February 2010 Selected Zoonotic Diseases Conference Call

February 3, 2010

Selected Zoonotic Diseases Conference Call

*Proposed

**

February 3, 2010

Selected Zoonotic Diseases Conference Call

 Update on Dengue in the United States 

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Christopher J. Gregory, MD, MPH; Epidemic Intelligence Service Officer Dengue Branch, CDC 787-706-2399cgregory1@cdc.gov

Carina Blackmore, DVM, PhD, Dipl. ACVPMState Public Health Veterinarian Florida Department of Health850-245-4732carina_blackmore@doh.state.fl.us

Christopher J. Gregory, MD, MPHEIS Officer, Dengue Branch

Centers for Disease Control and Prevention

San Juan, Puerto Rico, USA

Update on Dengue in the United States

February 3, 2010

Dengue Flavivirus – related to WNV, JE, Yellow Fever

Four serotypes: DENV-1, -2, -3, -4 − All cause full spectrum of disease− Infection confers lifelong serotype-specific

immunity

Dengue virus causes an acute febrile illness (called dengue) that is transmitted by bite of infected Aedes mosquito

Dengue Infections Most common mosquito-borne viral disease

40% of world at risk of infection; at least 4 million U.S. citizens live in dengue-endemic areas

50 - 100 million cases of dengue occur annually

− Five fold increase in cases in Americas in 20 years

Leading cause of febrile illness in US travelers returning from Asia, South America, Caribbean

Dengue in the Continental US Transmission in US after a 35 year absence

− Texas: 7 outbreaks since 1980− Hawaii: outbreak in 2001− Key West, FL: outbreak in 2009

Aedes aegypti present in AZ,LA,GA,TX,NM,FL− A. albopictus widespread through south

Increased international travel and immigrant population with ties to endemic country of origin − 2006-08: >1000 travel-associated cases

Dengue Diagnosis and Reporting Clinical Diagnosis alone unreliable

PCR for diagnosis during viremic phase ( ~1st 5 days of illness)

IgM antibodies reliably detectable after day 5

− IgG remains elevated for life, not useful for diagnosis

Dengue added as nationally notifiable condition in June 2009; 32 states currently mandate reporting

− Dengue is not reportable in 7 states that have competent mosquito vectors

Dengue as Public Health Issue Evidence of geographic spread and increased

severity of disease

No effective, sustainable way to eliminate mosquito and breeding sites

No vaccine; although 5 candidates in field studies

Evidence of dengue transmission via receipt of donor organs or tissue, blood transfusions, and occupational exposure in healthcare settings

− Blood donations not currently screened;1 in 600 donations in PR positive for dengue viral RNA in 2007

Contact information:Dengue Branch

Division of Vector-Borne Infectious Disease

Centers for Disease Control and Prevention

1324 Calle Cañada

San Juan, Puerto Rico   00920

Tele:    787.706.2399

Fax:     787.706.2496

E-mail: hgk4@cdc.gov

Human Salmonella Associated with Aquatic Frogs 

January 6, 2010

Selected Zoonotic Diseases Conference Call

Shauna L. Mettee, MSNEIS OfficerEnteric Diseases Epidemiology Branch, CDC404-639-5277smettee@cdc.gov

It’s Not Easy Being Green–A It’s Not Easy Being Green–A Multistate Outbreak of Human Multistate Outbreak of Human

Salmonella Typhimurium Salmonella Typhimurium Infections Associated with Aquatic Infections Associated with Aquatic

Frogs–United States, 2009Frogs–United States, 2009

Outbreak Response and Prevention BranchDivision of Foodborne, Bacterial and Mycotic Diseases

National Center for Emerging and Zoonotic Infectious Diseases Centers for Disease Control and Prevention

Shauna L. Mettee, RN, MSN, MPHLTJG, United States Public Health Service

Epidemic Intelligence Officer

OutlineOutline

• Outbreak detection

• Outbreak investigation

• Field investigation

• Recommendations

• Next steps

Outbreak DetectionOutbreak Detection

• April 2009: Utah identified 5 cases of Salmonella Typhimurium in children

• Indistinguishable PFGE pattern identified (outbreak strain)

0

1

2

3

4

5

6

7

8

9

10

3/8

/09

3/1

5/0

93/2

2/0

93/2

9/0

94/5

/09

4/1

2/0

94/1

9/0

94/2

6/0

95/3

/09

5/1

0/0

95/1

7/0

95/2

4/0

95/3

1/0

96/7

/09

6/1

4/0

96/2

1/0

96/2

8/0

97/5

/09

7/1

2/0

97/1

9/0

97/2

6/0

98/2

/09

8/9

/09

8/1

6/0

98/2

3/0

98/3

0/0

99/6

/09

9/1

3/0

99/2

0/0

99/2

7/0

910/4

/09

10/1

1/0

910/1

8/0

910/2

5/0

911/1

/09

11/8

/09

11/1

5/0

911/2

2/0

911/2

9/0

912/6

/09

12/1

3/0

912/2

0/2

009

12/2

7/2

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Infections with the outbreak strain of Infections with the outbreak strain of Salmonella Salmonella Typhimurium, by week of illness onset (n=83 for whom Typhimurium, by week of illness onset (n=83 for whom information was reported as of 12/31/09)*information was reported as of 12/31/09)*

No. of cases

Week of Illness Onset

*Some illness onset dates have been estimated from other reported information(Estimated onset dates range 4/9 – 12/11; Reported onset dates (n=48) range 5/24 – 11/30)

