WINTER IS NORO- ISSUE 1 VOLUME 7 2014 VIRUS SEASON ....... 2 ASSESSING DISPENS- ING ACCURACY FOR MEDICAL COUNTER- MEASURE EXCERCIS- ES .......................... 2 ONE HEALTH: WILD PIGS, HUNTERS AND BRUCELLOSIS……...3 WATCHING OUT FOR FLU ........................ 3 THE LIST OF REPORT- ABLE DISEASES AND EVENTS .................. 3 Tennessee TENNESSEE DEPARTMENT OF HEALTH COMMISSIONER JOHN J. DREYZEHNER, MD, MPH epi-news Legionnaires’ Disease Outbreak in Shelby County In June 2013, the Shelby County Health areas and to conduct environmental sam- Department received multiple reports of pling, testing and remediation using estab- Legionnaires’ disease among inpatients at lished methodologies. The investigators local hospitals. Health department epide- also initiated active surveillance for le- miologists quickly responded, conducting gionellosis and soon found four more cases detailed interviews with the patients using sharing this exposure. an interview form they had adapted with questions specific to Shelby County expo- Legionnaires’ disease is a form of commu- sures. nity-acquired pneumonia caused by Le- gionella species. A less severe form of Interviews with the first seven identified legionellosis is known as Pontiac fever. patients revealed that five of them had fre- Legionella bacteria are ubiquitous in the quented the same hot tub and steam room environment and thrive in warm, manmade conditions are predisposing factors. Most in a fitness center within two to ten days water systems. People can become infected cases occur sporadically and cannot be before their illness onset. The health de- by inhaling aerosolized water containing traced to a source; however, legionellosis partment instructed the fitness center to the bacteria. Older age, smoking, and outbreaks have been associated with a vari- close the pool, hot tub and steam room chronic lung or other immunosuppressive (Continued on page 2) Middle East Respiratory Syndrome Coronavirus Update Middle East Respiratory Syndrome no confirmed cases have been identified in changes in travel plans because of MERS, (MERS) is viral respiratory illness first the U.S. Healthcare providers are asked to travel notices with information regarding reported in Saudi Arabia in 2012. The report patients under investigation and how travelers can protect themselves can agent is a coronavirus (CoV) with an as-yet unusual cases or clusters of severe acute be found at http://www.cdc.gov/ -unidentified reservoir host. This virus has respiratory infection (SARI) to public coronavirus/mers/travel.html. TDH is pre- spread from ill people to others through health officials. This includes patients with paring to respond should there be a case of close contact but has not spread in a sus- fever and pneumonia or acute respiratory MERS in the U.S. or sustained human-to- tained way in communities. distress syndrome with a history of travel human transmission anywhere in the to an affected area or contact with a symp- world. Key areas for preparedness include As of January 3, 2014, 177 cases of MERS tomatic person who traveled to an affected surveillance, isolation of ill patients, quar- -CoV infection, including 74 deaths, have area. Clusters of patients with SARI or ill antine of exposed contacts, and guidance been reported to the World Health Organi- healthcare workers who have cared for on infection control practices. More infor- zation. These cases have all been linked to patients with SARI should also be report- mation on MERS-CoV, including the most countries in or near the Arabian Peninsula; ed. Though CDC has not recommended (Continued on page 3) Page 2 Tennessee Epi-News Legionnaires’ Disease Outbreak in Shelby County (continued) (Continued from page 1) 318 people became infected from a hot source led to corrective action being taken ety of environmental exposures, including tub on display at a festival. that almost certainly prevented more ill- air conditioning systems, hospital and hotel nesses in the community. — by David hot water systems, decorative fountains, The Shelby County Health Department Sweat, MPH grocery store vegetable misters, and hot was able to identify the source of this tubs and spas. One of the largest known outbreak by recognizing an increase in legionellosis outbreaks was associated with reports and promptly conducting detailed a hot tub in the Netherlands in 1999, where interviews. Early identification of the Winter is Norovirus Season Norovirus is the most common cause of decade, new GII.4 strains have emerged tings. CDC has developed a norovirus pre- acute gastroenteritis in the U.S. Each year, every 2–3 years, replacing previous pre- vention toolkit for healthcare settings, it causes about 20 million illnesses and dominant strains. TDH, in collaboration available at www.cdc.gov/HAI/organisms/ contributes to as many as 71,000 hospitali- with CDC, collects information on no- norovirus.html. zations and 800 deaths. Hospitalization rovirus strains associated with outbreaks in and mortality associated with norovirus the U.S. through CaliciNet, an electronic The following general prevention infection occur most frequently among laboratory surveillance network. measures can reduce the risk of transmis- young children, older adults and immuno- sion: compromised patients. Norovirus is also In 2012, a new strain of norovirus was Practice proper hand hygiene the most common cause of foodborne- detected in Australia called GII.4 Sydney. Wash fruits and vegetables and cook disease outbreaks in the U.S. This new strain is currently the leading seafood thoroughly cause of norovirus outbreaks the U.S. Do not prepare food or care for others Although norovirus illness is often called From August 1, 2012 through July 31, when you are sick “stomach flu”, it is not related to influenza. 