public of Health Public Health Page 31 Sexually Transmitted Diseases Chlamydia, Gonorrhea, & Syphilis

Table 13: Fresno County case counts and rates of Chlamydia and Gonorrhea stratified by Ethnicity/Race for 2014.

Ethnicity/Race Chlamydia Gonorrhea Cases Rate* Cases Rate* Hispanic/Latino 2,486 495.51 629 25.37 Rates of Chlamydia and Gonorrhea White 624 205.04 219 71.96 continue to increase. The Black/African Black/African American 702 1,473 256 537.33 American population continues to Asian/Pacific Islander 282 287.16 40 40.73 experience a disproportionate burden of American Indian/Alaskan Native 18 462.84 9 231.42 disease. Rates of Chlamydia and Gonorrhea Unknown 1,572 -- 348 -- are 1,473 per 100,000 population and 537 per All Races 5,684 584.6 1,501 180 100,000 population, respectively. Table 14: Fresno County case counts and rates of Syphilis Total (Primary & Secondary) and Congenital Syphilis stratified by

Table 14 displays statistics on primary and Ethnicity/Race Syphilis (Total) Congenital Syphilis Cases Rate* Cases Rate* secondary syphilis (Syphilis Total) stratified by Hispanic/Latino 57 11.36 4 42.33 race and ethnicity. The rates for syphilis total White 20 6.57 9 281.78 are per 100,000 population and the rates for Black/African American 9 18.9 1 109 congenital syphilis are per 100,000 births Asian/Pacific Islander 0 0 0 0 American Indian/Alaskan Native 3 77.14 0 0

Unknown 28 — 4 — The disparity regarding syphilis in Fresno All Races 117 12 18 114 County is among Hispanic/Latino and Black African American population. Whereas con- Figure 28: Total syphilis (including primary and secondary genital syphilis appears to disproportionately syphilis) in Fresno County, 2014. affect White, non-Hispanics.

Figure 28 displays the total syphilis counts and rates for Fresno County from 2004—2014. There is a dramatic increase from 2012 on- ward. Fresno County also observed a corre- sponding increase in syphilis among women, which resulted in an increase of congenital syphilis.

Figures 29 and 30 contain the age distribution of total syphilis and a annual trend analysis of congenital syphilis compared to the State of California, respectively.

Fresno CountyDepartment Department of Public of Health Public Health Page 32 Sexually Transmitted Diseases Chlamydia, Gonorrhea, & Syphilis

Figure 29: Age distribution of Primary and Secondary Syphilis cases, Fresno County, 2014.

Figure 30: Congenital syphilis annual trend, case counts and rates, Fresno County, 2009-2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 33 Sexually Transmitted Diseases Chlamydia, Gonorrhea, & Syphilis

Figure 31: Chlamydia and Gonorrhea cases by Zip Code in Fresno County, 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 34 Sexually Transmitted Diseases Chlamydia, Gonorrhea, & Syphilis

The zip codes that were highlighted in the initial 2011 report for STDs still remain impacted with disproportionate levels of morbidity. Fresno County observed a shift in the epidemiology of syphilis staring in 2013 and continuing on into 2015. Women started presenting with more syphilis when compared to the state proportion. Chlamydia and gonorrhea have remained stable with a slight decrease, which was not statistically significant.

In 2014, Fresno County Department of Public Health started engaging with other local health jurisdic- tions to develop plans to address the significant increase in congenital syphilis. Cases of congenital

syphilis were mapped and health care providers who had practices in areas with high rates were contacted and met by Fresno County Department staff. Plans were established and a project to stem the increase in congenital syphilis cases will start in 2015.

This report along with the data analysis that is not permitted to be shared publically, which is omitted from this report due to privacy concerns, is permitting Fresno County to target what resources it has to addressing the changing needs of the community. New community partnerships are developing as a

result of this targeted approach and collaboration with other non-governmental organizations, county departments, and health care providers that will make these efforts sustainable and productive.

Fresno County Department of Public Health Activities:

 Fresno County Health Department continues to hold meetings and provide continuing education units (CEUs) on the epidemiology of STDs within the County.

 Fresno County Health Department and the California Department of Public Health collaborated on a new project designed to encourage complete STD reporting by health care providers within the County of Fresno. Proper STD reporting should include a patients name, address, contact information, disease diagnosis, laboratory results, and type of treatment.

 Fresno County Health Department has partnered with the Fresno County Jail’s medical providers to give them appropriate information on treatment, screening, and identification of high risk inmates for STDs.

 Fresno County Health Department Pilot tested a project for 18 months designed to offer case manage- ment activities for gonorrhea cases within a zip code that has a disproportionately high rate of gonorrhea.  Fresno County Health Department began training new syphilis investigator staff to address the emerging problem of syphilis among residents.

 Fresno County Health Department became aware of the emerging issue of congenital syphilis and is starting to set a priority to target syphilis positive females of reproductive age for investigation and outreach to assess pregnancy status and ensure compliance with treatment.

