Bureau of Epidemiology
Bureau of Epidemiology August 1998 Utah Department of Health
  Hepatitis B In Grand County, 1998
  Sexually Transmitted Disease Treatment & Prevention Programs Slow the Spread of HIV
  Bureau Changes It's Name
  Monthly Morbidity Summary


Hepatitis B in Grand County, 1998

Background. On June 2, the Bureau of Epidemiology was notified by the Grand County Unit of the Southeastern Utah District Health Department that five residents of Grand County had been diagnosed with acute hepatitis B since April 1998. This was a marked increase in the number of cases of acute hepatitis B in this county as no cases had been reported from Grand County since one case of acute hepatitis B had been diagnosed in 1995.

Investigation results. Nine confirmed cases and two probable cases of acute hepatitis B were diagnosed in Grand County residents between April and August of 1998. A resident of an adjacent county who had known contact to one or more of the cases was also confirmed as having acute Hepatitis B. (A confirmed case of acute hepatitis B is defined as someone with: 1) a positive IgM antibody test for hepatitis B core antigen; and/or, 2) a positive hepatitis B surface antigen test with evidence of acute viral hepatitis. The two probable cases had a positive hepatitis B surface antigen test, but did not meet other criteria for the case definition.) The patients were young adults (their ages ranged from 15 to 29 years of age with a median age of 18). Nine were male, and three were female. The dates of onset of their illnesses are shown in the chart below.

While the ten people with confirmed acute hepatitis B sought medical care for their condition, none were hospitalized as a result of their disease. However, one of the people with probable acute hepatitis B has been hospitalized with liver damage. There were no deaths associated with this outbreak.

The interviews that were conducted by the Utah Department of Health and the Grand County Unit as part of this investigation revealed that disease transmission in this group of people may have been related to the practice of sharing needles to inject intravenous drugs, although other modes of transmission could not be absolutely ruled out. It was also determined that continued transmission of hepatitis B to others in this community was very possible.

The following recommendations were made to reduce the further spread of disease in this community:

1. All close contacts of the individuals associated with the outbreak should be identified and evaluated to determine their possible need for hepatitis B immunoglobulin (HBIG).

2. The three dose hepatitis B vaccine series should be initiated and completed for all of the above contacts; for anyone in the community who may also be at risk for contracting hepatitis B; and, for anyone who simply wishes to reduce their risk of contracting hepatitis B. [Note: There is no recommendation at this time for persons who have been previously vaccinated against hepatitis B to be tested for immunity or receive booster doses of vaccine unless there is a known exposure incident.]

3. People need to be educated as to how hepatitis B is spread, and they need to realize that participating in such activities may place them at risk for contracting other diseases as well.

Since June, two additional cases of acute hepatitis B with reported contact to one or more of the individuals associated with this outbreak have been diagnosed in Utah.

Discussion. This outbreak serves as an example of what a serious public health problem hepatitis B poses. This is a disease that affects people of all ages in the United States and around the world. Each year, more than 240,000 people contract hepatitis B in the United States alone. While most people fully recover from hepatitis B, not all do. People who do not recover may not look or feel ill, but they carry the hepatitis B virus in their bodies and can infect others. They are also at increased risk for developing liver failure or liver cancer. More than 6,000 people in the U.S. die every year from liver disease caused by hepatitis B.

Hepatitis B virus (HBV) is found in blood and certain body fluids, such as semen, vaginal secretions, and saliva, of people infected with HBV. HBV is not found in sweat, tears, urine, or respiratory secretions. Contact with even small amounts of blood that is contaminated with HBV can cause an infection. Hepatitis B can be spread from an infected person in a number of ways, including having unprotected sex; sharing needles to inject drugs; during birth from mother to child; having contact with blood or open sores of an infected person; sharing household items with an infected person, such as razors, toothbrushes, or washcloths; pre-chewing food for babies or sharing chewing gum; and using unsterilized needles in ear or body piercing, tattooing, or acupuncture.

Hepatitis B can be prevented with a three-dose series of hepatitis B vaccine. The vaccine is recommended for all children less than 18 years of age, and people in certain high risk groups, including health care workers who have contact with blood, persons who are undergoing hemodialysis, users of illegal injectable drugs, men who have sex with men, and immigrants or refugees from areas of the world where there is a higher rate of HBV infection in people (Asia, Pacific Islands, Sub-Saharan Africa, Amazon Basin, Eastern Europe, Middle East). (Reference: Immunization Action Coalition, Hepatitis B Coalition. Needle Tips. Internet address: www.immunize.org)

[Note: There has been a recent change in the immunization requirements for children in Utah. Students who are enrolling for the first time at a Utah school after July 1, 1999 (except for a student in the first grade or above) will be required to provide written documentation of receiving three appropriately timed doses of hepatitis B vaccine.] If you want more information about hepatitis B or where to obtain the vaccine, contact your local health department, the Utah Department of Health, Immunization Program (801) 538-9450, or the Bureau of Epidemiology (801) 538-6191.

