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11/2/2015
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Incidence of Infectious Disease in Florida: Perspectives from the Division of Disease
Control and Health Protection
Anna M. Likos, MD, MPHState Epidemiologist and Director
Division of Disease Control and Health ProtectionFlorida Department of Health
11/2/2015 1
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Objectives
A little bit about the DivisionDisease Control and Health Protection
Review Infectious Disease Threats in FloridaNew Bugs
Old “Friends”A couple of commercialsGlobal Health News Report
11/2/2015 2
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015
2
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 4
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
NEW BUGS
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
EbolaSept 30, 2014
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Florida’s Response
Oct 6, 2014 Incident Management TeamTwice-daily calls, state and local partners
Daily calls with County Health DepartmentsFielded lots of calls
Technical assistance for testingFlorida-specific guidance
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
CDC Response
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[email protected]: DGMQ Enhanced Ebola Entry Screening: Contact List for Flight UAL 0951 on 08/15/2015 for FL
[email protected]: Interstate Movement Notification-Active Monitoring for Ebola -- NYC to FL, Transfer Depart Date: 08/16/2015
Airport Monitoring
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Florida’s Response
Oct 25, 2015: Executive Order 2014-280Establishes Ebola Virus Disease Response Protocol
Twice a day, face to face, monitoring of travelers
As of Oct 27:Total of 747 travelers have been monitoredCurrently monitoring: 17
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Florida’s ResponseLaboratory Testing
Miami Laboratory: 1 of first 11 labs nationally with EVD testing capability
Now all 3 BPHL labs can test
Tested total of 4 individuals 2 prior to monitoring: Negative
2 after monitoring began: Negative
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
West Africa Today
Week Oct 11-18: 3 cases reported3 in Guinea, 0 in Sierra Leone
5th consecutive week with 0 cases in Sierra Leone
Total of 28,476 cases
11,298 Deaths
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Chikungunya and Dengue
Chikungunya: “Man who walks stooped over”“All bent up”
NOT: An illness of chickens
BUT: “Chicken gumbo” is close enoughAND: It could be worse:
O’nyong nyong virus
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Patient StoryPatient Story� 68-year-old Puerto Rican general surgeon and medical school
professor� History of mosquito bites� 5 days later developed 102°F fever � High fever for 3 days � Fever subsided 1-2 days� High fever recurred along with severe, migratory joint pain –
hands, wrists, shoulder, feet, hips � Disrupted sleep: awakened by fever and stabbing joint pains � Severe symptoms: Trouble walking due to swollen feet –
couldn’t wear shoes and couldn’t work. Cancelled vacation. � Lasting symptoms: 10 weeks later still had joint pain
� 6 months later – still mildly symptomatic
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Arthritis – swollen joints
What does it look like?
Rash covering torso and extremities Blistering rash
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Chikungunya Virus Disease“That which bends over”
• Mosquito-borne viral disease characterized by acute onset of fever and severe pain in multiple joints
• Mortality low but extremely debilitating • Most infected persons become symptomatic• No antiviral therapy
• Treatment is symptomatic
• Lifelong immunity following infection• No licensed vaccines• Prevention relies on avoidance of mosquito bites and
mosquito control
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Diagnostic TestingPCR and Serology
• Florida DOH BPHL• Tampa and Jacksonville
• CA, NY State Labs • CDC Arboviral Diseases Branch • Single commercial laboratory
• Focus Diagnostics
11/2/2015
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
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2014: 510 Imported Cases12 Locally Transmitted Cases (2.3% of total cases in 2014)
4 Counties: Broward (1), Miami-Dade (2), Palm Beach (5), St Lucie (4)2015: 65 as of Oct 24, 2015
0 Locally Transmitted Cases so far
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Chikungunya virus Disease Cases Reported by Territory — United States, 2014
(as of February 10, 2015)
*30,983 suspected cases also reported to Puerto Rico Dept of Health†1,321 suspected cases also reported to U.S.VI Dept of Health
Note: 99.2% of Puerto Rican and 94.7% of U.S.VI cases are locally-transmitted cases
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Why the Difference?
