B otulism is a rare, but serious, paralytic illness caused by a neurotoxin that is produced by the bacterium Clostridium botulinum. In the United States, there are approximately 100 cases of infant botulism diagnosed annually. New Jersey has about six cases yearly. For the past 10 years, New Jersey has ranked third (after California and Pennsylvania) with the highest number of cases of infant botulism. C. botulinum prefers certain soil types and infant botulism is more common in those areas. While there is no definitive evidence, it is believed that soil ecology plays a large role in determining which states have the highest prevalence of cases. Infant botulism occurs when babies ingest the spores of botulinum bacteria, which then germinate and produce a toxin in the intestines. An infant can ingest these spores through food (most commonly, honey/corn syrup), soil or contaminated dust. In general, the disease occurs in children less than one year old due to the inability of the immature intestines to move the spores through and out of the body before the toxin forms. Therefore, once an infant ingests the spores, the bacteria germinate, multiply, and produce a toxin which, in turn, can affect the infant’s nervous system. The most common symptoms of infant botulism are difficulty feeding (diminished sucking reflex), a weak cry, loss of head control (“floppy baby”) and poor muscle tone. Clinicians who have a suspect infant botulism case should contact the California Department of Public Health, Infant Botulism Treatment and Prevention Program (IBTPP) for consultation (510-231-7600, 24/7). If it is determined that the infant does have botulism, the IBTPP will dispense BabyBIG (Botulism Immune Globulin), an antitoxin approved by the FDA in 2003 for the treatment of infant botulism. This drug significantly reduces the severity of symptoms and prevents further progression of the disease. Improvement is usually seen within Spring 2014 Communicable Disease Service Mission Statement Our mission is to prevent communicable disease among all citizens of New Jersey, and to promote the knowledge and use of healthy lifestyles to maximize the health and well-being of New Jerseyans. We will accomplish our mission through our leadership, collaborative partnerships, and advocacy for communicable disease surveillance, research, education, treatment, prevention and control. Chris Christie, Governor Kim Guadagno, Lt. Governor Mary E. O’Dowd, MPH Commissioner COMMUNICABLE DISEASE SERVICE Christina Tan, MD, MPH State Epidemiologist/ Assistant Commissioner Gary Ludwig, MS, Director Suzanne Miro, MPH, MCHES Editor, Research Scientist Continued on page 8 C2038 Infant Botulism The above photo is a depiction of a "floppy baby," a classic clinical sign of infant botulism.
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The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New Jersey Com-muni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Continued from/on page x
Caption is this
Subhead
PHOTO BY: ANWAR WALKER, PUBLIC HEALTH REPRESENTATIVE
Funding to Expand continued from page 1
Botulism is a rare, but serious,paralytic illness caused by aneurotoxin that is produced
by the bacterium Clostridiumbotulinum. In the United States, thereare approximately 100 cases ofinfant botulism diagnosed annually.New Jersey has about six casesyearly. For the past 10 years, NewJersey has ranked third (afterCalifornia and Pennsylvania) withthe highest number of cases of infantbotulism. C. botulinum preferscertain soil types and infant botulismis more common in those areas. Whilethere is no definitive evidence, it isbelieved that soil ecology plays a largerole in determining which states havethe highest prevalence of cases.
Infant botulism occurs when babiesingest the spores of botulinumbacteria, which then germinate andproduce a toxin in the intestines. Aninfant can ingest these sporesthrough food (most commonly,honey/corn syrup), soil orcontaminated dust. In general, thedisease occurs in children less thanone year old due to the inability ofthe immature intestines to move thespores through and out of the bodybefore the toxin forms. Therefore,once an infant ingests the spores, thebacteria germinate, multiply, andproduce a toxin which, in turn, canaffect the infant’s nervous system.The most common symptoms of
infant botulism are difficulty feeding(diminished sucking reflex), a weakcry, loss of head control (“floppybaby”) and poor muscle tone.
Clinicians who have a suspect infantbotulism case should contact theCalifornia Department of PublicHealth, Infant Botulism Treatmentand Prevention Program (IBTPP) forconsultation (510-231-7600, 24/7). Ifit is determined that the infant doeshave botulism, the IBTPP willdispense BabyBIG (Botulism ImmuneGlobulin), an antitoxin approved bythe FDA in 2003 for the treatment ofinfant botulism. This drugsignificantly reduces the severity ofsymptoms and prevents furtherprogression of the disease.Improvement is usually seen within
Spring 2014
Communicable DiseaseService Mission StatementOur mission is to prevent communicable disease amongall citizens of New Jersey, andto promote the knowledge anduse of healthy lifestyles to maximize the health and well-being of New Jerseyans.
We will accomplish our mission through our leadership,collaborative partnerships, andadvocacy for communicable disease surveillance, research,education, treatment, prevention and control.
