Epi Watch - Whatcom County

January 29, 2015
Volume 8, Issue 1
Whatcom County Health Department
EPI-WATCH
Influenza Circulating in Whatcom County
Although most cases of
influenza are not reportable by law, Whatcom
County Health Department has access to data
on influenza tests performed by the PeaceHealth Laboratory (PHL).
As of January 17, 2015
there have been one hundred thirty-nine cases of
influenza A, and seven
cases of influenza B, reported by the PeaceHealth Lab in Whatcom
County.
Influenza is affecting all
ages this season. The
graph below demonstrates the ages of those
reported, as well as the
ages of those hospitalized
this season. Of the reported cases, 26% have
been hospitalized as of
January 17, 2015. One
case with a positive influenza test while hospitalized has died.
The best way to prevent
seasonal flu is to get vaccinated, even though this
year’s vaccine may not be
a good match for the circulating influenza viruses. For more information
see: http://
www.cdc.gov/mmwr/
preview/mmwrhtml/
mm6401a4.htm?
s_cid=mm6401a4_e
Good health habits like
covering your cough and
washing your hands often can help stop the
spread of germs and prevent respiratory illnesses
like the flu.
Previously, the neuraminidase inhibitors oseltamivir and zanamivir
were the only recommended influenza antiviral drugs. On December
19, 2014, the U.S. Food
and Drug Administration
approved Rapivab®
(peramivir) to treat influ-
enza infection in adults.
See http://www.cdc.gov/
flu/professionals/
antivirals/summaryclinicians.htm for a summary of influenza antiviral medications.
See http://
wwwdev.co.whatcom.wa.
us/health/flu/index.jsp
for the Whatcom County
Health Department’s
weekly influenza report.
If you would like to be
notified via e-mail when
the weekly influenza report is published, please
contact Wendy Hancock
at whancock@whatcomcounty.us
Influenza-associated
deaths (lab confirmed)
and novel/unsubtypable
influenza cases are still
reportable. Call 360-7382503 to report to the
Whatcom County Health
Department 24 hours
per day.
2014-2015 Whatcom County Influenza Cases Reported by PHL
(through 1/17/2015)
Number of Cases
Public Health: Always
Working for a Safer
and Healthier
Whatcom County
40
Inside this issue:
Hepatitis C Treatment/
Travel Diseases
30
20
2
Travel Diseases Continued 3
10
Hospitalized
0
Not Hospitalized
Age of Case
Norovirus
4
STI Update
5
Confirmed/Probable
Notifiable Conditions
6
Page 2
Volume 8, Issue 1
Great News for Hepatitis C Genotype 1 Patients
The last few months of 2014 has given
much promise for hepatitis C genotype 1 patients. On October 10, 2014 a
new drug combination of ledipasvir
and sofosbuvir (Harvoni) was approved by the FDA for the treatment
of chronic hepatitis C genotype 1 infections in adults. The drug is the first
all-oral medication and does not require interferon or ribavirin. In addition to the benefits of an all-oral re-
gime, there are also significantly less
side effects and better sustained virologic response rate (SVR). More
recently on December 19th, 2014 a
new combination of ombitasvir,
paritaprevir, and ritonavir (Viekira
Pack) was approved by the FDA for
treatment of Hepatitis C genotype 1.
This is also an all-oral medication
that boasts similar SVR rates as Harvoni and is a little cheaper, but has a
few more side effects and a
more complicated dose
schedule that would require
more management.
Following is a table showing
the two drugs as they compare
for a patient without renal or
hepatic impairment for a 12week treatment course.
Harvoni
Viekira Pack
SVR12 Rate
Cost for 12 wk Tx
Dose
>90%
$94,500
Fixed Dose Ledipasvir/sofosbuvir (90
mg/400 mg) Once Daily
Side Effects
Well tol.
Most common S/E: fatigue and headache
Company
Gilead Sciences
>90%
$83,319
Two tablets of the co-formulated ombitasvir-paritaprevir-ritonavir (12.5/75/50
mg) once daily plus one dasabuvir tablet
(250 mg) twice daily
Well tol.
