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
VOL. 9, No. 2		MAY 2003

DISEASE REPORTING REQUIREMENTS UPDATED FOR 2003

      Riverside County Department of Public Health has added Severe Acute Respiratory Syndrome (SARS) and West Nile Virus (WNV) to the list of reportable diseases. 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. It is also essential that organisms that pose a high risk of being used as a biological weapon be reported immediately to Public Health.

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; AND CAN:

• Cause high mortality with potential for major public health impact.
• Cause public panic and social disruption.
• Require special action for public health preparedness.

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.

Public Health Reporting is EXEMPT from HIPAA, Confidential Morbidity Reporting is EXEMPT from HIPAA and does not change

      The Health Information and Portability and Accountability Act (HIPAA) took effect on April 14, 2003. There has been concern about how this would affect public health reporting.
      In general, activities that involve mandated public health surveillance will not be materially affected by the new Privacy Rule because they are exempt from the HIPAA regulation. The Privacy Rule allows for the existing practice of sharing protected health information (PHI) with public health authorities who are authorized by law to collect or receive such information to aid them in their mission of protecting the health of the public. This practice is described in the preamble to the actual Rule: “The final rule continues to permit covered entities to disclose protected health information, without individual authorization, directly to the public health authorities, such as the Food and Drug Administration, the Occupational Safety and Health Administration, and the Centers for Disease Control and Prevention, as well as state and local public health departments, for public health purposes as specified in the Notice of Proposed Rulemaking for the Privacy Rule (NPRM).” (65 F. R. p. 82526).
      Sharing of PHI with public health authorities is addressed in Section §164.512, “Uses and disclosures for which consent, an authorization, or an opportunity to agree or object is not required.” Section §164.512(a) permits disclosures that are required by law, which may be applicable to certain public health activities. Section §1643512(b) explicitly permits disclosures to public health authorities for public health activities:
      “(1) Permitted disclosures: A covered entity may disclose protected health information for the public health activities and purposes described in this paragraph [Section §164.512(b)(1)] to: (i) A public health authority that is authorized by law to collect or receive such information for the purpose of preventing or controlling disease, injury, or disability, including but not limited to: the reporting of disease, injury, vital events, such as birth or death, and the conduct of public health surveillance, public health investigations, and public health interventions; or at the direction of a public health authority, to an official of a foreign government agency that is acting in collaboration with a public health authority: (ii) A public health authority…authorized by law to receive reports of child abuse or neglect. … (iv) A person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading a disease or condition, if the covered entity or public health authority is authorized by law to notify such a person as necessary in the conduct of a public health intervention or investigation, or… “(See Section §164.512(b)(1), 65, F. R. p. 82813-82814 for complete requirements).
      The Full Text of the Privacy Rule is available at: www.hhs.gov/ocr/combinedregtext.pdf.
      It is important for medical providers and laboratories to continue to adhere to the Disease Reporting laws to facilitate prompt disease control intervention.
      All patient information is treated in a confidential manner.
      Please contact Barbara Cole, Director for Disease Control at (909) 358-5107 if you need any additional information.

Guidelines for use of PEDIARIX™

      A new pentavalent vaccine is now available for VFC enrolled providers to administer to infants in California. This new combination vaccine consists of Diphtheria and Tetanus Toxoids and Acellular Pertussis Absorbed (DTaP), Hepatitis B (Recombinant) and Inactivated Poliovirus Vaccine (IPV) vaccines. It was developed by GlaxoSmithKline Biologicals, under the trade name PEDIARIX™ and recently approved by the Food and Drug Administration (FDA) for use in the United States.
The Advisory Committee on Immunization Practices (ACIP) has published in MMWR supplemental guidelines for use of this product – March 14, 2003/ 52(10); 203-204). See additional information on the CDC website at www.cdc.gov/mmwr/PDF/wk/mm5210/pdf. The FDA has currently licensed this vaccine for use only as a primary series at 2, 4, and 6 months of age.

• PEDIARIX™ is approved for use in infants and children aged 6 weeks through 6 years. Primary usage will be for infants at ages 2, 4, and 6 months.
• The recommended interval between successive PEDIARIX™ doses is 6-8 weeks, but intervals as short as 4 weeks are acceptable when rapid acquisition of immunity to one or more of the diseases against which this vaccine protects is desired.
• Interchangeability of PEDIARIX™ with other vaccines containing one or more of the same components in an infant or child’s immunization series. This is acceptable, though for the DTaP component it is preferred that Infanrix® (which is identical to the DTaP component of PEDIARIX™) be used for such “mix and match” immunization series.
• Special Guidelines for the hepatitis B component of Pediarix:
  • In addition to the FDA’s approval for use of PEDIARIX™ only in infants of HBsAg negative mothers, ACIP recommends that it can be used for all infants (aged 6 weeks and older), regardless of whether the mother’s HBsAg status is positive, negative, or unknown.
  • Use of a 3-dose series of PEDIARIX™ at, for example, ages 2, 4, and 6 months in an infant who has already received a dose of hepatitis B vaccine at birth, resulting in receipt of a total of 4 hepatitis B vaccine doses is fully acceptable.
  • The final dose of the hepatitis B vaccine series should be given no earlier than age 6 months, regardless of what vaccine product is used, including PEDIARIX™.

