1. Sherif Ibrahim, MD, MPH Division of Infectious Disease Epidemiology May, 2011 1

2.  Describe 2010 Outbreaks  Discuss types of outbreak reported in 2010  Describe healthcare-associated outbreaks (HAOs)  Conclusions and lessons learned  Recommendations 2

3.  In WV, outbreaks are reportable immediately to local health departments(LHDs)  LHDs are required to report outbreaks to Bureau for Public Health (BPH) within 60 minutes  LHDs report and investigate outbreaks with assistance from regional epidemiologists & BPH  There was a 13-fold increase in reported outbreaks from 2001 to 2010 3

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5.  124 outbreaks were reported  96 (77.4%) were confirmed  28 (51%) counties reported outbreaks  Jurisdictions  95 (99%) were limited to WV residents  1 (1%) involved residents of other states 5

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9. Type of Outbreaks Number of OutbreaksPercent Enteric3536.5% Rash3334.4% Respiratory2627% Other22.1% Total96100% 9

10.  Total: 35  16 (29%) counties  1 reported multi-state outbreak (CDC: Lead)  Norovirus and acute gastroenteritis: 28 (80%)  Acute gastroenteritis outbreaks were defined as “outbreaks of illness with short duration (2-3 or fewer days) and characterized by acute onset of vomiting and /or diarrhea and no laboratory confirmation”. 10

11. Transmission Settings Number of OutbreaksPercent Healthcare Facilities2262.8% Schools411.4% Communities38.6% Households25.6% Banquet12.9% Basketball tournament12.9% Restaurant12.9% Schools / Community12.9% Total35100% 11

12. Etiologic Agent Number of OutbreaksPercent Norovirus1645.7% Acute Gastroenteritis (Undetermined etiology)1234.3% Salmonella Species38.6% Hepatitis A25.7% Bacillus cereus12.9% Shigella sonnei15.7% Total35100% 12

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14.  Salmonella serotype Enteritidis:  Family of 10 from 3 households  6 cases (3 confirmed and 3 probable)  Salmonella serotype Montevideo:  One WV resident among 272 US residents  Traced to salami products containing contaminated imported black and red pepper. 14

15.  Salmonella serotype Enteritidis  18 confirmed and 4 probable cases.  Case control study  illness associated with eating at multiple locations of a single chain restaurant  Lab (PFGL &MLVA) 11 isolates were identical  Identical to a 2009 outbreak strain associated with multiple locations of the same chain restaurant  Recommendations to the corporate 15

16.  First Hepatitis A Outbreak  Two family members  Epi-link to a hepatitis A outbreak in a daycare in KY  Hepatitis A is asymptomatic in children < 6 years in 70% of cases 16

17.  Second Hepatitis A Outbreak  11 cases  Delayed reporting (2 months)  Retrospective identification of several cases  Transmission  person-to-person among friends and secondary spread to households  LHD  press releases, education, outreach and community-wide vaccination 17

18.  The outbreak  10 family members  acute gastroenteritis  Pizza from a local restaurant  Laboratory testing of the patients was negative  Testing of the remaining pizza at OLS revealed contamination with Bacillus cereus  Bacillus cereus:  B. cereus is an aerobic, spore-forming, gram-positive rods  Food-poisoning can result from two types of toxins  Diarrheal syndrome : (incubation period of 10-12 hrs) associated with heat-labile (meat, stews, gravies)  Emetic syndrome: (incubation period of 1-6 hrs) associated with a heat-stable toxin (fried rice, meat, improper refrigeration) 18

19. Clinical Diagnosis Number of outbreaksPercent Varicella (Chickenpox)2060.6% Scabies824.2% Hand, Foot and Mouth Disease26.1% Skin infection - MRSA26.1% Rash / Folliculitis13.0% Total33100% 19

20.  A ten-fold increase from 2009.  Varicella Vaccine Effectiveness Project:  Hired two full-time staff  Offered free laboratory testing  Active surveillance in WV public schools  Education campaign  Change in varicella outbreak definition for schools  19 from schools and 1 from a community.  Lab testing  7 laboratory confirmed  3 negative or non-contributory  10 did not have laboratory testing. 20

21. Transmission Settings Number of outbreaksPercent LTCFs562.5% Jail112.5% School112.5% Women Shelter112.5% Total8100% 21

