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February 2005 2004 Epidemiology Recognition Awards Selected Reportable Diseases in Maine, 2004 Influenza Surveillance – Maine, 2004-2005 State Viral Hepatitis Action Plan Released “Think Old TB” When Treating Inflammatory Conditions in the Elderly The 2003 Reportable Infectious Diseases in Maine Summary PDF
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OF THE EPI-GRAM
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The purpose of the Epi-Gram is to distribute timely and science-based information to guide Maine's healthcare professionals in issues of public health and infectious disease importance and to promote statewide infectious disease surveillance. Director, Bureau of Health,
State Health Officer: Director, Division of
Disease Control: State Epidemiologist: |
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Heartfelt thanks from the Bureau of Health to all the healthcare professionals who worked so hard in collaboration with us throughout the flu vaccine crisis and put all their patients first! Lani Graham, MD, MPH |
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2004
Epidemiology Recognition Awards The
Division of Disease Control, Maine Bureau of Health has the pleasure of
announcing the recipients of the 13th Annual Public Health
Epidemiology Recognition Awards.
The recognition awards are presented to members of the health care
community who work above and beyond the call of duty to promote public
health surveillance within their communities throughout the year.
The awards were given during the Division of Disease Control’s
Annual Infectious Disease Symposium, “Emerging Infectious Diseases in
Maine: The Public Health
Response,” held in Augusta on November 4, 2004. |
The
recipients of this year’s awards were Kelly McCarthy, RN, Healthcare for
the Homeless, Portland; Phillip Carter, MD, Healthcare For The Homeless, Portland;
Kimberly Ware, RN, ICP, Maine General Hospital, Augusta;
Alfred Cichon, PA, Medical Officer, County Jail System, and Judith
Kenney, RN, School Nurse, Cheverus
High School, Portland.
The award consists of a
certificate with the image of the “Broad Street Pump,” implicated as
the source of infection by John Snow in his classic investigation of an
1854 cholera epidemic in London. Almost one and one-half centuries later, it remains clear
that by striving to improve, promote and maintain an active disease
surveillance system, the health of Maine citizens will be better
protected. The staff of the Division of Disease Control congratulates the recipients of this year’s awards for their exemplary efforts in promoting and protecting the public health of Maine’s citizens. |
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Kelly
McCarthy RN and Phillip Carter, MD, Health Care for the Homeless; Geoff
Beckett, PA and Sally Lou Patterson, Division of Disease Control; Alfred
Cichon, PA, County Jail System; Judith Kenney, RN, School Nurse, Cheverus
High School; Kimberly Ware, RN, ICP, Maine General Hospital and Kathleen
Gensheimer, MD, MPH, Division of Disease Control
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Botulism is a rare but deadly disease. It is a paralytic illness caused by the neurotoxin produced by the bacterium C. botulinum. Paralysis first affects the cranial nerves, then the skeletal muscles; untreated intoxications can lead to dense flaccid paralysis, respiratory failure, and death. Although rare and sporadic, foodborne
botulism is a persistent cause of morbidity and mortality in the United
States. In 1997, an annual survey of state epidemiologists and directors
of state public health laboratories identified 24 cases of food borne
botulism with one associated death (CDC, unpublished data, 1998). During
1989 through 1998, a median of 23 cases (range: 17--42 cases) of foodborne botulism was reported each year with a median of one death (range:
0--2 deaths). In 2001, Maine
experienced its first documented cases, a father and son from northern
Maine, of botulism in approximately 50 years.
A pharmacist requesting botulism antitoxin made the initial
disease report. The father
initially complained of nausea, vomiting and dysphagia, and was
dehydrated and dysphonic. He developed a progressive bulbar palsy that
included ptosis, profound weakness of extraocular muscles, and
increasing difficulty with ventilation and with handling oral
secretions. The son presented with a 36-hour history of sore throat,
dysphagia, and vomiting leading to dehydration.
He required frequent suctioning and was noted to have widely
dilated pupils, absent gag reflex, and difficulty supporting his head.
