The Santa Barbara County Public Health Department (PHD) and the University of California, Santa Barbara (UCSB) have confirmed a 4th case of meningococcal disease in a UCSB undergraduate student. All four students with meningococcal disease became ill within a three week time period of November 2013. One case has resulted in permanent disability.
A number of steps have been taken to minimize the spread of the disease including:
• Providing preventive antibiotics to more than 500 students who were identified as close contacts of the initial three ill students and close contacts of the fourth case have also identified and have received antibiotics.
• Providing information on meningococcal disease and strategies for prevention to all students, staff and faculty at UCSB.
• Ongoing consultation with the Centers for Disease Control and Prevention (CDC).
• Providing information about the outbreak to healthcare providers across the state to raise awareness.
No currently available disease prevention and control strategies can ensure that no additional cases will occur as part of this outbreak. However, the PHD and UCSB are working jointly with the California Department of Public Health to implement a number of actions that have the potential to reduce the risk of future cases. Any possible impact of these actions to prevent additional cases is unknown.
In the setting of an ongoing outbreak of a serious disease, we believe that these actions are reasonable. While these actions may not prevent additional cases, we hope they may reduce the number of persons exposed to the outbreak strain of Neisseria meningitidis bacteria.
Therefore, this week we will be:
• Providing antibiotics to additional individuals who we believe may have already been exposed to the bacteria based on a scientific assessment of the social networks of existing cases. These students will be directed to obtain antibiotics at UCSB no later than Tuesday and will be directed to take the medication onsite.
• Informing all students, staff and faculty at UCSB about the importance of seeking medical care if they are ill (especially if they have signs and symptoms of meningococcal disease such as fever and headache) as timely treatment is very important to recovery. Even students who have been given preventive antibiotics can become ill depending on the timing of exposure; preventive antibiotics only offer protection for about one day, so students can become ill if exposed to the bacteria again in the future.
• Informing all students, staff and faculty at UCSB of the importance of maintaining healthy personal habits during the normal stressful exam period (e.g. good sleep, nutrition and hygiene behaviors) and staying home when ill to minimize exposure to others.
• Suspending specific social events on campus, i.e., parties sponsored by Greek organizations, in an effort to interrupt transmission of the outbreak strain in social networks.
These actions are initiated with the goal of protecting health and preventing additional cases of meningococcal disease. They are important and compliance is greatly appreciated!
If there are any new developments with the meningococcal disease outbreak in our community, these will be communicated in a timely manner.
Fourth meningitis case confirmed at UC Santa Barbara
By Joseph SernaDecember 3, 2013, 7:12 a.m.
“Officials are suspending fraternity events and parties at UC Santa Barbara after a fourth student was diagnosed with the disease that causes meningitis……All four people became infected last month and one of the patients had to have both feet amputated…….”
From November 25th (International End Violence Against Women Day) through December 10th (International Human Rights Day), USAID joins the international community for 16 Days of Activism Against Gender Violence
Over the past two years, the United States Government and USAID have increased awareness of gender-based violence (GBV) and made the prevention and response to GBV a priority in foreign policy and development assistance programming. Preventing and responding to GBV is a core element of a number of policies and strategies including the:
Clinical Findings for Fungal Infections Caused by Methylprednisolone Injections
Tom M. Chiller, M.D., M.P.H.&T.M., Monika Roy, M.D., M.P.H., Duc Nguyen, M.D., Alice Guh, M.D., M.P.H., Anurag N. Malani, M.D., Robert Latham, M.D., Sheree Peglow, M.D., Tom Kerkering, M.D., David Kaufman, M.D., Jevon McFadden, M.D., M.P.H., Jim Collins, M.P.H., R.S., Marion Kainer, M.B., B.S., M.P.H., Joan Duwve, M.D., M.P.H., David Trump, M.D., M.P.H., Carina Blackmore, D.V.M., Ph.D., Christina Tan, M.D., M.P.H., Angela A. Cleveland, M.P.H., Tara MacCannell, Ph.D., Atis Muehlenbachs, M.D., Ph.D., Sherif R. Zaki, M.D., Ph.D., Mary E. Brandt, Ph.D., and John A. Jernigan, M.D. for the Multistate Fungal Infection Clinical Investigation Team
N Engl J Med 2013; 369:1610-1619
October 24, 2013
“…………..Of 328 patients without peripheral-joint infection who were included in this investigation, 265 (81%) had central nervous system (CNS) infection and 63 (19%) had non-CNS infections only. Laboratory evidence of E. rostratum was found in 96 of 268 patients (36%) for whom samples were available. Among patients with CNS infections, strokes were associated with an increased severity of abnormalities in cerebrospinal fluid (P<0.001). Non-CNS infections were more frequent later in the course of the outbreak (median interval from last injection to diagnosis, 39 days for epidural abscess and 21 days for stroke; P<0.001), and such infections developed in patients with and in those without meningitis……….”
