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Health Alerts

The Snohomish Health District Health Officer Dr. Gary Goldbaum sends alerts via email to local health care providers. Alerts cover current local, regional or national health threats and important updates on medical care and protocols. Alerts are written as needed to cover urgent or emergent health issues.

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Acute Flaccid Myelitis; Vaccines; TB

Today’s topics:

  • Acute Flaccid Myelitis
  • Vaccine Guidance: Influenza, Human Papillomavirus, & Meningococcus
  • Tuberculosis Reporting & Screening

Acute Flaccid Myelitis

Actions requested:  Be aware of a cluster of acute flaccid myelitis and report suspect cases promptly.


A cluster of suspected acute flaccid myelitis (AFM) has been reported among Washington residents.  As of November 4th, 2016, eight cases have been confirmed by the Centers for Disease Control & Prevention (CDC).  One additional suspect case died; although the investigation continues, that case is now considered not to be AFM.  All cases are among children between 3 and 14 years of age who presented with acute paralysis of one or more limbs. All had a febrile prodrome 1 to 2 weeks before presenting with symptoms of AFM.  The earliest onset of limb weakness was on September 14th and the most recent on October 27th.  The cases are residents of King County (3), Pierce County (1), Franklin County (2), Snohomish County (1), and Whatcom County (2).

From January 1st to September 30th, 2016, a total of 89 people in 33 states across the country have been confirmed to have AFM. This represents an increase over the previous 2 years (reporting only started in 2014). Most of these have been in children. No etiology for the infections has been established, although a potential association with enterovirus D68 has been reported. AFM is also known to be associated with other neurotropic enteroviruses, adenovirus, herpes viruses, arboviruses including West Nile virus, and other etiologies. Non-infectious causes have not been ruled out.


  • Assure that any providers who may see children with neurologic symptoms are aware of this outbreak.
  • Report suspected cases of AFM promptly to the Snohomish Health District at 425-339-5278.  Suspect cases are defined as patients presenting with acute onset of limb weakness AND:

A magnetic resonance image (MRI) showing spinal cord lesions largely restricted to gray matter and spanning one or more spinal segments


Cerebrospinal fluid (CSF) showing pleocytosis (white blood cell count >5 cells/mm3).

  • Cerebrospinal fluid
  • Serum (acute and convalescent) and whole blood (whole blood should be sent refrigerated to CDC and arrive within 24 hours of collection)
  • Two stool specimens separated by 24 hours (whole stool preferred over rectal swab)
  • Upper respiratory tract sample (in order of preference: nasopharyngeal swab > nasal swab > nasal wash/aspirate > oropharyngeal swab)
  • Oropharyngeal swab should always be collected in addition to the nasopharyngeal specimen on any patient suspected to have polio.
  • Notify the Health District if you are aware of patients of any age who presented to your facility or practice in 2016 and fit the case definition (please have CSF results or MRI report available).
  • Obtain travel and immunization histories as soon as possible on all suspected AFM cases to help rule out polio as a possible cause.  Patients with no sensory or cognitive loss who present with a syndrome meeting the clinical criteria for AFM also meet the criteria for consideration as a possible paralytic poliomyelitis case. These cases are immediately notifiable to local health jurisdictions in Washington under WAC 246-101.
  • Contact the Health District at 425-339-5278 for guidance, especially about sampling and shipping specimens.

For more information, see the Washington State Department website at


Vaccine Guidance: Influenza, Human Papillomavirus, & Meningococcus

Actions requested:  Be aware of new guidance for influenza, HPV, & meningococcus vaccines.

Background & Recommendations

Following is updated guidance for three vaccines.

Influenza—Annual influenza vaccination has been recommended for everyone 6 months and older.  However, CDC now notes that “children 6 months through 8 years getting vaccinated for the first time, and those who have only previously gotten one dose of vaccine, should get two doses of vaccine this season. All children who have previously gotten two doses of vaccine (at any time) only need one dose of vaccine this season.”  For more information, see

Also, studies suggest that serious reactions to egg components of modern vaccines are extremely rare, such that any influenza vaccine may be administered to patients with a history of egg allergy.  However, CDC notes “a person who has previously experienced a severe allergic reaction to flu vaccine, regardless of the component suspected of being responsible for the reaction should not get a flu vaccine again.” For more information, see

Human Papilloma Virus (HPV)—Two doses of HPV vaccine given at least 6 months apart have been shown to provide safe, effective and long-lasting protection when given to adolescents aged 9 through 14 years. Reducing the number of shots and trips to the doctor will make it easier for parents to get their child protected. Therefore, CDC now recommends:

  • Give the first HPV vaccine dose at 11-12 years old (the series may be started as young as 9 years).  If the first HPV vaccine dose was given before the teen turned 15 years, only one more dose is needed and should be given at least 6 months after the first dose.
  • Three doses are still recommended for adolescents ages 9 through 14 years who have already received two doses of HPV vaccine less than 5 months apart (the minimum interval), for teens and young adults who start the series at ages 15 through 26 years, and for people ages 9 through 26 years with weakened immune systems.

For more information, see

Meningococcal—Although CDC has recommended routine use of meningococcal vaccine for all healthy adolescents in the United States and for persons with certain medical conditions, CDC now also recommends routine use of meningococcal conjugate vaccine (serogroups A, C, W, and Y; including MenACWY-D [Menactra, Sanofi Pasteur] or MenACWY-CRM [Menveo, GlaxoSmithKline]) for persons aged ≥2 months with human immunodeficiency virus (HIV) infection. For more information, see


Tuberculosis Reporting & Screening

Actions requested:  Report promptly any suspect cases of active tuberculosis and screen persons at high risk for developing tuberculosis.

Background & Recommendations

The Health District recently reviewed deaths associated with active tuberculosis.  In one case, the individual was being treated while in a rehabilitation facility, but the case had not been reported to the Health District.  In another case, treatment was delayed pending confirmation.  Although we cannot determine if the deaths could have been avoided had the Health District been consulted, these cases serve as reminders that providers have a legal obligation to notify public health promptly whenever active tuberculosis is suspected.  Health District staff can provide guidance on management and will assure directly observed therapy, which is critical to avoiding relapse or emergence of resistance.  To report suspected active tuberculosis, call 425-339-5225 or Fax 425-339-5217.

The U.S. Preventive Services Task Force (USPSTF) recently reviewed the evidence for effectiveness and risks of screening for tuberculosis.  The USPSTF concluded that there is reasonable evidence to recommend screening asymptomatic persons at high risk for tuberculosis, specifically persons who were born in, or are former residents of, countries with increased tuberculosis prevalence and persons who live in, or have lived in, high-risk congregate settings (e.g., homeless shelters and correctional facilities).  For details, see USPSTF: Screening for latent tuberculosis infection: US Preventive Services Task Force recommendation statement. JAMA  2016;316(9):962-969.

You can find my recent health alerts posted on the Provider pages of our website, at


Gary Goldbaum, MD, MPH | Health Officer & Director | Administration

3020 Rucker Avenue, Ste 306 | Everett, WA 98201 | 425.339.5210 |


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Health alerts include information about diseases or other health risks or issues that affect Snohomish County.