Disease Control Bulletin: November 1998
- Diabetes in Vermont
- Reporting of Diseases
- Reportable Laboratory Findings
- Selected Reportable Diseases Vermont, Year to Date (10/31/98)
- Group B Streptococcal Infections
- Testing Update at the VDHL
Diabetes in Vermont
- Diabetes is the seventh leading cause of death in Vermont. It is estimated that 29,000 adult Vermonters have diabetes, about one-third of whom have not yet been diagnosed (1).
- In the United States, the prevalence of Type 2 diabetes may be increasing as much as 2 to 5 percent per year among white non-Hispanics(2). In Vermont the increase has been approximately 0.5 percent per year since 1990.
- Diabetes is also a major cause of lower limb amputations, blindness and kidney disease, and a contributor to high blood pressure, heart disease, stroke and infection. Between 1983 and 1996,there were 1,934 lower extremity amputations among Vermont residents; 62.6 percent were among people known to have diabetes. During the same period, there were 6,762 hospital discharges for renal failure, with nearly one-third related to diabetes.
- Nationally, direct medical expenditures attributed to diabetes in 1997 totaled $44.1 billion. Attributable in direct costs totaled $54.1 billion (includes premature mortality and disability). Total medical expenditures incurred by people with diabetes totaled $10,071 per capita, compared with $2,669 for people without diabetes (3).
- The national Healthy People 2000 objective is to reduce diabetes-related deaths to no more than 34 per 100,000 people. In Vermont, the rate for 1993-1997 was far worse, at 44.4.
The graph represents Vermont’s five-year average mortality ending at the year of the data point. The point at 1997 represents the 1993-1997 five-year average of 44.4 per 100,000 population.
Vermont Diabetes Control Program
Recognizing that diabetes has become a common, life-threatening and costly disease, the Vermont Department of Health began a Diabetes Control Program in 1996 with funding from the Centers for Disease Control and Prevention (CDC). The goals are:
- to reduce the number of people with medical complications resulting from diabetes;
- to assist people with diabetes in successfully managing the disease; and
- to promote appropriate, high quality care by health care providers and insurers.
Secondary Prevention — the first step
The Diabetes Complications and Control Trial established that good glycemic control could reduce the complications of Type 1 Diabetes (4). Subsequently, several studies have supported a similar benefit for Type 2 Diabetes (5,6). Efforts are underway in Vermont to expand secondary prevention strategies, that is, strategies to improve glycemic control and thereby reduce the complications of diabetes among those known to have the disease.
Patient Care Recommendations: the key to success
Consensus on the components of management of diabetes is viewed as the most critical component of clear, coordinated and consistent messages about diabetes. These recommendations will serve as the basis for all communications regarding diabetes directed at providers, patients, policy makers and the public. The department worked with the Vermont Program for Quality in Health Care (VPQHC) to convene an expert panel to review national guidelines and adapt them for use by Vermont providers.
The product of that work, Recommendations for Management of Diabetes in Vermont, was distributed to more than 1,800 physicians, nurse practitioners, dietitians, diabetes educators and others this past summer. This manual focuses on clinical monitoring of disease progression and clinical preventive services. Practitioners are encouraged to: 1) measure hemoglobin A1c at least every six months and lipids once a year; 2) screen for the presence of microalbuminuria and diabetic retinopathy annually; 3) examine feet, monitor blood pressure, advise smoking cessation at every office visit; and, 4) refer every person with diabetes for education from trained diabetes educators on self-management and diet.
The manual will be updated as new information is available. Additions planned include screening guidelines, immunizations, and diabetes in pregnancy. Activities are underway to support and implement the recommendations. These activities are directed toward the health care system (providers, insurers, etc.), people with diabetes and their families, and the community at large.
Diabetes Awareness Wellness Network
It is not possible for one service or one provider group to reduce the burden of diabetes alone. With that in mind, the department established the Diabetes Awareness Wellness Network, acoalition of providers, policymakers and consumers. This coalition developed a plan which outlines goals and objectives for a comprehensive system of care for people with diabetes in Vermont and has several subcommittees that meet on an ad hoc basis. The larger group meets twice a year.
Communication has been identified as an area of concern. What the patient hears, or thinks he or she hears from the primary care provider can make the difference between good self-care management and poor control. Patients consistently preface comments about their diabetes with“...my doctor never told me,” and it is not uncommon to hear providers say, “...but she/he just didn’t listen.” The department is working with the Diabetes Wellness Awareness Network to bridge this communications gap.