The Great American Smokeout, sponsored by the American Cancer Society, is an annual event that encourages smokers to make a plan to quit, or to plan in advance and quit smoking on that day, in an effort to stop permanently (1). This year, the Smokeout will be held on November 21.
Fifty years after the release of the first Surgeon General’s report on smoking and health, remarkable progress has been made. Since 1964, smoking prevalence among U.S. adults has been reduced by half. Unfortunately, tobacco use remains the leading preventable cause of disease, disability, and death in the United States (2).
In 2010, nearly two out of three adult smokers wanted to quit, and more than half had made a quit attempt for >1 day in the preceding year (3). However, an estimated one out of five U.S. adults still smokes (2).
Quitting smoking is beneficial to health at any age and has immediate and long-term benefits. Getting help through counseling or medications can double or triple the chances of quitting successfully (4).
Additional information and support for quitting is available by telephone (800-QUIT-NOW [800-784-8669]). Additional quit support and real stories of persons who have quit successfully are available on CDC’s Tips from Former Smokers website at http://www.cdc.gov/tips.
When something as devastating as Typhoon Haiyan occurs, it can be daunting to consider what a recovery effort might look like. Providing for basic needs and preventing potential injuries and outbreaks are usually at the forefront of any recovery plan. Despite the widespread devastation and lack of infrastructure people still need access to food and water. Groups with special needs, such as pregnant women or the elderly, still need care. These basic needs can present a host of health problems in the face of disaster. And as people begin to get their lives back in order, injuries from cleanup efforts and potential outbreaks due to contaminated food or water sources are a constant concern.
“……….In 2011, the US experienced 16 outbreaks with 107 confirmed cases. The average duration of an outbreak was 22 days (range: 5-68). The total estimated number of identified contacts to measles cases ranged from 8936 to 17,450, requiring from 42,635 to 83,133 personnel hours. Overall, the total economic burden on local and state public health institutions that dealt with measles outbreaks during 2011 ranged from an estimated $2.7 million to $5.3 million US dollars.………….”
Hundreds of cannabis workers fall ill in Albanian village
Source: Reuters – Fri, 1 Nov 2013 02:03 PM
By Benet Koleka
TIRANA, Nov 1 (Reuters) – “Doctors in Albania say hundreds of people have fallen ill from harvesting cannabis in a lawless region that for years has been out of bounds to police, Albanian media reported on Friday.
The hospital in the southern city of Gjirokaster said a total of 700 have sought treatment since June for the effects of planting, harvesting, pressing and packing the cannabis in the village of Lazarat…………”
Fungal Infections Associated with Contaminated Methylprednisolone Injections
Rachel M. Smith, M.D., M.P.H., Melissa K. Schaefer, M.D., Marion A. Kainer, M.B., B.S., M.P.H., Matthew Wise, Ph.D., Jennie Finks, D.V.M., M.V.P.H., Joan Duwve, M.D., M.P.H., Elizabeth Fontaine, M.S.P.H., Alvina Chu, M.H.S., Barbara Carothers, L.P.N., Amy Reilly, R.N., Jay Fiedler, M.S., Andrew D. Wiese, M.P.H., Christine Feaster, M.S.M., Lex Gibson, B.S., Stephanie Griese, M.D., Anne Purfield, Ph.D., Angela A. Cleveland, M.P.H., Kaitlin Benedict, M.P.H., Julie R. Harris, Ph.D., M.P.H., Mary E. Brandt, Ph.D., Dianna Blau, D.V.M., Ph.D., John Jernigan, M.D., J. Todd Weber, M.D., and Benjamin J. Park, M.D. for the Multistate Fungal Infection Outbreak Response Team
N Engl J Med 2013; 369:1598-1609
October 24, 2013
“………..By October 19, 2012, more than 99% of 13,534 potentially exposed persons had been contacted. As of July 1, 2013, there were 749 reported cases of infection in 20 states, with 61 deaths (8%). Laboratory evidence of Exserohilum rostratum was present in specimens from 153 case patients (20%). Additional data were available for 728 case patients (97%); 229 of these patients (31%) had meningitis with no other documented infection. Case patients had received a median of 1 injection (range, 1 to 6) of implicated methylprednisolone acetate. The median age of the patients was 64 years (range, 15 to 97), and the median incubation period (the number of days from the last injection to the date of the first diagnosis) was 47 days (range, 0 to 249); 40 patients (5%) had a stroke………..”
