Bureau of Epidemiology
Bureau of Epidemiology February 2001 Utah Department of Health
inside... Emergency Winter Shelter Tuberculosis Testing
Pneumococcal Disease
Exceptional Efforts in Public Health
Bioterrorism Library
Important Information
Monthly Morbidity Summary

Emergency Winter Shelter Tuberculosis Testing

The Utah Department of Health, Bureau of HIV/AIDS & Tuberculosis (TB) Control/Refugee Health, has been placing and reading tuberculin skin tests (TSTs) on persons seeking shelter at the Community Winter Emergency Housing facility in Midvale. The TB Control/Refugee Health Program coordinated the program with Travelers’ Aid Society and the Fourth Street Clinic to ensure as many people as possible from this high risk population would be tested and treated if necessary. TSTs are given to identify clients with latent TB infection or active TB disease. This project was started in November 1998 and has operated each year since, from early November to the last day that the shelter is open for the winter season (typically around April 1). During the winter season, each new client receives a TST as part of a general screening process used to protect the health of all the shelter clients. Testing began this year on November 6, 2000 and, as of February 3, 2001, 314 people have had a TST placed. Eighty-four people did not return to have their TST read. Of the 230 clients who were both tested and read, 28 had a positive reaction (interpreted as a TST reaction of greater than or equal to 10 millimeters induration) and 202 had negative reactions.

Every week during the winter season, TB Control/Refugee Health Program staff and University of Utah medical students have placed TSTs on Monday and Tuesday nights, and read the results on Wednesday and Thursday nights. All clients who have a positive TST have been referred to the Fourth Street Clinic for further evaluation. Although the importance of follow up at the Fourth Street Clinic has been explained to the clients, only 11 clients out of the 28 who had positive TSTs have gone to the Fourth Street Clinic for further evaluation. None of the eleven have been found to have active TB disease. Two major problems facing the Emergency Winter Shelter Testing Program are getting clients to return 48-72 hours after having a TST placed to get their TST result read, and getting clients with positive TSTs to go to the Fourth Street Clinic for further evaluation. Incentives, or small rewards (i.e., food coupons, sweatshirts, socks, underwear), are given to those clients who do return for a test reading or clinic follow-up in an attempt to address these problems. It is anticipated, however, that getting clients to return for appropriate follow-up will be an ongoing problem. Most homeless people live under extreme circumstances and may have other problems (i.e., substance abuse) that make it difficult for them to comply with follow-up instructions.

Based on the numbers from previous years, it is estimated that from 100 to 300 more people will receive a TST before April 2001, the anticipated end of this winter season. The objectives of this project are to identify persons with latent TB infection or active TB disease, and to refer them for appropriate follow-up. It is hoped that, by addressing these objectives, the TB Control/Refugee Health Program and its partners will be able to reduce the overall incidence of TB in this high-risk population.

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Pneumococcal Disease

With the recent introduction of the Pneumococcal 7-valent pediatric vaccine (PrevnarTM) it seemed like a good time for a review of pneumococcal disease.

The bacterium Streptococcus pneumoniae (pneumococcus) is the most common cause of invasive bacterial infections in children. Since the Haemophilus influenzae type B conjugate vaccine has been available, pneumococci and meningococci have become the two most common causes of bacterial meningitis in infants and young children. Pneumococci are also a frequent cause of otitis media, sinusitis, and community-acquired pneumonia. As with many other microorganisms, pneumococci find their ecologic niche in colonizing the nasopharynx and may be isolated from the nasopharynx of five to 70% of healthy adults1. The rate of asymptomatic carriage varies with age and environment. The spread of the organism within a family or household is influenced by factors such as crowding, season, and the presence of upper respiratory infections. Transmission occurs as the result of direct person-to-person contact via respiratory droplets. The spread of invasive pneumococcal disease is usually associated with increased carriage rates. Resistance to antibiotics commonly used to treat pneumococcal disease is increasing. In some areas of the U.S. up to 35% of invasive pneumococcal isolates are not susceptible to penicillin2.

Utah has averaged 17 cases of invasive pneumococcal disease annually over the last five years with the majority of cases occurring in children >2 years of age (Figure 1). Pneumococci cause an estimated 50,000 cases of invasive disease in the U.S. annually. Children with functional or anatomic asplenia, particularly those with sickle cell disease, and children with HIV infection are at very high risk of invasive disease, with rates in some studies more than 50 times higher than children of the same age without these conditions. Children of certain racial and ethnic groups also have increased rates, particularly children of Alaskan Native, certain American Indian groups, and of African American origin1. The reason for this increased risk by race and ethnicity is not known.

