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Published for Healthcare Professionals1st Quarter 2014

EPI UPDATE

Oakland County Health Division1200 N. Telegraph Rd., Pontiac, MI 48341

L. Brooks Patterson Oakland County Executive

In This Issue

RABIES UPDATE RICHARD RENAS, MPH

Rabies virus continues to circulate in Oakland County. During the five year period 2009-2013, infections were primarily in wildlife (17 bats, 14 skunks, one fox and one woodchuck) which is consistent with trends seen in Michigan and the United States. Additionally, two dogs and two cats tested positive. Skunk rabies increased significantly from the five cases seen during 2004-2008. Skunk strain spilled over into other wildlife and domestic cases, including the woodchuck which was the first ever seen in Michigan. While skunks are a significant source of rabies, bats are the overwhelming source of human exposure in Oakland County.

A bite or a scratch is the most common means of becoming infected with rabies. Particularly with bats, due to their very small teeth, a bite wound may not be obvious. The Centers for Disease Control and Prevention (CDC) suggests post exposure prophylaxis (PEP) where there is a reasonable probability that contact with a bat may have occurred (e.g. a deeply sleeping person awakens to find a bat in the same room, an adult witnesses a bat in a room with a previously unattended child, mentally

disabled person or intoxicated individual) and when rabies cannot be ruled out through testing of the bat.

To evaluate animal bites and the need for PEP, refer to the Rabies Post Exposure Prophylaxis (PEP) Protocol on page 3 which has been summarized from the Advisory Committee on Immunization Practices (ACIP) recommendations for PEP to prevent human rabies. The Oakland County Health Division Communicable Disease Unit (OCHD-CDU) has the protocol available electronically or on laminated, pocket sized cards. To obtain copies contact the OCHD-CDU at 248-858-1286. PEP reference documents can also be accessed at:

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5902a1.htm

http://www.cdc.gov/mmwr/pdf/rr/rr57e507.pdf

Initiating rabies PEP is an urgent matter, not an emergency. In most cases it is not necessary to initiate treatment immediately. PEP can wait 48-72 hours to

(continued on page 2)

Rabies Upate 1OCHD - CDU Rabies Post Exposure Prophylaxis Protocol 3Influenza 2013-2014 Season Summar 4World TB Day - A Reminder of an Ever-Present Diagnostic Dilemma 52013 Active Tuberculosis Cases Summary 6Oakland County Selected Diseasses 7Think TB Poster 8

1st Quarter 2014 - EPI Update

OAKLAND COUNTYHEALTH DIVISION OFFICES

North Oakland Health Center1200 North Telegraph 34EPontiac, MI 48341-0432248.858.1280Toll Free 1.888.350.0900FAX 248.858.0178

South Oakland Health Center27725 Greenfield RoadSouthfield, MI 48076-3663248.424.7000FAX 248.424.7144

Visit us at our website:oakgov.com/health

Oakland County Health Division will not deny participation in its programs based on race, sex, religion, national origin, age or disability. State and federal eligibility requirements apply for certain programs.

OAKLAND COUNTY HEALTH DIVISION - CD UNIT 248.858.1286

Pamela Hackert, MD, JD, MPH Chief of Medical Services Nicole Parker, MPH Epidemiologist Richard Renas, MPH Epidemiologist

Suzanne Brunette, RN, BSN Communicable Disease Nurse

Anne Hocking, RN, BSN Communicable Disease Nurse

Carolyn Padro, RN, BSN Communicable Disease Nurse

After hours urgent calls: 248.858.0931, ask for the health administrator on call.

RABIES UPDATE (continued from page 1)

receive animal testing results or find and confine the dog, cat, or ferret in order to avoid unnecessary administration of PEP, which has significant cost, pain and inconvenience for the patient. Any potential exposure does, however, need to be evaluated. If it is determined that an exposure did occur, then PEP should be given. For questions and advice on risk assessment and prophylaxis call OCHD-CDU at (248) 858-1286. For medical staff questions regarding evaluation of a patient seen after hours in the emergency department or after hours clinic, contact the Health Administrator On Call at (248) 858-0931.