Both patients received botulism antitoxin, which was flown in
from the Centers for Disease Control and Prevention (CDC) Quarantine
Station in New York. Botulinin
toxin serotype A was identified in the serum of both patients.
The father and son fully recovered after spending 1-2 months in a
rehabilitation facility. The same toxin
identified in the patients was also detected in the remnants of a meal
they consumed. The meal
included homemade canned
tomato sauce. As part of
the epidemiological investigation of this outbreak, samples of the home
canned food were taken and tested.
The sauce was prepared with home-canned tomatoes from the family
garden. The sauce also included green peppers and onions, celery,
hamburger, frozen commercial meatballs, store-bought tomato products
(juice, sauce, paste, and puree) and spices.
These added ingredients may have contributed to the proliferation
of botulism in the sauce by increasing the pH and supporting growth in a
protein rich environment. The
sauce was prepared for canning on a stovetop without a pressure canner.
Jars of the sauce were stored in the family’s basement.
The sauce used in the suspect meal was warmed in a microwave with
hot dogs and rice and consumed approximately 36 hours before the
earliest onset of symptoms.
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More recently in 2004, a highly suspect case of botulism in a woman from southern Maine was investigated. The woman became ill with diarrhea and neurological signs consistent with botulism. Home canned foods were in her food history. Testing for this case is continuing at the CDC. The importance of safe food preservation was highlighted in an editorial from the CDC’s September 1, 2000 Morbidity and Mortality Weekly Report, pages, 778-780:
Clearly,
better understanding and promotion of proper home canning practices and
other food preservation methods are critical to prevent this serious
disease entity. When
foodborne botulism is suspected, investigations should include
questioning about the preparation and consumption of foods preserved by
any home preservation method, such as canning, pickling, curing, and
fermenting. Persons seeking advice on home-food preservation should
consult their local county or university cooperative extension service,
or contact the U.S. Department of Agriculture Food Safety Hotline, (800)
535-4555. The Maine Bureau of Health provides epidemiological consultation for suspected botulism cases and works with the CDC, which conducts laboratory testing and authorizes release of botulism antitoxin. To report a case of suspect botulism, please contact the Maine Bureau of Health at 1-800-821-5821. This telephone number is staffed 24/7. For detailed information on botulism see the CDC website: http://www.cdc.gov/health/botulism.htm. Contributed
by: Jennifer Gunderman-King |
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Selected
Reportable Diseases in Maine, 2004
A number of infectious diseases of public health importance are reportable by law in Maine by health care providers, laboratories, and health care facilities. To monitor trends, the Division of Disease Control publishes a monthly graph of reportable diseases in Maine. The graph displays the Year To Date (YTD) totals for the current year against the median YTD totals for the previous five-year period. By comparing the current year with the previous five years, we can determine if the incidence of a disease differs from the historical baseline. Diseases of high incidence are displayed in the horizontal bar chart; diseases of low incidence are displayed in the table. Chlamydia is the most commonly reported disease in Maine. |
The
numbers for chlamydia in the bar chart should be multiplied by a factor of
10.
For example, the number of cases of chlamydia in 2004 displayed in
the bar chart is 211.9.
The true number of cases is 211.9 x 10 = 2,119.
Due to space limitations, not all notifiable conditions are
displayed on the graph.
The complete list of notifiable conditions is available at: http://www.maine.gov/dhhs/boh/ddc/ DiseaseReporting.htm Data presented in the graph should be considered preliminary as the numbers may be revised as additional reports are received with onset dates in 2004. Monthly graph of reportable diseases Contributed
by: Andrew Pelletier
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Influenza
Surveillance -- Maine, 2004-2005
Introduction
The
Maine Department of Health and Human Services (DHHS), Bureau of Health
routinely conducts surveillance for influenza.
Surveillance efforts are enhanced during the winter months, when
an increase in influenza activity is typically observed nationwide.
