Infant Botulism

Spring 2014

Communicable Disease Service Mission Statement Infant Botulism Our mission is to prevent communicable disease among otulism is a rare, but serious, all citizens of New Jersey, and paralytic illness caused by a to promote the knowledge and neurotoxin that is produced use of healthy lifestyles to bBy the bacterium Clostridium maximize the health and botulinum . In the United States, there well-being of New Jerseyans. are approximately 100 cases of We will accomplish our infant botulism diagnosed annually. mission through our leadership, New Jersey has about six cases collaborative partnerships, and yearly. For the past 10 years, New advocacy for communicable Jersey has ranked third (after disease surveillance, research, California and Pennsylvania) with education, treatment, the highest number of cases of infant prevention and control. botulism. C. botulinum prefers certain soil types and infant botulism The above photo is a depiction of a "floppy baby," a is more common in those areas. While classic clinical sign of infant botulism. there is no definitive evidence, it is believed that soil ecology plays a large infant botulism are difficulty feeding role in determining which states have (diminished sucking reflex), a weak the highest prevalence of cases. cry, loss of head control (“floppy baby”) and poor muscle tone. Infant botulism occurs when babies ingest the spores of botulinum Clinicians who have a suspect infant bacteria, which then germinate and botulism case should contact the TChreis NChJrDisOtieH, GCoovmernmorunicable produce a toxin in the intestines. An California Department of Public DKiims eGauasdea gSneo,r Lvti.c Geo vienrcnolur des: infant can ingest these spores Health, Infant Botulism Treatment IMnfaercyt Eio. uOs’ Daonwd dZ,o MonPoH tic Disease through food (most commonly, and Prevention Program (IBTPP) for PCroomgmraimss (iIoZnDePr ): 609-826-5964 honey/corn syrup), soil or consultation (510-231-7600, 24/7). If contaminated dust. In general, the it is determined that the infant does VCaOcMciMneU PNrIeCvAenBtLaEb lDeI DSiEsAeSaEs eS ERVICE Program (VPDP): 609-826-4860 disease occurs in children less than have botulism, the IBTPP will Christina Tan, MD, MPH one year old due to the inability of State Epidemiologist/ dispense BabyBIG (Botulism Immune We’re on the Web! the immature intestines to move the wAswsiwst.annjt. gComv/mheisasliothn/ecr d Globulin), an antitoxin approved by spores through and out of the body continued from page 1 Gary Ludwig, MS, Director thFeu nFdDinAg tion E2x0p0an3d for the treatment of Past issues of the New Jersey Com - before the toxin forms. Therefore, infant botulism. This drug mSuuznain-CnAeB MLEir oa,r eM aPvHa,i lMabClHeE oS nline at: once an infant ingests the spores, the signifiPcHOaTOn BtYl: y A NrWeARd WuALcKEeR,s P UtBhLICe H EsAeLTvH ReErPRiEtSyEN ToATf IVE Editor, Research Scientist http://nj.gov/health/cd/pub.shtml . bacteria germinate, multiply, and symptoms and prevents further produce a toxin which, in turn, can progression of the disease. affect the infant’s nervous system. Improvement is usually seenC awptiitohn iins this The most common symptoms of Continued from/on page x Subhead Continued on page 8

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Know the Facts: Vaccine Storage and Handling

roper vaccine storage and aspects of routine vaccine handling practices play a management, from ordering very important role in vaccines and managing pProtecting individuals and inventory to storing vaccines communities from and monitoring storage vaccine-preventable diseases. conditions. Failure to adhere to required v The relocation plan would be protocols for storage and handling used in the event of power can reduce vaccine potency, failures, refrigerator resulting in inadequate immune malfunctions, natural responses in patients, as well as disasters, and anytime there is Get more information at inadequate protection against a known threat to the vaccine disease. http://nj.gov/health/cd/ha inventory. ndwashing.shtml. Vaccine quality is the shared Use Proper Storage Equipment: responsibility of everyone, from the o Store vaccines in time vaccine is manufactured until temperature-monitored, it is administered. In response to alarm-equipped, stand-alone recent scientific studies on refrigerators and freezers. If an equipment used for vaccine storage office only has a household-style and a better understanding of best combination unit, the CDC practices for vaccine storage and recommends using one unit for handling, the following are the refrigerated vaccines only and to most recent Centers for Disease use a separate stand-alone Control and Prevention (CDC) freezer to store frozen vaccines. recommendations: o Use “Do Not Unplug” signs next to electrical outlets for the Establish Storage and Handling refrigerator and freezer and a The NJDOH Communicable Disease Service includes: Policies: “Do Not Stop Power” warning label o Select a designated primary by the circuit breaker which Infectious and Zoonotic Disease powers the refrigerator and Program (IZDP): 609-826-5964 vaccine coordinator and at least one alternate coordinator to be freezer. Vaccine Preventable Disease o Program (VPDP): 609-826-4860 in charge of vaccine storage and Do not store vaccines in a handling. dormitory-style or bar-style We’re on the Web! o refrigerators/freezers (a small www.nj.gov/health/cd Develop a detailed, up-to-date, written policy for general combination freezer-refrigerator Past issues of the New Jersey vaccine management and a plan unit with the freezer Communi-CABLE are available online at: for how vaccines would be compartment inside the http://nj.gov/health/cd/pub.shtml . relocated in the event of an refrigerator). emergency. o Do not store food or beverages in v The routine vaccine storage a vaccine storage unit. plan should include all Continued on page 6 Spring 2014

