Archive for the 'Infectious Diseases' category

MERS-CoV: Why We Are Not Panicking

By Tyler Wolford, Specialist, Laboratory Response NetworkPublic Health Preparedness and Response Program; and Stephanie Chester, Senior Specialist, Influenza Program, Infectious Disease Program, APHL

MERS-CoV: Why We Are Not Panicking | www.aphlblog.orgBy now you have probably heard that CDC has confirmed two cases of Middle East Respiratory Syndrome (MERS-CoV) infection in the US. Both were imported from Saudi Arabia; travelers became sick on their journey and sought care here in the US. This is the kind of stuff that typically gets us, infectious disease and preparedness folks, amped up, reaching for coffee and telling our loved ones we might be working late. We know that MERS-CoV is a serious infection – as of mid-May 2014, there have been 536 laboratory-confirmed cases and 145 deaths of MERS-CoV. However, the laboratory community is accustomed to responding to these situations—and that’s good news for public health. We have written, tested and rewritten preparedness plans, policies and procedures for dealing with novel and/or unexpected events and pathogens. We have dealt with white powders (more times than we can count), influenza A(H3N2)v, re-emerging vaccine preventable diseases and many other threats. In addition, we were given a lengthy (roughly two-year) heads-up with MERS-CoV. And while we know not to expect this luxury every time (we’re looking at you, 2009 H1N1 pandemic), the lead time meant that CDC, public health laboratories, health departments and clinicians were alerted and prepared well before the first US two cases occurred. Efforts by CDC and the public health labs ensured that, when the first cases arrived, they could be rapidly identified so proper precautions and epidemiologic investigations could begin. What are the reasons for our relative calmness despite the arrival of MERS-CoV on our shores? We were – and still are – prepared as the case count mounted on the other side of the Atlantic. Here are the specifics:

  • Planning. MERS-CoV was first reported in 2012 in Saudi Arabia. Once transmission became sustained in the Middle East, public health officials knew it was likely that a case would arrive in the US: we just didn’t know when. We had time to plan our response.
  • An approved test. CDC rapidly developed a real-time reverse transcriptase polymerase chain reaction (rRT-PCR) test which was granted emergency use authorization (EUA) by the FDA on June 5, 2013, and deployed the same month to 44 state public health laboratories and one local public health laboratory.
  • Infrastructure. The Laboratory Response Network (LRN) provided critical infrastructure for rapid distribution of the MERS-CoV test to public health laboratories across the US.
  • Training. Once laboratories received the test, they trained their staff and completed proficiency testing to demonstrate that they were trained and ready to perform testing should the need arise.
  • Experience. With health departments and physicians on alert, over 150 patients with MERS associated symptoms have been tested using the CDC assay. All were found to be negative.  This testing provided valuable opportunities for laboratories to familiarize themselves with the test.
  • Communication. CDC, APHL and other partner organizations have maintained timely communications with states, and others partners to keep everyone abreast of the current situation.
  • Dedication. Our public health labs are full of amazing scientists who are willing to spend countless hours, seven days a week to ensure rapid test results.

So if we aren’t panicking now that we have MERS-CoV cases in the US, what are we doing? We’re sprinting to keep pace with MERS-CoV and so far we have performed well, managing every step in the process with precision.

  • Indiana promptly notified CDC of a presumptive positive MERS-CoV infection and CDC rapidly confirmed this result.
  • CDC and Indiana started epidemiologic investigations and tested samples from close contacts of the infected patient.
  • APHL and CDC began communications immediately after the first case was confirmed.
  • APHL, in collaboration with CDC, held a laboratory alert call on May 6, 2014, to provide state and local public health labs with a situational update and to review laboratory testing guidance.
  • Currently CDC is distributing new proficiency testing panels so labs can refresh their competency on the CDC MERS-CoV test.

MERS-CoV is a serious threat that deserves the highest level of preparedness and attention.  Fortunately for the American public, we in the public health system are poised to handle MERS-CoV and other health threats whenever, wherever and however they enter our country. This is why we aren’t panicking, but it’s also why public health requires steady support.  Pathogens have no regard for budgets, funding cycles or economic trends. They won’t wait, and neither can we.

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Testing for MERS-CoV: The Indiana Lab’s Story

May 08 2014 :: Published in Infectious Diseases, Member News

By Lixia Liu, Deputy Director, Indiana State Department of Health Laboratories

Stephanie Dearth is a cheerful young supervisor with blond hair and black-framed eye glasses.  This was her third week as the supervisor of the virology laboratory at the Indiana State Department of Health Laboratories (ISDHL). When she arrived at work on Wednesday, April 30, she felt lighter as she had submitted her portion of a grant application the day before. She thought she might be able to catch up on her many tasks that had been put on hold. She took a sip of her coffee and walked to the laboratory.

Stephanie put her things away and went to her desk inside the laboratory. Between responding to her emails, discussing training plans for the new hire in her area and preparing for an upcoming CLIA inspection, the day went by quickly. She finally sat down at her desk after many trips to the lab bench; the voicemail light was blinking on her phone.

Testing for MERS-CoV: The Indiana Lab’s Story | www.aphlblog.org

Stephanie listened to the message. It was from Community Hospital in Munster requesting MERS-CoV testing. Recognizing the urgency of the request, she returned the call immediately and then sent an email to alert the ISDH respiratory epidemiologist about the request. Within an hour, the epidemiologist authorized the MERS-CoV test request from Community Hospital and held a teleconference with the ISDH (laboratory and epidemiology), CDC and the hospital. The specimens were scheduled to be delivered to the laboratory for testing the next morning.

