Archive for August 23rd, 2008

OMNI Postings of 8/23/08

by Paul Rega, MD — published on August 23rd, 2008
Well, have you heard that the IOC wants another investigation into the charges that some of the Chinese gymnasts were underage?  Committee members tried to interview a number of the Chinese trainers, but they were busy breast-feeding and diaper-changing a couple of their gold-medal athletes.
But I digress…
1)  There is an association between homocysteine concentration and risk of cardiovascular disease.  It’s been shown that folic acid and the B vitamins can lower homocysteine.  So, can the vitamins have a positive impact on cardiac deaths?  This trial (abstract in the link) did not find an effect of treatment with folic acid or the B vitamins on total mortality or cardiovascular events. Their findings, published in the recent JAMA, did not support the use of B vitamins as secondary prevention in patients with coronary artery disease.
2)  As a result of all the politicians biting and scratching each other in this election year, the rabies vaccine supplies are low.  This is coming from the CDC.  The recommendation (8/22) to local public health is that, when there may be a case for rabies prophylaxis, the treating physician discuss the case with public health before the prophylaxis is carried out.  If this is going to happen in NW Ohio (I suggest you check with Infection Control at your hospitals), then we’ll have to follow some protocol before administering the vaccine.  In this posting, there is a link to the MMWR recommendations about rabies prophylaxis which you should download for easy reference.
3)  Researchers believe that codeine, given to some Moms, may be unsafe to babies being breast-fed.  Some individuals have a genetic variance which causes them to metabolize codeine at a rapid rate, producing significantly more morphine in their system than most of the population. While this genetic predisposition is rare, women who possess it and who take codeine for pain while breastfeeding can end up exposing their babies to high levels of morphine through their breast milk. This can cause babies to experience central nervous system depression as a result. 
4)  This is a MMWR article about the upsurge of measles in this country this year.  We’re only talking about 131 cases, but the average the previous 6 years has been 63.  Of the 131 cases, 89% were imported from or associated with importations from other countries, particularly countries in Europe, where several outbreaks are ongoing. 
Bye for now,
Paul R

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categories: Emergency Medicine

Folic acid/B vitamins on cardiovascular mortality

by Paul Rega, MD — published on August 23rd, 2008

JAMA. 2008;300(7):795-804.

Mortality and Cardiovascular Events in Patients Treated With Homocysteine-Lowering B Vitamins After Coronary Angiography

ABSTRACT

Context  Observational studies have reported associations between circulating total homocysteine concentration and risk of cardiovascular disease. Oral administration of folic acid and vitamin B12 can lower plasma total homocysteine levels.

Objective  To assess the effect of treatment with folic acid and vitamin B12 and the effect of treatment with vitamin B6 as secondary prevention in patients with coronary artery disease or aortic valve stenosis.

Design, Setting, and Participants  Randomized, double-blind controlled trial conducted in the 2 university hospitals in western Norway in 1999-2006. A total of 3096 adult participants undergoing coronary angiography (20.5% female; mean age, 61.7 years) were randomized. At baseline, 59.3% had double- or triple-vessel disease, 83.7% had stable angina pectoris, and 14.9% had acute coronary syndromes.

Interventions  Using a 2 x 2 factorial design, participants were randomly assigned to 1 of 4 groups receiving daily oral treatment with folic acid, 0.8 mg, plus vitamin B12, 0.4 mg, plus vitamin B6, 40 mg (n = 772); folic acid plus vitamin B12 (n = 772); vitamin B6 alone (n = 772); or placebo (n = 780).

Main Outcome Measures  The primary end point was a composite of all-cause death, nonfatal acute myocardial infarction, acute hospitalization for unstable angina pectoris, and nonfatal thromboembolic stroke.

