Issue
Number 508
January 31, 2005
CONTENTS OF THIS ISSUE
- CDC reports on an outbreak of invasive pneumococcal
disease in Alaska during 2003-04
- CDC reports on outbreaks of pertussis associated with
hospitals in the United States during 2003
- Note: On February 1, IAC will publish an Unprotected
People report about a fatal case of pertussis in West Virginia
- Update: CDC continues to supplement its Influenza web
section
- New: January issue of CDC's Immunization Works
electronic newsletter now available on the NIP website
- Association of Immunization Managers seeks nominations
for the 2nd annual "Natalie J. Smith, MD, Award"
- Save the date: National Viral Hepatitis Prevention
Conference set for December 5-9 in Washington, DC
- CDC launches web page devoted to perinatal hepatitis B
information and resources
- IAC updates immunization and viral hepatitis materials
- New: January 21 issue of IAC's Hep Express electronic
newsletter available online
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ABBREVIATIONS: AAFP, American Academy of Family Physicians; AAP, American
Academy of Pediatrics; ACIP, Advisory Committee on Immunization Practices;
CDC, Centers for Disease Control and Prevention; FDA, Food and Drug
Administration; IAC, Immunization Action Coalition; MMWR, Morbidity and
Mortality Weekly Report; NIP, National Immunization Program; VIS, Vaccine
Information Statement; VPD, vaccine-preventable disease; WHO, World Health
Organization.
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January 31, 2005
CDC REPORTS ON AN OUTBREAK OF INVASIVE PNEUMOCOCCAL DISEASE IN ALASKA DURING
2003-04
CDC published "Outbreak of Invasive Pneumococcal Disease--Alaska, 2003-2004"
in the January 28 issue of MMWR. Portions of the article are reprinted
below.
**********************
[From the article text]
In Alaska, statewide laboratory-based surveillance revealed an increase in
invasive pneumococcal disease (IPD) in a rural region during 2003-2004. This
report summarizes the outbreak, regional trends in serotype-specific
pneumococcal carriage, and an assessment of use of standing orders for
vaccination. The results of this analysis underscore the preventability of
IPD and the importance of vaccination. . . .
[From the Editorial Note]
During 2003-2004, region A [a remote area of Alaska; 80% of its residents
are Alaska Natives] experienced an outbreak of IPD in which seven (50%) of
14 patients had indications for vaccination and had disease caused by a
vaccine-preventable serotype. Pneumococcal carriage is a dynamic process,
and carriage of specific serotypes in a population fluctuates over time. On
a statewide level, during 1986-1990, [serotype] 12F was the most common
pneumococcal serotype isolated in Alaska Natives aged >=2 years, accounting
for 20.1% of IPD. However, during 1991-2000, the frequency of IPD caused by
serotype 12F in this same population subset decreased to 2.2%. In the
2003-2004 region A outbreak, an increase in carriage of serotype 12F was
temporally associated with an increase in serotype 12F IPD.
The Advisory Committee on Immunization Practices (ACIP) recommends a
one-time vaccination with PPV-23 [pneumococcal polysaccharide vaccine,
23-valent] for all persons aged >=65 years on the basis of its effectiveness
against pneumococcal bacteremia. One revaccination after >=5 years is
recommended for persons aged >=65 years if the first vaccine was
administered before age 65 years. Revaccination >=5 years after the first
dose is also recommended for persons aged >=2 years who are at high risk for
invasive pneumococcal infection and who are likely to have rapid declines in
pneumococcal antibody levels.
Surveillance for IPD in Alaska has documented that Alaska Natives have one
of the highest rates of IPD in the world. In addition, age-related increases
in rates of IPD occur at a younger age among Alaska Native adults compared
with non-Alaska Native adults. Because of these findings, the Alaska
Division of Health and Human Services recommends that all Alaska residents
receive PPV-23 beginning at age 55 years and be revaccinated every 6 years.
In the region A outbreak, adequate vaccination might have averted 50% of IPD
cases.
A national health objective for 2010 is to achieve pneumococcal vaccination
in 90% of adults aged >=65 years. The national self-reported prevalence of
pneumococcal vaccination among persons aged >=65 years was 61.8% (95%
confidence interval [CI] = 61.0-62.6) in 2002. The corresponding rate for
residents of Alaska was 59.8% (CI = 50.3-69.1).
On the basis of evidence that standing orders programs improve vaccination
rates, ACIP strongly recommends standing orders for pneumococcal and
influenza vaccinations in inpatient and outpatient settings, long-term-care
facilities, managed-care organizations, assisted-living facilities, and home
healthcare agencies. Standing orders programs allow clinical staff to
administer vaccinations according to an institution- or physician-approved
protocol without the need for a physician's examination or direct order.
