GARY M. FELDMAN, M.D., FAAP, FABMG Public Health Officer
	COUNTY OF RIVERSIDE PUBLIC HEALTH DISPATCH
COMMUNITY HEALTH AGENCY • DEPARTMENT OF PUBLIC HEALTH • 4065 COUNTY CIRCLE DRIVE, RIVERSIDE, 92503
	FALL/WINTER 2004

CURRENT STATUS OF INFLUENZA VACCINE

       The California Department of Health Services (CDHS) began distributing influenza vaccine to local health departments at the end of October. The health department is charged with assessing the need for influenza vaccine in Riverside County. Hospitals, long term care facilities, and Vaccine For Children providers have been surveyed to assess which facilities, have received or expect to receive, influenza vaccine in the near future. All providers must adhere to the Public Health Order to Control Influenza Vaccination. Dr. Richard Jackson, California Public Health Officer, issued the order in response to the shortage of influenza vaccine. The goal is to ensure that individuals at highest risk have the opportunity to be vaccinated. High risk categories include:

• Individuals 65-years and older
• Individuals with chronic health problems, such as; asthma, diabetes, TB, HIV/AIDS, and heart disease
• Infants 6-months to 23-months of age
• Healthcare workers with direct patient contact
• Women pregnant during the flu season
• Children on chronic aspirin therapy
• Household contacts and out-of-home caregivers of children 0-6 months of age

The responses by CDHS to frequently asked questions about the 2004-05 influenza vaccine shortage are provided for your reference.

Does the CDHS Order to Control Influenza Vaccination apply to pharmacists?

Yes. The State Health Order that mandates all healthcare providers vaccinate in high risk categories only. A healthcare provider is defined as “any person authorized under the laws of California to administer influenza vaccinations”. California B&P code 4052 allows pharmacists to administer immunizations outside a licensed healthcare facility while under the supervision of a prescribing physician; the health order applies to pharmacists.

Does CDC recommend using partial doses of influenza vaccine?

No. CDC does not advise using less than recommended dosages of inactivated influenza vaccine (TIV or flu shot) regardless of the health or risk-category of the individual. Although a few studies have assessed the antibody response to one-half of the normal dose of inactivated influenza vaccine in healthy adults aged 18-49 years, influenza vaccine is not approved by the Food and Drug Administration for use at reduced doses. There is no data on whether partial doses of the current 2004-05 vaccine would provide an adequate antibody response.

With the vaccine shortage, what are recommendations for use of antivirals for outbreaks in long term care facilities for both residents and healthcare workers?

An influenza outbreak in a long term care facility is defined as an increase in the incidence (number of new cases per time interval) of illness over baseline. In June, because influenza is normally a seasonal infection, the number of new cases of influenza would be expected to be zero. However, in October through April the number of new cases may exceed baseline. When the incidence exceeds baseline (zero) by 2 or 3 cases in as many days, the facility is most likely experiencing an outbreak. Studies of prophylaxis using antivirals have shown good benefit, with 70-90% efficacy in preventing influenza after exposure in nursing homes and long term care facilities. When institutional outbreaks occur, CDHS recommends that antiviral chemoprophylaxis be administered to all residents in nursing home settings as soon as possible. Chemoprophylaxis should continue for at least 2-weeks. If surveillance indicates that new cases continue to occur, chemoprophylaxis should be continued until approximately 1-week after the end of the outbreak. Chemoprophylaxis also can be offered to unvaccinated staff who provide care to persons at high risk. Prophylaxis should be considered for all employees, regardless of their vaccination status, if the outbreak is caused by a variant strain of influenza A that is not well matched by the vaccine.

Who should receive the remaining doses of LAIV (FluMist®) for the 2004-05 influenza seasons?

