Presence of rabies in community
Springfield-Greene County Health (SGCHD) has identified two positive cases of rabies in bats in September. While the exposure risk to the community remains low, the percentage of animals positive for rabies in Springfield and Greene County is unknown and remains a present risk.

Assessment
Post-exposure assessment for administration of Prophylaxis (PEP):

1. Has the person been bitten by a mammal?
   
   • Rabies is only transmitted by mammals.
   • Unprovoked attacks are especially concerning.
2. Does the person have an open wound, broken skin or mucous membrane contact with the saliva or CNS of the animal?
3. Has the person had contact with a bat such that a bite or scratch cannot be ruled out? (Ex: sleeping person, child)
   
   • Administer PEP if the bat is not present to test.
4. Can the animal be monitored or tested?
   
   • If a high risk wild animal (such as a bat, raccoon, skunk, fox, coyote, bobcat, woodchuck) is not present to test, administer PEP. Treatment can be discontinued if the animal is found and tests negative.
5. If the animal is domestic, is it vaccinated against rabies?
   
   • If unvaccinated, consider PEP over observation if there has been a bite to the person’s face.
   • Any outside, unsupervised animal is considered at-risk.

PEP vaccination considerations

Never received rabies vaccine series	RIG rabies immune globulin	On Day 0 administer total dose of HRIG 20 international units/kg body weight, As much of the full dose as feasible should be infiltrated around the wound(s). Remaining should be given IM at a different location and syringe than the vaccine. Deltoid is preferred
	Vaccine	HDCV or PCECV: one dose (1 mL) IM on days 0, 3, 7, and 14. (4 total doses) Deltoid preferred, should NEVER be administered in the glute as this may result in lower titers Resume schedule maintaining the same interval between dosage if patient misses a dose If patient is immunocompromised, administer a fifth dose on day 28 of the series.
**Previously vaccinated	RIG	Not indicated
	Vaccine	HDCV or PCECV: one dose (1 mL) IM on days 0 and 3

**Previously vaccinated defined as:

• Prior completion of a 3-dose pre-exposure or 4-dose post-exposure series.
• Completion of at least two doses of a pre-exposure prophylaxis series within the 3 years prior to exposure.
• Prior partial completion of a pre- or post-exposure series with a subsequent titer ≥0.5 IU/mL (Check titer if patient was immunosuppressed at time of vaccination).
• Prior vaccine doses given after the 1980s (advent of modern vaccines including PCECV, HDCV or PVRV).

Source: Committee on Infectious Diseases, American Academy of Pediatrics. (2024). Rabies. In Red Book: 2024–2027 report of the Committee on Infectious Diseases (33rd ed., pp. 702‑711). American Academy of Pediatrics.

For unvaccinated individuals, PEP should always include both HRIG and rabies vaccine. This combination is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment. HRIG can be administered up to seven days after the administration of the first dose of vaccine. Beyond this time frame, it is presumed an antibody response will have occurred.
Contact the Health Department if you are unsure about whether to administer PEP.

Reporting animal bites/exposures

Missouri Secretary of State: Code of State Regulations (mo.gov)

• Reportable within one (1) day, diseases or findings are—Animal (mammal) bite, wound, humans.
  • Information Hospitals/clinics are required to send to your Health Department/State Health Department: a case report as required in section (6) of this rule shall include the patient’s name, home address with zip code, date of birth, age, sex, race, home phone number, name of disease, condition or finding diagnosed or suspected, the date of onset of the illness, name and address of the treating facility (if any) and the attending physician, any appropriate laboratory results, name and address of the reporter, treatment information for sexually transmitted diseases, and the date of report.

When reporting cases of rabies, include:

• Patient address
• Phone number
• Dosage administered
• Date of bite occurrence
• Date patient was seen

Attempt to locate confirmatory medical records for previously vaccinated individuals. Show Me Vax does not have RIG records, but the Health Department may.

The investigation

• General Guidance for Domestic Animal (cat, dog, or ferret) that bites a person
  • Call Animal Control/Sheriff to see if they are aware of the situation, gather details about the circumstances of the bite and the animal’s health status.
  • Call animal owner and determine if the animal has had their rabies vaccines. If so, when was the last vaccine administered? Who was the veterinarian that administered the vaccine?
  • Call the veterinarian to verify the animal is up to date (fax/email record).
  • Call bite victim and determine extent of injury (where is the bite located, etc). Where did the bite occur, was the bite provoked, what were the circumstances leading up to the bite? Did the victim seek medical care? Where? Were antibiotics prescribed? Did the physician provide rabies education and offer/discuss RPEP? Was RPEP initiated or declined?
  • Call and recheck on biting animal and bite victim to share updates or results.
• All persons bitten by wild animals (and not tested for Rabies via the SPHL) should be educated about rabies risk and referred to their medical provider to discuss the need for RPEP as soon as possible.
• There is no approved observation period allowed for wild animals that bite humans (including wild/domestic animal hybrids such as a wolf/dog hybrid). The 10 day quarantine period does not apply to any animal that is not a cat, dog, or ferret.