22.  Incubation period: 2-6 weeks  Outbreak definition: 2 or more cases of scabies among residents/staff within 4-6 week  Confirm the diagnosis  consult a dermatologist  Isolation /exclusion of ills  a day after effective treatment  Offer treatment to contacts /families  Provide education  Environmental measures 22

23.  Total 26 (27%)  Reported by 14 (25%) counties.  In 2009  53 respiratory disease outbreaks  No influenza outbreaks in 2010 23

24. Clinical Syndrome Number of OutbreaksPercent Upper Respiratory Illness1661.6% Pertussis (Whooping Cough)519.2% Streptococcal Pharyngitis311.6% Influenza-Like Illness13.8% Upper Respiratory Illness / Pneumonia13.8% Total26100% 24

25.  16 outbreaks  15 from LTCFs and one from a school  Case definition: new onset of at least two of the following symptoms:  Runny nose or sneezing  Stuffy nose / congestion  Sore throat / hoarseness  Difficulty swallowing  Dry cough, and/or cervical lymphadenopathy  Rule out allergy  Rule out influenza  fever of 100 or more 25

26.  Total # 5  Reported by 4 Counties  4 Communities and 1 daycare  No pertussis-related deaths  All outbreaks were PCR confirmed  Cyclical pattern every 3-5 years  Vaccine is not 100% effective 26

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28.  2 outbreaks of conjunctivitis (pink eye)  Reported from schools  Laboratory testing  1 was not done  1 negative or non-contributory  Testing can be done for these outbreaks  Hand washing and environmental cleaning 28

29. Clinical Diagnosis Number of OutbreaksPercent Varicella (Chickenpox) 2074.1% Pertussis (Whooping Cough) 518.5% Hepatitis A 27.4% Total 27100% 29

30.  Outbreaks where exposure / transmission is associated with healthcare facility(ies)  43 (45%)  16 Counties (29%)  41 (95%) from LTCFs and 2 (5%) from hospitals.  33 in 2009  55 in the first 3 months, 2011(90% from LTCFs) 30

31. Type of outbreak Number of OutbreaksPercent Enteric2251.2% Respiratory1637.2% Rash511.6% Total43100% 31

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34.  URI outbreak in a LTCF complicated by pneumonia  AR: 47% and Death rate 1%  HMPV:  Identified in 2001  RNA virus related to RSV and PIV  Transmission: droplet and contact  Seasonality: winter and spring  IP: 2-8 days  At-risk populations: infants, children, elderly and LTCFs  Clinical presentation: URI, pharyngitis, pneumonia, bronchiolitis  CXR findings: diffuse interstitial infiltrates, hyperinflation  Precautions: standard and contact (droplet if indicated) 34

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36.  81 (81.4%) outbreaks with complete data on date and time of reporting  Mean= 35.8 hours  Median= 1 hours  Range= 0 to 864 hours  71 (88%)  same day notification  15 (15.6%) outbreaks were missing info on date and/or time of reporting 36

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38.  LHD is required to report outbreaks within 60 minutes under  Reportable disease rules  Threat preparedness funding  Program plan 38

39.  Scientific and technical support  Case definition  Diagnosis and prevention measures  Descriptive epidemiology  Special studies if needed  Laboratory support  Resources support  Communication support 39

40.  Marked improvement in reporting and management of outbreaks in WV  Outbreak investigation requires:  Problem-solving skills, training and experience  Collaboration between epidemiology, laboratory and environmental  Collaboration between local, regional, healthcare providers, state, and CDC  Most HAOs are reported from LTCFs 40

41.  Report outbreaks to DIDE within 60 minutes  Use DIDE’s guidelines for outbreak investigation  Consult and get assistance from your regional epidemiologist (Field investigation, Training)  Training and education  Plan to improve your communication with LTCFs  Feedback information on outbreaks to reporting sources and other partners  Outbreaks = opportunities for improvements 41

42. Outbreak Report, West Virginia, 2010 http://www.wvidep.org/Portals/31/PDFs/IDEP/Outbr eaks/2010_Final_%20Outbreak%20Report.pdf Contact Information: 304-558-5358 OR 800-423-1271 (24/7) Office:304-356-4074 Cell: 304-553-9165 sherif.m.ibrahim@wv.gov 42

43. Questions 43