      For additional information on the use of PEDIARIX™, please contact Karon Jones, Immunization Coordinator at (909) 358-5568.

SEVERE ACUTE RESPIRATORY SYNDROME (SARS) UPDATE
FOR RIVERSIDE COUNTY

      To-date, five (5) patients who were considered suspect SARS cases have been reported to Riverside County Department of Public Health. Test results on one patient were negative for the coronavirus, which CDC feels may be the causative agent of SARS. Three suspect cases remain under investigation.
Information on SARS continues to evolve on a daily basis. CDC recently revised the case definition for SARS, which is outlined below.

SUSPECT CASE:
Respiratory illness of unknown etiology with onset since February 1, 2003, and the following criteria:

• Measured temperature greater than 100.4°F (greater than 38°C); AND
• One or more clinical findings of respiratory illness (e.g., cough, shortness of breath, difficulty breathing, or hypoxia; AND
• Travel within 10 days of onset of symptoms to an area documented or suspected community transmission; OR
• Close contact within 10 days of onset of symptoms with a person known to be a suspect case.

PROBABLE CASE:
      A suspect case with one of the following:

• Radiographic evidence of pneumonia or respiratory distress syndrome;
• Autopsy findings consistent with respiratory distress syndrome without an identifiable cause.

      It is important that patients presenting with cough, fever, and a history of travel, be triaged as a possible SARS patient, so appropriate infection control precautions can be taken. Individuals meeting the case definition of a probable or suspect SARS case must be instructed in home isolation, and sign the Home Isolation Agreement, until an assessment can be made by Public Health staff.
Please immediately report possible SARS patients to the Disease Control office:

Weekdays, 8:00 a.m. to 5:00 p.m. . . . . . . . (909) 358-5107
After Hours, Holidays and Weekends . . (909) 782-2974

      The Public Health Laboratory Director can be reached at (909) 358-5070 for questions on submission of specimens.
      Updated guidance will be provided as it is received. Information is also available on the CDC Website at www.cdc.gov/ncidod/sars.

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NEWS BRIEFS

RIVERSIDE COUNTY RESUMES SMALLPOX VACCINATIONS

      Riverside County Department of Public Health resumed administering smallpox vaccinations after the California Department of Health Services (CDHS) distributed new CDC guidance on the possible link between cardiac problems and vaccination. Individuals with physician diagnosed cardiac disease with or without symptoms, or three (3) or more risk factors for heart disease are not to be vaccinated as part of the pre-event vaccination clinics. To-date no one vaccinated by the Riverside County Department of Public Health has reported experiencing cardiac problems, or other severe adverse events following smallpox vaccination. It is important for health care providers to be alert for individuals seeking care as a result of adverse reactions due to smallpox vaccinations.

MAJOR POST-SMALLPOX VACCINATION ADVERSE EVENTS TO BE REPORTED
• Eczema vaccinatum
• Erythema multiforme major or Stevens-Johnson Syndrome
• Fetal vaccinia
• Generalized vaccinia
• Inadvertent inoculation
• Ocular vaccinia
• Post-vaccinial encephalitis or encephalomyelitis
• Progressive vaccinia
• Pyogenic infection of vaccination site
• Vaccinia infection of vaccination site
• Vaccinia transmission to contacts
• Vaccination of persons with a contraindication to vaccination
• Other serious adverse events (i.e., those resulting in hospitalization, permanent disability, life-threatening illness, or death).

      Significant adverse events following smallpox vaccination need to be reported to Riverside Department of Public Health by telephone at (909) 358-5107 during regular business or (909) 782-2974 after hours, holidays and weekends.

FREE HEALTH SERVICES FOR CHILDREN WITH ASTHMA AND QUIT SMOKING COUNSELING FOR PARENTS/GUARDIANS

      The Childhood Asthma Program provides education, treatment and case management of children with asthma from birth through age 18. These services include: home visits for one-on-one education on the use of medications and asthma aids, educational material, and a home assessment of potential asthma triggers. For more information on how to refer your patients or their parent/guardian for these services, please call (909) 358-7127.
      The Tobacco Free Families Program provides one-on-one smoking cessation counseling and secondhand smoke information for parents/guardians of children under five years old. For more information on how to refer your patients who would like these services, please call (909) 358-5126.
The Riverside County Department of Public Health Asthma and Tobacco Programs are funded by the Commission on Children and Families, the University of California at San Francisco, CAASA Project, and the Community Foundation.

TIME FRAME FOR PRE-ENTRY TB SKIN TEST EXTENDED

The Department of Public Health is continuing the school TB Mandate, which requires children K-12 who are first-time entrants to a Riverside County School to have a TB clearance prior to entry. Children in preschool/headstart require a TB test if the clinician assess the child to have a risk factor for TB. Effective May 2003, TB skin tests administered within 15 months (instead of 12) will be accepted for school entry.
During 2002, six (6) active cases were diagnosed in school aged children. Over 1400 children had evidence of latent TB infection. This data emphasizes the need to continue the TB Mandate.

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County of Riverside – Community Health Agency
Department of Public Health
Monthly Morbidity Report - April 2003

REPORTED CASES OF SPECIFIED NOTIFIABLE DISEASES
Chart also available as a printable file (PDF 49KB)

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

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