Population Health for JMOs

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Population Health for JMOs

• Dr Tony Merritt
• Public Health Physician
• Hunter New England Population Health

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Key points

• Public Health Unit contact details
• Priority notifications
• Outbreak detection and response
• Rabies and ABLV
• Resources
• Public Health careers

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Population Health

• HNE Population Health / Public Health Unit
• 24 Hour contact via JHH switchboard or
• Newcastle 4924 6477
• Tamworth 6764 8000
• Key roles in
• Communicable Disease Control
• Outbreak detection and management
• Controlling community spread
• Immunisation
• Environmental Health

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Priority notifications

• Urgent telephone notification on suspicion
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Priority notifications

• Urgent telephone notification on suspicion
• Meningococcal disease
• Measles
• Outbreaks and foodborne illness
  (particularly in institutions)
• Haemolytic Uraemic Syndrome (HUS)
• Avian influenza
• Exotics eg botulism

Meningococcal infection
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28 yo male with fever and rash?
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Meningococcal disease

• Prodrome cold hands and feet, leg and joint pain
  
• Acute onset of fever, nausea, vomiting, intense
  headache, stiff neck, photophobia
• Often a petechial rash.
• Non-blanching
• Some cases of mild disease
• Senior colleague to review suspect cases

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Meningococcal septicaemia

• Rapid progression to coma and shock may occur
• CFR up to 50 if untreated
• Early treatment critical (CFR lt10)

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Meningococcal disease

• Request PCR on blood and CSF
• Available at HAPS JHH
• Rapid
• Sensitive
• Notify Population Health on suspicion

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Meningococcal contacts

• Close household contacts have increased risk of
  meningococcal disease (x800)
• Clearance antibiotics given to close contacts to
  clear nasopharyngeal carriage and reduce further
  transmission / invasive disease in that network
• Typically use
• Rifampicin (children, 4 doses over 2 days)
• Ciprofloxacin (adults, OK if on OCP, stat dose)
• Ceftriaxone (OK if pregnant, IMI single dose)

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Meningococcal contacts

• Health care workers (very low risk).
• Clearance antibiotics if
• Intubation without a face mask or
• Mouth to mouth resuscitation

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Clearance Antibiotic for case

• Penicillin not reliably effective for clearance
• Options
• Rifampicin (children, 4 doses over 2 days)
• Ciprofloxacin (adults, OK if on OCP, stat dose)
• Ceftriaxone (OK if pregnant, IMI single dose)

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Meningococcal key points

• Urgent notification when clinically suspected.
  Dont wait for pathology
• National Guidelines for AB clearance.
• Pop Health will coordinate contact Mx
• Timeliness of clearance antibiotics to contacts
  is critical
• Coroner has been critical of delays in
  notification and response

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Case study Meningococcal clinic

• Suspected meningococcal disease in 3yo boy
  notified late Easter Thursday 2009
• Immediate family given clearance ABs at JHH
• Clinic held at childcare centre Easter Friday.
  Team of doctors (x2), nurses (x2) and admin.
  Clearance ABs to all children in same room
• Clearance ABs started within 24 hours of
  notification

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Measles

• Regular importations, potential for local
  transmission
• Clinical feature of suspect measles
• Rash fever cough
• Often coryza, conjunctivitis, Kopliks spots
• Rash face/head to body, maculopapular to
  confluent, onset after 2-4 days of prodrome,
  persists 5-6 days
• Highly infectious (reproductive rate approx. 20)
  from 4 days before to 4 days after rash onset
• Potentially severe (pneumonia 6, encephalitis
  0.1)

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Measles active in NSW

• Multiple importations from SE Asia, Pacific,
  Europe
• Local transmission in Sydney in 2011
• Source not identified for some 2011 cases

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Measles

• History of local and overseas travel important
• Tourists
• International students

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Measles Clinical Samples

• Pathology collection
• Discuss with Pop Health prior to collection
• Serum for serology
  (IgM present in 75 3d after rash onset, in
  100 by 7d)
• For sporadic cases also
• Nose/throat swab or NPA in viral transport medium
  AND
• First pass urine (50ml) for measles IF

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Measles transmission control

• Public Health response options
• Immunisation with MMR if within 3 days
• Immunoglobulin (NHIG) if within 7 days
• Infection control advice

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Case study Measles May 2011

• Measles IgM pos in 12yo male in Newcastle.
  Under-immunised, recent travel to Philippines
• Potential community exposures while infectious
• Household family plus visitors
• GP surgery
• Primary school
• Serolgy confirmed immunity in household
• GP clinic NHIG to 7 unimmunised waiting room
  contacts
• Information letter to school class
• No further confirmed cases

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Measles key points

• Urgent notification to Pop Health on suspicion
• Infection control wear mask, isolate case, leave
  room empty for 2 hours following
• Pop Health will organise prophylaxis for close
  contacts urgently

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Foodborne illness

• Foodborne illness in 2 or more linked cases
  notifiable
• Ask about related cases.. Do you know of anyone
  with a similar illness at present?
• Consider a stool sample

