S a n M at e o C o u n t y
Physician
March 2013 | Volume 2, Issue 3
A publication of the San Mateo County Medical Association
Infectious Diseases
Varicella-Zoster Virus Infection Update on Chickenpox and Shingles
Hepatitis B: The Silent Killer Do You Know Who’s at Risk?
Vaccination Update STD Update
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Editorial Committee Russ Granich, MD, Chair; Sharon Clark, MD; Edward Morhauser, MD; Gurpreet Padam, MD; Sue U. Malone, SMCMA Executive Director; Shannon Goecke, Managing Editor
Contributing Authors Jamila Champsi, MD; Kim S. Erlich, MD; Shannon Goecke; Russ Granich, MD; Gregory Lukaszewicz, MD; Sue U. Malone
SMCMA Leadership Gregory C. Lukaszewicz, MD, President Amita Saxena, MD, President-Elect Vincent Mason, MD, Secretary-Treasurer John D. Hoff, MD, Immediate Past President Raymond Gaeta, MD; Russ Granich, MD; Edward Koo, MD; C.J. Kunnappilly, MD; Michael Norris, MD; Michael O’Holleran, MD; Irwin Shelub, MD; Chris Threatt, MD; Kristen Willison, MD; David Goldschmid, MD, CMA Trustee; Scott A. Morrow, MD, Health Officer, County of San Mateo; Dirk Baumann, MD, AMA Alternate Delegate
Editorial and Advertising Inquiries San Mateo County Physician is published ten times per year by the San Mateo County Medical Association. Members are encouraged to submit articles, commentary and letters to the editor. Opinions expressed by authors are their own and not necessarily those of the SMCMA. San Mateo County Physician reserves the right to edit contributions for clarity and length, as well as to reject any material submitted. Advertising in San Mateo County Physician is a great way to reach out to the San Mateo County medical community. Classified ads begin at $40 (for up to five lines) for members. Acceptance and publication of advertising does not constitute approval or endorsement by the San Mateo County Medical Association of products or services advertised.
S a n M at e o C o u n t y
Physician
March 2013
Editor’s Intro | Russ Granich, MD Welcome to the March issue of San Mateo County Physician, which focuses on infectious diseases. Our cover story comes from Kim Erlich, MD, Medical Director of Infection Control at MillsPeninsula. Many of us have seen those prescription drug commercials that warn, “If you’ve had chickenpox, the shingles virus is already inside you!” But how much do you know about Varicella-zoster virus ( VZV ), the neurotropic herpesvirus that causes both primary infection and recurrent disease? Dr. Erlich’s article clearly lays out the pathogenesis, diagnosis, and treatment options for varicella (chickenpox) and zoster (shingles). SMCMA staff has also contributed and article on the hepatitis B virus (HBV ), which is responsible for 60-80% of primary liver cancer worldwide. Asians and Pacific Islanders bear an disproportionate risk of contracting HBV (one in ten are chronically infected with HBV, compared to one in 1,000 Caucasians), but San Mateo Hep B Free, a program administered by the SMCMA Community Service Foundation, is working hard to eradicate HBV in San Mateo County. Finally, this issue also contains two informative contributions from my Kaiser colleague, infectious diseases doctor Jamila Champsi, MD—the first an update on vaccination recommendations, the second on the treatment of gonorrhea, syphilis and HPV.
President’s Message | The High Cost of Medical Bills.. .............................. 5 Gregory Lukaszewicz, MD Executive Report | Clinic by the Bay Celebrates 2nd Anniversary........... 7 Sue U. Malone Varicella-Zoster Virus Infection.................................................................. 8 Kim S. Erlich, MD Hepatitis B: The Silent Killer..................................................................... 13 SMCMA Staff
For more information, contact managing editor Shannon Goecke at (650) 312-1663 or sgoecke@smcma.org.
Vaccination Update................................................................................... 14 Jamila Champsi, MD
Visit our website at www.smcma.org, like us at www.facebook.com/smcma, and follow us at www.twitter.com/ SMCMedAssoc.
