Alberta has reported its first West Nile virus infection in two magpies, on July 9 (Camrose area) and July 11, 2003 (Medicine Hat area). Surveillance for the virus in birds of the Corvidae family (crows, magpies, ravens and jays) will continue, and will now commence in mosquito populations in Alberta. Surveillance for cases in horses and humans will also continue. Surveillance results are posted at: 

With the arrival of WNv in Alberta, please maintain a high index of suspicion for WNv infection in patients who have a history of exposure to mosquitoes where WNv activity is occurring (see above), or who may have been exposed through an alternate mode of transmission (blood transfusion, organ or tissue transplant, in utero, breast milk, laboratory-acquired), and are presenting with:

• Symptoms of meningoencephalitis, acute flaccid paralysis or other neurologic syndromes
• Unexplained fever more than 3 days and less than 8 weeks after blood transfusion
• Fever and a history of blood, organ or tissue donation within 8 weeks
• Fever NYD and are immune compromised

Laboratory testing for WNv is being done by the Provincial Laboratory for Public Health, and requires completion of a Prov Lab requisition as well as an Arboviral History Form (see www.provlab.ab.ca). Samples for WNv testing should include: acute serum (5-10 mL in gold top serum separator tube); CSF, if an LP is done (dedicated 1 mL sample for PCR viral testing, and specify what virus(es) to test for – WNv, enterovirus, HSV as clinically appropriate); convalescent serum 2-3 weeks later (5-10 mL in gold top serum separator tube); stool (sterile container) and throat swab (in M5 viral transport medium) for enterovirus culture; acute whole blood, especially if immune compromised (5-10 mL EDTA, purple top tube for PCR testing). Testing for mild, uncomplicated WNv infection is not generally indicated.

Case definitions for WNv infection (West Nile Neurological Syndrome and West Nile Fever) have been previously distributed by Alberta Health and Wellness, and are attached for your reference.

West Nile Neurological Syndrome is notifiable by immediate telephone call to the Medical Officer of Health (MOH) at 264-5615. West Nile Fever is notifiable to the MOH within 48 hours by calling Communicable Disease Control at 403-944-7075 or the MOH at 264-5615.

There is a risk of WNv transmission through transfusion of platelets, red cells or frozen plasma products, though this risk is seasonal and regional, and depends on the presence or absence of WNv in the donor population. The risk has been further decreased by the introduction of an investigational test for all donations as of July 1, 2003. However, Canadian Blood Services recommends that information on this risk be provided as part of the informed consent process for transfusion. See the Canadian Blood Services' WestNile Virus Update for details about the risk, and the contact information for CBS Medical Directors.

As well, organ and tissue recipients should be similarly advised about the risk of WNv transmission through this means. The Provincial Laboratory is carrying out PCR screening tests on plasma of donors of tissue and organs, but potential recipients should still be counselled appropriately.

For additional information on West Nile virus, please see http://www.westnilevirusalberta.ca or check  http://www.calgaryhealthregion.ca/clin/cme/NewsletterQuickLinks.htm

Sincerely,
Judy MacDonald, BSc, MD, MCM, FRCPC
Deputy Medical Officer of Health

********************************************************************************************

2003 West Nile Virus Clinical Case Definitions for Surveillance 
West Nile virus Neurological Syndrome:

* A person with West Nile virus-associated acute flaccid paralysis may present with or without fever or mental status changes.

1History of exposure when and where West Nile virus transmission is present, or could be present, or history of travel to an area with confirmed WN virus activity in birds, horses, other mammals, sentinel chickens, mosquitoes, or humans.

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

Preliminary information indicates that the lesions are caused by acid-fast bacteria, possibly Mycobacterium abscessus. Patients that present with symptoms consistent with this infection should be questioned regarding travel to the Edmonton area and attendance at recreational facilities (particularly swimming pools) in Edmonton in the 6 weeks prior to onset of the rash. The rash is characterized by raised, erythematous nodules or pustules.

For treatment and diagnostic advice, physicians should consult with dermatologists in their area.

For the purpose of assisting in the investigation, we would appreciate you reporting all such cases with history of travel to the Edmonton area to Calgary Health Region Communicable Disease Control at 403-944-7075 or 403-266-6137 (fax). Please include patient names and phone numbers to facilitate contact by public health staff.

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

Severe Acute Respiratory Syndrome
  (SARS)   
(Last updated - April 30, 2003)

SARS information and recommendations change frequently as more knowledge is gained about the epidemiology, transmission, diagnosis and treatment. 

