Published monthly by the VIRGINIA DEPARTMENT OF HEALTH PRESORTED Office of Epidemiology STANDARD P.O. Box 2448 U.S. POSTAGE Richmond, Virginia 23218 PAID http://www.vdh.virginia.gov Richmond, Va. Telephone: (804) 864-8141 Permit No. 591

VIRGINIA EPIDEMIOLOGY BULLETIN

Robert B. Stroube, M.D., M.P.H., Health Commissioner Christopher Novak, M.D., M.P.H., Editor Carl W. Armstrong, M.D., State Epidemiologist Vickie L. O’Dell, Layout Editor

October 2005 Volume 105, No. 10 : Clinical and Public Health Impacts

Introduction obesity).1 Unfortunately, the drug can I n f o r - be made relatively easily with inex- mation on Methamphetamine, a chemical struc- pensive over-the-counter ingredients. methamphet- turally similar to the neurotransmitter As a result, methamphetamine has a amine abuse dopamine, was developed in the early high potential for widespread abuse in Virginia is 1900s from its parent drug amphet- and in some areas, it is more popular sparse; how- amine. The drug was used originally in than .2 ever, the data nasal decongestants and in bronchial According to the National Survey on suggest that inhalers. However, it is a powerfully Drug Use and Health, in 2004 an esti- its presence is increasing. For example, addictive psychostimulant that causes mated 12 million persons (4.9 percent while admissions for methamphetamine increased activity, decreased appetite, of persons aged 12 or older) had used abuse in Virginia currently account for and a general sense of well-being. As a methamphetamine at least once in their a relatively small proportion of total result, methamphetamine is now avail- lifetime, 1.4 million (0.6 percent) had admissions for substance abuse treat- able only by prescription as a Schedule used it in the past year, and 600,000 (0.2 ment (3.2% in 2002), this represents II stimulant, with few accepted medical percent) had used it in the past month.3 an increase of almost 356% from indications (e.g., narcolepsy, attention Methamphetamine was 1992.5 This trend suggests deficit disorder, and for short-term use, the primary substance of that methamphetamine is abuse in almost 117,000 likely to become a problem In This Issue: substance abuse treatment in Virginia in the future. As Methamphetamine Impact...... 1 admissions nationally in a result, concern exists over Outbreaks in Virginia...... 6 2003 (6.3 percent of all the increased public health admissions for substance consequences related to: Public Health Award...... 8 abuse treatment).4 1) the medical and social Drug impurities from produc- tion by-products can also cause severe and permanent neurological disabilities following intravenous injection. For example, a common method of illegal methamphet- amine production uses lead acetate as a reagent, and production errors may contaminate the drug with lead. Therefore, abusers may pres- ent with acute lead poisoning. Increased risk of human immu- Primary methamphetamine/ admission rates by State: TEDS 1992-2002 nodeficiency virus (HIV), hepatitis (per 100,000 population aged 12 and over) B and hepatitis C transmission are likely consequences of meth- impact on individuals; and, euphoria—a high but not an intense amphetamine abuse. Infection with 2) the health effects of clandestine rush. Snorting produces effects within HIV and other bloodborne infectious laboratories on community mem- 3-5 minutes, and oral ingestion produces diseases may spread among injection bers and first responders. effects within 15 to 20 minutes. The ef- drug users primarily through the re-use This article reviews methamphet- fects of