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Infectious Disease Advisory Archives

2010

Multistate Outbreak of Mumps in Northeast

The Department of Health wants members of the Rhode Island Hasidic Jewish Community to be aware of a multistate mumps outbreak. As members of the community prepare to travel or receive guests for Pesach, there is a possibility of spreading mumps. Individuals with symptoms of mumps (swollen tender salivary glands, under the ears or jaws, fever, headache, muscle aches and/or loss of appetite) should contact their doctors. CDC Mumps Alert for the Hasidic Jewish Community During Pesach | Health Advisory, March 12, 2010

2009

Outbreak of Salmonella Typhimurium Infections -- United States, 2008-2009

CDC Health Advisory, January 20, 2009

2008

CDC Issues Interim Recommendations for the Use of Influenza Antiviral Medications in the Setting of Oseltamivir Resistance among Circulating Influenza A (H1N1) Viruses, 2008-09 Influenza Season

December 19, 2008

2007

2006

Vibrio vulnificus

August 4, 2006 The Rhode Island Department of Health has received a report of a confirmed case of Vibrio vulnificus ( V. vulnificus ) infection in a high-risk adult who presented at a local hospital with an infected leg wound and septicemia. The patient remains hospitalized and is improving. This is the first recorded case of V. vulnificus acquired by exposure to local seawater and/or shellfish consumption. Annually 50 cases are reported nationally from the Gulf Coast region with 30% to 50% mortality.

V. vulnificus is a bacterium in the same family as those that cause cholera. It normally lives in warm seawater and is part of a group of vibrios that are called "halophilic" because they require salt. It occurs naturally, rather than as a result of pollution. Oysters can accumulate the bacterium as they filter the water in which they live. The bacterium is frequently isolated from oysters and other shellfish in warm coastal waters during the summer months.

Water and shellfish testing from Conimicut Point in Warwick, where the exposure occurred has revealed low levels of V. vulnificus . Further testing is planned from the upper bay and other warm salt-water areas. Of particular concern are the areas of the upper bay (north of Greenwich Bay), inlets, shallow water areas and coastal ponds.

V. vulnificus can cause disease in those who eat raw or undercooked shellfish or have an open wound that is exposed to seawater. In otherwise heathy persons, V. vulnificus can cause mild illness such as vomiting, diarrhea, or localized wound infection. However, in high-risk individuals, V. vulnificus can invade the bloodstream via ingestion or wound infection, causing a severe and life-threatening illness characterized by fever, chills, decreased blood pressure (septic shock), blistering skin lesions, and often, death.

Persons at high risk of invasive disease include persons who are immunocompromised, especially those with chronic liver disease, AIDS; chronic alcohol abuse; liver, stomach, or blood disorders; cancer; diabetes; or kidney disease. There is no evidence for person-to-person transmission of V. vulnificus . V. vulnificus infection is an acute illness, and those who recover should not expect any long-term consequences.

If V. vulnificus is suspected, treatment should be initiated immediately because antibiotics improve survival. Culture of wound or hemorrhagic bullae is recommended, and all V. vulnificus isolates should be forwarded to the state public health laboratory. Blood cultures are recommended if the patient is febrile, has hemorrhagic bullae, or has any signs of sepsis. Aggressive attention should be given to the wound site, necrotic tissue should be debrided; severe cases may require fasciotomy or limb amputation .

Antibiotic Therapy:

  • Doxycycline (100 mg PO/IV twice a day for 7-14 days) and a third-generation cephalosporin (e.g.,ceftazidime 1-2 g IV/IM every eight hours) is generally recommended
  • single agent regimen with a fluoroquinolone such as levofloxacin, ciprofloxacin or gatifloxacin, has been reported to be at least as effective in an animal model as combination drug regimens with doxycycline and a cephalosporin.
  • Children, in whom doxycycline and fluoroquinolones are contraindicated, can be treated with trimethoprim-sulfamethoxazole plus an aminoglycoside.

