CDC Warnings & Updates: March 3-10, 2008

The Centers for Disease Control and Prevention (CDC) sends weekly updates to clinicians about public health issues. This past week has been particularly active, warranting public awareness.

Food Safety:

• Gourmet Boutique of N.Y. is voluntarily recalling almost 7000 lbs. of meat and poultry products that may be contaminated with Listeria monocytogenes. The products were released February 26 & 27, 2008 bearing the production code "GBD 08058" on the package. The products shipped to retail vendors in:
• Connecticut, Massachusetts
  
• Florida, South Carolina, Georgia
  
• New Jersey,New York, Pennsylvania
  
• Wisconsin, Minnesota
• Costco Wholesale (Issaquah, WA) is voluntarily recalling over 10,000 lbs. of frozen chicken entrees (4-pack 12 oz. packages of Discover Cuisine Red Curry Chicken and Jasmine Rice) that may be contaminated with Listeria monocytogenes. The food products were produced on October 18, 2007, bearing the item number "2880" on the UPC sticker and were shipped to retail vendors in:
• Alaska
• Idaho, Montana, Oregon, Washington State

Vaccinations
A shortage of Hib vaccine has been reported and clinicians are being asked to not give the vaccine booster to healthy children 12-15 months of age, while continuing regular vaccination schedule for children under 12 months of age and for high-risk children (HIV, asplenia, sickle cell disease, immune system syndromes or Alaskan and Native American children). Keep track of children who miss the vaccination and vaccinate them when the supply of the Hib vaccine improves.

Ricin
The Ricin incident in Las Vegas on 2/29/08 has prompted renewed concern about the substance and how to handle it. The CDC has a comprehensive website dedicated to Ricin. Most relevant for clinicians is an 88 page manual, Response to a Ricin Incident: Guidelines for Federal, State and Local Public Health and Medical Officials.

Seasonal Flu
The good news is that influenza activity is decreasing in the US. The bad news is that deaths attributed to pneumonia and influenza continues to be above the epidemic threshold for the eighth consecutive week.

• Tamiflu: Roche and the FDA have informed of neuropsychiatric events associated with the use of Tamiflu in patients with influenza. These events were noted primarily in pediatric patients and had an abrupt onset with rapid resolution. Monitor flu patients receiving Tamiflu carefully for signs of abnormal behavior. There have been some reports of delirium and death, but the relationship to Tamiflu is unclear.

Avian Flu
Egypt reported a new case of an 11 year old with H5N1 virus infection. In 2008, 3 cases have been confirmed in Egypt resulting in 1 death. Indonesia has reported 12 cases in 2008 with 10 deaths, and Vietnam has had 4 reported cases, with 4 deaths.

Travelers' Health

• Paraguay: Yellow fever vaccination is now recommended for all travelers older than 9 months who travel to Paraguay, due to a resurgence identified yellow fever outbreak. A total of 22 cases resulting in 6 deaths have been confirmed by the Paraguay Ministry of Health.
  
• Brazil: the Brazilian Ministry of Health has issued a yellow fever disease alert due to 35 confirmed cases resulting in 19 deaths. Most of Brazil is considered an area of risk and a vaccination is recommended. See the CDC website for further guidance.
• Argentina: has reported the first human case of yellow fever. One of 17 monkeys found to be infected with the virus. Argentinian health officials are increasing yellow fever vaccination in humans living in the area.
  
• The CDC reminds all travelers to these areas to use mosquito repellent with DEET and to wear long sleeved shirts and pants when out of doors.
  

Labels: CDC, flu, travelers health, vaccines

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What You Need to Know Now about MRSA

The Centers for Disease Control and Prevention (CDC) hosted today an important clinician update about community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA). School closures and student deaths due to the so called Superbug are dominating the news. How do we protect our loved ones and ourselves?

The main thing the CDC wants us to be aware of is that 80% of these infections are skin infections. Staphylococcus aureus is a very common organism - 60% of us have it in our nose right now. Otherwise healthy people are getting extremely sick due to this infection as it becomes invasive. Why?

The infection presents as a common skin infection. It looks like a skin abscess or is commonly mistaken for a spider bite. It starts as a painful red bump that becomes necrotic (tissue dies). Clinicians assessing it may mistake it for a furuncle, boil or abscess. In newborns it may appear a breakdown of the skin under the diaper. MRSA now belongs in the differential diagnosis of every soft tissue infection. It is one of the most common causes of osteomyelitis after it becomes invasive.

MRSA infection will need to be treated with incision and drainage and antibiotics. If severe and recurrent, the infection will need to be treated aggressively with IV antibiotics and hospitalization.

Risk factors in the community are:

• Crowded living conditions (military barracks, boarding school)
• Frequent skin to skin contact (e.g. football)
• Compromised skin surfaces (e.g. turf burns - football)
• Sharing contaminated items (e.g. towels - football)

Prevention tactics:

• Good personal hygiene and cleanliness
• Keep all cuts and scrapes clean and covered
• Clean all common surfaces with commercially available disinfectants
• Alcohol based hand sanitizers are as effective as hand washing for MRSA per CDC
• Shower immediately after contact sports
• Wear uniforms and practice clothes only one time
  
• Wash uniforms and practice clothes in hot water and soap
• Do not share soap, towels, deodorant or razors
• Clean and disinfect athletic gear, equipment and gym areas
• Report any infections to school nurse and coach
• Avoid contact with other people's infections
  

Every patient with an MRSA infection needs thorough patient education about wound care. This is crucial to prevent further infection and spread in the community.

Thank you dan wandery for use of photo: Priceless.

