Updates
By Carol A. Kemper, MD, FACP
CDC update on polio vaccination for travelers
CDC Health Alert Network, June 2, 2014; Health Advisory Regarding Polio Vaccination. http/www.polioeradication.org/Portals/O/Document/Emergency/PolioPHEICguidance.pdf
For only the second time since 2005, the Director General of the WHO, under the authority of the International Health Regulations Act, has issued a directive for those traveling to or from countries endemic for polio, in order to stem the recent and somewhat alarming spread of disease. In reality, this directive is more of a "suggestion", as it is not clear at all how the governments of the countries involved will respond or are capable of enforcing the recommendations.
Presently, 10 countries are experiencing active transmission of wild-type polio virus (WPV), including Cameroon, Somalia, Nigeria, Ethiopia, Equatorial Guinea, Iraq, Israel, Afghanistan, Pakistan and Syria (Syrian Arab Republic). Travelers from 3 of these countries have recently been responsible for exporting WPV to another country — including travelers from Cameroon, Pakistan and Syria.
The recommendations are as follows:
• Travelers to polio-affected areas should receive oral polio vaccination or booster polio vaccination (IPV) prior to travel (only IPV is available in the United States);
• Residents or long-term visitor of > 4 weeks duration traveling from Pakistan, Cameroon, and Syria (responsible for exporting WPV) should receive oral polio vaccine or inactivated poliovirus vaccine (IPV) between 4-52 weeks prior to any travel;
• Those who must travel from these 3 countries with less than 4 weeks notice, and who have not received OPV or IPV within the past year, must receive a dose at least by departure;
• Residents and long-term travelers of > 4 weeks duration traveling from the remaining 7 countries should be "encouraged" to receive OPV or IPV within 4-52 weeks of travel, or at least by the time of departure.
• These recommendations will remain in place for the above countries for at least 6 months following improved control of WPV transmission and no further exportation of disease.
The booster should be documented on the yellow International Vaccine Certificate of Vaccination.
Washington state: Not just for apples?
CDC. Notes from the field: Coccidioides immitis identified in soil outside of its known range Washington, 2013. MMWR 2014;63(20):450.
Coccidioidomycosis ("Valley fever") is acquired from a narrow strip of hot, dusty earth, commonly called the "Sonoran Life Zone", roughly stretching south of Fresno down the San Joaquin Valley of California, to the more arid portions of the Southwestern United States, parts of Texas, and northern Mexico (C. immitis), as well as occasional cases occurring in South America (C. posadasii). My late friend, Dr. Richard Tucker, who held down the infectious disease turf in Wenatchee Washington for many years, saw more cases of cocci in "non-cocci country" than I ever did in San Jose migrants would come up the California central valley, picking strawberries and lettuce, and by the time they arrived in central Washington to pick apples in the fall, they had developed symptomatic infection. Similarly, many of his older patients would winter in Arizona or New Mexico and return to Wenatchee in the spring with active cocci. He referred to these as his "snow bunny" cases.
Three cases of acute coccidioidomycosis occurring in south central Washington State in 2010-2011 did not, however, fit these descriptions and none of the 3 patients had been to areas of risk for at least 22 months, well outside the usual window for exposure. Given the atypical presentation, the cases prompted further investigation and soil samples in areas where the patients had fallen or played, adjacent to animal burrows or snake holes, near a residential complex were collected. In addition, soil samples from a road frequented by all-terrain vehicles were collected — and banked — as there was no good way at the time to test the samples for cocci.
Three years later, newer PCR technologies for detecting C. immitis DNA, developed by the Translational Genomics Research Institute, became available. Six of 22 soil samples yielded Coccidioides DNA. Viable C. immitis was isolated from 4 of these 6 samples using a modified yeast extract medium. Whole genomic sequencing demonstrated homology between one of the patient isolates and the soil isolates. The Washington State soil isolates were both viable and had obviously resulted in active disease in humans.
