Issue
Number 468
July 6, 2004
CONTENTS OF THIS ISSUE
- CDC confirms first reported cases of rabies transmission
through solid organ transplantation
- CDC reports on 2003-04 influenza activity in the U.S.
and worldwide and on composition of the 2004-05 influenza vaccine
- CME teleconferences on childhood influenza prevention
are scheduled for July 13-15
- Attention: July 19 is the application deadline for the
position of director, Division of Viral Hepatitis
- Reminder: July 31 is the early-bird registration
deadline for the National Conference on Immunization Coalitions
- Coming soon: HFI's National Viral Hepatitis Summit
scheduled for August 26-27 in Baltimore, MD
- September 7 is registration deadline for Immunize
Georgia's Little Guys conference
- CDC notifies readers about free software for influenza
pandemic preparedness planning
- CDC reports on progress toward measles mortality
reduction in South East Asia, 1999-2002
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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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July 6, 2004
CDC CONFIRMS FIRST REPORTED CASES OF RABIES TRANSMISSION THROUGH SOLID ORGAN
TRANSPLANTATION
CDC published "Investigation of Rabies Infections in Organ Donor and
Transplant Recipients--Alabama, Arkansas, Oklahoma, and Texas, 2004" in the
July 2 issue of "MMWR Dispatch." CDC publishes the web-based "MMWR Dispatch"
only for the immediate release of important public health information. The
article will be published in a print issue of MMWR in the future.
The July 2 "MMWR Dispatch" is reprinted below in its entirety, excluding
references and two figures.
***********************
On June 30, 2004, CDC confirmed diagnoses of rabies in three recipients of
transplanted organs and in their common donor, who was found subsequently to
have serologic evidence of rabies infection. The transplant recipients had
encephalitis of unknown etiology after transplantation and subsequently
died. Specimens were sent to CDC for diagnostic evaluation. This report
provides a brief summary of the ongoing investigation and information on
exposure risks and postexposure measures.
Organ donor
The organ donor was an Arkansas man who visited two hospitals in Texas with
severe mental status changes and a low-grade fever. Neurologic imaging
indicated findings consistent with a subarachnoid hemorrhage, which expanded
rapidly in the 48 hours after admission, leading to cerebral herniation and
death. Donor eligibility screening and testing did not reveal any
contraindications to transplantation, and the patient's family agreed to
organ donation. Lungs, kidneys, and liver were recovered. No other organs or
tissues were recovered from the donor, and the donor did not receive any
blood products before death. The liver and kidneys were transplanted into
three recipients on May 4 at a transplant center in Texas. The lungs were
transplanted in an Alabama hospital into a patient who died of
intraoperative complications.
Liver recipient
The liver recipient was a man with end-stage liver disease. The patient did
well immediately after transplantation and was discharged home on
postoperative day 5. Twenty-one days after transplant, the patient was
readmitted with tremors, lethargy, and anorexia; he was afebrile. The
patient's neurologic status deteriorated rapidly during the next 24 hours;
he required intubation and critical care support. A lumbar puncture
indicated a mild lymphocytic pleocytosis (25 white blood cells/cubic mm) and
a mildly elevated protein. Magnetic resonance imaging (MRI) of the brain
indicated increased signal in the cerebrospinal fluid. His neurologic status
continued to deteriorate. Six days after admission, a repeat MRI indicated
diffuse encephalitis. The patient subsequently died.
Female kidney recipient
The first kidney recipient was a woman with end-stage renal disease caused
by hypertension and diabetes. She had no postoperative complications and was
discharged home on postoperative day 7. Twenty-five days after transplant,
she was readmitted with right-side flank pain and underwent an appendectomy.
Two days after this procedure, she had diffuse twitching and was noted to be
increasingly lethargic. Neurologic imaging with computed tomography and MRI
indicated no abnormality. During the next 24-48 hours, the patient had
worsening mental status, seizures, hypotension, and respiratory failure
requiring intubation. Her mental status continued to deteriorate, and
cerebral imaging 2 weeks after admission indicated severe cerebral edema.
The patient subsequently died.
