Issue
Number 426
November 24, 2003
CONTENTS OF THIS ISSUE
- CDC issues warning about possible severe influenza season and
urges vaccination
- CDC publishes information about current hepatitis A outbreak
in Pennsylvania
- Updated: Reformatted Fahrenheit and Celsius vaccine
temperature logs available on IAC's website
- Find "IAC EXPRESS" valuable? Then, please email your
colleagues and ask them to sign up
- New VIS translation: 2003-04 inactivated influenza VIS now
available in Ilokano
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November 24, 2003
CDC ISSUES WARNING ABOUT POSSIBLE SEVERE INFLUENZA SEASON AND URGES
VACCINATION
On November 17, the Centers for Disease Control and Prevention (CDC) issued
a press release informing the public that the 2003-04 influenza season may
be severe and urging influenza vaccination as soon as possible. The press
release is reprinted below in its entirety.
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Press Release
November 17, 2003
EARLY EVIDENCE SUGGESTS CURRENT FLU SEASON COULD BE SEVERE:
Health Officials Say It's Not Too Late to Get a Flu Shot
Health and Human Services Secretary Tommy G. Thompson once again encourages
Americans, particularly those at high risk of serious complications from
influenza, to get their flu shot as soon as possible.
"Each year in the United States 36,000 people die from complications related
to the flu," Secretary Thompson said. "Early indications are that we may be
in for a more severe season than in the previous three years. There is
plenty of vaccine to meet demand so protect yourself and those who you love
and go out and get vaccinated right now."
Centers for Disease Control and Prevention (CDC) Director Dr. Julie
Gerberding said that the United States may be in for a more severe season
for several reasons. "First, it's early in the season and flu viruses are
circulating at a higher level than usual at this time and second, a strain
of influenza is circulating that in previous years has resulted in a lot of
people getting sick," she said. Dr. Gerberding echoed the Secretary's call
for people to get vaccinated as soon as possible.
"It takes about two weeks to develop maximum protection after a flu shot, so
we urge people not to delay," she said. "The vaccine is safe and effective,
and because the vaccine is made with killed virus it will not give you the
flu."
The CDC recommends the following individuals get vaccinated against
influenza:
- persons 50 years and older;
- residents of nursing homes and other
long-term care facilities that house persons of any age who have long-term
illnesses;
- adults and children 6 months of age and
older who have chronic heart or lung conditions, including asthma;
- adults and children 6 months of age and
older who need regular medical care or had to be in a hospital because of
metabolic diseases (like diabetes), chronic kidney disease, or weakened
immune system (including immune system problems caused by medicine or by
infection with HIV/AIDS);
- children and teenagers 6 months to 18
years who are on long-term aspirin therapy and therefore could develop
Reye Syndrome after the flu; and
- women who will be more than 3 months
pregnant during the flu season.
In addition, CDC recommends the following
groups of people get vaccinated to prevent spreading flu to individuals at
high risk of complications from flu:
- doctors, nurses, and other employees in
hospitals and doctors' offices, including emergency response workers;
- employees of nursing homes and long-term
care facilities who have contact with patients or residents;
- employees of assisted living and other
residences for people in high-risk groups;
- people who provide home care to those in
high-risk groups; and
- household members (including children)
of people in high-risk groups.
For more information on influenza, visit
www.cdc.gov
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To access the press release from the CDC website, go to:
http://www.cdc.gov/od/oc/media/pressrel/r031117.htm
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November 24, 2003
CDC PUBLISHES INFORMATION ABOUT CURRENT HEPATITIS A OUTBREAK IN PENNSYLVANIA
The Centers for Disease Control and Prevention (CDC) published
"Hepatitis A Outbreak Associated with Green Onions at a
Restaurant--Monaca, Pennsylvania, 2003" in the November 21 issue of "MMWR
Dispatch." CDC's policy is to publish "MMWR Dispatch" only for the
"immediate release of important public health information." It is
published "on the Web outside of the routine weekly publication
schedule" and will be available in a print issue of "Morbidity and
Mortality Weekly Report" in the future.
Following is the November 21 "MMWR Dispatch" in its entirety, excluding
references and one figure.