Resources

• The CDIRM link: https://health.mo.gov/living/healthcondiseases/communicable/com municabledisease/cdmanual/index.php
  • The CDIRM is Missouri’s Communicable Disease Investigation Reference Manual and it’s where you’ll find info on how MO handles each reportable condition
  • Animal Bites / Injuries Section
  • Rabies, Animal Section
  • Rabies, Human Section
• Compendium for Animal Rabies Prevention and Control: http://www.nasphv.org/Documents/NASPHVRabiesCompendium.pdf
• ACIP Recommendations: https://www.cdc.gov/mmwr/PDF/rr/rr5703.pdf
  • In 2010, ACIP moved from a 5 dose series to a 4 dose series for rabies post-exposure prophylaxis. The document outlining the rationale for moving to a 4 dose series is here: https://www.cdc.gov/mmwr/pdf/rr/rr5902.pdf.
  • All of the background information about exposures, administration, adverse reactions, etc. remains unchanged from the 2008 document. While both documents contain helpful information, the 2008 document is much more comprehensive and detailed.
• Immunosuppression: Because corticosteroids, other immunosuppressive agents, antimalarials, and immunosuppressive illnesses might reduce immune responses to rabies vaccines substantially, for persons with immunosuppression, rabies PEP should be administered using a 5-dose vaccine regimen (i.e., 1 dose of vaccine on days 0, 3, 7, 14, and 28), with the understanding that the immune response still might be inadequate. Immunosuppressive agents should not be administered during rabies PEP unless essential for the treatment of other conditions. If possible, immunosuppressed patients should postpone rabies preexposure prophylaxis until the immunocompromising condition is resolved.
• CDC Rabies Homepage: https://www.cdc.gov/rabies/index.html
• Rabies Vaccine: What is postexposure prophylaxis? (https://www.cdc.gov/rabies/medical_care/index.html)
  • Postexposure prophylaxis (PEP) consists of a dose of human rabies immune globulin ( and rabies vaccine given on the day of the rabies exposure (day 0), and then a dose of vaccine given again on days 3, 7, and 14. For people who have never been vaccinated against rabies previously, postexposure prophylaxis (PEP) should always include administration of both HRIG and rabies vaccine. The combination of HRIG and vaccine is recommended for both bite and non-bite exposures, regardless of the interval between exposure and initiation of treatment.
  • Human Rabies Immune Globulin
    • Human rabies immune globulin (HRIG or RIG) is administered only once, at the beginning of anti-rabies prophylaxis, to previously unvaccinated persons. This will provide immediate antibodies until the body can respond to the vaccine by actively producing antibodies of its own. If possible, the full dose of HRIG should be thoroughly infiltrated in the area around and into the wounds. Any remaining volume should be injected intramuscularly at a site distant from vaccine administration.
    • HRIG should never be administered in the same syringe or in the same anatomical site as the first vaccine dose. However, subsequent doses of vaccine in the four-dose series can be administered in the same anatomic location where the HRIG dose was administered.
    • If HRIG was not administered when vaccination was begun, it can be administered up to seven days after the administration of the first dose of vaccine. Beyond the seventh day, HRIG is not recommended since an antibody response to the vaccine is presumed to have occurred.
    • Because HRIG can partially suppress active production of antibody, no more than the recommended dose should be administered. The recommended dose of HRIG is 20 IU/kg body weight. This formula is applicable to all age groups, including children.
• Programs for Uninsured and Underinsured Patients (found within the CDC Rabies Homepage) If you have patients that should get RPEP but are concerned about cost, this is a good link for uninsured/under insured patients: https://www.cdc.gov/rabies/medical_care/programs.html
• MO DHSS Rabies Reports: https://health.mo.gov/living/healthcondiseases/communicable/rabies/reports.php

 

As of April 18, 2025 Missouri has detected measles in the state following outbreaks in several states and countries. Measles is highly contagious and can be life-threatening to anyone who is not vaccinated. Measles can be prevented with the measles-mumps-rubella (MMR) vaccine. DHSS is working with local health departments to investigate and respond to prevent further spread.

Read the CDC Health Advisory.

Key Points

• Measles is one of the most contagious diseases. MMR vaccine provides the best protection.
• Isolate infected patients for 4 days after they develop a rash and follow airborne precautions in healthcare settings.
• Report suspected measles cases to your local health department. During business hours:
  • Jodi Caruthers (417) 864-1582
  • Mariah Inman (417) 864-1698
• 24/7: DHSS Emergency Response Center: (800) 392-0272
• Laboratory confirmation is essential for all sporadic measles cases and all outbreaks.

Clinical Features
Healthcare providers (HCP) should consider measles in patients presenting with the following symptoms, particularly those who have traveled abroad or had contact with known measles cases:

• Fever ≥101°F (38.3°C) AND
• Generalized maculopapular rash lasting ≥3 days AND
• Rash usually begins at the hairline/scalp and progresses down the body.
• Cough, runny nose, or conjunctivitis OR Koplik spots (bluish-white specks or a red-rose background appearing on the buccal and labial mucosa usually opposite the molars).

 The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Sometimes immunocompromised patients do not develop the rash.

Measles is one of the most contagious of all infectious diseases. Up to 9 out of 10 susceptible people with close contact to a measles patient will develop measles. The virus is transmitted by:

• Direct contact with infectious droplets.
• Airborne spread when an infected person breathes, coughs, or sneezes.

Measles virus can remain infectious in the air for up to 2 hours after an infected person leaves an area.

Infection Prevention

Upon arrival to a healthcare setting: Persons with signs or symptoms of measles should be identified, provided a facemask to wear, and separated from other patients prior to or as soon as possible after entry into a facility.

• Adhere to Standard and Airborne Precautions when caring for patients with known or suspected measles.
• Immediately place patients with known or suspected measles in an airborne infection isolation room (AIIR).
• HCP should use respiratory protection (i.e., a respirator) that is at least as protective as a fit-tested, NIOSH-certified disposable N95 filtering facepiece respirator, regardless of presumptive evidence of immunity, upon entry to the room or care area of a patient with known or suspected measles.
• HCP without acceptable presumptive evidence of measles immunity should not enter a known or suspected measles patient's room if HCP with presumptive evidence of immunity are available.

Laboratory Testing

Measles testing should be performed for patients who:

• Meet the clinical case definition for measles (generalized maculopapular rash; and fever ≥101̊F; and cough, coryza, or conjunctivitis) AND
• Within the 21 days prior to symptom onset, had an elevated risk of exposure to measles including:
  • Had a known exposure to measles, or
  • Traveled internationally or to an area with known measles cases, or
  • Had contact with someone with a febrile rash illness, particularly if those individuals had traveled internationally or to an area with known measles cases.

Testing for measles is available through the Missouri State Public Health Laboratory and the CDC with prior authorization. Providers pursuing measles testing should collect specimens for both PCR testing (either a nasopharyngeal or throat swab) and serology (IgM, IgG). Measles testing to be performed by the MSPHL should go through the Virology Unit, phone # (573) 751-3334 before submission.

NOTE: Clinical specimens or isolates positive for measles performed by commercial clinical laboratories are to be submitted to the MSPHL for epidemiological or confirmation purposes.

Vaccination

Children

CDC recommends children should routinely get 2 doses of MMR vaccine:

• First dose at age 12 through 15 months
• Second dose at age 4 through 6 years (before school entry)

Adults

Adults and teens should be up to date on MMR vaccinations with either 1 or 2 doses (depending on risk factors); unless they have other presumptive evidence of immunity to measles, mumps, and rubella.

MMR efficacy against measles

Two doses of measles vaccine are 97% (range: 67% to 100%) effective at preventing measles.

One dose is 93% (range: 39% to 100%) effective at preventing measles.

ACIP recommends that people who don't have presumptive evidence of immunity to measles, mumps, and rubella should get vaccinated against these diseases.

Presumptive evidence of immunity can be established in any of the following ways:

• Written documentation of adequate vaccines for measles, mumps, and rubella
• Laboratory confirmation of disease
• Birth before 1957

 Travel

• Measles cases in the United States originate from unvaccinated international travelers.
• You should be vaccinated against measles at least 2 weeks before international travel.
• Call your doctor immediately if you think you or your child have been exposed to measles.

 Infants under 12 months old who are traveling:

• Get an early dose at 6 through 11 months.
• Follow the recommended schedule and get:
  • Another dose at 12 through 15 months.
  • A final dose at 4 through 6 years.

Children over 12 months old:

• Get first dose immediately.

• Get second dose 28 days after first dose.

Teens & adults with no evidence of immunity*:

• Get first dose immediately.
• Get second dose 28 days after first dose.

