Quarterly Summary Report Fourth Quarter – 2012 (Oct – Dec) Volume 3; Issue Number 4; 2012
Communicable Diseases Bulletin
800 555
www.haad.ae
Foreword We all know how hard it is to graduate as a medical doctor, and how challenging is your life to continue in this field. Nevertheless, we love challenges and difficult paths, and we are always ready to do the best to reach there; simply because we believe it is worth it! Yes, it is really a wonderful job to save lives and help people and this is basically what we do as physicians. However, have we ever seen the actual impact we do in the real life? Yes, much of what we do does save lives and help others, but there are some unintentional harms that we need to be very cautious about, such as our antibiotic prescribing practices. Antimicrobial resistance is an increasingly growing problem everywhere and truly became one of the most important public health challenges of our today’s life. Sadly, we as physicians stand as one of the main reasons behind this problem. Our reckless prescribing behavior, despite all alarming calls by the health community, causes uncontrolled escalation of antibiotic resistance, with continuous emergence of new resistant bacterial strains that used to be easily treated in the near past. The list of resistant strains is growing and many of them are acquired as healthcare associated infections (HAI); they cause difficult to treat illnesses, with several unfavorable consequences including long-term disabilities and death. Moreover, they lead to long hospitalizations, and the costs on the health care systems are terribly tremendous. We seriously need to work together at all levels of health care, to stop this medical practice problem, and prevent its associated infections, towards a better confront of antimicrobial resistance.
Dr. Farida Al Hosani, Manager Communicable Diseases Department Health Authority – Abu Dhabi Tel: 02 4193208 Fax: 02 4496966 Email:
[email protected]
Page 2
Quarterly Summary Report: 4th Quarter - 2012
Table of Contents Item
Content
I
Foreword
2
II
Table of contents
3
III
Notified illnesses in Abu Dhabi Emirate by region (Quarter 4, 2012)
4
IV
Notified illnesses in Abu Dhabi Emirate by age & gender (Q4, 2012)
5
V
Monthly trends for selected notified diseases in Abu Dhabi Emirate (Q1-Q4/2012 Vs 2010 and 2011)
6
VI
Visa screening applicants in Abu Dhabi Emirate (Q4 /2012)
7
VII
Topic of the volume: Foodborne illnesses and HAAD efforts
8-11
VIII
Sharing Reports: Reported infectious diseases – 2012 End of Year Selected Figures!
12-14
IX
Activities
15-18
X
Flash news
19-20
XI
The volume “Flash- on-an-Illness”: Influenza
21-22
Quarterly Summary Report: 4th Quarter - 2012
Page
Page 3
Table 1: Notified Illnesses in Abu Dhabi Emirate by Region (Quarter 4, 2012)
Cases
Abu Dhabi
Eastern Western Region Region Cumulative in Abu Dhabi Emirate ( Q1-Q4 )
Quarter 4
Q1
Q2
2012
Q3
Q4
Year Total
2012 2011 2010
AFP *
5
0
1
7
6
2
6
21
14
11
Brucellosis
12
3
1
20
58
41
16
135
73
52
Chickenpox
880
187
59
2791
4635
1
0
0
0
1
5
1
7
9
11
130
108
15
253
374
267
253
1147
667
561
Haemophilus influenzae invasive
0
0
0
0
0
0
0
0
23
14
Hepatitis A
75
25
2
53
51
73
102
279
138
193
Hepatitis B
136
43
1
131
194
160
180
665
655
711
Hepatitis C
113
26
3
107
169
109
142
527
559
668
Influenza
80
76
10
79
31
20
166
296
238
248
Malaria * ¶
286
233
78
265
692
1160