methamphetamine can last 6-8 of contaminated syringes, needles, or amine for healthcare providers and hours or longer (compared to one hour other paraphernalia. Methamphetamine some of the initiatives taken by the for crack cocaine). After the initial rush, abuse also results in increased libido Virginia Department of Health (VDH) there is typically a state of agitation that and feelings of invulnerability. This to help protect the public. in some individuals can lead to violent may lead to increased sexual activity behavior.1 and increased sexual risk-taking during Physical Properties Methamphetamine, even in small periods of methamphetamine abuse.1 A doses, has physiological effects. Both Methamphetamine, commonly 1995 study from 11 city and state health the rush and the high may result from known as “speed,” “go,” “meth,” or departments found that 16% of 1,147 the release of significant amounts of the “chalk” is an odorless, bitter-tasting drug injectors with HIV infection or neurotransmitter dopamine into areas of crystalline powder that easily dissolves acquired immunodeficiency syndrome the brain that regulate feelings of plea- in water or alcohol. Its color can range (AIDS) reported as the sure.1 Short-term effects include insom- from white to light brown, but may also primary drug injected. In all regions of nia, hyperactivity, decreased appetite, be some shade of pink, depending on the the United States, men having sex with increased respiration and tremors. Other manufacturing process. Methamphet- men were substantially more likely than systemic effects may include shortness amine can be injected, smoked, snorted heterosexuals to report amphetamines as of breath, nausea, vomiting and diar- (inhaled), or taken orally or rectally; the primary drug they injected.2 There- rhea.7 Methamphetamine can cause a the effect on mood depends on how it fore, these factors may result in HIV 1 variety of cardiovascular problems, is taken. becoming a significant problem among such as tachycardia, dysrhythmias, In the 1980s, methamphetamine hy- methamphetamine abusers.1 drochloride (“ice,” “crystal,” “crystal increased blood pressure, and stroke. meth,” “tina,” “crank,” or “glass”) ap- Hyperthermia and seizures can occur Chronic Use peared.1,6 “Ice” is a large, usually clear with methamphetamine overdoses, and As with other stimulants, abusers of crystal of high purity that is smoked in a if not treated immediately, can result 1 methamphetamine most often follow glass pipe like crack cocaine. The smoke in death. a “binge and crash” pattern. How- is odorless, and leaves a residue that can Methamphetamine abuse during ever, chronic abuse causes tolerance be re-smoked.1 Methamphetamine can pregnancy may result in prenatal com- for methamphetamine. In an effort to also be in the form of small, brightly plications, prema- intensify the desired colored tablets. The pills are often called ture delivery, and effects, abusers may by their Thai name, yaba. altered neonatal be- havioral patterns, take higher doses Clinical Effects such as abnormal of the drug, take it reflexes and ex- more frequently, or Immediately after smoking metham- treme irritability. change their method phetamine or injecting it intravenously, Fetal exposure to of drug intake. In the user experiences an intense “rush” methamphetamine some cases, abus- or “flash” that lasts only a few minutes may lead to some ers go without food and is described as extremely pleasur- congenital defor- and sleep while in- able. Snorting or oral ingestion produces mities.1 dulging in a form

