3/16/2017

1

Infectious Disease Outbreaks in 

South Dakota and Beyond:  

a pubic health perspectiveperspective

American Society for Clinical Laboratory Science

7 April 2017

Mitchell, South DakotaLON Kightlinger, MSPH, PhD

State Epidemiologist

South Dakota Department of Health1

+Category I diseases: Report immediately on suspicion of disease Category II diseases: Report within 3 daysSend isolate to South Dakota Public Health Laboratory

+Anthrax (Bacillus anthracis)

Anaplasmosis (Anaplasma phagocytophilum)Arboviral encephalitis, meningitis and infection (West Nile, Zika, St. Louis,

Eastern equine, Western equine, Chikungunya, California, Japanese, Powassan, LaCrosse, Colorado tick fever)

Babesiosis (Babesia spp)

+Botulism (Clostridium botulinum)+Brucellosis (Brucella spp)

Campylobacteriosis (Campylobacter spp)

Carbon monoxide poisoningChancroid (Haemophilus ducreyi)

Chicken pox / Varicella (Herpesvirus)

Chlamydia infections (Chlamydia trachomatis)

Cholera (Vibrio cholerae)

Coccidioidomycosis (Coccidioides spp)+Coronavirus respiratory syndromes, such as MERS (Middle East respiratory

syndrome) and SARS (Severe acute respiratory syndrome) Cryptosporidiosis (Cryptosporidium spp)

Cyclosporiasis (Cyclospora cayetanensis)Dengue viral infection (Flavivirus)

+Diphtheria (Corynebacterium diphtheriae)

Drug resistant organisms:

Human immunodeficiency virus (HIV) infection, including:- Stage III, Acquired immunodeficiency syndrome, (AIDS)- CD4 counts in HIV infected persons - HIV viral loads, and - pregnancy in HIV infected females

+Influenza, novel strainsInfluenza: including hospitalizations, deaths, lab confirmed cases

(culture, DFA, PCR), weekly aggregate totals of rapid antigen positive (A and B) and total tested

Lead, elevated blood levels

Legionellosis (Legionella spp)Leprosy / Hansen’s disease (Mycobacterium leprae)

Leptospirosis (Leptospira)

Listeriosis (Listeria monocytogenes)

Lyme disease (Borrelia burgdorferi)

Malaria (Plasmodium spp)+Measles / Rubeola (Paramyxovirus)

+Meningococcal disease, invasive (Neisseria meningitidis)

Mumps (Paramyxovirus)

Pertussis / Whooping cough (Bordetella pertussis)Pesticide-related illness and injury, acute

+Plague (Yersinia pestis)

+Poliomyelitis paralytic and nonparalytic (Poliovirus)

Streptococcus pneumoniae, invasive

Syphilis (Treponema pallidum) including primary, secondary, latent, early latent, late latent, neurosyphilis, late non-neurological, stillbirth, and congenital

Tetanus (Clostridium tetani)

Toxic shock syndrome (Streptococcal and non-Streptococcal)

Transmissible spongiform encephalopathies, such as Creutzfeldt-Jakob disease

Trichinosis (Trichinella spiralis)

+Tuberculosis, active disease (Mycobacterium tuberculosis or Mycobacterium bovis)

Tuberculosis, latent infection (only in certain high risk persons: foreign-born <5 yrs in US, close contacts, diabetes, renal dialysis, children <5 yrs, and certain medical conditions)

+Tularemia (Francisella tularensis)Typhoid (Salmonella typhi)Vaccine Adverse Events

+Viral Hemorrhagic Fevers (Crimean-Congo Hemorrhagic Fever virus, Ebola virus, Lassa virus, Lujo virus, Marburg virus, New World Arenavirus –Guanarito virus, Junin virus, Machupo virus, Sabia virus)

Vibriosis (Vibrionaceae)

+Yellow fever (Flavivirus)

Reportable Diseases – South DakotaEffective 

1 January 2017

- Carbapenem-resistant Enterobacteriaceae (CRE)

- Methicillin-resistant Staphylococcus aureus (MRSA), invasive- Vancomycin–resistant Staphylococcus aureus (VRSA)

+E. coli, shiga toxin-producing(Escherichia coli), includes E. coli O157:H7, O26, O111, O103 and others

Ehrlichiosis (Ehrlichia spp)

Giardiasis (Giardia lamblia / intestinalis )

Gonorrhea (Neisseria gonorrhoeae)

Haemophilus influenzae, invasive disease

Hantavirus pulmonary syndrome or infectionHemolytic uremic syndromeHepatitis, viral, acute A, B and C; chronic B and C; and perinatal B

+Poliomyelitis, paralytic and nonparalytic (Poliovirus)

Psittacosis (Chlamydophila psittaci)Q fever (Coxiella burnetii)

+Rabies, human and animal (Rhabdovirus)

+Rubella and congenital rubella syndrome (Togavirus)

Salmonellosis (Salmonella spp)

Shigellosis (Shigella spp)Silicosis

+Smallpox (Variola)

Spotted fever rickettsiosis (Rickettsia)

- - - - - - - - - - - - - - -+Outbreaks of:

+Acute upper respiratory illness+Diarrheal disease+Foodborne disease+Healthcare-associated infections+Illnesses in child care setting+Rash illness +Waterborne disease

+Syndromes suggestive of bioterrorism and other public health threats

+Unexplained illnesses or deaths in human or animal

The South Dakota Department of Health is authorized by SDCL 34-22-12 and ARSD 44:20 to collect and process mandatory reports of diseases and conditions by physicians, hospitals, laboratories, and other institutions.