Survey results suggest that successful standing orders programs depend on
convenient access to reliable immunization records and adequate clinical
staff support. When resources are available, computer-based standing orders
effectively increase vaccination rates. In the case of missing immunization
records, providers should follow the 1997 ACIP recommendations to vaccinate
patients who are uncertain about their vaccination histories or have
incomplete records.
The 2003-2004 region A outbreak emphasizes the need to take every
opportunity for vaccination in both inpatient and outpatient settings. Many
patients with risk factors indicating vaccination might not have a regular
primary-care provider but instead might seek medical attention in an
emergency department or urgent-care clinic. Screening and subsequent
immunization of persons with indications for vaccination in both
primary-care and urgent-care settings could substantially reduce
complications and death associated with pneumococcal disease. Region A
initiated provider education and a standing orders program in response to
the outbreak; surveillance for IPD continues. Other healthcare providers,
both in Alaska and nationally, should identify and address barriers to
vaccination. Implementation of ACIP recommendations for standing orders
programs is strongly recommended to take advantage of opportunities for
vaccination and reduce pneumococcal morbidity and mortality.
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a5.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5403.pdf
To receive a FREE electronic subscription to MMWR (which includes new ACIP
statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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January 31, 2005
CDC REPORTS ON OUTBREAKS OF PERTUSSIS ASSOCIATED WITH HOSPITALS IN THE
UNITED STATES IN 2003
CDC published "Outbreaks of Pertussis Associated with Hospitals--Kentucky,
Pennsylvania, and Oregon, 2003" in the January 28 issue of MMWR. Portions of
the article are reprinted below.
***********************
[From the article text]
Pertussis outbreaks have been reported in various settings, including sports
facilities, summer camps, schools, and health-care facilities. Mild and
atypical manifestations of pertussis among infected persons and the lack of
quick and accurate diagnostic tests can make pertussis outbreaks difficult
to recognize and therefore difficult to control. Outbreaks among healthcare
workers (HCWs) are of special concern because of the risk for transmission
to vulnerable patients. This report describes three pertussis outbreaks
among HCWs and patients that occurred in hospitals in Kentucky,
Pennsylvania, and Oregon in 2003. These outbreaks illustrate the importance
of complying with measures to reduce nosocomial infection when evaluating or
caring for patients with acute respiratory distress or cough illness of
unknown etiology. . . .
Case Investigations
Kentucky. In early August 2003, an infant aged 2 months, who was born at 26
weeks' gestation and hospitalized in the intermediate care nursery (ICN)
since birth, exhibited cough and apnea. Two days later, the infant was
transferred to a neonatal intensive care unit (NICU) and ventilated
mechanically. Seven days later, pertussis was suspected; 3 days later,
nasopharyngeal (NP) secretions tested positive for B. pertussis DNA by PCR
[polymerase chain reaction]. The infant was treated with azithromycin (10
mg/kg/day on day 1 and 5 mg/kg/day on days 2-5), and droplet precautions
were initiated in the NICU. . . .
Pennsylvania. In early September 2003, an infant aged 3 weeks was admitted
to the pediatric unit at hospital A for 1 day before being transferred to a
referral hospital. The infant had cough, posttussive vomiting, and fever for
5 days. Pertussis infection was considered unlikely in the differential
diagnosis, the patient was not tested for pertussis, and droplet precautions
were not observed by staff. NP secretions were obtained for culture from the
infant at the referral hospital, and B. pertussis was isolated 16 days
later. Pediatrician B, who cared for the infant at hospital A, had onset of
a cough illness 9 days after exposure. Even though he remained symptomatic,
the pediatrician continued to treat patients without wearing a mask and was
in contact with other HCWs, family members, and friends. Twenty-two days
after his initial exposure, NP secretions obtained from pediatrician B were
positive for B. pertussis DNA by PCR. . . .
Oregon. In late September 2003, physician C treated an infant aged 12 months
with PCR-confirmed pertussis in the pediatric ICU. Physician C, who wore a
mask while providing care to the infant, had been exposed to a colleague who
had prolonged cough illness since mid-September. The colleague was
subsequently found to have elevated IgG anti-pertussis-toxin antibody levels
(i.e., >20 [micrograms]/mL, as measured by the MSLI [Massachusetts State
Laboratory Institute] assay) consistent with recent pertussis infection. . .
.
