October 2005 / Contents

• Maine Maternal Screening and Infant Vaccination Survey
• New Recommendations for Expanded Prenatal and Perinatal Human Immunodeficiency Virus Testing
• 2005 Influenza Vaccine Distribution
• Re-screening and Test of Cure for Chlamydia Infection
• Lyme Disease: 2005 Update for Maine Clinicians
• PCR Testing for Pertussis at State LaboratoryPreparing for Influenza, 2005-2006
• Selected Reportable Diseases in Maine Year-to-Date (YTD) through August 2005
• Save These Dates
• PDF VERSION OF THIS EPI-GRAM
  Use this version if you want to print
  a hardcopy of the Epi-Gram

MAINE MATERNAL SCREENING AND INFANT VACCINATION SURVEY

INTRODUCTION

Prenatal screening practices and infant vaccinations are critically important. Intrauterine or perinatally transmitted STDs can have severely debilitating effects on pregnant women, their partners, and their fetuses.

The American College of Obstetricians and Gynecologists, the Advisory Committee on Immunization Practices, the American Academy of Pediatrics, the American Academy of Family Physicians, and the Centers for Disease Control and Prevention, among others, recommend routine prenatal screening of all pregnant patients for hepatitis B, syphilis, gonorrhea, chlamydia and HIV. In addition, it is recommended that all infants born to women with hepatitis B receive a first dose of hepatitis B vaccine and hepatitis B immune globulin (HBIG) within 12 hours of birth to prevent perinatal HBV infections. For hepatitis B-negative mothers, infants should receive hepatitis B vaccine within 2 months of age, preferably at birth before hospital discharge.

During 2003 and 2004, Maine Health and Human Services, Public Health (MPH [formerly Bureau of Health]) studied 2002 birth records in 30 of 32 Maine birthing hospitals to better understand maternal screening and infant vaccination practices in the state. MPH Regional Epidemiologists visited each site and examined a random sample of birth charts. Objectives of the study were as follows:

1. Determine the current maternal screening rate for hepatitis B surface antigen (HBsAg) and STD/HIV in the state.

2. Determine the percent of infants born to HBsAg-negative mothers who receive hepatitis B vaccine prior to leaving the hospital.

3. Determine the percent of infants born to HBsAg-positive mothers who received hepatitis B immune globulin (HBIG) and hepatitis B vaccine within 12 hours of birth.

4. Determine if there is any correlation between birth weight, birth order, or mother’s demographic characteristics and either the mother’s prenatal screening or infant vaccination.

5. Gather data that will assist in identifying strategies for improvement of prenatal screening, as well as administration of birth dose hepatitis B vaccination and immune globulin.

METHODS

To obtain data about maternal screening and infant vaccination, medical records were selected and data abstracted from each chart. Records were pulled based upon a stratified sampling method which assured accuracy through calculating sample size at a 95% confidence interval and then slightly over-sampling. The sampling pool included all women who had a live birth during 2002.

To ensure confidentiality, no mother or infant names, addresses or other identifiable information, other than medical record numbers, were collected. The only exception to this were those records containing evidence of a positive HBsAg, STD, or HIV screening, which are reportable by Maine law to MPH.

Data obtained from the maternal medical record included the following: race and ethnicity, age, gravity and parity status, number of prenatal care visits, education, type of health insurance, HBsAg test date and status, gonorrhea test date and result, chlamydia test date and result, syphilis test date and result and HIV test date. Testing data was noted if it occurred within approximately nine months before birth.

Data obtained from the infant medical record included the following: delivery date, mothers HBsAg status, birth weight, gestational age, hepatitis B vaccination date, and HBIG administration.

It is important to note that this study obtained data exclusively from birthing hospitals. Prenatal screening activity that occurred at outpatient sites was not reflected in study data unless it was recorded in the hospital medical record.

RESULTS

The study was performed at 30 of 32 birthing hospitals. Table 1 (next column) summarizes chart audit results concerning screening and vaccination for 2,112 patients at the 27 hospital sites. Results show that 87% of pregnant patients were tested for hepatitis B, 82% for syphilis, 62% for gonorrhea, 62% for chlamydia, and 34% for HIV. In addition, 62% of infants received hepatitis B vaccination before leaving the hospital.