Male kidney recipient
The second renal recipient was a man with end-stage renal disease caused by
focal, segmental glomerulosclerosis. His posttransplant course was
complicated briefly by occlusions of an arterial graft leading to infarction
of the lower pole of the transplanted kidney. The patient was discharged
home 12 days after transplantation. Twenty-seven days after transplantation,
he visited a hospital emergency department and was then transferred to the
transplant center with myoclonic jerks and altered mental status; he was
afebrile. An MRI of the brain performed on admission revealed no
abnormalities. His mental status deteriorated rapidly during the next 24
hours. A lumbar puncture revealed mild lymphocytic pleocytosis (16 white
blood cells/cubic mm) and a mildly elevated protein. His mental status
continued to deteriorate, leading to respiratory failure requiring
intubation. A repeat MRI performed 10 days after admission indicated diffuse
edema. The patient subsequently died.
Laboratory investigation
In all three patients, histopathologic examination of central nervous system
(CNS) tissues at CDC revealed an encephalitis with viral inclusions
suggestive of Negri bodies; the diagnosis of rabies in all three recipients
was confirmed by immunohistochemical testing and by the detection of rabies
virus antigen in fixed brain tissue by direct fluorescent antibody tests.
Electron microscopy of CNS tissue of one of the renal transplant recipients
also identified characteristic rhabdovirus inclusions and viral particles.
Suckling mice inoculated intracranially and intraperitoneally with brain
tissue from one kidney recipient died 7-9 days after injection. Thin-section
electron microscopy of CNS tissue of the mice had visible rhabdovirus
particles, and immunohistochemical testing detected rabies viral antigens.
Antigenic typing performed upon brain tissue from one recipient was
compatible with a rabies virus variant associated with bats. Rabies virus
antibodies were demonstrated in blood from two of the three recipients and
the donor. Detecting rabies antibodies in the donor suggests that he was the
likely source of rabies transmission to the organ recipients. Testing of
additional donor specimens is ongoing.
Editorial Note:
Rabies is an acute fatal encephalitis caused by neurotropic viruses in the
genus Lyssavirus, family Rhabdoviridae. The majority of rabies cases are
caused by bites by rabid mammals. Nonbite exposures, including scratches,
contamination of an open wound, or direct mucous membrane contact with
infectious material (e.g., saliva or neuronal tissue from rabid animals),
rarely cause rabies. After an incubation period of several weeks to months,
the virus passes via the peripheral nervous system and replicates in the
central nervous system. Rabies virus can then be disseminated to salivary
glands and other organs via neural innervation. Rabies can be prevented by
administration of rabies postexposure prophylaxis, which is highly effective
in preventing rabies when administered before onset of clinical signs.
Although transmission of rabies has occurred previously among eight
recipients of transplanted corneas in five countries, this report describes
the first documented cases of rabies virus transmission among solid organ
transplant recipients. Infection with rabies virus likely occurred via
neuronal tissue contained in the transplanted organs, as rabies virus is not
spread hematologically. In collaboration with CDC, state and local health
departments in Alabama, Arkansas, Oklahoma, and Texas have initiated
investigations to identify a potential source of exposure for the donor and
to identify contacts of patients among health care providers or domestic
contacts who might need rabies PEP.
The risk for health-care-associated transmission of rabies is extremely low;
transmission of rabies virus from infected patients to health care providers
has not been documented. The use of Standard Precautions for contact with
blood and body fluids (e.g., gloves, gown, mask, goggles, or face shield as
indicated for the type of patient contact) prevents exposure to the rabies
virus. No laboratory-confirmed cases of human-to-human transmission of
rabies among household contacts have been reported. No cases of rabies have
been reported in association with transmission by fomites or environmental
surfaces.
Routes of possible exposure include percutaneous and mucocutaneous entry of
the rabies virus through a wound, nonintact skin, or mucous membrane
contact. Intact skin contact with infectious materials is not considered an
exposure to the rabies virus. Persons with exposure as defined above to
saliva, nerve tissue, or cerebral spinal fluid from any of the four infected
patients should receive rabies PEP. Types of exposures in domestic settings
for which administration of PEP would be appropriate include bites, sexual
activity, exchanging kisses on the mouth or other direct mucous membrane
contact with saliva, and sharing eating or drinking utensils or cigarettes.
