. LV \"/ Morbidity and Mortality Weekly Report January 28, 2005 / Vol. 54/ No. 3 Rapid Health Response, Assessment, and Surveillance After a Tsunami — Thailand, 2004-2005 On December 26, 2004, an earthquake triggered a devas- land underscore the value of written and rehearsed disaster tating tsunami that caused an estimated 225,000 deaths in plans, capacity for rapid mobilization, local coordination of eight countries (India, Indonesia, Malaysia, Maldives, relief activities, and active public health surveillance. Seychelles, Somalia, Sri Lanka, and Thailand) on two conti- nents. In Thailand, six provinces (Krabi, Phang-Nga, Phuket, Rapid Response Ranong, Satun, and Trang) were impacted (Figure 1), MOPH rapidly activated mass casualty plans and deployed including prominent international tourist destinations. The personnel and resources to meet local health-care needs. On Thai Ministry of Public Health (MOPH) responded with December 26, a central command center in Bangkok and com- rapid mobilization of local and nonlocal clinicians, public mand centers in each of the six impacted provinces were health practitioners, and medical supplies; assessment of established to coordinate activities. Deployments included health-care needs; identification of the dead, injured, and approximately 100 teams providing emergency clinical care, missing; and active surveillance of syndromic illness. The 12 teams providing technical support and health education, MOPH response was augmented by technical assistance from five teams conducting active surveillance and investigating the Thai MOPH-U.S. CDC Collaboration (TUC) and the potential outbreaks, six teams providing mental health sup- Armed Forces Research Institute of Medical Sciences port, and three teams of MOPH-accredited massage thera- (AFRIMS), with support from the office of the World Health pists providing traditional Thai massage therapy for relief Organization (WHO) representative to Thailand. This workers and displaced persons. report summarizes these activities. The experiences in Thai- The first team from Bangkok arrived on December 26, approximately 6 hours after the tsunami struck. As of January 9, FIGURE 1. The six provinces in southern Thailand impacted by the tsunami an estimated 90,000 persons in affected communities, relief centers, and displaced-person camps had received medi- INSIDE 64 Public Health Consequences from Hazardous Substances Acutely Released During Rail Transit — South Carolina, 2005; Selected States, 1999-2004 67 Outbreaks of Pertussis Associated with Hospitals — Kentucky, Pennsylvania, and Oregon, 2003 71 Fatal Case of Pertussis in an Infant — West Virginia, 2004 72 Outbreak of Invasive Pneumococcal Disease — Alaska, 2003-2004 75 QuickStats Notice to Readers DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR DISEASE CONTROL AND PREVENTION MMWR January 28, 2005 cal and mental health care; 9,798 received outpatient services, The MMWR series of publications is published by the 2,233 received inpatient services (398 were in intensive care, Coordinating Center for Health Information and Service", and 1,254 underwent major surgical procedures), and approxi- Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human Services, Atlanta, GA 30333. mately 80,000 persons received other types of care from mobile teams. Outbreak risks and sanitation, environmental, SUGGESTED CITATION and community mental health needs were rapidly assessed and Centers for Disease Control and Prevention. [Article Title]. addressed. Health education programs on personal hygiene, MMWR 2005;54:[inclusive page numbers]. water and food safety, garbage disposal, toilet construction, injury prevention, and mental health were initiated. Labora- Centers for Disease Control and Prevention tories used for disease surveillance were supplemented with Julie L. Gerberding, MD, MPH additional staff and equipment; food, drinking water, and sea Director water were assessed for safety. Dixie E. Snider, MD, MPH Chief Science Officer Health and Needs Assessment Tanja Popovic, MD, PhD During December 30, 2004—January 6, 2005, three teams (Acting) Associate Director for Science of Thai and U.S. health professionals from TUC and AFRIMS Coordinating Center for Health Information conducted a rapid health and needs assessment in the impacted and Service* provinces. Logistic and strategic support was provided by the Blake Caldwell, MD, MPH, and Edward J. Sondik, PhD Joint U.S.-Thai Military Advisory Group, Thailand. (Acting) Directors Using a WHO rapid assessment tool (/), investigators col- lected data on hospital characteristics; damage to buildings National Center for Health Marketing* and communication, electricity, water, and sewage systems; Steven L. Solomon, MD adequacy and condition of health-care personnel, medical (Acting) Director supplies, and morgue facilities; and anticipated medical needs. Division of Scientific Communications* Questions were initially directed to provincial health office John W. Ward, MD staff members. However, on the provincial staffs’ recommen- (Acting) Director dation, staff from 10 mainland hospitals (four in Phuket, two Editor, MMWR Series in Phang-Nga, and one each in Krabi, Ranong, Satun, and Suzanne M. Hewitt, MPA lrang) and leaders from approximately 12 coastal and island Managing Editor, MMWR Series communities in the six impacted provinces also were inter- Douglas W. Weatherwax viewed. (Acting) Lead Technical Writer-Editor lhe 10 hospitals, with approximately 2,000 inpatient beds and 24 operating rooms, served as the primary referral centers Stephanie M. Neitzel for tsunami-related medical care. None of the 10 hospitals Jude C. Rutledge Teresa F. Rutledge had been damaged by the tsunami; all had activated previ- Writers-Editors ously rehearsed, written mass casualty plans. Shortages of blood, blood products, and certain medical supplies (e.g., sur- Lynda