When Neglected Tropical Diseases Knock on California s Door
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1 When Neglected Tropical Diseases Knock on California s Door Anne Kjemtrup, DVM, MPVM, PhD California Department of Public Health Vector-Borne Disease SecFon
2 Overview of Today s Topics Neglected tropical diseases: selng the stage for impact on California California Public Health Overview Surveillance/response structure Vector-Borne Disease program areas Two examples: Arbovirus introducfon (dengue, chikungunya, zika) Re-emergence of Rocky Mountain sposed fever (not really NTD but similar principals) THE MONSTER RETURNS Peter McCarty
3 Neglected Tropical Diseases Buruli Ulcer Chagas disease Dengue and Chikungunya Dracunculiasis (guinea worm disease) Echinococcosis Endemic treponematoses (Yaws) Foodborne trematodiases Human African trypanosomiasis (sleeping sickness) Leishmaniasis Leprosy (Hansen disease) LymphaEc filariasis Onchocerciasis (river blindness) Rabies Schistosomiasis Soil-transmiLed helminthiases Taeniasis/CysEcercosis Trachoma
4 Neglected Tropical Diseases Buruli Ulcer Chagas disease Dengue and Chikungunya Dracunculiasis (guinea worm disease) Echinococcosis Endemic treponematoses (Yaws) Foodborne trematodiases Human African trypanosomiasis (sleeping sickness) Leishmaniasis Leprosy (Hansen disease) LymphaEc filariasis Onchocerciasis (river blindness) Rabies Schistosomiasis Soil-transmiLed helminthiases Taeniasis/CysEcercosis Trachoma California has vector and/or disease agent
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6 State Reportable Diseases California Department of Public Health! 81 human diseases or condieons (including all the naeonal diseases), 2 animal diseases (rabies and plague) Vector-Borne diseases include: Anaplasma/Ehrlichiosis Babesiosis Colorado Tick Fever (to be removed next year) Dengue Hantavirus cardiopulmonary syndrome Lyme Disease Malaria Plague (human or animal) Relapsing fever Rocky Mountain spoled fever Tularemia West Nile virus Yellow Fever
7 Intervention/Response Surveillance Disease burden (Improved) diagnosis, treatment(s) recommendations Public education Vaccination, prophylaxis hospital Notifiable/reportable Health care provider General pop.:symptomatic General pop.: (A)symptomatic infected Sero-surveillance, surveys General population: exposure Risk Vector control pathogen control Vector: presence/absence/abundance/distribution Reservoir hosts: presence/absence/abundance/distribution Vector-surveillance pathogensurveillance Adapted from Braks et al, Parasites and Vectors 2011, 4: 192 7
8 NoEfiable Disease Surveillance: Route of InformaEon ReporEng mandated by state law (Title 17 CCR) Health care providers, laboratories, others, report to local health department (LHD) LHD submits reports to CDPH Reports transmitted to Centers for Disease Control and Prevention (CDC)
9 NoEfiable Disease Surveillance: Route of InformaEon Reporting mandated by state law (Title 17 CCR) Reportable TBD include: anaplasmosis, babesiosis, Lyme disease, relapsing fever (B. hermsii), spotted fever and non-spotted fever group rickettsia Local health department (LHD) receives, follows-up, reviews reports LHD submits reports to CDPH Reports transmitted to Centers for Disease Control and Prevention (CDC)
10 Vector-Borne Disease SecFon Primary Vector Programs Mosquito Flea Tick Rodent
11 Some vector-borne diseases require complex surveillance efforts to monitor, intervene, anecipate, detect, and study their epidemiology (just a few of surveillance funceons) West Nile virus transmission cycles in California Rural cycles Urban cycle???? Aedes, Culiseta Aedes, Culiseta Culex tarsalis Bird/Mosquito Movement? Culex pipiens stigmat.? erythro.?? Dead end hosts
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13 Plague Surveillance CDPH has expanded and refined the statewide plague surveillance program to include: investigations of human and domestic felid plague cases serologic monitoring of wild carnivores evaluation of epizootic activity in rodents Exposure poteneal to humans from vector fleas assessed Past history of epizooecs and/or human plague cases in the region reviewed RecommendaEons and aceons taken to reduce vectors and public exposure
14 Tick Surveillance
15 Human Dengue, Chikungunya and Zika Surveillance in California Looking Beyond the Unfortunate Travel Souvenir
16 Viruses and Transmission Chikungunya is an alpha virus similar to WEE and Ross River virus Dengue and Zika viruses are both flaviviruses similar to yellow fever and Japanese encephalifs virus All are arboviruses and transmised primarily human to human by Aedes aegyp* and Ae. albopictus
