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 pulmonary edema.

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) 538-6191.

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 possible.

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 doses.

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.

Please join the Utah Department of Health and the American Lung Association of Utah at this year’s 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 registration fee.

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.

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:

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 vaccinated:

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 growth properties.

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 O157:H7 OR
     - 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.

Send comments to:

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

Approval 8000008: Appropriation 3705