For the most current information, please check the Quick links posted to the right

SARS Update # 2 (March 26, 2003) - for physicians in the Calgary Health Region. Recommendations for physicians' actions, telephone triage and office management.

Health Canada SARS information for health care professionals, including most recent updates, case definitions, infection control guidelines

Health Canada Travel Information

Centers for Disease Control and Prevention - FAQ file, fact sheets, guidelines and recommendations, travel and international resources

SARS - Canadian Medical Association Shortcuts - links to information about how physicians can protect themselves, available clinical information, what to tell patients travelling to Ontario and abroad, etc. 

SARS in Ontario - The Ontario Medical Association's page provides information about SARS in Ontario and tools for physicians.

World Health Organization - information about Severe Acute Respiratory Syndrome (SARS). The site will be updated daily to ensure that the most current information is available

SARS Office Poster  - in several languages, it asks people who are feeling unwell and who have travelled within the last 10 days to an affected area to return home and phone their family physician.  (Updated April 29, 2003)

SARS Hospital Poster  - in several languages, it asks people who have travelled within the last 10 days to an affected area to present themselves immediately to the triage nurse or the front desk. Further it tells them to go to the front of the line if necessary ( Updated April 29, 2003)

As of March 26, Health Canada has received reports of 28 probable cases of Severe Acute Respiratory Syndrome (SARS) in Canada [Ontario (27 cases) and British Columbia (1 case)]. There have been three deaths in Canada. All Canadian cases have occurred in individuals who had travelled to Asia or had close contact with SARS cases in the home or health-care settings. Ontario has made both suspect and probable SARS a notifiable disease and persons suspected of being infected are subject to isolation, either in hospital or at home. These measures have been implemented in an attempt to prevent spread in the community at large. Globally, the number of cases reported as well as the number of countries reporting cases is increasing. For up to date reports, check the Health Canada website www.hc-sc.gc.ca and the World Health Organization website at http://www.who.int/csr/sars/en/. Information for health care professionals is available from Health Canada at www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/index.html.

The causative organism has still not been definitively identified, though there are hypotheses that it is a virus. Collaborative investigations are ongoing internationally.

Health Canada modified its travel advisory on March 25, given the increasing concern about transmission of SARS in community settings in the City of Hanoi, Vietnam; Hong Kong Special Administrative Region and Guangdong Province in China; and Singapore. They recommend that persons planning to travel to these areas should defer all travel until further notice. Updates to this advisory can be obtained on the Health Canada website http://www.hc-sc.gc.ca/pphb-dgspsp/tmp-pmv/.

The case definitions of suspect and probable cases are (March 24 and subject to revision):

Suspect Case:

A person presenting with fever (over 38 degrees Celsius), AND one or more respiratory symptoms including cough, shortness of breath, difficulty breathing, AND one or more of the following: close contact within 10 days of onset of symptoms with a probable case; history of travel within 10 days to affected areas in Asia (Guangdong Province in China, Hong Kong Special Administrative Region of China, Taiwan Province; City of Hanoi, Vietnam; Singapore), AND no other known cause of current illness

Probable Case:

A person meeting the suspect case definition together with severe progressive respiratory illness suggestive of atypical pneumonia or acute respiratory distress syndrome with no known cause OR a person with an unexplained acute respiratory illness resulting in death, with an autopsy examination demonstrating the pathology of acute respiratory distress syndrome with no known cause.

Recommended Physician Actions:

1. Be vigilant for suspect or probable cases of SARS as defined above. Ensure that your office nurse or receptionist asks patients who phone complaining of respiratory symptoms if they have travelled recently to Hong Kong, Taiwan, Hanoi, Singapore or Guangdong Province in China. If patients have this travel history, then the physician should contact them by phone to assess further. Patients suspected of having SARS should be triaged by phone rather than having them come into the office. (One of the initial health care workers infected in Ontario was a family physician who saw the index case and other family members in their office.)
2. If the patient meets the suspect case definition, then contact the Medical Officer of Health (MOH)/Public Health at 264 - 5615. They will review case details and confirm the SARS case definition is met. These patients should then be referred to ER, with prior notification (see 5 below). Patients not meeting the definition can be managed as they normally would be. Patients who have general questions about SARS can be referred to HEALTH LINK 403-943 - 5465 for further information.