17 Dengue, Chikungunya, Zika mosquito transmission cycles
18 Dengue virus area of risk Geographic spread Spread of Chikungunya virus
19 Arboviruses Ease of IntroducFon
20 Aedes modes of introducfon into U.S. Lucky Bamboo (California) Imported used Fres (Southeastern U.S.)
21 Aedes albopictus and Aedes aegyp* have arrived and become established in CA Aedes albopictus Asian Fger mosquito 2008: First introduced then eradicated 2011: Los Angeles County Aedes aegyp* Yellow fever mosquito 2013: Madera, Fresno, San Mateo CounFes
22 Impact of invasive Aedes introduceon to California Vector: Dengue, chikungunya, and several encephalifs viruses Increased risk of introducfon of exofc mosquito-borne viruses Aggressive day-bifng mosquitoes Prefer to bite people (rather than birds or other animals) Difficult to control: Breed in containers
23 Invasive Aedes Mosquitoes DetecFon Sites in California, Aedes Aedes albopictus Hayward Menlo Park Atherton Commerce Pico Rivera Anaheim Exeter Madera Madera Ranchos Parkwood Arvin Escondido San Diego Chula Vista Clovis Fresno Andrade Calexico El Monte Arcadia Irwindale Duarte Monrovia Temple City Baldwin Park Rosemead Monterey Park City of Industry Bradbury South El Monte Avocado Heights Whi_er San Gabriel La Puente
24 Climate Change and Invasive Aedes Tropical species Mosquitoes in CA Warm weather enhances survival, reproducfon, and spread Drought: unintended consequence Residents store water in backyard buckets, containers, and rain barrels Do not maintain swimming pools Aedes establishment and spafal distribufon may serve as indictors of climate change
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26 Local mosquito response
27 Surveillance for Chikungunya, Dengue and Zika in California CDPH is working closely with local health departments and vector control agencies IdenFfying viremic cases Mapping co-locafon of viremic cases and invasive Aedes PrompFng mosquito surveillance near case residents CommunicaFon between local Vector Control Agencies and Health Departments is crifcal to ensure rapid response to reduce risk of local transmission
28 Dengue in the Americas 2015 In 2015: 561,501 confirmed and 2,326,829 probable cases Including 10,276 deaths Highest incidence rate (820/100,000) was in Brazil with over 1.5 million cases Cases were reported from 49 countries or territories in the Americas
29 Data for map available from hsp:// Confirmed Dengue Cases in Mexico by State January 1, 2015 December 31, confirmed cases confirmed cases Sonora confirmed cases Chihuahua confirmed cases Coahuila More than 1000 confirmed cases Durango Nuevo León Tamaulipas Ag. Yucatán Ag. = Aguascalientes Quer. = Querétaro DF = Distrito Federal Tl. = Tlaxcala Colima Jalisco Tl. Puebla Guerrero Oaxaca Morelos Campeche Tabasco Chiapas
30 Dengue Outbreak in Hawaii 260 Cases to Date 260
31 Chikungunya in the Americas
32 Confirmed Chikungunya Cases in Mexico by State January 1, 2015 December 31, confirmed cases confirmed cases Sonora confirmed cases Chihuahua confirmed cases Coahuila More than 1000 confirmed cases Durango Nuevo León Tamaulipas Nayarit Ag. Yucatán Ag. = Aguascalientes Quer. = Querétaro DF = Distrito Federal Tl. = Tlaxcala Colima Jalisco Tl. Puebla Guerrero Oaxaca Morelos Tabasco Chiapas Data for map available from hsp://
33 Countries, Territories and Areas with Autochthonous Zika Virus CirculaFon ( )
