Health Update: Reporting guidelines changed for vaping-associated lung injury

The Centers for Disease Control and Prevention (CDC) and public health agencies in Washington State continue to investigate a multi-state outbreak of vaping-associated lung injury. The latest information about the outbreak can be found on the CDC and Department of Health websites. 

Symptoms

Patients in this investigation have reported symptoms such as cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, fatigue, fever, and/or abdominal pain. Some patients have reported that their symptoms developed over a few days, while others have reported that their symptoms developed over several weeks.

Healthcare providers should ask patients presenting with the above symptoms whether they have vaped or dabbed in the past 90 days.

Reporting Cases to Public Health

Healthcare providers are required to report cases of vaping-associated lung injury to their local health department within 3 days. Please report patients who meet the following criteria.

Any hospitalized patient who:

Reports vaping or dabbing in the 90 days prior to symptom onset

AND

Has a chest X-ray with pulmonary infiltrates or a chest CT scan with ground-glass opacities

AND

Has no pulmonary infection (i.e., negative respiratory viral panel, negative flu test, and other clinically-indicated respiratory infectious disease testing negative) or an infection has been identified, but you feel this is not the sole cause of the lung injury or complete infectious disease testing was not performed, but you feel an infection is not the sole cause of the lung injury

AND

There is no other alternative plausible diagnosis such as a cardiac, rheumatologic no neoplastic process.

 For more information, see the full CDC case definition.

Healthcare providers and healthcare facilities are required to report vaping-associated lung injury per an emergency rule passed by the State Board of Health on October 9th and, as a  rare disease of public health significance, per WAC 246-101-101 and WAC 246-101-301.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Advisory: Severe pulmonary disease associated with using e-cigarette products

There are no confirmed or suspect cases pulmonary disease associated with using e-cigarette products in Grays Harbor County.

215 cases have been reported to the Center of Disease Control and Prevention from 25 states and others are under investigation.  E-cigarettes typically contain nicotine, most also contain flavorings and other chemicals, and some may contain marijuana or other substances. They are known by many different names and come in many shapes, sizes and device types. Devices may be referred to as “e-cigs,” “vapes,” “e-hookahs,” “vape pens,” “mods,” “tanks,” or electronic nicotine delivery systems (ENDS). Some e-cigarette devices resemble other tobacco products such as cigarettes; some resemble ordinary household items such as USB flash drives, pens, and flashlights; and others have unique shapes. Use of e-cigarettes is sometimes referred to as “vaping” or “juuling.” E-cigarettes used for dabbing are sometimes called “dab” pens. 

 Recommendation for clinicians :

1. Report cases of severe pulmonary disease of unclear etiology and a history of e-cigarette product use within the past 90 days to your state health department. Reporting of cases may help CDC and state health departments determine the cause or causes of these pulmonary illnesses. (Hospitals only)

2. Ask all patients who report e-cigarette product use within the last 90 days about signs and symptoms of pulmonary illness.

3. If e-cigarette product use is suspected as a possible etiology of a patient’s severe pulmonary disease, obtain detailed history.

4. Determine if any remaining product, including devices and liquids, are available for testing. Testing can be coordinated with the state health departments.

 Recommendation for the public :

1. While this investigation is ongoing, if you are concerned about the risks, stop using e-cigarette products.

2. Regardless of the ongoing investigation, e-cigarette products should not be used by youth, young adults, pregnant women, as well as adults who do not currently use tobacco products. 

3. If you are concerned about harmful effects from e-cigarette products, call your local poison control center at: 1-800-222-1222.

4. We encourage the public to submit detailed reports of any unexpected tobacco or e-cigarette-related health or product issues to the FDA via the online Safety Reporting Portal: https://www.safetyreporting.hhs.gov. 

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Update: New measles outbreak has 7 confirmed cases in WA State

King County has 4 cases,  Pierce County has 2 cases and Snohomish County has 1 case.  All cases were present at SeaTac International Airport on 4/25/2019.  You can view other exposure sites and dates at www.doh.wa.gov.

There are no confirmed or suspect cases of measles in Grays Harbor County. Most people in Grays Harbor County have immunity to measles through vaccination, so the risk to the general public is low.  People at highest risk from exposure to measles include those who are unvaccinated, pregnant women, infants under twelve months of age and those with weakened immune systems.

