Global & Disaster Medicine

Archive for the ‘Tetanus’ Category

CDC recommendations to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas during the period of September 2017 – March 2018.

CDC

Advice for Providers Treating Patients in or Recently Returned from Hurricane-Affected Areas, Including Puerto Rico and US Virgin Islands

Distributed via the CDC Health Alert Network
October 24, 2017, 1330 ET (1:30 PM ET)
CDCHAN-00408

Summary
The Centers for Disease Control and Prevention (CDC) is working with federal, state, territorial, and local agencies and global health partners in response to recent hurricanes. CDC is aware of media reports and anecdotal accounts of various infectious diseases in hurricane-affected areas, including Puerto Rico and the US Virgin Islands (USVI). Because of compromised drinking water and decreased access to safe water, food, and shelter, the conditions for outbreaks of infectious diseases exist.

The purpose of this HAN advisory is to remind clinicians assessing patients currently in or recently returned from hurricane-affected areas to be vigilant in looking for certain infectious diseases, including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. Additionally, this Advisory provides guidance to state and territorial health departments on enhanced disease reporting.

 

Background
Hurricanes Irma and Maria made landfall in Puerto Rico and USVI in September 2017, causing widespread flooding and devastation. Natural hazards associated with the storms continue to affect many areas. Infectious disease outbreaks of diarrheal and respiratory illnesses can occur when access to safe water and sewage systems are disrupted and personal hygiene is difficult to maintain. Additionally, vector borne diseases can occur due to increased mosquito breeding in standing water; both Puerto Rico and USVI are at risk for outbreaks of dengue, Zika, and chikungunya.

Health care providers and public health practitioners should be aware that post-hurricane environmental conditions may pose an increased risk for the spread of infectious diseases among patients in or recently returned from hurricane-affected areas; including leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza. The period of heightened risk may last through March 2018, based on current predictions of full restoration of power and safe water systems in Puerto Rico and USVI.

In addition, providers in health care facilities that have experienced water damage or contaminated water systems should be aware of the potential for increased risk of infections in those facilities due to invasive fungi, nontuberculous Mycobacterium species, Legionella species, and other Gram-negative bacteria associated with water (e.g., Pseudomonas), especially among critically ill or immunocompromised patients.

Cholera has not occurred in Puerto Rico or USVI in many decades and is not expected to occur post-hurricane.

 

Recommendations

These recommendations apply to healthcare providers treating patients in Puerto Rico and USVI, as well as those treating patients in the continental US who recently traveled in hurricane-affected areas (e.g., within the past 4 weeks), during the period of September 2017 – March 2018.

  • Health care providers and public health practitioners in hurricane-affected areas should look for community and healthcare-associated infectious diseases.
  • Health care providers in the continental US are encouraged to ask patients about recent travel (e.g., within the past 4 weeks) to hurricane-affected areas.
  • All healthcare providers should consider less common infectious disease etiologies in patients presenting with evidence of acute respiratory illness, gastroenteritis, renal or hepatic failure, wound infection, or other febrile illness. Some particularly important infectious diseases to consider include leptospirosis, dengue, hepatitis A, typhoid fever, vibriosis, and influenza.
  • In the context of limited laboratory resources in hurricane-affected areas, health care providers should contact their territorial or state health department if they need assistance with ordering specific diagnostic tests.
  • For certain conditions, such as leptospirosis, empiric therapy should be considered pending results of diagnostic tests— treatment for leptospirosis is most effective when initiated early in the disease process. Providers can contact their territorial or state health department or CDC for consultation.
  • Local health care providers are strongly encouraged to report patients for whom there is a high level of suspicion for leptospirosis, dengue, hepatitis A, typhoid, and vibriosis to their local health authorities, while awaiting laboratory confirmation.
  • Confirmed cases of leptospirosis, dengue, hepatitis A, typhoid fever, and vibriosis should be immediately reported to the territorial or state health department to facilitate public health investigation and, as appropriate, mitigate the risk of local transmission. While some of these conditions are not listed as reportable conditions in all states, they are conditions of public health importance and should be reported.

 

For More Information


Obstetric Tetanus in an Unvaccinated Amish Woman After a Home Birth Delivery

Yaffee AQ, Day DL, Bastin G, et al. Notes from the Field. Obstetric Tetanus in an Unvaccinated Woman After a Home Birth Delivery — Kentucky, 2016. MMWR Morb Mortal Wkly Rep 2017;66:307–308. DOI: http://dx.doi.org/10.15585/mmwr.mm6611a7.

Obstetric Tetanus in an Unvaccinated Woman After a Home Birth Delivery — Kentucky, 2016

Anna Q. Yaffee, MD1,2; David L. Day, DVM3; Glenda Bastin, MA3; Mary Powell, MPH4; Sandra Melendez4; Nancy Allen, MSN5; Julie Miracle1; Margaret Jones1; Robert Brawley, MD1 (View author affiliations)

On July 11, 2016, state and local health departments in Kentucky were notified of a case of obstetric tetanus in an unvaccinated woman. Obstetric tetanus, which occurs during pregnancy or within 6 weeks of the end of pregnancy, follows contamination of wounds with Clostridium tetani spores during pregnancy, or the use of contaminated tools or practices during nonsterile deliveries or abortions. CDC did not identify any cases of obstetric tetanus in the United States during 1972–2008 (1,2). State and local health departments in Kentucky investigated this case to identify risk factors and provide recommendations.