G. Cupell gical devices and antibiotics) were noted during the first 2 Malbea A. LaPete Visual Information Specialists days after the tsunami. Hospital morgue facilities were inad- equate for the number of dead, and corpses were moved from Kim L. Bright, MBA hospitals to temporary morgues at nearby wats (temples). Quang M. Doan, MBA Rapid mobilization of health professionals from multiple Erica R. Shaver areas in Thailand resulted in adequate numbers of staff. By Information Technology Specialists Notifiable Disease Morbidity and 122 Cities Mortality Data December 30, hospiIt al }p atient loads were returningg to usual Patsy A. Hall Donna Edwards levels, and the supplementary medical staff were released. By Deborah A. Adams Mechelle Hester January 4, provincial health officials reported that needs for Felicia |. Connor Tambra McGee staff and supplies were being met. However, coordination of Rosaline Dhara Pearl C. Sharp relief efforts was a challenge. One province was required to : Proposed Vol. 54 / No.3 MMWR 63 coordinate the concurrent activities and service areas of 14 Cases of acute diarrheal disease increased steadily until health teams from volunteer organizations. January 3; since then, the number has stabilized at approximately A small hospital on the island of Koh Phi Phi in Krabi Prov- 100 case reports per day (Figure 2). During December 26- ince was destroyed by the tsunami, and four health clinics in January 11, seven disease clusters were detected; all were diar- coastal villages and islands were severely damaged or destroyed. rheal disease. Implementation of active surveillance Temporary clinics were established by provincial medical staff enhanced detection of diarrheal disease. The annualized rate and volunteer organizations in some coastal villages and in from active surveillance was 1.7 times greater than that displaced-person shelters. In the hospitals and communities recorded from passive surveillance during the same period a assessed, food and bottled water were plentiful, and written year ago (2,950 cases per 100,000 population versus 1,758). guidance on water decontamination was posted. Incidence of wound infections was substantially higher than that recorded in previous years. Preliminary results from an Public Health Surveillance ongoing investigation of 33 patients at two government hos- pitals in Phuket Province indicated that approximately two As of January 25, in the six impacted provinces, 5,388 deaths thirds of the infections were polymicrobial. The most com- had been confirmed; 8,457 persons were reported injured, mon organisms recovered included Proteus spp., Klebsiella spp., and 3,120 persons remained missing (2). Phang-Nga Pseudomonas spp., Staphylococcus aureus, Enterobacter spp., and Province was most severely affected, with 4,217 (78%) deaths, Escherichia coli. Aeromonas hydrophila was recovered from two 5,597 (66%) persons injured, and 1,813 (58%) persons infections. Active disease surveillance continues in the six missing. Among the 3,762 confirmed dead whose nationality impacted provinces. was established, 1,814 (48%) were reported to be Thai nationals (2). Reported by: Ministry of Public Health; World Health Organization Since 1970, MOPH has operated a national passive surveil- representative to Thailand; Thai Ministry of Health-US CD¢ Collaboration, Nonthaburi; Armed Forces Research Institute of Medical lance system for infectious diseases by using a standard Sciences, Bangkok, Thailand reporting form; as of 2000, the system had 68 diseases under surveillance. After the tsunami, MOPH implemented active Editorial Note: Thailand has a well-developed public health surveillance for 20 of these diseases plus wound infections infrastructure that provides residents with more than 90% of and electric shock; five of these disease syndromes (i.e., clini- their health care. The MOPH response to the December 26 cally diagnosed acute diarrhea, wound infections, respiratory tsunami was rapid and effective at mitigating the health con- illness, meningitis, and febrile illness) are summarized in this sequences of the tsunami among survivors. Mass casualty plans report. were immediately activated, and medical personnel, technical Active surveillance was initiated in all 20 districts in the six experts, and supplies arrived soon after the tsunami struck provinces impacted by the tsunami. Surveillance was estab- (3). Health assessments conducted 1 week after the tsunami lished during December 26—January 2. Data for the 20 dis- FIGURE 2. Number of post-tsunami cases of acute diarrhea, tricts were collected from all medical facilities (77 health respiratory illness, febrile illness, and wound infection, by date centers, 22 public hospitals, and four private hospitals), the of report — six provinces*, Thailand, 2004—2005 two shelters for displaced persons, and the two forensic iden- Active surveillance being established tification centers. Surveillance team members visited each site daily and collected individual case-report forms that included information on disease syndrome, age, sex, and nationality. Each day, these teams analyzed data and identified events Acute diarrhea requiring further investigation and preventive measures. Popu- Respiratory illness Number Febrile iliness lation data for 2004 from the Thai Ministry of the Interior Tsunam s : «++++ss+. Wound infection were used to calculate incidences. During December 26—January 1 1, the six provinces reported the following cases: 1,237 cases of acute diarrhea, 356 wound infections, 177 febrile illnesses, and 156 respiratory illnesses (including six cases of aspiration pneumonia). No cases of Meningitis were reported; two deaths were attributed to pneu- monia. The incidences of febrile illness and pneumonia were comparable with those during the same period a year ago. , Phang-Nga, Phuket, Ranong, Satun, and Trang. 