Chris Christie, Governor
Kim Guadagno, Lt. Governor
Mary E. O’Dowd, MPHCommissioner
COMMUNICABLE DISEASE SERVICEChristina Tan, MD, MPHState Epidemiologist/Assistant Commissioner
Gary Ludwig, MS, Director
Suzanne Miro, MPH, MCHESEditor, Research Scientist
Continued on page 8
C2038
Infant Botulism
The above photo is a depiction of a "floppy baby," aclassic clinical sign of infant botulism.
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Page 2
Get more information athttp://nj.gov/health/cd/handwashing.shtml.
Proper vaccine storage andhandling practices play avery important role in
protecting individuals andcommunities fromvaccine-preventable diseases.Failure to adhere to requiredprotocols for storage and handlingcan reduce vaccine potency,resulting in inadequate immuneresponses in patients, as well asinadequate protection againstdisease.
Vaccine quality is the sharedresponsibility of everyone, from thetime vaccine is manufactured untilit is administered. In response torecent scientific studies onequipment used for vaccine storageand a better understanding of bestpractices for vaccine storage andhandling, the following are themost recent Centers for DiseaseControl and Prevention (CDC)recommendations:
Establish Storage and HandlingPolicies:o Select a designated primaryvaccine coordinator and at leastone alternate coordinator to bein charge of vaccine storage andhandling.
o Develop a detailed, up-to-date,written policy for generalvaccine management and a planfor how vaccines would berelocated in the event of anemergency. v The routine vaccine storageplan should include all
aspects of routine vaccinemanagement, from orderingvaccines and managinginventory to storing vaccinesand monitoring storageconditions.
v The relocation plan would beused in the event of powerfailures, refrigeratormalfunctions, naturaldisasters, and anytime there isa known threat to the vaccineinventory.
Use Proper Storage Equipment:o Store vaccines intemperature-monitored,alarm-equipped, stand-alonerefrigerators and freezers. If anoffice only has a household-stylecombination unit, the CDCrecommends using one unit forrefrigerated vaccines only and touse a separate stand-alonefreezer to store frozen vaccines.
o Use “Do Not Unplug” signs nextto electrical outlets for therefrigerator and freezer and a“Do Not Stop Power” warning labelby the circuit breaker whichpowers the refrigerator andfreezer.
o Do not store vaccines in adormitory-style or bar-stylerefrigerators/freezers (a smallcombination freezer-refrigeratorunit with the freezercompartment inside therefrigerator).
o Do not store food or beverages ina vaccine storage unit.
Know the Facts: Vaccine Storage and Handling
Continued on page 6
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Page 3
As part of New Jersey’songoing injection safetyinitiative, “Keeping the
Infection out of the Injection,” anothercadre of safe injection ambassadorswere trained on February 26, 2014.Safe injection ambassadors arehealth professionals (infectionpreventionists, nurses andepidemiologists) who volunteer toeducate healthcare providers aboutissues surrounding injection safety.The first group of 25 Ambassadorswas trained in 2012 and has
impressively conducted outreachand education to more than 800health professionals throughout thestate.
The NJ Ambassador program is amodel project and has beenreplicated in North Carolina andNevada. After recruitment,ambassadors must pass a qualifyingexam and agree to present at leasttwo times within one year of beingtrained. New Jersey Department ofHealth staff are looking forward totraining the next class of safeinjection ambassadors!
Injection safety
Three regional outbreaktrainings were completed inDecember, 2013 and January
2014. More than 200 public healthprofessionals attended the threesessions. The New JerseyAssociation of City and CountyHealth Officials (NJACCHO)received a grant for the New JerseyDepartment of Health (NJDOH) toconduct the trainingsto clarify the outbreakinvestigation processto ensure thatinvestigations areconsistent. Speakersincluded staff fromthe NJDOHCommunicableDisease Service andlocal public healthprofessionals. TheNJACCHOCommunicableDisease subcommittee
created a manual for public healthprofessionals to refer to whenworking on an outbreak diseaseinvestigation. Pictured here are theNJDOH speakers at the January2014 training at Rutgers in NewBrunswick: Dr. Alice Shumate, JasonMehr, Rebecca Greeley and TerrieWhitfield. Special thanks to GeorgeVan Orden, PhD, Health Officerfrom Hanover Township whochaired the subcommittee.
Outbreak Training
Dr. Alice Shumate, Jason Mehr, Rebecca Greeley, and Terrie Whitfield servedas speakers for the training.
