Disease Control Bulletin: September 2002

Contents

disease control bulletin

Flu Season Again: Recommendations for Influenza & Pneumococcal Vaccination

“The health impact of a flu season varies from year to year…it is estimated that approximately 10 to 20 percent of U.S. residents get the flu, and an average of 114,000 persons are hospitalized for flu-related complications. About 20,000 Americans die on average per year from the complications of flu.” (www.cdc.gov/ncidod/diseases/flu/facts.htm)

The 2002-2003 recommendations of the Advisory Committee on Immunization Practices (ACIP) for the prevention and control of influenza contain important changes concerning the target groups and timing for vaccination. ACIP recommends that vaccination efforts during October focus on persons at greatest risk for influenza-related complications and that vaccination of other groups begin in November. Vaccination efforts for all groups should continue into December and later, for as long as vaccine is available. The special needs of young children for influenza vaccination are also addressed. These updated guidelines are described below.

The Vermont Department of Health web site (www.HealthyVermonters.org) will have a link to influenza surveillance information during the influenza season (late Sep-tember through mid-May). This web page will provide weekly updates of influenza activity by county, as well as links to the Centers for Disease Control and Prevention (CDC) influenza web page and to the influenza vaccine clinic schedule for the public. CDC has new educational materials for this season available on the web (www.cdc.gov/nip/flu).

Recommendations

Vaccination of these groups should begin in October:

Begin in November:

Continue December-January and beyond:

Influenza Surveillance

National surveillance for influenza is coordinated by the CDC Influenza Branch. Surveillance data are used to guide prevention and control activities, vaccine strain selection, and patient care recommendations. Two major components of influenza surveillance are weekly state Health Department reports of the estimated level of influenza activity and the U. S. Influenza Sentinel Physician Surveillance Network. State Health Department surveillance is based on the report of both individual laboratory- confirmed cases of influenza and outbreaks of influenza-like illness (ILI) in places such as schools, nursing homes, and other institutions. For surveillance purposes, ILI is defined as fever (temperature of ³100° F) plus either a cough or a sore throat. The Health Department encourages testing to confirm influenza in institutional settings.

Sentinel physicians collaborating with the state Health Department and the CDC report the total number of patients seen and the number of those patients with ILI by age group. During the regular influenza season, Vermont’s four sentinel medical practices (located in Burlington, Williston, St. Johnsbury and Townshend) reported ILI activity to CDC weekly or as often as possible. Influenza sentinel physician surveillance continued this summer with one emergency department physician in Windsor County. CDC hopes to eventually have this surveillance done year-round by all states.

Summary: 2001–2002 Influenza Season in Vermont

During the 2001–2002 influenza season (September 20, 2001-May 18, 2002), the Vermont Department of Health Laboratory tested over 300 respiratory specimens for influenza. Of the 124 isolates identified, 117 (96%) were influenza A viruses and seven (4%) were influenza B viruses. Of the 117 Influenza A specimens, 84 were strain typed and all were A/Panama/2007/99-like (H3N2). Of the seven Influenza B specimens, one was strain typed and it was B/Hong Kong/ 330/2001-like.The influenza vaccine for 2001–2002 was a good match for most of the influenza strains circulating in the United States during this season.

Confirmed influenza cases ranged in age from 1 week to 101 years. Vermont’s first positive viral culture was received on December 14, 2001 from a school-aged child in Windsor County. The last positive cultures, received on May 13, 2002, were from nursing home residents in central Vermont. Of the confirmed cases, all positive cultures were influenza A until late March, when a school-aged child from Windsor County had a positive influenza B culture. All confirmed influenza B cases were in school-aged children.

Eleven Vermont counties reported culture-confirmed influenza (all except Bennington, Essex and Grand Isle). Positive influenza cultures represent only part of the actual influenza activity, as some hospitals and medical practices use rapid influenza testing without culture confirmation, and most people with ILI are not tested or do not seek medical attention. The Health Department worked with nine nursing homes that had influenza outbreaks.

