Annual Report 2014

The 2014
Fresno County Department of Public Health
Annual Report

Acknowledgements

Fresno County Department of Public Health Page 1
The 2014 Annual Report is a project of The Fresno County Department of Public Health (FCDPH). This
research was supported by funds provided by the State of California for the purpose of public health
surveillance.
FCDPH Author: Jared Rutledge, PhD
Epidemiologist, Fresno County
FCDPH Advisory Group:
Ken Bird, MD, MPH Health Officer, Fresno County
David Pomaville, MBA, REHS Director of Public Health, Fresno County
David Luchini, RN, PHN Assistant Director of Public Health, Fresno County
Joe Prado Division Manager Community Health, Fresno County
Suggested Citation:
Rutledge, J. T. (2015, November 20). Fresno County Department of Public Health: 2014 annual report.
Retrieved from Fresno County Department of Public Health website: http://www.fcdph.org

Table of Contents
1 Acknowledgements
2 Table of Contents
3 Executive Summary
12 Airborne Pathogens
16 Blood–Borne Pathogens
20 Food-Borne Pathogens
25 Sexually Transmitted Diseases
36 Vaccine Preventable Diseases
40 Vector-Borne Diseases
4 Activities and Progress
Fresno Department of Public Health Page 2Fresno County Department of Public Health

Executive Summary
Summary of Key Points: 2013 Compared to 2014
In the 2013 Annual Reports there were several trends that were noted. Some of the more interesting trends
were the end of year increases in both tuberculosis and pertussis. Significant increases were also observed
in syphilis. Rates in HIV/AIDS decreased slightly but were statistically insignificant and rates for gonorrhea
and chlamydia stabilized. Lastly, west nile virus had a very low year in all classifications of illness.
In 2014, Fresno County observed significant changes in annual rates in several diseases. 2014 was an epi-
demic year for pertussis. Pertussis had not occurred at this level since 2010, which is expected for a disease
that will behave in a cyclic pattern. Cyclical diseases usually occur in 3 to 5 year intervals. The acellular
vaccine that is used to protect the population from this disease is not as protective as previous whole cell
vaccines. That being stated, there is still significant protection from severe presentation of illness that would
usually require hospitalization of infants and children.
There were several other diseases that observed a reduction in reported cases, which included valley fe-
ver, campylobacteriosis, and salmonellosis. Of the observed declines in morbidity only the reductions ob-
served in valley fever were significant.
Focus Areas
Despite the decreases observed in gonorrhea and chlamydia, Fresno County continues to be one of the
highest morbidity counties for these two diseases in the entire State of California. Additionally, Fresno Coun-
ty observed the highest change in rate of congenital syphilis compared to the state and other counties
starting in 2013. For the first time, this report explored the basic descriptive epidemiology of the cases of
congenital syphilis.
It is important to note that many of the women who gave birth to babies positive with syphilis had a history
of drug use, sex work, survival sex, and low utilization or no access to prenatal care. Fresno County has tak-
en the steps to address its congenital syphilis problem through engaging with providers, conducting more
timely investigations, and attempting to remove barriers to treatment both with OBGYN providers and pa-
tients.
Aside from the investigation and provider engagement regarding syphilis, Fresno County also began ap-
proaching health care providers in the community to encourage policies such as expedited partner thera-
py and accurate, complete, and timely reporting of these diseases to Fresno County Department of Public
Health.
Geographic Stability
Many of the diseases observed little to any significant change in the geographic distribution of reported
cases throughout 2014. In fact, there appears to be fairly stable patterns from 2011-2014 in terms of where
these diseases are present in the community. The Health Department along with community partners
should take these factors into consideration when planning for the health of communities.


Activities and Progress

Coccidioides (Valley Fever)
Recommendations:
 Providers should utilize targeted screening of
patients who present with pneumonia to the
Central San Joaquin Valley.
 Educational materials should be disseminated to
schools and other organizations in areas that
experience a disproportionate burden of infec-
tion during: construction, wind storms, or other
activity that might increase the local concentra-
tion of the Coccidioides immitis in the atmos-
phere.
 Air quality alerts for hazardous air days dis-
pensed through CAHAN when there are natural
environmental conditions that are conducive to
high concentrations of fungal spores such as
high wind advisories or warnings.
Status 2014:
 Fresno County Department of Public Health
(FCDPH) continues to work with community
providers to provide education on Valley Fever
and the populations at risk.
 Fresno County crafted developed educational
pamphlets in English and Spanish and
disseminated them to providers and community
members in high risk areas of the county of
Fresno. Fresno County also updated the valley
fever website to make it easier to obtain
information.
 Fresno County regularly participates with local
universities in regional activities designed to im-
prove surveillance and research of valley fever
within the community.
 Air quality alerts have not been standardized as
of yet. There is insufficient research to support
what conditions may put residents most at risk for
exposure to the disease.

Disease: Tuberculosis
2011 Recommendations:
 To further improve the County’s ability to detect
LTBI and move in line with CDC
recommendations the County should adopt QFT
testing methodology.
 A policy and procedure should be crafted to
target testing of homeless, immigrants from
endemic TB areas, and HIV positive individuals.
 The 9 week drug therapy should be utilized by
providers and the public health department to
maximize the likelihood of adherence and
completion of therapy to reduce the risk of
antibiotic resistant strains emerging in Fresno
County.
 Universal screening is no longer recommended
in Fresno County. Instead targeted screening of
specific at-risk individuals should be pursued.
Status 2014:
 The QFT testing equipment and testing
guidelines have been adopted and are being
used under the recommendation of the public
health physicians.
 A policy designed to target testing of homeless,
immigrant population from endemic TB areas,
and HIV positive individuals is under
development.
 The 9 week drug therapy for latent TB infection is
explored for use with patients in the 2015 report.
 Fresno County continues to recommend against
universal screening for TB.


Food-Borne (Campylobacteriosis and Salmonellosis)
Recommendations:
 FCDPH should conduct population based
studies to enhance the understanding of the
impact of campylobacteriosis in the County.
 Increase awareness of community partners of
the observed increase in campylobacteriosis
among residents of the County of Fresno.
 Investigations should be conducted on a portion
of the cases of campylobacteriosis that occur in
areas with disproportionate burden of disease.
Status 2014:
 Studies have been conducted to determine the
scope of campylobacter and their increases
annually. Results indicated that safe food han-
dling and practices were needed to reduce
these infections. Health Alerts and notifications
have been periodically sent out to the commu-
nity and news media to provide them that guid-
ance.
 Presentations regarding the prevalence of
campylobacteriosis as well as other foodborne
pathogens have been provided to community
members at the Emerging Infectious Disease
Task Force meetings in Fresno County. Hospitals
were made aware and educated through
presentations to infection control organizations.
Disease: Hepatitis C
 FCDPH needs to engage with community,
academic, and medical partners to raise
awareness of HCV and recommend increase
testing among high risk populations.
 Medical facilities and providers should screen all
patients with a history of IDU, HIV + status, and/or
blood transfusions prior to 1992.
 Providers should consider screening patients
who were born between 1945 and 1965, have a
confirmed HIV diagnosis, or have been
incarcerated at any time.
 Implement additional local studies to identify the
factors contributing to high rates of HCV in
certain population groups.
 Fresno County needs to consider obtaining addi-
tional funding to allow additional in-depth
research on the burden of HCV to the County’s
at risk population.
 FCDPH needs to continue to contribute to
professional and academic publications to
promote awareness of HCV to counter the silent
nature of this epidemic.
Status 2014:
 FCDPH has participated in local and national
conferences on correctional health care
describing the epidemic within the county
boundaries.
 FCDPH has worked with local prisons to provide
education and materials regarding hepatitis C
in their population along with trainings.
 Medical facilities are aware of the new USPSTF
(United States Preventative Services Task Force)
through a Hepatitis C conference hosted at Fres-
no State.
 Local surveillance has been maintained and
updates provided annually.
 FCDPH has worked with a Community Based
Organization to provide education and research
to community members, providers, and other
groups regarding the scope of the epidemic
and the new recommendations put forth by
CDC and USPSTF.