*Acceptable evidence of immunity against measles includes at least one of the following:

• Written documentation of adequate vaccination
• Laboratory evidence of immunity
• Laboratory confirmation of measles
• Birth in the United States before 1957

Resources

For Healthcare Professionals – Clinical Overview of Measles

Interim Measles Infection Prevention Recommendations in Healthcare Settings | CDC

Measles Infection Control in Healthcare Personnel | CDC

Acceptable Presumptive Evidence of Immunity to Measles | MMWR

ACIP Recommendations: Measles, Mumps and Rubella (MMR) Vaccine

Measles – Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

Plan for Travel – Measles | CDC

Laboratory Testing for Measles | CDC

Measles Serology Testing | CDC

CDC Measles Resources

Global Measles Outbreaks | CDC

Measles fact sheet: Missouri Department of Health and Senior Services

Measles virus information: Missouri State Public Health Laboratory

Think measles: American Academy of Pediatrics

Clinicians and laboratorians are reminded to test for influenza in patients with suspected influenza and to expedite the subtyping of influenza A-positive specimens from hospitalized patients, particularly those in an intensive care unit (ICU). This approach can help prevent delays in identifying human infections with avian influenza A(H5N1) viruses, supporting optimal patient care and timely infection control and case investigation.

Notify the Health Department promptly if avian influenza A(H5N1) virus infection is suspected, probable or confirmed in a hospitalized patient.

Read the full Health Alert.

December 2024

In 2024, reported cases of pertussis increased across the United States, indicating a return to more typical trends. Preliminary data show that more than five times as many cases have been reported as of week 43, reported on October 26, 2024, compared to the same time in 2023. The number of reported cases this year is higher than what was seen at the same time in 2019, prior to the pandemic.

As of December 19, 2024 there have been 72 cases identified in Greene County in 2024. There were 19 cases investigated in November, accounting for 26% of the cases in 2024. In comparison, Greene County saw 1 pertussis case in 2023 and 2 cases in 2022. The average number of cases from 2003-2023 is 10 per year.

Pertussis (whooping cough) usually starts with cold or flu-like symptoms such as runny nose, sneezing, fever and a mild cough. These symptoms can last up to two weeks and are followed by increasingly severe coughing spells. Fever, if present, is usually mild. Symptoms appear between six to twenty-one days (average 7-10) after exposure to the pertussis bacteria.

Among older children and adults, the disease usually results in symptoms that can be mistaken for bronchitis and Upper Respiratory Infections - persistent cough, but no whoop. In infants younger than 6 months, apnea (cessation of breathing) is a common manifestation and whoop may be absent.

It is important to remember that while pertussis is most often considered a young child's disease, it can occur at any age. Pertussis should be considered in older children and adults who have a persistent cough lasting more than 7-14 days that cannot be attributed to another specific illness. Untreated, these older children and adults can act as a reservoir for pertussis disease and infect younger children.

Pertussis can cause serious and potentially life-threatening complications in infants and young children, especially those who have not received all the recommended vaccines. Pertussis can also be more severe for infants younger than 2 months of age whose mothers did not get Tdap while pregnant. In infants younger than 12 months of age who get pertussis, about a third need treatment in a hospital. Hospitalization is most common in infants younger than 6 months of age.

Clinical Features

Specimen Collection and Diagnostic Testing
Whenever possible, clinicians should obtain an NP swab or aspirate from all persons with suspected pertussis. A properly obtained NP swab or aspirate is essential for optimal diagnostic results. The same specimen can be used both for culture and PCR. Ideally, specimens should be collected during the first 2 weeks of illness following cough onset.

Culture:

• Culture is the gold standard test for pertussis, as it provides 100% specific identification of Bordetella pertussis.
• Best when collected during the first 2 weeks following cough onset; sensitivity decreases and the risk of false negatives increases after 2 weeks.
• If culture is planned, the NP swab should be directly plated or immediately placed in a transport medium. Specimens should be plated within 24 hours of collection.
• It may take up to 7 - 10 days to obtain results via culture.

Polymerase Chain Reaction (PCR):

• Most commonly used laboratory method for B. pertussis due to the rapid turnaround time and high sensitivity.
• Specimen should be collected during the first 3 to 4 weeks of illness following cough onset.

Serology:

• Serologic tests can be helpful for diagnosis later in the course of illness (2 – 8 weeks after onset of cough, but up to 12 weeks following onset).

The Missouri State Public Health Laboratory (MSPHL) can perform PCR and culture testing for Bordetella pertussis. Testing for pertussis at MSPHL should be coordinated through the Microbiology Unit (1-573-751-3334) or through the Springfield-Greene County Health Department.

Vaccination Schedule

• Infants—3 doses DTaP—at 2, 4 and 6 months of age.
• Children—2 doses DTaP—at 15 to 18 months and at 4 to 6 years of age.
• Adolescents—1 dose Tdap—at 11 to 12 years of age.
• Pregnant people—1 dose Tdap between 27 and 36 weeks gestation during every pregnancy.
• Non-pregnant adults—1 dose Tdap and a booster every 10 years.

See Diphtheria, Tetanus, and Pertussis Vaccination: Information for Healthcare Professionals for information on all pertussis vaccine recommendations by vaccine, age, and indication.

Post-exposure prophylaxis (PEP) through antimicrobial therapy options is recommended for:

• All household contacts of a pertussis case.
• High risk contacts within 21 days of exposure to an infectious pertussis case. High risk persons include:
  • Infants and women in their third trimester of pregnancy.
  • All people with pre-existing health conditions may be exacerbated by a pertussis infection.
  • People who have close contact with infants (under 12 months of age), pregnant women, or individuals with pre-existing health conditions.
  • All people in high -risk settings (i.e., neonatal intensive care units, childcare settings, maternity wards).
• Broad use of PEP may be appropriated in limited closed settings when the number of identified cases is small and when a community-wide outbreak is not ongoing.

Treatment

A 5-day course of azithromycin is the appropriate first-line choice for treatment and post-exposure prophylaxis. After the paroxysmal cough is established, antimicrobial agents have no discernible effect on the course of illness but are recommended to limit the spread of organisms to others. Erythromycin or Clarithromycin are also recommended, or Trimethoprim-sulfamethoxasole can be used as an alternative.

Early treatment of pertussis is most effective for reducing symptom severity. The earlier a person, especially an infant, starts treatment the better. If a person starts treatment during the first 1 to 2 weeks before coughing paroxysms occur, symptoms may be lessened. Antibiotics will not alter the course of the illness or prevent transmission if they are given later in the course of illness.

Clinicians should strongly consider treating prior to test results if any of the following are present:

• Clinical history is strongly suggestive of pertussis
• The person is at risk for severe or complicated disease (e.g., infants)
• The person has or will soon have routine contact with someone that is considered at high risk of serious disease (e.g., pregnant women)

Reporting suspected or confirmed cases:

Pertussis is a Category 2 (A) disease and shall be reported to the local health authority or to MDHSS within one (1) calendar day of first knowledge or suspicion; for after-hours notification, contact the MDHSS - ERC at (800) 392-0272 (24/7).