In Vermont, influenza activity increased in late January through February and peaked in March, when there was widespread activity in the state according to CDC’s influenza surveillance guidelines. Elsewhere in the United States, influenza activity peaked in late February, when 40 states reported regional or widespread activity. Nationally, the influenza season was assessed as mild to moderate, with influenza A (H3N2) viruses predominating. Nationally and in Vermont, influenza B viruses were isolated more frequently during the late spring through June.

Laboratory Diagnostic Procedures for Influenza

Influenza can be difficult to diagnose based on clinical symptoms alone. Symptoms of influenza can be similar to those caused by other infectious agents including, but not limited to, Mycoplasma pneumoniae, adenovirus, respiratory syncytial virus, rhinovirus, parainfluenza viruses, and Legionella species.

Influenza cultures are especially helpful early in the season to determine which strain(s) of influenza are circulating and whether the vaccine is a good match. For individual patients, tests are most useful when they are likely to give a doctor results that will help with diagnosis and treatment decisions. During a respiratory illness outbreak, testing for influenza can help determine if it is the cause of the outbreak.

Diagnostic testing is available at no charge through the Department of Health laboratory and consists of virus isolation/immunofluorescent antigen detection from throat or na-sopharyngeal swabs. In order to maximize recovery of the virus, throat/nasopharyngeal swab specimens should be collected within 3 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 also be available as positive isolates are recovered.

To obtain specimen kits for influenza testing, contact the Vermont Department of Health laboratory at 1-800-660-9997, ext.7560 or (802) 863-7560.

Rapid tests

Rapid influenza tests provide results within 30 minutes to 24 hours. However, rapid tests differ in the types of influenza viruses they can detect and whether they can distinguish between influenza types. Most of the rapid tests are 70 percent sensitive and 90 percent specific for detecting influenza. Because as many as 30 percent of samples that would be positive for influenza by viral culture can give a negative rapid test result, negative rapid tests should be followed by viral culture in a sub-sample of the swabs collected. Viral culture can also identify causes of ILI other than influenza.

Use of antivirals agents for influenza

Antiviral agents are not a substitute for influenza vaccination, however they may be used as adjuncts to the vaccine for control and prevention of influenza. When started within the first two days of illness, antiviral drugs can reduce the duration of the disease. Amantadine and rimantadine can be used to treat and prevent influenza A infections. These drugs do not work against influenza type B viruses. Zanamivir and oseltamivir can be used to treat influenza A and B infections. Oseltamivir can also be used to prevent influenza A and B.

Influenza and Pneumococcal Vaccination Vermont

Increasing to 90 percent the percentage of non-institutionalized adults ages 65 and older who receive annual influenza immunizations and the percentage who have ever been vaccinated against pneumococcal disease are Healthy Vermonters 2010 goals. Data on Vermonters ages 65 and older interviewed in 2001 through the Vermont Behavioral Risk Factor Surveillance System showed 71.5 percent received an influenza immunization during the past year and 67.3 percent had been vaccinated against pneumococcal disease.

The ACIP also recommends pneumococcal polysaccha-ride (PPV23) vaccine for persons aged 2 years or more who reside in nursing homes or other long-term care facilities. PPV-23 and influenza vaccines may be safely administered simultaneously in separate syringes at different anatomical sites.

References:

  1. CDC. Prevention and control of influenza: recommendations of the Advisory Committee on Immunization Practices. MMWR 2002;51(No.RR-3). http://www.cdc.gov/mmwr/preview/mmwrhtml/ rr5103a1.htm
  2. CDC. Prevention of pneumococcal disease; recommendations of the Advisory Committee on Immunization Practices. MMWR 1997;46(No.RR-8)
  3. CDC. Erratum: Vol. 51, No. RR-3. MMWR 6/28/02;51(25);563
  4. Quality Care Alert.AMA, vol 2, #1, 2/99
  5. Laboratory testing for influenza: www.cdc.gov/ncidod/hip/INFECT/ flu_acute.htm

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Chronic Disease in Vermont: Breast Cancer Screening

Vermont’s Ladies First Program1 has been helping eligible Vermont women receive mammography screening for breast cancer since 1995 with the goal of removing income and insurance barriers to receiving mammograms in Vermont. Still, approximately 22 percent of Vermont women age 40 and over are not receiving mammograms at least every two years.2 Women enrolled in the Ladies First program cite many barriers to mammography screening: poor health status, anxiety/fear, lack of childcare/eldercare, lack of mobility, conflicts with work schedule, lack of primary health care provider, and concern about the cost of treatment, if needed.3 Vermont women outside the program might have additional barriers to mammography screening that we have yet to identify.