Results  Mean plasma total homocysteine concentration was reduced by 30% after 1 year of treatment in the groups receiving folic acid and vitamin B12. The trial was terminated early because of concern among participants due to preliminary results from a contemporaneous Norwegian trial suggesting adverse effects from the intervention. During a median 38 months of follow-up, the primary end point was experienced by a total of 422 participants (13.7%): 219 participants (14.2%) receiving folic acid/vitamin B12 vs 203 (13.1%) not receiving such treatment (hazard ratio, 1.09; 95% confidence interval, 0.90-1.32; P = .36) and 200 participants (13.0%) receiving vitamin B6 vs 222 (14.3%) not receiving vitamin B6 (hazard ratio, 0.90; 95% confidence interval, 0.74-1.09; P = .28).

Conclusions  This trial did not find an effect of treatment with folic acid/vitamin B12 or vitamin B6 on total mortality or cardiovascular events. Our findings do not support the use of B vitamins as secondary prevention in patients with coronary artery disease.

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categories: Emergency Medicine

Churg-Strauss Syndrome

by Paul Rega, MD — published on August 23rd, 2008

 For full report go to:  http://www.medscape.com/viewarticle/579354

SUMMARY 

Background: A 36-year-old white male with a history of allergic rhinitis and sinusitis presented to the emergency room with abdominal pain and diarrhea. Physical examination revealed fever, hypoxemia and a maculopapular rash. Laboratory tests showed proteinuria, hematuria, leukocytosis, eosinophilia and an elevated erythrocyte sedimentation rate.
 

Investigations: Physical examination, urine and blood analysis and culture, chest radiography, chest and abdominal CT, esophagogastroduodenoscopy, skin and kidney biopsy, serology and renal ultrasound.
 

Diagnosis: Pauci-immune focal necrotizing glomerulonephritis with crescents and interstitial eosinophilia, consistent with Churg-Strauss syndrome.
 

Management: The patient was treated with methylprednisolone 1 g/day intravenously for 3 days. He also received oral clotrimazole and combined oral sulfamethoxazole and trimethoprim for prophylaxis against candidiasis and pneumonia, respectively. He left the hospital against medical advice and was lost to follow-up.

DISCUSSION on Churg-Strauss

Churg-Strauss Syndrome

The syndrome of “allergic granulomatosis and angiitis” was first described in 1951 by Churg and Strauss in a report of 13 autopsies.[1] The 1994 Chapel Hill Consensus Conference on the nomenclature of systemic vasculitides defined Churg-Strauss syndrome as a granulomatous inflammation involving the respiratory tract in combination with necrotizing vasculitis of both small-sized and medium-sized blood vessels, asthma and eosinophilia.[2] The incidence of Churg-Strauss syndrome in the general population is approximately 0.5-6.8 per million, the mean age at diagnosis is 48 years and the male to female distribution is 1:1.[3]

Churg-Strauss syndrome progresses via three successive stages: the ‘prodromal phase’, involving asthma and/or allergic rhinitis, with or without sinus polyposis; the ‘eosinophilic phase’, which is characterized by eosinophil infiltration into tissues such as the lungs, heart and gastrointestinal tract, with or without granulomas; and finally the ’systemic phase’, during which necrotizing vasculitis develops in the skin, kidneys and peripheral nerves.[3] This final phase usually occurs 3-4 years after the onset of asthma.[3]

The clinical presentation of Churg-Strauss syndrome is variable and can involve any organ system, but pulmonary involvement is the hallmark of Churg-Strauss syndrome, with asthma reported in 98% of cases and pulmonary infiltrates in 50% of patients.[3] Allergic rhinitis is reported in about 70% of patients. Neurologic manifestations, which include peripheral neuropathy, occur in about 50% of patients, and cardiac involvement, usually in the form of myocarditis or pericarditis, occurs in 60%. Gastrointestinal involvement is found in about 50% of patients, and symptoms range from abdominal pain and diarrhea to eosinophilic gastroenteritis, an irritable-bowel-syndrome-like condition.[4] Skin manifestations, most commonly palpable purpura, affect 40-70% of patients and can also include urticaria, maculopapular rash and subcutaneous nodules.[3]