*****************************
The Pennsylvania Department of Health and CDC are investigating an
outbreak of hepatitis A outbreak among patrons of a restaurant
(Restaurant A) in Monaca, Pennsylvania. As of November 20, approximately
555 persons with hepatitis A have been identified, including at least 13
Restaurant A food service workers and 75 residents of six other states
who dined at Restaurant A. Three persons have died. Preliminary sequence
analysis of a 340 nucleotide region of viral RNA obtained from three
patrons who had hepatitis A indicated that all three virus sequences
were identical. Preliminary analysis of a case-control study implicated
green onions as the source of the outbreak.
Among 207 persons with hepatitis A who were interviewed and who ate at
Restaurant A only once during the 2-6 weeks (i.e., the typical
incubation period for hepatitis A) before illness, dates of illness
onset were between October 14 and November 12. These 207 patrons
reported eating food prepared in Restaurant A during September
14-October 17; a total of 181 (87%) persons reported eating at
Restaurant A during October 3-6. All infected Restaurant A food service
workers became ill after October 26, suggesting that a food service
worker could not have been the source of the outbreak. However, during
late October-early November, these ill food service workers were working
in Restaurant A when they could have been infectious. For this reason,
immune globulin has been provided to approximately 9,000 persons who ate
food from Restaurant A during this time or had exposures to ill persons
involved in the outbreak. The restaurant has been closed.
A case-control study was conducted to identify menu item(s) or
ingredient(s) associated with illness. A case-patient was defined as a
person who had illness onset during October 14-November 12, had
laboratory confirmation of acute hepatitis A virus (HAV) infection
(i.e., positive IgM anti-HAV), reported eating food prepared at
Restaurant A during October 3-6, and had eaten only once at Restaurant A
during the 2-6 weeks before illness onset. Controls included persons
without hepatitis A who either had dined with case-patients at
Restaurant A or were identified through credit card receipts as having
dined at Restaurant A during October 3-6. Controls with a previous
history of hepatitis A, hepatitis A vaccination, or receipt of immune
globulin within 2 weeks after eating Restaurant A food were excluded.
Enrolled case-patients and controls were asked about Restaurant A food
that they had eaten.
The median age of the 181 case-patients in the study was 34 years
(range: 4-73 years), and that of the 83 controls was 28 years (range:
2-81, p greater than 0.05). Of 133 menu items, only chili conqueso and
mild salsa were associated significantly with illness. Mild salsa was
eaten by 94% of case-patients, compared with 39% of controls (odds ratio
[OR] = 24.2; 95% confidence interval [CI] = 11.4-51.4). Chili con queso
was eaten by 15% of case-patients, compared with 3% of controls (OR =
5.2, 95% CI = 1.5-17.8). Both menu items associated with illness
contained uncooked or minimally heated fresh green onions. Among 11
case-patients who reported not eating mild salsa, seven ate at least one
of the other 52 menu items that contained green onions. Of 103
ingredients used at the restaurant, 12 were associated with illness in a
univariate analysis. Of these, 10 had been consumed by fewer than 50% of
case-patients. Eating a menu item containing green onions was reported
by 98% of case-patients, compared with 69% of controls (OR = 20.2, 95%CI
= 6.8-59.9). Eating a menu item containing white onions also was
associated with illness. However, among the 176 case-patients who
reported eating white onions, 174 (99%) also ate green onions. Among the
four case-patients and 28 controls who reported not eating green onions,
white onions were not associated with illness (OR = 2.5, 95% 0.3-20.9).
During interviews conducted at Restaurant A, food service workers
described green onion storage, washing, and preparation practices. Green
onions were shipped in 8.5-lb. boxes containing multiple small bundles
(6-8 green onions per bundle). Each box was unpacked, and bundles were
stored upright (root side down) and refrigerated in a bucket with ice
included in the shipment. Green onions were stored 5 or more days before
processing, which consisted of rinsing intact onion bundles, cutting the
roots off, and removing the rubber bands. Green onions from each box
were chopped by machine to yield approximately 8 qts. Chopped green
onions were refrigerated for approximately 2 days.
Periodically (i.e., every 1-3 days), salsas were prepared in batches of
40-80 qts. Mild salsa included chopped fresh green onions; hot salsa did
not. Salsas were refrigerated in 8-quart containers with a shelf life of
3 days. Mild and hot salsa were ladled into bowls and provided free with
tortilla chips upon seating at Restaurant A.
