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
 
SPRING 2004

DISEASE REPORTING REQUIREMENTS UPDATED FOR 2004

       Riverside County Department of Public Health added Severe Acute Respiratory Syndrome (SARS) and West Nile Virus (WNV) to the list of reportable diseases in 2003. Suspected cases of SARS must be immediately reported to Disease Control at (909) 358-5107 during business hours, or (909) 782-2974 after hours, holidays, or weekends. Suspected, as well as confirmed cases of WNV must be reported within one (1) working day of identification. The significant change in reporting requirements for 2004 is the reporting of hospitalized varicella cases.

       It is also essential that organisms that pose a high risk of being used as a biological weapon be reported immediately to Public Health. Early recognition by clinicians of unusual occurrences or patterns of disease is a critical component of instituting a rapid response to a potential bio-terrorist event. These Category A Agents include:· Bacillus anthracis (anthrax)· Clostridium botulinum toxin (botulism)· Francisella tularensis (tularemia)· Variola major (smallpox)· Yersinia pestis (plague)· Filoviruses (Ebola virus, Marburg, hemorrhagic fever, and Arenaviruses, such as Lassa fever). These agents are a high priority because they can be easily disseminated or transmitted from person-to-person. Health care professionals should be aware of syndromes that may be indicative of a problem.

These include;

ENHANCED SURVEILLANCE FOR HOSPITALIZED PATIENTS WITH VARICELLA

       As of January 1, 2004 hospitals are required to report individuals hospitalized with primary or secondary diagnosis of varicella. It is important for prevention and control efforts to characterize hospitalized varicella cases and related complications. Evaluating vesicular lesions is an important aspect of rash surveillance which may be indicative of smallpox. Disease Control staff are available to assist with completion of the Varicella Surveillance Worksheet. Please contact Sharon Fortino at (909) 358-7119 if assistance is needed.

       Patients seen in outpatient settings who are diagnosed with varicella do not need to be reported. Please note that Varicella Zoster (Shingles) is also not reportable at this time.

       Disease reporting by the medical community and laboratories is essential to facilitate prompt intervention and containment activities. Updated Disease Reporting Requirements are included for your reference.

HIPPA: HEALTHCARE INFORMATION PRIVACY STANDARDS EXEMPT REPORTING TO PUBLIC HEALTH AGENCIES

Patient authorization is NOT required when you, as a healthcare professional or clinical laboratory director, suspect or diagnose a disease of public health importance that is reportable by law in California.

       The Department of Public Health still receives questions regarding the legality of disease reporting in light of the Health Insurance Portability and accountability Act of 1996 (HIPPA). Congress established the HIPPA regulations to safeguard personal medical information from inappropriate disclosure and misuse. Full implementation of these regulations was mandated in April 2003. While much has been written about HIPPA standards, health care providers continue to question the legality of communicable disease reporting without obtaining prior patient consent. New patient record privacy standards do not preclude sharing information with public health officers. In fact, HIPPAA regulations contain specific language permitting reporting to public health agencies of disease and conditions listed in state public health laws and regulation. Patient authorization is NOT required when you, as a healthcare professional or clinical laboratory director, suspect or diagnose a disease of public health importance that is reportable by law in California. The public health reporting exceptions are described in Section 164.512b (p. 82813-4) under “permitted disclosures."

       The full HIPPA regulations, background, and technical assistance are available at www.hhs.gov/ocr/hipaa.
Please contact Disease Control at (909) 358-5107 if additional information is needed.

TEMPORARY SUSPENSION OF THE THIRD AND FOURTH DOSE OF PNEUMECOCCAL CONJUGATE VACCINE (PREVNAR)

       Due to a shortage of Prevnar vaccines, CDC has recommended suspending the third and fourth dose for healthy children.

       Clinicians are asked to follow the temporary recommendations listed below:

1. Suspend routine administration of both the third and fourth doses to healthy children.
2. Vaccinate unvaccinated, healthy children aged 12 to 23 months with a single dose of PCV7.
3. Routine vaccination of healthy children between 24 and 59 months is not recommended.