Counsel your patients as follows:

  • Do not eat raw oysters or other raw shellfish.
  • Cook shellfish (oysters, clams, mussels) thoroughly
  • For shellfish in the shell, either a) boil until the shells open and continue boiling for 5 more minutes, or b) steam until the shells open and then continue cooking for 9 more minutes. Do not eat those shellfish that do not open during cooking. Boil shucked oysters at least 3 minutes, or fry them in oil at least 10 minutes at 375°F.
  • Avoid cross-contamination of cooked seafood and other foods with raw seafood and juices from raw seafood.
  • Eat shellfish promptly after cooking and refrigerate leftovers.
  • Avoid exposure of open wounds or broken skin to warm salt or brackish water, or to raw shellfish harvested from such waters.
  • Wear protective clothing (e.g., gloves) when handling raw shellfish.

Clinicians and microbiology laboratories should report cases of V. vulnificus directly to the Office of Communicable Diseases

Corrected: Investigation of U.S. Traveler with Extensively Drug Resistant Tuberculosis (XDR TB) CDC Health Update: May 29, 2007

Polio Identified in a Somali Child in a Refugee Camp in Kenya

On Monday, October 16, 2006 a case of polio was reported in a refugee child from the Dadaab camps in Kenya. Other refugees from the same camp were destined to be resettled in Texas, Washington, Kentucky, and Pennsylvania on October 16. However, it is currently unknown if refugees from the same region who were resettled prior to October 16 were also exposed. The Center for Disease Control and Prevention (CDC) is actively involved in this case and is making recommendations for refugees who have arrived from the Nairobi transit center in Kenya.

The RI Refugee Health Program will identify any refugees resettled in Rhode Island from that region since September 1, 2006 and work with their resettlement agency and medical providers to ensure vaccination and active surveillance.

Multi state Investigation of Potential Rabies Exposure at a Summer Camp

August 3, 2006

2005

Presence of low levels of Francisella tularensis in the Washington D.C. area

September 30, 2005

CDC has become aware that from September 24th through September 25th environmental air monitors in SW Washington D.C., more specifically the Capitol Mall area, signaled the low level presence of Francisella tularensis, the bacterium that causes Tularemia, also known as “rabbit fever.” At this time, public health agencies have no reports of any related human or animal illnesses. This announcement is a precautionary measure to assure that clinicians are aware of the situation and are able to recognize, test, and report any suspected cases to the appropriate medical and public health authorities. This is a national alert because the Capitol Mall area is a highly‑trafficked tourist destination, and on Saturday, September 24th, was the site of several very well attended outdoor events.

Clinical Presentations

The clinical presentations most likely to occur after an aerosol exposure to F. tularensis are pneumonic, oculoglandular and oropharyngeal. The usual incubation period is 3‑5 days, but in rare instances can be longer. The disease is not communicable from person to person and can be effectively treated with readily available antimicrobials.

Preliminary Case Definition

Onset from Monday September 26 through October 5 of an acute febrile illness associated with at least one of the following:

  • conjunctivitis with preauricular lymphadenopathy (oculoglandular)
  • stomatitis or pharygitis or tonsillitis and cervical lymphadenopathy (oropharyngeal)
  • cough, shortness of breath, pleuritic chest pain (pneumonic), which is not otherwise explained in a resident or visitor to the National Capitol Region on Saturday or Sunday, September 24‑25.

Human Diagnostic Specimens

Clinical specimens may include :

  • Bronchial/tracheal washes or aspirates, sputum, trans‑thoracic lung aspirates, or pleural fluid collection
  • Swabs of visible lesions or affected areas (e.g., conjunctiva or pharynx)
  • Aspirates from lymph nodes
  • Whole blood or blood cultures are acceptable specimens, but are generally positive in cases of severe illness only.

Laboratory Testing (Culture )

Microbiology laboratory personnel should be alerted when F. tularensis is clinically suspected, so that appropriate laboratory precautions can be taken. F. tularensis is a fastidious, slow‑growing organism that requires cysteine for growth. F. tularensis may be cultured on the following:

  • cysteine supplemented agar including chocolate agar (CA)
  • cysteine heart agar with 9% chocolatized blood (CHAB)
  • buffered charcoal yeast extract (BYCE)
  • Thayer‑Martin agar

Culture plates should be held for 5‑7 days at 35‑370C (C02 is acceptable) and checked for growth daily.

