Disease Control Bulletin: December 2004

Contents

2004–2005 Influenza Season

Influenza Vaccine Shortage—Background

On October 5, 2004, the Centers for Disease and Prevention (CDC) was notified by Chiron that none of its influenza vaccine Fluvirin ® would be available for distribution in the United States for the 2004-2005 season. The company indicated that the Medicines and Healthcare Products Regulatory Agency in the United Kingdom, where Fluvirin® is produced, had suspended the company’s license to manufacture this vaccine, preventing any release of this vaccine for this influenza season. This action reduced by approximately one half the expected supply of trivalent inactivated vaccine ( flu shot) available in the United States, and left only one manufacturer, Aventis Pasteur, which by this time had distributed over half of its vaccine, as the sole supplier of trivalent inactivated vaccine.

Following this announcement, CDC, in coordination with its Advisory Committee for Immunization Practices (ACIP) issued interim recommendations for use of the available influenza vaccine. This action effectively reduced the number of persons that would be eligible to receive vaccine, thus helping to ensure the limited vaccine would be available to those at the greatest risk for complications or death from influenza.

This shortage was very apparent in Vermont. Preliminary surveys revealed that almost all nursing homes, Visiting Nurses Association (VNA) and home health agencies, as the majority of hospitals had no vaccine. Furthermore, the vaccine that was available in Vermont was not equitably distributed to be able to meet the needs of those at highest risk. Clearly, additional measures were needed to respond to this shortage.

Influenza Vaccine Shortage—Vermont’s Response

Several efforts involving the input and cooperation
number of statewide partners were undertaken. They are briefly described here:

Influenza Surveillance

The Vermont Department of Health is in the process of reviewing influenza reporting requirements to both ease the burden of reporting and to facilitate prompt reporting of significant influenza-related events. The department currently recommends that laboratories report positive influenza cultures and weekly aggregate numbers of rapid influenza tests. Physicians and other health care providers are encouraged to report outbreaks of influenza-like illness that occur in institutional settings, and deaths due to influenza in children.

In addition to the data reported from laboratories and providers, influenza activity is monitored through the CDC-sponsored sentinel influenza surveillance program. This program includes the participation of a network of sentinel surveillance sites—thirteen such sites in Vermont—that collect and report rates of influenza-like illness (ILI). This data, in combination with other surveillance data, provides a statewide and a national picture of influenza activity and can be used to guide prevention and control activities. Health care providers of many types (e.g., family practice, internal medicine, pediatrics) and in many types of practice settings (e.g., individual or group practice, urgent care centers, emergency rooms, student health centers) are eligible to be a sentinel provider. Sentinel providers receive feedback on the data they submit, reports on regional and national influenza activity, free subscriptions to the Morbidity and Mortality Weekly Report (MMWR) and the Emerging Infectious Disease Journal. Additionally, providers receive a free supply of rapid influenza test kits as well as influenza viral culture kits. For more information, please contact Sally Cook at 802-863-7240 or 800-640-4374 (in VT).

During the 2003–2004 influenza season, rates of ILI reported by sentinel providers peaked in early January.

vermont influenza statistics 2003-2004 for more infor contact the dept of health

Influenza Testing

Rapid influenza tests are available and are useful for diagnostic purposes. Health care providers should request such testing through their hospital laboratory. For additional information on rapid tests, please see the CDC web site: www.cdc.gov/flu/professionals/labdiagnosis.htm.

Rapid influenza testing is also available through the Vermont Department of Health Laboratory, but only to aid in the investigation of outbreaks within nursing homes or other institutional settings. To report an outbreak, or to request such testing, please call the department’s Epidemiology Field Unit at 802-863-7240 or 800-640-4374 (in VT).

Viral culture tests are available and are useful for surveillance purposes. Viral cultures are of limited diagnostic value due to the time it takes to obtain a final result. The Health Department Laboratory offers this testing throughout the year. Please note the following related to such testing:

Health care providers are encouraged to call the Health Department’s Epidemiology Field Unit for updates on local or statewide influenza activity (updates will be posted at www.healthyvermonters.info). For more information on the sentinel influenza program, or to consult with an epidemiologist regarding suspected influenza outbreaks call 802-863-7240 or 800-640-4374 (in VT). For assistance from the Health Department Laboratory, call 802-863-7335 or 800-660-9997.

influenza reporting requirments, for more info contact the dept of health.