Disease: HIV/AIDS
 Health care providers and the public health
department should increase HIV testing efforts
among 18-25 year old Black/African American
and Hispanic/Latino MSM populations in Fresno
County.
 Health care providers are strongly recommend-
ed to utilize the opt-out testing policy for their
patients in Fresno County.
 Inmates should be offered an HIV test upon be-
ing admitted to all correctional facilities.
 FCDPH should utilize social media to provide
outreach to the youth of Fresno County.
 The public health department should conduct
survey research among the MSM population of
Fresno County to assess barriers to testing, per-
ceived societal pressures, adherence to thera-
py, and other issues pertaining to HIV care.
 The public health department needs to engage
with community partners such as faith-based
organizations to disseminate educational materi-
als.
Status 2014:
 FCDPH has worked with Community Regional
Medical Center to research and evaluate the
trends of opportunistic infections among the
county’s HIV/AIDs population.
 FCDPH has continued to hold block parties, and
attend events where high risk individuals
participate and offer HIV testing.
 FCDPH have used heat maps to determine
which communities are disproportionately high
for HIV and sent the mobile testing facility to test
in these high risk communities.
 In 2015, the health officer started a Facebook
page to start engaging the community in social
media. All health related events and messages
are also being posted through this media outlet.
 Focus groups and surveys have been attempted
to assess the needs of the MSM population in
Fresno County. However, these have had histori-
cally low participation and have not provided
the health department with information beyond
what has already been published on the topic.
 FCDPH continues to work with faith based
organizations to promote testing HIV in
communities.


Vaccine Preventable Diseases
The Health Officer should issue an order suggesting
medical facilities mandate seasonal influenza vac-
cine for healthcare workers to be in compliance
with the health and safety code (CA Health & Safe-
ty Code 1288.7 effective January 1, 2007 and 5199
Aerosol Transmissible Diseases standard of Cal
OSHA, effective September 1, 2010).
Providers should follow the immunization schedule
put forth by the CDC and ACIP
All ACIP and Immunization policies should be pro-
vided to local providers as updates occur to ensure
the population is sufficiently vaccinated.
Status 2014:
 The health officer provided incremental
changes to mandate flu vaccination among
employees that work in a acute care setting,
clinic, and other health care environment.
 Regular updates and recommendations from
ACIP have been provided to local providers
through educational presentations , e-mail, or
fax correspondence.
 Research on pertussis was conducted to
determine the vaccine coverage in those who
were positive in the pertussis epidemic year and
provided within this report.
Disease: STDs
 The FCDPH should reach out to teenagers with
age appropriate STD education materials to
ensure this at risk group is aware of their risk of
STDs.
 The FCDPH should engage with community
partners including congregations and other
non-governmental organizations in geographic
areas that are most at risk and disproportionate-
ly affected by these organisms.
 Providers and hospitals should follow the new
treatment recommendations for these diseases
as put forth by the CDC.
 Providers and hospitals should adopt a policy
that embraces Expedited Partner Therapy to
reduce the number of infected individuals that
are continuing to spread these pathogens in the
community.
 Physicians and healthcare providers should
engage in a candid discussion with their patients
regarding prevention of STDs and/or refer them
to programs designed to provide educational
materials that are culturally sensitive.
Status 2014:
 From 2011-2014 FCDPH sponsored a STD
program designed to provide school aged
children with appropriate access to materials
and education regarding sexual health.
Information was also disseminated through faith
based organizations.
 Regular site visits, conferences, health alerts, and
other notification and education events have
been held from 2012—2014 to educate
providers on the appropriate use of the new
treatment guidelines and expedited partner
therapy.
 Expedited partner therapy has continued to be
promoted in Fresno County.
 FCDPH along with the State of California have
two presentations scheduled for 2015 that will
offer an educational series on how to have a
culturally competent discussion regarding STDs,
number of partners, and sexual health with local
providers and hospitals.

Airborne Pathogens
Fresno Department of Public Health Page 8
Coccidioidomycosis
Year Community
Rate*
Institutional
Rate*
Total
2007 13 4,342 49
2008 11 2,724 33
2009 21 4,237 55
2010 42 4,284 75
2011 38 4,500 73
2012 35 3,270 53
2013 26 1,967 32
2014 15 389 16
*Rate per 100,000 population
Figure 1: Annual trend of reported cases of coccidioidomycosis
in Fresno County from 2007-2014.
Table 1: Annual trend of reported cases of coccidioidomycosis in
Fresno County from 2007-2014, stratified by community and
institutional rate.
Summary of the Results:
*personal communica on with PVSP nursing staﬀ
In 2014, Fresno County continued to
observe significant decreases in cases
of reported coccidioidomycosis (Valley
Fever) since 2010. Total cases include
community cases, which were defined
as residents of Fresno County, and
institutional cases, which were defined
as cases from inmates at Pleasant
Valley State Prison (PVSP) or Coalinga
State Hospital. Reported institutional
cases represented only 7.6% of total
cases, which was the lowest
contribution to total cases in the last
five years.
Pleasant Valley State Prison began
active control measures, which
involved spraying soil sealants and
providing masks to inmates and
employees during time spent
outdoors*. Also a skin test is being
offered to inmates to prevent
susceptible inmates from being
assigned to PVSP. All case definitions
remained consistent with the 2011
Annual Report.
The annual rate for institutional cases
a n d c om m u n it y c as e s b ot h
decreased in 2014. The institutional rate
dropped significantly (82%) compared
to the previous year’s rate. The
community observed a 42.3%
decrease from the previous calendar
year 2013, overall the community rate
of reported valley fever has decreased
53.7% over a 5 year baseline.