64 MMWR January 28, 2005 indicated that, despite a huge influx in the number of pa- References . World Health Organization. Rapid health assessment protocols fot tients, the medical system was intact and functioning effec- emergencies. Geneva, Switzerland: World Health Organization; 1999. tively. As seen in other disasters, rapid health assessments can . Provincial Civil Service Center for the Prevention of Disaster, Depart identify immediate health needs and help prioritize public ment of Disaster Prevention and Mitigation, Ministry of Interior, Thai health interventions (4). land. Announcement 57; 2005. Watts J. Thailand shows the world it can cope alone. Lancet 2005;365. Active disease surveillance was useful in identifying disease . CDC. Rapid assessment of the needs and health status of older adults events and clusters requiring intensive investigation. Although after hurricane Charley—Charlotte, DeSoto, and Hardee Counties, active surveillance demonstrated an increase in the number of Florida, August 27 31, 2004. MMWR 2004;53:837—40. . World Health Organization. Situation report 4. Geneva, Switzerland: acute diarrhea cases, much of this increase can likely be attrib- World Health Organization; 2005. Available at http://www.who.int uted to active searchinfgo r rather than passive reportingo f cases. hac/crises/international/asia_tsunami sitrep O4/en. Concerns by WHO and other authorities about post-tsunami . Goma Epidemiology Group. Public health impact of Rwandan refu gee crisis: what happened in Goma, Zaire, in July, 1994? Lancet 1995; infectious disease mortality have centered on massive outbreaks 345:339_-44. of cholera and other epidemic forms of diarrhea (5). In com- CDC. Surveillance for fatal and nonfatal injuries—United States, 2001. parison with the post-tsunami rates of diarrheal disease observed MMWR 2004;53:20-1 in Thailand (2,950 cases per 100,000 population), the rate of Holian AC, Keith PP. Orthopaedic surgery after the Aitape tsunami Med J] Aust 1998;169:606—9 diarrhea during previously studied outbreaks in disaster settings Cailleaux V, Dupont MJ, Hory B, Amsallem D, Michel-Briand Y. Why in other countries has been much higher (i.e., 87,000—120,000 did infection with ila occur when water contains so cases pet 100,000 population) (6). many other microorganisms? Clin Infect Dis 1993;16:174. 10. Tacket CO, Brenner F, Blake PA. Clinical featureasn d an epidemiologic rhe increased number of wound infections suggests that study of Vibrio vulnificus intections. | Intect Dis 1984:149:558-61 many who survived the initial impact of the tsunami were injured by debris (7). A large tsunami in 1998 in Aitape, Papua New Guinea, had high numbers of persons with traumatic wounds; an Australian team of three surgeons and one nurse Public Health Consequences reported performing 182 surgical procedures in 15 days (8). from Hazardous Substances Acutely he large number of enteric pathogens cultured from wounds Released During Rail Transit — in Thailand suggests surface contamination with enteric patho- gens or true polymicrobial infections. Treatment should South Carolina, 2005; include empiric antibiotic coverage for a range of organisms Selected States, 1999-2004 until results from wound tissue cultures are available to guide On January 6, 2005, two freight trains collided in therapy. Infection with organisms commonly associated with Graniteville, South Carolina (approximately 10 miles north- wounds exposed to sea water, including A. hydrophila and east of Augusta, Georgia), releasing an estimated 11,500 gal- Vibrio vulnificus, should be considered in the differential lons of chlorine gas, which caused nine deaths and sent at diagnoses of these patients (9, /0). least 529 persons seeking medical treatment for possible chlo- Substantial challenges remain for Thailand, including iden rine exposure (/,2; South Carolina Department of Health and tification of approximately 5,000 bodies and reconciliation Environmental Control [SCDHEC] unpublished data, of remains with the bereaved in Thailand and other coun 2005). The incident prompted the Agency for Toxic Substances tries. Forensic experts from Thailand and approximately 30 and Disease Registry (ATSDR) to review data from its Haz- other countries are working together to complete the identifi ardous Substances Emergency Events Surveillance (HSEES) cation and processing of human remains. Other challenges system and update an analysis of 1993-1998 railroad events include maintaining active surveillance to detect infectious (3). The HSEES system is used to collect and analyze data disease outbreaks, treating wound infections, preventing post concerning the public health consequences (e.g., morbidity, traumatic injuries, maintaining safe drinking water and sani mortality, and evacuations) associated with hazardous- tation, and meeting mental health needs. As of January 19, a substance—release events that occur in facilitieso r during trans- total of 7,423 survivors had sought psychiatric help (MOPH unpublished data, 2005). Further mental health interventions will likely be needed to mitigate the postdisaster effects on *An HSEES event residents of coastal communities. substance(s) into the environment in an amount that requires (or would have required) removal according to tede ocal law / \ hazardous IDstanc ne that cant use an adverse healtl Vol. 54 / No. 3 MMWR 65 portation. This report describes the event in South Carolina, Texas. In June 2004, a moving train struck a stationary train which is not part of the HSEES system, and two others from at a rail substation, causing a derailment. One tanker car was HSEES, and summarizes all rail events reported to HSEES punctured, releasing approximately 90,000 pounds of chlo- from 16 state health departments’ during 1999-20049. rine gas. At least 60,000 pounds of chlorine reacted with Local government agencies, employers, and first responders