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Population Health for JMOs

Population Health for JMOs. Dr Tony Merritt Public Health Physician Hunter New England Population Health. Key points. Public Health Unit contact details Priority notifications Outbreak detection and response Rabies and ABLV Resources Public Health careers. Population Health.

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Population Health for JMOs

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  1. Population Health for JMOs Dr Tony Merritt Public Health Physician Hunter New England Population Health

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

  3. 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

  4. Priority notifications • Urgent telephone notification on suspicion • ?? • ?? • ??

  5. 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

  6. 28 yo male with fever and rash?

  7. 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

  8. Meningococcal septicaemia • Rapid progression to coma and shock may occur • CFR up to 50% if untreated • Early treatment critical (CFR <10%)

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

  10. 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)

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

  12. 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)

  13. Meningococcal key points • Urgent notification when clinically suspected. Don’t 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

  14. 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

  15. 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%)

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

  17. Measles • History of local and overseas travel important • Tourists • International students

  18. 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

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

  20. 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

  21. 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

  22. 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

  23. Stool collection?

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

  25. Foodborne illness pathogens

  26. 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

  27. 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

  28. 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….

  29. 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

  30. Case study: Mettwurst outbreak • South Australia, January 1995 • 23 children with HUS (all < 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 child’s death. Potential for negligence claim.

  31. 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 O104:H4 • Epi link to fenugreek seeds from Egypt

  32. 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.

  33. Priority notifications • Urgent telephone notification on suspicion • ? • ? • ? • ?

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

  35. 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)

  36. 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

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

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

  39. 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

  40. Questions? Questions?

  41. 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.

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