Airborne Pathogens

Coccidioidomycosis
Age
Groups
<15 15 – 24 25 – 44 45 – 64 65+ Total**
2007 18 42 240 125 25 450
2008 14 39 150 94 12 309
2009 22 73 258 141 24 518
2010 56 108 319 197 43 723
2011 78 75 222 125 44 544
2012 42 49 179 162 42 474
2013 14 29 108 103 40 294
2014 2 14 46 64 20 146
*Includes both institutional and community cases.
**May not add up to annual totals due to incomplete data
Table 2: Annual trend of reported cases of coccidioidomycosis in
Fresno County from 2007-2014, stratified by age group.
Figure 2: Annual trend of reported cases of coccidioidomycosis
in Fresno County from 2007-2014, stratified by race/ethnicity.
The most significant drop in cases was
observed among the age group of
under 15 years old. In 2014, the total
number of cases of 14 years old and
younger dropped 85.71% from the
previous year. All age groups observed
drops in the number of cases. It is
currently being investigated as to
whether the drought has had any
impact on the number of Valley Fever
cases.
Calendar year 2014 observed a
decrease in the rate of reported Valley
Fever among Black/African Americans,
Whites, and Hispanic/Latinos. The
annual incidence rate decreased
among Black/African Americans,
Whites, and Hispanic/Latinos by
78.43%, 26.67%, and 46.15%,
respectively. Nationally, Black/African
Americans continued to have
significantly higher rates of Valley
Fever. Fresno County has observed a
drop among the Black/
African American
population

Airborne Pathogens

Coccidioidomycosis
Figure 3: Valley Fever cases by Zip Code in Fresno County, 2014.

Airborne Pathogens

Coccidioidomycosis
The western region of Fresno County has traditionally been disproportionately affected by Valley Fever. This
has to do with a myriad of reasons which include soil type, low population density, and climate. Lower
population density in a given region increases the likelihood of open fields with no vegetation, asphalt, or
other constructs that have been shown to reduce the risk of acquiring the causative agent of Valley Fever.
There were several regions that had similar case counts to the traditionally endemic regions of the County
of Fresno. While it does appear that zip codes close to metropolitan Fresno and Clovis are experiencing a
burden of Valley Fever, it should be emphasized that these areas are more densely populated, which
would result in a much lower rate than these same color shaded regions in the western region of Fresno
County.
As the drought continues and fields lay fallow there is reduced risk of increasing cases of Valley Fever in the
western region of Fresno County. Any activities that will disturb the dust will put people at risk for Valley
Fever. Fresno County residents are encouraged to educate themselves on how to prevent Valley Fever by
visiting: www.fcdph.org/valleyfever
Fresno County Department of Public Health Activities:
 Fresno County Department of Public Health disseminated pamphlets on Valley Fever education
and conducted several radio interviews to get the information out to residents.
 Fresno County Department of Public Health continues to collaborate with regional health
departments and academic institutions to perform research, engage the population, and bring
about awareness of Valley Fever in the Central San Joaquin Valley.
 Fresno County Department of Public Health has collaborated with University of California, San
Francisco to evaluate the different individual risk factors that could predispose a resident to
disseminated Valley Fever infection, which is the most severe form of the disease.
 Fresno County Department of Public Health is currently researching the potential for valley fever
cases to increase once agricultural activity increases again in the central valley.

Airborne Pathogens

Tuberculosis (TB)
Figure 5: Monthly trend of reported cases of active TB in Fresno
County from 2014.
Figure 4: Annual trend of reported cases of active TB in Fresno
County from 2004-2014.
FCDPH observed a slight increase in
the annual incidence rate in active TB
cases in 2014 compared to previous
years. There was a 4.55% increase in
the annual rate of disease reported
compared to a 5 year baseline.
In total, there were 51 cases of TB
reported to FCDPH in 2014. The months
of June, August, October, and
November observed the highest
number of cases of reported active TB.
An in-depth discussion of latent TB
infection and its effect on active TB
disease rates can be found in the 2011
Annual Report.
In figure 5, there is a clear depiction
that cases of active TB do not have
any strong seasonal trends in Fresno
County for 2014, but the risk profile
which will be described in the
demographics section match the
national trend among the Fresno
County population groups.
This resurgence highlights the
importance of targeted testing of high
risk residents, follow up, and treatment
of LTBI cases.

Airborne Pathogens

Tuberculosis (TB)
*Does not meet 100% due to rounding
Country of Origin Cases Percent
Asia 22 43.13%
Mexico 14 27.45%
United States 15 29.41%
Total 51 100%*
Ethnicity Mean Count Std. Deviation Median
Asian/Pacific
Islander
55 26 24 59
All Other Race
Categories
54 25 19 55
*per 100,000 population
Table 3: Active TB cases and annual incidence rates* stratified by
Ethnicity/Race in Fresno County, 2014.
Table 4: Active TB cases age distribution stratified by highest risk
racial groups..
Table 5: Active TB cases stratified by region of origin.
People of Hispanic or Latino ethnicity
comprise 45.09% of cases of active TB
identified in 2014. Fresno County
consisted of more than 50% Hispanic or
Latino residents in 2014, according to
the American Community Survey.
While Asian/Pacific Islanders constitute
less than 10% of the County’s
population they accounted for 51% of
cases.
While there is a disproportionate rate
among Asian/Pacific Islanders in Fresno
County, there is no statistically
significant difference in the age
distribution when comparing Asian/
Pacific Islanders to non-Asian/Pacific
Islanders. There was also a slight
increase in the rate among Asian/
Pacific Islanders compared to 2013.
Active TB in Fresno County is still
present disproportionately among
non-native born residents. Only 29.41%
(n=15) of cases identified with active TB
in 2014 were born in the US, which is an
increase from 2013. The remaining
residents (70.59%; n=36) were born
outside of the United States. Cases
were distributed across Asia (43.13%,
n=22) and Mexico (27.45%; n=14).
Discussions and research regarding
these finding were presented in the
2011 Annual Report.
Ethnicity/Race Cases Annual Incidence Rate*
Asian/Pacific Islander 26 26.70
Hispanic/Latino 23 4.62
Black/African American 2 4.23
Total: 51 5.29

Airborne Pathogens

Tuberculosis (TB)
Figure 6: TB susceptibility tests for specimens isolated in 2014.
In 2014, 72.55% (n=37) of TB specimens
analyzed exhibited no resistance to
antibiotic therapies. In total, 13.73%
(n=7) presented some type of drug
resistance. Only 7.04% (n=5) of total
cases reported were not able to be
assessed for antibiotic resistance.
Fresno County Department of Public
Health Activities:
T h e 2 0 1 1 r e p o r t m a d e
r e c o m m e n d a t i o n s b a s e d o n
peer-reviewed journals and data
regarding Fresno County’s TB data.
 Fresno County is now implementing
testing of TB infection among jail
inmates who will be in the facility
longer than 2 weeks with a TST.
 Fresno County purchased the
Interferon-Gamma Release Assay
equipment. This was purchased to
aid in the evaluation of TB infection
and TB disease in situations where
this is more appropriate than the
use of TST.
 Fresno County continues to
advocate against universal
screening for TB infection. Data
and best practice indicate there
are specific groups that are at
disproportionate risk for disease. In
2014 Fresno County will work on
identifying these groups that may
be unique to Fresno County.
*
*No Culture

Airborne Pathogens

Tuberculosis (TB)
Figure 7: Active TB cases by Zip Code in Fresno County, 2014.