Fresno CountyDepartment Department of Public of Health Public Health Page 35 Vaccine Preventable Diseases

Summary of the Results:

To date, no vaccine protects 100% Figure 32: Selected vaccine preventable disease rates, Fresno County of the population 100% of the time. 2014. There are too many variations in the human immune system to create a foolproof vaccine. The goal of any vaccine is to provide herd immunity and prevent outbreaks of diseases that pose a significant risk to the population.

In Figure 32 and Table 15, there is a detailed analysis of the case counts and rates of selected vaccine preventable diseases in Fresno County. Each disease has a specific age group or ethnic/racial

group disproportionately effected *Includes all bacterial meningitis cases. by that specific illness. Annual trend analysis of the emergence of cases of these selected diseases can give the FCDPH information regarding vaccine compliance or risk profiles for large community groups in the population. Table 15: Selected vaccine preventable disease case counts, Fresno County 2014. As is displayed in the table and

graphs, only one significant change Hepatitis B Hepatitis B Year Hepatitis A Pertussis was observed in rate or case (Acute) (Chronic) counts from the four selected 2006 9 7 229 224 vaccine preventable diseases. 2007 10 17 241 37 2008 4 15 201 18 Hepatitis B virus and Pertussis will be 2009 3 3 251 27 discussed in more depth due to 2010 7 4 206 559 historically high rates, or rates that 2011 1 4 240 58 do not appear to change in the 2012 4 2 199 18 presence of an effective vaccine. 2013 4 5 168 18 2014 0 5 186 392 *Includes all bacterial meningitis cases.

Fresno CountyDepartment Department of Public of Health Public Health Page 36 Vaccine Preventable Diseases Hepatitis B Virus (HBV)

Table 16: Chronic Hepatitis B rates with mean age, Fresno County 2014.

Mean 95% Confidence Ethnicity/Race STD Deviation Cases Rate* Age Interval (CI) Ω Hispanic/Latino 45 14 15 2.99 (1.74-4.82)

White 50 17 14 4.6 (2.62-7.54)

Black/African American 48 22 5 10.49 (3.85-23.26)

Asian/Pacific Islander 44 16 104 105.9 (86.97-127.8)

Other 44 22 2 — —

Unknown 41 14 40 — —

Total 44 16 185 19.03 (16.43-21.98)

*Annual Incidence rate per 100,000 population Ω Fisher’s Exact Test

Minimal variation was present among the mean age of onset among the different Ethnicity and Race categories in Fresno County’s reported Chronic Hepatitis B cases. Regardless of mean age of onset, the disparity is clearly among the Asian/Pacific Islander population. This group had a rate of 105.9 per 100,000 population far exceeding the rate observed in other racial categories. Fresno County needs to continue to provide culturally sensitive education material regarding Hepatitis B and vaccine information to increase compliance. Figure 33: Chronic Hepatitis B cases by zip code, Fresno County 2014.

Fresno CountyDepartment Department of Public of Health Public Health Page 37 Vaccine Preventable Diseases Pertussis (Whooping Cough)

Table 17: Percentage of pertussis cases and count by ethnicity/race and vaccine status, Fresno County, 2014. Unknown race and other race In 2014, there were a total of 392 not documented. cases of pertussis. As was observed Hispanic/ Asian/Pacific Black/African Vaccine Status White in figure 32, Fresno County Latino Islander American 40.32% 33.94% 41.67% 30.77% experienced an epidemic of Compliant (100) (37) (5) (4) pertussis in 2014. A total of 38% 2.82% 0.92% Did not Qualify 0% 0% (n=149) cases were compliant with (7) (1) Non-Compliant, 35.08% 41.28% 41.67% 46.15% their vaccine status. The remaining Under vaccinated (87) (45) (5) (6) 21.77% 23.85% 16.67% 23.08% population either did not qualify for Unvaccinated the vaccine due to age, exempted (54) (26) (2) (3) 100% 100% 100% 100% Total Cases out, or were out of compliance (248) (109) (12) (13) and under vaccinated per the CDC guidelines. Figure 34: Hispanic/Latino pertussis cases by age group in 2014, Fresno County. Hispanic/Latinos constituted a majority of cases of pertussis in 2014. Approximately 20% (n= 77) cases were under the age of 15 months old, which means they are reliant on household members to be immunized to create a cocoon of immunity. These patterns were observed across many of the different race and ethnic categories.

The California Department of Public Health (CDPH) has acknowledged Figure 35: Pertussis percentage of vaccine compliance of cases in the limitations of the acellular Fresno County, 2014. vaccine for pertussis. The maximum protection is approximately 2—3 years, which explains why Fresno County experienced a surge of cases. Fresno County experienced an epidemic year in 2010 and took appropriate action along with the State of California to get students and children vaccinated. Four years after the campaign protection waned.

Fresno CountyDepartment Department of Public of Health Public Health Page 38 Vaccine Preventable Diseases Pertussis (Whooping Cough)

Figure 36: Distribution of Pertussis cases reported in 2014, Fresno County.