Approximately one-third of patients with Churg-Strauss syndrome display renal involvement as indicated by a raised serum creatinine level; of these, about one-fifth have rapidly progressive renal failure (Table 1).[1,5-8] Patients with renal involvement usually present with nephritic urinary sediment, although nephrotic syndrome has also been reported.[3]

Laboratory evaluation in patients with Churg-Strauss syndrome often shows eosinophilia, but this finding is not universal.[9] Less-specific findings include normocytic anemia, elevated ESR and raised serum IgE levels.[9] ANCA, usually directed against myeloperoxidase, are found in only about 35-50% of patients with Churg-Strauss syndrome.[7,10-12] ANCA-negative patients usually present with eosinophilic tissue infiltration involving the heart and the gastrointestinal tract, whereas ANCA-positive patients tend to present with small-vessel vasculitis in the form of glomerulonephritis, pulmonary hemorrhage or mononeuritis multiplex.[11] This difference suggests that the pathogenic mechanisms of ANCA-negative and ANCA-positive Churg-Strauss syndrome are different.[7,10-12] However, the role of ANCA in the development of Churg-Strauss syndrome remains hypothetical at present (Figure 3).[10] In the ANCA-negative subset of patients, the pathogenesis of Churg-Strauss syndrome is thought to be mediated by cytotoxic products of eosinophils.[3,7,12]

Various diagnostic criteria are available for the classification of small-vessel vasculitis such as Churg-Strauss syndrome, but the most specific appear to be those formulated by the American College of Rheumatology (Box 3).[13] The presence of at least four of the six criteria indicates that Churg-Strauss syndrome is very likely to be the correct diagnosis (85% sensitivity and 99.7% specificity in the original sample of 20 patients reported by Masi et al.).[13]

The patient described here had both typical and atypical features of Churg-Strauss syndrome. In line with the American College of Rheumatology classification criteria, he had eosinophilia (albeit below the 10% threshold), pulmonary infiltrates, allergic rhinitis and sinusitis, and extravascular eosinophil infiltration of the skin and kidney. He also had urticaria, rash, gastrointestinal involvement, normocytic anemia and elevated ESR, all of which are commonly reported in patients with Churg-Strauss syndrome. Like most patients with renal involvement, he had a nephritic urinary sediment.

The patient presented with a maculopapular rash, which is a rare skin manifestation of Churg-Strauss syndrome.[3] The skin biopsy showed subepidermal vesicular dermatitis, which is consistent with dermatitis herpetiformis, a condition not previously reported in association with Churg-Strauss syndrome. Unlike some other cases, the patient had no neurologic manifestations. Most importantly, he displayed no asthma symptoms and exhibited ANCA-negative glomerulonephritis. Although the patient reported chronic cough, he denied a prior diagnosis of asthma or use of a β-adrenoceptor agonist inhaler. Fewer than 10 reported cases of Churg-Strauss syndrome have occurred in the absence of asthma.[9] Of the two that were associated with rapidly progressive glomerulonephritis, both were ANCA-positive.[14,15] We acknowledge that vasculitis might simply have preceded the onset of asthma in the patient described here. However, the finding of glomerulonephritis, a typical manifestation of ANCA-positive Churg-Strauss syndrome, questions the concept that the pathogenesis of the ANCA-negative disease differs from that of the ANCA-positive disease. As ANCA negativity has not previously been reported in the absence of asthma, we planned to repeat serologic testing for ANCA, but the patient was lost to follow-up.

