HEALTH INFORMATION OPERATIONS (HIO)
WEEKLY UPDATE
20 March 2002
The HIO Weekly Update provides information regarding global
medical and veterinary issues of interest to the United States (US) Army. The
weekly update does not attempt to analyze the information regarding potential
strategic or tactical impact to the US Army and as such, should not be regarded
as a medical intelligence product. Medical intelligence products are available
at http://mic.afmic.detrick.army.mil/.
The information in the HIO Weekly Update should provide an increased awareness
of current and emerging health-related issues. This
report and other items of interest are available on the USACHPPM website at
http://chppm-www.apgea.army.mil/.
TABLE OF CONTENTS
HOT ISSUES.
Anthrax, Cutaneous - Laboratory
Worker
Anthrax Detector - Sandia National
Laboratories.
Influenza Surveillance DoD.
Influenza Surveillance - US.
International Conference on
Emerging Infectious Diseases - CDC.
Medical Statement - Senate Armed
Services Committee.
OB/GYN Devices - FDA Alert
USCENTCOM..
Medical Statement - Command
Surgeon.
USEUCOM..
Influenza Surveillance Europe.
Medical Statement - Command
Surgeon.
Meningococcal Meningitis - African
Meningitis Belt (AMB)
USJFCOM..
Allograft-Associated Bacterial
Infections - US.
Bacterial Conjunctivitis Outbreak
- US College Campuses.
Cat-Scratch Disease (CSD) in
Children - Texas.
Chagas Disease After Organ Transplantation
- US.
USPACOM..
Medical Statement - Command
Surgeon.
Antibiotic Residues - Southeast
Asia.
USSOUTHCOM..
Medical Statement - Command
Surgeon.
Yellow Fever - PAHO..
ACRONYMNS.
A presumptive case of cutaneous anthrax has been identified in Texas in a worker
at a private laboratory that is helping CDC process environmental samples from CDC's anthrax investigations.
The laboratory where this individual works was able to culture
Bacillus anthracis from the swab obtained by the worker's private physician.
The isolate from this culture was sent to CDC on March 12 and CDC confirmed
later that day that the isolate was Bacillus anthracis. CDC does not
believe that the case poses any risk to public health. The report is at: http://www.cdc.gov/od/oc/media/pressrel/r020313.htm
On 6 March, Sandia National Laboratories announced
that a patent application had been submitted for a prototype handheld detector
under development, which can identify the fatty acid methyl esters (FAME) of
anthrax in less than five minutes. The technique works by pre-concentrating
airborne particles on a tiny hotplate that vaporizes the fatty acids in bacteria's
cell walls to create the FAME that forms a unique fingerprint of the bacteria.
A small computer program compares the amount of mass of each ester emitted in
the analyzed gases - a process called elution - with already categorized elution
peaks indicative of anthrax of other diseases. The report is at http://www.sandia.gov/media/NewsRel/NR2002/anthrax.htm.
The DoD Worldwide Influenza Surveillance Program is a laboratory-based influenza
surveillance program managed by the Air Force. As of 14 March, 474 (20%) of 2,408
submitted specimens have been identified as positive for influenza since the start
of the influenza season (29 September): 461 (97%) were influenza A and 13 (3%)
were influenza B. Of the 15 influenza isolates identified from NAB Little Creek,
Virginia, one-third were influenza B viruses. Army laboratories in San Antonio,
TX (BAMC) and Washington DC (WRAMC) identified 23 influenza isolates during the
month of February: 21 were influenza A and two were influenza B. Of the 461
influenza A isolates, 92 (20%) have been subtyped, and 86 (93%) were influenza
A (H3N2) and 6 (7%) were influenza A (H1N1). Further info, including data from
the CDC and international sites, is available at: https://pestilence.brooks.af.mil/Influenza/
Note: Some users may experience difficulty accessing this link directly from
this document; if this occurs, copy and paste the hyperlink in your browser address
bar.
