Warm Weather and Ticks are Here. May through July is the busiest time of the year for tick bites and tickborne diseases in the United States

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1 Volume 13 Issue 3 Summer 2013 MECKLENBURG COUNTY HEALTH DEPARTMENT A Quarterly Publication Disease Detectives Warm Weather and Ticks are Here Inside this issue: NC Measles Outbreak 2 MMR Update 2 Changes at MCHD 3 Public Health Surveillance 3 Reportable Disease List 4 Q Fever 5 Flublock 5 Reporting Form 6 CD Contact List 7 Visit us on the web at May through July is the busiest time of the year for tick bites and tickborne diseases in the United States Each year, nearly 30,000 confirmed cases of Lyme disease are reported to CDC, but a recent national survey reported that nearly 20% of people in areas where Lyme disease is common were unaware that it was a risk. And even in those areas where the disease is common, 42% of individuals reported taking no personal preventive measures against ticks. Other key tickborne diseases include Rocky Mountain Spotted Fever (RMSF), anaplasmosis, ehrlichiosis, and babesiosis. These diseases tend to be concentrated in specific parts of the country. Nearly 95% of Lyme disease cases occur in 12 states: Connecticut, Massachusetts, New York, Delaware, Minnesota, Pennsylvania, Maine, New Hampshire, Virginia, Maryland, New Jersey, and Wisconsin. More than 60% of RMSF cases occur in five states: Arkansas, North Carolina, Tennessee, Missouri, and Oklahoma. Babesiosis occurs in some of the same areas as Lyme disease and anaplasmosis, mainly in the Northeast and upper Midwest. Reducing exposure to ticks is the best defense against Lyme disease and other tickborne infections. CDC recommends that people: Avoid areas with high grass and leaf litter and walk in the center of trails when hiking. Use repellent that contains 20% or more DEET on exposed skin for protection that lasts several hours. Parents should apply repellent to children; the American Academy of Pediatrics recommends products with up to 30 % DEET for kids. Always follow product instructions. Use products that contain permethrin to treat clothing and gear, such as boots, pants, socks and tents or look for clothing pre-treated with permethrin. Treat dogs for ticks. Dogs are very susceptible to tick bites and to some tickborne diseases, and may also bring ticks into your home. Tick collars, sprays, shampoos, or monthly top spot medications help protect against ticks. Bathe or shower as soon as possible after coming indoors to wash off and more easily find crawling ticks before they bite you. Conduct a full-body tick check using a hand-held or full-length mirror to view all parts of your body upon returning from tick-infested areas. Parents should help children check thoroughly for ticks. Remove any ticks right away. Tickborne diseases can cause mild symptoms to severe infections requiring hospitalization. The most common symptoms of tick-related illnesses can include fever, chills, aches and pains, and rash. Early recognition and treatment of the infection decreases the risk of serious complications, so see your doctor immediately if you have been bitten by a tick and experience any of these symptoms. For more information, visit CDC website or contact Beth Quinn at Elizabeth.Quinn@ MecklenburgCountyNC.gov.

