Two Utah residents have been recently diagnosed with illnesses associated with
hantavirus. A case of Hantavirus Infection was diagnosed in a 32-year- old male from Juab
County who became ill around the first of June. The patient was admitted to a small rural
hospital for a four-day stay. He was never intubated and in fact never had significant
respiratory illness. A case of Hantavirus Pulmonary Syndrome (HPS) was diagnosed in a
37-year-old man from Emery County who became ill around the first of July. The patient was
seen at a rural hospital emergency room and then transferred to a tertiary care facility.
After a four-day stay the patient was discharged. Along with these two Utah cases,
Colorado and New Mexico have had three cases each and of the six cases, three have died.
Given the rapidity of onset, shock and respiratory failure, early
recognition of the illness is critical in reducing the risk of mortality. HPS begins four
days to six weeks after exposure to infected rodents or their excreta, although not all
patients will give a history of rodent exposure. All patients experience a prodromal phase
with fever, chills and myalgias, persisting for 1 to 7 days before progression to the
cardiopulmonary phase. Pain in the legs and back can be very severe during the
hantavirus prodrome. Many patients also experience nausea, vomiting, diarrhea, and
abdominal pain. Cough and other upper respiratory symptoms are not present at the onset of
the prodromal phase but instead begin hours before the onset of the noncardiogenic
Because there is no way to clinically distinguish between the prodrome
of HPS and that of many other viral and bacterial infections, we recommend the liberal use
of the complete blood count (CBC) with differential and platelet count in the appropriate
setting. A low platelet count (<150,000 in 98% of cases; <130,000 in 92%) is the
only CBC abnormality consistently seen during the prodromal phase. All HPS cases
eventually have platelet counts <100,000. Other nonspecific lab results suggestive of
prodromal HPS include elevated LDH, elevated AST, and reduced serum bicarbonate. Patients
with symptoms consistent with early HPS but with platelet counts of >150,000 should be
advised to return to the clinic in 24 hours for re-evaluation.
The transition from hantavirus prodrome to respiratory failure occurs 4
to 12 hours after onset of cough and shortness of breath. With the onset of pulmonary
edema, the CBC now shows thrombocytopenia, elevated hematocrit, leukocytosis with
circulating myelocytes, promyelocytes, and immunoblasts, recognized as large atypical
lymphocytes with deep blue cytoplasm. Acidosis, abnormal PTT, elevated LDH and hepatic
enzymes, and reduced serum albumin are usually seen. Serum creatinine is usually not
elevated. Hypotension in HPS is due to cardiogenic shock with low cardiac output and
normal or elevated peripheral vascular resistance. Patients presenting with bilateral
alveolar-interstitial infiltrates, hypotension plasma lactate greater than 4 meq/L have a
high case fatality.
Patients with suspected HPS (thrombocytopenia and compatible clinical
picture) should be transported to a critical-care unit as early as possible, because the
fluid management may require guidance by Swan-Ganz catheter data, hypotension must be
treated with inotropes (initiate early treatment with dobutamine), and oxygenation may be
difficult even with mechanical ventilation.
If you or your patients have general questions about the signs and
symptoms of HPS, what to do after exposure to rodents, prevention of hantavirus
infections, or other issues not related to a specific case of suspected HPS, the following
resources are available:
Printed material and videos - Utah Department of Health - (801)
General information - local and state health departments, or www.cdc.gov/ncidod/diseases/hanta/hps/index.htm.
