ERIC FRYKMAN, MD, MPH, MBA Public Health Officer
	COUNTY OF RIVERSIDE PUBLIC HEALTH DISPATCH
COMMUNITY HEALTH AGENCY • DEPARTMENT OF PUBLIC HEALTH • 4065 COUNTY CIRCLE DRIVE, RIVERSIDE, 92503
	WINTER 2008

PREPARING FOR THE 2007-2008 INFLUENZA SEASON

Recommended Antiviral Agents for Seasonal Influenza for 2007-2008

Although yearly vaccination is the primary strategy for preventing complications of influenza virus infections, antiviral medications with activity against influenza viruses can be effective for the prevention and treatment of influenza. Two licensed influenza antiviral agents are recommended for use in the United States during the 2007-2008 influenza season: oseltamivir and zanamivir. These are chemically related antiviral medications known as neuraminidase inhibitors that have activity against both influenza A and B viruses.

• Oseltamivir is approved for treatment of persons aged 1 year and older and is licensed for use as chemoprophylaxis in persons aged 1 year and older.
• Zanamivir is approved for treatment of persons aged 7 years and older and is licensed for use as chemoprophylaxis in persons aged 5 years and older.

The two medications differ in pharmacokinetics, adverse events, routes of administration, dosages, and costs.

Amantadine and rimantadine are also licensed in the U.S. for the treatment and prevention of influenza. However, because a high proportion of circulating influenza viruses in the U.S. in recent years have been resistant to the adamantanes, CDC recommends that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza in the United States during the 2007-08 influenza season. Additional information on antiviral medication can be found at www.cdc.gov/flu/protect/antiviral/index.htm.

Managing Respiratory Illness In Clinical Settings

As influenza activity begins to increase, it is important for health care facilities to take steps to reduce disease transmission. A summary of action steps is listed below:

Surveillance

• Document the incidence of reported respiratory illness and influenza-like illness.
• Consider respiratory testing of patients admitted from the Emergency Department who have influenza-like illness with no other identified pathogens (contact Public Health for free assistance with samples and testing).
• Consider patients who develop influenza-like illness >72 hours after facility admission as potential cases of nosocomial acquired respiratory or influenza-like illness.
• Initiate respiratory illness testing and droplet precautions when healthcare facility-acquired respiratory illness is detected.
• Consider daily monitoring for respiratory illness in selected settings, such as units with particularly vulnerable patients, including intensive care units and oncology units.
• Report disease outbreaks to Disease Control at (951) 358-5107; after hours at (951) 782-2974.

Respiratory hygiene/cough etiquette

The following measures to contain respiratory secretions are recommended for all individuals with signs and symptoms of a respiratory infection.

• Cover the nose/mouth when coughing or sneezing.
• Use tissues to contain respiratory secretions and dispose of them in the nearest waste receptacle after use.
• Perform hand hygiene (e.g., hand washing with non-antimicrobial soap and water, alcohol based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials.

Initiate droplet precautions for persons with respiratory or influenza-like illness or confirmed influenza including

• Physically segregate patients with respiratory symptoms from other patients by at least three feet when possible.
• Designate a separate unit for patients with respiratory or influenza-like illness.
• Wear a mask when within 3 feet of the patient.
• Wear a gown if clothing is likely to be soiled by body fluids, and ensure proper disposal.
• Provide tissues and no-touch receptacles for used tissue disposal.
  

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REPORTING POTENTIAL FOODBORNE ILLNESS OUTBREAK FACILITATES PUBLIC HEALTH INTERVENTION

Foodborne illness is a significant public health problem. The medical community plays a critical role in the prevention and control of foodborne illness outbreaks. Causative agents include biological and non-biological agents. Common bacterial agents include salmonella, shigella and recently E. coli 0157:H7.

During 2007, six outbreaks appeared to be related to food. Implicated foods have included spinach, raw milk, veggie snacks and ground beef.

If foodborne illness is suspected, it is important to collect appropriate specimens for laboratory testing. It is also crucial for clinicians to report significant increases in unusual illness or disease patterns to Public Health. This may be the first indication of a bioterrorism event or other Public Health emergency. Individual diseases, as well as disease outbreaks need to be reported to Public Health. Prompt reporting facilitates early Public Health intervention to try and identify the source and contain the outbreak.

Public Health staff interviews individuals who are identified as part of a foodborne illness outbreak. Individuals found to be infected with an enteric organism such as salmonella, shigella or e. Coli 0157:H-7 are excluded from settings where disease might be transmitted to others through food or direct contact. Clearance specimens are collected to ensure they are no longer infectious prior to the individual returning to a sensitive setting.