F. tularensis can be isolated from nutrient enriched specimens (tissues) on sheep blood agar (SBA), but the organism will usually fail to thrive with passage on SBA. Growth on CHAB provides for presumptive identification of F. tularensis as the organism shows characteristic growth on this media (green, opalescent, raised, shiny colonies at 24‑48 hours).

Note: Specimens for recovery of live bacteria, should be collected before antibiotics are administered

Prophylaxis

CDC does not recommend mass or targeted prophylaxis at this time because:

  • the usual incubation period has passed without an increase in suspicious illnesses in the area, and air sampling since September 25th has been negative
  • infection is readily treatable and generally has a low mortality rate with medical care
  • infection cannot be transmitted to others

Treatment

Adults
  • Preferred choices:
    • Streptomycin, 1g IM twice daily
    • Gentamicin, 5 mg/kg IM or IV once daily†
  • Alternative choices:
    • Doxycycline, 100 mg IV twice daily
    • Ciprofloxacin, 400 mg IV twice daily†
Children
  • Preferred choices:
    • Streptomycin, 15 mg/kg IM twice daily (should not exceed 2 gm/d)
    • Gentamicin, 2.5 mg/kg IM or IV 3 times daily†
  • Alternative choices:
    • Doxycycline, If weight >= 45 kg, 100 mg IV or If weight < 45 kg, give 2.2 mg/kg IV twice daily
    • Ciprofloxacin, 15 mg/kg IV twice daily‡
Pregnant Women
  • Preferred choices:
    • Gentamicin, 5 mg/kg IM or IV once daily†
    • Streptomycin, 1 g IM twice daily
  • Alternative choices:
    • Doxycycline, 100 mg IV twice daily
    • Ciprofloxacin, 400 mg IV twice daily†

One antibiotic, appropriate for treatment for patient age, should be chosen from among the alternatives. Treatment with streptomycin, gentamicin, or ciprofloxacin should be continued for 10 days; treatment with doxycycline should be continued for 14‑21 days. Persons beginning treatment with intramuscular (IM) or intravenous (IV) doxycycline, ciprofloxacin can switch to oral antibiotic administration when clinically indicated.

†Not a U.S. Food and Drug Administration‑approved use.

‡Ciprofloxacin dosage should not exceed 1 g/d in children.

Additional information

RI Health Advisory: Changes in Lyme Disease Surveillance

July 20, 2005

The Office of Communicable Disease is proposing to change the way it conducts Lyme disease surveillance. This decision is based on an evaluation of the functionality of past surveillance methods. As always, physicians are required to report only new onset cases of Lyme disease. However, the Rhode Island Department of Health will no longer prompt health care providers to report cases in response to positive lab reports.

WHY THE CHANGE? In the past few years, for every new onset case, HEALTH had to work through 100 positive western blot reports, then invite physician reports. It is no longer feasible for HEALTH to sustain this labor-intesive process.

WHAT GETS REPORTED? Physicians, Nurse Practitioners and Physician Assistants who are required by regulation to report cases of disease should use the following criteria for selecting cases for reporting:

  1. Erythema migrans (greater than 5cm) present: Case is considered confirmed. No laboratory test or report is necessary. REPORT CASE .

OR

  1. EIA or IFA positive AND Western blot positive on a laboratory report AND one other sign or symptom of late Lyme disease (below): Case is considered confirmed. REPORT CASE.
  • Arthritis (objective joint swelling---new onset)
  • 2 nd or 3 rd degree heart block (new onset)
  • Bell’s palsy or other cranial neuritis, radiculoneoropathy, lymphocytic meningitis, encephalomyelitis, or positive Lyme titer in CSF.

Note: Do not report cases where the Western blot results are pending or unclear.

Community Acquired MRSA June 7, 2005

Outbreak of Marburg Virus Hemorrhagic Fever in Angola

March 30, 2005

On March 23, 2005, the World Health Organization (WHO) confirmed Marburg virus (family Filoviridae, which includes Ebola virus) as the causative agent of an outbreak of viral hemorrhagic fever (VHF) in Uige Province in northern Angola. Testing conducted by CDC's Special Pathogens Branch detected the presence of virus in nine of 12 specimens from patients who died during the outbreak. According to WHO reports, a total of 124 cases (117 deaths) were identified during October 1, 2004-March 29, 2005. Approximately 75% of the reported cases occurred in children aged <5 years; cases also have occurred in adults, including health-care workers.

