 |
GARY
M. FELDMAN, M.D., FAAP, FABMG Public Health Officer |
|
|
PUBLIC HEALTH DISPATCH |
||
|
COMMUNITY
HEALTH AGENCY • DEPARTMENT OF PUBLIC HEALTH • 4065 COUNTY CIRCLE
DRIVE, RIVERSIDE, 92503 |
||
FALL/WINTER
2005 |
|
|
THE AVIAN INFLUENZA THREAT
The World Health Organization (WHO) has warned that a highly pathogenic form of avian influenza could mutate into a virus that is easily transmitted between humans, with the potential of causing a worldwide pandemic. WHO presented the following findings:
- No virus of the H5N1 subtype probably has ever circulated among humans, and certainly not within the lifetime of today’s world population. Population vulnerability to an H5N1-like pandemic virus would be universal.
- Many of the public health interventions that successfully contained Severe Acute Respiratory Syndrome (SARS) will not be as effective against a disease that is far more contagious, has a short incubation period, and can be transmitted prior to the onset of symptoms.
- Evidence strongly indicates that H5N1 now is endemic in parts of Asia, having established a permanent ecological niche in poultry. The risk of further human cases will continue, as will opportunities for a pandemic virus to emerge.
- Studies comparing virus samples over time show H5N1 has become progressively more pathogenic in poultry, and in the mammalian mouse model. It is now hardier than in the past, surviving several days longer in the environment. Evidence further suggests H5N1 is expanding its mammalian host range.
- Recent publications have suggested similarities between H5N1 and the 1918 virus in the severity of disease, its concentration in the young and healthy, and the occurrence of primary viral pneumonia in the absence of secondary bacterial infection.
- All prerequisites for the start of a pandemic have been met except one, namely the onset of efficient human-to-human transmission. Should the virus improve its transmissibility, everyone in the world would be vulnerable to infection by a pathogen passed along by a cough or sneeze.
Advance planning for pandemic influenza is essential to ensure a prompt and effective response. It is important for Public Health to collaborate with hospitals and the medical community to address this emerging public health threat.
INFECTION CONTROL AND AVIAN INFLUENZA RECOMMENDATIONS
The Centers for Disease Control and Prevention (CDC) has issued recommendations for infection control in health care facilities to prevent possible spread of avian influenza.
Patients who present to a health care setting with fever and respiratory symptoms should be managed according to recommendations for respiratory hygiene and cough etiquette and should be questioned regarding recent travel history. Those with a history of travel within 10 days to a country with avian influenza activity should be managed using isolation precautions outlined below.
Standard Precautions
- Pay careful attention to hand hygiene before and after patient contact or contact with items potentially contaminated with respiratory secretions.
Contact Precautions
- Use Gloves and gown for all patient contact.
- Use dedicated equipment such as stethoscopes, disposable blood pressure cuffs, disposable thermometers, etc.
Eye Protection (i.e., goggles or face shield)
- Wear protection when within 3 feet of patients.
Airborne Precautions
- Place patient in an airborne isolation room (AIR). These should have monitored negative air pressure in relation to corridor, with 6 to 12 air changes per hour (ACH), and exhaust air directly outside or re-circulated air filtered by a high-efficiency particulate air (HEPA) filter. If an AIR is unavailable, the facility engineer should be contacted to assist or use portable HEPA filters to augment the number of ACH.
- Use a fit tested respirator, at least as protective as a National Institute of Occupational Safety and Health-approved N-95 filtering (i.e., disposable) respirator, when entering the room. These precautions should be continued for 14 days after onset of symptoms or until either an alternative diagnosis is established or diagnostic test results indicate the patient is not infected with influenza A virus. Patients managed as outpatients or hospitalized patients discharged before 14 days with suspected avian influenza should be isolated in the home setting. For additional information regarding these and other health care isolation precautions, see Guidelines for Isolation Precautions in Hospitals (www.cdc.gov/ncidod/hip/ISOLAT/Isolat.htm).
CASE DEFINITION FOR AVIAN INFLUENZA
Hospitalized patients with:
- Radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which and alternate diagnosis has not been established, AND
- History of travel within 10 days of symptom onset to a country with documented H5N1 avian influenza in poultry and/or humans (see above or visit the Web site of the World Organization of Animal Health (OIE) at http://www.oie.int/eng/en_index.htm) OR
Hospitalized or ambulatory patients with:
- Documented temperature of >38°C (>100.4° F), AND
- One or more of the following: cough, sore throat, shortness of breath, AND
- History of contact with poultry (e.g., visited a poultry farm, a household raising poultry, or a bird market) or a known or suspected human case of influenza A (H5N1) in an H5N1-affected country within 10 days of symptom onset.
