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1. MPX (Monkeypox)
Situational Update: Cases of MPX are now decreasing globally, nationally, and locally. As of September 21, 2022, there are 173 probable or confirmed cases of MPX In Santa Clara County with a rolling 7-day average of <1 new case/day down from a peak of 4 cases/day in August. Transmission continues to be primarily among men who have sex with men (MSM) and transgender individuals and associated with sexual contact. The majority of cases are less than 45 years of age, and 55% are Latinx. A minority of cases have occurred due to household transmission. There has been no evidence locally of respiratory transmission.
Updated California Department of Health Community Exposure Management Guidance
With these transmission patterns also observed at the state level, CDPH updated their exposure guidance for the general community on September 8, 2022. Key distinctions from previous CDC guidance include (a) renaming of exposure categories from High, Intermediate, and Low, to Exposed, Potentially Exposed, and Low Risk of Exposure, respectively, (b) removal of shared air space as an exposure criterion regardless of masking, and (c) change of monitoring requirements for the lowest risk category from “monitor” to “consider monitoring.”
Please continue to follow the CDC guidance for health care settings and CalOSHA’s Aerosol Transmissible Diseases Standard where applicable. Additional guidance is anticipated for custody and other congregate settings.
Updates to Vaccine Eligibility, Administration, and Minor Consent
- On September 8, 2022, the County of Santa Clara expanded vaccine eligibility to all MSM or transgender people and sex workers. Those with new or multiple sex partners within these groups are at highest risk and are encouraged to be vaccinated. Further expansion of eligibility criteria is expected in the near future. See our website for current vaccine eligibility criteria.
- Use of recommended personal protective equipment (PPE) remains the most important tool for preventing transmission to health care workers. Health care workers seeking pre-exposure prophylaxis (PREP) should follow ACIP criteria.
- For adults receiving the Jynneos vaccine intradermally, the volar surface of the forearm is the “preferred” location. However, if this site is not an option (e.g. strong patient preference), other acceptable locations for intradermal administration include the upper back below the scapula and the skin over the deltoid.
- California law allows minors who are 12 years of age or older to consent to diagnosis and treatment of any reportable disease and to prevention of a sexually transmitted disease. (Fam. Code, § 6926, subd. (a)-(b).) The County of Santa Clara Health Officer has determined that MPX is a sexually transmitted disease, although it is also spreading by other means. Therefore, individual care systems may determine that minors ages 12 and up can consent to MPX testing, treatment, and vaccine for prevention. In instances where a minor consents to services, health care providers are not permitted to inform a parent or legal guardian about the care received without the minor’s consent. However, these minors should be informed that anyone with the legal authority to access their health information (i.e., parents/legal guardians) may be able to view/obtain vaccine records (e.g., through the State's CAIR2 immunization registry). Providers should consult with legal counsel for any questions regarding compliance with relevant laws.
Updates to Treatment Indications
- Due to concerns for viral mutation with over-use of Tecovirimat (TPOXX), CDC revised its treatment indications on September 15, 2022. New guidelines recommend treatment only for those with severe disease, involvement of anatomic areas which might result in serious sequelae that includes scarring or strictures, and people at high risk of severe disease.
- Both CDC and CDPH have released guidance on supportive measures and pain control for individuals, particularly those with genital/anorectal lesions.
2. COVID-19 and Influenza
Situational Update: Although laboratory-reported COVID-19 case counts are declining, community transmission of COVID-19 remains significant, as evidenced by wastewater data. In addition, the newest emerging variants of concern (BA.2.75 and BF.7) have been detected in Santa Clara County. While transmission patterns during the winter season are not entirely predictable, increases in indoor and travel-related transmission are anticipated this winter. Due to changes in masking policies and other factors, influenza activity is also anticipated to be higher this season than during the 2020 or 2021 influenza seasons.
Provider Updates:
- Indoor masking continues to be strongly recommended in public settings and required in high risk settings in Santa Clara County, independent of changes to state masking requirements.
- Both Pfizer and Moderna COVID-19 bivalent booster vaccines are now widely available throughout the county. Providers should use all patient encounters to provide vaccination and/or encourage patients to get vaccinated if at least 2 months from last vaccination (primary series or booster dose).
- This year, the ACIP influenza recommendations preferentially recommends adults aged 65 or older receive higher dose or adjuvanted flu vaccine formulations.
3. West Nile Virus
Situational Update: As of September 16, 2022, there have been 54 human cases of WNV in California, including 4 deaths, reported from 15 counties. In Santa Clara County, increased West Nile Virus activity has been detected in both mosquitoes and birds, particularly in the Northern part of the county (Sunnyvale, Mountain View, and Los Altos Hills). Although no human cases in SCC have been reported to date, current weather conditions are thought be promoting WNV transmission and pose an increased threat to humans in the coming month.
Recommended Action Steps for Providers:
(a) Maintain high suspicion for WNV: WNV should be considered in any person with a febrile or acute neurologic illness who has had recent exposure to mosquitoes, blood transfusion, or organ transplantation. Severe WNV can present as meningitis, encephalitis, or acute flaccid myelitis (like polio). More information for clinical providers can be found here.
(b) Test suspect cases (serum or cerebrospinal fluid (CSF) to detect WNV-specific IgM antibodies.
(c) Report WNV cases promptly to the PHD (Call 408-885-4214, ext 3 within 1 business day)
4. Acute Flaccid Myelitis (AFM)
Situational Update: Prior to COVID pandemic, there have been periodic surges in late summer and early fall of enterovirus D68 (EV-D68) (the virus most commonly associated with AFM cases), followed by surges in AFM in subsequent weeks. From January 1, 2022, through September 14, 2022, there have been 11 suspected cases in California, 6 of which have been confirmed by CDC as AFM. In August 2022, an increase in EV-D68 respiratory disease was detected in sentinel surveillance sites in the United States, including California, raising concern for a surge in AFM cases in coming weeks.
Recommended Action Steps for Providers:
(a) Retain high vigilance for AFM: Cases generally occur among children. Symptoms typically include a preceding febrile respiratory illness followed by sudden onset of limb weakness and loss of muscle tone and reflexes. Acute flaccid myelitis due to poliovirus may have a similar presentation.
(b) Hospitalize the patient immediately: Monitor the respiratory status of patients. Order an MRI of the spine and brain with the highest Tesla scanner available. Consult promptly with specialists in neurology and infectious diseases. Follow CDC’s standard, contact and droplet infection control precautions for suspected or confirmed AFM cases.
(c) Test suspect cases: Collect cerebrospinal fluid (CSF), serum, stool (x2), and respiratory specimens (nasopharyngeal or oropharyngeal swabs) as early as possible to maximize likelihood of finding etiology.
(d) Report patients of any age suspected to have AFM or polio as soon as possible: Report immediately by phone: 408-885-4214, ext 3.
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