EPI Newslet ter Expanded Program on Immu ni za tion in the Americas Volume XXVI, Number 3 IM MU NIZE AND PRO TECT YOUR CHILDREN June 2004 Diphtheria Outbreak in the Dominican Republic Diphtheria is an endemic disease in the Dominican Re- The national authorities have initiated outbreak control public. In the last fi ve years, between 35 and 50 cases have measures. Actions implemented to guarantee adequate case been reported. Until epidemiological week 27 of 2004, the management include use of diphtheria antitoxin, antibiotics, Dominican Republic reported 51 cases of diphtheria, all of and support measures. Prophylactic antibiotics and vaccina- them in children between 1 and 14 years of age. The Corine- tion appropriate for the age and immunization status have been bacterium diphteriae has advocated for the manage- been isolated in 12 (24%) Figure 1. Reported diphtheria cases by province and ment of the contacts. For of the 51 reported cases and epidemiological week, Dominican Republic, 2004* areas at risk, intensifi cation toxigenicity test results are Cases of diphtheria vaccination pending. activities is being done. Further actions in order to Preliminary analysis of guarantee that the newborn the available data indicates cohorts receive adequate that the most affected age diphtheria protection with group this year is that of 3 primary doses of diphthe- children aged 1-4 years ria vaccine and boosters in (67% of the cases), which accordance with their age represents an annual cu- are being planned. mulative incidence of 3.8 The fact that diph- cases per 100,000 children theria is endemic in the in this age group. The cases Epidemiological Weeks Dominican Republic and occurred mainly in Santo 6DQWR'RPLQJR 6DQWLDJR 2WKHU the majority of cases have Domingo -National Dis- Source: Expanded Program on Immunization and Dirección General de Epidemiología/ occurred in the 1-4 year old Secretaria de Estado de Salud Pública y Asistencia Social age group strongly sug- trict and Province of Santo * Preliminary Data Domingo- (19 cases) and gests that one of the main the Province of Santiago (14 cases), where approximately causes of disease endemicity and the current outbreak is low 42% of the population live. The other 18 cases occurred in 15 vaccination coverage. The presence of pockets of susceptibles of the remaining 29 provinces of the country (Figure 1). The in areas of poverty and/or with limited access to routine vac- cination services is a call for action to improve coverage in majority of the cases present with unknown or incomplete all communities. vaccination history and come from areas of extreme poverty and overcrowding. The case-fatality rate in the different health Editorial: This note is to alert the countries of the Region and encourage them to strengthen their routine vaccination facilities was 43% in the children referral hospital of Santo services, evaluate their risk areas, take preemptive measures, Domingo and 8% in the referral hospital of Santiago. No deaths and strengthen the epidemiological surveillance of vaccine- have been reported in the other health care facilities. preventable diseases. In this issue: Diphtheria Outbreak in the Dominican Republic..................................... 1 Current Recommendations for the Use of BCG to prevent Severe Infl uenza Vaccination among Risk Groups in Costa Rica: Tuberculosis........................................................................................... 4 An Evidence-based Decision ................................................................. 2 TechNet21 2004 Consultation in Antalya, Turkey .................................. 6 Measles Surveillance in the Americas: Final Data, 2003........................ 7 Infl uenza Vaccination among Risk Groups in Costa Rica: An Evidence-based Decision Infl uenza is a highly infectious viral disease characterized month running averages to smooth the curve, show two annual by seasonal outbreaks. Attack rates are usually high, resulting peaks of infection of different magnitude. A major peak occurs in an increase in doctor visits and hospitalizations that can be during the months of May through July, and a second peak quite concerning in view of the threat of a pandemic. Infl uenza occurs during September to November (Figure 1). mortality refers not only to the disease caused by the virus, Strengthening of laboratory surveillance but also to the complications it can cause among people suf- fering from chronic diseases and among demographic groups From 1998, the National Hospital of Children (HNN - Hos- at risk1. pital Nacional de Niños) started diagnosing respiratory viral infections and collecting samples from hospitalized children. Following an analysis of the epidemiology of infl uenza The HNN clinical samples with positive results were sent to the and its complications, the health authorities of Costa Rica virology laboratory of the School of Microbiology of the Uni- offi cially introduced a plan of action aimed at strengthening versity of Costa Rica (UCR), where, in collaboration with the surveillance for