Geographical barriers to mammography have also been reported.4 Caledonia was the only Vermont county in which the percentage of women being screened for breast cancer was statistically significantly lower than the Healthy Vermont-ers 2010 goal for breast cancer screening (64% vs. goal of 70%).1 Another measure of access to health care suggests more counties could be affected: nine of 14 Vermont counties are in limited or severe need of primary care physicians.5

Potential Barriers to Screening for Vermont Women

The Behavioral Risk Factor Surveillance System 1996 to 2000 data6 were used to characterize all Vermont women aged 40 and older who had not received a mammogram in the previous two years. Potential barriers to screening were broken down into those related to:

Having no health insurance outweighed both income and education as a predictor for Vermont women not receiving a mammogram in the previous two years. Other chronic disease screening behavior variables were strong predictors for mammography screening. The lack of colorectal cancer, blood pressure, cholesterol, and cervical cancer screening tests were all strong predictors for not receiving a mammogram in the previous two years. Smoking status and seatbelt use were not

good predictors for mammography use. Among mobility surrogates, having pre-school children in the home and age group (40-49, 50-64, 65+ years) were better predictors of mammog-raphy use than general health status.10 The chronic disease variables, diabetes, overweight/obesity and the “at risk” for depression screener, did not predict mammography use.

Table 1: Multivariate Odds Ratio for Women Age 40+ NOT Getting Mammograms, Vermont BRFSS 1996-2000
Odds Ratio 95% CI
Blood pressure check (w/in 2 years)
YES 1.00
NO 11.68 (5.16, 26.42)
Ever had a Pap test
YES 1.00
NO 4.00 (2.45, 6.53)
Had either colorectal cancer screening
YES 1.00
NO 3.16 (2.29, 4.36)
Cholesterol check (w/in 5 years)
YES 1.00
NO 2.89 (2.18, 3.84)
Has any type of health insurance
YES 1.00
NO 2.82 (1.83, 4.35)
Age groups:
40–49 1.90 (1.41, 2.57)
50–64 1.00
65+ 1.87 (1.35, 2.60)

* Adjusted for all other variables in the model.

Best Predictors for Lack of Mammography Screening

The variables in the final logistic regression model11 are shown in Table 1. Blood pressure check within two years was associated with the largest odds ratio (OR), after adjusting for all of the other factors in the model. Vermont women age 40 and over who had not had their blood pressure checked within two years were almost 12 times as likely to have not received a mammogram as women who had their blood pressure checked within two years. Women who had never had a pap test, had neither type of colorectal cancer screening , nor cholesterol screening within five years were four times, over three times, and almost three times, respectively, less likely to have had mammograms than their counterparts in the same age groups who did receive these screening tests (see Table 1 for odds ratios). The lack of health insurance (OR=2.82) was a strong predictor for lack of mammograms despite the Ladies First program in Vermont. Vermont women in the youngest (OR=1.90) and oldest age groups (OR=1.87) were less likely to receive mammograms than the women in the 50 to 64 year old age group.

Prevalence of “Best Predictors” in Vermont Women

Figure 1 shows the prevalence of examined screening behaviors and health insurance status for Vermont women. Overall, fewer than 5 percent of women did not receive blood pressure checks within two years. Women age 65+ had the highest percentage of missed cervical cancer screening (10.6 %) compared to women under age 65, of whom fewer than 4 percent had never had a pap test.12 Colorectal screening was the screening missed by the largest percentage of women. The percentage of women who did not receive screening declined with increasing age, but more than half of women over age 50 did not receive this screening although it is recommended for people age 50 and older.13 Nearly one quarter of the youngest women (40-49 years) did not have cholesterol screening within five years compared to approximately 15 percent of women over 50. For women under age 65,14 approximately 10 percent had no health insurance compared to fewer than 2 percent of women over age 65, the majority of whom are eligible for Medicare.