sodium hydroxide to form sodium hypochlorite. Also released can help reduce morbidity and mortality from transit-associ- were approximately 78,000 gallons of urea fertilizer and 7,000 ated hazardous-substance releases by examining historical spill gallons of diesel fuel. Forty-four persons were injured, includ- data for planning purposes, developing emergency response ing three who died. The train conductor died from trauma plans, undergoing proper hazardous materials (HazMat) train- sustained during impact, and two elderly residents near the ing, and reviewing epidemiologic investigation data. site died from chlorine inhalation. Of the remaining 41 injured, 22 were members of the general public, 13 were Case Reports employees, and six were first responders. The most frequent injuries were respiratory and eye irritation. The majority of South Carolina. At approximately 2:40 a.m. on January 6, in Graniteville, South Carolina, a freight train with three chlo- those injured (22 [54%]) were treated at a hospital and released, rine tanker cars and one sodium hydroxide tanker car col- 12 (29%) were treated on the scene, and seven (17%) were treated at a hospital and admitted. Nearby residents initially lided with a train parked on an industrial rail spur. The collision were ordered to shelter-in-place while a site assessment was caused a breach in one chlorine car, which resulted in the conducted. Later, evacuation of 45 residents for 13 days was immediate release of an estimated 11,500 gallons of chlorine ordered when the company prepared to unload the chlorine gas. As a result, nine persons died, and at least 529 persons sought medical care. Because exposure to high levels of chlo- car. Responding to the event were a certified HazMat team; railroad response team; EPA response team; teams from the rine can result in corrosive damage to the eyes, skin, and res- National Transportation Safety Board and Federal Railroad piratory tissues and lead to pulmonary edema and, in extreme Administration; and local health, environmental, fire, law cases, death (5), local emergency management officials ini- enforcement, and emergency medical services (EMS) person- tially issued a shelter-in-place order for a 1-mile radius around nel. Twenty railroad employees and 80 first responders were the site until 4:30 p.m. At noon, South Carolina declared a decontaminated after responding to the event. The cause of state of emergency, giving local authorities responsibility for the derailment was determined to be human error (i.e., fail- issuing a mandatory evacuation for the 5,453 residents within ure to stop). the 1-mile radius. Area schools and businesses were closed. Missouri. In August 2002, approximately 16,900 pounds Four days later, an operation to patch the leaking chlorine of chlorine gas were released from a railroad tanker car when tank car succeeded by applying a temporary repair (2). Fed- a flex hose ruptured during unloading at a chemical plant. An eral responders from ATSDR, the U.S. Environmental Pro- automatic shut-off valve on the car and an emergency shut- tection Agency (EPA), and the U.S. Coast Guard arrived to off system at the plant failed to work as back-up prevention assist SCDHEC in sampling air in factories, homes, and measures. Sixty-seven persons were injured: 61 members of schools within the 1-mile radius. the general public and six employees. The most common A rapid epidemiologic assessment determined that, of the injury was respiratory irritation. Sixty-five (97%) of the 511 persons examined in emergency departments after expo- injured were treated at a hospital and released; two (3%) were sure to chlorine gas, 69 were hospitalized in seven area hospi- admitted. Approximately 400 nearby residents were evacu- tals. An additional 18 persons were treated at area physician ated for 7.5 hours; the release was stopped and contained offices. An ongoing assessment is examining the public health through the efforts of a certified HazMat team; company impact associated with exposure to chlorine gas. Those response team; EPA response team; and .aw enforcement, fire, exposed are being interviewed about their symptoms, the EMS, and local environmental personnel. location and duration of the exposures, and demographic information necessary for monitoring any long-term health effects and psychosocial consequences. HSEES Data Of the 49,450 events reported to HSEES during 1999-2004, a total of 12,845 (30%) were transportation related; of these, Alabama, Colorado, lowa, Louisiana, Minnesota, Mississippi, Missouri, New 1,165 (9%) were rail events. Fifteen of the 16 HSEES states Jersey, New York, North Carolina, Oregon, Rhode Island, Texas, Utah Washington, and Wisconsin reported rail events, with Texas (249 [21%] events) and Loui- Data for 2004 are preliminary siana (175 [15%]) reporting the most. Rail events occurred 66 MMWR January 28, 2005 most frequently in industrial (47%) and commercial areas of the release (range: 0-3,000 persons; median: 38 persons). (2770% ). A total of 1,080 (93%) events involved the release of Seventy-five (6%) railroad events involved ordered evacua- only one chemical. Of the 1,299 total substances released, the tions, of which 61 had a known number of evacuees. A total most common were sulfuric acid (73 [6%] releases), sodium of 11,497 persons (range: 2—2,500 persons; median: 50 per- hydroxide (60 [5%]), and hydrochloric acid (53 [4%]) (Table). sons) were known to have evacuated. Durations of evacuation Chlorine gas, the substance released in all three case reports, ranged from <1 hour to 13 days (median: 4 hours). accounted for 11 (0.8%) of the releases reported to HSEES in Reported by: C Henry, Missouri Dept of Health and Senior Sves. rail events. A Belflower, MSPH, D Drociuk, MSPH, ]] Gibson, MD, Div of Acute Approximately 60% of the known quantities released were Disease Epidemiology, South