How to report: Secure website: sd.gov/diseasereportTelephone: 605-773-3737 or 800-592-1861 during business hours, or 800-592-1804 confidential answering device,

After hours emergency Category I diseases, call 605-773-3737 or 800-592-1861Fax: 605-773-5509Mail or courier: Infectious Disease Surveillance, Department of Health, 615 East 4th Street, Pierre, SD 57501;

marked "Confidential Disease Report"

What to report: Reports must include as much of the following as known:- Disease or condition - Case name, age, birth date, sex, race, address, occupation- Date of disease onset - Attending physician’s name, address, phone number- Relevant lab results and specimen collect date - Name and phone number of person making report

CANCER (SDCL 1-43-14) Report to SD Cancer Registry, call 800-592-1861

2

Measles basicsMeasles or Rubeola or Hard Measles or Red Measles.

• Paramyxovirus, Morbillivirus:  RNA, protein, lipid.

• First described in 910 AD in Baghdad.• Formerly a “childhood disease”.

• Vaccine licensed in US, 1963.• One of the most highly contagious diseases• One of the most highly contagious diseases.

• Still kills about a million people a year globally.

• Transmission:  direct contact, droplets, airborne.

• Incubation period:  10 days (7‐21 days).• Communicability period:  4 days before rash onset to 4 days after rash appearance.

• Life‐long immunity after disease or immunization.3

Measles signs and symptoms 

Measles typically begins with

• High fever,

• Cough,

• Runny nose (coryza) and• Runny nose (coryza), and

• Red, watery eyes.

• 2‐3 days after symptoms begin, tiny white spots (Koplik spots) may appear inside the mouth.

• 3‐5 days after symptoms begin, a rash appears.

4

Measles rash

Measles rash• Rash begins on face and proceeds down the body to involve the extremities last, including palms and soles.  

• Erythematous and maculopapular, may become confluent.  

• Rash lasts about 5 days• Rash lasts about 5 days. • Maculopapular rash contains both macules and papules.  

A macule is flat discolored skin, and a papule is a small raised bump.  A maculopapular rash is usually a large area that is red, and has small, confluent bumps. 

Treatment• No specific treatment.  

• Supportive care:  Maintain hydration, control fever. 

• Vitamin A. 5

Baby in Manila with measles

Woman in United States with 

measles

NEJM 372;23 nejm.org June 4, 2015 http://www.nejm.org/doi/pdf/10.1056/NEJMicm1407399 and CDC Photo Library  6

3/16/2017

2

Characteristic red blotchy rash during third day of the measles rash  

Source: Centers for Disease Control and Prevention  7

Measles complications (per 1,000 cases), US 1985‐1992

100

100

50

0 20 40 60 80 100 120

Diarrhea

Otitis media

Pneumonia

7

1

3

Seizures

Encephalitis

Death

• May cause premature birth or low birth weight. • Subacute sclerosing panencephalitis: rare, but fatal.• Case-fatality in among malnourished children as high as 30%.

8

Measles Laboratory Testing

Serum sample for detection of measles‐specific IgM antibody.

Throat swab (or nasopharyngeal swab) for RNA detection by real‐time polymerase chain 

reaction (RT‐PCR). 9

Differential Diagnosis• Rubella• Fifth disease• Enterovirus• Adenovirus• Mononucleosis• Scarlet fever• Scarlet fever• Roseola• Kawasaki’s disease• Rocky Mountain spotted fever• Drug reactions• MMR vaccine during past 2 weeks.  • And others . . . . . . . .

10

Diagnostic glitches

• False positive IgM.

• False negative IgM

• Cross reactivity with CMV, Herpes.

• Rheumatoid factor.

• Inexperienced clinicians.

• Recent MMR vaccinations.

11

Evidence of Measles ImmunityAcceptable presumptive evidence of immunity against measles includes at least one of the following:• Written documentation of adequate vaccination: 

• 1 or more doses of a measles‐containing vaccine administered on or after the first birthday for preschool‐age children and adults not at high risk,

• 2 doses of measles‐containing vaccine for school‐age children and adults at high risk, including college students, healthcare personnel, and international travelerstravelers.

• Laboratory evidence of immunity (measles IgG in serum).• Laboratory confirmation of measles.• Birth before 1957.• Healthcare providers should not accept verbal reports of vaccination without written documentation as presumptive evidence of immunity. 

• For additional details about evidence of immunity criteria, see Table 3 in “Prevention of Measles, Rubella, Congenital Rubella Syndrome, and Mumps, 2013: Summary Recommendations of the Advisory Committee on Immunization Practices (ACIP)”  (www.cdc.gov/mmwr/preview/mmwrhtml/rr6204a1.htm).

12

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3

Measles response measures ‐A• Assure proper care of patient.

• Verify diagnosis.  

• Active surveillance to find other cases in family, school and community.

• Prospective contact study to find individuals who the p ycase may have exposed (4 days before to 4 days after rash onset).

• Retrospective contact study to determine source of infection (back to 21 days before rash onset).

• MMR vaccination for all unvaccinated individuals who were exposed (must be done within 72 hours of exposure).

