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
	WINTER 2006

PREPARING FOR THE UPCOMING INFLUENZA SEASON

As the influenza season approaches, it is important to target high risk groups for influenza vaccination. High risk groups include:

Persons 60 years of age and older

Anyone with chronic disorders of the cardiovascular or pulmonary systems, including asthma

Women who will be pregnant during the influenza season

The Advisory Committee on Immunization Practices (ACIP) also recommends that healthy children aged 24-59 months, their household contacts and their out-of-home caregivers be vaccinated against influenza. This change extends the recommendations for vaccination of healthy children from 24 months to 59 months of age.

Influenza vaccine for use in the 2006-2007 United States influenza season includes the following influenza virus strains:

A/Wisconsin/67/2005(H3N2) –like

A/New Caledonia/20/99 (H1N1) –like

B/Malaysia/2506/2004 –like strains

It is important for hospitals and other medical facilities to promote influenza vaccination of health care workers (HCW). Protecting HCWs can also help to protect patients against influenza.

USE OF ANTIVIRALS FOR SEASONAL INFLUENZA

Due to high levels of resistance, the Centers for Disease Control and Prevention (CDC) recommends that neither amantadine nor rimantadine be used for the treatment or chemoprophylaxis of influenza A in the United Sates at this time. Oseltamivir or zanamivir can be prescribed if antiviral treatment of influenza is indicated.

Report Respiratory Illness Outbreaks

Influenza outbreaks must be reported to Public Health. (Refer toGuidelines for Managing Respiratory Illness in Clinical Settings below). The Department also maintains surveillance for influenza-like illness. Hospitals provide data on the number of visits to emergency departments for influenza-like illness. In addition, data is collected from sentinel providers. Refer to graph 1 & 2 for current surveillance data.

Graph 1

Graph 2

CDC REVISES AVIAN INFLUENZA TESTING GUIDANCE

Although no highly pathogenic avian influenza (H5N1) has been identified in the United States, it is important for clinicians to be aware of testing guidelines. The Centers for Disease Control and Prevention (CDC) issued revised interim guidance for testing suspected human cases of avian influenza H5N1. The guidance addresses testing of health care and lab workers who may have had exposure to H5N1, as well as travelers.

According to the guidance, testing for avian H5N1 infection is recommended for a patient who:

has an illness that requires hospitalization or is fatal

has had a documented temperature equal to or greater than 100.4° F

has radiographically confirmed pneumonia, acute respiratory distress syndrome, or other severe respiratory illness for which an alternative diagnosis has not been established, and

had a potential exposure within 10 days of symptom onset

A potential exposure is defined as including close contact with a person who was hospitalized or died due to a severe unexplained respiratory illness; close contact with an ill patient confirmed or suspected to have H5N1 infection; working with live influenza H5N1 in a laboratory; and other specified situations. Suspect cases must be reported to Public Health immediately by telephone. Business hours (951) 358-5107 and after hours (951) 782-2974.

ROTOVIRUS DISEASE CAUSES SEVERE GASTROENTERITIS IN INFANTS AND YOUNG CHILDREN

Rotavirus is the most common cause of severe gastroenteritis in infants and children the first 3-5 years of life in the United States. Rotavirus usually starts with gastric upset, followed by vomiting, fever and diarrhea lasting for 3 to 7 days. Children between the ages of 3–35 months have the greater risk for developing the virus, which can quickly lead to a dangerous level of dehydration related to severe diarrhea. This can result in death if the child is left untreated.

Rotavirus is easily transmitted through fecal-oral contact from contaminated hands or contaminated objects. Children can spread the virus both before and after getting diarrhea. It is important to stress prevention through hand washing, which decreases disease transmission.

In the United States, 4 of 5 children will get rotavirus disease in their first 5 years of life. One in seven children with rotavirus disease will require a clinic or emergency department visit. About 1 in 78 children will require hospitalization, and an estimated 1 in every 200,000 children dies from rotavirus each year.

NEW ROTAVIRUS VACCINE (RV): RotaTeq®

While rotavirus has many serotypes which cause the disease, RotaTeq® is indicated for the prevention of rotavirus gastroenteritis in infants and children caused by the serotypes G1, G2, G3, and G4. RotaTeq® is a live oral pentavalent vaccine. It is a 3 dose series recommended for infants 6 weeks to 32 weeks of age. It is to be routinely administered orally at 2 months, 4 months and 6 months of age. The efficacy of RV against rotavirus gastroenteritis is 74% and 98% against severe rotavirus gastroenteritis. RV reduced the hospitalization for rotavirus gastroenteritis by 96%.

This vaccine is available through private providers and public health family care clinics. Children without a medical provider may obtain Rotavirus and other immunizations at a Riverside County Family Care Center or at Immunization Outreach Clinics. Information is located on the on the Disease Control website at www.rivco-diseasecontrol.org

GUIDELINES FOR MANAGING RESPIRATORY ILLNESS IN CLINICAL SETTINGS

Preparing for possible respiratory illness outbreaks:
It is important to:

Have and disseminate a written policy concerning respiratory illness outbreak management

Encourage employees who have a respiratory illness to remain at home until they are no longer contagious.