Carolina Dept of Health and measured in gallons. Of these, quantities ranged from <1 gal- Environmental Control. R Harris, Texas Dept of Health. DK Horton, lon to 400,000 gallons (median: 7.5 g allons). Of the 1,055 MSPH, S Rossiter, MPH, M Orr, MS, Div of Health Studies; B Safay, T Forrester, Div of Regional Operations; S Wright, Div of Toxicology; (91%) railroad events for which a primary cause was identi- Agency for Toxic Substances and Disease Registry. MA Wenck, DVM, fied, 645 (61%) resulted from equipment failure and 258 EIS Officer, CDC. (24%) from human error. Forty-six (4%) of the 1,165 identified rail events resulted in Editorial Note: Approximately 800,000 shipments of haz- injuries to 271 persons, including four deaths. The persons ardous substances travel daily throughout the United States most frequently injured were members of the general public by ground, rail, air, water, and pipeline; approximately 4,300 (e.g., nearby residents) (150 [55%]) and employees (e.g., of shipments of hazardous materials travel each day by rail, railroads and plants) (77 [28%]). Of the 370 total injuries including chemical and petroleum products (6). Although sustained by the 271 persons, the most frequently reported nearly all of these materials safely reach their destinations (7), were respiratory irritation (147 [40%]), headache (40 [11%)]), many are explosive, flammable, toxic, and corrosive and can and eye irritation (36 [10%]). Of the 271 injured, 205 (76%) be extremely dangerous when improperly released. These were treated at hospitals and released, 29 (11%) were treated materials frequently are transported over, through, and under on the scene, 15 (6%) were treated at hospitals and admitted, areas that are densely populated or populated by schools, hos- and four (1%) died. pitals, or nursing homes, where the consequences of an acute Of the 938 (81%) railroad events for which population data release could result in environmental damage, severe injury, were available, 185,801 persons lived within one-quarter mile or death (8). Findings from the HSEES system suggest that rail events constitute only 2% of total hazardous-substance releases. Fur- TABLE. Most common hazardous substances released during rail events — Hazardous Substances Emergency Events Sur- thermore, most rail events involved small-scale releases (75% veillance (HSEES) system, 16 states*, 1999-20041 of events involved <70 gallons). However, large-scale, acute Substance No. of releases‘ (%) releases during rail transit can occur (10% of events involved Sulfuric acid 73 (5.6) »2,200 gallons) and can cause substantial injury and death, as Sodium hydroxide 60 (4.6) demonstrated by the case reports. Hydrochloric acid 53 (4.1) Ammonia 51 (3.9) lhe findings in this report are subject to at least two limita- Methanol : (2.8) tions. Reporting of any event to HSEES is not mandatory; Phosphoric acid \c2 .3) therefore, participating state health departments might not Mixture (2 Argon y (1.7 be informed about every event. Second, only 16 state health Ethylene glycol 22 (1.7 departments provided data to HSEES during the analysis Diesel fuel (1.5) period; therefore, the data represent only a proportion of the Ethanol ] (1 Hydrogen peroxide (1 total hazardous-substance releases in the United States. Potassium hydroxide . (1.1) Examining data on locations, types, and times of previous Alcohol NOS** 11 (0.8) hazardous-substance releases is crucial to preventing or plan- Ammonium nitrate 11 (0.8) Chlorine 11 (0.8) ning responses to future releases (Box). HSEES does not Sodium chlorate 11 (0.8) anticipate a new funding announcement until 2008; how- * Alabama, Colorado, lowa, Louisiana, Minnesota, Mississippi, Missouri ever, nonparticipating states can use the U.S. Department of New Jersey, New York, North Carolina, Oregon, Rhode Island, Texas [ransportation Hazardous Materials Information Reporting Utah, Washington, and Wisconsin . 2004 data are preliminary System (HMIRS) to acquire data on railroad and other trans- ~ A total of 1,299 substances were released during the 1,165 rail events portation-related hazardous materials incidents in their area. Substances mixed before release (e.g., benzene/toluene) ** Not otherwise specified Although HMIRS does not actively collect detailed public Vol. 54/ No.3 MMWR 67 BOX. Measures that government, employers, and first respond- 7. Association of American Railroads. Railroads: the safe way to move. ers can implement to reduce morbidity and mortality from Washington, DC: Association of American Railroads; 2004. Available transit-associated hazardous-substance releases at http://www.aar.org/pubcommon/documents policy/safe_way to move.pdf. * Route hazardous materials away from densely populated 3. US Department of Transportation. Biennial report on hazardous mate areas, where feasible. rials transportation, calendar years 1996-1997. Washington, DC: US Use Hazardous Substances Emergency Events Surveil- Department of Transportation; 1999. Availablea t http://hazmat.dot.gov pubs/biennial/96_97biennial.rpt.pdf. lance data or other federal, state, and local databases to . Horton DK, Berkowitz Z, Haugh GS, Orr MF, Kaye WE. Acute public determine where most releases occur. health consequences associated with hazardous substances released dus Develop emergency response plans before hazardous- ing transit, 1993-2000. ] Hazard Mater 2003;B98:161-75 substance events occur, including a community-based public education campaign detailing proper evacuation (hetp://www.bt.cdc.gov/planning/evacuationfacts.asp), shelter-in-place plans (http://www.bt.cdc.gov/planning/ Outbreaks of Pertussis Associated shelteringfacts.asp), and decontamination procedures with Hospitals — Kentucky, (http://www.bt.cdc.gov/planning/personalcleaning Pennsylvania, and Oregon, 2003 facts.asp). Deploy public warning systems (e.g., sirens), practice Pertussis outbreaks have