When she told me the news I had goose bumps. I realized this may be the first MERS-CoV case in the United States. The weight of the situation was also felt by Dr. Omar Perez, the director of clinical microbiology. Stephanie, Omar and I stayed after the teleconference and discussed the plan for the next day.  Although the MERS-CoV assay was in place, the last MERS-CoV run was performed more than a year ago when the assay was first validated. To be cautious, the team decided to use BSL-3 practice for the entire process. We also agreed that the most experienced senior microbiologist, Jamie Yeadon-Fagbohun, would be the best choice to run the test. Jamie, who was known for her high quality work, had over five years of experience at the ISDHL. She worked on the response to the H1N1 pandemic, the discovery of novel H3N2v and many other high-profile outbreak investigations. She had worked under pressure before, but nothing like this.

The next morning I updated Dr. Judith Lovchik, ISDH assistant commissioner of public health protection and laboratory services, on the testing plan and discussed the testing approaches.  Meanwhile on the clinical microbiology floor, Stephanie, Omar and Jamie were detailing the testing plan.  The same conclusion was reached by all: time was of the essence in this situation.

Immediately after the arrival of a nasopharyngeal swab and serum sample from the patient, Jamie took the specimens to the bioterrorism suite where she gowned-up, put on the respirator and began processing the specimens. She wiped all the surfaces that the specimens might come into contact with and took every precaution to prevent potential carryover. Around noon Jamie resurfaced from the BT suite, her face reddened by the pressurization in the lab and her respirator.

By 3:00 that afternoon, the test runs were completed. Despite the increased anticipation of the nation’s first possible MERS-CoV case, Jamie was not expecting positive results.  “There is no way this would happen in Indiana. After all, Indiana is only a fly-over state,” Jamie thought to herself. After carefully reviewing the test results, Stephanie and Omar came to my office. I knew the results just by the looks on their faces. They told me that the serum sample was positive for all three genetic markers detected by the screening and confirmatory tests. As much as I was prepared for a positive result, I was still shocked to hear it. I immediately called Dr. Lovchik and broke the news to her.  She was equally shocked.

The perceived pressure earlier in the day turned into real pressure that was building with every thought of the potential impact. The lab team – Jamie, Stephanie, Omar and I – met again to review the testing details such as how the samples were arranged in the run, where the controls were situated, etc. With all possible errors ruled out, the team was confident in the results and ready to share the news with the rest of the nation.

As planned, the nasopharyngeal swab and serum sample were shipped to the CDC lab on Thursday for final confirmation of the MERS-CoV results on Friday morning.

The ISDH, Community Hospital and various CDC teams reconvened to plan the response actions based on the public health lab’s test results. The response plan would be executed as soon as CDC’s confirmatory test results were made available, which was scheduled to occur around 1:30 pm on Friday.

First thing on Friday morning the lab team met to discuss the action plan for a potential surge in testing once CDC confirmed results from the first case. Each team member was assigned a task: ordering reagents and supplies, requesting laboratory information management system (LIMS) modifications for easier sample submission, identifying microbiologists from other areas for surge capacity, and others.

Testing for MERS-CoV: The Indiana Lab’s Story | www.aphlblog.org

By noon, planning slowed, and the lab team had time to comprehend what the ISDH lab’s MERS-CoV results meant. But would the results be confirmed by CDC? The wait felt like eternity. I read every email that came across my computer screen. An email from CDC with the subject line “Confirmation” finally arrived at 1:43 pm. I felt like I was about to hear a courtroom verdict. I took a deep breath and continued to read the email: “CDC confirms Indiana MERS-CoV on 5/2/2014 at 1:30 pm.”

”WE DID IT!” I shouted with great relief. I couldn’t wait to share the news with the rest of the team. While it was not good news to hear that MERS-CoV had made its way into the US, it was extremely validating to know that our team quickly and successfully accomplished the task at hand. I was very proud of my colleagues.

After the detection of the first MERS-CoV case on May 1, the ISDH laboratory brought in two additional microbiologists, Stephanie Dalenberg and Brian Pope, to help with testing. During two consecutive 13-hour days, ISDH lab microbiologists, supervisors and directors tested a total of 124 specimens from all of the patient’s direct contacts, including health care workers and household contacts. All contacts continue to be observed, and there have been no additional cases to date.

The ISDH laboratory staff’s quick response, safe testing and accurate results were critical to detecting and containing MERS-CoV. Once again, our national laboratory first responders had quietly and effectively done their job to protect the public’s health.

Top Photo: Jamie Yeadon-Fagbohun in the BSL-3 laboratory

Bottom Photo (from left to right): Dr. Lixia Liu, Dr. Omar Perez, Stephanie Dalenberg, Stephanie Dearth, Jamie Yeadon-Fagbohun, Brian Pope, and Dr. Judith Lovchik 

Photo credit: Indiana State Department of Health Laboratories staff

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TB Vanquished by Lab System in the “Malibu of the Midwest”

Mar 24 2014 :: Published in Infectious Diseases

By William Murtaugh, specialist, HIV/TB programs, Infectious Disease, APHL

“Defeat TB: Now and in the Future.”  This was the first theme of World Tuberculosis Day declared by the International Union Against Tuberculosis and Lung Disease (IUATLD) 32 years ago today in 1982, and 100 years after Dr. Robert Koch announced his discovery of the bacteria that cause tuberculosis disease (TB).