Most common S/E:
fatigue, nausea, pruritus, other skin reactions, insomnia, and asthenia
AbbVie
Information received from http://www.hepatitisc.uw.edu/page/treatment/drugs
Travel Diseases
Chikungunya Virus
Chikungunya virus is mainly transmitted
to humans through the bites of infected
mosquitoes, primarily Aedes aegypti and
Aedes albopictus. The highest risk of transmission is during the first week of illness
when the patient is viremic by a biting
mosquito or contact with blood. There are
documented cases of blood-borne transmission in laboratory personnel handling
infected blood and a health care worker
drawing blood from an infected patient.
In 2014, a total of 2,021 chikungunya virus disease cases were reported in the U.S.
Most cases occurred in travelers returning from the Caribbean, Asia or the Pacific
Islands. However, there were no locally
-transmitted cases reported in Washington.
Figure 1. Aedes aegypti
Figure 2. Aedes albopictus
Who is at Risk?
Travelers who go to Africa, Asia, tropical areas of Central and South America, and islands in the Caribbean, Indian
Ocean, and Western Pacific are at risk.
With the ongoing export of Humanitarian aid workers and volunteers to West
Africa in support of the Ebola epidemic, the number of chikungunya cases
among travelers returning to the United States from affected areas may continue to increase.
Page 3
Volume 8, Issue 1
Travel Diseases Continued
With an average incubation period of 3–7 days
(range 1–12 days), the
majority of infected people show symptoms of
fever, severe and debilitating polyarthralgia
(usually bilateral and
symmetric), nausea/
vomiting conjunctivitis
or maculopapular rash
and headache. Laboratory findings may include elevated creatinine, elevated hepatic
transaminases, lymphopenia and thrombocytopenia. Acute symptoms
typically resolve within
7–10 days.
For more information
on Chikungunya, see:
http://www.cdc.gov/
chikungunya/pdfs/
CHIKV_Clinicians.pdf
Chikungunya is a notifiable condition in Washington as one of the Arboviral (Arthropodborne viral) diseases.
Travelers’ Diarrhea
Travelers' diarrhea (TD)
is the most common
illness affecting travelers. Each year between
20%-50% of international travelers, an estimated 10 million persons, develop diarrhea.
The onset of TD usually
occurs within the first
week of travel but may
occur at any time while
traveling, and even after
returning home. The
most important determinant of risk is the
traveler's destination.
High-risk destinations
are the developing
countries of Latin America, Africa, the Middle
East, and Asia. The primary source of infection
is ingestion of fecally
contaminated food or
water.
Most TD cases begin
abruptly. The illness
usually results in increased frequency, volume, and weight of
stool. Altered stool consistency also is common,
with experiences of four
to five loose or watery
bowel movements each
day. Other common
symptoms include abdominal cramping,
bloating, nausea, vomiting, fever, urgency, and
malaise. Most cases are
benign and resolve in 1-
2 days without treatment.
Bacterial enteropathogens cause approximately 80% of TD cases.
The most common causative agent isolated in
countries surveyed has
been enterotoxigenic
Escherichia coli (ETEC).
ETEC produce watery
diarrhea with associated cramps and lowgrade or no fever.
Should Antimotility
agents be used?
In several studies, antimotility agents have
been useful in treating
travelers' diarrhea by
decreasing the duration
of diarrhea. However,
these agents should not
be used by travelers
with fever or bloody
diarrhea, because they
can increase the severi-
ty of disease by delaying
clearance of causative organisms. CDC does not recommend antimicrobial
drugs to prevent TD. Management of infectious diarrhea may also include antibiotics and oral rehydration therapy.
For more information on
Travelers’ diarrhea, see:
http://wwwnc.cdc.gov/
travel/yellowbook/2014/
chapter-2-the-pre-travelconsultation/travelersdiarrhea
As always, clinical judgment is based on the symptoms, clinical presentation
and recent travel or exposure history. Inquiring
about prophylaxis and immunization status may also
help simplify the process.
