Acupuncture and Mycobacterium abscessus by xyh75214


									Acupuncture and Mycobacterium abscessus
In October of 2002 Toronto Public Health (TPH)       gluteraldehyde. Mycobacterium abscessus rarely
was notified by a local dermatologist of four        causes infection in humans and is not spread
cases of an unusual skin infection. All four         from person to person. Skin and soft tissue
individuals had received acupuncture at the          infections with this organism have been
same clinic in Toronto. An investigation was         associated with acupuncture in a report from
initiated by TPH; as of February 6, 2003, 28         Hong Kong1, with tattooing, and following
suspect cases have been identified and six           puncture wounds or inoculations with
cases have had cultures positive for                 contaminated medication (one outbreak was
Mycobacterium abscessus. All six organisms           linked to use of a contaminated multi-dose vial of
were identical and cultures were sensitive to        lidocaine2).
macrolides, although treatment may
                                                                     During a follow up inspection by
be required for up to six months.
                                                                     TPH in November 2002, the
Mycobacterium abscessus, known                                       acupuncturist reported that in the
in the past as Mycobacterium                                         past she had re-used needles and
chelonae subspecies abscessus, is                                    had experienced some difficulty
a rapidly growing, atypical, non-                                    with sterilization equipment during
tuberculous mycobacterium. It is                                     the summer of 2002. This
ubiquitous in the environment and                                    revelation of potential re-use of
can be found in water, soil and dust                                 improperly sterilized needles
as well as in animals. It is resistant                               caused TPH to direct that the
to chlorine so it can be found in                                    acupuncture clinics (two sites) be
municipal or well water treated with                                 closed immediately until the
chlorine. It can also grow in other                                  situation could be reviewed and
chemical disinfectants such as                                       the risk of bloodborne infections in
                                                                                             Cont’d on page 4

Smallpox: an old disease with new worries?
Smallpox has been one of the most devastating        from the onset of fever until all skin lesions have
diseases known to humanity, with epidemics           scabbed over. The prominence of the rash on the
recorded from as long as 3000 years ago that         face and extremities helps distinguish smallpox
spread across continents. It is a contagious, life   from chickenpox in which the rash is most
threatening disease with a fatality rate of 30%.     prominent on the trunk. In addition, chickenpox
Smallpox is caused by variola virus, a member of     lesions are more superficial, are not generally
the orthopoxviruses, which also includes cowpox      seen on the palms or soles and lesions appear in
(vaccinia) and monkeypox viruses.                    different stages of maturation on the same area
                                                     of the body (see figure page 3).
Variola only infects humans and has no animal
reservoir. It is transmitted from person to person   Edward Jenner developed the first vaccine for
through respiratory droplets although it can also    smallpox in 1796 using vaccinia virus. In 1958,
be transmitted through aerosols and contact with     the World Health Organization (WHO) launched
clothing or bedding from a person with infectious    a global program to eradicate smallpox.
lesions. The incubation period is 12-14 days         Eradication efforts were intensified in 1967 and
(range 7-17 days) followed by the sudden onset       the last case of wild smallpox was reported in
of fever, malaise, headache, backache and            Somalia in 1977. In 1978, two laboratory cases
prostration. Two to three days later the fever       occurred in the United Kingdom but since then
drops and a maculopapular rash with painful,         no cases have occurred anywhere in the world.
deep pustules appears on the mucosa of the           In 1980, the 33rd World Health Assembly
mouth and on the face, hands and forearms,           declared the global eradication of smallpox.
progressing to the trunk, legs and feet. The                                                 Cont’d on page 3
lesions appear in crops with all lesions on a
given area of the body at the same stage of                     Inside this issue
maturation. Eight to 14 days after the onset of       • Prevnar . . . . . . . . . . . . . . . . . . . . . .2
rash, scabs form which eventually lead to             • Female Condom . . . . . . . . . . . . . . . . .4
depressed, pitted scars. A person is infectious
    Invasive Streptococcus pneumoniae and PCV7 (Prevnar™)
    Epidemiology of Invasive S. pneumoniae (ISP)                       The vaccine should be considered for other children in this age
    S. pneumoniae is an organism that causes invasive infections       group, especially those who attend child care.
    such as bacteremia and meningitis, as well as pneumonia,
                                                                       4. What is the dose and schedule for PCV7?
    otitis media and sinusitis. Toronto’s rate of ISP in children
    between 1995 and 1998 ranged from a high of 85 cases per           PCV7 (0.5 mL IM) is administered in the anterolateral thigh of
    100,000 per year in children 12 to 17 months of age to a low       infants less than 1 year of age and the deltoid in those greater
    of 13 cases per 100,000 per year in children over 36 months        than 1 year of age (unless the muscle is too small). The
    of age (personal communication – Dr. Allison McGeer,               manufacturer’s schedule may differ from NACI
    Department of Microbiology, Mount Sinai Hospital). An              recommendations. NACI bases its decisions on a review of the
    organism is rarely isolated in pneumonia cases so these rates      literature and may draw conclusions not reflected in the
    under state the true ISP rate. ISP infections are now reportable   manufacturer’s instructions.
    in Ontario therefore population-based Toronto specific
                                                                        Age at first dose                   Primary series            Additional doses
    incidence data for ISP will be available in the near future.
                                                                        2 to 6 months                       3 doses, 2 months apart   1 dose at 12-15 months
    1. What is PVC7 or PrevnarTM?
                                                                        7 to 11 months                      2 doses, 2 months apart   1 dose at 12-15 months
    An inactivated conjugate vaccine that protects against 7 S.
                                                                        12 to 23 months                     2 doses, 2 months apart   None
    pneumoniae serotypes which cause 80 % of childhood ISP
    infections. An antigen from each serotype is linked to a carrier    24 to 59 months – (healthy child)   Consider giving 1 dose    None
    protein, creating a T-cell dependent immune response. This          24 to 59 months – at high risk of  2 doses, 2 months apart    Polysaccharide vaccine
    increases the vaccine’s immunogenicity in infants and young         ISP infection (as described above)                            may be used as a
    children and creates an antibody booster response to multiple                                                                     booster and to
                                                                                                                                      increase serotype
    vaccine doses.                                                                                                                    coverage.