Well, the future is March 24, 2014, and TB has not yet been defeated.  But year after year,  and theme after inspiring theme,  the global public health community still proclaims a call to arms, aiming to inspire the world to take up the cause of TB elimination.

TB Vanquished by Lab System in the “Malibu of the Midwest” | www.aphlblog.org

In the United States, the burden of TB is very low relative to many parts of the world. Why then should we be concerned with Mycobacterium tuberculosis, the obligate bacillus demanding our attention today?

It is common to cite TB statistics to emphasize the disease’s impact and the progress toward its elimination. Indeed any TB expert can pull some staggering historical numbers out of his or her pocket.  But reconciling unembellished phrases like “billions infected,” “millions of new cases,” “over a million deaths,” with the experience of those of us average Americans who’s TB “exposure” is limited to news bulletins on World TB Day, is challenging. For us, World TB Day serves as a gentle nudge that the disease is still a threat, and the fight for its elimination continues. Yet while I would be remiss if I did not mention that the United States has seen 21 years of consecutive decline in annual TB cases, I must contend that TB awareness is particularly important here in the United States because of the country’s low TB burden.

Lest we take our progress for granted, repeating the mistakes of the 1980’s and 90’s, it’s important to remember the consequences when the health system falters.  But for the one day, hour or minute that we consider World TB Day, let’s recognize that our progress to date has been achieved through the quiet efforts of a public health system that functions not one day, but all year long.

A TB outbreak in April 2013 exemplifies this point. Along the shores of Lake Michigan sits Sheboygan, WI, a city whose description could be mistaken for a Garrison Keillor monologue “where all the children are above average” and so too are its TB case rates. This Midwestern community learned the hard way that the damaging effects of TB can still be very real.

Prior to 2013, Sheboygan County typically saw fewer than three TB cases per year.  Known as the “Malibu of the Midwest” for its lake surfing competition (the largest in the world in fact), Sheboygan was a place more familiar with the phrase “Hang Ten” than “MDR-TB.”  Then in mid-April, the Sheboygan County Health Department was notified of a suspected TB case that would lead to an outbreak that would engage its resources and generate national media coverage for the remainder of the year.

Before it was over, the outbreak would cross the county and spread through multiple generations of a single family, school children and healthcare workers. It would lead to a case of MDR-TB, 11 additional cases of active pulmonary TB disease and 38 latent (non-symptomatic, non-contagious) TB infections. Over $6 million in state and federal funds ($4.7 million state, $1.4 million federal) would be expended to cover costs associated with outbreak investigation, testing, treatment and prevention measures.

Because TB is uncommon in the US, doctors may not consider it as a potential diagnosis. The first (i.e., index) case in the Sheboygan outbreak sought medical care for symptoms at least eight months before receiving a diagnosis of TB. What should have been a straightforward case – in which a suspected TB patient is diagnosed, treated and transmission prevented – led to eight months of transmissions.

Once TB was finally proposed as a diagnosis, the Wisconsin State Laboratory of Hygiene (WSLH) responded quickly, performing initial screening in two days and confirming diagnosis in less than two weeks. This diagnosis kick-started the TB control system into high gear. The patient was isolated and treated, and contact investigations were initiated to find related cases.

Next the WSLH assessed the standard drug regimen to determine if it would prove effective with this patient. With assistance from the Centers for Disease Control and Prevention (CDC), the lab identified  multi-drug resistant TB (MDR-TB) a category of infection that involves resistance to multiple drug therapies, is more difficult and expensive to treat, and holds a higher risk of death — as the cause of the patient’s illness. Now the concern was, “Had other patients been exposed to MDR-TB in the past eight months?”

More specimens began arriving at the local laboratory near Sheybogan, which quickly exceeded its capacity. With the threat of an MDR-TB outbreak, a solution was needed quickly. Enter the integrated public health laboratory system!  State and local laboratories coordinated with the community hospital in Sheboygan and decided jointly that all specimens from TB suspects would go to the WSLH.

As diagnosis after diagnosis of active pulmonary TB was confirmed, the state TB Control Program wanted to know if all these cases were part of the same outbreak.  While this may seem an obvious “YES!”, not all TB is created equal. Numerous strains of TB are continually in circulation. Without identification of the specific strain, public health officials could not understand the chain of transmission, and without this information, they could not control the outbreak.

Through a CDC initiative designed to strengthen national response to TB outbreaks, state public health laboratory in Michigan performed complex testing to uniquely identify each strain of M. tuberculosis (called genotyping). They determined that the MDR-TB patient was infected with two different strains of TB, one of which was not MDR-TB.  The state laboratories confirmed that other TB strains also belonged to the outbreak. None of these strains, however, were MDR-TB and therefore were more easily treated.

Not bad for a low burden TB setting.

Sheboygan’s story reminds us that TB outbreaks can happen anywhere. Yet if an outbreak does occur in our community we can look with confidence to the response capability of the nation’s public health laboratory system. The impressive response to the outbreak in Sheboygan testifies to the expertise and commitment of  these laboratory professionals. It also epitomizes CDC’s World TB Day theme:  “Find TB. Treat TB. Working together to eliminate TB.”

To learn more about public health laboratories and TB, check out APHL’s TB page. Additional information and resources for World TB Day and related events can be found at CDC’s dedicated website.

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The Problem with Clap in the Yap — A Valentines Day Post

Feb 12 2014 :: Published in Infectious Diseases

By anonymous, NAAT-savvy laboratory scientist

The Problem with Clap in the Yap -- A Valentines Day Post | www.aphlblog.org

Valentine’s Day is typically a time to express heartfelt wishes to loved ones and close friends. The preceding days are the busiest for florists as sales spike from people who are programmed to translate botanic gifts into signals of love. If these gifts and unspoken intentions are accepted, sexual advancement may start with a kiss and end with a variety of infectious sensations—some perhaps a little more nefarious than others. Gonorrhea, anyone?