 October 2005 of binging known as a “run,” injecting high calorie carbonated beverages, an for the depressive symptoms frequently as much as a gram of the drug every increase in tooth grinding and clench- seen in methamphetamine abusers who 2-3 hours over several days until the ing, and/or its long duration of action recently have become abstinent.1 abuser runs out of the drug or is too leading to extended periods of poor Some protocols have been estab- disorganized to continue.1 With meth- .7 lished by emergency room physicians amphetamine, the stages of progressive Although no physical manifestations to treat methamphetamine overdose. and loss of function occur of a withdrawal syndrome occur when Acute methamphetamine intoxication much more quickly than for other drugs methamphetamine use ends, when can often be handled by observation in of abuse, sometimes evolving over chronic users stop taking the drug they a safe, quiet environment. In cases of months compared to decades. may experience depression, anxiety, extreme excitement or panic, treatment Chronic methamphetamine abus- fatigue, paranoia, aggression, and an with anxiolytic agents (e.g., benzodiaz- ers exhibit symptoms that can include intense craving for the drug. Heavy epines) has been helpful. For metham- violent behavior, anxiety, confusion, users also show progressive social and phetamine-induced psychoses, short- memory loss, repetitive activity and occupational deterioration. Psychotic term use of neuroleptics has proven insomnia.1,2 They also can display a symptoms can sometimes persist for successful. Because hyperthermia and number of psychotic features, includ- months or years after use has ceased.1 convulsions are common and often fatal ing paranoia, visual and auditory hal- complications, emergency room treat- lucinations, mood disturbances, and Treatment ment focuses on the immediate physical delusions (e.g., the sensation of insects Drug abuse treatment, prevention, symptoms. Overdose patients are cooled creeping on the skin). The paranoia can and community-based outreach pro- off in ice baths, and anticonvulsant drugs 1 result in homicidal as well as suicidal grams can significantly reduce drug- may be administered. Clinicians should thoughts, and out-of-control rages can related risk behaviors, such as needle- be aware that methamphetamine abusers be coupled with extremely violent sharing and unsafe sexual practices.1 frequently have secondary substances of 1 behavior. Methamphetamine abuse in The current treatments for meth- abuse (e.g., alcohol, marijuana/hashish, 2,4 young people can also affect critical amphetamine addiction use cognitive cocaine, heroin) that may require ad- stages of their development, with loss behavioral interventions, helping to ditional treatment considerations. of function in emotional development, modify the patient’s thinking, expectan- Methamphetamine Production education, relationships, employment, cies, and behaviors and to increase skills and parenting. in coping with various life stressors. Most of the methamphetamine Methamphetamine This may occur on an available in the U.S. is produced and also appears to have a inpatient basis, or in a trafficked by well-organized foreign neurotoxic effect, dam- supervised/structured groups.8 However, since methamphet- aging brain cells that outpatient setting. Oth- amine is relatively easy to produce from contain dopamine as er models include con- commonly available materials, the do- well as serotonin. Over tingency management, mestic production of methamphetamine time, methamphet- where vouchers are has become a significant problem. amine may reduce do- earned in response to Data from the Drug Enforcement pamine levels, resulting participants’ supplying Administration (DEA) show a rapid 6 in Parkinson’s disease-like symptoms. drug-free urines and where voucher val- increase in the number of metham- Chronic methamphetamine abuse can ues increase as the number of consecu- phetamine laboratories seized by law also cause endocarditis, and among us- tive drug-free urines increase. Although enforcement officials in the US, from ers who inject the drug, damage blood relapse rates are high, it is important to 263 in 1994 to 1,815 in 2000 (a 590% 1 vessels and cause skin abscesses. Skin remember that duration of treatment for increase).10 In 2004, there were 82 lab lesions and infections may also result methamphetamine abuse is strongly cor- seizures in Virginia. from the obsessive picking and scratch- related with better outcomes. Aftercare Illicit methamphetamine is made ing that accompanies methamphetamine is also important: methamphetamine by using a “recipe” obtained from any abuse. recovery support groups (e.g., Narcot- number of sources, including the In- The dental effects of methamphet- ics Anonymous) appear to be effective ternet. The person manufacturing the amine abuse can be devastating. Re- behavioral interventions that can lead to drug is called the “cook.” Most meth- ports have described “meth mouth,” long-term drug-free recovery. amphetamine recipes start with common a distinctive caries pattern often seen There are currently no FDA-ap- over-the-counter (OTC) cold medica- on the buccal smooth surface of the proved pharmacologic treatments for tions containing pseudoephedrine or teeth and the interproximal surfaces of dependence on amphetamine-like ephedrine. These can be purchased at the anterior teeth that resembles early drugs such as methamphetamine. No retail stores and pharmacies. Additional childhood caries. This effect may result single agent has proven efficacious in chemicals that may be used include lye, from the drug’s acidic nature, its xeros- controlled clinical studies, although rock salt, battery acid, lithium batteries, tomic effects, the cravings it causes for antidepressant medications are helpful pool acid, iodine, lighter fluid, matches,