Mammogram chart

Figure 1. Prevalence (Percent) of Characteristics Related to Not Getting Mammograms, Vermont BRFSS 1996-2000

Type of screening tests not received

The large odds ratio (OR=11.68) associated with blood pressure screening is likely to be a measure of risk associated with low access to health care, since more than 95 percent of Vermont women age 40 and older receive appropriate blood pressure screening. The strong relationship between lack of mammography and lack of other screening suggests some barriers in common in addition to lack of health insurance.

References

  1. Ladies First offers free mammograms and Pap tests for Vermont women ages 40 to 64 of limited income. The household income for two people can be up to $29,850 a year. Services are also available to women of limited income over age 64 without Medicare Part B, and those age 18 and over who have breast symptoms or an abnormal Pap test. Call Kate at 1-800-508-2222 to find out more.
  2. Vermont Department of Health. Health Status Report. June 2002. Data source: VT BRFSS 1996-2000.
  3. Ladies First Program, Vermont Department of Health.
  4. Brustrom JE, Hunter DC. Going the distance: how far will women travel to undergo free mammography? Mil Med 2001 Apr;166(4):347-9.
  5. Vermont Department of Health. Health Status Report. June 2002, p.2. Limited or severe need corresponds to fewer than 79 primary care physicians per 100,000 population.
  6. Behavioral Risk Factor Surveillance System is a telephone survey representing non-institutionalized adult Vermonters.
  7. Use of mammography services by women aged > or = 65 years enrolled in Medicare—United States, 1991-1993. MMWR 1995 Oct 20;44(41):777-81.
  8. Burack RC et al. Health status and mammography use among older women. J Gen Intern Med 1998 Jun;13(6):366-72.
  9. Beckman TJ, Cuddihy RM, Scheitel SM et al. Screening mammo-gram utilization in women with diabetes. Diabetes Care 2001 Dec;24(12):2049-53.
  10. At risk for depression: respondent reported feeling depressed for at least one full day during the preceding week AND feeling depressed for either a two-week period during the preceding year for “most of” the preceding year.
  11. Respondent reported “in general” health was excellent, very good, good, fair, poor.
  12. Generated with SUDAAN Release 7.5.4, Research Triangle Inst.
  13. Statistically significant difference. 95% confidence intervals do not overlap.
  14. Screening for colorectal cancer: recommendation and rationale.

Ann Intern Med 2002 Jul 16;137(2):129-31.

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Ongoing Legionnaires’ Disease Outbreak Investigation

As this newsletter goes to press, the Vermont Department of Health continues to investigate an outbreak of Legionnaires’ disease in the Waterbury area. The investigation began on August 1, when an inpatient at Central Vermont Hospital with severe pneumonia was confirmed as having Legionnaires’ disease. As of August 22, there were 18 confirmed cases of Legionnaires’ disease associated with the outbreak, and 11 cases of milder legionellosis.

The department investigates every case of Legionaires’ disease to try to determine if there are any potential sources of the organism that could pose a risk to the general public. If a case occurs in association with an institutional setting, such as the case in Waterbury, the department also institutes active case finding to look for other related cases that might not have been recognized.

Nationally, outbreaks of this disease have been related to cooling towers, evaporative condensers, whirlpool spas, showers, fountains, and ultrasonic mist machines. At this time, evidence seems to point to one or more cooling towers as the likely source of the outbreak. Once the outbreak is over and the investigation is complete, a summary will be published in a future issue of the Disease Control Bulletin.

Thank you to the doctors, nurses, and many other people throughout the state who have worked so hard in helping us identify cases and educate patients and the public about Legionnaires’ disease.