STD Update. . .............................................................................................. 15 Jamila Champsi, MD
© 2013 San Mateo County Medical Association
New SMCMA Members.............................................................................. 17 Classifieds, Index of Advertisers.............................................................. 18
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President’s Message | Gregory Lukaszewicz, MD
The High Cost of Medical Bills The March 4, 2013 Time cover story is a must-read for anyone trying to understand the current state of the American medical economic system. To give some sense of the social and cultural significance of this article: It is both the longest story (more than 24,000 words) and the first featured section written by a single author in Time’s history. In “Bitter Pill: Why Medical Bills Are Killing Us,” author Steven Brill examines the fundamental issues underlying the costs of the American medical system. Rather than speculate about how we are going to pay for the rapidly escalating costs of health care in the United States, Brill asks the more fundamental question of why these expenses are so high in the first place and why they continue to grow unabated. His conclusion is that the economic system incentivizing American health care exists in a separate universe, apart from the rest of our economy and not subject to the normal free market mechanisms that help keep prices under control. Brill focuses his critique on several key players: the pharmaceutical industry, hospitals, providers of durable goods such as walkers and wheelchairs, and ambulance services. In fact, in an interview with Jon Stewart of the Daily Show (perhaps I am revealing too much about the source of my news!), he states that, while many in the health care industry are getting quite rich off the system, the doctors and nurses who actually provide the care are not amongst them. Using individual patients as case studies, he illustrates that the rules that govern most of our economy—transparency, accountability, competition, consumer choice—do not apply to medical economics. A main cause of excessive costs is the “chargemaster,” a computer program that provides a cost for every single item used in the care of the patient during his or her hospital stay. Brill asserts that the chargemaster lists highly inflated prices “devoid of any calculation related to cost.” For example, there will be a $1,700 charge for the room, plus charges for everything from venipuncture ($36, not
including lab costs) to an acetaminophen tablet ($1.50 per tablet, compared to a bottle of 100 pills available on Amazon for $1.49). In most cases, the patient’s insurance company has negotiated for lower rates and are not actually paying these prices, (though the prices they are paying are dramatically marked up from actual costs). However, in situations where a patient has no insurance or inadequate insurance, these massive bills can force a person into bankruptcy. In fact, here is an industry developing around consultants who work with hospitals to reduce the charges an individual has to pay so that the person may actually be able to pay the bill and avoid bankruptcy. How did we get to this point? When a person becomes sick, he doesn’t get online to search for the most competitive price. He calls 911 or goes to the nearest hospital. If he has adequate insurance, he probably does not check his individual bill. Instead, he notes that his insurance company obtained a 50% discount, which lowered his own out-of-pocket expense. It seems like a win. How many people actually go through their bills and note the high costs, such as the $7 alcohol swab? Hospital charges and reimbursements are only one issue behind a health care system that costs the nation 17% of its GDP. It is not possible here to give Brill’s article the full attention it deserves. I recommend finding it at www.time.com and taking the time to really digest it. One may not always agree with the author, but we as physicians need to be part of the spark that drives the debate around health care costs. If we don’t get involved, if we ignore all the factors that drive costs, then where can we expect Congress to look when attempting to cut health care costs? Cutting physician reimbursements can be an easy target. Controlling health care costs is the absolute right thing to do from a moral standpoint; it is also in our own interest to do so. ■
March 2013 | SAN MATEO COUNTY PHYSICIAN 5
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Executive Report | Sue U. Malone
Clinic by the Bay Celebrates 2nd Anniversary I recently had the privilege of touring the Clinic by the Bay facilities on Mission Street in San Francisco’s Excelsior District. While the clinic is located in San Francisco, about half of the clinic’s patients are Daly City residents. The clinic, which opened in September 2010, is the 82nd Volunteers in Medicine (VIM) clinic to open and the first in the Bay Area. The Clinic provides medical care to San Francisco and San Mateo residents, age 18 and older, who do not have Medicare or Medi-Cal coverage, do not have private insurance, and have income at or below 250% of the Federal Poverty Level (FPL). A little bit about Jack McConnell A physician and researcher, Jack McConnell proved to be a terrible retiree when he relocated to Hilton Head, South Carolina, to play golf. During his career Dr. McConnell directed the development of the tuberculosis tine test, Tylenol tablets, and MRI technology. However, when he got to Hilton Head he discovered that a lot of the resort island was populated with low-income residents who had no health care. So he started a free medical clinic to serve them, recruiting other retired physicians and nurses to help him out. The Volunteers in Medicine Clinic opened in 1994; last year, nearly 30,000 patients received medical care. Now the Volunteers in Medicine Institute, using McConnell’s model, has built a network of free medical clinics nationwide. Dr. McConnell believes that “every community in the country has all the resources it needs to operate a facility like the Hilton Head Clinic, but someone has to step up and take the risk.” Now McConnell, who is 81, is in the process of starting a clinic in Africa. Back to Clinic by the Bay Dr. McConnell and his wife were present to celebrate the first day of clinic operations at the Clinic by the Bay in 2010. The local co-founders were Scott Hauge and Janet Reilly. Scott is president and owner of CAL Insurance and Associates, and Janet serves on the Board of Directors of the Golden Gate Bridge, Highway and Transportation District. The Clinic receives no taxpayer money, relying on the generous support of its volunteers, partners, and donors,