Suspect avian influenza cases should be reported immediately to Disease Control by telephone (951) 358-5107, after hours (951) 782-2974.
Immunization Registries Benefit Victims of Hurricane Katrina
Whenever a natural disaster strikes, no one can predict the magnitude or effects on the population. Such was the case recently with Hurricane Katrina. Countless people from Louisiana, Mississippi and Alabama have not only lost homes and possessions, but personal records as well. Thousands of residents were evacuated, and many of them have settled in the Inland Empire. In the midst of the destruction, immunization registries have demonstrated their value repeatedly by assisting in the recovery of children’s immunization records.
Although special provisions were made to ensure that relocated children could get enrolled into local schools without proof of immunizations, the parent of these children needed to provide proof of immunizations within 30 days. Fortunately, each of the states affected by Hurricane Katrina had an operational state-wide immunization registry. More than 30 states were given “view only” access to the Louisiana Immunization Network for Kids Statewide (LINKS), the Mississippi Patient Management Information System (PMIS) and the Alabama Immunization Registry (ImmPRINT) through their respective websites within a few days of the evacuees’ arrival. In Riverside County, VaxTrack Immunization Registry staff has queried both the Louisiana and Mississippi registries to search for the electronic immunization records of 140 children whose parents have settled in the Inland Empire. Immunization records were found for 99 of these children. Being able to provide the parents with copies of their children’s immunization records provides extra assurance that no delays will occur with school registration, and more importantly, that immunizations will not be repeated needlessly.
Because disasters can strike without warning, it is important to be prepared. One way that health care professionals can be prepared is to participate in their local immunization registry. Currently in Riverside County, there are more than 130 private providers who have signed up with the VaxTrack Regional Immunization Registry. VaxTrack currently has more than 320 public and private providers, schools and day care organizations that submit children's immunization records to the registry. If you would like to enroll in VaxTrack or just learn more about the registry, please call Letty Cherry, VaxTrack Program Manager at (951) 354-1400, or (toll free 1-(866)-434-8774).
NEWS BRIEFS
INCREASED PERTUSSIS ACTIVITY
Increased pertussis activity has been noted in Riverside County and other parts of California. Thirty-four cases have been reported in Riverside County through August
30, 2005 compared to 11 cases during the same time period last year. Fifty percent of the cases were under 1 year of age; with 29% occurring in school age children ranging from 5 to 15 years of age. Although pertussis is usually diagnosed in children, seven cases occurred in individuals19 to 58 years of age.The California Department of Health Services indicated that through August 2005, 1276 cases of pertussis, with 4 infant deaths occurred in the state. Four hundred and
fifty cases were reported during the same time period in 2004.The clinical manifestations of pertussis vary with age and immunity. Classic pertussis is a cough lasting > 2 weeks with paroxysmal coughing with post-tussive whoop or vomiting. This presentation is more common in non-immune children between 1 and 10 years of age. Infants aged less than 6 months may have apnea without paroxysms or whoop. Adolescents and adults who have been previously immunized or infected may have only prolonged cough. Recognition and diagnosis are important, since close contacts and high risk contacts may benefit from prophylactic or early symptom treatment. Disease Control should be consulted for questions on the management of contacts.
It is important to report confirmed and suspect pertussis cases to Disease Control within 1 day of diagnosis. Reports may be called to (951) 358-5107 or fax (951) 358-5102.
Two Tetanus Toxoid, Reduced Diphtheria Toxoid and Acellular Pertussis Vaccine, Adsorbed (Tdap) products were licensed by the FDA in 2005 as single dose booster vaccines to provide protection against tetanus, diphtheria, and pertussis. GlaxoSmithKline’s BOOSTRIXÒ is indicated for persons aged 10 – 18 years and Sanofi Pasteur’s ADACELä is indicated for persons aged 11 – 64 years. On June 30, 2005 the Advisory Committee on Immunization Practices (ACIP) voted to recommend the routine use of Tdap vaccines in adolescents aged 11 – 18 years in place of tetanus and diphtheria toxoids (Td) vaccines. Tdap is administered as a single dose 0.5ml intramuscularly in the deltoid, using a 1” needle for all IM injections. Please see (www.cdc.gov/nip/pr/pr tdap jun2005.htm).