    2. How effective is PCV7 at preventing ISP infections?             Note: Always allow a minimum of 4 weeks duration between any two

                                                                       doses of PCV7. Also, always allow a minimum of 6 weeks duration
    PCV7 is 95% effective at preventing vaccine serotype ISP

                                                                       between the primary series and additional doses.
    infections, as well as reducing acute otitis media (AOM)

    episodes by 7 % and tympanostomy tube placements by 20%.           5. What are the contraindications for PCV7?

    Preliminary studies have shown reduced nasopharyngeal              PCV7 should not be given to children with an allergy to a

    carriage of vaccine serotypes following PCV7 vaccination.          component of the vaccine (diphtheria toxoid, yeast proteins,

    3. For whom is PCV7 recommended?                                   aluminium phosphate).

                                                                       6. What are the side effects of PCV7?

    PCV7 is licensed for use in children 6 weeks to 9 years of age.

    The National Advisory Committee on Immunization (NACI)             Local injection site tenderness was seen in 15 to 20% of
    recommends routine use of PCV7 for all infants and children        children, but did not increase with subsequent doses. Fever
    less than 24 months of age and children 24 to 59 months of         above 38°C occurred in 15 to 25% of children, more commonly
    age at increased risk of ISP because of the following:             with the primary series. Systemic reactions (irritability,
                                                                       drowsiness, decreased appetite or restless sleep) occurred in
      • sickle cell disease (and other abnormalities of haemoglobin
                                                                       15 to 60% of children. 0.5% to 1.5% had rash or hives, 5% to
        such as haemoglobin S-C disease or S-ß-thalassemia),
                                                                       17% had vomiting and 8% to 12% had diarrhea. Systemic
      • congenital or acquired asplenia (functional or anatomical)
                                                                       reactions were greatest after the second or third dose. Serious
      • HIV infection.                                                 side effects were not increased in trials of PCV7 where PCV7
      • Congenital immune deficiencies                                 was given concomitantly with DTaP-Hib.
      • Diseases associated with immunosuppressive therapy or
                                                                       7. Can PCV7 be given with other vaccines?
        radiation such as Leukemias, Lymphomas and Hodgkin’s
        Disease                                                        Concurrent administration of PCV7 with other vaccines is safe.
      • Malignant neoplasms                                            If convenient, PCV7 may be given with Pentacel™
                                                                       (DTaP/Hib/IPV), Quadracel™ (DpaT-IPV) or hepatitis B
      • Chronic renal insufficiency including nephrotic disease
                                                                       vaccines. Data on the immunogenicity of MMR and Varicella
      • Chronic cardiopulmonary diseases except asthma (unless
                                                                       vaccines when co-administered with PCV7 are not available,
        the asthma is being treated with high dose steroids)
                                                                       although live vaccines given concomitantly with inactivated
      • Cerebrospinal fluid leaks
                                                                       vaccines generally show satisfactory immune response. PCV7
      • Poorly controlled diabetes mellitus                            should be given using a separate syringe and at a different site
      • Hepatic cirrhosis                                              from other vaccines.
      • Solid organ transplantation
8. Is PCV7 covered by OHIP?                                         pneumoniae serotypes responsible for 85 to 90% of all ISP
PCV7 is currently not covered through Ontario’s universal           cases and should continue to be used as indicated. When both
