Disease Control Bulletin: September 2001

Contents

disease control bulletin

Influenza 2001-2002

Recommendations of the Advisory Committee on Immunization Practices (ACIP) for Prevention and Control of Influenza (2001-02) were published in the April 20, 2001 Morbidity and Mortality Weekly Report.1 The primary patient groups to be targeted for annual vaccination are as follows.

  1. Groups that are at increased risk for influenza-related complications:

    • persons age 65 and older
    • residents of nursing homes and other chronic-care facilities that house persons of any age who have chronic medical conditions
    • adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma
    • adults and children 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 immuno-suppression (including immunosuppression caused by medications or by HIV)
    • children and teenagers (age 6 months to 18 years) who are receiving long-term aspirin therapy and might be at risk for developing Reye syndrome after influenza infection
    • women who will be in the second or third trimester of pregnancy during the influenza season
  2. Adults age 50–64, because of an elevated prevalence of certain chronic medical conditions

  3. Persons who live with or care for those at high risk (e.g., health-care workers and household members who have frequent contact with persons at high risk and can transmit influenza infections to these persons at high risk).

Quick points:

In many cases, vaccination levels can be improved through the use of techniques such as reminder or recall systems and standing orders.

Guidelines on influenza vaccine dosage by age group are presented in Table 3, page 13, of the MMWR article.

Be certain to read the package insert before using any vaccine.

Use of Antiviral Agents for Influenza

Antiviral agents are not a substitute for influenza vaccination, however they may be used as adjuncts (for treatment or prophylaxis) to the vaccine for control and prevention of influenza. Amantadine, rimantadine, zanamivir, and oseltamivir are the four antiviral agents currently licensed and available in the United States. Use of these agents for treatment in otherwise healthy adults can decrease the duration of uncomplicated influenza A illness (ramantadine and amantadine) and of uncomplicated influenza A and B illness (zanamivir and oseltamivir) by one day, however none has been shown to be effective in preventing serious influenza-related complications, such as pneumonia or exacerbation of chronic disease.

Amantadine and rimantadine are indicated for the prophylaxis of influenza A infection and can be 70-90 percent effective in preventing illness, although subclinical infection and development of protective antibodies can occur. Oseltamivir has also been approved for prophylaxis. Prophylaxis is indicated for:

Table 4 in the MMWR article3 provides the recommended daily dosage of influenza antiviral medications for treatment and prophylaxis of influenza.

Accurate and timely diagnosis of respiratory illness allows for appropriate treatment including the option of using antiviral therapy for influenza and sensitivity-guided antibiotic use for bacterial infections (either primary or as a complication of influenza). Knowledge of the current incidence of influenza cases and the type of influenza (A or B) circulating in the community can guide antiviral use.

Diagnostic tests for influenza include viral culture, serology, rapid antigen testing, and immunofluorescence. The types of specimens acceptable for use with rapid antigen testing vary, and although results can be available within 30 minutes, sensitivity and specificity are lower than for viral culture and they cannot identify circulating subtypes and strains. Viral cultures also provide material needed to monitor the emergence of antiviral resistance and to detect the emergence of new influenza A subtypes that are potential pandemic threats.

Summary of Vermont’s 2000-2001 Influenza Season

During the 2000-2001 influenza season, 47 confirmed cases of influenza were reported. The first case was reported on January 2, 2001. Sporadic activity around the state was reported during the first three weeks of January. Activity then increased to regional, where it remained through the end of February. Reports of sporadic cases continued, with the last confirmed case being reported on April 2, 2001. There has been no influenza activity reported since then (through August, 2001).

Of the 47 cases reported, 16 were influenza A and 31 were influenza B. This is quite different from the previous influenza season, when all but one of the 73 confirmed cases were influenza A. All of the 2000-2001 season influenza A isolates were strain-typed as H1N1. Of the 25 influenza B isolates that were typed, 24 were identified as Beijing 184/ 93-like and one was identified as Beijing 243/97-like, which was not included in the season’s vaccine.

Three individuals reported with confirmed influenza were 60 years of age or older, and all three had influenza B. Two of the individuals had been vaccinated. Only one long-term care facility had laboratory-confirmed cases.

Confirmed influenza cases were reported from 13 of 14 Vermont counties. The distribution was as follows: Addison 6, Bennington 1, Caledonia 1, Chittenden 17, Essex 1, Franklin 1, Lamoille 2, Orange 1, Orleans 5, Rutland 3, Washington 3, Windham 2, and Windsor 4.

The cases ranged in age from 5 months to 96 years; 30 of the cases (64%) were 21 years of age or younger. The vaccination status of 45 of the cases was provided. Of these, only three had been vaccinated. None of the 14 children (age 16 or younger) had been vaccinated.