whose commitment make it possible for the Clinic to offer health care free of charge. LabCorp, which provides all patient lab tests at no charge, has integrated its lab reports with the Clinic’s EMR system, Practice Fushion. Health Diagnostics is another medical partner providing pro ono imaging services for ths Clinic’s patients at its San Francisco and Daly City locations. Patients receive eye care from Pacific Eye Specialists, a San Francisco medical office, and CPMC conducts all plain film x-rays at St. Luke’s Hospital. There is also an AmeriCorps VISTA volunteer, who is a Stanford graduate in global public health. The Clinic is fortunate to work with Operation Access, which provides patients with a range of surgical and specialty care, augmenting the Clinic’s other partnerships. The Clinic’s patients are very fortunate to have this extensive network of care and resources available to them. Guess what? The new Clinic Medical Director is our own David Goldschmid, head of the emergency department at Seton Medical Center and former president of SMCMA. Another of our members, Mary Ann Miner, now retired, was the founding Medical Director. Not specifically mentioned here are the numerous retired physicians and nurses who volunteer their time to serve the Clinic patients. In a short time, the Clinic has amassed an impressive army of volunteers and pro bono services to provide medical care to those in need. Of the volunteers, 74 percent have volunteered for at least six months and 48 percent have volunteered for at least one year. On its 2nd birthday, the Clinic had enrolled more than 1,000 patients with nearly 4,000 completed medical visits. All of newly enrolled patients are seen by a medical provider within two weeks. The Clinic plans to start offering Saturday services as well as a small dental program. It is truly amazing how one or two people with a shared goal can bring something like the Clinic to life in such a short period of time, offering primary and preventive care, general health exams, prescription assistance, specialty care referrals, community resource referrals, and multilingual health education workshops. ■ March 2013 | SAN MATEO COUNTY PHYSICIAN 7
Varicella-Zoster Virus Infection
Update on Chickenpox and Shingles
Kim S. Erlich, MD
Varicella-zoster virus (VZV) is a neurotropic herpesvirus that causes both primary infection and recurrent disease. Similar to the other herpes viruses, VZV causes both acute illness and lifelong latency. Prior to widespread vaccination, acute primary infection (“chickenpox” or varicella) was common during childhood. Primary infection in the United States is much less common in recent years due to routine and widespread childhood vaccination, but chickenpox may still occur in unvaccinated individuals or as a result of vaccine failure. Chickenpox is usually a benign and self-limiting illness, but can be more severe in adults and in individuals with an underlying immunodeficiency, with high risk for pneumonia and disseminated disease with visceral involvement. Recurrent VZV infection (“shingles” or zoster) occurs with advancing age, but may occur earlier in the immunocompromised host as a result of decreased cellular specific VZV immunity. Shingles typically presents as a painful, localized cutaneous eruption occurring along one or more contiguous dermatomes. Like chickenpox, shingles is usually self-limited in the normal host, but immunocompromised hosts are at risk for more severe illness with cutaneous or visceral dissemination. Pain is a frequent complication of shingles, and pain that persists following complete healing of cutaneous lesions, referred to as post-herpetic neuralgia, can be debilitating and difficult to control. Acyclovir, valacyclovir, and famciclovir are the antiviral therapies of choice for most VZV infections. Steroids may be added for patients with shingles as an attempt to reduce the incidence and severity of post-herpetic neuralgia. Two vaccines are currently available to prevent VZV infections. Administration of the live attenuated varicella vaccine to prevent primary infection is an important strategy to protect children and adults who have not had prior VZV infection. The shingles vaccine, which is a higher titered live attenuated vaccine, is approved for non-immunocompromised adults over the age of 50, and is recommended by the CDC to prevent the development of shingles in populations who are at high risk.
Epidemiology Humans are the only known natural hosts of VZV. Varicella is primarily a disease of childhood in temperate climates, but individuals born in tropical and subtropical areas often escape primary infection during childhood
8 San Mateo county physician | March 2013
and are at higher risk for developing chickenpox as adults. Transmission occurs through direct contact with infectious lesions or by inoculation of aerosolized infected droplets onto a susceptible mucosal surface. The virus is easily transmitted; the rate of secondary cases of chickenpox in susceptible household contacts typically exceeds 90%. Infectivity usually begins 1 to 2 days before the onset of rash, and patients remain infectious until all vesicular lesions are dried and crusted. In the normal host, the period of infectiousness is usually 5 to 7 days after the lesions first appear, but an immunocompromised host with chickenpox may heal slowly and remain infectious for up to several weeks. With routine and widespread childhood vaccination against chickenpox with the live attenuated varicella vaccine, there are fewer cases and fewer hospitalizations for chickenpox, but the vaccine strain results in viral latency, and vaccinated individuals are at risk of developing reactivation later in life with the development of classic shingles. Shingles occurs due to waning of cytotoxic VZV specific T-cell immunity that had been keeping the virus latent. The risk of shingles increases with advancing age, with the highest incidence occurring between the ages of 50 and 80 years. Shingles occurring at a young age may be the first clinical clue to suggest an undiagnosed immunosuppressed state, and an episode of zoster in a young individual warrants consideration of underlying HIV infection. Although an episode of shingles boosts T-cell specific immunity to VZV, recurrent episodes of shingles can occur even in the immunocompetent hosts.