immunization program. The vaccine costs approximately $100          polysaccharide vaccine and PCV7 are given, PCV7 should be
a dose.                                                             given first and at least 8 weeks should elapse before giving
                                                                    polysaccharide vaccine. Children vaccinated with
9. When should a Polysaccharide vaccine for ISP be used?

                                                                    polysaccharide vaccine before they are 10 years of age should
The Ontario government provides polysaccharide S.                   have another dose 3 to 5 years later if a) they are

pneumoniae vaccine for adults 65 years of age or older and          immunocompromised, b) have sickle cell disease or c) suffer

others 2 years of age or older with a high risk of ISP infection.   from functional or anatomical asplenia.

Polysaccharide vaccines do not protect infants and young

                                                                    For more information: National Advisory Committee on
children less than 2 years of age and have limited
                                                                    Immunization, Statement on the Recommended Use of

effectiveness in children 2 to 5 years of age (they may be used
                                                                    Pneumococcal Conjugate Vaccines. Canadian Communicable

in this age group as a booster and to increase serotype
                                                                    Disease Report, Vol. 28, January 15th, 2002, pp. 1- 36.
coverage). The polysaccharide vaccines protect against 23 S.

                                                                    Much debate about the use of smallpox vaccine has ensued in
Smallpox cont’d from page 1                                         the US and Canada. It is a vaccine with a relatively high rate

In Canada, the last endemic case of smallpox was reported in        of adverse reactions, including severe complications such as

1946 and the last imported case occurred in 1962. Vaccination       disseminated vaccinia and eczema vaccinatum as well as a

of the general population in Canada ceased in 1972 and was          case fatality rate of 1 per million primary vaccinations.

stopped for healthcare workers in 1977 and military personnel       Vaccination up to four days after exposure to an infectious

in 1988. Today very few Canadians born after 1972 have been         case of smallpox has been shown to prevent illness and
immunized against smallpox and it is believed few of those          severe disease or death. Given the very low risk of a bioterror

immunized prior to 1972 have adequate residual immunity to          attack with smallpox and the high complication rate of the

prevent infection. It is likely, however, that the risk of severe   vaccine, no country has recommended a return to universal

disease and death is reduced in persons                                                    vaccination. Debate primarily involves the

who have received vaccination.                                                             need for pre vaccination of some people

                                                                                           in order to respond to an attack and the
During the eradication program, the WHO

                                                                                           purchase of sufficient vaccine should it
made concerted efforts to decrease the

                                                                                           become necessary to vaccinate large
number of laboratories retaining variola

                                                                                           numbers of people. In Canada 365,000
virus. By 1984, only the Centers for
                                                                                           doses of smallpox vaccine are held by

Disease Control and Prevention (CDC) in
                                                                                           Health Canada in a secure location.

the United States and the Research
                                                                                           Vaccine is not available through any
Institute of Viral Preparations in Moscow

                                                                                           private organization or company (i.e.
were known to retain variola virus isolates.

