CDC: US measles cases top 150

The number of US measles cases since Jan 1 has reached at least 154, an increase of 13 in the past week, the Centers for Disease Control and Prevention (CDC) said today in its weekly update, and 118 of those cases are linked to Disneyland in California.

The total number of Disney-related outbreak cases, however—going back to Dec 28—is 133 in seven states because it includes 15 cases that occurred in 2014. Thirteen of the 2014 Disney-linked cases were in California, with one each in Oregon and Utah.

The outbreak total may actually be 139, though, as the latest number linked to Disneyland reported by the California Department of Public Health (CDPH, from Feb 20) is 123, compared with 117 listed by the CDC. (The CDC for unknown reasons doesn't specify Disney, instead using the term "amusement park in California.")

The Disney-linked outbreak involves a measles type identical to one that caused more than 21,000 confirmed and 58,000 suspected cases in the Philippines in 2014 and, by importation, a 383-case outbreak last year in Ohio. The CDC also reported two other 2015 outbreaks not linked to Disneyland, one in Illinois and one in Nevada.

As far as the 154 cases in 2015, California has by far the most, with 105 cases, followed by Illinois with 14, Arizona with 7, Nevada with 6, and Washington with 5.

In Canada, meanwhile, Montreal has recorded its 19th case in an outbreak linked to Disney, while Toronto has confirmed its 10th case and Ontario its 18th in an outbreak with no apparent links to the theme park, according to a Canadian Press and Toronto Star report, respectively.
Feb 23 CDC update on 2015 cases
Feb 23 CDC update on Disney-linked cases
Most recent CDPH updates
Feb 22 Canadian Press story
Feb 22 Toronto Star report

HHS releases national health security strategy and review

The US Department of Health and Human Services (HHS) has released a broad health security strategy designed to guide health security enhancements over the next 4 years, along with a review that claims progress in that realm over the past 4 years.

The National Health Security Strategy and Implementation Plan for 2015-18 "provides strategic direction to ensure that efforts to improve health security nationwide over the next four years are guided by a common vision; based on sound evidence; and carried out in an efficient, collaborative manner," HHS said in a statement.

The strategy announces five objectives: to build and sustain healthy, resilient communities; enhance capability to make and use medical countermeasures and non-drug interventions; ensure "comprehensive health situational awareness" to support decision-making; enhance the integration of the public health, healthcare, and emergency management systems; and strengthen global health security.

The implementation plan describes activities that stakeholders in US health security "may perform" in support of the objectives.

The National Health Security Review 2010-2014, the first of its kind, examines progress toward the goals that were set in the health security strategy for that period. The goals were to build community resilience and to strengthen and sustain health and emergency response systems.

HHS said the greatest improvement was seen in five areas:

• Integrating public health, healthcare, and emergency response systems
• Planning at the federal, state, and local levels
• Building health security workforce capabilities
• Coordination within government and between government and the private sector through such endeavors as the development of medical countermeasures
• Strengthening community resilience

As for persistent challenges, HHS cites three in particular:

• Progress is threatened by reductions in funding for the public health work force and practice-based research.
• Engaging and coordinating the full range of stakeholders can be difficult.
• The nation's ability to objectively assess health security progress is limited because it is a new science.

Feb 13 HHS statement on health security plan
Feb 19 HHS statement on health security review
Full text of health security strategy and plan

WHO recommends 'smart' syringes to promote safe injections

To reduce the spread of disease via unsafe injections, the World Health Organization (WHO) today urged the adoption of "smart" syringes to prevent needle reuse and urged reduced use of injections in general.

Up to 1.7 million people were infected with hepatitis B, up to 315,000 with hepatitis C, and as many as 33,800 with HIV through an unsafe injection in 2010, the WHO said in a news release. The agency encouraged countries by 2020 to transition to exclusive use of "smart," syringes, which use various mechanisms to prevent multiple use of the syringes.

A traditional syringe costs the United Nations 3 to 4 US cents, and the advanced syringes would cost at least twice that, the WHO said. It called on its donors to make up the difference, anticipating that costs will decline as demand increases.

The agency also said that 16 billion injections are administered each year worldwide, with 5% involving child immunization, 5% for procedures like blood transfusions and contraceptives, and the remaining 90% for medication. In many cases, however, the latter are unnecessary or could be replaced by oral drugs.

Edward Kelley, PhD, director of the WHO Service Delivery and Safety Department, listed various reasons for injection overuse. "One reason is that people in many countries expect to receive injections, believing they represent the most effective treatment. Another is that for many health workers in developing countries, giving injections in private practice supplements salaries that may be inadequate to support their families."
Feb 23 WHO press release

Studies note risk factors, epidemiology of Arizona RMSF cases

CDC and Arizona scientists note that early gastrointestinal symptoms, a history of alcoholism, and a history of chronic lung disease are risk factors for death with Rocky Mountain spotted fever (RMSF), a disease with a distinct epidemiologic pattern in indigenous populations in Arizona, according to two new studies in Clinical Infectious Diseases.

Both studies analyzed data from 205 RMSF cases from two Indian reservations from 2002 through 2011. The area has a 7% case-fatality rate (CFR) for the disease, compared with under 1% for the rest of the nation.

The first study noted that doxycycline was administered significantly later in fatal cases—by a median of 7 days—than in nonfatal cases, even though patients in both groups presented for care early, an average of 2 days after symptom onset. The researchers noted that early nausea and diarrhea, a history of alcoholism or chronic lung disease, and abnormal lab results all were associated with elevated CFR and delayed doxycycline use.

In the second study, which compared the 205 cases with 175 patients with non-RMSF illness that prompted RMSF testing, the investigators noted that RMSF case-patients were younger by 11 years and reported fever, rash, and tick exposure less often than other US patients. They also found that fever was present in 81% of Arizona RMSF cases but did not differ significantly from non-RMSF cases.

The authors concluded in the second study, "No specific pattern of signs, symptoms or laboratory findings occurred with enough frequency to consistently differentiate RMSF from other illnesses. Due to the nonspecific and variable nature of RMSF presentations, clinicians in this region should aggressively treat febrile illnesses and sepsis with doxycycline for suspected RMSF."
Feb 19 Clin Infect Dis abstract on fatality risk
Feb 19 Clin Infect Dis abstract on comparison with other diseases