Epidemiology Bulletin  acid traps, dogs, etc.) Methamphetamine Production: Ephedrine/Pseudoephedrine Reduction Methods used to protect the cook site while it’s Hydriodic acid/red phosphorus. The principal chemicals are ephedrine or pseudoephedrine, hydriodic acid, and red phosphorus. This method can yield multipound quantities of high quality unoccupied. EMTs d-methamphetamine. sustain most injuries through on-site expo- Iodine/red phosphorus (“Red P Method”). The principal chemicals are ephedrine or pseu- sure or direct contact doephedrine, iodine, and red phosphorus. The required hydriodic acid in this variation of the with the clothing or hydriodic acid/red phosphorus method is produced by the reaction of iodine in water with red skin of contaminated phosphorus. This method yields high quality d-methamphetamine. Another iodine/red phospho- persons. Firefighters rus method, limited to small production batches, is called the “cold cook” method because the are the least often chemicals, instead of being heated, are placed in a hot environment such as in direct sunlight. injured on-site first Lithium or sodium (“Birch” or “Nazi Method”). The principal chemicals are ephedrine or responders since pseudoephedrine, anhydrous ammonia, and sodium or lithium metal. This method typically they are the most yields ounce quantities of high quality d-methamphetamine. likely to be wearing personal protective fireworks, road flares, antifreeze, pro- phetamine laboratories are discovered equipment (PPE). 8 9 pane, paint thinner, and drain cleaner. because of fires and explosions. Hospital personnel injuries may result As a result, methamphetamine produc- Chemical exposures (e.g., solvents, from injured persons who have not been tion carries a high risk of explosion, corrosives, cyanide, etc.) are also a con- decontaminated before being brought to chemical fire, and the release of toxic cern. Corrosive substances may cause the hospital. gases. burns as well as inhalational injuries As state and federal agencies re- Of special concern are small “mom with symptoms including shortness of duce the availability of precursors by and pop” labs. While these may only breath, cough, or chest pain. Solvents regulation and enforcement, it can be be able to manufacture 1-4 ounces of can be absorbed through the lungs anticipated that producers will resort methamphetamine per production cycle and if the dose is sufficient may cause to more exotic methods of production, (2-12 hours/cycle), these labs can be symptoms of intoxication, including resulting in the creation of contaminants established almost anywhere, including dizziness, lack of coordination, nausea, and by-products with unexpected and motel rooms, self-storage units, private and disorientation. The skin, to a lesser potentially adverse effects to the drug residences, campgrounds, and motor extent, may also absorb some solvents abuser, citizens and the environment. vehicles, and have been discovered if chemicals remain in direct contact. in rural areas as well as in cities and However, ingestion of chemicals (e.g., Long-term Impact towns. Small labs typically produce by children) will result in the greatest Chemicals used during the meth- the drug for personal use, with enough risk of toxicity. amphetamine manufacturing process extra to sell to finance the purchase of These laboratories also pose a signifi- aerosolize or produce gases that can materials. However, while these labs cant risk for other groups, including law leave residues on the surfaces of walls produce only about 20% of the meth- enforcement personnel, first responders and ceilings, in and around air handling amphetamine used in the U.S., they (firefighters, emergency medical techni- equipment, and on furniture, carpet, and account for a disproportionate fraction cians [EMT], and HAZMAT workers), draperies in the room. Therefore, in 9 of the explosions, fires, uncontrolled and hospital personnel. The most buildings where residual contamination hazardous waste dumping, and child frequently reported injuries include is present, new occupants (especially endangerment. This is largely because respiratory irritation (39%), headache young children) could unwittingly be less-skilled cooks operate the small labs, (26%), eye irritation (8%), and burns exposed to hazardous materials. Expo- 10 using more primitive equipment and (8%). Of the types of responders usu- sure may cause respiratory problems, 8 facilities. From the public health per- ally on site first, police officers have skin and eye irritation, headaches, spective, these laboratories carry both the greatest number of injuries because nausea, and dizziness. There are also acute and long-term public risks. they are pres- possible risks of ex- ent during and Acute Exposure Risk posure to infectious immediately disease (e.g., AIDS, Clandestine laboratories produce after a chemi- hepatitis B) in the a variety of acute health hazards. The cal release. event of skin punc- greatest threat is to those individuals They may also ture by undiscovered within the confines of a building when be injured by sharps or other open methamphetamine production is un- “booby traps” wound contact with derway. (e.g., pipe - unseen bloodborne Danger of fire and explosion com- bombs, jugs of pathogens. Some prises the greatest risk. Overall, an gasoline with methamphetamine- estimated 20%-30% of known metham- blasting caps,  October 2005 related chemicals are either known or 11 Box 1. Summary of the State Health Commissioner Emergency Order – suspected carcinogens. Meth Precursors Public Health Actions September 15, 2005 (www.vdh.virginia.gov/pdf/Methamphetamine.pdf) To mitigate some of the impact of For any product containing ephedrine, pseudoephedrine, or any of their salts, isomers, or salts of isomers, alone or in a mixture, provided or sold by a retail distributor or methamphetamine in Virginia, the pharmacy, the vendor must now ensure that: Commonwealth of Virginia has recently started to address two areas: I. Retail sales are limited to three (3) individual packages (no more than nine grams 1) reducing the availability of meth- total of active ingredient) per transaction. amphetamine precursors (e.g., II. Retail personnel must be trained on special procedures used in the sale of covered ephedrine, pseudoephedrine); and, OTC drug products containing ephedrine or pseudoephedrine. 