13

Measles response measures ‐B• Immunoglobulin prophylaxis to exposed and susceptible persons within 6 days of exposure.

• Mass vaccination effort in community for unvaccinated individuals born in 1957 or after.

• Raise awareness to find susceptible persons (unvaccinatedRaise awareness to find susceptible persons (unvaccinated persons too young, <1 yr, or unvaccinated by choice).

• Case exclusions from daycare or school until 4 days after onset of rash.

• Exclude unvaccinated susceptible persons from daycare, school, and healthcare setting until  21 days after last rash onset.

14

Measles Case Definition (2013)http://wwwn.cdc.gov/NNDSS/script/casedef.aspx?CondYrID=908&DatePub=1/1/2013%2012:00:00%20AM

Clinical Description• An acute illness characterized by:

– Generalized, maculopapular rash lasting ≥3 days; and– Temperature ≥101°F or 38.3°C; and– Cough, coryza, or conjunctivitis.

Case Classification• Probable

In the absence of a more likely diagnosis, an illness that meets the clinical description with:– No epidemiologic linkage to a laboratory‐confirmed measles case; and– Noncontributory or no measles laboratory testing.

• ConfirmedAn acute febrile rash illness† with:– Isola on of measles virus‡ from a clinical specimen; or– Detection of measles‐virus specific nucleic acid‡ from a clinical specimen using polymerase chain 

reaction; or– IgG seroconversion‡ or a significant rise in measles immunoglobulin G an body‡ using any evaluated 

and validated method; or– A posi ve serologic test for measles immunoglobulin M an body‡§; or– Direct epidemiologic linkage to a case confirmed by one of the methods above.

† Temperature does not need to reach ≥101°F/38.3°C and rash does not need to last ≥3 days.

‡ Not explained by MMR vaccination during the previous 6‐45 days.

§ Not otherwise ruled out by other confirmatory testing or more specific measles testing in a public health lab.

15

Measles deaths, United States, 1950‐2015

468

683

618

462

518

345

530

389

552

385380

434

408

364

421

400

500

600

700

Vaccine Licensed1963

276261

81

2441

8990

24232020121511 6 11 2 2 4 1 4 2 2 3

32

64

27

4 0 0 2 1 2 0 2 1 1 0 1 0 0 0 0 0 0 0 0 0 0 0 10

100

200

300

1950

1952

1954

1956

1958

1960

1962

1964

1966

1968

1970

1972

1974

1976

1978

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

2010

2012

2014

Source:  CDC, Epidemiology and Prevention of Vaccine‐Preventable Diseases, 13th ed, 2015

16

Measles cases reported, USA, 1975‐2016

41,126

57,435

27 78630 000

40,000

50,000

60,000

213

963

309

508

138100 100 86

11644 56 37 66 55 43

131

1763

220

55

187

667

188

78

0100200300400500600700800900

1000Measles, USA, 1993-2016

24,374

26,871

13,59713,506

3,1241,7141,497

2,5872,822

6,282

3,6553,396

18,193

27,786

9,643

2,237213963309508138100100 86 116 44 56 37 66 55 43 131 17 63 220 55 187667188 78

0

10,000

20,000

30,000

17

Measles Strikes AgainReported Cases in South Dakota,

1913-2016

6 000

7,000

8,000

9,000

10,000

0 0 0 0 0 0 0 0 0 0

23

0 0 0 0 0 0

8

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

8

20

0

5

10

15

20

25SD measles, 1980-2016

0

1,000

2,000

3,000

4,000

5,000

6,000

19

13

19

15

19

17

19

19

19

21

19

23

19

25

19

27

19

29

19

31

19

33

19

35

19

37

19

39

19

41

19

43

19

45

19

47

19

49

19

51

19

53

19

55

19

57

19

59

19

61

19

63

19

65

19

67

19

69

19

71

19

73

19

75

19

77

19

79

19

81

19

83

19

85

19

87

19

89

19

91

19

93

19

95

19

97

19

99

20

01

20

03

20

05

20

07

20

09

20

11

20

13

20

15

0

18

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4

Recent measles outbreaks in South Dakota

• 1990 measles outbreak:  University of South Dakota,  23 cases.

• 1997 measles outbreak in Central South Dakota.– 8 cases.8 cases.– 3 generations of transmission.– Counties:  Hughes (3) and Hyde (5).– Age median 23 yrs (range 12 mo – 37 yr).

– Outbreak burnt out before DOH notified.– 7,678 people immunized in Pierre, Ft Pierre, and Highmore.

19

Dodging the viral bullet in South Dakota

• 2007:  Group of South Dakota students exposed to measles while attending science fair in Albuquerque. No cases.

• 2010:  Group of Sioux Falls school children exposed to measles while on Omaha field trip.  No cases.

• 2011: Measles outbreak in Minneapolis immigrant community exposed several South Dakota children Nocommunity exposed several South Dakota children.  No cases.   

• 2011: North Dakota resident became sick with measles while staying in Rapid City motel and received care in local clinic.  No secondary cases.    

• 2016:  Refugee to Sioux Falls from Arizona Detention Center with measles outbreak.  

We have been lucky, but it’s not all luck.  It is good primary prevention by maintaining high vaccination coverage.  