Life with Diabetes — This six-week course for people with diabetes was developed by the Michigan Diabetes Research and Training Center and has been adopted as the standard curriculum for Vermont classes. The Vermont Association of Diabetes Educators(VADE)isusingagrantfromtheDepartmentofHealth to train nurses and dietitians statewide to conduct the course. The goal is to have trained staff available to offer classes on an ongoing basis in all health care service areas in the state.
Survival Skills—VPQHCandVADEarecurrentlyintheprocess of developing a training program based on “Life with Diabetes” for office nurses and others. The purpose is to give newly diagnosed diabetics some basic information that will help them manage their disease until they are able to get individual counseling or attend one of the courses.
Community Assessments — Groups in nine of the 13 Vermont hospital service areas conducted assessments of the needs of people with diabetes and the provider community over the summer of 1998. Assessment is the first step in what we hope to be an ongoing effort in each community to develop the programs and services that will support people with diabetes. Among the needs identified in the assessments were:1)gettingpeoplewithdiabetes and their families more actively involved with development of their own care plan; 2) expanding the availability of classes and support systems; 3) developing more adult-friendly recreational programs in each town; 4) setting up a hot-line for questions; and 5) making health insurance more user-friendly.
Recommendations for Management of Diabetes for Children at School — This manual is being developed in response to parent concerns about the support that their children received in school. It provides guidance to school staff on management of diabetes in the school setting and promotes the full integration of students with diabetes in school activities. It will be available in early 1999. An assessment of the unmet needs of children with diabetes is currently underway at Parent-to-Parent of Vermont.
One secondary prevention strategy that has not yet been addressed by the Diabetes Awareness Wellness Network and the department is the need to promote expanded diabetes screening to assure earlier diagnosis of the disease. The CDC grant that supports this program encourages grantees to first address a coordinated system of care that can provide the needed services before increasing the number of people demanding those services. Over the next year we expect to provide updated screening guidelines for primary care providers so that they may offer this service to their patients. It is expected that public education efforts to encourage people to request screening will follow.
Primary Prevention—When and How?
Currently there is no funding for primary prevention strategies, however, there is no question that primary prevention of Type 2 diabetes will be the best strategy for long term reduction in the personal, social and economic costs of diabetes. At this time, the knowledge and skills to accomplish this are still elusive. The known risk factors for Type 2 diabetes are family history, older age, obesity and lack of exercise. The latter two would appear to be amenable to change. However, examination of recent trends in Vermont shows that obesity increased from 20 to 30 percent and the percentage of adults who are inactive or get no regular exercise remained unchanged at 50 percent between 1990 and 1997, this despite widespread consensus that overweight and inactivity are risk factors for numerous chronic conditions.
FOR MORE INFORMATION orcopies of the documents, contact:
Steve Fettner, Diabetes Program Manager, Vermont Department of Health, 108 Cherry Street, P.O. Box 70, Burlington, VT 05402. 802-865-7708.
Cyrus Jordan, MD, MPH, Medical Director, Vermont Program for Quality in Health Care, 136 Main Street, Montpelier, VT 05601. 802-229-2152.
- National Institutes of Health. National Institute of Diabetes and Digestive and Kidney Disease. Diabetes in America, 2nd ed. 1995.
- American Diabetes Association. Press release June 14, 1998.
- American Diabetes Association. Economic consequences of diabetes mellitus in the US in 1997. Diabetes Care 1998; 21:296.
- The Diabetes Control and Complications Trial Research Group. The effect of intensive treatment of diabetes on the development and progression of long-term complications in insulin-dependent diabetes mellitus. NEngl J Med 1993; 329:977-86.
- Turner R, Mills H, Neil Hetal. Risk factors for coronary artery disease in non-insulin dependent diabetes mellitus: United Kingdom prospective diabetes study. Br Med J 1998;316:823-8
- Vijan S, Hofer T, Hayward R. Estimated benefits of glycemic control in microvascular complications of Type 2 diabetes. Ann Intern Med 1997;127:788-95.
Reporting of Diseases
The law requires that health care providers report diseases of public health importance. Those persons who are required to report include: health care facilities, health care providers, health maintenance organizations, hospital administrators, laboratory directors, managed care organizations, nurse practitioners, nurses, physician assistants, physicians, school health officials, town health officers.