34 Confirmed Zika Cases in Mexico by State January 1, 2016 February 19, confirmed cases 1 25 confirmed cases Sonora confirmed cases Chihuahua confirmed cases Coahuila More than 100 confirmed cases Durango Nuevo León Tamaulipas Nayarit Ag. Yucatán Colima Ag. = Aguascalientes Quer. = Querétaro DF = Distrito Federal Tl. = Tlaxcala Data provided by the Mexican Ministry of Health hsp:// Jalisco Tl. Puebla Guerrero Oaxaca Morelos Tabasco Chiapas
35 Imported Dengue in the United States, 2015 N=540
36 Imported Human Dengue Cases in California * n = Number of reported dengue cases Confirmed Probable * As of February 17, Year
37 Imported Dengue in California, cases reported in 2015* From 22 counfes, 10 with invasive Aedes 62 cases returned to counfes with invasive Aedes Of those 76% were likely viremic while in California 54% of cases were female 32% of cases required hospitalizafon 45% of cases had travel to LaFn America Mexico 17%, El Salvador 12% *EsFmated February 2016
38 Chikungunya in the United States : 2,811 imported cases reported in US, 12 locally acquired cases in Florida 2015: 679 imported cases reported in US, no locally acquired cases
39 Imported Chikungunya Cases in California, cases reported in 2015* (140 cases in 2014) From 30 counfes, 10 with invasive Aedes 152 cases returned to counfes with invasive Aedes Of those 53% were likely viremic while in California 67% of cases were female Only 8% of cases required hospitalizafon 91% of cases had travel to LaFn America Mexico 40%, El Salvador 16%, Guatemala 13% *EsFmated as of February 2016
40 California, USA Dengue and Chikungunya Cases in California and LocaFon of Invasive Aedes Aedes aegypti Aedes albopictus 2015 Human dengue and/or chikungunya cases San Mateo Alameda Madera Fresno No reported cases 1-10 reported cases reported cases >21 reported cases Tulare Kern San Bernardino Los Angeles Orange Riverside San Diego Imperial
41 Imported Zika in the United States, District of Columbia No reported cases 1-4 reported cases 5-9 reported cases reported cases N= 107 >15 reported cases
42 Imported Zika in California Year CDC Final Confirmed Cases* CDC Preliminary PosiEve Cases* NA NA All 14 Zika cases reported to date have traveled to a region with a known Zika outbreak at Fme of travel Travel countries include: French Polynesia, Cook Islands, Easter Island, KiribaF, El Salvador, HaiF, Colombia, Mexico and Honduras Of the 10 cases in , 5 were residents of counfes with invasive Aedes 8 were potenfally viremic while in California *CDPH has received the final wrisen lab report from CDC **CDPH has received preliminary nofficafon of a posifve case from CDC
43 Factors MiFgaFng Dengue, Chikungunya and Zika Transmission in California RelaFvely short viremia (average 5-7 days) Housing condifons and lifestyles minimize vector - human contact Vector distribufon and longevity is variable and uneven Vector density needed for transmission may not be high enough Comprehensive mosquito control programs in California
44 Conclusion Risk of local dengue, chikungunya or Zika transmission is low No locally acquired infecfons have been documented in California The detecfon of Aedes aegyp* and Aedes albopictus and viremic travelers in the same area is a public health concern Climate change/drought may impact distribufon/abundance of vector based on human response Enhanced surveillance of both mosquitoes and case pafents is necessary to reduce risk of autochthonous transmission
