Volume 50, Number 2 Summer 2000    

Page Navigation Panel

1 2 3 4

Page 1 2  

VOLUME 50, NUMBER 2 Summer 2000

This Issue. . . 

Children and Environmental Health . . . . . 2

Pitfalls in Pre-employment Testing . . . . . . . 2

Causes of Death and Death Certificates . . . . 3

Hepatitis A and Immune Globulin 

Hepatitis A: The Real Story Despite the fact that the number of cases of hepatitis A (HA) reported to Orange County Public Health remains at relatively low levels, several months ago HA was making headlines in the County. An immune globulin (IG) clinic at a school in South County coincided with the public announcement recommending IG for patrons of a South County restaurant. We would like to take this opportunity to review the epidemiology of HA in Orange County and the actions Public Health takes when a case of HA is reported to us.

Epidemiology of hepatitis A 

HA is spread by the fecal-oral route. Infected persons excrete the virus in their stool for approximately 2 weeks before to 1 week after the onset of jaundice. The HA virus can persist in the environment for weeks. Transmission of HA virus infection most commonly occurs among household and other close contacts. Children under the age of 6 years rarely have significant symptoms of hepatitis and often serve as silent transmitters of the infection to other household members. Foodborne HA can occur when an infected person, especially one with diarrhea, does not wash his/ her hands well after a bowel movement (or after changing the diapers of someone with HA) and contaminates food that is not subsequently cooked. The rate of hepatitis A in Orange County has steadily decreased since its peak in 1977 at 35.7 cases per 100,000 population. The 1999 rate was the second lowest recorded in Orange County, 9.5 per 100,000. Just under 40% of the reported 1999 cases were in children ages 5-14, making HA a significant cause of disease in the pediatric population. Overall, males outnumbered females with 59.6% of cases. Thirty-five percent of reported cases were white, and 56% were Hispanic. 

Diagnosis of Hepatitis A 

Diagnosis of acute HA requires laboratory documentation of HA IgM antibody. 1 Unless the HA IgM antibody test is specifically requested, separately or as part of an acute hepatitis panel, laboratories will usually only do the "total" HA antibody test, 2 which is positive when either HA IgG antibodies or HA IgM antibodies are present. A positive total HA antibody result does not distinguish be-tween current and past HA infection. The laboratory will not automatically do the HA IgM antibody test when the total HA antibody result is positive. HA IgM must be ordered to confirm acute HA infection. An acute hepatitis panel should include tests for HA IgM antibody, hepatitis B core IgM anti-body, hepatitis B surface antigen, and hepatitis C virus antibody. The Current Procedural Terminology (CPT 2000) code for an acute hepatitis panel, CPT #80074, has been revised to include all of these tests.

What Public Health does when a case of hepatitis A is reported 

When a case of laboratory-documented acute HA is reported to the health department, an attempt is made to interview the patient to deter-mine where he/ she contracted the infection and if he/ she might have transmitted the infection to others. It is helpful if you have instructed the patient that by law you are required to report the infection to Public Health and that some-one from the health department should be contacting them. Close contacts to the case are identified and, if fewer than 14 days have passed since the exposure, immune globulin (IG) is recommended for the contacts. The Centers for Disease Control and Prevention (CDC) does not recommend HA vaccine for post-exposure prophylaxis; however, the vaccine can be given at the same time as IG. If a contact does not have a source of medical care, he/ she must call (714) 834-8180 for an appointment to administer the IG. In the case of a school child reported with HA, the school is included in the investigation to determine if there were any high-risk activities at school during the time when the child could have transmitted the infection to others. Spread of hepatitis A in elementary, middle and high schools is uncommon; however, if high-risk activities are identified, IG will be recommended for the students who participated if less than 14 days have passed since the activity. If more than 14 days have passed, information will be provided to parents about hepatitis A and its prevention, including vaccination. If there is evidence that infection has spread beyond close contacts of an infected child, IG may be recommended for an entire class or school. Food handlers are removed from work if they are still in the infectious period. Three criteria must be met before Public Health will make a recommendation for IG for restaurant patrons: 1) the infected person is directly involved in handling, without gloves, foods that will not be cooked before they are eaten; 2) the hygienic practices of the food handler are deficient OR the food handler has had diarrhea; and 3) patrons can be identified and given IG within 2 weeks of exposure.