Marburg virus disease presents as an acute febrile illness and can progress within 6-8 days to severe hemorrhagic manifestations. After an incubation period of 5-10 days, the onset of the disease is sudden and is marked by fever, chills, headache, and myalgia. Around the fifth day after onset of symptoms, a maculopapular rash may occur. Nausea, vomiting, chest pain, a sore throat, abdominal pain, and diarrhea then may appear. Signs and symptoms become increasingly severe and may include jaundice, inflammation of the pancreas, severe weight loss, delirium, shock, liver failure, massive hemorrhaging, and multi-organ dysfunction.

Clinicians should consider the diagnosis of Marburg VHF among febrile patients who, within 10 days before onset of fever, have either 1) traveled in northern Angola; 2) had direct contact with blood, other body fluids, secretions, or excretions of a person or animal suspected of having VHF; or 3) worked in a laboratory or animal facility that handles hemorrhagic fever viruses. The likelihood of acquiring VHF is considered extremely low in persons who do not meet any of these criteria. The cause of fever in persons who have traveled in areas where VHF is endemic is more likely to be a different infectious disease.

Hospital infection control practices for infected patients should include contact and droplet precautions, in addition to eye protection or face shield. Clinicians caring for patients with suspected Marburg virus infection should contact CDC or local public health officials for additional information on VHF infection control.

On March 25, CDC posted a notice on its website to inform travelers about the outbreak. This website will be updated as new information becomes available. No U.S. travel restrictions to the affected area are recommended at this time.

Additional information

Update on Avian Influenza A (H5N1)

This update reviews 1) the current epidemiologic situation in Asia and 2) the U.S. surveillance, laboratory diagnostic, and infection control recommendations for avian influenza A (H5N1), which were most recently stated in August 2004. As detailed in the recommendations below, identification of possible imported cases of avian influenza A (H5N1) in the U.S. clinical setting depends on health-care providers consistently obtaining information on recent international travel and other potential exposures from persons who have certain respiratory symptoms.

Current Situation

Outbreaks of avian influenza A (H5N1) among poultry are ongoing in several countries in Asia, including Thailand, Vietnam, and Cambodia. Reports of sporadically occurring human cases of influenza A (H5N1) continued through January 2005. Thailand reported five human cases of influenza H5N1 (with four deaths) in September and October 2004, but no additional cases to date. Thirteen human cases of influenza A (H5N1) infection (with 12 deaths) have been reported by Vietnam since mid-December 2004; WHO has reported that 10 of these cases (with 9 deaths) have been confirmed.

One instance of probable limited human-to-human transmission of influenza A (H5N1) virus was reported in Thailand between a child and her mother and aunt in September 2004. Health authorities in Vietnam are investigating two possible instances of limited human-to-human transmission in family clusters. One instance involves two brothers in Vietnam with confirmed influenza A (H5N1) infections; a third brother was hospitalized for observation only and did not become ill. In the second instance, a daughter developed symptoms within 6 days of her mother's onset of illness, which was confirmed as influenza A (H5N1). Investigations are exploring possible sources of exposure and looking for other signs of illness in family members, other close contacts, and the general community.

In addition, the first human case of influenza H5 infection in Cambodia has been confirmed in a woman who was hospitalized in Vietnam and died. A joint mission between the Cambodian Ministries of Health and Agriculture and WHO is in Cambodia investigating the circumstances surrounding this case.

As of February 4, 2005, the cumulative number of confirmed human cases of influenza A (H5N1) reported in Asia since January 28, 2004, is 55 cases (with 42 deaths), according to WHO. This total includes the case from Cambodia. The avian influenza A (H5N1) epizootic in Asia poses an important public health threat, and CDC is in communication with WHO and will continue to monitor the situation. The epizootic in Asia is not expected to diminish substantially in the short term, and it is likely that influenza A (H5N1) infection among birds has become endemic to the region and that human infections will continue to occur. So far, no sustained human-to-human transmission of the influenza A (H5N1) virus has been identified, and no influenza A (H5N1) viruses containing both human and avian influenza virus genes, indicative of gene reassortment, have been detected.

