Disease Control Bulletin: November 2002

Contents

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Plans for Emergency Response to Public Health Threats

The first article on this topic appeared in the special October 2001 issue of the Disease Control Bulletin, with a response to biological incidents update appearing in the January 2002 issue. As we are now just over a year past the events of Fall 2001, we’d like to provide you with a status report from the Vermont Department of Health.

The Vermont Department of Health has received $6.8 million in grant funding from the Centers for Disease Control and Prevention (CDC) and Health Resources and Services Administration (HRSA). Funding from the CDC is intended to assist the department to achieve 32 critical capacities along with several enhanced capacities in six focus areas, three of which were previously funded (at much lower levels) under the bioterrorism grants of 1999, 2000 and 2001. Components of the grant are briefly described below.

Hospital Bioterrorism Preparedness Program

The HRSA component of the grant is $485,464, which has been provided to upgrade the capacity of Vermont hospitals and emergency responders to respond to bioterrorism, infectious disease epidemics, and other public health emergencies. Under this grant, the state is required to develop a timeline for implementation of regional hospital plans that would accommodate at least 500 patients in an emergency.

The department has defined all of Vermont as a region and will develop a single state plan and timeline that will be submitted to HRSA by the end of March 2003. This plan must be on file before additional resources will be released to the state. The department has provided grants to Vermont hospitals for needs assessment, planning and to purchase goods and services necessary to implement the plan.

National Pharmaceutical Stockpile (NPS)

The NPS, part of the HRSA grant, is a national repository of pharmaceuticals and medical material that will be delivered to the site of an emergency to reduce morbidity and mortality. It includes drugs, IV and airway supplies, bandages, dressings, and vaccines. The stockpile, which fills an entire 747 cargo plane, is adequate to provide prophylactic service to half the population of Vermont for a week or therapeutic care for 6000 people for a week. The department has prepared a plan for breaking a stockpile delivery into smaller units to be sent to hospitals and clinics serving the affected sites.

Preparedness Planning and Readiness Assessment

The program executive director was named in February 2002. An assessment and planning team leader and a project coordinator were recently hired. The department is also working with an independent consultant to assess capabilities, resources, and competencies and create response plans.

Surveillance and Epidemiology Capacity

This portion of the grant funds public health nurses in the district offices to support increased surveillance activities and epidemiologic investigations. Ongoing surveillance efforts with hospital infection control professionals and with school nurses have been strengthened, and hospital emergency department surveillance is being expanded. The bioterrorism surveillance coordinator will be working with hospitals to identify their information technology capacities and ability to contribute to electronic syndromic surveillance. In the past year, infectious disease epidemiology staff has made many presentations on bioterrorism to various groups of health care and law enforcement professionals.

Smallpox planning

On September 23, 2002, the CDC released information on plans for mass vaccination following an outbreak of smallpox. The final federal policy on pre- and post-event vaccination had not yet been released by the Department of Health and Human Services at the time that this article was written. The Vermont Department of Health has several strategies under consideration for implementing federal policy when it is determined.

Laboratory Capacity – Biologic Agents

The Vermont Department of Health Laboratory continues to enhance its capabilities to respond to bioterrorism. These enhancements include:

  1. modification of an existing laboratory space (Decem-ber 2001) to achieve Biosafety Level 3 conditions and a dedicated bioterrorism test area,
  2. staff training in packaging and shipping of specimens,
  3. staff training in laboratory procedures for the rapid detection of agents of bioterrorism,
  4. development of the capacity to perform rapid real-time polymerase chain reaction detection of agents of bioterrorism,
  5. assisting the Laboratory Response Network to validate protocols for the detection of additional agents.

Goals for the upcoming year are:

Health Alert Network and Information Technology

During this grant year, the department will develop and maintain a technological system that can facilitate effective contact with public health partners during an emergency. As part of this effort, the department will conduct an assessment to determine the most effective ways to contact health care providers and will use information from the assessment to update our secure contact directory. A review will be made of the department’s telecommunications infrastructure including its ability to receive a large volume of calls from the public during an emergency. Strategies will be developed to respond to gaps in the department’s current telecommunications infrastructure. The department’s Health Alert Network website will continue to be used as a clearinghouse for terrorism and disaster information and for training opportunities for health care practitioners in the state.

