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Wisconsin Immunization Program- Urgent Measles Information 4.19.17
The Infection Prevention Council co-chairs are sharing a recent alert sent from Wisconsin Department of Health Services with regards to the current Measles situation in Minnesota. It is important that all Ascension Wisconsin clinicians are aware of the situation, the necessary precautions and testing requirements for suspect cases in our facilities. 
Please review the attached information.
Thank you.
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DPH Information Update
Wisconsin Immunization Program
The Minnesota Department of Health announced on Friday April 14, 2017 five new cases of measles in Hennepin County, bringing the total number of cases to eight. Hennepin County includes the Minneapolis-St. Paul-Bloomington, MN-WI metropolitan area. The cases are in unvaccinated children ages 1-4 years and seven of the cases are Somali Minnesotan.
Local health departments and tribal clinics should work with health care providers in their jurisdiction to raise awareness about the disease and take immediate steps if there is a suspected or confirmed case.
This email contains information about reporting, symptoms, transmission, specimen collection and testing, isolation, and resources. However, for further guidance on these topics, please see the DPH measles website.

All measles cases-suspected or confirmed- must be reported to the Wisconsin Division of Public Health. Measles is a Wisconsin Disease Surveillance Category I disease. Health care providers who have patients with suspected or confirmed measles should report immediately by telephone to the patient’s local health department. The local health department shall then notify the state epidemiologist immediately calling 608-258-0099. In addition to calling, within 24 hours, LHDs should submit a complete case report electronically through the Wisconsin Electronic Disease Surveillance System (WEDSS). For additional details and reporting forms, please visit the Wisconsin Division of Public Health Measles’s webpage

Symptoms include a rash with flat, red spots and fever and cough or runny nose or watering/mattering eyes. Symptoms appear about eight to 12 days after a person is exposed to measles. The first symptom is usually fever and the rash usually appears two to three days after the fever begins. The rash begins at the hairline, moves to the face and upper neck, and then down the body. This rash pattern is sometimes called a “bucket of measles” because the rash pattern appears as if someone poured a bucket of water over the head of the patient. For photos of the rash, please visit the CDC website (warning-some of the photos may be disturbing to some viewers).
Measles can be a serious disease that can lead to hospitalizations and even death, especially for immunocompromised patients. Many people infected with measles have complications such as diarrhea, ear infections, pneumonia or acute encephalitis. Measles during pregnancy increases the risk of complications such as premature labor and miscarriages. For additional information on symptoms or complications, please visit the Centers for Disease Control and Prevention (CDC) website.

Measles is a highly infectious virus that is spread when an infected person coughs or sneezes. The virus can live for up to two hours in the airspace where the infected person coughed or sneezed. Measles is so contagious that if one person has it, 90% of the people close to that person who are not immune will also be infected. The CDC website has additional information on measles transmission.

Specimen Collection and Laboratory Testing
The Wisconsin State Laboratory of Hygiene (WSLH) Measles Specimen and Laboratory Testing Customer Service phone number is 1-800-862-1013.
Both specimens listed below should be collected for testing on a symptomatic individual:
  • Combined Throat and Nasopharyngeal Swab:
As soon as measles is suspected (preferably within the first 3 days of illness, but no later than 10 days after rash onset), collect a throat swab AND a nasopharyngeal swab, combined in the same vial of virus transport medium. Synthetic swabs (e.g., Dacron) are required for specimen collection. Do not use cotton or calcium alginate swabs as they may be inhibitory to enzymes used in PCR. Place both swabs in a single tube of virus transport medium is acceptable. Maintain specimen at refrigerator temperature prior to and during transport.  The test to order: PCR 
  • Acute Serum:
As soon after onset as possible, collect 7-10 mL of blood in a red top or serum separator tube (SST). Store specimens at refrigerator temperatures. Transport at refrigerator temperatures using cool-packs. A repeat serum specimen should be collected and tested if IgM serology testing is negative for specimens collected within 72 hours of rash onset. The test to order: IgM serology.
WSLH typically does not test over the weekend. The State Immunization Program can request testing be done if it is determined to be critical for case surveillance. The local health department should be in communication with the State regarding feasibility. This is also dependent upon the specimen arriving in a timely manner which is paramount to ensure timely testing.

