PUBLIC HEALTH Bulletin

Inside this issue...

Update on avian influenza A/H5N1 - Page 1
WNV impact in 2006 unpredictable - 2
Azithromycin should not be used for syphilis treatment - 2
Hepatitis online training offered -  2
Recognizing a chemical terrorist attack - 3
Mumps vaccination update - 3

Update on avian influenza A/H5N1

Avian influenza A/H5N1 has spread dramatically in the last year and could occur in the United States in the near future. It is important to convey the following points to your patients:

• Avian influenza is NOT pandemic influenza

• The best way to prepare for a possible pandemic is to plan as you would for any major disaster and stay informed of the current situation

• The best defense against any infection that is transmitted by the respiratory route is to practice good respiratory hygiene

Many questions that the public has are answered on our website at: www.ochealthinfo.com/epi/af/.

Clinicians should also prepare and stay informed. Guidance for pandemic influenza planning in various medical settings is available at:
www.pandemicflu.gov/plan/tab6.html#chklst. Topics covered include elements of a plan, triage and patient management, infection control, and managing staffing shortages.

OCHCA Epidemiology provides updates on influenza (seasonal, avian and pandemic) to clinicians through an electronic newsletter. To receive the newsletter, please contact us at epi@ochca.com.

Current Situation

The avian influenza A (H5N1) epizootic (animal outbreak) in Asia has expanded to wild birds and/or poultry in parts of Europe, the Near East and Africa. Sporadic human infections with H5N1 continue to be reported and have most recently occurred in China, Egypt, Indonesia, Azerbaijan, Cambodia, and Djibouti. In addition, rare instances of probable human-to-human transmission associated with H5N1 viruses have occurred, most recently in a family cluster in Indonesia. So far, however, the spread of H5N1 virus from person to person has been rare, inefficient, and unsustained.

The epizootic in Asia and parts of Europe, the Near East and Africa is not expected to diminish significantly in the short term and it is likely that H5N1 infection among birds has become enzootic in certain areas. It is expected that human infections resulting from direct contact with infected poultry will continue to occur in affected countries. CDC is in communication with the World Health Organization (WHO) and other national and international agencies and continues to monitor the situation closely.

Reporting and Testing Guidelines

Early identification of the occurrence of human cases of influenza A/H5N1 into the United States is critical for slowing transmission and depends on health care providers such as yourself promptly reporting to us patients with the appropriate exposure history who may have avian influenza.

Recommendations:

(subject to change as the avian influenza situation evolves)

Clinical criteria:
Please contact OCHCA Epidemiology at 714-834-8180 with any patients meeting the following criteria:

1. Hospitalized patients with:

• radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other unexplained severe respiratory illness, AND

• history of travel to or immigration from a country with documented H5N1 infections in poultry and/or humans within 10 days of symptom onset (for current information on affected countries, see www.ochealthinfo.com/epi/af/);

OR

2. Hospitalized or ambulatory patients with:

• documented temperature >38^oC (>100.4^oF), AND

• cough, sore throat, and/or shortness of breath, AND

• history of contact with poultry (e.g., visited a poultry farm, a household raising poultry, or a bird market) in an H5N1-affected country or with a known or suspected human case of influenza A/H5N1 within 10 days of symptom onset.

More detailed screening criteria for suspected cases are available at: www.phppo.cdc.gov/HAN/ArchiveSys/ViewMsgV.asp?AlertNum=00246.

Laboratory Testing: Commercial antigen detection testing can be conducted at hospital laboratories but specimens should ALSO be sent to Public Health for polymerase chain reaction (PCR) testing for influenza and subtyping. Please contact Epidemiology at 714-834-8180 to arrange for testing for suspected cases of H5N1. The best specimens are nasopharyngeal aspirates or swabs; in addition, throat swabs may increase the ability to detect the virus. Respiratory viral cultures should NOT be performed on suspect H5N1 cases because of laboratory safety requirements, but testing to establish other causes of community-acquired pneumonia should go forward.

Travel Health Notice

CDC has not recommended that the general public avoid travel to any of the countries affected by H5N1. However, CDC does recommend that travelers to these countries avoid poultry farms and bird markets or other places where live poultry are raised or kept. For details about other ways to reduce the risk of infection, see www.cdc.gov/travel/other/avian_influenza_se_asia_2005.htm.

Azithromycin should not be used for syphilis treatment

The New England Journal of Medicine recently published results from a Tanzanian study comparing azithromycin to Benzathine penicillin G for treatment of early syphilis, finding them equivalent.* The conclusions promote the use of azithromycin in resource-poor settings.