45 More InformaFon California Department of Public Health (CDPH) hsps:// Centers for Disease Control and PrevenFon (CDC) hsp:// Pan American Health OrganizaFon (PAHO) hsp:// Charsey Cole Porse, PhD, MPH California Department of Public Health, Vector-Borne Disease SecFon
46 Rocky Mountain SpoLed Fever: a Re- Emerging Disease
47 California has several endemic Fck-borne pathogens in RickeSsiales order RickeSsial diseases called, sposed fever group because rashes are typically seen with infecfons with these bacteria
48 RMSF in Humans Clinical: Nonspecific (can be difficult to diagnose) Fever, headache, nausea, muscle aches 2-14 days a}er Fck bite Rash develops 3-5 days a}er fever Decreased clolng cells leading to severe complicafons: Acute respiratory distress syndrome (ARDS), abdominal pain (leading to surgery), neurologic or bleeding disorders, loss of circulafon (gangrene) Case fatality reports ranging from 5-90% 48
49 RMSF in Humans Diagnosis: Serology: Rising anfbody Fters (4X change in acute and convalescent samples). IFA or ELISA tests. PCR, immunohistochemical staining of Fssue, culture: (Fssues difficult to obtain) Treatment: Doxycycline adults and children Can not wait for diagnosis must treat on suspicion 49
50 Life cycle of RickeCsia rickecsii Mammal reservoir but Tick may be both reservoir and vector Rarely find agent in the Fck American Dog Tick Dermacentor variabilis Rocky Mountain wood Eck Dermacentor andersoni
51 Rocky Mountain SpoSed Fever NaFonally Source: CDC hsp://
52 Rocky Mountain SpoSed Fever, Arizona : 11 confirmed cases of RMSF idenffied in close geographic area in Arizona No Dermacentor spp Fcks found in area Homes and areas around homes infested with brown dog Fcks; many free-roaming dogs in area R. ricke9sia detected molecularly and cultured from area Fcks First Eme brown dog Eck implicated as vector for RMSF in N. America
53 RMSF Response: SHORT TERM EducaFon for residents & clinicians Tick control on dogs Pest control around homes Community clean-up LONG TERM Animal control program Sustained vector control Structural changes to homes skirfng Clean-up campaign: Tribal Members and others Team: CDC, HIS, Tribes, ADHS, ORKIN, WATSONIANS, USDA, Army Ft. Huachuca 53
54 Tick Control for Dogs: Animal Services Agency CoordinaFon USDA, Army, CDC, IHS & ADHS Zodiak Eck collars (propoxur 3 month residual) were placed on 1,000 s of dogs (est. 70%+ coverage) Also, spot-on treatments & sprays 54
55 Not all dogs were approachable 55
56 Rocky Mountain SpoSed Fever, Mexico Urban outbreak of RMSF in Mexicali, Mexico, 2009 Brown dog Fck-associated > 1200 suspect cases, 217 confirmed 6 deaths (2.3%) among confirmed cases 56
57 Brown dog Fck habitat, Mexico hsps:// documents/ rmsf_on_the_border_where_children_contagion_and_cli mate_converge.pdf
58 Are dogs in California Affected? Dogs are a common Fck host for R. ricke9sii Fck-vectors. They can get illeven die- from infecfons with R. ricke9sii. Reports in the literature of concomitant infecfon of owners and their dogs, suggesfng a common exposure Anecdotal reports of RMSF in CA dogs
59 The InfestaEon of Rhipicephalus sanguineus in a ResidenEal Area, Riverside, 2005
60 Dog Mansion
61 Findings On July 26, 2005, more than 200 Rh. sanguineus Fcks were collected at the site in Riverside R. ricke9sii DNA was detected in 1 of 62 (1.6%) adult Rh. sanguineus Fcks by CDC (different from those isolated from Montana and Arizona.)