The department will continue its development and use of secure electronic exchange of clinical, laboratory and environmental data.

Public Information and Communication

In the event of a bioterrorist event or other public health emergency, the department is committed to providing timely, credible, accurate and helpful information to the public and key partners. To accomplish this, the department will convene a group of emergency communicators, including TV, radio and print reporters, to take stock of communication capabilities, technical expertise, and training and technology needs of state and local response agencies. This needs assessment will also identify major non-English speaking or other special needs populations. Findings will be used to develop public messages tailored to various populations and media, emergency information for www.HealthyVermonters.info, spokesperson training, and a comprehensive emergency communication plan. The Health Department’s communication office will also hire a public information officer and a web writer/editor to specialize in emergency communication.

Education and Training

The department will develop a three year training initiative based on training needs assessments of public health partners, including health care providers, to increase thier ability to respond to public health emergencies. This initiative will include the development of various training opportunities such as classroom training, web-based training, satellite programs, and on-line learning techniques. Training topics will include immunization, epidemiology and surveillance, communication practices, Incident Command System, lab specialties, and other training necessary to develop an effective and efficient public health workforce. Tabletop exercises and a simulation drill will also be conducted.

In addition to the training initiative described above, the department workforce development specialist will collaborate with the HRSA hospital preparedness grant staff and the

Vermont Association of Hospitals and Healthcare Systems to assess the effectiveness of the Vermont health care system to respond to a large surge of patients in the event of an emergency. Plans will be developed to fill gaps that exist.

A Physician Advisory Group is being formed, including representatives from each of the hospitals in Vermont, various sub-specialties, and large group practices. This group will advise the department on preparedness and response activities and will attend special informational workshops. Members of the group will share the information with their colleagues throughout Vermont, providing peer education on issues such as disease recognition and diagnosis, syndromic surveillance, and collaboration with partners. The first meeting of the group is scheduled for November 16, 2002.

Intrastate collaboration

The department continues to meet regularly with our partners throughout state government for emergency plan enhancement. Representatives from the Vermont State Police and Emergency Management sit on the Medical Advisory Committee to the Governor’s Terrorism Task Force. The department is participating in training sessions being offered to local emergency planners and responders throughout the state. The funding from the CDC will allow the department and our partners to purchase or design and participate in a number of exercises and event simulations to test and fine-tune our plans and become well practiced in our roles.

Regional and international collaboration

During the Northeast Regional Epidemiology Conference in Burlington in October 2002, epidemiologists from Maine, New Hampshire, Vermont, Massachusetts, Rhode Island, Connecticut, New York, New Jersey, Pennsylvania, Delaware, Canada and the CDC assembled to discuss issues such as public health law, public health workforce development, and bioterrorism. Issues to be addressed and next steps to be taken were identified.

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Vermont: Selected Reportable Diseases October 28, 2002

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New Tuberculosis Guidelines

The department and consultants from Fletcher Allen Health Care have prepared an algorithm and guidance sheets for primary care providers faced with evaluating a patient, refugee, or immigrant for possible tuberculosis (TB). The packet of six sheets presents information from a wide variety of source materials. It is designed to supply the provider with a brief summary of basic information on TB and current recommendations for when consultations with public health and an infectious disease expert are indicated.

The top sheet, titled Flowsheet for Evaluation for Active Pulmonary TB or LTBI, presents a flow-diagram for evaluating a person for tuberculosis, either active disease or latent tuberculosis infection (LTBI). Decision points in the algorithm refer the provider to color-coded information sheets that go into greater depth on four topics. These are titled: TB Skin Testing – PPD Placement; TB Skin Testing – PPD Interpretation; TB – Evaluation for Active Disease or LTBI Following a Positive PPD; and LTBI Treatment Flow Sheet – Patient Self-Administered Medication or – DOPT (directly observed preventive therapy). A complete list of the reference materials used to compile the algorithm and guidance is included in the packet. Many of the references are available on the internet and through the Vermont Department of Health.