[From the Editorial Note]
Despite high childhood coverage for pertussis vaccination, reported
pertussis incidence in the United States has increased from a low of 1,248
cases (0.54 per 100,000 population) in 1981 to an annual average of 9,431
cases during 1996-2003 (average annual rate: 3.3 per 100,000 population).
During 1996-2004, the majority of pertussis patients were either aged <6
months (35.1%) (i.e., too young to have received the 3-dose primary series)
or aged >=7 years (60.7%) (i.e., too old to receive a pertussis
vaccination). Adolescents and adults, including HCWs, might become
susceptible to pertussis because of waning immunity. No pertussis vaccine is
approved in the United States for persons aged >=7 years; however, in 2004,
two pharmaceutical companies submitted biologics license applications to the
Food and Drug Administration (FDA) for two tetanus toxoid and reduced
diphtheria toxoid and acellular pertussis vaccine adsorbed (Tdap) products,
one for persons aged 10-18 years and the other for persons aged 11-64 years.
This report highlights two primary difficulties in the diagnosis of
pertussis. First, diagnosis might be delayed or missed because symptoms are
atypical. In adolescents and adults, symptoms during the catarrhal stage are
most often nonspecific, but the disease is already highly communicable. In
infants, diagnosis might be delayed when the presentation is respiratory
distress with apnea without the typical cough. Second, sensitive and
specific diagnostic tests for pertussis are not readily available in many
settings; culture, the standard test, has diminishing sensitivity with
progression of the classic symptoms of the infection. PCR for pertussis is
not standardized, and false-positive and false-negative results can occur.
In addition, no serologic test for pertussis has yet been validated and made
available nationally, although CDC and FDA are developing such a test.
Because droplet transmission of pertussis can occur at the first contact
with an ill patient, HCWs and hospital infection-control services should
take measures to prevent hospital transmission. Many nosocomial outbreaks
might be prevented by HCWs' observing droplet precautions (i.e., wearing
procedural or surgical masks and hand washing). Delay in recognizing
pertussis can result in spread of disease to HCWs, patients, and other
contacts. HCWs should suspect pertussis in unvaccinated or partially
vaccinated infants with respiratory distress (e.g., apnea or cough) and
obtain NP secretions for culture. Isolation precautions are recommended for
confirmed and suspected cases of pertussis.
Erythromycin is recommended for treatment and prophylaxis of pertussis.
However, because erythromycin frequently causes gastrointestinal
disturbance, many patients do not complete the recommended 2-week course.
Azithromycin was used during all the outbreaks described in this report
because it causes fewer and milder side effects than erythromycin and its
longer half-life means that fewer daily doses are required, thereby
increasing the potential for patient compliance. A recent study that
compared azithromycin administered as 10 mg/kg (maximum: 500 mg) on day 1
followed by 5 mg/kg (maximum: 250 mg) on days 2-5 with a 7-day treatment of
erythromycin demonstrated equivalence between the two treatments.
Nosocomial pertussis outbreaks can result in substantial public health and
economic costs. Public health professionals and hospital decision-makers
should consider potential savings and benefits from implementing effective
infection-control strategies and from selective pertussis vaccination of
HCWs when adult vaccines become available in the United States.
[Excerpted from the box titled "Epidemiology, diagnosis, treatment, and
prevention of transmission among healthcare workers (HCWs) and close
contacts"]
Prevention
- Vaccination of children is available in a
5-dose series administered at ages 2, 4, 6, and 15-18 months and age 4-6
years.
- HCWs or patients with pertussis-like cough
illness (i.e., highly suspected for pertussis) should be tested and
treated.
- HCWs with pertussis should be excluded
from work for 5 days from the start of antibiotic use; if no antibiotic is
taken, HCWs should be excluded from work for 21 days from onset of
symptoms.
- HCWs should keep coughing patients >3 feet
from other persons and implement droplet precautions, including wearing of
procedural or surgical masks.
- Isolation precautions are recommended for
confirmed and suspected pertussis cases.
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5403a3.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5403.pdf
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January 31, 2005
NOTE: ON FEBRUARY 1, IAC WILL PUBLISH AN UNPROTECTED PEOPLE REPORT ABOUT A
FATAL CASE OF PERTUSSIS IN WEST VIRGINIA
On February 1, IAC will publish an IAC Express Unprotected People report
about a fatal case of pertussis in West Virginia in 2004. The report is
based on information reported to CDC by hospitals and local and state
public health departments in West Virginia.
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January 31, 2005
UPDATE: CDC CONTINUES TO SUPPLEMENT ITS INFLUENZA WEB SECTION
CDC recently posted the following new and updated information to its
Influenza web section.