STDs surge, young men lack a healthy fear’
ProMED-mail post. June 2, 2014; www.promedmail.org
Just as cell phones have transformed commerce in rural Africa, cell phones apps have transformed sex in the United States. Alaska reports a 60% increase in cases of syphilis from 2012 to 2013 — all in men, and Oregon recently reported an 18% jump in cases of gonorrhea. San Francisco County has recorded spikes in all STDs for the past six years — and the number of early syphilis cases rose from 659 in 2010 to 682 in 2011 (the last year for which unofficial numbers are available). It is estimated that each new cases of syphilis results in, on average, exposure to 10 additional people.
And, as mentioned in the May issue of IDA, we’ve observed similarly alarming trends in the frequency of STDs in MSM newly presenting or returning for care to our Santa Clara County-based HIV/AIDS Clinic. In calendar year 2013, 500 MSM were screened for GC/Chlamydia using nucleic acid amplification (NAAT) (using the APTIMA GenProbe Unisex swab testing kit) (informal data, Wilson Ly, PharmD.). The patients did self-swabbing of 2 sites (oral and rectum), under the supervision of the HIV Pharmacy Specialist, who assists with the initial intake visit, and urine samples were collected. Overall, 14% of cultures from all sites were positive for at least one organism. The highest prevalence of GC was 11% in the oropharynx; and the highest prevalence for Chlamydia was 23% from the rectum. Most of these infections were asymptomatic.
This resurgence of STDs may be largely attributed to the availability of internet hook-ups and networking mobile smartphone apps, such as Grindr, Tinder, and GROWLr, as well as the increased use of methamphetamines, and what is euphemistically termed "prevention fatigue". As one man phrased it, younger people who did not live through the AIDS crisis in the 1980s and 1990s lack "healthy fear."
Grindr is a gay social networking application launched in 2009 and available worldwide — it runs on the iPhone, blackberry and Android. Using GPS technology, the app allows users to meet other men within close proximity who are interested and available for whatever specified sexual activity using the phones mobile location services — we tried it in our Santa Clara county HIV clinic the other day and someone was available and interested in having sex not more than 75 feet away — they were in the same building!
What can be done to stem this rising tide of STDs?
Pubic lice finding fewer landing strips’
Dholakia S, et al. Pubic lice: An endangered species? Sexual Trans Dis 2014;41:388-391.
These British investigators noted a continued decrease in cases of pubic lice in their unit, which they hypothesized may be due, in part, to the increased popularity of pubic hair removal. While I admit to having seen many a case of "crabs" while moonlighting in the ER in the 1990s, I am unable to recall seeing a case of pubic lice in more than decade. Granted, I am no longer on the front lines, but I do provide primary care to 150 HIV+ men and women, and cases of syphilis are a dime a dozen these days.
The incidence of pubic lice is estimated to be 1.3% to 4.6%, with an average world-wide incidence of about 2%. But over the past 10 years, the incidence of pubic lice in Buckinghamshire fell from 1.8% to .07%, with only 17 cases recognized in 2013.
Concurrently, the frequency of pubic hair removal seemed to be increasing.
The authors conducted an anonymous survey of 500 randomly selected clinic visitors every year for 10 years. A total of 3850 surveys were returned. The average age of respondents was 24 years. During the 10-year period, a clear shift in practices towards pubic hair removal was observed: partial or total removal of pubic hair increased from 33% to 87.5%. Only 12.5% of respondents "went native". Total removal of all pubic hair increased from 24% to 56% — meaning the majority of younger folks attending the clinic had gone "Yul Brynner." Shaving was the most common means of hair removal (70%), followed by waxing and laser. The only reasons provided for this practice were appearance and hygiene.
There was a strong inverse linear correlation between the declining incidence of pubic lice and hair removal. Hair removal was somewhat more frequent in women than men (data not provided), although the practice was also gaining in popularity amongst men. The authors suggest the observed shift in frequency of pubic lice in men compared with women may be because the practice is not quite as common yet in men.
Maybe these youngsters are onto something? Just think, if there was a world-wide annual pubic hair shaving week, pubic lice might truly become extinct. Too bad it doesn’t work for other STDs.
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