In health care settings, additional opportunities that can lead to
contamination of mucous membranes or nonintact skin with oral secretions
include procedures such as intubation or suctioning of respiratory
secretions or injuries with sharp instruments (e.g., needlesticks or scalpel
cuts). Percutaneous injuries (e.g., needlesticks) are considered exposures
because of potential contact with nervous tissue. Contact with patient
fluids (e.g., blood, urine, or feces) does not pose a risk for rabies
exposure.
All potential organ donors in the United States are screened and tested to
identify if the donor might present an infectious risk. Organ procurement
organizations are responsible for evaluating organ donor suitability,
consistent with minimum procurement standards. Donor eligibility is
determined through a series of questions posed to family and contacts,
physical examination, and blood testing for evidence of organ dysfunction
and selected bloodborne viral pathogens and syphilis. Laboratory testing for
rabies is not performed. In the case reported here, the donor's death was
attributed to noninfectious causes. The role of organ donor deferral is to
optimize successful transplantation in the recipient, including minimizing
risk of infectious disease transmission to the lowest level reasonably
achievable without unduly decreasing the availability of this life-saving
resource. The benefits from transplanted organs outweigh the risk for
transmission of infectious diseases from screened donors. CDC is working
with federal and organ procurement agencies to review donor screening
practices.
Additional information about rabies and its prevention is available from
CDC, telephone (404) 639-1050, or at
http://www.cdc.gov/ncidod/dvrd/rabies Additional information about
organ transplantation is available at
http://www.optn.org/about/donation
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To access a web-text (HTML) version of the "MMWR Dispatch," go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm53d701a1.htm
To access a ready-to-copy (PDF) version of it, go to:
http://www.cdc.gov/mmwr/pdf/wk/mm53d701.pdf
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July 6, 2004
CDC REPORTS ON 2003-04 INFLUENZA ACTIVITY IN THE U.S. AND WORLDWIDE AND ON
COMPOSITION OF THE 2004-05 INFLUENZA VACCINE
CDC published "Update: Influenza Activity--United States and Worldwide,
2003-04 Season, and Composition of the 2004-05 Influenza Vaccine" in the
July 2 issue of MMWR. Portions of the article and of a summary made
available to the press are reprinted below.
***********************
FROM THE PRESS SUMMARY
In the United States, the 2003-04 influenza season began and peaked earlier
than usual, and was more severe than the previous three seasons. . . . In
several Asian countries, widespread outbreaks of avian influenza A (H5N1)
among poultry were reported. In Vietnam and Thailand, these poultry
outbreaks were associated with 34 confirmed human infections with avian
influenza A (H5N1) viruses, resulting in severe illnesses and 23 deaths. No
evidence of efficient person-to-person spread of H5N1 has been found to
date. CDC continues to recommend enhanced surveillance for suspected H5N1
cases among travelers with severe unexplained respiratory illness returning
from H5N1-affected countries.
FROM THE ARTICLE
Composition of the Influenza Vaccine for the 2004-05 Season
On the basis of antigenic analyses of recently isolated influenza viruses,
epidemiologic data, and postvaccination serologic studies in humans, the
Food and Drug Administration's Vaccines and Related Biological Products
Advisory Committee (VRBPAC) recommended that the 2004-05 trivalent influenza
vaccine for the United States contain A/New Caledonia/20/99-like (H1N1), A/Fujian/411/2002-like
(H3N2), and B/Shanghai/361/2002-like viruses.
Because of the growth properties of the A/Wyoming/3/2003 and B/Jiangsu/10/2003
viruses, U.S. vaccine manufacturers are using these antigenically equivalent
strains in the vaccine as the H3N2 and B components, respectively. The A/New
Caledonia/20/99 virus will be retained as the H1N1 component of the vaccine.
. . .
Editorial Note
Beginning with the 2004-05 influenza season, the Advisory Committee on
Immunization Practices (ACIP) recommends that all children aged 6-23 months
and close contacts of children aged 0-23 months receive annual influenza
vaccination. ACIP continues to recommend that all persons aged >6 months
with certain chronic underlying medical conditions, their household
contacts, and health care workers receive annual influenza vaccination. . .
.
