Missouri Department of Health & Senior Services Healt h Health Advisory February 19, 2019 Advi•s ory: FROM: RANDALL W. WILLIAMS, MD, FACOG DIRECTOR Sustained Increase in Syphilis Cases SUBJECT: Sustained Increase in Syphilis Cases in Missouri in Missouri The Missouri Department of Health and Senior Services (DHSS) continues to observe a sustained increase in the number of syphilis cases reported in the state. The number of early syphilis cases reported in Missouri in 2017 (930 February 15, 2019 cases) increased by 38% over the number of cases in 2016 (676 cases), and has increased 218% since 2012 (292 cases). Provisional data indicate that This document will be updated as new this upward trend continued in 2018 with the number of reported cases information becomes available. The through December 31, 2018, up 40% over the same time period in 2017. The current version can always be viewed purpose of this DHSS Health Advisory is to alert health care providers of the at http://www.health.mo.gov. significant increase in rates of syphilis among multiple populations including The Missouri Department of Health & gay, bisexual, and other men who have sex with men; people who use drugs; Senior Services (DHSS) is now using and heterosexual men and women. A significant increase has also been 4 types of documents to provide observed in the number of reported congenital syphilis cases. important information to medical and public health professionals, and to other interested persons: Background Health Alerts convey information Syphilis is a sexually transmitted disease (STD) that can have very serious of the highest level of importance complications for adults and newborns if left untreated. Initial symptoms of syphilis which warrants immediate action or include a sore and/or rash that goes away after a few weeks without treatment, though attention from Missouri health serious health issues may emerge later without appropriate treatment. Syphilis can be providers, emergency responders, public health agencies, and/or the treated and cured with antibiotics yet many cases go undiagnosed and untreated, public. leading to increased transmission and future negative health consequences. Congenital Health Advisories provide syphilis occurs when a mother with untreated syphilis passes the infection on to her important information for a specific baby during pregnancy – causing miscarriages, premature births, stillbirths, or death of incident or situation, including that newborn babies. Babies born with congenital syphilis can experience serious health impacting neighboring states; may not complications that may present at delivery or later in life. require immediate action. Health Guidances contain Missouri’s increase in syphilis cases was initially observed among gay, bisexual, and comprehensive information pertaining to a particular disease or condition, other men who have sex with men, though other groups, including heterosexual and include recommendations, women, have also experienced an increase in cases recently. While the initial increase guidelines, etc. endorsed by DHSS. in cases occurred primarily in the Kansas City and St. Louis metropolitan areas, other Health Updates provide new or areas including smaller metropolitan areas and rural counties throughout Missouri are updated information on an incident or also experiencing a steep increase in cases, particularly among people who use drugs situation; can also provide informa- and their partners. With the increase in cases in women, Missouri has seen a tion to update a previously sent Health Alert, Health Advisory, or corresponding increase in the number of babies born with, or stillborn due to, syphilis. Health Guidance; unlikely to require In 2017, 13 congenital syphilis cases were reported in Missouri, representing the immediate action. highest number of cases reported since 1998. Missouri has also experienced an increase in ocular syphilis, which can cause blurry vision and/or blindness. Syphilis Office of the Director can cause ocular and neurological issues at any stage of infection. 912 Wildwood P.O. Box 570 The increasing rates of STDs in Missouri, including syphilis and congenital syphilis, Jefferson City, MO 65102 mirror nationwide trends seen in recent years. Ongoing public health efforts to reverse Telephone: 800-392-0272 current trends will require a renewed commitment from, and continued partnership Fax: 573-751-6041 with, healthcare providers. Website: http://www.health.mo.gov 2 Recommendations • Providers should assess the sexual health of patients and discuss STD risks for the patient and partners of the patient. • Providers should routinely test for syphilis in individuals who have signs or symptoms suggestive of infection. Individuals exposed to syphilis within the past 90 days should receive testing and preventive treatment. • Sexually active gay, bisexual, and other men who have sex with men should be tested for syphilis annually or more frequently depending on risk. • Pregnant women should be tested at the first prenatal visit, in the third trimester (28-32 weeks), and at delivery regardless of perceived risk. Bicillin LA is the only CDC-recommended treatment for pregnant women, including those who are allergic to penicillin. Pregnant women who are allergic to penicillin should be desensitized and treated with Bicillin LA. • Any woman who has a fetal death after 20 weeks gestation should be tested for syphilis. • Individuals who are living with HIV who are sexually active should be tested for syphilis annually. • Patients with diminished visual