|
ANDREW J SPANO County Executive Joshua Lipsman, M.D., M.P.H. Commissioner, Department of Health |
ATTENTION Public
Health Update |
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The Westchester County Department of Health
provides public health updates to members
of the medical community on
important issues affecting public health in Westchester
June 26, 2003
2003 WEST NILE VIRUS UPDATE:
REPORTING AND TESTING OF
SUSPECTED CASES OF
WEST NILE VIRUS INFECTION
PLEASE DISTRIBUTE TO INTERNAL MEDICINE, FAMILY PRACTICE,
PRIMARY CARE AND PEDIATRIC STAFF, EMERGENCY ROOM, INFECTIOUS DISEASE,
NEUROLOGY, INTENSIVE CARE UNIT AND AMBULATORY CARE STAFF
1. The
Westchester County Department of Health will begin enhanced active surveillance
for West Nile virus infection for the 2003 season on July 1, 2003. This includes contacting all acute care hospitals in WC regularly to
identify patients potentially infected with WNV and arranging laboratory
testing for such patients
2.
Please
report immediately by telephone to the Westchester County Department of Health
any adult or pediatric patient with suspected viral encephalitis
(914) 813-5159 Mon-Fri 8:30 AM - 4:30 PM/(914)
813-5000 24 hours/day; 7 days/week)
3. The first
confirmation of West Nile Virus activity in New York State this season was a WNV
(+) bird collected in Westchester on 5 May 2003.
4. Please refer to the Physician's Corner page on the Westchester County
Health Department web site, www.westchestergov.com/health,
for additional information, including materials for patient education.
Dear
Colleagues:
This
update reviews the 2002 West Nile Virus (WNV) season and describes WNV
activities for 2003, including testing of human suspect cases.
Update on WNV Developments – 2002 Season
During 2002, two cases of West Nile Virus
infection, none fatal, were identified in Westchester County residents. These were the first human cases of West
Nile virus in the county since 1999, the first year the disease was seen in the
U.S. and western hemisphere. In 2002
the Westchester County Department of Health provided consultation and
facilitated WNV testing for over 50 patients.
The cases occurred in an 83 y/o male resident of Mamaroneck and a 62 y/o
female resident of Mount Vernon. Both
presented with fever, either altered mental status or signs of
meningoencephalitis, had CSF pleocytosis, and required hospitalization. Both patients required stays at long term
care facilities following hospital discharge.
Both individuals spent extensive amounts
of time outdoors, almost exclusively on their own property. In each instance, mosquito breeding areas
were identified either on the patient’s property or in very close proximity to
their property. Based on this
experience and that reported elsewhere, and similar to tick borne diseases, the
greatest risk for acquiring WNV infection may be peridomestic or in the
immediate vicinity of one’s home or property.
This underscores the
importance for all property owners to eliminate or reduce all stagnant water
(which serve as mosquito breeding sites) around their homes and property.
Educational information and materials for download are available at www.westchestergov.com/health/Westnile.htm or can be requested by calling 914-813-5000.
The 2002
West Nile virus epidemic in the United States was the largest arbovirus
meningoencephalitis epidemic reported in the U.S. WNV activity was reported from 44 states and the District of
Columbia. Nationwide, over 4,000 cases of human WNV disease were reported
and several new modes of
person-to-person transmission were documented, including organ transplantation,
blood and blood product transfusion, transplacental infection, and possibly
breastfeeding. In New York State during 2002, WNV activity was reported from New
York City and 53 of the 57 counties outside of New York City. Eighty-two cases of human WNV disease were
reported in 2002, compared with 15 cases in 2001, 14 cases in 2000, and 62
cases in 1999.
Preventing Transmission of WN virus through Transfusion or
Transplantation
The FDA, CDC and the NIH are working
collaboratively to develop new blood and organ donor screening assays for WN
virus. Since a large proportion of
infected persons may not experience symptoms, deferral of donors on the basis
of clinical criteria alone is not enough. Because
certain blood products may be stored prior to use, and WNV transmission has
been reported in the winter months in southern areas of the U.S. where organs
going to WC residents may originate, a history of receiving blood products
should be obtained. WNV infection
should be considered in the differential of recent organ or blood products
recipients with a clinical presentation consistent with WNV regardless of time
of year. Such suspect cases of WNV
should be immediately reported to the WCDH as other units of blood or tissues
from the same donor will not be released for use until WNV infection is ruled
out. FDA has issued a guidance document
for blood bank deferral of donors with suspect or diagnosed WN virus infection
that have illness onset before or after donation. This information can be found on FDA's
website at www.fda.gov/cber/gdlns/wnvguid.htm.
Guidance for Pregnant
or Lactating Women Regarding Prevention of WN Virus Infection*
The health
benefits of breast-feeding have been well established. The risk for WN viral transmission through
breast-feeding is unknown, and the new findings from 2002 do not change current
breast-feeding recommendations. Pregnant
or lactating women who have laboratory evidence of acute or recent WN virus
infection should consult their physicians for more detailed medical advice.