grade fever, and myalgia. Skin lesions begin as small erythematous macules and progress over 12 to 36 hours to Primary VZV infection occurs following inoculation of become papules and true vesicles. Lesions typically appear infected airborne droplets onto a mucosal surface of a initially and are most numerous on the face, trunk, and previously uninfected individual. Initial virus replication neck; fewer lesions appear on the extremities. Vesicles occurs in tonsillar and lymphoid tissue, and is followed are variable in size and shape, and are filled with straw4 to 7 days later by primary viremia. Virus spreads to colored fluid and rest on an erythematous base. The internal organs, and a secondary, more prolonged viremic vesicles ulcerate, dry, and form crusts and scabs. Pruritus stage occurs 10 to 21 days after the initial infection. is often present and can be severe, resulting in excoriation Virus reaches the cutaneous surface during the secondary and a risk for secondary bacterial infection. Lesions in all viremia, and results in the characteristic vesicular rash of stages of development (macules, papules, vesicles, ulcers, chickenpox. Skin lesions typically begin on the face and and crusts) are characteristic of chickenpox, and occur then develop on the trunk and extremities. Successive due to the successive waves of viremia occurring during crops of new vesicles occurring over several days are the first few days of illness. Chickenpox can be confused typical during chickenpox, attesting to the waves of with other exanthems, but the centripetal distribution viremia that occur during the acute illness. New lesion of the rash and the presence of lesions in all stages of formation ceases with the appearance of circulating serum development are clues that VZV is the etiologic agent. antibody and a detectable immune response, usually The differential diagnosis in a patient with suspected within 1 to 5 days following onset of the illness. chickenpox includes other viral infections (measles, coxsackievirus, rubella, disseminated HSV), rickettsial During primary infection (or infections (Rocky Mountain spotted following vaccination with the live fever, typhus), secondary syphilis, attenuated virus vaccine), VZV Shingles occurring at bacterial infections, adverse drug enters cutaneous endings of sensory reactions, systemic allergic reactions, nerves and migrates centripetally a young age may be and infestations such as scabies. along nerve fibers to reach sensory nerve ganglia. Latency is established the first clinical clue to Shingles within these sensory ganglia by incorporation of virus nucleoprotein suggest an undiagnosed Shingles typically begins with local within ganglionic cells, and latency pain and discomfort, and then is maintained through intact cellular immunosuppressed state, progresses to a localized or segmented immune mechanisms. With the erythematous, maculopapular waning of VZV specific cellular and an episode of zoster in eruption along a single dermatome. immunity due to advancing age or Lesions evolve to vesicles, pustules, immunosuppression, shingles can a young individual warrants and crusts. Vesicles often become occur as virus reactivates and travels consideration of underlying confluent with bullae formation. New peripherally along sensory nerves lesions may develop over several days to reach the mucocutaneous surface if left untreated. Although shingles HIV infection. innervated by the ganglia associated usually remains localized and resolves with virus reactivation. Although spontaneously, the illness typically uncommon, disseminated shingles with viremia and results in significant pain and cutaneous scarring. In infection of distant cutaneous or visceral sites may occur; immunocompromised hosts, shingles lesions may be this may be more common in patients with cellular particularly severe and may last several weeks. immunodeficiency. Since several ganglia become latently infected during primary VZV infection, reactivation of Diagnostic clues in a patient with suggestive findings more than one ganglion can occur with shingles involving include the presence of lesions and sensory symptoms that more than one noncontiguous dermatome. Recurrent do not cross the midline, and pain or sensory signs that are episodes of shingles are not uncommon, and may occur in characteristic of nerve injury. Dissemination of shingles different locations. outside the dermatomal pattern can make the diagnosis of shingles difficult, and cutaneous dissemination may resemble other exanthems. Clinical Syndromes
Pathogenesis
Chickenpox The rash of primary VZV infection appears at an average of 14 days after infection (range of 10 to 21 days). Prodromal symptoms often occur in adults 1 to 2 days before the appearance of the rash, and may include malaise, low-
Immunocompromised patients with shingles may present with prolonged lesion formation, progressive local extension, and virus dissemination. Cutaneous dissemination can result in hundreds of vesicles outside the primary dermatome and may be difficult to distinguish from chickenpox. Disseminated zoster may appear
Continued on next page March 2013 | SAN MATEO COUNTY PHYSICIAN 9
as widespread blisters with or without an associated dermatomal eruption, or may present as widespread ecthymatous ulcers or hyperkeratotic verrucous lesions. The verrucous pattern is more often seen with prolonged infection in immunocompromised patients who have been treated with antivirals.
acute retinal necrosis, and severe post-herpetic neuralgia. Rapidly progressive outer retinal necrosis (PORN) and acute retinitis are feared ocular manifestations of VZV disease, and respond poorly to therapy.
The differential diagnosis in a patient with suspected shingles includes bacterial cellulitis, recurrent herpes simplex virus, or contact dermatitis (such as poison oak).
Pain, described as burning, stabbing, or aching, is a common complication of shingles. Although acute pain may resolve as the skin lesions heal, pain may persist long after healing has occurred (“post-herpetic neuralgia”). Post-herpetic neuralgia can be severe and disabling and results in significant long-term morbidity. The risk of post-herpetic neuralgia increases with age, and is more likely to occur in elderly patients as compared to younger individuals.