A person is considered immune to measles if any of the following apply:

· You were born before 1957

· You are certain you had the measles

· You are up-to-date on measles vaccines (1 dose age 1-3 years, 2 doses age 4 years & up.)

Testing for immunity after MMR vaccination is not routinely recommended.

 Please consider measles in patients who :

1. Present with febrile rash illness and the “three Cs”: cough, coryza, or conjunctivitis.

2. Recently traveled internationally or potentially exposed to someone with measles.

If you suspect measles, immediately mask and isolate patients to avoid disease transmission  and contact Grays Harbor County Public County Health to arrange for testing.

Grays Harbor County Public Health does not provide measles immunizations or testing for immunity.

We have developed a Q & A document in response to community concerns about measles.  Please let us know if you hear commonly asked questions or concerns that would be helpful to include in the  Q & A document.  As always, we are available to discuss any questions about measles diagnosis or testing requirements.

Due to the current increase in measles cases in the United States (https://www.cdc.gov/mmwr/volumes/68/wr/mm6817e1.htm), the Centers for Disease Control and Prevention has developed a summary for vaccination of adults against measles with measles, mumps, rubella (MMR) vaccine.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Advisory: Measles case confirmed in Pierce County resident

The Pierce County resident spent time in Pierce and King Counties while contagious from  May 6-11.  See https://www.tpchd.org/Home/Components/News/News/126/286?backlist=%2fhome for a  list of  known exposure locations. 

 There are no confirmed or suspect cases of measles in Grays Harbor County. Most people in Grays Harbor County have immunity to measles through vaccination, so the risk to the general public is low.  People at highest risk from exposure to measles include those who are unvaccinated, pregnant women, infants under twelve months of age and those with weakened immune systems.

A person is considered immune to measles if any of the following apply:

· You were born before 1957

· You are certain you had the measles

· You are up-to-date on measles vaccines (1 dose age 1-3 years, 2 doses age 4 years & up.)

Testing for immunity after MMR vaccination is not routinely recommended.

 Please consider measles in patients who :

1. Present with febrile rash illness and the “three Cs”: cough, coryza, or conjunctivitis.

2. Recently traveled internationally or potentially exposed to someone with measles.

If you suspect measles, immediately mask and isolate patients to avoid disease transmission and contact Grays Harbor County Public Health to arrange for testing.

Grays Harbor County Public Health does not provide measles immunizations or testing for immunity.

We have developed a Q & A document in response to community concerns about measles.  Please let us know if you hear commonly asked questions or concerns that would be helpful to include in the Q & A document.  As always, we are available to discuss any questions about measles diagnosis or testing requirements.

For questions or further information contact Lisa Leitz RN, Communicable Disease Program Coordinator at (360) 500-4044 or lleitz@co.grays-harbor.wa.us or our main line at (360) 532-8631.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Advisory: Influenza season continues with an increase in influenza A (H3N2)

The Centers for Disease Control and Prevention (CDC) is issuing a health advisory to notify clinicians that influenza activity remains high in the United States, with an increasing proportion of activity due to influenza A (H3N2) viruses, continued circulation of influenza A (H1N1) viruses, and low levels of influenza B viruses.       

Influenza should be considered as a possible diagnosis for patients with respiratory illness while local  influenza activity remains elevated.  Because influenza A (H3N2) viruses may be associated with severe disease in older adults, this health advisory serves as a reminder that early empiric treatment with influenza antiviral medications is  recommended for hospitalized and high-risk patients, especially those 65 years and older. 

Antiviral treatment should be started as soon as possible after illness onset and should not wait for laboratory confirmation. CDC recommends antiviral medication for the treatment of influenza, regardless of a patient’s influenza vaccination status.  Influenza antiviral medications are most effective in treating    influenza and reducing complications when  treatment is started early (within 48 hours of illness onset). However, some studies suggest clinical benefit among hospitalized patients and young children with febrile illness even when  treatment starts three to five days after illness onset.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Alert: Clark County confirms 14 cases of measles and is investigating 3 suspected cases of measles

Washington State Department of Health is supporting Clark County Public Health to limit the spread of measles through epidemiological investigation and testing. 