Available doses of LAIV in California should be given only to healthy, non-pregnant persons aged 5-49 years who are either:

• Healthcare workers involved in direct patient care, with a few exceptions (see next question); OR
• Out-of-home caregivers and household contacts of children aged <6-months

Persons in these groups may receive either LAIV or inactivated vaccine (TIV or flu shot). TIV is preferred for healthcare workers who have contact with severely immunosuppressed patients, such as bone marrow transplant recipients, who are under treatment in special isolation units. Healthy persons aged 5-49 years who do not belong to either of these groups should not be immunized with LAIV or TIV during the 2004-2005 influenza seasons to maximize the doses available for individuals in high-priority groups.

LAIV is contraindicated in those with a history of:

• Severe (anaphylactic) allergy to eggs or other vaccine components, who also should not receive TIV; both TIV and LAIV use hen’s eggs in their production.
• Guillain-Barre’ Syndrome, individuals should consult their provider about whether to receive TIV.

Which healthcare workers may administer LAIV?

Severely immunosuppressed persons should not administer LAIV (but are unlikely to be working in a healthcare setting). Other persons at high risk for influenza complications may administer LAIV. These include persons with underlying medical conditions placing them at high risk, pregnant women, and person aged >50 years. The use of gloves or masks is not required when administering LAIV.

What measures can be taken in patient care settings to reduce transmission of influenza and other respiratory infections?

Medical providers and immunization clinics are advised to incorporate components of a respiratory hygiene program in the office or clinic as follows:

• Place a box of surgical masks as close to the entry as possible
• Provide masks to all patients with symptoms of a respiratory illness with instructions to patients on their proper use and disposal
• For patients who cannot wear a mask, provide tissues and instructions to cover the mouth and nose when coughing or sneezing
• Provide a readily accessible waterless hand hygiene product
• Separate patients with respiratory illness from other patients by either placing them in a cubicle, examination room or some physical separation of at least 3 feet.

Enhanced Surveillance

       The Department of Public Health is participating with the California Department of Health Services on several important enhanced surveillance activities. These include; avian influenza, pediatric cases hospitalized in ICU and influenza testing through sentinel sites utilizing rapid test kits. In light of the vaccine shortage these surveillance activities are critical to monitor disease activity in the community. Please contact Disease Control at (951) 358-5107 if you did not receive the Public Health Advisory or need additional information on these important surveillance activities.

Effective Management of Late Latent Syphilis

       Effective management is important for early and latent syphilis cases. Significant syphilis activity continues in the Coachella Valley. Seventy seven infectious cases were reported as of 8/04 compared to 75 cases during the same time period last year. Early and appropriate screening and treatment are essential to decrease progression of disease to latent stages. A synopsis of treatment and management of late latent syphilis (MMWR2002) is outlined below.

Late Latent Syphilis Treatment and Management Considerations for Adults MMWR 2002

All patients who have latent syphilis should be evaluated clinically for evidence of tertiary disease. Patients who have syphilis and who demonstrate any of the following criteria should have a prompt CSF examination:

• Neurologic or ophthalmic signs or
symptoms;
• Evidence of active tertiary syphilis (e.g., aortitis, gumma, and iritis);
• Treatment failure; or
• HIV infection with late latent syphilis or syphilis of unknown duration.

If dictated by circumstances and patient preferences, a CSF examination may be performed for patients who do not meet these criteria. Some specialists recommend performing a CSF examination on all patients who have latent syphilis and a non-treponemal serologic test of >1:32. The risk of neurosyphilis in this circumstance is unknown. If a CSF examination is performed and the results indicate abnormalities consistent with neurosyphilis, the patient should be treated for neurosyphilis. If a patient misses a dose of penicillin in the course of weekly therapy for late syphilis, the appropriate course of action is unclear. Pharmacologic considerations suggest that an interval of 10-14 days between doses of benzathine penicillin for late syphilis or latent syphilis of unknown duration might be acceptable before restarting the sequence of injections. Missed doses should not be considered acceptable for pregnant patients receiving therapy for late latent syphilis; pregnant women who miss any dose of therapy must repeat the full course of therapy.

Recommended Regimen

Benzathine penicillin G 7.2 million units total, administered as three doses of 2.4 million units IM each at 1-week intervals.