Office Management

3. If a patient with suspect SARS presents at your office, triage immediately as above. If SARS is suspected:

• give the patient a surgical mask to wear

• move them to a private room away from the waiting room, with the door closed
• ensure health care workers wear a N95 mask (preferably) or surgical mask, long-sleeved gown, disposable gloves and eye protection when in contact with the patient. Hand hygiene is the most important preventive measure.

(A poster is available for your waiting area. It asks people who have a history of travel within 10 days to an affected area to identify themselves immediately to the nurse/receptionist. Check the Quick Links section of this Clinical Alert to download this poster.)

4. If a patient meets the case definition for SARS, contact the MOH/Public Health at 264-5615.
5. Arrange transport of suspect or probable cases to ER, with prior notification to ER triage or duty physician. Suspect cases must wear a surgical mask at all times. Transportation should be by private vehicle rather than public transit.
6. Advise patient to report directly to triage on arrival at ER and advise them of SARS possibility. They should not stand in line waiting at ER.
7. Laboratory investigations including x-rays should be carried out at ER. Suspect SARS cases should not be referred to CLS sites or local radiology clinics because of the difficulty in ensuring appropriate infection control measures to protect staff and other patients.
8. Accurate telephone triage to determine which travellers truly need to be assessed in ER is essential to avoid overloading of emergency services and creating infection control risks in that setting.
9. Suspect SARS cases who do not require hospitalization for clinical care may be managed by home isolation. Patients will be discharged from ER with public health follow up. Further information on home isolation requirements will be available on the Doctors’ Page - Clinical Alerts or from the MOH.

Health Canada recommendations are subject to revision as further information becomes available. The most recent Health Canada case definitions, and more detailed instructions for infection control guidance are available at www.hc-sc.gc.ca/pphb-dgspsp/sars-sras/index.html A link to this page will be posted for your information on the Doctors’ Page – Clinical Alerts at www.crha-health.ab.ca/clin/cme/calert.htm. This information and other resources will also be sent out in hard copy to physician offices within a few days.

Summary of resources for information:

Health Canada – www.hc-sc.gc.ca/english/

Centers for Disease Control and Prevention – www.cdc.gov/

World Health Organization – http://www.who.int/csr/sars/en/

Calgary Health Region Doctors’ Page – www.crha-health.ab.ca/clin/cme/calert.htm

Brent T. Friesen, MD, FRCPC
Medical Officer of Health

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

BC Ear Bank Homografts   
(February 20, 2003)

Calgary Health Region has been notified by the B.C. Ear Bank that bone and tissues (including ossicles, tympanic membranes, tympanic membranes with mallei attached, ear bone plugs, temporal bones, costal cartilage and dura mater) used for Inner Ear Reconstruction between 1986 and 1997 may pose a small risk of infection to patients.

A recent review of the B.C. Ear Bank’s procedures related to the procurement, processing, sterilization, packaging and distribution of bone and tissues showed inadequate documentation. Accordingly, the B.C. Ear Bank is unable to verify with 100% certainty that the materials pose no risk of HIV, Hepatitis B or Hepatitis C transmission.

• Eighty-seven (87) hospitals or individual physicians across Canada received ear tissue from the B.C. Ear Bank and all have been notified of this risk.
• The risk of transmission to these transplant patients is low. Health Canada estimates that in the worst case scenario, risk of transmission is 1 in 10,000. It is more likely that the actual risk is about 1 in 100,000 for Hepatitis C or Hepatitis B and about 1 in 1 million for HIV.
• Between 1986 and 1987 the Colonel Belcher Hospital received three (3) harvested incus bones from the B.C. Ear Bank for use in Inner Ear Reconstruction surgery. Calgary Health Region has not been able to confirm the tissue material was actually transplanted and is currently checking its medical records to determine if the material was used.
• The material has not been used in the Calgary health region since 1987.
• Tissue harvesting centres in Alberta routinely screen and test tissue to minimize the risk of transmitting disease.

• Calgary Health Region is reviewing its records to identify the patients who may have received Inner Ear Reconstruction surgery in this time period with the incus bones from the B.C. Ear Bank.
• Where possible, Calgary Health Region will contact by phone and by letter all identified patients and their physicians.
• Patients will be encouraged to visit their family physicians for information and testing.
• Any person who may have had Inner Ear Reconstruction surgery between 1986 and 1987 at the Colonel Belcher Hospital can phone 403-944 – 1378 for information.

