CDC ZOHU Call June 6, 2018


[ Music ]>>Good afternoon, and
thank you all for holding. Your lines have been
placed on a listen-only mode until the question and answer
portion of today’s conference. I would like to remind
all parties, the call is now being recorded. If you have any objections,
please disconnect at this time. I would now like to turn the
call over to Helen Talley-McRae. Thank you. You may begin.>>Thank you, Elan. Good afternoon, everyone. My name is Helen Talley-McRae, and I work in the One Health
Office of the National Center for Emerging Zoonotic
and Infectious Diseases, at the Centers for Disease
Control and Prevention. On behalf of the
One Health Office, I’m pleased to welcome you to the monthly Zoonoses &
One Health Updates Call. So before we get started,
I wanted to remind everyone that although the content
of these calls are directed to veterinarians,
physicians, epidemiologists, and related public health
professionals in federal, state and local positions,
the CDC has no control over who participates
on this conference call. Therefore, please exercise
discretion on sensitive content and material as confidentiality
during these calls cannot be guaranteed. Finally, today’s call
is being recorded. If you have any objections, you
may disconnect at this time. Free continuing education
is available for ZOHU Calls. Detailed instructions are
available on our website, cdc.gov/onehealth/ZOHU
and will be given at the end of this call. Please spread the word to your
colleagues about the ZOHU call and this new free
CE opportunity. In compliance with continuing
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as well as any use of unlabeled products
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reviewed content to ensure there is no bias. And the presentation will
not include any discussion of the unlabeled use of
a product or a product under investigational use. CDC did not accept
any commercial support for this activity. Before we turn the call
over to our speakers today, we’d like to share some One
Health news updates with you. Dr. Barton Behravesh, you
may begin when you’re ready.>>Thanks, Helen. Hi, everyone. This is Casey Barton Behravesh, the Director CDC’s
One Health Office. And first, I’d like to welcome
all the new participants to today’s ZOHU call. And I’d like to thank all of you
for helping us spread the word about the ZOHU call and
letting your colleagues know that we now offer CE. Our ZOHU call audience is
really growing, and we now have over 4,100 subscribers
representing a variety of One Health partners at
different levels; federal, state and local, as well as
colleagues and professionals from non-governmental
organizations, industry, and academia. So please continue to
share the ZOHU call website with information on how to
subscribe to the ZOHU call. And we greatly appreciate
your continued support at increasing awareness
about the call and the free CE opportunities. So to kick us off today, I’d like to share the latest
One Health news and resources. And all of these
have links included in today’s ZOHU call
e-mail reminder. First is CDC’s new rapid rabies
test could revolutionize testing and treatment, and is a topic
of today’s first presentation. We’ve included a link
to that new paper. USDA APHIS has updated its
animal welfare regulations to provide certain small
scale dealers and exhibitors with additional exemptions
from licensing requirements. There are three new
steps in the fight against global antimicrobial
resistance that were updated recently
at the World Organization for Animal Health, or OIE
general session held in Paris, and they’ve also
released the results of their 2018 photo
competition winners with some beautiful photos, including some representing
the Americas region. We’ve also included a link
to some video presentations for two recent events; CDC’s Public Health Grand Rounds
called Be Antibiotics Aware: Smart Use, Best Care. And also to a symposium on
the 1918 pandemic influenza. We’ve included some links
to upcoming conferences and meetings that
might be of interest. And again, you can check
the news to see those. And we also wanted to
share some highlights from recent publications,
including the June issue of the Emerging Infectious
Diseases Journal has a Zoonoses theme. World Bank has released a One
Health Operational Framework. And there’s a new article on
Zika Virus Shedding in Semen of Symptomatic Infected Men. Highlighted MMWR topics include
malaria, outbreaks associated with treated recreational water,
Lyme disease surveillance, and summaries of
Salmonellaoutbreaks, one linked to ball
python exposure, and another to the consumption
of rattlesnake pills. There are also a few current
outbreaks under investigation, and we highlight those. A multi-state outbreak of
SalmonellaEnteritidis linked to pet Guinea pigs, a
multi-state outbreak ofSalmonellaBraenderup
infections linked to shell eggs and a multi-state
outbreak ofE.Coli0157:H7 infections
linked to Romaine lettuce. As always, a selected list of
ongoing and past U.S. outbreaks of zoonotic diseases is
available on the Healthy Pets, Healthy People website. Lastly, if you would
like for us to share news from your organization,
or if you want to suggest presentation
topics or volunteer to present on a future ZOHU call, please
contact us at [email protected] Thank you again for your
support of the ZOHU call and for joining today. I will now turn it
back over to Helen.>>Thank you so much,
Dr. Barton Behravesh. Our overall series objectives for ZOHU call include
