Disease Control Bulletin: October 2000
- Influenza Season 2000–2001
- Selected Reportable Diseases 1/1/2000–10/28/2000
- New Recommendations for Refugee and Immigrant Health Screening
- Chronic Fatigue Syndrome
- CDC Finds No Proven Link Between Mold and Pulmonary Hemorrhage/Hemosiderosis in Infants
- Travelers Health Information Polio Outbreak in Dominican Republic and Haiti
- Health Alert Outbreak of Poliomyelitis in the Dominican Republic and Haiti
Influenza Season: 2000 - 2001
The Vermont Department of Health has been in touch with physician and hospitals regarding this fall’s delayed shipments of influenza vaccine. In addition, on October 26, 2000, Health Commissioner Dr. Jan Carney madea joint press statement with Vermont Hospital Association Executive Director Norm Wright and Vermont Assembly of Home Health Agencies Executive Director Peter Cobb addressing the delay and emphasizing the importance of vaccinating people at highest risk for complications from influenza first this season.
To ensure that vaccine is available for high-risk individuals, the department is working with hospitals and physicians throughout the state. The Vermont Department of Health does not havea stockpile of influenza vaccine. Hospitals, physicians and others in need of vaccine for their high-risk patients or those who may have vaccine for redistribution to colleagues without any vaccine may contact the Vermont Department of Health Immunization Program at (802) 863-7638 or (800) 464-4343, ext. 7638 in Vermont.
The influenza vaccine delay affects the entire country. The delay arose because of lower than anticipated production yields for one component of this year’s vaccine and other manufacturing issues. Therefore, in July, the Centers for Disease Control and Prevention (CDC) issued adjunct influenza vaccine use recommendations that stressed using available vaccine first for individuals at high risk for complications from influenza and delaying general vaccination campaigns. Those recommendations were summarized in the Vermont Disease Control Bulletin, volume 2, issue 2, 2000.
On October 6, 2000 because of the potential health impact of delayed influenza vaccine availability, CDC and the Advisory Committee on Immunization Practices (ACIP) updated recommendations for the 2000-2001 season. The goal of these recommendations is to minimize the adverse health impact of delays. This will require an effective response by the private and public sectors. The following report summarizes the highlights of the latest recommendations.1,2,3 The complete documents may be accessed through the CDC website at: www.cdc.gov/ncidod/diseases/flu/fluvirus.htm.
During last year’s influenza season, approximately 77 million doses of vaccine were distributed nationwide, of which 3 million doses were returned. On the basis of information provided by manufacturers, distribution of approximately 75 million doses is anticipated for the 2000-2001 season. However, many people may experience a four to six week delay in vaccine delivery.
Updated ACIP Recommendations1
People at high risk for complications from influenza include all of the following:
- People age 65 and older
- Residents of nursing homes and other chronic-care
facilities that house people of any age who have chronic medical conditions
- Children and adults who have chronic disorders of the pulmonary or cardiovascular systems, including asthma
- Children and adults who have required regular medical follow-up or hospitalization during the preceding year because of chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (for example, caused by medications or human immunodeficiency virus)
- Children and youth between age 6 months and 18 years who are receiving long-term aspirin therapy and therefore might be at risk for developing Reye syndrome after influenza
- Women who will be in the second or third trimester of pregnancy during the influenza season
Vaccination of people age 65 and older substantially reduces influenza morbidity and mortality. For each additional million elderly people vaccinated, CDC estimates that approximately 900 deaths and 1300 hospitalizations would be averted during the average influenza season.1,4 The health impact of individual seasons can vary widely on the basis of the size of the susceptible population, the prevalence of influenza infections, the type and strain of the predominating virus(es), and the match between the vaccine strains and those circulating in the community. The primary goal of vaccination is to prevent severe illness and death from influenza infection and its complications.
Vaccine available early in the season should be used to maximize protection for those people at highest risk for complications associated with influenza disease and health care workers who care for these individuals. Plans should be made to continue vaccination of high-risk individuals and health care workers into December and later. Vaccination efforts for all groups should continue as long as influenza vaccine is available.