Additional information

• Clinical information
• Treatment 
• Pregnancy 

 

On November 15, 2024, the California Department of Public Health (CDPH) confirmed the first reported case of clade I mpox in the United States. This individual had recently traveled to areas experiencing clade I monkeypox virus (MPXV) transmission and sought medical care for mpox symptoms in the United States. Consistent with other recent clade I mpox cases, the patient has relatively mild illness and is recovering. CDC and the local and state health departments are investigating potential contacts; no additional cases in the United States have been detected as of November 18, 2024. The risk of clade I mpox to the public in the United States remains low.

Read the CDC Health Advisory.

Evaluation and Diagnosis

• Symptoms of mpox include flu-like symptoms such as fever, headache, muscle aches, backache, swollen lymph nodes, chills, and/or exhaustion.
• A rash (usually within 1-3 days after the onset of fever) that can look like blisters that can appear on the face, inside the mouth, hands, feet, chest, genitals or anus
• Consider mpox as a possible diagnosis in patients with epidemiologic characteristics and lesions or other clinical signs and symptoms consistent with mpox.
  • This includes symptomatic people who have been in Central or Eastern Africa in the previous 21 days.
  • This also includes people who had close or intimate contact with symptomatic people who have been in these countries.
• Follow CDC guidance on mpox infection prevention and control to minimize transmission risk when evaluating and providing care to patients with suspected mpox.
• Ask patients with signs and symptoms of mpox but no recent travel whether they have had contact with people who had recently been in Central or Eastern Africa and who were symptomatic for mpox.
• Advise all patients suspected of having mpox to stay at home and isolate themselves from others until mpox has been ruled out by laboratory testing. In the event of a positive mpox diagnosis, advise patients to isolate until their mpox lesions have cleared up and fresh skin has formed, which could take several weeks.
• Test all suspected cases for MPXV. If a symptomatic patient reports travel to Central or Eastern Africa in the 21 days prior to relevant symptom onset, work with your state or local public health agency to facilitate testing for MPXV that includes clade I MPXV testing.
• Follow specimen collection guidelines (including collecting two swabs per 2-3 lesions) to ensure specimen availability for clade-specific testing. This testing will help distinguish cases that are part of the ongoing clade II mpox global outbreak from those that are part of this clade I outbreak.
  • Avoid unroofing or aspirating lesions (or otherwise using sharp instruments for mpox testing) to minimize the risk of a sharps injury.
• Promptly report suspected cases of clade I mpox to state, local, or territorial public health authorities and collaborate with health departments to submit case information as per CDC case reporting recommendations for health departments. CSTE maintains availability 24/7 for reporting cases.
• CDC encourages the state health department and diagnosing clinician to contact the CDC Emergency Operations Center (EOC) at 770-488-7100 and request a clinical mpox consult after clade I mpox is diagnosed, regardless of the severity of illness.

Prevention

• Recommend vaccination to people who are eligible for mpox vaccine, including those who may have a recent MPXV exposure.
• Continue to follow CDC’s current vaccine guidance to prevent mpox. Two doses of JYNNEOS vaccine offer substantial protection against mpox, and are expected to offer protection regardless of clade.
• Discuss mpox prevention and risk reduction strategies with all travelers to countries with ongoing human-to-human transmission of clade I MPXV. An updated list of the countries with ongoing spread of clade I MPXV is available on the CDC website.
• Discuss patients’ sexual history and travel plans, including if patients anticipate sexual or intimate activity during travel.
• Counsel patients on activities that may increase risk for MPXV exposure and risk reduction strategies if they have plans to travel to a country where ongoing human-to-human transmission of clade I MPXV is occurring. Travelers to affected countries should:
  • Avoid close contact with people who are sick with signs and symptoms of mpox, including skin or genital lesions.
  • Avoid contact with contaminated materials used by people who are sick, such as clothing, bedding, toothbrushes, sex toys, or materials used in healthcare settings.
  • Avoid contact with animals that can carry the virus that causes mpox or their products (e.g., bushmeat, lotions, hides) in areas where mpox is endemic.
• Clinicians should counsel patients about what to do to prevent household transmission if they have mpox symptoms, including staying away from other people, not sharing things they have touched with others, and cleaning and disinfecting the spaces they occupy regularly to limit household contamination.

 

For more information:

• Clinical overview of mpox
• DHSS resources on mpox
• Mpox prevention toolkits

 

• CDC Poxvirus and Rabies Branch: poxvirus@cdc.gov or for emergencies, CDC’s 24/7 Emergency Operations Center (EOC): 770-488-7100. General inquiries: CDC-INFO (1-800-232- 4636).
• State and Local Health Department Contacts: After Hours/Epi-on-Call Contact Lists - Council of State and Territorial Epidemiologists (cste.org)
• Mpox Clinical Recognition and Vaccine Information for Healthcare Providers: Information For Healthcare Professionals | Mpox | Poxvirus | CDC
• Mpox Information for the Public: Your Health | Mpox | Poxvirus | CDC
• Biosafety and Select Agent Considerations: Laboratory Procedures | Mpox | Poxvirus | CDC
• Diagnostic Specimen Packaging and Shipping: Transporting Infectious Substances Safely.pdf (dot.gov)

Download the update from Missouri Department of Health and Senior Services

Summary
The Missouri Department of Health and Senior Services (DHSS) continues detecting cases of Candida auris (C. auris) within health care facilities in the Saint Louis Metro area. The DHSS first identified locally acquired C. auris infection in October of 2023.

While patients have been identified in health care facilities in the Saint Louis Metro area, patients may receive further care in other regions of the state. The DHSS HAI/AR program promotes interfacility communication of patient’s C. auris status on transfer between healthcare facilities through use of an Interfacility Transfer Form, such as CDC’s found here. Additionally, upon admission health care personnel should assess patients’ C. auris and other MDRO status by reviewing medical records and utilizing EHR or HL7, especially for patients admitted from long term acute care hospitals or ventilator units.

C. auris Background
C. auris is an emerging yeast that, due to resistance to many antifungal drugs, is considered an urgent antimicrobial resistance threat by the Centers for Disease Control and Prevention (CDC). C. auris spreads easily in health care settings and is difficult to treat due to drug-resistance. Invasive infections with C. auris are particularly concerning and have caused death in about one in three persons who developed severe disease due to this infection. According to the CDC’s C. auris. tracking tool, there were 2,377 clinical cases and 5,754 colonization/screening cases identified from January 2022 – December 2022 across 29 states.

C. auris mostly affects individuals with severe underlying conditions, those requiring complex medical care, as well as those with indwelling devices. Patients with invasive medical devices like breathing tubes, feeding tubes, catheters in a vein, or urinary catheters tend to be at increased risk for acquiring C. auris infection. Healthy people without these risk factors, including health care workers and family members, have a low risk for becoming infected with C. auris.