describing two key points from each presentation, describe
how a multisectoral One Health approach can be applied to
the presentation topics. Identify an implication for
animal and human health. Identify a One Health approach
strategy for prevention, detection, or response
to public health threats, and identify two new
resources from CDC partners. We have three very
interesting presentation topics for you today. Rabies diagnosis in
animals using PCR. Excuse me one second. Let me go back one slide. Okay, national pet
week and trends in reported vector-borne
disease cases. You’ll find resources and
links for each presentation in today’s ZOHU call
reminder e-mail. Questions may be typed into
the Q&A box in Adobe Connects. Please name the presenter
or topic at the beginning of each question you type in. If you are using the
phone line, press star 1 and give the operator
your name and affiliation. We will have time for questions
at the end of the call. Okay, our first presentation,
rabies diagnosis in animals using PCR, will be
given by Dr. Crystal Gigante. Dr. Gigante, you may
begin when you’re ready.>>Good afternoon. I am Crystal Gigante, a member of the Molecular Diagnostics
Team in the Poxvirus and Rabies Branch at CDC. Today, I’m happy to give
a short presentation on postmortem diagnosis of
rabies in animals using PCR. The objectives of
this presentation are to introduce the
strengths, weaknesses and critical considerations
when using PCR, to compare PCR-based rabies
tests to the gold standard in rabies diagnostics, and
to describe the LN34 assay, a PCR test developed at CDC. Rabies is a global threat. Most of the nearly
60,000 human deaths caused by rabies each year
are associated with exposure to a rabid dog. Across the world, canine rabies and wildlife rabies
are being targeted by vaccination campaigns. A good understanding of
rabies burden is critical when organizing and
evaluating the success of vaccination campaigns. And being able to accurately and reliably identify
rabies cases is critical to prevent rabies
and expose humans. An integrated approach to rabies
management includes accurate surveillance and diagnosis
of rabies in animals. The gold standard
in rabies diagnosis in animals is the direct
fluorescent antibody test, known as the DFA or FAT. It is sensitive, specific,
reliable, and robust. It does not miss positive
rabies cases, which is critical, because missing a positive
can result in death that could have been prevented. The DFA does have
several limitations. The use and availability of antibody conjugates is
not standardized across labs, and conjugates can vary
from batch to batch. The interpretation of
results can also be difficult. The DFA test uses a florescence
microscope, and the ability to distinguish non-specific
florescence from true signal
requires hands-on training and experience. And lastly, the DFA
requires fresh frozen tissue and maintenance of cold
chain from the location where the sample is collected
to the testing facility, which can be expensive and
impractical in some areas. The requirement for fresh frozen
tissue leaves many samples unfit for rabies testing. So how does PCR compare? The sequences and
concentrations of primers and probes are standardized and can be produced
commercially by many companies. There is less hands-on
time to do a PCR assay. Many labs across the globe
are already using PCR to detect other pathogens
and diseases, and adding a rabies
PCR test is easy and requires minimal
training in these labs. The results are very
easy to interpret. And lastly, there are commercial
reagents for preserving RNA at room temperature that
can eliminate the need for cold chain. Some of the weaknesses of PCR
include its high sensitivity, which makes it prone to false
positives due to contamination of samples, or improper
lab techniques. As you may suspect, PCR,
a realtime PCR machine, is required, but this
machine can be used for other diagnostics. And lastly, PCR is only approved as a confirmatory
diagnostic test for postmortem rabies
in animals. However, PCR is being
included as a primary test in the newly revised rabies
chapter of the OIE manual, and this update should
be reflected shortly on their website. Other groups are
considering similar changes. So there are many PCR assays
out there, and they fall into three major categories; reverse transcription
PCR, or RTPCR. The other two types are
realtime, or quantitative RTPCR, using either cyber green
dye or TaqMan probe to detect the rabies virus RNA. Each type of PCR test
has its own advantages and disadvantages. Consider these main points when choosing a PCR
assay to use for rabies. One, has it been validated to detect all viruses
that cause rabies? And two, how does it
perform compared to the DFA? Any rabies diagnostic
test should be able to detect all viruses
that cause rabies. Because of global
travel, the risk of rabies from other areas is never
completely avoidable. Not all PCR assays
are made the same. Make sure the test you’re
using has been validated using diverse samples. The LN34 assay, a TaqMan
realtime RTPCR assay developed at CDC, can detect all
known lists of viruses. The primers and probes used in the LN34 assay target
highly-conserved regions of the genome, shown
here in this figure. So how does a PCR assay
compare to the DFA? Here’s data from 14 labs across
the world who participated in a pilot study comparing
the LN34 assay to the DFA. So almost 3,000 samples tested, the LN34 had great diagnostic
sensitivity and specificity. No DFA positive samples
were negative by LN34. During the pilot study,