Early vaccination of young children with high-risk conditions is a priority because two doses of vaccine administered at least one month apart are recommended for children under age9 who are receiving influenza vaccine for the first time. Two influenza vaccines (Flushield™, Wyeth Laboratories, Inc., and Fluzone® split, Aventis Pasteur, Inc.) are licensed and recommended for use in high-risk children age 6 months and older. One other influenza vaccine, Fluvirin™ (Medeva Pharma Ltd, Leatherhead, England) is labeled in the U.S. for use only in people age 4 and older because its efficacy in younger children has not been demonstrated. Because Fluvirin™ is not indicated for children age 6 months through 3 years, other approved influenza vaccines should be used for children in this age group.
Vaccination efforts for all groups should continue into December and beyond as long as vaccine is available. Production of vaccine will continue through December and providers should plan for how vaccine delivered late in the season can be used most effectively. After high-risk groups have been vaccinated, special efforts should be made in December and later to vaccinate people age 50 through 64, including those who are not at high risk and are not household contacts of high-risk people. Individuals in this age group with high-risk conditions should be vaccinated along with the other high-risk individuals as early as possible.
2000-2001 Influenza Vaccine Components3
The trivalent influenza vaccine prepared for the 2000-2001 season includes A/Moscow/10/99 (H3N2)-like, A/New Caledonia/20/99 (H1N1)-like, and B/Beijing/184/93-like antigens. For the A/Moscow/10/99 (H3N2)-like antigen, U.S. manufacturers are using the antigenically equivalent A/ Panama/2007/99 (H3N2) virus and for the B/Beijing/184/ 93-like antigen, they are using the antigenically equivalent B/Yamanashi/166/98 virus. These viruses are used because of their growth properties and because they represent currently circulating viruses.
People Who Should Not Be Vaccinated3
Inactivated influenza vaccine should not be administered to individuals known to have anaphylactic hypersensitivity to eggs or to other components of the influenza vaccine without first consultinga physician. Prophylactic use of the antiviral agents amantadine or rimantadine is an option for preventing influenza A among this group. However, individuals who have a history of anaphylactic hypersensitivity to vaccine components but who are also at high risk for complications of influenza can benefit from vaccine after appropriate allergy evaluation and desensitization. Information about vaccine components can be found in the package inserts from each manufacturer.
People with acute febrile illness usually should not be vaccinated until their symptoms have abated. However, minor illnesses with or without fever do not contraindicate the use of influenza vaccine, particularly among children with mild upper respiratory tract infection or allergic rhinitis.
Recommendations For Use Of Antiviral Agents
Antiviral drugs for influenza are an important adjunct to vaccine for the control and prevention of influenza. However, they are nota substitute for vaccination. Four currently licensed agents are available in the U.S.: amantadine, rimantadine, zanamivir and oseltamivir.
Amantadine and rimantadine are chemically related antiviral drugs with activity against influenzaA viruses but not influenza B viruses. Amantadine is approved for treatment and prophylaxis of influenza A infections in children age 1 and older and in adults. Rimantadine is approved for treatment and prophylaxis of influenzaA infection in adults. Although rimantadine was approved only for prophylaxis of infection in children, many experts consider it appropriate for treatment among children.3 Zanamivir and oseltamivir are neuraminidase inhibitors with activity against both influenza A and B viruses. Both zanamivir and oseltamivir were approved in 1999 for the treatment of uncomplicated influenza infections, but neither have yet been approved for prophylaxis. Zanamivir is approved for treatment for people age 12 and older. Oselt-amivir is approved for treatment of people age 18 and older.
The four drugs differ in terms of their pharmacokinetics, side effects, and costs. Consult the package inserts for more information.
Pneumococcal vaccinations are recommended by ACIP for many of the same high-risk individuals for whom influenza vaccine is recommended. Assuring pneumococcal vaccination in accordance with ACIP recommendations early in the influenza season will confer substantial protection from a major complication of influenza infection—pneumococcal pneumonia.
Annual influenza vaccination provides an opportunity to review the pneumococcal vaccination status of patients for whom this vaccination is recommended by ACIP. This season, pneumococcal vaccine should be administered when indicated even if influenza vaccine is not yet available. Patients may need to be reminded that pneumococcal vaccination is nota substitute for influenza vaccination, and so, patients need to return for influenza vaccine when it becomes available.
Influenza Laboratory Testing
Two types of diagnostic testing for influenza are available at no charge through the Vermont Department of Health Laboratory: serology and virus isolation/immunofluorescent antigen detection from throat or nasopharyngeal swabs.