Transmission
C. auris can spread from one patient to another in health care settings. It can spread through close contact with infected or colonized patients and contaminated surfaces or equipment. C. auris can live on surfaces for several weeks. Contact with these surfaces allows the fungus to spread to other people. Once a patient has tested positive for C. auris infection or colonization, they are considered colonized for life and infection control measures should be utilized indefinitely.

Symptoms and Colonization
C. auris can cause infections in different parts of the body such as in the bloodstream, open wounds, and ears. The symptoms depend on the location and severity of C. auris infection. Symptoms may be similar to an infection caused by bacteria. There is not a common set of symptoms specific for C. auris infections. People can get C. auris on their skin and other body sites without getting sick or having an active infection with symptoms. Health care providers may refer to this as ‘colonization.’ Someone who is colonized can still contaminate surfaces or objects they contact with C. auris, which can then spread it to other patients.

Diagnosis
Health care providers can diagnose a patient as actively infected or colonized with C. auris in two ways:

• Colonization screening– a health care provider swabs the patient’s skin by rubbing a swab near the armpits and groin and sends the swab to a laboratory for testing.
• Clinical specimen testing– If a patient is showing symptoms of an infection of an unknown cause, a health care provider may collect a clinical sample, like blood or urine. They usually test for many types of infections, including those caused by bacteria, and the results may show that the patient has C. auris.

Retesting patients infected or colonized with C. auris is not recommended and should not be used to change infection control measures. A negative test after a previous positive does not ensure that the patient no longer has C. auris on their skin or other body sites and will not spread it to others.

Treatment
Some C. auris strains have been resistant to all three main classes of antifungal medicines, meaning none are able to treat the infection. In this situation, multiple antifungal medicines or newer antifungals may be used to treat the infection. Most strains of C. auris found in the United States have been susceptible to echinocandins, although reports of echinocandin-resistant (or pan-resistant) cases are increasing. Patients who are colonized (have C. auris detected on their body but do not have symptoms of infection) should not be treated with antifungals for C. auris. There is no evidence this prevents future illness.

Epidemiology of C. auris in Missouri
C. auris was first detected in Missouri in late 2020. Between January 1, 2024 and June 30,2024, DHSS has detected 56 additional cases with the majority in the St. Louis Metro area. At least one C. auris case has been detected in a variety of health care facilities including: Acute Care Hospitals, Long Term Acute Care Hospitals, Skilled Nursing Facilities, and Rehabilitation Hospitals. Additionally, some C. auris positive patients have also been receiving healthcare through hemodialysis and home health services.

Cases have continued to be largely identified through point prevalence surveys (PPS) conducted by health care facilities as part of epidemiologic investigation and public health surveillance. Colonized individuals have been detected via axilla/groin and rectal swabs, and clinical cases have been identified from positive tests of abdominal aspirate, blood, bile, bronchial wash, peritoneal dialysis fluid, sputum, tissue, urine and wounds.

From the 65 cases reported in Missouri since 2020:

• Patient age ranges from 26 to 93 years old with a median age of 63 years.
• Eighteen patients reported receiving health care in geographic areas outside of Missouri with a high C. auris incidence.
  

Missouri DHSS Recommendations
Infection Prevention and Control
The CDC and the Missouri DHSS recommends health care facilities take the following actions to identify and control further spread:

• Immediately initiate and regularly reinforce appropriate use of transmission-based precautions based on the setting (described below).
• Inform and educate appropriate personnel about the presence of a patient with C. auris and the need for rigorous adherence to infection control practices.
• Ensure strict adherence to hand hygiene and appropriate personal protective equipment (PPE) use. Alcohol-based hand sanitizer is effective against C. auris and is the preferred method for cleaning hands when they are not visibly soiled. Wearing gloves is not a substitute for hand hygiene.
• Perform thorough cleaning and disinfection of the patient care environment and any shared equipment (daily and terminal cleaning) used by patients with confirmed or suspected C. auris. Use a disinfectant active against C. auris identified by the Environmental Protection Agency (EPA) from EPA List P.
• If possible, use dedicated medical equipment for patients with confirmed or suspected C. auris.
• Promote antimicrobial stewardship to limit the emergence of C. auris and other multi-drug resistant organisms (MDROs).

Transmission-Based Precautions
Health care facilities should not decline admission based on colonization or presence of MDRO infection including C. auris. All patients with C. auris infection or colonization should be placed on the appropriate transmission based precautions based on the setting:

• Acute care hospitals, post-acute care facilities (including long-term acute care hospitals) should place patients with C. auris on contact precautions.
• Skilled Nursing Facilities should place patients on Enhanced Barrier Precautions (when contact precautions do not otherwise apply). More information on enhanced barrier precautions can be found here: https://www.cdc.gov/hai/containment/PPE-Nursing-Homes.html
  
  • Skilled nursing facilities with ventilator units, should initially place patients on contact precautions. Patients may be able to be moved to Enhanced Barrier Precautions.
• Dialysis clinics and providers should care for patients with C. auris by having health care personnel wear disposable gowns and gloves during patient care or when touching items at the dialysis station. Gowns and gloves should be removed and disposed of carefully, and hand hygiene should be performed when leaving the patient’s station. Minimize exposure to other patients by placing the patient away from others or seeing the patient at the end of day.
• Outpatient Settings should care for patients with C. auris by having health care personnel wear disposable gown and gloves if extensive patient contact is anticipated or contact with infected areas is planned (e.g., debridement or dressing of colonized or infected wound). Gowns and gloves should be removed and disposed of appropriately, and hand hygiene should be performed when leaving the patient’s room.
• Home Health care settings should care for patients with C. auris by having health care personnel wear disposable gown and gloves when entering the area of the home where providing patient care. Gowns and gloves should be removed and disposed of appropriately. Hand hygiene should be performed when leaving the patient care area. Minimize exposure to other patients by seeing the patient at the end of day.

Place all patients with confirmed or suspected C. auris infection or colonization in a private room. If a private room is not available:

• Patients infected or colonized with C. auris and/or other MDROs should be placed in rooms with patients colonized with the same organism(s). CDC does not recommend placing patients with C. auris in rooms with patients who have other types of MDROs.
• Avoid placing C. auris patients with patients who have indwelling devices (e.g., central venous catheter, tracheostomy tubes and mechanical ventilators), serious underlying medical conditions, or are otherwise immunocompromised.

Missouri DHSS does not currently recommend the discontinuation of precautions for a patient or resident with a current or history of C. auris colonization or infection.

Interfacility Communication
Robust communication at the time of transfer ensures the continuation of infection prevention and control measures during transitions of care. This can be accomplished via verbal report at the time of transfer, in the discharge summary, or through the use of an interfacility transfer tool.