Blood-Borne Pathogens
Since HCV lab reporting became
mandated in 2008, reported cases
of chronic HCV have been fairly
stable with very little fluctuation.
Figure 8 displays the change in
cases and rate from 2004-2014. A
drop in cases was observed in 2013.
However, this is likely due to the
efforts that the California
Department of Public Health has
made to de-duplicate cases across
county boundaries.
The number of cases in 2014
appears stable. The guidelines for
screening baby boomers from the
United States Preventative Services
Task Force has not appeared to
impact the rate of reported cases.

Deaths attributed to HCV as a
primary or contributing cause have
been declining since 2008. These
data are based on Automated
Vital Statistics System (AVSS) for
Fresno County. To be included in
this graph, a physician must list HCV
as a primary or contributing cause
on the death certificate. Patients
that died as a result of
complications associated with HCV,
but whose HCV status was omitted
or not determined, were not
included in this analysis. It is possible
that this artifact of the data could
result in the downward curve
observed for Fresno County.
Hepatitis C Virus (HCV)
Figure 8: Annual trend of reported cases of chronic hepatitis C in
Fresno County from 2004-2014.
Figure 9: Annual trend of reported deaths associated with
chronic hepatitis C in Fresno County from 2005-2014.


*Non-incidence rate per 100,000 population ¥ Population figures procured from the California Department of Corrections & Rehabilitation. Figures on Asian/Pacific Is-
landers, AI/AN, were all provided as other. € The general population of Fresno County as reported by State of California Department of Finance Table 1: E-4 Population
Estimates for Counties and State Ω Mid-P Exact Test -- Suppressed values to protect privacy or not available
Table 6: Chronic HCV cases and rates Fresno County 2014, stratified by incarceration status.
Figure 10: Gender distribution of chronic HCV cases in Fresno
County for 2014, non-incarcerated.
The mean age at diagnosis of chronic HCV skewed
significantly younger among incarcerated
populations when compared to non-incarcerated
populations across racial and ethnic categories. In
total, there were 206 incarcerated cases and 1,026
non-incarcerated cases of chronic HCV reported in
2014. The younger age at diagnosis among the
incarcerated population is concerning because this
is a deviation from the traditional epidemiological
distribution in terms of age alone. Incarceration has
always been a significant risk factor when an
individual’s HCV risk profile is assessed.
Among non-incarcerated populations the gender
distribution was expected. Female cases
constituted 37% (n=381) and male cases
constituted 63% (n=645). Previous reports provided
research to support why this disparity exists.
Ethnicity/Race Mean Age STD Cases
Population
Estimate
Rate*
95% Confidence
Interval (CI)Ω
Incarcerated Populations ¥
Hispanic/Latino 38.5 10.83 59 1,941 3,040 2,335 – 3,894
White 44.3 13.46 58 921 6,298 4,826 – 8,084
Black/African American 44.4 10.14 5 53 9,434 3,457 – 20,910
Asian/Pacific Islander -- -- 1 162 61.73 30.89 – 3,044
American Indian/Alaskan Native 0 0 0 0 -- --
Other 0 0 0 0 -- --
Unknown 42.37 12.07 83 0 -- --
Total: 41.74 12.30 206 3,077 6,695 5,826 – 7,657
Non-Incarcerated Populations €
Hispanic/Latino 51.96 12.79 255 501,705 50.8 44.9 – 57.4
White 51.50 13.62 307 304,329 100.9 90 – 113
Black/African American 57.55 8.90 76 47,643 159.5 126.6 – 198.6
Asian/Pacific Islander 56.33 16.97 27 98,202 27.49 18.49 – 39.45
American Indian/Alaskan Native 54.57 6.78 7 3,889 180 78.72 – 356
Other 36 30.51 6 -- -- --
Unknown 52.92 12.29 348 -- -- --
Total: 52.65 12.93 1,026 972,297 105.5 99.22 – 112.1


*American Community Survey 2013 (5 year estimate)
¥ Non-incidence rate per 100,000 population
Ω Mid-P Exact Test
Table 7: Top 6 Chronic HCV zip codes: Cases and rates Fresno County 2014, stratified by incarceration status.
Fresno County has several zip codes which carry a disproportionate burden of reported HCV cases. The top 6
zip codes are listed in table 7. The six zip codes listed in the aforementioned table account for over 25% of the
total newly reported cases in Fresno County. The population size estimates from the American Community
Survey were included along with the Confidence Interval at 95%. This impact mapping can help guide testing
activities as well as assist the County in prioritizing resources to address the epidemic (which is a widespread
occurrence of an infectious disease) of HCV in Fresno County.
 FCDPH representatives attended a conference and presented findings from the 2013 annual report to a
national representative sample of correctional health care personnel.
 FCDPH continues to work with Wings for Life and California State University, Fresno to build an educational
intervention designed to target low socioeconomic groups and educate them regarding the risk factors
and dangers of HCV.
 FCDPH continues to offer HCV testing in addition to HIV testing in the community through its mobile testing
van.
The next page contains the map of Fresno County and the distribution of HCV cases in the county. Please
review the map for details. The map displays number of cases. The number of cases in any individual zip code
are so small that they could lead to drastic fluctuations in rate. While it can be helpful to compare two zip
codes in terms of rates, rates are most helpful when comparing counties as opposed to zip codes.
Zip
Code
Cases
Percent of Total HCV
Positive 2014
Non-Incarcerated
Population of Zip Code*
Non-
Incarcerated
Rate ¥
95%
Confidence
Interval (CI)Ω
Incarcerated Non-Incarcerated
93210 206 14 18.26% 21,846 64.08 36.48—105
93722 0 73 6.06% 79,727 91.56 72.29—114.5
93706 0 70 5.81% 38,963 179.7 141.1—225.6
93727 0 64 5.31% 70,774 90.43 70.22—114.7
93705 0 54 5.23% 38,600 139.9 106.1—181.2
93721 0 60 4.98% 6,445 931 716.7—1,190


Figure 11: Chronic HCV cases by Zip Code in Fresno County, 2014.

Food-Borne Pathogens
S a l m o n e l l o s i s a n d
campylobacteriosis are
foodborne pathogens. Both
diseases can originate from
c r o s s - c o n t a m i n a t i o n ,
inadequately cooked foods,
inappropriate handling of pet
waste, and many other risk
f a c t o r s . R a t e s o f
c a m p y l o b a c t e r i o s i s
decreased for the first time
since 2004, while cases of
Salmonellosis are remaining
The annual incidence rate
decrease of salmonellosis
observed in 2014 is not signifi-
cant with a p-value of 0.93
and a rate ratio of 1, and
campylobacteriosis observed
a non-significant decrease in
2014 compared to a 5 year
baseline with a p-value of
0.67 and a rate ratio of 1.28.