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Vermont Yankee Potassium Iodide Predistribution

Since April 15, 2002, the Vermont Department of Health has been making available one dose of potassium iodide to any person who lives or works in the six towns within the emergency planning zone for the Vermont Yankee Nuclear Power Station. This voluntary pre-distribution program is part of Vermont’s terrorism preparedness effort; it comes as a result of the Nuclear Regulatory Commission’s offer in late 2001 to provide pills free to any of the 34 states with people living within 10 miles of nuclear power plants.

To date, 13 states have accepted the federal offer; Vermont was among the first. New York, Massachusetts and, soon, New Hampshire are also distributing potassium iodide.

Vermont’s Plan

Vermont’s plan allows individuals who live or work in Brattleboro, Dummerston, Guilford, Halifax, Marlboro, or Vernon to have one dose per person of potassium iodide to keep at home. Before receiving the pill, individuals are informed of the risks and benefits, proper dosage, medical contraindications, and the importance of following emergency directives such as evacuation and sheltering. Potassium iodide is to be taken only when directed by public health officials in the event of a nuclear emergency. If evacuation becomes necessary, people in the area will be directed to a reception center or other location where there will also be a supply of potassium iodide for emergency distribution.

Persons interested in predistribution must apply, using forms available at town clerks’ offices in each of the six towns, at the Brooks Memorial Library, and at the Vermont Department of Health’s local office in Brattleboro. Applications have also been placed with large employers, pharmacies, and other agencies in the area. The forms can also be downloaded from the department’s website: www.HealthyVermonters.info.

Each person applying to receive potassium iodide must fill out an informed consent and a health screening form. (Parents/guardians may apply for each of their children.) Individuals with certain health conditions must also get a medical release from their physician.

By mid-July, 2002, approximately 650 individuals had applied and received their potassium iodide pill. The Health Department is also working with community hospitals, nursing homes, schools and day cares on plans for patients and children in their charge.

Protection against Thyroid Cancer

Potassium iodide, also known as KI, is a form of iodine. Classified as a drug approved for over-the-counter sale, potassium iodide has been determined by the U.S. Food and Drug Administration (FDA) to be a safe and effective method to block exposure to radioactive iodine, which is one product of a nuclear release. Radioactive iodine, either inhaled or ingested through contaminated food or milk, can increase the risk of developing thyroid cancer.

Treatment guidance from the FDA (November 2001) confirms that the benefits of potassium iodide far outweigh the rare risks of serious side effects. This is especially true for children, who are more likely than adults to develop thyroid cancer following exposure to radioactive iodine.

FDA’s guidance is based on a comprehensive review of studies conducted after the Chernobyl nuclear reactor accident in 1986. KI’s effects last approximately 24 hours. For best protection, one dose of potassium iodide should be taken before or at the time of exposure, although it may still lower risk of thyroid cancer even if taken three or four hours following exposure. Emergency directives such as evacuation, staying indoors, or restricting the use of contaminated food and milk are designed to minimize human exposure to all types of harmful radiation that could be released in a nuclear emergency.

Dosage, Side Effects and Contraindications

Individuals should NOT take potassium iodide unless directed to do so by public health officials in the event of a radiological emergency at Vermont Yankee. If directed to take potassium iodide, it should be taken once every 24 hours until the risk of exposure has passed. It should not be taken more often.

Risk Group Dose Number of 130 milligram tablets
age 18 and older 130 mg 1
age 3 to 18 years and
pregnant or lactating women 65 mg 1/2
age 1 month to 3 years 32 mg 1/4
birth to age 1 month 16 mg 1/8

Exceptions: Pregnant or lactating women should not have a repeat dose. Pregnant women, lactating women, and newborns up to age 1 month who have taken potassium iodide should have medical follow-up.

Because the pills are supplied only in single 130 milligram tablet size, special instructions for administering potassium iodide to children are provided to people participating in the pre-distribution.

Short-term use of potassium iodide at the proper dosage is safe for most people. Side effects are generally mild and include gastrointestinal distress (up to 2 percent) and rash (approximately 1 percent in children and adults). Allergic reactions can be seen in adults with known iodine sensitivity.