The Food and Drug Administration (FDA), CDC, and the state health
departments are investigating the source of the green onions associated
with this outbreak and how they became contaminated with HAV.
Preliminary traceback information indicates that green onions supplied
to Restaurant A were grown in Mexico.
Editorial Note:
This report describes a large hepatitis A outbreak associated with
eating a food item containing green onions at a single restaurant. The
majority of ill patrons interviewed as of November 21 were exposed
during a 3-day period in early October. No ill food service worker
identified could have been the source of the outbreak. The green onions
likely were contaminated with HAV in the distribution system or during
growing, harvest, packing, or cooling. Traceback investigations
completed to date have determined that the green onion source is one or
more farms in Mexico.
Both green onions and white onions were associated with illness in the
univariate analysis. However, white onions were not associated with
illness among those who did not eat green onions. This association with
white onions observed in the univariate analysis might not remain when
multivariate modeling is completed. Restaurant A purchases previously
chopped white onions and adds them to several menu items, including hot
and mild salsa. Mild salsa, which contains both green onions and white
onions, was associated with illness; however, hot salsa, which contains
only white onions, was not associated with illness.
The genetic sequence of the outbreak strain is very similar to viral
sequences obtained from persons involved in hepatitis A outbreaks in
Tennessee, Georgia, and North Carolina during September 2003 that were
linked epidemiologically to green onions. These sequences also were
identical or very similar to sequences observed among persons with
hepatitis A living along the United States-Mexico border and travelers
returning from Mexico, consistent with a source in Mexico (CDC,
unpublished data, 2003). Raw green onions from three firms in Mexico
have been implicated in the Tennessee and Georgia outbreaks. FDA is
still reviewing records to determine if additional firms are involved.
The Mexican government is assisting with the traceback investigation in
Mexico and the investigation to determine the source of the
contamination.
Previous hepatitis A outbreaks linked to green onions have been reported
and have involved patrons of a single restaurant. However, the outbreak
at Restaurant A was unusually large. Several characteristics of the way
food was prepared and served in Restaurant A could have contributed to
the outbreak's size, including 1) multiple opportunities for
intermingling of uncontaminated and contaminated green onions in a
common bucket for 5 days with the ice in which they were shipped and 2)
serving contaminated items with a relatively long shelf life (e.g., mild
salsa) to a large proportion of patrons over several days.
HAV is transmitted by the fecal-oral route. Green onions require
extensive handling during harvesting and preparation for packing.
Contamination of green onions could occur 1) by contact with HAV-infected
workers, especially children, working in the field during harvesting and
preparation and 2) by contact with HAV-contaminated water during
irrigation, rinsing, processing, cooling, and icing of the product.
Green onions and other selected produce items (e.g., strawberries) might
be more vulnerable to contamination because of plant surfaces [that] are
particularly complex or adherent to viral or fecal particles. Outbreaks
of other enteric pathogens linked to green onions have been reported.
On November 15, FDA issued an alert to consumers about the recent
hepatitis A outbreaks associated with green onions (available at
http://www.fda.gov/bbs/topics/ANSWERS/2003/ANS01262.html). FDA
advised consumers concerned about the possibility of getting hepatitis A
from green onions to cook green onions thoroughly before eating and to
ask about use of green onions in prepared foods. Unless directed
otherwise by public health officials, persons who have recently eaten
green onions do not need postexposure prophylaxis (i.e., immune
globulin).
CDC is working with state health departments to identify other hepatitis
A outbreaks associated with green onions. As of November 21, no other
hepatitis A outbreaks have been identified. To identify other cases
related to these outbreaks, state and local health officials should
interview persons with hepatitis A with onset after October 1. Persons
without typical risk factors for hepatitis A should be asked about food
and restaurant exposures during their incubation period. Because
molecular epidemiologic techniques have been useful for identifying
related cases of foodborne hepatitis A in previous outbreaks, health
departments might consider obtaining serum specimens for cases of
interest.
