Public Health Dispatch


	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 2006

INFECTIOUS SYPHILIS CASES CONTINUE TO PRESENT A PUBLIC HEALTH CHALLENGE

Syphilis continues to present a significant public health concern in Riverside County. Data for 2005 indicate 168 infectious syphilis cases were reported compared to 112 cases in 2004. Although the majority of cases continue to be in men who have sex with men, it is important to note that there were 11 cases in women in 2005 compared to no cases in women in 2004. One congenital case was also identified. The majority of the cases occurred in the Coachella Valley, where approximately 75 percent of the individuals are also infected with HIV.

Primary and secondary syphilis are of particular concern because they facilitate sexual transmission of HIV and are highly contagious. Here are some important guidelines for medical providers:

Assess the risk status of your patients. Routinely inquire about the gender and number of sexual partners; inquire if your patient is in a sexually monogamous relationship, and if the patient is having sex with a partner of unknown HIV status.

Screen all high-risk individuals initially and at least yearly (every 3-6 months if high-risk behavior is continuing), using RPR or VDRL. High risk individuals include HIV positive men, as well as men having sex with men, and those with multiple or anonymous partners. Remember, signs and symptoms often go unrecognized.

Keep a high level of suspicion for primary skin lesions in areas of sexual contact (penile, rectal, or oral) and for generalized maculo-papular rashes, particularly when the rash involves the palms and soles of the feet. Evaluate all patients with a new onset of genital lesions for primary syphilis.

Screen all pregnant women for syphilis in the first trimester; re-screen high risk women in the third trimester. During the labor and delivery process, be observant for signs suggestive of primary and secondary syphilis (i.e., lesions).

Counsel safer sex practices and the need for partners to be tested and treated. Inform your patients that the Health Department will need to contact them to ensure adequate follow-up and/or partner management, and will protect their confidentiality.

Follow CDC Treatment Guidelines

Recommended treatment for primary, secondary and early latent syphilis is benzathine penicillin G 2.4 million units IM. Special alert from State STD Controller: Due to increased resistance to zithromycin, it should not be used to treat syphilis. Please contact Disease Control if you would like a copy of the 2002 CDC Treatment Guidelines.

REPORT ANY SUSPECTED OR CONFIRMED CASE OF SYPHILIS TO DISEASE CONTROL WITHIN 1 DAY OF DIAGNOSIS: 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.

CDC PUBLISHES GUIDELINES ON USE OF QFT-G TB TEST

Riverside County Department of Public Health (DOPH) is evaluating the use of Quantiferon – TB Gold (QFT-G) for identifying latent TB infection (LTBI). QFT-G is a blood assay for M. tuberculosis, which was approved by the U.S. Food and Drug Administration in May 2005. CDC indicated that the QFT-G test has some advantages over the TB skin test (TST). These include the following:

QFT-G results can be available in less than 24 hours, while a TST requires a second encounter with the person to read the skin test result in 48 to 72 hours after administration of the test.

As a laboratory based assay, QFT-G is not subject to the biases and errors of TST placement and reading.

A QFT-G result is not affected by a prior Bacille Calmette-Guerin (BCG) vaccination and is expected to be less influenced by previous infection with nontuberculosis mycobacteria, which can affect the TST.

QFT-G does not require injection of purified protein derivative, as the TST does, and thus not boost subsequent TST responses.

CDC indicates that it is important to note that errors in collecting or transporting blood specimens or in running and interpreting the assay can decrease the accuracy of the QFT-G. TB Control programs or institutions that elect to use QFT-G should work with laboratories in their systems to ensure that specimens are properly obtained, handled and processed prior to and after arrival in the laboratory.

Title 22 regulations require the use of an intradermal TB skin test (TST) to screen employees in licensed health care facilities, therefore program flexibility must be obtained prior to utilizing QFT-G.

For more Information, the document “Guidelines for Using the QuantiFERON - TB Gold Test for Detecting Mycobacterium tuberculosis Infection, United States,” is available online at http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5415a4.htm.