Testing is particularly important at the beginning and end of the influenza season to document the presence of influenza disease in the community. Testing is also very important in institutional settings so that effective outbreak control can be implemented. Once influenza has been confirmed in an institutional setting, it is no longer necessary to submit additional specimens from symptomatic individuals during the same time period.
In order to obtain maximum recovery of the virus, throat/ nasopharyngeal swab specimens should be collected within three days of symptom onset. Influenza virus isolation test results are usually available within seven days of specimen receipt. Strain typing for characterization of the circulating influenza strains in Vermont will be available as positive isolates are recovered.
Serology involves the collection of acute and convalescent blood specimens. The acute specimen should be collected within seven days of symptom onset and the convalescent specimen should be obtained 14 days later. Serologic test results for influenza are usually available in 10 days from receipt of the convalescent specimen.
Specimen kits for both types of testing are available at the Vermont Department of Health Laboratory, 195 Colchester Avenue in Burlington. They can also be obtained by calling 1-800-660-9997 (in VT) or 802-863-7560.
Reporting of Influenza
It will be of particular importance this season to know of early influenza activity in the state. Both sporadic and cluster cases of confirmed or suspected influenza should be reported to the Vermont Department of Health Immunization Program at 802-863-7638 or 1-800-464-4343 (in VT).
- CDC. Updated recommendations from the Advisory Committee on Immunization Practices (ACIP) in response to delays in supply of influenza vaccine for the 2000-01 season. MMWR 2000;49: 888-892.
- CDC. Delayed supply of influenza vaccine and adjunct ACIP influenza vaccine recommendations for the 2000-01 influenza season. MMWR 2000;49:619-622.
- CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49(no. RR-3).
- CDC, unpublished data, 2000.
REPORT DISEASE: VERMONT TOLL-FREE 1-800-640-4374 OR 1-802-863-7240
CDC Finds No Proven Link Between Mold and Pulmonary Hemorrhage/Hemosiderosis in Infants
In the past few years, there has been growing public and media attention brought to a possible association between mold, specifically Stachybotrys atra (also know as Stachybotrys chartarum), and serious adverse health effects. The focus of this attention has been on preliminary findings of a possible link between S. atra and an outbreak of pulmonary hemorrhage/hemosiderosis in infants in Cleveland, Ohio. Those preliminary findings have now been found to be unsubstantiated.
From a report in MMWR, March 10, 2000, Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants--Cleveland, Ohio, 1993-1996.
In December 1994 and January 1997, articles in MMWR described a cluster of 10 infants from Cleveland, Ohio with acute idiopathic pulmonary hemorrhage, also referred to as pulmonary hemosiderosis. The children lived in seven contiguous postal tracts and had one or more hemorrhagic episodes, resulting in one death, during January 1993-December 1994. Preliminary results of a CDC case-control study indicated that hemorrhage was associated with 1) major household water damage during the six months before illness and 2) increased levels of measurable household fungi, including the toxin-producing mold S. atra.
These findings have been published and referenced in peer-reviewed scientific literature. The findings were also cited in environmental health guidelines, congressional testimony, and the popular media. Despite the caution that “further research is needed to determine...causality,” the findings have influenced closure of public buildings, cleanup and remediation, and litigation.
In 1997, CDC convened a multidisciplinary working group of senior scientists and outside experts to conduct separate reviews of the Cleveland investigation. Based on their reports the CDC now advises that earlier conclusions regarding the possible association between cases of pulmonary hemorrhage/hemosiderosis in infants in Cleveland and household water damage or exposure to S. atra are not substantiated adequately by scientific evidence. Serious shortcomings in the collection, analysis and report of data resulted in inflated measures of association.
Mold Health Concerns
Contrary to beliefs based on preliminary CDC findings, the mere presence of mold does not constitutea public health hazard. Mold and mold spores are ubiquitous. However, due to possible health effects to people who have allergies to molds, who have asthma or other diagnosed respiratory problems, or compromised immune systems, it is advisable to limit respiratory exposure to mold.
The common health concerns from molds include hayfever-like allergic symptoms. Certain individuals with chronic respiratory disease (chronic obstructive pulmonary
disease, asthma) may experience difficulty breathing. Individuals with immune suppression may be at increased risk for infection from molds.3 An estimated one in five or six people in the U.S. have allergies; somewhat fewer are allergic to mold. The way in which a mold-sensitive person may react depends on several factors, including the type of mold, the amount of mold present, the length and number of times that the person is exposed, family history and overall health status.