2 Page 2 NC Measles Outbreak Measles (Rubeola) returned to North Carolina with a vengeance in Spring To date a total of 23 cases were identified in Orange and Stokes counties. The index case developed symptoms on April 4, 2013, following a trip to India. All of the cases were linked by direct exposure to each other. The majority of the cases had not been vaccinated against measles, though four of the cases had been partially vaccinated with one dose. Measles worldwide continues to be a major health problem. In 2008, the last year that statistics were available, worldwide there were approximately 20 million cases and 164,000 deaths. Before vaccination, measles infected 3-4 million Americans, causing 48,000 hospitalizations and between deaths. Other serious complications can result from measles as well. Diarrhea is reported in 8% of cases; 1 in 10 will develop an ear infection; 1 in 20 will develop pneumonia; 1 out of 1000 will be diagnosed with encephalitis; and 1 or 2 out of 1000 will die. In pregnant women, measles can cause miscar- MMR Update On June 14, 2013, the CDC published updated immunization recommendations for the prevention of measles, rubella, congenital rubella syndrome, and mumps. The publication in the Morbidity and Mortality Report is a compendium of all current recommendations for the prevention of measles, mumps, rubella, and congenital rubella syndrome and new guidelines adopted by the Advisory Committee on Immunization Practices (ACIP). At the October 24, 2012 ACIP meeting, the following revisions were adopted: For acceptable evidence of immunity, removing documentation of physician diagnosed disease as riages, premature birth, or a low birth weight baby. Measles is a highly infectious viral disease of humans. The virus lives in the mucus and nose of the infected person. Measles is spread through coughing, sneezing, and contact with secretions from the nose, mouth, and throat of an infected person. In about 10 days (range 7-18 days) after exposure, the infected person usually develops a blotchy rash, fever, cough, runny nose, conjunctivitis, malaise, and tiny white spots in the mouth called Koplik spots. Between the 3 rd and 7 th day of illness, a maculopapular rash develops that begins on the face at the hairline and spreads to the neck, trunk, arms, legs, and feet. There is no treatment. The patient with measles is most contagious from 4 days prior to rash onset to 4 days after rash onset. Measles can be prevented by receiving 2 doses of the MMR (Measles, Mumps, and Rubella) vaccine. Receiving 2 doses of MMR makes patients almost immune to these diseases. MMR has led to a 99% reduction of measles in the U.S. Receiving an acceptable criterion for evidence of immunity for measles and mumps, and including laboratory confirmation of disease as a criterion for acceptable evidence of immunity. For persons with HIV infection, expanding recommendations for vaccination and changing the recommended timing of the 2 doses of MMR. For measles post-exposure prophylaxis, expanding recommendations for use of immune globulin administered intramuscularly. The full CDC report is available on-line at MMWR. For more information, contact Jane.Hoffman@Mecklenburg CountyNC.gov. MMR is important for everyone. Before starting kindergarten, children are required to receive 2 doses of the vaccine. Other groups that are at high risk for disease who should receive a MMR after exposure are medical workers, college students, women of childbearing age, and those planning to travel internationally where Measles is widespread. MMR is administered at both Health Department locations. To schedule an appointment call For more information, contact Brian Lackey at or Brian.Lackey@MecklenburgCounty NC.gov. This periodical is written and distributed quarterly by the Communicable Disease Control Program of the Mecklenburg County Health Department for the purpose of updating the medical community in the activities of Communicable Disease Control. Program members include: Medical Director Stephen R. Keener, MD; Deputy Health Director Bobby Cobb; Director, Community Health Carmel Clements; Sr. Health Manager Jane Hoffman; Nursing Supervisor Beth Quinn; CD Control nurses Freda Grant, Brian Lackey, Penny Moore, Belinda Worsham; Beth Young (CD/ Childcare) Earlene Campbell-Coleman (CD/Adult Day Health); Rabies/Zoonosis Control Al Piercy; Health Supervisor Carlos McCoy; DIS Mary Ann Curtis, John Little, Michael Rogers, Jose Pena; Office Assistants Pamela Blount, Vivian Brown, Janet Contreras. Freda Grant, Beth Quinn, Beth Young Editors Lorraine Houser Consulting