Gonorrhea is the second most common notifiable communicable disease in the US right behind chlamydia, the ubiquitous love bug. Many of the colloquial terms of gonorrhea, such as GC (Gentlemen’s Complaint), clap, dripsy and morning dewdrop were derived from symptomatic infection in the male reproductive tract. Transmission requires some form of insertive behavior since gonorrhea does not remain viable for extended periods outside of human bodies. However, gonorrhea does not discriminate between anatomic sites and will infect non-genital mucosa (including one’s oral cavity) as well as genital mucosa.

Getting clap in the yap may not seem like a big deal since it’s not associated with any colloquialisms, but there are risks for disease and transmission.  While most infections are asymptomatic, one study showed that sore throats were reported in 15% of patients that had an oropharyngeal gonococcal infection and purulent tonsillitis was observed in 5%. Laboratory diagnosis of gonorrhea in the oropharynx can be made by traditional methods of culture isolation and biochemical identification. However, most public health laboratories have abandoned these procedures  with the use of nucleic acid amplification tests (NAATs) replacing culture as the primary laboratory test since NAATs can detect the organism in a wider range of clinical specimens independent of viability. However, the use of NAATs is complicated since they are not cleared by the FDA for specimens collected from non-genital anatomic sites and laboratories need to perform an off-label verification study to satisfy CLIA requirements. Some but not all commercially available NAATs may cross-react with non-gonococcal Neisseria species and these commensals are typically found in a higher numbers in the oropharynx. Even though NAATs are not FDA cleared for non-genital tract specimens and some may yield a false-positive result, APHL published a report that was developed from a meeting with CDC and laboratory experts recommending the use of NAATs to detect chlamydia and gonorrhea from rectal and oropharyngeal specimens.

Luckily, gonorrhea is a treatable disease.  Current CDC treatment recommendations are available at http://www.cdc.gov/std/treatment. However, even though it’s treatable today, gonorrhea has developed resistance to several antibiotics over time after acquiring a gene from another bacteria species.

Gonorrhea loves to hook-up with other bacteria and the oropharynx may be analogous to a bacterial brothel for genetic sharing. If oropharyngeal gonorrhea isn’t treated quickly and correctly, there is an increased chance of developing new drug resistance and infections requiring protracted therapy. Though ceftriaxone resistant gonorrhea has not been detected in the US, the first case was found in the throat of a woman in Japan.

The adage that ‘no money, no honey’ has been drilled into people at Valentine’s Day may be difficult to change. Flowers are the primary choice for mental lubrication, but other options exist such as plays and shows.  However, if any involve clowns, be certain that none are named “Dripsy.”

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Sochi? So What? Public and Environmental Health at the Winter Olympics

By Michael Heintz, MS, JD, senior specialist, environmental laboratories, APHL

Sochi? So What? Public and Environmental Health at the Winter Olympics | www.aphlblog.org

Hi. I’m Michael and I admit it: I’m a Winter Olympics fanatic. From learning new geography at the Opening Ceremonies, to hoping for that US-Canada hockey game, and seeing the short-track speed skaters hurl themselves in roller-derby-on-ice, I can’t get enough. I’ll even watch a couple hours of curling. I’m all-in for two weeks (well, except ice dancing, but that’s another post).

However, in the midst of the competition and spectacle, the public and environmental health aspects can get lost. With the international locations, huge crowds and new buildings, the footprint of the Olympics can be significant. So where do the Olympics intersect with public and environmental health?

The Centers for Disease Control and Prevention provides basic information if you’re heading to the Games (and more generally for international travel). In addition to routine vaccinations, like chicken pox and your flu shot (which you should already have!), the CDC recommends specific ones for Russia, such as hepatitis-A and others if you are particularly at-risk or heading to remote areas. Visitors should also prepare a travel health kit, including the medications they might need during travel. The CDC even provides a list of Russian phrases to use if you are sick or injured.

Next, one particular aspect of public health at the Games is interaction with the other spectators or athletes. Always remember to wash your hands, wear your seatbelt and generally stay aware of your surroundings. And yes, sexually transmitted infections are a concern at the Olympics. Organizers help the athletes by distributing condoms (150,000 were distributed to athletes at the London Games), but you might be on your own, so be prepared.

Finally, we cannot ignore the environmental impact of the Games. Sochi has an average population of 350,000 people. The 2010 Winter Games in Vancouver attracted an estimated 500,000 visitors plus another 10,000 journalists and 2,700 athletes (not counting security or volunteers). In all, Sochi’s size may double (or more) for the Games. The huge number of people coming to this Black Sea resort town, plus the construction of the new venues and other capacity improvements, will stress Sochi’s environment.

In 1996, the International Olympic Committee added environmental protection as the third pillar of the Olympics. As part of this commitment, Sochi organizers are making efforts to build and conduct the Games in an environmentally responsible manner, including a Green Building recognition program. But with a $50 billion price tag to build and run the events, the environmental impacts include increased construction waste, water shortages, habitat disruption and increased logging. All of these activities increase the amount of pollution in air, soil and water resources. Add the increased demand for drinking and wastewater services, transportation, and curiously, saving last year’s snow, and the overall environmental impact of the Games may be significant. However, we won’t know the full effects until after the Games are over. Looking ahead, the Rio Summer Games have already launched their sustainability program for 2016. Expect future Olympics host-cities to continue concentrating on environmental concerns when preparing for the Games.