597
2714 2760
1415
Measles *
31
3
1
14
2
5
35
56
55
50
Meningitis (bacterial)
8
0
0
9
11
12
8
40
31
39
Meningitis (viral)
16
0
0
6
14
16
16
52
38
36
Mumps
33
15
6
37
69
38
54
198
194
221
Pertussis
3
0
0
9
27
14
3
53
39
73
Rubella *
6
0
0
2
6
4
6
18
43
22
Scabies
176
60
1
195
176
151
237
759
585
654
Shigellosis
5
1
0
7
9
10
6
32
41
51
Tetanus
1
0
0
1
0
0
1
2
3
1
Tuberculosis (Pulmonary) *
44
23
9
89
93
92
76
350
452
450
Tuberculosis (Extra-Pulmonary)
26
7
3
43
55
57
36
191
180
175
Typhoid /Paratyphoid
61
10
3
130
129
110
74
443
394
347
Other diseases
307
63
24
327
373
316
394
1410 1342
968
Total
2435
883
217
4575
7175
3979
3535
19264 20281 14400
Grand total including ruled out notifications
2714
955
266
4889
7522
4371
3935
20717 21373 14949
Cholera Foodborne illnesses **
1317 1126
9869
11748 7429
Illnesses covered by national control programs (only confirmed cases and cases that cannot be ruled out are included in the table) Refers to Foodborne illnesses other than those reported separately in the list of notified diseases (See page 6 and 10 for further clarifications on the apparent increase during 2012) All notified malaria cases are “imported” Reported Haemophilus influenzae cases during last two years were not meeting the case definition of the invasive type. Indicates increase or decrease in number of notified cases during the 4th quarter of 2012 compared to previous quarters Indicates increase or decrease in numbers of notified cases over Q1-Q4 2012 compared to the cumulative over previous two years Close to 20% decrease in cases of chickenpox in 2012 (Vs.2011) is a good achievement that can be attributed to the introduction of Varicella vaccine. A confirmed outbreak of measles occurred in Abu Dhabi Region during December 2012 – January 2013 (interventions taken, and outbreak contained)
Page 4
Quarterly Summary Report: 4th Quarter - 2012
Table 2: Notified Illnesses in Abu Dhabi Emirate by Age & Gender (Q4, 2012)
Cases
Total 1
AFP 23
3
1
1
1
1
6
4
24 143 148 135 141 31
84
69 199 18
83
3
6
1
3
13
16
3
21
1
3
423
11
17
33
44
15
23
8
15
9
32
8
19
3
9
3
3
0
1
90
163
253
0
0
0
51
51
102
2
56
124
180
1
Haemophilus influenzae 15
Hepatitis A
13
29
Hepatitis B
26
3
7
3
4
1
1
1
7
6
28
47
14
39
5
19
2
10
1
1
7
28
6
33
8
27
8
16
5
2
35
107
142
3
27
12
8
12
6
11
1
3
3
3
83
83
166
141 11 213
2
130
1
58
1
23
1
1
22
575
597
9
26
35
3
5
8
5
11
16
25
29
54
1
2
3
4
2
6
56
181
237
1
5
6
0
1
1
27
49
76
11
25
36
22
52
74
166
228
394
Hepatitis C Influenza
7
11
17
Malaria Measles
1
Meningitis bacterial
1
Meningitis viral
4
Mumps
1
7 4
Rubella
1
Scabies
1
17
9
11
5
5
3
4
3
8
5
8
1 6
2
Pertussis
2
5
8
1 1
1
1
2
2
10
2
2
6
7
1
1
1
1
1 2
2
1
3
1 5
8
12
1
Shigellosis
1 18
9
1
38
11
1
1
1
56
11
32
5
1
20
1
1
1
7
1
1
1
Tetanus 0
Tuberculosis (Pulmonary) Tuberculosis (Extra-Pulmonary)
3
1
2 1
1
703 1126
1
1
Cholera Foodborne Illness
3
1 1
Brucellosis Chickenpox
1
0
11
7
12
22
2
12
0
4
0
1
6
3
13
4
4
1
2
2
3
0
1
1
Typhoid /Paratyphoid Fever
1
1
5
3
2
6
1
6
10
25
3
7
Other Diseases
6
5
46
44
20
24
13
18
52
56
20
46
0
15
1
Total
58
73 274 298 244 276 96 341 250 728 101 425 40 197 18
85
16 15 1097 2438 3535
4 8
17
3
3935 * The highlighted cells (with red numbers) indicate the age/gender categories that had the largest numbers of reported cases for the given illness. The grand total for Quarter 4 after including all ruled out notifications.
