NEWS

• THE EBOLA EPIDEMIC – While Ebola case numbers are no longer doubling each month, the epidemic is far from controlled. In the high intensity-transmission countries of Sierra Leone, Guinea, and Liberia, 21,689 cases with 8,626 deaths have been reported during the outbreak. The declining caseload now allows adequate isolation and treatment of all patients and improved tracing and monitoring of contacts. Some resistance to nontraditional funeral practices continues, but safe burials are increasing. Continuing and long lasting problems: an estimated 10,000 children have lost one or both parents, 5 million have been closed out of school for months, and areas with highest community resistance to infection control procedures also have the highest intensity of ongoing disease transmission. Losses of healthcare workers and resources to the Ebola epidemic have taken away from treatment of far more numerous patients with other needs (malaria, HIV, obstetric care, immunizations). Clinical trials of Ebola-specific treatment have begun, results to follow in future months.

• MEASLES – A dangerous measles outbreak in the US has infected 644 patients during 2014, with 79 confirmed cases in California during January. At the end of January, several states are tracking thousands of individuals who have been exposed by infected patients. Recognition: fever, cough, runny nose; 2-3 days later white spots (Koplik spots) appear on the mucosal surfaces of the mouth; 3-5 days after the onset of symptoms a red flat or raised rash appears on the face near the hairline, with subsequent spread downward to the rest of the body. As the rash progresses, spots join to become continuous. Complications include pneumonia and encephalitis. Patients are contagious for 4 days PRIOR to the appearance of the rash, while the symptoms are nonspecific. The incubation period after exposure is 7-21 days. Clusters of underimmunization have been linked to communities with high rates of vaccine refusal. In some California school districts more than half of kindergartners have incomplete immunizations and 40% of families have sought “personal belief exemptions” to vaccine requirements. Measles is one of the most contagious infections. In the prevaccine era, measles infected 500,000 Americans annually, with 48,000 hospitalizations, causing brain injury due to encephalitis in 1,000 patients, and 500 deaths. Measles vaccine, with an effectiveness exceeding 90%, eliminated continuous endemic transmission in the US 15 years ago. The current measles outbreak is due to vaccine refusal by parents who assume the safety of their own children because so many other families have participated in immunization. Unfortunately, when immunization rates fall below 92-95%, sustained measles transmission occurs among virtually all exposed susceptible individuals. And the outbreak in unimmunized individuals endangers those children with health conditions that preclude immunization (eg, immune deficiencies). In economics, the technical term for those who do not contribute, but depend on public generosity to pay for their own safety, is “free-rider”.

• CHIKUNGUNYA – In the US, 2,344 cases have been reported by January. Most of these occurred in travelers returning from endemic areas of the Caribbean, South America, Pacific Islands, or Asia. New York State leads with 688 cases, all acquired after travel to endemic areas. 11 locally acquired cases have been identified in Florida (no new cases in several months).

• PERTUSSIS – The national pertussis outbreak continues, led by California: 10,831 cases in 2014. In California, 376 patients were hospitalized, and 60% of these were infants younger than 4 months of age. 2 deaths in 2014 occurred in infants 5 weeks or younger at the time of disease onset. Whether expressed as an absolute number of cases or cases per population, the current outbreak is California’s worst since the 1950s. Pertussis is vaccine preventable, but see the January Bulletin for a discussion of limitations in vaccine effectiveness.

TOOLS

• VITAL RESOURCES – WATER – Throughout history, droughts have caused economic losses, malnutrition, interregional commercial and legal disputes, and international armed conflict. In the US, regions suffering drought can be tracked at the University of Nebraska-Lincoln website. In a cruel irony, arid areas often suffer alternating drought and flooding. New approaches to control and store water runoff may mitigate extreme variation in water supplies. Pilot projects are in development in California and Las Vegas.

• NEW GUIDANCE ON DECONTAMINATION FOR CHEMICAL EXPOSURES – From the US Department of Homeland Security.

• RESOURCES FOR CHILDREN AND DISASTERS – From the National Library of Medicine, Health Resources and Services Administration, and Emergency Medical Services for Children National Resource Center.

• 2014-2015 INFLUENZA – This year’s influenza continues to be sensitive to oral oseltamivir and inhaled zanamivir. In addition, peramivir is available for intravenous administration. Resistance of influenza A to amantadine and rimantadine precludes their current use.

SCIENCE

• SHELTER-BASED MENTAL HEALTH SCREENING FOR CHILDREN – A feasibility demonstration of children’s mental health screening in a homeless shelter may provide insight for use in disaster shelters.

Edited by: Dr. Bob Kanter