Labels: CA-MRSA, CDC, prevention

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Unsolved Mysteries: The Continuing Saga of our XDR-TB case

XDR-TB and all other emerging, infectious diseases have had my attention for a while. For some background information, read:

• XDR-TB: Extremely Drug Resistant, Extremely Scary
• Runaway Bridegroom: XDR-TB Comes (Back) to America

One of my colleagues here at Healthline is a microbiologist, and she was kind enough to help me track down some information to try to answer some of the unanswered questions in the case of our runaway bridegroom. I asked her about the process for identifying the strain of TB a patient has. She said, " In the old day, multiple drug resistance was rare, so TB susceptibility testing was not routinely done. The steps in the process are

• Obtain the specimen [sputum] from the patient
• Identify the bug (microorganism causing the infection)
• Subculture the bug to grow a pure culture: this is where the process can get bogged down, just growing enough inoculum to test
  
• Use the pure culture of the bug to test for drug resistance"

She went on to say "Patients with TB are treated empirically." This means patients are given the usual medications used to treat the causative organism, in this case the bacterium Mycobacterium tuberculosis(M. tuberculosis) ." Susceptibility tests are done only after patients fail to respond to empirical treatment and typically, the most common drugs would be tested. If the patient's sputum sample was resistant to all common medications, then additional medications would be tested. The National Jewish Hospital is/was way ahead of the Public Health Department in developing new drug susceptibility tests."

National Jewish Medical and Research Center, Global Leader in Lung, Allergic and Immune Diseases, is on the international radar because that is where our most famous TB patient since Mimi in Puccini's operaLa Boheme is being treated. Would it take 4 months to test the sputum sample? No. Focus Diagnostics Reference Laboratory indicates the studies would be done in 14 to 21 days from the time they received the pure isolate of the microorganism culture. My microbiologist colleague reports that the culture can be grown from a liquid sample within a week, and if you have just "...a single colony on a solid culture, it can take up to 6 weeks..."

I am no math whiz, but I'm pretty sure that is a little over 2 months. OK. So the scenario I imagine is that he falls, has a chest X-ray, TB is diagnosed and reported to the county public health office and he is treated empirically. He proceeds with his wedding plans. His TB doesn't respond to treatment and the lesion in his lung gets bigger. The only part of this that still doesn't add up to me is Dr. Cooksey, his father-in-law, TB investigator for the CDC. Would not he have discussed his case with him?

• According to the Atlanta Journal-Constitution, Dr. Cooksey "...prepared his son-in-law's specimen for DNA testing as part of his regular duties."
• The CDC's own website reports that Drug Susceptibility testing takes one month. The HPLC genotyping is most likely the aspect of testing Dr. Cooksey is involved in.
  
• AJC reports that Mr. Speaker feels the Fulton County public health officials and the CDC are casting aspersions on his character to "deflect questions about their own actions"
• What actions would those be? Working hard to try to solve some of the most challenging problems of humanity? Dedicating their lives to helping others?
  

Another source of my information is the CDC itself. I receive their Clinician Updates via email, and am on the Terrorism Listserve. Yesterday, I received CDC Clinician Communication: Information from Clinician Outreach and Communication Activity (COCA). The June 7, 2007 communique is a particularly robust "...summary of clinical guidance...of persons potentially exposed to XDR-TB on two transatlantic flights." Per this communique to Health Professionals who may be involved in evaluation and treatment directly impacted by this case, the CDC states:

• If a person is infected, it can take 8-10 weeks after exposure until the tuberculin skin test (TST) to become positive
• A first round of TST should be done as soon after exposure as possible, and a second round repeated in 8-10 weeks after exposure
• Consultation with a TB expert, one experienced in managing MDR and XDR TB, is highly recommended in any contact who is positive, who is suspected of having the disease or who is immunocompromised
• Resources for TB consultation include State TB Control Offices
• and the Regional Training and Medical Consultation Centers under the Division of Tuberculosis Elimination with the CDC
• Then there is the issue of the contacts of the contacts...
  

The case has triggered international investigations in Greece, Canada, the US and Italy. The DHS border guard who allowed the patient back into the US without detaining him has been suspended. Georgia State law does not allow health officials to restrict a patient's movement unless h/she violates a written directive. Mr. Speaker eluded being served a written directive when his fiancee (daughter of CDC TB expert) advised him to leave the country early so that he could rest and relax. Dr. Katkowsky, Director of the Fulton County Department of Health and Wellness, stated the patient changed his flight plan after he was advised not to travel during a May 10, 2007 family care conference. Health officials knew at this time he had MDR-TB.

• May 11, 2007 Fulton County Health officials wrote up a medical directive advising Speaker against traveling. A county disease investigator attempted to hand deliver the directive to Speaker at his home and business.
  
• May 12, 2007 A county disease investigator attempted to hand deliver the directive to Speaker at his home an business, but learned he had already left the country. He had informed health officials that his departure date was May 14, 2007. Sources confirmed that Mr. Speaker called Air France and asked to leave on an earlier flight.
• May 17, 2007: Health officials learned that Mr. Speaker has XDR-TB. Sources say he was instructed to go into voluntary isolation in a hospital in Italy. Speaker already knew enough about his diagnosis to have pre-arranged to be treated at National Jewish Hospital with medications and surgery. He had been told he had "...one chance to get the treatment right."
• Mr. Speaker was "...appalled..." that the CDC and the government was not going to help him out by footing the $140,000 bill for the private air ambulance.
  

Thank you alexanderljung for use of photo Partial microscope bacteria view.

Labels: CDC, consumption, La Boheme, microbiology, TB

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