PUBLIC HEALTH UPDATEsdapic.org/wp-content/uploads/2018/10/PH-Update-9.22.18...1 PUBLIC HEALTH UPDATE Eric C. McDonald, MD, MPH, FACEP Medical Director, Epidemiology and Immunizations

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PUBLIC HEALTH UPDATE

Eric C. McDonald, MD, MPH, FACEP

Medical Director, Epidemiology and Immunizations

Services, Public Health Services

County of San Diego Health and Human Services Agency

Annual SoCal APIC Meeting

28 September 2018

DISCLOSURE STATEMENT

I have no relevant financial relationships with

any commercial supporters.

Unlabeled/Investigational products and/or

services will not be mentioned in this talk.

OBJECTIVE

To provide an overview of investigations by epidemiology staff and current status of infectious disease issues in San Diego County

TOPICS

Influenza

MERS-CoV

Aedes-borne Diseases

Hepatitis A

Ebola

Meningococcal Disease

Measles

Influenza

“Widespread”

“Worst season in years”

“Deadly”

“Severe SeaSon”

Flu Season in the Media

“The United States 2017–18

influenza season was a high severity

season…” June 7, 2018

Morbidity & Mortality Weekly Report

Centers for Disease Control and Prevention

The severity of influenza disease in the United

States can vary widely and is determined by a

number of factors including:

Source: CDC

• Characteristics of circulating viruses [Virus]

• Timing of the season [Timing]

• Effectiveness of the vaccine [Vaccine]

• How many people got vaccinated [Immunity]

INFLUENZA SEASON SEVERITY

INFLUENZA SEASON 2017/18

20,833

320 342

Total Reported

influenza cases

DEATHS

ICU CASES

TOTAL REPORTED

INFLUENZA CASES

117 CONFIRMED

OUTBREAKS

INFLUENZA TYPE, 2017/18

Flu A

Flu B

Flu A/B

Influenza A

Influenza B

Influenza A (H3) Seasonal

Influenza A (H1N1)pdm09

Influenza B/Yamagata

Influenza B/Victoria

Influenza A/B

13,128

593

62

66.2%

6,811

42

19

33.0%

178 0.8%

Flu Type Flu Sub-type/Strain Count Percentage

N = 20,833

WEEKLY CASES BY SEASON

0

500

1,000

1,500

2,000

2,500

3,000

3,500

4,000

Wk27

Wk29

Wk31

Wk33

Wk35

Wk37

Wk39

Wk41

Wk43

Wk45

Wk47

Wk49

Wk51

Wk1

Wk3

Wk5

Wk7

Wk9

Wk11

Wk13

Wk15

Wk17

Wk19

Wk21

Wk23

Wk25

2017-18 2016-17 2015-16 2014-15 Previous 5 Year Avg 2003-04

• Earlier season in 2017/18

• New historical weekly high

Cases

Cases

CUMULATIVE CASES BY SEASON

0

5,000

10,000

15,000

20,000

25,000

Wk28

Wk30

Wk32

Wk34

Wk36

Wk38

Wk40

Wk42

Wk44

Wk46

Wk48

Wk50

Wk52

Wk2

Wk4

Wk6

Wk8

Wk10

Wk12

Wk14

Wk16

Wk18

Wk20

Wk22

Wk24

Wk26

2017-18 2016-17 2015-16 2014-15 Previous 5 Year Avg 2003-04

1 22 5 14 4 9 8 58 25 13 65 70 97 71 87 342 0

50

100

150

200

250

300

350

FLU DEATHS BY SEASON

Deaths

Season

INFLUENZA DEATHS, 2017/2018

96% Had underlying health conditions

26% Residents of a skilled

nursing or long term

health facility

33% Known to

be

vaccinated

342 Deaths

Average days

between positive

influenza

lab result and death 11

58%

19%

18%

4% 1%

Influenza A Influenza B Influenza A/H3

Influenza A/B Influenza H1N1

INFLUENZA DEATHS

BY VIRUS TYPE, 2017/2018

342 Deaths

INFLUENZA DEATHS, 2017/2018

UNDERLYING CONDITION COUNT PERCENT HEART DISEASE 106 31% COPD 86 25% HTN 66 19% ALZH/DEMENTIA 60 18% DIABETES 59 18% RENAL DISEASE 40 12% AFIB 39 11% OTHER CONDITION 33 10% CANCER 28 8% ASTHMA 5 1% LIVER DISEASE 4 1% STROKE 5 1% TOTAL DEATHS 342 100%

