EPIDEMIOLOGIC SUMMARIES OF SELECTED GENERAL COMMUNICABLE .
EPIDEMIOLOGIC SUMMARIES OF SELECTED GENERALCOMMUNICABLE DISEASES IN CALIFORNIA, 2001-2008SURVEILLANCE AND STATISTICS SECTIONINFECTIOUS DISEASES BRANCHDIVISION OF COMMUNICABLE DISEASE CONTROLCENTER FOR INFECTIOUS DISEASESCALIFORNIA DEPARTMENT OF PUBLIC HEALTHEdmund G. Brown Jr.GovernorState of CaliforniaDiana S. Dooley, SecretaryHealth and Human Services AgencyRonald W. Chapman, MD, MPH, DirectorDepartment of Public Health
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-2008Table of ContentsAcknowledgements .2Technical Notes .3Selected Communicable DiseasesBrucellosis .7Campylobacteriosis.9Cholera. 13Coccidioidomycosis . 15Cryptosporidiosis . 19Foodborne Botulism . 23Foodborne Disease Outbreaks. 25Giardiasis . 29Hantavirus . 33Infant Botulism . 35Legionellosis . 37Listeriosis . 41Lyme Disease . 45Q Fever . 47Rabies . 49Salmonellosis. 53Shiga toxin-producing Escherichia coli (STEC) . 57Shigellosis . 61Tularemia . 65Typhoid Fever . 67Vibriosis (non-cholera) . 71West Nile Virus. 75Wound Botulism. 791
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-2008AcknowledgementsWe thank the California health care providers including the clinicians, infection control practitioners,hospital administrators, and laboratorians who reported the cases to their local health departments.We thank the local public health workers including the local Health Officers, communicable diseasecontrollers, epidemiologists, health data managers, public health nurses, morbidity clerks andsupport staff for providing these data to the California Department of Public Health (CDPH) and fortheir daily contributions to communicable disease surveillance and outbreak investigations.We thank the current and former CDPH program staff and subject matter experts for their expertiseand collaboration and for their contributions to communicable disease surveillance and outbreakinvestigations. In particular, we would like to acknowledge: Stanley Bissell, MS, Maria TeresaBonafonte, MPH, PhD, Kate Brown, Kate Cummings, MPH, Daniel Gonzales, Melissa Moffett, MichelleNguyen, Linda Sandoval, Shu Sebesta, Mark Starr, DVM, MPVM, Colleen Steward, Farzaneh Tabnak,MS, PhD, and Ying Yang, MS, of the Surveillance and Statistics Section; Jeff Higa, MPH, Akiko Kimura,MD, Bela Matyas, MD, MPH, Janet Mohle-Boetani MD, MPH, Jon Rosenberg, MD, Jennifer Schneider,MPH, and Charlotte Wheeler, MD, MPH, of the Disease Investigations Section; Claudia Erickson, MA,Sharon Ernst, James Glover, DVM, MPVM, MPH, Michele Jay-Russell, DVM, MPVM, and Ben Sun, DVM,MPVM, of the Veterinary Public Health Section; Curtis Fritz, DVM, PhD, MPVM, Anne Kjemtrup, DVM,PhD, MPVM, Vicki Kramer, PhD, and Jonathan Kwan, MS, of the Vector-Borne Disease Section; MeileenAcosta, MPH, Debra Gilliss, MD, MPH, Cynthia Jean Yen, MPH, Janice Kim, MD, MPH, Trish McLendon,MPH, and Hilary Rosen, MPH, of the Bioterrorism Epidemiology Section; Amy Karon, DVM, and JeanYuan, MD, of the CDC Epidemic Intelligence Service; Janey Butner, and Duc Vugia, MD, MPH, ofthe Infectious Diseases Branch.We also thank Haydee Dabritz, PhD, Steve Arnon, MD, of the InfantBotulism Treatment and Prevention Program, Douglas Hatch, MD, MPH, James Watt, MD, MPH, ofthe Division of Communicable Disease Control, and Gilberto Chavez, MD, MPH, of the Center forInfectious Diseases.2
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-2008Epidemiologic Summaries of Selected General Communicable Diseasesin California, 2001 - 2008: Technical Notesdiseases that did not require a case history formby regulation (campylobacteriosis, coccidioidomycosis, cryptosporidiosis, giardiasis, salmonellosis,and shigellosis).BackgroundThe California Department of Public Health(CDPH) maintains a mandatory, passive reportingsystem for a list1 of communicable disease casesand outbreaks. Health care providers and laboratories are mandated to report cases or suspectedcases of these communicable diseases to theirlocal health department (LHD). LHDs are alsomandated to report these cases to CDPH.We extracted data on foodborne and waterborneoutbreaks with estimated onset dates from 2001through 2008 from outbreak report forms submitted to CDPH by July 1, 2009. These reports werethe source for the number of outbreak-associatedcases for each disease.These Technical Notes describe the definitions,methods, and limitations used to summarize theepidemiology of selected communicable diseasesreported to CDPH2. In particular, these selectedcommunicable diseases come from the generalcommunicable diseases not covered by the categorical programs for tuberculosis, sexually transmitted diseases, HIV/AIDS, and vaccinepreventable diseases, all of which produce regularsummaries of their diseases.Population data sourceWe used projections for state, county, and agespecific population totals that were published in:State of California, Department of Finance, Race/Ethnic Population with Age and Sex Detail, 2000–2050. Sacramento, CA, July 2007.DefinitionsIn general, we defined a case as laboratory and/orclinical evidence of infection or disease in a person that satisfied the most recent communicabledisease surveillance case definition published bythe United States (US) Centers for Disease Control and Prevention (CDC) or by the Council ofState and Territorial Epidemiologists (CSTE)3.Surveillance case definitions are described in individual disease summaries. By