REVISED INTERIM GUIDANCE
(1) On January 27, the Health Alert Network issued an official Health
Update titled Revised Interim Guidance for Late-Season Influenza
Vaccination. The revised interim guidance is now available on CDC's
Influenza web section. To access a ready-to-print (PDF) version of it, go
to:
http://www.cdc.gov/flu/protect/pdf/fluvaccine-lateseasonguidance.pdf
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/lateseasonguidance.htm
CDC updated the following to reflect the revised interim guidance:
(2) Questions and Answers: Flu Vaccination in the 2004-05 Season
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/about/qa/0405vaccination.htm
(3) Fact Sheet: Key Facts About Flu Vaccine
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/vaccinekeyfacts.pdf
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/keyfacts.htm
(4) Fact Sheet: Who Should Get Flu Vaccine This Season?
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/0405shortage.pdf
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/0405shortage.htm
(5) Business and the Workplace: 2004-05 Influenza Season
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/protect/pdf/workplace-flu0405.pdf
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/protect/workplace.htm
(6) Colleges and Universities: 2004-05 Influenza Season
To access a ready-to-print (PDF) version of it, go to:
http://www.cdc.gov/flu/school/pdf/college.pdf
To access a web-text (HTML) version, go to:
http://www.cdc.gov/flu/school/college.htm
AVIAN INFLUENZA OUTBREAKS IN ASIA
(7) On January 24, CDC added a revised case count to its web page Recent
Avian Influenza Outbreaks in Asia. To access it, go to:
http://www.cdc.gov/flu/avian/outbreaks/asia.htm
For ongoing information about new and updated materials on CDC's Influenza
web section, go to:
http://www.cdc.gov/flu/whatsnew.htm
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January 31, 2005
NEW: JANUARY ISSUE OF CDC'S IMMUNIZATION WORKS ELECTRONIC NEWSLETTER NOW
AVAILABLE ON THE NIP WEBSITE
The January issue of Immunization Works, a monthly email newsletter
published by CDC, is available on NIP's website. The newsletter offers
members of the immunization community non-proprietary information about
current topics. CDC encourages its wide dissemination.
To access the January issue from the NIP website, go to:
http://www.cdc.gov/nip/news/newsltrs/imwrks/2005/200501.htm
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January 31, 2005
ASSOCIATION OF IMMUNIZATION MANAGERS SEEKS NOMINATIONS FOR THE 2ND ANNUAL
"NATALIE J. SMITH, MD, AWARD"
The Association of Immunization Managers (AIM) is seeking nominations for
the 2005 "Natalie J. Smith, MD, Award." The award, which will be presented
at the National Immunization Conference in March, was established to honor
the memory of Dr. Smith's outstanding management and leadership skills in
the area of state and national vaccine-preventable disease programs.
Eligible candidates are current or recently retired immunization program
managers who are designated as the persons primarily responsible for
directing the 64 city, state, or territorial immunization programs
directly funded by the National Immunization Program. THE DEADLINE FOR
NOMINATIONS IS FEBRUARY 28.
Dr. Smith, who died in 2003 at age 41, was deputy director, National
Immunization Program, CDC. Prior to accepting the NIP position, she served
for eight years as chief, Immunization Branch, California Department of
Health Services. Dr. Smith served as a member of the Advisory Committee on
Immunization Practices and as chair of the Association of Immunization
Managers. She wrote numerous significant publications on immunization and
was a frequent presenter and consultant on immunization-related issues.
To access more information about the award, including the nomination
criteria and a 2005 nomination form, go to:
http://www.immunize.org/news.d/smithaward05.pdf
For additional information, contact Claire Hannan, AIM Executive Director,
by email at channan@astho.org,
by phone at (202) 715-1676, or by fax at (202) 371-9797.
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January 31, 2005
SAVE THE DATE: NATIONAL VIRAL HEPATITIS PREVENTION CONFERENCE SET FOR
DECEMBER 5-9 IN WASHINGTON, DC
[The following is cross posted from IAC's Hep Express electronic
newsletter, 1/21/05.]
The 2005 National Viral Hepatitis Prevention Conference (previously known
as the National Hepatitis Coordinators' Conference) will be held on
December 5-9, in Washington, D.C.
The focus of the conference will be on the prevention of viral hepatitis
through every stage of life. Attendees will receive the latest scientific
updates related to hepatitis A, B, and C. Workshops will address providing
services to injection drug users and men who have sex with men; overcoming
health disparities; designing, implementing, and evaluating successful
outreach, education, and counseling activities; identifying and overcoming
barriers to integrating hepatitis prevention activities into existing
programs; and obtaining funding and other resources.