During week 10 (March 3-9, 2002), 448 (23.5%) of 1,905 respiratory specimens tested
by World Health Organization (WHO) and National Respiratory Virus Surveillance
System (NREVSS) laboratories were positive for influenza. The overall proportion
of patient visits to sentinel physicians for influenza-like illness (ILI) was
2.3%, which is above the national baseline of 1.9%. The proportion of deaths attributed
to pneumonia and influenza was 8.8%, which is above the epidemic threshold of
8.3% for week 10. Twelve state and territorial health departments reported widespread
influenza activity, 27 reported regional activity, 10 reported sporadic activity,
and 1 reported no influenza activity. Since September 30, 10,081 (15.4%) of 65,494
submitted specimens were positive for influenza. Of the 10,081 isolates identified,
9,865 (98%) were influenza A viruses and 216 (2%) were influenza B viruses. Two
thousand seven hundred and eighty-three (28%) of the 9,865 influenza A viruses
identified have been subtyped; 2,748 (99%) were H3 viruses and 35 (1%) were H1
viruses. Thirty-six percent of the influenza B isolates reported this season were
identified in the Mid-Atlantic region. The CDC classified influenza during the
tenth week of the 2002 influenza season as in the map below The current weekly
report is at: http://www.cdc.gov/ncidod/diseases/flu/weekly.htm
Picture courtesy of the CDC at: http://www.cdc.gov/ncidod/diseases/flu/weekly.htm
Conference sessions of the 2002 International
Conference on Emerging Infectious Diseases will be available as webcasts following
the conference's closing date. Email notification of webcast availability is
at http://www.cdc.gov/iceid/program.htm.
On 13 March, the Assistant Secretary of Defense
for Health Affairs and the Executive Director, TRICARE Management Activity, testified
before the Personnel Subcommittee of the Senate Armed Services Committee regarding
medical issues in President Bush's fiscal 2003 budget request. Highlights of
the statement include the following: (1) formation of a high-level working group
with DHHS
representatives to improve collaboration on defense against biological and chemical
terrorism such as IND
protocols on smallpox vaccine, pyridostigmine bromide (PB) tablets, botulinum
toxoid vaccine, and anthrax vaccine post-exposure with antibiotics; (2) develop
and implement a seamless system of electronic healthcare and surveillance data,
integrating the entire spectrum from fixed facility systems to field hand-held
technology; (3) fully utilize the eight joint ventures established with VA
throughout the country and before FY 2005, transmit/receive computerized patient
medical record data to/from VA; (4) perform operational test and evaluation of
CHCS
II this summer with potential worldwide implementation in third quarter FY02;
and (5) deployment of TRICARE Online worldwide later this year following operational
testing now underway. TRICARE Online uses the Internet to assist medical beneficiaries
in gaining access to the Military Health System by providing information on health,
medical facilities, and providers. The testimony is at http://www.senate.gov/~armed_services/e_witnesslist.cfm?id=200.
On 14 March, the FDA issued a nationwide/international
alert on OB/GYN medical devices manufactured by A&A of Alpharetta, Georgia,
which are labeled as sterile but in fact may not have undergone any sterilization
process. These products include but are not limited to curettes (flexible and
rigid), uterine dilators, endometrial sampling sets, fetal blood samplers, fetal
bladder drains, laparoscopy accessories, bone marrow needles, harvesting pumps
used in in-vitro fertilization, and aspiration sets. The report is at http://www.fda.gov/bbs/topics/NEWS/2002/NEW00799.html.
On 13 March, the USCENTCOM Command Surgeon
testified before the Personnel Subcommittee of the Senate Armed Services Committee
regarding theater medical support. Highlights of the statement include the following:
(1) publication of regional threats by the USACHPPM; (2) publication of detailed
medical operations and preventive medicine planning as part of the CINC's OEF
campaign plan; (3) issuance of force health protection and medical surveillance
guidance and requirements in all deployment orders; (4) issuance of follow up
messages on potential threats and specific health issues such as Rift Valley Fever,
meningococcal disease, malaria, and TB; (5) institution of sound preventive policies
and procedures to address health threat potential posed by detainee operations;
and (6) implementation of preventive medicine measures to acquire DNBI rates that
are among the lowest of any US armed conflict to date. The testimony is at http://www.senate.gov/~armed_services/e_witnesslist.cfm?id=200.
For week ten, 4-10 March, the EISS reported widespread influenza activity in five countries:
Germany, Italy, Netherlands, Norway, and Romania. In general, European clinical
morbidity rates were declining or stable; however, increasing rates were observed
in four countries: Germany, Poland, Romania, and Sweden. Influenza A, primarily
the H3N2 subtype, was dominant in nine countries. Influenza B was dominant
in five countries: Belgium, Slovakia, Slovenia, Spain, and Switzerland. For
week 10, no cases of influenza A (H1N2) or influenza B/Victoria/2/87-like viruses
were reported. The report is at
http://www.eiss.org/cgi-files/bulletin_v2.cgi?display=1&code=59&bulletin=59.
