2012 Arizona Public Health Update MARCH this issue Pertussis & Health Care Workers P.1 Changes in Emergency Care P.3 Save the Date! Registration is now open for the 2012 Arizona Infectious Disease Training & Exercise that takes place July 31st—August 2nd at Arizona State University’s Memorial Union. This 3-day infectious disease training and exercise introduces participants to a variety of topics in infectious disease including: vaccine preventable diseases; nosocomial infections; tu be rc ul os i s a nd s e x u a l l y transmitted diseases; vectorborne and zoonotic diseases; fo od -b o rn e dise ases ; an d information on outbreaks and investigations. Participants will obtain the most current infectious disease information and have the opportunity to network with a variety of partners including state and local health agencies, infection preventionists, public and community health nurses, health educators, epidemiologists, sanitarians, correctional facility representatives, animal control agencies, preparedness coordinators, laboratorians, border health counterparts, and university faculty and students. Sessions shall be led by experts in the field of infectious disease with emphasis on current trends. Participants are encouraged to forge connections with partners and exchange information and knowledge of current infectious disease topics. Visit the website to register now or explore the latest information. Please periodically check the event site to get the most up-todate information regarding agenda, speakers, continuing education, etc. azdhs.gov/phs/oids/ training/2012training.htm Pertussis and Health Care Workers Seema Yasmin, MD, EISO Compared with prior years in Arizona, the missed as a sign of pertussis among number of reported pertussis cases infants. during prevention 2011 has increased. During Consequently, isolation and were not measures January 1 – November 30, 2011, a total implemented. of 672 probable and confirmed pertussis The index patient for the 2011 health cases were reported, an increase of 23%, care facility outbreak was an infant aged compared with the same period during 11 weeks (born at 28 weeks’ gestation) 1 2010. An awareness of increasing rates who experienced apnea on July 28 and of pertussis in the community might help cough curb future outbreaks. hospitalization. After the apneic episodes, A pertussis outbreak during 2011 at an she was tested for gastro-esophageal Arizona health care facility resulted in 16 reflux confirmed considered illnesses; 5 were among on Aug ust disease; 14 pertussis among the d uring was not differential infants aged ≤19 weeks, 11 were among diagnoses. The patient was tested for health care workers. A total of thirty-nine pertussis after transfer to Hospital B; health care workers required exclusion Bordetella pertussis was isolated from from work as a result of their acute cough the samples provided. During treatment illness; 40 infants and 365 health care at Hospital A, the patient had not been workers postexposure isolated during her cough illness and had prophylaxis; and 330 health care workers been located in close proximity to 2 required pertussis booster vaccinations. infants (aged 15 and 19 weeks), who also The outbreak resulted in substantial acquired pertussis; these 2 cases were financial cost to the facility, over $93,000. confirmed by positive polymerase chain Pertussis reaction (PCR) results. received diagnosis was delayed because apnea (without cough) was 1 Continued on next page Public Health Update 2012 Pertussis and Health Care Workers Confirmed & Probable Pertussis Cases-Arizona, 2006-2011 References 1 Health and Wellness for all Arizonans, Arizona Department of Health Services azdhs.gov/ phs/oids/data/current.htm. 2 Bisgard KM, Pascual FB, Ehresmann KR, et al. Infant pertussis: who was the source? Pediatr Infect Dis J. 2004;23:985–9. Source: Arizona Department of Health Services, Office of Infec ous Disease Services A heightened suspicion for pertussis can prompt early diagnosis and isolation measures. 3 Immunization of Health-Care Personnel. Recommendations Physicians should be aware that infants can initially present with apneic episodes, especially when intubated and unable to cough. Adults are responsible for 76% of pertussis transmission of the Advisory Committee on to infants.2 Therefore, health care workers who come into contact with infants too young to be Immunization Practices. vaccinated should also receive pertussis vaccination. The Advisory Committee on Morbidity and Mortality Weekly Immunization Practices recommends that all health care workers, especially those working Report. November 25, 2011 / with infants aged ≤12 months, should receive the tetanus, diphtheria, and acellular pertussis 60(RR07);1-45. (Tdap) vaccine.3 Health care workers should receive Tdap as soon as feasible if they have not previously received it and regardless of the time since their most recent Td vaccination. Health care workers with an acute cough illness should refrain from work or wear personal 4 Pertussis Diagnosis, Centers for Disease Control protective equipment and abstain from direct patient care. and Prevention. cdc.gov/pertussis/ clinical/diagnostic-testing/ diagnosis-confirmation.html. The only diagnostic tests included in the pertussis case definition are culture and PCR. Culture should be used ≤2 weeks after cough onset; PCR can be used ≤4 weeks from cough onset until 3–4 weeks after onset.4 Current blood tests for pertussis are not validated. Use of culture and PCR, vaccination and control and prevention measures, might help curb future outbreaks. Please report suspected cases of pertussis to your local health department. 