3 Volume 13 Issue 3 Changes at Mecklenburg County Health Department The most significant change effective July 1, 2013 is the merging of CHS and Mecklenburg County Public Health employees. We have always worked together as a team to promote and protect the public health. Now we are a unified organization. Other recent changes in the Communicable Disease Control Program include: In March 2013, Elizabeth (Beth) Quinn, RN accepted the position of Nursing Supervisor. Beth moved to Gastonia in 1988 from western Kentucky. She has 25 years of public health experience with Communicable Disease in Tuberculosis Clinic Management, Immunizations, as a Tuberculosis Clinical Trials coordinator and in Communicable Disease Investigation and Reporting. She has worked for Gaston County Health Department, Carolinas HealthCare System and came to Mecklenburg County Health Department in February Beth received her ADN from the University of Kentucky in 1976 and her BSN from UNCG in She has two grown sons. Beth states that she enjoys working with Communicable Disease because each case is different. It s like solving a puzzle. Knowing that you can make a difference that will impact not only an individual but perhaps the entire community is the reward one gets from working in Public Health. In May 2013, Brian M. Lackey, RN accepted the position of Senior Nurse in. Brian is a Charlotte native and received his BSN from UNC-Charlotte in He has 17 ½ years of experience with Communicable Disease, Tuberculosis, and Immunizations with different area local health departments. Brian received his Master of Science in Nursing from Queens University of Charlotte in He lives in Mint Hill with his wife and two teenage daughters. Brian states that he is excited to have the opportunity to assist, control, and educate the citizens of Mecklenburg County about communicable diseases. Farewell to Dr. Earl Winters (Wynn) Mabry, Mecklenburg County Health Director, who retired at the end of June. He became the Health Director in Dr. Mabry is a retired Major General in the USAF Medical Corps. During his 30-year Air Force career, Dr. Mabry served as a senior flight surgeon, a surgical specialist at major USAF Medical Centers and as a Commander of 5 military hospitals and medical centers. During wartime, he was Chief of Combat Casualty Evacuation Operations in Desert Shield/Desert Storm and Medical Support Commander for United Nations soldiers during the Bosnian conflict. He received an undergraduate degree at Dartmouth College, a Medical Doctorate from the University of Oklahoma, and surgical specialty training from Duke University Medical Center. Dr. Mabry, thank you for nine years as Health Director and your many years of devotion to the military, to Homeland Security and to public health. Public Health Surveillance In 1878, the US Congress authorized the Public Health Service to collect morbidity data for cholera, smallpox, plague and yellow fever. Since then, surveillance has been the cornerstone of public health. Like all of the states, North Carolina has state laws and regulations mandating communicable disease reporting. The state relies on physicians and laboratories to comply with the directive to report diseases and laboratory results which indicate a disease considered to be a threat to public health. These reports are required to be submitted to the health department within a specified period (i.e., immediately, within 24 hours, or within 7 days). At the Mecklenburg County Health Department, Communicable Disease Control, HIV/STD Investigations and Tuberculosis Clinic are responsible for investigating, issuing control measures and reporting the information to the NC State Department of Health and Human Services (NC DHHS). The state administrative code was amended in September 1998 to require diagnostic laboratory administrators to report positive laboratory results for most diseases already reportable by physicians. The intent of this measure was to improve completeness, timeliness and accuracy of surveillance. In 2002, NC expanded efforts to improve surveillance by introducing seven regional public health teams and eleven hospital-based public health epidemiologists. In 2008, the NC DHHS implemented an electronic disease surveillance system. Major laboratories feed abnormal test results electronically into this system and the Health Department frequently receives tests results before the healthcare provider does. As of 2013, there are more than 70 reportable diseases that are mandated to be investigated and reported. (See page 4 of this publication for a list of all reportable diseases.) Outbreaks of certain non reportable diseases (e.g., Noroviurs) are also required to be investigated and reported. For more information about communicable disease reporting and investigation in Mecklenburg County, contact Penny Moore at or Wilma.Moore@MecklenburgCounty NC.gov.