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Stool collection?
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Stool collection

• Yes if
• Suspected outbreak. Identifying the pathogen is
  extremely helpful if foodborne illness suspected
• Clinical suggestion of bacterial illness
• Temperature gt 38.5 0C
• Bloody stool
• Duration gt 3 days
• Vulnerable patient
• Young, old, immunocompromised

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Foodborne illness pathogens
Pathogens Examples Features
Bacterial toxins Bacillus cereus Cl. perfringens Staph. aureus IP lt 20 hours Duration lt 20 hours abdo pain, diarrhoea, vomiting (SA)
Viruses Norovirus Kaplan criteria gt 50 vomiting IP 24 48 hours Duration 12-60 hrs No bacterial pathogen
Bacteria Salmonella Campylobacter Fever, Abdo cramps, /- blood lt 50 vomiting IP 1 4 days Duration gt 3 days
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Stool collection

• Routinely tested for common bacterial pathogens
  Salmonella, Campylobacter and Shigella
• Some viral testing Norovirus, Rotavirus,
  Adenovirus
• If suspected, ensure specific requests for
• Norovirus
• Bacterial toxins

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Foodborne illness

• Public Health response prevention of further
  cases
• Contact other potential cases
• Epidemiological investigation
• Joint field inspections with NSW Food Authority
• Case studies
• Salmonella montevideo
• Salmonella typhimurium 170, Newcastle cafe

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Other Outbreaks

• Outbreaks notifiable under Public Health Act
• Gastro and respiratory syndromes
• Particularly in institutions Aged Care
  Facilities, Child Care, Schools
• Early notification critical to intervention
• Recent examples.

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Haemolytic Uraemic Syndrome

• Clinical triad
• Acute renal failure
• Anaemia
• Thrombocytopaenia
• Infectious form usually preceded by gastro caused
  by STEC (Shiga-toxin producing E coli)
• Bloody diarrhoea typical
• Can be fatal, result in chronic renal failure
• Commonly affects children
• Outbreak potential

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Case study Mettwurst outbreak

• South Australia, January 1995
• 23 children with HUS (all lt 16 years)
• 16 required dialysis
• 1 death (4 yo girl)
• Stools positive for STEC PCR, E.coli O111
• Epi link to mettwurst from a local producer
• Coroners review critical of delayed public health
  response. Each notification reviewed for
  timeliness and potential contribution to childs
  death. Potential for negligence claim.

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Case study 2011 German and French outbreak

• First HUS cases identified in Germany 19 May 2011
• Ongoing cases (At 22 July)
• 4075 outbreak cases
• 908 (25) with HUS
• 50 deaths
• Epidemiological features
• HUS cases predominantly in adults, 68 female
• Pathogen E.coli O104H4
• Epi link to fenugreek seeds from Egypt

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HUS key points

• Consider in differential for bloody diarrhoea.
  Request STEC PCR on stool
• Urgent telephone notification on suspicion. HUS
  is a clinical diagnosis.
• Look for linked cases
• Population Health will investigate potential
  exposures immediately.

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Priority notifications

• Urgent telephone notification on suspicion
• ?
• ?
• ?
• ?

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Priority notifications

• Urgent telephone notification on suspicion
• Meningococcal disease
• Measles
• Outbreaks and foodborne illness
• Haemolytic Uraemic Syndrome (HUS)

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Rabies and ABLV

• Risk areas
• Australian Bat Lyssavirus detected in fruit and
  insectivorous bat species throughout Australia. 2
  human cases, both fatal.
• Rabies active in Bali (120 deaths in 2010), many
  other countries
• Transmission
• Bites / scratches from infected bats / mammals
• Incubation period typically 3 - 8 weeks (9 days
  to 7 years)

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Rabies and ABLV

• Post Exposure management
• Wash area with soap and water
• HRIG for all bites and high risk scratches
• At site of bite
• Given within 7 days of first vaccine dose
• Rabies vaccine at days 0, 3, 7, 14 and 30
• Contact Population Health urgently to organise PEP

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Influenza vaccination

• Vaccinated last year?
• Health worker vaccination provides important
  protection for vulnerable patients and family
  members
• Focus of Tamiflu resistance in Newcastle 2011

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Resources

• NSW Health A to Z site for fact sheets and Pop
  Health response
• http//www.health.nsw.gov.au/PublicHealth/Infecti
  ous/a-z.asp

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Public Health careers

• Public Health Physician training
• 3 year scheme
• Post graduate (3 years)
• Require Masters Public Health
• Field placement eg Hunter New England
• AFPHM, a faculty of RACP
• Public Health Physicians in NSW
• Health Protection
• PHUs, research, policy

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Questions?
Questions?
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Acknowledgements

• With grateful acknowledgements of

Hunter New England Population Health is a unit of
the Hunter New England Area Health Service.
Supported by funding from NSW Health through the
Hunter Medical Research Institute.
Developed in partnership with the University of
Newcastle.