Thirty-four percent of mothers received all five of the above prenatal screening tests and 27% received four of five. Thirteen percent of birth facility medical records showed no indication of any prenatal HIV or STD screening.

Chart audits revealed four reactive maternal HBsAg tests, one positive syphilis screen, one positive gonorrhea test, and nine positive chlamydia tests. HIV results were not obtained for this study.

It is recommended that infants of HBsAg-positive mothers be given HBIG and hepatitis B vaccine within 12 hours of birth. Chart audits showed that HBIG was administered at birth to three of the four infants (75%) born to HBsAg-positive mothers. All four of these infants received hepatitis B vaccine before leaving the birthing facility.

TABLE 1 . Performance of Maternal Prenatal Screening and Infant Hepatitis B Vaccination at 30 Maine Birthing Hospitals, 2002

Maternal sociodemographic characteristics generally matched population characteristics for mothers of childbearing age. Thirty-four percent of the sample was 24 or under, and 97% was non-Hispanic White (where race was known). Sixty percent had private health insurance. Thirty-two percent of women gave birth for the first time, 34% for the second time, and 19% for the third time.

Statistical testing was performed to determine if the above characteristics were related to prenatal screening or infant vaccination (p<= 0.05). Women under 25 years old were more likely to be screened for gonorrhea, chlamydia and HIV than were women aged 25 and older. Likewise, infants of younger women were slightly more likely to have received hepatitis B vaccine before hospital discharge.

In addition, women in their first pregnancy were more likely to be screened for hepatitis B, gonorrhea, chlamydia and HIV. Because women in their first pregnancy are much more likely to be under 24 than women who have experienced multiple pregnancies, it is difficult to determine which factor, age or gravity, most influenced screening and vaccination practices.

Other factors that influenced testing include race and insurance status. Women who were non-White were much more likely to have been tested for HIV, as were those who did not have private health insurance.

DISCUSSION

Numerous professional medical organizations recommend routine prenatal HIV/STD screening for all pregnant patients. Based on the results of this study, this recommendation is not being fully implemented in Maine.

Patient records at birthing hospitals revealed that prenatal testing for hepatitis B and syphilis occurred at fairly high rates, with testing for gonorrhea, chlamydia and HIV reflected at markedly lower rates in patient charts. In particular, HIV screening appeared to occur at very low rates, with just over one-third of pregnant women screened. Based on the hospital medical record, only one-third of women received all five screening tests, with 13% receiving no HIV or STD screening.

Because this study obtained data from birthing hospitals, outpatient screening may have been underreported if results were not recorded in the hospital chart. Because HIV test results tend to be viewed as highly sensitive and confidential, HIV screening may have occurred with much greater frequency at outpatient sites, with results subsequently not recorded in the hospital birthing chart. This may help to explain the very low rates of prenatal HIV testing found by this study. Nonetheless, it is important that the results of all prenatal HIV/STD screening be present in the birth record to help insure the health of both mothers and infants.

A similar study conducted by MPH in 1999-2000 found prenatal testing rates of approximately 90% for hepatitis and syphilis, 70% for gonorrhea and chlamydia, and 26% for HIV. In comparison, the present study shows a decline in rates for all testing except HIV, which increased slightly, but is still extremely low.

In this present study, women who were younger, non-White, and those without private health insurance were tested at higher rates than other women. Prenatal screening recommendations should be followed uniformly regardless of age, race/ethnicity, or insurance/financial status.

Regarding infant hepatitis B vaccination, rates were adequate, with approximately two-thirds of infants vaccinated before leaving the hospital. The study did not determine whether infants were vaccinated against hepatitis B within two months of birth.

RECOMMENDATIONS

MPH offers the following recommendations concerning prenatal screening and infant vaccination:

• All health professionals providing prenatal care to women should review and implement national recommendations for infant vaccination and HIV, STD and hepatitis B prenatal screening. Recommendations should be implemented regardless of the mother's age, race or insurance status.