California regulation, an animal case was one that was determined, by a person authorized to do so, to haverabies or plague.The distribution of information on the health of thecommunity is a core function and essential service of public health. The data in the epidemiologic summaries provide important health information on the magnitude and burden of communicable diseases in California. Bearing in mind theirlimitations, these data can contribute toward identifying high risk groups needing preventive actionsand tracking the effectiveness of control and prevention measures.Materials and methodsWe defined the estimated onset date for eachcase as the date closest to the time when symptoms first appeared. Because date of onset maynot be recorded, the estimated date of onset canrange from the first appearance of symptoms tothe date the report was made to CDPH. For diseases with insidious onset (for instance, coccidioidomycosis), estimated onset was more frequentlydrawn from the diagnosis date. We defined thesurveillance period as 2001 through 2008.Case data sources and inclusion criteriaWe extracted data on communicable disease cases with an estimated onset date from 2001through 2008 from California Confidential Morbidity Reports that were submitted to CDPH by May8, 2009 and which met the surveillance case definitions (see below). Because of inherent delaysin case reporting and depending on the length offollow-up clinical, laboratory and epidemiologicinvestigation, cases with eligible onset dates maybe added or rescinded after the date of this report.Therefore, data for 2008 contained in this report are provisional and may differ from datapublished in future reports.We defined single race-ethnicity categories asfollows: Hispanic (of any, including unknown,race); White, non-Hispanic; Black, non-Hispanic;Asian/Pacific Islander, Native American; and Other or multi-race. Cases with unknown race andethnicity were listed as unknown.CDPH reviewed detailed clinical and laboratorydata provided on disease-specific case historyforms to determine if surveillance case definitionswere met. LHDs applied surveillance criteria forWe defined regions of California by collapsingcounties with similar geography, demography,Center for Infectious Diseases - Division of Communicable Disease ControlInfectious Diseases Branch - Surveillance and Statistics Section3
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-2008and economic conditions as described by the Public Policy Institute of California4. Regions includedthe Far North (Butte, Colusa, Del Norte, Glenn,Humboldt, Lake, Lassen, Mendocino, Modoc, Nevada, Plumas, Shasta, Sierra, Siskiyou, Sutter,Tehama, Trinity, and Yuba Counties); SacramentoMetro (El Dorado, Placer, Sacramento, and YoloCounties); Sierras (Alpine, Amador, Calaveras,Inyo, Mariposa, Mono, and Tuolumne Counties);Bay Area: (Alameda, Contra Costa, Marin, Napa,San Francisco, San Mateo, Santa Clara, Solano,and Sonoma Counties); San Joaquin Valley(Fresno, Kern, Kings, Madera, Merced, SanJoaquin, Stanislaus, and Tulare Counties); CentralCoast: (Monterey, San Benito, San Luis Obispo,Santa Barbara, and Santa Cruz Counties); InlandEmpire: (Riverside and San Bernardino Counties);South Coast: (Los Angeles, Orange, and VenturaCounties); and San Diego (Imperial and San DiegoCounties). We defined Southern California as thecounties comprising the Inland Empire, SouthCoast, and San Diego regions. All other countiescomprised Northern California.cent), we did not calculate incidence rates. However, because race/ethnicity can be an importantmarker for complex social, economic, and politicalfactors that influence health, we presented the distribution of single race/ethnicity categories amongcases with complete information.We evaluated the temporal trends in incidencerates for selected diseases using Poisson regression models. Values of p 0.05 were consideredstatistically significant. Analyses were conductedusing SAS Release 9.1 (SAS Institute, Inc, CaryNorth Carolina) and maps were created usingArcGIS version 9.3 (ESRI, Inc, Redlands, California).LimitationsData qualityCDPH relied on LHDs to apply surveillance andcounting criteria for campylobacteriosis, coccidioidomycosis, cryptosporidiosis, giardiasis, salmonellosis, and shigellosis. It is possible that some cases did not meet surveillance case definitions orcounting criteria.We defined a rate as unreliable if the relativestandard error was 23 percent or more (a thresholdrecommended by the National Center for HealthStatistics). The formulas used to calculate the relative standard error were: DeathsWe presented the number of cases reported toCDPH as having died with their disease. There isno standardized method for determining whether acommunicable disease caused or contributed tothe death for the purposes of reporting here.Deaths may have occurred after the report wasfiled (and thus not reported). The numbers ofdeaths and case-fatality ratios reported should beinterpreted with caution.Incidence rate (IR) Number of cases/population x 100,000Standard error (SE) IR/ number of casesRelative standard error SE/IR x 100Data analysesWe reported case totals and rates per 100,000population (unless otherwise indicated) stratified byestimated year of onset, age, and geographic residence. We calculated geographic-based rates bycounty, region, and bisection of the State (Northernor Southern California). Cases reported from