This article presents a brief overview of the 2004-2005 influenza
season surveillance activities and a comparison of influenza and
influenza-like illness trends by reporting source.
Influenza surveillance information is updated weekly and is
available at the Maine Bureau of Health website, www.mainepublichealth.gov. Influenza
is a viral illness that typically occurs during the winter months.
Characterized by the abrupt onset of constitutional and
respiratory signs and symptoms, including but not limited to fever,
muscle aches, headache, severe malaise, non-productive cough, sore
throat, and runny nose, influenza is spread from person to person
primarily through the coughing and sneezing of infected persons.
A diagnosis of influenza can be confirmed with several diagnostic
laboratory tests. The term influenza-like illness (ILI) is used to describe a clinical syndrome with the typical signs and symptoms of influenza without diagnostic test information. For disease surveillance purposes, ILI is 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. Monitoring the frequency at which Maine residents present for medical care due to ILI may help in estimating levels and trends in influenza activity. Methods
Influenza data are collected through six reporting sources. Mild to moderate disease is tracked by outpatient visits for influenza-like illness, and severe disease is monitored through inpatient hospital admissions for respiratory illness. Influenza-related mortality is assessed through influenza and pneumonia death certificate reports by city vital records offices and through reports of influenza-related pediatric deaths reported by health professionals and the state medical examiner. Influenza-positive culture results, including subtype information, are reported by participating laboratories, and provide some indication of the burden of community laboratory-confirmed infection. Finally, rates of school absenteeism provide complementary information on the intensity of outbreaks of influenza in the community. Each of these reporting sources, and the analysis performed on the data received, is described in the following sections; figure 1 depicts the geographical dispersion of many reporting sources. Outpatient
influenza-like illness (ILI)
Outpatient ILI data are collected through the U.S. Influenza Sentinel Provider Surveillance Network, a collaborative effort between the Centers for Disease Control and Prevention (CDC), Maine DHHS Bureau of Health, and local health care providers. During the 2004-2005 season, 20 Maine physicians are enrolled in the U.S. Influenza Sentinel Provider Surveillance Network and have agreed to report the total numbers of patients seen in their practices and the numbers of those patients with influenza-like illness by age group on a weekly basis. From these data, the percent of patient visits for ILI is calculated. School
Absenteeism
The Bureau of Health, in collaboration with the Maine Department of Education and local schools districts, collects school absenteeism data. During the 2004-2005 season, approximately 40 schools representing 12 school districts will participate by reporting the total numbers of students enrolled at each school and the numbers of those students who were absent from school each day on a weekly basis. From these data, the percent of students absent at participating sentinel schools is calculated. Additionally, all schools in Maine are asked to report student absenteeism that exceeds 15% of their student population. Hospital
inpatients
Surveillance for respiratory illness admissions has been established in a collaboration of the Bureau of Health and three regional hospitals. Respiratory illness is defined broadly based on each hospital’s data collection system, and includes influenza-like illness and other conditions that may present like influenza. During the 2004-2005 season, three regional hospitals are enrolled, and on a weekly basis, report the total numbers of hospital admissions from the emergency department and the proportion of those admissions that are attributable to respiratory illness. Laboratory
Reporting
The Maine Health and Environmental Testing Laboratory (HETL) works collaboratively with hospitals and private laboratories around the state to collect specimens for respiratory virus culturing and subtyping. Each week, HETL reports the total number of specimens received for respiratory virus culturing and the number of isolates positive by subtype. These data are used to calculate the percent of specimens received that are positive for influenza, and the proportion of influenza positives for each subtype. |
Death
Certificates
The vital statistics offices of three Maine cities report the total numbers of death certificates filed and the numbers of death certificates in which pneumonia or influenza are mentioned as the primary or secondary cause of death. These data are used to calculate the percentage of deaths attributable to influenza and pneumonia. A death reported to a vital records office in a specific city is indicative of the place of death and not the actual residence of the deceased. Pediatric
Fatalities
Maine Health professionals are asked to report all deaths in persons under age 18 that may be related to influenza or complications of influenza. The Office of the Medical Examiner also reports such cases. The Bureau of Health reports pediatric influenza fatalities to the CDC. Influenza