On 13 March, the USEUCOM Command Surgeon testified
before the Personnel Subcommittee of the Senate Armed Services Committee regarding
theater medical support. Highlights of the statement include: (1) provided contingency
medical support to include hospitalization, blood, medical supplies, and patient
movement capabilities for USCENTCOM operations, (2) provided forward stabilization
of critically injured patients closer to the forward edge of the battle areas
than ever before through the use of forward surgical teams in the Balkans and
in Nigeria and with planned deployment to Georgia, and (3) instituted the Multinational
Integrated Medical Unit initiative in Kosovo, where a medical facility staffed
by both Americans and British health care providers provide world-class support
to all NATO
and coalition forces in the British and American sectors of Operation Joint Guardian.
USCENTCOM is using this initiative in Kosovo as a template for coalition medical
operations in OEF.
The Command Surgeon stated that he believed this type of international and coalition
cooperation is the wave of the future. The Command Surgeon also stated that of
the OEF patients moved to the Landstuhl Regional Medical Center to date, 75% were
due to DNBI
and 25% were WIA,
which is consistent with operations in the Balkans over the last six years. The
testimony is at http://www.senate.gov/~armed_services/e_witnesslist.cfm?id=200.
On 14 March, the CDR
Weekly reported a changing pattern in recent years for meningococcal meningitis
in the AMB (picture follows). Historically, epidemics in this area would occur
in cycles, usually during the dry season (November-June in west Africa and variable
in east Africa). In recent years epidemics have flared for two to three consecutive
years. The present African meningococcal meningitis pandemic began in 1996 with
over 300,000 cases reported to the WHO
by the end of 1998. The most affected countries have been Burkina Faso, Cameroon,
Chad, Mali, Niger, and Nigeria. In 2001, six countries in the AMB experienced
large epidemics: Benin, Burkina Faso, Central African Republic, Chad, Ethiopia,
and Niger. Benin reported 6,147 cases including 265 deaths. In addition, Angola,
which is outside the belt, reported an outbreak between May and October. Four
countries are currently reporting outbreaks, two within the belt (Ethiopia and
Burkina Faso) and two outside the belt (Somalia and the Democratic Republic of
the Congo). Cases in these outbreaks have been laboratory confirmed as Neisseria
meningitidis serogroup A, which is the most common outbreak strain in the
AMB. During epidemics, a smaller number of cases are usually reported to be due
to serogroup C. Vaccines licensed in the US contain groups A, C, Y, and W135
meningococcal polysaccharides. The vaccine used for routine immunization programs
in the UK
provides protection for only group C. The report is at http://www.phls.co.uk/publications/CDR%20Weekly/PDF%20files/2002/cdr1102.pdf.
On 15 March, the CDC reported that as of 11 March, 26 patients with allograft-associated
infections have been identified: 13 with Clostridium spp. infection
and 14 associated with a single tissue processor. The CDC solicited these reports
after the reported death of a recipient of an allograft contaminated with Clostridium
spp. Sterilization of tissue that does not adversely affect the functioning
of tissue when transplanted into patients is the best way to reduce the risk
for allograft-associated infections. However, two sterilization methods (ethylene
oxide and gamma irradiation) that would eliminate spores have associated technical
problems that limit their use in processing of tissues for transplantation.
New low-temperature chemical sterilization technologies that kill spores but
preserve the biomechanical integrity and function of some allografts are being
evaluated. The FDA has
released new guidelines for tissue processors at http://www.fda.gov/cber/guidelines.htm#tissval. The CDC report is at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5110a2.htm.
On 15 March, the CDC reported an outbreak of conjunctivitis due to an unusual
non-typeable strain of Streptococcus pneumoniae, which occurred in 574
students over the course of the winter term in mostly undergraduate students
at Dartmouth College, New Hampshire. Sensitivity revealed resistance to erythromycin
and susceptibility to bacitracin, sulfonamides, and quinolones. A survey of
college faculty and interviews with local childcare centers, schools, ophthalmologists,
and primary-care physicians did not identify excessive episodes of conjunctivitis
in persons other than college students. School health officials used various
media in an effort to educate students, faculty, and staff about ways to reduce
transmission to include frequent handwashing and avoidance of shared personal
items such as towels, drinking glasses, and other utensils. The student health
service also provided all undergraduate students with an alcohol-based antiseptic
gel and instructions on proper use for hand antisepsis. Although this method
improves hand hygiene in hospital settings, the benefit of antiseptic gel in
a community outbreak setting is unknown. The college's winter term ended on
14 March with students departing for spring break. As of 13 March, the student
health service continued to report new cases of conjunctivitis. The CDC expressed
concern about spread of the conjunctivitis in students crowding popular vacation
spots with limited access to handwashing facilities. Between 1 February and
14 March, Princeton University also reported 247 cases of conjunctivitis with
preliminary evidence pointing to a bacterial infection. The Princeton University
update is at http://www.princeton.edu/Siteware/WebAnnounce.Princeton_Announcements.shtml#1 and the CDC report is at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5110a1.htm.