       Immunization providers should continue to use the standard schedule to vaccinate children at increased risk for severe disease. Consult the March 5, 2004 issue of the MMWR for additional information on PCV7 vaccine supply and estimated effectiveness of the reduced number of doses. (www.cdc.gov/mmwr/preview/mmwrhtml/mm5308a5.htm)

CDC ADDS RASH ASSESSMENT TOOL

       The Centers for Disease Control and Prevention (CDC) has added a rash illness evaluation tool to its suite of smallpox related information included on the CDC website.

       The rash illness evaluation, found at http://www.bt.cdc.gov/agent/smallpox/diagnosis/riskalgorithm/index.asp, asks questions about the type of rash illness, followed by inquiries about major and minor smallpox criteria. After entering all requested information, users receive a computer-based evaluation of the risk for smallpox and are provided with recommendations. A link to the page is also found on the CDC’s main smallpox resource page at: http://www.bt.cdc.gov/agent/smallpox/index.asp.

       Smallpox posters are also available from Disease Control by calling (909) 358-5107.

DHHS Secretary Extends Smallpox Preparedness Programs

       In January, Health and Human Services Secretary Tommy Thompson signed a new emergency declaration on smallpox preparedness. The declaration extends current provisions allowing states to continue smallpox vaccination programs as part of comprehensive smallpox preparedness and allows the current liability and compensation programs to remain in force. For more information, contact George E. Hardy, MD of ASTHO at (202) 371-9090.

Smallpox Vaccine Injury Compensation Program

       A new Smallpox Vaccine Injury Compensation Program has been established. Funded at $42 million, the program provides financial and medical benefits to eligible members of a smallpox emergency response team who sustain certain medical injuries caused by a smallpox vaccine. There is also a provision relating to unvaccinated individuals inured after coming into contact with vaccinated members of a response team. In addition, the program provides benefits to survivors of eligible individuals whose death resulted from a covered injury.

       For more information about this program, check out www.hrsa.gov/smallpoxinjury.gov. Questions also may be directed to smallpox@hrsa.gov or (888) 496-0338.

West Nile Virus Has Been Identified in Riverside County

       Riverside County Department of Public Health was notified on 4/8/04 that three (3) Brown Headed Cow Birds in the Corona area tested positive for WNV as part of the Northwest Mosquito Abatement District wild bird surveillance program. The first positive findings in California for 2004 were from the dead bird surveillance program in Los Angeles and Orange counties.

       These findings are not unexpected based on the arrival of West Nile Virus in Southern Californialast year. To date there has been no report of human illness in Riverside County.

       Suspect cases should be reported to Disease Control at (909) 358-5107 or Faxed at (909) 358-5102. Testing for Anti-SLE, Anti-WEE, and Anti-WNV IgM will be done by the State Viral and Rickettsial Disease (VDR) Laboratory, which will forward the specimens to the State VDRL. Riverside County Public Health Laboratory will be performing EIAs on specimens submitted on individuals hospitalized with encephalitis or meningitis. A West Nile case history form must accompany specimens.

       Specific questions related to submission of specimens can be directed to the Department of Public Health Laboratory Manager, Janna Troy at (909) 358-5070.

Syphilis Activity Continues

       One hundred and five (105) infectious syphilis cases were reported in Riverside County in 2003, compared to 94 cases in 2002. The majority of cases have occurred in the Coachella Valley, with approximately 75% of the individuals co-infected with HIV.

       Primary and secondary syphilis are of particular concern because they facilitate HIV transmission and are highly contagious. Patients presenting with a generalized maculopapular rash, especially when the palms and soles of the feet are involved, should be screened for syphilis.

       The recommended treatment for primary, secondary and early latent syphilis is benzathine penicillin G 2.4 million units IM. Please contact Disease Control if you would like a copy of the 2002 Treatment Guidelines. It is important to immediately report any suspected or confirmed case of syphilis to Disease Control by phone at (909) 358-5107, or by Fax at (909) 358-5102.