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Injection safety impressively conducted outreach and education to more than 800 s part of New Jersey’s health professionals throughout the ongoing injection safety state. initiative, “Keeping the InfectionA out of the Injection,” another The NJ Ambassador program is a cadre of safe injection ambassadors model project and has been were trained on February 26, 2014. replicated in North Carolina and Safe injection ambassadors are Nevada. After recruitment, health professionals (infection ambassadors must pass a qualifying preventionists, nurses and exam and agree to present at least epidemiologists) who volunteer to two times within one year of being educate healthcare providers about trained. New Jersey Department of issues surrounding injection safety. Health staff are looking forward to The first group of 25 Ambassadors training the next class of safe was trained in 2012 and has injection ambassadors!

Outbreak Training created a manual for public health professionals to refer to when hree regional outbreak working on an outbreak disease trainings were completed in investigation. Pictured here are the December, 2013 and January NJDOH speakers at the January T2014. More than 200 public health 2014 training at Rutgers in New professionals attended the three Brunswick: Dr. Alice Shumate, Jason sessions. The New Jersey Mehr, Rebecca Greeley and Terrie Association of City and County Whitfield. Special thanks to George Health Officials (NJACCHO) Van Orden, PhD, Health Officer received a grant for the New Jersey from Hanover Township who Department of Health (NJDOH) to chaired the subcommittee. The NJDOH Communicable conduct the trainings Disease Service includes: to clarify the outbreak Infectious and Zoonotic Disease investigation process Program (IZDP): 609-826-5964 to ensure that Vaccine Preventable Disease investigations are Program (VPDP): 609-826-4860 consistent. Speakers We’re on the Web! included staff from www.nj.gov/health/cd the NJDOH Communicable Past issues of the New Jersey Disease Service and Communi-CABLE are available online at: http://nj.gov/health/cd/pub.shtml. local public health professionals. The NJACCHO Communicable Dr. Alice Shumate, Jason Mehr, Rebecca Greeley, and Terrie Whitfield served Disease subcommittee as speakers for the training. Spring 2 014

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Hepatitis incorporate information and messages about all of these aura Taylor, Adult Viral infections. The training is designed Hepatitis Prevention to help participants to gain basic Coordinator and Amelia knowledge about hepatitis and to LHamarman, STD Educator, help them generate realistic provided a training in January to strategies for integrating hepatitis HIV grantees and other public prevention into the services their health partners. The training, agencies already provide. “Birds of a Feather: Integrating Hepatitis into Existing HIV and This training is a collaborative effort STD Prevention Messages,” is a between the Communicable Disease full-day training designed to help Service and the Division of HIV, STD HIV and STD professionals and TB Services. (counselors, educators, outreach workers, health care workers, etc.) to integrate hepatitis prevention messages into their existing prevention activities. Rates of co-infection with hepatitis and HIV, or other STDs, continue to rise due to common transmission routes of these infections. Given the overlap of risk factors and behaviors, especially in at-risk populations, it is logical to

COMMUNICABLE DISEASE OUTBREAK MANUAL The NJDOH Communicable Disease Service includes: This manual is available on-line and Infectious and Zoonotic Disease includes appendices and other usable Program (IZDP): 609-826-5964 templates. Go to: Vaccine Preventable Disease http://njlmn2.rutgers.edu/sites/default/files/ Program (VPDP): 609-826-4860 NJACCHO%20Outbreak%20Investigation%2 We’re on the Web! 0Manual_0.pdf www.nj.gov/health/cd

Past issues of the New Jersey Communi-CABLE are available online at: http://nj.gov/health/cd/pub.shtml . Spring 2014

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CDS Service Project Center in Ewing and Salvation Army n December, CDS staff Jose in Trenton. More than 20 boxes of Cortes, Alice Shumate and personal care items and flu Laura Taylor delivered boxes of prevention kits (tissues, hand personalI care items donated by New sanitizer and hand wipes), were distributed to these three Jersey Department of Health

organizations that serve NJ employees to three organizations: 

Project HOPE in Camden, The Vet residents. 