Contraindications:

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Vermont Death Surveillance

Functions of Death Certificates

Death certificates serve several functions, some going back many centuries. The death of a person has many legal consequences, especially with regard to the ownership of property. Starting in 1538, English parish laws required the clergy to record burials in a weekly record. The Massachusetts Bay Colony enacted a law in 1639 ordering a government record of each death. Cotton Mather, a clergyman, noticed during a smallpox epidemic in 1721 that more than one in six natural cases died, but only one in 60 inoculated cases died. This is one of the earliest uses of cause-of-death statistics to evaluate the effectiveness of disease prevention techniques.

Cause of death is one of the most important items on death certificates. The objectives of Healthy Vermonters 2010, the state’s blueprint for improving public health, include reducing the number of deaths from: alcohol-related motor vehicle crashes, diabetes, heart disease, stroke, residential fires, suicide, and chronic obstructive pulmonary diseases. To measure the incidence of such deaths and thereby judge the success of interventions, the immediate cause of death, the underlying cause of death, every condition in the sequence of death, and any significant contributing causes must be entered accurately on every death certificate. Physicians must enter the complete sequence accurately so that analysts can reconstruct the contribution of associated or related chronic diseases that started the chain of events ultimately leading to death. For example, the proximal cause might be myocardial infarction (MI). Underlying the MI, there might have been evidence of atherosclerosis and underlying that there might have been diabetes mellitus. The diabetes started the chain of events leading to the MI and would be the underlying cause.

Quality Improvement

Death certificates report both the Cause of Death and the Manner of Death. As part of new death surveillance practices and to improve death reporting, the Office of the Chief Medical Examiner now reviews the cause and manner of death statements on all certificates. Death certificates can only be amended after discussion and agreement between the chief medical examiner and the certifying physician.

In November 2001, the cause of death was amended on approximately 7 percent of all death certificates. Recently the rate of amendment has dropped to about 5 percent, indicating improved reporting. In addition, the Manner of Death has been changed on 2 percent of certificates. In most cases, discussions about amendments take only a few minutes and can be done at the physician’s convenience.

Common Errors in Cause of Death

By far, the most common error in Cause of Death statements has been lack of etiologic specificity. The Cause of Death section should explain completely why someone died by listing the Underlying Cause and its sequelae that led to the Immediate Cause of Death. Physicians sometimes enter only the Mechanism of Death but not the underlying cause.

Definitions

The Mechanism, Mode or Immediate Cause of Death is the altered physiology or biochemistry by which the cause exerts its lethal effect. Mechanisms lack etiologic specificity and cannot stand alone on the death certificate. Examples of mechanisms of death include bronchopneumonia, liver failure, and pulmonary embolism. Immediate causes of death are sequelae of the underlying cause of death.

The Underlying Cause of Death is the original cause, which in a natural and continuous sequence, unbroken by any efficient intervening cause, produces the fatality and without which the end result would not have occurred.

Cause of Death Examples:
Incorrect: Sudden cardiac death
Correct: Sudden cardiac death
Due to hypertensive and atherosclerotic cardiovascular disease

Incorrect: Aspiration pneumonia
Correct: Aspiration pneumonia
Due to
dysphagia
Due to cerebral infarct
Due to atherosclerotic cardiovascular disease

Incorrect: Renal failure
Correct: Renal failure
Due to
acute/chronic pyelonephritis
Due to indwelling catheter
Due
to dementia

The Manner of Death describes how the cause arose or the circumstances surrounding the death. The Death Certificate allows only four possible manners of death: Natural, Accident, Suicide, or Homicide. By law a physician who is not a medical examiner can only certify natural deaths. Natural deaths are by definition deaths caused solely by natural disease. Anything else that contributes (such as trauma) makes the death not natural and must be certified by a medical examiner. The timeframe does not matter. For example: a person with dementia who sustains a femoral fracture from a fall, has it repaired surgically, and then develops pneumonia several weeks later as a result of being bedridden since the fall. This is an accidental death, not a natural death. It should be classified as follows:

Part 1. Immediate Cause: Bronchopneumonia
Due to Immobility
Due to
Femoral fracture
Due to
Blunt Impact (fell from standing height)
Part 2. Other significant conditions contributing to death but not resulting in the underlying cause listed in Part 1: Dementia; Atherosclerosis;
Osteoporosis 27a. Manner of Death: Accident

To discuss the wording in difficult cases or for more information, call the Office of the Chief Medical Examiner at (802) 863-7320.