While the public and environmental health concerns don’t decrease my appreciation for the spectacle that is the Olympics, including the athlete’s amazing abilities and the two weeks of global good will, it does add context to what goes into making such an event happen. Just another reminder that public and environmental health is part of everything.

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Girl Finds Real Bat in Halloween Store Toy Bin — What Would You Do?

Oct 30 2013 :: Published in Infectious Diseases

By Laura C. Iwig, MPH, Senior Specialist, Infectious Disease Program, APHL

Ghosts, goblins, and ghouls are among many of the elusive creatures you will see lurking around during the Halloween season.  What is the most elusive creature hiding in dark corners on All Hallows’ Eve?  That, my friends, would be the bat.  No, not because it might be a vampire.

Girl Finds Real Bat in Halloween Store Toy Bin -- What Would You Do? | www.aphlblog.org

While not an innately harmful or scary animal, bats can carry the risk of rabies.  Is the risk high?  Not exactly… CDC estimates that around 6% of bats have rabies.  So why worry?  The most common way humans get rabies is from bats, and rabies is an extremely serious disease.  Like with any other disease risk, it is important to know how to safely and quickly handle an encounter.

How would you handle this situation?

[True story] A mother and her young daughter were shopping for Halloween decorations at a local party store in Washington.  The daughter was fascinated by the bin of toy bats.  She wanted a new stuffed toy for Halloween and was especially smitten with one that was especially life like!  She immediately showed this realistic bat to her mother and asked if she could have it.  After touching the bat, the mother suddenly gasped and threw the bat on the ground.  That bat was not a toy, but in fact a real dead bat!

The mother frantically called her local health department to report the incident.  Health department staff immediately called the disease detectives at the Washington State Public Health Laboratory because public health laboratories are among the only laboratories that test suspect mammals for rabies.  The bat found at the party store was quickly sent to the lab for rabies testing.  If the lab did not act fast, the innocent mother and child could be in serious trouble and could even face death.   In keeping with their usual protocol, the scientists reported the results to the health department as rapidly as possible.

The bat was infected with rabies.

Thankfully, the dedicated scientists realized the urgency of this situation and acted fast. The rabies was detected in the bat quickly, allowing for the immediate prophylactic treatment to be initiated.  Once symptoms begin, it is usually too late for intervention. The treatment prevented the mother and daughter from a miserable illness and near-certain death.

What should you do if you encounter a bat?

Here are some great tips from CDC:

  • Don’t touch it!  If you have children, make sure they know not to touch a bat or any unfamiliar animal.  As CDC says, “Love your own, leave other animals alone.”
  • If you are wounded by an animal, wash the area thoroughly with soap and water.  Then see a doctor immediately.  Same goes for your pets – if they are wounded by another animal, wash the area if you are able and contact a veterinarian immediately.
  • Call your local or state health department to report all dead, sick or easily captured bats so they can be tested for rabies.  You might be saving another person or animal’s life.

Want to learn more?  Check out CDC’s site on rabies.

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Flu FAQ – What’s with the new vaccines?

Oct 22 2013 :: Published in Infectious Diseases

By Sarah Muir-Paulik and Stephanie Chester, Senior Specialists, Influenza Program, APHL 

It’s that time of year again! The leaves are changing, the temperatures are dropping, kids are going back to school, and your local pharmacy is advertising flu shots.  We can’t see into the future, but as William Schaffner, MD (Immediate Past-President, National Foundation for Infectious Diseases) said “Flu will be here!”  That means it’s time to get your yearly flu shot.

According to the CDC, thousands of people in the United States die from flu-related causes. Even though the majority of deaths occur in those 65 years or older, healthy people can still get very sick from the flu leading to serious complications and possibly hospitalization. Getting your flu shot is still the best way to reduce your chances of getting sick and the possibility of getting those around you sick.                    

Which vaccine should I get?

If you are like us, you have heard about all the different vaccines from flu shots to nasal sprays to the new kid on the block: the quadrivalent vaccine. It can be hard to decipher which to get and when.   While the best option is always to make the decision with your doctor, we can explain the differences in general terms.

Flu FAQ – What’s with the new vaccines? | www.aphlblog.org

Most of the flu shots currently on the market protect against three types of seasonal influenza: influenza B viruses, influenza A (H1N1) viruses, and influenza A (H3N2) viruses. Each year, the vaccine is manufactured using a specific virus for each of those three virus types that are predicted to be the best match for the coming season. Two types of vaccines are available to people each year that protect against these three types of flu: the flu shot and the nasal spray. Flu.gov created a great info graphic that describes the difference between these two vaccine types.

New to this year’s lineup, is the quadrivalent vaccine. The quadrivalent vaccine is the first flu vaccine available in the US to contain four strains of the influenza virus (two influenza A strains and two B strains). It is available in both vaccine forms – the shot and the nasal spray. Including a second B strain in the quadrivalent vaccine increases the chance that people will be protected against influenza viruses circulating in the community. All of the nasal spray (FluMist) vaccines this year will be quadrivalent.  To note, the quadrivalent shots are being supplied by several manufacturers so you might hear different names and brands being referenced.

Also new this year an egg-free vaccine called Flublok for people with severe egg allergies.

So many choices, what’s a person to do?