Travel Health Precaution

It is expected that the number of people traveling between the United States and certain parts of Asia will increase around the Lunar New Year, which occurs on February 9 this year. Chinese, Vietnamese, Cambodian, and Korean people celebrate the start of the lunar calendar year. Lunar New Year celebrations last for approximately 15 days in China, 3 days in Vietnam, and typically only 1 day in Cambodia and Korea.

On January 26, 2005, CDC issued a Travel Health Precaution notice about avian influenza A (H5N1). This notice is directed at travelers who may be returning from Vietnam to visit family and friends, especially during the upcoming holiday, and who may be at greater risk for exposure to poultry through food preparation or at farms and bird markets where infected poultry may not be readily detected. The notice outlines specific measures for travelers to take before, during, and after travel to Vietnam. CDC has not recommended that the general public avoid travel to any countries affected by influenza A (H5N1). For more information, see CDC's Travelers' Health .

Enhanced U.S. Surveillance, Diagnostic Evaluation, and Infection Control Precautions for Avian Influenza A (H5N1)

CDC recommends maintaining the enhanced surveillance efforts by state and local health departments, hospitals, and clinicians to identify patients at increased risk for avian influenza A (H5N1) as described in HAN notices that were issued on February 3, and again on August 12. . Guidelines for enhanced surveillance are as follows.

Testing for avian influenza A (H5N1) is indicated for hospitalized patients with

  • radiographically confirmed pneumonia, acute respiratory distress syndrome (ARDS), or other severe respiratory illness for which an alternate diagnosis has not been established, AND
  • history of travel within 10 days of symptom onset to a country with documented H5N1 avian influenza in poultry and/or humans (for a regularly updated listing of H5N1-affected countries, see the OIE websiteand the WHO website ).

Testing for avian influenza A (H5N1) should be considered on a case-by-case basis in consultation with state and local health departments for hospitalized or ambulatory patients with:

  • documented temperature of >38°C (>100.4°F), AND
  • one or more of the following: cough, sore throat, shortness of breath, AND
  • history of contact with poultry (e.g., visited a poultry farm, a household raising poultry, or a bird market) or a known or suspected human case of influenza A (H5N1) in an H5N1-affected country within 10 days of symptom onset.

Laboratory Testing Procedures

Virus Culture

Highly pathogenic avian influenza A (H5N1) is classified as a select agent, and culturing of clinical specimens for influenza A (H5N1) virus must be conducted under laboratory conditions that meet the requirements for Biosafety Level (BSL) 3 with enhancements. These enhancements include controlled access double-door entry with change room and shower, use of respirators, decontamination of all wastes, and showering out of all personnel. Laboratories working on these viruses must be certified by the U.S. Department of Agriculture. CDC recommends that virus isolation studies be conducted on respiratory specimens from patients who meet the above criteria only if requirements for BSL 3 with enhancements can be met.

Polymerase Chain Reaction (PCR) and Commercial Antigen Testing

Clinical specimens from suspect influenza A (H5N1) cases may be tested by PCR assays under standard BSL 2 conditions in a Class II biological safety cabinet. In addition, commercial antigen detection testing can be conducted under standard BSL 2 conditions used to test for influenza.

Specimens That Should Be Sent to CDC

Specimens from persons meeting the above clinical and epidemiologic criteria should be sent to CDC if

  • The specimen tests positive for influenza A virus by PCR or by antigen detection testing, OR
  • PCR assays for influenza are not available at the state public health laboratory.

CDC also will accept specimens from persons meeting the above clinical criteria even if they test negative by influenza rapid diagnostic testing if PCR assays are not available at the state laboratory. This is because the sensitivity of commercially available rapid diagnostic tests for influenza may not always be optimal.

Requests for testing should come through the state and local health departments, which should contact (404) 639-3747 or (404) 639-3591 and ask for the epidemiologist on call before sending specimens to CDC for influenza A (H5N1) testing.