62 Does Spot get Spots? Survey for Canine Cases of Rocky Mountain SpoSed Fever in California.
63 Results 338 completed responses Predominately small animal pracfces though a few mixed and exofc-mixed pracfces also responded. PracFce size ranged from 5-50,000 dog visits per year (median 2500 dog visits).
64 RMSF diagnosed in Californian dogs, CDPH Survey, 2007 Number of responses (n=338) County # Reported RMSF Cases Orange 6 San Diego 5 Contra Costa 3 San Mateo 3 Alameda 2 Calaveras 1 Kern 1 Los Angeles 1 Riverside 1 Sacramento 1 Santa Barbara 1 Total 25 64
65 Clinical PresentaFon Clinical Sign Number (percentage) n=25 Fever 17 (68%) Other* 11 (44%) Multiple painful joints 11 (44%) tiny hemorrhages on gums, mucous membranes 4 (16%) Abdominal Pain 3 (12%) *Tiredness most common other sign Edema (swelling) 2 (8%)
66 Comparison of reported tick species between veterinary practices with and without RMSF K9 cases 90 Percentage of practices Practices with NO RMSF (n=321) Practices with RMSF (n=17) 0 Brow n dog tick Unknow n spp. American dog tick None to rare tick Western blacklegged tick Pacific Coast tick Rocky Mtn Wood tick Lone Star tick Winter tick Tick Species Small number of clinical cases precludes statistical comparison, however, note that a large percentage of clinics with RMSF dogs reported high exposure in their general practice to the brown dog tick, followed by the American dog tick and the western black-legged tick when compared to all practices.
67 Does Spot get Spots? Conclusions RMSF is rare in dogs in California Large number of cases reported from urban areas and with no travel history supports idea that RMSF ecology has changed over the past 50 years. Spot does get spots, though rarity of disease both in humans and dogs and complexity of surveillance precludes using canines as regular senfnel for human disease.
68 Could dogs in Southern California be infected with R. rickecsii and/ or infested with infected brown dog Ecks? (CDC, CDPH and Imperial Co. DOH study) Established Two Sites for Dog Surveillance City Animal Shelter in Calexico County Animal Shelter in El Centro
69 Training Animal Shelter Staff
70 Results 116 dogs examined (45 in Calexico and 71 in El Centro) March - April 2009 Ticks found on 35 (30%) dogs (16 in Calexico and 19 in El Centro) Overall, 200 Fcks were collected (111 females, 87 males, and 2 nymphs) and all were idenffied as Rh. sanguineus PCR tesfng results showed that one female Fck was presumpfvely posifve for rickessial DNA but species (or strain) was not confirmed
71 Conclusions Rh. sanguineus infestafon on dogs in Imperial Co. is more heavier than inifally thought and the Fcks can be potenfally relocated into neighboring areas Lack of R. ricke9sii detecfon in Fcks suggested that the risk of RMSF in the area is minimal at the Fme AcFve Fck surveillance and control of freeroaming dogs are important aspects for keeping the risk of RMSF below epidemic thresholds
72 2013 Resident, Fresno county Presented late December 2012 to local ED with fever, headache, muscle aches, rash on wrist, leg, and torso. PaFent succumbed to illness Organ Fssues tested posifve by immunohistochemistry and PCR at CDC PaFent had history of visifng local rural California areas one week preceding disease onset 36 Dermacentor spp. Fcks recovered from one area pafent visited; all tested negafve
73 2014 Resident, Imperial County Presented May to local ED with fever, nausea, vomifng During course of illness, RMSF serologic tests showed rising Fter (confirmed case) PaFent could not recover and died late June PaFent s mother traveled with dogs across Mexican border Brown dog Fcks present in and around home; 1/95 posifve for R. ricke9sii News release issued by Imperial County a}er pafent s death to increase awareness of disease, importance of treafng Fck infestafons
