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. É 2. How effective is PCV7 at preventing ISP infections? Note: Always allow a minimum of 4 weeks duration between any two U doses of PCV7. Also, always allow a minimum of 6 weeks duration PCV7 is 95% effective at preventing vaccine serotype ISP Q between the primary series and additional doses. infections, as well as reducing acute otitis media (AOM) I episodes by 7 % and tympanostomy tube placements by 20%. 5. What are the contraindications for PCV7? N Preliminary studies have shown reduced nasopharyngeal PCV7 should not be given to children with an allergy to a U carriage of vaccine serotypes following PCV7 vaccination. component of the vaccine (diphtheria toxoid, yeast proteins, M 3. For whom is PCV7 recommended? aluminium phosphate). M 6. What are the side effects of PCV7? O PCV7 is licensed for use in children 6 weeks to 9 years of age. C 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? L 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 O pneumoniae vaccine for adults 65 years of age or older and immunocompromised, b) have sickle cell disease or c) suffer R others 2 years of age or older with a high risk of ISP infection. from functional or anatomical asplenia. T Polysaccharide vaccines do not protect infants and young N For more information: National Advisory Committee on children less than 2 years of age and have limited Immunization, Statement on the Recommended Use of O effectiveness in children 2 to 5 years of age (they may be used Pneumococcal Conjugate Vaccines. Canadian Communicable C 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. E 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 A In Canada, the last endemic case of smallpox was reported in of adverse reactions, including severe complications such as E 1946 and the last imported case occurred in 1962. Vaccination disseminated vaccinia and eczema vaccinatum as well as a S of the general population in Canada ceased in 1972 and was case fatality rate of 1 per million primary vaccinations. I stopped for healthcare workers in 1977 and military personnel Vaccination up to four days after exposure to an infectious D 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 E immunized prior to 1972 have adequate residual immunity to attack with smallpox and the high complication rate of the L prevent infection. It is likely, however, that the risk of severe vaccine, no country has recommended a return to universal B disease and death is reduced in persons vaccination. Debate primarily involves the A who have received vaccination. need for pre vaccination of some people C in order to respond to an attack and the During the eradication program, the WHO I purchase of sufficient vaccine should it made concerted efforts to decrease the N become necessary to vaccinate large number of laboratories retaining variola U numbers of people. In Canada 365,000 virus. By 1984, only the Centers for doses of smallpox vaccine are held by M Disease Control and Prevention (CDC) in Health Canada in a secure location. M the United States and the Research Vaccine is not available through any Institute of Viral Preparations in Moscow O private organization or company (i.e. were known to retain variola virus isolates. C 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 F million doses of smallpox vaccine that can be diluted to ensure Institute) in Novosibirsk, Russia. After the anthrax bioterror O 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 R 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 E 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 E possess smallpox stores. The US has therefore committed to relationship will be to local public health units in Canada. L purchasing enough smallpox vaccine to vaccinate its entire S 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 W US government has also started vaccinating several million Ontario Ministry of Health and Long-Term Care and Health E military personnel, healthcare workers and first responders Canada to ensure our plans are compatible and that we will be N 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. firstname.lastname@example.org. 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 ch 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 5,00 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 aa 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. email@example.com 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 www.toronto.ca/health. Anyone who has concerns about the or email: Rshahin@toronto.ca 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: firstname.lastname@example.org For electronic copies of Communique: 1 Woo P, Leung K, Wong S et al. Relatively alcohol-resistant mycobacteria are www.toronto.ca/health (A-Z listings, Physician’s Newsletter) emerging pathogens in patients receiving acupuncture treatment. 2002. J Clin Micro. PH0301RT004 40(4):1219-1224. 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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