2013 Tennessee reported 60 norovirus Clean and disinfect contaminated sur- Noroviruses belong to the family Calici- outbreaks, most of which were due to faces viridae and can be grouped into five GII.4 Sydney. Wash laundry thoroughly genogroups (GI through GV), which are further divided into at least 34 genotypes. The majority of norovirus outbreaks in More information about norovirus can be Human disease is primarily caused by GI Tennessee occur in long-term care facili- found at www.cdc.gov/norovirus. — by and GII noroviruses, with most outbreaks ties. Effective prevention measures are Katie Garman, MPH, CHES caused by GII.4 strains. During the past crucial to limit transmission in such set- Assessing Dispensing Accuracy for Medical Countermeasure Exercises Large-scale emergencies, whether natural medical attributes as they pass through a POD or dose assigned is considered an error. or manmade, can necessitate mass dispens- to receive medication. These mock attributes Dispensing errors are tallied for each ing of pharmaceuticals or other medical indicate prophylaxis with one of several anti- exercise, and results are compared products to an entire affected population. biotics. As medications are dispensed, copies among exercises. During these exercis- TDH routinely conducts medical counter- of drug labels are retained with patient- es, PODs have dispensed up to 1830 measure dispensing exercises to simulate units of medication per hour, with ac- mass prophylaxis in response to public curacy rates averaging 96.8% (range: health emergencies. These Point of Dis- 96.4- 97.5%). pensing (POD) exercises have traditionally emphasized only the speed of medication Planning for countermeasure dispens- dispensing. However, TDH is piloting a ing should focus not only on amount of method for evaluating the accuracy of mass medications delivered, but also on ac- antibiotic dispensing. The objectives in- curacy of dispensing. TDH intends to clude predicting the number of drug-related assess accuracy of POD dispensing for adverse events that could result from such a all 13 of the state’s public health re- large-scale operation. Dispensing accuracy gions as they conduct medical counter- is important because many people have measure exercises. This will enable contraindications to certain drugs, such as health departments to anticipate and the commonly stockpiled antibiotics specific dispensing records. Afterward, the prepare for medication-related adverse doxycycline and ciprofloxacin. registration forms, indicating the drug that events. — by Tristan Victoroff, MPH patients were meant to receive, are compared To assess accuracy, volunteers serving as to the drug labels showing what they actually community members are assigned mock received. Any deviation from the medication Page 3 Tennessee Epi-News One Health: Wild pigs, Hunters and Brucellosis When a 27 year-old man from East Ten- In the U.S., brucellosis is almost exclu- tion in the U.S.; therefore great care must nessee presented with fever, body aches sively seen in wild animals such as bison, be taken to protect laboratorians who work and night sweats that had begun during a deer, elk, caribou and feral swine, as eradi- with specimens from suspected brucellosis month-long trip through Asia, his doctors cation programs have long been in place patients. About 100 human brucellosis were faced with a daunting list of potential for domestic livestock. Brucella can be infections are reported per year in the U.S. diagnoses. The patient was a farmer and transmitted from animals to humans avid hunter who had been exposed to risk through contact with infected meat, pla- Symptoms of acute brucellosis can be flu- factors for numerous infectious diseases centas and birth fluids; inhalation of air- like, with fever, chills, muscle aches, fa- prior to and while traveling abroad. A myr- borne particles contaminat- iad of tests were run, and finally a blood ed with the bacteria; and culture provided a clue. Gram negative consumption of unpasteur- rods were seen, sparking suspicion of bru- ized milk and cheese. Peo- cellosis. Further testing at the state public ple who work closely with health laboratory confirmed that the organ- animals, including hunters, ism was Brucella suis, found in feral swine veterinarians and slaughter in Tennessee. Case investigation revealed plant workers, are at a high- that the patient had killed and dressed a er risk of infection.