FLU CASES BY AGE GROUP

2017/2018 Number & Age Specific Incident Rate

0.0

1,000.0

2,000.0

3,000.0

4,000.0

0

500

1000

1500

2000

2500

3000Count Rate per 100K

Co

un

t

Rate

per

100K

INFLUENZA OUTBREAKS

Confirmed

outbreaks 117

1 0 0 1 2

51 50

8 4

JUL AUG SEP OCT NOV DEC JAN FEB MAR

80% 7%

13%

Flu A Flu B Unknown Type

Total cases

1,655 Average cases

per outbreak

14.1

Influenza Type

Month Reported

52

37

56 60

47 49 51

19

48

39 40

0

10

20

30

40

50

60

70

80

Source: CDC

Influenza Season

ESTIMATED VACCINE

EFFECTIVENESS BY SEASON

Note: estimated effectiveness for preventing medically

attended, laboratory-confirmed influenza virus infection.

Percent 25% A(H3N2)

65% A(H1N1)

49% Flu B

Flu Forecast

?

48 0 DEATHS

TOTAL REPORTED

INFLUENZA CASES

CURRENT UPDATE Reported Cases Since July 1, 2018

Flu A 81%

Flu B 19%

0 OUTBREAKS

N=48

Cases by Flu Type

Preliminary Results

Data Source: Reported Influenza Case Reports

Prepared by County of San Diego, Health & Human Services Agency, Public Health Services, Epidemiology and Immunization Services Branch, 9/22/2018

http://www.cdc.gov/nchs/data/nvsr/nvsr59/nvsr59_01.pdf

0

10,000

20,000

30,000

40,000

50,000

60,000

70,000

80,000

26 28 30 32 34 36 38 40 42 44 46 48 50 52 2 4 6 8 10 12 14 16 18 20 22 24 26

Week Number 2016-2017 2017-2018 2018-2019

2016/2017 Total: 601,251

2017/2018 Total: 770,072

2018/2019 To date: 28,761

Data through 09/08/2018

Vaccines Administered

INFLUENZA VACCINES

ADMINISTERED

* Influenza vaccinations administered and registered into the San Diego Immunization Registry (SDIR)

https://www.sandiegoimmunizationregistry.org/sdir_home.htm

INFLUENZA

WHAT CAN YOU DO?

Consider testing for novel influenza in patients with travel history,

avian or swine contacts

Remember influenza causes disease year-round in San Diego

Report ALL positive flu cases to Epidemiology Program

Sign up for Flu Watch

(EISB (619) 692-8499 or [email protected])

Promote early immunization of staff to be consistent with health

officer order “vaccinate or mask” Nov 1- March 31

Promote flu immunizations to patients, especially those at risk for

increased morbidity

SURVEILLANCE REPORTS

• Influenza Watch report posted and emailed weekly

• On the web at: www.sdepi.org

• Information used in HHSA reports and press releases

http://www.sandiegocounty.gov/hhsa/programs/phs/community_epidemiology/

MERS-COV

CURRENT STATUS

GLOBAL TOTAL

CONFIRMED

2,243 GLOBAL

DEATHS

795

CURRENT

CASES

KSA

9/24/18

Downloaded 9/27/18 from

https://www.moh.gov.sa/en/CCC/events/national/Documents/Epiwk36.pdf



Source: GHK CHP. Downloaded 9/20/17 from:

http://www.chp.gov.hk/files/pdf/distribution_of_mers_cases_en.pdf




Source: WHO http://www.who.int/csr/don/31-august-2018-mers-united-kingdom/en/

Source: WHO http://www.wpro.who.int/mediacentre/releases/2018/20180909/en/

MERS-COV

WHAT CAN YOU DO?