With the arrival of spring and summer the number of exposures to bats and other potentially rabid animals will increase dramatically. In order to minimize this health problem the following measures will help protect pets, children and adults:

• Have pets vaccinated and keep up with regular booster shots• Warn children (and adults) to stay away from wild or stray animals• Wild-life proof your home

For animal collection call Oakland County Animal Control at (248) 391-4102.

Helpful websites for rabies prevention and control information are:

• OCHD Rabies Fact Sheet www.oakgov.com/health/Documents/Facts%20Sheets/fs_rabies.pdf

• MI Rabies Maps, PEP Protocols, On line PEP course – CE credits www.michigan.gov/rabies

• ACIP Guidelines, physician info www.cdc.gov/rabies • CDC Safe Bat Capture Guidelines www.cdc.gov/rabies/bats/contact/index.html

OAKLAND COUNTY HEALTH DIVISION RABIES PRESENTATION

The Oakland County Health Division (OCHD) Public Health Speakers Team offers rabies educational presentations for professionals or for community groups. If you are interested in scheduling a presentation visit the OCHD Public Health Speakers Team web site at:

www.oakgov.com/health/Pages/Public-Health-Speakers-Team.aspx

1st Quarter 2014- EPI Update

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INFLUENZA 2013-2014 SEASON SUMMARYNICOLE PARKER, MPH

The 2013-14 influenza season has been similar to the 2012-13 influenza season. Figure 1 shows that the 2013-14 season did not have a mid-February peak that is typically seen in Oakland County and nationwide. Instead the peak of the 2013-14 influenza season occurred during late December – early January, similar to the peak of 2012-13 season, and consistent with what occurred nationwide. The 2013-14 season quickly declined after its peak during the first week of January; whereas, the 2012-13 season was sustained throughout the month of February. In contrast to the 2012-13 season, this season started around the same time as in years past, with the first cases of influenza being reported in late November and early December.

In terms of strains seen, this season was atypical, 97.2%, of laboratory confirmed and probable cases of influenza reported to the Oakland County Health Division (OCHD) were influenza A positive (Figure 2).

Sixty-four of the 419 influenza A cases were subtyped by MDCH-BOL. Of those, 96.9% were confirmed as being positive for influenza A H1N1 2009. Throughout Michigan and the United States influenza A H1N1 2009 was observed to be the predominant circulating strain.

The statewide surveillance system identified a majority, 92.1%, of specimens positive for influenza A 2009 H1N1, as of April 17, 2014. Of the 366 influenza specimens tested at the state level, 3.5% were positive for influenza A/H3 and 3.8% were positive for influenza B. This is unique to this season within the state and nationwide because despite the influenza A H1N1 2009 strain being a good match to the vaccine, the strain was still able to circulate and infect the population.

During the 2013-14 season, Oakland County hospitals reported 191 inpatient cases to OCHD. This diligent reporting and continued participation in reporting hospitalized influenza patients is much appreciated. As part of their reporting, these facilities provide additional information about the patient’s stay in the hospital and pre-existing risk factors that may lead to complications with influenza. This season 169 hospitalized patients had additional stay and risk factor information reported.

Of the hospitalized patients reporting risk factors for complications with influenza:• 59.2% were taking an immunosuppressive drug• 42.0% had a chronic underlying heart disease• 37.2% were obese based upon their body mass index• 29.0% had a chronic underlying metabolic disease including diabetes• 27.2% had a chronic underlying lung disease• 21.3% had asthma• 11.2% had been diagnosed with cancer in the last 12 months• 10.7% had another immunosuppressive condition• 8.3% had a chronic underlying renal disease• 7.7% had a chronic underlying neurologic disease• 1.9% of the 105 females were pregnant

*Figure 1 and 2 reported as of end of MMWR Week 14-2014 (continued on page 5)


INFLUENZA SUMMARY (continued from page 4)

Tragically, two pediatric deaths were associated with laboratory confirmed influenza in Michigan during the 2013-14 season. No pediatric deaths were recorded in Oakland County. However, consistent with the predominance of the influenza A H1N1 2009 strain, three deaths of 20-30 year olds were attributed to complications related to influenza A H1N1 2009 infection. All three individuals were unvaccinated.