Pre-exposure Prevention: Vaccine, Hygiene 

Two highly effective HA vaccines are avail-able for those aged 2 years or more. Both prod-

(Continued on Page 3)

1 HA IgM antibody may appear in laboratory results as IgM anti-HAV, HAV-M, HAV-IgM, HEPA IgM, HAM, etc. 2 Total HA antibody may appear in laboratory results as HEP A AB TOTAL, anti-HAV, HAVAB, anti-HAV (IgG/ IgM), etc. 

1

1 Page 2 3  

2 

VOLUME 50, NUMBER 2

Children and Environmental Health

Announcing the EPA-ordered phase out of the popular household and industrial pesticide Dursban recently, EPA Administrator Carol Browner said: "It is particularly good news for children, who are among the most vulnerable to the risks posed by pesticides." This comment is music to the ears of pediatricians and advocacy groups who have long recognized what regulators have been slow to acknowledge: young children, for a variety of reasons, are particularly susceptible to and disproportionately affected by environmental toxins. This is true for three basic reasons: First, a child's faster metabolism requires him or her to take in proportionately more food, water and air, and the contaminants therein, than adults. Second, a child's organ systems are still developing and are thus more vulnerable to toxins. And third, children physically occupy and explore the floors, carpets, lawns and lower air spaces that are more often contaminated and which we rarely frequent as adults. While we, as a nation, lag far behind in reflecting this unique vulnerability in our policy and research, there has been one huge success and much additional progress in recent years. The huge success has been the removal of lead from

gasoline and paint which has resulted in a 40% reduction in the average blood lead level in the U. S. over the past twenty five years. (This success has been more than offset, however, by research showing the toxic effect of lead at much lower levels in the blood than previously thought.) Re-search on childhood environmental health issues has been given a great boost by the joint EPA/ CDC/ NIH funding of eleven research centers across the country, two of which are located in California. Progress in the policy arena is reflected in the reauthorization of the federal Food Safety Act in the mid-nineties requiring that the unique vulnerability of children be factored in when setting regulatory thresholds for food contaminants. Advocacy for policy change has been led by such groups as the Children's Environmental Health Network. Most recently, the American Academy of Pediatrics has published a handbook for pediatricians on Pediatric Environmental Health. While we await further progress in research and policy to address childhood environmental threats there is much each of us can do, whether public health or clinical practitioner, to minimize the impact of environmental threats on children. I would suggest three objectives that we can all

work toward. They address what I believe to be the three most significant environmental threats to a child's health. First, every child at risk is appropriately screened for lead poisoning. Second, every smoking pregnant woman and every smoking parent of an infant or young child is urged and assisted to quit. And third, every parent of a young child is educated about the dangers of ultraviolet light and urged to minimize the child's exposure. More generally, we all need to learn more about the unique vulnerability of children to environmental toxins and apply that knowledge to our public health and clinical practice.

Avoiding Pitfalls in Pre-employment Testing of Health Care Workers

Health care workers (HCWs; e. g., physicians, nurses, emergency medical personnel, dental professionals and students, medical and nursing students, laboratory technicians, hospital volunteers) are often screened for certain vaccine-preventable diseases as part of the pre-employment process or before their clinical contact begins. The Advisory Committee on Immunization Practices (ACIP) strongly recommends 1 that all HCWs be vaccinated against hepatitis B 2 , influenza, measles, mumps, rubella, and varicella or have documented immunity (except for influenza). A reliable history of varicella infection is considered adequate evidence of immunity. The decision between testing for immunity or vaccinating a new employee is a cost-effectiveness one, based on the likelihood the employee is immune, the cost of the vaccine, the cost of the laboratory test, and the number of visits required to complete testing or vaccine. Problems and unnecessary expense can occur in documenting immunity if the appropriate laboratory tests are not requested. This is especially common with measles and rubella antibody

testing. If the IgG antibody, which indicates past infection or previous vaccination, is not specifically requested, some laboratories will do an IgM antibody test only or both IgG and IgM antibody tests. Some of the IgM antibody tests are prone to false positive results. In the case of measles or rubella, a positive IgM result should be reported to Orange County Public Health and will lead to an investigation of the case. This sort of confusion wastes time and money and can delay the hiring process. The appropriate test for establishing immunity to measles, mumps, rubella and varicella is the IgG antibody for each of these. When testing for IgG antibody to varicella, more sensitive tests, such as enzyme-linked immunosorbent assay (ELISA) or latex agglutination, are preferable to the complement fixation test. Immunity due to past hepatitis B virus (HBV) infection can be assessed by the HBV core antibody (total, not IgM). Serologic testing for vaccine-induced immunity to HBV (HBV surface antibody) is only recommended for HCWs after completion of the vaccine series (to document a response) and at the time of an exposure. Studies have shown that up to