Pregnant or lactating women should take precautions to avoid mosquito bites
during the summer months, when adult mosquitoes are most active. Detailed information on prevention of
mosquito bites is available on the Westchester County Department of Health
website at: http://www.westchestergov.com/health/Westnile.htm
Paralytic
Poliomyelitis-like Syndrome Associated with WN Virus*
Studies of
patients with WN-associated acute flaccid paralysis during last year’s epidemic
have shown that the muscle weakness associated with infection may be attributable
to involvement of anterior horn cells and motor axons, causing a syndrome
similar to that found in acute poliomyelitis.
The diagnosis of WN virus should be considered in patients with
asymmetric acute flaccid paralysis or paresis, or with other movement disorders
including symptoms such as tremor, myoclonus, or Parkinson’s-like features,
even in the absence of other evidence of central nervous system
involvement. In the setting of possible
WN virus-associated acute flaccid paralysis, careful evaluation by a
neurologist to determine the underlying etiology is recommended before
instituting empiric treatment for Guillain-Barré
syndrome.
* We would like to thank New York City
Department of Health and Mental Hygiene, especially Jacqueline Kellachan, MPH
and Annie Fine, MD, for this information
WNV Activity for 2003 Season
A crow
found in Bedford on May 5, 2003 has tested positive for the West Nile virus.
This is the first confirmation of West Nile virus in a bird in Westchester
County and New York State this year.
Since then, there has been one additional WNV positive bird in NYS. Now that WNV has
established itself in throughout North America and with recent evidence of WNV
activity in Westchester County and NYS, health care providers, laboratorians,
and public health practitioners should maintain vigilance for suspected human
cases during the summer months. The Westchester County Health Department and New York State
Department of Health (NYSDOH) are enhancing surveillance activities for suspected
WNV infections to facilitate the prompt recognition of a human outbreak. A
critical component of this effort is the rapid detection and timely reporting
of cases of viral encephalitis and viral meningitis from July through October.
Reporting cases of viral
encephalitis:
To ensure the rapid identification of human WNV infection
should it recur this year, we are requesting that providers report
immediately by telephone to
the Westchester County Department of Health any adult or pediatric patient with
suspected viral encephalitis as defined below:
a.
Fever ³ 38°C or
100°F, and
b.
Altered
mental status (altered level of consciousness, agitation, lethargy) and/or
other evidence of cortical involvement (e.g., focal neurologic findings,
seizures), and
c.
CSF
pleocytosis with predominant lymphocytes and/or elevated protein and a negative
gram stain and culture, with or without
d.
Muscle
weakness (especially flaccid paralysis) confirmed by neurologic exam or EMG.
Note: Particular care should be given to determine if individuals
experiencing encephalitis have received a transfusion or transplantation in the
four weeks prior to illness onset or if they have donated blood or organs in
the two weeks prior to illness onset.
A NYSDOH Viral Encephalitis/Meningitis Case Report Form is
attached. This form is similar to the
one used in past seasons, however also inquires about blood transfusion and
donation and tissue/organ transplantation and donation, issues new to WNV in
the 2002 season. This form should be
completed for each suspect case and faxed to the WCDH at (914) 813-5182. A copy
of the form should also be submitted with the laboratory specimens.
TO REPORT A SUSPECT
CASE AND ARRANGE FOR TESTING, CALL THE WESTCHESTER COUNTY DEPARTMENT OF HEALTH
AT:
(914) 813-5159 Mon-Fri 8:30 AM - 4:30 PM
(914) 813-5000 24
hours/day; 7 days/week
Testing for viral encephalitis and
viral meningitis, including West Nile virus:
The NYSDOH Laboratory, Wadsworth
Center, offers diagnostic testing for a wide range of
viruses, including West Nile virus,
that have been associated with encephalitis and meningitis.
Appropriate specimens for testing
include cerebrospinal fluid (CSF), acute and convalescent sera, and brain
biopsy or autopsy material. If you have a patient that meets the enclosed clinical
criteria for WNV testing, WCDH will assist you in arranging testing at the
Wadsworth Center. Instructions on the collection and submission of clinical
specimens, the polymerase chain reaction (PCR) consent form and the Viral
Encephalitis/Meningitis Case Report Form are also enclosed.
Serologic testing for asymptomatic
patients or those with mild symptoms, such as fever and
headache, is not necessary. The
likelihood of WNV infection in these patients is extremely low, especially in
the absence of an outbreak. Also, since there is no specific treatment for WNV
infections, patients with mild symptoms do not require specific diagnostic
testing. Providers pressed for WNV testing by patients with milder symptoms
should be aware that commercial serologic tests for WNV are available. (Please
note: these commercial tests are screening tests and any positive result will
need to be confirmed at Wadsworth Center). Mildly ill patients should be
advised to seek medical attention if they develop more severe symptoms such as
confusion, muscle weakness, severe headache, stiff neck or photophobia.