Control and Prevention of Mold
The Vermont Department of Health receives many inquiries regarding mold and provides a fact sheet that describes how to reduce mold growth in a building, special precautions to take after a flood or water leak, and how to remove or clean up mold once it has become established. People with health concerns are referred to their physician.
The Health Department does not generally recommend air sampling, wipe sampling, or bulk sampling for mold. This is, in part, because there are no established “safe” or “unsafe” levels of mold. No current method of measuring fungal material, gases or biochemicals from mold has been shown to be related to objective human symptoms from indoor mold. That is, no measurement-based standard or guidelines are currently possible for mold contamination.2 In cases where extensive building remediation is undertaken to remove mold, occupants should not be in the affected area.
For a copy of the fact sheet, call the Vermont Department of Health, Health Protection Division at1-800-439-8550 (in VT) or 802-863-7220.
- MMWR weekly, March 10, 2000 / 49(09); 180-4, or http:// www.cdc.gov/epo/mmwr/preview/mmwrhtml/mm4909a3.htm
- Conference, 09/2000, “Assessment, Remediation, and Prevention of Mold Growth in Buildings”, MidAtlantic Environmental Hygiene Resource Center, (with EPA support)
- Centers for Disease Control and Prevention web fact sheet, 03/ 09/2000 “Questions and Answers on Stachybotrys chartarum and other molds” http://www.cdc.gov/nceh/asthma/factsheets/ molds/default.htm
- Applied Occupational and Environmental Health Hygiene, “Health Effects of Mycotoxins in Indoor Air: A Critical Review,” GobalTox Inc., Internatl. Ctr. for Toxicology & Medicine, 10/00. • Medscape General Medicine, “Stachybotrys chartarum; Current Knowledge of its Role in Disease” Daniel L. Sudakin, MD, MPH, 02/29/2000.
- Indoor Air Quality Diagnostics and Mitigation Training Course, H.L. Turner Group, 07/99.
- NIOSH Case Studies in Indoor Air Quality, Ed. by Shirley A. Ness, Government Institutes, Inc. 1996.
- Bioaerosols: Assessment and Control, Ed. Janet Macher, ACGIH, 1999.
- Fundamentals of Industrial Hygiene, Ed. Barabara A, Plog, National Safety Council, 1996.
Chronic Fatigue Syndrome
Chronic fatigue syndrome (CFS) isa complex, debilitating disorder characterized by at least six months of severe, persistent or relapsing fatigue and other characteristic but nonspecific symptoms. After more than a decade of research the cause remains unknown and no diagnostic tests exist.1 This illness has gained the attention of the Vermont Legislature and, in 2000, a bill was introduced to increase public awareness about chronic fatigue syndrome.
Over the past 15 years, scientists have identified numerous clues to the cause of the illness. These clues provide evidence that the illness involves both the brain and the immune system.2 Such abnormalities appear to influence and alter the function of each other in a reciprocal cycle.2 Low levels of circulating cortisol can increase immune activation, which is also a key feature of the disease.3,4 Many cases follow an infection such as Lyme disease,5,6,7 acute mononucleosis,8 or Q fever.9 The research indicates that no single infectious agent is likely to be the cause. Instead, the cause is likely some abnormality in the body’s response to any of several different infectious agents.2 The Centers for Disease Control and Prevention (CDC) hasa program devoted to the research and control of chronic fatigue syndrome. This marks the beginning of a major new effort to identify the extent of the chronic fatigue syndrome problem, diagnostic techniques and effective treatment and control strategies. General information and program updates are posted at http://www.cdc.gov/ncidod/diseases/cfs/.
Definition of Chronic Fatigue Syndrome10
The working definition of chronic fatigue syndrome as defined by a working committee of the Centers for Disease Control and Prevention (CDC) in 1994 is:
- Clinically-evaluated, unexplained persistent or relapsing chronic fatigue that is of new or definite onset (i.e., not lifelong), is not the result of ongoing exertion, is not substantially alleviated by rest, and results in substantial reduction in previous levels of occupational, educational, social or personal activities.