Cases of reportable diseases should be reported to the Division within 24 hours or as soon as possible. The report of communicable diseases and other diseases dangerous to the public health and rare infectious diseases shall include the following information as it relates to the affected person: name of person, age, sex, address, name and address of health care provider/ physician, name of disease being reported, date of onset of the disease, any other pertinent information. The report should be made by telephone or in writing to the Department of Health, Epidemiology Field Unit at 802-863-7240 or 800-640-4374 (in Vermont only). The Department has established procedures that ensure the confidentiality of the reports.
The Epidemiology Field Unit of the Health Surveillance Division should also be notified if there are outbreaks of undiagnosed disease or diseases that are not on the mandatory reporting list (e.g., food poisoning outbreaks).
Diseases, Syndromes, and Treatments Required to be Reported
1. Reportable Diseases and Syndromes (to include any rare infectious disease or one dangerous to public health).
- Campylobacter infection
- Chlamydia trachomatis infection
- E. coli O157:H7 infection
- Enterococcal disease, vancomycin -resistant
- Group A streptococcal disease, invasive
- Guillain Barre Syndrome
- Haemophilus influenzae disease, invasive
- Hantavirus disease
- Hemolytic uremic syndrome (HUS)
- Hepatitis A
- Hepatitis B
- Hepatitis C
- Hepatitis, unspecified
- Kawasaki Disease
- Lead poisoning
- Lyme Disease
- Measles (Rubeola)
- Meningitis, bacterial
- Meningococcal disease
- Pertussis (Whooping cough)
- Pneumococcal disease, drug-resistant, inv
- Rabies, human and animal cases
- Reye syndrome
- Rheumatic fever
- Rocky Mountain Spotted Fever
- Rubella (German Measles)
- Toxic Shock Syndrome
- Typhoid Fever
- Yellow Fever
2. Reportable Treatments
Human rabies postexposure treatment (HRPET) is reportable even where no evidence of rabies has been found. Full identifying information as indicated above must be provided to the Department of Health.
As of 7/6/98, new confidentiality requirements have been added to the communicable disease regulations:
CONFIDENTIALITY REQUIREMENTS: Any person or entity required to report under these regulations must have written policies and procedures in place that ensure the confidentiality of the records. Such policies and procedures must, at a minimum, include the following:
- identification of those positions/individuals who are authorized to have access to confidential disease-reporting information and the limits placed upon their access
- a mechanism to assure that the confidentiality policies and procedures are understood by affected staff
- process for training staff in the confidential handling of records
- a quality assurance plan to monitor compliance and to institute corrective action when necessary
- process for the confidential handling of all electronically-stored records
- process for authorizing the release of confidential records, and
- provision for annual review and revision of confidentiality policies and procedures
Reportable Laboratory Findings
Positive, presumptive or confirmed, isolation or detection of the following organisms OR positive, presumptive or confirmed, serological results for the following organisms (to include any rare infectious disease or one dangerous to public health):
- Bacillus anthracis
- Bordetella pertussis
- Borrelia burgdorferi
- Brucella sp.
- Campylobacter sp.
- Chlamydia psittaci
- Chlamydia trachomatis
- Clostridium botulinum
- Clostridium tetani
- Corynebacterium diphtheriae
- Cryptosporidium parvum
- Entamoeba histolytica
- Enterococcus sp., intermediate or greater vancomycin-resistance, isolated from any site
- Escherichia coli O157:H7 Giardia lamblia
- Group A streptococci isolated from a normally sterile site
- Haemophilus influenzae, isolated from a normally sterile site
- Hepatitis A virus (anti-HAVIgM)
- Hepatitis B virus
- (HBsAg, anti-HBcIgM, anti-HDV, HBeAg)
- Hepatitis C virus
- Influenza virus
- Legionella sp.
- Listeria monocytogenes
- Measles virus
- Mumps virus
- Mycobacterium tuberculosis
- Neisseria gonorrhoeae
- Neisseria meningitidis, isolated from a normally sterile site
- Plasmodium sp. Poliovirus Rabies virus
- Rickettsia rickettsii
- Rubella virus
- Salmonella sp.
- Shigella sp.
- Streptococcus pneumoniae, intermediate drug resistance or greater, isolated from a normally sterile site
- Treponema pallidum
- Trichinella spiralis
- Vibrio cholerae
- Yellow fever virus
- Yersinia pestis
In addition, all positive findings for the following laboratory tests must be reported:
- AFB smears
- Blood lead (>9 micrograms per deciliter)
- CSF cultures
- Nontreponemal tests for syphilis
Laboratory reporting shall include:
- name of patient
- name of health care provider/physician
- address of health care provider/physician
- positive test results
- specimen type, e.g., serum, swab, etc.
