The Epi-Log Newsletter (Volume 42, No. 1

First year of mandatory reporting of Hepatitis C and Chronic Hepatitis B

In September 2000, chronic hepatitis B and all cases of hepatitis C became legally reportable conditions by health care providers and institutions (Washington Administrative Code 246-101). The primary reason for making these changes in hepatitis reporting was to obtain a more accurate measure of the burden of these diseases in Washington State. Cases of hepatitis C and chronic hepatitis B are provisionally reportable for a period of four years, at which time the surveillance data will be reviewed and the reporting requirement will be re-evaluated.

Chronic Hepatitis B Reporting

In 2001, we received 632 new reports of chronic hepatitis B in King County residents, a substantial increase over the 200 to 400 reports received yearly since 1996. Consistent with national trends, however, the number of reported acute hepatitis B cases has steadily declined from 80 in 1998 to 36 in 2001.

Perinatal Hepatitis B Reporting

Identification of hepatitis B surface antigen (HBsAg)-positive pregnant women prior to delivery is an important component of mandatory reporting that helps assure appropriate and timely post-exposure prophylaxis (PEP) of perinatally-exposed infants. The Centers for Disease Control and Prevention (CDC), the American College of Obstetricians and Gynecologists (ACOG), and the American Academy of Family Physicians (AAFP) strongly recommend HBsAg-testing of all pregnant women with each pregnancy. Since its inception over a decade ago, the goal of the Perinatal Hepatitis B Prevention Program (PHBPP) has been to prevent perinatal transmission of hepatitis B by assuring timely and appropriate PEP for infants born to HBsAg-positive women. However, without mandatory reporting, a large portion of women are either never reported or are not reported until after delivery, when it is too late to assure timely PEP for their infants.

Subsequent to the reporting change, in 2001 Public Health received an increased number of reports of HBsAg-positive pregnant women. There were 189 reports of HBsAg-positive women in 2001, compared to 135 in 1999 and 150 in 2000. In addition, among HBsAg-positive women delivering in 2001, more were reported prior to their delivery. In 2001, 50% of HBsAg-positive pregnant women who delivered in the same year were reported prior to delivery compared to an average of 39% reported before delivery between 1996 and 2000. This positive trend will likely continue as more health care providers and institutions become aware of the reporting requirement and report cases promptly. The goal is that all HBsAg-positive pregnant women will be reported prior to delivery.

Hepatitis C Reporting

Although reporting of hepatitis C was not mandatory prior to September 2000, between 1996 and 2000, Public Health received approximately 1000 reports of chronic hepatitis C each year. In 2001, there were 1959 new chronic hepatitis C reports (Chart 1). Even with the increased number of hepatitis C reports overall, the number of reported acute hepatitis C cases remains low. There were only 9 acute cases identified in 2001, which is comparable to previous years.

Hepatitis C Case Reports, 1995-2001

Chronic hepatitis C virus (HCV) infection reports are categorized as possible, probable, or confirmed. A confirmed case of chronic HCV infection is defined as a case with a positive anti-HCV enzyme immunoassay (EIA) plus supplemental confirmatory testing by recombinant immunoblot assay (RIBA) or any case with positive qualitative or quantitative HCV RNA testing. A probable case is defined as a positive HCV EIA test result in the absence of confirmatory testing in persons at high risk for HCV infection including persons who:

a.	have ever used injection drugs
b.	have received blood factor concentrates prior to 1987, and
c.	have persistently elevated liver enzymes with no other explanation. Cases with a positive HCV EIA test and not meeting the "confirmed" or "probable" case definitions are classified as possible HCV cases.

The number and quality of hepatitis C reports has steadily increased with a) the availability of improved serologic testing, b) increased knowledge among health care providers and institutions reporting cases, and c) improved capacity of Public Health to investigate reports. In 1995, only 21% of chronic hepatitis C cases were classified as probable or confirmed, but in 2001, over 72% of the reports were classified as probable/confirmed (Chart 1). This increase in probable and confirmed cases is due, in part, to increased reporting of risk factors and of confirmatory test results. Additionally, health care providers may be ordering confirmatory testing more often than in the past.

Though the quality and quantity of hepatitis case reports have improved over the last year, there are still a number of health care providers and institutions that do not report any hepatitis cases, and others inappropriately rely exclusively upon the laboratories to submit these reports for them.

Your prompt reporting of chronic hepatitis cases will improve our understanding of this disease in King County. Including all pertinent information at the time of case report submission will reduce the time it takes for your staff and ours to complete the report.