- The concurrent occurrence of four or more of the following symptoms: substantial impairment in short-term memory or concentration; sore throat; tender lymph nodes; muscle pain; multi-joint pain without swelling or redness; headaches of a new type, pattern or severity; unrefreshing sleep; and post-exertional malaise lasting more than 24 hours. These symptoms must have persisted or recurred during six or more consecutive months of illness and must not have predated the fatigue.
A complete definition including guidelines for the evaluation and study of chronic fatigue syndrome is available at http://www.cdc.gov/ncidod/diseases/cfs/defined/index.htm.
Clinical Evaluation of Prolonged/Chronic Fatigue11
Prolonged fatigue is defined as self-reported, persistent fatigue of one month or longer. Chronic fatigue is defined as
self-reported persistent or relapsing fatigue of six or more consecutive months. The presence of prolonged or chronic fatigue requires clinical evaluation to identify underlying or contributing conditions that require treatment. Further diagnosis or classification of chronic fatigue cases cannot be made without such an evaluation. Because there is no definitive diagnostic test, it is usually diagnosed by ruling out other possible diseases and conditions. CDC recommends that the following areas be included in the clinical evaluation.11
- A thorough history that covers medical and psychosocial circumstances at the onset of fatigue; depression or other psychiatric disorders; episodes of medically unexplained symptoms; alcohol or other substance abuse; and current use of prescription and over-the-counter medications and food supplements.
- A mental status examination to identify abnormalities in mood, intellectual function, memory, and personality. Evidence ofa psychiatric or neurologic disorder requires that an appropriate psychiatric, psychological, or neurologic evaluation be done.
- A thorough physical examination.
- A minimum battery of laboratory screening tests including complete blood count with leukocyte differential; erythrocyte sedimentation rate; serum levels of alanine aminotransferase, total protein, albumin, globulin, alkaline phosphatase, calcium, phosphorus, glucose, blood urea nitrogen, electrolytes, and creatinine; determination of thyroid-stimulating hormone; and urinalysis.
Further tests may be indicated on an individual basis to confirm or exclude another diagnosis, such as multiple sclerosis. Tests should be directed toward confirming or excluding other etiologic possibilities. Some examples of specific tests that do not confirm or exclude chronic fatigue syndrome and are not recommended for screening: serologic tests for Epstein-Barr virus, retroviruses, human herpesvirus 6, enteroviruses, and Candida albicans; tests of immunologic function; and imaging studies, including magnetic resonance imaging scans and radionuclide scans (such as single-photon emission computed tomography and positron emission tomography) of the head.
Support is available for patients with chronic fatigue syndrome through the Vermont CFIDS Association. For information, call 1-800-296-1445. Information is also available at the Massachusetts CFIDS Association website (http://www.masscfids.org/).
Thanks to Dr. Dennis Plante, Associate Professor of Medicine at the UVM College of Medicine, for his assistance with this article.
References are available on request. Please contact Debbie Dameron at the Vermont Department of Health, Division of Health Improvement at email@example.com.
Health Alert: Outbreak of Poliomyelitis in the Dominican Republic and Haiti
An outbreak of poliomyelitis is occurring in Dominican Republic and Haiti. The Ministries of Health in both countries, with the assistance of the Pan American Health Organization and the Centers for Disease Control and Prevention (CDC), are investigating the outbreak to determine the extent of spread and evaluate the reasons for the outbreak.
Aggressive control measures have already been initiated. A mass vaccination campaign with oral poliovirus vaccine (OPV) has started in the Dominican Republic. In Haiti, three nationwide vaccination rounds with OPV are planned for January, February, and March 2001.
From the report in MMWR December 8, 2000, Public Health Dispatch: Outbreak of Poliomyelitis--Dominican Republic and Haiti, 2000.1
During July 12 to November 18, 2000, 19 persons with acute flaccid paralysis (AFP) were identified in the Dominican Republic, including six laboratory-confirmed cases with poliovirus type1 isolates. Of the 19 case-patients, 16 (84%) were aged 6 years or younger (range: 9 months to 21 years). All case-patients were either unvaccinated (n=14) or inadequately vaccinated (n=5). In Haiti,a single laboratory-confirmed poliovirus type 1 case was reported in an inadequately vaccinated child aged2 years; paralysis onset was August 30, 2000. Despite intensive case-finding activities, no additional cases have been identified.