WORLD TB DAY: MARCH 24, 2006

Each year March 24th is recognized as World TB Day. This annual event commemorates the date in 1882 when Robert Koch announced his discovery of Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB). Worldwide TB remains one of the leading causes of death from an infectious disease. An estimated 2 billion persons (i.e., one third of the world’s population) are infected with M. tuberculosis. Each year, approximately 9 million persons become ill from TB, and approximately 2 million die as a result. World TB Day provides an opportunity for TB programs, nongovernmental organizations, and other partners to describe TB-related problems and solutions and to support TB Control worldwide.

During 1985-1992, after more than 30 years of decline, the number of TB cases reported in the United States increased by 20%. This resurgence generated a renewed emphasis on TB control and prevention during the 1990’s which reversed the trend. Although the 2005 TB rate was the lowest recorded in the United States since national reporting began in 1953, the average annual decline has slowed during the past 3 years, multidrug-resistant TB remains a threat, and disparate rates of TB persist among certain racial, ethnic, and foreign-born populations.

Twenty nine hundred (2900) TB cases were reported in California in 2005 compared to 2,989 in 2004. Although progress is being made, the increasing occurrence of drug-resistant TB, including extensively drug resistant cases, presents significant challenges to treatment and control of the disease in the United States and abroad. In addition, every 3 days a child less than 5 years of age contracts TB in California and 200 Californians die each year from TB. Locally, 60 new TB cases were reported in Riverside County in 2005 compared to 75 in 2004. There were 2 MDR TB cases. Cases continue to be diagnosed in school age children with 5 cases occurring in this age group in 2005. Intensive TB control strategies continue to be applied to further reduce morbidity from this disease.

WOUND BOTULISM LINKED TO “SKIN POPPING” BLACK TAR HEROIN

Riverside County Department of Public Health (DOPH) recently investigated a report of an individual diagnosed with wound botulism. The patient was a 53 year old male who gave a history of “skin popping” Black Tar heroin.

Signs and symptoms included ptosis, double vision, speech difficulty, trouble swallowing and dry mouth. The patient subsequently required intubation. Pre-treatment serum toxin demonstrated clostridium botulinum toxin type A. No botulinum toxin was detected in the post treatment serum toxin. Fortunately the patient recovered and was discharged to home.

Wound botulism can be life threatening if the person does not receive anti-toxin in a timely manner. DOPH has a Duty Officer on call after hours and on weekends. Public Health will facilitate obtaining the anti-toxin. The Duty Officer can be reached by calling (951) 782-2974. Please contact Disease Control at (951) 358-5107, during regular business hours. Botulism, including suspect cases must be reported immediately by telephone. Please see the Botulism Fact Sheet for detailed information on the management of botulism.

NEW VARICELLA ZOSTER IMMUNE GLOBULIN (vzig) TO ADDRESS PRODUCT SHORTAGE

US FDA and CDC recently issued guidance (summarized below) on a replacement supply of Varicella Zoster Immune Globulin (VZIG), that is produced and licensed in Canada, but is currently considered investigational in the US: http://www.fda.gov/cber/infosheets/mphvzig020806.htm
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm55e224a1.htm
The only manufacturer of U.S.-licensed VZIG, Massachusetts Public Health Biologic Laboratories (Boston, MA), has discontinued production of VZIG. An investigational (not licensed) VZIG product manufactured by Cangene Corporation (Winnipeg, Canada) is now available under an investigational new drug application (IND) protocol. This product may be requested through FFF Enterprises (Temecula, CA, telephone 1-800-843-7477) for individuals who have been exposed to varicella and who are at increased risk of complications from varicella.

INDICATIONS FOR USE OF INVESTIGATIONAL VZIG

Varicella vaccine continues to be recommended for post exposure prophylaxis of other persons without evidence of varicella immunity and who have no contraindications to vaccination. The vaccine should be administered preferably within 96 hours and possibly up to 120 hours post exposure. Those recommended to receive investigational VZIG include:

Immunocompromised patients (VZIG is not indicated for prophylactic use in immunodeficient children or adults who have a known past history of varicella, unless the patient has undergone bone marrow transplantation.)