20

4th generation

1

2 3rd generation

2014 ‐2015 South Dakota Measles Outbreak 14 cases         [each box = 1 case] 

2nd generationSD residents visit sick brother in KS hospital

0

30 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 1 3 5 7 9 11 13 15 17 19 21

December 2014 January 2015

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Measles outbreak:  chain of events• November 2014: Exposure Event: Unvaccinated adult Kansas resident takes trip to India. 

• 30 Nov:  Case 1:  Rash onset, hospitalized in Kansas, misdiagnosed.  Visited by South Dakota family. 

• 14 December:  Case 2:  Rash onset, unvaccinated adult male, SD resident. 

• 15 Dec:  Case 3:  Rash onset, unvaccinated teen male, SD resident. 

22

Measles outbreak:  chain of events• 22 Dec:  Case 4:  Rash onset, unvaccinated teen 

female, SD resident. 

• 25 Dec:  Case 5:  Rash onset, unvaccinated adult female, SD resident. 

26 D Case 6 R h t i t d b• 26 Dec:  Case 6:  Rash onset, unvaccinated boy child, SD resident. 

• 26 Dec:  Case 7:  Rash onset, unvaccinated girl child, SD resident. 

27 Dec:  Case 8:  Rash onset, unvaccinated baby, SD resident.   REPORTED to DEPT of HEALTH.  

23

Measles outbreak:  chain of events

• 29 Dec:  Case 9:  Rash onset, unvaccinated adult female, SD resident.

• 30 Dec:  Press release.  News Conference.  

• 3 January 2015: Case 10: Rash onset3 January 2015:  Case 10:  Rash onset, unvaccinated boy child, Arizona resident visiting SD family. 

• 4 Jan:  Case 11:  Rash onset, unvaccinated girl child, Arizona resident visiting SD family. 

24

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5

Measles outbreak:  chain of events

• 5 Jan:  Case 12:  Rash onset, unvacc pregnant Arizona resident visiting SD family. 

• 10 Jan:  Case 13:  Rash onset, unvaccinated adult male, SD resident. ,

• 14 Jan:  Case 14:  Rash onset, unvacc girl childin Sioux Falls not connected with outbreak family. 

25

Davison County, South Dakota Measles Outbreak:  13 cases and 187 contacts (as of 13 Jan 2015) 

• 14 cases in 3 states.• At least 187 contacts in 7

states.• 4 generations of

transmission.• None immunized by

l h ipersonal choice.• No deaths, one

hospitalization. • Age range 19 mo – 41 yr.• DOH notified 27 December

2014 by Queen of Peace hospital.

• Active surveillance until 21 days after last case.

• Not related to concurrent Disney Land outbreak.

26

Disney Measles Outbreak, 

Dec 2014–Feb 2015

125 Measles cases:  California 110, Arizona 7, Colorado 1, Nebraska 1, Oregon 1, Utah 3, Canada 10, Mexico 1. 

27

MMR vaccination (Measles, Mumps and Rubella)

Recommendations www.cdc.gov/vaccines/hcp/vis/vis‐statements/mmr.html

• CHILDREN:  2 doses of MMR vaccine:

– 1st Dose: 12‐15 months of age.

– 2nd Dose: 4‐6 years of age (may be given earlier, if at least 28 days after the 1st dose)28 days after the 1 dose).

• Some infants younger than 12 months should get a dose of MMR if they are traveling out of the country.  (This dose will not count toward their routine series.)

• MMR vaccine may be given at the same time as other vaccines.

28

MMR vaccination (Measles, Mumps and Rubella)

Recommendationswww.cdc.gov/vaccines/hcp/vis/vis‐statements/mmr.html

• ADULTS should also get MMR vaccine:  Generally, anyone 18 years of age or older h b f 1956 h ld l 1who was born after 1956 should get at least 1 

dose of MMR vaccine, unless they can show that they have either been vaccinated or had all 3 diseases.

29

MMR vaccination (Measles, Mumps and Rubella)

Recommendations

•HEALTHCARE workers:  If you were born in 1957 or later and have not had the MMR vaccine, or if you don't have an up‐to‐date blood test that shows you are immune to measles or mumps (i.e., no serologic evidence of immunity or prior vaccination), get 2 doses fof MMR (1 dose now and the 2nd dose at least 28 days later).

• If you were born in 1957 or later and have not had the MMR vaccine, or if you don't have an up‐to‐date blood test that shows you are immune to rubella, only 1 dose of MMR is recommended.  

• For HCWs born before 1957, see the MMR ACIP vaccine recommendations  www.cdc.gov/vaccines/hcp/acip‐recs/vacc‐specific/mmr.html .