Fresno County along with the State of California experienced an epidemic year for pertussis in 2014. There was wide distribution of cases in the Fresno and Clovis metropolitan areas. The rural areas of the County of Fresno also experienced cases, but the vast majority of cases were observed within the boundaries of Fresno and Clovis. Fresno County Department of Public Health Activities:  Fresno County targeted OBGYN practices and hospitals with education materials to ensure mothers as well as household members were vaccinated for pertussis prior to delivery or prior to the mother being discharged from the facility. This booster shot for the mother is essential to protect and insulate the infant in a cocoon of protection.

Fresno CountyDepartment Department of Public of Health Public Health Page 39 Vector-Borne Diseases West Nile Virus (WNV)

Summary of the Results: Table 18: WNV 2013 and 2014 comparison, Fresno County Total Confirmed Cases Received up to 12/31/2014

Summary of WNV Activity 2013 2014 In 2014 in Fresno County, there was a Total Number of Cases 8 43 437.5% increase compared to 2013 in Hospitalized 5 33 total number of cases of West Nile Virus. Non-Neuroinvasive 3 29 Hospitalized cases increased 560%. Neuroinvasive 5 14 Neuroinvasive cases increased 180%. The Male to Female Ratio 4:3 4:3 mean age of patients reported with Median Age 51 62 WNV of any type skewed older in 2014. Range (42-81 Years old) (17-88 Years old) There were no fatalities in 2014 Mean Age 58 59 associated with WNV. Fatalities 2 0

Figure 37: WNV annual trend 2005-2014 by disease severity, Fresno County

Figure 37 and Table 19 provide historical trends of WNV cases by severity of illness in case counts from 2005-2014. Prevention methods require close collaboration between public health and mosquito abatement organizations to ensure rates are reduced.

Table 19: WNV annual trend 2005-2014 by disease severity, Fresno County

Disease Type 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Non-Neuroinvasive 53 7 12 1 7 9 3 8 3 29 Neuroinvasive 15 4 4 2 6 14 6 16 5 14 Presumptive (PVDs) 0 0 1 0 0 0 0 4 0 11 Total 68 11 17 3 13 23 9 28 8 43 Fatality 2 1 1 1 1 1 1 2 0 0

Fresno CountyDepartment Department of Public of Health Public Health Page 40 Vector-Borne Diseases West Nile Virus (WNV)

Figure 38: WNV ethnic/race difference by age group, Fresno County 2014. WNV has several risk factors, previously described in the background section of the 2012 Annual Report. The racial differences presented in this figure are likely to be due to activities that might predispose one group to increased risk of exposure to the mosquito that is responsible for transmitting the virus.

White, Non-Hispanic/Latino and Hispanic/Latino populations were the two populations that were reported with the greatest burden of WNV. 53% (n=23) of the total reported cases were over the age of 60.

Figure 39: WNV seasonal trend 2014 in cases, Fresno County

WNV is primarily spread in the human population by specific mosquitoes. These mosquitoes are not active in the winter. Thus, the highest burden of cases will occur during specific times of the year. Figure 39 reflects this unique characteristic of this disease.

Fresno CountyDepartment Department of Public of Health Public Health Page 41 Vector-Borne Diseases West Nile Virus (WNV)

Figure 40: Distribution of WNV cases reported in 2014, Fresno County.

WNV activity in Fresno County was high in 2014. Fresno County continues to observe the spread of a new mosquito species known as Aedes aegypti. This mosquito is often called the yellow fever mosquito and is capable to transmitting yellow fever, dengue, and a few other viral encephalopathies if infected when it bites a host.

The spread of this vector for disease can be monitored here: http://www.mosquitobuzz.net/

This mosquito species is not native to Fresno County. Mosquito abatement activities were increased in targeted regions of Fresno County. It could be that these enhanced surveillance and abatement methods led to Fresno County experiencing a low burden of disease in 2013. The more mosquito control and prevention measures that are in place, the fewer WNV cases the County will experience. Residents who observe mosquitos in their house, improperly maintained pools, or other standing water are encouraged to contact mosquito abatement for their region to help address these issues.

Fresno CountyDepartment Department of Public of Health Public Health Page 42 Vector-Borne Diseases West Nile Virus (WNV)

Fresno County Department of Public Health Activities:

 Fresno County Department of Public Health holds Emerging Infectious Disease Task Force meetings six times a year to discuss emerging infectious diseases and keep community stakeholders informed of WNV activity. This venue engages community partners from both the private and public sector.

 Fresno County Department of Public Health regularly collaborates with local mosquito abatement districts for the purposes of mosquito control activities and reports of mosquito borne illness.

 As new vectors for disease emerge within country boundaries the Fresno County Department of Public Health notifies both local control services and the State of California.

 Fresno County Department of Public Health has made regular educational presentations to Infection Control Programs at local hospitals and sent out health alerts from the County Health Officer to all health providers. New vectors mean that there is potential for the emergence of new diseases. Fresno County Department of Public Health is attempting to keep the health providers educated on the new diseases that might be emerging in the community.  Additionally, Fresno County Department of Public Health issued several news releases about the potential emergence of diseases like Dengue and Chikungunya.

Fresno CountyDepartment Department of Public of Health Public Health Page 43