2 Changes in Emergency Care in Arizona Terry Mullins & Bentley Bobrow, MD Safety the last 10 years have realized several of the Agenda’s Medical attributes and recommendations for integrating EMS with the Services – Agenda for the Future (Agenda), which describes 14 disease model of organized public health systems. With the EMS attributes toward integrating EMS into public health. The advent of systematized guidelines and databases for Trauma, Agenda’s companion document: EMS Agenda for the Future – Out-of-Hospital Cardiac Arrest (OHCA), Myocardial Infarction Implementation Guide, contained the following Vision: with ST-segment Elevation (STEMI), and Stroke, the vision and The 1996 Administration National Highway (NHTSA) Transportation published Emergency recommendations of the Agenda are becoming mainstream Emergency medical services (EMS) of the future will be components of emergency care in Arizona. A disease-based community-based health management that is fully integrated model improves the efficiency of our EMS and trauma system, with the overall health care system. It will have the ability to saves lives, and reduces the burden of disease in Arizona. identify and modify illness and injury risks, provide acute illness and injury care and follow-up, and contribute to treatment of Prehospital Data Collection, Analysis and Reporting chronic conditions and community health monitoring. This new The following three databases enable the Arizona Department entity will be developed from redistribution of existing health of Health Services to collect, analyze and report important EMS care resources and will be integrated with other health care and trauma system information. This in turn, provides Arizona’s providers and public health and public safety agencies. It will emergency medical healthcare providers with critical data for improve community health and result in more appropriate use system benchmarking and quality improvement. of acute health care resources. EMS will remain the public's emergency medical safety net. 1. The Arizona State Trauma Registry (ASTR), with more than 150,000 records, collects data from eight Level I, The Agenda contains several public health three Level III, 14 Level IV trauma centers, and two non- related trauma center hospitals; recommendations, including: Expand the role of EMS in public health. 2. The Save Hearts in Arizona Registry & Education (SHARE) Develop involvement and/or support of EMS research by Program, received just under 1200 OHCA records in 2011, those responsible for EMS structure, processes, and outcomes. and 1718 STEMI records during 2010 from EMS providers Incorporate research, quality improvement, and management learning objectives in higher level EMS education. Include principles of prevention and its role in improving community health as part of EMS education core contents. Subject EMS clinical care to ongoing evaluation to determine impact on patient outcomes. Develop information systems that are able to describe an across the state; and 3. The Arizona Prehospital Information and EMS Registry System (AZ-PIERS), launched in late 2011, collects electronic Patient Care Reports (ePCRs) from participating EMS agencies for all medical and injury incidents – with special emphasis on OHCA, STEMI, trauma, and Acute Stroke patients. entire EMS event. These databases are designed with the primary function of Evaluate EMS effects for multiple medical conditions. reporting blinded, aggregate system and treatment benchmark It’s now 2012, and while the roots of EMS are deep in history, data, providing the impetus for emergency medical healthcare Continued on next page HOW CAN YOU HELP? Encourage your local EMS providers and hospital to participate in these important initiatives by contacting: Terry Mullins, Bureau Chief (602)364-3149 terry.mullins@azdhs.gov Ben Bobrow, Medical Director3(602) 364-3154 bobrowb@azdhs.gov Reminder to R e p o r t Communicable Diseases Public Health Update 2012 Changes in Emergency Care in Arizona Evidence-Based Changes in Treatment: Recent clinical studies have identified changes to historic treatment protocols that are more effective than traditional methods. Revised protocols are being introduced to emergency care providers across the state, and their use and effect on patient Why is communicable disease reporƟng important? outcomes can be collected, analyzed and reported from the databases described above. Some examples include: Bystander Cardiopulmonary Resuscitation (CPR): Patients suffering OHCA and receiving bystander CPR have a three- to four-fold increase in survival-to-hospital discharge. Arizona Communicable disease repor ng is the cornerstone of public health surveillance and disease control. Prompt repor ng gives the local health agency me to interrupt disease transmission, locate and prophylax or treat exposed contacts, iden fy and contain outbreaks, ensure effec ve treatment and follow‐up of cases, and alert the health community. The informa on obtained through disease repor ng is used to monitor disease trends over me, iden fy high risk groups, allocate resources, develop policy, design preven on programs, and support grant applica ons. currently has the only statewide bystander CPR registry. The Cardiac Arrest Registry to Enhance Survival (CARES) is a similar database developed in cooperation with the CDC and Emory University, but CARES is implemented through individual communities agencies in various states, but none are a single “statewide” system like SHARE. Thousands of students and citizens across Arizona have been trained in Continuous Chest Compression-CPR as part of a bold public health initiative. Therapeutic Hypothermia Post Cardiac Resuscitation: Therapeutic Hypothermia (TH) is currently guideline therapy for post-arrest care after Out of Hospital Cardiac Arrest (OHCA). Arizona has begun regionalizing post-arrest care in an attempt to assure that the maximum number of OHCA victims receive standardized care in medical centers equipped to provide it. Since 2007, thirty-six hospitals have agreed to implement a hypothermia protocol for patients that are comatose following cardiac resuscitation and participate in a quality improvement program. In 2010, 67% of TH-eligible cardiac arrest patients at Cardiac Arrest Centers received the TH protocol. Traumatic Brain Injury (TBI): Approximately 25,000 TBIs are suffered annually by Arizonans. For severe TBI, the care rendered during the first few minutes may profoundly impact the effectiveness of subsequent “definitive” care. The proper management of airway, ventilation, and hemodynamics are at the core of the TBI guidelines. By implementing evidence-based changes in the way prehospital providers manage these core areas can significantly reduce the impacts of severe traumatic head injury patients. Myocardial Infarction with ST-Segment Elevation: Working with EMS providers to acquire and interpret 12-lead ECGs and provide prehospital notification to hospitals which have 24/7 cardiac catheterization capability. Reducing time to reperfusion will significantly improve the Visit this website to learn more: azdhs.gov/phs/ oids/repor ng/ index.htm outcomes for Arizonan’s suffering acute myocardial infarction. Arizona Department of Health Services Division of Public Health Services 150 N. 18th Ave., Ste. 100 Phoenix, AZ 85007 USA Tel: (602) 364-3860 azdhs.gov/phs/index.htm 4