the LN34 assay helped to identify 10 false positive
DFA results from one laboratory and one false negative
DFA result. The LN34 assay was also able
to provide definitive results for 80 out of 81 DFA
and conclusive results. An important thing to remember when implementing a
rabies PCR assay is that you must follow rabies
sample collection guidelines similar to what is
done for the DFA. The minimum tissue
accessible to rule out rabies is a full
cross section of brain stem and cerebellum. One advantage of PCR is that practically any tissue can
be tested to confirm rabies, including formal and fixed
tissue, antemortem samples, and severely deteriorated
specimen. This image shows unilateral
rabies virus spread in a large animal,
highlighting the importance of testing a full cross-section of brain stem instead
of just a piece. This is the only tissue that
is required to rule out rabies. As I mentioned earlier, PCR assays have very
high sensitivity. The LN34 assay can detect RNA
in positive clinical samples that have been diluted
one million times. Therefore, the utmost
care must be taken to avoid cross-contamination,
especially in labs unfamiliar with molecular techniques. Not sure what happened there. I’ve lost visual on the slides.>>Crystal, I can
advance them for you if you need for me to do that. I see they’re still moving.>>Okay, I just have
blank slides.>>Okay, the one that I
see now, it says a positive and a negative control must
be included in each assay run. Is that the one you’d
like to start over with?>>Okay, yes, so
we can start here. PCR tests can incorporate
several built-in controls. The first control
measures host RNA levels.>>Sorry, sorry. I think somebody else was
moving the slides to you. So, okay, I’m back on the
one that says a positive and a negative control.>>Okay, can you go to the
one just before that one?>>Yes.>>Thank you.>>Great. Each sample
must be tested?>>Yes, thank you.>>Okay, just tell
me next slide, and I’ll just continue for you.>>Thank you.>>Thanks.>>PCR tests can incorporate
several built-in controls. The first control
measures host RNA levels. This control helps distinguish
true negative samples from negative results caused
by sample degradation, sample insufficiency, failed
extraction, or PCR inhibition. Next slide. Positive and negative controls
help ensure the assay is working properly. Positive controls allow labs
to monitor assay performance over time and identify issues
and abnormal assay runs. Negative controls can identify
some forms of contamination. Next slide. I mentioned earlier that PCR
assays can be easy to interpret. Here are the guidelines for result interpretation
for the LN34 assay. Positive samples produce
smooth amplification curves, as shown in the bottom
of this slide. These curves are given a
cycle threshold value based on PCR machine analysis. The cycle threshold
value is used to determine whether a
sample is positive, negative, or needs further testing
using the table shown in the middle of the slide. Next slide. As an added bonus, in addition to identifying a positive
sample, the PCR product produced by the LN34 assay
can be sequenced for a low resolution
rapid typing. Next slide. Now I’d like to thank all of
the people at CDC and the labs that participated
in the pilot study. And thank you for listening.>>Thank you so much,
Dr. Gigante. Our next presentation,
AVMA National Pet Week – A Lifetime of Love will be given
by Dr. Emily Patterson-Kane. Dr. Patterson-Kane, you may
begin when you’re ready.>>Hello, everyone. It’s a bit of a change of pace, but I would like to explain
today how the AVMA National Pet Week is actually a
One Health program. And it particularly addresses
the role of attachment within a One Health system. So attachment to
ideas and to places and to other individuals
really drives behavior that is very important for
one medicine and one welfare. And so that’s why we place
one of our main programs that is devoted to the
treatment of companion animals within a One Health context, and
it’s why a person like myself, as a psychologist, is employed
in the animal welfare division, to try and impact the way that
people interact with animals. So the National Pet Week is
in the first week of May. It’s a longstanding program. I have the full details
on the slide here. But the most important
thing to point out is that National Pet Week is about
the human companion animal bond. And it’s encouraging pet
owners to follow expert advice on responsible pet ownership. We have a lot of programs that
are underneath this initiative, that veterinary technicians,
different groups in the community and
charities can use to create a really fun message
to say, while you’re motivated to be with your pets, to have
a good time, and you love them, but this love comes
with a responsibility because of the way it impacts
the health of other people and animals and the environment. If you want to look at the
underpinning of our program that occurs each year,
the policy to look at is the guidelines for
responsible pet ownership. For a long time, we didn’t
have a specific policy on what you should do in
relation to companion animals. We have a tendency to
focus on the things that you should not do, or
things that are going wrong. But within a One Health mantra,
the idea is as people focus in on how the system should
work and how they should behave, it really helps organize a more
positive and convincing way to explain a proper way
to interact with animals. At the beginning of this policy, it outlines that owning