 F c



Alice Shumate and Jose Cortes deliver donated Alice Shumate and Jose Cortes pictured with a Vet items. Center staff member.

Training for County between the Public Health Infrastructure, Laboratory and Public Health Officials Emergency Preparedness division and uzanne Miro, a health educator the Communicable Disease Service. The NJDOH Communicable for the Communicable Disease Disease Service includes: Service, delivered a focus group Infectious and Zoonotic Disease skills training for county public health Program (IZDP): 609-826-5964 S officials on January 30, 2014. The Vaccine Preventable Disease counties represented at the training Program (VPDP): 609-826-4860 are receiving funding through the We’re on the Web! Superstorm Sandy Block Grant to www.nj.gov/health/cd assist local residents in their ongoing efforts to recover from the storm. Part Past issues of the New Jersey Communi-CABLE are available online at: of the grant requires the officials to http://nj.gov/health/cd/pub.shtml. conduct focus groups among their constituents to learn more about their ongoing struggles and to target resources to assist in this matter. This Carl Michaels, Suzanne Miro and Luis Torrens at the training was a collaborative effort training for county public health officials on January 30. Spring 2 014

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Vaccine Storage , continued from page 2 Store and maintain vaccines at

o Remove all vegetable and deli bins appropriate temperatures: from the storage unit, and do not o Maintain refrigerator store vaccines in temperature at 35-46 º F (2-8 º C), these empty THIS REFRIGERATOR/FREEZER IS FOR areas. o Use a National VACCINES ONLY! Institute of ALL VACCINES must arrive in an insulated Standards and container and be stored immediately as follows: Technology FREEZE 5º F (-15º C) or colder: (NIST) certified, MMR (may be stored in freezer or refrigerator)

calibrated MMRV thermometer in Varicella (chickenpox) Zoster (shingles) both the

refrigerator and REFRIGERATE 35-46 º F (2-8º C): freezer. Note the DTaP/DT/Tdap/TT/Td Hepatitis A & B calibration HIB

expiration date HPV Do Influenza (TIV/LAIV) NOT freeze and recalibrate or IPV or expose to freezing Meningococcal temperatures replace the MMR thermometer as Pneumococcal needed. Rotavirus o Use a biosafe VACCINE STORAGE TIPS! glycol-encased Store vaccines in the center of the Store vaccines with the earliest compartment. expiration date up front. thermometer Make sure the correct vaccine Log temperatures twice a day using storage temperature range is a NIST certified thermometer. probe or a similar maintained. IMMEDIATELY take corrective action temperature to OUT OF RANGE temperatures.

buffered probe. Please contact the Vaccines for Children (VFC) Program at 609-826-4862 or Place the [email protected] for more information. thermometer 10/11 C1708 The NJDOH Communicable Disease Service includes: probe in the center of the Infectious and Zoonotic Disease and aim for 40 º F (5 º C). Program (IZDP): 609-826-5964 refrigerator away from the walls. o Use digital data loggers with o Maintain the freezer temperature Vaccine Preventable Disease at an average of +5 º F (-15 º C) or Program (VPDP): 609-826-4860 detachable probes that record and store temperature information at colder, but no colder than -58 ºF We’re on the Web! frequent programmable intervals (-50 º C). www.nj.gov/health/cd for 24 hour temperature o Keep extra containers of water in the refrigerator (e.g., in the door Past issues of the New Jersey monitoring rather than Communi-CABLE are available online at: non-continuous temperature and/or on the floor of the unit http://nj.gov/health/cd/pub.shtml . monitoring. where the vegetable bins were located) to help maintain cool