Quarterly Summary Report: 4th Quarter - 2012
Page 5
Monthly Trends for Selected Notified Diseases in Abu Dhabi Emirate (Q1-Q4/2012 Vs 2010 and 2011) The number of reported cases increased during the last quarter of 2012. However, those cases were not linked (only eight patients had history of contact with other cases). More than two thirds had travel history. The risk was not specified in quarter of the cases. About 30% of all Q 4 cases got hospitalized.
There is a remarkable decline in number of reported cases over the last quarter of 2012. Additionally, more than three quarters of them were not confirmed by culture. Travel history was reported in only 34% of those cases (almost all confirmed cases had a travel history).
Hepatitis A
70
Typhoid/Paratyphoid
2011 80
2012
50
Number of notified cases
Number of notified cases
2010 60
40 30 20 10
2010
70
2011
60
2012
50 40 30 20 10
0
Jan
Feb
Mar
Apr May
Jun
Jul
Aug
Sep
Oct
0
Nov Dec
Jan
Feb
Mar Apr May Jun
MONTH
The trend over the three years shows increase in reported cases during the first and last quarters of each year. Such increase was even more prominent during the last quarter of 2012, but it is believed that the actual number of cases is even more (it is one of the most under-reported illnesses). Find more figures about influenza in page 22.
Influenza
Sep Oct Nov
450
2011 2012
80 60 40 20
2010
400
2011
350
2012
300 250 200 150 100 50 0
Jan
Feb
Mar Apr May
Jun
Jul
Aug
Sep
Oct Nov
Dec
Jan
Feb
Mar Apr May
Jun
Jul
Aug
Sep
Oct Nov
These two figures make it clear that most of the apparent increase in reported foodborne illnesses during 2012 was due to rotavirus infections that are not necessarily foodborne.
Notified Foodborne illnesses due to Rotavirus infection 2010 2011 2012
100 80 60 40 20
Causes of these foodborne illnesses during 2012:
Foodborne illnesses (after excluding Rotavirus cases)
100
2010 2011 2012
90
Number of notified cases
Number of notified cases
120
80 70 60 50 40 30
Salmonella 156 Adenovirus 16 Campylobacter 3 Unspecified 463
20 10
Jan
Feb
Mar Apr May Jun
Jul Aug
Dec
MONTH
MONTH
0
Dec
Malaria
500 2010
100
0
Aug
Malaria keeps almost the same picture like last year, however all cases are imported that mostly develop after being back from home countries. A new geographic information system (GIS) is going to be implemented shortly by HAAD for more vigilant surveillance of breeding sites.
Number of notified cases
Number of notified cases
120
Jul
MONTH
Sep Oct Nov
Dec
0
Jan
Feb
Mar Apr May Jun
MONTH
Jul
MONTH
Aug
Sep Oct Nov
Dec
Note: HAAD surveillance officers investigate individual cases, assess for outbreaks, and take action whenever indicated.
Page 6
Quarterly Summary Report: 4th Quarter - 2012
Visa Screening in Abu Dhabi Emirate (Q1-Q4-2012) Visa screening is mandatory for all expatriates applying for work and/or residence in Abu Dhabi Emirate. It consists mainly of screening for Human Immunodeficiency Virus (HIV), pulmonary tuberculosis, and leprosy. Screening for Hepatitis B and syphilis are limited to a few occupational categories. HAAD Visa Screening Standard is available at http://www.haad.ae/HAAD/LinkClick.aspx?fileticket=DDCVCmde9R0%3d&tabid=819 Around quarter a million people or more apply for visa medical screening every three months in Abu Dhabi Emirate. During the fourth quarter of 2012, a total of 271,499 applicants were screened in all HAAD-licensed Screening Centers (a total of ten centers in the three regions of Abu Dhabi).