Influenza vaccine manufacturers project that approximately 90-100 million
total doses of influenza vaccine will be available for distribution during
the 2004-05 season in the United States. These influenza vaccine projections
are preliminary and could change as the season progresses. CDC has
contracted to purchase up to 8 million doses of influenza vaccine for use in
the public sector, including up to 3 million doses of preservative-free
vaccine for children. CDC also has received $40 million through the Vaccines
for Children program to purchase approximately 4-4.5 million doses of
influenza vaccine for a national stockpile, which could be made available to
state and local health departments and manufacturers for distribution. . . .
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a1.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5325.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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July 6, 2004
CME TELECONFERENCES ON CHILDHOOD INFLUENZA PREVENTION ARE SCHEDULED FOR JULY
13-15
Intended for health professionals who provide services for children, the
hour-long CME [continuing medical education] teleconference New Developments
in Childhood Influenza Prevention, will cover the following topics:
- Disease burden and prevention (10 minutes)
- Vaccination and strain drift (10 minutes)
- Efficacy and safety of trivalent
inactivated influenza vaccine and live attenuated intranasal vaccine (15
minutes)
- Questions and answers (25 minutes)
The presenter is Robert B. Belshe, MD,
professor of medicine, pediatrics, and molecular microbiology, St. Louis
University School of Medicine. The sponsor is the Chatham Institute,
Chatham, NJ.
Participants have a choice of three sessions:
- July 13, 7PM ET
- July 14, 12PM ET
- July 15, 7PM ET
To access a registration form and register
online, go to:
http://www.subassoc.com/influenza/influenza.html
To register by phone, call (800) 305-2303 between 9AM and 5PM ET, Monday
through Friday.
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July 6, 2004
ATTENTION: JULY 19 IS THE APPLICATION DEADLINE FOR THE POSITION OF
DIRECTOR, DIVISION OF VIRAL HEPATITIS
CDC announced it has extended the application deadline to July 19 for
the position of director, Division of Viral Hepatitis. The following
partial description of the position's responsibilities is taken from the
vacancy announcement:
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DUTIES: The National Center for Infectious Diseases (NCID) is seeking
exceptional candidates for the position of Director, Division of Viral
Hepatitis (DVH), CDC. The mission of this Division is to prevent,
control, and eliminate hepatitis virus infections. The Division is
divided into 4 major organizational units, Office of the Director,
Epidemiology, Prevention, and Laboratory Branches. The Director manages
a division budget exceeding $25 million and approximately 130
professional and support staff. The Director is responsible for
providing the scientific, programmatic, and management leadership
required for a program to prevent infection with hepatitis viruses and
the liver disease associated with these infections. The programs
conducted by the Division are national and international in scope and
involve laboratory, epidemiologic, and clinical research; surveillance;
and development, implementation, and evaluation of prevention programs.
. . .
********************
To access the entire vacancy announcement, go to:
http://www.immunize.org/cdc/dirdvhncid.pdf
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July 6, 2004
REMINDER: JULY 31 IS THE EARLY-BIRD REGISTRATION DEADLINE FOR THE
NATIONAL CONFERENCE ON IMMUNIZATION COALITIONS
The National Conference on Immunization Coalitions will be held
September 20-22 in Norfolk, VA. The early-bird registration deadline is
July 31.
Intended to provide training in creating, leading, and sustaining
effective local and state coalitions that address childhood, adolescent,
and adult immunization, the conference will bring together more than 400
attendees from immunization coalitions across the nation. This year's
program will focus on coalitions as agents of social change, elements of
a successful coalition, and social and ethnic diversity in coalitions.
For information, go to:
http://www.cme.hsc.usf.edu/coph/immcoal
To register online, go to:
https://www.cme.hsc.usf.edu/coph/iz/register.html
Contact Annemarie Beardsworth with questions about content by email at
annemarieb@doh.state.ri.us or by phone at (401) 222-5658.
Contact Tracey Ryan with questions about logistics by email at
tryan@hsc.usf.edu or by phone
at (813) 974-6682.
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July 6, 2004
COMING SOON: HFI'S NATIONAL VIRAL HEPATITIS SUMMIT SCHEDULED FOR AUGUST
26-27 IN BALTIMORE, MD
[The following is cross posted from the Immunization Action Coalition's
"HEP EXPRESS" electronic newsletter, 6/25/04.]