The outbreak virus is unusual because it is derived from oral poliovirus vaccine (OPV) and has 97 percent genetic similarity to the parental OPV strain (normally vaccine-derived isolates are more than 99.5% similar to the parent strain) and appears to have recovered the neurovirulence and transmissibility characteristics of wild poliovirus type1. In comparison, wild polioviruses normally have less than 82 percent genetic similarity to OPV.2 The differences in nucleotide sequences among the outbreak isolates suggest that the virus has been circulating for approximately two years in an area where vaccination coverage is very low and that the virus had accumulated genetic changes that restored the essential properties of wild poliovirus.
Circulation of OPV-derived polioviruses in areas with very low OPV coverage has been documented in one other setting; type2 OPV-derived virus circulated in Egypt for an estimated 10 years (1983–1993) and was associated with less than 30 reported cases.3 Vaccination coverage was very low in the affected areas, and circulation ofa vaccine-derived poliovirus stopped when OPV coverage increased. The key factor in controlling circulating OPV-derived viruses and wild polioviruses is achieving and maintaining high vaccination coverage. No evidence for circulation of OPV-derived virus has been found in areas with high coverage.
Since 1991, no cases of polio attributed to wild poliovirus have been detected in the Western Hemisphere. The current outbreak underscores the need for polio-free areas to maintain high coverage with polio vaccine until global polio eradication has been achieved. OPV is safe and effective and recommended for the eradication of polio. All countries should maintain high quality AFP and poliovirus surveillance and accelerate current activities to complete the global eradication of wild polioviruses.
Health care providers should consider polio asa diagnosis in case-patients witha history of travel to other countries of the Western Hemisphere from the Dominican Republic and Haiti who present with AFP usually accompanied by fever. These possible cases should be investigated properly, including collection of stool samples. Suspected cases should be reported immediately to state and local health departments. Travelers to the Dominican Republic and Haiti who are not vaccinated adequately should be considered at risk for polio. All travelers should be vaccinated fully against polio according to national vaccination policies.4
- Ministry of Health, Pan American Health Organization, Santo Domingo, and Dominican Republic.
- Ministry of Health, Pan American Health Organization, Port-au-Prince, Haiti.
- Caribbean Epidemiology Center Laboratory, Pan American Health Organization, Trinidad and Tobago.
- Division of Vaccines and Immunization, Pan American Health Organization, Washington, DC.
- Respiratory and Enteric Viruses Branch, Div of Viral and Rickettsial Diseases, National Center for Infectious Diseases, and Vaccine Preventable Disease Eradication Division, National Immunization Program, CDC.
- MMWR Weekly, December 8, 2000 Volume 49(48) 1094, 1103.
- Kew OM, Mulders MN, Lipskaya GY, et al. Molecular epidemiology of polioviruses. Sem Virol 1995;6:401–14.
- Naguib T, Yang SJ, Pallansch M, Kew O. Prolonged circulation of Sabin2-derived polioviruses. In: Program and abstracts of progress in polio eradication: vaccination strategies for the end game. Geneva, Switzerland: International Association for Biologicals, 2000.
- CDC. Poliomyelitis prevention in the United States: updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2000;49 (no. RR-5).
Travelers’ Health Information Polio Outbreak in Dominican Republic and Haiti
Currently, there are no recommended travel restrictions to the Dominican Republic, Haiti, or any other countries where polio cases are being reported. However, adults who are traveling to countries reporting polio cases and who are not immunized or whose vaccination status for polio is unknown should contact their health care provider to review vaccination options. At a minimum, these adults should receive one dose of inactivated poliovirus vaccine (IPV).
According to Dr. Ciro de Quadros, Director of the Pan American Health Organization, Division of Vaccines and Immunization, “The current outbreak is a powerful reminder that even polio-free areas need to maintain high coverage with polio vaccine until polio eradication has been achieved.
Nearly four decades of experience with OPV has shown that it is very safe and effective in preventing poliomyelitis. OPV is the vaccine of choice for the eradication of wild polioviruses. However, it is crucial to maintain high OPV coverage to protect against imported wild polioviruses and to prevent person-to-person transmission of OPV-derived viruses. It is also important that all countries maintain high quality AFP (acute flaccid paralysis) and poliovirus surveillance, that current activities to complete the global eradication of wild polioviruses be accelerated, and that a global strategy is developed for the orderly cessation of immunization with OPV after global certification of polio eradication is achieved.”