60% of people who initially respond to the vaccine will lose detectable antibody over 12 years; however, they are still protected against infection. 1 Although the ACIP recommendations only address HCWs, the California Department of Health Services recommends that all staff working in hospitals have immunity at least to measles. Health care facilities may want to evaluate the immune status of non-clinical staff who have direct patient contact, particularly in areas such as emergency departments where contact occurs before clinical evaluation of patients.

1 Immunization of Health-Care Workers. MMWR December 26, 1997 / Vol. 46 / No. RR-18 http://www.cdc. gov/epo/mmwr/preview/ind97_ rr.html

2 Occupational Health and Safety Administration (OSHA) regulations require that within 10 days of hire an offer of hepatitis B vaccine be made to HCWs who have the potential for blood exposure.

Mark Horton, MD, MSPH, is Deputy Agency Director and Public Health Officer of the County of Orange Health Care Agency

Hepatitis C Training Available on the Web The Centers for Disease Control and Prevention (CDC) has launched an interactive training program entitled "Hepatitis C: What Clinicians and Health Professionals Need to Know" located at http://www.cdc.gov/hepatitis Continuing medical and nursing education credits are available from CDC on completion of the training and the American Academy of Family Physicians will grant credits if filed at the completion of the program. 

2 

2 Page 3 4

3 

VOLUME 50, NUMBER 2 Summer 2000

Causes of Death and Death Certificates

(Death Certificate Graphic)

Death Certificate data constitute an available, comprehensive, relatively uniform and generally reliable source of information to describe mortality trends in the population. Central to the process of calculating mortality rates and determining leading causes of death is the correct coding of the underlying cause of death. The underlying cause of death, which is the last listed cause in Box 107 of the Death Certificate, is defined as the disease, abnormality, or injury that led to death. It must have an etiologic or pathologic relationship to the intervening and immediate causes of death listed above it, and it must have initiated the lethal chain of events, no matter how long the time interval. 

Completing Causes of Death Certificate

To better aid the physician in completing the causes/ conditions of death sections on a Death Certificate, the following rules are provided (refer to graphic below): (1) Up to 4 causes of death can be listed in Box 107 (only 1 cause can be entered on each line). Causes listed in lines A, B, C, and D in Box 107 should be in chronological and pathological order such that the most immediate cause of death is listed in A, any cause listed in B led to the cause in A and preceded it, any cause listed in C led to B and preceded it, and any cause listed in D led to the cause in C and preceded it. (2) Time intervals listed in lines A, B, C, and D in Box 107 must be in chronological order with the most recent event or condition first. (3) Box 112 should be reserved for conditions contributing to death but not an underlying cause or one of the causes in the chain of events that led to death. (4) If an operation is specified in Box 107 or Box 112, then it must also be listed in Box 113. (5) If a biopsy is specified in Box 107 or Box 112, then "Yes" must also be checked in Box 109. (6) If no autopsy was performed (" No" checked in Box 110), then either "No" should be checked in Box 111 or Box 111 should be left blank. A Death Certificate completed in accordance with the rules above will reduce the amount of time spent by the physician, mortuary and registration staff in correcting errors. Additionally, a correct certificate will eliminate the need to file an amendment to the Death Certificate at a later date.

 Beginning on January 1, 2000, the County of Orange Health Care Agency, Birth and Death Registration Unit began coding the underlying cause of death on Death Certificates using the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). The Tenth Revision differs from the Ninth Revision (ICD-9) in a number of respects although the overall content is similar. Changes have been made in the coding rules for mortality to improve the usefulness of the mortality statistics by giving preference to certain categories and by systematically selecting a single cause of death from a reported sequence of conditions. In order for the coding rules to be applied appropriately, the physician certifying the death and its causes must complete the appropriate sections of the Death Certificate correctly. Should you have further questions regarding the Death Certificate registration process, please telephone the Birth and Death Registration Unit at (714) 480-6700.