• Birthing facilities should consider vaccinating all infants for hepatitis B at birth. Some providers may choose to vaccinate within 2 months of birth for HBsAg-negative mothers.

• All birthing hospitals should insure that the results of all prenatal screening, whether performed at the hospital or off-site, be entered into the hospital birthing record.

• If hospital prenatal screening records are incomplete, birthing sites should develop standard procedures to screen women for sexually transmitted diseases, including HIV, at delivery.

• Consumer education materials about prenatal screening for sexually transmitted diseases should be made available to pregnant patients.

For additional information, please contact: Mark Griswold, Maine Public Health HIV, STD and Viral Hepatitis Program, at (207) 287-5193 or mark.griswold@maine.gov.

Contributed by Mark Griswold

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NEW RECOMMENDATIONS FOR EXPANDED PRENATAL AND PERINATAL HUMAN IMMUNODEFICIENCY VIRUS TESTING

An estimated 6,000 to 7,000 HIV-infected women give birth each year in the United States, resulting in 280 to 370 new perinatal infections. Approximately 40% of mothers whose infants are perinatally infected have no documentation of HIV status, despite recommendations that all pregnant women be tested for HIV prenatally. About 40% of women of childbearing age are unaware that treatment is available to prevent perinatal transmission.

Although the acceptability and feasibility of rapid HIV screening in labor and delivery have been demonstrated by research sponsored by the Centers for Disease Control and Prevention (CDC) (JAMA 2004; 292; 219-223), only about one-third of U.S. hospitals have rapid HIV testing available to women in labor, and less than half of those have policies or protocols to routinely offer rapid HIV testing to women with undocumented HIV status (CDC unpublished data).

CDC has promoted an expanded approach to rapid HIV screening in labor and delivery in a number of ways, including:

• Developing a national protocol to promote rapid HIV screening in labor and delivery when the mother’s HIV status is unknown;
• Funding five national organizations to help programs and providers achieve high rates of prenatal HIV testing and to promote rapid HIV testing as the standard of care for women in labor with undocumented HIV status;
• Collaborating with the American College of Obstetricians and Gynecologists (ACOG) to study obstetricians’ perinatal HIV prevention practices including opt-out testing during prenatal care and at labor and delivery;
• Collaborating with the ACOG on their updated, expanded recommendations for prenatal and perinatal HIV testing.

Studies show that an opt-out testing approach (i.e., pregnant women are told that an HIV test will be included in the standard group of prenatal tests and that they may decline the test) results in higher testing rates than an opt-in approach (i.e., pregnant women receive pre-test HIV counseling and must provide HIV test consent). However, opt-out testing has not been implemented in many prenatal settings. The Expanded Recommendations published in November 2004 (ACOG Committee Opinion, Number 304), suggest early identification and treatment of all pregnant women with human immunodeficiency virus (HIV) is the best way to prevent neonatal disease. Pregnant women universally should be tested for HIV infection with patient notification as part of the routine battery of prenatal blood tests unless they decline the test (i.e., opt-out approach). Repeat testing in the third trimester and rapid HIV testing at labor and delivery are additional strategies to further reduce the rate of perinatal HIV transmission.

The Committee on Obstetric Practice makes the following recommendations:

• As allowed by state laws and regulations, follow an opt-out prenatal HIV testing approach whenever possible. [Note: In Maine, state law currently prohibits using the opt-out approach, although changes to the law may be considered in the future. At present, it is recommended that all pregnant women receive HIV testing, and that test results be recorded in the patient’s medical record at the birthing facility.]
• Repeat offer of HIV testing in the third trimester to women in areas with high HIV prevalence, to women known to be at high risk for HIV infection, and to women who declined testing earlier in pregnancy.
• Use conventional HIV testing for women who are candidates for third-trimester testing.
• Use rapid HIV testing in labor for women with undocumented HIV status.
• If a rapid HIV test result is positive, initiate antiretroviral prophylaxis (with consent) without waiting for the results of the confirmatory test.