been reported in various settings, drills, and public shelters. including sports facilities, summer camps, schools, and health- Ensure that employees who work with or around haz- care facilities. Mild and atypical manifestations of pertussis ardous substances undergo continuous job safety train- among infected persons and the lack of quick and accurate ing (e.g., hazardous materials training) and have access diagnostic tests can make pertussis outbreaks difficult to rec- to appropriate personal protective equipment. ognize and therefore difficult to control. Outbreaks among Ensure that emergency medical service and hospital health-care workers (HCWs) are of special concern because emergency department staffs have the necessary guid- of the risk for transmission to vulnerable patients (/). This ance to plan for, and improve their ability to respond report describes three pertussis outbreaks among HCWs and to, incidents that involve human exposure to hazardous patients that occurred in hospitals in Kentucky, Pennsylvania, materials (http://www.atsdr.cdc.gov/mhmi.html). and Oregon in 2003. These outbreaks illustrate the impor- Emphasize the importance of preventive maintenance tance of complying with measures to reduce nosocomial of equipment and vehicles used in transport (3,9). infection when evaluating or caring for patients with acute respiratory distress or cough illness of unknown etiology. health consequence data, nonparticipating states can request Case Definitions such data from HSEES participant states to increase their A clinical case of pertussis is defined as a cough illness last- knowledge of hazardous-substance releases. ing at least 2 weeks with one of the following: paroxysm of References coughing, inspiratory “whoop,” or posttussive vomiting, with- 1. Environmental Protection Agency. Norfolk Southern Graniteville derailment. Washington, DC: Environmental Protection Agency; 2005. out other apparent cause (2). In addition, for the outbreaks Available at http://www.epa.gov/region4 described in this report, persons with cough lasting for >14 South Carolina Emergency Management Division. Graniteville train days were also considered to represent clinical cases of pertus- accident situation reports. Available at http://www.scemd.org sis. A confirmed case was defined as 1) a cough illness of any Orr MF, Kaye WE, Zeitz P, Powers ME, Rosenthal L. Public health risks of railroad hazardous substance emergency events. | ¢ Jccup Environ Med duration with isolation of Bordetella pertussis, or 2) a case that 2001:43:94-—100 met the clinical case definition and was either confirmed by a Agency for Toxic Substanceasn d Disease Registry. Hazardous Substances Emergency Events Surveillance System biennial report, 1999-2000. polymerase chain reaction (PCR) assay positive for B. pertus- Atlanta, GA: US Department of Health and Human Services, Agency sis DNA or had epidemiologic linkage to a confirmed case for Toxic Substances and Disease Registry; 2001. Available at hetp: (2). In addition, sera from several patients with suspected per- www.atsdr.cdc.gov/ HS/HSEES tussis were submitted to the Massachusetts State Laboratory Agency for Toxic Substanceasn d Disease Registry. ToxFAQs™ for chlo Institute (MSLI) for serologic testing to support diagnoses.” rine. Atlanta, GA: US Department of Health and Human Services, Agency for Toxic Substances and Disease Registry; 2002. Available at hetp://www.atsdr.cde.gov/tfacts 172. html US Department of Transportation. Hazardous materials shipments, * MSLI has validated and standardized an enzyme-linked immunosorbent assay Washington, DC: US Department of Transportation; 1998. Available ELISA) for IgG antibodies to pertussis toxin that is used to confirm pertussis at hetp://hazmat.dot.gov/pubs/hms/hmship.pdf. in Massachusetts 3 MMWR January 28, 2005 Case Investigations Kentucky. In early August 2003, an infant aged 2 months, who was born at 26 weeks’ gestation and hospitalized in the intermediate care nursery (ICN) since birth, exhibited cough and apnea. Two days later, the infant was transferred to a neo- "When the mind 1s ready, natal intensive care unit (NICU) and ventilated mechanically. Seven days later, pertussis was suspected; 3 days later, nasopha- a teacher appears.” ryngeal (NP) secretions tested positive for B. pertussis DNA by PCR. The infant was treated with azithromycin (10 mg/kg/day Chinese Proverb on day | and 5 mg/kg/day on days 2—5), and droplet precau- tions were initiated in the NICU. A resident (physician A) in her first trimester of pregnancy examined the infant daily for 5 days in mid-August and did not wear a procedural or surgical mask. She experienced face- MMWR Continuing Education is to-face exposure within 3 feet of the infant and was therefore designed with your needs in designated as a close contact’. Nine days after initial exposure mind: timely public health and to the infant, physician A exhibited rhinorrhea and, 4 days clinical courses, online exams, later, a cough. Physician A declined recommended instant course certificates, and azithromycin prophylaxis. NP secretions obtained from the economical tuition (it's free physician 4 days after symptom onset tested positive by PCR for B. pertussis DNA, and B. pertussis was isolated by culture. Visit MMWR Online to learn Che source of pertussis in the infant might have been one more about our programs of four ICN nurses who provided care to the infant and who features and available courses. had onset of a pertussis-compatible cough illness during the 3-week period preceding the infant's illness. NP secretions MMWR CE obtained from these nurses more than 4 weeks after cough It's ready when you are. onset were negative for B. pertussis DNA by PCR and nega- tive for B. pertussis by culture; however, three of the nurses had levels of IgG antibody to pertussis toxin that met MSLI criteria for a positive result (i.e., >20 yg/ml) (3), indicating response to recent B. pertussis infection. Azithromycin pro- phylaxis was administered to 72 exposed patients and 72 HCWs who were identified as close contacts. No additional CaCc.20OV/MMwi cases were identified. Pennsylvania. In early September 2003, an infant aged 3 veeks was admitted to the pediatric unit at hospital A for 1 day before being transferred to a referral hospital. The infant had cough, posttussive vomiting, and fever for 5 days. Pertus- sis infection was considered unlikely in the differential diag- nosis, the patient was not tested for pertussis, and droplet precautions were not observed by staff. NP secretions were obtained for culture from the infant at the referral hospital, and B. pertussis was isolated 16 days later. Pediatrician B, who cared for the infant at hospital A, had onset of a cough illness 9 days after exposure. Even though he remained symptom- At Continuing For all outbreaks cited in cl Education who experienced face to-Tace co , including those who shared a room or living space with a pertussis patient « who were directly cared for by an HCW with pertussis Vol. 54/ No.3 MMWR 69 atic, the pediatrician continued to treat patients without wear- confirmed pertussis and three symptomatic contacts were ing a mask and was in contact with other HCWs, family mem- treated with a 5-day course of azithromycin; the remaining bers, and friends. Twenty-two days after his initial exposure, 125 contacts accepted prophylaxis. NP secretions obtained from pediatrician B were positive for Because of increased awareness among staff and active case- B. pertussis DNA by PCR. finding by hospital infection-control personnel, three addi- Further investigation identified seven other pertussis cases in tional pertussis cases unrelated to the cases described previously HCWs (a respiratory therapist, a radiograph technician, and were identified among employees, including a medical assis- five student nurses) who had been exposed to the infant at hospi- tant from the perinatal clinic who might have exposed as many tal A. In addition, nine of their HCW contacts had cough ill- as 300 pregnant women, a surgical physician assistant who nesses lasting >14 days. The first seven | 1 "Ws w ere tested too might have exposed 26 patients and 17 staff members, and a late (i.e., 3 weeks after symptom onset) and were negative; nurse midwife who might have exposed 17 patients and 21 their nine contacts were tested within 2 weeks of symptom staff members. An NP specimen from one of the employees onset but were negative by culture and by PCR. In addition, tested positive by PCR, but the source of infection was two children who had been examined by pediatrician B tested unknown. The other two symptomatic employees reported positive for B. pertussis DNA by PCR. exposure to their children who had recent PCR-confirmed lo prevent further transmission, hospital infection-control pertussis. All three employees were treated, and their contacts personnel screened exposed employees for cough illness and were offered prophylaxis with azithromycin. treated all symptomatic HC Ws with a 5-day course of The hospital used e-mail with a link to an Internet-based azithromycin (500 mg on day | and 250 mg on days 2-5), questionnaire to survey approximately 14,000 employees, stu- and these HCWs were excluded from work for 5 days. A total dents, and volunteers for recent onset of cough illness; 209 of 307 close contacts of the symptomatic HCWs, including employees with cough illness responded, and 189 employees other HCWs, household members, patients, residents of an were interviewed. Azithromycin was recommended for 90 institution for mentally impaired persons, and residents of a persons with cough illness of >7 days’ duration. NP secre- dormitory for student nurses, received prophylaxis with a 5-day tions were obtained from 64 survey respondents; all tests were course of azithromycin. In addition to notifying exposed negative for B. pertussis DNA by PCR. No additional linked patients by letter and by telephone, the hospital established cases among hospital employees were identified an informational telephone hotline and conducted press con- Reported by: K Bryant, MD, Univ of Louisville; K Brothers, MD, ferences to inform patients and health-care providers of Univ of Louisville School of Medicine; K Humbaugh, MD, Louisville potential exposures. Vetro Health De pt, Kentu ky. V Kistler, Allentown Health Bur; S Stites, Oregon. In late September 2003, physician C treated an §$ Madeja, Bethlehem Health Bur; JA Jahre, MD, S] Schweon, B Coyle, infant aged 12 months with PCR-confirmed pertussis in the MD, C Kalman, St. Lukes Hospital, Bethlehem; TL Burger, Lehigh Valley Hospital, Lehigh Valley; P Lurie, MD, Div of Infectious Disease pediatric ICU. Physician C, who wore a mask while providing Epidemiology; H Stafford, P Tran, MEd, Div of Immunizations; care to the infant, had been exposed to a colleague who I Metcalf, ] Naugle, W Miller, ] Bart, DO, Bur of Community Health had prolonged cough illness since mid-September. The Systems, Pennsylvania Dept of Health. P Lewis, MD, R Taplitz, MD, colleague was subsequently found to have elevated IgG M Post, MS, A Ashby, T Soden, T Clover, Oregon Health and Sciences anti—pertussis-toxin antibody levels (i.e., >20 wg/mL, as Univ, Portland: kK Segnitz, Multnomah County Health Dept; H Gillette, measured by the MSLI assay) (3) consistent with recent pertus- MPH, Oregon Health Svcs. T Tiwari, MD, FB Pascual, MPH, sis infection. 