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 2005

DISEASE REPORTING IS ESSENTIAL FOR OUTBREAK CONTROL

Community Protection

       Reporting cases of infectious disease has been, and continues to be a vital step in controlling the spread of communicable diseases in the community. The information contained in these reports is useful to both disease surveillance and disease control activities. Disease surveillance activities include identifying important changes in trends, monitoring long and short term trends, and determining disease related morbidity and mortality. Activities related to disease control include assurance of appropriate medical treatment, detection of common source outbreaks, contact identification and referral, and planning and evaluating disease control prevention activities.

Legal Mandate

       The authority to require reporting of cases of infectious diseases resides in the state legislature. The California Health and Safety Code, Section 120250 and the California Code of Regulations, Title 17, Section 2500 require the physician to report listed infectious diseases.

       Although physicians are an integral part of communicable disease control activities, many physicians are not aware of their reporting responsibilities. Two areas that frequently require clarification include laboratory reporting of infectious diseases and confidentiality issues. Laboratory reporting of a particular disease does not relieve the physician of their reporting responsibility. Patient consent is not required for reporting purposes or to supply additional information requested by Public Health staff. Reporting to Public Health is exempt from the Health Insurance Portability and Accountability Act (HIPAA) requirements.

Late Reporting

       Late reporting or failure to report can have serious consequences. For example, employees in sensitive occupations (food handlers, child care providers) may stay on the job and cause further spread of disease. For the reporting system to be successful, it is important that all cases of reportable diseases be submitted within the required timeframe, with all requested information provided on the report form.

RAPID RESPONSE TO A POTENTIAL BIOTERRORISM EVENT

       It is also essential that organisms that pose a high risk of being used as 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.

Category A Agents of concern include:
• Bacillus anthracis (anthrax)
• Biological Toxin (botulism)
• Francisella tularensis (tularemia)
• Variola major (smallpox)
• Yersinia pestis (plague)
• Filoviridae (Ebola virus, Marburg, hemorrhagic fever, and Arenaviruses, such as Lassa
fever).

       These agents are a very 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.

       Disease reporting by the medical community and laboratories is essential to facilitate prompt intervention and containment activities.

Epidemiologic Clues to Potential Terrorist Incidents

Large numbers of ill persons with a similar disease or syndrome Large numbers of cases of unexplained diseases or deaths Unusual illness in a population (e.g., renal disease in a large population may suggest exposure to a toxic agent such as mercury) Higher morbidity and mortality in association with a common disease or syndrome or failure of such patients to respond to usual therapy Large number of ill persons who seek treatment at about the same time (point source with compressed epidemic curve) Single case of disease caused by an uncommon agent (smallpox, pulmonary anthrax) Multiple disease entities in the same patients, indicating that mixed agents have been used in the attack Illness limited to fairly localized or circumscribed geographical areas Simultaneous clusters of similar illness in noncontiguous areas Apparent aerosol route of transmission No illness in persons who are not exposed to common ventilation systems (have separate closed ventilation systems) when illness is seen in persons in close proximity who have a common ventilation system Atypical disease transmission through aerosols, food or water, which suggest deliberate sabotage Stable endemic disease with an unexplained increase in incidence (i.e., tularemia, plague) Sentinel dead animals of multiple species

ENHANCED SURVEILLANCE FOR HOSPITALIZED PATIENTS WITH VARICELLA

       Hospitals are reminded of the importance of reporting individuals hospitalized with a 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 (951) 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.

SYPHILIS CONTINUES TO BE A PUBLIC HEALTH CONCERN

       One hundred and twelve (112) infectious syphilis cases were reported in Riverside County in 2004, compared to 105 cases in 2003. As of March 2005, 52 infectious cases have been reported indicating an ongoing escalation of the disease. 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 maclopapular rash, especially when the palms and soles of the feet are involved, should be screened for syphilis.

       Clinicians are reminded of the importance of using the appropriate formulation of penicillin for the treatment of syphilis, which is Bicilliln L-A. Because this formulation has a longer half-life, which is considered essential for effective syphilis treatment, CDC recommends Bicillin L-A for the treatment of 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 CDC Treatment Guidelines.

       It is important to report any suspected or confirmed case of syphilis to Disease Control by phone at (951) 358-5107, or by fax at (951) 358-5102.

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

TUBERCULOSIS CONTINUES TO BE A SIGNIFICANT PUBLIC HEALTH THREAT

       Tuberculosis continues to be a significant public health concern in Riverside County. A review of data for the past 5 years indicates fluctuations in TB morbidity. Seventy-five cases were reported in 2003 and in 2004. This represents an increase in morbidity compared to 2002 (68 cases) and 2001 (66 cases), respectively. Although TB primarily affects the elderly, it is also identified in children. In the last 5 years, 11 cases occurred in children, 4 years or younger. This is an indicator of recent disease transmission, and emphasizes the importance of early intervention with patients who have active TB.

       It is essential that Public Health work closely with the medical community to ensure appropriate diagnosis, treatment and management of tuberculosis. Failure of patients to adhere to appropriate treatment regimens can result in multiple drug resistant TB (MDR-TB). Individuals with MDR-TB require treatment with second line drugs for a minimum of 18-24 months. The Department of Public Health conducts a risk assessment for non-adherence on each patient started on anti-tuberculosis treatment. Individuals assessed to be at risk for non-adherence are provided medication through a Directly Observed Therapy (DOT) Program. TB Control staff make home visits to deliver and observe patients ingesting their TB medication. DOT is an important strategy to ensure completion of therapy and prevent the development of drug resistance. TB treatment guidelines can be located at www.ctca.org.

