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INSIDE THIS ISSUE: An Update on SARS in Tennessee Updated Interim U.S. Case 2 The first two cases of (probable) case occurred 2003. He traveled to To- Definition for Severe Acute Respiratory Syndrome SARS (1 suspect and 1 in a Mississippi resident ronto, Canada. He did not probable) were identified who had traveled to both require hospital care and Raccoon in Tennes- 2-3 by the Memphis –Shelby Hong Kong and Taiwan. has recovered. All close see: A Significant First County Health Depart- Both presented to health- contacts have been noti- ment on May 14, 2003. care facilities in Shelby fied by the local health Monkeypox: An Emerging 3-4 County; neither required department and have been Infectious Disease in Amer- One (suspect) case oc- hospital care; both have requested to monitor their ica curred in a Shelby county recovered. A third health. All have remained resident who had traveled (suspect) case of SARS, well. West Nile 4 to Toronto, Canada. One from Rutherford County, was identified on June 1,

The Tennessee Epi-News is pub- SARS Cases among Healthcare Workers Wearing lished quarterly by the Communi- cable and Environmental Disease N95 Respirators in Canada Services section, Tennessee De- A recent Mortality and th • incorrect removal of partment of Health, 425 5 Ave- Morbidity Weekly Report1 nue North, Nashville TN 37247. N-95 respirators lead- HCWs caring for SARS Phone: 615-741-7247 reports the transmission ing to contamination patients should be prop- of SARS from an ICU of hands. erly trained in the correct Editor-In-Chief: patient to several health- use and removal of per- Marion Kainer, MD, MPH care workers (HCWs) in This cluster is part of a sonal protective equip- Managing Editor: an ICU in Canada, de- larger number of cases in ment and reminded of the Diane Eigsti Gerber, MS, RN spite the use of N 95 HCWs in hospitals in the importance of hand hy- Design Editor: equivalent respirators. giene. Patients who are Amanda Ingram, MPH greater Toronto area who Factors that may have have become infected experiencing rapid clini- contributed include: For address changes and/or to while caring for SARS cal progression with se- be placed on the e-mail distribu- • high viral load patients since directives vere cough during their tion list, contact Samir Hanna, (patient was in second for contact, droplet, and second week of illness MD, MSPH at week of illness) airborne precautions were should be considered par- [email protected]. instituted at the provincial ticularly infectious. Proce- • aerosol producing procedures (use of level on March 28. Fur- dures that might generate aerosols (e.g., nebulized non-invasive ventila- ther investigation is nec- medications) should be tion- BiPAP, intuba- essary to determine fac- tion of the patient) tors associated with trans- avoided if possible. When intubation is necessary, • leakage of N-95 respi- mission despite the appar- Department of Health. Authoriza- measures should be taken rators (fit testing not ent use of recommended tion No. 343227, 9,000 copies. -control precau- to reduce unnecessary This public document was prom- required in Canada) (Continued on page 2) ulgated at a cost of $0.16 per tions. copy. 07/03 Page 2 Tennessee Epi-News

(Continued from page 1) paralyzing the patient to reduce opment and will be available from cough. Updated interim infection CDC at http://www.cdc.gov/ncid exposure to HCWs, including re- control precautions for aerosol- od/sars/ic.htm. ducing the number of HCWs pre- generating procedures on patients sent and adequately sedating or who have SARS are under devel-

1Centers for Disease Control and Prevention, Cluster of severe acute respiratory syndrome cases among protected health care workers, Toronto, Canada, April 2002. MMWR 2003;52:433-6.

Updated Interim U.S. Case Definition for Severe Acute Respiratory Syndrome (SARS) The current CDC case definition as A measured temperature > 100.4ºF syndrome of June 27, 2003 includes the fol- (38ºC) AND 1 lowing elements: AND Either recent travel (including tran- One or more respiratory signs or sit in an airport) to areas reporting A person presenting with a respira- symptoms, including cough, short- community transmission of SARS tory illness of unknown etiology ness of breath, difficulty breathing, (see below) or close contact with a with an onset since February 1, hypoxia, or radiographic findings of person with respiratory illness after 2003, that includes: pneumonia or respiratory distress travel to a SARS area or suspected of having SARS. Travel criteria for suspect or probable U.S. cases of SARS Area First date of illness onset for Last date of illness onset for In order to be able to institute meas- inclusion as reported case inclusion as reported case ures to prevent or control a possible SARS outbreak in Tennessee, it is China (mainland) November 1, 2002 Ongoing imperative that suspected cases be immediately reported to the local Hong Kong February 1, 2003 Ongoing health department or the Tennessee Hanoi, Vietnam February 1, 2003 May 25, 2003 Department of Health, day or night, at 615-741-7247. Physicians Singapore February 1, 2003 June 14, 2003 are available for consultation Toronto, Canada April 23, 2003 Ongoing around the clock as well. Taiwan May 1, 2003 Ongoing

1 Centers for Disease Control and Prevention. Updated Interim U.S. case definition of severe acute respiratory syndrome (SARS). June 5, 2003(online). http://www.cdc.gov/ncidod/sars/casedefinition. Accessed June 27, 2003.