Interim Recommendations:

Infection Control Precautions for Influenza A (H5N1)

Infection control precautions for H5N1 remain unchanged from the CDC interim recommendations issued on February 3. All patients who present to a health-care setting with fever and respiratory symptoms should be managed according to recommendations for Respiratory Hygiene and Cough Etiquetteand questioned regarding their recent travel history. Isolation precautions identical to those recommended for SARS should be implemented for all hospitalized patients diagnosed with or under evaluation for influenza A (H5N1) as follows:

  • Standard Precautions
    • Pay careful attention to hand hygiene before and after all patient contact
  • Contact Precautions
    • Use gloves and gown for all patient contact
  • Eye protection: Wear when within 3 feet of the patient
  • Airborne Precautions
    • Place the patient in an airborne isolation room (i.e., monitored negative air ressure in relation to the surrounding areas with 6 to 12 air changes per hour).
    • Use a fit-tested respirator, at least as protective as a NIOSH-approved N-95 filtering facepiece respirator, when entering the room.

Additional information

2004

Revised Recommendations for Malaria Prophylaxis in Dominican Republic

November 30, 2004

CDC has received reports of 2 cases of malaria in November 2004 in U.S. travelers to the Dominican Republic whose visits were limited to Punta Cana (La Altagracia Province) and San Francisco de Macoris (Duarte Province). During the same period at least 2 more cases have been reported in European travelers who visited Punta Cana. CDC has recommended malaria prophylaxis for travelers to rural areas in the Dominican Republic but not for travel to resorts. In light of these reports, as a precautionary measure, CDC is expanding the recommendations to include chloroquine prophylaxis for travelers to all areas in La Altagracia Province, including the Punta Cana area, and also to all areas of Duarte Province. The Ministry of Health in the Dominican Republic has implemented malaria control measures, including intensified surveillance, prompt case management, and intensive mosquito control activities. CDC will continue to monitor the situation and provide updates on these recommendations.

Health care providers needing assistance with diagnosis or management of suspected cases of malaria should call the CDC Malaria Hotline: 770-488-7788 (M-F, 8am-4:30 pm, eastern time). For emergency consultation after hours, call: 770-488-7100 and request to speak with a CDC Malaria Branch clinician.

Additional information

Rabies Vaccine Recall

April 2004

CDC and the Food and Drug Administration (FDA) were previously notified of a voluntary recall of certain lots of IMOVAX® Rabies Vaccine (Aventis Pasteur, Swiftwater, Pennsylvania). Information regarding the recall was distributed in a Health Alert Network (HAN) message and an MMWR Dispatch on April 2, 2004. In addition, a list of frequently asked questions regarding the recall was posted on the CDC Rabies website.

Aventis Pasteur (Swiftwater, PA) recalled three lots of IMOVAX® Rabies Vaccine on April 2, 2004 due to a remote possibility of the presence of inactivated virus. The four lots, distributed between September 23, 2003 and April 2, 2004, include: X0667-2, X0667-3, W1419-2, and W1419-3. The Department of Health has received guidance from FDA and CDC for providers who have administered pre exposure and/or post exposure human rabies vaccine involved in the recall. According to the manufacturer, the potential risk to those vaccinated with the virus is likely to be low. No unusual adverse events associated with the recalled virus have been reported.

Health Care Providers should:

  • Check all rabies vaccine supplies; return any recalled vaccine to the manufacturer.
  • Contact any patient who is currently receiving recalled vaccine.
  • For information about the medical management of cases go to: Aventis Pasteur website and hotline: 800-835-3587

For consultation regarding management of individuals receiving recalled vaccine use the above resources or contact the Office of Communicable Diseases

The vaccine recall only affects two specific groups of people

  • Patients currently undergoing rabies vaccine treatment after exposure to a potentially rabid animal (post exposure prophylaxis): Some patients may have received recalled vaccine, they need to complete the course with non-recalled vaccine. Providers may obtain replacement vaccine from HEALTH at 222 2577.

Those who have completed a complete course are considered immune and do not need any intervention, and are not at any risk.

  • People currently getting pre-exposure vaccination for rabies for occupational risk (for example, animal control officers, veterinarians, animal handlers)
  • If the person received a primary series of 3 doses with recalled vaccine, they need to get two more doses (3 days apart) and RIG only if less than 7 days has elapsed since first dose.
  • If the person received a booster with recalled vaccine they should get 2 more doses (3 days apart) and no RIG.