The conference is intended for public health professionals, counselors,
administrators, health policy makers, educators, and others interested in
the control of viral hepatitis, including those working in perinatal or
immunization programs, STD and HIV clinics, correctional health care, and
substance abuse programs.
For more information, visit
http://www.cdc.gov/ncidod/diseases/hepatitis/conference.htm
Registration information, abstract submission guidelines, and a draft
conference agenda will be forthcoming on this site.
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January 31, 2005
CDC LAUNCHES WEB PAGE DEVOTED TO PERINATAL HEPATITIS B INFORMATION AND
RESOURCES
[The following is cross posted from IAC's Hep Express electronic
newsletter, 1/21/05.]
CDC's National Immunization Program (NIP) has recently added a web page of
perinatal hepatitis B information to its website. The new section features
pertinent brochures, flyers, slide sets, and websites for parents,
healthcare professionals, and state hepatitis B coordinators.
The new web page also includes a link to 2003 National Immunization Survey
(NIS) data, which includes the 2003 birth dose data.
Visit this valuable new resource at
http://www.cdc.gov/nip/diseases/hepB/pubs_other.htm
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January 31, 2005
IAC UPDATES IMMUNIZATION AND VIRAL HEPATITIS MATERIALS
IAC recently reviewed several of its print pieces related to immunization
and viral hepatitis for accuracy and updated some of them. Following is a
list of pieces reviewed and/or updated in January 2005.
IMMUNIZATION MATERIALS
The following pieces were REVIEWED AND UPDATED:
(1) "What would happen if we stopped vaccinations" was revised to reflect
2003 data.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/4037stop.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/4037stop.htm
(2) "Vaccines and autism" was revised to add a new study.
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2065.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2065.htm
VIRAL HEPATITIS MATERIALS
The following pieces were REVIEWED AND UPDATED:
(3) "States Report Hundreds of Medical Errors in Perinatal Hepatitis B
Prevention"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2062.pdf
To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2062.htm
(4) "Unprotected Babies: Two more infants chronically infected with
hepatitis B virus . . . the medical errors continue"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2127.pdf
To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2127.htm
(5) "Management of Chronic Hepatitis B in
Adults" by Brian J. McMahon, MD
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2161.pdf
To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2161.htm
(6) "Every day, teens are infected with hepatitis B"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4100tee.pdf
To access web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4100tee.htm
The following pieces were REVIEWED AND LEFT UNCHANGED:
(7) "Hepatitis B and the Health Care Worker"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/2109hcw.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/2109hcw.htm
(8) "Hospitals & Doctors Sued for Failing to Protect Newborns from Hepatitis
B Virus Transmission"
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p2061.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p2061.htm
(9) "If you have chronic hepatitis B virus (HBV) infection..."
To access a ready-to-print (PDF) version of it, go to:
http://www.immunize.org/catg.d/p4120eng.pdf
To access a web-text (HTML) version, go to:
http://www.immunize.org/catg.d/p4120.htm
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January 31. 2005
NEW: JANUARY 21 ISSUE OF IAC'S HEP EXPRESS ELECTRONIC NEWSLETTER AVAILABLE
ONLINE
The January 21 issue of Hep Express, an electronic newsletter published by
IAC, is now available online. Hep Express is intended for health and
social service professionals involved in the prevention and treatment of
viral hepatitis. The January 21 issue includes articles on the following:
Upcoming conferences: (1) the National Viral Hepatitis Prevention
Conference (see article #7 above) and (2) a conference on hepatitis C
sponsored by the American Association for the Study of Liver Diseases.
Hepatitis-related information from CDC and the Department of Health and
Human Services (DHHS): (1) CDC fact sheets about hepatitis A and hepatitis
E for tsunami survivors, (2) NIP's web page of perinatal hepatitis B
information (see article #8 above), and (3) DHHS funds available for
prevention of substance abuse, HIV, and hepatitis in minority populations.
Recently reviewed and revised IAC materials related to viral hepatitis
(see article #9) above.
Presentations made at the Viral Hepatitis Prevention Board's November 2004
meeting.
To access the January 21 issue, go to:
http://www.hepprograms.org/hepexpress/issue25.asp
To sign up for a free subscription to Hep Express, go to:
http://www.hepprograms.org/hepexpress/signup.asp
To access previous issues of Hep Express, go to:
http://www.hepprograms.org/hepexpress/index.asp |
