Population Health for JMOs

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

16. 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%)

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

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

21. 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

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

23. 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

24. 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

26. 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

27. Stool collection?

28. 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

29. Foodborne illness pathogens

30. 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

31. 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

32. 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….

33. 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

34. 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.

35. 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

36. 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.

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

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

39. 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)

40. 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

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

42. 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

43. 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

44. Questions? Questions?

45. 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.