Activity Code
The Maine Bureau of Health reports the estimated level of influenza activity each week to the CDC. Influenza activity is reported as no activity, sporadic, local, regional, or widespread. These levels are defined as follows: (1) No activity: No laboratory-confirmed cases of influenza and no reported increase in the number of cases of ILI; (2) Sporadic: Small numbers of laboratory-confirmed influenza cases or a single influenza outbreak has been reported, but there is no increase in cases of ILI; (3) Local: Outbreaks of influenza or increases in ILI cases and recent laboratory-confirmed influenza in a single region of the state; (4) Regional: Outbreaks of influenza or increases in ILI and recent laboratory confirmed influenza in at least 2 but less than half the regions of the state; and (5) Widespread: Outbreaks of influenza or increases in ILI cases and recent laboratory-confirmed influenza in at least half the regions of the state. Data
for the 2004-2005 Influenza Season
During October 3, 2004 to November 27, 2004, no influenza activity was reported in Maine. On November 28, an outbreak of ILI was reported at a long-term care facility, and on November 30th the first culture-confirmed influenza cases of the season were reported. In mid-December, influenza activity increased from “sporadic” to “local,” due to reports of small increases in ILI at sentinel medical offices and of an ILI outbreak at a second long term care facility. Since late December, influenza activity in Maine has been “regional,” due to significant increases in reported outpatient visits for influenza-like illness and outbreaks of influenza-like illness in long-term care facilities. Additionally, an influenza-associated pediatric death was reported during the week of December 26, 2004 in an otherwise-healthy adolescent from Sagadahoc County. During October 3, 2004 to January 18, 2004, a total of 46 (39.0%) of 118 viral cultures have been confirmed as influenza by the Health and Environmental Testing Laboratory; 43 (93.5%) of these were subtyped and characterized as influenza A (H3), and 3 (6.5%) of these were subtyped and characterized as influenza B (Shanghai/361/2002). Figure 2 summarizes levels and trends of four of the major indicators used to track influenza in Maine as of January 22, 2005. Discussion
The 2004-2005 influenza surveillance system is providing a greater range of detail for influenza-related activity in Maine than in previous seasons. Several surveillance activities are new this year, including those assessing inpatient hospital admissions for respiratory illness and pneumonia- and influenza-attributable deaths. Many state
and local professionals and agencies are collaborating on influenza
surveillance activities, including physician practices, the Maine
Department of Education and locally participating school districts and
schools, regional hospitals, the Maine Health and Environmental Testing
Laboratory and two commercial reference laboratories, three city vital
record offices, and the Department of the Attorney General, Office of the
Medical Examiner. The information presented here, and the disease control
efforts that stem from these surveillance data, is a result of their
consistent reporting. The purpose
of influenza surveillance is to provide information that may be useful to
health professionals and to public health specialists in disease
prevention, management, and control. As this year’s influenza season
progresses, we will be evaluating the utility of the surveillance system.
We welcome the comments and suggestions of readers; please contact Anne
Redmond, influenza surveillance coordinator, for more information at
1-800-821-5821. Contributed by: Anne Redmond |
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Percentage of students absent, physician visits for influenza-like illness (ILI), hospital emergency department (ED) admissions for respiratory illness, and deaths from pneumonia and influenza – Maine, 2004-2005*
*As of January 15, 2005 |
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Viral Hepatitis Action Plan Released Regional Meetings Scheduled Although thousands of Maine people are affected by viral hepatitis, many are unaware that they are infected or at risk. With the potential for outcomes such as cirrhosis, liver cancer, or death, earlier rather than later intervention is essential. The Maine Department of Health and Human
Services, Bureau of Health recently released a 3-year plan for
confronting this emerging health issue. The publication, entitled, “Viral
Hepatitis Prevention and Control: An Action Plan for Maine,” was
created after receiving input from a statewide group of 70 experts and
patient advocates. The Plan can be found online at: http://www.maine.gov/dhhs/boh/pubs.htm
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The
Plan includes goals, objectives, and action steps describing how to
prevent new hepatitis infections as well as how to help persons who are
already infected. It is a document that encourages all partners to
actively work, support and advocate for viral hepatitis services in
Maine. With no official funding allocated for implementation, building
on the existing infrastructure and creating new collaborations will be
essential to the success of the strategies outlined in the Plan.