Every year approximately 2,600 people develop meningococcal disease in the U.S. Ten to 15% of these cases are fatal in spite of treatment with antibiotics. Meningococcal disease often begins with symptoms that can be mistaken for common illnesses, such as the flu. The disease’s clinical features include fever, headache,
and stiff neck in meningitis cases; with sepsis and rash in meningococcemia. Of those who recover from this devastating disease, another 10% - 15% suffer permanent hearing loss, limb amputations, mental retardation, seizures, or stroke.N. meningitides is the leading cause of bacterial meningitis in children 2-18 years of age in the U.S. and is generally spread though direct contact with respiratory secretions from a nasopharyngeal carrier though coughing, sneezing, and kissing.
To foster the most rapid reduction of meningococcal disease, the Advisory Committee on Immunization Practice (ACIP) recommended that for the next 2-3 years, teens entering high school be vaccinated in addition to students entering college. In addition college freshmen who live in dormitories are at higher risk of meningococcal disease than other college students and should also be vaccinated. Meningococcal vaccine may be provided to college students who do not live in dormitories and adolescents who want to reduce their risk from meningococcal disease.
FDA and CDC Issue Alert on Menactra Meningococcal and Guillain Barre Syndrome
The Food and Drug Administration (FDA) and Centers for Disease Control and Prevention (CDC) are alerting consumers and health care providers about five reports of Guillain Barre Syndrome (GBS) following administration of meningococcal conjugate vaccine A, C, Y and W135 (trade name Menactra) manufactured by Sanofi Pasteur. It is not known yet whether these cases were caused by the vaccine or are coincidental. FDA and CDC are sharing this information with the public now and actively investigating the situation because of its potentially serious nature.
GBS is a serious neurological disorder that can occur often in healthy individuals, either spontaneously or after certain infections. GBS typically causes increasing weakness in the legs and arms that can be severe and require hospitalization.
Meningococcal infection, which Menactra prevents, is a major cause of bacterial meningitis, affecting approximately 1 in 100,000 people annually. The infection can be life threatening. Ten to 14 percent of cases are fatal.
According to Jesse Goodman, MD, Director of FDA’s Center for Biologics Evaluation and Research, at the present time there are no changes in recommendations for vaccination; individuals should continue to follow their doctors’ recommendations. The current information is very preliminary and the two agencies are continuing to evaluate the situation. Because of the potentially serious nature of this matter, FDA and CDC are asking any persons with knowledge of any possible cases of GBS occurring after Menactra to report them to the Vaccine Adverse Event Reporting System (VAERS) to help the agencies further evaluate the matter. Individuals can report to VAERS on the web at www.vaers.hhs.gov or by phone at 1-800-822-7967.
The Department of Public Health has requested hospitals identify and report cases of GBS to Disease Control. One probable case has been reported through November 2005.
Based on several surveillance projects, the California Department of Health Services has reported that influenza activity in the state continues to be sporadic. Enhanced surveillance has identified 7 pediatric cases ranging in age from 5 weeks to 10 years. Laboratory testing confirmed influenza A in six of the cases. One case of Influenza encephalitis was fatal.
Clinicians are reminded of the importance of vaccinating high risk patients. Although some vaccine shipments have been delayed, there is still sufficient time to vaccinate and protect health care workers and patients against influenza.
MENINGOCOCCAL CONJUGATE VACCINE
MCV4 Vaccination Schedule:
ImmunobiologicPrimary Schedule
Revaccination Schedule
Menactra
(Sanofi pasteru)
Single dose: 0.5 mL
Intramuscular (IM) in the deltoid region
Vaccine supplied in single dose vials – no reconstitution required
Revaccination schedule has not been established
Revaccination with MCV4 may be indicated within 3-5 years for persons age > 11 years previously vaccinated with MPSV4 who remain at high-risk for meningococcal disease (i.e., those with terminal complement deficiency, anatomic or functional asplenia, or HIV, or travelers
Indications:
MCV4 is licensed for adolescents and adults 11-55 years of age for the prevention
of invasive meningococcal disease caused by N. meningitidis serogroups A, C, Y, and W-135. The
following groups are recommended to be vaccinated:
Under the Vaccines for Children (VFC) Program, MCV4 is available for adolescents 11
through 18 years of age. If vaccine supplies are limited, priority should be given to those
listed above.
Contraindications and Precautions:
Adverse Reactions:
Vaccine Storage and Handling:
Monthly Morbidity ReportLatest 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
| Contact
Persons: |
Health Officer (951) 358-5058 Assistant Health Officer (951) 358-4487 Director, Disease Control / Editor (951) 358-5107 |
CLICK HERE FOR PAST ISSUES of Public Health Dispatch