W-08 Contact Information Objectives

4/9/2014
W-08
Infection Control
Simplified
Contact Information
Diane M. Bonifas BSN, CNE, RN-BC
Director Clinical Campus Support
303 N. Hurstbourne Parkway
Louisville, KY
[email protected]
Objectives:
•
2007 CDC isolation guidelines
•
•
Review Federal Regulations, F-441 and F-334
Review MDRO’s with discussion on epidemiological
important pathogens
Review surveillance techniques to assist identifying
infections and potential spread
•
•
Infection Control Program,
1
4/9/2014
Changes in terminology from
the 2007 CDC guidelines
• Nosocomial infection are now referred to as
Healthcare-Associated Infection (HAI)
– onset of clinical manifestation occurs >2 calendar days after
admission (APIC Implementation Guide)
• New addition to Standard Precautions is
Respiratory Hygiene/Cough Etiquette
• “Airborne Precautions” is changed to “Airborne
Infection Isolation Room (AIIR)”
• Protective Environment has been added to the
precautions used to prevent HAI’s
CDC Guidelines for Isolation
Precautions (2007)
• Provide recommendations for all components of
the healthcare delivery system
• Reaffirm Standard Precautions
• Implementing Transmission-Based Precautions
base on the clinical presentation until the
infectious etiology has been determined
2
4/9/2014
1. Infectious Agent
• Any microorganism that can cause a
disease such as a bacterium, virus,
parasite, or fungus. Reasons that the
organism will cause an infection are
virulence (ability to multiply and grow),
invasiveness (ability to enter tissue),
and pathogenicity (ability to cause
disease).
2. Reservoir
Definition
High touch surfaces
• The reservoir of an
infectious agent is the
habitat in which the
agent normally lives,
grows, and multiplies.
Reservoirs include
humans, animals, and
the environment.
3. Portal of Exit
• The place where the organism leaves the
reservoir, such as the respiratory tract
(nose, mouth), intestinal tract (rectum),
urinary tract, or blood and other body
fluids.
3
4/9/2014
4. Mode of Transmission
• The means by which an organism
transfers from one carrier to another by
either direct transmission (direct contact
between infectious host and susceptible
host) or indirect transmission (which
involves an intermediate carrier like an
environmental surface or piece of
medical equipment).
5. Portal of Entry
• The opening where an infectious disease
enters the host’s body such as mucus
membranes, open wounds, or tubes
inserted in body cavities like urinary
catheters or feeding tubes.
6. Susceptible Host
• The person who is at risk for developing
an infection from the disease. Several
factors make a person more susceptible
to disease including age (young people
and elderly people generally are more at
risk), underlying chronic diseases,
conditions that weaken the immune
system , certain types of medications,
invasive devices like feeding tubes, and
malnutrition.
4
4/9/2014
Standard Precautions
•Hand hygiene
•Safe injection practices
•The proper use of personal protective
equipment
•Care of the environment, textiles and
laundry
•Resident placement
•Appropriate waste disposal and
management
Standard Precautions
Transmission-Based Precautions
• Contact Precautions
• Droplet Precautions
• Airborne
Precautions (in
AIIR)
5
4/9/2014
Contact Isolation
• Infection/Condition
– Draining wound not contained in dressing
– C. difficile
– Rotovirus
– CRE
– Shingles
– Lice, scabbies
*not inclusive list-information from Appendix A1 CDC isolation
guidelines p.93-116
Droplet Isolation
• Infection/Condition
– Influenza
– Mumps
– Pertussis- Whooping Cough
*not inclusive list-information from Appendix A1 CDC isolation
guidelines p.93-116
Airborne Isolation-AIIR
• Infection/Condition
– Tuberculosis (M. tuberculosis)
– Smallpox
– SARS
– Measles- 4 days after onset of rash
– *not inclusive list-information from Appendix A1 CDC isolation
guidelines p.93-116
6
4/9/2014
Airborne Isolation
The preferred placement for resident who
require Airborne Precautions is in an
airborne infection isolation room (AIIR). An
AIIR is a single-resident room that is
equipped with special air handling and
ventilation capacity that meet the American
Institute of Architects/Facility Guidelines
Institute (see pg. 71 for specifics)
http://www.cdc.gov/hicpac/pdf/isolation/Isolation2007.pdf
Type of
Type(s) of PPE
Precaution
Required
Airborne
Mask or
Respirator,
Gloves
Resident Placement
Other
Considerations
Private room, Cohorting, Private AIIR
Room sharing with
room (active TB)
limited risk factors
Contact
Gown, Gloves
Private room, Cohorting,
Room sharing with
limited risk factors
Droplet
Mask/Facial
Protection,
Gloves
Private room, Cohorting, 3-10 ft.