2) developing guidelines for cleaning III. For Single Active Ingredient Products (any substance where ephedrine or pseudo- up clandestine laboratories. ephedrine is the only active ingredient): 1. The product may only be displayed for sale behind a store counter (not Methamphetamine Precursors necessarily a pharmacy counter) that is not accessible to consumers, or in a locked case that requires assistance by a store employee for customer access. In an effort to reduce the availability 2. Any person purchasing or otherwise acquiring the product must present of the raw materials for methamphet- government-issued or educational-institution-issued photo identification.The seller amine production, on September 1, must record in a written or electronic log the purchaser’s name, quantity sold, and 2005, the Governor of Virginia issued the date of the transaction. The purchaser must sign the record acknowledging an Executive Directive #8 that included di- understanding of the applicable sales limit. rections to limit access to methamphet- 3. Records of these transactions must be maintained by the establishment for at amine precursors, as well as to develop least one year from the date of each purchase. However, using or disclosing comprehensive educational efforts to the information in the log for any purpose other than to ensure compliance with help curb methamphetamine use, and this Order or to facilitate a product recall necessary to protect public health and treatment plans for methamphetamine safety is prohibited. Disclosure of the information in the log to law enforcement addiction. To address methamphetamine personnel is required upon request. precursor availability, on September 15, IV. For Multi-active Ingredient Products (any substance in which ephedrine or pseudo- 2005, the State Health Commissioner ephedrine is one of two or more active ingredients): issued an Order restricting the sale 1. The product may only be displayed for sale behind a store counter (not of any product containing ephedrine, necessarily a pharmacy counter) that is not accessible to consumers, OR pseudoephedrine, or any of their salts or 2. The product is displayed in a locked case that requires assistance by a store isomers (see Box 1). This approach has employee for customer access, OR been implemented in other states (e.g., 3. The product is sold from the sales floor if the retailer adopts at least one of the Oklahoma), and has been effective at following four options: reducing the number of methamphet- i. The product must be kept within 30 feet and in direct line of sight of a cash amine laboratories. register or store counter staffed by one or more store employees; ii. Reliable anti-theft devices are used on packages; Clandestine Laboratories iii. Restricted access shelving is used so that only one package may be removed by a consumer at a time and a delay of at least 15 seconds occurs between Cleaning up clandestine drug labs is package replacement on shelf; an enormously complex, time-consum- iv. The product is kept under constant video surveillance. ing and costly process. If the lab is in op- eration when police find it, it must first Note that liquid, liquid capsule, and gel capsule products containing pseudoephedrine be safely neutralized so that it does not are exempt from this order. In addition, this order does not apply to pediatric products explode or chemically contaminate the containing pseudoephedrine or ephedrine, or their salts or isomers, where the pediatric environment. Then, the immediate and product: apparent hazardous materials must be (a) is primarily intended for administration to children under 12 years of age, according removed and disposed of safely. Local to label instructions, and is either in solid dosage form with individual dosage units law enforcement may contract with cer- not exceeding 15 mg of ephedrine or pseudoephedrine; or in liquid form and recom- tified hazardous material disposal com- mended dosage units do not exceed 15 mg of ephedrine or pseudoephedrine per 5 panies for this task. Storing evidence mL of liquid product; OR, and conducting laboratory analysis of (b) is in liquid form primarily intended for administration to children under two years of chemicals are resource intensive. Many age with a recommended dosage not exceeding 2 mL, and the total package con- jurisdictions find that the demands of tains not more than one fluid ounce. processing the evidence strain their These limits do not apply to product properly dispensed under a valid prescription. In forensic laboratory resources.8 addition, the Board of Health may exempt specific products if they cannot be used in the Once appropriate investigations have illegal manufacture of methamphetamine or any other controlled dangerous substance. been completed and all of the chemicals