While the material from the B.C. Ear Bank was used only at the Colonel Belcher Hospital in Calgary, for up to three people who had Inner Ear Reconstruction surgery between 1986 and 1987, there is the possibility that the material was used by other hospitals. In Alberta the other hospitals using material from the B.C. Ear Bank were Lethbridge Regional Hospital and St. Michael’s Health Centre. Both hospitals are located in the Chinook Health Region. For information regarding Inner Ear Reconstruction surgeries at those two hospitals please call 1-403-382 – 6006.

If your patient had Inner Ear Reconstruction surgery at a hospital in another province, then the B.C. Ear Bank has an information phone line for health professionals that you can call to check if that hospital also received material. Please call 1-877-806 – 9222.

• The appropriate tests would be for Hepatitis B (HBsAg and anti-HBs.) Hepatitis C antibody, and an HIV test.
• All tests should be sent to the Provincial Laboratory of Public Health, and should be accompanied by information that the person is being tested because of having received a transplant from tissues from the B.C. Ear Bank.

The risk of transmission to these transplant patients is low.

Health Canada estimates that in the worst case scenario, risk of transmission is 1 in 10,000. It is more likely that the actual risk is about 1 in 100,000 for Hepatitis C or Hepatitis B and about 1 in 1 million for HIV.

Questions or concerns regarding the risks of transmission: please contact Dr. Judy MacDonald, Deputy Medical Officer of Health at (403) 943 – 8032.

Questions or concerns regarding people who may have had surgery: please contact Ms. Muriel Shewchuk, Director Surgical Services at (403) 944 – 1378.

Brent T. Friesen, MD, FRCPC
Medical Officer of Health

Acknowledgement: Dr. Margaret Russell, MOH, Regional Health Authority 5

BTF:tw\g\b\earbank\alert

2003-02-20

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

It is not too late for vaccination! Influenza vaccine is still available from Communicable Disease Control (403-944-7075) for physician use in vaccinating those who are eligible for provincially-funded vaccine – high risk individuals and those who can transmit influenza to high risk individuals. It is also available at Community Health Centres.

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

These outbreaks in the Calgary Health Region have occurred in various closed and semi-closed populations including long term care facilities, assisted living sites, schools and acute care facilities. In most of the outbreaks where stool samples have been obtained for testing, Norwalk-like virus has been identified as the causative agent. This kind of outbreak activity usually signals a high amount of GI illness in the community.

Norwalk-like viruses (NLV) belong to the Calicivirus family, and include such strains as Norwalk virus, Snow Mountain agent, and Hawaii virus. NLV are quite hardy, and can withstand freezing and fairly high temperatures. They are also difficult to inactivate, and are not killed with usual quaternary ammonium compounds. NLV cannot be cultured in the laboratory, so it is difficult to do studies to determine what, if anything, is different about this particular strain this year.

Clinical aspects: Patients presenting with symptoms of viral gastroenteritis due to Norwalk-like virus, will usually experience sudden onset of vomiting and/or watery diarrhea predominantly, but may also have headache, mild fever, abdominal cramps, and myalgia. Though the vomiting and diarrhea may be quite severe, the duration of illness is normally 24-48 hours. Maintenance of hydration is critical, especially in the very young and the elderly. Stool testing for suspect NLV infection is only appropriate in an outbreak situation, and will not be done for sporadic cases from the community.

Prevention: Because this virus is readily spread through contaminated food or water, or from person to person via the fecal-oral route or through contact with contaminated environmental surfaces, there are several important preventive measures that should be emphasized when dealing with NLV:

• Wash hands thoroughly before eating or preparing food, and after using the toilet or changing diapers.
• Anyone with symptoms of vomiting and diarrhea should not return to day care, school or work, or visit anyone until they have been symptom-free for 48 hours.
• If there is GI illness in a household, washroom fixtures should be cleaned and then disinfected at least once a day with household chlorine bleach-based products (a dilution of one part bleach to nine parts water provides sufficient chlorine activity to kill this virus). Caution should be used with this product – follow precautions on the label.
• Towels and face cloths should not be shared. Children should not be bathed together when one has diarrhea.
• Soiled clothing or linen should be handled as little as possible and laundered separately in hot water and dried at hot temperatures.
• Visits to the swimming pool should be postponed for anyone with diarrhea symptoms until at least 48 hours after symptoms have resolved.

A fact sheet about Norwalk-like virus   suitable for patient use is available. 

General information for patients about prevention of gastrointestinal illness is available at: http://www.crha-health.ab.ca/hlthconn/items/diarrheasp.htm.