       Cases in the Coachella Valley may be reported to the Indio Disease Control Office by phone at (760) 869-8448, or by Fax at (760) 863-8183.

Preparing for the Re-Emergence of SARS

       Although no cases of Severe Acute Respiratory Syndrome (SARS) have been reported in California in 2004, it is important for health care providers to maintain a heightened level of awareness for patients presenting with symptoms suggestive of SARS. The California Department of Health Services has requested that enhanced surveillance for SARS be maintained on an ongoing basis to ensure early detection should the disease re-emerge as a Public Health threat. It is important that hospitals and other health care facilities be prepared to contain the disease should it reappear.

       The Centers for Disease Control and Prevention (CDC) has emphasized that prevention must begin at the first point at which a person with suspect or probable SARS encounters the health care system. Specific guidelines are outlined below:

       Train personnel to query patients about respiratory symptoms and to observe for such symptoms in patients and visitors. Instruct personnel in procedures to follow with patients who are symptomatic.

1. Waiting rooms:

       As the infected patient (or an infected person accompanying the patient) waits for care, other people in the waiting area could be exposed. Steps for preventing exposures could include:

2. Respiratory etiquette:

       Because SARS primarily spreads via respiratory droplets, practicing respiratory etiquette is a simple intervention that confines infectious material at its source. To facilitate respiratory etiquette, outpatient facilities should consider:

3. Protecting the health care worker:

       When a patient with respiratory symptoms presents to an emergency department (ED) or outpatient office, there are numerous contact points at which opportunities arise for transmission, including triage and reception, waiting rooms, and examination by the health care provider.

       In preparing for the possibility that a patient may be a suspect or probable case of SARS, it is important to plan in advance where the examination will be conducted and what personal protective equipment (PPE) the provider will wear.

       Health care providers should wear a gown, gloves, respirator, and if the patient is coughing, a face shield or goggles. An N95 or higher respirator that has been fit-tested to the health care worker is the preferred respiratory protection for SARS. If respirators are not available, a surgical mask should be worn. Establish a protocol and provide training on the use of PPE.

4. Transport of patient:

       Preventing SARS transmission in an ED or outpatient facility requires consideration of such routine procedures as patient transport and movement in the office or ED setting:

       Preparing for SARS will assist health care facilities to prepare for other airborne pathogens, such as Smallpox.

NEWS BRIEFS

check Recall of Human Rabies Vaccine (Imovax Rabies - Aventis Pasteur)

       Aventis Pasteur has just announced that it is recalling 4 lots of Imovax® Rabies, Rabies Vaccine (Human Diploid Cell), that were distributed in the U.S. The four recalled lots and expiration dates are:
X0667-2    6/24/2006
X0667-3    6/24/2006
W1419-2   12/6/2005
W1419-3   12/6/2006

       “A recent Quality Assurance test of Imovax Rabies Vaccine revealed the presence of non-inactivated Pitman-Moore virus (the attenuated vaccine strain) in a single product lot. Imovax Rabies Vaccine is an inactivated viral vaccine and should not contain live virus. This above-mentioned lot was not distributed.” However, because the four recalled lots were produced at the same time as the lot found to contain the live attenuated vaccine strain, and although these four lots passed testing to confirm the absence of live virus, “there remains a theoretical possibility that persons who received a recalled lot of vaccine could have been exposed to the non-inactivated Pitman-Moore strain of rabies virus”. Thus, patients who received recalled vaccine should receive treatment equivalent to post exposure prophylaxis, similar to published guidelines, as follows: http://www.cdc.gov/ncidod/dvrd/rabies/professional/publications/ACIP/ACIP99.pdf

       The company has posted a set of documents at http://www.vaccineshoppe.com/secure/index.cfm?fa=RabiesRecall, which includes information on the recall and provides recommendations for persons vaccinated with the recalled lots. The company has set up a special toll-free number, 1-800-835-3587 for more information. The FDA recall notice is available at http://www.fda.gov/cber/recalls/rabave040204.htm

check Childhood Asthma Program

       In the last two decades, asthma related deaths have doubled overall, and are four times higher for children. Nationwide, there are 6.3 million children with asthma and they will have to learn how to control their symptoms for life. Even when the correct medication is prescribed, parents are often unaware of how to reduce trigger exposure in the home. They may also be confused about how to monitor asthma symptoms and take their medications properly. Studies show that families who know how to better manage their child’s asthma symptoms do not have to visit the emergency room as much.