To learn more about the rationale for expanded HIV screening in Healthcare settings, view the upcoming CDC-sponsored satellite broadcast and webcast entitled “Revised Recommendations for HIV Screening of Adults, Adolescents and Pregnant Women in Health-Care Settings” on Thursday, November 17 from 1:00pm to 3:00pm EST. See the announcement at http://www.cdcnpin.org. Click on “Satellite Broadcasts.”

HIV test counseling training for clinicians is available through the HIV, STD and Viral Hepatitis Program. For information on upcoming trainings in your area or to find out how to sponsor training at your facility, contact Jennah Godo at 287-3916.

Contributed by Charles Dwyer

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2005 INFLUENZA VACCINE DISTRIBUTION

Each year Maine Health and Human Services, Public Health, Immunization Program works with the U.S. Centers for Disease Control and Prevention (CDC) to plan for the allocation and distribution of influenza vaccine. Using national guidance and state demographic information, including Maine’s annual birth cohort and estimated percent of population identified as at-risk for influenza-associated morbidity and mortality, Maine Public Health requests an allocation of influenza vaccine from CDC. Because national vaccine supplies rely upon manufacturer’s projected vaccine production and federal licensing regulations, the exact number of influenza vaccine doses Maine will receive is unknown, though an estimate of 130,000 doses is anticipated. As additional guidance is received, vaccine distribution plans may change.

Influenza vaccine supplied to MPH is distributed each fall to contracted health-care providers who agree to provide vaccination at a reduced patient cost to those at risk. The amount of vaccine each provider receives is determined through an estimate of past usage (based on a two-year history) and provider-projected need.

Maine Public Health anticipates supplying contracted providers with adequate supply to vaccinate 100% of the at-risk pediatric population and 100% of the at-risk adult population (using each provider’s historical vaccine uptake).

Currently, Maine Public Health plans to distribute vaccine to long-term care facilities and health care providers ordering vaccine for children aged 6-23 months first; these plans will be finalized in the coming weeks.

According to nationally projected supplies, the receipt of this vaccine is anticipated to begin in mid-September, with final shipments in late October.

For more information or to learn how to become a contracted influenza vaccine provider, please call the Maine Public Health Immunization Program at 1-800-867-4775. Information on Maine’s influenza vaccine supply and distribution will be posted and updated regularly at: www.mainepublichealth.gov.

Contributed by Tonya Philbrick and Anne Redmond

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RE-SCREENING AND TEST OF CURE FOR CHLAMYDIA INFECTION

Chlamydia trachomatis (chlamydia) is the most frequently reported sexually transmitted disease (STD) in Maine and the United States. In 2004, 2,120 chlamydia infections were reported to MPH. People 15 - 24 years old are disproportionately affected by this disease, accounting for three quarters of all Maine cases. Females are diagnosed with chlamydia more often than males and comprised 73% of reported cases in 2004. However, this does not necessarily mean the prevalence of chlamydia is higher in females than males, but that females are tested for chlamydia more frequently than men.

The 2002 STD Treatment Guidelines (http://www.cdc.gov/STD/treatment/), published by the Centers for Disease Control and Prevention (CDC), provide recommended treatment regimens, information on the management of sex partners, and other information to assist physicians and other health-care providers prevent and treat chlamydia. The CDC recommends that sexually active adolescent females be screened for chlamydia infection at least annually, even if symptoms are not present. Annual screening of sexually active females aged 20-25 is also recommended as is the screening of older females with risk factors. All females should receive an appropriate sexual risk assessment because more frequent screenings may be indicated for some individuals.

One area of specific focus in the guidelines is the distinction between chlamydia re-screening versus testing for therapeutic failure, also known as a test-of-cure. Chlamydia re-screening refers to screening a previously positive female to detect re-infection. A test-of-cure is defined as testing a female to ensure that treatment was effective. These two forms of chlamydia follow-up are distinct and are recommended under specific circumstances.