Campylobacteriosis and Salmonellosis

*Includes data from 2009-2013
** Two tail test
Figure 12: Annual trend of reported cases of Salmonellosis and
Campylobacteriosis in Fresno County from 2004-2014.
Table 8: Rate difference among Campylobacteriosis and Salmonellosis rates in 2014 compared to a 5 year
baseline.
The decrease in rate observed in 2014 for campylobacteriosis might
be a result of people not seeking medical care as a result of
infection. Traditionally, the population under 5-years of age has been
disproportionately reported with this illness. This population is more
likely to require hospital intervention as a result of infection. The age
distribution among cases 5-years of age and younger remained
stable, while the cases in adults decreased. This is highly suggestive
that the adults are simply not seeking medical care, which would
result in a diagnostic test and a report to the health department.
Disease Rate Comparison* Rate Ratio
Confidence
Limits 95%
Lower, Upper
Test Statistic:
z-score**
Campylobacteriosis 5 Year Base Line
to 2013 1.28 0.70, 1.82 P = 0.6706
Salmonellosis 5 Year Base Line
to 2013 1 .50, 1.98 P = 0.9384

Figure 13 contains a break
down of the number of cases
reported each month of
S a l m o n e l l o s i s a n d
C a m p y l o b a c t e r i o s i s .
Traditionally, foodborne
pathogens are reported in
higher numbers in the
summer months. This can be
due to increased outdoor
cooking, family events, or
dining outside the home
more often. As is displayed in
Figure 13, summer months
were reported as having the
greatest case counts for
salmonellosis.
Campylobacteriosis appears
to be relatively active
throughout the year, but
Salmonellosis retains the more
characteristic distribution of
foodborne illness. Fresno
County first documented the
irregular distribution of
Campylobacteriosis in the
2011 Annual Report. Further
i n v e s t i g a t i o n i n t o
environmental and individual
level characteristics did not
result in an explanation for
Fresno County’s unusual
Campylobacteriosis cases.
Figure 13: Monthly trend of reported cases of Salmonellosis and
Campylobacteriosis in Fresno County in 2014.
Figure 14: Age group trend of reported cases of Salmonellosis
and Campylobacteriosis in Fresno County from 2014.
The age distribution for Salmonellosis was characteristic of national and
regional trends. Children are more likely to require hospitalization or care
as the result of foodborne illness and they are often over represented in
surveillance data such as displayed in Figure 14. With regards to
Campylobacteriosis, the 65+ age group appeared to be the only group
that appeared to not follow the trend. However, this difference was not
statistically significant.


Ethnicity/Race Campylobacteriosis Rate*
Salmonellosis
(excluding S. typhi)
Rate*
Hispanic/Latino 188 37.47 87 17.34
White 77 25.30 46 15.12
Black/African American 9 18.89 6 12.59
Asian/Pacific Islander 13 13.24 19 19.35
Other 3 — 1 —
Unknown 59 — 5 —
Total 350 36 164 16.87
Zip Code Campylobacteriosis Percent
Zip
Code Salmonellosis Percent
93706 27 7.78% 93722 17 10.37%
93702 25 7.20% 93727 14 8.54%
93722 22 6.34% 93706 13 7.93%
93703 22 6.34% 93726 12 7.32%
93727 20 5.76% 93657 10 6.10%
Total 116 33.14% Total 66 40.24%
Table 9: Cases and Rates of Salmonellosis and Campylobacteriosis stratified by Ethnicity
and Race for 2014. *Rates are per 100,000 population
Table 10: Top 5 Zip Codes for Cases of Salmonellosis and Campylobacteriosis for 2014.
Hispanic/Latino and White residents displayed the highest rates of Campylobacteriosis, while the Asian/
Pacific Islanders and Black/African Americans appeared to experience a significantly lower rate.
Salmonellosis appears to be evenly distributed among Hispanic/Latino, Black/African American, White
residents, and Asian/Pacific Islander population. In 2013, there were several outbreaks among families that
were responsible for significant rate disparities for Salmonellosis. Regardless of the source of the infection,
common food safety practices can eliminate the observed disparity among these population groups.
Please visit the following website for Food Safety Tips: h p://www.cdc.gov/foodsafety/cdc‐and‐food‐safety.html
Table 10 displays the top five zip codes with the highest case counts. Several zip codes displayed higher
case counts than surrounding areas. These populations were selected to determine if there was a rate
difference and if the higher case counts could be explained by crowding and increased population
density. As is observed in the figure above, several zip codes are co-morbid for both diseases, which is not
surprising considering the similarities among risk factors. There appears to be persistence of high rates in
several of these zip code. Previous annual reports have identified a disproportionate burden among these
specific zip codes. Five zip codes of the 61 total zip codes in Fresno County account for 33.14% of
campylobacteriosis and 40% of salmonellosis.


Figure 15: Salmonellosis and Campylobacteriosis cases by Zip Code in Fresno County, 2014.


Salmonellosis and Campylobacteriosis cases are
displayed in a map of the County of Fresno
(Figure 15). Salmonellosis cases are depicted
with the diagonal lines, whereas
Campylobacteriosis cases are represented by
the color shading. The darker the red shading
the higher the case count of
Campylobacteriosis, and the more diagonal
lines the higher case count of Salmonellosis.
West and South East Fresno City (93706, 93722,
93702, & 93727) appears to experience a higher
number of both Salmonellosis and
Campylobacteriosis.
Available from CDC at:
h p://t.cdc.gov/ecards/message.aspx?cardid=561
 FCDPH worked closely with the California
Department of Public Health and several other
regional health departments to investigate
several outbreaks of Salmonellosis that were
discovered through epidemiological
investigation this year.
 FCDPH has conducted several health alerts and
educational presentations to increase awareness
of food safety in the home.
 Creation of an enhanced investigation protocol
for campylobacteriosis cases continues being
pursued.
Through standard surveillance practices and
investigations Fresno County assisted with the
investigation of several cases of salmonellosis that
were linked to larger national or state wide
outbreaks.
FCDPH Participated in National Outbreak
Investigation in the Following Outbreak:
Salmonella Infantis, Newport, or Hadar,

Sexually Transmitted Diseases

Human Immunodeficiency Virus (HIV)
Figure 16: Treatment cascade for all HIV positive resident of Fresno
County January 1, 2014—December 31, 2014.
€ Patients had a viral load reported for 2013 that was defined as non-
detected.
∞ Ordered some type of HIV viral load, CD4, or other lab in 2014.
*Start ART at some point
*Age ranges are broad to protect privacy
Figure 17: Residents of Fresno County who are living with HIV and AIDS by
age group from January 1, 2014—December 31, 2014.
There are several limitations to the
treatment cascade presented in
this document. The limitations are
clearly noted below the figure and
discussed in great detail in the
2011 Annual Report. As the 2014
treatment cascade is evaluated,
the concerning figure is that only
314 cases out of a total of 1,777
cases have controlled HIV.
Approximately 17% of cases are
effectively controlling their HIV
through a combination of drug
therapy and regular office visits.
This is a reduction from 33% with
controlled HIV in 2013. Fewer HIV
positive patients are effectively
controlling their HIV.
Figure 17, displays the current age
distribution of those living with HIV
in Fresno County. These are not
new cases, but are cases that
were actively seeking treatment
while residing in the County of
Fresno for calendar year 2014.
Approximately 39.7% of the
patients living with HIV (regardless
of AIDS status) are under 45. Of
those under 45, 22.2% (n=391)
were diagnosed as HIV positive
only and have not progressed to
AIDS. When the remaining HIV
positive individuals were
evaluated, 17.7% (n=316) of the
total had progressed to AIDS.
€ ∞
*