Room sharing with
distance* for
limited risk factors
transmission
All Transmission-based Precautions require appropriate hand hygiene
practices
F-441
Infection Control
• The facility must establish and maintain an
infection control program designed to provide a
safe, sanitary, and comfortable environment
and to help prevent the development and
transmission of disease and infection.
Facility must investigate, control and prevent
infections
Procedures for individual residents
Maintains records of incidents and corrective action
7
4/9/2014
Preventing Spread of
Infection
1) When the infection control program
determines that a resident needs
isolation to prevent the spread of
infection, the facility must isolate the
resident
2) The facility must prohibit employees with
a communicable disease or infected skin
lesions from direct contact with residents
or their food, if direct contact will
transmit the disease.
Preventing Spread of
Infection—cont.
3. The facility must require staff to wash
their hands after each direct resident
contact for which hand washing is
indicated by accepted professional
practice.
4. Personnel must handle, store, process
and transport linens so as to prevent the
spread of infection.
Updated 09/30/09
Intent of regulation
• The intent of this
regulation is to assure that
the facility, develops,
implements and maintains
an Infection Prevention
and Control Program in
order to prevent, recognize,
and control, to the extent
possible, the onset and
spread of infection within
the facility.
8
4/9/2014
Components of an Infection
Prevention and Control Program
• Program Development
and Oversight
• Policies and Procedures
• Infection Preventionist
• Surveillance
Documentation
Monitoring
Data Analysis
Communicable
Disease Reporting
• Education
• Antibiotic Review
•
•
•
•
•
http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/downloads/so
m107ap_pp_guidelines_ltcf.pdf pg. 560
QIS Observations
• Are proper hand-washing techniques observed
• Are gloves worn appropriately and changed
between residents
• Staff free of communicable diseases
• Are precautions observed for the disposal of
soiled linens, dressings, etc.
• Are linens and laundry handled or
transported in manner to prevent spread
QIS Observation
• Are isolation precautions implemented
when it is determined they are needed
• Are all staff practices consistence with
current infection control principles and
do these practices prevent cross
contamination
• Does the facility establish and maintain
and infection control program
9
4/9/2014
QIS Questions
• Instructs surveyors to use investigative
protocol in F-441 (SOM pp.586-591)
• The facility demonstrates that it uses
records of incidents to improve its
infection control processes and outcomes
by taking corrective action
• CMS 20054 (11/2010)
Influenza F-334
• Facility must develop policies and
procedures regarding Influenza (Oct.1Mar.31) and Pneumococcal Disease
– The regulation indicates that receiving
vaccinations is essential to the health and
well-being of long-term care residents.
– Intended to decrease the risks of residents
acquiring, transmitting, or experiencing
complications.
Facts about Influenza Vaccine
• Inactivated influenza vaccine contains
noninfectious killed viruses and cannot cause
influenza.
• Since there is a delay in developing antibodies
after vaccination, the resident may develop
influenza if there was exposure prior to
receiving the vaccine. Coincidental
respiratory disease unrelated to influenza
vaccination can occur at any time after
vaccination.
10
4/9/2014
Recent citation regarding
F-334
• Education provided every year when
influenza immunization given
• If declines influenza immunization
yearly need to document risks and
benefits explained
• Once refuse pneumococcal not offered
again
Vaccine Recommendations for
Health Care Workers
Hepatitis B- series of 3 doses
Influenza vaccine yearly
MMR
Varicella vaccine if no history of
chicken pox
• Tetanus, diphtheria, pertussis
•
•
•
•
C. difficile
• Gram positive, spore forming, anaerobic
bacillus (1978)
• C. difficile infection (CDI)occurs when the
normal intestinal flora is altered, allowing
C. difficile to flourish in the intestinal tract
and produce a toxin that causes a watery
diarrhea.