Reports should be called in to Disease Control at (951) 358-5107, or by FAX to (951) 358-5102. For reporting disease outbreaks and other urgent diseases after hours, call (951) 782-2974, and request the Public Health Duty Officer.

Table 1: Etiologic Agents to Consider for Various Manifestations of Foodborne Illness

Clinical Presentation	Potential Food-Related Agents to Consider
Gastroenteritis (vomiting as primary symptom; fever and/or diarrhea also may be present)	Viral gastroenteritis, most commonly rotavirus in an infant or norovirus and other caliciviruses in an older adult; or food poisoning due to performed toxins (et, vomitoxin, Staphylococcus aureus toxin, Bacillus cereus toxin) and heavy metals.
Inflammatory diarrhea (invasive gastroenteritis; grossly bloody stool and fever may be present)	Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic), but is a classic symptom of:  Enterotoxigenic Escherichia coli, Giardia, Vibrio cholerae Enteric viruses (astroviruses, noroviruses and other caliciviruses, enteric adenovirus, rotavirus) Cryptosporidium Cyclospora cayetanensis
Neurological manifestations (e.g., paresthesias, respiratory depression, bronchospasm, cranial nerve palsies)	Botulism (Clostridium botulinum toxin) Organophosphate pesticides Thallium poisoning Scombroid fish poisoning (histamine, saurine) Ciguatera fish poisoning (ciguatoxin) Tetradon fish poisoning (tetrodotoxin) Neurotoxic shellfish poisoning (brevitoxin) Paralytic shellfish poisoning (saxitoxin) Amnesic shellfish poisoning (domoic acid) Mushroom poisoning Guillain-Barre syndrome (associated with infectious diarrhea due to Campylobacter jejuni)
Non-inflammatory diarrhea (acute watery diarrhea without fever/dysentery; some patients may present with fever)	Can be caused by virtually all enteric pathogens (bacterial, viral, parasitic), but is a classic symptom of:  Enterotoxigenic Escherichia coli, Giardia, Vibrio cholerae Enteric viruses (astroviruses, noroviruses and other caliciviruses, enteric adenovirus, rotavirus) Cryptosporidium Cyclospora cayetanensis
Persistent diarrhea (lasting > 14 days)	Prolonged illness should prompt examination for parasites, particularly in travelers to mountainous or other areas where untreated water is consumed.  Consider Cyclospora cayetanensis; Cryptosporidium, Entamoeba histolytica, and Giardia lamblia.
Systemic illness (e.g., fever, weakness, arthritis, jaundice)	Listeria monocytogenes Brucella species Trichinella spiralis Toxoplasma gondii Vibrio vulnificus Hepatitis A and E viruses Salmonella Typhi and Salmonella  Paratyphi Amoebic liver abscess

Source:  Adapted from “Diagnosis and Management of Foodborne Illnesses - A Primer for Physicians and other Health Care Professionals.”  February 2004.

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RABIES POSTEXPOSURE PROPHYLAXIS

Rabies is a preventable viral disease of mammals most often transmitted through the bite of a rabid animal. The vast majority of rabies cases reported to the Centers for Disease Control and Prevention (CDC) each year occur in wild animals like raccoons, skunks, bats and foxes. Domestic animals account for less than 10% of the reported rabies cases, with cats, cattle, and dogs most often reported rabid.

During the time period of 2000-2006, 19 of the 24 human rabies cases reported in the United States were acquired indigenously. Six cases of human rabies occurred during this timeframe in California. Data for 2007 is not available at this time. Human rabies is preventable with proper wound care and timely, appropriate administration of human rabies immune globulin (HRIG) and rabies vaccine before onset of clinical symptoms.

Post-Exposure prophylaxis (PEP) is recommended for all persons who have been scratched or bitten by an animal suspected to have rabies virus. Because bats have small teeth, a bite may go undetected.

Rabies PEP is also recommended for persons whose mucous membranes have been exposed to the virus. Although there have been no human rabies cases in Riverside County, bats with human contact have tested positive for rabies. In 2006, four bats were confirmed to have rabies; and in 2007, six cases of rabies in bats were confirmed.

Rabies is Usually Fatal in Humans

The virus infects the central nervous system, causing encephalopathy and ultimately death. Early symptoms of rabies in humans are nonspecific, consisting of fever, headache and general malaise. As the disease progresses, neurological symptoms appear and may include insomnia, anxiety, confusion, slight or partial paralysis, excitation, hallucinations, agitation, hypersalivation, difficulty swallowing, and hydrophobia. Death usually occurs within days of the onset of symptoms.