acuity, blindness, uveitis, panuveitis, optic neuropathy, interstitial keratitis, anterior uveitis, and retinal vasculitis should be tested for syphilis and referred to an ophthalmology specialist. If ocular syphilis is suspected, the patient should be treated according to the Centers for Disease Control and Prevention’s (CDC’s) 2015 treatment recommendations (see below under Additional Resources) for neurosyphilis and undergo a lumbar puncture with cerebrospinal fluid (CSF) examination. Questions should be directed to DHSS’ Bureau of HIV, STD, and Hepatitis at 573-751-6439, or via email at [email protected]. Additional Resources Complete CDC testing and treatment recommendations: https://www.cdc.gov/std/tg2015/default.htm CDC Syphilis Pocket Guide: https://www.cdc.gov/std/syphilis/Syphilis-Pocket-Guide-FINAL-508.pdf CDC STD Treatment Guide: A mobile app is available for download from the Apple or Android store (search for STD Tx Guide) DHSS Syphilis Overview: https://health.mo.gov/living/healthcondiseases/communicable/stds/syphilis.php Missouri Department of Health & Senior Services Healt h Health Advisory May 20, 2019 AdvHeisaltohry: Ques tions should FROM: RANDALL W. WILLIAMS, MD, FACOG DHSS H ealth Advisory DIRECTOR for Legionella SUBJECT: DHSS Health Advisory for Legionella - The Fulton Presbyterian Manor, located at 811 Center Street, Fulton, Missouri is under investigation after two residents tested positive for Legionella. Public information May 20, 2019 released on May 19, 2019 directs individuals with symptoms of Legionnaire’s disease that This document will be updated as new have visited the facility within 14 days of illness onset to seek medical care. This health information becomes available. The alert provides general guidance for healthcare providers that may see patients who fit current version can always be viewed these criteria. at http://www.health.mo.gov. The Missouri Department of Health & Most people with Legionnaires' disease will have pneumonia since the Legionella bacteria Senior Services (DHSS) is now using 4 types of documents to provide grow and thrive in the lungs. Legionellosis is not spread from person to person. Legionella important information to medical and grow best in warm water sources, such as hot tubs or hot water tanks. The infection is public health professionals, and to primarily acquired through inhalation of mist or vapor containing the bacteria, or by other interested persons: aspiration of contaminated water into the lungs. Environmental risk factors associated Health Alerts convey information with legionellosis outbreaks are travel, residence in a health care facility, and proximity to of the highest level of importance cooling towers, whirlpool spas, decorative fountains, and grocery produce misters. which warrants immediate action or attention from Missouri health providers, emergency responders, Though most individuals exposed to Legionella will not get sick, some persons have an public health agencies, and/or the elevated risk of acquiring legionellosis. Such individuals include those with the following public. risk factors: Health Advisories provide important information for a specific incident or situation, including that • Age of 50 years or older impacting neighboring states; may not • Diabetes require immediate action. • Current or former smoker Health Guidances contain • Chronic lung disease comprehensive information pertaining to a particular disease or condition, • Weakened immune system, including recipients of a transplant or chemotherapy and include recommendations, guidelines, etc. endorsed by DHSS. The most commonly used laboratory test for diagnosis of Legionnaires’ disease is the Health Updates provide new or urinary antigen test, which detects a molecule of the L. pneumophila serogroup 1 in urine. updated information on an incident or situation; can also provide informa- L. pneumophila serogroup 1 is the serogroup that most commonly causes disease. Along tion to update a previously sent with the urinary antigen test, isolation of the bacteria via culture of respiratory secretions, Health Alert, Health Advisory, or lung tissue, pleural fluid, or a normally sterile site is highly recommended since culture is a Health Guidance; unlikely to require immediate action. preferred diagnostic modality. Sputum should ideally be obtained prior to antibiotic __________________________________ administration, but antibiotic treatment should not be delayed. The Infectious Disease Society of America (IDSA) guidelines recommend fluoroquinolone Office of the Director or azithromycin, as preferred, and doxycycline as an alternative treatment. 912 Wildwood P.O. Box 570 Legionellosis is a reportable disease in Missouri. All known or suspected cases should be Jefferson City, MO 65102 Telephone: 800-392-0272 reported to the local public health agency, or to DHSS at 573/751-6113 or 800/392-0272 Fax: 573-751-6041 (24/7). Questions should be directed to DHSS’ Bureau of Communicable Disease Control Website: http://www.health.mo.gov and Prevention at 573/751-6113. Missouri Department of Health & Senior Services Healt h Health Advisory August 20, 2019 Advisory: FROM: RANDALL W. WILLIAMS, MD, FACOG DIRECTOR Severe Lung Disease Associated with SUBJECT: Severe Lung Disease Associated with Vaping Vaping There have been 94 possible cases of severe lung illness associated with vaping in 14 states (30 cases in Wisconsin) from June 28, 2019, to August 15, 2019. As of August August 20, 2019 17, 2019, the Centers for Disease Control and Prevention (CDC) is assisting several states (Wisconsin, Illinois, California, Indiana, and Minnesota) in investigation of This document will be updated as new information becomes available. The clusters of pulmonary illnesses linked to e-cigarette product use, or “vaping,” primarily current version can always be viewed among adolescents and young adults. While some cases in each of the states are similar at http://www.health.mo.gov. and appear to be linked to e-cigarette product use, more information is needed to The Missouri Department of Health & determine what is causing the illnesses. Even though no severe lung disease associated Senior Services (DHSS) is now using 4 types of documents to provide with vaping has been reported in Missouri to date, the Missouri Poison Center has important information to medical and received over 600 calls with various complaints related to e-cigarettes over the last 10 public health professionals, and to other interested persons: years, and has managed over 30 cases with breathing difficulties associated with vaping Health Alerts convey information over the last 5 years. of the highest level of importance which warrants immediate action or Patients presented with cough, shortness of breath, chest pain, and fatigue, which attention from Missouri health providers, emergency responders, became worse over days or weeks before hospital admission. All patients reported public health agencies, and/or the “vaping” (i.e., use of e-cigarette devices to aerosolize substances for inhalation) in the public. weeks and months prior to hospital admission. Many have acknowledged recent use of Health Advisories provide important information for a specific tetrahydrocannabinol (THC)-containing products; however, no specific product has incident or situation, including that been identified by all cases, nor has any product been conclusively linked to this impacting neighboring states; may not require immediate action. clinical syndrome. The severity of the disease has varied among patients, with some needing mechanical ventilation to assist with breathing, and subsequently those patients Health Guidances contain comprehensive information pertaining improved with corticosteroid treatment. All confirmed cases required hospitalization. to a particular disease or condition, Some patients also had fever, anorexia, pleuritic chest pain, nausea, and diarrhea. and include recommendations, guidelines, etc. endorsed by DHSS. Evaluation for infectious etiologies was negative among nearly all patients. Chest Health Updates provide new or radiographs of those patients showed bilateral opacities, mostly in the lower lobes. updated information on an incident or Chest CT imaging was consistent with diffuse ground-glass opacities. While patients situation; can also provide informa- have improved with treatment, long-term health effects are unknown at this time. tion to update a previously sent Health Alert, Health Advisory, or Health Guidance; unlikely to require As of today, e-cigarettes available in the U.S. have not been systemically reviewed by immediate action. the Food and Drug Administration (FDA) to determine their impact on lung health. Nevertheless, it is known that e-cigarettes both contain and emit a number of Office of the Director potentially toxic substances. In January 2018, the National Academies of Science, 912 Wildwood P.O. Box 570 Engineering and Medicine released a consensus study report stating that inhalation of Jefferson City, MO 65102 harmful chemicals through “vaping” can cause irreversible lung damage and lung Telephone: 800-392-0272 disease. The Academies' report also states there is moderate evidence that youth who Fax: 573-751-6041 Website: http://www.health.mo.gov use e-cigarettes are at increased risk for cough and wheezing and an increase in asthma exacerbations. 2 The Missouri Department of Health and Senior Services (DHSS) recommends: 1. Any person, particularly young people, experiencing unexplained chest pain or difficulty breathing after vaping in the days or weeks prior to their symptom onset should seek medical attention. 2. Health care providers caring for patients with respiratory or pulmonary illness, especially of unclear etiology, should ask about the use of e-cigarette products for “vaping” and inquire about the types of drugs (legal or illicit) used and methods of drug use (e.g., smoking, “vaping”). 3. Clinicians should report cases of significant respiratory illness of unclear etiology in patients with a history of vaping to the local public health agency (LPHA), or to DHSS. 4. Evaluation for common infectious etiologies when also suspected should be pursued, and less common infections, and rheumatologic or neoplastic processes, considered as clinically indicated. 5. If an e-cigarette product is suspected as a possible etiology of a patient’s illness, it is important to inquire, and when possible document, what type of product as well as if the patient is: - using commercially available devices and/or liquids (i.e. bottles, cartridges, or pods); - sharing e-cigarette products (devices, liquids, refill pods, and/or cartridges) with other people; - re-using old cartridges or pods (with homemade or commercially bought products); or - heating the drug to concentrate it and then using a specific type of device to inhale the product (i.e., “dabbing”). This information is preliminary and subject to change as CDC provides further guidance. Questions should be directed to DHSS’ Tobacco Prevention and Control Program at 573-522-2824. References Public Health Consequences of E-Cigarettes. January 23, 2018. https://www.nap.edu/read/24952/chapter/1