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. 1		JANUARY 2003

SYPHILIS CASES ON THE RISE IN RIVERSIDE COUNTY

Riverside County has seen a significant increase in infectious syphilis cases among men who have sex with men (MSM). The most dramatic increase has been seen in Eastern Riverside County, particularly in Palm Springs and surrounding communities. The majority of the cases are among MSM, with approximately 60% of the cases also positive for HIV. As of November 30, 2002, eighty-one cases have been reported in Riverside County, compared to 25 cases in 2001. This represents a 374% increase in the number of reported infectious syphilis cases.

The medical community can play a key role in efforts to control the syphilis outbreak. Clinicians are asked to maintain 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 the soles of the feet. Individuals at increased risk such as MSM who have multiple and/or anonymous partners, should routinely be tested for syphilis every 3-6 months. It is also important for clinicians to take a sexual history as part of assessing the patients risk status.

Patients with syphilis should be counseled and tested for HIV if their status is not known. Syphilis can increase the risk of HIV transmission from two to five times, and can result in serious complications in HIV positive individuals. Appropriate diagnosis and treatment of primary, secondary and early latent syphilis cases are crucial components of syphilis outbreak control efforts.

MANIFESTATIONS: States of syphilis infection

• Primary Syphilis

One or more painless ulcer(s) or chancre(s) at site of infection, which heal slowly over 2-8 weeks if untreated. Humoral antibodies do not usually appear until 1-4 weeks after chancre has formed.

• Secondary Syphilis

Invasion of the organism in every organ of the body and virtually all body fluids. About 1-5 weeks after the primary lesion, nonspecific symptoms may appear: fever, headache, sore throat, arthralgias, and anorexia. The most characteristic signs of secondary syphilis include: a generalized rash (syphilide) mucous patches, and in moist intertiginous areas, wart-like growths (condylomata lata). The earliest of the eruptions in secondary syphilis is a macular or roseolar syphilide with discrete pinkish macules uniformly distributed over the trunk. Rashes are generally widespread, including the palms and soles, non-irritant and slow in progression. Mucous patches are oval, shallow erosions, which may be anywhere in the mouth or throat, and the well-defined white or grey areas may become confluent. Many patients may have generalized lymphadenopathy. Spontaneous resolution of these manifestations is possible within 2 to 6 weeks, but relapses may occur during the first 4 years, if untreated. In pregnancy, transplacental transmission of T. pullidum is possible for up to 4 years after the initial infection, although with decreasing frequency as the infection persists. Screening of pregnant women is, therefore, of great importance. At the secondary stage of syphilis, almost all serologic tests for syphilis are reactive.

• Latent syphilis

A stage of infection where T. palladium persists in the body of the infected person without causing symptoms or signs.
Latent syphilis is subdivided into 3 categories:

Early Latent syphilis: initial infection occurred within the previous 12 months. Serologic tests are reactive, but reactivity of nontreponemal tests decreases with increasing latency. Since lesions may be present, this stage is considered infectious.

Late latent syphilis: Initial infection occurred more than 12 months.

Latent syphilis of unknown duration: The Centers for Disease Control and Prevention (CDC) 2002 Treatment Guidelines identify benzathine penicillin G 2.4 million units IM as the preferred treatment regimen for infectious syphilis cases. It is (Continued on next page) (Continued from front page) important to have patients return for follow-up clinical evaluation and repeat serology to detect treatment failures. HIV-infected individuals, and anyone treated with an alternative regimen require close follow-up. Evaluation and treatment of sexual partners are important interventions for syphilis management and outbreak control. Patients should be informed that the Health Department will need to contact them to ensure adequate follow-up and/or partner management, and that patient confidentiality will be protected. Although there is an effective treatment for syphilis, the presence of the disease can have a negative impact on prevention efforts targeting HIV infection. Clinicians are asked to immediately report suspect, as well as confirmed cases of infectious syphilis to the Department of Public Health by PHONE at (909) 358-5107, or by FAX at (909) 358-5102.

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NEWS BRIEFS

FIRST CASE OF WEST NILE VIRUS FOUND IN VENTURA COUNTY

    An Oxnard man has contracted West Nile Virus, but health department officials have indicated that they believe he became infected while working in Florida or the Caribbean. This case is the first in Ventura County and the sixth in California. Five victims acquired the virus east of the Rocky Mountains, while the origin of one Los Angeles case remains a mystery. Although health and environmental officials said they assumed the local case was "imported" they warned that the virus - which is harbored by birds and transmitted by mosquitoes - will arrive in the area within the next year or so.

    A second case has occurred in Los Angeles County and other cases were reported in Orange and Contra Costa counties, and in San Francisco. In those cases, the patients had traveled outside the state prior to being infected.

    People experience mild symptoms in about one in five cases, and about one in 150 of those infected need hospitalization. Symptoms include: fever, headache, nausea, body aches, mild skin rash, or swollen lymph nodes. In a few cases the disease will progress to encephalitis. A vast majority of patients display no symptoms.

