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Archive for February, 2014

Health Alert – Pertussis found in Canyon County

Tuesday, February 18th, 2014

Southwest District Health
13307 Miami Lane ♦ Caldwell, Idaho 83607 ♦ (208) 455-5300 ♦ FAX (208) 454-7722

HEALTH ALERT
FOR IMMEDIATE RELEASE For more information, contact:
FEBRUARY 14, 2014 Southwest District Health at (208) 455-5442
Officials warn of Pertussis increase in Canyon County
Southwest District Health is reporting an increased number of pertussis cases this month. Case investigations are ongoing, but early results demonstrate a number of confirmed and probable cases amongst elementary and middle school-aged children in Canyon County. We believe that you, the health care professionals, will potentially see more patients with suspected pertussis in the coming days.
Due to the highly infectious nature of pertussis and the potential for further spread, Southwest District Health urges health care providers to maintain a heightened degree of suspicion for pertussis and to test and treat patients with clinically-compatible illness.
Clinical Manifestations
 Pertussis begins with 1-2 weeks of mild upper-respiratory tract symptoms similar to the common cold (catarrhal period).
 Fever is usually minimal if present.
 With classic pertussis, the catarrhal period is followed by several weeks or months of paroxysmal cough, inspiratory whoop and post-tussive vomiting. Paroxysmal cough is often worse at night. Persons may not seem significantly ill between paroxysms.
 Adults and adolescents infected with pertussis often go undiagnosed due to mild illness without classic pertussis symptoms and are often the source of infection for infants and young children.
 Infants may have atypical disease with apneic spells and minimal cough or other respiratory symptoms. Infants are at highest risk for acquiring pertussis-associated complications such as pneumonia, seizures, encephalopathy, and death.
Laboratory Testing
Southwest District Health recommends that PCR testing be performed on all suspected cases of pertussis. Pertussis PCR testing requires a nasopharyngeal swab or aspirate collected from the posterior nasopharynx. The specimen should then be placed in a sterile tube without medium and refrigerated for transport to the laboratory. PCR testing for pertussis has optimal sensitivity during the first 3-4 weeks of coughing, and within 5 days of antibiotic therapy initiation. PCR has excellent sensitivity and provides rapid results compared to traditional culture methods. More information about specimen collection and testing is available by calling Southwest District Health Department, or by visiting the CDC website at: http://www.cdc.gov/pertussis/clinical/diagnostic-testing/diagnosis-confirmation.html.
Transmission
Pertussis is a highly communicable disease with an 80% secondary attack rate among susceptible household contacts. Pertussis is transmitted from person to person via aerosolized droplets produced from a cough or
sneeze or by direct contact with respiratory secretions of an infected person. The incubation period for pertussis is 5-21 days. Postexposure prophylaxis should be administered to asymptomatic household contacts regardless of immunization status within 21 days of the index case’s onset of cough. Coughing (symptomatic) household members of a pertussis patient should be treated as if they have pertussis.
Pertussis cases are no longer contagious after five days of appropriate antimicrobial therapy or 21 days after cough onset, whichever comes first. Close contacts can be administered postexposure prophylaxis to prevent secondary cases.
* Close contacts are defined as:
 Direct face-to-face contact, within 3 feet, for a period (not defined) with a case-patient who is symptomatic
 Shared confined space in close proximity for a prolonged period of time such as >1 hour, with a symptomatic case-patient
 Direct contact with respiratory, oral, or nasal secretions from a symptomatic case-patient
Treatment and Postexposure Prophylaxis Details
The following table is an excerpt from American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012. http://aapredbook.aappublications.org/content/1/SEC131/SEC237/T86.expansion.html
Table 3.44 Recommended Antimicrobial Therapy and Postexposure Prophylaxis for Pertussis in Infants, Children, Adolescents, and Adultsa
Age Group
Recommended Drugs
Alternative
Azithromycin
Erythromycin
Clarithromycin
TMP-SMX
Younger than 1 month
10 mg/kg/day as a single dose for 5 daysb
40 mg/kg/day in four divided doses for 14 days
Not recommended
Contraindicated at younger than 2 months of age
1-5 months
10 mg/kg/day as a single dose for 5 daysb
40 mg/kg/day in four divided doses for 14 days
15 mg/kg/day in 2 divided doses for 7 days
2 months of age or older: TMP 8 mg/kg/day; SMX 40 mg/kg/day in 2 doses for 14 days
Infants (aged > 6 months) and children
10 mg/kg as a single dose on day 1 (maximum of 500 mg), then 5 mg/kg/day as a single dose on days 2-5 (maximum 250 mg/day)
40 mg/kg/day in 4 divided doses for 7-14 days (maximum 1-2 g/day)
15 mg/kg/day in 2 divided doses for 7 days (maximum 1 g/day)
2 months of age or older: TMP 8 mg/kg/day; SMX 40 mg/kg/day in 2 doses for 14 days
Adolescents and adults
500 mg in a single dose on day 1, then 250 mg as a single dose on days 2 through 5
2 g per day in 4 divided doses for 7-14 days
1 g per day in 2 divided doses for 7 days
TMP 320 mg per day, SMX 1,600 mg per day in 2 divided doses for 14 days
TMP indicates trimethoprim; SMX, sulfamethoxazole.
a Centers for Disease Control and Prevention. Recommended antimicrobial agents for the treatment and postexposure prophylaxis of pertussis: 2005 CDC guidelines. MMWR Recomm Rep. 2005;54(RR-14):1–16
b Preferred macrolide for this age because of risk of idiopathic hypertrophic pyloric stenosis associated with erythromycin.
Prevention of Pertussis
The best way for children, adolescents, and adults to prevent pertussis is to be fully immunized. Immunization recommendations and schedules can be found on CDC’s website at: http://www.cdc.gov/vaccines/schedules/hcp/index.html
Reporting Pertussis Cases
All suspect and confirmed cases of pertussis are reportable within 1 working day. Physicians, hospital & health care facility administrators, laboratory directors, and school administrators are required to report even suspect cases.
Southwest District Health confidential reporting fax: (208) 455-5350
Southwest District Health confidential reporting phone line: (208) 455-5442
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Healthcare Delivery Needs Changing