a pet is a privilege, and that it should be mutually
beneficial as a relationship. So a pet owning relationship is
not exploitative, it’s positive, and this positivity goes out
from the primary relationship to other members of the
community and the environment, making sure that our companion
animals are contributing positively within this
entire One Health framework. What we do within the policy
is outline a paradigm, and also some very specific
expectations for care and management of companion
animals, and these evolve as we have new ways for
conducting preventative care for identifying animals and
make sure that they don’t stray, they don’t breed uncontrollably,
they’re properly contained. And there are some evolving
expectations around this as time goes on, and generally
a higher standard associated with veterinary care
having more advances, and people having
higher expectations for humane conduct and behavior. At the moment, the theme of national pet week
is a lifetime of love. It does evolve over time, but
this one we’ve been working with for a few years now, promoting the healthy
human animal bond. And then secondary to that,
the submessages, which relate to controlling disease
and dog bite prevention and other negative outcomes for when the bond is
not working properly. We have evolving daily themes,
and currently they’re organized around the lifespan
of the animal, because it introduces
this responsibility idea that when you choose an animal,
you’re making a commitment that this is the right animal,
that they’re going to benefit from being in your household,
and that you’re committing to taking proper care of them
throughout their lifespan. And so currently, it’s
organized on these themes. They relate to pet selection,
to early socialization and training, to
nutrition and exercise and your day-to-day
management of an animal, to preventative health care and
going to see your veterinarian, the control of pet population
and breeding, having plans for emergencies, including
personal emergencies, and also larger scale disasters,
so that you’re as prepared as you can be to leave the
shelter in place or evacuate or take other responses. And then issues to do
with aging and euthanasia. Currently, looking at the
adoption of older animals from shelters, as the older
animals tend to be neglected. You can see how this
program relates outward to other organizations
and their programs, which have other
focuses in the community. So, for example, recently,
the idea of people exercising, particularly with their
dogs, contributing to the walkable community and
the surgeon general’s program, and the idea that when people
are out and interacting with their communities, the
community tends to be safer, and there are more positive
interactions between neighbors and different people
within the community, and it generally contributes to good public health
and community safety. There are human health
benefits become directly from exercising animals, which
does include walking outside with dogs, but also, for
example, providing good play and exercise for indoor cats, so that they have a nice
enriched happy environment, a good bond inside the home,
and they’re not depending on going outside
for their exercise where they might have
a negative effect on the environment
and other animals. We also have messages to
do with workplace safety, with humane education of
children, and the link, which is the concept
that animals as victims of violence have connections
with humans as victims of violence and abuse, and that
when we can have cross-reporting and people who respond to these
different targeted audiences, training and working and
communicating together, this causes a much more
effective response to violence to at-risk households,
and to vulnerable people who may be showing
anti-social behavior, and require some
compassionate intervention. And so within this general
framework, it sprouts off a lot of our more specific programs, with which there’s
actually quite a few. But I like the One Health
idea and the strengthening, the good responsible
attachment to animals, particularly companion
animals, in a different and appropriate response to other working
agricultural wild animals. And that it gives a
positive angle to trying to reinforce the
correct behavior rather than focusing entirely on
stamping out the bad behavior. And the good behavior, over
time, becomes more acceptable, tends to crowd out
the bad behavior. And a good example
of this is the issue of assistance animal fraud,
which we’re seeing a lot, for example, in relation
to the behavior of animals being
brought into airlines and transportation
and other areas. Preventing assistance animal
fraud really requires engaging with different parts
of the system. Just trying to stamp out
the fraud can cause some inappropriate challenging
of people with disabilities who are making appropriate
use of the service or emotional support animal. We like to avoid that. We want to strengthen the care
provided to assistance animals, including by veterinarians,
and coordinating the care between the handler
of the animal, their health professional, and
their veterinary professional, so that those animals
are appropriate, and they’re being prescribed
in an appropriate way, and everyone is educated about
the different legal categories of animals and their rights. We really want to support
access to the pet owners also. For example, to accommodations. So that they have
less of a motivation to either wishful thinking or deliberately misrepresent
their animal, as a companion animal,