Isolation of a Person with Measles and their Contacts 
1.     Implement control measures before laboratory confirmation. If the laboratory results are negative, the decision to continue control measures should be made in consultation with the treating physician, the local health department, and the DPH.
2.     Exclude and isolate the case-patient during his/her infectious period from 4 days before through 4 days after rash onset, counting the day of rash onset as day zero. He/she may return to normal activities on the fifth day after rash onset.
3.     Exclude susceptible contacts until 21 days after rash onset in the final case. If vaccinated within 72 hours, patient may return to normal activities.
·       Please see Surveillance and Control Guidance (P-00892) for additional specimen collection and laboratory details.
·       For information on ACIP’s recommendation for vaccination of health care professionals against measles.
·       For information on routinely recommended vaccines, please visit the CDC vaccine schedule page

Resources for patients and the public
MMR vaccine: What you should know. A resource for parents on routine MMR vaccine administration.
Parents and patients may view their vaccine record through the Wisconsin Immunization Registry. For more information, visit the Immunization Program website.
The Immunization Action Coalition (IAC) has multiple language translations, including Somali, of the MMR and MMRV vaccine information statements here: http://www.immunize.org/vis/vis_somali.asp  
The Wisconsin Immunization Program recently updated the measles disease fact sheet to be more visually appealing and uses patient-friendly language. The fact sheet is currently being translated into Hmong and Spanish and will be available on the Immunization Program website in the next few weeks.
For parents/patients who have concerns around the disproven idea that MMR vaccine causes autism, the Autism Science foundation has information to help address parents’ concerns: http://autismsciencefoundation.org/ and the link to autism/immunizations page: http://autismsciencefoundation.org/what-is-autism/autism-and-vaccines/.
The Mayo Clinic developed You Tube videos that address vaccine hesitancy in Somali language. https://www.youtube.com/watch?v=mcsdreBpODI&feature=youtu.be
Thank you for your attention to this matter. If you have any additional questions or concerns, please visit the Wisconsin Immunization Program measles website or call your Regional Office Staff (scroll about halfway down the page).
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Guidelines for enhanced surveillance and testing for novel avian influenza A/H7N9 virus in Wisconsin

Health care providers,

Please see the attached letter from the Division of Public Health. Public health officials should consider H7N9 virus infection as a possible etiology among travelers returning from China with severe respiratory illness, especially if they have exposure to poultry. Influenza A H7N9 PCR testing can be performed on a fee-exempt basis by the Wisconsin State Lab of Hygiene, however, must be pre-approved by the Wisconsin DPH (608)266-5326 or (608)258-0099 (after hours). Approval paperwork must accompany the specimen STATto the Columbia-St. Mary’s laboratory who will send it out for testing. The order should be placed as a “Miscellaneous Lab test” and the specimen of choice for submission is: One oropharyngeal (throat) swab and one nasopharyngeal (NP) swab in the same vial of viral transport medium (VTM). Please call the above number or myself if you have any more questions regarding this matter.   
Your help is greatly appreciated,
Eric Lenz MT (ASCP)
Molecular Microbiology/Immunology
Technical Specialist
Ascension | Columbia St. Mary’s
2323 North Lake Drive
Milwaukee, WI 53211
Ph: 414.585.1935
Fax: 414.585.1129
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Zika virus update

Dear Healthcare providers,

The W.H.O. ended the Zika public health emergency in November, however, Zika still remains a threat to public health and the effects from this outbreak will be long-lasting. As of January 25th, 2017 Wisconsin has had a total of 60 confirmed travel associated Zika virus cases. Even though it’s not mosquito season in our region, it is important to remember that Zika is still being transmitted in areas of the U.S. and internationally. Please continue to ask your patients about plans to travel and travel history at every encounter and provide the appropriate counseling. For a list of updated Zika affected areas, please visit: https://www.cdc.gov/zika/geo/index.html.
Please see below for more Zika updates and guidance:
•       Zika Virus – 10 Public Health Achievements in 2016 and Future Priorities: https://www.cdc.gov/mmwr/volumes/65/wr/mm6552e1.htm?s_cid=mm6552e1_e
•       Zika virus testing: For pregnant women who may have been exposed to Zika 2-12 weeks ago: https://www.cdc.gov/zika/pdfs/igm.pdf  
•       Zika virus testing: For pregnant women who have been exposed to Zika within the past 2 weeks: https://www.cdc.gov/zika/pdfs/pcr.pdf  
If you suspect a patient has Zika Virus infection, immediately report to the City of Milwaukee Health Department or local health department of the jurisdiction for the residence of the patient. For the City of Milwaukee, call SurvNet during business hours at 414-286-3624, or after hours at 414-286-2150 or 608-267-9003. Send serum and urine specimens along with approval paperwork to Ascension - Columbia St. Mary’s Laboratory for testing.
Thank you,
Milwaukee SurvNet
841 N Broadway
Milwaukee, WI 53202
Phone: (414) 286-3624
Fax: (414) 286-0280
Email: SurvNet@milwaukee.gov
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