13 of the lab-confirmed cases are unimmunized and 1 has an unknown immunization status (this was the index patient). The index case had fever onset 12/27/18 and rash on 12/30/18.  All patients are under 18 years old.

This investigation is in the early stages and currently there is not clear evidence of linkages to a particular population. 

Please visit Clark County Public Health  website at:  https://www.clark.wa.gov/public-health/measles-investigation for the most up to date status and listing of exposure dates and locations.

Please consider measles in patients who:

1.  Present with febrile rash illness and the “three Cs”: cough, coryza (runny nose) or conjunctivitis (pink  eye).

2.  Recently traveled internationally or potentially exposed to someone with       confirmed measles..

If you suspect measles, immediately mask and isolate patients to avoid disease  transmission and contact Grays Harbor County Public Health to arrange for testing.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Health Advisory: Outbreak of E. coli infections linked to romaine lettuce

CDC is advising U.S. consumers to not eat any romaine lettuce, and retailers and restaurants not serve or sell any, until more is learned about the outbreak.  This investigation is ongoing and the advice will be updated as more information is available.

 · Thirty-two people infected with the outbreak strain of Shiga toxin-producing E. coli O157:H7 have been reported. Currently there are no cases in WA State.

· Illnesses started on dates ranging from October 8 to October 31, 2018.

· Thirteen people were hospitalized, including one person who developed hemolytic uremic syndrome. No deaths have been reported.

· Consumers who have any type of romaine lettuce in their home should not eat it and should throw it away, even if some of it was eaten and no one has gotten sick. 

 Advice to Clinicians

· Antibiotics are not recommended (https://www.cdc.gov/ecoli/clinicians.html) for patients with E. coli O157 infections. Antibiotics are also not recommended for patients whom E. coli O157 infection is suspected, until diagnostic testing rules out this infection.

· Some studies have shown that administering antibiotics to patients with E. coli O157 infections might increase their risk of developing hemolytic syndrome, and the benefit of the antibiotic treatment has not been clearly demonstrated.

 For questions or further information contact Lisa Leitz RN, Communicable Disease Program Coordinator at (360)500-4044 or lleitz@co.grays-harbor.wa.us or our main line at (360)532-8631.

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Health Alert: Immediate action needed
Health Update: Updated information on Alert or Advisory

Health Advisory: May require immediate action
Info Service: Not of an emergent nature

Mumps outbreak in Washington; health officials urge immunizations

As of December 28, 2016 no cases of mumps have been reported in Grays Harbor County; 124 cases* have been reported in Washington state, and health officials urge immunization.

*Confirmed and probable cases in WA as of 12/28/2016; cases have been reported in King, Pierce, Yakima and Spokane Counties.

Actions Requested

• Consider symptoms of mumps virus.

  • Prodromal symptoms may occur with mumps and are nonspecific; they include myalgias, anorexia, malaise, headache, and low-grade fever.

  • Parotitis (inflammation and swelling of the parotid glands) is the most common manifestation of clinical mumps.

• Advise patients on immunization status and urge immunization.

  • Remind patients that mumps can affect people of all ages.

  • Outbreaks most often occur on college campuses, among sports teams, and in other places with long-term close contact. People in these settings should make sure they are up to date on their MMR vaccine.

• If you have a suspect case, please immediately contact Grays Harbor Public Health and Social Services for consultation. You can reach us at (360) 532-8631 during business hours, or after hours at (360) 581-1401.

MMR Vaccine Recommendations

• Babies and children, who need two doses: Administer the first dose between 12 through 15 months of age. Administer the second dose between 4 through 6 years of age.

• Adults born after 1956.

• People at higher risk of contracting the virus, such as health care workers, college students, and international travelers.

• MMR vaccine cannot be administered during pregnancy.

Washington State Trends of Reported Mump Infections:

• Between 1992 and 2005: up to .5 per 100,000 persons or less (zero to 26 cases per year).

• 2006-2007: following the 2006 outbreak in the Midwest, there was increased awareness of mumps. 42 cases were reported in 2006, and 53 cases were reported in 2007.