Between March and June 2005, three half-day regional planning meetings will be held to discuss how local communities can begin implementation. Successes in each community will be highlighted. Meetings will be held in:
For more information about the regional meetings, contact Adcare Educational Institute of Maine at 207-626-3615 or email: adcare@neias.org. Contributed by: Mary Kate Appicelli |
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“Think
Old TB” When Treating Inflammatory Conditions in the Elderly Traditionally,
one of Maine’s high risk population for tuberculosis has been the elderly.
In 2005, 35% of tuberculosis cases reported in Maine occurred among
individuals over 65 years of age. U.S. Census data shows that Maine’s
elderly population is growing at a faster rate than the national average. As
the population ages, and the burden of chronic disease increases, medical
providers need to “Think Old TB” (past exposure to
tuberculosis or presence of latent tuberculosis infection) when evaluating
their patients who present with chronic illness or inflammatory conditions
such as rheumatoid arthritis, psoriasis or Crohn’s disease. Before
beginning immunosuppressive therapy for chronic or inflammatory conditions,
physicians should have a heightened awareness of the
relationship between such treatment and
progression of latent tuberculosis infection to active disease. The
following article
was abstracted from the CDC's August 6, 2004 Morbidity and Mortality
Weekly Report, pages 683-6 detailing this
interesting treatment dilemma and makes
recommendations for evaluation and treatment. The Food and
Drug Administration (FDA) has determined that tuberculosis (TB) disease is a
potential adverse reaction from treatment with the tumor necrosis
factor-alpha (TNF‑a)
antagonists infliximab (Remicade®), etanercept (Enbrel®),
and adalimumab (Humira®); the three products are labeled
accordingly. These products
work by blocking TNF-a,
an inflammatory cytokine, and are approved for treating rheumatoid arthritis
and other selected autoimmune diseases.
TNF-a
is associated with the immunology and pathophysiology of certain infectious
diseases, notably TB; blocking TNF-a
can allow TB disease to emerge from latent Mycobacterium tuberculosis
infection. We are not aware of
cases of TB disease occurring in association with infliximab therapy in
Maine, but encourage healthcare providers to take steps to prevent TB in
immunocompromised patients and to remain vigilant for TB as a cause of
unexplained febrile illness. As of January
2004, FDA’s adverse-event reporting system had received several hundred
reports, mostly from outside the United States, of TB disease in patients
who received TNF-a
antagonists. Manufacturers of
these products are required to report known cases, but reporting is
voluntary for others. The majority of the cases probably represent
progression of LTBI to TB disease, although the contribution of newly
acquired M. tuberculosis infection to the total number of reports is
unknown. Reports have included atypical presentations, extrapulmonary and
disseminated disease, and deaths. TNF-α, an
inflammatory cytokine expressed by activated macrophages, T-cells, and other
immune cells, plays a crucial role in the host response against M.