No. of Applicants
300000
288915
New Renew Total
279722
900
271499 245033
250000
800
No. of Applicants/ 100,000
350000
Prevalence per 100,1000 visa screening applicant in Abu Dhabi Emirate, 2012 *
Visa screening applicants in Abu Dhabi Emirate, 2012
200000 150000 100000
Overall New Renew
700 600 500 400 300 200
50000
ph ili s
ro sy
Sy
er cu Tu b
Quarter
Le p
B
Q4
He
Q3
HI
Q2
V
0 Q1
pt iti s
0
lo sis
100
Disease
The table below shows the number and prevalence of positive cases among new and renewal visa applicants during the fourth quarter of 2012. HIV Number Prevalence * Overall Prevalence
Hepatitis B
Tuberculosis
Leprosy
Syphilis***
New
Renew
New
Renew
New
Renew
New
38
5
150
8
119
42
0
0
205
0
27.8
3.7
530
42.6
87.0
31.2
0
0
723.8
0
15.8
335.3
59.3
Renew
0
New
Renew
435
* Prevalence: In the Prevalence bar chart and the table above, the term prevalence refers to the number of positive cases per 100,000 visa screened applicants. For Hepatitis B and Syphilis: it applies to tested occupational categories (a total of 47126 in quarter 4, and 194097 during the whole year of 2012). For TB: it refers to active TB cases
Quarterly Summary Report: 4th Quarter - 2012
Page 7
TOPIC OF THE VOLUME Foodborne illnesses and HAAD efforts! Background
Foodborne illnesses are a well-known public health problem that occurs in all countries; from most to least developed ones. However, the lack of reliable data makes it difficult to estimate the burden of foodborne illnesses worldwide. This is mainly due to the different definitions used in various studies, most diarrheal illnesses are not reported to public health authorities, and only few illnesses can be definitely linked to food. The WHO estimated that there are about two billion cases of diarrheal disease worldwide and around 1.8 million die annually from diarrheal diseases. A great proportion of these cases are attributed to contamination of food and drinking water. The WHO is currently working on initiating a Global Strategy for the surveillance of foodborne diseases by urging member states to set up laboratory-based surveillance systems that cover outbreaks and sporadic cases, and to monitor contamination of food by chemicals and microorganisms. The United Arab Emirates, with its main health bodies including the Health Authority of Abu Dhabi (HAAD), are not far away from those international efforts, and HAAD is currently working intensively on enabling the establishment of a national public health reference lab, that can effectively serve in better diagnosis and reporting of many illnesses including the foodborne ones. Foodborne illnesses – The common missed outbreaks! Too often, outbreaks of foodborne illnesses go unrecognized or unreported. This is due to many factors including the fact that most people who fall sick do not seek medical care because the symptoms are usually mild and self-limited; specific diagnostic tests are usually not available and/or not easy to perform; and only a small number of those who get diagnosed are reported. Therefore, reported foodborne illnesses are literally the tip of the iceberg for actual cases in the community. The below two figures show the situations of underreporting and usual scenarios for such cases, which can further explain why foodborne illnesses are generally underestimated and specification of causative pathogens are usually not reached. Usual Scenairo Timeline for Foodborne illnesses Reported Cases Confirmed Lab tests for organisms
Ingesting contaminated food
Specimen obtained People seek care
Stool sample collection
Hours -7 Days - Seeks medical care in 1-5 days - The health facility might do testing in 1-5 days
Becoming sick
Possible identification of pathogen in 1-3 days
People become ill
The cause gets specified
Infection in the Population
This indicates that public health efforts are continually needed to enhance both testing and reporting of those illnesses, so that health bodies and related stakeholders can take proper and timely intervention. Page 8
Quarterly Summary Report: 4th Quarter - 2012
Foodborne illnesses, Food poisoning, Gastroenteritis -The Definitions Dilemma!
According to WHO, foodborne illnesses (FBI) can be defined as diseases that are commonly transmitted through food. They comprise a broad group of illnesses caused by microbial pathogens, parasites, chemical contaminants, and biotoxins. A foodborne illness is therefore an infection or intoxication that results from eating food contaminated with microorganisms or their toxins. It also includes allergic reactions and other conditions where food acts as a carrier of the allergen. While not all gastroenteritis is foodborne, and not all foodborne diseases cause gastroenteritis, food poisoning is a foodborne illness that is caused by the ingestion of preformed toxins. A variety of methods have been used to ascertain the proportion of illnesses caused by foodborne agents using a syndromic case definition of gastrointestinal disease and/or pathogen specific causes likely to be attributable to food consumption. Therefore, ascertaining the burden of those diseases is usually not straightforward and should always be interpreted with caution. Gastroenteritis is the most frequent clinical syndrome that can be attributed to a wide range of microorganisms, including bacteria, viruses, and parasites. The following are the most common pathogens that cause foodborne illnesses: • Bacteria: Salmonella, Campylobacter jejuni, Clostridium perfringens, and E.coli. • Viruses: Enterovirus, Hepatitis A, Hepatitis E, Norovirus, and Rotavirus. • Parasites: Platyhelminthes (Taenia saginata, Taenia solium) , Nematode(Ascaris lumbricoides,) and Protozoa (Entamoeba histolytica, Giardia lamblia). According to the US Center for Diseases Control and Prevention (CDC), more than 250 known diseases can be transmitted through food. Unknown or undiscovered agents have been estimated to cause 81% of all food-borne illnesses and related hospitalizations. Viral infections make around one third of cases of food poisoning in developed countries. Important Foodborne Outbreaks in the World!