The Third Annual National Viral Hepatitis Summit will be held August
26-27, 2004, in Baltimore, MD. The conference is sponsored by Hepatitis
Foundation International (HFI) and is intended for physicians, nurses,
psychologists, counselors, outreach workers, patient advocates, and
others working with people who are affected by or infected with viral
hepatitis.
For information about the agenda and/or registration, go to
http://www.hepfi.org/pdfs/registrationsummit.pdf or call (800)
891-0707.
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July 6, 2004
SEPTEMBER 7 IS REGISTRATION DEADLINE FOR IMMUNIZE GEORGIA'S LITTLE GUYS
CONFERENCE
Immunize Georgia's Little Guys Conference is scheduled for September 28
at the Georgia International Convention Center, College Park, GA. The
registration deadline is September 7.
The theme is "Seeking the Gold Standard--Strategies for Improving
Immunization Practices." Speakers include William Atkinson, MD, MPH,
from NIP, and Michael Chaney and others from Georgia Immunization
Program.
To access registration information and the conference agenda online, go
to:
http://www.choa.org/forprofessionals/cme/iglg2004.pdf
For additional information, contact Angie Matthiessen, conference
coordinator, by phone at (404) 785-7216 or email at
angie.matthiessen@choa.org
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July 6, 2004
CDC NOTIFIES READERS ABOUT FREE SOFTWARE FOR INFLUENZA PANDEMIC
PREPAREDNESS PLANNING
CDC published "Notice to Readers: Availability of Influenza Pandemic
Preparedness Software for Hospital Planning" in the July 2 issue of MMWR.
The notice is reprinted below in its entirety, excluding references.
***********************
Influenza pandemics have occurred three times during the 20th century:
in 1918, 1957, and 1968. Another influenza pandemic is likely, if not
inevitable. To help public health officials and hospital administrators
prepare for the next influenza pandemic, CDC has developed FluSurge 1.0,
a specialized spreadsheet-based software that estimates the potential
surge in demand for hospital-based health care during a pandemic. For
each week of a pandemic, FluSurge calculates the potential demand for
hospital beds, intensive care unit beds, and mechanical ventilators.
Demand for resources is compared with actual capacity. FluSurge is a
companion to the previously released FluAid 2.0, which provides
estimates of the total deaths, hospitalizations, and outpatient visits
that might occur during an influenza pandemic.
Both FluSurge 1.0 and FluAid 2.0, including accompanying manuals, are
now available from the National Vaccine Program Office's website at
http://www.dhhs.gov/nvpo/pandemics The software programs and
manuals are available free of charge.
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To access a web-text (HTML) version of the notice, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a7.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5325.pdf
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July 6, 2004
CDC REPORTS ON PROGRESS TOWARD MEASLES MORTALITY REDUCTION IN SOUTH EAST
ASIA, 1999-2002
CDC published "Progress Toward Sustainable Measles Mortality Reduction,
South East Asia Region, 1999-2002" in the July 2 issue of MMWR. A
portion of a summary made available to the press is reprinted below.
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Measles remains the leading cause of vaccine-preventable deaths among
children worldwide. This report summarizes progress in measles control
in SEAR [the South East Asia Region] during 1999-2002 and outlines plans
for future activities. During this time, reported measles cases
increased, primarily due to increases in India, Indonesia, and Thailand,
and several nationwide outbreaks. This increase in reported measles
incidence was primarily due to inadequate measles vaccination coverage
as well as improvements in surveillance. From 1999-2002, four countries
in SEAR introduced case-based measles surveillance, and a regional
measles laboratory network was established. Six countries conducted
national or sub-national measles vaccination campaigns. In June 2003,
the South East Asian Regional (SEAR) Technical Advisory Group on
Immunization endorsed a Regional Strategic Plan for Measles Mortality
Reduction (2003-2005) with the ultimate goal of achieving sustainable
measles mortality reduction. Countries should prepare national action
plans for measles control that are linked to their national Expanded
Program on Immunization Plans.
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To access a web-text (HTML) version of the complete article, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5325a4.htm
To access a ready-to-copy (PDF) version of this issue of MMWR, go to:
http://www.cdc.gov/mmwr/PDF/wk/mm5325.pdf |
