Archives of Health Communiqués from Ottawa Public Health

December 6,2007 Adverse events associated with influenza vaccine, Fluviral Lot # AFLLA089AA
August 30, 2007 Memo: Ontario Recommendations on Mumps Immunization
October 30, 2006 CA-MRSA.

December 6,2007 Adverse events associated with influenza vaccine, Fluviral Lot # AFLLA089AA

M E M O / N O T E D E S E R V I C E

Date: December 6, 2007

To: Influenza Vaccine Providers

From : Dr. David Salisbury, Medical Officer of Health

Subject: ADVERSE EVENTS ASSOCIATED WITH FLUVIRAL LOT # AFLLA089AA

There has been a cluster of adverse events reported to Ottawa Public Health (OPH) in the past month associated with influenza vaccine, Fluviral Lot # AFLLA089AA. This lot number was distributed to approximately 200 physician offices, health care agencies and workplaces commencing November 7th, 2007. Reactions reported include tingling and or swelling of the mouth, lips and face, for which four persons received adrenalin. All persons have fully recovered. OPH is working with the Ministry of Health and Long-Term Care to further investigate this cluster of reports. OPH recommends that vaccination with Fluviral, Lot# AFLLA089AA only, cease immediately and requests that this lot number be returned to the Vaccine Distribution Office.

Influenza vaccination should continue with all other lot numbers of Fluviral and Vaxigrip vaccine. If required additional orders for influenza vaccine may be placed, through the Vaccine Distribution Office, following the usual procedure.

With the administration of any vaccine, it is recommended that health care practitioners screen all vaccine recipients to ensure there are no contraindications to receiving the vaccine.

Monitor all patients for immediate reactions for a period of at least 15 minutes after inoculation.

Epinephrine Hydrochloride Solution (1:1000) and other appropriate agents should be routinely available for immediate use in case an anaphylactic or other acute hypersensitivity reaction occurs.

Report any adverse reactions using the provincial Report of Adverse Events Following Immunization (AEFI) to Ottawa Public Health, Communicable Disease Program by fax: 613-580-9640.

With any questions contact Ottawa Public Health, Ottawa Public Health Information Line at

613-580-6744 ext. 15414 or the Communicable Disease Program at 613-580-6744 ext. 24224.

Sincerely,

David Salisbury, MD, MHSc, FRCPC

Medical Officer of Health

August 30, 2007 Memo: Ontario Recommendations on Mumps Immunization

To: City of Ottawa Physicians, Emergency Departments, Community Health Centres, Walk-in Clinics, Infection Control Departments
From: Dr. David Salisbury, Medical Officer of Health
Subject: Ontario Recommendations on Mumps Immunization
Date: August 30^th, 2007

I am writing to advise you of the recently released Ontario recommendations on mumps immunization.

In August 2007, the Public Health Agency of Canada’s, National Advisory Committee on Immunization (NACI) released new recommendations for mumps immunization. The NACI statement on mumps immunization can be seen at: http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/07pdf/acs33-09.pdf.

Following the publication of any NACI recommendations, each province/territory reviews these recommendations and determines to what extent, and how, they will be implemented in that jurisdiction based on the local epidemiology as well as logistical issues.

The Ontario Ministry of Health and Long-Term Care currently recommends that:

1. All children and adults should ensure that their mumps immunization status is up to date, as per the Publicly Funded Immunization Schedules for Ontario, as well as the requirements under the Immunization of School Pupils Act and the recommendations of the local medical officer of health under the Day Nurseries Act
2. Students returning to or starting university/college in Nova Scotia or New Brunswick who have not received two documented doses of MMR, and who have not had laboratory confirmed mumps infection or laboratory documented immunity against mumps, should be offered a second dose of the publicly funded vaccine. (Recommendations for University and College Students)
3. The OMA/OHA surveillance protocol for Ontario hospitals for measles has recently been revised. A new mumps protocol is being developed, and will be available soon.

The above recommendations do vary somewhat from the NACI statement because there are key issues that must be resolved prior to the implementation of any catch-up immunization program. These include: the availability of sufficient vaccine to support the catch up program; timing and logistics of the vaccine administration; potential changes to the legislative requirements; communications to health care providers and the general public; and other logistical and funding issues.

There is currently an insufficient supply of vaccine available to implement a major catch-up program in Ontario. Manufacturers require six to twelve months lead time to produce vaccine. Various options will be reviewed for the future expansion of the current mumps immunization program in Ontario.

Please contact us if you require a French copy of this letter.