The below table shows the world largest outbreaks that occurred over the last five years, with the causative organisms, number of infected people, and deaths. Year
Event
2008
Canadian listeriosis outbreak in cold cuts
2008
United States salmonellosis outbreak in peanuts
2011
Germany E. coli O104:H4 outbreak
2011
United States listeriosis outbreak in cantaloupes
Agent
Vehicle
infected
Death
Listeria
Cold cuts
> 50
22
Salmonella
Peanuts
> 200
9
> 4300
52
146
30
E. coli O104:H4 Fenugreek sprouts Listeria
Cantaloupe
Figures from Abu Dhabi
The list of reportable infectious diseases includes many infections in which food can be a vehicle of transmission. Those illnesses are either appearing in the list as separate reportable disease entities (like typhoid/paratyphoid fever, brucellosis, hepatitis A, shigellosis, and other), or reported under the category of “Foodborne illness” with requesting specification of the pathogen in the blank space next to it. During 2012, the total notifications received under the category of foodborne illnesses in Abu Dhabi Emirate were 1147 cases (compared to 667 cases in 2011). However, the apparent large increase is due to rotavirus infections that have been reported under this group. This can be misleading, since a good proportion of rotavirus infections are not necessarily foodborne. However, reported foodborne illnesses in the two years after excluding rotavirus, are comparable (527 and 638 cases in 2011 and 2012 respectively). Quarterly Summary Report: 4th Quarter - 2012
Page 9
Foodborne/Food poisoning incidents On average, about ten outbreaks of food poisoning incidents are reported per year in the Emirate of Abu Dhabi. During 2012, the following 14 incidents of medium to large food poisoning outbreaks have been identified; nine of them were reported from Abu Dhabi region, four from the western region, and one from the Eastern Region (smaller incidents of 3 or less clustered cases have not been included here). Of those listed in the table, the smallest incidents involved five family members who developed food poisoning after eating from the same restaurant; and the largest one involved 113 laborers living in the same camp. All cases and outbreaks were reported to ADFCA, who investigated the suspected food and premises, took a corrective action as needed, and provided HAAD with a feedback report. No Month
No. of Cases/No. reported Stool results
Abu Dhabi Region 1
January
12 students /12
No stool samples tested (developed after going in a trip and eating from a fast meal restaurant, reported by the school nurse but did not go to hospital-mild cases)
2
February
20 labors/2
Stool culture Negative for 2 cases (only 2 cases were reported)
3
February
25 labors/25
4
April
10 labors/2
5
May
11 students/10
6
July
22 labors/10
7
August
9 family members/4
Stool culture positive for Salmonella species group E
8
August
50 hotel staff/3
3 cases tested, 1 grew Salmonella enterica, 1 had negative stool culture, 1 had negative stool culture but had E.histolytica trophozoites in routine stool analysis
9
December 113 labors/39
Stool culture Negative Stool culture Negative
Stool culture Negative (developed after going in a trip) Stool culture Negative
Negative stool cultures -25 cases tested
Eastern Region 1
Stool culture positive for Salmonella species group B
November 5 households/5
Western Region
No stool samples tested
1
January
8 labors/8
2
April
14 labors/5
3
July
37 people/5
4
July
19 labors/19
No stool samples tested Stool cultures Negative Stool cultures Negative
HAAD Communicable Disease Department is making it a top priority for this year to improve the capacity and infrastructure for outbreak response management by all health bodies in the Emirate of Abu Dhabi (this is for all illnesses including the foodborne ones).