Transmission of Mycobacterium tuberculosis in a High School and School-Based Supervision of an Isoniazid-Rifapentine Regimen for Preventing Tuberculosis — Colorado, 2011–2012
What is already known on this topic?
Tuberculosis (TB), caused by a contagious airborne bacterium, can be widely transmitted in congregate settings. Tracing contacts and treating new infections are complex, time-intensive, interventions in congregate settings, and completion of treatment for preventing TB is historically 70% or less. An investigative approach starting with contacts who had the most exposure, with interim analyses of findings, clarifies the need for including contacts with less exposure. In jurisdictions with low TB incidence, TB control programs might not have sufficient local resources to respond to extensive transmission.
What is added by this report?
Screening at a school of 1,249 (90.4%) contacts of a student with TB found one person with pulmonary TB disease and 162 with latent Mycobacterium tuberculosis infection (LTBI), of whom 159 started LTBI treatment regimens for preventing progression to TB disease and 153 completed a regimen. A state emergency response plan pulled together dozens of health professionals, who devoted hundreds of hours to testing persons who were exposed to TB and providing care for those with TB disease and LTBI.
What are the implications for public health practice?
TB control programs and other public health agencies should be aware that investigating TB in a school can outstrip the response capabilities of local agencies and require large-scale mobilization with state and county leadership. Public health agencies should have a plan for keeping the public informed and educated about TB and apportion the necessary resources to meet the acute needs until they are resolved.
October 4, 2013 / 62(39);805-809
Mycobacterium tuberculosis, the bacterium that causes tuberculosis (TB), is spread from person to person by the airborne route. It can be transmitted extensively in congregate settings, making investigating exposures and treating infected contacts challenging. In December 2011, a student at a Colorado high school with 1,381 students and school personnel received a diagnosis of pulmonary TB disease. One of five household contacts had TB disease, and the other four had latent M. tuberculosis infection (LTBI). Screening of 1,249 school contacts (90%) found one person with pulmonary TB disease, who was fully treated, and 162 with LTBI, of whom 159 started an LTBI treatment regimen for preventing progression to TB disease and 153 completed a regimen. Only the index patient required inpatient care for TB, and TB caused no deaths. Use of short-course treatment regimens, either 12-dose weekly isoniazid and rifapentine directly observed at school or 4 months of self-supervised rifampin daily, facilitated treatment completion. State and county incident command structures led by county TB control authorities guided a response team from multiple jurisdictions. News media reports brought public scrutiny, but meetings with the community addressed the concerns and enhanced public participation. Two contacts of the index patient outside of the school had TB disease diagnosed after the school investigation. As of July 2013, no additional TB disease associated with in-school exposure had been found. An emergency plan for focusing widespread resources, an integral public communications strategy, and new, efficient interventions should be considered in other large TB contact investigations.
TB disease is confirmed by detection of M. tuberculosis by culture or nucleic acid amplification, or it can be diagnosed clinically from symptoms and chest radiography findings that are consistent with TB and resolve with treatment (1). In most instances, a clinical diagnosis includes positive results from an immunologic test for M. tuberculosis infection, either the tuberculin skin test (TST) or an interferon gamma release assay (IGRA) blood test (1,2). LTBI is diagnosed by positive TST or IGRA results, absence of TB disease symptoms, and a normal chest radiograph or a stable abnormal chest radiograph with tests of sputum negative for M. tuberculosis (1–3).
In late December 2011, a student at a high school with 1,381 students and school personnel in Longmont, Colorado, was admitted to a hospital after 2 months of cough, fever, and night sweats. The student was U.S.-born, and the only TB risk (3) was living abroad at age 8–10 years in a country with a TB disease incidence 10 times greater than that for the United States. The chest radiograph showed a pulmonary cavity, and sputum-smear microscopy revealed acid-fast bacilli. Both findings are markers for potential contagiousness. The M. tuberculosis from sputum culture was susceptible to isoniazid, rifampin, ethambutol, and pyrazinamide, and treatment with the standard four-drug regimen was completed in September 2012.