CDC. MMWR.  November 25, 2011 / 60(RR07);1‐45 30

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6

Pre‐ and Post‐Vaccination cases, South Dakota (10 years prior to vaccine licensure 

vs. 10 years after licensure)

3,509

5,440

3 000

3,500

4,000

4,500

5,000

5,500

s

Pre‐Vaccine

Post‐Vaccine

2,158

111

778

1340

500

1,000

1,500

2,000

2,500

3,000

Polio 1955 Measles 1963 Hepatitis A 1995

Cases

Disease and year of vaccine licensure

‐97% decrease

‐86% decrease

‐94% decrease

31

Vaccination 4:3:1* coverage rates: children 19‐35 months, South Dakota and United States, NIS 1994‐2015

79 2

83.2 83.4

80.5

82.0

83.4

89.288.4

84.1

87.4

82.681.4

84.4

85.7

82.9

82.2

83.5 83.1 83.1 82.8 82.581.5

82.082.6

81.5

82.683.2

80

85

90

ated

South Dakota

United States

32

74.0

79.278.0

75.1

78.477.9

74.9

76.9

75.076.0

78.477.9

80.679.9

77.678.6 78.5

80.5

70

75

80

1994 30th

1995 15th

1996 12th

1997 28th

1998 47th

1999 15th

2000 24th

2001 23rd

2002 13th

2003 22nd

2004 6th

2005 7th

2006 20th

2007 6th

2008 22nd

2009 25th

2010 40th

2011 47th

2012 44th

2013 15th

2014 11th

2015 26th

Percent vaccina

Year and South Dakota's national ranking

*4:3:1   ≥4 doses of DTaP, ≥3 doses of polio and ≥1 doses of MMR vaccine

Vaccination coverage and exemptions for Kindergarten students, South Dakota and United States, 2014‐15 school year

97.2%

97.1%

94.2%

94.0%

0% 20% 40% 60% 80% 100%

DTaP ≥4 doses

MMR ≥2 doses

96.8%

0.2%

1.5%

93.6%

0.2%

0.9%

Varicella ≥2 doses

Medical exemptions

Non‐Medical exemptions

South Dakota

United States

33CDC.  Vaccination Coverage Among Children in Kindergarten — United States, 2014–15 School Year;  MMWR 28 Aug 2015. 64(33);897‐904.

Teens 13‐17 years, vaccination coverage rates, South Dakota, North Dakota and United States, 2014 (NIS) 

39.7%

81.0%

90.7%

33.1%

63.0%

94.8%

HPV ≥3 doses, female

Varicella ≥2 doses*

MMR ≥2 doses

*No history of disease

87.6%

79.3%

21.6%

75.0%

57.0%

23.5%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Tdap ≥1 doses since age 10

Meningococcal ≥1 dose

HPV ≥3 doses, male

South Dakota

United States

34CDC. MMWR 31 July 2015, Vaccination coverage among adolescents aged 13 through 17 years – United States, 2014. 

South Dakota school immunization statuteSDCL 13‐28‐7.1. Tests and immunizations for communicable diseases required for admission to school or early childhood program‐‐Exceptions‐‐Rules. Any pupil entering school or an early childhood program in this state, shall, prior to admission, be required to present to the appropriate school authorities certification from a licensed physician that the child has received or is in the process of receiving adequate immunization against poliomyelitis, diphtheria, pertussis, rubeola, rubella, mumps, tetanus, and varicella, according to recommendations provided by the Department of Health. The Department of Health may modify or delete any of the required immunizations.  As an alternative to the requirement for a physician's certification, the pupil may present:

(1) Certification from a licensed physician stating the physical condition of the child would be(1) Certification from a licensed physician stating the physical condition of the child would be such that immunization would endanger the child's life or health; or

(2) A written statement signed by one parent or guardian that the child is an adherent to a religious doctrine whose teachings are opposed to such immunization; or

(3) A written statement signed by one parent or guardian requesting that the local health department give the immunization because the parents or guardians lack the means to pay for such immunization.

The Department of Health may promulgate reasonable rules, in accordance with chapter 1‐26, to require compliance and documentation of adequate immunization, to define appropriate certification, and to specify standard procedure.

Source: SL 1971, ch141; SL 1972, ch97; SL 1978, ch114; SL 1992, ch129; SL 2000, ch83, § 1; SL 2005, ch101, § 1.

35

Vaccination MMR coverage (%) at kindergarten entry by state, 2014‐2015

90

95

100

80

85

Mississippi

Marylan

d

North Carolin

a

New York

Delaware

New M

exico

West Virginia

Texas

South Dakota

Connecticut

Louisiana

Wyo

ming

South Carolina

Nebraska

Missouri

Rhode Island

Tennessee

Illinois

Massachusetts

Montana

Michigan

Arizona

Orego

n

USA

 Median

Georgia

Nevada

Utah

Alabam

a

Minnesota

Virginia

Florida

Alaska

Kentucky

Verm

ont

California

New Jersey

Maine

Iowa

Ohio

Pennsylvan

ia

Wisconsin

New Ham

pshire

Oklah

oma

North Dakota

Idah

o

Washington 

Indiana

Kan

sas

Arkan

sas

Colorado

36CDC.  MMWR 28 Aug 2015.  64/33. 