Please note that azithromycin should NOT be used in California because resistant strains to azithromycin have been identified. Thus, the only recommended treatment remains Bicillin. Only in situations in which Bicillin is medically contraindicated should doxycycline be used. Current Centers for Disease Control and Prevention (CDC) treatment guidelines list doxycycline as an “alternative regimen,” but it should be used only if allergy or a significant medical contraindication is present.

*Riedner G, et al. Single-Dose Azithromycin versus Penicillin G Benzathine for the Treatment of Early Syphilis. N Engl J Med 2005; 353:  1236-44.

Hepatitis online training offered

CDC’s Division of Viral Hepatitis (DVH) has developed an online training course titled “Viral Hepatitis Serology: Hepatitis A-E.” Participants will learn how to recognize the serologic interpretations for hepatitis A, B, C, D, and E virus infections.

This course is approved for continuing education credit for physicians and nurses. Participants will need a web browser, internet connection, and Macromedia Flash plug-in to access the materials. For more information, or to start the training program, go to: www.cdc.gov/ncidod/diseases/hepatitis/serology/index.htm.

Recognizing a chemical terrorist attack

Derived from information compiled by The Minnesota Department of Health, Environmental Health Division.

A potential terrorist attack using chemical agents is likely to be very different from terrorism involving only biological agents (bioterrorism). Harmful chemical exposures are usually characterized by rapid onset of medical symptoms (minutes to hours) and easily observed signs like unusual colored residue, odors, dead or dying plants, insects, and animals.

Some other important items to remember about hazardous chemicals:

• The fading of a chemical odor does not necessarily indicate a reduced amount of the chemical in the area—it may just mean that your sense of smell has become dulled to the odor.

• Signs and symptoms depend on the amount and type of chemical(s) to which people are exposed, and route(s) of exposure (breathing, swallowing, skin contact).

• Children, the elderly, and animals may experience health effects more quickly and at lower exposure levels than healthy adults.

Harmful biological exposures involving infectious agents are typically characterized by the slower onset of symptoms (hours to days) after the exposure. Also, few or no characteristic signatures are expected because most biological agents are odorless and colorless. Exposures to hazardous chemicals may cause a wide range of possible health effects depending on the nature of the chemical(s) used, and a number of other factors. Both acute and long-term health effects are possible.

For more information about the clinical management of chemical exposures, please review the following resources:

• Agency for Toxic Substance and Disease Registry (ATSDR) Managing Hazardous Materials Incidents www.atsdr.cdc.gov/mhmi.html

• Centers for Disease Control and Prevention, Center For Environmental Health Emergency Room Procedures in Chemical Hazard Emergencies—A Job Aid www.cdc.gov/nceh/demil/articles/initialtreat.htm

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Mumps vaccination update

In response to the mumps epidemic in the Midwest, on May 17, 2006, the Advisory Committee on Immunization Practices (ACIP) updated criteria for mumps immunity and mumps vaccination recommendations (see CDC.MMWR 2006;55:22:629-630, available at www.cdc.gov/mmwr). In addition, on June 2, 2006, the CDC and the American College Health Association (ACHA) sent a letter to all US residential colleges and universities recommending that schools require two doses of MMR or other acceptable evidence of mumps immunity for all students. Emphasis this summer should be on ensuring college students, staff and children attending summer camps, overseas travelers, and healthcare workers get vaccinated, and implementing systems to ensure the routine vaccination of these groups.

*Healthcare workers (HCW) born before 1957 without other evidence of mumps immunity should receive one dose of mumps-containing vaccine; in outbreak settings, two doses are recommended. For more information for healthcare settings, see www.ochealthinfo.com/epi/mumps.htm.

¹Source: CDC HARS Reporting System
²Due to delays in reporting, 2004 incident chlamydia and gonoccocal infections were reported in 2005. This table reallocates those 2005 to 2004.
³Previously included in Hepatitis B acute or chronic totals. Separate reporting started in 2002 for perinatal Hepatitis B. reports from ⁴From Sept. 2004 - Oct. 2005, E&A temporarily stopped reporting chronic Hepatitis B except for mothers of childbearing age.
NA= Not Available
⁵Source: CDC HARS Reporting System. 2002 numbers are from July-Dec. OC officially began HIV case reporting 7/1/2002; data is unavailable for previous years.

COUNTY OF ORANGE ^- HEALTH CARE AGENCY

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

Editorial Board:
Hildy Meyers,D,MPH, Medical Director
Epidemiology & Assessment

Steven Wong, REHS, MPH,Director
Environmental Health Services

Editors:
Howard Sutter
Public Information

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