IDENTIFY ISOLATE INFORM

OBTAIN A TRAVEL HISTORY EARLY IN EVALUATION

Travel to affected area in last 2 weeks (HAJJ!)

Camel contact, healthcare contact

Be aware of the clinical spectrum of reported illness

Inform Epidemiology Program to facilitate testing

Three specimens needed (upper tract, lower tract, serum)

Specimens go to CDPH lab – 24 hour turn around

Counsel patients prior to travel to take precautions

MERS-COV

WHAT CAN YOU DO?

OBTAIN A TRAVEL HISTORY EARLY IN EVALUATION

Identify, isolate, inform

Be aware of the clinical spectrum of reported illness

Inform Epidemiology Program to facilitate testing

Three specimens needed (upper tract, lower tract, serum)

Specimens go to CDPH lab – 24 hour turn around

Counsel patients prior to travel to take precautions

AEDES-BORNE DISEASES

ZIKA

Image Credit: Getty Images

Source: CDC. Downloaded 3/22/17 from

https://wwwnc.cdc.gov/travel/page/world-map-areas-with-zika

Where is Zika now?

Africa: Angola, Benin, Burkina-Faso, Burundi,

Cameroon, Cape Verde, Central African Republic,

Chad, Congo Congo-Brazzaville), Côte d’Ivoire,

Democratic Republic of the Congo (Congo-Kinshasa),

Equatorial Guinea, Gabon, Gambia, Ghana, Guinea, Guinea-Bissau, Kenya,

Liberia, Mali, Niger, Nigeria, Rwanda, Senegal, Sierra Leone, South Sudan,

Sudan, Tanzania, Togo, Uganda

Asia: Bangladesh, Burma (Myanmar), Cambodia, India, Indonesia, Laos,

Malaysia, Maldives, Philippines, Singapore, Thailand, Vietnam

Caribbean: Anguilla, Antigua and Barbuda, Aruba, Barbados, Bonaire, British

Virgin Islands, Cuba, Curaçao, Dominica, Dominican Republic, Grenada, Haiti,

Jamaica, Martinique, Montserrat, Puerto Rico, Saba, Saint Kitts and Nevis, Saint

Lucia, Saint Martin, Saint Vincent and the Grenadines, Sint Eustatius, Sint

Maarten, Trinidad and Tobago, Turks and Caicos Islands, US Virgin Islands

North/Central/South America: Argentina, Belize, Bolivia, Brazil, Colombia,

Costa Rica, Ecuador, El Salvador, French Guiana, Guatemala, Guyana,

Honduras, Mexico, Nicaragua, Panama, Paraguay, Peru, Suriname, Venezuela

Pacific Islands: Fiji, Papua New Guinea, Samoa, Solomon Islands, Tonga

AREAS WITH

ZIKA RISK

American Samoa (4/17)

Bahamas (2/18)

Cayman Islands (7/17)

Cook Islands (3/17)

Guadeloupe (6/17)

French Polynesia (3/17)

Ilsa de Pascua, Chile (3/17)

AREAS WITH

INTERRUPTED

TRANSMISSION

Travelers’ Health

Marshall Islands (1/18)

Martinique (6/17)

Micronesia (11/17)

New Caledonia (3/17)

Palau (11/17)

Saint Barthelemy (5/17)

Vanuata (3/17)

Source: PAHO. Downloaded 9/27/18 from http://ais.paho.org/phip/viz/ed_zika_countrymap.asp

Local case count:

580,496 suspect

221,093 confirmed

Travel case count

6,162 travel

Total case count

807,751 as of 9/21/17 (!)