tuberculosis and other intracellular pathogens. Infliximab and
adalimumab are monoclonal antibodies; etanercept is a dimeric soluble form
of the TNF-α receptor. All three products are approved for the
treatment of patients with rheumatoid arthritis. Infliximab also is approved
for Crohn's disease, and etanercept is approved for specific other
arthritides and for psoriasis. Use of these agents has been associated with
other life-threatening infectious diseases besides TB, including candidiasis,
histoplasmosis, aspergillosis, and listeriosis. TNF-α antagonists often
are used in conjunction with other immunosuppressive therapies, particularly
glucocorticoids and methotrexate. Whether the increased rates of TB or other
infectious diseases are caused by interactions among these therapies is
unknown. Diagnosing LTBI in candidates for TNF-α antagonist therapy is challenging. For patients who undergo treatment for LTBI, the optimal time for starting TNF-α antagonist therapy is undetermined. Some experts advocate postponing therapy until LTBI treatment is complete. However, this delay might be impractical. The risk for TB relapse in patients previously cured of TB disease and subsequently treated with TNF-α antagonists is unknown. If active TB disease develops during TNF-α antagonist therapy, the TNF-α antagonist should be discontinued, at least until the anti-TB regimen has been started and the patient's condition has improved. The optimal time for resuming TNF-α antagonist therapy is undetermined. Outcomes with other immunosuppressive agents during the treatment of TB disease have been variable. |
Etanercept, administered in a phase-1 clinical trial along with a standard initial anti-TB regimen, did not delay the resolution of TB disease markers in a group of patients coinfected with human immunodeficiency virus in comparison with historical controls; adverse effects were not detected. However, use of anti--T-cell agents in transplant recipients with TB disease is associated with increased mortality; whether this increased mortality is because of the suppression of immune response or the dysfunction of the transplanted organ is unclear. Practitioners
who prescribe TNF-α antagonists should educate their patients about the
symptoms of TB disease, with added emphasis on extrapulmonary symptoms,
which can include fever, malaise, or development of a mass. A patient with
symptoms should undergo diagnostic testing for TB. In addition to following
local reporting requirements, health-care providers should report TB cases
associated with TNF-α antagonists to FDA's Medwatch system (available
at http://www.fda.gov/medwatch). Ongoing
clinical trials are using both approved and experimental TNF-α
antagonists in the treatment of additional conditions. Novel therapies that
inhibit other related inflammatory cytokines are under development. As the
use of these blocking agents expands, associated cases of TB might increase.
Vigilance for TB in association with these agents is critical to early
recognition and successful treatment. The Maine Tuberculosis Control Program is available to provide consultation on this and any other tuberculosis-related issues. Telephone: 207-287-8157. Recommendations for Screening, Diagnosis, and Treatment of Latent TB Infection (LBTI) and Tuberculosis (TB) in Patients Administered or Scheduled to Receive Tumor Necrosis Factor-Alpha (TNF- α) Antagonists. Screen patients for risk factors for Mycobacterium tuberculosis and test them for infection before initiating immunosuppressive therapies, including TNF-α antagonists. Risk factors include birth in a country where TB is prevalent or history of any of the following: residence in a congregate setting (e.g., jail or prison, homeless shelter, or chronic-care facility), a positive tuberculin skin test (TST) result, substance abuse (i.e., injection or noninjection), health-care employment in settings with TB patients, and chest readiographic findings consistent with previous TB.
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The 2003 Reportable Infectious Diseases in Maine Summary The 2003 Reportable Infectious Disease in Maine Summary is now available online. The summary highlights surveillance reports of notifiable conditions in Maine, which include:
If you would like more information about these outbreaks and other notifiable conditions in Maine, please download the 2003 Reportable Infectious Diseases in Maine Summary at 2003 Annual Summary.pdf |
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call the Bureau of
Health to report all reportable diseases:
Consultation
and Inquiries (24 hours / 7 days): Facsimile
Disease Reporting Line (24 hours / 7 days): 1-800-293-7534 Division
of Disease Control Website:
Bureau of Health Division of Disease Control 11 State House Station Augusta, Maine 04330-0011 (207) 287-6582 webmaster: robert.burman@maine.gov |
The
Epi-Gram Editorial Board:
Board Members Geoff Beckett, PA-C, MPH Kathleen Gensheimer, MD, MPH Mark Griswold, MSc Jiancheng Huang, MD, MS Andrew Pelletier, MD, MPH Anne R. Redmond, MPH Bob Woods, MA, LSW Design Editor |
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