– #1 risk exposure to antibiotics
• Cephalosporins, clindamycin and floroquinolones
– #2 transmission by fecal-oral route
http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f90-43d1-9325e8be75d86888/File/2013CDiffFinal.pdf pgs9-10
11
4/9/2014
Antibiotic Usage
• Cephalosporins
– Keflex ®, Ancef ®, Duricef, Ultracef
• Clindamycin
• Floroquinolones
– Levaquin, Cipro, Avelox
• Not inclusive list of brand names
Potential Reasons for
Increased CDI Incidence and
Severity
• Changes in underlying host
susceptibility
• Changes in antimicrobial
prescribing
• New strain with increased virulence
• Changes in infection control
practices
Supplemental Prevention
Strategies: Environmental
Cleaning
Bleach can kill spores, whereas other standard
disinfectants cannot
• Limited data suggest cleaning with bleach (1:10
dilution prepared fresh daily) reduces C. difficile
transmission
• Two before-after intervention studies
demonstrated benefit of bleach cleaning in units
with high endemic CDI rates
• Therefore, bleach may be most effective in
reducing burden where CDI is highly endemic
(Note; Some disinfectant claim to kill C.difficile and maybe referring to vegetative cells
and not spores)
Mayfield et al. Clin Infect Dis 2000;31:995-1000.
Wilcox et al. J Hosp Infect 2003;54:109-14.
12
4/9/2014
Testing for C. difficile
Check with contracted laboratory services
• Rejection of specimens that are not liquid or
soft(take the shape of the container=rejection)
• Testing will be restricted to one specimen in 7
days
Note-diarrhea, defined as at least 3 unformed or
watery stools in a 24-hour period, some
recommend for 1-2 days.
It is recommended to NOT ‘test of cure’ inpatients
who have responded to therapy
John Hopkins University laboratory website
http://www.mc.vanderbilt.edu/documents/infectioncontrol/files/Guidance%20for%20Providers
%20FINAL%202011.pdf
Education for C. difficile
• Posted on EIDC- Ohio gateway on 2/20/14
– Challenge #1: CDI Awareness and
Accountability Thursday, February 27
– Challenge #2: Antibiotic Stewardship
Thursday, March 27
– Challenge #3: Environmental Cleaning
Thursday, May 1
– Challenge #4: Hand Hygiene Thursday, May
22
Norovirus
Named after the original strain ‘Norwalk
virus’ which caused an outbreak of
gastro-enteritis in a school in Norwalk,
Ohio in 1968.
Noroviruses are highly contagious
Analysis suggests that a national
increase has occurred in the frequency
of acute gastroenteritis outbreaks
caused by norovirus
13
4/9/2014
Norovirus
• Average Incubation period 12 – 48
hours
• Transmission- fecal-oral route
• Signs and symptoms
– Nausea, vomiting, abdominal pain, nonbloody stools
• Duration- 24-60 hours
• Increase environmental cleaning with
1:10 bleach solution or product that
lists norovirus
LTC Facilities Predisposed
to High Attack Rates
• Shared bathrooms
• Immobile or incontinent residents
• Low infectious dose (<10 viral particles)
Control of norovirus outbreaks depend on
consistent enforcement of measures such
as strict hand hygiene and use of
effective environmental disinfectants
MRSA
• Methicillin resistant
Staphylococcus
aureus
• If you have staph on
your skin or in your
nose but aren't sick,
you are said to be
"colonized" but not
infected with MRSA.
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4/9/2014
MRSA
• Methicillin-resistant strains of
Staphylococcus aureus (MRSA) was
first recognized in 1961, one year
after the antibiotic methicillin was
introduced for treating S. aureus
infections.
• First documented outbreak occurred
at a Boston Hospital in 1968
The Iceberg Effect
Infected
Colonized
Good News about MRSA
• In 2010, encouraging results from a CDC study
published in the Journal of the American Medical
Association showed that invasive (life-threatening)
MRSA infections in healthcare settings are
declining. Invasive MRSA infections that began in
hospitals declined 28% from 2005 through 2008.
Decreases in infection rates were even bigger for
patients with bloodstream infections. In addition,
the study showed a 17% drop in invasive MRSA
infections that were diagnosed before hospital
admissions (community onset) in people with recent
exposures to healthcare settings.
