Action requested: Be aware of potential exposure to listeria in foods sold in Washington State.
Background & Recommendations: Since September, eight people infected with outbreak strains of listeria have been hospitalized in California, Washington, and Maryland. Two people died (including one in Washington), although listeria was not considered the cause of death in either case. Epidemiologic and laboratory evidence suggests that frozen vegetables produced by CRF Frozen Foods of Pasco, Washington, and sold under various brand names are a likely source of illness in this outbreak. Although investigations are ongoing, CRF Frozen Foods has recalled all organic and traditional frozen vegetable and fruit products processed in its Pasco, Washington facility since May 1, 2014. The Centers for Disease Control & Prevention (CDC) advises that consumers not eat and restaurants and retailers not serve or sell recalled organic and traditional frozen vegetables and fruit products. A table of recalled products is at http://www.fda.gov/Safety/Recalls/ucm498841.htm.
Listeria is ubiquitous in the environment, but infection can cause complications, especially in pregnant women, older adults, and people with compromised immunity. Diagnosis requires isolation from a sterile site (blood or spinal fluid). Treatment is with intravenous penicillin or ampicillin alone or with an aminoglycoside. For patients allergic to penicillin, trimethoprim-sulfamethoxazole or erythromycin is preferred. Cephalosporins are not effective.
Testing for Zika virus infection
Action requested: Be aware that a commercial test for Zika virus in blood is now available.
Background: The Food & Drug Administration (FDA) has granted an Emergency Use Authorization (EUA) to Focus/Quest Diagnostics for use of a Zika virus RNA Qualitative Real-Time RT-PCR test: http://www.fda.gov/downloads/medicaldevices/safety/emergencysituations/ucm498274.pdf. Testing guidance (below) has not changed. RT-PCR testing should only be ordered for patients with signs and symptoms of Zika virus infection AND for whom specimens are collected within 7 days of illness onset. Positive results indicate current infection. Negative results on specimens collected 4 or more days after illness onset DO NOT RULE OUT INFECTION. RT-PCR testing is not indicated for asymptomatic patients, including asymptomatic pregnant women. For patients whose onset is >7 days prior to specimen collection, for patients with a negative RT-PCR obtained on days 4-7 after symptom, and for asymptomatic pregnant women with Zika exposure, specimens should continue to be sent to the Washington State Public Health lab after approval from the Health District (425-339-5278) for ELISA IgM testing (currently only available at CDC). Also consider testing for dengue and chikungunya if the patient is exhibiting clinical symptoms consistent with Zika or other arboviral infections.
Recommendations for Zika virus testing:
- Test all persons (regardless of pregnancy status) reporting two or more of the following symptoms: acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis during or within two weeks of travel to an area of active Zika virus transmission OR within two weeks of unprotected sex with a man who tested positive for Zika virus or had symptoms of Zika infection during or within two weeks of return from travel to an area with Zika transmission. Obtain specimens during the first week of illness if possible.
- Offer testing to pregnant women (regardless of symptoms) with possible exposure to Zika virus through travel to an area of active Zika virus transmission during pregnancy or through sexual exposure to a man who has traveled to an area of Zika transmission and developed symptoms of Zika virus infection. Obtain specimens within the first week of illness if ill or within 2-12 weeks of exposure (including any travel to a Zika affected area in the 8 weeks before conception) if asymptomatic.
- If fetal ultrasounds detect microcephaly or intracranial calcifications, pregnant women who originally tested negative for Zika virus infection following travel should be retested for Zika virus infection. In these cases, also consider amniocentesis for Zika virus testing.
- Offer testing to pregnant women with at least one sign or symptom of Zika virus disease after unprotected sex with an asymptomatic male partner who had exposure to Zika virus. Obtain specimens during the first week of illness if possible.
- Test women experiencing fetal loss who have traveled to an area with known Zika virus transmission during pregnancy, if not previously tested
- Test infants born to women who traveled during pregnancy to an area with Zika virus transmission and have evidence of maternal infection (mothers with positive or inconclusive test results for Zika virus infection) or fetal infection (infants with microcephaly or intracranial calcifications)
- Test infants who have two or more of the following symptoms within 2 weeks of birth: acute onset of fever, maculopapular rash, arthralgia, or conjunctivitis AND are born to a mother who traveled to an area with active Zika virus transmission within 2 weeks of delivery.
- Testing is NOT recommended for exposed, asymptomatic men for the purpose of assessing risk of sexual transmission.
For more information, see http://www.cdc.gov/zika/hc-providers/index.html.
Testing for blood lead
Action requested: Be aware of targeted screening recommendations for children in Washington State.
Background & Recommendations: The lead contamination in the drinking water of homes in Flint, Michigan, and schools in Tacoma, Washington, reminds us of the potential for children to ingest lead. In Washington State old paint, folk medicines, and occupations employing lead are more common sources of exposure to lead. Regardless, even relatively low levels of blood lead (<10 mcg/dl) can affect the developing nervous system, resulting in IQ loss, learning difficulties, poor school performance, decreased attention span, and inappropriate behavior. Clinicians should follow our state’s targeted screening guidelines, which can be found in a concise two-page guidance document at www.doh.wa.gov/Portals/1/Documents/Pubs/334-394.pdf.
Antiretroviral post-exposure prophylaxis after non-occupational exposure to HIV
Action requested: Be aware of new guidelines for antiretroviral post-exposure prophylaxis after non-occupational exposure to human immunodeficiency virus (HIV).
Background & Recommendations: Although preventing exposure through abstinence, monogamy with an uninfected partner, or consistent condom use are the most effective ways to prevent HIV infection, prophylaxis following exposure is an important adjunct strategy to help reduce transmission. The CDC has just issued new evidence-based guidelines addressing antiretroviral post-exposure prophylaxis for persons with isolated exposure outside health care settings to blood, genital secretions, or other potentially infectious body fluids that might contain HIV. Post-exposure prophylaxis should be started within 72 hours of exposure and continued for 28 days; the preferred regimen is tenofovir disoproxil fumarate (TDF) 300 mg with emtricitabine 200 mg once daily, plus raltegravir 400 mg twice daily or dolutegravir 50 mg daily. Detailed management guidance (including alternative regimens) may be downloaded at https://stacks.cdc.gov/view/cdc/38856.
You can find my recent health alerts posted on the Provider pages of our website, at http://www.snohd.org/Providers/Health-Alerts.
Gary Goldbaum, MD, MPH | Health Officer & Director | Administration
3020 Rucker Avenue, Ste 306 | Everett, WA 98201 | 425.339.5210 | firstname.lastname@example.org
Public Health: Always working for a safer & healthier Snohomish County