Neonates whose mothers have signs and symptoms of varicella around the time of delivery (i.e., 5 days before 2 days after delivery).

Premature infants born at >28 weeks of gestation who are exposed during the neonatal period and whose mothers do not have evidence of immunity.

Premature infants born at <28 weeks of gestation or who weigh <1,000 g at birth and were exposed during the neonatal period, regardless of maternal history of varicella disease or vaccination.

Pregnant women.

Clinicians are reminded that patients who are hospitalized with or who die from varicella, must be reported to Public Health. The review of varicella cases is an important component of the Department’s rash surveillance activities.

NEWS BRIEFS

HIV Names Reporting Now Reportable in California

On April 17, 2006, Governor Arnold Schwarzenegger signed into law, Senate Bill 699 (Soto) requiring health care providers and laboratories to report cases of HIV infection by name to local health departments. The new law also requires the Riverside County Department of Public (DOPH) to report all unduplicated HIV cases to the California Department of Health Services. This shift to a confidential name-bases HIV reporting system will allow the state to come into compliance with federal standards and remain competitive for federal funding for HIV/AIDS programs. Confidential name-based HIV reporting is the Centers of Disease Control and Prevention’s standard for ensuring accurate and complete reporting of HIV cases within the states and territories. A name-bases HIV reporting system will enhance both state and local efforts to track the HIV epidemic, monitor emerging trends in HIV transmission, and allocate HIV education, prevention, and care solutions.

Under the new law, enhanced civil and criminal penalties will be imposed for willful, malicious, or negligent disclosures of confidential HIV case information. To protect individual privacy and ensure the secure exchange of individuality identifiable information pertaining to HIV case reports, the DOPH, HIV/AIDS Program will review data security protocols and upgrade confidentiality procedures as necessary. Additionally, the HIV/AIDS staff will be available to provide technical assistance relating to data security and confidentiality.

The new reporting requirements are effective immediately and we are asking that all HIV related cases, both AIDS and HIV infection (positive HIV tests) be reported to DOPH HIV/AIDS Program.

Cases can be reported to the HIV/AIDS Program by mail at:

            HIV/AIDS Surveillance
            P.O. Box 7600
            Riverside, CA 92513-7600

HIV/AIDS cases can also be reported by calling the HIV/AIDS Program at (951) 358-5307 or 1-800-243-7275.

Please call the HIV/AIDS Program if you have any more questions about HIV or AIDS reporting.

Mumps Activity Stable in Riverside County

As of May 2, 2006, more than 2100 possible mumps cases were reported from Iowa and surrounding states. Approximately 20 cases have been investigated in California, with 4 confirmed cases. Locally in Riverside County, 5 suspect cases are under investigation. Two confirmed cases were reported in the county in 2005. Due to the concern about a possible increase in mumps activity, cases should be reported to Disease Control at (951) 358-5107 or FAX (951) 358-5102, within one day of identification.

The CDC Case Definition and Case Classification are listed below.

Clinical Case Definition: An illness with acute onset of unilateral or bilateral tender, self-limited swelling of the parotid or other salivary gland, lasting > 2 days, and without other apparent cause.

Case Classification
Probable: a case that meets the clinical case definition, has noncontributory or no serologic or virologic testing, and is not epidemiologically linked to a confirmed or probable case.
Confirmed: a case that is laboratory confirmed OR that meets the clinical case definition and is epidemiologically linked to a confirmed or probable case. A laboratory confirmed case does not need to meet the clinical case definition.

Laboratory Testing and Confirmation

Positive serologic test for mumps IgM antibody in serum collected 0-28 days after onset of symptoms.

Significant rise in mumps IgG in paired acute and convalescent sera drawn two weeks apart. Acute specimen should be collected as soon as possible after onset of symptoms, including parotitis.