Reported influenza activity in Vermont under-represents the actual amount of illness present in the state for several reasons. The Health Department receives reports of total numbers of tests done by hospitals that perform only rapid tests for influenza on specimens, however there is no differentiation between influenza A and influenza B and those numbers are not included in the reports cited above. Determination of the flu activity in the state (sporadic, regional, etc.) is made by combining information on the number of specimens submitted, estimates of school and work absenteeism, information from hospital infection control practitioners, and estimates of the number of patients seen in offices with influenza-like illness (whether or not a viral culture was obtained).

Please contact Infectious Disease Epidemiology (802-863-7240) with questions regarding the availability of influenza vaccine, for updates on state influenza activity, to report influenza outbreaks, and for advice on outbreak control. Physicians may request kits for taking and submitting specimens for viral culture by calling the Vermont Department of Health Laboratory at 802-863-7560. Cultures taken early in the season are especially helpful.

Free CME Category I credit is available for physicians who read this issue of the MMWR 1 and complete on-line testing.

References

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Vermont Department of Health Reportable Diseases

Division of Health Surveillance

Updated 8/1/2001

REPORTABLE: Any unexpected pattern of cases, suspected cases, deaths or increased incidence of any other illness of major public health concern, because of the severity of illness or potential for epidemic spread, which may indicate a newly recognized infectious agent, an outbreak, epidemic, related public health hazard or act of bioterrorism.

Diseases which are possible indicators of bioterrorism:

Treatment:Human rabies postexposure treatment (HRPET) is reportable even where no evidence of rabies has been found.

Reporting of Diseases

The law requires that health care providers report diseases of public health importance. Persons who are required to report: 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.

24-hour Disease Reporting

802-951-4080
or toll-free in Vermont
888-588-7781

Consultation and Inquiries

802-863-7240
or toll-free in Vermont
800-640-4374

24-hour Disease Reporting

802-951-4061
Secure FAX

HIV/AIDS Reporting Questions

802-863-7572

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Vermont Department of Health Reportable Laboratory Findings

Division of Health Surveillance Updated 8/1/2001

Positive, presumptive, or confirmed, isolation or detection of the following organisms OR positive, presumptive or confirmed, serological results for the following agents (to include any rare infectious disease or one dangerous to the public health):

In addition, all positive findings for the following laboratory tests must be reported:

Laboratory reporting shall include:

Reporting of Diseases

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 test results for reportable diseases, or any unusual findings, or where epidemiologic typing is desirable, the serum or a pure culture of the organism be sent to the Vermont Department of Health Laboratory. The Laboratory should be contacted directly at 802-863-7335 or 1-800-660-9997 (in Vermont only) for information on how to submit cultures and specimens.

Laboratory (contact directly for how to submit cultures and specimens)

802-863-7335
toll-free in Vermont
800-660-9997

24-hour Disease Reporting

802-951-4080
or toll-free in Vermont
888-588-7781

Consultation and Inquiries

802-863-7240
or toll-free in Vermont
800-640-4374

24-hour Disease Reporting

802-951-4061
Secure FAX:

HIV/AIDS Reporting Questions

802-863-7572

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New Guidelines for Treatment of Latent Tuberculosis

The August 31, 2001, issue of Morbidity and Mortality Weekly Report1 contains new guidelines for use of the two month regimen of rifampin plus pyrazinamide (2RZ) for the treatment of latent tuberculosis infection, or LTBI (also known as prophylactic therapy). Between February and August 2001, 21 cases of liver injury, including five fatalities, associated with 2RZ were reported to the Centers for Disease Control and Prevention (CDC). The new guidelines supplement recommendations for LTBI previously published.2 Since the total number of patients receiving this regimen is unknown, the rate of liver injury cannot be calculated, however the number and severity of these instances aroused sufficient concern that the American Thoracic Society (ATS) and CDC, with the endorsement of the Infectious Diseases Society of America (IDSA), revised their recommendations regarding the use of 2RZ. A brief summary of the changes is included here.

Guidelines

Asymptomatic increases in AT are expected, however treatment should be stopped when the AT level is >5x the upper limit of the normal range, an elevated AT is accompanied by symptoms of hepatitis, or the serum bilirubin is greater than normal. Treatment with this regimen should not be resumed.

The article2 contains additional guidelines for determining if treatment for LTBI is indicated and for treatment with INH.

References

  1. Morbidity and Mortality Weekly Report August 31, 2001; 50(34): 733-5, on the Web at www.cdc.gov/mmwr/preview/mmwrhtml/ mm5034a1.htm
  2. The original publication describing the use of 2RZ for the treatment of LTBI appeared in the American Journal of Respiratory and Critical Care Medicine 2000; 161:S221-S247 (available on the Web at ajrccm.atsjournals.org/cgi/content/full/161/4/S1/S221).

