Consider the following two scenarios.
| 1) |
An 18-year-old with fever, headache, stiff neck, and petechial lesions is admitted early Saturday morning after evaluation in the hospital emergency department (ED). He is accompanied by his extended family and several friends. Gram-negative diplococci are seen in the cerebrospinal fluid, and menin-gococcal meningitis is suspected. Intravenous antibiotics are administered to the patient, and ciprofloxacin is liberally offered to staff who may have had contact with the patient in the ED (although most did not have intimate contact with the case).
Public Health is notified of the case by the hospital epidemiologist on Monday (whoops – this is an immediately notifiable condition by the health care provider) when a positive culture result for N. meningitidis is reported by the laboratory. The patient’s friends and family members are no longer present, and there is no record of their names or contact information in the clinical note. After numerous phone calls, these persons are finally located and several intimate close contacts are identified that have been exposed to the patient’s respiratory secretions and require post-exposure prophylaxis (PEP).
|
| 2) |
A 35-year-old male physical therapist is seen by his primary care physician for a cough of two weeks duration. The patient reports that there have been cases of pertussis in his son’s school recently, and he recalls that his son was treated for pertussis about a month ago. The physician astutely suspects pertussis, obtains a pertussis culture (after donning a mask and eye protection), and prescribes a course of azith-romycin. The patient’s wife, an intensive care unit nurse, accompanied him to the appointment and also has a cough illness of 7 days duration, but remains in the office waiting room (coughing quietly). This information is not elicited in the clinical history. The physician does not inquire about other work or social contacts of his patient with symptoms compatible with pertussis. |
Missed opportunities
These scenarios illustrate several missed opportunities for the primary care physician to optimally manage common communicable diseases of public health significance. Delays and missed opportunities in administering PEP to contacts can result in preventable serious illnesses, which can spread to others in the community, including those in high-risk environments, such as hospitals. In both outbreaks of naturally-occurring diseases, and potential bioterrorism, mass administration of post-exposure prophylaxis and/or vaccine may be recommended.
It is important to obtain a thorough social history from cases with communicable diseases of public health significance, eliciting contacts/exposures that may require PEP.
In fact, Washington Administrative Code (WAC) 246-101 states that “health care providers are to provide adequate and understandable instruction in disease control measures to each patient who has been diagnosed with a communicable disease, and to contacts that may have been exposed to the disease.”
Whenever possible, as described in the WAC, health care providers should identify contacts of their patients who are at risk for disease, and administer PEP when indicated. This is optimally done when the contacts are on-site. Referring patients to other health care providers or facilities for PEP can result in failure of the contact to receive preventive therapy in a timely manner, or at all. This is particularly important since prompt administration of PEP is more effective. If exposed persons are not immediately available, recording their names and contact information and reporting this information to Public Health will help facilitate the investigation and follow-up.
For patients who are indigent and/or cannot pay for medications, Public Health can arrange for medications to be dispensed by hospital pharmacies and some community pharmacies at no charge to the patient. That pharmacy is then replenished by Public Health. If appropriate, Public Health clinics can also see patients for PEP during business hours (after consultation with the Communicable Disease Section), and administer therapies that may not readily available such as immune globulin, and vaccines for hepatitis A, hepatic B, measles. Public Health can provide assistance in evaluation of persons for PEP and, when necessary, help facilitate administration of preventive therapy. You can reach Public Health’s Communicable Disease Section 24/7 at (206) 296-4774. After hours, a medical epidemiologist is on-call to assist with urgent consultations.
How do I determine who is a candidate for PEP?
Diseases requiring PEP of contacts after exposure to an infected person include (but at not limited to) pertussis, hepatitis A, hepatitis B, meningococcal disease, tuberculosis, and measles. Contacts of persons with sexually transmitted diseases (STDs) should also be evaluated and treated if indicated (for more information on STDs, see: www.metrokc.gov/health/apu/std). Rabies PEP should be recommended for exposures to potentially rabid animals after consultation with Public Health.