If you would like a copy of the packet, please contact Infectious Disease Epidemiology, 802-863-7240. The packet will also be available on the department’s website in the near future.

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Meningococcal Disease in Vermont: 1997 through Sept. 2002

Neisseria meningitidis is a leading cause of meningitis in the U.S. Invasive disease is characterized by meningitis, bacter-emia, septicemia, and/or pneumonia. The rate of meningococ-cal disease in the U.S is 0.8–1.3 per 100,000 population per year, with a case-fatality ratio of 10 percent. Although outbreaks can occur, most cases are sporadic and occur most commonly in winter and early spring. Risk factors for disease include antecedent viral infection, household crowding, underlying illness, and exposure to cigarette smoke.

From January 1, 1997 through September 30, 2002, there were 29 cases of culture confirmed N. meningitidis in Vermont residents, resulting in a rate of 0.8 cases per 100,000 population per year. Cases occurred throughout the state in 11 counties. Approximately half (48%) occurred December through February. There were no outbreaks. Fifteen (52%) patients were female. The age breakdown was: three (10%) <1 year; three (10%) 1–4 years; three (10%) 5–9 years; six (20%) 10–19 years; five (17%) 20–29; two (7%) 30–49 years; two (7%) 50–69; and five (17%) 70 years. Ten (35%) patients had meningitis only; nine (31%) had primary bacteremia / septicemia; five (17%) had pneumonia only; two (7%) had bacteremia and pneumonia. The remaining three patients had meningitis and pneumonia;1 meningitis and bacteremia;1 and meningitis, bacteremia and pneumonia.1 Two patients of 25 with known outcome (8%) died. Overall, serogroup B was most frequently isolated. Serogroup Y was more often associated with pneumonia and was more often seen in older age groups.

Prevention of secondary cases is mainly achieved though chemoprophylaxis of close contacts of a case (e.g., household members). The quadrivalent polysaccharide meningococcal vaccine protects against serogroups A, C, Y and W-135. It may be used to control outbreaks of N. meningitidis serogroup C and for persons who are at elevated risk for meningococcal disease. Routine immunization is recommended for persons with terminal complement component deficiencies and those with anatomic or functional asplenia, as well as those who may be occupationally exposed in a laboratory. Travelers to areas where meningococcal disease is hyperendemic and college freshmen, especially those living in dormitories, should be educated about and offered vaccination.

References

REPORT DISEASE: VERMONT TOLL-FREE 1-800-640-4374 OR 1-802-863-7240

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2001 Adult Tobacco Survey Results: Facts For Health Care Providers

The main reason smokers give for wanting to quit is concern about the health effects, and their main source for quit information is from a doctor. Health professionals are in the best position to help smokers quit, by talking to them about quitting, assessing their readiness to quit, and giving them specific messages about how to quit.

Most health care professionals advise smokers to quit when they talk to them about smoking.

If one or more health professionals advise a patient to quit smoking the more likely they are to set a quit date.
The more specific health professionals are in their advice to patients to quit smoking, the more likely smokers are to set a quit date.

The nicotine patch is the quit method recommended most by dentists and pharmacists. Zyban is recommended most by doctors.

Recommendation Doctor/Nurse Dentist/Hygienist Pharmacist
Zyban 57% 5% 12%
Nicotine patch 44% 81% 59%
Nicotine gum 8% 24% 49%
Group sessions or class 6%    
Nicotine inhaler 5%    
Individual counseling 2% 10% 5%
Toll free telephone 2%    

The Vermont Department of Health has set an ambitious goal—to cut smoking rates in half by 2010. To achieve this goal, we have put in place a comprehensive program based on the Centers for Disease Control and Prevention’s recommendations, offering communi-ty based prevention programs, cessation services, countermarketing, health care provider education, and surveillance and evaluation.

VDH 5/02

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Indoor Air : Carbon Monoxide

What is carbon monoxide?

Carbon monoxide (CO) is a colorless, odorless, poison gas that is produced when liquid, solid, or gas fuel is burned.