Epidemiology Bulletin  have been removed, management of effects. The social effects include vio- References 1. Methamphetamine: Abuse and Addiction. NIDA the building or property returns to the lent offenses (such as domestic violence Research Report. 1998. National Institutes of Health. owner. Any subsequent cleanup then be- and child abuse) committed by drug 2. Morb Mortal Wkly Rep. 1995. 44[47]: 882-886. comes the responsibility of the property abusers, and property offenses to obtain 3. U.S. DHHS, Substance Abuse and Mental Health owner. This may involve a significant money to buy drugs or the chemicals to Services Administration, Office of Applied Studies. National Survey on Drug Use and Health Report: loss of permeable materials (carpets, produce them. The risks to the public Methamphetamine Use, Abuse, and Dependence: furniture, etc.), and require cleaning of from clandestine laboratories include 2002, 2003, and 2004. 2005. http://oas.samhsa. the ventilation and plumbing systems, physical injury from explosions, fires, gov/2k5/meth/meth.cfm. Accessed: 10/20/2005. 4. U.S. DHHS, Substance Abuse and Mental Health and re-painting/re-sealing to encap- chemical burns, and toxic fumes. In Services Administration, Office of Applied Studies. sulate residues. However, complete addition, each pound of manufactured Treatment Episode Data Set (TEDS). Highlights remediation may not be done because of methamphetamine produces about - 2003. National Admissions to Substance Abuse Treatment Services, DASIS Series: S-27, 2005. the cost, and owners sometime abandon five to six pounds of hazardous waste. wwwdasis.samhsa.gov/teds03/2003_teds_highlights. the property rather than undertake that Clandestine drug lab operators com- pdf. Accessed: 11/14/2005. task.8 monly dump this waste into the ground, 5. U.S. DHHS, Substance Abuse and Mental Health Because methamphetamine labs are sewers, or streams and rivers. Residual Services Administration, Office of Applied Studies. Primary Methamphetamine/Amphetamine Treatment still an emerging problem, there are no contamination of the ground, water sup- Admissions: 1992-2002. The DASIS Report. 2004. uniform guidelines, regulations, or stan- plies, buildings, and furniture may last www.drugabusestatistics.samhsa.gov/2k4/methTX/ dards for cleanup.11 However, VDH’s for years.8 Efforts to reduce this impact methTX.htm. Accessed: 10/20/2005. 6. NIDA InfoFacts: Methamphetamine. 2005. Na- Division of Health Hazards Control require coordination by many agencies tional Institutes of Health. www.nida.nih.gov/Info- (www.vdh.virginia.gov/HHControl/ and groups. For example, VDH’s Center facts/methamphetamine.html. Accessed: 10/20/2005. index.asp) is working with other agen- for Injury and Violence Prevention is 7. Dental Topics A-Z: Methamphetamine Use. 2005. American Dental Association. www.ada. cies to develop practical, economical, working to develop a methamphetamine org/prof/resources/topics/methmouth.asp. Accessed: effective guidance for the clean-up of awareness campaign. As a result, the 10/20/2005. abandoned and deactivated metham- Virginia Department of Health will 8. Scott MS. 2002. Clandestine Drug Labs. Problem- phetamine production sites. be actively collaborating with many Oriented Guides for Police Series No.16. Depart- ment of Justice. www.cops.usdoj.gov/mime/open. Conclusions agencies to minimize the effects of this pdf?Item=74. Accessed: 10/20/2005. The impact of methamphetamine drug. 9. Morb Mortal Wkly Rep. 2000. 49[45]: 1021-1024. 10. Morb Mortal Wkly Rep. 2005. 54[14]: 356-359. abuse extends beyond individual health 11. J Environ Health. 2003. 65[9]: 50.