                                                                    pharmacies) or through public health. The federal government
In 1994, the Russian isolates were moved to the Research
                                                                    recently announced plans for Canada to obtain a further 10
Institute of Viral Preparations and Biotechnology (the Vektor

                                                                    million doses of smallpox vaccine that can be diluted to ensure
Institute) in Novosibirsk, Russia. After the anthrax bioterror

                                                                    vaccine for all 30 million Canadians should the need arise.
incidents in the US in 2001, renewed concern arose that
                                                                    Health Canada will also hold this vaccine. In addition, Health
variola virus could reside outside these laboratories and that it

                                                                    Canada has announced a plan to vaccinate a small number of
could be used as a weapon by terrorists. Possible sources are
                                                                    people across the country pre-event who would then be part of

virus in countries who claim to have destroyed their stocks and
                                                                    a smallpox response team available to respond should a case
virus acquired from laboratories in the former Soviet Union.                                                                            T
                                                                    of smallpox appear in Canada. No details have yet been              T
Reports from the US indicate both Iraq and North Korea may
                                                                    released about who these people would be or what their

possess smallpox stores. The US has therefore committed to
                                                                    relationship will be to local public health units in Canada.

purchasing enough smallpox vaccine to vaccinate its entire

population and has been developing extensive plans for              Toronto Public Health is developing plans for mass vaccination
surveillance and vaccination should a case be identified. The       and surveillance for smallpox and is working closely with the

US government has also started vaccinating several million          Ontario Ministry of Health and Long-Term Care and Health

military personnel, healthcare workers and first responders         Canada to ensure our plans are compatible and that we will be

before any event occurs. In Israel, vaccination of healthcare       able to link quickly and effectively should the need arise. For
workers, first responders and the military began in the summer      more information about smallpox vaccine or smallpox
of 2002. Neither country has plans to vaccinate the general         contingency planning contact Dr Bonnie Henry, Associate
population at this time, although the US may consider               Medical Officer of Health at 416 338-7267 or
voluntary vaccination of the public starting in 2004.     
Female Condom works                                      intercourse. Counselling should include:
                                                         review of female anatomy; assessment of
Marketed under the name Reality, the                     comfort level regarding vaginal insertion;
female condom has been available in                      demonstration and information on
Canada since 1994. However, there has                    insertion techniques; offering of insertion
been some concern about its acceptability                check; advice to practise insertion prior to
and accessibility since few Canadian                     use with a partner; availability of the
women use the female condom.                             health care provider to provide support.
Community agencies that currently
                                                         We found that women at risk for
receive male condoms from Toronto
                                                         unplanned pregnancy and sexually
Public Health (TPH) began asking TPH to
                                                         transmitted disease, including HIV,
also provide them with female condoms.
                                                         increased their use of male and female                                                Ea
                                                                                                                                                           y ea r
Given the rates of chlamydia, gonorrhoea                                                                                                            us w
                                                                                                                                                           i ll h
                                                                                                                                                                    av e a
                                                                                                                                                                             i n Tor
                                                                                                                                                                                                     o nto, 2 0 , 0 0 0 o f
                                                         condoms by 20% after receiving an                                                               a nd
                                                                                                                                                                       0 of u
                                                                                                                                                                                n u np l
                                                                                                                                                                                   s w i ll g e
                                                                                                                                                                                               a nn e d p r e g n a n c y

and HIV in women and an increase in
                                                                                                                                                           t ra n
                                                                                                                                                                    s mit
                                                                                                                                                                                                     t a s e x u a ll y
                                                                                                                                                                            te d d i
                                                                                                                                                                                       sease , i n
                                                                                                                                                             HIV.                                    cluding
                                                                                                                                                                       I t ' s ti m