back to top

Summary of Recommendations for Adult Immunization

Vaccine For whom it is recommended Routine Schedule
Tetanus,
Diphtheris (Td)
All adults, including pregnant women
  • 1 dose booster every 10years.
  • People with uncertain histories of a complete primary vaccination series should receive a primary series of Td.
  • A primary series for adults is 3 doses: the first 2 doses given at least 4 weeks apart and the 3rd dose, 6-12 months after the second. 1 dose annually.
Influenza For the most current recommendations please visit the Centers for Disease Control and Prevention (CDC) web site at http://www.cdc.gov/nip/publications/acip-list.htm All adults 65 years and older of age Anyone over 2 years of age who has a long-term health problem. 1 dose annually
Pneumococcal
(polysaccharide)
  • All adults 65 years and older of age
  • Anyone over 2 years of age who has a long-term health problem.
  • Anyone over 2 years of age who has a chronic disease or condition that lowers the body's resistance to infection
1 dose
A second dose of vaccine if the patient received vaccine >= 5 years previously and were < 65 years of age.
Hepatitis B
  • People who have more than one sex partner in 6 months
  • Men who have sex with other men
  • Sex contacts of infected people
  • People who inject illegal drugs
  • Health care workers and public safety workers who might be exposed to infected blood or body fluids
  • Households contacts of persons with chronic hepatitis B virus infection
  • Hemodialysis patients
  • Some international travelers
  • Inmates of correctional facilities
3 doses (0, 1-2, 4-6 months)
Hepatitis A
  • Men who have sex with men.
  • Persons who use street drugs.
  • Persons with chronic liver disease.
  • Persons who are treated with clotting factor concentrates.
  • Persons who work with H.A.V. infected primates or who work with H.A.V. in research laboratories.
  • Some international travelers
2 doses (0, 6-12 months)
Measles, Mumps,
Rubella

Adults born in or after 1957 should receive at least one dose of MMR unless they have a medical contraindication, documentation of at least one dose or other acceptable evidence of immunity.

A second dose of MMR is recommended for adults who:

  • are recently exposed to measles or in an outbreak setting
  • were previously vaccinated with killed measles vaccine
  • were vaccinated with an unknown vaccine between 1963 and 1967
  • are students in post-secondary educational institutions
  • work in health care facilities
  • plan to travel internationally

1 dose if measles, mumps, or rubella vaccination history is unreliable

2 doses (0, 4weeks) for persons with occupational risks or college entry.

Varicella Recommended for all adults who do not have reliable clinical history of varicella infection, or serological evidence of varicella zoster virus (VZV) 2 doses (0, 4-8 weeks) for persons who are susceptible
Meningococcal
(polysaccharide)

Consider vaccination for adults with medical indications or:

  • adults with terminal complement component deficiencies
  • atomic or functional asplenia
  • Some international travelers
  • College freshmen, especially those who live in dormitories.

1 dose

Revaccination at 3-5 years may be indicated for persons at high risk for infection.

 

For a copy of the Recommended Adult Immunization Schedule by age group and Medical conditions United States, 2003-2004 visit http://www.cdc.gov/nip/recs/adult-schedule-2page.pdf or call the Vermont Department of Health Immunization Program at 1-800-464-4343 ext. 7556

For specific ACIP recommendations please visit www.cdc.gov/nip

Back To Top

Chronic Disease in Vermont: Breast Cancer 2004

Vermont breast cancer incidence, a measure of new breast cancer cases in the population, does not differ statistically from the U.S. White rate.1,2 In the U.S. and in Vermont, more early stage breast cancers are being detected, but mammography has not yet caused the predicted decrease in late-stage cancers.1,3 (See Figure 1)

Figure 1. Breast Cancer Incidence by Age and SEER Summary Stage at Diagnosis

figure 1. for more info contact the dept of health

Mammography Guidelines & Vermont Trends

For Vermont women with breast cancer, age is a good predictor of stage at time of diagnosis, probably because of the history of screening recommendations. Although screening is now recommended for all women 40 years of age and older, women over 50 have had the most consistent mammography recommendations over time.4 Since 1999, Vermont women 50 to 74 years of age have been more likely to have current mammograms (within the previous two years) than those 75 years of age and older or those 40 to 49 years of age.5

Vermont women 50 to 74 years of age also had higher percentages of localized breast cancer than women in the extreme age groups (40 to 49, 75+), although only the youngest women were significantly different.1(See Figure 2) Women 40 to 49 had the highest percentage of regional stage breast cancer, followed by women 50 to 74, and then women 75 and over. All of these differences were statistically significant.1 Distant stage breast cancers were significantly higher for women 75+ years of age compared to those 50 to 74.1 Women in the oldest age group were also significantly more likely to have unstaged breast cancers compared to those in the two younger age groups.1

Figure 2. Breast cancer incidence and mortality. for more info contact the dept of health.

Breast Cancer Mortality

The goal of screening is to detect breast cancer at a stage that is easier to treat and is associated with a higher survival rate. While 97 percent of U.S. women with localized breast cancer survive at least five years, only 23 percent of U.S. women with distant stage breast survive that long.6 Vermont mortality rates remain very similar to those in the U.S., where breast cancer mortality has been declining steadily since the 1990s.7 (See Figure 1) The decline to date has been attributed largely to treatment advances. As more of the population is routinely screened, the downward trend is expected to continue.8 In Vermont, women 40 to 49 years of age and women 75+ do not appear to be receiving screening according to established guidelines. Increasing screening in these populations may have a beneficial influence on Vermont breast cancer mortality rates.

Ladies First Program

This program for Vermont women with limited income was expanded to include screening for cardiovascular disease risk factors, including cholesterol, hypertension, diabetes and tobacco use, in addition to cancer screening. For more information, contact the Provider Support Line at 1-800-510- 2282 or visit the program’s website at www.LadiesFirstVt.org

References:

  1. Vermont Department of Health. Vermont Cancer Registry, incidence data for 1995-2001, age and stage data for 1997-2000.
  2. Ries LAG, Eisner MP, Kosary CL et al (eds). SEER Cancer Statistics Review, 1975-2001, National Cancer Institute. Bethesda, MD, http://seer.cancer.gov/csr/1975_2001/, 2004.
  3. Schootman M, Jeffe D, Reschke A, Aft R. The full potential of breast cancer screening use to reduce mortality has not yet been realized in the United States. Breast Cancer Res Treat 2004 Jun;85(3):219-22.
  4. US Preventive Services Task Force. Screening for Breast Cancer: Summary of recommendations. February 2002. Agency for Healthcare Research and Quality, Rockville, MD. http:// www.ahrq.gov/clinic/uspstf/uspsbrca.htm
  5. Vermont Department of Health. Behavioral Risk Factor Surveillance System, 1997-2000, 2002-03.
  6. Jemal A, Tiwari RC, Murray T et al. Cancer Statistics,2004. CA A Journal for Clinicians. Jan/Feb 2004;54(1):26.
  7. Vermont Department of Health. Vital Statistics System, 1995-2001.
  8. Nasseri K. Secular trends in the incidence of female breast cancer in the United States, 1973-1998. Breast J. 2004 Mar-Apr;10(2):129-35.

Back To Top

Chronic Disease in Vermont: Overview 2004

According to the 2003 Vermont Behavioral Risk Factor Surveillance Survey (BRFSS), 55 percent (approximately 260,000) of adult Vermonters have a chronic disease or condition.1 The risk increases with age: 34 percent of 18–44 year olds, 68 percent of 45–64 year olds and 88 percent of those aged 65+ years reported one or more chronic diseases. These Vermonters are less likely to meet recommendations for physical activity and are more likely to be overweight or obese than Vermonters without any chronic diseases. Figure 1 provides a more detailed look at the prevalence of specific chronic diseases in the Vermont adult population.

figure 1. for more info contact the dept of health

In general, Vermonters are hospitalized less frequently compared to the rest of the U.S. population. As seen in Figure 2, Vermont hospitalization rates are signficantly lower than U.S. rates for nine of 12 chronic conditions. Vermont osteoarthritis and acute myocardial infarction hospitalization rates are signi cantly higher than the U.S. rate and are increasing. COPD and cardiac dysrhythmia hospitalization rates in Vermont, while lower than the U.S. rate, are also on the rise.

figure 2. for more info contact the dept of health

Figure 2. Leading Causes for Chronic Disease Hospitalizations
(source: VT Hospital Discharge Dataset 1999-2001; US data from HCUP 2000)

For the past two decades, Vermont death rates have been below that of the U.S. White population.2 Of the top 10 leading causes of death in Vermont,3 seven are regarded as chronic in nature (Figure 3). The leading causes of death vary with age and by gender. The 2002 Vermont Vital Statistics Annual Report4 provides further details on this variability.

figure 3. for more info contact the dept of health

A recent article5 stated that 38.2 percent of mortality in the United States in 2000 could be attributed to three modifiable risk factors: tobacco consumption, poor diet/physical inactivity, and alcohol consumption. Information on risk behaviors and screening for chronic diseases in Vermont can be obtained by visiting the Vermont Department of Health’s website at http://www.healthyvermonters.com. National websites6-8 provide resources to monitor chronic disease in Vermont, and often allow for comparisons to the U.S. average.