Table 11: HIV and AIDS cases and prevalence figures for residents of Fresno County from
January 1, 2014—December 31, 2014, stratified by Ethnicity/Race.
The health disparity in Fresno County clearly resides among Black/African American (230.89 per 100,000
population) and American Indian/Alaskan Natives (231.42 per 100,000 population) for those who are classified
as HIV positive only and have not progressed to AIDS. Among those who have progressed to AIDS, the Black/
African Americans remain disproportionately affected at 392.5 per 100,000 population.
In Figure 18, there is a stratification
of risk factors for the acquisition of
HIV. These risk factors are self
reported. In Fresno County, 72%
(n=67) of new cases of HIV were
attributed to a history of MSM
activity as the only risk factor. All
new female cases of HIV were
attributed to IDU, Heterosexual sex,
or multiple risk factors.
According to the epidemiological
data, most of the new transmission
of HIV in the County of Fresno is
due to MSM activity. Targeted
testing and outreach here are
essential activities to control the
continued growth of this disease.,
which the county regularly engag-
es in looking at high risk
populations and geographies.
Ethnicity/Race HIV Prevalence** AIDS Prevalence**
Hispanic/Latino 339 67.57 513 102.25
White 213 69.99 327 107.45
Black/African American 110 230.89 187 392.5
American Indian/Alaskan Native 9 231.42 4 102.9
Multi-Race 7 — 8 —
Unknown 0 — — —
Total 701 72.1 1076 110.67
*Some cases were censored to protect privacy
**Per 100,000 population

Figure 18: Risk factors for acquisition of the virus that causes AIDS
for residents of Fresno County, new cases from January 1, 2014—
December 31, 2014.


Table 12: Fresno County new cases of HIV/AIDS for 2014 by disease category.
20.21% (n=19) of the new cases of HIV/AID in 2014 received their AIDS diagnoses within a calendar year of
being informed that he or she was HIV positive. This suggests the patient was not getting tested regularly.
Either the patient did not want to know his or her status or they were not able to access or were not aware of
the testing services in their community.
Figure 20: Age distribution of the cases of HIV/AIDS
diagnosed in Fresno County, 2014.
Disease Cases Percent Incidence*
HIV only 72 76.60% 7.41
HIV and later AIDS ∞ 3 3.19% 0.31
HIV and AIDS diagnosed simultaneously 19 20.21% 1.95
Total 93 100.00% 9.66
*Per 100,000 population ∞ Within the calendar year
Figure 19: Ethnic/Race distribution of new cases of HIV/AIDS in
Fresno County, 2014.
In 2014, 55% (n=52) of the new HIV/AIDS
cases were Hispanic/Latino. While this is a
large number, it is important to note that
Hispanic/Latinos constitute 51.2% of the
population in Fresno County. Approximately
14% (n=13) of the new cases of HIV/AIDS
were Black/African American, which is a
concern because they only constitute 5% of
the total population.
In 2014, patients that received a diagnosis
of HIV only skewed younger when
compared to those in the County that
received a diagnosis of AIDS at the same
time or within that calendar year. In
previous years there was little to no
difference between these two groups.
This year the department observed a shift.
Increased testing of young adults may be
showing an impact.
*Data were censored due to cell sizes being to small.


Figure 21: HIV/AIDS annual incidence rate trend data 2004-2014.
Figure 22: Diagnosis of AIDS at the same time or within that same
calendar year, trending data 2004-2014.
Fresno County observed a slight
increase in the new cases of HIV/
AIDS reported to the Department
in 2014. In 2014, the County found
that the rate has slightly
increased.
Uncontrolled HIV/AIDS infection
continues to be a concern.
Displayed in Figure 22 is the rate of
people who were diagnosed late
in Fresno County. Although, there
appears to be a drop in those that
are late diagnosed. It is imperative
to get patients linked into care
and on anti-viral therapy early in
the disease to decrease the risk of
converting to AIDS, which can be
more costly to treat and increase
the risk of mortality.


Figure 23: HIV annual incidence rate by female gender and ethnicity for
residents of Fresno County, 2014.
*Two-hundred and thirty seven cases were incomplete regarding age or were
censored to ensure confidentiality.
Figure 24: HIV annual incidence rate by male gender and ethnicity for
residents of Fresno County, 2014.
Fresno County observed a drop in
new cases of HIV among Black/
African American women for the
fourth consecut ive year.
No increases were observed. To
protect residents who are HIV posi-
tive from being identified numbers
are zeroed out if the number in
that category is too small and
there is potential for that person to
be identified. This is a requirement
from the State of California.
The rate of new cases of HIV
among Black/African American
males increased from the previous
year, and appears to be
fluctuating. Rates among White
and Hispanic/Latino males de-
creased and remained stable
compared to 2013. Data had to
be suppressed for confidentiality
issues, which is excellent. This
shows the rates are dropping
across race and ethnic
categories.


Figure 25: Distribution of people living with HIV/AIDS in Fresno County, 2014.

Fresno County has had a persistently high
rate of Chlamydia and Gonorrhea for several
years. The California Department of Public
Health (2012, [CDPH]) found that Fresno
County ranked 52 out of 58 counties for
male, and 56 out of 58 for female GC
infection rates from 2009-2011. In 2014, Fresno
County is ranked 57 out of 58 counties for
rates of Chlamydia infection among males
and females.
Figure 26 shows there was a 14% decrease in
Gonorrhea from 2013 to 2014. There was a
22.84% increase in 2014 compared to a 5
year average (spanning 2009-2013).
Chlamydia experienced a 7.9% decrease in
2014 as compared to 2013.
Traditionally, Chlamydia and Gonorrhea
cases appeared disproportionately among
15—24 year olds. Figure 27 provides a
breakdown of Gonorrhea and Chlamydia by
age group. In 2014, 91.6% (n=5,189) of
Chlamydia and 82.77% (n=1,235) of
Gonorrhea occurred in patients younger
than 34 years old.
Chlamydia, Gonorrhea, & Syphilis
Figure 26: Chlamydia and Gonorrhea case counts and annual
incidence rate for residents of Fresno County, 2014.
Figure 27: Chlamydia and Gonorrhea case counts stratified by
age group for residents of Fresno County, 2014.
1. California Department of Public Health. (2012, September 22). State of California, Department of Finance, race/Hispanics population with age and gender detail, 2000-2010.

Rates of Chlamydia and Gonorrhea
continue to increase. The Black/African
American population continues to
experience a disproportionate burden of
disease. Rates of Chlamydia and Gonorrhea
are 1,473 per 100,000 population and 537 per
100,000 population, respectively.