Table 1 shows a comparison of 2012-13 and 2013-14 hospitalized patients with information available:

Table 1 – 2012- 2013 and 2013-2014 Inpatient Demographics 2012-2013 2013-2014 <65 Years 40.6 64.4 Average Age 48.6 53.3 Age Range 1 month - 102 years 1 month - 90 years Reported Being Vaccinated 32.3 37.2 Average Days Hospitalized 4.5 5.2 Admitted to ICU 11.8 24.6 Ventilator 1.3 15.2 ECMO 2.2 3.1 Pneumonia 24.9 42.4 ARDS 1.3 14.1

More detailed and up to date information on influenza surveillance is available online at:• Michigan.gov (http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_22779_40563-143382--,00.html ) • Centers for Disease Control and Prevention (http://www.cdc.gov/flu/weekly/fluactivitysurv.htm )

WORLD TB DAY – A REMINDER OF AN EVER-PRESENT DIAGNOSTIC DILEMMAPAMELA B HACKERT, MD, JD, MPH

World TB Day, March 24, serves as an annual reminder of just how devastating a burden tuberculosis (TB) is to most of the world and how much of an impact it still has in Michigan. This annual event commemorates the date in 1882, when Dr. Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacillus that causes TB. Although Michigan is a low incidence state, TB is still a significant health issue, not only for individuals, but for anyone who breathes that same air.

This year, the Centers for Disease Control and Prevention (CDC) selected the theme “Find TB. Treat TB. Working together to eliminate TB.” Even with the declining number of TB cases in the United States, our current efforts to find and treat latent TB infection and TB disease are not sufficient. Misdiagnosis of TB still exists and health care professionals often do not “Think TB,” until several rounds of antibiotics have been given without curing that persistent “pneumonia.” Also, we are seeing rarer manifestations of TB. Even while our overall numbers indicate low incidence, the complexity of cases is seemingly higher, with some recent examples such as central nervous system TB, drug resistant TB or multiple types of mycobacterium in a patient.

On March 26, I had the opportunity to present at Michigan’s commemorative event for World TB Day in Lansing. It was a full day of up to the minute information about TB, including topics such as the epidemiology of TB, the dilemmas of diagnosis, the particular concerns of patients with TB/HIV co-infection, etc., but the most moving and inspiring part of the day was when a patient shared her story of how her life changed when she was diagnosed with multi-drug resistant TB. Through the sharing of these stories we can bring attention to this critical public health problem and ensure that resources continue to be available to eradicate this disease because, “Everyone has a role in ensuring that one day TB will be eliminated.”

Conference resources are available at: https://mphi-web.ungerboeck.com/wri/wri_p1_display.aspx?oc=10&cc=WORLDTB

CDC TB information is located at: www.cdc.gov/tb

http://www.michigan.gov/mdch/0,1607,7-132-2940_2955_22779_40563-143382--,00.html


2013 ACTIVE TUBERCULOSIS CASES SUMMARY, NICOLE PARKER, MPH

During 2013, twenty-six cases of active Tuberculosis (TB) disease were reported to the Oakland County Health Division - TB Unit (OCHD TB Unit). The case rate per 100,000 population is 2.2 (Figure 1), this case rate is slightly higher than previous years but is well below the national case rate for the United States. Of the 26 cases:

• 57% were male • Average age 48.7 years, ranging from 17 to 88 years

Active TB disease can present in three different forms: Pulmonary, Extra-pulmonary, or a combination of both. Pulmonary TB is the most infectious form of active TB disease. Of the active cases in Oakland County, 57% had the pulmonary form and 7.6% had evidence of both pulmonary and extra-pulmonary TB infection.