Conclusions

Churg-Strauss syndrome is challenging to diagnose because of its highly variable presentation. Renal involvement is not universal and rapidly progressive glomerulonephritis is uncommon. This patient seems to be the first reported nonasthmatic case of ANCA-negative Churg-Strauss syndrome with necrotizing glomerulonephritis. The presence of glomerulonephritis in the absence of ANCA raises questions about the differences in the pathogenesis of ANCA-negative and ANCA-positive Churg-Strauss syndrome that have been postulated on the basis of differences in organ involvement.[10] Treatment of Churg-Strauss syndrome should be started early in the course of the disease, and poor prognostic factors should prompt the addition of cyclophosphamide to glucocorticoid therapy.

References

  1. Churg J and Strauss L (1951) Allergic angiitis and periarteritis nodosa. Am J Pathol 27: 277-301
  2. Jennette JC et al. (1994) Nomenclature of systemic vasculitides: proposal of an international consensus conference. Arthritis Rheum 37: 187-192
  3. Pagnoux C et al. (2007) Churg-Strauss syndrome. Curr Opin Rheumatol 19: 25-32
  4. Noth I et al. (2003) Churg-Strauss syndrome. Lancet 361: 587-594
  5. Shimamoto C et al. (1990) Churg-Strauss syndrome (allergic granulomatosis angiitis) with peculiar multiple colonic ulcers. Am J Gastroenterol 85: 316-319
  6. Guillevin L et al. (1999) Churg-Strauss syndrome: clinical study and long-term follow-up of 96 patients. Medicine (Baltimore) 78: 26-37
  7. Sablé-Fourtassou R et al. (2005) Antineutrophil cytoplasmic antibodies and the Churg-Strauss syndrome. Ann Intern Med 143: 632-638
  8. Sinico RA et al. (2006) Renal involvement in Churg-Strauss syndrome. Am J Kidney Dis 47: 770-779
  9. Sevinc A et al. (2004) Allergic granulomatosis and angiitis in the absence of asthma and blood eosinophilia: a rare presentation of limited Churg-Strauss syndrome. Rheumatol Int 24: 301-304
  10. Kallenberg CG (2007) Antineutrophil cytoplasmic autoantibody-associated small-vessel vasculitis. Curr Opin Rheumatol 19: 17-24
  11. Kallenberg CG et al. (2006) Mechanisms of disease: pathogenesis and treatment of ANCA-associated vasculitides. Nat Clin Pract Rheumatol 2: 661-670
  12. Sinico RA et al. (2005) Prevalence and clinical significance of antineutrophil cytoplasmic antibodies in Churg-Strauss syndrome. Arthritis Rheum 52: 2926-2935
  13. Masi AT et al. (1990) The American College of Rheumatology 1990 criteria for the classification of Churg-Strauss syndrome (allergic granulomatosis and angiitis). Arthritis Rheum 33: 1094-1100
  14. Yamashita Y et al. (1998) Nonasthmatic case of Churg-Strauss syndrome with rapidly progressive glomerulonephritis. Intern Med 37: 561-563
  15. Malik TQ et al. (2002) Atypical presentation of Churg-Strauss syndrome: another “forme fruste” of the disease? Am J Med Sci 324: 276-278
  16. Cohen P et al. (1995) Persistence of antineutrophil cytoplasmic antibodies (ANCA) in asymptomatic patients with systemic polyarteritis nodosa or Churg-Strauss syndrome: follow-up of 53 patients. Clin Exp Rheumatol 13: 193-198
  17. Gayraud M et al. (2001) Long-term followup of polyarteritis nodosa, microscopic polyangiitis, and Churg-Strauss syndrome: analysis of four prospective trials including 278 patients. Arthritis Rheum 44: 666-675
  18. Guillevin L et al. (1996) Prognostic factors in polyarteritis nodosa and Churg-Strauss syndrome: a prospective study in 342 patients. Medicine (Baltimore) 75: 17-28
  19. Ribi C et al. (2008) Treatment of Churg-Strauss syndrome without poor-prognosis factors: a multicenter, prospective, randomized, open-label study of seventy-two patients. Arthritis Rheum 58: 586-594
  20. Cohen P et al. (2007) Churg-Strauss syndrome with poor-prognosis factors: a prospective multicenter trial comparing glucocorticoids and six or twelve cyclophosphamide pulses in forty-eight patients. Arthritis Rheum 57: 686-693
  21. Jayne D et al. (2003) A randomized trial of maintenance therapy for vasculitis associated with antineutrophil cytoplasmic autoantibodies. N Engl J Med 349: 36-44
  22. Jayne D et al. (2007) Randomized trial of plasma exchange or high-dosage methylprednisolone as adjunctive therapy for severe renal vasculitis. J Am Soc Nephrol 18: 2180-2188
  23. Danieli MG et al. (2004) Long term effectiveness of intravenous immunoglobulin in Churg-Strauss syndrome. Ann Rheum Dis 63: 1649-1654