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Reporting to the Vermont Cancer Registry

The Vermont Cancer Registry was established in 1993 to collect, analyze, and report cancer incidence data. Operated by the Vermont Department of Health, the Registry monitors cancer incidence among Vermont residents. The Department of Health and other researchers use registry data to study cancer trends, research cancer causes and improve cancer education and prevention efforts.

As with any disease registry, the key to the accurate assessment of cancer incidence is complete reporting. Complete reporting is also necessary to calculate small area incidence rates, to compare Vermont’s rates with other states, to compare county or hospital region rates, and to make Vermont eligible to participate in national studies.

Vermont’s Cancer Registry Law, 18 VSA § 153, requires health care facilities and health care providers to report to the Registry within 120 days of diagnosis all in situ or malignant cancer cases (ICD-Oncology behavior codes 2 or 3). According to the law, if a facility fails to report, Registry personnel may enter the facility, obtain the information, and report it in the appropriate format. In these cases, the facility would be required to reimburse the State for the cost of obtaining and reporting the information. Willful failure to grant access to such records may be punishable by a fine of up to $500.00 for each day access is refused.

Many physicians have responded to the mandate, and with their continued support, the Registry will be able to assess the challenges and successes of the case reporting.

In exchange for mandated reporting, the Vermont Cancer Registry Law includes protections for the information itself as well as for those who report the information. All identifying information collected by the Registry regarding individual patients, providers and health care facilities is deemed “confidential and privileged.” Physicians and other cancer data reporters have immunity from damages for good faith disclosures of patient information to the Registry in accordance with the law. The requirement to report cancer cases to the Registry and the disclosure protections will continue under the federal Health Insurance Portability and Accountability Act (HIPAA). Physicians will not be required to obtain permission from a patient prior to notifying the Registry of a cancer case.

Goal is 100 Percent Reporting

With the collaboration of various members of the Vermont medical community, the Registry will continue to move toward complete reporting. Cancer cases that are not reported at diagnosis or during treatment are sometimes discovered by a review of death certificates. The Vermont Cancer Registry uses this review or “death clearance” as the final stage in case ascertainment. For example, of the 1,174 Vermont resident cancer deaths in 1997 eligible for reporting, approximately 17 percent had not been reported and were only identified through the death clearance process.

Physician-Only Reporting

Most cancer cases are reported to the Registry by Vermont hospitals. However, not all cancer cases are diagnosed and treated in a reporting facility. As health care systems change, more patients are diagnosed exclusively in practitioner offices or outpatient clinics. The most notable examples of such cases are those in which the diagnosis and all treatment are performed in the physician office or clinic. These typically include cases involving leukemia, prostate cancer, melanoma, and patients with advanced disease (such as lung cancer) for which treatment is not indicated, the patient refuses treatment, or the patient fails to return to the physician for follow-up.

It is the responsibility of practitioners to report the following cases directly to the Registry:

If you have questions about whether a case is reportable, or to request physician reporting forms or a copy of Cancer in Vermont, contact the Vermont Cancer Registry at (802) 651-1977.

For More Information

Vermont Cancer Registry Law: available at http:// www.leg.state.vt.us/statutes/title18/CHAP004.HTM#00151

Vermont Cancer Registry Rules: available at http://www.state.vt.us/ health/regs.htm

“Cancer in Vermont” and “Cancer Registration in Vermont:” posted in the 2000 Publications section of the Vermont Department of Health website http://www.state.vt.us/health/pubs.htm Centers for Disease Control and Prevention. National Program of Cancer Registries. http://www.cdc.gov/cancer/npcr/

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National Adult Immunization Awareness Week in October

While every health care encounter is an opportunity to bring adults up-to-date on their immunizations, October 14-20, 2001, has been specially designated as National Adult Immunization Awareness Week to remind providers and the public that adult immunizations are safe and effective. The adult immunization goals of Healthy Vermonters 2010 include increasing the percentage of non-institutionalized adults (age 65+) who receive annual influenza immunizations and who have ever been vaccinated against pneumococcal disease to at least 90 percent.

Often, adults are not up-to-date on other recommended vaccinations (see table below). Since routine childhood immuniztion has decreased the incidence of vaccine-preventable diseases in children, adults now represent the majority of cases of tetanus, diphtheria, and rubella.

ACIP Recommendations for Routine Adult Immunizations*1
Age group (years) 18–24 25–65 >65 Indicated
Td (every 10 years) Indicated Indicated Indicated
Measles (a) (a)
Mumps (b) (b)
Rubella (c) (c)
Influenza (annual) starting at age 50 (d) Indicated
Pneumococcal (e) Indicated
Hepatitis B (series) (f)
Varicella (series) (g) (g) (g)

*Information about immunizations for adults in special populations (e.g., hepatitis A in residents of endemic areas, men who have sex with men, or in travelers, Lyme disease in residents of endemic areas or with special medical conditions (e.g., hepatitis A in persons with chronic liver disease) is not included in this table.