Persons who had spent the most time indoors with the index patient, as determined from interviews with the patient and later from school records, were tested for M. tuberculosis infection ahead of others (4). All five members of the household had positive IGRA results. One had culture-confirmed genito-urinary TB disease and a normal chest radiograph, with an M. tuberculosis genotype matching that of the index patient. A second person was initially treated for possible TB disease but after 2 months of a four-drug regimen was determined to have had LTBI (1,3). The other three had LTBI and took 4 months of daily rifampin for preventing TB disease (3).
The index patient’s six teachers and 13 students who shared at least two classes were tested by IGRA (Table). None had TB disease, but 10 (53%) of 19 had LTBI. Testing was then extended to 140 additional students who shared only one class with the patient. One received a diagnosis of TB disease initially, but the diagnosis was changed to LTBI after 2 months of four-drug treatment; 49 (35%) were diagnosed with LTBI.
The findings suggested M. tuberculosis transmission at the school; therefore, the investigation was extended to all students and school personnel enrolled or working during the fall 2011 semester. Because TB disease typically develops 6–18 months after initial M. tuberculosis infection (5), prompt diagnosis and treatment of LTBI were urgent. The rapid evaluation of approximately 1,000 additional contacts with IGRA was not feasible at the local laboratory; a combined strategy using IGRA and TST was adopted. Students and school personnel who had lived outside the United States, who had been vaccinated with bacille Calmette-Guérin (BCG), or who reported a positive TST result were tested with IGRA and all others with TST (2).
During 12 screening clinics held at the school from mid-February to mid-March, public health personnel interviewed and tested 1,053 contacts, and 37 more were screened in other settings, for a total of 1,090 (89.2%) of the 1,222 who were sought (Table). One had pulmonary TB disease diagnosed by chest radiography, but a negative sputum culture result, and was fully treated; 102 (8.3%) were diagnosed with LTBI. Combined with the earlier groups of school contacts, a total of 1,249 (90.4%) of 1,381 school contacts were evaluated: four who had previously been treated for LTBI were evaluated with a chest radiograph only, 435 were tested with IGRA, and 810 received TST.
Treatment of Infected School Contacts
Contacts with LTBI were offered a choice between self-supervised daily isoniazid for 9 months or rifampin for 4 months until a rifapentine supply was secured in late February 2012. Then, once-weekly isoniazid and rifapentine for 12 weeks supervised at school by directly observed therapy (6) was recommended preferentially. Among the 90 contacts known to have been offered the latter regimen, 60 chose it, as well as five others for whom the options that were offered were not recorded. The workers supervising the doses used telephone calls, text messages, and home visits to encourage adherence and consulted daily with public health nurses about problems such as missed doses. Because rifampin and rifapentine can reduce the effectiveness of hormonal contraceptives, condoms were offered at the public health clinics.
Overall, 162 (13%) school contacts of the index patient had LTBI. This included the person who completed 2 months of four-drug treatment for TB disease before the diagnosis was changed to LTBI and whose treatment was regarded as sufficient (1,3). Of the remaining 161 contacts with LTBI, 159 (99%) started treatment, of whom 153 (96%) completed it. Treatment completion was similar by LTBI regimen: three of three (100%) for 9 months of isoniazid, 88 of 91 (97%) for 4 months of rifampin, and 61 of 65 (94%) for 12 doses of once-weekly isoniazid and rifapentine. One of the four not completing the latter regimen completed 9 months of isoniazid.
Of the three contacts who did not complete the rifampin regimen, two stopped for unknown reasons. The other had treatment interrupted because of an adverse event (rash). Then isoniazid was prescribed, but it was discontinued because of another adverse event (hepatitis). Of the four contacts not completing the isoniazid-rifapentine regimen, one stopped for unknown reasons after 6 doses. Three had their treatment interrupted because of adverse events. One had headache, nausea, and depression and completed 9 months of daily isoniazid. One had rash, dizziness, and blurred vision that recurred with daily isoniazid and declined further treatment. One had fever, aches, malaise, and interactions between rifapentine and other medications and declined further treatment.
Response Capacity, Communications, and Community Relations
The surge in workload exceeded the capacity of the local health department. Colorado officials activated public health preparedness programs for the state and Denver and Boulder counties, which established an incident command structure led by the TB control authorities of Denver and Boulder counties. Eighty-one persons from seven city or county health departments and the state health department, two county medical reserve corps members, and representatives from two schools of nursing and one school district served at the in-school screening clinics, with 43 of these persons attending multiple sessions. Five registered nurses from four health departments, who were supported by one clerk, counseled the patients, administered the first directly observed doses of isoniazid-rifapentine and provided the monthly supplies of isoniazid or rifampin for daily self-supervised treatment. Two persons from CDC were reassigned from other state health department duties to supervise the weekly isoniazid-rifapentine regimen at the school, 1 month each consecutively, followed by two Denver Metro TB Clinic outreach workers who supervised doses at the school and then at homes after summer vacation began. The workload for the screening clinics was 885 person-hours and for the LTBI treatment was 890 person-hours, which included 560 person-hours for supervising isoniazid-rifapentine doses and tracing patients who missed doses. These measures of workload did not include the hours spent planning, keeping records, and communicating with the public or the hours spent investigating the earlier groups of contacts in the school and other settings.