Chikungunya virus disease cases reported by state – United States, 2014 (as of December 16, 2014)
Page 4
Volume 8, Issue 1
Norovirus Season
It’s that time of year,
when the terms
“stomach flu” and
“food poisoning” become heard more, as
people increasingly
report symptoms of
abdominal pain, vomiting and diarrhea.
What those terms,
“stomach flu” and
“food poisoning” typically—but certainly
not always—refer to is
an infection with norovirus. Norovirus is
not a flu virus, and it is
not always contracted
via food, so both common terms are a bit
misleading.
Norovirus is very contagious and may be
transmitted by an infected person, contaminated food or water,
or by touching contaminated surfaces.
Norovirus infections
occur year round, but
over 80% occur between November and
April, according to the
CDC. Each year norovirus causes 19 – 21
million acute illnesses,
with 56,000 – 71,000
hospitalizations and
570 – 800 deaths, primarily among young
children and the elderly.
Norovirus can spread
quickly among staff
and patrons of care
facilities and over half
of the outbreaks in the
US have been in health
care facilities including hospitals and nursing homes. Proper hygiene, sanitation and
use of personal protective equipment
(PPE) are very important in any setting
where norovirus is
suspected.
Persons infected with
norovirus can be contagious before symptoms appear. They are
most contagious while
symptomatic and into
the first few days after
symptoms resolve. It
is important to understand a person infected with norovirus is
still contagious for up
to two weeks after illness, and especially so
in the first 48 hours
after symptoms resolve. People that
work in health care
that become infected
with norovirus should
not return to work
until at least 48 hours
after symptoms resolve.
It is important to educate everyone about
proper hygiene, including good hand
washing practice, not
just using hand gels.
Hand gels must have
an alcohol content of
greater than 60% to
be effective, and even
then are not a substitute for hand washing.
Even if a hand sanitizer “kills 99.99% of
germs” a viral load on
contaminated hands of
an ill person may be 1
million to 1 billion
particles. Even if
99.99% are eliminated, 100 to 100,000
viral particles may still
remain. An infectious
dose of norovirus is
approximately 18 viral
particles, and on contaminated hands that
used only hand gel
there may still be 5.5
to 5,500 infectious
doses.
Fortunately, most
healthy persons infected with norovirus
recover without treatment. Special care may
be needed if illness
persists, is complicated by other underlying
factors, or the patient
is immunocompromised, young, or elderly.
For additional information see http://
www.cdc.gov/
norovirus/
What those terms,
“stomach flu” and
“food poisoning”
typically—but
certainly not
always—refer to is
an infection with
norovirus.
Norovirus is not a
flu virus, and it is
not always
contracted via
food, so both
common terms are
a bit misleading.
Page 5
Volume 8, Issue 1
Sexually Transmitted Infection Update
In General:
The Washington State Department of
Health (WA DOH) has updated the
Sexually Transmitted Infection (STI)
Case Report. The new case report is
available at: http://
www.doh.wa.gov/Portals/1/
Documents/Pubs/347-102WhatcomCsRpt.pdf
Per DOH legal reporting requirements for chlamydia, gonorrhea,
syphilis, and initial genital and neonatal herpes infections are “notifiable
to local health jurisdiction within
three (3) work days.” Cases should
be reported using the STI Case Report form provided above.
This allows the Whatcom County
Health Department (WCHD) greater
success at locating patients when we
are asked to assume partner management. Resulting in increased success
at getting partners treated more rapidly, thereby decreasing the spread of
STI’s within the community and preventing re-infection of your patients.
Good News:
Expedited Partner Therapy (EPT) is
still available from the DOH . Page
three (3) of the electronic case report
includes the prescription order form
and a list of participating pharmacies
throughout our community.