References

  1. In 2003, the BRFSS asked questions of the 18 year old +, non-institutionalized population about 12 chronic diseases.These include current asthma, and the lifetime diagnosis (yes/no) of the following 11 conditions:multiple sclerosis, osteoporosis, Parkinsonfs disease, COPD, diabetes, arthritis, coronary heart disease, myocardial infarction, stroke, high blood pressure, or high cholesterol.
  2. Vermont Vital Statistics Annual Report 2002.April 2004.
  3. Ranking corresponds to calendar year 2002.
  4. http://www.healthyvermonters.info/hs/stats/VSB2002/toc.shtml
  5. Mokdad AH. Marks JS. Stroup DF. Gerberding JL. Actual causes of death in the United States, 2000.JAMA. 291(10):1238-45, 2004 Mar 10.
  6. http://cdi.hmc.psu.edu/preface.html
  7. http://cancercontrolplanet.cancer.gov/
  8. http://www.cdc.gov/

Back To Top

Hepatitis C: Epidemiology and Recommendations for Testing

Epidemiology

The hepatitis C virus is a leading cause of chronic liver disease and the leading cause of death from liver disease. With a prevalence rate of 1.8 percent in the general population, more than 3.9 million Americans, including some 11,100 Vermonters, are estimated to be infected.

The prevalence of infection among persons with different risk factors is shown in Table 1. The highest prevalence is found among those with large or repeated direct percutaneous exposures to blood, such as intravenous drug users. Intravenous drug use is now the primary mode of transmission in the U.S. A recent study indicates that the prevalence of illicit drug use in Vermont is higher than the national average. The percentage of Vermonters reporting past month use of any illicit drug is 11.04 compared to a national average of 8.3 percent. The past month usage of any illicit drug other than marijuana is 7.38 percent among 12 17 year olds and 10.39 percent among 18 25 year olds, higher than the national averages of 5.74 percent and 7.93 percent respectively.1This points to the importance of screening, testing and counseling patients with remote or recent intravenous drug use.

Hepatitis C infection is a reportable condition in Vermont. Laboratories submit positive test results to the Vermont Department of Health. The department then requests that physicians provide clinical, diagnostic, demographic and risk-factor information. We appreciated your cooperation in helping the Department of Health monitor the incidence of hepatitis C infection.

TESTING RECOMMENDATIONS

Persons who have injected illicit drugs in the recent or remote past, including those who injected only once and do not consider themselves to be drug users. n Persons with conditions associated with a high prevalence of hepatitis C infection including: Persons with HIV infection Persons with hemophilia who received clotting factor concentrates before 1987 Persons who were ever on hemodialysis Persons with unexplained abnormal aminotransferase levels n Prior recipients of transfusions or organ transplants including: Persons who were noti ed that they had received blood from a donor who later tested positive for hepatitis C infection Persons who received a transfusion of blood or blood products before July, 1992 Persons who received an organ transplant before July, 1992 n Children born to hepatitis C-infected mothers n Healthcare, emergency medical and public safety workers after a needle stick injury or mucosal exposure to hepatitis C-positive blood and Current sexual partners of hepatitis C-infected persons

Table 1: Estimated average prevalence of hepatitis C virus infections by various characteristics and estimated prevalence of persons characteristics in the population.
HCV Infection Prevalence Range (%) Prevalence of persons with characteristic, %
Persons with hemophilia treated with products made before 87 (74-90) <0.01
Injecting -drug users: 79 (72-86) 0.5
history of prior No Data 5.0
Persons with abonormal alanine aminotransferase 15 (10-18) 5.0
Chronic hemodialysis 10 (0-64) 0.1
Persons with >50 sex partners 9 (6-16) 4.0
Persons with 10–49 sex partners 3 (3-4) 22.0
Persons with 2–9 sex partners 2 (1-2) 52.0
Persons reporting a history of sexually transmitted 6 (1-10) 17.0
Persons receiving blood transfusions before 6 (5-9) 6.0
Infants born to infected 5 (0-25) 0.1
Men who have sex with 4 (2-18) 5.0
General 1.8 (1.5-2.3) N
Health-care workers 1.0 (1-2) 9.0
Pregnant 1 1.5
Military 0.3 (0.2-0.4) 0.5
Volunteer blood 0.16 5.0

