ERIC FRYKMAN, MD, MPH, MBA
Public Health Officer


COUNTY OF RIVERSIDE

PUBLIC HEALTH DISPATCH
COMMUNITY HEALTH AGENCY • DEPARTMENT OF PUBLIC HEALTH • 4065 COUNTY CIRCLE DRIVE, RIVERSIDE, 92503
 
SPRING/SUMMER 2007

INCREASING FLUROQUINOLONE RESISTANCE IN CALIFORNIA

In response to the persistent high level of fluroquinolone-resistant gonorrhea in California and the lack of availability of cefixime and pectinomycin, the California Department of Health Services STD Control Branch and the California STD Controllers Association are issuing the following revised recommendations based on available data and the newly released 2006 CDC STD Treatment Guidelines. Factors considered in developing these recommendations include therapeutic efficacy (see Table 1), cost and side effects of particular agents, and concerns about emerging antimicrobial resistance. For more information on treatment of gonorrhea, please refer to the 2006 STD Treatment Guidelines (www.cdc.gov/std/treatment).

California Gonorrhea Treatment Recommendations

CERVICAL, URETHRAL, AND RECTAL INFECTIONS

Recommended Antibiotics

Recommended antibiotics for treatment of uncomplicated gonococccal infections of the cervix, urethra, and rectum include:

  • Ceftriaxone 125 mg intramuscularly in a single dose;1
    OR
  • Cefixime 400 mg orally in a single dose.2


1 Based on the pharmacokinetics of ceftriaxone 125 mg, this is the preferred treatment for gonorrhea. Since the drug is packaged as a 250 mg vial, some clinicians in low-volume settings elect to use 250 mg given the product shelf-life. While 125 mg remains the recommended dose, use of 250 mg is acceptable.

2 Cefixime suspension is available in the U.S. The manufacturer, Lupin Ltd. (phone: 800-826-9556), plans to release a tablet form of the drug, but availability has been delayed since 2004 and remains uncertain.

TABLE 1

California Legislation Allowing PDPT for Chlamydia and Gonorrhea

Expedited partner treatment (EPT) for chlamydia and gonorrhea is an alternative strategy for ensuring that sex partners get needed medication. EPT is the general term for the practice of treating sex partners of patients diagnosed with a STD without an intervening medical evaluation. Patient Delivered Partner Therapy (PDPT) is the most common type of EPT in which the patient delivers the medication to his or her sex partner(s). Other types of EPT involve alternative delivery mechanisms, such as pharmacies.

In 2001, SB 648 (Ortiz, Chapter 835) amended California law to allow PDPT for Chlamydia, and in January 2007, AB 2280 (Leno, Chapter 771) further amended the law to allow PDPT for gonorrhea. The current law allows physicians to prescribe and nurse-practitioners, physician assistants and certified nurse-midwives to dispense antibiotic therapy for the male and female sex partners of individuals infected with Chlamydia trachomatis or Neisseria gonorrhea, even if they have not been able to perform an exam of the patient’s partner(s).

The legislation (Section 120582 of the Health and Safety Code) provides an exception to the Medical Practice Act, which states that the prescribing, dispensing, or furnishing of dangerous drugs, as defined, without a good faith prior examination and medical indication constitutes unprofessional conduct. The new law provides that a licensee acting in accordance with provisions of the law with regard to a prescription for antibiotic therapy has not committed unprofessional conduct under this provision. This new law provides an important means to combat a serious public health problem and prevent adverse reproductive health outcomes.

Although this law allows providers to use PDPT, this option is not intended as the first and optimal choice of treatment for partners of individuals diagnosed with gonorrhea and chlamydia. However, this strategy can serve as a useful alternative when the partner is unable or unlikely to seek care. Providers should use their best judgment to determine whether partners will or will not come in for treatment, and decide whether or not to dispense or prescribe additional medication to their patient index.

Chlamydia and gonorrhea are reportable to the Public Health Department within seven (7) calendar days. Confidential Morbidity Reports may be faxed to Disease Control at (951) 358-5102. Chlamydia remains the most commonly reported communicable disease in Riverside County, with over 4,000 cases reported in 2006.

Graph

Key Changes in 2006 CDC Treatment Guidelines

The 2006 guidelines include:

The new guidelines are available at www.cdc.org, or by calling Disease Control at (951) 358-5107.

World TB Day: March 24, 2007 - TB Anywhere is TB Everywhere

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 identify TB-related problems and solutions and to support TB Control worldwide. TB rates among foreign-born Californians are nine times higher than U.S.-born residents. Among U.S.-born Californians, only non-Hispanic whites have achieved the Healthy People 2010 objective of one TB case per 100,000. TB rates among U.S.-born Asians, Hispanics and African-Americans are two to six times higher than rates for non-Hispanic, U.S.-born whites, and these wide disparities have not substantially improved over the last decade.

California continues to contribute the most TB cases, deaths and child TB cases in the nation. In 2006, 77 percent of TB cases in California were identified among foreign born individuals. These cases require culturally appropriate health care strategies to ensure treatment results in cure.