For more information on mumps diagnosis, lab testing and immunization;

• Call Ottawa Public Health Information Line, at 613-580-6744
• Visit Ottawa Public Health’s website
• Visit Ontario Ministry of Health and Long-Term Care

I hope this information is of practical value for you.

Sincerely,

David Salisbury, MD, MHSc, FRCPC
Medical Officer of Health

October 30, 2006 CA-MRSA.

To: City of Ottawa Physicians, Emergency Departments, Community Health Centers, Urgent Care Clinics, Infection Control Departments
From: Dr. David Salisbury, Medical Officer of Health
Subject: CA-MRSA
Date: October 30, 2006

Throughout August and September 2006, community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have been seen at a significantly increased rate in emergency departments, hospitals, and clinics in the Ottawa area. The emergence of this organism impacts empiric management of suspected S. aureus infections, as β-lactam antibiotics are not effective against CA-MRSA.

Background

Methicillin resistance is present in up to 75% of S. aureus isolates in some communities in the United States. In Canada, outbreaks of CA-MRSA infections have been reported but the prevalence of CA-MRSA is currently unknown. In the Ottawa area, several severe CA-MRSA infections requiring surgery, and at least two deaths, have been reported to Public Health over the past several months.

CA-MRSA differs from hospital-acquired MRSA (HA-MRSA) in the following ways:

• None of the typical risk factors associated with HA-MRSA is present. Features consistent with HA-MRSA include: a) isolation of MRSA more than 48h after hospital admission; b) isolation of MRSA within 12 months of hospitalization, surgery, dialysis or residence in a long-term care facility; c) the presence of an indwelling catheter or percutaneous device at the time of MRSA isolation; d) prior isolation of MRSA. 1
• Patient risk factors also differ in that many CA-MRSA cases have been reported in young individuals with or without underlying illness, but who have been incarcerated, living in shelters or group homes, or who are IV drug users. Outbreaks in the US have been reported in otherwise healthy athletes on sports teams.
• Clinical presentations typically include severe skin and soft tissue infections (SSTIs) such as abscesses that require drainage or severe cellulitis, and necrotizing pneumonia.
• Antimicrobial susceptibility patterns differ. Both CA- and HA-MRSA are by definition resistant to all β-lactam antibiotics (such as cloxacillin, cefazolin, cephalexin, etc.), but CA isolates may be susceptible to additional antibiotics (e.g., clindamycin, trimethoprim-sulfamethoxazole, doxycycline) whereas HA isolates are more often resistant to these antibiotics.

Recommendations

A working group including infectious disease physicians, microbiologists, infection control professionals and Ottawa Public Health met to develop the following collaborative recommendations for Ottawa practitioners.

Broaden admission screening criteria in acute care facilities to include those who have had a 24 hour stay within the preceding 12 months in:

• Acute and long-term care facilities
• Correctional facilities
• Other group residences (including shelters and group homes)

CA-MRSA should be suspected and wound cultures obtained if possible in the following clinical settings:

• Likely S. aureus infection not responding after 48-72 hours of empiric antimicrobial therapy
• Severe skin and soft tissue infections
• Recurrent SSTIs requiring hospitalization or surgery (2 or more in six months)

• For patients without identified risk factors for CA-MRSA, no change in empiric therapy for presumed S. aureus infections is recommended.
• For S. aureus infections suspected or known to be caused by CA-MRSA, therapy should be based on susceptibility results (if available). Empiric therapy should include trimethoprim-sulfamethoxazole, clindamycin, or doxycyline orally, or intravenous vancomycin. Rifampin may be added to either oral or IV therapy, but rifampin alone is NOT recommended. Consultation with an Infectious Diseases physician and / or transfer to an acute care facility may be indicated.

Prevention: Routine infection control practices are recommended to reduce the transmission of CA-MRSA. For patients and individuals with or at risk for CA-MRSA, these include measures such as:

• Regular and frequent hand hygiene with soap and water or alcohol based hand rub, especially after contact with non-intact skin (e.g. dressing changes)
• Regular bathing with soap and water
• Covering skin lesions with bandages or dressings to minimize drainage
• No sharing of personal care items (soaps, combs, razors, towels) or other personal items (beverages, cigarettes, cosmetics)

Contact Ottawa Public Health if an outbreak is suspected (spread beyond a family unit to a community group) at 613-580-6744, ext. 26325

¹ Barton M, Hawkes M, Moore D et al. Guidelines for the prevention and management of community- associated methicillin-resistant Staphylococcus aureus (CA-MRSA). A perspective for Canadian health care practitioners. In press, Can J Infect Dis Med Microbiol. Available online at http://www.chica.org/pdf/MRSA_draft-Pulsus-Final.pdf