Monday, February 3rd, 2014

John Kaiser, MD

Saltzer Medical Group has a long history of providing the best care possible for our patients. Dr. Joseph Saltzer started the group more than 50 years ago with the goal of bringing much-needed care to the residents of Canyon County, offering primary and specialty care and forging strong and lasting relationships with our friends, colleagues, and patients.
Our decision to seek an alignment strategy with St. Luke’s came out of the recognition that a close affiliation was the best way to achieve the changes we thought were necessary to address the future. The model of healthcare delivery we were engaged in has been fragmented and focused on the fee-for-service model of care that Judge B. Lynn Winmill, in his recent ruling, cited as being “the leading factor in increasing health care costs.” St. Luke’s has made significant strides in developing a model for the future to achieve the goals of better health, better care, and lower cost.
With the alignment, we started working with St. Luke’s on adopting this model. We believe health care must change. The movement across the entire country has been to find ways to improve care and reduce cost and is part of the law implemented through the Affordable Care Act.
In his written decision, Judge Winmill said that “St. Luke’s is to be applauded for its efforts to improve the delivery of health care in the Treasure Valley,” and that “The Acquisition was intended by St. Luke’s and Saltzer primarily to improve patient outcomes. The Court is convinced that it would have that effect if left intact.”
Judge Winmill also stated that changes in healthcare delivery must occur; we agree, and felt this was the best way to achieve these needed changes in our community.
Unfortunately, the decision will delay or possibly prevent us from being at the forefront of improving health care for our beloved patients in the Treasure Valley. Saltzer has always been dedicated to caring for our patients’ health and we have prided ourselves in placing our patients first. We have never been afraid of taking risks to provide that care.
We hope we can overcome this decision by the court and be a part of the changes we feel are necessary for the future, but we are concerned that the decision, if upheld in the appeals process, will require us to focus back on the fee-for-service business and will prevent us from continuing the expanded care we have been able to provide for the underinsured patient population with St. Luke’s support. This is unfortunate, because caring for patients in the lower-cost office environment is significantly better than seeing these patients in the expensive emergency room setting where they otherwise wind up.

Every member of our team wishes to thank all of our patients who allow us the privilege of providing care for them, and every member of their families. We pledge to continue to seek ways to provide the best care we can. Our hope is that our efforts to continually improve that care will be recognized by the courts and government agencies as we move forward.

Dr. Kaiser is the President of Saltzer Medical Group

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