- specimen source, e.g., cervix, throat, etc.
Laboratories are required to provide a written report even if the reportable disease has been reported by others required to report. If no positive reportable laboratory findings have been made during a given week, then a written or electronic report of “No reportable findings” shall be made.
The Department of Health requests and strongly recommends that for all presumptive tests results for reportable diseases, or any unusual findings, or where epidemiologic typing is desirable that a pure culture of the organism or the serum be sent to the Vermont Department of Health Laboratory. The Laboratory should be contacted directly at 802-863-7335 or 800-660-9997 (in Vermont only) for information on how to submit cultures and specimens.
Vermont’s communicable disease regulations were most recently revised as of July 6, 1998. Two major changes were incorporated into this revision. First, the list of mandated reporters was expanded. Health maintenance organizations, managed care organizations, and health care facilities were added. Nurses have been mandated reporters; this list has specifically added nurse practitioners.
Confidentiality requirements have also been added, specifying that reporters have written confidentiality policies and procedures. The Health Department has a sample policy available.
To obtain a copy, contact the Epidemiology Field Unit at 802-863-7240 or 800-640-4374 (in Vermont only).
During the winter of 1999, the Epidemiology Field Unit will be reviewing the State’s communicable disease regulations to determine what changes, if any, should be made in the listed diseases. We will also be creating a new form that can be used by health care providers for reporting. If you are interested in participating in the review of the reportable disease list, or providing feedback on the reporting form, please contact Susan Schoenfeld, Epidemiology Field Unit Chief, at 802-863-7240 or 800-640-4374.
Selected Reportable Diseases Vermont, Year to Date (10/31/98)
Campylobacteriosis Chlamydia Giardiasis Gonorrhea Pertussis Salmonellosis
Cryptosporidiosis E. coli O157:H7 Group A Strep, Inv.
Hepatitis A Hepatitis B
Legionnaires Disease Meningococcal Inf.
Shigellosis Early Latent Syphilis Primary Syphilis Secondary Syphilis Tuberculosis
No 5-year median available: Chlamydia; Cryptosporidiosis, E.coli O157:H7; GroupAStrep, Invasive
Group B Streptococcal Infections
The Centers for Disease Control and Prevention (CDC) have been conducting a public awareness campaign for the prevention of group B Streptococcal infections (group B strep) in newborns. Group B strep causes meningitis, pneumonia, and sepsis in thousands of newborn infants each year and deaths in approximately 4 percent of these cases. It is the most common cause of life-threatening infections in newborns.
In a multistate survey concerning group B strep prevention, CDC found a correlation between hospital activities and the incidence of group B strep infection. The data in the report show that since 1994 the number of hospitals that have adopted a policy consistent with the 1996 CDC Consensus Guidelines on group B strep prevention has increased and that the incidence of group B strep disease has decreased. Geographic areas in which a higher proportion of hospitals had group B strep prevention policies had lower incidences of early-onset group B strep disease.
For free group B strep patient education materials, dial the CDCfax-on-demandserviceat1-877-INFECTS,or visit the group B strep prevention at URL <http://www.cdc.gov/ncidod/dbmd/ gbs/index.htm>. For further information contact the Division of Bacterial and Mycotic Diseases, Health Communications Activity, 404-639-4634.
Testing Update at the VDHL
Beginning January 4, 1999, the Vermont Department of Health Laboratory (VDHL) will be offering a nucleic acid amplification test, the Gen-Probe transcription-mediated amplification (TMA) test for the detection of Chlamydia trachomatis in urine. The TMAtestwillnotreplacethecurrentnucleicacidprobescreening test method used at the laboratory. The TMA test will be used as an alternative test method when the clinician is unable to obtain a swab specimen.
First voided urine specimens (30-50 ml) must be collected in a sterile container and submitted to the laboratory within 24 hours at room temperature or within seven days if stored at 2° - 8° C. Specimen collection kits for Chlamydiatrachomatis are available on request by contacting the laboratory at 800-660-9997,ext.7560 (in Vermont only), or 802-863-7560. Questions or comments about the TMA test can be directed to Mary Celotti, Microbiology Program Chief, at 800-660-9997, ext 7629, or 802-863-7629.
Testing for influenza virus A and B at the Vermont Department of Health Laboratory began in November, and will continue to be offered through mid-May, 1999. Throat and/or nasopharyngeal swab specimen collection kits, which also contain aviral transport medium, can be obtained by calling the VDHL at 800-660-9997, ext 7560, o r802-863-7560.