Public Health in Congregate Living (Phares, 7/17/2024)

We welcomed our new-ish Sonoma County Public Health Officer (PHO), Dr. Tanya Phares, this week to give the first Grand Rounds of the 2024-2025 Academic Year, titled Public Health Perspectives , Communicable Disease and Congregate Settings. An internist by training, Dr. Phares joined our public health department in November of 2023, replacing our former PHO, Dr. Mase. Before coming to SoCo, Dr. Phares was working in Reno, NV, but she is a California girl at heart (and by training) and is excited to be back in California.

In her presentation, Dr. Phares gave us an introduction to Public Health, including reportable vs. notifiable illnesses, congregate settings, and how clinicians can and should consider public health in their daily clinical interactions. 

A recording of the Grand Rounds is available HERE. 

My notes: 

Title 17 is the California Code of Regulations that defines reportable disease, and describes our duty to report to the PHO. The list of what diseases needs to be reported in CA is long and is available HERE for your reading enjoyment. This same list specifies how urgent you must report each disease. Basically everyone working in clinical settings, including laboratory, clinicians, hospitals, etc. are required to report these disease. Dr. Phares encouraged us to "double report" reportable illnesses; that is, don't be worried about reporting results that the laboratory may also be reporting. The double coverage ensures a better public health.

For SoCo public health reporting, go here: https://sonomacounty.ca.gov/health-and-human-services/health-services/divisions/public-health/disease-control/disease-reporting

Any questions about reporting can also be directed to phnurse@sonoma-county.org, an email that is monitored daily.

The Public Health Officer in California is required by law to be a physician--  for every county in CA-- appointed by the County board of supervisors. Her job is to investigate disease outbreaks, issue isolation and quarantine orders, and can declare local emergencies. 

Communication tools at the disposal of the Public Health Department include: 

• The California Health Alert Network -- CAHAN--the official statewide public health alerting and notification system
• SoCo Health Alerts, including recent alerts about rising rates of pertussis in the county as well as recent norovirus outbreaks
• Health Advisories, including issues like air quality and heat advisories.
• PHO also meets with organizations like the community health centers, hospital leadership, etc.

***

A congregate setting is any environment in which people gather and share space for a period of time. This includes, but is not limited to, jails, shelters, schools, workplaces, prisons, nursing homes, etc. 

Patterns of congregation determine if and how a disease can spread. It can influence and create risk factors for communicable and other disease in communities. It can also influence the ability and scope of a disease to spread via various modes of transmission (e.g. airborne, foodborne, waterborne, vectorborne, and person to person).

An important part of public health's role is, once disease is identified in an individual, to prevent introduction of disease to a congregate setting. This, then, limits outbreak and disease spread. This is particularly important in vulnerable populations.

***

Three real life examples:

Tuberculosis: 46 year old man with ESRD (on HD), distant history of incarceration (20+ years) and distant hx immigration from Mexico (20+ years) with pulmonary TB

• TB rates have been increasing in CA (24% increase since 2020!)
• TB incidence in CA is 5.4/100K persons
• This may be due to temporary reduction in transmission and detection during the pandemic, followed by increased travel and migration, as well as return to seeking healthcare
• LTBI may not have been sufficiently identified and treated during the pandemic
• 85% of TB cases are due to progression of LTBI
• risk of progression is increased by comorbidities: DM, ESRD, HIV, HC
• Rate of TB is 13X higher among foreign-born compared to US born
• among those born outside the us, about half occurred 20 years after arrival to US
• 

Pertussis: 15 year old high schooler with non-productive cough x 7 days, post-tussive emesis, friend with similar symptoms. Attends large public high school. Has 5 month old baby brother at home. Lives in house with pregnant aunt.

• Pertussis ebbs and flows q3-5 years, unknown reasons
• Case reports of pertussis have increased in 2024 across the US and CDC expects the trend to increased in both vaccinated and unvaccinated
• Vaccine loses effectiveness over time
• Per WHO, Pertussis is a leading cause of vaccine-preventable deaths worldwide
• CA 2024 YTD 734 cases (compared to 172 in 2023), SoCo 2024 23 cases YTD
• Most pertussis deaths occur in infants, either unvaccinated or incompletely vaccinated
• Post-exposure prophylaxis (PEP): antibiotics should be given to ALL asymptomatic household contacts within 21 days of onset of cough in index patients
• special attention with PEP to infants < 1 year of age and their contacts

Shigella: 52 year old woman with schizophrenia, unhoused, living in homeless encampment presents with 3 days nausea/vomiting/diarrhea

• Increased risk of shigella infection in children <5, travelers (especially to places with poor sanitation and unsafe water), MSM, people experiencing homelessness
• spreads rapidly where there is crowding, limited access to clean water and toilets
• Shigella can shed in stool for up to 2 weeks after symptoms resolve
• Shigella is a reportable disease
• CDC has found increasing drug resistance

Random Public Health pearls from Dr. Phares:

• Rabies: low threshold for PEP if contact with animal saliva or for whom contact with the animal's saliva cannot be ruled out
• Suspect measles? Isolate patient ASAP, measles can live for up to 2 hours in airspace after an infected person leaves the area
• Botulism? report immediately CDPH is available 24/7 to release botulinum antitoxin (which is stored at CDC quarantine stations, NOT available at ER)

Useful links: