Publication of the Division of Public Health Services September/October 2004, Vol. 18, No. 5 Steal This Issue & Seize The Insert By Bob England, M.D., M.P.H. We have a special “pin-up” edition of the Prevention Bulletin for you this time. Enclosed is the new list of reportable diseases, in a simple table format showing reporting deadlines. Post it or keep it handy so you can find it for later reference. Why should you care? You’re insanely busy caring for your patients and keeping up with all your paperwork. After all, isn’t this a bureaucratic exercise? No way! We really do use these reports to help people. Often, the very patients you’ve reported actually benefit, through offers of information or services that may follow. Persons you’ve never heard of are protected, as they are found to be contacts to disease and are offered prophylaxis or other preventive measures. Overall, lots of people are protected because they are never exposed, as we keep outbreaks or even endemic diseases from spreading further than necessary. Even though these people may never appear in your office or we may never even know who they are, they are real. A summary of important changes to the reporting rules is shown below. We didn’t just pile on more requirements; we also took many things out. For example, we removed many requirements that providers educate their patients about particular diseases they’ve diagnosed – it’s still as important as it ever was, but we figured you didn’t need a government rule to tell you to practice your profession. Some additions actually give you more flexibility – adding “emerging or exotic disease” allows you to report suspect cases of new diseases we haven’t even yet contemplated, or to call your local health department when you just aren’t sure. Our rules deal with more than just reporting. One change in the tuberculosis rules relates to discharge planning for TB cases (see article on TB rules). This is to prevent recurrences of past events when a still-infectious patient was sent home to expose a highly susceptible household member, such as a newborn. The bottom line: now more than ever, think about the public health implications of the patient in front of you, and CALL YOUR LOCAL HEALTH DEPARTMENT! Do you need a reason to report besides the fact that you’re required to by law? How about a couple of recent examples, one good, one not… Local health departments frequently respond to reports of vaccine preventable disease by vaccinating or prophylaxing potentially exposed persons around the initial case. One physician’s recent failure to report pertussis resulted in numerous new cases before local health authorities were able to intervene in the first wave of transmission. Because of the extent of initial spread, the local health department had to resort to intensive, communitywide intervention. Eventually, nearly 500 confirmed or probable cases resulted. Sometimes clusters of disease are preventable even when there is a certain amount of uncontrollable background transmission. Routine reporting of salmonella cases and our laboratory comparison of isolates recently allowed us to identify a cluster of cases of a single strain in a school. The resulting investigation identified a single asymptomatic cafeteria worker as the likely source. Removal of this person from foodhandling ended the outbreak, no doubt preventing an unknown number of further cases. There are many such examples. After all, almost everything public health does to control diseases begins with your diagnosis – and your report. Visit the ADHS Web site at www.hs.state.az.us How to deal with the upcoming flu season Page 2 September/October 2004 State Lab seeking nominations Page 2 Communicable Disease Summary Page 3 New TB Reporting Focuses on Intervention Page 4 Prevention Bulletin 1 How to deal with the upcoming State Laboratory flu season: Shoot yourself... Seeking By Bob England, M.D., M.P.H. ...with flu vaccine, that is. Two take home points for this coming flu season: 1) the demand for flu shots may remain high due to expanded recommendations and continued public awareness of deaths in children, whether or not there are more of those deaths than usual; and 2) we in the health care community do a lousy job of vaccinating ourselves, which results in harming and even killing some of those patients we work so hard to help. Much of the public concern during last year’s flu season seemed fueled by media reports of child deaths. As tragic as deaths in children are, it is not clear that more children died last year than is often the case. Nevertheless, this level of concern will not soon go away, as national reporting and updating of flu-related deaths in children will begin this year. So plan to vaccinate your high-risk patients, including children, early this year. Don’t forget to include other patients at high risk for complications, including persons aged >50 years; residents of chronic-care facilities; adults and children who have chronic disorders of the pulmonary or cardiovascular systems, including asthma; adults and children who have chronic metabolic diseases (including diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression; children and adolescents (aged 6 months–18 years) who are receiving long-term aspirin therapy and, therefore, might be at risk for experiencing Reye syndrome after influenza infection; women who will be pregnant during the influenza season; as well as children aged 6–23 months. Don’t forget that children less than 9 years of age who have not been previously vac2 Prevention Bulletin cinated must receive two doses at least one month apart, so you have to plan ahead to get them protected before the flu season hits. That means get them their first shot in October and be sure to get them back a month later. Also include those who are in frequent contact and might spread the flu to any of the above, including yourself! While we’ve had mixed success with getting higher-risk patients immunized, we’ve done miserably in vaccinating household contacts and healthcare workers. Every healthcare worker who works with high-risk patients can be a vector of disease to these patients. You shed flu virus for a day before having symptoms, so you may unwittingly expose others. You cannot rely on your patients’ own vaccine – while flu vaccine is typically 70-90% protective in healthy adults, it plummets to 3040% protection against disease for the frail elderly (although it is still 80% protective against death). So vaccinating people around those most susceptible is at least as important as vaccinating high-risk individuals themselves. We did a survey this past year among a sample of acute care hospitals in Arizona. On average, only 14% of healthcare workers in hospitals were vaccinated! Come this fall, remember last year’s level of concern. Help us get high-risk persons vaccinated, including their household contacts. And if you are a healthcare worker, get yourself vaccinated. Let’s start making a real dent in flu deaths. Dr. Bob England is the State Epidemiologist and can be reached at benglan@hs.state.az.us or 602.364.3582 Nominations By Steve Baker The Arizona Department of Health Services (ADHS) is soliciting applications for appointment to the Advisory Committee on Clinical Laboratories (ACCL). The ACCL was created by Laws 2004, Chapter 49, and is required to advise ADHS in developing a list of direct access tests—tests that may be obtained without a physician referral—and on the use and renewal of standing orders. ADHS is required to adopt rules based on the ACCL’s recommendations. ADHS is seeking: • 4 Physicians (M.D. or D.O.) licensed in Arizona and actively engaged in the practice of medicine • 2 Physicians (M.D. or D.O.) licensed in Arizona and employed as pathologists by clinical laboratories To submit an application, send the following information about the nominee, using one of the methods provided below, by November 1, 2004: • Name, mailing address, and telephone number • Fax number and e-mail address, if any • Arizona M.D. or D.O. license number • Employer name, mailing address, and telephone number, if applicable • Area of specialization • Whether employed as a pathologist by a clinical laboratory By mail: Arizona Department of Health Services, Office of Laboratory Licensure, Certification, and Training 250 N. 17th Ave. Phoenix, AZ 85007 Attn: Steve Baker By e-mail: sbaker@hs.state.az.us By fax: (602) 364-0759 Steve Baker is the Office Chief for Laboratory Licensure and Training at the State Laboratory and can be reached at 602.364.0735 or sbaker@hs.state.az.us. September/October 2004 SUMMARY OF SELECTED REPORTABLE DISEASES Year to Date (January - July, 2004)1, 2 Jan - July 2004 Jan - July 2003 5 Year Median Jan - July 0 (0) 0 0 81 (49) 0 (0) 9 (6) 1 0 83 (51) 0 (0) 4 (2) 0 1 41 (27) 0 (0) 493 11 5 415 235 520 20 5 372 272 342 20 8 357 229 171 162 N/A 2 N/A 168 166 646 6 5,501 (2,246) 247 113 655 9 4,133 (2,243) 445 159 36 9 502 143 21 24 565 142 20 22 9,680 2,034 96 (28) 8,469 2,263 120 (16) 8,469 2,330 112 (15) 9 (2) 840 2 (0) 591 7 (0) 591 1 0 46 0 0 41 1 0 51 2,057 116 292 241 1,357 87 288 258 1,226 112 287 258 VACCINE PREVENTABLE DISEASES: Haemophilus influenzae, serotype b invasive disease (<5 years of age) Measles Mumps Pertussis (<12 years of age) Rubella (Congenital Rubella Syndrome) FOODBORNE DISEASES: Campylobacteriosis E.coli O157:H7 Listeriosis Salmonellosis Shigellosis VIRAL HEPATITIDES: Hepatitis A Hepatitis B: acute Hepatitis B: non-acute3 Hepatitis C: acute Hepatitis C: non-acute3 (confirmed to date) INVASIVE DISEASES: Streptococcus pneumoniae Streptococcus Group A Streptococcus Group B in infants <30 days of age Meningococcal Infection SEXUALLY TRANSMITTED DISEASES: Chlamydia Gonorrhea P/S Syphilis (Congenital Syphilis) DRUG-RESISTANT BACTERIA: TB isolates resistant to at least INH (resistant to at least INH & Rifampin) Vancomycin resistant Enterococci isolates VECTOR-BORNE & ZOONOTIC DISEASES: Hantavirus Pulmonary Syndrome Plague Animals with Rabies4 ALSO OF INTEREST IN ARIZONA: Coccidioidomycosis Tuberculosis HIV AIDS 1 2 3 4 Data are provisional and reflect case reports during this period. These counts reflect the year reported or tested and not the date infected. Case counts for non-acute Hepatitis B and C are not available before 1998. Based on animals submitted for rabies testing. September/October 2004 Prevention Bulletin 3 ❍ Change of Address/Name ❍ Delete my name from your mailing list ❍ I received more than one copy Arizona Department of Health Services Public Information Office 150 North 18th Avenue Phoenix, AZ 85007 Please include your mailing label with all requests for changes. Fax changes to 602.364.3860 or call 602.364.3266 PRSRT STD US Postage PAID Phoenix, AZ Permit No. 957 Janet Napolitano, Governor Catherine R. Eden, Ph.D., Director ADHS Rose Conner, Assistant Director, Public Health Services Editorial Board Bob England, M.D., M.P.H., State Epidemiologist Victorio Vaz, D.V.M., Ph.D. Tim Flood, M.D. Kathy Fredrickson, M.P.H. Will Humble, M.P.H. Karen Lewis, M.D. Cheryl McRill, M.D. Wesley Press, M.S. Lisa Shumaker, M.A. Managing Editor: Will Humble e-mail: whumble@hs.state.az.us Contributors: Steve Baker, Bob England, Cheryl McRill This publication is supported by the Preventive Health and Health Services Block Grant from the Centers for Disease Control and Prevention (CDC). Its contents do not necessarily represent the views of the CDC. If you need this publication in alternative format, please contact the ADHS Public Information Office at 602.364.1201 or 1.800.367.8939 (State TDD/TTY Relay). New TB Reporting Focuses on Intervention The new communicable disease rules that will take effect October 2, 2004, have several new requirements relating to tuberculosis (TB), all with the important goal of interrupting disease transmission in the community by making sure that cases and suspects come to public health attention as soon as possible and receive appropriate treatment until cured. Health care providers and health care facility administrators are still required to report a TB case, a TB suspect, or TB infection in a child under six years of age to the local health department within one working day of detection. [R9-6-202] Health care providers who treat patients for tuberculosis will be expected to follow the guidelines jointly published by the American Thoracic Society, the Centers for Disease Control and Prevention (CDC), and the Infectious Diseases Society of America or provide, upon request, an explanation for deviation from the guidelines to the local or state health department. These guide4 Prevention Bulletin lines are available for free at the following website: http://www.cdc.gov/ mmwr/PDF/rr/rr5211.pdf [R9-6-604] Clinical laboratories are now required to submit an isolate of cultures positive for M. tuberculosis to the Arizona State Laboratory (ASL). The reporting requirement is unchanged. [R9-6-204] Health care institutions are required to notify the local health department at least one working day before discharging a TB case or suspect in addition to reporting when identified. Discharge notification helps local health departments make sure that patients are going to an appropriate home environment and that follow-up treatment plans are in place. Isolation requirements for TB patients within health care institutions now allow release from isolation when three sputum smears negative for acidfast bacillus are collected eight hours apart, rather than on three separate days, as long as one specimen was collected first thing in the morning. [R9-6-373] By Cheryl McRill, M.D., M.P.H. Correctional facilities are now required to screen inmates for TB. There were no previous requirements. All inmates must be asked about symptoms suggestive of tuberculosis at the time of booking and measures must be taken to isolate and evaluate those with symptoms. Inmates who will be incarcerated for 14 days or longer will need to have a test for tuberculosis and, if positive, a chest xray and medical evaluation. Like health care facilities, correctional facilities must notify the local health department at least one working day before a TB case or suspect is released. [R9-6-601, 602, 603] By following the rules, you become a partner with public health in the effort to eliminate TB in the U.S. If you have any questions about the new rules, please call the Arizona Department of Health Services TB Program at 602-364-4750. Dr. McRill is the Arizona Department of Health Services’ Chief Medical Officer and the State TB Control Officer. She can be reached at cmcrill@hs.state.az.us or 602.364.4250. September/October 2004