RE-SCREENING

Most post-treatment infections result from re-infection due to the patient’s sex partner(s) not being treated or because the patient continued sex among a network of persons with a high prevalence of infection. Repeat infections increase the risk of pelvic inflammatory disease and other complications when compared with initial infections; therefore, recently infected females are a high priority for re-screening. Healthcare providers should consider advising all females with chlamydia infection to be re-screened 3-4 months after treatment. Providers are encouraged to re-screen all females treated for chlamydia infection whenever they present for care within the following 12 months, regardless of whether the patient reports that her sex partners received treatment.

TEST-OF-CURE

A test-of-cure is only recommended for non-pregnant females completing treatment with doxycycline or azithromycin if symptoms persist or reinfection is suspected. Non-pregnant females treated with erythromycin may be considered for a test-of-cure 3 weeks after finishing this medication. Testing sooner than 3 weeks after completion of antibiotics can yield both false positive and false negative results. Repeat testing of pregnant females, preferably by culture, is recommended 3 weeks after completion of therapy.

The CDC STD Treatment Guidelines are being revised and should be released in the first quarter of 2006. For more information call the STD Program at (207) 287-2046.

Contributed by Geoff Beckett

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PCR TESTING FOR PERTUSSIS AT STATE LABORATORY

The Health and Environmental Testing Laboratory has recently validated and implemented a molecular method for the detection of Bordetella pertussis DNA. This test is a real-time polymerase chain reaction (PCR) detection of the sequence known as insertion element IS481. This test will replace the currently used direct fluorescent antibody (DFA) test for the detection of B. pertussis. The PCR is less specific than the DFA, but is more sensitive. All specimens will continue to be cultured as well.

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PREPARING FOR INFLUENZA, 2005-2006

Maine Health and Human Services, Public Health coordinates statewide surveillance for influenza and influenza –like illness (ILI), defined as fever greater than or equal to 100’F (37.8’C) and cough and/or sore throat, in the absence of a known cause other than influenza. Each year, in preparation for influenza season (generally October – May), Maine Public Health works with multiple health partners to implement influenza surveillance activities, plan vaccination activities, and promote good health practices to minimize morbidity and mortality associated with influenza infection. This article discusses influenza surveillance results from the 2004-05 season, influenza seasonal preparation activities including vaccination priority groups, and planned influenza surveillance activities for the 2005-06 season.

SUMMARY OF MAINE 2004-2005 INFLUENZA ACTIVITY

Maine influenza surveillance information is summarized in the Maine Weekly Influenza Surveillance Update and at the season’s end. 1 This report is available online at the Maine Public Health website (www.mainepublichealth.gov ) and via electronic message by list serve. Through influenza surveillance, the onset of influenza and influenza-like illness and trends in influenza subtype circulation are monitored to guide control measures to limit the transmission of influenza. Surveillance results also inform influenza prevention and control policy.

During the 2004-2005 season, influenza activity across the state was moderate when compared to previous seasons. Influenza activity first peaked in late December and early January, when sentinel schools reported 8.4% of students absent during week 51 (December 19-25, 2004) and Maine Sentinel Providers reported 2.6% patient-visits as ILI-related during week 3 (January 16-22, 2005). Emergency Department (ED) admissions for respiratory illness peaked during week 8 (February 20-26, 2005) when participating hospitals reported 4.5% of ED admissions as respiratory illness-related. During weeks 5 and 6 (January 30-Feburary 12, 2005), the number of culture-confirmed respiratory specimens identified as influenza peaked, with 22 and 19 specimens confirmed respectively. Deaths attributable to pneumonia and influenza peaked during week 6 (February 6-12, 2005) when 19.3% of deaths were pneumonia and influenza-related; there were also two influenza-associated pediatric deaths reported during the 2004-2005 season. There were a total of 36 influenza-like illness outbreaks in long-term care facilities, 3 nosocomial ILI outbreaks in acute care facilities, and six ILI outbreaks in schools reported in Maine during the 2004-2005 influenza season.