An increasing proportion of reported foodborne outbreaks have been
linked to fresh produce. This increase might be attributed to increased
consumption of fresh produce or better surveillance techniques. HAV
contamination of fresh produce can be reduced by using approaches such
as the application of Good Agricultural Practices/Good Manufacturing
Practices recommended by FDA. Recommended control measures include
providing sanitary facilities for field workers, ensuring appropriate
water quality, use of properly treated manure or biosolids, and ensuring
worker health. Reducing HAV transmission in areas where produce is grown
and discouraging the presence of children in areas where food is
harvested also will reduce opportunities for HAV contamination. Further
investigation of this and other hepatitis A outbreaks linked to green
onions, including observation of cultivation and harvesting practices,
can guide additional specific critical control measures.
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To access a web-text (HTML) version of the article online, go to:
http://www.cdc.gov/mmwr/preview/mmwrhtml/mm52d1121a1.htm
To access a ready-to-copy (PDF) version of this issue of "MMWR
Dispatch," go to:
http://www.cdc.gov/mmwr/pdf/wk/mm52d1121.pdf
To receive a FREE electronic subscription to MMWR (which includes new
ACIP statements), go to:
http://www.cdc.gov/mmwr/mmwrsubscribe.html
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November 24, 2003
UPDATED: REFORMATTED FAHRENHEIT AND CELSIUS VACCINE TEMPERATURE LOGS
AVAILABLE ON IAC'S WEBSITE
Early in November, the Immunization Action Coalition (IAC) reformatted
its two vaccine temperature logs, "Temperature Log for Vaccines
(Fahrenheit)" and "Temperature Log for Vaccines (Celsius)." Each
two-page log gives immunization providers a foolproof way to record a
month's worth of vaccine storage temperatures.
To access a ready-to-copy (PDF) version of the Fahrenheit log, go to:
http://www.immunize.org/catg.d/p3039.pdf
To access a ready-to-copy (PDF) version of the Celsius log, go to:
http://www.immunize.org/news.d/celsius.pdf
Two additional pieces on vaccine storage and handling are also available
on the IAC website, "Checklist for Safe Vaccine Handling and Storage"
(updated 11/01) and "Don't Be Guilty of These Errors in Vaccine Storage
and Handling" (updated 4/03).
To access a ready-to-copy (PDF) version of "Checklist for Safe Vaccine
Handling and Storage," go to:
http://www.immunize.org/catg.d/p3035chk.pdf
To access a web-text (HTML) version of it, go to:
http://www.immunize.org/catg.d/p3035chk.htm
To access a ready-to-copy (PDF) version of "Don't Be Guilty of These
Errors in Vaccine Storage and Handling," go to:
http://www.immunize.org/catg.d/p3036.pdf
To access a web-text (HTML) version of it, go to:
http://www.immunize.org/catg.d/p3036.htm
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November 24, 2003
FIND "IAC EXPRESS" VALUABLE? THEN, PLEASE EMAIL YOUR COLLEAGUES AND ASK
THEM TO SIGN UP
Readers, we would like you to encourage your colleagues to subscribe to
"IAC EXPRESS." Why? One reason is that by becoming subscribers they will
be able to stay up to date on immunization issues on a weekly basis.
Another reason is that an increase in subscribers helps the Immunization
Action Coalition gain visibility in the medical and immunization
communities.
Encouraging your colleagues to subscribe is easy: Just forward this link
to them:
http://www.immunize.org/express They can
subscribe by clicking the button labeled "Click here to
subscribe automatically by email." When the email form pops up,
they click "send." That's it! Thank you for taking time to do
this.
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November 24, 2003
NEW VIS TRANSLATION: 2003-04 INACTIVATED INFLUENZA VIS NOW
AVAILABLE IN ILOKANO
The 2003-04 inactivated influenza Vaccine Information Statement
(VIS) in Ilokano is now available on the Immunization Action
Coalition (IAC) website. IAC gratefully acknowledges the Hawai'i
Department of Health for providing the translation.
To obtain a ready-to-copy (PDF) version of the inactivated
influenza VIS in Ilokano, go to:
http://www.immunize.org/vis/il_flu03.pdf
To obtain a ready-to-copy (PDF) version of it in English, go to:
http://www.immunize.org/vis/2flu.pdf
For information about the use of VISs, and for VISs in up to
30 languages, visit IAC's VIS web page at
http://www.immunize.org/vis |