There are more choices than ever this year, but some, particularly the newer types, may be in limited supply at your doctor’s office or local pharmacy. But don’t wait for options to become available – all options provide protection against flu. It takes two weeks for your body to respond and provide protection so the sooner you get your vaccine the better! To find flu vaccines near you, please visit the HealthMap Vaccine Finder (you can search for specific flu vaccine types by expanding the right checklist under “Flu”).  Again, talk to your doctor if you have questions about which vaccine is right for you.

I got my flu shot last year, I don’t need to get one this year, right?

No, you should still get a flu shot every year. Influenza viruses are constantly changing and it’s not unusual for new flu viruses to appear each year. The vaccine is determined every year to make sure that it contains the most recent flu viruses. Influenza is always being researched and always being monitored in order to develop the safest vaccine possible. The research and science is never done.

I’m vaccinated so I won’t get the flu, right?

While getting vaccinated each year provides the best protection for you, your family, and the community, there is still a possibility you may get the flu even if you have gotten the vaccine. The vaccine contains the strains that are estimated to most likely circulate in the community. But due to the virus’ love for change, it could mean that there are strains that will be circulating that aren’t covered by the vaccine. However, the vaccine can still provide protection. Even if you do get sick, the vaccine may help limit the effect of the virus meaning less symptoms and possibly shorten the time of being sick! For more information about vaccine effectiveness, visit How Well Does the Seasonal Flu Vaccine Work? on CDC’s website.

So don’t wait, there are no excuses – get your flu shot!  Want to encourage others to get their yearly shot? Send them a CDC Flu e-card!

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Public Health Labs Lend a Helping Hand During Federal Government Shutdown

Oct 15 2013 :: Published in Food Safety, Infectious Diseases, Public Policy

By APHL staff Stephanie Chester, Senior Specialist, Influenza; Laura Iwig, Senior Specialist, Infectious Diseases; and Jennifer Adams, Lead Specialist, PulseNet Quality Assurance

Public Health Labs Lend a Helping Hand During Federal Government Shutdown | www.aphlblog.org

As the government shutdown continues, we are becoming acutely aware of how the shutdown impacts public health and safety. From delayed testing for drug resistant TB to postponed distribution of quality assessment panels, our public health infrastructure is undeniably weakened without the full support of federal agencies such as CDC and FDA. A skeleton staff is doing their best to maintain critical functions but important surveillance efforts are being put on hold. For example, right now CDC is unable to publish their weekly FluView report which provides critical information about influenza activity to health departments and physicians across the country. Flu surveillance, along with many public health activities, comprises a complex puzzle. Right now this puzzle is broken into many pieces that can’t be linked together to create a complete national picture. The ever-ready and dedicated public health laboratories are stepping into help wherever possible. Despite being already stretched thin and dealing with their own dwindling budgets, efforts by the public health laboratories are filling in important gaps of the surveillance puzzle.  Additionally, these acts by the public health laboratories will help our federal partners get back up to speed faster once the shutdown is lifted.

Influenza Stops for No One

It would be nice if we could ask flu season to hold off for a few weeks, but unfortunately that is not an option. The season officially started on October 1st and positive specimens are already being identified across the country. During a normal season, early flu specimens are sent directly to CDC so they can rapidly determine if the vaccine is a good match for circulating flu types and help determine next year’s vaccine makeup. With the shutdown looming at the end of September, CDC recognized that they would have limited laboratory capacity during the shutdown so an emergency teleconference was scheduled with three states (California, Utah and Wisconsin). As part of an already routine surveillance project, these states were contracted by APHL to perform national surveillance testing on flu specimens after the first few early season specimens were sent to CDC. Fortunately, all three states were ready and willing to accept this unanticipated, influx of early season specimens. As Hugo Guevara of the California Public Health Laboratory explained, “Each year, two months before the official influenza season starts, our group performs quality control. Because of this, we were ready when the first specimens arrived 2 days after our emergency teleconference with CDC and APHL.”

Preparedness efforts such as this do not happen overnight. These contract labs were instituted during the 2009 H1N1 pandemic, and, since their inception, CDC and the labs have put extensive efforts into training so that national surveillance testing is consistent between CDC and the three public health laboratories. Already having this additional capacity and expertise available outside of CDC means that this critical piece of the surveillance system will continue despite the government shutdown. Even though the results of the surveillance testing cannot be processed and shared nationally via FluView until the necessary surveillance staff return to work at CDC, the data and specimens will be readily available for them to analyze and distribute preventing further delays in completing a national picture of influenza activity.

Responding to Rare Disease Outbreaks

In addition to early flu season testing, four public health laboratories have been able to help CDC by being prepared to test for vaccine preventable diseases (VPDs) such as measles, mumps and whooping cough.  The four VPD Reference Centers are trained and experienced in using CDC protocols to test the most common specimen types for nine VPDs.  During the shutdown, public health laboratories have been asked to submit specimens to one of the VPD Reference Centers instead of CDC for testing whenever possible to ensure rapid results, avoiding unnecessary delays in investigating cases and outbreaks of these uncommon diseases.

Foodborne Disease Surveillance

As the shutdown approached, the PulseNet Area Laboratories stepped up to the occasion. Each of the seven Area Laboratories (Massachusetts, Virginia, Michigan, Minnesota, Texas, Utah, and Washington) were willing to help. The PulseNet Area Laboratories exist for this sort of incident: to assist their fellow laboratories with a sudden influx of PFGE testing, data submission and outbreak communication should the need arise. PulseNet laboratorians from across the country submit DNA fingerprints of bacteria from sick patients to CDC. When these fingerprints are matched, investigations may be launched by public health laboratories, CDC, USDA and/or FDA to detect the source of the illness. Without full coverage of the national DNA databases at CDC, national outbreak detection could have been severely hindered. Most of the cluster and outbreak detection and communication would have been up to the public health laboratories possibly without the presence of federal authorities to aid in the investigations. Fortunately the majority of the PulseNet database team and OutbreakNet staff at CDC was brought back to work after seven days of furlough. However, there are still many staff members out and there will be backlog to overcome as government employees return to work. The public health laboratories will play a crucial role assisting CDC with national outbreak detection while employees are playing catch up.