Pneumococcal Vaccines

The 23-valent pneumococcal polysaccharide vaccine has been available for the prevention of pneumococcal disease since 1983. It is 60% to 70% effective in preventing invasive pneumococcal disease and is recommended for all persons >65 years of age, as well as persons >2 years of age with chronic cardiovascular, pulmonary, metabolic, or hepatic illnesses, or those with immune compromise. This vaccine is not effective in children <2 years of age or in reducing nasopharyngeal carriage of pneumococci3.

The first pneumococcal conjugate vaccine (PCV7) PrevnarTM was licensed in the United States in 2000. It includes purified capsular polysaccharide of the seven serotypes most commonly isolated from children with invasive disease. It was shown to reduce invasive disease caused by vaccine serotypes by 97%. PrevnarTM contains no thimerosal or other preservatives. This vaccine is recommended for all children <2 years of age as well as children 24-59 months of age who are at high risk for invasive pneumococcal disease (e.g., children with sickle cell disease, human immunodeficiency virus infection, and other immunocompromising or chronic medical conditions). This vaccine should be considered for children 24-59 months of age who are of African-American, Alaska Native, or American Indian descent; and those who attend group child care1. It is currently unknown if this vaccine is effective in reducing nasopharyngeal carriage.

References:

1. CDC. Preventing pneumococcal disease among infants and young children: Recommendations of the ACIP. MMWR 2000;49:1-35.

2. CDC. Active Bacterial Core Surveillance. Available at HYPERLINK http://www.cdc.gov/ncidod/dbmd/abcs. (Accessed March 2,2001).

3. CDC. Update: pneumococcal polysaccharide vaccine usage-United States. MMWR 1984; 33:273

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Exceptional Efforts in Public Health

Florida health officials recently announced the investigation of a multi-state hepatitis A outbreak associated with a popular seafood restaurant. This was old news to Charlotte Pace, a Public Health Nurse in Utah County who investigated two hepatitis A cases with histories of travel to Florida. Charlotte obtained detailed lists of restaurants from the two unrelated patients who had traveled to Florida on business the previous month. This information prompted Charlotte to immediately call the Bureau of Epidemiology. The list of restaurants was reported to officials in Florida, and the outbreak was announced two days later. The epidemiologists in Florida had been piecing together several reports and were grateful for the timeliness and details provided by Charlotte’s investigation. It should also be mentioned, that Heidi Tippetts, another nurse in Utah County, followed up with these two patients in an effort to obtain additional clinical specimens for molecular epidemiology at CDC.

We need to remember the impact that the information from one or two reported cases may have in identifying and preventing an outbreak. These two dedicated Public Health Nurses make a great investigative team. Thanks!

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Bioterrorism Library

The Surveillance Program in the Bureau of Epidemiology has organized an extensive bioterrorism library. The Surveillance Program continues on an ongoing basis to augment material to this library. The library contains training videos, CDs and text documents. There are currently over 70 journal articles covering topics in bioterrorism and emergency planning and response. Many of these articles address bioterrorism agents and preparedness/response to public health emergencies, including bioterrorism. Many articles and material are taken from the Journal of the American Medical Association, Emerging Infectious Diseases, MMWR reports and from the U. S. Army. A catalogue of material and references can be made available to anyone upon request. Some documents are in PDF format and can be forwarded via email to anyone interested. If you have interest in obtaining a listing of articles and other material, please email Dean Penovich at dpenovic@utah.gov or call at (801) 538-6191.

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Important Information

When Reporting a
Communicable Disease:
Call: (801) 538-6191
Or:
Fax: (801) 538-9923

“Exceptional Efforts in Public Health” is a new addition to the Epidemiology
Newsletter. If you know of someone or an agency whose efforts deserve

recognition, please contact us.

The February 2001 Newsletter is the most current Newsletter online.

For Information on Fact Sheets for Diseases or
Annual Report  Information, as well as The Epidemiology Newsletter, you can browse our website:

health.utah.gov/epi/

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 Utah Department of Health, Bureau of Epidemiology
Monthly Morbidity Summary
February 2001 - Provisional Data

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The Epidemiology Newsletter is published monthly by the Utah Department of Health, Division of Epidemiology and Laboratory Services, Bureau of Epidemiology, to disseminate epidemiologic information to the health care professional and the general public.

Send comments to:  The Bureau of Epidemiology, Box 142104, Salt Lake City, UT 84114-2104, or call (801) 538-6191

Approval 8000008:  Appropriation 3705

Rod Betit, Executive Director, Utah Department of Health
Charles Brokopp, Dr.P.H., Division of Epidemiology and Laboratory Services
Craig R Nichols, MPA, Editor, State Epidemiologist, Director Bureau of Epidemiology
Gerrie Dowdle, MSPH, Managing Editor
Connie Dean, Production Assistant

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