3/16/2017

7

Estimated percentage of kindergarten children with exemption from vaccination, 

by state, 2014–15 school year

4

5

6

7

0

1

2

3

Idah

o

Verm

ont

Orego

n

Alaska

Colorado

Wisconsin

Michigan

Arizona

Washington

Maine

Utah

Montana

Haw

aii

New Ham

pshire

California

North Dakota

Florida

Georgia

Ohio

Pennsylvan

ia

Connecticut

Iowa

New Jersey

South Dakota

USA

 Median

Nebraska

Oklah

oma

Kan

sas

Massachusetts

Arkan

sas

Delaware

Marylan

d

Nevada

New M

exico

South Carolina

Virginia

Indiana

Rhode Island

Tennessee

North Carolina

Kentucky

Alabam

a

New York

Louisiana

West Virginia

Mississippi

Illinois

Minnesota

Missouri

Texas

Wyo

ming

na na na na na

37Source:  www.cdc.gov/mmwr/preview/mmwrhtml/mm6341a1.htm

Kindergarten vaccination exemptions, South Dakota 2002‐2016

140

21

4121

2122

21

2.2%

1.7%1.9%

1.8%1.7% 1.6%

2.0%2.0%

2.5%

3.0%

150

200

250

Perce

nt o

f s

Number

Religious exemptions Medical exemptions Percent exempt

192

22

89

5772 80 83

136120

182199

181 176

219

3147

51

35

33

113

38

30

0.5% 0.5%

0.7%

0.9%1.0%

1.1%

1.3%1.2%

%

0.0%

0.5%

1.0%

1.5%

0

50

100

200220032004200520062007200820092010201120122013201420152016

studen

ts exempt

r of exem

ptio

ns

38Source:  South Dakota Department of Health

American Academy of Pediatrics Reiterates Safety and Importance of Vaccines, 17 Sept 2015

• Claims that vaccines are linked to autism, or are unsafe when administered according to the recommended schedule, have been disproven by a robust body of medical literature.  It is dangerous to public health to suggest otherwise.

• “There is no ‘alternative’ immunization schedule. Delaying vaccines only leaves a child at risk of disease for a longervaccines only leaves a child at risk of disease for a longer period of time; it does not make vaccinating safer.

• “Vaccines work, plain and simple.  Vaccines are one of the safest, most effective and most important medical innovations of our time.  Pediatricians partner with parents to provide what is best for their child, and what is best is for children to be fully vaccinated.”

Karen Remley, MD, MBA, MPH, FAAP, Executive Director, American Academy of Pediatrics .

39

Salmonella Javiana Outbreak at a South Dakota Powwow 2016

40

Salmonellosis • Bacteria:  Gram negative enteric bacilli.  

• Incubation period:  Usually 12‐36 hours (range 6‐72 hours)

• Symptoms:  Gastroenteritis.  Sudden onset of diarrhea (may 

be bloody), abdominal cramps, fever, nausea, vomiting.   May be invasive.  

• Duration of illness:  Usually 4 to 7 days.

• Treatment:  Most individuals recover without treatment.

• Reservoir:  Wild and domestic animals.  

• Taxonomy:  Approximately 2,500 serotypes.  Most common in South Dakota:  Typhimurium, Enteritidis, Newport.  

41

196

273

241

216

232

264

298 297 301

276

295307

346

450

197

230

304

248225

250

275

300

325

350

375

400

425

450

es r

epor

ted

Shiga toxin-producing E. coli

Campylobacter

Salmonella

Cryptospordiosis

Foodborne & Waterborne Disease CasesSouth Dakota, 1994 – 2016 

42

18 23 26 2937

4756

43 4333 35 33

50 47 53

71

3541

47 43 41

62

8281

100

71

108 103

140 141

160

196190

143

108119

90

132

100 100

151

120133

153162

132

174

154

197186

162170

182

164

0

23 25

715

8

4253

4130

86

169

88

138

107

146

113

174

153 157

0

25

50

75

100

125

150

175

200

1994 19951996 19971998 1999 20002001 20022003 2004 20052006 20072008 2009 20102011 20122013 2014 20152016

Cas

Source: SD-DOH NETSS

3/16/2017

8

20.621.9

24.422.8

19 720.9

21.8

19.9

26.8

35.6

25

30

35

40

100,

000

popu

latio

n

South Dakota

United States

Salmonellosis Incidence (cases per 100,000 population)South Dakota and United States, 2002 – 2015 

43

17.3 16.9 17.3

19.1 19.7 19.9

15.2 14.715.4 15.5 16.0

16.916.2

17.716.9 17.3

16.3 16.4

0

5

10

15

20

2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016

Cas

e pe

r 1

Source: CDC. 2015 MMWR 62/53

38.6

23.925

30

35

40

es p

er 1

00,0

00)

South DakotaMinnesotaColoradoAll FoodNet States

South Dakota foodborne illness culture‐confirmed incidence compared to FoodNet States, 2015

44

7.0

0.0

16.917.9

4.4

0.1

13.2

10.5

3.6

0.2

13

15.9

2.6

0.20

5

10

15

20

Campylobacter Salmonella E. coli shiga Listeria

Inci

denc

e (c

ase

http://www.cdc.gov/foodnet/reports/data/infections.html#table3b

Salmonellosis case classifications

• Suspect case:  Self diagnosed or physician guess.  

• Probable case:  Culture Independent Diagnosed or “Epi‐Linked”.or  Epi Linked .

• Confirmed case:  Isolation of Salmonella spp. from a clinical specimen. 

45

Epidemiologically linked case

A patient who had contact with someone who has the disease or was exposed to a source of infection.