Isolation of mumps virus from buccal swabs (preferred) and/or throat swabs (collected from 7 days before until 9 days after salivary enlargement) or a urine specimen (collected from 6 days before to 15 days after onset of symptoms, including parotitis).

Note: False positive IgM results by immunofluorescent antibody assays have been reported. There are currently no FDA approved enzyme immunoassays (EIA) for detection of mumps IgM antibody. If the suspected case has received one or more doses of MMR, missing, delayed or transient IgM responses may also be seen.

Please contact Janna Troy, Riverside County Public Health Laboratory Manager, for questions on laboratory testing at (951) 358-5070.

What's New at the Public Health Lab?

Riverside County Public Health Lab is growing be leaps and bounds and addressing the demands of increased testing.
The chlamydia and gonorrhea testing work load has grown over the last few years due to the implementation of nucleic acid amplification methodology (ProbeTEC) which provides increased specificity, sensitivity and a RAPID turnaround time compared to previous methods. The Public Health Lab has increased the number of daily runs that are performed to accommodate our internal program demands and requests from outside submitters.

Due to increased demand for HIV and syphilis testing, the Public Health Lab felt it was necessary to automate testing with the DiaSorin ETI-MAX. This instrumentation allows HIV, syphilis and the newly added Hepatitis assays from a single blood tube. Adding the Hepatitis battery to the testing menu will be a definite advantage to our Community Health Agency programs and our community partners.

TB testing has also taken a leap with the implementation of the QuantiFERON-TB Gold test. QuantiFERON is an indirect test for exposure to M. tuberculosis utilizing whole blood. The Public Health Lab initiated a two month restricted pilot study with Occupational Health and Disease Control. The goal of the pilot study is to determine if QuantiFERON will be offered as a routine testing option. The pilot has been temporarily suspended to address several operational issues.

Our next step over the cutting edge will be the validation of our newly acquired Roche Real-Time PCR Light Cycler. This instrument utilizes the polymerase chain reaction (PCR) to rapidly amplify and identify organisms that typically take days to culture. Our first assays to validate will be Herpes simplex and Bordetella pertussis.

Even with our increased growth and testing, the Public Health Lab is also always available for consultations on infectious disease testing performed internally or other laboratories. For questions, please contact Janna Troy, Public Health Lab Manager at (951) 358-5070.

Emergency Care Simulators

The Bioterrorism Preparedness and Response Branch is pleased to announce that is has taken a delivery of 4 Emergency Care Simulator mannequins made by the Medical Education Technologies Company (METI). These mannequins represent the latest in simulation technology for training medical personnel and emergency responders. The mannequins have the computerized ability to automatically provide a realistic physiologic patient response to emergency care situations.

The mannequins will be housed in various locations throughout Riverside County to facilitate their use. They will be used to enhance training opportunities delivered by the Bioterrorism Branch, and will be available for other health and emergency response partners to augment their staff development programs. To learn more about this project or to request training on Emergency Care Simulators for your organization, please contact Ramon Leon, Health Educator at (951) 358-7100.

Planning For Action Using the Asthma Action Plan

The Asthma Action Plan can help families become proactive in the control of asthma symptoms. The National Institutes of Health (NIH) recommends that primary care providers fill out this form for all of their patients with asthma.

Every person that cares for a child with asthma should have a copy of the child’s Asthma Action Plan, including the babysitter, school nurse, day care center, teacher, and grandparent. It is very important that all caretakers understand the Asthma Action Plan, so they know what steps to take to control the child’s asthma.

Prescribed medications, every day prevention steps, and directions in case of emergency, are listed on the Asthma Action Plan. This simple at-a-glance form can be a life saving tool for parents with asthmatic children.

For more information about the Asthma Action Plan, please contact the Childhood Asthma Program at (951) 358-4977.

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

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 (951) 358-5058
Assistant Health Officer (951) 358-4487
Director, Disease Control / Editor (951) 358-5107

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