       The Department of Public Health Childhood Asthma Program works with hospitals, clinics, physicians, schools, childcare providers, other health programs and community organizations to help children with asthma. Free education and case management services are available for families with children ages 1-18 years old, living in Riverside County, and diagnosed with asthma by a physician. Our unique program provides home visits, where families are taught how to reduce triggers in the home, how to monitor their child’s asthma and how to use asthma medications properly. Given the right tools necessary to control their symptoms, these children will be able to live an active healthy lifestyle.

       Please contact our office for more information about referring clients to our program: Mildred Flores, Health Education Assistant II (909) 358-4977.

check Tobacco Free Families Program (TFF)

       Did you know that more than 30%of children in the U.S. are exposed to secondhand smoke on a regular basis? Studies also show that those children, who live with smoke around them, get sick more often and stay sick longer. They have more coughs, colds, ear infections and asthma attacks. The good news is that there is a free tobacco education and counseling program designed to educate parents about the dangers of secondhand smoke, as well as to assist them in quitting smoking.

       This First 5 (Riverside County Children and Families Commission) funded program serves Riverside County parents and family members with children under 6-years old.

       The TFF program also provides gift bags to all mothers who deliver a baby at seven partnering hospitals in Riverside County, including: Corona Regional Medical Center, Desert Regional Medical Center, Hemet Valley Medical Center, John F. Kennedy Memorial Hospital, Moreno Valley Community Hospital, Parkview Hospital, and Riverside County Regional Medical Center. These gift bags contain useful information on second hand smoke, as well as other helpful resources for the new moms.

       If you would like to receive more information about the TFF program or would like to schedule a short presentation for your staff members regarding our services, please contact James Jo, the TFF Health Educator at (909) 358-7149.

check National Childhood Vaccine Injury Act

       Immunization providers are reminded that the National Childhood Vaccine Injury Act requires that health care providers give parents/patients copies of the Vaccine Information Statements (VIS) before administering each dose of the vaccines listed in the schedule.

       Information on using the VIS and copies of the different VIS forms can be found on the CDC website at www.cdc.gov/nip/publications/vis or can be obtained from the Riverside County Immunization Program by calling (909) 358-5107.

Mark Your Calendar

Epidemiology and Prevention of Vaccine-Preventable Disease
Sacramento, CA - November 15-16, 2004
Torrance, CA – November 18-19, 2004

Campaign to Encourage Respiratory Hygiene
Place card available through: County of Riverside – Department of Public Health – Disease Control Branch – Immunization Program @ (909) 358-5107 or the California Health Services website @ www.dhs.ca.gov – DHS DCDC Immunization Branch.

Additional Material

• Recommended Childhood and Adolescent Immunization (PDF)
Schedule - United States January - June 2004

• County of Riverside – Community Health Agency – Department of Public Health
Monthly Morbidity Report - January 2004
Reported Cases of Specified Notifiable Diseases (PDF)

• County of Riverside – Community Health Agency – Department of Public Health
Disease Reporting Requirements (PDF)

Source: Disease Control Program, Department of Public Health, Community Health Agency, County of Riverside, CMR Reporting
Compiled: Health Statistics Branch, Department of Public Health, Community Health Agency, County of Riverside

Contact Persons:
Gary M. Feldman, GARY M. FELDMAN, M.D., FAAP, FABMG
Susan Mackintosh, D.O.
Barbara Cole, R.N., P.H.N., M.S.N.
Health Officer (909) 358-5058
Assistant Health Officer (909) 358-4487
Director, Disease Control / Editor (909) 358-5107

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