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Vermont: Selected Reportable Diseases August 1, 2002

selected reportable diseases august 2002

milligram tablets

Note:

There is no five year median for Hepatitis C (acute).

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Creutzfeldt-Jakob Disease Surveillance

Effective August 2001, Creutzfeldt-Jakob disease (CJD) became reportable under Vermont’s Communicable Disease Regulations. Health care providers are required to report suspect and confirmed cases of CJD to the Vermont Department of Health.

The Health Department is participating in CDC’s Creutzfeldt-Jakob disease mortality surveillance system. This system was initiated in 1996, after the announcement in the United Kingdom of the emergence of a new variant form of CJD (vCJD) in humans due to infection by the agent of bovine spongiform encephalopathy (mad cow disease). As part of this surveillance system, CDC reviews routinely collected multiple cause-of-death data submitted to the National Center for Health Statistics (NCHS). Because of the over 12-month delay in the availability of NCHS mortality data, CDC has asked state health departments to conduct quarterly reviews of vital statistics data to identify CJD deaths among individuals younger than age 55. For any such deaths, clinical records are reviewed to consider the diagnosis of CJD vs. vCJD.

CJD deaths among individuals younger than age 55 occur at the rate of approximately one case per ten million United States population per year. We expect an average of fewer than one CJD death per year among Vermonters younger than age 55. Since over 99 percent of vCJD cases to date have occurred among people under the age of 55, detailed review of young CJD cases is a sensitive way to assess the presence or absence of vCJD in the United States. There have been four deaths from CJD in Vermont in individuals younger than 55 years of age between 1968 and 2001.

Prompt reporting of suspect and confirmed cases of CJD is an important part of this surveillance effort. To report a case, call the Health Department at 802-863-7240 or 1-800-640-4374 (in VT) or call the 24-hour confidential reporting line at 802-951-4080 or 1-888-588-7781 (in VT).

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HIV Prophylaxis for Survivors of Sexual Assault Now Available

On July 1, the Vermont Center for Crime Victim Services (CCVS) launched a new system of free and confidential HIV services for victims of sexual assault. In addition to HIV counseling and testing for victims of sexual assault, the state now provides payment for Post Exposure Prophylaxis (PEP) to individuals who may have been exposed to HIV through a sexual assault.

Although post exposure prophylaxis has been standard procedure for some time for health care workers after occupational exposure to HIV, its use for victims of sexual assault is more recent. Centers for Disease Control and Prevention (CDC) guidelines were published for the first time in May. The guidelines are available at http://www.cdc.gov/mmwr/ preview/mmwrhtml/rr5106a1.htm#RiskHIVInfection.

Prophylaxis must be initiated within 72 hours of a sexual assault. A new protocol developed by the Vermont Center for Crime Victim Services ensures quick access to prophylaxis in hospital emergency rooms. The cost of all tests, lab fees, medications, and doctor visits will be paid by the state for victims who do not have health insurance or do not wish to use their insurance. It is not necessary for a victim to have a rape exam or report the crime to the police in order to receive the free services.

Victims who do not wish to use the emergency room, as well as their health care providers, are encouraged to call infectious disease specialists at Fletcher Allen Health Care or Dartmouth-Hitchcock Medical Center without delay after a sexual assault.

A new brochure for victims about PEP, Are You Concerned About HIV/AIDS After A Sexual Assault?, is available from the Vermont Center for Crime Victim Services. To request copies of the brochure, a list of confidential and anonymous HIV counseling and testing sites, or for more information about services available to victims of sexual assault, contact the Center at 1-800-750-1213.

Erica Garfin, MA, is a Montpelier-based health planning consultant who worked on the development of the PEP protocol and wrote this article for the Disease Control Bulletin.

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

Contributing Authors:
Sally Cook, RN
Public Health Nurse Specialist

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