7\ Murphy, MD, KM Bisgard, DVM, JS Moran, MD, Epidemiology Approximately 2 weeks after treating the infant, physician and Surveillance Div, National Immunization Program; A Calugar, C had onset of a cough illness; 2 weeks later, the physician's MD, EIS Officer, CDC. NP secretions tested positive for B. pertussis DNA by PCR. Editorial Note: Despite high childhood coverage for pertus- Physician C was treated with a 5-day course of azithromycin sis vaccination (4), reported pertussis incidence in the United (500 mg on day | and 250 mg on days 2—5) and was excluded States has increased from a low of 1,248 cases (0.54 per from work for 5 days. The hospital infection-control program 100,000 population) in 1981 to an annual average of 9,431 identified 129 close contacts of physician C, including 22 cases during 1996-2003 (average annual rate: 3.3 per 100,000 pediatric ICU patients, 78 employees, and 29 medical stu- population) (5). During 1996-2004, the majority of pertus- dents and physicians. One exposed patient had severe cough sis patients were either aged <6 months (35.1%) (i.e., too illness and tested positive for B. pertussis DNA by PCR, and young to have received the 3-dose primary series) or aged >7 three employees had pertussis-like illness. The patient with years (60.7%) (i.e., too old to receive a pertussis vaccination) 70 MMWR January 28, 2005 (6). Adolescents and adults, including HCWs, might become BOX. Epidemiology, diagnosis, treatment, and prevention of transmission of pertussis among health-care workers (HCWs) susceptible to pertussis because of waning immunity. No per- and close contacts tussis vaccine is approved in the United States for persons aged years; however, in 2004, two pharmaceutical companies Epidemiology submitted biologics license applications to the Food and Drug ¢ Pertussis is endemic and can be severe in nonimmunized Administration (FDA) for two tetanus toxoid and reduced infants. diphtheria toxoid and acellular pertussis vaccine adsorbed ¢ Transmitted from patients to close contacts by aero- (Tdap) products, one for persons aged 10-18 years and the solized respiratory droplets. other for persons aged 11-64 years. ¢ Highly communicable during the catarrhal stage and This report highlights two primary difficulties in the diag- the first 3 weeks after cough onset. nosis of pertussis. First, diagnosis might be delayed or missed Laboratory Diagnosis/Testing because symptoms are atypical. In adolescents and adults, ¢ Isolation of Bordetella pertussis by culture is the stan- symptoms during the catarrhal stage are most often nonspe- dard test. Success in isolating the organism declines with cific, but the disease is already highly communicable (2). In antibiotic therapy, delay in specimen collection beyond infants, diagnosis might be delayed when the presentation is the first 3 weeks of illness, and immunity. ¢ Polymerase chain reaction (PCR) testing of specimens is respiratory distress with apnea without the typical cough. Sec- rapid but is not yet nationally validated or standardized; ond, sensitive and specific diagnostic tests for pertussis are once validated, PCR could be used in addition to culture. not readily available in many settings; culture, the standard ¢ Standardized and validated enzyme-linked immuno test, has diminishing sensitivity with progression of the classic sorbent assay for anti—pertussis-toxin IgG is under symptoms of the infection. PCR for pertussis is not standard- development. ized, and false-positive and false-negative results can occu Clinical Findings 2). In addition, no serologic test for pertussis has yet been ¢ Incubation period: 7—10 days (range: 4 —21 days). validated and made available nationally, although CDC and ¢ Catarrhal stage: 1-2 weeks; coryza, low-grade fever, and FDA are developing such a test | mild cough. Because droplet transmission of pertussis can occur at the * Paroxysmal stage: 1-6 weeks; paroxysmal cough, post- first contact with an ill patient, HCWs and hospital infec- tussive vomiting, and inspiratory “whoop.” tion-control services should take measures to prevent hospital * Convalescent stage: >3 weeks; cough lessens and disappears. transmission (Box). Many nosocomial outbreaks might be Treatment/Prophylaxis prevented by HCWs' observing droplet precautions (i.¢., wear ¢ Macrolides (erythromycin, azithromycin, or clarith- ing procedural or surgical masks and hand washing) (8) romycin) are preferred. Delay in recognizing pertussis can result in spread of disease * ‘Trimethoprim-sulfiasma ne atltheronaxtea azntoiblioeti c for to HCWs, patients, and other contacts. HCWs should sus use in persons with allergy or intolerance to macrolides. pect pertussis in unvaccinated or partially vaccinated infants Prevention with respiratory distress (e.g., apnea or cough) and obtain NP ¢ Vaccination of children is available as a 5-dose series secretions for culture. Isolation precautions are recommended administered at ages 2, 4, 6, and 15—18 months and age for confirmed and suspected cases of pertussis (2) t—O years. Erythromycin is recommended for treatment and prophy ¢ HCW or patients with pertussis-like cough illness (i.e., laxis of pertussis (/). However, because erythromycin fre highly suspected for percussts) should be tested and quently causes gastrointestinal disturbance, many patients do treated. not complete the recommended 2-week course. Azithromycin ¢ HCWs with pertussis should be excluded from work was used during all the outbreaks described in this report for 5 days from the start of antibiotic use; if no antibi- because it causes fewer and milder side effects than erythro- otic is taken, HCWs should be excluded from work for mycin and its longer half-life means that fewer daily doses are 21 days from onset of symptoms. required, thereby increasing the potential for patient compli ¢* HCWs should keep coughing patients >3 feet from other ance. A recent study that compared azithromycin adminis- persons and implement droplet precautions, including tered as 10 mg/kg (maximum: 500 mg) on day | followed by wearing of procedural or surgical masks. * Isolation precautions are recommended for confirmed and suspected pertussis cases. Additional iorma |p ress2004/press_0707 2004. pdt 20040811 ADACEL.pdt