In mid-January 2012, local news media began featuring the investigation. This was followed by Internet social media reporting, including perceptions that students were dying from TB, that illegal immigrants brought the TB, and that the school would be closed. Throughout the contact investigation, public health and school officials convened public meetings with school personnel, students, their families, and news reporters to address concerns and perceptions about TB. At follow-up meetings, the officials reported the progress of the investigation and showed evidence that transmission had ended. The importance of preventing future TB disease by completing LTBI treatment was stressed.
The index patient did not disclose 20 nonschool social contacts until December 2012, when one had developed pleural TB disease with negative culture results. Nine others were completely evaluated, and two had LTBI. The remaining 10 were either not found or not completely evaluated. One had left Colorado and was diagnosed with culture-confirmed TB disease in another jurisdiction in 2013. The genotypes for the M. tuberculosis isolates from that patient matched those from the index patient. As of July 2013, no additional TB disease in school contacts had been reported, and no additional M. tuberculosis isolates with this genotype had been found in Colorado.
Carolyn Bargman, MA, Boulder County Public Health/Denver Metro TB Clinic; Randall Reves, MD, Matt Parker, Robert Belknap, MD, Denver Metro TB Clinic; Juli Bettridge, Colorado Dept of Public Health and Environment. Deborah T. Bedell, MBA, Div of Viral Hepatitis; Maria E. Galvis, Christine S. Ho, MD, John A. Jereb, MD, Div of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC. Corresponding contributor: John A. Jereb, firstname.lastname@example.org, 404-639-8120.
Colorado is a low-incidence TB state, with 64 cases of TB disease reported in 2012 for a rate of less than 1.4 per 100,000 person-years, compared with 3.2 per 100,000 in 2012 for the United States overall. TB contact investigations, especially those in congregate settings, are intrinsically complex and labor-intensive (4), requiring mobilization of a large, flexible workforce for a prolonged response. This investigation at a high school demonstrated how an emergency response plan can gather widely dispersed expertise to one site. Augmenting the local health department with additional personnel expedited the evaluation of more than 1,200 contacts and the treatment of those who were infected. Transmission of M. tuberculosis at schools is unusual, but this investigation found that numerous contacts had been infected, particularly those who had shared classes with the index patient. The absence of TB disease in school contacts after the investigation indicates that the interventions were effective.
The Colorado experience with the weekly 12-dose isoniazid-rifapentine regimen is one of the earliest reported after the controlled clinical trials (6). The regimen shows promise for congregate settings, where treatment is convenient for the patients and efficient for the health department. Adverse events in this report resembled those in the treatment trials and limited or changed treatment for three of 65 patients. CDC is collaborating with health departments and institutions nationwide in collecting data on this regimen in routine usage.
Of contacts initially diagnosed with LTBI in this investigation, 99% started treatment, which exceeded the 2010 U.S. treatment-start rate of 72% (Division of Tuberculosis Elimination, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC, unpublished data, 2010). The two short-course regimens including either rifampin or rifapentine for LTBI treatment probably contributed to the treatment completion rate of 98% of those starting an LTBI-specific regimen. For Colorado overall, the treatment completion rate for infected contacts who started self-supervised daily isoniazid in 2007–2011 was 73% (Colorado Department of Public Health and Environment, unpublished data, 2013), although in this report, all three contacts who started this regimen completed it. For the United States overall, the completion rate in 2010 was 68%. The campaign for public education in Colorado might have facilitated the successes at the school.
Drug-susceptible TB disease is curable, but its historical reputation as a lethal contagious disease generates stigma, and misinformation can amplify fears. When communicating to the public about a crisis, the information should be simple, credible, accurate, consistent, and on time. One of the best ways to counter the public’s fears is to provide useful information about the event and let them know what they can do (7).
American Thoracic Society. Diagnostic standards and classification of tuberculosis in adults and children. Am J Respir Crit Care Med 2000;161:1376–95.