15
4/9/2014
Acinetobacter baumannii
• Multidrug-resistant Acinetobacter
baumannii (80%)is recognized to be
among the most difficult antimicrobialresistant gram-negative bacilli to control
and treat
• Survives for prolonged periods under a
wide range of environmental conditions
• Poses very little risk to healthy people
CDC website
Acinetobacter baumannii
• aerobic gram-negative bacillus
• baumannii is a water organism and
preferentially colonizes aquatic
environments
• Acinetobacter infections are uncommon
but, when they occur, usually involve
organ systems that have a high fluid
content (eg, respiratory tract, CSF,
peritoneal fluid, urinary track)
Treatment options for
Acinetobacter
• Carbapenems still represent the
treatment of choice
• Amongst these the most widely used
Carbapenems include:
– Meropenum
– Imipenum +Cilastin
• Mechanism of Action: inhibition of cell wall
synthesis
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4/9/2014
ESBL’s
• Extended-Spectrum BetaLactamases– ESBL’s are enzymes made by some
germs
– Disease caused by ESBL organisms is
no more acute than the disease caused
by another bacteria of the same type.
However, due to their immunity to some
antibiotics, they can be trickier and
more difficult to treat
ESBL Epidemiology
•Today, 30 –50% of E. coli are
resistant to ampicillin and
amoxicillin due to a beta-lactamase
•ESBLs have been reported for E.coli,
Klebsiella, Enterobacter,
Proteus,Pseudomonas,
Salmonella,Serratia
ESBL producing organisms
are still susceptible to:
Cephamycins:
• –Cefoxitin
• –Cefotetan
• •Carbapenems:
• –Meropenem
• –Imipenem
Carbapenems are becoming the therapeutic
option of choice
17
4/9/2014
New Kid on the Infection
Control Block- CRE
• Hospitals and healthcare providers are
being alerted to the growing occurrence
of CRE infections in the United States
and the need for careful infection control
measures in healthcare settings to
prevent the spread of CRE.
CRE
Carbapenem-resistant
Enterobacteriaceae
• Carbapenems (ertapenem, imipenem,
meropenem, and doripenem) are the
last line of defense antibiotics
• Healthy people usually do not CRE
infections
• CRE kills almost 50% of patients
that have bloodstream infection from
them
CRE
• CRE is an emerging threat in
healthcare facilities across the
continuum of care
• Currently, the most prevalent
carbapenemase in the United States
is the Klebsiella pneumoniae
carbapenemase (KPC).
•
MDH Recommendations for the Management of CRE in Longterm Care Facilities 5/2012
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4/9/2014
Facility level CRE- Prevention
• 8 core measures facilities should follow
1. Hand Hygiene
2. Contact Precautions- for colonized or
infected with CRE
Not enough information for a firm
recommendation about when to stop Contact
Precautions-some CDC investigations indicate
prolonged > 6 months
3. Healthcare personnel Education
Facility level CRE- Prevention
4. Use of devices- central venous catheters,
ET tubes, urinary catheters
5. Patient and Staff Cohorting
6. Laboratory Notification
7. Antimicrobial Stewardship
8. CRE Screening-might include
•
Stool, rectum, or peri-rectal cultures and
sometimes wounds and urine
Information from CDC 2012 CRE toolkit
CRE
• Suggestion to send a ‘Inter-facility
Infection Control Transfer Form’ when
transferring any resident to another
health care setting
– Information regarding
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•
•
•
•
Isolation
Prior infections- MRSA, VRE, C. difficile
Devices resident currently has
Recently prescribed antibiotics
Vaccines
http://www.cdc.gov/HAI/toolkits/InterfacilityTransferCommunicationForm11-2010.pdf
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4/9/2014
CRE- CDC Commentary
http://www.medscape.com/viewarticle/762961
• A link to the following Medscape article
was sent to you by: Diane Bonifas
• Stopping Outbreaks of CarbapenemResistant Enterobacteriaceae
CDC Expert Commentary, 2012-05-02
Carbapenemase-producing CRE in the
United States
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4/9/2014
What surveyors will monitor
• In-service education
• Review policy and
procedures
• Watch an aseptic
dressing change
• Hand-washing
• Glove use
• Use of disinfectants
• Handling of linen
Infection Control Checklist
• Written infection
control policy
• Isolation procedures