PREPARING FOR 2005-2006 INFLUENZA SEASON

In the United States, influenza morbidity and mortality is reduced through the use of vaccine. Yearly vaccination of persons at high risk and their contacts before the influenza season begins is the most effective method of preventing and reducing influenza complications. Health care providers can help by ensuring vaccine is administered to persons during hospitalizations or routine health-care visits, making special office or clinic visits unnecessary.

The Advisory Committee on Immunization Practices (ACIP), in collaboration with the U.S. Centers for Disease Control and Prevention (CDC), publishes national guidance on preventing and controlling influenza annually (www.cdc.gov/mmwr/preview/mmwrhtml/rr5408a1.htm).

Although it is still unknown as to whether there will be a vaccine shortage during the 2005-06 influenza season, Maine Public Health anticipates following the established national guidelines for influenza priority vaccination target groups. These priority vaccination target groups are ranked using national influenza-associated mortality and hospitalization rates. Based on projected 2005 influenza vaccine supplies, CDC recommended in the September 2, 2005 MMWR (www.cdc.gov/mmwr/preview/mmwrhtml/mm5434a4.htm) that the following priority groups receive trivalent inactivated influenza vaccine (TIV) until October 24, 2005:

• Persons aged >65 years with comorbid conditions;
• Residents of long-term care facilities; Persons aged 2-64 years with comorbid conditions;
• Persons >65 years without comorbid conditions;
• Children aged 6-23 months;
• Pregnant women;
• Healthcare personnel who provide direct patient care
• Household contacts and out-of-home caregivers of children aged <6 months.

MAINE 2005-2006 INFLUENZA SURVEILLANCE ACTIVITIES

Surveillance activities are heavily dependent on the collaboration and active participation of multiple health partners who compile and report influenza data on a weekly basis. For the 2005-06 season (October 2, 2005 – May 20, 2006) Maine Public Health plans the following activities to track influenza and influenza-like illness cross the state: 1) characterization of statewide influenza activity by the state epidemiologist; 2) monitoring of outpatient influenza-like illness among sentinel health care providers; 3) report of culture-positive influenza by reference and state laboratories; 4) investigation of influenza outbreaks in schools, long-term care and acute care facilities; 5) regional hospital surveillance for respiratory illness among patients admitted from the emergency department; 6) select city vital record offices reporting influenza and pneumonia-associated deaths; and 7) individual case reports of influenza-associated pediatric deaths.

Surveillance efforts this season will move toward year-round monitoring of influenza to facilitate increased understanding of virus circulation and to rapidly detect any novel influenza strains that might be introduced in Maine. Because human cases of avian influenza A (H5N1) continue to be identified in Asian countries, national public health partners recommend enhanced surveillance activities. Maine Public Health relies upon health-care providers consistently obtaining information on recent international travel and other potential exposures from persons who have influenza-like illness to identify possible imported cases of avian influenza A (H5N1). Enhanced avian influenza A (H5N1) surveillance guidelines can be found on the influenza web page at www.mainepublichealth.gov

As with any reportable condition or communicable disease, Maine Public Health epidemiologists are available to provide consultation and resources on health issues, including influenza. Epidemiologists can be reached 24 hours a day, 7 days a week by calling 1-800-821-5821. For more information on influenza surveillance in Maine, see the Maine Public Health influenza web page accessible at www.mainepublichealth.gov

Contributed by: Anne Redmond

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SELECTED REPORTABLE DISEASES IN MAINE YEAR-TO-DATE (YTD) THROUGH AUGUST 2005

Contributed by Andrew Pelletier

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2004 REPORTABLE INFECTIOUS DISEASES IN MAINE SUMMARY

The 2004 report of infectious diseases in Maine is now available online. This is the eleventh year the report has been published. The report provides an overview of communicable diseases in public health importance in Maine.

The summary highlights surveillance of notifiable conditions in Maine, which include:

• Sexually transmitted diseases
• Zoonotic diseases

If you would like more information about these and other notifiable conditions in Maine, please find the 2004 Reportable Infectious Diseases in Maine Summary at the Publications page of the Maine Public Health's Publications page: Publications

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