References

  1. State Estimates of Substance Abuse from the 2002 National Survey on Drug Use and Health, SAMHSA, pp. 83,91.
  2. Text adapted from CDC Physician Education Materials and Doris Strader, et.al., “Diagnosis Management and Treatment of Hepatitis C” AASLD Practice Guidelines, p.2.

Back To Top

Vermont Selected Reportable Diseases: January–November 20, 2004

reportable diseases jan–nov. 2004. for more info contact the dept of health

reportable diseases jan–nov. 2004. for more info contact the dept of health

Back To Top

West Nile Virus Update

As of late November, a total of 2,344 human cases of West Nile virus (WNV) from 41 states have been reported during 2004. The majority of cases occurred in California, Colorado, and Arizona. West Nile virus activity has been lower in the New England states this season compared with previous seasons, with only 56 positive dead birds, 60 positive mosquito pools, and one human case reported. In Ver-mont, nine birds from Chittenden, Franklin, Rutland, Windham and Windsor counties tested positive for West Nile virus. Seven mosquito pools, all from Chittenden county, tested positive. There were no human or equine West Nile virus cases reported in Vermont in 2004.

The reduction in WNV activity in New England may be partly an artifact due to surveillance, such as changes in states’ surveillance practices or reduced public interest in reporting dead birds. However, the relatively cool, wet weather in New England this summer may have caused a true reduction in seasonal WNV activity. In Vermont, Culex mosquitoes are the most important vectors in the WNV transmission cycle. Female Culex mosquitoes prefer organically polluted stagnant water for oviposition. Frequent rains this summer flushed out catch basins, rain gutters, and other areas reducing the number of Culex breeding sites. Cooler weather slows the development of mosquito larvae into adults, and larger rainfall amounts support an abundance of natural mosquito predators. In contrast, higher temperatures and drier weather support the WNV transmission cycle when birds congregate around available water sources, providing mosquitoes with ready access to large numbers of hosts that serve as reservoirs for the virus in nature.

Back To Top

Rabies Control Update

Rabies is a fatal viral disease, found mainly in wildlife (especially raccoons, foxes, bats, skunks and woodchucks) but can infect domestic animals and humans. Hundreds of cases of animal rabies (both domestic and wild, including bats) have been reported throughout Vermont in recent years and the outbreak will continue to be a problem for a long time. Raccoon rabies entered southern Vermont in 1994. Bats are an important part of our ecosystem but should be appreciated at a distance. Bats are increasingly implicated in human rabies cases. A bat found in a room with a sleeping individual or an unattended child or a bat that has made physical contact with an individual should be tested for rabies.

Prevention Efforts Working

Due to prevention efforts, including rabies education, pre- and post-exposure prophylaxis and animal vaccination and control, human rabies cases in the United States have been significantly reduced. However, since 1990, 40 cases of human rabies have been reported to the CDC; 31 were acquired in the U.S. Of these 31 cases, two were infected with the canine strain in south Texas (1991 and 1994), one with the raccoon strain in Virginia (2003) and 28 with bat strains.

Transmission

Rabies is mainly transmitted by a bite. Rare non-bite exposures can occur if wet infectious saliva or nervous tissue contacts a fresh open wound or the eyes, nose or mouth. Rabid animals can appear to be normal or can be aggressive or lethargic. Rabies virus is very fragile in the environment and is not found in blood, urine, feces or skunk spray. When saliva is dry the virus is quickly inactivated.

In the event of potential human rabies exposure:

The Vermont Rabies Hotline/USDA, Wildlife Services, 1-800-4-RABIES or (802)223-8690, also provides excellent rabies and wildlife information.

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
Paul E. Jarris, MD, MPH
Commissioner

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

Curt Lohff, MD, MPH
State Epidemiologist
Managing Editor

Report Disease: Vermont Toll-Free 1-800-640-4374 or 1-802-863-7240

Back To Top