Since the Global Polio Eradication Initiative was launched in 1988, the number of polio cases globally has dropped by over 95 percent, from an estimated 350,000 in 1988 to 7094 reported in 1999. There have only been 1481 confirmed cases of polio so far this year. The WHO European Region (made up of 51 countries, including the Commonwealth of Independent States) has not had any new cases of indigenous polio for almost two years.
The Western Pacific Region of WHO was certified as polio-free in October 2000, becoming the second region after the Americas, which was declared polio-free in 1994.
The last case of wild-virus polio acquired in the United States was in 1979; the last imported case occurred in 1993. The Western Hemisphere has been free of wild poliovirus circulation since 1991. The last reported case of polio reported in Vermont was in 1963.
Since these cases have occurred in proximity to the United States and there is frequent travel between the United States and the Island of Hispaniola, which includes the Dominican Republic and Haiti, CDC is advising all state health departments to enhance their poliomyelitis surveillance.
Vermont health care providers seeing a patient with clinically consistent illness should notify the Vermont Department of Health immediately at 800-640-4374 (in VT).
Outside of regular business hours, the epidemiologist on-call can help arrange laboratory testing.
Paralytic poliomyelitis typically presents with rapid onset of flaccid paralysis and fever. Paralysis progresses to its maximal extent within a few days, and usually progresses no further once fever resolves. Paralysis is typically asymmetric, associated with decreased or complete loss of deep tendon reflexes and without involvement of sensory nerves. Paralysis, if not complete, is usually more marked proximally. The diagnosis of poliomyelitis should be considered in all patients who present with acute flaccid paralysis, especially those who have traveled to or have been exposed to persons who have traveled to the Dominican Republic or Haiti. Poliomyelitis can sometimes present as aseptic meningitis.
If poliomyelitis is suspected, clinicians should promptly obtain stool samples, throat swabs, acute and convalescent serum samples, and cerebrospinal fluid samples for viral culture. Advice on collecting specimens and arranging cultures can be obtained by calling the Vermont Department of Health Laboratory at 1-800-660-9997 (in VT).
Persons who are traveling to countries reporting polio cases and who are not immunized or whose vaccination status for polio is unknown should contact their health care provider to review vaccination options.
Current recommendations for children in the United States include a four-dose vaccination series with inactivated poliovirus vaccine (IPV) at ages 2, 4, 6 to 18 months, and 4 to6 years. Infants and children who are up-to-date for their routine immunization schedule and have received at least two (preferably three) doses of poliovirus vaccine should be adequately protected. School-age children and adolescents who completed a primary series may receive an additional dose of IPV before travel to polio-infected areas to further decrease the small risk of acquiring poliomyelitis.
Unvaccinated adults should receive three doses of IPV, the first two doses at intervals of4 to8 weeks and the third dose 6 to 12 months after the second. If three doses cannot be administered within the recommended intervals before protection is needed, alternative schedules are proposed. For incompletely vaccinated persons, additional IPV doses are recommended to complete a series. Adults who may be traveling to areas where polio is endemic and have received a primary series with either IPV or OPV can receive another dose of IPV. Available data do not indicate the need for more thana single lifetime booster dose with IPV for adults.
Additional information is available from the CDC website: http://www.cdc.gov/travel/
Vermont: Selected Reportable Diseases
January 1, 2000 - October 28, 2000
Note: There is no five-year median for Cryptosporidiosis or Hepatitis C (Acute).
New Recommendations for Refugee and Immigrant Health Screening
The Centers for Disease Control and Prevention (CDC) is now recommending additional medical screening for refugees and immigrants from some countries in sub-Saharan Africa. The recommendations arose because of problems detected with identification of tuberculosis and HIV in some individuals.
For more information about these new recommendations, or to receive an informational packet on refugee health assessments, please contact the Refugee Health program at the Vermont Department of Health at 863-7333.
REPORT DISEASE : VERMONT TOLL-FREE
1-800-640-4374 OR 1-802-863-7240
Vermont Department of Health
Division of Health Surveillance P.O. Box 70 Burlington, VT 05402-0070
Agency of Human Services
Jan K. Carney, MD, MPH
THIS BULLETIN IS PRODUCED BY THE EPIDEMIOLOGY PROGRAM STAFF.