What are the signs and symptoms of carbon monoxide poisoning?

The early symptoms of carbon monoxide poisoning can seem similar to flu-like symptoms — headache, dizziness and nausea. Breathing carbon monoxide causes these symptoms even in healthy people. Carbon monoxide poisoning can also cause sleepiness, vision problems (including blurred vision), ringing in the ears, aching arms and legs, irregular breathing, fatigue and confusion. At very high levels, it causes loss of consciousness and death.

If symptoms go away when you leave your home, but come back when you return, there may be a carbon monoxide problem in your home.

What are the health effects?

Nationwide, hundreds of people die from carbon monoxide poisoning every year, and thousands are treated in hospitals.

Breathing low levels of carbon monoxide over a few hours or breathing high levels for a shorter time can be equally harmful. Carbon monoxide lowers the body’s ability to carry oxygen to vital organs such as the heart and brain. In general, the more carbon monoxide a person inhales, the more serious the damage that occurs. The elderly, young children, infants, and people with anemia or heart or lung problems are more sensitive to the effects of carbon monoxide. During strenuous exercise, people are also more sensitive to the effects of carbon monoxide.

What are possible sources of carbon monoxide in the home?

Under certain conditions, any fuel burning vehicle, tool, appliance or device can produce harmful levels of carbon monoxide if used inside a building, in an attached garage or basement, or near windows and doors. Common sources of carbon monoxide include furnaces and boilers; space heaters with pilot lights; gas stoves or ovens; dryers, water heaters or refrigerators that use gas or liquid fuel; lawnmowers, snow-blowers and other gas-powered yard equipment; cars, trucks, snowmobiles and other vehicles. Tobacco smoke is also a source of carbon monoxide.

Can carbon monoxide be detected?

Yes. You can install a carbon monoxide detector in your home to measure the amount of carbon monoxide in the air and sound an alarm at elevated levels. Before purchasing a carbon monoxide detector, be sure that it meets the requirements of Underwriters Laboratory (UL) standard 2034.

What should I do if the carbon monoxide detector alarm goes off?

If your carbon monoxide detector alarm goes off, AND you or others in the household have symptoms of carbon monoxide poisoning (like headaches and nausea), immediately leave the house and call for emergency medical assistance.

If no one is feeling ill, it is possible that your carbon monoxide detector is not working correctly. One way to find out if a battery-operated detector is working is to take it outside. If the alarm continues, there may be something wrong with it. If there seems to be no problem with the detector or you cannot tell if there is a problem, you may want to contact the local fire department, a heating contractor or gas company, or the manufacturer of the device to assist you.

What should I do if I suspect carbon monoxide poisoning?

If anyone in the household has symptoms and you think it may be carbon monoxide poisoning, everyone should get out of the building right away. If anyone is unconscious or not breathing, bring the person outside into the fresh air and call your local emergency medical service. If the person is not breathing administer CPR. If you cannot bring people outside, ventilate the area by opening doors and windows.

Tips for Preventing Carbon Monoxide Poisoning

DO obtain and install a carbon monoxide detector.

DO change the battery in your carbon monoxide detector twice a year, when daylight daylight savings time is changed.

DO have your heating system checked and serviced at least once each year.

DO have your chimney cleaned as often as is necessary.

DO follow the directions that come with heating or cooking equipment.

DO have your kitchen gas stove checked and serviced at least once a year.

DO make sure that all heating, cooking, and other fuel burning devices are installed according to code.

DO make sure that stove pipes and other types of vents are tightly joined, and not cracked or rusty.

DO use the proper fuel in space heaters and be sure they are properly vented to the outdoors.

DO install and use an outside-venting exhaust hood above a kitchen gas stove.

DO NOT run engines in a garage that is attached to or beneath the house.

DO NOT use a charcoal grill or hibachi inside your home or garage. DO NOT use the kitchen gas stove for heating an apartment or house.

DO NOT allow snow or ice to pile up outside a gas appliance vent.

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
Jan K. Carney, MD, MPH
Commissioner

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

Ann R. Fingar, MD, MPH
State Epidemiologist Managing Editor

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