Table 14 displays statistics on primary and
secondary syphilis (Syphilis Total) stratified by
race and ethnicity. The rates for syphilis total
are per 100,000 population and the rates for
congenital syphilis are per 100,000 births
The disparity regarding syphilis in Fresno
County is among Hispanic/Latino and Black
African American population. Whereas con-
genital syphilis appears to disproportionately
affect White, non-Hispanics.
Figure 28 displays the total syphilis counts and
rates for Fresno County from 2004—2014.
There is a dramatic increase from 2012 on-
ward. Fresno County also observed a corre-
sponding increase in syphilis among women,
which resulted in an increase of congenital
syphilis.
Figures 29 and 30 contain the age distribution
of total syphilis and a annual trend analysis of
congenital syphilis compared to the State of
California, respectively.
Ethnicity/Race Chlamydia Gonorrhea
Cases Rate* Cases Rate*
Hispanic/Latino 2,486 495.51 629 25.37
White 624 205.04 219 71.96
Black/African American 702 1,473 256 537.33
American Indian/Alaskan Native 18 462.84 9 231.42
Unknown 1,572 -- 348 --
All Races 5,684 584.6 1,501 180
Table 13: Fresno County case counts and rates of Chlamydia and
Gonorrhea stratified by Ethnicity/Race for 2014.
Table 14: Fresno County case counts and rates of Syphilis Total
(Primary & Secondary) and Congenital Syphilis stratified by
Figure 28: Total syphilis (including primary and secondary
syphilis) in Fresno County, 2014.
Ethnicity/Race Syphilis (Total) Congenital Syphilis
Cases Rate* Cases Rate*
Hispanic/Latino 57 11.36 4 42.33
White 20 6.57 9 281.78
Black/African American 9 18.9 1 109
American Indian/Alaskan Native 3 77.14 0 0
Unknown 28 — 4 —
All Races 117 12 18 114
Asian/Pacific Islander 0 0 0 0

Figure 29: Age distribution of Primary and Secondary Syphilis cases, Fresno County, 2014.
Figure 30: Congenital syphilis annual trend, case counts and rates, Fresno County, 2009-2014.


Figure 31: Chlamydia and Gonorrhea cases by Zip Code in Fresno County, 2014.


The zip codes that were highlighted in the initial 2011 report for STDs still remain impacted with dispropor-
tionate levels of morbidity. Fresno County observed a shift in the epidemiology of syphilis staring in 2013
and continuing on into 2015. Women started presenting with more syphilis when compared to the state
proportion. Chlamydia and gonorrhea have remained stable with a slight decrease, which was not
statistically significant.
In 2014, Fresno County Department of Public Health started engaging with other local health jurisdic-
tions to develop plans to address the significant increase in congenital syphilis. Cases of congenital
syphilis were mapped and health care providers who had practices in areas with high rates were
contacted and met by Fresno County Department staff. Plans were established and a project to stem
the increase in congenital syphilis cases will start in 2015.
This report along with the data analysis that is not permitted to be shared publically, which is omitted
from this report due to privacy concerns, is permitting Fresno County to target what resources it has to
addressing the changing needs of the community. New community partnerships are developing as a
result of this targeted approach and collaboration with other non-governmental organizations, county
departments, and health care providers that will make these efforts sustainable and productive.
 Fresno County Health Department continues to hold meetings and provide continuing education units
(CEUs) on the epidemiology of STDs within the County.
 Fresno County Health Department and the California Department of Public Health collaborated on a
new project designed to encourage complete STD reporting by health care providers within the County
of Fresno. Proper STD reporting should include a patients name, address, contact information, disease
diagnosis, laboratory results, and type of treatment.
 Fresno County Health Department has partnered with the Fresno County Jail’s medical providers to give
them appropriate information on treatment, screening, and identification of high risk inmates for STDs.
 Fresno County Health Department Pilot tested a project for 18 months designed to offer case manage-
ment activities for gonorrhea cases within a zip code that has a disproportionately high rate of gonor-
rhea.
 Fresno County Health Department began training new syphilis investigator staff to address the emerging
problem of syphilis among residents.
 Fresno County Health Department became aware of the emerging issue of congenital syphilis and is
starting to set a priority to target syphilis positive females of reproductive age for investigation and
outreach to assess pregnancy status and ensure compliance with treatment.

To date, no vaccine protects 100%
of the population 100% of the time.
There are too many variations in the
human immune system to create a
foolproof vaccine. The goal of any
vaccine is to provide herd immunity
and prevent outbreaks of diseases
that pose a significant risk to the
population.
In Figure 32 and Table 15, there is a
detailed analysis of the case counts
and rates of selected vaccine
preventable diseases in Fresno
County. Each disease has a
specific age group or ethnic/racial
group disproportionately effected
by that specific illness. Annual trend
analysis of the emergence of cases
of these selected diseases can give
the FCDPH information regarding
vaccine compliance or risk profiles
for large community groups in the
population.
As is displayed in the table and
graphs, only one significant change
was observed in rate or case
counts from the four selected
vaccine preventable diseases.
Hepatitis B virus and Pertussis will be
discussed in more depth due to
historically high rates, or rates that
do not appear to change in the
presence of an effective vaccine.
*Includes all bacterial meningitis cases.
*Includes all bacterial meningitis cases.
Year Hepatitis A Hepatitis B
(Acute)
Hepatitis B
(Chronic) Pertussis
2006 9 7 229 224
2007 10 17 241 37
2008 4 15 201 18
2009 3 3 251 27
2010 7 4 206 559
2011 1 4 240 58
2012 4 2 199 18
2013 4 5 168 18
2014 0 5 186 392
Figure 32: Selected vaccine preventable disease rates, Fresno County
2014.
Table 15: Selected vaccine preventable disease case counts, Fresno
County 2014.


Hepatitis B Virus (HBV)
*Annual Incidence rate per 100,000 population Ω Fisher’s Exact Test
Ethnicity/Race
Mean
Age
STD Deviation Cases Rate*
95% Confidence
Interval (CI) Ω
Hispanic/Latino 45 14 15 2.99 (1.74-4.82)
White 50 17 14 4.6 (2.62-7.54)
Black/African American 48 22 5 10.49 (3.85-23.26)
Asian/Pacific Islander 44 16 104 105.9 (86.97-127.8)
Other 44 22 2 — —
Unknown 41 14 40 — —
Total 44 16 185 19.03 (16.43-21.98)
Table 16: Chronic Hepatitis B rates with mean age, Fresno County 2014.
Figure 33: Chronic Hepatitis B cases by zip code, Fresno County 2014.
Minimal variation was present among the mean age of onset among the different Ethnicity and Race
categories in Fresno County’s reported Chronic Hepatitis B cases. Regardless of mean age of onset, the
disparity is clearly among the Asian/Pacific Islander population. This group had a rate of 105.9 per 100,000
population far exceeding the rate observed in other racial categories. Fresno County needs to continue to
provide culturally sensitive education material regarding Hepatitis B and vaccine information to increase
compliance.