400
Notifications received under the category of "Foodborne illness"
450
350
Number of cases
250 200 150 100
350
Nationals
300
Expatriate
250 200 150 100 0
Page 10
Am
cifi ed
r
sp e
cte Un
py lo ba
vi ru no ne
m Ca
el la Ad
Sa
lm
on
vi ru ta Ro
Causative pathogens
eb ia sls Gi Ty ar ph di oi as d/ ls Pa ra ty ph oi Br d uc el lo sis E. co He li pa tit is Sh A ig Ca el lo m sis ph lo ba ct er Ch ol er a
50
0
s
50
s
Number of cases
400
Nationals Expatriate Western Region
300
Foodborne illnesses that are notified as separate disease entities
Infectiuos Disease
Quarterly Summary Report: 4th Quarter - 2012
The role of physicians in investigating the causative organisms is crucial, and all care should be taken to do that.
Foodborne illnesses – HAAD Requirements! HAAD classified Foodborne illness as a “Category A” reportable disease!
Requiring immediate reporting! The primary goal of this reporting requirement is the prompt identification of any unusual clusters of the disease that have possibly been developed by ingesting a contaminated food. Isolation of the pathogen from the suspected food specimens would usually need to be done within 72 hours; therefore immediate reporting will allow the Food Control Authority to do necessary investigation and testing on time, hence preventing bigger outbreaks in the community. Reporting of foodborne illnesses should not be undervalued at all. Although in most of the cases the illness is mild, some illnesses can be very serious, requiring hospitalization, and might cause long-term disability and even death.
HAAD Efforts to Improve Actions Investigation of foodborne illnesses and related outbreaks requires a multidisciplinary approach where all stakeholders need to get involved and take their roles to ensure timely control and prevention. Once a foodborne illness is reported to the Health Authority of Abu Dhabi, the surveillance team starts performing a case-based epidemiological investigation to identify the source of infection, risk factors, and possible epi-linkage among cases, especially when there is clustering by time or place. HAAD immediately reports any suspected foodborne illness or incident to Abu Dhabi Food Control Authority (ADFCA) to investigate the suspected food. ADFCA team goes on a field visit to the implicated place to take food specimens and inspect the food establishment. This helps in identifying the source of infection and take appropriate preventive measures to avoid repeated occurrence of such incident in the future. More vigorous actions might be taken by ADFCA, which may include a warning letter or even closing the food establishment if those violations were recurring ones.
Health care providers report Foodborne illnesses to HAAD (e-notification/phone) Abu Dhabi Food Control Authority (ADFCA)
Automated reporting from HAAD to ADFCA will start soon!
Do Not Delay notification of Foodborne illnesses This may result in deterioration of food specimens!
Quarterly Summary Report: 4th Quarter - 2012
Page 11
Sharing Reports: Reported infectious diseases –2012 End of Year Selected Figures!
Chickenpox by Age group in Abu Dhabi Emirate (2011-2012) 2011 IR*100,000
Frequency
2012 IR*100,000
Age group
Frequency
0-4
3708
2485.8
2719
1690.6
5-9
3088
2440.7
2744
2139.1
10-14
769
764.0
657
646.9
15-19
303
340.8
238
259.0
20-24
916
368.6
775
298.9
25-29
1342
308.9
1176
254.7
30-34
792
220.9
740
195.0
35-39
455
169.4
426
155.1
40-44
214
104.7
202
96.1
45-49
89
66.1
88
63.4
50-54
40
40.4
55
55.4
55-59
19
32.2
27
42.9
60-64
12
49.1
10
37.5
65-69
1
9.9
5
43.4
70-74
1
15.5
2
28.9
75+
2
58.4
0.0
0.0
Total
11751
506.3
9864
407.2
Good news! The impact of introducing the varicella vaccine started to be seen: The incident rate of chickenpox has declined from 506 per 100,000 in 2011 to 407 per 100,000 in 2012. However, a natural secular change can also be a reason for that, therefore we may need a few more years for such effect to be more clear.
A decrease of 20% from last year!
Note: This is a real time data, so figures abstracted at different points of time can show small difference
Disease
Childhood Diseases (MC"&%0'(*'[*)B"%*b/X' #(*;"E-,4'GNJG'
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