Persists in Children and Adults
Contrary to common belief, pertussis is not exclusively a disease of infants. In
1996, there were a total of 7,555 pertussis cases in the U.S., with 17.9% of those
occurring in persons >20 years of age. In Utah, 15% of the 1996 cases were among
adults and in 1997, adults made up 32% of the total cases. To date, 21% of the 1998 cases
have also been in the adult population. However, the age group most frequently affected by
pertussis is children under five years of age with the highest occurrence in infants under
one year of age. During the past three years Utah has averaged 31 cases of pertussis
yearly, while neighboring western states have experienced large outbreaks of pertussis
Pertussis, also known as whooping cough, is a highly contagious
bacterial infection of the respiratory tract caused by the bacterium Bordetella
pertussis. Pertussis causes violent spells of coughing that may be followed by
difficulty in breathing, vomiting, or "whooping". Transmission of pertussis
occurs primarily by aerosol droplet and is most easily transmitted in the period starting
7 days following exposure to three weeks after the onset of spasmodic coughing. Seventy to
90 percent of susceptible household and other close contacts of a person with pertussis
will develop the disease within 7 to 14 days, commonly 5 to 10 days. The disease may last
up to 3 months and be complicated by pneumonia, seizures, encephalopathy or death.
Protection of infants too young for immunization requires increased
awareness of pertussis by health care providers. Providers should consider the diagnosis
of pertussis in children, adolescents and adults who develop cough lasting more than 7
days. The disease can be diagnosed by isolation of Bordetella pertussis from a
nasopharyngeal swab. The later the culture is obtained in the course of illness (usually
after 1-2 weeks), the less likely it is to be helpful in making the diagnosis. Under
optimal conditions 80% of suspected cases in outbreak investigations can be confirmed by
culture; in most clinical situations isolation rates are much lower. Due to the
insensitivity of the test, it is critical that the specimen is collected as accurately as
Transmission of pertussis may be reduced in household or close contacts
by early treatment of cases with an effective antimicrobial agent. Erythromycin (40
mg/kg/day for children, 1 gram/day for adults) should be continued for a minimum of 14
days. All household and other close contacts should receive treatment, regardless of age
and vaccination status. All close contacts <7 years of age, who have not received four
doses of pertussis vaccine should complete the series with the minimum interval between
Immunization with pertussis vaccines has reduced the number of
pertussis cases and related deaths. However, due to inadequately immunized infants and
children and difficulty in diagnosing the disease, pertussis remains a very real threat.
The best defense currently available is to immunize children appropriately and on
schedule. The newer pertussis vaccines (acellular or DTaP) are quite effective and are
less reactogenic than whole cell DTP vaccines. A variety of DTaP vaccines have recently
been licensed for infants and have shown high levels of efficacy. Additionally, studies
are underway for assessing the use of acellular pertussis vaccines in adults. Future
strategies for reducing the incidence of pertussis and possibly eradicating it may include
booster immunizations for adolescents and adults.
For further information on pertussis disease, vaccines, or other
vaccine preventable disease issues, contact the Utah Immunization Program, (801) 538-9450.
References: Vaccine Bulletin, February
1996; Immunization Action News, April 1994; CDC 1996 Pertussis Surveillance Summary;
National Immunization Program (NIP), Background on European Studies of Acellular Pertussis
Vaccine; NIP 1997 Manual for the Surveillance of Vaccine Preventable Diseases.
the 5th Annual Tuberculosis Conference
"The Continuum of TB Case
Please join the Utah Department of Health
and the American Lung Association of Utah at this years Tuberculosis Conference. It
will be held October 20, 1998 at the State Office Building Auditorium from 8:00 AM - 4:00
PM. Cost for the one-day conference is $40 pre-registration, $45 day of registration, $20
for students and $35 per person for groups of 5 or more. Lunch is included in the
We are happy to have as the keynote speaker Betty Gore, RN,
President-Elect of the National TB Nurses Consultant Coalition and Nurse Consultant for
the Division of Tuberculosis Control, South Carolina Department of Health and
Environmental Control. She will be discussing different ways to use Directly Observed
Therapy and incentives/enablers in the treatment of TB. There will also be a discussion on
Client Case Management and a presentation on the essence of diversity in Utah. Three
afternoon breakout sessions will expand on the topics above and allow the participants
more time with the presenters to ask questions about current case management issues they
may be encountering with clients.