Piecing It All Back Together

While the shutdown is an unfortunate situation and has far reaching effects beyond public health, our federal partners and public health laboratories are doing as much as possible to continue to ensure national public health and safety. These are only a few examples. We extend our appreciation to our partners and public health laboratories for their preparedness efforts over many years that minimize catastrophic effects during emergency events such as this one. This too will provide an opportunity for further growth as we exercise preparedness plans and can institute improvements for the future. Once the federal government reopens, we look forward to seeing the pieces of the puzzle patched back together, getting a full picture of the arriving flu season and having critical federal support for many public health activities.

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What Exactly Does the Shutdown Mean for Public Health?

As we face day three of the federal government shutdown, we are hearing more about the deeply felt impact on our federal partners.  While we can be grateful that local and state public health agencies are still hard at work, the federal portion of the continuum is minimally staffed and operating a bare-minimum of essential programs that ensure the public’s health and safety.  Below are some of the negative effects we are hearing from the Centers for Disease Control and Prevention (CDC), the United States Department of Agriculture (USDA), the Food and Drug Administration (FDA), and the Department of Health and Human Services (HHS).

What Exactly Does the Shutdown Mean for Public Health? | www.aphlblog.org

Reference Testing Services Will be Delayed or Absent

CDC provides highly specialized reference testing for rare pathogens and for rare instances of drug resistance. Although CDC will maintain many of these services, the number of staff performing these tests will be greatly reduced. The result will be a delay in delivery of potentially lifesaving test results.

For example, the Division of Tuberculosis Elimination performs sequencing to detect mutations associated with drug resistance to rapidly identify persons with drug resistant TB.  It is the only laboratory in the country that is currently utilizes this method (which provides a high level of detail) for public health investigations.  Delayed results will lead to delays in delivering optimal treatment to patients and mounting an appropriate public health response.

National Disease Surveillance Will Be Weakened

CDC collects data on infectious diseases from all 50 states, local jurisdictions and territories.  The compiled data tracks how diseases are spreading and helps scientists to identify multi-state outbreaks.  One of the best examples of this function is influenza surveillance.  Flu season is upon us; CDC monitors the flu virus strains that are circulating nationally, keeps track of any resistance to drugs, and determines how well this season’s flu shot will work against circulating strains, and sends national alerts to public health professionals when things look out of the ordinary.  It shares the data generated from this activity with state and local health departments, providing them with a “big picture” view of flu activity across the country. Armed with this information, they can prepare effectively for potential outbreaks in their area. But a prolonged government shutdown will reduce the clarity of the big picture view, since less data will be collected.

CDC Support of Local Outbreak Response will be Limited

CDC services like advanced testing and consultation to state and local public health programs facing cases or outbreaks of relatively rare diseases. Because these diseases are so rare, many jurisdictions rely heavily on subject matter expertise at CDC for advice and information when responding. Although CDC’s skeleton crew of staff will do its best to assist, state and local public health departments will be largely on their own when it comes to responding to outbreaks of relatively rare diseases like measles or mumps.

Food Safety Will be Negatively Impacted – More People Could Get Sick

  • If you and others who ate the same food become ill from certain types of foodborne bacteria, you may never know the cause of your illness, as CDC will not be analyzing all of the data submitted, and FDA and USDA will not be following up on those leads to track the source of the illness.  These are necessary steps to ensuring fewer people get sick.
  • CDC will delay assessing the proficiency of state and local laboratories that participate in PulseNet.  This bi-annual assessment may be pushed back for several weeks, even if the shutdown only lasts several days.
  • State and local scientists who want to begin submitting DNA fingerprints to PulseNet will not be allowed to, as CDC certification of new PulseNet participants will be on hold.
  • In normal operating status, state and local food regulators do not have enough resources to properly inspect all retail food establishments and restaurants.  With federal inspection personnel on furlough, even fewer establishments will be inspected to make sure that they are following the regulations.
  • CDC’s IT staff have been furloughed. PulseNet IT staff are not present to aid public health laboratories if they are unable to connect or submit data to the national databases. If the system fails, national outbreak detection could come to a halt. If communication list-serves fail, there are few remaining staff with the know-how to repair these critical national communication tools.

Select Agent Program Has a Delayed Response

Due to the absence of either an FY 2014 appropriation or a Continuing Resolution for HHS and USDA, the Federal Select Agent Program, which oversees the possession, use and transfer of biological select agents and toxins that have the potential to pose a severe threat to public, animal or plant health or to animal or plant products, is not fully staffed and thus unable to provide timely regulatory compliance support to state and local entities. These regulatory gaps could have serious implications for safety and security.

Laboratory Response Network Anticipates Delays

Because the CDC is operating with minimal staff throughout, the Laboratory Response Network, which is the nation’s premier system for responding to potential bioterrorism, chemical terrorism and other public health emergencies, is down to just a few staff with anticipated delays in responding to requests for assistance from state and local public health laboratories and no support for daily reagent shipments.

