Recently,, some candies (such as Chaca Chaca, Bolirindo and Tama Roca) have been reported to the California Department of Health Services (CDHS) Food and Drug Branch with elevated lead levels. Follow-up has been conducted to ensure that the products with lead are no longer being sold in California. However, various brands/types of Mexican or other imported candies are still being sold that may contain lead.
Items such as paint, dust, soil, home remedies, traditional pottery, metal or painted toys and jewelry, miniblinds, dried fruits, herbs and spices, crayons, insecticide chalk, candles, cosmetics or other items may also contain various amounts of lead.
Medical providers may use well-child and other visits as opportunities to ask parents whether their children may have been exposed to these items. In Orange County, immigrant children who have been in the US for one year or less are at high risk for lead poisoning even if their current environment is low risk for lead. If there is concern about possible exposure, the provider should consider ordering a blood lead test.
State of California guidelines minimally require the following:
• Test at age 12 months and at age 24 months
• or between ages 25 and 72 months if not previously tested
Using the risk assessment questions that follow, assess children at age 12 months and at age 24 months or between the ages of 25 and 72 months if not previously assessed or tested.
• "Does your child live in, or spend a lot of time in, a place built before 1978 that has peeling or chipped paint or that has been recently renovated?"
• If the response to the question is "Yes"
or "Don't know," a blood lead test needs to
be
ordered on the high risk child. Given the chronic nature of lead poisoning,
immigrant children (one year or less) should be
considered "don't know."
In addition, any child may receive a blood test at the provider's discretion or parental request.
The target audience for the plague-training module is medical professionals in hospital and primary care settings (physicians, physician assistants, nurses, nurse practitioners, nurse-midwives), as well as veterinarians and other health care professionals. In addition to CME credits, nursing contact hours and CE Contact Hours for health education are offered for completion of the lessons.
The plague training module is found on the CDC's website at www.bt.cdc.gov/agent/plague/trainingmodule. Objectives of the plague-training module are to allow participants to:
• Identify where plague occurs naturally in order to recognize possible bioterrorism.
• Identify patient symptoms that will lead to a diagnosis of bubonic, pneumonic, or septicemic plague.
• Describe how to rule out other diseases when diagnosing plague.
• Identify the appropriate specimens to obtain in order to diagnose plague.
• Describe the medical management of confirmed plague cases.
• Describe the public health response needed for naturally occurring versus bioterrorist plague.
• Describe the diagnosis of plague in animals.
Future modules will cover anthrax, botulism, smallpox, tularemia and viral hemorrhagic fevers.
Infections in health care settings targeted - 2
Influenza vaccination, surveillance info - 2&3
West Nile Virus disease reportable - 3
The Centers for Disease Control and Prevention's campaign to prevent antimicrobial resistance in health care settings now includes specific recommendations for prevention among residents of long-term care facilities.
The recommendations fall into four categories and total 12 recommended steps.
• Give influenza and pneumococcal vaccinations to residents
• Promote vaccination among all staff
• Step 2. Prevent conditions that lead to infection
• Prevent aspiration
• Prevent pressure ulcers
• Maintain hydration
• Step 3. Get the unnecessary devices out
• Insert catheters and devices only when essential and minimize duration of exposure
• Use proper insertion and catheter-care protocols
• Reassess catheters regularly
• Remove catheters and other devices when no longer essential
• Target empiric therapy to likely pathogens
• Target definitive therapy to known pathogens
• Obtain appropriate cultures and interpret results with care
• Consider C. difficile in patients with diarrhea and antibiotic exposure
• Step 5. Use local resources
• Consult the infectious disease experts for complicated infections and potential outbreaks
• Know your local and/or regional data
• Get previous microbiology data for transfer residents
• Minimize use of broad-spectrum antibiotics
• Avoid chronic or long-term antimicrobial prophylaxis
• Develop a system to monitor antibiotic use and provide feedback to appropriate personnel
• Step 7. Treat infection, not colonization or contamination
• Perform proper antisepsis with culture collection
• Re-evaluate the need for continued therapy after 48-72 hours
• Do not treat asymptomatic bacteriuria
• Step 8. Stop antimicrobial treatment
• When cultures are negative and infection is unlikely
· • When infection has resolved
• Use Standard Precautions
• Contain infectious body fluids (use appropriate Droplet and Contact isolation precautions)
• Step 10. Break the chain of contagion
• Follow CDC recommendations for work restrictions and stay home when sick
• Cover your mouth when you cough or sneeze
• Educate staff, residents and families
• Promote wellness in staff and residents
• Step 11. Perform hand hygiene
• Use alcohol-based handrubs or wash your hands
• Encourage staff and visitors
• Step 12. Identify residents with multi-drug resistant organisms (MDROs)
• Identify both new admissions and existing residents with MDROs
• Follow standard recommendations for MDRO case management
The CDC's Campaign to Prevent Antimicrobial Resistance is found on the CDC website at: www.cdc.gov/drugresistance/healthcare.