• After 2008: the rate of reports returned to pre-2006 levels.

• 2015: seven cases were reported.

Resources

Washington State Department of Health, Mumps Outbreak

Centers for Disease Control and Prevention, Mumps

Centers for Disease Control and Prevention, the Pink Book

For questions or further information, contact Lisa Leitz, RN, Communicable Disease Program Coordinator, at 532-8631 x4044.

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Increase in suspected cases of Acute Flaccid Myelitis in Washington state since September 2016

As of November 4, 2016 no cases of Acute Flaccid Myelitis have been reported in Grays Harbor County.

Current Situation in Washington

• A cluster of suspected acute flaccid myelitis (AFM) has been reported among Washington residents.

• As of November 3rd, 2016, two cases have been confirmed and seven others are being evaluated by CDC.

• All cases are among children between 3 and 14 years of age who presented with acute paralysis of one or more limbs. All had a febrile prodrome 1 to 2 weeks prior to presentation with symptoms of AFM.

• The earliest onset of limb weakness was on September 14th and the most recent on October 27th.

• The cases are residents of King County (3), Pierce County (1), Franklin County (2), Snohomish County (1) and Whatcom County (2).

Actions Requested

• Report suspected cases of AFM promptly (see case definition below) to Grays Harbor County Public Health and Social Services at 360-532-8631, or the 24 hour emergency number: 360-581-1401.

• Complete the AFM patient summary form when reporting patients to Grays Harbor County Public Health and Social Services.

• Collect specimens from patients suspected of having AFM as early as possible in the course of illness (see details below)*.

• Notify Grays Harbor County Public Health and Social Services if you are aware of patients of any age that presented to your facility or practice in 2016 and fit the case definition (must have CSF results or MRI report available).

• Contact Grays Harbor County Public Health and Social Services for guidance.

Background Information

From January 1st to September 30th, 2016, a total of 89 people in 33 states across the country have been confirmed to have AFM. This represents an increase over the previous 2 years (reporting only started in 2014). Most of these have been in children. No etiology for the infections has been established although a potential association with enterovirus D68 has been reported. AFM is also known to be associated with other neurotropic enteroviruses, adenovirus, herpes viruses, arboviruses including West Nile virus, and other etiologies. Non-infectious causes have not been ruled out.

Resources

CSTE case definition: Clinicians should be vigilant and consider AFM in patients presenting with:

• Onset of acute limb weakness

• AND a magnetic resonance image (MRI) showing spinal cord lesion largely restricted to gray matter and spanning one or more spinal segments

• OR cerebrospinal fluid (CSF) showing pleocytosis (white blood cell count >5 cells/mm3)

Specimen collection guidance

Collect specimens from patients suspected of having AFM as early as possible in the course of illness including:

• Cerebrospinal fluid,

• Serum (acute and convalescent) and whole blood*,

• Two stool specimens separated by 24 hours (whole stool preferred over rectal swab),

• Upper respiratory tract sample (in order of preference: nasopharyngeal swap > nasal swab > nasal wash/aspirate > oropharyngeal swab,

• Oropharyngeal swab should always be collected in addition to the nasopharyngeal specimen on any patient suspected to have polio.

*Whole blood should be sent refrigerated to CDC and arrive within 24 hours of collection.

WA Department of Health – AFM Investigation

Centers for Disease Control and Prevention – Acute Flaccid Myelitis website

 For questions or further information, contact Lisa Leitz, RN, Communicable Disease Program Coordinator, at 532-8631 x4044.

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West Nile virus: Tests confirm first death in WA from disease

The Washington State Department of Health (DOH) confirmed the first death due to West Nile virus this year in Washington. The decedent was a female in her 70s, was a resident of Benton County and was most likely exposed to infected mosquitoes in Benton County. A second reported case, a man in his 80s from Benton County, is currently hospitalized with West Nile virus disease. He was also most likely exposed to infected mosquitoes in Benton County. Currently, there are no cases of West Nile virus disease in Grays Harbor County.

As of August 18th, 2016, West Nile virus activity has been found in seven counties in eastern Washington: Benton, Yakima, Spokane, Adams, Franklin, Grant, and Stevens counties. Although eastern Washington is where most West Nile virus is detected, the mosquito species that carry West Nile virus are found throughout the state.