4 Page 4 Diseases and Conditions Reportable in North Carolina Diseases and Conditions Reportable in North Carolina Reporting of suspected or confirmed communicable diseases is mandated under North Carolina Administrative Code 10A NCAC 41A.0101 Reportable Diseases and Conditions: The following named diseases and conditions are declared to be dangerous to the public s health and are hereby made reportable within the time period specified after the disease or condition is reasonable suspected to exist. The primary responsibility for reporting rests with the physician as mandated under North Carolina General Statute 130A-135 Physicians to Report: A physician licensed to practice medicine who has reason to suspect that a person about whom the physician has been consulted professionally has a communicable disease or communicable condition declared by the Commission to be reported shall report information required by the Commission to the local health director of the county or district in which the physician consulted. Diseases in ( BOLD ITALICS should be reported immediately to the local health department (see below). Reportable within 24 hours Disease/Condition Disease Code A-G AIDS ( Anthrax...3 ( Botulism, foodborne...10 ( Botulism, intestinal (infant) ( Botulism, wound Campylobacter infection...50 Chancroid Cholera...6 Cryptosporidiosis...56 Cyclosporiasis...63 Diphtheria...8 E. coli infection, shiga toxin-producing Foodborne disease: Clostridium perfringens Foodborne: staphylococcal Foodborne poisoning: ciguatera Foodborne poisoning: mushroom Foodborne poisoning: scombroid fish Gonorrhea Granuloma inguinale H-N Haemophilus influenzae, invasive disease...23 Hemolytic-uremic syndrome (HUS)...59 ( Hemorrhagic fever virus infection...68 Hepatitis A...14 Hepatitis B, acute...15 HIV Influenza pediatric death (<18 years)...73 Influenza adult death (>18 years) Listeriosis...64 Measles (rubeola)...22 Meningococcal disease, invasive...27 Monkeypox...72 ( Novel influenza virus infection...75 O-U Ophthalmia neonatorum Pertussis (Whooping Cough)...47 ( Plague...29 Poliomyelitis, paralytic...30 Rabies, human...33 Rubella...36 Salmonellosis...38 S. aureus with reduced susceptibility to vancomycin...74 SARS (coronavirus infection)...71 Shigellosis...39 ( Smallpox...69 Syphilis, all stages Syphilis, congenital Tuberculosis...TB ( Tularemia...43 Typhoid Fever, acute...44 Typhus, louseborne V-Z Vaccinia...70 Vibrio infection, other than cholera & vulnificus...55 Reportable within 7 days Disease/Condition Disease Code A-G Brucellosis....5 Chlamydia laboratory confirmed..200 Creutzfeldt-Jakob Disease...66 Dengue... 7 Ehrlichiosis, HGA Ehrlichiosis, HME...72 Ehrlichiosis, unspecified Encephalitis arboviral, WNV Encephalitis arboviral, LAC Encephalitis arboviral, EEE...97 Encephalitis arboviral, other H-N Hantavirus infection Hepatitis B, carriage..115 Hepatitis B, perinatally acquired Hepatitis C, acute...60 Legionellosis...18 Leprosy (Hansen s Disease)...19 Leptospirosis...20 Lyme disease...51 Lymphogranuloma venereum Malaria...21 Meningitis, pneumococcal...25 Mumps...28 Non-gonococcal urethritis O-Z PID Psittacosis...31 Q fever...32 Rocky Mountain spotted fever...35 Rubella, congenital syndrome...37 Streptococcal infection, Group A, invasive...61 Tetanus...40 Toxic shock syndrome, non-streptococcal Toxic shock syndrome, streptococcal...65 Trichinosis...42 Typhoid, carriage (Salmonella typhi) Yellow fever...48 Disease reports can be made to any of the following: Belinda Worsham Beth Quinn Freda Grant Beth Young Penny Moore Brian Lackey Earlene Campbell-Coleman Revised 6/25/2013

5 Page 45 (Q)uery Fever Query Fever or Q fever is a z o o n o t i c b a c t e r i a l d i s e a s e f o u n d worldwide and is caused by the microorganism Coxiella burnetii. Importantly. no vector is needed for transmission from animal to animal or animal to human. Dr. E. H. Derrick first described a febrile disease seen in abattoir workers in Australia in 1935 and is likely to have named the newly observed animal-related disease as Q fever. Later two scientists, Dr. Herald Cox and Sir Frank Burnetti, isolated the causative organism that was named for them in recognition of their work Coxiella burnetii. In 1999 the febrile illness, Q fever or C. Burnetii, became a reportable disease in the United States due to its potential as a bioterrorism agent (rapid aerosolization, high rate of human infectivity, and stability in the environment). Globally however the disease is not universally reported, leaving scientists with no reliable numbers of cases occurring each year. Illness in humans is commonly acquired through airborne