More than eight million infants and children should receive influenza vaccine each year, yet only one-third of these children actually receive the vaccine. This is the lowest vaccination rate for any recommended childhood vaccine in the United States. To support the recommendation of the Advisory Committee on Immunization Practices (ACIP) that influenza vaccine be given to all children ages six to 23 months, the National Foundation for Infectious Disease has developed a free online CME course entitled Increasing Pediatric Influenza Immunization in Infants and Children.
The online course is intended to be completed in two hours, and is available at www.pedflumodels.com. A CD-Rom of the course can be requested by calling (866) 686-6343 or by sending an e-mail to info@pedflumodels.com. The course is intended for family physicians, pediatricians, pediatric infectious disease specialists and others interested in lessening the burden of influenza in children. Subject matter is divided into four topics:
(1) influenza epidemiology and disease burden in children;
(2) safety, immunogenicity and efficacy of influenza vaccine in children;
(3) ten tips to increase influenza vaccination rates in your office; and
(4) increasing pediatric immunization rates with influenza vaccine clinics in a private practice.
Orange County health care providers are being sought to participate in a nationwide influenza surveillance network, with several benefits offered to participants in return for a few minutes of their time.
An influenza sentinel provider conducts surveillance for influenza-like illness (ILI) in collaboration with Orange County Public Health, the state health department and the Centers for Disease Control and Prevention. Data reported by sentinel providers, in combination with other influenza surveillance data, provide a national picture of influenza virus and ILI activity in the U.S.
Sentinel providers report the number of patient visits for influenza-like illness by age group (0-4 years, 5-24 years, 25-64 years, >65 years) along with the total number of patient visits each week. These data are transmitted once a week via fax to Orange County Public Health, using a simple form that just involves checking boxes. Most providers report that it takes them less than 30 minutes a week to record and report their data. In addition, sentinel providers can submit specimens from a subset of patients for virus isolation free of charge.
Providers of any specialty (e.g., family practice, internal medicine, pediatrics,
infectious diseases) in any type of practice (e.g.,
private practice, public health clinic, urgent care
center, emergency room, university student health
center) are eligible to be sentinel providers. In
addition, sentinel providers may be physicians,
nurse
practitioners, or physician assistants.
Influenza viruses are constantly evolving and cause substantial morbidity and mortality (approximately 36,000 deaths) almost every winter. Data from sentinel providers are critical for monitoring the impact of influenza and, in combination with other influenza surveillance data, can be used to guide prevention and control activities, vaccine strain selection, and patient care. In addition, many agents of bioterrorism may present as influenza-like illnesses and monitoring ILI may help detect a bioterrorism event. Sentinel providers receive feedback on the data submitted, summaries of regional and national influenza data, and a free subscription to CDC's Morbidity and Mortality Weekly Report and Emerging Infectious Diseases journal. The most important consideration is that the data provided are critical for protecting the public's health.
For more information on participating in Influenza Sentinel Provider Surveillance, please contact Michele Cheung, M.D., MPH, Orange County Epidemiology, at 714-834-7729 or by e-mail at mcheung@ochca.com.
Following the confirmation of the first human West Nile Virus infection in Orange County, County Health Officer Mark B. Horton, M.D., added West Nile Virus disease to the county's list of reportable diseases, as authorized under the California Health and Safety Code, Section 120175.
As stated in Dr. Horton's order, the case definition of West Nile Virus disease is:
West Nile Virus disease, defined as an illness
1) Clinically compatible with
a) West Nile Fever (WNF) — fever, headaches, myalgias, lymphadenopathy, rash, fatigue and weakness lasting at least seven days OR
b) West Nile Neuroinvasive Disease (WNND) — meningitis, encephalitis or acute flaccid paralysis
AND with
2) Supportive laboratory results
a) serum or CSF enzyme immunoassay (EIA) for WNV-specific IgM, OR
b) fourfold or greater change in WNV-specific IgG titer (or equivalent change using alternate IgG method) between acute and convalescent sera, OR
c) isolation of WNV or demonstration of WNV antigens or genomic sequences in tissue, blood, cerebrospinal fluid, or other body fluid.
WNV disease is reportable within one working day of identification by telephone, fax or mail to Orange County Epidemiology at:
Telephone (714) 834-8180
Fax (714) 834-8196
Or by Mail to P.O. Box 6128, Santa Ana, CA 92706-0128.
Aseptic meningitis and encephalitis of any etiology are currently reportable diseases under State law (California Code of Regulations, Title 17, Section 2500). The California Department of Health Services and the California Conference of Local Health Officers support the implementation of WNV disease reporting to improve surveillance and raise awareness of the disease.