The patient, a woman aged 30 years, is a member of an Amish community. In late June, she delivered a child at home, assisted by an unlicensed community childbirth assistant. She had never received a vaccination for tetanus. Delivery was complicated by breech presentation, but no birth trauma, unsterile conditions, or other complications were reported. Nine days postpartum, the patient experienced facial numbness and neck pain, which progressed over 24 hours to stiff neck and jaw and difficulty swallowing and breathing. She was admitted to the hospital where a clinical diagnosis of tetanus was made, and 6,000 international units of tetanus immunoglobulin were administered intramuscularly. Endotracheal intubation and mechanical ventilation were required. Her hospital course was complicated by seizures and a need for prolonged respiratory support. After approximately a month, the patient was stable and discharged home.

The infant was monitored at home during the mother’s hospitalization. Tetanus immunoglobulin was recommended; however, the family declined treatment. A local advanced practice nurse performed weekly follow-up visits and noted no problems in the infant.

The close relationship between the local health department, health care providers, and the approximately 400-member Amish community facilitated contact with community leaders for an opportunity to discuss implementing Advisory Committee on Immunization Practices (ACIP) recommendations for tetanus immunization through a vaccination campaign. Door-to-door home visits in areas with vaccine-supportive community leaders were made by local health department staff members and the advanced practice nurse to explain the benefits of vaccination and provide vaccine. At the time of the campaign, there was one pregnant woman and one woman who was immediately postpartum in the community; both declined vaccination. Forty-seven (12%) persons were vaccinated, including 32 children aged ≤18 years. An age-appropriate diphtheria, tetanus, and pertussis vaccine (DTaP or Tdap) was administered to 30 (64%) of the 47 vaccine recipients. Because many community members reported having had pertussis disease and were opposed to receiving pertussis vaccine, 17 (36%) persons received age-appropriate tetanus and diphtheria toxoids without pertussis vaccine (DT or Td). Although none of the persons receiving vaccine had been previously vaccinated against any disease to date, none have agreed to complete the series because of little perceived ongoing vaccination need. Additional outreach initiatives are planned.

To prevent tetanus, ACIP recommends a 5-dose series of diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) for children at ages 2, 4, 6, 15–18 months, and 4–6 years, followed by 1 dose of tetanus and diphtheria toxoids and acellular pertussis vaccine (Tdap) for adolescents aged 11–12 years. Previously vaccinated adults are recommended to receive routine booster doses of a tetanus-containing vaccine every 10 years, and unvaccinated adults should complete a 3-dose primary series (3,4). Pregnant women with unknown or incomplete tetanus vaccination histories should receive a series of 3 doses of tetanus and reduced diphtheria toxoids (Td) to protect against obstetric and neonatal tetanus (5). ACIP also recommends a dose of Tdap to all previously vaccinated pregnant women at 27 to 36 weeks’ gestation during each pregnancy, regardless of time of previous vaccination, to provide protection from pertussis to infants.

This case highlights the importance of tetanus vaccination for all persons as recommended by ACIP (5,6). Although Amish communities generally do not have religious objections to vaccination (7), preventive health care has not historically been accessed by this Amish community. Trust between the Amish community, local health department, and a familiar health care provider, as well as working within community members’ homes, and providing culturally appropriate education and recommendations through community leaders, facilitated vaccination of some persons. Ongoing outreach by health departments is beneficial to vulnerable, nonimmunized or underimmunized populations.

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Corresponding author: Anna Q. Yaffee, ayaffee@cdc.gov, 734-657-3581.

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1Kentucky Department for Public Health; 2Epidemic Intelligence Service, CDC; 3Lincoln Trail District Health Department, Elizabethtown, Kentucky; 4Louisville Metro Public Health and Wellness, Louisville, Kentucky; 5Central Medical Associates, Elizabethtown, Kentucky.

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References

  1. Murphy TV, Slade BA, Broder KR, et al. Advisory Committee on Immunization Practices (ACIP), CDC. Prevention of pertussis, tetanus, and diphtheria among pregnant and postpartum women and their infants recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Recomm Rep 2008;57(No. RR-4). PubMed
  2. CDC. Tetanus surveillance — United States, 2001-2008. MMWR Morb Mortal Wkly Rep 2011;60:365–9. PubMed
  3. CDC. Recommended immunization schedule for children and adolescents aged 18 years or younger—United States, 2017. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/vaccines/schedules/hcp/child-adolescent.html
  4. CDC. Recommended immunization schedules for adults—United States, 2017. Atlanta, GA: US Department of Health and Human Services, CDC; 2017. https://www.cdc.gov/vaccines/schedules/hcp/adult.html
  5. CDC. Updated recommendations for use of tetanus toxoid, reduced diphtheria toxoid, and acellular pertussis vaccine (Tdap) in pregnant women—Advisory Committee on Immunization Practices (ACIP), 2012. MMWR Morb Mortal Wkly Rep 2013;62:131–5. PubMed
  6. Advisory Committee for Immunization Practices. CDC. Tdap/Td ACIP vaccine recommendations. Atlanta, GA: Advisory Committee for Immunization Practices, CDC; 2014. https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/tdap-td.html
  7. Grabenstein JD. What the world’s religions teach, applied to vaccines and immune globulins. Vaccine 2013;31:2011–23. CrossRef PubMed

 


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