Pneumonitis
Pain
All adults with chickenpox or disseminated zoster are at risk for varicella pneumonia; the risk is especially high in pregnant women with primary infection. Varicella pneumonia is much less common in children with uncomplicated illness. Although many patients have only Diagnosis mild respiratory symptoms, severe pulmonary involvement (with hypoxemia, cyanosis, and death) can occur. For this The diagnosis of VZV infection is often suspected from reason, all adults with chickenpox should be followed the clinical presentation, but laboratory studies may be closely for respiratory symptoms. required for confirmation. Testing Chest radiography is warranted for options include virus culture, antigen patients who complain of dyspnea, detection, nucleoprotein detection, Although acute pain may cough, or other respiratory symptoms. and serology. In most instances Radiographic abnormalities in VZV of cutaneous manifestations, the resolve as the skin lesions pneumonia are more pronounced than diagnostic procedure of choice is are clinical signs and symptoms, and heal, pain may persist long the demonstration of virus antigens include diffuse coalescent nodular on cells obtained directly from densities. cutaneous lesions. Scrapings obtained after healing has occurred from the lesions are stained with Encephalitis specific monoclonal antibodies. (“post-herpetic neuralgia”). This technique is rapid, relatively Encephalitis is a rare complication Post-herpetic neuralgia can inexpensive, and reliable. of VZV infection. Symptoms usually
develop 3 to 8 days after onset be severe and disabling and Virus culture is less sensitive than of chickenpox and 1 to 2 weeks direct antigen staining in the diagnosis after development of shingles. of VZV. Unlike herpes simplex virus, results in significant longEncephalitis occurs more frequently VZV remains highly cell associated in with zoster in the ophthalmic term morbidity. tissue culture and is not released in distribution, and cerebellar findings high titer into the overlying media. are typical; including ataxia, tremors, Cytopathic effects develop slowly and dizziness. Corticocerebral in tissue culture, and culture results are typically not involvement may result in headache, vomiting, and available soon enough to be clinically useful. A virus lethargy. Cerebrospinal fluid findings are usually culture in a patient with suspected VZV infection is often nonspecific, showing mononuclear pleocytosis, elevated obtained to exclude the presence of herpes simplex virus. protein concentration, and negative viral cultures. Diagnosis can be made most reliably by demonstration of Serologic testing can determine whether a patient has VZV nucleoprotein in CSF through PCR testing. prior VZV infection, but it usually is not useful in the evaluation of a patient with an acute illness suspected to be Ophthalmic Zoster due to VZV. Serologic testing is indicated when immunity to VZV must be determined, as in a patient without a Zoster of the ophthalmic division of the trigeminal nerve history of chickenpox. When performed, serologic testing can result in permanent visual loss. Pain may precede the should be performed by using fluorescence antibody to development of skin lesions, and may be severe. Skin lesions membrane antigen (FAMA) or enzyme immunoassay (EIA) may be extensive and confined to the affected dermatome techniques. Complement fixation is not used, because this with involvement of the conjunctivae, cornea, and other assay becomes negative after resolution of acute infection. eye structures. Virus infection and inflammation of eye structures can result in anterior uveitis, corneal scarring,
10 San Mateo county physician | March 2013
Detection of VZV nucleoprotein by PCR is sensitive but more costly that other testing options. This assay is most useful when applied to CSF in patients with suspected VZV central nervous system infection.
Treatment Antiviral treatment for chickenpox or shingles should begin as early as possible once the infection is identified. Treatment of severe or disseminated VZV infection usually mandates hospitalization and intravenous antiviral therapy. Whether a patient requires inpatient or outpatient therapy should be determined on the basis of the extent and severity of the infection, the immune status of the host, and whether visceral or cutaneous dissemination has occurred. Acyclovir
Valacyclovir and Famciclovir Valacyclovir and famciclovir have improved bioavailability as compared to acyclovir and result in higher antiviral serum levels. Both agents have good in vitro activity against VZV. As compared to oral acyclovir, valacyclovir 1 gram 3 times daily significantly accelerated the resolution of “zoster-associated pain,� and fewer valacyclovirtreated patients still had pain 6 months later. High dose oral valacyclovir (8 grams per day) has been linked to thrombotic thrombocytopenic purpura and hemolytic uremic syndrome in severely immunocompromised patients, so valacyclovir dosing should not exceed 1 gm 3 times daily. Famciclovir 500 mg 3 times daily results in accelerated healing of zoster lesions and faster resolution of acute pain as compared with placebo. Both famciclovir and valacyclovir are excreted by renal mechanisms, and dosage adjustment of both medications is required in renal dysfunction.