74 Another Tick to Add to the Story. Life cycle of RickeCsia rickecsii Tick Vectors in California Brown Dog Tick Ripicephalus sanguineus Urban areas and natural areas throughout California Mammal reservoir but Tick may be both reservoir and vector Rarely find agent in the Fck Pacific Coast Eck, CA Dermacentor occidentalis Humid, natural areas throughout California American Dog Tick Dermacentor variabilis Natural areas throughout California Rocky Mountain wood Eck Dermacentor andersoni Natural areas northeastern California
75 a 2012 a a,b Rocky Mountain SpoLed Fever in Humans in California Since 2002 there have been 13 confirmed cases of RMSF reported in California a Travel history out of county b Fatality County of residence of confirmed RMSF human cases , 2014 a,b 2014 a 2014 b
76 Number Confirmed and Probable RMSF Cases,
77 RMSF Seasonality NaFonwide, California,
78 Demographics, RMSF Confirmed and Probable Reported Cases, Frequency Percent 95% CI Lower 95% CI Upper Female % 30.3 % 57.7 % Male % 42.3 % 69.7 % TOTAL 55
79 North/South DistribuFon County of Residence, RMSF Case PaFents Southern California Northern California ProporEon of case-paeents (confirmed and probable) whose county of residence is in North/South CA, by year of symptom onset, p < 0.05.
80 Frequency of Hispanic/LaEno ethnicity self reported, by year -Trend (not significant) toward greater frequency of Hispanic/LaFno ethnicity, (N=39) Chi Squared (MxN) p > 0.05 NonHispanic/NonLatino Hispanic/Latino
81 Typical Dermacentor spp Life Cycle
82 Brown Dog Tick (Rhipicephalus sanguineus) typical life cycle
83 Impact on Messaging For both Fck vectors: Awareness of Disease Avoid Fck bites Remove Fcks promptly and correctly Inspect pets and remove Fcks See physician if develop fever, headache or rash a}er Fck bite Take pet to veterinarian if it develops fever, lethargy a}er Fck-bite
84 Impact on Messaging: Dermacentor spp Awareness of RMSF Disease More general approach Target audience (California): outdoor enthusiasts, rural residents Avoid Fck bites Stay in middle of trails When in Fck habitat: wear repellents containing DEET or clothing treated with permethrin Remove Fcks promptly and correctly See physician if develop fever, headache or rash a}er Fck bite Take pet to veterinarian if it develops fever, lethargy a}er Fck-bite
85 Impact on Messaging Brown Dog Tick (Rhipicephalus sanguineus) Awareness of Disease May need community approach Local resident/physician awareness Avoid Fck bites Host and environmental issue Keep dogs on Fck prevenfon (collars, vetapproved product) Environmental treatment may be required by licensed pest-control operator (mulfple treatments somefmes necessary) Clean up yard to remove debris where Fcks can hide Remove Fcks promptly and safely Inspect pets and remove Fcks See physician if develop fever, headache or rash a}er Fck bite Take pet to veterinarian if it develops fever, lethargy a}er Fck-bite Source: Az. Dept. of Health Services
86 TreaFng Brown Dog Tick InfestaFons
87
88 Conclusions: re-emerging Ricke9sia Newly idenffied Fck vector for California demonstrated PotenFal south to north introducfon Impacts health educafon messaging One health approach (canine/human) useful for surveillance and control Sustained surveillance/control effort needed for brown dog Fck-transmiSed RMSF
89 Final Thoughts on Diseases at California s Door More pandemics likely to be seen knocking at the door Air travel/massive rapid movement of people Increased income disparity will contribute to emergence Climate change may influence vectors as well as social structure that will encourage more migrafon Public health infrastructure allows for early detecfon and planning for introduced disease Ongoing, systemafc surveillance Build on previous experience (e.g. West Nile virus) and mulf-agency (One-Health) collaborafon THE MONSTER RETURNS Peter McCarty
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91 QuesEons?
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