    No human cases or positive findings from surveillance testing of mosquitoes and chickens have been reported in Riverside County.

INCREASE IN PERTUSSIS CASES NOTED IN RIVERSIDE COUNTY

As of October 31, 2002, 23 cases of pertussis were reported compared to 8 cases for the same time frame in 2001. Cases ranged in age from 1 month to 62 years of age; one infant died. The majority of the cases were in children too young to have completed the DTaP series. However, the six adult cases indicate the importance of clinicians considering pertussis in their differential diagnosis in adults presenting with compatible symptoms. Confirmed and suspect pertussis cases should be reported to Disease Control by telephone at (909) 358-5107 or by FAX at (909) 358-5102.

PRE-TEEN IMMUNIZATION WEEK

January 19-25, 2003 is Preteen Vaccine Week. We are taking advantage of this statewide observance to alert area health care providers that 11-12-year-old patients are required to complete a hepatitis B series and a second MMR shot prior to entering 7th grade. The annual fall assessment for seventh grades for the 2001-2002 school year showed that 31% of the children entering 7th grade in Riverside County were not up to date with their Hepatitis B series at school entry. Since it takes 4-6 months to complete the hepatitis B series we are encouraging all 6th graders to see their provider now to get their hepatitis B series completed in time to enter 7th grade. Flyers have been distributed to all the school districts and will be sent home with every 6th grade child informing their families of the hepatitis B requirement. Starting early will help reduce the last minute rush this year, and these children will be ready to start 7th grade on time. It is anticipated that nearly 90% of California students entering high school this coming fall will be protected from hepatitis B. In addition to the required hepatitis B shots and MMR2, preteens should receive a Td booster (unless they have had one within the last five years) and a Varicella shot if they have no history of chickenpox. These immunization visits will also provide an excellent opportunity for a preteen health assessment. Please contact Karon Jones, RN, Immunization Coordinator at (909) 358-5568, for additional information on immunization requirements for school entry.

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PNEUMOCOCCAL CONJUGATE VACCINE (PCV7) UPDATE

The national shortage of pneumococcal conjugate vaccine (PCV7) continues and is now expected to last throughout 2002. In December 2001, ACIP requested that all health-care providers reduce the number of vaccine doses used and ordered, regardless of their vaccine supply, so that vaccine was more widely available. This request remains in effect. Until adequate supplies are available, the following table should be used to determine who should be immunized and the number of doses needed.

ACIP-based recommendations for pneumococcal conjugate vaccine (PCV7) use During current (2002) moderate and severe shortages 1
Age at first Vaccination	High-Risk Children 2	Low- to Moderate3- Risk Children
	Standard Schedule 1	Moderate Vaccine Shortage 4	Severe Vaccine Shortage 5
< 6 months	2, 4, 6, and 12-15 months	2, 4, 6 months (defer 4th dose)	2 doses at 2-month interval in 1st 6 months of life (defer 3rd and 4th doeses)
7 - 11 months	2 doses at 2-month interval; also 12-15 month dose	2 doses at 2-month interval; also 12-15 month dose	2 doses at 2-month interval (defer 3rd dose)
12 -23 months	2 doses at 2-month interval	2 doses at 2-month interval	1 dose (defer 2nd dose)
> 24 months	2 doses	Defer vaccination	Defer vaccination

1. During the current national vaccine shortage, all providers are requested to conserve vaccine by implementing one of the two shortage schedules. Only use the Standard Schedule for infants and children 2 months to 59 months of age who are high-risk for invasive pneumococcal disease.

2. Children at high-risk for invasive pneumococcal disease include children with sickle cell disease, congenital or acquired asplenia, chronic cardiac or pulmonary disease, diabetes mellitus, renal failure, nephritic syndrome, or who are immunosuppressed, including those with human immunodeficiency virus (HIV) infection.

3. Moderate-risk children for invasive pneumococcal disease include children age 24-35 months, children of Alaskan Native, American Indian, or African American descent, and children who attend group day care 4 or more hours a week.

4. Moderate vaccine shortage is defined as a shortfall of less than 25% of the 4-dose infant schedule.

5. Severe vaccine shortage is defined as a shortfall of 25-50% of the 4-dose infant schedule. If shortages are estimated to be more severe (greater than 50%), health-care providers should set infant vaccination priorities based on the assessment of risk, deferring infants at lowest risk.

6. When the national vaccine supply is sufficient one PCV7 dose should be considered for low- and moderate-risk children 24-59 months of age, with priority given to moderate-risk children.

County of Riverside – Community Health Agency
Department of Public Health
3rd Quarter Morbidity Report - July to September

REPORTED CASES OF SPECIFIED NOTIFIABLE DISEASES
Chart also available as a printable file (PDF 55KB)

~ = New Syphilis sub-groups included as of 01/02. Data reflects STD database.
+ = Effective 6/01, revision in definition for reporting acute and chronic Hepatitis B.
* = excluding Haemophilus influenza/meningococcal infections
ˆ = Effective 11/01, new diseases added to report

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
RL 10/23/2002

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