Two thousand seven hundred and eighty one (2781) cases were reported in California in 2006 compared to 2900 in 2005. This represents a 4.2% decrease compared to the previous year. Although the overall number of TB cases statewide has decreased, 20 out of 61 jurisdictions in California had an increase in the number of reported cases. Despite the progress being made, the increasing occurrence of drug-resistant TB, including extensively drug resistant cases (XDR), presents significant challenges to treatment and control of the disease in the United States and abroad. It is also important to note that, every 3 days a child less than 5 years of age contracts TB in California and 200 Californians die each year from TB.

Locally, 74 new TB cases were reported in Riverside County in 2006, compared to 60 in 2005. Riverside County’s case rate of 3.8 exceeds the 2010 national objective of 1.0 case/100,000. Six patients were identified as having multiple drug resistant TB (MDR-TB). Patients with MDR-TB must be treated for 18-24 months compared to the 6 months for pan-sensitive TB. Clinicians play an important role in preventing the development of drug resistant tuberculosis by prescribing an appropriate treatment regimen.

One hundred and twenty years after Robert Koch’s discovery of the tubercle bacillus, TB is still a life threatening disease across the globe. It is important that Public Health and the medical community work closely together to ensure patients complete an adequate course of treatment.

Prompt reporting of confirmed as well as suspected cases of TB are essential for Public Health interventions. TB is reportable by laboratories and providers within 1 day of identification.
Reports may be faxed to TB Control at
(951) 358-7922.

Interpreting Hepatitis Laboratory Results

Hepatitis A is reportable to the Public Health Department within one (1) day of identification. Hepatitis B & C are reportable within seven (7) calendar days. Appropriate interpretation of lab results is important to determine if a Confidential Morbidity Report must be submitted to Public Health. A summary of hepatitis markers follows below.

HEPATITIS A

Anti-HAV: Antibody to hepatitis A virus. This diagnostic test detects total antibody of both IgG and IgM subclasses of HAV. Its presence indicates either acute or resolved infection.

IgM anti-HAV: IgM antibody subclass of anti-HAV. Its presence indicates a recent infection with HAV (6 mos. or less). It is used to diagnose acute hepatitis A.

HEPATITIS B

HBsAg: Hepatitis B surface antigen is a marker of infectivity. Its presence indicates either acute or chronic HBV infection.

Anti-HBs: Antibody to hepatitis B surface antigen is a marker of immunity. Its presence indicates an immune response to HBV infection, an immune response to vaccination, or the presence of passively acquired antibody. (It is also known as HBsAb, but this abbreviation is best avoided since it is often confused with abbreviations such as HBsAg.

Anti-HBc (total): Antibody to hepatitis B core antigen is a nonspecific marker of acute, chronic, or resolved HBV infection. It is not a marker of vaccine-induced immunity. It may be used in pre-vaccination testing to determine previous exposure to HBV infection. (It is also known as HBcAb, but this abbreviation is best avoided since it is often confused with other abbreviations.)

IgM anti-HBc: IgM antibody subclass of anti-HBc. Positivity indicates recent infection with HBV (within the past 6 mos.). Its presence indicates acute infection.

HBeAg: Hepatitis B “e” antigen is a marker of a high degree of HBV infectivity, and it correlates with a high level of HBV replication. It is primarily used to help determine the clinical management of patients with chronic HBV infection.

Anti-HBe: Antibody to hepatitis B “e” antigen may be present in an infected or immune person. In persons with chronic HBV infection, its presence suggests a low viral titer and a low degree of infectivity.

HBV-DNA: HBV Deoxyribonucleic acid is a marker of viral replication. It correlates well with infectivity. It is used to assess and monitor the treatment of patients with chronic HBV infection.

HEPATITIS C

ANTI-HCV: Anti HCV detects antibody to Hepatitis C virus. The test does not distinguish between acute, chronic or resolved infection.

NATS: Nucleic acid tests (NATS) used to detect HCV RNA. A single positive qualitative assay for HCV RNA confirms active HCV replication.

It is important to perform confirmatory testing for hepatitis B and C prior to reporting the case to the Public Health Department. This is especially important if the signal to ratio cut off is not provided for Hepatitis C. Hepatitis C is the second most commonly reported communicable disease in Riverside County. Two thousand thirty-three (2033) cases were reported in 2006 compared to 1,631 cases in 2005.

graph

Recognizing Potential Bioterrorism Activities

Riverside County Department of Public Health (DOPH) recognizes the importance of awareness and preparation for bioterrorism on the part of healthcare facilities and clinicians.

Hospitals and clinicians have the first opportunity to recognize and initiate a response to a bioterrorism attack. Healthcare facilities need to have infection control policies in place authorizing the infection control practitioner or designee to rapidly implement prevention and control measures in response to a suspected outbreak. In the case of a suspected event, communication must include DOPH, infection control practitioners, and healthcare facility administration. Riverside County DOPH will coordinate with the California Department of Health Services.