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Page 4
Laura Taylor, Adult ViralHepatitis PreventionCoordinator and Amelia
Hamarman, STD Educator,provided a training in January toHIV grantees and other publichealth partners. The training,“Birds of a Feather: IntegratingHepatitis into Existing HIV andSTD Prevention Messages,” is afull-day training designed to helpHIV and STD professionals(counselors, educators, outreachworkers, health care workers, etc.)to integrate hepatitis preventionmessages into their existingprevention activities. Rates ofco-infection with hepatitis andHIV, or other STDs, continue torise due to common transmissionroutes of these infections. Giventhe overlap of risk factors andbehaviors, especially in at-riskpopulations, it is logical to
incorporate information andmessages about all of theseinfections. The training is designedto help participants to gain basicknowledge about hepatitis and tohelp them generate realisticstrategies for integrating hepatitisprevention into the services theiragencies already provide.
This training is a collaborative effortbetween the Communicable DiseaseService and the Division of HIV, STDand TB Services.
Hepatitis
COMMUNICABLE DISEASEOUTBREAK MANUALThis manual is available on-line andincludes appendices and other usabletemplates. Go to:http://njlmn2.rutgers.edu/sites/default/files/NJACCHO%20Outbreak%20Investigation%20Manual_0.pdf
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Page 5
In December, CDS staff JoseCortes, Alice Shumate andLaura Taylor delivered boxes of
personal care items donated by NewJersey Department of Healthemployees to three organizations:Project HOPE in Camden, The Vet
Center in Ewing and Salvation Armyin Trenton. More than 20 boxes ofpersonal care items and fluprevention kits (tissues, handsanitizer and hand wipes), weredistributed to these threeorganizations that serve NJresidents.
CDS Service Project
Alice Shumate and Jose Cortes pictured with a VetCenter staff member.
Alice Shumate and Jose Cortes deliver donateditems.
Suzanne Miro, a health educatorfor the Communicable DiseaseService, delivered a focus group
skills training for county public healthofficials on January 30, 2014. Thecounties represented at the trainingare receiving funding through theSuperstorm Sandy Block Grant toassist local residents in their ongoingefforts to recover from the storm. Partof the grant requires the officials toconduct focus groups among theirconstituents to learn more about theirongoing struggles and to targetresources to assist in this matter. Thistraining was a collaborative effort
between the Public HealthInfrastructure, Laboratory andEmergency Preparedness division andthe Communicable Disease Service.
Training for CountyPublic Health Officials
Carl Michaels, Suzanne Miro and Luis Torrens at thetraining for county public health officials on January 30.
c
F
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
o Remove all vegetable and deli binsfrom the storage unit, and do notstore vaccines inthese emptyareas.
o Use a NationalInstitute ofStandards andTechnology(NIST) certified,calibratedthermometer inboth therefrigerator andfreezer. Note thecalibrationexpiration dateand recalibrate orreplace thethermometer asneeded.
o Use a biosafeglycol-encasedthermometerprobe or a similartemperaturebuffered probe.Place thethermometerprobe in thecenter of therefrigerator away from the walls.
o Use digital data loggers withdetachable probes that record andstore temperature information atfrequent programmable intervalsfor 24 hour temperaturemonitoring rather thannon-continuous temperaturemonitoring.
Store and maintain vaccines atappropriate temperatures:o Maintain refrigeratortemperature at 35-46º F (2-8ºC),
and aim for 40º F (5ºC).o Maintain the freezer temperatureat an average of +5º F (-15ºC) orcolder, but no colder than -58º F(-50ºC).
o Keep extra containers of water inthe refrigerator (e.g., in the doorand/or on the floor of the unitwhere the vegetable bins werelocated) to help maintain cool
Page 6
Vaccine Storage, continued from page 2
DTaP/DT/Tdap/TT/Td Hepatitis A & B HIB HPV Influenza (TIV/LAIV) IPV Meningococcal MMR Pneumococcal Rotavirus
THIS REFRIGERATOR/FREEZER IS FOR VACCINES ONLY!
ALL VACCINES must arrive in an insulated container and be stored immediately as follows:
REFRIGERATE 35-46 º F (2-8º C):
FREEZE 5º F (-15º C) or colder:
Do NOT
freeze or expose to
freezing temperatures
VACCINE STORAGE TIPS!
Please contact the Vaccines forChildren (VFC) Program at 609-826-4862 [email protected] for more information.
Store vaccines in the center of the compartment.
Store vaccines with the earliest expiration date up front.
Make sure the correct vaccine storage temperature range is maintained.
Log temperatures twice a day using a NIST certified thermometer. IMMEDIATELY take corrective action to OUT OF RANGE temperatures.
MMR (may be stored in freezer or refrigerator)
MMRVVaricella (chickenpox)Zoster (shingles)
C170810/11
Continued on page 7
Spring 2014
The NJDOHCommunicable DiseaseService includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are availableonline at:http://nj.gov/health/cd/pub.shtml.
Page 7
protocols. Please visit the followingresources to help you create acomprehensive plan for your office.