Oral acyclovir is effective in the treatment of chickenpox in both immunocompetent children and adults, with Antiviral Resistance reduced total number of lesions, duration of fever, and duration Persistent disseminated VZV infection of illness as compared to placebo In most cutaneous that fails to respond to intravenous treatment. Treatment should begin or oral acyclovir has been described within 24 hours of the onset of the manifestations, the in severely immunocompromised skin rash for maximal efficacy, but is patients. When tested in vitro, virus likely to still be effective as long as new diagnostic procedure of strains isolated from these lesions lesions continue to occur. Treatment have developed altered or deficient of shingles with oral acyclovir is choice is the demonstration activity of viral thymidine kinase, an effective in accelerating skin healing enzyme necessary to activate acyclovir and preventing virus dissemination, of virus antigens on cells by phosphorylation. Since crossand may also reduce the risk of postresistance is to be expected to both herpetic neuralgia. For optimum obtained directly from famciclovir and valacyclovir, neither benefit, treatment of shingles should of these agents should not be used begin as soon as possible (preferably cutaneous lesions. Scrapings in this setting. Intravenous foscarnet within 72 hours of onset of the skin should be considered for drugrash) and continued for at least 7 days obtained from the lesions resistant VZV infection, although or until all lesions have dried and careful study has been limited by the crusted. Since VZV is more resistant are stained with specific rarity of this condition. to acyclovir than herpes simplex monoclonal antibodies. virus, higher doses of oral acyclovir Steroids (800 mg 5 times daily in adults) are Treatment with corticosteroids in needed to produce serum levels that patients with zoster to prevent postare adequate to treat VZV infection. herpetic neuralgia remains controversial. One trial Intravenous acyclovir is used for severe or disseminated demonstrated that administration of corticosteroids in VZV infection in patients who require hospitalization. combination with an effective antiviral agent reduces acute The dose of intravenous acyclovir for the treatment of pain and improves the quality of life in immunocompetent VZV infection in patients with normal renal function is patients 50 years of age or older, but had no effect on the 10 mg/kg every 8 hours. Because acyclovir is primarily presence of post-herpetic neuralgia 6 months later. In eliminated by glomerular filtration, adequate hydration view of the potential risk of virus dissemination while should be maintained to prevent crystallization of the on steroids, immunocompromised patients with zoster drug in the renal tubules and the dosage must be adjusted should not be treated with steroids alone, but treatment for renal dysfunction. As of February 2013, there remains with a combination of tapering steroids and an effective a national shortage of IV acyclovir, and the drug is not antiviral regimen could be used cautiously for individuals widely available. In this setting, IV ganciclovir or IV at high risk of post-herpetic neuralgia. foscarnet could be used.
Continued on next page March 2013 | SAN MATEO COUNTY PHYSICIAN 11
Specific Treatment Recommendations
VZV Vaccines
Prompt antiviral therapy is indicated for all patients with chickenpox and shingles. Treatment should begin as soon as possible to be maximally effective, and may consist of oral acyclovir, intravenous acyclovir, oral famciclovir or oral valacyclovir. Intravenous acyclovir (10 mg/kg every 8 hours with dosage adjustment for impaired renal function) is indicated for patients with primary varicella complicated by visceral involvement, ophthalmic zoster, or disseminated recurrent zoster (cutaneous or visceral). Patients with severe localized zoster may also require hospitalization and intravenous acyclovir therapy, especially if parenteral analgesia for pain control is required or if high-dose oral antiviral drug therapy is not tolerated. As mentioned above, if IV acyclovir is not available, IV ganciclovir or IV foscarnet are alternative parenteral agents.
Two attenuated live VZV vaccines are licensed for use in the United States. These vaccines contain the attenuated OKA strain of VZV in different amounts and have separate clinical indications. The vaccine used to prevent primary VZV infection (Varivax ®, Merck) is given as two doses one to three months apart. Studies show that this regimen protects against primary VZV infection, but two doses are needed for maximal protection due to vaccine failure following a single dose. Patients with an uncertain history of prior VZV infection should be screened serologically before vaccination to determine whether immunity is present. Because the vaccine is composed of a live virus, latency occurs after vaccination and recipients are at risk of developing zoster from the vaccine strain. The duration of protection afforded by the vaccine remains under investigation, and vaccinated individuals may require additional booster doses later in life. Due to the theoretical risk of virus dissemination from this live virus vaccine, patients should be evaluated promptly should a post-vaccination, varicella-like rash occur, and consideration should then be given to effective antiviral therapy.
Patients with localized dermatomal zoster who do not require hospitalization can be treated with oral acyclovir 800 mg 5 times daily, famciclovir 500 mg 3 times daily or valacyclovir 1 gm 3 times daily. Therapy should be initiated within 72 hours of the onset of symptoms, and should be continued until all external lesions are crusted. Initial high dose and subsequent tapering steroids administered along with an effective antiviral drug can be used in patients with shingles who are at risk for postherpetic neuralgia. Proper local care of cutaneous lesions is important to prevent secondary bacterial or fungal infection in patients with chickenpox or zoster. Lesions should be kept clean and dry whenever possible. Necrotic areas can be gently debrided with “wet-to-dry” saline dressing changes. Antihistamines, Calamine lotion, or other anti-pruritic agents can be used to reduce pruritis and scratching. Empiric antibacterial or antifungal therapy is usually not indicated, but areas suspected of being secondarily infected should be evaluated by gram stain and culture for bacteria and fungi. Treatment of secondary bacterial or fungal infection should be started based of clinical suspicion and identification of the pathogenic organisms.
The vaccine used to prevent reactivated VZV disease (Zostavax ®, Merck) contains 14 fold greater amount of OKA virus as compared to Varivax ®. In nonimmunocompromised hosts 50 years of age and above, the vaccine reduces the risk of developing zoster and developing post-herpetic neuralgia. The Centers for Disease Control and Prevention recommends that all non-immunocompromised adults 60 years of age and older receive the vaccine, including those individuals who have already had shingles. Due to the theoretical risk of virus dissemination from this live virus vaccine, Zostavax is not routinely recommended for immunocompromised patients. Patients who receive Zostavax should be evaluated promptly should a post-vaccination, varicellalike rash occur, and consideration should then be given to effective antiviral therapy. ■
Post-Herpetic Neuralgia
About the Author
Post-herpetic neuralgia can be severe and incapacitating, and may be a major source of morbidity in many patients. Several treatment options are available, but no comparative trials have been published to assist in selection of therapy. Most patients with post-herpetic neuralgia have gradual improvement in symptoms over time. Treatment options include non-narcotic analgesics, narcotics, gabapentin, pregabalin, anticonvulsant agents (phenytoin and carbamazepine), tricyclic antidepressants (amitriptyline, desipramine), phenothiazines, cimetidine, or topical capsaicin.