1 Example: Sick sibling of a laboratory1. Example:  Sick sibling of a laboratory confirmed case.  

2. Example:  Sick person who ate the same food at a picnic as laboratory confirmed cases. 

46

Culture Independent Diagnostic Tests1. Commercial antigen‐based tests (FDA‐approved),

2. Commercial DNA‐based syndrome panels (FDA‐approved),

3. Laboratory‐developed tests.

FilmArray® GI Panel 11. Shigella/Enteroinvasive E. coli (EIEC)FilmArray GI Panel1. Campylobacter 2. Clostridium difficile3. Plesiomonas shigelloides4. Salmonella5. Yersinia enterocolitica6. Vibrio 7. Vibrio cholerae8. Diarrhegenic E. coli9. Shiga‐like toxin‐producing E. coli10. E. coli O157

11. Shigella/Enteroinvasive E. coli (EIEC)12. Cryptosporidium13. Cyclospora cayetanensis14. Entamoeba histolytica15. Giardia lamblia16. Adenovirus F40/4117. Sapovirus (I, II, IV & V)  18. Astrovirus19. Norovirus GI/GII20. Rotavirus A

47

Why Dept of Health needs Salmonella isolates? 

• Serotyping.

•Molecular typing for case linkage:• Pulse Field Gel Electrophoresis (PFGE).

• Whole Genome Sequencing (WGS).  

•National databases and linkages.

48

3/16/2017

9

Recommendations for clinical laboratories using CIDT

• Reflexive culturing of CIDT specimens.  

• Submit isolates of foodborne pathogens to South Dakota Public Health Laboratory (SDPHL). 

• If isolates are not available, submit clinical material (stool, broths) to SDPHL.  ( , )

• Review South Dakota’s disease reporting and mandatory isolate submission requirements (see handout).

• Use courier service to send isolates or clinical material to SDPHL in Pierre.

• Maintain effective and open communication with the SDPHL (Phone:  800‐592‐1861). 

• Notify the SDPHL of your intent to implement CIDT. 49

July 1, 2016

5 Salmonella cases reported from multiple labs.

Investigation identified common exposure:  powwow.

Outbreak investigation initiated:

Salmonella Outbreak

Outbreak investigation initiated: Start of July 4th weekend.

Health Alert sent to area healthcare providers.

Yankton Sioux Tribe and Wagner IHS contacted.

>1,100 people attended Powwow on 24‐26 June 2016.

2 catered meals at powwow.

Food history questionnaire created with menu items.

50

5 July 2016

30 cases (confirmed, probable, and suspect).

Outbreak serotype identified by SDPHL – SalmonellaJaviana

Rare in SD (only 14 cases reported in past 6 years).

Salmonella Outbreak

6 July 2016

Media Blitz:  local TV, radio, newspaper, and Facebook

51

Pork sandwich, Turkey sandwich, Beef sandwich, Chili dogs, I di t

Dinner roll, Fruit salad,Cheesy hash browns, Baked beans, M i l d

Wateca:  Food served

Indian tacos, Hamburgers, Hotdogs, Chili, Chili fries,

Macaroni salad, Potato salad,Cake,Kool‐Aid.

52

Outbreak Case Definitions:

• Confirmed:   An individual from whom Salmonella Javiana with the outbreak pattern (JGGX01 0172) was isolated

Methods

(JGGX01.0172) was isolated.

• Probable: An individual who became ill with diarrhea after eating food served at the powwow, OR contact with a Confirmed case (epi‐linked).

53

112 cases (46 confirmed, 66 probable)

0 1

14

20

14 15

21

1510

2

05

10152025

Age:  median 40 yrs, range 4‐85 yrs

South Dakota (n=109) Buffalo 1 Charles Mix 76 Davison 2 Dewey 4 Gregory 6

Oglala Lakota 1 Pennington 3 Todd 7 Yankton 4 Ziebach 1

Results

Gregory 6 Lyman 2Minnehaha 2

Ziebach 1

Arizona (2)Minnesota (1)

Diarrhea 100%Bloody diarrhea 19%

Vomiting  51%Fever 71%Hospitalized: 28% (N=30)Duration of illness: 6 days median (range 1‐20)Race: 96% American Indian, 3% White, 1% Other

Male38%

Female62%

54

3/16/2017

10

20

25

30

35

40

r of Cases

Confirmed case (Culture positive)Probable caseAte Leftovers Only (did not attend powwow)

1st case reported

4 cases d

Outbreak timeline

0

5

10

15

Numbe

Onset Date

Powwow 

SDPHL isolates S. Javiana

reported 

55

Case‐Control Analysis:  98 cases and 66 controls

Food/DrinkCases

Yes         No

ControlsYes          No

Odds

Ratio 95% CI p

Macaroni Salad 68 30 12 54 10.2 4.8 – 21.8 <0.001

Baked Beans 55 42 11 55 6.5 3.1 – 14.0 <0.001

Brisket sandwich (beef) 64 35 16 49 5.6 2.8 – 11.3 <0.001

Fruit Salad 72 25 24 42 5.0 2.6 – 9.9 <0.001

Kool‐Aid 43 54 10 56 4.5 2.0 – 9.8 <0.001

Soup 61 37 19 47 4.1 2.1 – 8.0 <0.001

Cake 54 42 19 47 3.2 1.6 – 6.2 <0.001

Turkey sandwich 12 81 3 62 3.1 0.8 – 11.3 0.10

Pork loin sandwich 38 56 13 53 2.8 1.3 – 5.8 0.005

Hamburger 7 89 2 64 2.5 0.5 – 12.5 0.31

Fried Bread 39 57 16 50 2.1 1.1 – 4.3 0.03

Potato Salad 14 80 6 59 1.7 0.6 – 4.7 0.29

Hot Dog 4 92 2 64 1.4 0.2 – 7.8 0.96

Water 41 57 23 43 1.3 0.7 – 2.6 0.37

Cheesy Hash Browns 19 76 11 55 1.3 0.6 – 2.8 0.59

Chili 15 77 10 55 1.1 0.4 – 2.6 0.88

Chili Fries 7 86 5 60 1.0 0.3 – 3.2 0.97

Lemonade 21 75 18 48 0.7 0.4 – 1.5 0.43

Indian taco 13 83 14 52 0.6 0.3 – 1.3 0.20 56

Environmental Investigation Inspected local caterer, casino and powwow food serving station. Food served from 4:30 – 6:10PM at powwow.