as a service or emotional support animal. And through these coordinated
programs, create social norms that celebrate the
assistance animals and the companion animals, and
discourage people from trying to move their animals
inappropriately from one category to the other. If you’re interested
in this program, it’s avma.org/assistanceanimals. And we have an interdisciplinary
working group that’s working on coordinating medical and
veterinary professionals, as well as social work
and some other areas, to strengthen some
appropriate systems of managing these animals. Another smaller case, vehicular
heatstrokes, so that’s animals, particularly dogs, who are
left in cars in the summer. We’re coming into
that season now. It’s a persistent problem, causes harm and death
to animals. It’s also extremely distressing
to the human caretakers and to other people
who come across it. And it causes a lot of conflict and disagreement in
some communities. And as we’ve looked into
this, we’ve determined, unlike most forms of abuse, cases of heatstroke
are often driven by there being a
human-animal bond. And this is what
motivates the person to bring their animal with them. They’re often an older
animal and well cared for. And it’s a failure of
understanding rather than a failure to
care about the animal. And this brings out that just
because people might feel love for other people, animals
and the environment, it doesn’t necessarily mean that they will show
the right behaviors. So the person loves the animal,
and then brings it with them into a place where it’s in
danger of heatstroke and death. So we’re redirecting our
materials based on a study of this area so that they at
less confronting and dramatic, which causes loving pet owners to believe those messages
don’t apply to them, because they would
never hurt their animal. And the new message that if
you love us, leave us at home, follows with information into
travel preparation rather than as an abuse message that loving people people are
ever going to tend to ignore, assuming it doesn’t
apply to them. And then finally,
dog bite prevention. Just before National Pet Week, we have National
Dog Bite Prevention. We have a document,
Dog Bite Prevention: A Community Response, which pushes a responsible
community approach of education, legislation and enforcement. It includes key messages,
again, that have to do with responsible ownership,
and that are correlated with animals being less likely
to be involved in dog bite, which is usually
socialization, vaccination and essentially being in control
of what your dog is doing and who they are
hanging out with. This competes with the
more isolated messages like breed specific approaches. They seem to focus down on I
don’t like this and I want it to stop rather than how is
the overall system of people, animals and the environment
spinning off with unintended problem, and how
do we change that entire system in order to reduce
that negative outcome? So the main outcomes we’re
looking for are safety for people and animals
in their communities. And you can see how having a
multisystem approach brings in different partners
and allows us to work across different
parts of the problem. So we have the United
States Postal Service, postal carriers being people
who often have a problem with dog attacks,
insurance companies who don’t particularly want to
be paying out after attacks, humane association looking
at the welfare of the animal, and Victoria Stillwell
involved in animal training. So in summary, National Pet
Week promotes responsible pet ownership, and it does it
within a holistic system, very much acknowledges
the One Health approach, and specifically the role of
attachment within that approach, and the subset of the
attachment between people and their companion animals,
and how you manage the way that attachment motivates
different behaviors, human behaviors like responsible
pet ownership behaviors, animal behaviors, like
aggression and propensity to bite, and tries to
improve the overall system, the idea being that this
identifies and engages all of the stakeholders and
encourages an understanding of the larger picture and
more effective responses, and responses that are
positive and engaging rather than negative and blame-based. And it promotes improvements
that benefit all stakeholders, not only limited to our members, or even the veterinary
profession, but the larger community. So the human-companion
animal bond is, as far as the AVMA is concerned,
an important part of One Health, and responsible pet ownership is
a key message for the protection and promotion of neutrally
beneficial interactions between people and
their animals.>>Thank you. Thank you, Dr. Patterson-Kane. Our final presentation, Trends in Reported Vector-Borne
Disease Cases – United States and Territories, 2004-2016,
will be given by Dr. Ben Beard. Dr. Beard, you may
begin when you’re ready.>>Thanks, Helen. Good afternoon, or good morning, depending on where
you’re calling in from. What I’ll be doing in the next
few minutes is reviewing the findings of a recently
published report on trends in reportable vector-borne
disease cases in the U.S. and territories from
2004 through 2016. And this report is part of
the CDC Vital Sign Series, and it was published
on May 4th in the MMWR, in case you didn’t see
this when it came out. So we’ve seen an alarming
increase in the number of reported cases of
vector-borne diseases. In fact, between 2004
and 2016, there were more than 640,000 cases of
vector-borne diseases that were reported in the U.S.