Outbreaks Investigated

At any given time, the different strain of S. ty- investigation implicated hamburgers Office of Epidemiology phimurium, involved or tomatoes served on June 28th as the may be participating in three Virginia residents likely vehicle. local, state and/or national and one traveler to Vir- outbreak investigations. ginia. The source of ill- Campylobacteriosis Outbreak Just a sample of some of ness was thought to be An outbreak of these investigations from contaminated ice cream campylobacterio- this summer and fall are from a national chain; sis possibly linked provided to illustrate the the suspect ingredient to raw milk con- scope of these investigations. was dry commercially-prepared cake sumption was in- mix added into some of the ice cream vestigated in July. Salmonella typhimurium flavors. VDH worked with the Virginia One confirmed case Outbreaks Department of Agriculture and Con- and three clinically In July, the Virginia Department of sumer Services on traceback efforts to compatible cases of Health (VDH) participated in two multi- prevent further illness. campylobacteriosis were identified in state investigations of outbreaks caused Salmonella hartford Outbreak by Salmonella typhimurium. One out- persons with a histo- break included seven Virginia residents A Salmonella hartford outbreak ry of raw cow milk diagnosed with S. typhimurium that was identified at a bible study camp in consumption from a matched a strain of the bacterium linked Augusta County. Sessions were held at farm operating a “cow share” program. to the consumption of contaminated the end of June in the evenings, and par- Four other persons who received milk unpasteurized fresh-squeezed orange ticipants ate dinner together each night. from the same farm contacted VDH; juice produced in Florida. Thirty-eight attendees were reported none of these reported illness in them- Another outbreak, caused by a ill. Findings from the epidemiologic selves or their family members.  October 2005 Hurricane Katrina Surveillance and the Rappahannock Area Health Dis- VDH Participates in Tularemia – Red Cross trict participated by providing technical Investigation advice regarding the assessment. The VDH Office of Epidemiology The assessment found that the school The VDH was notified by the CDC worked closely with the American Red did have mold and moisture, but that it on the morning of September 30, 2005, Cross’ Greater Richmond Office to did not present a general public health that routine air sampling testing sites monitor Hurricane Katrina evacuees problem. It could not be concluded that near the National Mall in Washington, presenting to the facility with poten- various reported illnesses were due to D.C. showed aberrant sample data. tially infectious conditions. Although mold exposure at the schools since mold The samples, taken on September 24- some evacuees presented with mild testing results showed levels that were 25, 2005, indicated the presence of gastrointestinal, respiratory symptoms, typical of indoor environments. Mold Francisella tularensis, the bacterium or rashes diagnosed as contact derma- spore levels were also higher outside that can cause tularemia. An estimated titis, no outbreaks were detected. VDH the school than inside, and since these 100,000 to 300,000 individuals may also worked with local hospitals on molds are ubiquitous, families prob- have been in and around the National surveillance activities since most of ably have these molds in their homes as Mall during the time frame in ques- the evacuees with medical conditions well. VDH recommended tion (including visitors, were referred to those facilities for maintaining dehumidifi- employees working on treatment. cation equipment, enforc- the mall, demonstra- ing general housekeeping tors participating in an Systemic Inflammatory Response anti-war rally, and law Syndrome (SIRS) Cluster requirements, remaining vigilant for moisture-re- enforcement officials). In September, 2005, the Rappahan- lated damage and remov- Press materials and a nock Area Health District and the Office ing carpeting to the maxi- Health Alert Network notification were dis- of Epidemiology investigated reports of mum extent possible. an increase in the number of patients seminated on the evening of September diagnosed with Systemic Inflammatory Hepatitis B in Assisted Care and 30 as a joint response from VDH, the Response Syndrome (SIRS) in a local Adult Home Facilities Maryland Department of Health and hospital. The cluster was reported by Mental Hygiene, and the D.C. Depart- Sharing devices or failing to follow ment of Health. a hospital after five patients became infection control practices related to seriously ill following cardiac surgi- VDH worked closely with officials blood glucose monitoring may allow from the National Capitol Region, De- cal procedures. The hospital and VDH the transmission of hepatitis B virus personnel collaborated with the Federal partment of Homeland Security, CDC, and other bloodborne pathogens. This Governor Warner’s Office of Com- Drug Administration and Centers for summer, two assisted care facilities in Disease Control and Prevention (CDC) monwealth Preparedness, the Virginia Richmond were found to have cases Department of Emergency Management to determine the cause. Analysis of of hepatitis B associated with the im- the solution (manufactured by Central and other state and federal agencies dur- proper use (sharing) of blood glucose ing this investigation. Admixture Pharmacy Services, Inc. monitoring devices. The Richmond (CAPS)) used to induce cardioplegia Hospital surveillance was also used City Health District worked with the to try to identify potential cases. suggests that bacterial contamination of facilities to improve infection preven- the product may have been the cause of Continued follow-up testing did not tion procedures. VDH also sent a letter generate conclusive results indicating the illnesses. As a result, the FDA issued to all assisted-living facilities in Virginia a product recall for Cardioplegia and the presence of F. tularensis in the envi- that included recommendations written ronment, and no spike in the incidence several other products manufactured by the CDC that address safe practices by CAPS. of compatible illness was observed. to follow while performing diabetic care Although isolated cases of suspected VDH Addresses Mold and p r o c e d u r e s in healthcare and illnesses were reported, including in Moisture Issue in Stafford g r o u p residence settings five Virginia residents, clinical testing (www.cdc.gov/ County School did not confirm any case of tularemia ncidod/diseases/ and the clinical presentations were In June 2005, the Stafford County hepatitis/spot- consistent with illnesses other than Schools conducted a fungal and pes- lights/glucose. tularemia. ticide/herbicide assessment at an el- htm#4). An intentional release of tularemia ementary school following a history of is not suspected as the cause of the moisture and mold issues, complaints, observed signals. However, investiga- and concerns by parents and teachers. tions continue into the possible source The VDH Northwestern Region Emer- of the organism to better understand the gency Preparedness and Response Team strengths and limitations of air sampling systems.