• System to monitor
and investigate
• Maintain separate
record on infections
• Surveillance Data
• Written protocols for
hand-washing/hand
hygiene
• Immunization record
for residents
• Proper use of
disinfectants
• Work restrictions for
employees
Helpful Websites
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http://www.cdc.gov/ncidod/dhqp/guidelines.html
http://www.cms.hhs.gov/GuidanceforLawsAndRegulations/12_N
Hs.asp#TopOfPage
http://www.apic.org//AM/Template.cfm?Section=Home
http://www.amda.com/
http://www.ohiokepro.com/providers/nursinghome/events.asp
http://www.cdc.gov/hai/pdfs/toolkits/CDItoolkit2-29-12.pdf
http://www.cdc.gov/hai/pdfs/cre/CRE-guidance-508.pdf
http://www.mc.vanderbilt.edu/documents/infectioncontrol/files/G
uidance%20for%20Providers%20FINAL%202011.pdf
http://apic.org/Resource_/EliminationGuideForm/59397fc6-3f9043d1-9325-e8be75d86888/File/2013CDiffFinal.pdf
http://www.ohiokepro.com/shopping/default.aspx?keyword=CDI
&cat=sf
21
Know Your ABCs: A Quick Guide to Reportable Infectious Diseases in Ohio
From the Ohio Administrative Code Chapter 3701-3; Effective January 1, 2014
Class A:
Diseases of major public health concern because of the severity of disease or potential for epidemic spread – report immediately via telephone upon recognition that a case, a
suspected case, or a positive laboratory result exists.
•
•
•
•
Anthrax
Botulism, foodborne
Cholera
Diphtheria
•
•
•
•
Influenza A – novel virus
Measles
Meningococcal disease
Plague
•
•
•
Rabies, human
Rubella (not congenital)
Severe acute respiratory syndrome
(SARS)
•
•
•
•
Smallpox
Tularemia
Viral hemorrhagic fever (VHF)
Yellow fever
Any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other disease of major public health concern, because of the severity of disease or potential
for epidemic spread, which may indicate a newly recognized infectious agent, outbreak, epidemic, related public health hazard or act of bioterrorism.
Class B:
Disease of public health concern needing timely response because of potential for epidemic spread – report by the end of the next business day after the existence of a case, a
suspected case, or a positive laboratory result is known.
•
•
•
•
•
•
•
•
•
Amebiasis
Arboviral neuroinvasive and
non-neuroinvasive disease:
•
Eastern equine encephalitis
virus disease
•
LaCrosse virus disease (other
California serogroup virus
disease)
•
Powassan virus disease
•
St. Louis encephalitis virus
disease
•
West Nile virus infection
•
Western equine encephalitis
virus disease
•
Other arthropod-borne
diseases
Babesiosis
Botulism, infant
Botulism, wound
Brucellosis
Campylobacteriosis
Chancroid
Chlamydia trachomatis infections
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Coccidioidomycosis
Creutzfeldt-Jakob disease (CJD)
Cryptosporidiosis
Cyclosporiasis
Dengue
E. coli O157:H7 and Shiga toxin-producing (STEC) E. coli
Ehrlichiosis/anaplasmosis
Giardiasis
Gonorrhea (Neisseria gonorrhoeae)
Haemophilus influenzae (invasive
disease)
Hantavirus
Hemolytic uremic syndrome (HUS)
Hepatitis A
Hepatitis B, non-perinatal
Hepatitis B, perinatal
Hepatitis C
Hepatitis D (delta hepatitis)
Hepatitis E
Influenza-associated hospitalization
Influenza-associated pediatric
mortality
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
•
Legionnaires’ disease
Leprosy (Hansen disease)
Leptospirosis
Listeriosis
Lyme disease
Malaria
Meningitis:
•
Aseptic (viral)
•
Bacterial
Mumps
Mycobacterial disease, other than
tuberculosis (MOTT)
Pertussis
Poliomyelitis (including vaccine-associated cases)
Psittacosis
Q fever
Rubella (congenital)
Salmonellosis
Shigellosis
Spotted Fever Rickettsiosis, including Rocky Mountain spotted fever
Staphylococcus aureus, with resis-
•
•
•
•
•
•
•
•
•
•
•
•
•
•
tance or intermediate resistance to
vancomycin (VRSA, VISA)
Streptococcal disease, group A,
invasive (IGAS)
Streptococcal disease, group B, in
newborn
Streptococcal toxic shock syndrome
(STSS)
Streptococcus pneumoniae, invasive
disease (ISP)
Syphilis
Tetanus
Toxic shock syndrome (TSS)
Trichinellosis
Tuberculosis, including multi-drug
resistant tuberculosis (MDR-TB)
Typhoid fever
Typhus fever
Varicella
Vibriosis
Yersiniosis
Class C:
Report an outbreak, unusual incident or epidemic of other diseases (e.g. histoplasmosis, pediculosis, scabies, staphylococcal infections) by the end of the next business day.