       Recent exposures in health care facilities emphasize the importance of patient triage and maintaining a high index of suspicion for TB when individuals present with signs and symptoms suggestive of tuberculosis. As other medical conditions share the most frequent symptoms of pulmonary TB (cough; sputum production, fever, night sweats, loss of appetite, loss of weight, and fatigue), suspicion of tuberculosis can be obscured. TB in health care workers can result in exposure of a significant number of patients and staff.

       Although progress has been made in the fight against tuberculosis in the United States, the World Health Organization (WHO) indicates that almost 2 billion persons are infected worldwide. There are eight million new cases of TB, (including 170,000 in children) and three million deaths each year. These facts prompted the establishment of World TB Day on March 24, of each year to increase awareness of the medical community and the public of the ongoing threat, presented by tuberculosis.

       Reporting of TB cases at the local, state and national level is important for the surveillance and control of tuberculosis. Health care providers are reminded of the importance of reporting TB suspects, as well as TB cases within one (1) day of identification to the Disease Control Office at (951) 358-5107 or fax (951) 358-5102.

MULTI-DRUG RESISTANT TB (MDR-TB) IS A CONCERN IN RECENTLY RESETTLED HMONG REFUGEES

       Tuberculosis (TB) remains an ongoing problem in California. An estimated one out of every ten Californians is infected with TB (3.4 million). An untreated infected individual has a 10% risk of progression to active TB during their lifetime. This risk of progression translates to a projected 3,000 active TB cases per year for the next 60 years.

       The Advisory Council for the Elimination of Tuberculosis (ACET) recommends that high-risk groups be screened for TB and latent TB infection. High-risk groups include close contacts of persons known or suspected to have TB; persons who inject illicit drugs, persons who have medical risk factor known to increase the risk for disease, healthcare workers who serve high-risk clients, medically underserved populations, high-risk ethnic minority populations. The incidence of TB among refugees is gaining increasing attention. The TB case rate among the refugees who have arrived in California since June 2004 surpasses 800/100,000. The rate of TB as well as the proportion of multi-drug resistant (MDR) TB among this population have exceeded expectations.

       In light of the emergence of multi-drug resistant (MDR) TB, ensuring appropriate and complete treatment of TB patients is crucial. Multi-drug resistant TB is defined as resistance to isoniazid and rifampin, the two most important anti-TB drugs. Drug resistance is caused by inadequate, inconsistent, or partial treatment. Patients should be educated and advised to take all their medicines regularly for the required period of time even if they start feeling better. The Center for Disease Control and Prevention (CDC) recommends that “treatment must be individualized and based on the patient’s medication history and drug susceptibility studies”. The Riverside County Department of Public Health should be consulted on the management of patients with MDR-TB. The Department recommends that patients with MDR-TB as well as others who are assessed to be at risk for non-adherence with treatment, receive medications under direct observation (DOT).

       Clinicians are asked to contact TB Control at (951) 358-5107 to request DOT for patients managed in the private sector.

NEWS BRIEFS

Vaccinia Virus Transmitted to contact of a person receiving smallpox vaccination.

       Clinicians are reminded of the importance of assessing individuals presenting with vesicular lesions for the possibility of vaccinia virus. Although pre-event smallpox vaccinations were suspended for healthcare workers, the military is still vaccinating their personnel. An alert physician reported seeing a child who developed a vesicular lesion following contact with the parent who recently received smallpox vaccination. The lesion on the child tested positive for vaccinia virus. Live virus can be present on the vaccination site from day 4 up to 21 days post smallpox vaccination. Susceptible individuals must avoid contact with the vaccination site and contaminated items (e.g. dressings) during this time period.

       Guidelines for the management of adverse events following smallpox vaccination are available at CDC, www.bt.cdc.gov/agent/smallpox/response-plan/index.asp

       These secondary adverse events should be reported to Disease Control at (951) 358-5107 or (951) 782-2974 after hours.

Discontinuation of National Reporting of Invasive Pneumococcal Disease in Children Vaccinated with Pneumococcal Conjugate Vaccine (PCV7)

       The Respiratory Diseases Branch, Division of Bacterial and Mycotic Diseases, National Center for Infectious Diseases, CDC, is no longer requesting reports of cases of invasive pneumococcal disease occurring in children who have received the Pneumococcal conjugate vaccine. For the last several years, CDC has requested these reports and has been analyzing the strains to evaluate possible vaccine failures. Because the number of reported cases in vaccinated children is now adequate to permit analysis and surveillance data indicate that disease rates have dropped dramatically, these reports are no longer needed. The Respiratory Diseases Branch at the CDC is grateful for the efforts of those who have participated in this reporting system over the last few years.

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Mark Your Calendar

Epidemiology and Prevention of Vaccine-Preventable Diseases

Torrance, CA
November 17-18, 2005

This live course provides a comprehensive overview of the principles of vaccination, general recommendations, and immunization strategies for providers, and specific information about vaccine-preventable diseases and the vaccines that prevent them.

For information on registration:
Call: (510) 540-2065 or
E-mail: mnguyen2@dhs.ca.gov

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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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