The larger impact is the lack of federal support for state and local public health. While these state and local agencies continue to conduct routine surveillance and monitor the nation’s health, they rely on their federal counterparts to provide the big picture of disease spread, potential releases of biological threats as well as scientific guidance and methodologies to detect novel threats, like the MERS-coronavirus.

Newborn Screening Laboratory Quality Assessment Delayed

Closing CDC has delayed the fourth quarter assessment of newborn screening laboratory quality. If the delay is extended, then these laboratories will not be able to rely on the assistance of CDC to maintain their compliance with Clinical Laboratory Improvement Amendments, the federal law known as CLIA. Newborn screening depends upon high complexity laboratory operations that are governed by the requirements of CLIA, which include an independent external review to provide quality assurance – and is provided by CDC in the case of newborn screening.

The shutdown will force newborn screening laboratories to seek out non-traditional sources for external review, establish a working relationship with them – possibly at some expense, and pursue activities to meet the CLIA quality assurance requirements. This will not only be inefficient, cumbersome and potentially costly, it will also result in a greater degree of uncertainty because it has never been done.

As CDC’s website details, “The Newborn Screening and Molecular Biology Branch, Division of Laboratory Sciences, operates the Newborn Screening Quality Assurance Program (NSQAP). NSQAP is a voluntary, non-regulatory program to help state health departments and their laboratories maintain and enhance the quality of test results. The program is operated in partnership with APHL. The program provides services to more than 85 domestic newborn screening laboratories, 31 manufacturers of diagnostic products, and laboratories in 67 countries. NSQAP has been the only comprehensive source of essential quality assurance services for dried-blood spot testing for more than 33 years.”

The shutdown will add an unnecessary burden and additional complexity to one of the most successful public health programs in the United States.

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Federal Public Health Programs and Employees are Essential Despite Label

Oct 02 2013 :: Published in Food Safety, General, Infectious Diseases, Public Policy

By Scott J. Becker, executive director, APHL

It is day two of the federal government shutdown.

Every day, before I leave for work, I walk our family dog around the neighborhood.  The weather is beautiful today, just as it has been for the last couple weeks.  What’s different about today, however, is that my neighborhood is full of cars on the street and people milling about. It just dawned on me that I live in a nonessential neighborhood.  My neighbors are government employees.

Federal Public Health Programs and Employees are Essential Despite Label | www.aphlblog.org

APHL is headquartered in Montgomery County, Maryland, an ethnically and socioeconomically diverse area; our school system is known for being one of the top in the nation but today it’s known for having children from 70,000 families whose family members’ jobs are considered nonessential and are now furloughed.  Among those furloughed are the security guards who check IDs at the National Institutes of Health (NIH); our nation’s top scientists who are looking for cures for childhood cancer; the researchers doing work on influenza viruses; the food service workers who are usually hard at work by now helping to feed the many employees at the National Institute of Science and Technology (NIST); and the Maternal and Child health specialist at the Health Resources and Services Administration (HRSA) who supports the newborn screening programs in our public health labs.

Despite being given a “nonessential” label, they are all essential to us.

Public health is a local, state and federal continuum where all parts work together to ensure we have a healthy American populace. The public health system can’t work very well – or, I should say, doesn’t work very well – when one part of the system simply isn’t engaged. That’s the situation we face today on the second day of the federal government shutdown. Local public health is still hard at work, state public health is still hard at work, but the federal portion of public health is minimally staffed. If the local or state systems need technical assistance or laboratory support, they are largely on their own.

The federal portion of the continuum is essential.  In some ways you can think of it as the glue that holds the system together.  Public health laboratories and epidemiologists are busy tracking down disease outbreaks all the time. They do a great job in their local or state jurisdictions detecting diseases and other pathogens that can harm us. But it is the role of the federal government – the Centers for Disease Control and Prevention (CDC), in this case – to come up with a national picture of disease outbreaks. It’s the job of the CDC to knit together the mystery of how outbreaks unfold across the country, all with the goal of stopping them as soon as possible so that lives can be saved.

Take a foodborne outbreak for example. On any given day CDC is reviewing up to 30 (and sometimes more) clusters of foodborne illness across the country. We have an incredible system called PulseNet, which is essentially a DNA fingerprinting system for bacteria that cause foodborne outbreaks.  It’s those DNA patterns that are uploaded to a large database at CDC. It is then CDC’s role to review that data and to look for matching patterns across the country so that multistate outbreaks can be detected, the product pulled from market, the outbreak stopped and people can regain their health. What I just described isn’t only CDC’s role, it also involves the FDA. It’s their responsibility to test products that have been implicated in outbreaks and ensure they are pulled from the market. But because of the shutdown, only a skeleton crew of CDC disease investigators and FDA investigators and regulatory specialists are at work.

It’s also the beginning of the annual flu season. Public health laboratories around the country are busy collecting specimens and analyzing them to determine what influenza strains are circulating. That information is then shared with CDC so they can do their job of reviewing the information nationally to determine where flu outbreaks are occurring.  But because of the government shutdown there is no one at CDC able to review these reports.  That means we are likely to see influenza reported in each state but we will not see a national picture. While  that’s not devastating in the short run, if we go a few weeks or longer we will miss out on seeing what’s happening with influenza this year which will impact our knowledge base on what strains might be put into the flu vaccine for next year potentially compromising  the health – and possibly lives – of many.

I could go on and on but my point is really that public health remains an enterprise; as I said above, it is a local, state and federal continuum. The federal role in public health is essential. It is the part that holds together the other pieces and we are less safe when the federal contributions to public health are missing in action.

Congress must act soon; public servants deserve better and the American public deserves better.

 

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