INFECTIOUS DISEASES:
INVESTIGATION, SURVEILLANCE,
& PREVENTION
Communicable Disease Section
County of San Bernardino Department of Public Health
Stacey A. Davis, MPH
Epidemiologist
SAN BERNARDINO DEPARTMENT OF PUBLIC HEALTH
COUNTY OF SAN BERNARDINO
DEPARTMENT OF PUBLIC HEALTH
COMMUNICABLE DISEASE SECTION
ORGANIZATION CHART, POSITION NUMBERS
FY 2011-2012
Program Manager
Vanessa Long
TB Controller
Secretary I
Louise McNitt, MD
Joyce Hall
PH Program Coordinator
PH Clinic Supervisor
Lea Morgan
Jenny Hernandez
RN II
Terri Serna
Olu Teiko
LVN II
Jennifer Rosales
HSA
Epidemiologist
HES I
Supervising HSA
Stacey Davis
Pooneh Navab
Faith Mwiti
Leticia Navarette
Suzie Martinez
Katherine Myers
Bac Lam
Rigo Fernandez
Denise Ramirez
CDIs
HSA
Vicki Williams
Roger Gonzalez
Anita Haro-Garcia
Celia Saucedo-Smith
Denise Leon
Mayra Parga
Beverly Villa
OA II
Maricela Hernandez
Diane Hardy
TITLE 17, SECTION 2500 CALIFORNIA
CODE OF REGULATIONS (CCR)

Requires physicians and laboratories to report:
>85 communicable diseases
 Any occurrence of unusual disease
 Any outbreak


Non-communicable conditions
Animal bites (also for rabies exposure)
 Disorders characterized by lapses of consciousness
 Alzheimer’s disease and other dementia

Specifies reporting timelines
 Allows for the local Health Officer to add any
conditions for local reporting

SUMMARY
SBDPH COMMUNICABLE DISEASE SECTION
Investigation: individual cases & outbreaks
 Surveillance:

Passive for all diseases except TB contacts
 Active for identifying TB contacts (potential cases)


Prevention:




Case-patient education re: disease transmission &
vaccination,
TB screening for contacts to active TB case
Provider education on vaccine administration for
vaccine-preventable diseases
Information resource
http://www.sbcounty.gov/pubhlth/
1.800.722.4794
NOROVIRUS

Etiology: group of related non-enveloped RNA
virus
5 genogroups, 3 important in humans (GI, GII, GIV)
 >25 different genotypes identified within these
genogroups


Symptoms: watery non-bloody diarrhea, nausea,
vomiting, abdominal cramps, low-grade fever
In children, diarrhea more common that vomiting
 Studies have shown asymptomatic infection can
occur in as many as 30% of infections

NOROVIRUS
Incubation period: 12-48 hours (commonly 2448h)
 Infectious period: Few hours before onset to 72
hours after symptom resolution
 Transmission: fecal-oral

VIRAL GASTROENTERITIS (VGE)
OUTBREAK INVESTIGATION
Identify: What is above baseline? Suspect etiology?
 Notify:

Licensing & Certification
 County of San Bernardino Dept. of Public Health


Linelist: Collect case information





Name
Age
Location in facility (room, wing, unit, etc.)
Symptoms, including hospitalizations
Specimens collected & results
Establish case definition (work with DPH)
 Implement prevention & control measures

NOROVIRUS: PREVENTION &
CONTROL
CDPH Recommeds:
Residents
1. Cohort, if possible
2. Restrict movement: new admissions, transfers
3. Cancel group activities, dining
4. Clean equipment & facility surfaces*
5. Education
Staff
1. Cohort, if possible
2. Restrict ill staff, visitors, volunteers from work
3. Use PPE for symptomatic residents, cleaning
4. Education
IMPORTANT CONTRIBUTORY
FACTORS TO OUTBREAK SPREAD

Environmental persistence

Withstands freezing and temps up to 140 degrees F


Check your ice machine!
(**how lon
Short incubation period
 High Infectivity

Low infectious dose: 10-100 viral particles is
sufficient to cause infection
 Viral shedding can begin before symptom onset
 Viral shedding can occur up to 2 weeks after
symptoms stop, but it is unclear how viral shedding
after 72h post-recovery contributes to infectivity


Immunity is short-lived (a few months) and
strain-specific
VIRAL GASTROENTERITIS OUTBREAKS IN
COUNTY OF SAN BERNARDINO
NOROVIRUS RESOURCES

County of San Bernardino Dept Public Health, Communicable
Disease Section
Linelist template (MS Excel)
 Norovirus checklist
 Handwashing signs (electrostatic)
 Laboratory testing for Norovirus (min 2, max 4 specimens)