For a registration form or more information please call Kaye Staker at
the American Lung Association of Utah at 801-484-4456.
Prevention 1998 - 1999
Its time once again to update our information concerning the vaccine and
antiviral agents available for controlling influenza during the 1998-99 influenza season.
Antigenic variation of both influenza A and B viruses have resulted in major epidemics of
respiratory disease. The antigenic characteristics of circulating strains provided the
basis for selecting the virus strains included in each years vaccine.
Typical influenza illness is characterized by abrupt onset of fever,
myalgia, sore throat, and nonproductive cough. Unlike other common respiratory illnesses,
influenza can cause severe malaise lasting several days. During influenza epidemics, high
attack rates of acute illness result in both increased numbers of visits to
physicians offices, walk-in clinics, and emergency rooms and increased
hospitalizations for management of lower respiratory tract complications.
Vaccination of high-risk persons each autumn year before the influenza
season is currently the most effective measure for reducing the impact of influenza.
Groups at increased risk for influenza-related complications include:
Persons aged >65 years.
Residents of nursing homes and other chronic-care facilities that
house persons of any age who have chronic medical conditions.
Adults and children who have chronic disorders of the pulmonary or
cardiovascular systems, including children with asthma.
Adults and children who have required regular medical follow-up or
hospitalization during the preceding year because of chronic metabolic diseases (including
diabetes mellitus), renal dysfunction, hemoglobinopathies, or immunosuppression (including
immunosuppression caused by medications).
Children and teenagers (aged six months - 18 years) who are receiving
long-term aspirin therapy and therefore might be at risk for developing Reye syndrome
Women who will be in the second or third trimesters of pregnancy
during the influenza season.
Some persons at high risk can have a low antibody response to influenza
vaccine. Efforts to protect these groups against influenza might be improved by reducing
their exposure from their caregivers. Therefore, the following groups should also be
Physicians, nurses, and other personnel in both hospital and
Employees of nursing homes and chronic-care facilities who have
contact with patients or residents.
Providers of home care to persons at high risk (e.g., visiting nurses
and volunteer workers).
Household members (including children) of persons in high-risk
Influenza vaccine may be administered to any person who wishes to
reduce the chance of becoming infected with influenza. Only those with a known
anaphylactic hypersensitivity to eggs or to other components of the vaccine should not
receive the influenza vaccine.
The optimal time for organized vaccination campaigns is usually from
October through mid-November. The trivalent influenza vaccine prepared for the 1998-99
season will include A/Beijing/262/95-like (H1N1), A/Sydney/5/97-like (H3N2), and
B/Beijing/184/93-like hemagglutinin antigens. For the B/Beijing/184/93-like antigen, U.S.
manufacturers will use the antigenically equivalent strain B/Harbin/07/94 because of its
Please refer to the MMWR, Vol.47, No.RR-6 for more information on the
1998-99 influenza season or call the Utah Department of Health, Bureau of Epidemiology at
Some Utah laboratories are screening for E.
coli O157:H7 using the Meridian EHEC kit. This is a very sensitive way to screen for
enterohemorrhagic E. coli (EHEC). However, there are strains of EHEC that are NOT
E. coli O157:H7, and therefore it may appear that the Meridian test is giving a
false positive result.
If your lab is using the Meridian EHEC test, and obtains a sample that
gives a positive test result and EITHER:
- you are not culturing to find E. coli
- you cultured for but did not find E. coli O157:H7. THEN,
PLEASE send the EHEC test broth immediately to the Utah Public
Health Lab. We are actively looking for EHEC strains that are not E. coli O157:H7.
If you find E. coli O157:H7 from the broth, please submit the
isolate as you normally would the broth is not necessary.
Utah Department of
Health, Bureau of Epidemiology
Monthly Morbidity Summary - July
1998 - Provisional Data
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
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