                                                         education and counselling intervention
                                                                                                                                                                                        e w e took
                                                                                                                                                                c o nt r
                                                                                                                                                                           ol . G i v
                                                                                                                                                                                        e y ou r
                                                                                                                                                            v agin
perinatal HIV transmission, TPH, in                                                                                                                         c h oi ce .
                                                         and free male and female condoms. After
partnership with several community
                                                         the intervention, half of our sample of 117
agencies, conducted a pilot project
                                                         women used either a male condom or a
between October 2001 and March 2002                                                                               Clients who may benefit from male or
                                                         female condom during at least 80% of
to assess the factors associated with                                                                             female condoms but who are unable to
                                                         sexual intercourse acts. Over two-thirds of
successful female condom use.                                                                                     afford them can call the AIDS and Sexual
                                                         our sample prefer the female condom
In order for women to use the female                     alone or as an option along with male                    Health Infoline at 416-392-2437. For
condom effectively, they need health                     condoms. The female condom appears to                    information, contact Barbara Macpherson,
education or counselling and the                         be an acceptable option, along with the                  Health Education Consultant, AIDS/Sexual
opportunity to practise inserting the                    male condom, to protect women’s                          Health, at 416-338-0904 or
condom before they use it for sexual                     reproductive and sexual health.                

Acupuncture                         Cont’d from page 1                                                  Contact Information
clients be assessed. TPH obtained client lists from the                               Reportable/communicable diseases for all areas of Toronto should be reported to
acupuncturist. A total of 149 clients were identified, involving eight                our central Communicable Disease Surveillance Unit at:
public health units in Ontario. All clients were called by their local
                                                                                      CDSU, 277 Victoria St., 4th Floor
health unit and were sent an information package advising them of                     Toronto, ON M5B 1W2
the risk and recommending they see their family physician to be                       Phone: 416-392-7411        After hours: 416-690-2142
tested for hepatitis B, C and HIV and checked for signs of                            Fax: 416-392-0047
Mycobacterium abscessus skin infection. Physicians should be                          To order Hepatitis B Vaccine, please call:
alert for unusual, nodular lesions at acupuncture sites. These                        North Region – 416-338-8400 South Region – 416-338-7790
lesions can become swollen, red and painful and may require                           East Region – 416-338-7492 West Region – 416-338-1521
draining. If you have a patient who received acupuncture and may                      To report vaccine adverse events, please call:
be suffering from these lesions please contact Dr Michael                             Vaccine Preventable Disease Immunization Information Line 416-392-1250.

Finkelstein, Associate Medical Officer of Health, at 416 338-2489.                    For information about STDs or to order medications for treatment please call:
                                                                                      STD Program at 416-338-2373.
Acupuncture is not a regulated health profession in Ontario so
there are no requirements for training or regulations for practice                    For information about TB or to order medications for treatment of TB, please call:
                                                                                      TB Program at 416-392-7420.
such as there are for physicians, chiropractors, physiotherapists
and many other health professions. Physicians should advise                                                         Communiqué
patients who receive acupuncture to ensure that the acupuncturist                                                     Editor: Dr Barbara Yaffe
uses only disposable needles and maintains them in a sterile                            Staff contributors: Dr. Bonnie Henry, Dr. Michael Finkelstein, Deborah Hardwick
                                                                                                 External review: Dr. Lee Ford Jones, Hospital for Sick Children
manner prior to inserting them into the skin. For more information
                                                                                                            To give us your comments, please contact:
on acupuncture and ‘safe needling’ please refer to our web site at                           Dr. Barbara Yaffe at 416-392-7405 or Dr. Rita Shahin at 416-338-7924 Anyone who has concerns about the                                                          or email:
practice of acupuncture should contact their local Health Unit. In                               Mailing Address problems, contact: Anne Hillmer 416-392-1494
Toronto call TPH at 416-338-7600.                                                                                  or email:
                                                                                                              For electronic copies of Communique:
1 Woo P, Leung K, Wong S et al. Relatively alcohol-resistant mycobacteria are             (A-Z listings, Physician’s Newsletter)
emerging pathogens in patients receiving acupuncture treatment. 2002. J Clin Micro.

2 Camargo D, Saad C, Ruiz F, et al. Iatrogenic outbreak of M. chelonae skin
abscesses.1996. Epidemiol. Infect. 117:113-119.

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