Rabies Postexposure Prophylaxis

For persons who have never been vaccinated against rabies, postexposure anti-rabies vaccination should always include administration of both passive antibody and vaccine. Persons who have been previously vaccinated or are receiving preexposure vaccination for rabies should receive only the vaccine. The combination of human rabies immune globulin (HRIG) and vaccine is recommended for both bite and nonbite exposures, regardless of the interval between exposure and initiation of treatment. (Refer to Tables 2, 3 and Figure 1)

Rabies Immune Globulin

Human rabies immune globulin (HRIG) is administered only once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons to provide immediate antibodies until they respond to the vaccine by actively producing antibodies of their own. HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the five-dose series can be administered in the same anatomic location where the HRIG dose was administered.

Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight. This formula is applicable to all age groups, including children.

Rabies Vaccine

A regimen of five 1-mL doses of HDCV (Human diploid cell vaccine), or, PCECV (Purified chick embryo cell vaccine), should be administered intramuscularly to previously unvaccinated persons. The first dose of the five-dose course should be administered as soon as possible after exposure. Additional doses should be administered on days 3, 7, 14, and 28 after the first vaccination. For adults, the vaccination should always be administered intramuscularly in the deltoid area. For children, the anterolateral aspect of the thigh is also acceptable. The gluteal area should never be used for rabies vaccine injections because observations suggest administration in this area results in lower neutralizing antibody titers.

If exposed to rabies, previously vaccinated persons should receive two IM doses (1.0 ml each) of vaccine, one immediately and one three days later.

Previously vaccinated persons are those who have received one of the recommended preexposure or postexposure regimens of HDCV, PCECV, or those who received another vaccine and had a documented rabies antibody titer. HRIG is unnecessary and should not be administered to these persons because an
anamnestic response will follow the administration
of a booster regardless of the pre-booster antibody titer.

Animal bites must be reported to Animal Control at (951) 358-7387. A reporting form is available on the Disease Control web site in the Provider's Section. Clinicians can contact Disease Control at (951) 358-5107 for questions on Rabies PEP.

Table 2: Postexposure Prophylaxis For Non-Immunized Individuals

Treatment	Regimen
Wound cleansing	All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
HRIG	If possible, the full dose should be infiltrated around any wound(s) and any remaining volume should be administered IM at an anatomical site distant from vaccine administration. HRIG should not be administered in the same syringe as vaccine. Because RIG might partially suppress active production of antibody, no more than the recommended dose of 20 IU/Kg body weight should be given. If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh day, HRIG is not recommended since an antibody response to the vaccine is presumed to have occurred.
Vaccine	HDCV or PCECV,1.0mL, IM (deltoid area †), one each on days 0 §, 3, 7, 14, and 28.

Table 3: Postexposure Prophylaxis For Previously Immunized Individual

Treatment	Regimen
Wound cleansing	All postexposure prophylaxis should begin with immediate thorough cleansing of all wounds with soap and water. If available, a virucidal agent such as povidine-iodine solution should be used to irrigate the wounds.
HRIG	RIG should not be administered.
Vaccine	HDCV or PCECV 1.0 ml, IM (deltoid area), one each on days 0 and 3.

 

 

 

 

 

Click here to view the Rabies Post-Exposure Prophylaxis Guide - Riverside County

 

Rabies Vaccine	Contact Information
HDCV	Human Diploid Cell Vaccine (HDCV) Imovax® Rabies Sanofi Pasteur Phone: (800) VACCINE (822-2463) Website: www.vaccineplace.com/products/
PCEC	Purified Chick Embryo Cell (PCEC) Vaccine, RabAvert® Novartis Vaccines and Diagnostics Phone: (800) 244-7668 Website: http://www.rabavert.com
HRIG	Contact Information
	Imogam® Rabies-HT Sanofi Pasteur Phone: (800) VACCINE (822-2463) Website:www.vaccineplace.com/products/
	HyperRABTM S/D Talecris Biotherapeutics  Phone: (800) 243-4153 Website: www.talecris-pi.info

 

 

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NEWS BRIEFS

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Multidrug Resistant Organisms a Growing Concern for Patient Management

Drug resistant organisms are a growing concern for healthcare facilities. Multi-drug resistant organisms (MDROs) such as methicillin-resistant staphylococcus aureus (MRSA); vancomycin-resistant enterococci (VRE); multi-drug resistant tuberculosis (MDR-TB) and extremely drug resistant tuberculosis (XDR-TB) present treatment challenges for the clinician. Some strains of acinetobacter baumanii have become resistant to all antimicrobial agents, making the infected individual untreatable. This organism has been identified in intensive care unit patients and long term care facility residents. Control of MDRO’s in congregate settings is crucial to prevent disease outbreaks.