• Air Conditioning• Screened Windows and Doors
• ? Due to vector differences• Aedes albopictus is less efficient at
transmission
• Close working relationship with Mosquito Control at the county level
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Chikungunya and Dengue
Dual testing indicated
2014: 17 cases of co-infection 2015: 3 cases of co-infection so far
80% found by BPHL labsNo dual infections were local transmissions
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Dengue
2014: 83 imported cases7 local transmissions
3 in a single householdsplit into 3 living units
2015: 47 imported cases0 local transmission so far
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Old Bugs
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Measles
11/2/2015 23
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Measles in Florida2014: No Cases
2015: 5 imported cases in non-resident travelers
5 local cases:3 households in 2 counties
Temporally linked
Identical genotypeNo epidemiological linkage
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Value of ESSENCEIn outbreak setting:
Use broader search terms
Identify additional casesInform County Health Departments
Calls made to rule in/out cases
Measles: No additional cases detected
Chikungunya: Two additional cases found
11/2/2015 25
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Rubella2014: None
2015: 1 case (first case since 2008)Imported from Phillipines
1,338 Contacts identified620 reached in person
All received notification
No additional cases found
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Meningococcal Disease
2014: 50 Cases~ 7 Deaths
2015: 16 cases
~ 5 DeathsChild in Detention HomeNeed for vaccination in group settings
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Neisseria meningitidis W135
Florida: Different from rest of USPredominant serogroup is W135
Mostly in south-east FloridaSeen sporadically throughout state
Most isolates share PFGE patternWorking with UF for whole genome sequencingIsolates very closely related
11/2/2015 28
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Vibrio vulnificus
2014: 32 Cases7 Deaths
2015: 40 cases
16 DeathsMajority are wound relatedImmunocompromised individuals
11/2/2015 29
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
The Vibrios2004-2013: Vibrio vulnificus
~25% were foodborne
~50% were wound associated~25% either multiple causes or unknown
2004-2013: All VibriosFoodborne associated with less fatal infections
(V. mimicus, V. hollisae, V. fluvialis)
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Primary Amoebic Meningo-encephalitis
2014: 1 case Naegleria fowleri1 death
June 19-27: Costa Rican resort
June 27: Onset symptoms June 29: Hospitalized
July 2: Request for MiltefosineExpired
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Primary Amoebic Meningo-encephalitis
2015: 1 case Acanthomoeba66 year old male, multiple co-morbidities14 year hx ulcerative colitis; recent dx of HIV
6/22-6/25: Hospitalized in ChicagoAseptic Meningitis
6/28: Presented to Shands with HA, fever7/3: ExpiredSource is unknown
11/2/2015 32
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Carbapenem-Resistant Enterococcus
March, 2015: CRE linked to duodenoscopes
Data from historical outbreak in Florida
Today’s Emerging Pathogens:Antimicrobial Resistant Organisms
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Salmonella
2014: 6,019 confirmed and probable cases37 multi-state investigations
2015: 4,723 cases28 multi-state investigations
Forward specimens to BPHL for PFGE and serotyping
11/2/2015 34
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Legionella
2014: 280 confirmed cases4 outbreaks
2015: 253 confirmed cases
5 outbreaksFlorida non-residents are not included in
these numbers
11/2/2015 35
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Food and WaterborneComplaints and Cases
2014: 2,165 complaints
104 outbreaks identified1,311 cases associated with outbreaks
2015: 1,936 complaints
70 outbreaks587 cases
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Rabies
2014: 2201 Animals tested 91 Positive
895 Cats572 Dogs
Cats: more frequent vectors of rabies than dogs– Lack of vaccination– Cat food left outside attracts raccoons
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
2015: >1712 Animals tested60 Positive
29 Racoons
14 Bats7 Foxes6 Cats
2 Goats (frirst time in 57 years)
1 Dog
11/2/2015 38
Rabies
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
ArbovirusesSt Louis Encephalitis2014: 2 cases (first since 2003)
2015: 0 cases West Nile Virus2014: 16 cases (11 neuroinvasive)
4 asymptomatic blood donors2015: 9 human cases (9 neuroinvasive)
1 asymptomatic blood donors
11/2/2015 39
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Brucellosis2014: 3 Cases in pig hunters
– Brucella suis
2015: 8 cases (confirmed or probable)1. 7/8 have links to swine
2. Positive Blood Donor– Symptomatic– Spouse of a pig hunter
3. 2 members of same household positive– 1 year apart
11/2/2015 40
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Bugs and Tatoos
11/2/2015 41
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Tattoos
Early May, 2015:– Rash-like illness in 3 recipients of tattoos
from Studio X in Miami, same artist– Rash associated with grey color – Investigation initiated
394 clients contacted
38 cases found3 artists
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Tattoos
Collaborative investigation with FDA & DoH
FDA:– Opened and unopened bottles of ink– Tap water
DoH:– Clinical specimens– Provided treatment
11/2/2015 43
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Non-tuberculous Mycobacteria
Culture Results:– Variety of Mycobacteria
• Opened ink bottles: M. abscessus• Unopened bottles: M. chaeloni (unopened)• Other bacteria found as well
– Tap water: M. abscessus
Labs are doing PFGE
11/2/2015 44
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 45
Further Actions
Manufacturer not producing ink
Follow up investigation to characterize clinical course
Additional case finding (clients from last May)
Genotyping
11/2/2015
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
HIV Infection Cases and Rates*,by Year of Report, 2005-2014, Florida
Year Rate05 38.706 36.507 37.008 41.909 29.510 2611 26.412 23.713 28.314 31.4
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
HIV
2014: 6019 Cases diagnosedMiami-Dade: 23.44%
Broward: 16.5%4 Counties: Between 5 and 8.36%
13 Counties: Between 1 and 5%43 Counties: Less than 1%5 Counties: No identified cases
11/2/2015 47
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 48
11/2/2015
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 49
My Personal Leadership Vision
Integrated Public HealthMeans
Working Together
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Healthiest Weight
65% Floridians at unhealthy weight1 out of 3 kids considered obese
Chronic Disease due to obesity costs– $34 billion over next 17 years
11/2/2015 50
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
Healthiest Weight Strategies
1. Increase opportunities for physical activity2. Make healthy food available everywhere
3. Promote health in the worksite4. Strengthen schools as the heart of health
5. Market what matters for a healthy life
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
When Everything is Crashing Around You
Stay CalmAnd
Get a Flu Shot
11/2/2015 52
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 53
Global Health News
To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 54
To Cure DiseaseIs Glory
To Prevent DiseaseIs Victory
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To protect, promote and improve the health of all people in Florida through integrated state, county, and community efforts.
Division of Disease Control and Health Protection
11/2/2015 55
Contact Information:
Anna M. Likos, MD, MPHState Epidemiologist and Director
Division of Disease Control and Health ProtectionEmail: [email protected]
Phone: 850-245-4411