Continued on page 7 Spring 2014

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Vaccine Storage, continued from page 2 temperatures. Keep ice packs in the freezer to help maintain cold temperatures. o Store vaccines in the middle of the refrigerator or freezer (away from walls and vents), leaving room for air to circulate around the vaccine. o Record refrigerator and freezer temperatures at least twice a day (first thing in the morning and right before the Never store food or beverages inside the vaccine refrigerator facility closes). Document or freezer. minimum and maximum temperatures once a day, preferably in the morning. o Review vaccine expiration dates and rotate vaccine stock on a weekly basis. Vaccines with the “earliest” (soonest) expiration date should always go in front and be used first. o Notify the designated vaccine coordinator whenever you have an out-of-range temperature. Get the vaccines back into the recommended temperature Vaccines exposed to temperatures outside the recommended The NJDOH immediately. Contact the ranges can have reduced potency and protection. Communicable Disease vaccine manufacturer to Service includes: determine if vaccines are still Infectious and Zoonotic Disease useable. Program (IZDP): 609-826-5964 Improper vaccine storage and protocols. Please visit the following Vaccine Preventable Disease Program (VPDP): 609-826-4860 handling procedures cost time resources to help you create a and money, and jeopardize comprehensive plan for your office. We’re on the Web! patient safety. Expired or www.nj.gov/health/cd improperly stored vaccine won’t CDC Past issues of the New Jersey protect patients. The costs http://www.cdc.gov/VACCINES/ Communi-CABLE are available associated with loss and RECS/storage/default.htm online at: replacement of vaccines, as well http://nj.gov/health/cd/pub.shtml. as the resources necessary to Immunization Action Coalition: conduct a recall of patients, can http://www.immunize.org/handouts/ be avoided by simply following vaccine-storage-handling.asp proper storage and handling Spring 2 014

Page 8 In The NEWS...... Survey: Anti-MRSA Drugs Nearly 90% of more than 500 dermatologists surveyed said they would initially Routinely prescribe an antibiotic to cover possible methicillin-resistant Staphylococcus Prescribed for aureus when incising and draining an uncomplicated cutaneous abscess. Further, Simple Abscesses 24% reported prescribing antibiotics that are not active against the pathogen, and 82% said they culture simple abscesses in 50% of cases. The survey findings, while limited by their self-reporting nature, point to the need for clearer guidelines on the best approaches to simple abscesses. “A comprehensive clinical guideline based on local antimicrobial rates, and increased knowledge of local resistance patterns and microbiologic data could not only improve abscess management and antibacterial stewardship, but could also combat the rising health care costs associated with SSTIs (skin and soft tissue infections] and their complications,” wrote Dr. Adam Friedman and his colleagues in the February issue of the Journal of Drugs in Dermatology. (J. Drugs Dermatol. 2014; 13:611-16). Excerpt from Family Practice News by Heidi Splete: ( ) www.familypracticenews.com

Infant Botulism , continued from page 1 In the majority of infant botulism cases, the first 24-48 the exposure remains unknown. It was hours after concluded, after research that has been administration. conducted over the years, that most Laboratory testing infant botulism cases acquired the is not performed disease by ingesting microscopic dust to either rule in or particles that carry the spores. The only The NJDOH Communicable rule out the known prevention measure is to avoid Disease Service includes: disease, due to the feeding honey to infants 12 months of Infectious and Zoonotic Disease length of time it age and younger. Fortunately, the Program (IZDP): 609-826-5964 takes to receive prognosis for infant botulism patients is Vaccine Preventable Disease preliminary results BabyBIG®, Botulism a complete recovery. The key to Program (VPDP): 609-826-4860 (24 hrs. at a Immune Globulin recovery is early diagnosis and Intravenous (Human) minimum). treatment. We’re on the Web! (BIG-IV), is an orphan drug www.nj.gov/health/cd Therefore, that consists of treatment should human-derived For more information regarding infant Past issues of the New Jersey not be delayed. anti-botulism toxin botulism, visit the IBTPP website at Communi-CABLE are available online at: Stool specimen antibodies that is http://www.infantbotulism.org/ . http://nj.gov/health/cd/pub.shtml . approved by the U.S. Food testing is purely and Drug Administration confirmatory. for the treatment of infant botulism types A and B. Spring 2 014

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Award Winner

he New Jersey Department of Health, Vaccine Preventable Disease Program (VPDP) presented an award to one of the winners of the second Tannual statewide adolescent vaccine education contest, H “Protect Me with 3,” at West Deptford High School. NJ pre-teens and teens were challenged to create 30-second videos on the importance of getting vaccinated for tetanus, diphtheria, and acellular pertussis (Tdap), meningococcal conjugate (MCV4), and human papillomavirus (HPV). View all the winning videos at www.protectmewith3.com .

The NJDOH Communicable Disease Service includes: Infectious and Zoonotic Disease Program (IZDP): 609-826-5964 Vaccine Preventable Disease Program (VPDP): 609-826-4860 Jennifer Smith, Public Health Educator (left), and Vaccine Preventable Disease Program staff members Jenish Sudhakaran, Population Assessment We’re on the Web! Coordinator, and Tiffany Humbert-Rico, CDC Public Health Prevention www.nj.gov/health/cd Service Fellow, presented Ryan Zuzulock with the Grand Prize of the second annual, “Protect Me with 3,” statewide adolescent vaccine education Past issues of the New Jersey contest. Communi-CABLE are available online at: http://nj.gov/health/cd/pub.shtml .