Strongly encourage influenza vaccination of all employees and take measures to improve employee access to the vaccine

Educate employees about the risk of influenza to their patients, themselves, and their families, and about the benefits of vaccination

Offer influenza vaccine to unvaccinated patients before they are discharged

Surveillance Activities

Document the incidence of reported respiratory illness and influenza-like illness

Consider respiratory testing of patients admitted from the Emergency Department who have influenza-like illness with no other identified pathogens (contact Public Health for free assistance with samples and testing)

Consider patients who develop influenza-like illness >72 hours after facility admission as potential cases of nosocomial acquired respiratory or influenza-like illness

Initiate respiratory illness testing and droplet precautions when healthcare facility-acquired respiratory illness is detected

Consider daily monitoring for respiratory illness in selected settings, such as units with particularly vulnerable patients, including intensive care units and oncology units.

Control measures for influenza-like illness:
In patient waiting areas:

Place boxes of surgical masks close to the entrance and have them visible and readily available

Provide surgical masks to all patients/visitors with symptoms of respiratory illness with instructions on proper use and disposal

Physically segregate patients with respiratory symptoms from other patients by at least 3 feet

Designate a separate unit for patients with respiratory or influenza-like illness

Initiate droplet precautions for persons with respiratory or influenza-like illness or confirmed influenza including:

Wearing masks when within 3 feet of the patient

Wearing gowns if clothing is likely to be soiled by body fluids

Practicing hand hygiene before and after patient contact

Offer influenza vaccine to patients and healthcare personnel who have not been vaccinated

Consider offering influenza antiviral medications for treatment of ill patients, healthcare personnel, and for prophylaxis of exposed patients, unvaccinated personnel, and those vaccinated <2 weeks before exposure

Monitor personnel for respiratory illness with fever, and restrict ill personnel from patient care

Consider visitor restrictions during outbreaks.

Contact Disease Control at (951) 358-5107, for additional information or to report respiratory illness outbreaks.

NEWS BRIEFS

Funding Changes For The Childhood Asthma Program

The Riverside County Department of Public Health implemented the Childhood Asthma Program (CAP) in 2001, and has since assisted over 2,500 children in the management of their asthma. CAP services, such as home environmental assessments for allergens and
asthma education, have been made possible through funding from First 5 Riverside, the Desert Healthcare District (DHCD) and a variety of other sources. CAP has also provided administrative support for the Riverside County Asthma Coalition and the Asthma Coalition of the Desert Communities. Other accomplishments have included a reduction in emergency department and urgent care visits, a decrease in missed school days, and parents’ increased confidence in management of their child’s asthma.

Although CAP will experience major funding cuts after December 31, 2006, the program will continue to offer services to families affected by asthma.

Asthma education will be provided to eligible families for pediatric asthma visits to the Department of Public Health’s Jurupa Family Care Center and the Riverside Neighborhood Health Center. These services are made possible through the California Department of Health Services and are available through June 31, 2008.

In home patient education, environmental assessments, and case management services are available for families with children aged 0-18, who have an asthma diagnosis and reside in Western Riverside County. Generous funding from the South Coast Air Quality Management District has financed these services since January 1, 2006.

If you would like additional information or would like to refer a child to CAP, please call (951) 358-4977.

Recent Increase In Wound Botulism In California

Since 1994, California has experienced an epidemic of wound botulism among injecting drug users (IDUs). Over the past 5 years, 20-24 cases of laboratory-confirmed wound botulism among IDUs have been reported on a yearly basis in California. From January 1, 2006 to date, California has already logged 22 laboratory-confirmed cases. Although the reason for this year’s increase is unknown, the primary cause of wound botulism among IDUs has been skin-popping contaminated black tar heroin.

A clinician who suspects botulism in a patient must contact Riverside County Public Health in order to receive antitoxin and to trigger any local investigations that are necessary. During business hours call (951) 358-5107, after hours (951) 782-2974. Public Health will discuss the case with the calling physician and will contact the California Department of Health Services if antitoxin appears to be warranted. Please refer to the Guidelines for the Diagnosis and Management of wound botulism on the Disease Control web site.

Shiga Toxin in Feces Now Reportable in California

The California Department of Health Services has made the detection of Shiga toxin (STX) in feces reportable by health care providers and laboratories. Effective immediately, shiga toxin in feces must be reported to Riverside County Department of Public Health immediately by telephone. Telephone reports should be called to (951) 358-5107. Cases of hemolytic uremic syndrome (HUS) must also be reported.

This requirement follows a multi-state outbreak of E coli 0157 linked to spinach. As of October 2006, over 200 cases have been reported nationally with 3 deaths. One case of E coli 0157 linked to the outbreak has been reported in Riverside County.

Isolates or stool specimens should be submitted to the Public Health lab for confirmatory testing. Please contact the Public Health Lab director at (951) 358-5070, for questions of specimen submission. Questions on reporting requirements should be directed to Disease Control at (951) 358-5107.

Attachment: Guidelines for the Diagnosis and Management of Wound Botulism
http://www.rivco-diseasecontrol.org/guidelin/botulism_guide.pdf

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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