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categories: Emergency Medicine

BMJ: Alexander Technique & Back Pain

by Paul Rega, MD — published on August 23rd, 2008

Go to http://www.bmj.com/cgi/content/full/337/aug19_2/a884 for the full article.

Randomised controlled trial of Alexander technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

BMJ 2008;337:a884, doi: 10.1136/bmj.a884 (Published 19 August 2008)

Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain.

Design Factorial randomised trial.

Setting 64 general practices in England.

Participants 579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription.

Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling.

Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain.

Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage –0.58, 95% confidence interval –1.94 to 0.77, six lessons –1.40, –2.77 to –0.03, 24 lessons –3.4, –4.76 to –2.03, and exercise –1.29, –2.25 to –0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score –2.98 and –4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons –18, six lessons –10, massage –7) and quality of life improved significantly. No significant harms were reported.

Conclusions One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons.

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categories: Emergency Medicine

The Alexander Technique

by Paul Rega, MD — published on August 23rd, 2008

Medical News Today, 8/21/08 (http://www.medicalnewstoday.com/articles/118894.php)

A major study led by a Southampton researcher has found significant evidence that the Alexander Technique can provide long-term benefit for people with chronic or recurrent low back pain.

The study, one of the first of its kind, is being published online today by the BMJ at BMJ.com.

It shows that lessons in the Alexander Technique provide an individualised approach to reducing back pain through the teaching of life-long self-care skills that help people recognise, understand and avoid poor habits affecting postural tone and neuromuscular co-ordination.

Up until now there has been no good evidence of the long-term effectiveness of Alexander Technique lessons.

But the latest research by Professor Paul Little of the University of Southampton, in conjunction with Professor Debbie Sharp, of Bristol University, shows that the technique can help long-term back pain.

The multi-centre clinical trial involved 579 patients and compared 24 Alexander Technique lessons, six Alexander Technique lessons, six sessions of classical massage and normal GP care.

Half of the patients allocated to each of these groups also received a GP prescription for aerobic exercise (30 minutes of brisk walking or the equivalent each day), followed by behavioural counselling from a practice nurse.

The study showed that 24 Alexander Technique lessons led to important improvements in function, quality of life and a reduction in the number of days the patients suffered pain.

One year after the trial started, the average number of activities limited by back pain had fallen by 42 per cent, and the number of days in pain was only three a month compared with 21 days in the control group.

Massage also helped over the three months but the effect on activities was no longer significant after one year.

Exercise prescription alone had significant but modest effects on activities at both three and 12 months. However, a series of six Alexander Technique lessons followed by GP-prescribed exercise was about 70 per cent as beneficial as 24 Alexander Technique lessons at one year.

Professor Little said: “This is a significant step forward in the long-term management of low back pain.

“The results of this study revealed that the Alexander Technique can help back pain; it probably does this by limiting muscle spasm, strengthening postural muscles, improving co-ordination and flexibility and decompressing the spine.

“This means that patients can have fewer activities or functions limited by back pain.”