Epidemiology Bulletin  Cases of Selected Notifiable Diseases Reported in Virginia*

Total Cases Reported, September 2005

Total Cases Reported Statewide, Regions January - September

Disease State NW N SW C E This Year Last Year 5 Yr Avg AIDS 60 3 20 3 21 13 429 512 549 Campylobacteriosis 67 13 16 10 16 12 438 494 497 E. coli O157:H7 4 1 1 2 0 0 29 25 42 Giardiasis 57 10 27 5 9 6 412 366 289 Gonorrhea 829 39 59 111 266 354 6,418 6,700 7,401 Hepatitis, Viral A 6 2 3 1 0 0 61 89 96 B, acute 8 2 0 3 1 2 118 185 144 C, acute 0 0 0 0 0 0 10 13 7 HIV Infection 106 4 32 3 26 41 599 644 635 Lead in Children† 144 19 5 44 42 34 476 621 564 Legionellosis 2 0 0 0 1 1 33 37 35 Lyme Disease 28 9 14 2 0 3 167 116 108 Measles 0 0 0 0 0 0 0 0 <1 Meningococcal Infection 0 0 0 0 0 0 23 14 27 0 0 0 0 0 0 0 7 5 Pertussis 23 5 4 5 4 5 278 135 88 Rabies in Animals 40 19 4 8 8 1 363 384 414 Rocky Mountain Spotted Fever 25 1 2 13 3 6 73 22 19 Rubella 0 0 0 0 0 0 0 0 0 Salmonellosis 156 19 33 22 41 41 869 865 862 Shigellosis 14 1 6 0 2 5 99 116 346 Syphilis, Early§ 34 2 10 3 8 11 208 154 165 Tuberculosis 31 0 11 0 5 15 227 177 192 Localities Reporting Animal Rabies This Month: Amherst 1 fox; Arlington 1 raccoon; Bedford 1 raccoon; Buckingham 1 raccoon; Campbell 1 cat, 1 skunk; Caroline 1 skunk; Carroll 1 raccoon; Charles City 2 skunks; Chesterfield 2 raccoons; Fairfax 1 bat, 2 raccoons; Fauquier 1 fox, 1 raccoon; Fredericksburg 1 raccoon; Hanover 1 raccoon; King George 1 fox, 1 raccoon; Louisa 1 fox; Madison 1 fox; Mecklenburg 1 skunk; Montgomery 1 raccoon; Northampton 1 raccoon; Pittsylvania 1 skunk; Prince George 1 raccoon; Radford 1 bat; Rockbridge 1 skunk; Rockingham 1 raccoon, 2 skunks; Shenandoah 2 skunks; Stafford 2 foxes, 1 raccoon, 1 skunk; Warren 1 raccoon. Toxic Substance-related Illnesses: Adult Lead Exposure 30; Mercury Exposure 2; Pneumoconiosis 6. *Data for 2005 are provisional. †Elevated blood lead levels >10µg/dL. §Includes primary, secondary, and early latent.

Excellence in Public Health Director of Office of Epidemiology to Receive Award from the Medical Society of Virginia Dr. Carl Armstrong, director of the Office of Epidemiology, has been selected by the Medical Society of Virginia Foundation to receive the The Medical Society annual Salute to Service Award for Service on Behalf of All Virginians of Virginia on November 4, 2005. This award is presented to a physician, alliance member, or medical student who has provided exceptional service in the public health arena.

 October 2005