Action requested: Remind all patients about the precautions they can take to avoid being bitten by mosquitoes.

• Use an EPA-registered mosquito repellent when outdoors or in the woods.

• Stay indoors around dawn and dusk when mosquitoes are most active, if possible.

• If outdoors during dusk and dawn, wear long sleeves and pants to avoid bites.

  Prevention Tips for the Home:

• Make sure your door and window screens are in good condition, and mosquitoes cannot get indoors.

• Reduce mosquito habitat around the home by dumping standing water from buckets, tires, cans, flower pots, etc. Frequently change the water in kids’ wading pools, bird baths, pet dishes, and water troughs.

Symptoms: Most people bitten by a mosquito carrying West Nile virus will not get sick. Some people will develop mild symptoms (including headache, fever, body aches that go away without treatment). In rare instances, however, West Nile virus can be very serious and/or fatal. Severe disease can include meningitis or encephalitis. The risk for serious illness is highest among people over 60 years of age, and those with certain medical conditions (such as cancer, diabetes, hypertension, kidney disease, and people who have received organ transplants).

 Resources

• Washington State Department of Health, West Nile virus information line: 1-866-788-4787

• Washington State Department of Health, West Nile virus webpage

• Centers for Disease Control and Prevention

For questions or further information, contact Lisa Leitz, RN, Communicable Disease Program Coordinator, at 532-8631 x4044. 

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Lead exposure concern: Status update

Recent detections of lead in drinking water systems in Flint, Michigan and Tacoma, Washington have raised public awareness of the importance of safe drinking water and prevention of lead exposure. As of May 5, 2016, no current cases of lead poisoning (≥ 45µg/dL) or detections of lead in public drinking water have been reported in Grays Harbor.

At this time standard lead screening and assessment is requested. We will continue to monitor recommendations from the Washington State Department of Health and will share guidance for providers if any change in action is requested or exposure concerns arise.

Grays Harbor Environmental Health Department is responding to inquiries about public water safety, and questions can be directed to Environmental Health at 249-4222.

Standard action is requested – no new action at this time

• Assess all children for risk of lead poisoning at 12 and 24 months of age.

• WA Department of Health recommends performing a blood lead test on children with the following risk factors:

  • Lives in or regularly visits any house built before 1950.

  • Lives in or regularly visits any house built before 1978 with recent or ongoing renovations or remodeling.

  • From a low income family (income <130% poverty level, and Federal law mandates screening for all children covered by Medicaid).

  • Known to have siblings or frequent playmate with an elevated blood lead level.

  • Is a recent immigrant, refugee, foreign adoptee, or child in foster care.

  • Has a parent or principal caregiver who works professionally or recreationally with lead (examples: remodeling, painting, mining, makes lead fishing weights, works in or visits gun ranges, hobbies involving stained glass, pottery, soldering or welding, etc.).

  • Uses traditional, folk, or ethnic remedies or cosmetics (examples: Greta, Azarcon, Ghasard, Ba-baw-san, Sindoor, and Kohl).

• Healthcare providers should consider testing additional children per clinical judgment, including, but not limited to:

  • Children whose parents have concerns or request testing.

  • Children living within a kilometer of an airport or lead emitting industry, or on former orchard land.

  • Children with pica behavior.

  • Children with neurodevelopmental disabilities or conditions such as autism, ADHD, and learning delays.

• An elevated blood lead level ≥ 5µg/dL is a notifiable condition.

   Background information

• In Washington, the most common source of lead poisoning is lead-based paint. Paint containing lead was not banned until 1978.

• Other common sources of lead exposure are: contaminated soil, children’s toys and jewelry, drinking water, workplace and hobby hazards, home remedies and cosmetics, lead glazed ceramic ware, imported candy and mini blinds.

  Resources

• Washington Department of Health, Blood Lead Testing and Reporting: Information for Health Care Providers website.

• Washington Department of Health, Lead information website.

  For questions or further information, contact Lisa Leitz, RN, Communicable Disease Program Coordinator, at 532-8631 x4044  

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