A major component of a strong public health infrastructure is the capacity to monitor the ever changing picture of disease in the community. While many new and improved methods of disease surveillance are currently being developed and implemented, public health relies on clinicians to promptly report all reportable diseases. A list of reportable diseases and procedures for disease reporting are available at www.rivco.diseasecontrol.org.

In November 2001, Title 17 of the California Code of Regulations was amended to mandate immediate reporting by healthcare providers and clinical laboratory directors of the diseases, conditions, and/or agents that pose the most serious threat for bioterrorism.

The diseases/conditions having potential bioterrorist implications that healthcare providers must report immediately (including nights, weekends and holidays) by telephone to the local health department include suspected or confirmed cases of:

Healthcare providers are defined as physicians, surgeons, veterinarians, podiatrists, nurses, nurse practitioners, nurse midwives, school nurses, infection control practitioners, physician assistants, dentists, coroners and medical examiners. The requirement for laboratories to report these diseases does not replace the healthcare provider’s legal obligation to report.

Early detection by astute clinicians and rapid reporting to the local health department will be critical in minimizing the impact of a bioterrorism event or other infectious disease emergency. Riverside County DOPH maintains a 365/24/7 call system to receive urgent reports. During business hours call Disease Control at (951) 358-5107.
After hours call (951) 782-2974.

 

NEWS BRIEFS

check Online Radiation Emergency Toolkit Available for Physicians, Hospitals

The U.S. Department of Health and Human Services (HHS) has launched an online diagnostic and treatment toolkit for health care facilities, first responders and physicians who may have to provide medical care during a radiation incident.

The Radiation Event Medical Management (REMM) Web site includes easy-to-follow procedures for diagnosis and management of radiation contamination and exposure, guidance for the use of radiation medical countermeasures, and a variety of other features to facilitate medical responses.

HHS said the online guidance on diagnosis and treatment will help health care providers by describing the types of radiation emergencies they may face, the initial medical actions at the incident site or medical facility and key steps in patient care.
Under a tab marked “Initial Event Activities” is additional guidance on how to develop a hospital radiological emergency medical response team, with roles and responsibilities defined for the radiation safety officer, emergency room personnel, nuclear medicine personnel, hospital safety/security coordinator, nursing staff, physicians, engineering/housekeeping and the public information officer. Topics covered include:

The REMM Web site is online at: http://remm.nlm.gov
(Reprinted from OSHA Guide for Health Care Facilities - May 2007)

check National Infant Immunization Week Urges Parents to Celebrate Their Children Being Up-to-Date with Shots

Riverside County Department of Public Health launched National Infant Immunization Week (NIIW), April 21-28, 2007. NIIW is an annual observance that emphasizes the need to fully immunize children ages 2 years old and younger against vaccine-preventable diseases. This year, California’s theme, “Up-to-date? Celebrate!” promotes the message that being up-to-date with immunizations is reason to celebrate.
To protect the children in your practice against serious diseases, it is important to start their shots on time and encourage parents to stay on schedule (see below for the 2007 Immunization Schedule). The schedule can be downloaded at www.rivco-diseasecontrol.org. Immunizations are among the most successful cost-effective public health tools available for preventing vaccine- preventable diseases. Current Disease activity is summarized below.

In California, approximately 3 of 4 children between the ages of 19 to 35 months are up-to-date on immunizations. In Riverside County 70% of children 2 years old and younger are up-to-date with their immunizations.

It is important for medical practices to maintain the integrity of vaccines by ensuring proper storage and handling. Nurse Educators with the Immunization Program are available to provide in-services and/or assessments of immunization rates with the goal of enhancing immunization practices. To schedule an in-service, please contact Angie Gladstone at (760) 863-7851 or Cassandra Lynch at (951) 354-1416.

Medical practices are also encouraged to enroll in VaxTrack which is a confidential, secure, computerized information system that allows doctors to retrieve their patient’s immunization histories from a regional database. For more information, or to schedule an in-office demonstration please call (951) 354-1400

Incidence of Reportable Vaccine Preventable Diseases
Riverside County, 2002 – 2006

Disease

2002

2003

2004

2005

2006

 

Diphtheria

0

0

0

0

0

 

Haemophilus Influenzae,
invasive disease

 

3

 

1

 

1

 

4

 

4

 

Hepatitis A

63

51

45

89

35

 

Hepatitis B, acute

37

39

34

46

36

 

Hepatitis B, perinatal

2

1

0

0

0

 

 Meningococcal Disease

2

3

6

4

3

 

Measles

0

1

0

1

1

 

Mumps

1

3

0

3

0

 

Pertussis

25

15

25

64

42

 

Polio

0

0

0

0

0

 

Rubella

0

0

0

0

0

 

Tetanus

0

0

0

0

0

 

Visit the Disease Control Website for Recommended Immunization Schedules

 

Get TB shot

 


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:
Eric Frykman, M.D., M.P.H.
David J. Herfindahl, M.D.
Barbara Cole, R.N., P.H.N., M.S.N.

  
Public Health Officer (951) 358-5058
Deputy Public Health Officer (951) 358-6196
Director, Disease Control / Editor (951) 358-5107

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