Media attention given to the recent Ebola outbreak has overshadowed the fact that any number of communicable diseases can cause significant harm and death. Acute respiratory infections, such as pneumonia, and influenza are still the primary cause of infection-related deaths and in the top 10 leading causes of death in the United States. The overuse of antibiotics may be contributing to multidrug resistance of infectious diseases such as Staphylococcus aureus and Clostridium difficile, both of which kill thousands of people in the U.S. each year. In addition, weaknesses in vaccination programs, myths about potential harm from vaccines, and exemptions sought for a variety of reasons have all contributed to recent outbreaks of measles, an infectious disease that was previously declared eradicated in the U.S. Renewed attention is needed on infection control measures for primary prevention, improvements in vaccination programs, secondary prevention via screening for communicable diseases in the primary care setting, and efforts and care in the surveillance and reporting of communicable diseases.
Today in your outpatient, primary care practice you saw a 12-year-old male with an upper respiratory infection. His mother asked if he needed antibiotics and if his vaccinations were up to date. She was concerned because his school notified parents that a fellow student had been diagnosed with pertussis. Last night, you heard on the local news that not only had two children and one adult died from influenza in your medical center, but also that the 2014-15 influenza vaccine is not as effective this year against H3N2 viruses as in recent years. As a result, you are reminding everyone of preventive precautions such as hand washing, respiratory hygiene, and staying away from others when you are sick.
Last month, during your staff quality improvement meeting, a nurse said that your office practice reported 10 positive cases of chlamydia to your state’s communicable disease branch at the Department of Health and Human Services. These were predominately diagnosed during female pelvic screening exams. There were no new cases of HIV from the clinic’s screening program. The quality improvement nurse also reported that your clinic’s immunization rates in kindergarten physicals for the measles, mumps, and rubella vaccine (MMR) had improved from 97% to 99%, with less than 1% requesting exemptions since the summer of 2013 (when your community had a measles outbreak). Today, you are discussing what additional personal protective equipment your health care workers need at your outpatient clinic if a patient reports with a fever and answers “yes” to questions about recent travel to West Africa and/or potential exposure to Ebola.
What local, state, and national resources do you use to guide your practice with questions regarding these scenarios? What evidence-based resources are used for recommended vaccination and screening guidelines in primary care for communicable diseases? Are you required to report patients with signs and symptoms of pertussis, influenza, measles, mumps, rubella, positive chlamydia screening tests, or suspected cases of Ebola? If so, to whom do you report and within what amount of time? This continuing education article will focus on the following:
- Primary prevention of infectious diseases
- Secondary prevention: Screening for communicable diseases in primary care
- Surveillance and reporting of communicable disease in the United States and North Carolina.
Primary prevention of infectious diseases
Trends in infectious diseases. Preventing and controlling infectious disease outbreaks requires improving the resistance of the host (health of the individual, good hygiene, and vaccinations); intact public health environmental safety standards (sanitation and food/environmental safety); and having a strong public health system.1 People have always been surrounded by infectious microbes, but the morbidity and mortality burden of infectious disease in the United States decreased in the early 1900s prior to antibiotics and vaccines, mostly due to improvements in sanitation, hygiene, and safe drinking water.2 In low-resource countries such as Sierra Leone, Guinea, and Liberia in West Africa, infectious disease outbreaks such as Ebola continue to plague the population mainly due to poor sanitation, malnutrition, and a weak public health infrastructure. With the development of vaccinations and antibiotics, the burden of infectious disease declined further in the U.S. during the 20th century, yet pneumonia and influenza were still responsible for the largest number of infectious disease-related deaths.1,2
Rachel is a 7-year-old girl who presents to your clinic with a chief complaint of “fever and a rash.”
HPI: Her symptoms began a few days ago, after returning from a two-week-long vacation in California. Rachel complains of “feeling hot,” has a headache and sore throat, and is tired. Her mother states that she thought it was the flu, as her condition began with a high fever, cough, runny nose, and watery eyes: “Then her throat started hurting and this rash broke out on her body.” Sick contacts include her cousin in California who “had a cold.”
History: NKDA, medication—ibuprofen 200 mg p.o., given for a fever of 102°F with the last dose four hours ago. The patient has no history of hospitalizations, surgery, or chronic illness. Past childhood history is significant for varicella at age 6 years; her mother states, “We don’t believe in vaccines, so we had a chicken pox party.” Her last physical exam was the 5-year-old kindergarten physical, and the parents opted out of the recommended childhood vaccinations due to personal “religious belief.”
Vital signs: Temperature, 102°F orally; pulse, 100 beats per minute; respiration, 24 breaths per minute, unlabored; blood pressure, 90/60 mmHg.
She is alert, but clinging to her mother and coughing. Skin—a maculopapular rash on her entire body, small white spots in her red oral mucosal; coryza—clear nasal discharge and eyes; pupils equal, round, react to light, accommodation, with conjunctivitis bilaterally. Neck is supple with enlarged cervical lymph nodes. Lungs are CTA, heart RRR S1 S2. Abdomen is soft, nontender.
Assessment: You suspect a case of measles and ask the nurse to isolate her in the exam room and use airborne precautions. After making your initial assessment, treating the fever and the patient, you collect a throat swab and send out serum labs to include measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR).
What would be the most appropriate next step response to stop an outbreak in your community? You should notify the local health department if you suspect it is a possible measles infection within 24 hours.
Reflective question: How will you discuss vaccinations with your patients who “opt out” of recommended vaccines?