Kim S. Erlich, MD, is an Associate Clinical Professor of Medicine at the University of California, San Francisco; a consultant in Infectious Diseases with Northern Peninsula Infectious Diseases; and Medical Director of Infection Control at MillsPeninsula Health Services.
12 San Mateo county physician | March 2013
Hepatitis B: The Silent Killer Do You Know Who’s at Risk? Hepatitis B is a serious liver infection caused by the hepatitis B virus, which can cause both acute and chronic infections. People with chronic hepatitis B are at increased risk for developing serious liver damage or liver cancer. In fact, 60-80% of primary liver cancer worldwide is caused by chronic HBV infection. Hepatitis B is most often spread from mother to child at birth when the mother is infected. However, it can also be spread by coming in contact with infected blood after an injury that breaks the skin or through bodily fluids during intercourse with an infected person. More than two-thirds of HBV cases exhibit no symptoms, so many people who become chronically infected don’t realize until it’s too late. If symptoms develop, they are often mistaken for those of influenza: fever, fatigue, joint or muscle pain, loss of appetite, nausea, and vomiting. Jaundice, which is usually a sign of liver damage, may not occur. San Mateo Hep B Free, a program administered by the SMCMA Community Service Foundation, seeks to eradicate hepatitis B in San Mateo County. This grass roots movement of health care providers, community organizations, elected officials, student volunteers, and concerned citizens is led by SMCMA member Dirk Baumann, MD. The overall goal is to provide universal hepatitis B screening and vaccination for Asian, Pacific Islander and other high-risk residents of San Mateo County, who bear a disproportionate burden of liver disease and liver cancer as a result of undetected chronic hepatitis B infection. Dr. Baumann volunteers a great deal of his time attending free health screening
events, answering patient questions about hepatitis B, and ensuring follow-up care to all patients who’s results come back antigen positive. After each community outreach event, he personally calls all patients who test positive to ensure they understand their test results and have access to a primary care physician for follow-up treatment, regardless of their financial situation. Approximately 2 billion people worldwide have been infected by hepatitis B. An estimated 1.25 million Americans are chronically infected, and more than half are Asian and Pacific Islander (API) Americans. As many as one out of 10 API Americans are chronically infected with HBV, compared with one in 1,000 of Caucasian Americans. The only way to reduce this health disparity is to test every at-risk patient that comes in for hepatitis B. Since the inception of San Mateo Hep B Free, the program has provided free hepatitis B testing to more 700 at-risk individuals living in San Mateo County. It is of utmost importance that patients are being screened for this disease, especially those of Asian and Pacific Islander descent, and that physicians understand the different methods of treatment, which can prevent hepatitis B from becoming lifethreatening. There are many opportunities for physicians and hospitals to support this important program, including hosting screening and vaccination events and helping raise public awareness about hepatitis B. For more information, please contact Karen Stone at (650) 312-1663 or kstone@smcma.org. ■
San Mateo Hep B Free Financial Contributors The following SMCMA members made a financial contribution to support the work of San Mateo Hep B Free. Harvey Kaplan, MD Dean Kardassakiss, MD R. Levin, MD Peter Mandell, MD Edward K. Onuma, MD Karen Relucio, MD Ernest Ribera, MD Alvaro Rodriguez, MD William L Schwartz, MD John Skerry, MD Edward Sun, MD
Thank You
March 2013 | SAN MATEO COUNTY PHYSICIAN 13
Vaccination Update Pneumovax, Diphtheria & Acellular Pertussis, Influenza, Shingles, and HPV Jamila Champsi, MD Vaccination has significantly decreased the morbidity and mortality from infectious diseases. Just as the diseases evolve and change, so do their vaccines. For the most up-to-date information, I usually refer to the CDC’s Advisory Committee on Immunization Practices (APIC). Recent changes in adult immunization cover pneumovax, diphtheria and acellular pertussis (Tdap), influenza, shingles and human papillmavomavirus (HPV). Acellular pertussis (Tdap) coverage has been expanded to include one dose to patients aged 65 years and older. Pregnant women are to be given one dose of Tdap with each pregnancy, optimally at 27 to 36 weeks of gestation. The pneumococcal vaccine schedule has changed to include the use of 13 valent pneumococcal conjugate vaccine (PCV13) in certain groups. The schedule also limits the total lifetime dosages to three for pneumococcal polysaccharide vaccine (PPSV23). For individuals over the age of 65, only one lifetime dose of PPSV23 is recommended. If an individual is vaccinated before between age 19 and 64 years for chronic renal failure, nephrotic syndrome, chronic lung disease, chronic heart
disease, chronic liver disease, a repeat vaccine PPSV23 should be given in five years, with the last dose after age 65. Smokers and residents of care facilities are also included in this group. Patients who have asplenia (functional or anatomic), HIV, CSF leaks, cochlear implants, or immunocompromising conditions and have never received pneumococcal vaccine should be given PCV13 followed in eight weeks by PPSV23, with repeat vaccine PPSV23 in five years followed by the last dose at age 65. If the individual has received PPSV23, then PCV13 needs to be given at least one year after the PPSV23. Follow up PPSV23 should then be given five years after the first PPSV23. The influenza vaccine for the 2013-2014 season will be quadrivalent. Presently the trivalent flu vaccine contains A(H1N1)and A(H3N2) and one B strain. Next year, it will contain antigens from two linages of influenza B (Victoria and Yamagata) to give better coverage. The shingles vaccine has been approved by the FDA to be given to individuals over the age of 50 years, but the CDC continues to recommend it for individuals over the age of 60 years. The HPV vaccine quadrivalent is not a live vaccine. It has been approved for use in HIV-positive males up to age 26 years and men who have sex with men. ■
Vaccination Resources For the latest information from the CDC’s Advisory Committee on Immunization Practices (APIC), visit: www.cdc.gov/mmwr/pdf/wk/mm62e0128.pdf. Additionally, www.immunize.org has easy-toread, downloadable tables that help simplify the schedules.