And the number of reported cases of diseases from
mosquitoes, ticks, flees, and flees have tripled
over that period of time. And another interesting
finding overall is that tick-borne diseases
actually accounted for over 75% of all reported vector-borne
disease cases. Mosquito-borne disease
epidemics happen more frequently than they did over
previous time periods. And the reported data
substantially underestimates the actual number of disease
cases, and this ranges anywhere from eight to tenfold in
the case of Lyme disease to approximately sevenfold in
the case of arboviral diseases, such as West Nile
Virus infection. Both new agents and never-before-seen
agents were also documented in this report. As all of you know,
Chikungunya and Zika, though we’ve seen them
before, these caused outbreaks in the United States
for the first time. And also there were seven
new tick-borne disease agents that were shown to
infect people. These seven included
Heartland virus, Bourbon virus, Borrelia miyamotoi infection, Borrelia mayonii,
Rickettsia parkeri. Rickettsia species 364D. And Ehrlichia muris
ehrlichiosis. And in terms of the
drivers behind these, the study didn’t really go
into that in great detail. But certainly more
people are at risk today. And this is due, in
part, to global commerce, which moves mosquitoes, ticks
and fleas around the world. And, you know, a good case
of that, a good example of that very recently
is the introduction of Haemaphysalis longicornis,
the exotic tick species in the eastern U.S. And this
probably suggests recently that this may go back a
few years ago actually when it was introduced, even though it was just
recently documented. Secondly, infected
travelers can introduce and spread novel
pathogens across the world. And this is certainly the case
in what we saw with Zika virus, the introduction
into the new world. And then finally, mosquitoes
and ticks move diseases, disease agents, into new
areas of the United States, causing more people
to be at risk. And this is certainly
the case that we’ve seen with Ixodes
scapularis-transmitted diseases. We see the huge expansion in
Ixodes scapularis distribution over the last 20 years. And with that, we’ve seen
the expansion of Lyme disease and a number of other pathogens that are transmitted
by this tick vector. Vector-borne disease cases have
been reported by all states in the U.S. And according
to how you break this up, there are either 16 or 17
reportable vector-borne diseases in the U.S. And that
has to do with the fact that over this period of
time, early on anaplasmosis and ehrlichiosis were combined. And, of course, now
those are broken apart. But for mosquito-borne diseases, there are nine that
are reportable. These are California serogroup
viruses, Chikungunya, Dengue, Eastern equine encephalitis
virus, Malaria, St. Louis encephalitis
virus, West Nile virus, Yellow fever virus and Zika. For tick-borne diseases, it includes anaplasmosis
and ehrlichiosis. Babesiosis, Lyme
disease, Powassan virus, Spotted fever rickettsiosis,
and Tularemia. And then for flea-borne
diseases, there’s only one of those that’s actually
reportable, and you all would know, and that’s plague caused
by Yersinia pestis. So this slide shows the way
that the disease, reported cases from increased over time. It’s a simple bar graph. And you can see in 2004,
there were 27,388 cases. In 2016, there were
96,075 cases. Of course, 2016 was
greatly affected by the Zika virus outbreak. But what’s not shown in this
slide is underreporting due to related to Lyme
disease, and I’ll talk about that a little
bit in the next slide. This next slide actually breaks
down the numbers of cases by mosquito-borne
versus flea-borne. And the light color bars show
reported mosquito-borne cases in the United States. The orange bars show the
reported mosquito-borne disease cases in the U.S. territories. And then the greenish blue bars
show the reported tick-borne disease cases in
the United States. As you can see, that
particularly in territories, you can see how Zika
and Chikungunya and Dengue have had an
impact over the years. You can see that West Nile
virus, we have bad years and not so bad years, so
it’s very episodic. And then you can see with
the tick-borne diseases that we’ve seen this sort
of insidious increase in these throughout the years. And one point I’ll make, you can
notice in the last three years, those cases have
flattened out a bit. And this is largely due
to surveillance artifact, because in several
states, they’ve gone from reporting an actual number
of cases to counting cases to conducting surveys
and estimates of cases. And so that’s resulted in
probably 5,000 additional cases that have not been reported
in the last two years, each per year, in the
last two or three years. And other states that have just
been completely overwhelmed by Lyme disease reporting, so
this accounts, at least in 2016, for probably for
another 2,000 cases. So that curve actually should
be going up, continuing to go up pretty precipitously. were it not for underreporting. This next slide shows the
way that the disease cases, reported cases of mosquito-borne
disease cases are distributed across the United States. And the darker states
are the top 20%, so these are more
than 1,678 cases. The sort of dark brown
are the second 20%. And this is, you know,
1,100 to 1,600 cases. And the third 20%, which is
545 to 1,137, and so forth. But the main points to
make from this slide are that you can see
the darkest states, including the territories,
Puerto Rico, you know, a lot of these cases relate to
the recent Zika virus outbreak. You can see the cases
in the central part of the United States, the
Dakotas, Nebraska, Minnesota, a lot of those are associated,
Montana, those are associated with West Nile virus
cases that are reported. And then, of course,
you see that all of the states are
affected one way or another by mosquito-borne diseases. And if you look at