Providers should make EPT available
for all sexual partners of heterosexual patients testing positive for chlamydia and gonorrhea. EPT is not an
appropriate treatment approach for
cases of Males who have Sex with
Males (MSM) due to the decreased
efficacy of oral cephalosporin's
against gonococcal pharyngeal infections.
Partner Therapy for gonorrhea cases:
WCHD compared to local Providers
100%
80 %
60 %
40 %
20 %
0%
2012
2013
WCHD
Partner Management (not EPT):
The graph above shows that in
gonorrhea cases, local providers
have increasingly asked for the WC
Health Dept. to assume responsibility for partner management.
This is a missed opportunity for
providers to work directly with
their patients—especially MSM
patients needing provider administered IM ceftriaxone—in getting
partners treated more quickly and
with the recommended treatment
modality.
Syphilis:
Cases of syphilis are still on the
rise in Whatcom County and Washington state as a whole. Per the WA
DOH, many early syphilis cases are
co-infected with HIV. Syphilis infection increases an individuals
risk of contracting or transmitting
HIV.
In addition, syphilis and HIV infections disproportionately affect the
MSM population. Therefore, it is
extremely important to take a
thorough sexual health and risk
2014
Providers
history and ask those tough
questions. The CDC has an
excellent and concise guide
for taking a sexual history, it
can be found at the following
link: http://www.cdc.gov/
std/treatment/
sexualhistory.pdf
2014 HIV rates continued at
approximately the same rate
as 2013.
In the event of a positive HIV
confirmed infection, the communicable disease unit within the Whatcom County
Health Dept. can act as a valuable resource to the provider when notifying the patient
of their positive results. We
can help coordinate access to
case management and linkages to care when the patient is
being notified.
HIV cases do not require the
use of the STI Case Report
form, nevertheless, they are
still required to be reported
to the local health jurisdiction within 3 days.
Page 6
Whatcom County Health Department
Communicable Disease and Epidemiology
Communicable Diseases – (360) 676-4593
This is our main phone number. It is answered Monday through Friday from 8:30am4:30pm by front desk office staff. Ask to speak to a nurse in communicable disease. This
line is for both routine and emergency calls during regular business hours.
After hours Public Health Emergency Contact – (360) 715-2588
This is our answering service line. Ask to speak to the manager on call. This number is for
after hours IMMEDIATE or EMERGENCY disease consultation only.
Whatcom County
Health Department
Leading the community in promoting
health and preventing disease
1500 N State St
Bellingham, WA 98225
Phone: 360-676-4593
Report Line: 360-738-2503
Fax: 360-676-7646
www.whatcomcounty.us\health
Voicemail Disease Report Line – (360) 738-2503
This line is for reporting of routine notifiable conditions. This line is monitored Monday
through Friday from 8:30am-4:30pm.
Communicable Disease Fax – (360) 676-7646
Print out a Notifiable Conditions poster for your office:
Health Care Provider Notifiable Conditions Poster
Health Care Facility Notifiable Conditions Poster
Laboratory Notifiable Condition Poster
Confirmed/Probable Notifiable Conditions, Whatcom County
Condition
2014
2013
Condition
2014
2013
Campylobacteriosis
58
56
HIV/AIDS
9
8
Chlamydia
567
580
Measles
6
0
E. Coli 0157:H7
17
15
Meningococcal Disease
0
0
Giardiasis
17
35
Gonorrhea
58
60
Mumps
0
0
Hepatitis B, acute
1
1
Pertussis
23
38
Hepatitis B, chronic
16
9
Rubella
0
0
Hepatitis C, acute
10
9
Salmonellosis
15
20
Hepatitis C, chronic
311
287
Shigellosis
5
4
Hepatitis A
1
1
Syphilis
6
11
HBsAg + pregnancy
0
0
Tuberculosis, Class 3
4
4
Cases listed are preliminary and represent only those reported to the local health department.
Cases are counted at the time of report to the Health Department, not by date of onset.
For final case counts, refer to the Annual Communicable Disease Report.