(a) Indicated for persons born after 1956 and for health care workers even if born before 1957; two doses recommended for individuals in college settings and among health care workers.

(b) Indicated for all adults believed to be susceptible.

(c) Especially indicated for nonpregnant women of childbearing age.

(d) See indications in related article on influenza in this issue of the Disease Control Bulletin.

(e) Indicated for younger persons at high risk of pneumococcal disease (i.e., chronic disorders of the cardiovascular or pulmonary systems; metabolic diseases; alcoholism; cirrhosis; and/or compromised immune function); persons in special environments or social settings.

(f) Indicated if not previously immunized and at increased risk of occupational, social, family, environmental, or illness-related exposure to HBV.

(g) Indicated for susceptible adults who are at high risk for exposure or transmission of varicella disease, including persons who live or work in environments where transmission of VZV can occur and/ or is likely, persons who live in households with children, and international travelers. The need for serologic confirmation of susceptibility prior to vaccination is being assessed.

1 Several ACIP statements, available at www.cdc.gov/nip/ publications/ACIP-list.htm. This table is adapted from Fingar AF and Francis BJ. Routine Adult Immunization: American College of Preventive Medicine Practice Policy Statement. Am J Prev Med.

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Vermont: Selected Reportable Diseases
May 1, 2001 to September 8, 2001

reportable diseases september 2001

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Prevention of Meningococcal Disease in College Students

Based on studies demonstrating a moderately increased risk of developing meningococcal disease among college freshman living in dormitories,1 the Advisory Committee on Immunization Practices2 and the American Academy of Pediatrics3 recommended that college freshman, especially those living in dormitories, be educated about meningococcal disease and the potential benefits of the polysaccharide vaccine in preventing disease due to Neisseria meningitidis serogroups A, C, Y, and W-135. The vaccine does not protect against disease caused by serogroups other than those named. In Vermont, four to five confirmed cases of meningococcal disease were reported each year from 1997-2000; five confirmed cases have been reported in 2001 through 8/27.

The vaccine (Menomune ® -A,C,Y,W-135) is manufactured by Aventis Pasteur (1-800-Vaccine).

References

  1. JAMA 2001;286:688-93.
  2. MMWR 2000;49(RR-70):11-20.
  3. Pediatrics 2000;106:1500-4.

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Changes in Communicable Disease Reporting Requirements

Disease reporting by physicians and other health care providers plays a critical role in the control and prevention of disease. Public health surveillance is defined as the routine collection, analysis, interpretation, and distribution of data.

Timely reporting is essential for the implementation of effective public health interventions, such as providing pro-phylactic measures to protect exposed contacts, or recognizing and investigating outbreaks. Surveillance reports also lead to a more long-term understanding of disease trends.

Reporting helps us to inform physicians about the likelihood that a particular disease will occur in their patient population and can document new environmental risks in Ver-mont, such as from vector-borne diseases, leading to new warnings to the public. For vaccine-preventable diseases, the pattern of disease occurrence over time provides information important for developing improved control strategies, by identifying either populations that need to be targeted for increasing immunization rates or vaccine effectiveness issues.

All states have a list of diseases or conditions, chosen because of their potential impact on public health, that are required by law to be reported to the Department of Health. Section 4-201 of the Vermont Communicable Disease Regulations includes physicians and other health care providers as mandated reporters. The complete regulation is available at www.state.vt.us/health/regs.htm. Vermont’s list of reportable diseases has been revised effective August 1, 2001. A copy of the new list is included in this issue of the Disease Control Bulletin.

Additions to the list focus on 1) recognition of emerging infectious diseases currently rare or undocumented in Ver-mont, 2) improving the detection and documentation of antibiotic resistance, and 3) vaccine preventable diseases. In addition to specific diseases, wording has been added to strengthen the reporting of unexpected patterns of severe illness that might indicate an outbreak, public health hazard, or act of bioterrorism. Chickenpox has been added to the list. Health care providers are asked to report individual cases occurring in people age 19 or older, and to report either aggregate numbers or individual cases in those age 18 or younger.

The Health Surveillance Division has added a new 24-hour disease reporting line giving health care providers the option of leaving a confidential case report after regular business hours or accessing an epidemiologist for after-hours emergencies. HIV/AIDS reports should still only be sent through previously established methods.

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
Commissioner

THIS BULLETIN IS PRODUCED BY THE DISEASE CONTROL BULLETIN EDITORIAL STAFF.

Ann R. Fingar, MD, MPH
State Epidemiologist Managing Editor

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