tick-borne diseases, you see there’s a very
different pattern. You also see that all
states are affected. And the darkest states
really are the states where we see Ixodes scapularis
transmitted disease cases. So these are Lyme disease,
Anaplasmosis, Powassan virus, Encephalitis, Babesiosis,
primarily. And so those are the state’s
most heavily affected. In the central part of the U.S.,
you see the darker states there. Those are primarily
Spotted fever Rickettsia and Ehrlichiosis that are
transmitted respectively by Dermacentor ticks, and
by Amblyomma americanum. So the other important
point that the report makes, and it’s very concerning to
us, is that in our estimation, the U.S. is not fully prepared for these vector-borne
disease problems. And we really have three
different scenarios that we’re faced with. We have the risk of
exotic new viruses like Chikungunya and Zika. We also have the sporadic
episodic outbreaks of diseases that are here in the United
States, like West Nile virus, where you have really
bad years, like in 2012, followed by years
that aren’t so bad. But it calls for infrastructure
to be in place to be able to deal with those outbreaks, even though they may only
be every five or six years. And then finally, we have this
regular huge concerning increase in tick-borne diseases. So it’s really three
different scenarios. And what we’ve seen
is that local and state health departments and vector-controlled
organizations face increasing demands to respond to
these three different types of threats. More than 80% of vector-control
organizations report needing improvement in one or more
of five core competencies that I’ll show you
on the next slide. And this is some data that
came out of a NAACHO survey that was recently published. And then finally, more proven
and publicly-accepted mosquito and tick control methods
are needed to prevent and control these diseases. So the five core competencies,
as are defined, are, first of all, monitoring and tracking mosquitoes
and ticks locally. And this is conducting a
basic vector surveillance. Secondly, to use this
vector surveillance data to drive local decisions about
vector control, so as opposed to just spraying on a weekly,
monthly regular basis, spraying or other types of control
that this implemented, actually using surveillance
data to guide this can be done in the most effective manner. Thirdly is to have an action
plan to kill mosquitoes and ticks at all life stages. So this is not just simply the
biting and the adult stages of mosquitoes, but
also larval stages and immature stages of ticks. And then fourthly is
to have the capacity to control vectors using
multiple types of methods. And so this is something that we
routinely call integrated pest management, or IPM. And this allows us
to use pesticides in the most judicious methods to
ensure that resistance doesn’t– to make it– to optimize
the possibilities of resistance doesn’t
evolve to these compounds. And then finally,
and related to that, is to conduct
pesticide-resistance testing regularly to be able
to guide, again, the best decisions for control. So finally– so the
actions that state and local health departments
can take include the following that you see on this slide. First of all, to build and
sustain public health programs that test and track disease
agents and the mosquitoes and ticks that transmit them. And secondly, to train
vector control staff on five core competencies
for conducting prevention and control activities. And then finally, to
educate the public about how to prevent bites and controlled
diseases spread by mosquitoes, ticks and fleas in
their communities. And actually CDC is
involved in all three of these activities,
working closely. For example, for the second
bullet there, we have a number of programs that are
available to help with this if you’re interested in
knowing more about that. We also have a number of
resources that are available at our website to assist
with public education. So we’d be glad to
share those links with you if you’re interested. And I think I’ll stop with that. Thank you.>>Okay, great. Thank you so much, Dr. Beard. I’m afraid it looks like we
have not had our Q&A box working for folks on Adobe
Connects during the call. Our tech is trying
to get that fixed. So if you have a question,
please press star 1 on your phone and answer–
go ahead and leave your name and say which presenter that
you’re asking a question for. I’m going to go ahead and read
off the phone number to you in case any of you
don’t have that handy. Just one moment, I’ll get that. In the meantime Elon do
you have any questions yet?>>I’m showing no questions. As a reminder, to ask a
question, please press star 1.>>If you need to call
in, call 800-593-8936.>>And once again, if you would like to ask a question,
please press star 1.>>And the participants’
pass code, when you called in that number, is 9611836. Again, if you call
1-800-593-8936, and enter participant
pass code 9611836.>>I do have a few questions. Would you like to take
them at this time?>>Great, thank you.>>Okay, our first question
today is from Julia Murphy. And please state
your affiliation.>>Hi, this is Julia Murphy. I work for the Virginia
Department of Health. I had a question
for Dr. Gigante. I hope I’m pronouncing her name
correctly, the first speaker. I was wondering if the CDC,
you know, a transition to PCR for animal rabies
testing, and, you know, a thought that they would
develop standards and training, like they have now for the
DFA test, and then kind of as a follow-on to
that, I didn’t know if there was any data
on how PCR compared to the direct rapid
immunohistochemical test, which is a field test that’s
been used for a good while in this country as part
of the ORV program.>>Thank you for your question. So far, as standardizing
protocol, we are working– right now there’s a work group with APHL considering a national
protocol for PCR for the U.S. for rabies animal diagnostics. So that is currently