Raccoon Rabies in Tennessee: A Significant First On May 1, 2003, the Knoxville Re- coon strain of rabies in Tennessee. rabies from the Florida. Although gional Laboratory reported that a Additional rabid raccoons have previously identified as separate cat near Mountain City, Johnson been diagnosed in Carter County foci prior to 1994, the mid-Atlantic County, and a raccoon from near since. and southern foci have merged and Roane Mountain in Carter County raccoon rabies is now enzootic in were infected with the raccoon Raccoons have been recognized as all of the eastern coastal states as strain of rabies. These two counties a reservoir for rabies in the south- well as Alabama, Pennsylvania, are in the far northeast corner of the eastern US since the 1950s. An out- Vermont, West Virginia, and possi- 1 state and both rabid animals were break that began during the late bly Ohio. As late as 2000, CDC found close to the North Carolina 1970s in the mid-Atlantic states was reported, “rabies had been found in border where raccoon rabies has attributed to the translocation by western North Carolina in Watauga existed for several years. This report humans of animals infected with County, approximately 6 miles is the first confirmation of the rac- (Continued on page 3) July, 2003 Page 3

(Continued from page 2) Services in conjunction with state Raccoon rabies presents unique and agencies as a means to reduce the from the Tennessee border. No dangerous problems for three rea- human threat in northeast Tennes- cases of rabies among raccoons sons: raccoon populations are thick- see. have been reported in neighboring est in suburban areas where there is 2 Tennessee counties”. a higher population density; rac- Most potential human exposures to coons are extremely aggressive rabies come from dog and cat bites. The public health significance of when rabid and thus bite more hu- Tennessee law requires that all dogs the raccoon strains appearing in an mans, dogs, and cats; and, aggres- and cats have a current rabies vacci- area is that human and companion sive raccoons infect a greater vari- nation. This may be on an annual animal exposure to rabies greatly ety of other species such as foxes, or a three year interval basis de- increases when compared to skunk ground hogs, and squirrels so that pending on the vaccine. The two and bat strains of rabies. Bat rabies there are more indirect rabies most important actions that Ten- occurs at a low level in all counties, threats to people, livestock, and nesseans can take to protect them- but bats normally avoid humans companion animals. selves from rabies are: 1) keep all and other animals. Skunk rabies dogs and cats currently vaccinated, exists in middle and northeast Ten- The use of raccoon oral rabies vac- and 2) stay away from all wild ani- nessee but rabid skunks are slow- cine and depopulation of raccoons mals, especially any appearing ill, moving, not aggressive, and easy to near areas such as campgrounds are hurt or unusually friendly. avoid. being reviewed by USDA Wildlife

1 Krebs JW, Noll HR, Rupprecht CE, Childs JE. Rabies surveillance in the United States during 2001. JAVMA 2002;(12):1690-1701. 2 Centers for Disease Control and Prevention. Update: raccoon rabies epizootic—United States and Canada, 1999. MMWR 2000; 49:31-5.

Monkeypox: An Emerging Infectious Disease in North America Monkeypox is a rare dence of community-acquired mon- raised bumps), often first on the face that is found mostly in the rainforest keypox virus infection in the United but sometimes initially on other countries of central and . States. parts of the body. The lesions usu- It has recently been reported as a ally develop through several stages new and emerging infection in the Cause of Monkeypox before crusting and falling off. The United States. The following infor- The disease is caused by Monkeypox illness typically lasts for two to four mation comes from the Centers for virus, which belongs to the orthopox- weeks. Disease Control and Prevention. virus group of . Other viruses in this group that can cause infection Spread of Monkeypox in Humans The disease is called “monkeypox” in humans include variola People can get monkeypox from an because it was discovered in labora- (), (used in small- infected animal through a bite or tory monkeys in 1958. Studies of pox vaccine), and viruses. direct contact with the infected ani- animals in Africa later found sero- mal’s blood, body fluids, or lesions. logic evidence of infection in ground The disease also can be spread from squirrels, which are thought to have In humans, the clinical features of person to person, but it is much less an important role as a natural host monkeypox are similar to those of infectious than smallpox. The virus for the disease. Laboratory studies smallpox, except that swelling of is thought to be transmitted by large showed that monkeypox infection lymph nodes is associated with mon- respiratory droplets during direct also can occur in rats, mice, and rab- keypox. About 12 days after expo- and prolonged face-to-face contact. bits. In 1970, monkeypox was iden- sure, the illness begins with , In addition, monkeypox can be tified as the cause of a smallpox-like , muscle aches, backache, spread by direct contact with body illness in humans in remote African swollen lymph nodes, a general feel- fluids of an infected person or with locations. In early June 2003, mon- ing of discomfort, and exhaustion. virus-contaminated objects, such as keypox was reported among several Within one to three days (sometimes bedding or clothing. residents in the United States who longer) after onset of fever, the pa- became ill after having contact with tient develops a papular (i.e., sick prairie dogs. This is the first evi- (Continued on page 4) (Continued from page 3) pox; ill persons who exhibit the should also be discouraged. signs and symptoms discussed Treatment and Prevention above should be questioned about The federal government recently There is no specific treatment for their exposure to these animals. The issued a ruling prohibiting the im- monkeypox. has isolation of ill animals is essential to port, sale, trade or release of prairie been reported to reduce the risk of controlling the spread of this dis- dogs and six species of African ro- monkeypox among previously vac- ease. They should not be released dents in all areas of the United cinated persons in Africa. into the wild; doing so has the po- States. For more information, visit tential to make monkeypox endemic www.cdc.gov/ncidod/ monkeypox among wild animals. Because it is or call the CDC public response hot- Monkeypox in Tennessee difficult to trace the origin of exotic line at (888) 246-2675 (English), There are currently no cases of this animals in pet stores, people should (888) 246-2857 (Español), or (866) disease in Tennessee. Prairie dogs, be discouraged from purchasing 874-2646 (TTY). and exotic mice and rats from Af- them. Animal swap meets, another rica are possible sources of monkey- source for obtaining exotic pets,

West Nile Information To receive the latest information and statistics access the following CEDS website: http://tennessee.gov/health, under the heading Featured Topics, click on .