infl uenza virus through the development of a Centers for Disease Control and Prevention (CDC) in Atlanta, network of sentinel sites in Costa Rica. The three components viral isolation, molecular typing, and study of the infl uenza of the plan of action were2: virus were performed. Results showed that the A/Sydney/ 1. Strengthening surveillance for infl uenza and other res- 05/97(H3N2) infl uenza strain circulated from 1998 through piratory viruses; 2000, the A/NewCaledonia/20/99(H1N1) strain circulated in 2. Vaccinating high-risk groups against infl uenza; and September 2000, and the A/Panama/2007/99(H3N2) strain 3. Standardizing protocols for clinical management of respi- circulated in July 2001. In 1999 and 2001, several infl uenza B ratory infections. strains were also isolated. Figure 1. Discharges and three month running averages of In 2002, the sentinel surveil- The implementation of this discharges from infl uenza, Costa Rica, 1990 to 2002 plan has helped defi ne more ac- lance network for infl uenza and curately the burden of infl uenza Number of discharges other respiratory viruses was in the country, allowed for the implemented (Figure 2). Pro- identifi cation of seasonal trends, tocols were established for the and supported international proper management and study virus surveillance for develop- of samples from two sentinel ment of an effective infl uenza sites: the HNN and the National vaccine. In addition, the treat- Hospital of Geriatrics. These ment protocols for respiratory centers systematically send to infections have been updated, the National Reference Labora- tory (INCIENSA) viral samples and infl uenza vaccination of high-risk groups has been added from suspected infl uenza cases -XO -XO -XO -XO -XO -XO -XO -XO -XO -XO -XO -XO -XO to Costa Rica’s offi cial immuni- -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ -DQ reported by inpatient and out- zation schedule. Discharges 3-month running average of discharges patient services, including Source: Database of hospital discharges, Caja Costarricense de Seguro Social (1990-2002) emergency rooms. Results are Surveillance of respiratory published weekly for users of the infections network and positive isolates are Respiratory tract infections are the most frequently re- shipped to the CDC for molecular characterization. ported illnesses in the country. During the period from 1995 The surveillance network has also allowed the study to 2002, the incidence rate of respiratory infections in Costa of respiratory infection outbreaks in communities of the Rica ranged from 127 cases per 1,000 population during years country where the differential diagnosis of febrile diseases of endemic disease to 247 cases per 1,000 population during in endemic areas of dengue has been diffi cult. In 2004, the epidemic years. laboratory surveillance network will be expanded to include Surveillance for acute respiratory infections has demon- two more sentinel sites located in regional hospitals of the strated the seasonal nature of these illnesses. This is particu- coastal zones. larly relevant for Costa Rica since the country is located in an Hospitalization and outpatient visits intertropical convergence area. In addition to the country’s During 2002, groups at opposite ends of the age spectrum climatic conditions, the high infl ux of international visitors were at greatest risk for hospitalization (12.0 times more in to and from North America, Central America, and Europe children aged <5 years and 14.2 times more in adults aged >65 during infl uenza epidemic seasons most likely infl uences the years) and death (4.9 times more in children aged <5 years and infl uenza epidemiology in Costa Rica. 61.7 times more in adults aged >65 years) in comparison to The analysis of the seasonal patterns on the basis of hospital the 5-64 year age group (Figures 3 and 4). In that same year, discharges for infl uenza (1990-2002), and the use of three- discharges from infl uenza and pneumonia represented 2.2% 2 Figure 2. Infl uenza sentinel surveillance network of total hospital discharges; however, the proportion was 7.6% an outpatient visit frequency of 80% in both age groups and among children aged <5 years and 4.9% among adults aged >65 a hospitalization frequency of 15% and 20%, respectively. years. The average hospital stay was 5.7 days among children Vaccination costs included vaccine purchase, staff salary and aged <5 years and 14 days among adults aged >65 years. training, and management of waste generated by the activity (US $401,014). Costs avoided through outpatient visits and In 2001, infl uenza was the cause of 5% of total consulta- hospitalizations were assessed on the basis of the consultation tions in emergency rooms and 9% of outpatient consultations. and hospitalization estimates, and the average stay due to in- Furthermore, it was the main cause of disability among the fl uenza specifi c to each age group, under an endemic scenario population in general, with an average of 3.3 days of disability (US $4,034,366), and also under an epidemic scenario (US per episode.