CDPH


Recommendations for the Prevention & Control of Viral
Gastroenteritis Outbreaks in California Long-Term Care
Facilities , October 2006
Acute Viral Gastroenteritis Investigations in Residential
Facilities
http://www.cdph.ca.gov/pubsforms/Guidelines/Pages/HAIandIC.aspx

CDC Norovirus page
http://www.cdc.gov/ncidod/dvrd/revb/gastro/norovirus.htm
SCABIES
Etiology: human itch mite, Sarcoptes scabiei var
hominus
 Symptoms:






Intense itching;
Papules, vesicles, tiny linear markings containing
mites & eggs, mainly around finger webs, groin,
anterior wrists, elbows, other skin folds
Possible secondary skin infections from itching
Crusted lesions (immunecompromised or elderly
patients)
Few with immunecompromised patients or patients
with neurological conditions
SCABIES

Incubation period:
2-6 weeks (without previous exposure);
 1-4 days (with previous exposure)


Infectious period: time of infestation (even if sx
absent) to completion of at least 1 treatment with
scabicide


2 treatments for highly infested individuals, 1 week
apart
Transmission:
direct skin contact with infected person, including
sexual contact
 Shared fomites (clothing, bedding)

SCABIES OUTBREAK INVESTIGATION


Identify: skin scrapings

Symptomatic case, resident, or healthcare worker

Outbreak: 2 or more confirmed cases OR 1 confirmed
case and 2 suspect cases during a 2 week period
Notify:
Licensing & Certification
 County of San Bernardino Dept. of Public Health

SCABIES OUTBREAK INVESTIGATION

Linelist: collect case and contact information
(during 4 weeks before case’s onset)






Name
Age
Location in facility (room, wing, unit, etc.)
Symptoms, including hospitalizations
Specimens collected & results
Transfers to other facilities
SCABIES OUTBREAK PREVENTION
& CONTROL
Isolate cases
 Use PPE to apply scabicide to cases

Bathe case before application (if not bathed >24h)
 Bathe case after 8-12h treatment to remove scabicide

Restrict visitors (or ask to use PPE)
 Launder all washable items in hot soap & water,
dry on high


Separate from all other laundry
Bag all non-washable items for 7 days
 Disinfect equipment, mattresses, etc. after
scabicide washed off
 Discard any topical creams, ointments, lotions
used by symptomatic cases

SCABIES OUTBREAK PREVENTION
& CONTROL—ATYPICAL SCABIES
Atypical Scabies
 Isolate case in private room until at least 2
treatments and 2 negative skin scrapings
 Remove upholstered furniture from room & cover
with plastic for 7-10 days
Crusted or Norwegian Scabies
 Isolate case in private room until at least 3 negative
skin scrapings, may take 7-30 days or longer
 Remove upholstered furniture from room & cover
with plastic for 7-10 days
SCABIES PREVENTION & CONTROL:
CONTACTS

Evaluate contact
Can contact be substantiated?
 What type of contact? Direct or indirect?


If substantial contact, treat both asymptomatic &
symptomatic contacts 1X
Treat all contacts and cases during the same
treatment period
 Allow to return to work after one 8-12h treatment
 Allow non-contacts one treatment, if requested

SCABIES TREATMENT FAILURE

Poor application technique

Apply from hair & ear line to palms & soles of feet
Continued contact with untreated or
unsuccessfully treated residents, HCWs
 Reluctance of HCW to disclose sx
 Residents, staff with immunosuppressive
diseases who don’t respond to treatment
 Use of topical steroids during treatment period
 Failure to kill mites in clothing, furniture

SCABIES RESOURCES
County of San Bernardino Dept Public
Health Communicable Disease Section

Linelist template (MS Excel)
 CDPH Scabies Prevention & Control Guidelines
 Outbreak management

CDPH
 Healthcare Associated Infections & Infection
Control Guidelines page
http://www.cdph.ca.gov/pubsforms/Guidelines/Pa
ges/HAIandIC.aspx
 CDC Scabies page
http://www.cdc.gov/parasites/scabies/
INFLUENZA
Etiology: influenza virus, types A, B
 Symptoms: Fever, cough, sore throat,
runny or stuffy nose, muscle or body aches,
headaches, fatigue
 Incubation period: 2 days (range 1-4 days)
 Infectious period: highest 3-5 days after onset,
up to 7-10 days
 Transmission: droplet and contact spread

INFLUENZA OUTBREAK
INVESTIGATION

Identify:
Acute onset of fever and cough;
 LTCF residents not always typical presentation
 Laboratory testing recommended