Follow-up: Quantitative non-treponemal serologic tests should be repeated at 6, 12, and 24 months. Patients with a normal CSF examination should be re-treated for latent syphilis if, a) titers increase fourfold, b) an initially high titer (>1:32) fails to decline at least fourfold (i.e., two dilutions) within 12-24 months of therapy, or c) signs or symptoms attributable to syphilis develop. In rare instances, despite a negative CSF examination and a repeated course of therapy, serologic titers may still not decline. In these circumstances, the need for additional therapy or repeated CSF examinations is unclear.

Penicillin Allergy: The effectiveness of alternatives to penicillin in the treatment of latent syphilis has not been well documented. Non-pregnant patients allergic to penicillin who have clearly defined early latent syphilis should respond to therapies recommended as alternatives to penicillin for the treatment of primary and secondary syphilis (see Treatment of Primary and Secondary Syphilis in 2002 CDC Treatment Guidelines). The only acceptable alternatives for treatment of late latent syphilis or latent syphilis of unknown duration are doxycycline (100 mg orally twice daily) or tetracycline (500 mg orally four times daily) both for 28 days. These therapies should be used only in conjunction with close serologic and clinical follow-up. The efficacy of these alternative regimens in HIV infected persons has not been studied, and thus must be considered with caution.

Third Dose of Pneumococcal Conjugate Vaccine (PCV7) Reinstated

       The third dose of PCV7 had been deferred for healthy children since March of this year due to production problems with the vaccine. However, the production problems appear to have been resolved so the third dose can now be given to children who would have normally been eligible to receive it.

It is important for clinicians to be aware that healthy children who receive their first dose of PCV7 at less than 7-months of age will continue to have the fourth (booster) dose deferred. Also, healthy children 12-23 months of age who have not received any previous doses of PCV7 can now receive 2 doses, 2 months apart. PCV7 is still not recommended at this time for healthy children 24-59 months of age.

Medical providers should continue to use the standard full-dose schedule to vaccinate all children at risk for invasive pneumococcal disease.

Please see the updated recommendations for use of Pneumococcal Conjugate Vaccine.

NEWS BRIEFS

Brucellosis

       Brucellosis is a Category B Agent for Bioterrorism. Although only a limited number of cases are reported in Riverside County, it is important for clinicians to be aware of patients presenting with signs and symptoms suggestive of this systemic bacterial disease.

The clinical syndrome includes non-specific flu-like symptoms, fever, headache, chills, profound weakness, fatigue, and gastrointestinal symptoms. Bronchopneumonia abscesses, enlarged hilar nodes, or effusions may be seen on chest x-ray. Confirmatory culture and serological testing is available through the public health laboratory network. Please contact the Public Health Lab at (951) 358-5070 for questions on specimen submission.

Cattle, swine, goats, and sheep are reservoirs for the infectious agent, which vary according to geographic area. Brucellosis is primarily an occupational disease of individuals working with infected animals or their tissues.

Brucellosis must be reported to Public Health immediately by telephone at (951) 358-5107.

West Nile Virus Activity Slows in Riverside County

       The number of new human cases of West Nile Fever had declined over the last several weeks. Data from the California Department of Health Services indicate that 790 human infections with 23 WNV related deaths. As of 10-29-04, 101 cases and 9 asymptomatic blood donors have been reported in Riverside County. Of these cases 57% are WNV Fever and 43% experienced neuroinvasive disease. Two fatalities attributed to WNV have occurred. To date the majority have occurred in western Riverside County with only 5 cases being reported in the eastern portion of county. However, the Coachella Valley Mosquito and Vector Control District is reporting significant increases in mosquito activity. Thus it is important that clinicians continue to maintain a high index of suspicion for WNV when patients present with signs and symptoms suggestive of encephalitis or meningitis.

WNV is reportable to the Department of Public Health. West Nile Case History reports may be faxed to Disease Control at (951) 358-5102.

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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, RL 11/02/04

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