theCity of Berkeley were included in Alameda Countyand cases from the Cities of Long Beach and Pasadena were included in Los Angeles County.To reduce the level of random error, we expandedthe time and geographic range for incidence rateswhen few cases or small populations were identified. We produced multiple-year average rates andregion-specific (rather than county-specific) rates,as needed. We calculated relative standard errorsfor all county-specific rates.Completeness of reportingThe numbers of disease cases in this report arelikely to underestimate the true magnitude of disease. Among factors that may contribute to underreporting are: delays in notification, limited collection or appropriate testing of specimens, healthcare seeking behavior among ill persons, limitedresources and competing priorities in LHDs, andlack of cooperation of clinicians and laboratories.Among factors that may contribute to increasedreporting are disease severity, the availability ofnew or less expensive diagnostic tests, changes inthe case definition by CDC or CDPH, recent mediaor public attention, and active surveillance activities.During the surveillance period, CDC and CDPHconducted active surveillance in Alameda, ContraCosta, and San Francisco Counties through theBecause a substantial portion of race/ethnicity datawas missing (disease-specific range: 12 to 50 per-Center for Infectious Diseases - Division of Communicable Disease ControlInfectious Diseases Branch - Surveillance and Statistics Section4
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-2008California Emerging Infections Program (CEIP).CEIP conducted active laboratory-based surveillance for Salmonella, Shigella, Campylobacter,Escherichia coli O157, Shiga toxin-producing E. coli(STEC) non-O157, Listeria monocytogenes, Yersinia, Vibrio, Cryptosporidium, and Cyclospora infection and active physician-based surveillance of pediatric hemolytic uremic syndrome (HUS) through anetwork of nephrologists in the catchment area.AcknowledgementsWe thank California Communicable Disease Controllers and program staff for their continued excellence in communicable disease surveillance, investigation, and control.We thank CDPH subject matter experts for their expertise and collaboration in producing the diseasesummaries. We would like to acknowledge the contributions to communicable disease surveillance andoutbreak investigations made by the current andformer members of the Infectious Diseases Branch.We thank Duc J Vugia, M.D., M.P.H. for his valuablecomments throughout the development of the disease summaries.Because outbreak-related case reports were notalways identified as such on the Confidential Morbidity Report, it was not possible to ascertain theproportion of outbreak-related cases that were reported as individual cases in the passive reportingsystem. Additionally, case definitions used to classify probable outbreak-related cases may not meetthe more specific criteria required for individual casereporting. Therefore, outbreak-related cases maynot be included in the total number of cases reported for each disease and outbreak-related casesreported in the probable classification may not meetsurveillance reporting criteria.ReferencesCalifornia Code of Regulations, Title 17, Sections2500 and tableDiseases.aspx2Epidemiologic Summaries of Selected GeneralCommunicable Diseases in California, 2001 - EpiSummariesCDsCA-01-08.aspx3Centers for Disease Control and Prevention. National Notifiable Diseases Surveillance System,Case Definitions for Infectious Conditions UnderPublic Health SurveillanceSmall numbers and rate variabilityAll rates, even those based on full populationcounts, are subject to random error. Random errormay be substantial when the number of cases issmall (e.g., less than 20) and can make it impossibleto distinguish random fluctuations from true changesin the underlying risk of disease. Rates and proportions based on small numbers should be interpretedwith caution.http://www.cdc.gov/osels/ph surveillance/nndss/phs/infdis2011.htm4Johnson, H. ‘A State of Diversity: DemographicTrends in California’s Regions’, California Counts,Vol 3, No 1, Public Policy Institute of California, SanFrancisco, California 2002http://www.ppic.org/content/pubs/cacounts/CC 502HJCC.pdfLast updated 08/30/2011Rate comparisonsIncidence rate comparisons between geographicentities and over time should be done with caution.Because not all LHDs reported age data, the rates inthis report are not age-adjusted. Additionally, thelimitations previously listed (especially the completeness of reporting and random variability of rates)should be considered when interpreting and comparing incidence rates.Prepared by Kate Cummings, MPH, and FarzanehTabnak, PhD, Infectious Diseases BranchCenter for Infectious Diseases - Division of Communicable Disease ControlInfectious Diseases Branch - Surveillance and Statistics Section5
Epidemiologic Summaries of Selected General Communicable Diseases in California, 2001-20086
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COMMUNICABLE DISEASES IN CALIFORNIA, 2001-2008 SURVEILLANCE AND STATISTICS SECTION INFECTIOUS DISEASES BRANCH DIVISION OF COMMUNICABLE DISEASE CONTROL CENTER FOR INFECTIOUS DISEASES CALIFORNIA DEPARTMENT OF PUBLIC HEALTH Edmund G. Brown Jr. Governor State of California Diana S. Dooley, Secretary Health and Human Services Agency
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