The extreme shortage of influenza vaccine in the U.S. will make the 2004-05 flu season very challenging. The Orange County Health Care Agency (HCA) has adopted the State Health Officer's order (insert enclosed) to limit influenza vaccination to persons in high-risk categories. HCA has also been working with community health care providers to assess vaccine supply and, where possible, direct available vaccine to high-risk groups and individuals. Throughout the flu season, HCA will post current influenza-related information to its Internet site at www.ochealthinfo.com/epi/flu. Information will include recommendations for health care providers, prevention information and links to information from the Centers for Disease Control and California Department of Health Services.
Childhood (Continued from Page 1)
According to Dr. Gilberto Chavez, Associate Director and State Epidemiologist of the
California Department of Health Services (CDHS), "Lead
is toxic to humans, especially infants, young
children, and developing fetuses, in both short and
long-term exposures and can result in learning disabilities
and behavioral disorders that could last a lifetime."
Providers should be especially concerned about pregnant women and children who may have consumed contaminated imported candies or products, or who may have contact with leaded paint, dust, or soil.
According to the Orange County Childhood Lead Poisoning Prevention Program, almost all of the children found to have elevated blood lead levels in Orange County were discovered because a routine blood level was drawn as recommended by the guidelines.
Providers may also consider warning families to avoid the use of imported products such as candies to prevent ingestion of lead.
Questions regarding lead poisoning in children may be directed to your local Childhood Lead Poisoning Prevention Program. In Orange County, California, please contact (714) 834-8006.
Number of Cases by Year of Report
DISEASE 2004 2003 2002 2001
AIDS1 107 139 107 157
AMEBIASIS 7 3 8
17
CAMPYLOBACTERIOSIS 105 110 118
133
CHLAMYDIA 2,952 2,691 2,887
2,568
CRYPTOSPORIDIOSIS 3 8 4
4
E-COLI O157:H7 4 2 1 1
FOOD POISONING OUTBREAKS 16 19 38
17
GIARDIASIS 49 52 56 85
GONOCOCCAL INFECTION 439 325 360
287
H-FLU, INVASIVE DISEASE 3 2 2
2
HANSEN'S DISEASE, LEPROSY 0 0 0
0
HEPATITIS A (acute) 21 41 60
80
HEPATITIS B (acute) 15 14 30 24
HEPATITIS B (chronic) 500 631 651 779
HEPATITIS B (perinatal, acute &
chronic)2 515 645 681 803
HEPATITIS C (acute) 4 3 2 5
HEPATITIS C (chronic) 743 786 841 1,339
HEPATITIS OTHER/UNSPECIFIED 2 3 8 6
HIV3 285 364 n/a n/a
KAWASAKI DISEASE 11 17 12 7
LISTERIOSIS 7 1 8
8
MALARIA 6 2 7 5
MEASLES (RUBEOLA) 0 0 2
4
MENINGITIS, TOTAL 211 147 132
96
ASEPTIC MENINGITIS 192 124 103
77
MENINGOCOCCAL INFECTIONS 13 3 5
7
MUMPS 1 2 5 2
NON-GONOCOCCAL URETHRITIS 276 292 407
303
PERTUSSIS 41 35 40 5
PELVIC INFLAMMATORY DISEASE 20 20 40
25
RUBELLA 0 0 0 0
SALMONELLOSIS 118 87 121
118
SHIGELLOSIS 36 45 47 47
STREP, INVASIVE GROUP A 13 30 36
20
SYPHILIS, TOTAL* 111 140 179
106
PRIMARY 4 8 9 10
SECONDARY 13 8 6
14
EARLY LATENT 16 7 19 16
LATENT 1 7 1
5
LATE LATENT 76 109 142 61
CONGENITAL 1 1 2
0
NEUROLOGICAL 0 0 0 0
TUBERCULOSIS 59 56 90
78
TYPHOID FEVER, CASE 0 7 2 0
NA= Not Available 1 Source: CDC HARS Reporting System
2Previously included in Hepatitis B acute or chronic totals. Separate reporting started in 2002.
3 Source: CDC HARS Reporting System. HIV case reporting began July 1, 2002; data is unavailable for previous years.
Mark Horton, MD, MSPH, Health Officer
Editorial Board:
Hildy Meyers, MD, MPH, Medical Director
Epidemiology & Assessment
Amy Dale, MPH, Division Manager
Health Promotion
Steven Wong, REHS, MPH, Director
Environmental Health Services
Editors:
Howard Sutter
Public Information
Pat Markley
Public Information
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
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send your electronic subscription request to
mediainfo@hca.co.orange.ca.us.
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COUNTY OF ORANGE l HEALTH CARE AGENCY
QUALITY MANAGEMENT
P.O. BOX 355
SANTA ANA, CA 92702
Insert of Summer-Fall 2004 issue (PDF file)
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