inhalation of C. Burnetii in dust contaminated by placental tissues from the birthing process in home pets such as cats, many different farm animals (goats, sheep, and cattle), and contaminated animal products (wool, meat, and milk). Veterinarians and abattoir workers often present with symptoms of chills, fever, malaise, and severe sweats. Using x-ray examination, pneumonitis may be found without cough and mucus being prominent. An acute granulomatous hepatitis is often reported in severe cases. Heart valve damage may occur after endocarditis begins and may have an indolent course extending for years afterwards. Laboratory diagnosis confirms Q fever by a rise in antibodies during the interim period between acute and convalescing stages, by IgM detection through Immunofluorescent (IF) testing or Elisa. Case fatality rates are generally 1 to 4% with those individuals developing endocarditis requiring extensive use of antibiotics. Physicians treating such patients have reported a post-q fever fatigue syndrome lasting indefinitely. Inactivated vaccines are available for abattoir workers, laboratory technicians, and veterinary researchers working with pregnant sheep. The vaccine is not commercially available to the public and only obtainable by physicians from Fort Derrick, Frederick, Maryland. For humans with acute cases of Q fever, the drugs of choice for treatment are the tetracyclines (usually doxycycline) given orally for 15 to 21 days. Patients with valvulopathy may be treated with doxycycline and hydroxychloroquine. Infected heart valves may require surgical replacement for hemodynamic reasons. Pregnant women should be treated with cotrimoxazole for the duration of the pregnancy. Methods of prevention for the general public include use of pasteurized milk and milk products; cooking meats thoroughly; avoiding farms where cows, sheep, and other animals are giving birth; and also avoiding the handling of wild animals with newly born offspring. Any human contact with gestating animals should be approached with caution and a thorough washing of hands and clothing afterward should be strictly observed. For more information, contact Al Piercy at or Alford. Piercy@Mecklenburg CountyNC.gov. The Advisory Committee on I m m u n i - z a t i o n Practices ( A C I P ) voted in June 2013, 13 to 0, in favor of recommending Flublok during the influenza season for vaccination of persons 18 through 49 years of age with egg allergy of any severity. Flublok Flublok was licensed by the Food and Drug Administration (FDA) in January Unlike current production methods for other available seasonal influenza vaccines, Flublok does not use the influenza virus or chicken eggs in its manufacturing process. However, it does use a manufacturing process similar to that used to make vaccines that have been approved by the FDA for the prevention of other diseases. Flublok has a shorter shelf life, with an expiration period of 16 weeks from the production date. The ACIP recommends that individuals with a severe egg allergy consult with a physician about their allergic conditions prior to vaccination if Flublok is not available. Additional information about Flublok can be found at the CDC website or contact Freda Grant at or Freda.Grant@MecklenburgCountyNC. gov.

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7 Volume 13 Issue 3 Page 7 Reporting Communicable Diseases Mecklenburg County To request N.C. Communicable Disease Report Forms, telephone Mark all correspondence CONFIDENTIAL Tuberculosis: TB Clinic Mecklenburg County Health Department FAX Beatties Ford Road Charlotte, NC Sexually Transmitted Diseases, HIV, & AIDS: HIV/STD Surveillance Mecklenburg County Health Department FAX N. Tryon Street, Suite 214 Charlotte, NC All Other Reportable Communicable Diseases including Viral Hepatitis A, B & C: Report to any of the following nurses: Freda Grant, RN Elizabeth Quinn, RN Belinda Worsham, RN Brian Lackey, RN Penny Moore, RN Beth Young, RN (CD/Child Care) Earlene Campbell-Coleman, RN (CD/Adult Day Health) FAX Mecklenburg County Health Department 700 N. Tryon Street, Suite 271 Charlotte, NC Animal Bite Consultation / Zoonoses / Rabies Prevention: Al Piercy, RS FAX Mecklenburg County Health Department 618 N. College St. Charlotte, NC or State Veterinarian, Carl Williams, DVM State after hours Suspected Food borne Outbreaks / Restaurant, Lodging, Pool and Institutional Sanitation: Food & Facilities Sanitation (Mon-Fri) Mecklenburg County Health Department (evenings; Sat/Sun) N. Tryon Street, Suite 208 (pager evenings; Sat/Sun) Charlotte, NC FAX Mecklenburg County Health Department Revised February 2013