Recall Notices from Aventis Pasteur

  • Voluntary Recall of Imovax® Rabies, Rabies Vaccine (Human Diploid Cell) Lot Numbers X0667-2 and X0667-3 (Expiration date 6/24/06); W1419-2 and W1419-3 (Expiration date 12/06/05)
    April 5, 2004
  • Instructions For Complying With Recall April 5, 2004
  • Vaccine Recall Packing List
  • IMOVAX® RABIES, RABIES VACCINE (HUMAN DIPLOID CELL) PRODUCT RECALL: Medical Opinion from Aventis Pasteur Regarding Management of Patients April 2, 2004

Positive Screening for Bacillus anthracis in Washington, D.C.

Viral (aseptic) Meningitis Noted in Institutional Settings

Over the last 2 weeks HEALTH RI has received reports of several sporadic cases of viral meningitis from institutional settings. Reports have been from 4 separate high schools, 1 private day care, and from 1 college employee. Letters to parents have been sent by some of the schools. As a result physicians should expect calls from concerned parents.

Aseptic meningitis is a reportable illness. The following table illustrates and compares the case counts over the last two years.

Case Counts of Aseptic Meningitis 2002-2003

Year

Jan-March

April-June

July-Sept

Oct

2002

12

25

81

18

2003

16

21

58

16

From the table it can be observed that there is no absolute increase in numbers of cases; the reports received at HEALTH RI represent background activity. RI Hospital Virology laboratory has grown Echo virus from the spinal fluid of three (3) of these cases, and reports a higher than usual isolation of Echo virus from non invasive specimens as well. Several states across the U.S. reported increased ECHO viral activity this spring and summer. See the MMWR at this address for more information on aseptic meningitis associated with Echoviruses .

Viral (aseptic) meningitis is serious but rarely fatal in persons with normal immune systems. Usually, the symptoms last from 7 to 10 days and the person recovers completely. The viruses that cause viral meningitis are contagious by the oro-fecal route as well as via respiratory secretions. However, most infected persons either have no symptoms or develop only a cold or rash with low-grade fever. Typically, less than 1 of every 1000 persons infected actually develops meningitis. Therefore, if one is around someone who has viral meningitis, one has a moderate chance of becoming infected, but a very small chance of developing meningitis.

If one is in contact with someone who has viral meningitis, the most effective method of prevention is to wash one’s hands thoroughly and often. In institutional settings such as child care centers, washing objects and surfaces with a dilute bleach solution (made by mixing 1 capful of chlorine-containing household bleach with 1 gallon water) can be a very effective way to inactivate the virus. Exclusion from school is not indicated if the person is afebrile and otherwise well.

More information on viral meningitis can be found on the CDC web site

Guidelines for School Departments Related to SARS

June 2003

BACKGROUND: To date, all reported patients with Severe Acute Respiratory Syndrome (SARS) in the United States have been exposed and infected either through previous foreign travel to countries with community transmission of SARS or close contact (e.g., household members or healthcare workers) with SARS patients. The main geographic locations (and this will change with time), which are listed as SARS, affected areas are: China, Hong Kong, Taiwan, Hanoi, Singapore and Toronto. Casual contact with a SARS patient at schools, other institutions, or public gatherings (e.g., attending the same class or public gathering) has not resulted in reported transmission in the United States. People without symptoms cannot transmit SARS.

Guidelines:

  1. Travelers returning from SARS affected areas are routinely given written instructions (from the Division of Quarantine at CDC) at disembarkation on what procedures to follow should they become ill. Students, teachers and other school personnel who are known to have returned from one of the above SARS related areas and who are not exhibiting any signs of illness (fever of 100.4 or greater, cough, shortness of breath) should have no restrictions on their activities or school attendance.
  2. If school health personnel become aware of illness (fever of 100.4 or greater, cough, or shortness of breath) developing in the 10 day period after return from a SARS affected location, they should exclude the person from school pending medical and public health recommendations. If the illness develops during the course of the school day isolate the individual from other persons in the school environment (in a room or outdoors) and recommend that a health care provider evaluate them immediately. The parent or person affected must be advised to call ahead to the health care provider to inform them of the referral. At the same time the school health authorities (school nurse or school physician) should make a report to the Office of Communicable Diseases at 401 222 2577 (day), or 401 272 5952 (after hours). The Office of Communicable Diseases staff will provide expert guidance and support all aspects of the school response when such a report is made. Such a response includes assessment of the case, assessment of risk for persons exposed, management of the case (including recommendations for mask use and isolation), management of close contacts identified in the school, and risk communication messages to parents, staff and the press. It is important that the school authorities coordinate their media/public information responses with the Department of Health.
  3. In preparation for in-school management of cases pending pick up or transportation, it is advisable that school nurses offices are stocked with a few surgical masks and thermometers. Masks generally are to be used after the health department recommends how and by who they should be used on a case-by-case basis. Emergency contact information for students should be kept up to date. Exclusion from school of children and staff who are running fevers should be routinely enforced.
  4. It is important to reinforce basic hygienic practices (cover nose/mouth while sneezing or coughing with a tissue rather than a bare hand, wash hands frequently and avoid sharing utensils). School rest rooms should be kept stocked with a supply of paper towels, soap and running hot water. Hand washing posters should be posted in rest rooms. On field trips and other situations where access to running water is a problem a supply of alcohol hand gels for dry cleaning is advisable. Classrooms should have a supply of tissues, and receptacles for their proper disposal. The school environment, including cafeteria and bathrooms should be cleaned regularly.
  5. School authorities should keep up to date their knowledge of the most current Federal travel advisories and alerts in order to make informed decisions about scheduling school trips.
  6. Parents with questions can be referred to the CDC hotlines: 888-246-2675 (English) or 888-246-2857 (Spanish) or to the RI HEALTH Family Health Information Line at 1 800 942 7434.

NOTE: The above guidelines can be adapted for all congregate environments where children are cared for during the day such as camps, after school programs, day care programs, summer programs etc.

Smallpox Vaccination Advisory

25 January 2003

This alert is an update on information provided to you on December 13, 2001. The military has already begun vaccinating individuals at various sites around the country and locally a smallpox vaccine research project is underway at Memorial Hospital. Also in the very near future HEALTH will begin the voluntary smallpox vaccination of selected health care workers. Details of HEALTH's program will be broadcast later. It is expected that all vaccinated persons will have received instructions to contact the clinic site where they were vaccinated should they have questions, become ill, or need medical attention related to their vaccination. However, it is still possible that in the course of your practice you may encounter recently vaccinated individuals for issues related to their vaccination, or encounter them for other routine care. Physicians and health care facilities should know the following:

Infection Control Issues

  • Smallpox vaccination produces a skin lesion which is infectious. Vaccinia virus in the skin lesion can be transferred to others if the skin lesion is touched directly or if the bandage is handled casually with ungloved hands. The vaccination site is infectious until the scab falls off, approximately 21 days after vaccination.
  • Learn to recognize an active vaccination site. In the unlikely event that an injured and/or comatose person recently vaccinated for smallpox is seen by you, it is important that you know what to look for. There will be a bandage on the deltoid (usually but not always on the left). The bandage may be a transparent semi-occlusive dressing over gauze, gauze secured by paper tape or a bandaid. If you render medical care to an individual vaccinated for smallpox within the previous 21days who is unable to give a history but who has a bandage as described above, do not remove the bandage or touch the vaccination site with ungloved hands.
  • If you touch an active vaccination site or the bandage covering it with ungloved hands, wash your hands with soap and water, or with one of the alcohol-based handwash solutions. Bandages must be disposed of in biohazard waste bags.
  • Once the scab has fallen off, the vaccination site is no longer infectious.

Resourses for Consultaion

  • If needed, HEALTH suggests consultation with an infectious disease expert or infection control practitioner at your institution for questions on individual patients, as you would for any other infectious disease issue. Patients may also be referred back to the clinic where they were vaccinated.
  • If serious adverse events are suspected, report the case immediately to HEALTH at 401-222-2577 (day), or the on-call number 401-272-5952 (after hours). HEALTH can mobilize in-state and Federal specialty consultation, lab testing, and access to drugs as needed.