being considered. It’s also being evaluated
by OIE and WHO. So we’re hoping hopefully this
year we’ll get some guidance from those groups as to
whether PCR can be implemented as a primary diagnostic,
whether we envision a transition from DFA to PCR and
getting rid of all DFA. I don’t think that that’s
what we’re looking to do. We’re just looking to
provide the option of PCR for primary testing for those
labs that are interested, just because the PCR
test that we have seems to perform just as
well as the DFA. Now, we haven’t done a direct
comparison with the DRIT, but comparing previous studies
that have compared the DRIT to the DFA, it seems like
they would be similar. The PCR assay has similar
diagnostic specificity and sensitivity to the DFA test. So I can’t answer that
directly, but it should– you should be able to
compare the similarities between the DRIT and DFA
to the PCR indirectly. I hope I answered your question.>>Thank you. I appreciate it.>>And as a reminder, to ask a
question, please press star 1. And our next question
is from Lisa, and please state
your affiliation.>>Hi, my name is Lisa,
I’m from the Florida Fish and Wildlife Conservation
Commission. My question is for Dr. Beard. And I had a question about
the five core competencies for vector control. I’m wondering if those
competencies include somewhere addressing environmental impacts
of various control agents for mosquitoes and
other vectors. And I bring this up because
I had a recent conversation with a private company
that comes around to yards and controls mosquitoes,
and they told me that they had a product
called Bifenthrin, Bifenthrin. I’m not sure if I’m
pronouncing that correctly. That controls mosquitoes and
specific only to mosquitoes. And when I looked that up, I found that it was actually a
pyrethroid that’s highly toxic to bees, aquatic organisms. So I feel like some of these
private companies are not accurately being educated on
the products that they’re using, and I’m wondering if
that will be a component in this larger competency plan. Thank you.>>Yeah, thanks for
that question. The survey that I cited,
it’s the NAACHO report, and they actually looked at
about 10 different competencies. Five of these were
their core competencies, as they called them, and
there were five others that they looked at. And I’m trying to– I
certainly can follow up with the call organizers and
send the link to this report. I don’t– I’m looking
for it right now. I don’t have it in front
of me to send it to you. But the question that
you bring up, actually, is a really important question. And it’s kind of– and the
report only scratched the surface of that. But, you know, we are
very much concerned with the educational level of
local vector control companies. And there’s a huge
variation of this from some of the large control companies,
such as you have there in Florida, that are
incredibly professional, incredibly educated, you know,
state-of-the-art, and then some that we have, especially in
smaller towns in other parts of the U.S., they’re really
just mom-and-pop type shop. And someone has a part-time
job, you give them a call and they come out and
spray your yard for ticks or mosquitoes or whatever. And so what we’re doing
to address that is that we’ve provided funding to
a couple of different partners. One is the American
Mosquito Control Association. And so they’ve developed
an entire training program that they are working on to
be able to push this out, actually a train-the-trainer
program, and this is to be able to educate local pest
controllers, and even city, county, pest control is just–
and public health sanitarians on how to– what are
the most effective ways to control vectors,
including educating them on different groups of
compounds, and how to use those, and what their side effects are,
and how to use them according to label and all of that. We’ve also provided funding
to the Entomological Society of America, and they have a
couple of certificate programs that they offer; one for
professional entomologists, doctoral level people, but also
one for pest control operators. And these certificate
programs are quite rigorous, and they allow this training. So we’re working with NAACHO
and other partners to be able to make sure these tools
are out there and available so that we can get
better training of people at local levels who are– so
that they won’t make the kind of mistakes that you mention. Does that make sense?>>Yes, thank you. I would be interested
in reading that report if it’s somehow sent
out to the group. Thank you.>>And once again, if you
would like to ask a question–>>We have time for
one more question.>>Okay, as a reminder,
to ask a question, star 1. One moment, please. I am showing no further
questions at this time.>>Okay, all right, well,
thank you so much to everyone who listened, and
for their questions. Thanks, again, to
today’s speakers for their excellent
presentations. To receive free-continuing
education credits for today’s webcast,
WC2962-060618. Complete the evaluation at www.cdc.gov/tceonline
by July 2nd, 2018. A recording of today’s call will
be posted online on July 3rd, 2018 at
www.cdc.gov/onehealth/ZOHU/2018 /june.html. To receive free continuing
education credits for the web on demand, WD2962060618. Video of today’s call,
complete the evaluation at www.cdc.gov/tceonline
by July 3rd, 2020. Detailed instructions for
CE credits are available at www.cdc.gov/onehealth/ZOHU
/continuingeducation. So we’ll take off July. We don’t have a call. So please join us for our
next call on August the 1st at 2:00 p.m. eastern time. For more information, please
visit cdc.gov/onehealth/ZOHU. Please send suggestions and
questions to [email protected] Thanks again for
your presentation, participation, and presentation. Goodbye.>>Thank you. And this does conclude
today’s conference. You may disconnect.

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