Illnesses that began during this time may not yet be reported

3-4 Cases

AZ1

CA5

FL1

GA1

ID1

IL5

MD3

MA3

MI4

MO4

NJ2

NY2

OH2

PA4

TN2

TX4

UT14

WA7

More than 4 Cases

Case Counts by States reporting Case Counts by States reporting Salmonella Salmonella Typhimurium cases in Typhimurium cases in cluster 0909MAJPX-1, as of Thursday, December 31, 2009cluster 0909MAJPX-1, as of Thursday, December 31, 2009

MN1

LA1

CO4 KY

1

NM1 MS

1

VA3

WI1

NE1

SD3

AL1

IN1

NV1

1-2 Cases

Demographics for cases of Salmonella Typhimurium cases in cluster 0909MAJPX-1, as of Thursday, December 31, 2009

Demographics n=85Age, range (median)* <1-54 (5)

< 5 years old 42 (50%)< 10 years old 66 (79%)

Gender**, n (%)Female 40 (49%)Male 41 (51%)

*not including 1 without age information

**not including 4 without gender information

Outcomes n=47Hospitalization

n (%) 16 (34%)

Hypothesis Generation Hypothesis Generation Continues…Continues…

• April 2009: Utah identified 5 cases of Salmonella typhimurium in children

• August: CDC identified multistate outbreak predominantly in children

• CDC conducted hypothesis-generating interviews – 3/6 hypotheses identified

Matched Case-Control Study:Matched Case-Control Study:Case DefinitionCase Definition

• Salmonella Typhimurium infection with illness onset on or after April 1, 2009, with – 1) indistinguishable PFGE pattern, the

outbreak strain– 2) MLVA pattern either matching that of the

main outbreak strain, or MLVA unknown

Matched Case-Control Study:Matched Case-Control Study:Control SelectionControl Selection

• Controls were persons with recent infection of Salmonella strains other than the outbreak strain

• Matched to case-patients:– by age– county of residence

Matched Case-Control Study:Matched Case-Control Study:

• 19 cases and 31 age- and geography- matched controls enrolled

• Exposure histories collected – 7 days before illness onset for case-patients – 7 days before interview for controls

Results of Matched Results of Matched Case-Control StudyCase-Control Study

• Illness was significantly associated with exposure to frogs (63% cases vs 3% controls, mOR=24.4, CI=4.0-infinity).

• 6 case-patients knew frog type– All reported African Dwarf Frogs

Results of Results of Environmental SamplingEnvironmental Sampling

• Environmental samples from aquariums containing African Dwarf Frogs in 4 patient homes yielded Salmonella Typhimurium matching the outbreak strain– CO, UT, OH, NM

• Common breeder in California identified– Environmental samples from breeder’s facility yielded

outbreak strain

African Dwarf FrogsAfrican Dwarf Frogs

Lots o’ FrogsLots o’ Frogs

Lots o’ FrogsLots o’ Frogs

Lots o’ FrogsLots o’ Frogs

Lots o’ FrogsLots o’ Frogs

Historical Case Investigation Historical Case Investigation

• Asking states to interview historical cases from Jan 1, 2008 - present with revised case questionnaire

Public Health InterventionsPublic Health Interventions

• Conversations with veterinarians at large pet store chains

• CDC Web updates and media releases

• CDC Podcasts

• MMWR – Jan 8, 2010

• Recommendations to frog breeder regarding animal husbandry, water system and general biosafety practices

Advice to the Public: Advice to the Public: ConsumersConsumers

• Aquatic frogs and all water in the habitat should be considered contaminated

• Hand-washing

• Persons who should avoid contact

• Placement of habitats

Advice to the Public: Advice to the Public: Pet Store OwnersPet Store Owners

• Provide consumers information about the risk of acquiring salmonellosis from amphibians and reptiles

• 2009 Compendium of Measures to Prevent Diseases Associated with Animals in Public Settings

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5805a1.htm

Advice to the Public: Health Care Advice to the Public: Health Care Providers & VeterinariansProviders & Veterinarians

• Provide information to pet owners about risks of acquiring salmonellosis from amphibians and reptiles

• Advise patients on proper hand washing practices

• Veterinarians should teach pet owners how to properly clean the animal habitat

AcknowledgmentsAcknowledgments

• CDC– Samir Sodha, Casey Barton Behravesh, Linda Capewell, Gwen

Ewald, Nancy Garrett, Brenda Le, Leslie Hausman, Ian Williams

• State and Local Health Departments: – Alabama, Arizona, California, Colorado, Florida, Georgia, Idaho,

Indiana, Illinois, Kentucky, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, Nevada, New Jersey, New Mexico, New York, Ohio, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, and Wisconsin

For more informationFor more information

CDC PodcastsSalmonella Infection and Water Frogs:

http://www2c.cdc.gov/podcasts/player.asp?f=641101

Wash Away Salmonella:

http://www2c.cdc.gov/podcasts/player.asp?f=722515

For Kids:

Water Frogs, Aquariums, and Salmonella -- Oh My!

http://www2c.cdc.gov/podcasts/player.asp?f=442708

Contact: Shauna Mettee , smettee@cdc.gov

For more informationFor more information

CDC Web Updatehttp://www.cdc.gov/salmonella/typh1209/index.html

MMWR – Jan 8, 2009Multistate Outbreak of Human Salmonella Typhimurium

Infections Associated with Aquatic Frogs — United States, 2009

http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5851a1.htm

Contact: Shauna Mettee

smettee@cdc.gov

Rabies Postexposure Prophylaxis for Animals 

January 6, 2010

Selected Zoonotic Diseases Conference Call

Charles Rupprecht, VMD, PhD Poxvirus and Rabies Branch, CDC404-639-1053crupprecht@cdc.gov

February 3, 2010

Selected Zoonotic Diseases Conference Call

*Proposed

**