On 15 March, the CDC reported on an evaluation of medical records for 32
children seen at the Texas Children's Hospital in Houston for CSD, a bacterial
infection cause by Bartonella henselae. The findings emphasize that
although CSD is generally a mild, self-limiting illness, up to 25% of cases
have severe systemic illness that can result in protracted hospital stays and
lengthy treatments before diagnosis. CSD is a feline-associated zoonotic disease
with an estimated annual incidence in the US of 22,000 cases. Although CSD
occurs in persons of all ages, the highest age-specific incidence is among children
less than 10 years. Infection with CSD is one of the most common causes of
chronic lymphadenopathy in children. Serologic testing is the standard method
of diagnosis and should be considered for patients who present with adenopathy,
fever, malaise, and history of feline contact. A single elevated value for
IgG or IgM antibodies is generally sufficient to confirm CSD, because initiation
of a humoral immune response generally precedes or is concurrent with symptom
onset. The CDC reported that treatment recommendations for Bartonella-associated
diseases, including CSD, depend on the specific disease presentation. Azithromycin
has been shown to hasten resolution of adenopathy associated with CSD. For
patients with more severe disease, other antibiotic regimens have been successful,
including azithromycin or doxycycline in combination with rifampin or rifampin
alone; doxycycline or erythromycin are considered the drugs of choice for bacillary
angiomatosis and peliosis. The report is at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5110a4.htm.
On 15 March, the CDC reported the first recognized US occurrence of Trypansoma
cruzi infection through solid-organ transplantation. A cluster of three
cases occurred due to transplantation of organs from a single donor. Chagas
disease is endemic in parts of Central and South America and Mexico, where an
estimated 16-18 million persons are infected with T. cruzi. Transmission
of T. cruzi infection by solid-organ transplantation (particularly renal
transplants) has been reported in Latin America, where serologic screening of
organ donors and recipients for antibody to T. cruzi is standard practice.
No test has been licensed for use in the US for screening organ or blood donors.
The CDC is coordinating consideration of whether to recommend screening of potential
donors for T. cruzi infection and, if so, which donors to screen, how
to screen, and what to do if the screening tests are positive. The report is
at http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5110a3.htm.
On 13 March, the USPACOM Command Surgeon testified
before the Personnel Subcommittee of the Senate Armed Services Committee regarding
theater medical support. Highlights of the statement include the following
challenges: (1) vast distance of the theater, which impedes the ability to
move medical augmentation into theater when required and the ability to move
patients back to definitive care, (2) an aging medical infrastructure with many
facilities built during World War II, (3) medical professional shortages, (4)
vaccine availability for forward-deployed forces, (5) institution of real time
and near real time data streaming and aggregation of joint service medical encounter
data, medical facility reports, web-based clinical consultation tools, and an
advanced medical disease surveillance system. The testimony is at http://www.senate.gov/~armed_services/e_witnesslist.cfm?id=200.
On 15 March, the Food Standards Agency (FSA) of Northern
Ireland reported that the European Commission had issued an alert regarding
nitrofuran residues in shrimps and prawns from Southeast Asia (Thailand, Vietnam,
Indonesia, India, and Bangladesh). The FSA conducted a retail survey and found
that 16 (21%) of 77 samples were positive for nitrofuran residues. Nitrofurans
are no longer permitted in the European Union because of health risk concerns.
Nitrofurans are mutagens (damage genetic material), and there is concern that
they are potentially carcinogenic in humans. The FSA advised against consumption
of the affected batches of shrimp and prawns and issued a withdrawal from sale.
The FSA has removed the products from the food market. The report is at http://www.food.gov.uk/enforcement/alerts/51574.
On 13 March, the USSOUTHCOM Command Surgeon testified
before the Personnel Subcommittee of the Senate Armed Services Committee regarding
theater medical support. Highlights of the statement include: (1) institution
of sound preventive policies and procedures to address health threat potential
posed by detainee operations, (2) institution of the Emergency Medical Response
Program to provide medical training and to assess the capability of host nations
to respond to terrorist incidents at US Embassies/Security Assistance Offices,
and (3) development of deployable medical teams at JTF Bravo
and Roosevelt Roads to provide forward resuscitative surgery. The testimony
is at http://www.senate.gov/~armed_services/e_witnesslist.cfm?id=200.