• Upon admission, ask about a patient’s C. auris and other MDRO status, if not included in the accompanying medical records.
• Upon admission, assess C. auris and other MDRO status for all patients by reviewing medical records and utilizing EHR or HL7, especially for patients being admitted from long term acute care hospitals or from ventilator units.
• Upon discharge, communicate a patient’s C. auris and other MDRO status, including patients screened for an MDRO, but for whom laboratory results are not available at the time of transfer, to any receiving health care facility prior to transfer.
  
  • This should be done by including a written notification of the infection or colonization to the receiving facility in transfer documents. The referring facility should ensure that the documentation is readily accessible to all parties involved in patient transfer (for example, referring facility, medical transport, emergency department, receiving facility). CDC has a sample Interfacility Transfer Form that facilities can use.

Containment Response
A single case of C. auris (active infection or colonization) requires a robust containment response. The DHSS Healthcare Associated Infections/Antimicrobial Resistance (HAI/AR) Program may be conducting outreach to health care facilities and clinical laboratories with epidemiologic links to case patients or health care facilities with cases of C. auris infection. Infection Control Guidance from CDC including environmental disinfection.

Colonization Screening
Missouri DHSS recommends screening patients for C. auris who meet any of the following criteria:

• Patients newly colonized or infected with C. auris (immediately notifiable)
• Guidance on C. auris screening of roommates or other close contacts
• Guidance on patient cohorting (i.e., grouping patients infected with the same infectious agents together to confine their care to one area and prevent contact with susceptible patients)
• Guidance of infection control interventions
• HAI Surveillance including reporting, specimen collection, and specimen submission to the Missouri State Public Health Laboratory (MSPHL).

Testing of the environment or equipment for C. auris is not routinely recommended. Likewise, testing of health care workers or family members who care for patients with C. auris (or an exposure to C. auris) is not routinely recommended.

Clinical Laboratories
Clinical laboratories processing specimens from residents receiving health care in Missouri should implement methods to detect C. auris as outlined below:

• Use the CDC Candida auris laboratory resource and algorithm to identify C. auris based on the available phenotypic laboratory method and initial species identification.
• If your laboratory does not have methodologies required to speciate C. auris, talk with the HAI/AR Program to evaluate the utility of forwarding isolates suspicious for C. auris for further testing at commercial or public health laboratories that can perform C. auris identification. Please forward any positive C. auris isolates to the Missouri State Public Health Laboratory (MSPHL).
• If possible, perform speciation for all yeast isolates from an inpatient in a health care facility (acute care hospital, LTACH, or SNF), including from both normally sterile and nonsterile body sites. This activity may be particularly useful in the three months following the release of this alert, as we seek to understand the local epidemiology of C. auris in Missouri.
• CDC recommends that all yeast isolates obtained from a normally sterile site be identified to the species level so appropriate initial treatment can be administered based on the typical, species-specific susceptibility patterns.
• Species-level identification of Candida isolates from non-sterile sites should be conducted in the following circumstances:
  
  • If clinically indicated in the care of the patient.
  • To detect additional colonized patients when a case of C. auris infection or colonization has been detected in a facility or unit.
  • If the patient has had an overnight stay in a health care facility within an identified domestic hotspot, or outside the U.S. in the previous year, especially in a country or region with documented C. auris transmission.
  • If the patient currently or previously resided in skilled nursing facilities with ventilated patients or in long term acute care hospitals.

Reporting
Health care facilities, providers and laboratories with suspected or confirmed cases of C. auris (active infection or colonization), should report them to the DHSS HAI/AR Program at 573-751-6113 or the DHSS Emergency Response Center (ERC) at 800-392-0272. C. auris is implicitly reportable in Missouri as an emerging or unusual disease per the Regulatory Documentations of Reportable Diseases and Conditions in Missouri (19 CSR 20-20.020). C. auris became nationally notifiable in 2018.

Please contact the Missouri DHSS HAI/AR Program for:

• Patients newly colonized or infected with C. auris (immediately notifiable)
• Guidance on C. auris screening of roommates or other close contacts
• Guidance on patient cohorting (i.e., grouping patients infected with the same infectious agents together to confine their care to one area and prevent contact with susceptible patients)
• Guidance of infection control interventions
• HAI Surveillance including reporting, specimen collection, and specimen submission to the Missouri State Public Health Laboratory (MSPHL).

Full Background information on C. auris can be found in the original Emerging Candida auris Infection Cases in Missouri Health Care Facilities Health Alert from December 6, 2023 found at https://health.mo.gov/emergencies/ert/alertsadvisories/pdf/alert120623.pdf

The Missouri DHSS HAI/AR Program can be contacted at the following email address: info@health.mo.gov

References

• Worsening Spread of Candida auris in the United States, 2019 to 2021 | Annals of Internal Medicine (acpjournals.org)
• CDC C. auris Homepage Infection Control Guidance: Candida auris
• EPA List P
• Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) | HAI | CDC
• Identification of Candida auris | Candida auris | Fungal Diseases | CDC

Target Audience
Local Health Departments, Infectious Disease Physicians, Hospital Emergency Departments, Infection Control Preventionists, Health Care Providers, Long Term Care Facilities, Dialysis Clinics, and Laboratories

Author
MDHSS Healthcare Associated Infections/Antimicrobial Resistance Program, the State Epidemiologist, and Division of Community and Public Health.

Increased Risk of Dengue Virus Infections in the United States

***Missouri healthcare providers please contact your local public health agency (LPHA) or the Missouri Department of Health and Senior Services’ (DHSS) Bureau of Communicable Disease Control and Prevention at 573 751 6113 or 800 392 0272 (24/7) with questions regarding this CDC Health Advisory.***

Download the CDC advisory

Summary
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to notify healthcare providers, public health authorities and the public of an increased risk of dengue virus (DENV) infections in the United States in 2024. Global incidence of dengue in 2024 has been the highest on record for this calendar year; many countries are reporting higher than usual dengue case numbers. In 2024, countries in the Americas have reported a record breaking number of dengue cases, exceeding the highest number ever recorded in a single year. From January 1 June 24, 2024, countries in the Americas reported more than 9.7 million dengue cases, twice as many as in all of 2023 (4.6 million cases). In the United States, Puerto Rico has declared a public health emergency (1,498 cases) and a higher than expected number of dengue cases have been identified among U.S. travelers (745 cases) from January 1 June 24, 2024. In the setting of increased global and domestic incidence of dengue, healthcare providers should take steps including:

1. Have increased suspicion of dengue among people with fever who have been in areas with frequent or continuous dengue transmission within 14 days before illness onset,
2. Order appropriate diagnosti c tests for acute DENV infection: reverse transcription polymerase chain reaction [RT PCR] and IgM antibody tests, or non structural protein 1 [ antigen tests and IgM antibody tests,
3. Ensure timely reporting of dengue cases to public health authorities, and
4. Promote mosquito bite prevention measures among people living in or visiting areas with frequent or continuous dengue transmission.