Education, Surveillance and Control
During the past few years, WCDH has
developed and implemented comprehensive surveillance, control, and education
programs for WNV. Surveillance and
control programs include:
·
reporting
and selective testing of dead birds for WNV
·
inspection
of both natural and manmade habitats, and over 60,000 storm water catch basins
for mosquito breeding and either removing such sites when feasible or applying
larvicides when indicated; and
·
regular
trapping of adult mosquitoes at locations throughout the county, identifying
and testing mosquitoes for WNV;
These efforts have permitted more
sophisticated analyses of the risk of human infection from WNV and averted the
need for widespread pesticide spraying in Westchester County in 2001 and 2002.
Details are available on the Westchester County Department
of Health Website http://www.westchestergov.com/health/Westnile.htm.
The Westchester County Department of Health (WCDH) thanks
the medical and laboratory communities for their continued collaboration in the
investigation of communicable diseases.
Sincerely,
Belinda Ostrowsky Ada J. Huang
Belinda Ostrowsky, M.D., M.P.H. Ada J. Huang, M.D.
Director,
STD & Communicable Diseases Deputy
Commissioner, Disease Control
Please fax a completed copy of
this form to your Local County Health Department
NEW YORK STATE DEPARTMENT OF HEALTH Viral
Encephalitis/Meningitis Case Report Form
PATIENT INFORMATION
Last
name____________________ First Name __________________ MI _____ County
____________
Address
_________________________________City ___________________ Zip Code
_______State____
Telephone
(____)_____-_______ Date of Birth ____/____/____ Age____
Occupation:__________________
Sex: Male Female Race: White Black Am
Indian/Alaskan Asian Other
_____________
Ethnicity: Hispanic Non-hispanic Unk Pregnant:
Yes No Unknown
If pregnant, gestational weeks: ______
CLINICAL INFORMATION
Hospitalized? Yes No
If yes, Hospital
Name__________________________________________________
Street
Address____________________________ City____________________ State_____ Zip
__________
Medical record #
___________Date of admission ____/____/____ Date of discharge/transfer
____/____/___
Date of first symptoms ____/____/____ Date
of first neurologic symptoms
____/____/____
Current
Diagnosis: encephalitis meningitis other diagnosis
_______________________________
Fever (> 38ºC
or 100ºF) Yes No Unknown Altered
mental status Yes No Unknown
Headache Yes No Unknown Stiff
neck/Meningeal signs Yes No Unknown Seizures Yes No Unknown Muscle
weakness Yes No Unknown
Rash Yes No Unknown Muscle
pain Yes No Unknown
Other
______________________________________ Outcome Recovered Died Unknown
If patient died, date of death
____/____/____ Autopsy performed Yes No Unknown
Received 4 weeks
prior to first symptom: transfusion transplant
LABORATORY INFORMATION / TEST RESULTS
Glu ________
Prot ________ RBC _______ WBC ________ Diff: Segs% _____ Lymphs%_____
Gram stain
________________ Bacterial Culture ____________ Fungal / Parasitic tests
_____________
Viral test
results (Culture/ Serology / PCR)
_________________________________________________
CBC (specify
units) ______ Date ____/____/____ WBC ______ Diff: Segs% ________ Lymphs%
________
Bacterial
Culture _______________________________________
MRI Date
____/____/____
Result____________________________________________________________
CT Date
____/____/____ Result____________________________________________________________
EEG Date
____/____/____ Result__________________________________________________________
EMG Date
____/____/____
Result__________________________________________________________
Antiviral
Treatment Yes No Unknown If yes, list below. Date
started: ____________
1.
__________________________________________________________________________
Risk Factor Information: (during 1 month before onset)
Patient traveled: Outside country
Outside New York State Outside county of residence
Animal or arthropod contact? Yes No Unknown Specify:
______________________________
REPORTING INDIVIDUAL (Please Print Clearly) Title (ICN,
Resident, Attending) ____________________
Last name
____________________First name _________________ Telephone (____)_____-_______
Work
address____________________ City ___________________________ State___ Zip Code
________
REQUESTING PROVIDER: Last name ________________ First name
_________________________
Work address___________________
City ___________________________ State___ Zip Code ________
Page 1
of 2
Revised 4/03
NEW YORK STATE DEPARTMENT OF HEALTH Viral
Encephalitis/Meningitis Case Report Form
SPECIMENS BEING SUBMITTED TO NYSDOH FOR TESTING
Date Submitted ___ / ___ /
___
**PCR panel includes: WNV, SLE, EEE, California serogrp, Cache Valley, Powassan, Enterovirus, HSV, VZV, CMV and EBV
Serum