Outbreaks:
•
•
Community
Foodborne
•
•
Healthcare-associated
Institutional
•
•
Waterborne
Zoonotic
NOTE:
Cases of AIDS (acquired immune deficiency syndrome), AIDS-related conditions,
HIV (human immunodeficiency virus) infection, perinatal exposure to HIV,
and CD4 T-lymphocyte counts <200 or 14% must be reported on forms and in a manner prescribed by the Director.
Know Your ABCs (Alphabetical Order)
Effective January 1, 2014
Name
Class
Name
Class
Amebiasis
B
Meningitis, aseptic (viral)
B
Anthrax
A
Meningitis, bacterial
B
Arboviral neuroinvasive and non-neuroinvasive disease
B
Meningococcal disease
A
Babesiosis
B
Mumps
B
Botulism, foodborne
A
Mycobacterial disease, other than tuberculosis (MOTT)
B
Botulism, infant
B
Other arthropod-borne diseases
B
Botulism, wound
B
Outbreaks: community, foodborne, healthcare-associated,
institutional, waterborne, zoonotic
C
Brucellosis
B
Pertussis
B
Campylobacteriosis
B
Plague
A
Chancroid
B
Poliomyelitis (including vaccine-associated cases)
B
Chlamydia trachomatis infections
B
Powassan virus disease
B
Cholera
A
Psittacosis
B
Coccidioidomycosis
B
Q fever
B
Creutzfeldt-Jakob disease (CJD)
B
Rabies, human
A
Cryptosporidiosis
B
Rubella (congenital)
B
Cyclosporiasis
B
Rubella (not congenital)
A
Dengue
B
Salmonellosis
B
Diphtheria
A
Severe acute respiratory syndrome (SARS)
A
E. coli O157:H7 and Shiga toxin-producing (STEC) E. coli
B
Shigellosis
B
Eastern equine encephalitis virus disease
B
Smallpox
A
Ehrlichiosis/Anaplasmosis
B
Spotted Fever Rickettsiosis, including Rocky Mountain
spotted fever
B
Giardiasis
B
St. Louis encephalitis virus disease
B
Gonorrhea (Neisseria gonorrhoeae)
B
Staphylococcus aureus, with resistance or intermediate
resistance to vancomycin (VRSA, VISA)
B
Haemophilus influenzae (invasive disease)
B
Streptococcal disease, group A, invasive (IGAS)
B
Hantavirus
B
Streptococcal disease, group B, in newborn
B
Hemolytic uremic syndrome (HUS)
B
Streptococcal toxic shock syndrome (STSS)
B
Hepatitis A
B
Streptococcus pneumoniae, invasive disease (ISP)
B
Hepatitis B, non-perinatal
B
Syphilis
B
Hepatitis B, perinatal
B
Tetanus
B
Hepatitis C
B
Toxic shock syndrome
B
Hepatitis D (delta hepatitis)
B
Trichinellosis
B
Hepatitis E
B
Tuberculosis, including multi-drug resistant tuberculosis
(MDR-TB)
B
Influenza A – novel virus
A
Tularemia
A
Influenza-associated hospitalization
B
Typhoid fever
B
Influenza-associated pediatric mortality
B
Typhus fever
B
LaCrosse virus disease (other California serogroup virus disease)
B
Varicella
B
Legionnaires’ disease
B
Vibriosis
B
Leprosy (Hansen disease)
B
Viral hemorrhagic fever (VHF)
A
Leptospirosis
B
West Nile virus infection
B
Listeriosis
B
Western equine encephalitis virus disease
B
Lyme disease
B
Yellow fever
A
Malaria
B
Yersiniosis
B
Measles
A