Increased lengths of stay, costs and mortality have been associated with MDROs. The emergence of new epidemic strains of MRSA in the community in patients without identified risk factors indicates there may be new challenges for the control of MRSA in health care settings.

A variety of resources are provided below to assist clinicians and school personnel in the management of MRSA.

Resources for Physicians and Other Health Care Providers

• CDC, AMA, and Infectious Diseases Society of America algorithm: Outpatient management of skin and soft tissue infections in the era of community-acquired MRSA, including options for Antimicrobial treatment:
  http://www.cdc.gov/ncidod/dhqp/pdf/ar/AMA_Flyer_Final.pdf
  
  
• CDC presentation on CA-MRSA for clinicians:
  http://www.emergency.cdc.gov/coca/callinfo.asp
  
  
• Strategies for Clinical Management of MRSA in the Community: Summary of an Experts’ Meeting Convened by the Centers for Disease Control and Prevention
  http://www.cdc.gov/ncidod/dhqp/pdf/ar/CAMRSA_ExpMtgStrategies.pdf
  
  
• CDC questions and answers on community-associated MRSA for physicians:
  http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_clinicians.html
  
  

Resources for patients

• California Department of Public Health (CDPH): A Parent’s Guide to MRSA in California:
  http://www.cdph.ca.gov/healthinfo/discond/Documents/MRSAParentsGuide.pdf
  
  
• Methicillin-Resistant Staphylococcus aureus for Athletes (CDPH):
  http://www.cdph.ca.gov/healthinfo/discond/Documents/CAMRSAForAthletes.pdf

Resources for schools

• Skin Infections and MRSA for California Schools (CDPH):
  http://www.cdph.ca.gov/healthinfo/discond/Documents/07MRSAschool.pdf
  
  
• Community-Associated (CA-MRSA)/Staph Infections - A Guideline for Athletic Departments (CDPH): http://www.cdph.ca.gov/healthinfo/discond/Documents/CAMRSAInfectionsGuidelineAthleticsDepartment.pdf

General resources

• CDC:
  http://www.cdc.gov/ncidod/dhqp/ar_mrsa_ca_public.html
  
  
• CDPH:
  http://www.cdph.ca.gov/healthinfo/discond/Pages/MRSA.aspx

Reporting Please report any clusters or outbreaks, including those of MRSA to: County of Riverside Department of Public Health Disease Control Branch at (951) 358-5107 After Hours: (951) 782-2974 Individual cases of MRSA are not reportable.

FDA Expands Age Range for Use of Bacterial Meningitis Vaccine

The U.S. Food and Drug Administration recently expanded the approved age range for Menactra, a bacterial meningitis vaccine, to include children ages 2 to 10 years.

The Centers for Disease Control and Prevention’s (CDC) Advisory Committee on Immunization Practices (ACIP) currently recommends meningococcal vaccination for children ages 2 to 10 years who are at increased risk of developing meningococcal disease, such as those who have had their spleen removed or whose spleen is not functioning; those with terminal complement component deficiency which makes it difficult to fight infection; and those who expect to travel to areas outside of the United States where the disease is common. Vaccination is also used to control outbreaks of bacterial meningitis.

Menactra’s effectiveness was measured in clinical trials that included people ages 2 to 55 years. The vaccine was shown to produce an immune response one month after vaccination. The safety of Menactra was evaluated in eight clinical studies that included a total of 10,057 participants who received Menactra and 5,266 participants who received Menomune. The most common adverse events reported in the studies were pain at the injection site and irritability. Diarrhea, drowsiness, and lack of appetite were also common.

While not observed in these clinical trials, Guillain-Barre syndrome (GBS), was noted as a possible but unproven risk in some adolescents following immunization with Menactra occurring in an estimated 1 in 1 million vaccine recipients. As a precaution, people who have previously been diagnosed with GBS should not receive Menactra.

Burkholderia pseudomalli Is Now Reportable by Laboratories

Burkholderia pseudomalli (Melioidosis) was made reportable by laboratories, effective June 12, 2007. This organism, considered a potential agent for biological warfare and biological terrorism (BT), is designated as a Category B agent.

These agents are the second highest priority agents because they:

• Are moderately easy to disseminate;
• Can result in moderate morbidity rates and low mortality rates; and
• Require specific enhancements of CDC’s diagnostic capacity and enhanced disease surveillance.

A laboratory recently reported a positive culture for Burkholderia pseudomalli from a wound found on a 64 year-old-male. The individual was treated and is recovering. Although there was no indication of BT related activity, it is important for clinicians to be aware of this organism. Please refer to the “Frequently Asked Questions” below for additional information.