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categories: Emergency Medicine

Case Report: Recurrent Orbital Swelling

by Paul Rega, MD — published on August 23rd, 2008

An 11-year-old Male with Recurrent Orbital Swelling
Judith Ugale, MD; Chokechai Rongkavilit, MD 

An 11-year-old African American boy presented with four episodes of periorbital swelling. The first episode was characterized by 3 days of right periorbital swelling, blurring of vision, pain on eye movement, and frontal headache. Physical findings showed photophobia, right periorbital swelling, and conjunctival injection, with no limitation of extraocular movements or proptosis. Computed tomography (CT) showed extensive soft tissue swelling anterior to the right orbit with a post-septal, intraconal component surrounding the globe, opacification of the right ethmoid air cells and the right maxillary sinus, and mucosal thickening of the sphenoid sinus. He was started on intravenous ceftriaxone and clindamycin with a presumptive diagnosis of orbital cellulitis, and he improved.

Figure 1. Proptosis and periorbital edema in the right eye
Figure 1. Proptosis and periorbital edema in the right eye.

Five weeks later, he complained of right periorbital swelling associated with severe eye pain and headache. Eye movements became limited because of the swelling and pain. Right eye showed proptosis and periorbital edema (see Figure 1) with pain on movement and photophobia. He was started on intravenous ceftriaxone and clindamycin. CT of the orbits showed mild proptosis of the right eye globe and pre-septal soft tissue swelling extending into the intraconal fat around the posterior aspect of the globe. A small rim of fluid covered by ill-defined soft tissue mass extending along the posterior wall of the orbit was identified. Interval improvement of the sinus opacification was noted (see Figure 2). Despite 48 hours of antibiotic therapy, there was no clinical improvement. Re-evaluation by an ophthalmologist revealed decreased visual acuity of 20/40 (distance vision) and 20/25 (near vision), with limitation of eye movement. A cranial magnetic resonance imaging/magnetic resonance angiography (MRI/MRA) performed after 3 days of antibiotic therapy showed decreased proptosis of the right orbit. There was no evidence of retrobulbar, intraconal, or extraconal post-septal pathology, abscess formation, or carotid cavernous fistula. He was started on prednisone 80 mg daily and showed significant improvement in 48 hours.

He subsequently developed two similar episodes. An orbital biopsy was performed. The histopathologic examination showed adipose tissue with prominent small to large blood vessels without any vasculogenic or inflammatory lesion, lymphoid tumor, granulomas, or malignancy.

Answer: Orbital Pseudotumor (http://www.pediatricannalsonline.com/showPdf.asp?rID=30218)

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categories: Emergency Medicine

Codeine unsafe for some breast-feeding mothers

by Paul Rega, MD — published on August 23rd, 2008

Medical News Today, 8/22/08 (http://www.medicalnewstoday.com/articles/118900.php) :

“Using pain treatments which contain codeine may be risky for some breastfeeding mothers, according to researchers at The University of Western Ontario, and the Hospital for Sick Children (SickKids) in Toronto. Lead author Dr. Gideon Koren published research in the journal, Clinical Pharmacology & Therapeutics which suggests that the codeine used in some pain relief drugs can actually have harmful and even fatal results for infants when ingested by some breastfeeding mothers.

“With nearly half of all infants in North America being delivered by caesarean section or after episiotomy, there is clearly a requirement for pain relief for mothers,” says Koren. “However, our study confirms that codeine as a treatment for pain may be unsuitable and cannot be considered safe for all breastfed infants.”

Koren holds the Ivey Chair in Molecular Toxicology at the Schulich School of Medicine & Dentistry at The University of Western Ontario, and is a professor of pediatrics at both Western and the University of Toronto. He is also a senior scientist in the Child Health Evaluative Sciences program at SickKids Research Institute, and director of The Motherisk Program.

Codeine is commonly used for pain relief and is recommended by the American Academy of Pediatrics as being compatible with breastfeeding. Following numerous reports through the Motherisk counseling service and the tragic death of an infant who died from an overdose of morphine acquired from breast milk, Koren and his team, located at SickKids and The University of Western Ontario, investigated these negative reactions.