On 17 March, the PAHO reported provisional totals of
reported yellow fever cases for Central and South America as listed in the following
table.
|
Country
|
2001
Cases
|
2001
Deaths
|
2002
Cases (as of 17 Mar 02)
|
2002
Deaths (as of 17 Mar 02)
|
|
Bolivia
|
4
|
3
|
1
|
1
|
|
Brazil
|
38
|
19
|
1
|
0
|
|
Colombia
|
6
|
4
|
1
|
1
|
|
Peru
|
29
|
17
|
5
|
0
|
|
TOTAL
|
77
|
43
|
8
|
2
|
Please contact the below-listed POC for suggested improvements and/or
comments regarding this report. This report is also available on the USACHPPM
website at http://chppm-www.apgea.army.mil/Hioupdate/.
POC: Barbara E. Davis, DVM, MPH/MCHB-CS-OHD/584-7663
mailto:Barbara.Davis1@APG.amedd.army.mil
ACIP
- Advisory Committee on Immunization Practices
AFMIC -
Armed Forces Medical Intelligence Center
AFPS
American Forces Press Service
AIDS
Acquired Immunodeficiency Syndrome
APHIS
Animal and Plant Health Inspection Service
BSE
Bovine Spongiform Encephalopathy
CBRN Chemical, Biological,
Radiological, and Nuclear
CDC Centers for
Disease Control and Prevention
CDR
Communicable Disease Report (England)
CHCS
- Composite Health Care System
CIA
Central Intelligence Agency
CME
- Continuing Medical Education
CONUS
Continental United States
DARPA
Defense Advanced Research Projects Agency, the central research and development
organization for the Department of Defense
DHHS Department of Health and Human Services
DNBI - Disease
Non-Battle Injury
DoD - Department
of Defense
DOE Department
of Energy
DOS Department
of State
DOT Department of Transportation
ECG - Electrocardiogram
EISS European Influenza Surveillance Scheme
EPA Environmental Protection Agency
ESSENCE Electronic Surveillance System for the Early Notification of Community-Based
Epidemics
EU - European Union
FAO - Food and Agriculture Organization (of the United Nations)
FBI Federal Bureau of Investigation
FCC - Federal Communications Commission
FDA Food and Drug Administration
FEMA Federal Emergency Management Agency
FMD Foot and Mouth Disease
FSIS Food Safety Inspection Service
FTC - Federal Trade Commission
GAO US General Accounting Office
GEIS Global Emerging Infections System
HACCP Hazard Analysis Critical Control Points
HIV/AIDS Human Immunodeficiency Virus/Acquired Immune Deficiency Syndrome
IAEA International Atomic Energy Agency
ICBM Intercontinental Ballistic Missile
ICRC International Committee of the Red Cross
IDP Internally Displaced Persons
ILI Influenza-Like Illness
IND - Investigational New Drug
IRCS International Red Cross Society
JAMA - Journal of the American Medical Association
JTF Joint Task Force
K-FOR Kosovo Forces,
a NATO-led international peace enforcement force that entered Kosovo
on 12 June 99 under a UN mandate. http://www.kforonline.com/
MMR - Measles, Mumps, and Rubella
MRSA - Methicillin Resistance Staphylococcus aureus
NAS
National Academy of Sciences
NATO
North Atlantic Treaty Organization
NCI
National Cancer Institute
NEJM
New England Journal of Medicine
NICHHD National Institute of Child Health and Human Development
NIH
National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
NPIC National Pesticide Information Center
NRC Nuclear Regulatory Commission
OEF - Operation Enduring Freedom
OIE
World Organisation [sic] for Animal Health
OSHA
- Occupational Safety and Health Administration
PA
Protective Antigen
PAHO
- Pan American Health Organization: http://www.paho.org
PCBs
- Polychlorinated Biphenyls; more info is at EPA: http://www.epa.gov/opptintr/pcb/
PCR
Polymerase Chain Reaction
PHLS Public Health Laboratory Service
PHS Public
Health Service
PPE Personal
Protective Equipment
RSV Respiratory Syncytial Virus
TB Tuberculosis
UK United Kingdom England, Northern Ireland, Scotland, and Wales
UN United Nations
UNHCR United Nations High Commissioner for Refugees
USAID - United States Agency for International Development
USAMRIID United States Army Medical Research Institute for Infectious Diseases
USDA United States Department of Agriculture
USPSTF United States Preventive Services Task Force
VA - Veteran's Administration
vCJD - variant Creutzfeldt-Jakob Disease
VOA Voice of America, an international multimedia broadcasting service funded
by the US Government
WHO World Health Organization
WIA - Wounded in Action
WMD Weapons of Mass Destruction