Background
Dengue is the most common arboviral disease globally. It is caused by four distinct but closely related dengue viruses (DENV 1, 2, 3, and 4). DENVs are transmitted through bites of infected Aedes species mosquito vectors. Infection with one DENV generally induces life long protection against infection from that specific DENV but only protects against other DENVs for several months to years. Dengue is a nationally notifiable disease in the United States. Six U.S. territories and freely associated states are classified as areas with frequent or continuous dengue transmission Puerto Rico, American Samoa, the U.S. Virgin Islands, the Federated States of Micronesia, the Republic of Marshall Islands, and the Republic of Palau. In the rest of the United States, local transmission of DENV has been limited, with sporadic cases or small outbreaks in Florida, Hawaii, and Texas. However, confirmed local DENV transmission has also been reported by Arizona and California over the past two years.

Approximately one in four DENV infections are symptomatic and can be mild or severe. Symptoms begin after an incubation period of 5-7 days (range 3-10 days) and present as fever accompanied by non-specific signs and symptoms such as nausea, vomiting, rash, muscle aches, joint pain, bone pain, pain behind the eyes, headache, or low white blood cell counts. Warning signs are specific clinical findings that predict progression to severe disease. Warning signs include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation (e.g., ascites, pleural effusi on), mucosal bleeding, lethargy or restlessness, progressive increase of hematocrit, or liver enlargement >2cm. Severe disease, with associated severe bleeding, shock or respiratory distress caused by plasma leakage, or end organ impairment, develops in 1 in 20 people with symptomatic dengue. Infants aged 1 year, pregnant people, adults aged 65 years, and people with certain medical conditions are at increased risk of severe dengue. Although a second DENV infection (i.e., with a differentDENV from the first infection) carries  a rhigher risk of severe disease than a first, third, or fourth infection, any infection can lead to severe disease.

Patients with symptoms compatible with dengue can be tested with both molecular and serologic diagnostic tests. All patients with suspected DENV infection should be tested with RT-PCR (i.e., a nucleic acid amplification test (NAAT)) or a NS1 antigen test, and also with IgM antibody test to confirm DENV infection. These tests can be considered regardless of the symptom onset date, although the test sensitivity of RT-PCR and NS1 antigen tests decrease after the first 7 days. IgG detection by enzyme- linked immunosorbent assay (ELISA) in a single serum sample should not be used to diagnose a patient with acute dengue because it does not distinguish between current and previous DENV infection. U.S. Food and Drug Administration (FDA)-approved testing is available at public health laboratories and some commercial laboratories. State, tribal, territorial, and local health departments, and CDC can offer
additional testing guidance.

There are no antiviral medications approved to treat dengue. Treatment is supportive and requires careful volume management. Appropriate triage, management, and follow up remain the most effective interventions to reduce dengue morbidity and mortality. Expectant management of patients at high risk for severe disease and rapid initiation of a standardized fluid replacement strategy recommended by the World Health Organization (WHO) can decrease mortality from 13% to <1%. In June 2021, the Advisory Committee of Immunization Practices recommended a dengue vaccine, Dengvaxia for children aged 9-16 years with laboratory confirmation of previous DENV infection and living in areas with frequent or continuous dengue transmission such as Puerto Rico. While the vaccine is considered safe and effective, the manufacturer (Sanofi Pasteur, Inc., Paris France) has discontinued production citing a lack of demand. Vaccine administration will continue in Puerto Rico until available doses expire in 2026.There are no vaccines recommended for travelers, adults, or persons without a previous DENV infection.

Dengue cases resurged globally after the COVID 19 pandemic. In 2023, more than 4.6 million cases and 4000 deaths were reported in the Americas region. As of June 24, 2024, more than 9.7 million dengue cases have been reported in the Americas, twice as many as in all of 2023 (4.6 million cases). Dengue transmission peaks during the warmer and wetter months in many tropical and subtropical regions. Dengue cases are likely to increase as global temperatures increase. Higher temperatures can expand the range of the mosquitoes that spread dengue, as well as affect other factors that facilitate virus transmi ssion like faster viral amplification in the mosquito, increased vector survival, and changes in reproduction and biting rates. U.S. summer travel often overlaps with the months of increased dengue activity in many countries. Epidemics in the Americas region increase travel associated cases and limited local transmission in the continental United States. A higher than expected number of dengue cases (total of 2,241 cases, including 1,498 in Puerto Rico) were reported in the United States from January 1 Ju ne 24, 2024. Public health authorities in Puerto Rico declared a public health emergency in March 2024 because of the high number of cases reported during the low dengue season. Healthcare providers should be prepared to recognize, diagnose, manage, and report dengue cases to public health authorities; public health partners should investigate cases an d disseminate clear prevention messages to the public. The CDC is actively implementing several strategies to address the increase in cases of dengue in the United States, including:

• Launching a program-led emergency response, which was activated on April 8, 2024.
• Providing regularly scheduled monthly situational updates on dengue to partners, stakeholders, and jurisdictions.
• Expanding laboratory capacity to improve laboratory testing approaches.
• Collaborating with State, Tribal, Local, and Territorial Health Departments to strengthen dengue surveillance and recommend prevention strategies.
• Educating the public on dengue prevention.

Recommendations for Healthcare Providers

• Maintain a high suspicion for dengue among patients with fever and recent travel (within 14 days before illness onset) to areas with frequent or continuous dengue transmission.
• Consider locally acquired dengue among patients who have signs and symptoms highly compatible with dengue (e.g., fever, thrombocytopenia, leukopenia, aches, pains, rash) in areas with competent mosquito vectors.
• Order appropriate FDA-approved dengue tests (RT-PCR and IgM antibody tests, or NS1 and IgM antibody tests), and do not delay treatment waiting for test results to confirm dengue.
• Know the warning signs for progression to severe dengue, which include abdominal pain or tenderness, persistent vomiting, clinical fluid accumulation, mucosal bleeding, lethargy or restlessness, and liver enlargement.
• For people with suspected dengue who do not have warning signs and are not part of a population at high risk for severe dengue, consider outpatient management with close follow-up.
• Teach patients about the warning signs that may appear as their fever starts to decline and instruct them to seek care urgently if they experience any warning signs.
• Recognize the critical phase of dengue. The critical phase begins when fever starts to decline and lasts for 24–48 hours. During this phase, some patients require close monitoring and may deteriorate within hours without appropriate intravenous (IV) fluid management.
• Hospitalize patients with severe dengue or any warning sign of progression to severe dengue and follow CDC/WHO protocols for IV fluid management.
• Follow local guidelines to report dengue cases to state, tribal, local, or territorial health departments.