“Wateca” All leftover food left out (not refrigerated) and given to whomever wanted to take it hometake it home.

The only refrigerator available was full and ice used for salads had melted.

Some food sat out until midnight (>6 hours out of temperature control).

Trace back of implicated foods.  

The caterer denied any food workers being ill.57 58

Conclusions

Outbreak of Salmonella Javiana associated with food served at the powwow.

Ultimate source not determined, but most likely originated with an ill or asymptomatic infected food worker who hand extensiveinfected food worker who hand extensive bare‐hand contact with food items.

Deficiencies in temperature controls and potential for cross‐contamination may have contributed to survival and proliferation of Salmonella.

59

Influenza in South Dakota

60

3/16/2017

11

Influenza surveillance• Track influenza‐like illness (ILI).

• Determine what influenza viruses are circulating.

• Measure the influenza’s impact:  hospitalizations and deaths.  

• Influenza surveillance conducted year round.

• Enhanced surveillance October – May.

1. Laboratory confirmed influenza cases (PCR, culture, DFA). 

2. Aggregate Influenza Rapid Antigen reporting.

3. ILI Net:  34 sentinel physicians.

4. Influenza‐associated deaths.

5. Influenza‐associated hospitalizations.

6. Daily syndromic surveillance.  

7. School Illness Absentee Reporting.

8. Outbreaks (schools, day‐care, long term care facilities). 

61

Confirmed influenza cases, South Dakota 5 seasons 2012‐2017

134

192

257

279

205

135150

175

200

225

250

275

300

med cases

2012‐20132013‐20142014‐20152015‐20162016‐2017

1 1 1 3 2 0 1 0 4 2 7 920

45

71

134 135

0

25

50

75

100

125

150

40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20

Confirm

MMWR weeks (First week October to third week May) 62

Influenza hospitalizations, 

South Dakota 2007‐2016

429

793

500

600

700

800

900

Pandemic

Average H3N2 years    : 395 hospitalizationsAverage H1N1 years    : 241 hospitalizations

361

134

290

164

365

239

161

0

100

200

300

400

2007‐2008 A(H3N2)

2008‐2009 A(H1N1)

2009‐2010 A(H1N1)

2010‐2011 A(H3N2)

2011‐2012 A(H3N2)

2012‐2013 A(H3N2)

2013‐2014 A(H1N1)

2014‐2015 A(H3N2)

2015‐2016 A(H1N1)

Influenza season and major strain63

Influenza deaths, South Dakota 2003‐2016

4238

63

40

50

60

70

Pandemic

Average H3N2 years    :  30 deathsAverage H1N1 years    :  11 deaths

25

11

6

22

4

2420

17

129

0

10

20

30

2003‐04 A(H3N2)

2004‐05 A(H3N2)

2005‐06 A(H3N2)

2006‐07 A(H1N1)

2007‐08 A(H3N2)

2008‐09 A(H1N1)

2009‐10 A(H1N1)

2010‐11 A(H3N2)

2011‐12 A(H3N2)

2012‐13 A(H3N2)

2013‐14 A(H1N1)

2014‐15 A(H3N2)

2015‐16 A(H1N1)

Influenza season

c

64

2015‐16 influenza season, vaccination coverage (%) by state, National Immunization Survey‐Flu (NIS‐Flu) and BRFSS

45

50

55

60

25

30

35

40

South Dakota

Rhode Island

Connecticut

Iowa

Marylan

d

New Ham

pshire

North Carolina

Delaware

Massachusetts

Haw

aii

Minnesota

West Virginia

Virginia

Verm

ont

Colorado

Nebraska

New York

Maine

North Dakota

Pennsylvan

ia

Texas

Washington

Missouri

New M

exico

South Carolina

Tennessee

Oklah

oma

United States

Arkan

sas

New Jersey

Kan

sas

Kentucky

Louisiana

Alabam

a

Montana

Ohio

California

Utah

Indiana

Illinois

Wisconsin

Michigan

Mississippi

Orego

n

Arizona

Georgia

Florida

Idah

o

Wyo

ming

Alaska

Nevada

65www.cdc.gov/flu/fluvaxview/reportshtml/trends/index.html

Vaccine effectiveness (±95%CI) estimates for influenza seasons, 2004‐2017 

( www.cdc.gov/flu/professionals/vaccination/effectiveness‐studies.htm )

53

59

70

49

75

66

56 55

58

53

57

5256

60

47 49 5147 48

50

60

70

80

‐36 ‐52

22 22 23

36

43 43

8

3937

40

36

10

21

37

47

23

47

0

10

20

30

40

2004‐05 2005‐06 2006‐07 2008‐09 2009‐10 2010‐11 2011‐12 2012‐13 2013‐14 2014‐15 2015‐16 2016‐17

66