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No Risk?? No Way!! There are two major problems with not vaccinating infants with hepatitis B vaccine because of "Low Risk".
The first is that transmission can sometimes occur in uncommon ways:
1. 22 cases of hepatitis B were linked to a Florida dermatologist’s practice Result: inadequate sterilization methods after surgical procedures
2. 26 patients in a California hospital contracted acute HBV Result: contamination of the stabilizing platform on a spring-loaded finger-stick device
3. 35 patients of an acupuncturist in Rhode Island became infected with HBV Result: inadequately sterilized needles or the transfer of infectious material from the acupuncturist’s hands
4. 31 clinical cases of hepatitis B occurred among clients of a weight loss clinic in California Result: contaminated surfaces under the nozzle and cap of a jet injector for parenteral injections
5. Three co-workers and their spouses of a butcher in Israel Result: Hand cuts or punctures of the skin through contaminated blood on shared knives
6. Five members of a high school sumo wrestling club Result: Index case often bled from injuries received while wrestling, thereby transmitting HBV percutaneously through cuts and abrasions
The second problem is that it is dangerous to make vaccination decisions based on ethnicity, geographic area, or income:
1. 100 persons infected in International Falls and then spreading to other towns Result: workers in a paper mill shared a needle while injecting drugs
2. Four cases in the northern suburbs of Minneapolis Result: Junior high students used a contaminated needle to tattoo themselves


Sexually Transmitted Disease Treatment and Prevention Programs Slow the Spread of HIV

Since the beginning of the AIDS epidemic, there have been epidemiological ties that draw a parallel between HIV and other sexually transmitted diseases (STD) all over the world. Further studies have drawn conclusions toward greater susceptibility in contracting HIV when infected with an STD. Individuals who are infected with STDs are at least two to five times more likely than uninfected individuals to acquire HIV if exposed to the virus through sexual contact (Wasserheit, 1992). Even those with nonulcerative STDs, especially gonorrhea and chlamydia, are at great risk for contracting and transmitting HIV during sexual intercourse.

The Advisory Committee on HIV and STD Prevention, in conjunction with national, state, and local strategies, suggests that early detection and treatment of curable STDs have been shown to reduce HIV transmission to prevent HIV infection and AIDS. One observational study in Africa has shown that the continuous treatment and prevention of sexually transmitted diseases decreased new heterosexually transmitted HIV infections by 40% (Grosskurth et al., 1995). Thus, at the community level, controlling the high prevalence rate of STDs could reduce the rate of HIV transmission. Current knowledge now shows that education and prevention programs are also crucial to prevention of HIV and STD infection.

As an integral part of comprehensive HIV prevention programs, the Advisory Committee for HIV and STD Prevention at the Centers for Disease Control and Prevention (CDC), has now published a special Recommendations & Reports (R & R) issue on HIV and STD prevention in the Morbidity and Mortality Weekly Report. This report will be distributed throughout medical and substance abuse centers, managed care providers, and correctional facilities. The document can also be downloaded from the CDC web site at www.cdc.gov/nchstp/od.


Bureau Changes It’s Name

he Bureau of Environmental Services has changed its name to the Bureau of Food Safety & Environmental Health. This bureau, in cooperation with local health departments, has statutory authority to protect the public from environmental agents of disease. Environmental areas of responsibility include, but are not limited to: food protection, swimming pools and spas, recreation areas, schools, hotels and motels, and the Utah Indoor Clean Air Act. The activities mostly lie in the areas of policy development, rules promulgation and interpretation, training and standardization of local health department inspectors, serving as the state experts in environmental sanitation, serving on task forces, and coordinating with many federal, state, and local agencies.

When the Bureau of Environmental Services was created in 1991, the name "environmental services" was based on the need to retain the concept of environmental protection prominently in the Utah Department of Health structure. Bureau staff field many calls that actually deal with Utah Department of Environmental Quality issues as a result of the name in the telephone directory. Also, the old name did not accurately convey the bureau’s role and services. In the 1997 Legislature, this inaccuracy almost cost the bureau, and accompanying services, its existence. A clearer name will be beneficial in this regard and is appropriate in forwarding the Division of Epidemiology and Laboratory Services’ initiative to make food safety an important issue.

In the last several years, Utah has had an increase in certain disease rates that may have been transmitted by food. The emergence of new diseases communicable through food, antibiotic resistant strains of diseases, and our increasing reliance on food imported from outside the United States in the 1990's has made food protection much more complicated than it was ten years ago.

The Bureau of Food Safety & Environmental Health has two programs: Food Protection, managed by Bill Emminger and General Sanitation & Safety, managed by Ron Ivie. The Bureau Director is Richard Clark and the secretary is Cassandra Fairclough. When contacting the bureau, please use the following as guidance:

Food Protection issues and questions- Bill Emminger (801-538-6755), or email at bemminge@doh.state.ut.us.

Public facility sanitation issues and questions- Ron Ivie (801-538-6753), or email at rivie@doh.state.ut.us.

Indoor Clean Air Act and Policy issues and questions- Richard Clark (801-538-6750) or email at rwclark@doh.state.ut.us.

Copies of rules and general requests- Cassandra Fairclough (801-538-6856), or email at cfairclo@doh.state.ut.us.

The Bureau address is:
Bureau of Food Safety & Environmental Health
Utah Department of Health
P.O Box 142103
Salt Lake City, UT 84114-2103


Utah Department of Health, Bureau of Epidemiology

Monthly Morbidity Summary - August 1998 - 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
Cristie Chesler, BA Managing Editor