14 San Mateo county physician | March 2013
About the Author Jamila Champsi, MD, is an infectious diseases physician at Kaiser Permanente in South San Francisco. A graduate of the University of Arizona College of Medicine, she is board-certified in internal medicine and infectious diseases.
STD Update Gonorrhea, Syphilis & HIV
Jamila Champsi, MD The Centers for Disease Control and Prevention last updated its guidelines for the treatment of sexually transmitted diseases in 2010. This article will discuss recent changes in the recommended treatment of STDS. The most concerning change relates to the treatment of gonorrhea. Since 2012, there have been reports of resistance to cephalosporins in gonorrhea. CDC updated the recommended treatment to use two drugs: Ceftriaxone (250mg IM) with 1 gram oral azithromycin. If a patient is allergic to ceftriaxone, 2 grams of oral azithromycin can be used instead, but the patient needs to return to be retested for a cure. Always remember to test for HIV and other STDs when treating a patient with gonorrhea. (MMWR Aug 10,2012, 61(31)pg 590-594).
tertiary disease, then the patient is treated for latent syphilis with three weekly injections of benzathine penicillin. •
If the T pallidium IgM/IgG is positive. the RPR is negative, and the TP-PA or FTA is negative, you have a false positive test. If clinical suspicion is high, repeat the test in one month to rule out a false negative due to very early disease. (MMWR Aug 15 2008 Vol 57(32)pg 872-875).
Table: STD Cases Reported in San Mateo County Residents, 2012 and 2011
As an infectious diseases physician, I am frequently called upon to help interpret the new syphilis test. The syphilis test has been changed to an automated treponemal test, which is an automated enzyme immunoassay (EIA) that tests for T.Pallidum IgM/ IgG. This allows for the testing of a large number of specimens. If the initial test is positive, it is followed by retesting the specimen with a nontreponemal test (RPR), followed by a confirmatory test: either the Treponema pallidum particle agglutination (TP-PA) or fluorescent treponemal antibody (FTA-ABS). Not all laboratories will do the third step. Briefly: •
If the T pallidium IgM/IgG is positive and the RPR is positive, the patient has syphilis and needs treatment.
•
If the T pallidium IgM/IgG is positive and the RPR is negative, the result is unclear and the lab needs to do a TP-PA or an FTA.
•
If the TP-PA or FTA is positive, the patient may have syphilis, usually very early or very late latent syphilis, or may have been treated successfully for syphilis. Usually, a history of treatment needs to be elicited. If there is no history of treatment and no evidence of
**Data not available. Source: San Mateo County Health System, STD/HIV Program, Quarterly Report. For the full report, visit http://smchealth.org/sites/default/files/docs/PHS/STDHIV/STD_2012_4thQR.pdf.
Continued on next page March 2013 | SAN MATEO COUNTY PHYSICIAN 15
STD Update (continued) The most interesting recommendation is pre-exposure prophylaxis for HIV. Studies done in serodiscordant couples found that if the HIV negative partner took daily Truvada (Tenofovir/Emtricitabine), there was a 44-90% decrease in seroconversion. This regime requires very close follow-up with an infectious disease doctor. It is concerning because a healthy person is being exposed to the side effects of the medication and risking selecting for HIV resistance. (MMWR Jan 28 2011,60(03)pg 65-68). This protocol needs to be decided on a case-by-case basis and can be considered when a serodiscordant couple is considering pregnancy. The San Mateo County Public Health Department has a very active STD/HIV program. Please remember to send in a Confidential Morbidity report whenever you diagnose a sexually transmitted disease. The Department runs a STD clinic and can help with patient tracking and partner notification. The telephone number for the STD clinic is (650)573-2999. The Partner notification telephone number is (650) 573-2609. The knowledgeable public health staff are a great resource and I have always found them to be very helpful. ■
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*Source: Stephen F. Jencks, M.D., M.P.H., Mark V. Williams, M.D., and Eric A. Coleman, M.D., M.P.H.; NEJM 2009; 360:1418-1428
16 San Mateo county physician | March 2013
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