More information on hepatitis and the information needed to complete a report is available online at www.metrokc.gov/health/prevcont/hcvreporting.htm or by contacting Sandra Randels at (206)205-5808 or at sandra.randels@metrokc.gov. The current number of viral hepatitis cases (along with cases of other selected notifiable conditions in King County) can be found on the back page of each Epi-Log. The complete list of notifiable diseases is available online at: www.metrokc.gov/health/providers/epidemiology/reporting.htm

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Listeriosis in pregnant women linked to consumption of queso fresco

Since July 2001, three pregnant Hispanic women in King County developed infections with Listeria monocytogenes after consuming queso fresco, a soft Mexican cheese that is often made with unpastuerized milk and typically made at home for private distribution. One of the women delivered an infected stillborn infant at 23 weeks gestation; the second woman delivered an infected infant that survived. The third woman gave birth prematurely at 33 weeks. Both she and her infected infant were treated post-partum and recovered after lengthy hospitalizations.

All three cases reported purchasing unlabeled queso fresco-two from a door-to-door vendor and one through a friend. Two of the women were able to provide leftover cheese for testing, and Listeria was isolated from one of the cheese samples. None of the women were aware of the risks of consuming soft cheeses during pregnancy, nor were they aware that unpastuerized milk is typically used to make queso fresco. Pregnant women and others with weakened immune systems should be advised to avoid the consumption of soft cheeses, including queso fresco, brie, blue-veined, feta and Camembert (cream cheese and cottage cheese need not be avoided).

Soft cheeses made with unpastuerized milk are proven sources of Listeria monocytogenes infections. Pasteurization eliminates listeria from milk and milk products. Unlike most other foodborne pathogens, Listeria bacteria thrive in refrigerated foods. Infections caused by Listeria monocytogenes are diagnosed infrequently because the likelihood of severe, symptomatic illnesses is low among healthy, non-pregnant persons. Persons with weakened immune systems, including pregnant women, are more likely to become symptomatic, and are more likely to develop severe disease. Listeriosis may present as meningoencephalitis, septicemia or endocarditis. Although pregnant women are more likely to have a complicated course of disease, pregnant women who have mild or asymptomatic infections also can pass the infection on to their fetus or newborn. Maternal infections often result in stillbirth, premature delivery, or neonatal infection. Neonatal case fatality rates are estimated to be 35%, but these rates approach 50% when the newborn's illness onset occurs within four days of birth. Listeria monocytogenes infections are diagnosed by isolating the organism from the blood, spinal fluid, amniotic fluid, placenta, meconium, lochia, gastric washings or other sites of infection.

After the first two listeriosis cases were identified, Public Health visited the neighborhood where the cases resided and to near-by health care providers and distributed Spanish-language fact sheets describing the potential risks associated with consuming queso fresco. See www.metrokc.gov/health/news/01072401.htm

The most recent case resides in a different neighborhood, and obtained the cheese through a friend who had purchased the cheese in Yakima County. More information about preventing listeriosis in pregnant women and others with weakened immune systems can be found at: www.cdc.gov/od/oc/media/fact/lister.htm

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Communicable Disease and Epidemiology contact information

> Disease reporting

AIDS	(206) 296-4645
Sexually Transmitted Diseases	(206) 744-3954
Tuberculosis	(206) 744-4579
Other Communicable Diseases	(206) 296-4774
Automated 24-hour reporting line for conditions not immediately notifiable	(206) 296-4782

> Hotlines

Communicable Disease Hotline	(206) 296-4949
HIV/STD Hotline	(206) 205-7837

> For health providers:

Health Provider homepage
Resources to fact sheets, updated news, vaccine information, health educational materials and external links.
www.metrokc.gov/health/providers

Reported Cases of Selected Diseases in Seattle and King County

NR = Not reportable in 2000	Cases reported in December		Cases reported through December
	2001	2000	2001	2000
AIDS	23	15	259	275
Campylobacteriosis	27	17	325	320
Cryptosporidiosis	3	NR	29	NR
Chlamydial infections	349	406	4297	4493
Enterohemorhaghic E. coli (non-O157)	0	NR	4	NR
E. coli O157: H7	1	1	32	56
Giardiasis	11	12	150	229
Gonorrhea	111	165	1555	1221
Haemophilus influenzae B (cases <6 years of age)	0	0	0	0
Hepatitis A	1	4	26	98
Hepatitis B (acute)	5	2	36	42
Hepatitis B (chronic)	47	NR	632	NR
Hepatitis C (acute)	0	3	9	13
Hepatitis C (chronic, confirmed/probable	112	NR	1414	NR
Hepatitis C (chronic, possible)	24	NR	549	NR
Herpes, genital	35	66	672	744
Measles	0	0	12	2
Meningococcal Disease	2	1	15	17
Mumps	0	0	1	9
Pertussis	0	8	39	207
Rubella	0	0	0	1
Rubella, congenital	0	0	0	1
Salmonellosis	13	13	260	205
Shigellosis	5	9	112	156
Syphilis	5	3	61	70
Syphilis, congenital	0	0	0	1
Syphilis, late	12	18	55	50
Tuberculosis	12	21	127	139

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