Cluster: 3 or more cases of acute respiratory illness
within 48-72h in residents in close proximity

Outbreak: sudden increase in acute respiratory
illness over background rate OR one positive test for
influenza in a resident
INFLUENZA OUTBREAK
INVESTIGATION

Notify:
Licensing & Certification
 County of San Bernardino Department of Public
Health


Linelist (both Staff & Residents)





Name
Age
Location in facility (room, wing, unit, etc.)
Symptoms, including hospitalizations
Specimens collected & results
INFLUENZA PREVENTION &
CONTROL
Isolate symptomatic resident & exposed
roommate(s) in room
 Cancel group activities & dining

If many residents ill
 Serve meals in rooms

Cohort residents & staff, if possible
 Limit new admissions



If necessary, admit to unaffected units
Use PPE—Residents

Patient use surgical mask if transported
INFLUENZA PREVENTION &
CONTROL

Use PPE—Staff
Staff use surgical mask, gloves, gown when within 3
ft of patient or entering resident’s room & contact
anticipated
 Remove after leaving room, dispose in waste
receptacle
 Wash hands after PPE removal

Provide many waste receptacles
 Encourage hand washing
 Exclude ill staff from patient care for 5 d after
onset of sx


Encourage not to work in other facilities (both ill &
well staff)
INFLUENZA PREVENTION &
CONTROL

Enhance environmental cleaning of surfaces

Treatment & prophylaxis: CDC Recommends

Do not use amantadine or rimantadine
(amantadines)

(increased resistance in Influenza A viruses)
Do use oseltamivir (Tamiflu) & zanamivir (Relenza)
 Treat within 2 days of onset



May still be beneficial if after 2 days of onset in patients
with severe, complicated, or progressive illness
Treat confirmed and suspected cases (do not wait for
lab confirmation)
INFLUENZA PREVENTION &
CONTROL

CDC recommends vaccinating staff & residents
Every year
 After outbreak identified, if unvaccinated
 Standing orders for residents >50yo for pneumococcal
vaccination & annual influenza vaccination



Declination form for staff & residents
Vaccination pledge (optional)
INFLUENZA RESOURCES
County of San Bernardino Dept Public
Health, Communicable Disease Section
 Linelist template (MS Excel)
 CDPH Recommendations for Prevention & Control of
Influenza in LTCF
 Outbreak/cluster management
 CDPH
 Healthcare Associated Infections & Infection Control
Guidelines page
http://www.cdph.ca.gov/pubsforms/Guidelines/Pages/HAIa
ndIC.aspx
 CDC 2011-2012 Influenza Antiviral Medications
Recommendations
 http://www.cdc.gov/flu/professionals/antivirals/summar
y-clinicians.htm

PERTUSSIS (WHOOPING COUGH)
Etiology: Bordatella pertussis (bacteria)
 Symptoms: Cold-like symptoms, cough that
progresses to become paroxysmal and last up to 2
mo, sometimes post-tussive vomiting
 Incubation period: 6-20 days (9-10 days avg)
 Infectious period: 21 days after sx onset, or 5
days after start of appropriate antibiotics
 Transmission: Airborne via droplets
 Public Health Significance:

Can be lethal in children <6mo
 Pregnant women
 Contacts to children <6mo

PERTUSSIS (WHOOPING COUGH)

Identify:
Testing (PCR or culture)
 Symptoms


Notify:
Licensing & Certification
 County of San Bernardino Department of Public
Health


Linelist (both cases and contacts)






Name
Age
Location in facility (room, wing, unit, etc.)
Symptoms, including hospitalizations
Specimens collected & results
Vaccination status
PERTUSSIS (WHOOPING COUGH)

Implement prevention & control measures
Exclude case/limit contact while infectious

5 days after appropriate treatment completed OR
21 days after cough onset


Antibiotic prophylaxis to close contacts & high risk
contacts
Pre-exposure: Vaccination with Tdap


Infected Onset of sx
Antibiotics given
End if antibiotics given
END
Infectious Period
Exposure
-10
0
5
10
…21
PERTUSSIS OUTBREAK IN CALIFORNIA
9,477 cases for 2010 has surpassed the
number of cases reported in 1947
 State rate of 24.2 cases/100,000

PERTUSSIS RESOURCES
County of San Bernardino Dept Public
Health, Communicable Disease Section
 Linelist template (MS Excel)
 CDPH Pertussis Quicksheet
 Outbreak/cluster management
 CDPH
 Pertussis (Whooping cough) page
http://www.cdph.ca.gov/HealthInfo/discond/Pages/Pertus
sis.aspx
 CDC Pertussis page
 http://www.cdc.gov/pertussis/

Questions?
Thank you!