Hepatitis A (Continued from Page 1)

ucts are given as a series of 2 doses, with the second dose given 6-12 months after the first dose. A new product, Twinrix, that combines the HA and hepatitis B vaccines into a single injection, for protection against both diseases in a 3-dose series, is close to licensure in the U. S. In late 1999, the Advisory Committee on Immunization Practices (ACIP) made a recommendation for routine vaccination of all children who live in states that had rates exceeding the national aver-age during 1987-1997; California meets that criterion. For more information, see the Morbidity and Mortality Weekly Report (MMWR), "Prevention of Hepatitis A Through Active or Passive Immunization," October 1, 1999 (Vol. 48, No. RR-12), available at the Centers for Disease Control and Prevention (CDC) web site: http:// www2.cdc.gov/mmwr/indrr_ 99. html. The vaccine is available free of charge for children aged 2-18 years through the Vaccines for Children (VFC) program and Orange County Public Health programs. The Orange County Health Referral line at (800) 564-8448 provides information on the locations where free vaccine is available. It is also helpful to remind your patients of the importance of good hygiene, including hand washing after using the bathroom, after changing diapers, and before eating or preparing food.

Reporting HA 

HA infection must be reported within 1 working day of diagnosis to Public Health under California law. You may report cases by telephone to (714) 834-8180 or by fax to (714) 834-8196. Immune Globulin At times, there have been shortages of IG, making it difficult or impossible for physicians to obtain a supply; however, there is no shortage at present, and physicians should be able to order IG from the following sources: FFF Enterprises 1-800-843-7477 Health Coalition 1-800-456-7283 Chapin Medical 1-800-221-7180 NHS 1-800-344-6087 Nationwide 1-800-997-8846 ASD 1-800-837-5043 Biocare Blood Systems 1-800-304-3064

3 

3 Page 4  

4 

VOLUME 50, NUMBER 2 Summer 2000

COUNTY OF ORANGE l HEALTH CARE AGENCY 

QUALITY MANAGEMENT 

P. O. BOX 355

SANTA ANA, CA 92702

Public Health Bulletin is published by the County of Orange Health Care Agency, Quality Management/ Public Information under the direction of: 

Mark Horton, MD, MSPH, Health Officer

Editorial Board: 

Len Foster, Division Manager, Adult and Child Health Services 

Ron LaPorte, Division Manager, Health Promotion & Disease Control 

Jack Miller, Director, Environmental Health Services 

Hildy Meyers, M. D., Medical Director, Communicable Disease Control & Epidemiology Editors: 

Howard Sutter, Health Information Specialist 

Pat Markley, Public Information Officer

Carole Neustadt, Manager, Communications Public 

Health Bulletin provides up-to-date information on public health issues affecting the Orange County medical community. PHB welcomes your ideas, comments, and article submissions. Please direct all comments and/ or questions to:

County of Orange Health Care Agency 

Public Health Bulletin/QM 

P. O. Box 355 

Santa Ana, CA 92702

(714) 834-3166 

Graphic Design and Layout produced by the HCA Desktop Publishing Unit — a part of Quality Management. 

If you would like to receive the Public Health Bulletin by e-mail, please send your electronic subscription request to Karen Waheed at kwaheed@ochca.com. Please include your name, title, organization, address and e-mail address. If you choose to receive the Public Health Bulletin by e-mail, you will no longer receive a printed copy by U. S. mail. County of Orange Health Care Agency 4

Public Health Bulletin provides up-to-date information on public health issues affecting the Orange County medical community. PHB welcomes your ideas, comments, and article submissions. Please direct all comments and/or questions to: 

County of Orange Health Care Agency 

Public Health Bulletin/QM 

P.O. Box 355 

Santa Ana, CA 92702 

(714) 834-3166

ORANGE COUNTY REPORTED CASES OF SPECIFIED NOTIFIABLE DISEASES

(NA) Not Available

If you would like to receive the Public Health Bulletin by e-mail, please send your electronic subscription request to Prycetta Brooks at pbrooks@ochca.com. Please include your name, title, organization, address and e-mail address. If you choose to receive the Public Health Bulletin by e-mail, you will no longer receive a printed copy by U.S. mail.

4

Page Navigation Panel

1 2 3 4