http://ais.paho.org/phip/viz/ed_zika_countrymap.asp



2015 Total : US States = 62 + 0 , US Territories = 10 + 0

Source: CDC. Downloaded 6/4/18 from:

https://www.cdc.gov/zika/reporting/2015-case-counts.html

13








2016 Total : US States = 5,168 + 38 , US Territories = 36,512 + 325



496










2017 Total as of 7/3/18: US States = 452 + 32 , US Territories = 666 + 6

126










2018 Total as of 9/5/18: US States = 41 + 6 , US Territories = 82 + 0

39








Map prepared on 9/26/18 using data from:

https://www.gob.mx/salud/acciones-y-programas/zika-informacion-relevante

and software on: http://diymaps.net/

Mexican States with Confirmed Local Transmission of Zika, 2015-2018

Total Confirmed

Autochthonous

Cases = 12,149

as of 9/17/18

1

Confirmed local transmission

No local transmission

Case count

3

64

99

205

336 950

4

691

1 802

1

527

297

504

42 69

530

285

225

2,102

516

375

821

94

389

1,308

887

5

17











http://diymaps.net/

http://diymaps.net/

http://diymaps.net/





Case count

345

Mexican States with Confirmed Local Transmission of Zika, 2017

Case count 1



Total Confirmed

Autochthonous

Cases = 3,292

as of 6/18/18

3

60

22 107

274 108

2 1 653

493 614 15

8

2 15

4

134

6

106

78

17

27

22

5 3

196

415











http://diymaps.net/

http://diymaps.net/

http://diymaps.net/





Case count

Mexican States with Confirmed Local Transmission of Zika, 2018

1

Total Confirmed

Autochthonous

Cases = 232

as of 9/17/18

11 28

13

95

6

8

2

5

2

2 8

Case count 1



5

1

2

9

15

2

15

1











http://diymaps.net/

http://diymaps.net/

http://diymaps.net/

Mexican States with Confirmed/Probable Cases of Dengue, 2016

Source: Secretaría de Salud. Map downloaded on 1/9/17:

http://www.epidemiologia.salud.gob.mx/informes/2016/dengue-semanas.html

Baja California

9 confirmed

242 probable

Total Cases

Confirmed= 17,795

Probable = 132,055

Total = 149,850

as of 1/30/17

Incidence per

100,000 of

confirmed cases



https://www.gob.mx/cms/uploads/attachment/file/285237/Pano_dengue_sem_52_2017.pdf

Total Cases with

symptom onset in 2017

Confirmed= 14,138

Probable = 89,893

Total = 104,031

as of 1/2/18

Incidence per 100,000

of confirmed cases

Baja California

11 confirmed

161 probable

Baja California Sur

30 confirmed

605 probable





https://www.gob.mx/salud/documentos/panorama-epidemiologico-de-dengue-2018-semana-epidemiologica-37

Baja California

1 confirmed

60 probable

Baja California Sur

32 confirmed

495 probable

Total Cases with

symptom onset in 2018

Confirmed = 4,578

Probable = 32,744

Total = 37,322

as of 9/17/18

Incidence per 100,000

of confirmed cases



















Confirmed and Probable Dengue Cases in Mexico 2017, 2018

Epidemiology Curve by Week, Through Week 37



Total Zika referrals: 4,519 (985 in 2018)

Confirmed/Probable Zika cases: 109 (4 in 2018)

Confirmed cases in pregnant women: 15

Cases ruled out for Zika: 4,351

Cases pending lab results or submission: 25

Cases pending lab results in pregnant women: 2

Cases referred to Vector Control: 455

Other diagnoses made:

Dengue 35 (4 in 2018)

Chikungunya 15 (4 in 2018)

ZIKA REFERRALS

IN SAN DIEGO 2015-18

For more information contact:

Eric C. McDonald, MD, MPH, FACEP Medical Director, Epidemiology and Immunizations Services

Public Health Services

County of San Diego Health and Human Services Agency

3851 Rosecrans Street (MS-P578)

San Diego, CA 92110

Phone: (619) 692-8436

Fax: (858) 715-6458

Email: [email protected]