Codeine is a ‘prodrug’ which means that on its own it is relatively inactive. The pain relieving attributes are only activated when it is metabolized, or transformed by the body into a more active pain relieving compound, morphine. Some individuals have a genetic variance which causes them to metabolize codeine at a rapid rate, producing significantly more morphine in their system than most of the population. While this genetic predisposition is rare, women who possess it and who take codeine for pain while breastfeeding can end up exposing their babies to high levels of morphine through their breast milk. This can cause babies to experience central nervous system depression as a result.

“The good news is that those breastfeeding children who were exposed to these high levels of morphine showed dramatic improvement once they were taken off the morphine tainted breast milk,” says Koren. “By removing the exposure, most children will demonstrate a complete reversal of symptoms and show no long-term adverse effects.”

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categories: Emergency Medicine

Rabies Vaccine Supply is Limited

by Paul Rega, MD — published on August 23rd, 2008

CDC Update, 8/22/08

Rabies Vaccine Supply is Limited – update as of August 22, 2008

 The Centers for Disease Control and Prevention (CDC) has been notified by Novartis, maker of RabAvert ® (Rabies Vaccine), that the supply of human rabies vaccine is being used at a higher rate than expected, which may affect the near-term availability of vaccine for rabies post-exposure prophylaxis (PEP). This development follows the August 14 news release by Sanofi Pasteur, which announced the unavailability of the IMOVAX ® vaccine until late September-early October. Because of limited existing supplies, the CDC strongly recommends that health care providers, state and local public health authorities, animal control officials, and the public take immediate steps to ensure appropriate use of human rabies biologics. The Advisory Committee on Immunization Practices (ACIP) human rabies prevention recommendations outline animal exposures associated with the risk of rabies (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm). Judicious and appropriate use of rabies vaccines is crucial to avert a situation in which persons exposed to rabies are put at increased risk due to depleted vaccine supplies.

To ensure that thorough risk assessments are conducted, Novartis is now requiring that health care providers confer with public health officials, and obtain a confirmation code from a state health department before ordering vaccine doses for post-exposure prophylaxis.  Confirmation codes will be updated at a frequent interval. These codes should only be released by a state/local health authority that has reviewed the known facts of a given exposure and determined they indicate a sufficient level of exposure risk as outlined in the ACIP human rabies prevention recommendations (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5703a1.htm).

Public health authorities, health care providers, and veterinarians are encouraged to educate the public regarding precautions to avoid rabies exposure and actions to take if an exposure occurs. These precautions include vaccinating pets and livestock that have close human contact, avoiding stray and wild animals, and safely capturing or detaining biting animals (preferably using animal control officials), or obtaining owner contact information for follow up. For specific guidance, please see www.cdc.gov/rabies. Persons with possible rabies exposure should be evaluated as soon as possible by a health care provider. Since PEP is an urgent medical issue but not an emergency, it can be delayed until animal rabies testing or clinical observation is completed. This approach not only limits administration of PEP to persons with confirmed rabies exposure, but it is also cost-saving and conserves limited resources.

Until vaccine supply levels are restored, distribution of vaccine for pre-exposure prophylaxis (PreP) will continue to require approval by state and federal public health authorities.  Priority will be given to those individuals with occupational rabies exposure risk (e.g., rabies laboratory workers, animal control officers, veterinary staff, wildlife workers).

Discussions among federal, state, and local public health officials are ongoing to review additional strategies to manage this situation. A national working group has been convened to monitor the ongoing supply situation and provide updated recommendations as the situation evolves. 

For more information about rabies and its prevention, and updates regarding vaccine supply, contact your state or local public health official or CDC at 1-800-CDC-INFO or visit www.cdc.gov/rabies.

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categories: Emergency Medicine