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

West Nile Virus Update   
(August 20, 2002)

Alberta Health and Wellness informed us yesterday that a dead bird from Saskatchewan has tested positive for West Nile virus (WNV). This information increases the level of surveillance in Alberta to now include human surveillance. All Alberta physicians will receive a letter advising them to consider WNV infection in patients presenting with certain symptoms, to submit clinical specimens to the Provincial Laboratory, and to notify the Medical Officer of Health of any suspect cases. Specific instructions are outlined in this letter  

In the Calgary Health Region, please contact Communicable Disease Control at 403-944-7075 during regular working hours or the MOH on call after hours at 264-5615 to report any suspect cases of WNV infection in humans.

While no cases of WNV infection in humans have been reported in Canada (apart from a case in 1999 acquired in New York City), it is important to be watching for them. It is possible that the first cases in Canadians may be acquired during visits to areas with reported WNV activity, such as Louisiana, Mississippi, Texas, Alabama, Illinois, Florida, Indiana, Massachusetts, New York City and the District of Columbia in the US, rather than from a source in Canada. The risk of serious illness from mosquito bites is low - according to information from CDC, even in areas where mosquitoes are known to carry the virus, less than 1% of mosquitoes will be infected, and less than 1% of humans bitten by an infected mosquito will develop serious illness.

Mosquito precautions are the best preventive measure against arboviral infections such as WNV. These include reduction of standing water environments (old tires, toys, etc.) and personal protective measures such as: limiting time outdoors in the evening and early morning when mosquitoes are most likely to be active; wearing loose-fitting, long sleeved shirts and long pants; and using a DEET-based insect repellent.

The following websites provide excellent educational material for both clinicians and patients:

• Health Canada - general information about WNV (http://www.hc-sc.gc.ca/pphb-dgspsp/publicat/info/wnv_e.html) for patients and for clinicians
• Health Canada - use of insect repellents (http://www.hc-sc.gc.ca/pmra-arla/english/pdf/pnotes/deet-e.pdf) for patients
• Annals of Internal Medicine - an excellent review of mosquitoes and mosquito repellents at http://www.acponline.org/journals/annals/01jun98/mosquito.htm for clinicians (thanks to Dr. Margaret Russell for this reference).

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

If you have any questions or would like to review a case, contact Dr. Ron Read at the STD clinic (297-6562) or on regional pager 3744.

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075

Anthrax and Other Agents of Bio-terrorism
(October 15, 2001)

The Calgary Health Region is working closely with the City of Calgary Police, Fire and Emergency Services in response to packages of concern or suspicion. The Calgary City Police is the lead agency to respond to calls from the public about suspicious packages or letters. If patients contact your office for information about what to do please refer them to 911. (If they bring suspicious materials into your office they should be enclosed in a sealed plastic bag if this can be done without anyone else being exposed. The CHR is working closely with the City to get the message to the public that such packages should not be transported to other sites.) The Hazard Materials Response Team is also involved in containing and decontamination if there is concern about a spill. Any exposures of individuals are evaluated through the Medical Officer of Health to determine what if any further testing is required.

There have not been any cases of anthrax in Canada linked to packages of concern, nor has any testing of the materials involved in the incidents in Canada identified any biologic agent as of October 15. 

Information from the US indicates that physicians are often approached with requests for prescriptions for antibiotics. There is no indication in Calgary or Canada for the prescription of prophylactic antibiotics nor is there an indication for vaccination against anthrax or other biologic agents.

The following web sites provide further information including handouts that can be shared with your patients:
Health Canada: Biological Agents - Frequently Asked Questions   (Added link November 21, 2001)
(Added link November 21, 2001)
http://www.hc-sc.gc.ca/english/biological_agents/index.html

CDC - Disease Information listing about Anthrax: 
http://www.cdc.gov/ncidod/dbmd/diseaseinfo/anthrax_g.htm

CMA Statement Concerning Mental Health Issues: 
http://www.cma.ca/cmhsn/anthrax.htm 

AMA Statement Concerning Prescribing Prophylactic Antibiotics 
http://www.ama-assn.org/ama/pub/category/6383.html 

Information relevant to your office practice to share with staff:
Government of Alberta Information - Mail Handling Cautions  

If you have questions or comments about the contents
of this publication, please contact:
Dr. Judy MacDonald,
Deputy Medical Officer of Health, Healthy Communities
Email: judy.macdonald@calgaryhealthregion.ca
Phone: (403) 943-8032
Communicable Disease Unit - Phone: (403) 944-7075