CDChttp://www.cdc.gov/VACCINES/RECS/storage/default.htm
Immunization Action Coalition:http://www.immunize.org/handouts/vaccine-storage-handling.asp
temperatures. Keep ice packsin the freezer to help maintaincold temperatures.
o Store vaccines in the middleof the refrigerator or freezer(away from walls and vents),leaving room for air tocirculate around the vaccine.
o Record refrigerator andfreezer temperatures at leasttwice a day (first thing in themorning and right before thefacility closes). Documentminimum and maximumtemperatures once a day,preferably in the morning.
o Review vaccine expirationdates and rotate vaccine stockon a weekly basis. Vaccineswith the “earliest” (soonest)expiration date should alwaysgo in front and be used first.
o Notify the designated vaccinecoordinator whenever youhave an out-of-rangetemperature. Get thevaccines back into therecommended temperatureimmediately. Contact thevaccine manufacturer todetermine if vaccines are stilluseable.
Improper vaccine storage andhandling procedures cost timeand money, and jeopardizepatient safety. Expired orimproperly stored vaccine won’tprotect patients. The costsassociated with loss andreplacement of vaccines, as wellas the resources necessary toconduct a recall of patients, canbe avoided by simply followingproper storage and handling
Vaccine Storage, continued from page 2
Never store food or beverages inside the vaccine refrigeratoror freezer.
Vaccines exposed to temperatures outside the recommendedranges can have reduced potency and protection.
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Nearly 90% of more than 500 dermatologists surveyed said they would initiallyprescribe an antibiotic to cover possible methicillin-resistant Staphylococcusaureus when incising and draining an uncomplicated cutaneous abscess. Further,24% reported prescribing antibiotics that are not active against the pathogen, and82% said they culture simple abscesses in 50% of cases.
The survey findings, while limited by their self-reporting nature, point to the needfor clearer guidelines on the best approaches to simple abscesses.
“A comprehensive clinical guideline based on local antimicrobial rates, andincreased knowledge of local resistance patterns and microbiologic data could notonly improve abscess management and antibacterial stewardship, but could alsocombat the rising health care costs associated with SSTIs (skin and soft tissueinfections] and their complications,” wrote Dr. Adam Friedman and his colleaguesin the February issue of the Journal of Drugs in Dermatology. (J. Drugs Dermatol.2014; 13:611-16).
Excerpt from Family Practice News by Heidi Splete:(www.familypracticenews.com)
Page 8
Survey:
NEWS.......................................In The
Anti-MRSA DrugsRoutinelyPrescribed forSimple Abscesses
the first 24-48hours afteradministration.Laboratory testingis not performedto either rule in orrule out thedisease, due to thelength of time ittakes to receivepreliminary results(24 hrs. at aminimum).Therefore,treatment shouldnot be delayed.Stool specimentesting is purelyconfirmatory.
In the majority of infant botulism cases,the exposure remains unknown. It wasconcluded, after research that has beenconducted over the years, that mostinfant botulism cases acquired thedisease by ingesting microscopic dustparticles that carry the spores. The onlyknown prevention measure is to avoidfeeding honey to infants 12 months ofage and younger. Fortunately, theprognosis for infant botulism patients isa complete recovery. The key torecovery is early diagnosis andtreatment.
For more information regarding infantbotulism, visit the IBTPP website athttp://www.infantbotulism.org/.
Infant Botulism, continued from page 1
BabyBIG®, BotulismImmune GlobulinIntravenous (Human)(BIG-IV), is an orphan drugthat consists ofhuman-derivedanti-botulism toxinantibodies that isapproved by the U.S. Foodand Drug Administrationfor the treatment of infantbotulism types A and B.
Spring 2014
The NJDOH CommunicableDisease Service includes:Infectious and Zoonotic Disease Program (IZDP): 609-826-5964
Vaccine Preventable Disease Program (VPDP): 609-826-4860
We’re on the Web!www.nj.gov/health/cd
Past issues of the New JerseyCommuni-CABLE are available online at:http://nj.gov/health/cd/pub.shtml.
Page 9
The New Jersey Department of Health, VaccinePreventable Disease Program (VPDP) presentedan award to one of the winners of the second
annual statewide adolescent vaccine education contest,“Protect Me with 3,” at West Deptford High School. NJpre-teens and teens were challenged to create30-second videos on the importance of gettingvaccinated for tetanus, diphtheria, and acellularpertussis (Tdap), meningococcal conjugate (MCV4),and human papillomavirus (HPV). View all thewinning videos at www.protectmewith3.com.
Award WinnerH
Jennifer Smith, Public Health Educator (left), and Vaccine PreventableDisease Program staff members Jenish Sudhakaran, Population AssessmentCoordinator, and Tiffany Humbert-Rico, CDC Public Health PreventionService Fellow, presented Ryan Zuzulock with the Grand Prize of the secondannual, “Protect Me with 3,” statewide adolescent vaccine educationcontest.
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