Reporting Requirements for Hepatitis C

Any laboratory with a positive Hepatitis C virus (HCV) test which meets the CDC laboratory criteria for diagnosis of HCV infection in a California resident must report the positive test to Public Health. The following tests are reportable:

1. All HCV positive recombinant immunoblot assay (RIBA) tests:
2. All HCV RNA positive tests [e.g., nucleic acid tests (NAT)]
3. All HCV genotype reports; and
4. Anti-HCV reactive by a screening test [e.g., enzyme immunoassay (EIA) or chemiluminescence immuneassay (CIA)] with either:
   
   (A) The exact signal-to-cut-off (s/co) ratio or index value; or
   
   (B) A comment that indicates whether or not the screening tests a s/co ratio or index value is predictive of a true positive as determined for the particular assay as defined by the CDC in the case definition for “laboratory criteria for diagnosis” of Hepatitis C virus infection, past or present. The url for the s/co ratios that meet the CDC case definition is http://www.cdc.gov/ncidod/diseases/hepatitis/c/sc_ratios.htm.

For reactive anti-HCV screening test, (e.g. EIA pr CIA test) without a specific s/co or index value reported), the laboratory report MUST include a comment to indicate that the s/co or index value is low and that supplemental testing (e.g. RIBA or NAT) is recommended by the CDC.

MELIOIDOSIS - FREQUENTLY ASKED QUESTIONS

What is melioidosis?

Melioidosis, also called Whitmore's disease, is an infectious disease caused by the bacterium Burkholderia pseudomallei. Melioidosis is clinically and pathologically similar to glanders disease, but the ecology and epidemiology of melioidosis are different from glanders. Melioidosis is predominately a disease of tropical climates, especially in Southeast Asia where it is endemic. The bacteria causing melioidosis are found in contaminated water and soil. Humans and animals are believed to acquire the infection by inhalation of dust, ingestion of contaminated water, and contact with contaminated soil especially through skin abrasions, and for military troops, by contamination of war wounds. Glanders is contracted by humans from infected domestic animals.

Many animal species are susceptible to melioidosis. These include sheep, goats, horses, swine, cattle, dogs, and cats.

What are the symptoms of melioidosis?

Illness from melioidosis can be categorized as acute or localized infection, acute pulmonary infection, acute bloodstream infection, and chronic suppurative infection. Non-apparent infections are also possible. The incubation period is not clearly defined, but may range from 2 days to many years.

• Acute, localized infection: This form of infection is generally localized as a nodule and results from inoculation through a break in the skin. The acute form of melioidosis can produce fever and general muscle aches, and may progress rapidly to infect the bloodstream.
  
  
• Pulmonary infection: This form of the disease can produce a clinical picture of mild bronchitis to severe pneumonia. The onset of pulmonary melioidosis is typically accompanied by a high fever, headache, anorexia, and general muscle soreness. Chest pain is common, but a nonproductive or productive cough with normal sputum is the hallmark of this form of melioidosis.
  
  
• Acute bloodstream infection: Patients with underlying illness such as HIV, renal failure, and diabetes are affected by this type of disease, which usually results in septic shock. The symptoms of the bloodstream infection vary depending on the site of original infection, but they generally include respiratory distress, severe headache, fever, and diarrhea, development of pus-filled lesions on the skin, muscle tenderness, and disorientation. This is typically an infection of short duration, and abscesses will be found throughout the body.
  
  
• Chronic suppurative infection: Chronic melioidosis is an infection that involves the organs of the body. These typically include the joints, viscera, lymph nodes, skin, brain, liver, lung, bones, and spleen.

Burkholderia pseudomallei

Can melioidosis be spread from person to person?

Melioidosis can spread from person to person by contact with the blood and body fluids of an infected person. Two documented cases of male-to-female sexual transmission involved males with chronic prostatic infection due to melioidosis.

Is there a treatment for melioidosis?

Burkholderia psuedomallei, the organism that causes melioidosis, is usually sensitive to imipenem, penicillin, doxycycline, amoxicillin-clavulanic acid, azlocillin, ceftazidime, ticarcillin-vulanic acid, ceftriaxone, and aztreonam. Treatment should be initiated early in the course of the disease. Although bloodstream infection with melioidosis can be fatal, the other types of the disease are nonfatal. The type of infection and the course of treatment can predict any long-term sequelae.

 

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Monthly Morbidity Report

Latest report is available on the Disease Control web site.

Source: Disease Control Program, Department of Public Health, Community Health Agency, County of Riverside
Compiled: Epidemiology & Program Evaluation Branch

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