In 2014, there were a total of 392
cases of pertussis. As was observed
in figure 32, Fresno County
experienced an epidemic of
pertussis in 2014. A total of 38%
(n=149) cases were compliant with
their vaccine status. The remaining
population either did not qualify for
the vaccine due to age, exempted
out, or were out of compliance
and under vaccinated per the
CDC guidelines.
Hispanic/Latinos constituted a
majority of cases of pertussis in
2014. Approximately 20% (n= 77)
cases were under the age of 15
months old, which means they are
reliant on household members to
be immunized to create a cocoon
of immunity. These patterns were
observed across many of the
different race and ethnic
categories.
The California Department of Public
Health (CDPH) has acknowledged
the limitations of the acellular
vaccine for pertussis. The maximum
protection is approximately 2—3
years, which explains why Fresno
County experienced a surge of
cases. Fresno County experienced
an epidemic year in 2010 and took
appropriate action along with the
State of California to get students
and children vaccinated. Four
years after the campaign
protection waned.
Pertussis (Whooping Cough)
Vaccine Status
Hispanic/
Latino
White
Asian/Pacific
Islander
Black/African
American
Compliant
40.32%
(100)
33.94%
(37)
41.67%
(5)
30.77%
(4)
Did not Qualify
2.82%
(7)
0.92%
(1)
0% 0%
Non-Compliant,
Under vaccinated
35.08%
(87)
41.28%
(45)
41.67%
(5)
46.15%
(6)
Unvaccinated
21.77%
(54)
23.85%
(26)
16.67%
(2)
23.08%
(3)
Total Cases
100%
(248)
100%
(109)
100%
(12)
100%
(13)
Table 17: Percentage of pertussis cases and count by ethnicity/race
and vaccine status, Fresno County, 2014. Unknown race and other race
not documented.
Figure 34: Hispanic/Latino pertussis cases by age group in 2014, Fresno
County.
Figure 35: Pertussis percentage of vaccine compliance of cases in
Fresno County, 2014.


Pertussis (Whooping Cough)
Figure 36: Distribution of Pertussis cases reported in 2014, Fresno County.
Fresno County along with the State of California experienced an epidemic year for pertussis in 2014.
There was wide distribution of cases in the Fresno and Clovis metropolitan areas. The rural areas of the
County of Fresno also experienced cases, but the vast majority of cases were observed within the
boundaries of Fresno and Clovis.
 Fresno County targeted OBGYN practices and hospitals with education materials to ensure mothers
as well as household members were vaccinated for pertussis prior to delivery or prior to the mother
being discharged from the facility. This booster shot for the mother is essential to protect and insulate
the infant in a cocoon of protection.

Vector-Borne Diseases
In 2014 in Fresno County, there was a
437.5% increase compared to 2013 in
total number of cases of West Nile Virus.
Hospitalized cases increased 560%.
Neuroinvasive cases increased 180%. The
mean age of patients reported with
WNV of any type skewed older in 2014.
There were no fatalities in 2014
associated with WNV.

Figure 37 and Table 19 provide historical
trends of WNV cases by severity of illness
in case counts from 2005-2014.
Prevention methods require close collab-
oration between public health and
mosquito abatement organizations to
ensure rates are reduced.
West Nile Virus (WNV)
Total Confirmed Cases Received up to 12/31/2014
Summary of WNV Activity 2013 2014
Total Number of Cases 8 43
Hospitalized 5 33
Non-Neuroinvasive 3 29
Neuroinvasive 5 14
Male to Female Ratio 4:3 4:3
Median Age 51 62
Range (42-81 Years old) (17-88 Years old)
Mean Age 58 59
Fatalities 2 0
Disease Type 2005 2006 2007 2008 2009 2010 2011 2012
Non-Neuroinvasive 53 7 12 1 7 9 3 8
Neuroinvasive 15 4 4 2 6 14 6 16
Presumptive (PVDs) 0 0 1 0 0 0 0 4
Total 68 11 17 3 13 23 9 28
Fatality 2 1 1 1 1 1 1 2
2013
3
5
0
8
0
2014
29
14
11
43
0
Table 18: WNV 2013 and 2014 comparison, Fresno County
Figure 37: WNV annual trend 2005-2014 by disease severity, Fresno
County
Table 19: WNV annual trend 2005-2014 by disease severity, Fresno County

WNV has several risk factors, previously
described in the background section of
the 2012 Annual Report. The racial
differences presented in this figure are
likely to be due to activities that might
predispose one group to increased risk
of exposure to the mosquito that is
responsible for transmitting the virus.
White, Non-Hispanic/Latino and
Hispanic/Latino populations were the
two populations that were reported with
the greatest burden of WNV. 53% (n=23)
of the total reported cases were over
the age of 60.

WNV is primarily spread in the human
population by specific mosquitoes.
These mosquitoes are not active in the
winter. Thus, the highest burden of cases
will occur during specific times of the
year. Figure 39 reflects this unique
characteristic of this disease.
Figure 38: WNV ethnic/race difference by age group, Fresno County
2014.
Figure 39: WNV seasonal trend 2014 in cases, Fresno County


Figure 40: Distribution of WNV cases reported in 2014, Fresno County.
WNV activity in Fresno County was high in 2014. Fresno County continues to observe the spread
of a new mosquito species known as Aedes aegypti. This mosquito is often called the yellow
fever mosquito and is capable to transmitting yellow fever, dengue, and a few other viral
encephalopathies if infected when it bites a host.
The spread of this vector for disease can be monitored here: http://www.mosquitobuzz.net/
This mosquito species is not native to Fresno County. Mosquito abatement activities were
increased in targeted regions of Fresno County. It could be that these enhanced surveillance
and abatement methods led to Fresno County experiencing a low burden of disease in 2013.
The more mosquito control and prevention measures that are in place, the fewer WNV cases
the County will experience. Residents who observe mosquitos in their house, improperly main-
tained pools, or other standing water are encouraged to contact mosquito abatement for their
region to help address these issues.


 Fresno County Department of Public Health holds Emerging Infectious Disease Task Force meetings
six times a year to discuss emerging infectious diseases and keep community stakeholders informed
of WNV activity. This venue engages community partners from both the private and public sector.
 Fresno County Department of Public Health regularly collaborates with local mosquito abatement
districts for the purposes of mosquito control activities and reports of mosquito borne illness.
 As new vectors for disease emerge within country boundaries the Fresno County Department
of Public Health notifies both local control services and the State of California.
 Fresno County Department of Public Health has made regular educational presentations to
Infection Control Programs at local hospitals and sent out health alerts from the County
Health Officer to all health providers. New vectors mean that there is potential for the
emergence of new diseases. Fresno County Department of Public Health is attempting to
keep the health providers educated on the new diseases that might be emerging in the
community.
 Additionally, Fresno County Department of Public Health issued several news releases about the po-
tential emergence of diseases like Dengue and Chikungunya.

Annual Report 2014

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Annual Report 2014