There are a variety of risk factors associated with active TB disease (Table 1), these risk factors range from underlying medical conditions to socioeco-nomic factors. The three most common risk factors amongst Oakland County’s 2013 TB cases were: birth in a foreign country (73.1%); unemployment (34.6%);, and diabetes (19.2%). Other known risk factors such as homelessness, immunosuppressive conditions, and being a contact to a known case were also present.

OCHD TB Unit’s two case managers, under the direction of OCHD’s Medical Director, Dr Pamela Hackert, work tirelessly to ensure that all identified cases receive directly observed therapy (DOT). The standard of care set by the Centers for Disease Control and Prevention (CDC) is that all cases, both pulmonary and extrupulmonary, receive DOT. This ensures that the needed four drugs for successful treatment are administered appropriately and that any side effects from the therapy are caught early. For the 15 cases that completed treatment in 2013, the OCHD TB Unit case managers administered DOT for 26.5 weeks on average, with some cases continuing for as long as 40 weeks. Treatment for the remaining 11 cases is ongoing into 2014.

In addition, these case managers work to ensure that all case contacts: family members, friends, co-workers, are appropriately assessed at OCHD clinics or in their home, and follow-up treatment is conducted as indicated. During 2013 these case managers also directed the assessment of a large school based case contact investigation in which 280 case contacts were assessed. (See Second Quarter 2013 Epi Update for the full report on that investigation). The efforts of the TB case managers and the OCHD TB Unit work toward preventing further TB disease within Oakland County and help move Public Health closer to the goal of eliminating TB disease worldwide.

For additional information regarding TB data in Michigan visit the Michigan Department of Community Health’s (MDCH) TB Control Program page at: www.michigan.gov/mdch/0,1607,7-132-2945_5104_5281_46528---,00.html

For additional information regarding national TB data visit the Centers for Disease Control and Prevention’s (CDC) TB information page at: www.cdc.gov/tb/

0

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1

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2009 2010 2011 2012 2013

Rate

per

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Figure 1: 2009 - 2013 TB Case Rate per 100,000 population

Rate per 100,000

Table 1 - 2013 Case Risk Factors for active TB disease

Risk Factors %Foreign Born 73.1Unemployed 34.6Diabetes 19.2Contact to an Active Case 3.8Homeless 3.8Immunosuppressive Condition, not HIV/AIDS 3.8HIV Positive 0.0No Risk Factors 3.8

www.michigan.gov/mdch/0,1607,7-132-2945_5104_5281_46528---,00.html


Note: Data may change slightly as new information becomes available.1Includes all newly diagnosed HIV cases, including those diagnosed with Stage 3 (AIDS) at the same time as their HIV diagnosis, based on date of HIV diagnosis2Includes all newly diagnosed Stage 3 (AIDS) cases, including those diagnosed with HIV at the same time as their Stage 3 diagnosis, based on date of Stage 3 diagnosis

DISEASE Jan-March 2012

Jan-March 2013

Jan-March 2014

HIV (all stages)1 20 27 26AIDS (HIV infection stage 3)2 16 19 8Campylobacter 22 16 26Chickenpox 33 11 20Chlamydia 816 837 820Giardiasis 14 11 13Gonorrhea 202 237 159Hepatitis A 1 5 0Hepatitis B Acute 3 4 1Hepatitis C Chronic 150 123 124Legionellosis 3 2 4Listeriosis 0 0 0Measles 1 0 0Meningitis, viral (aseptic) 22 17 15Meningococcal Disease 0 0 0Pertussis 22 16 32Salmonellosis 24 16 18Shiga-toxin producing E. coli (STEC) 5 3 3Shigella 6 0 5Syphilis (primary&secondary) 6 12 4Strep pneumonia, invasive 13 18 15Tuberculosis-Pulmonary 2 3 1Tuberculosis-Extrapulmonary 2 1 1Typhoid Fever 0 0 2

OAKLAND COUNTY SELECTED DISEASE DATA