To determine if PEP is indicated for a particular person, the following questions must be answered:
| 1) |
How is the disease transmitted (respiratory droplets, airborne, fecal-oral, sexual contact etc)? |
| 2) |
What is the nature of the contact with/exposure to the ill person?
|
| 3) |
Is the contact susceptible to the disease they have been exposed to (immunization history, past infection)?
|
| 4) |
Are there contraindications to PEP?
|
| 5) |
Can PEP be administered within the recommended time frame to be effective?
|
Public Health can help you identify candidates for prophylaxis based on the specific infection and the circumstances relevant to your patient.
Where is rabies PEP available?
Hospitals are the only places where both rabies immune globulin and rabies vaccine (both of which are required for the first dose of PEP) are routinely stocked. Inventories can change day by day, so the hospital pharmacy or ED should be contacted prior to sending someone to a hospital for rabies PEP. After the first dose of immune globulin and vaccine, the follow-up shots can be administered by the primary care provider or other outpatient clinic (see web address below for information on ordering rabies vaccine). Potential rabies exposures should be reported promptly to Public Health at (206) 296-4774.
For comprehensive information about rabies exposure assessment and management and rabies vaccine, see: www.metrokc.gov/health/providers/epidemiology/rabies).
APIC Chapter Will Hold Infection Control Education Day on October 22nd
|
The Puget Sound APIC (Association of Professionals in Infection Control and Epidemiology) Chapter is sponsoring an educational meeting called “Sail Through Infection Control: Learning the Ropes” in Silverdale Washington on October 22nd, from 8-4 PM. The cost is $75 ($65 for APIC members). For more information and to register, please contact Ira Rice at (360) 754-3333 or ira.rice@hcahealthcare.com, or visit the Puget Sound ACIP website at: www.pugetsoundapic.org/Education.htm
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 Care 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
|
|
Cases reported
in August
|
Cases reported through August
|
| |
2004
|
2003
|
2004
|
2003
|
| Campylobacteriosis |
38
|
24
|
179
|
166
|
| Cryptosporidiosis |
5
|
2
|
21
|
31
|
| Chlamydial infections |
517
|
372
|
3,480
|
3,314
|
Enterohemorrhagic
E. coli (non-O157) |
0
|
0
|
0
|
0
|
| E. coli O157: H7 |
9
|
3
|
27
|
19
|
| Giardiasis |
8
|
12
|
81
|
75
|
| Gonorrhea |
94
|
102
|
745
|
916
|
| Hæmophilus influenzæ (cases <6 years of age) |
0
|
0
|
2
|
0
|
| Hepatitis A |
0
|
1
|
6
|
18
|
| Hepatitis B (acute) |
1
|
1
|
16
|
20
|
| Hepatitis B (chronic) |
59
|
45
|
415
|
385
|
| Hepatitis C (acute) |
0
|
1
|
7
|
7
|
| Hepatitis C (chronic, confirmed/probable) |
86
|
74
|
824
|
646
|
| Hepatitis C (chronic, possible) |
27
|
15
|
243
|
155
|
| Herpes, genital (primary) |
51
|
34
|
489
|
426
|
| HIV and AIDS (includes only AIDS cases not previously reported as HIV) |
39
|
20
|
289
|
288
|
| Measles |
0
|
0
|
6
|
0
|
| Meningococcal Disease |
1
|
0
|
12
|
3
|
| Mumps |
1
|
0
|
1
|
0
|
| Pertussis |
17
|
25
|
149
|
166
|
| Rubella |
0
|
0
|
0
|
0
|
| Rubella, congenital |
0
|
0
|
0
|
0
|
| Salmonellosis |
36
|
19
|
159
|
153
|
| Shigellosis |
7
|
4
|
44
|
74
|
| Syphilis |
15
|
7
|
85
|
57
|
| Syphilis, congenital |
0
|
0
|
0
|
0
|
| Syphilis, late |
3
|
2
|
42
|
29
|
| Tuberculosis |
5
|
18
|
88
|
108
|