Recommendations for State, Tribal, Local, and Territorial Health Departments

• Use FDA-approved dengue tests. Ensure access to dengue testing for all patients with suspected dengue.
• Remind clinicians of the high risk of dengue among patients with fever who have been in areas with frequent or continuous dengue transmission.
• Remind clinicians that local transmission can occur in areas with competent vectors and to test patients with compatible illnesses even without a history of having been in an area with dengue.
• Inform healthcare providers and the public when locally acquired and travel-associated dengue cases are detected in the area.
• Report dengue cases to CDC via ArboNET, the national arboviral surveillance system managed by CDC and state health departments.
• Take the lead in investigating dengue cases and outbreaks.
• Consider targeted outreach about increasing dengue risk to healthcare providers more likely to identify dengue cases (i.e., travel medicine clinics, infectious disease physicians, or healthcare systems serving highly mobile populations such as migrant and border health clinics, and clinics with frequent travelers to areas with frequent or continuous dengue transmission) and messaging
  to populations at higher risk for dengue.

Recommendations for the Public

• Learn how to prevent mosquito bites.
  • Use Environmental Protection Agency-approved repellents during travel to and after returning from areas with frequent or continuous dengue transmission.
  • Wear loose-fitting, long-sleeved pants and shirts.
• Control mosquitos at home indoors and outdoors.
  • Use air conditioning and window screens when possible, to lower risk for mosquito bites indoors.
  • Dump and drain containers that hold water to reduce mosquito egg-laying sites in your home and neighborhood.
• Seek medical care if you have a fever or have dengue symptoms and live in or traveled to an area with dengue outbreaks .
• If you plan international travel to a an area with frequent or continuous dengue transmission, protect yourself from mosquito bites during and after your trip.
  

For More Information

Healthcare Providers

• Clinical Testing Guidance for Dengue | Dengue | CDC
• Guidelines for Classifying Dengue | Dengue | CDC
• Clinical Features of Dengue | Dengue | CDC
• Dengue Case Management Pocket Guide | CDC
• Dengue During Pregnancy | Dengue | CDC
• Dengue Vaccine | Dengue | CDC
• Dengvaxia: What Healthcare Professionals Need to Know | Dengue | CDC
• Dengue | CDC Yellow Book 2024
• Dengue Clinical Management Course | Dengue | CDC
• Webinar: What Clinicians Need to Know about Dengue in the United States | CDC

Health Departments and Public Health Professionals

• Data and Statistics on Dengue in the United States | Dengue | CDC
• What You Can Do to Control Mosquitoes During an Outbreak | Mosquitoes | CDC
• ArboNET | Mosquitoes | CDC
• Dengue case investigation report | CDC
• Dengue Print Resources | Dengue | CDC
• Communication Resources | Mosquitoes | CDC
• Submitting Specimens for Dengue Virus Tests | Vector-Borne Diseases | CDC

Public

• Preventing Dengue | Dengue | CDC
• Dengue During Pregnancy | Dengue | CDC
• Caring for a Family Member with Dengue | CDC
• Mosquito Control at Home | Mosquitoes | CDC
• Get Rid of Mosquitos at Home | CDC
• Your Infant has Dengue | CDC
• Areas with Risk of Dengue | Dengue | CDC
• Travel Health Notices | Travelers' Health | CDC
• Find a Clinic | Travelers' Health | CDC

References

1. Pan American Health Organization. Epidemiological Update Increase in dengue cases in the Region of the Americas. https://www.paho.org/en/documents/epidemiological-update-increase- dengue-cases-region-americas-18-june-2024
2. Wong JM, Adams LE, Durbin AP, et al. Dengue: a growing problem with new interventions.
   Pediatrics. 2022;149(6):e2021055522. DOI: 10.1542/peds.2021-055522
3. Paz-Bailey G, Adams L, Wong JM, et al. Dengue vaccine: recommendations of the Advisory Committee on Immunization Practices, United States, 2021. MMWR Recommendations and Reports. 2021;70(6):1–16. DOI: 10.15585/mmwr.rr7006a1.
4. World Health Organization. Disease Outbreak News; Dengue - Global situation. May 30, 2024.
   https://www.who.int/emergencies/disease-outbreak-news/item/2024-DON518

Disrupted Access to Prescription Stimulant Medications Could Increase Risk of Injury and Overdose

Download the CDC advisory

Summary
The Centers for Disease Control and Prevention (CDC) is issuing this Health Alert Network (HAN) Health Advisory to inform public health officials, clinicians, and affected patients, their families, and caregivers about potential disrupted access to care among individuals taking prescription stimulant medications and possible increased risks for injury and overdose. On June 13, 2024, the U.S. Department of Justice announced a federal health care fraud indictment against a large subscription-based telehealth company that provides attention-deficit/hyperactivity disorder (ADHD) treatment to patients ages 18 years and older across the United States. Patients who rely on prescription stimulant medications to treat their ADHD and have been using this or other similar subscription-based telehealth platforms could experience a disruption to their treatment and disrupted access to care. A disruption involving this large telehealth company could impact as many as 30,000 to 50,000 patients ages 18 years and older across all 50 U.S. states.

This potential disruption coincides with an ongoing prescription drug shortage involving several stimulant medications commonly prescribed to treat ADHD, including immediate-release formulation of amphetamine mixed salts (brand name Adderall®). Patients whose care or access to prescription stimulant medications is disrupted, and who seek medication outside of the regulated healthcare system, might significantly increase their risk of overdose due to the prevalence of counterfeit pills in the illegal drug market hat could contain unexpected substances, including fentanyl. Given the national drug overdose crisis and threats associated with the illegal drug market, individuals struggling to access prescription stimulant medications are urged to avoid using medication obtained from anyone other than a licensed clinician and licensed pharmacy.

In addition to concerns about using illegally acquired stimulant medications, untreated ADHD is associated with adverse outcomes, including social and emotional impairment, increased risk of drug or alcohol use disorder, unintentional injuries, such as motor vehicle crashes, and suicide. Health officials and healthcare providers may need to assist affected patients seeking treatment for ADHD and should communicate overdose risks associated with the current illegal drug market as well as provide overdose prevention education and mental health support.

Background
ADHD is a brain disorder that can make it difficult to concentrate or control impulsive behavior. ADHD affects an estimated 9.8% of children and 4.4% of adults in the United States. Clinicians commonly treat ADHD and narcolepsy with prescription stimulant medications. The percentage of children and adults receiving prescriptions for stimulants to treat ADHD increased from 2016–2021, particularly during 2020–2021. Telehealth policies implemented during the COVID-19 pandemic have allowed for greater access to ADHD treatment, including treatment with prescription stimulants, without the need for an in-person health care visit.

Although prescription stimulants are commonly used safely and appropriately, they can be misused (i.e., taken in a manner or dose other than prescribed, taking someone else’s medication, or taking a medication to get high or for another desired effect unrelated to a medical condition). Misuse of prescription stimulants, particularly among young adults, is a growing public health concern, with 14.5% of college students reporting misusing prescription stimulants. U.S. rates of overdose deaths involving stimulants, including cocaine and psychostimulants with abuse potential (e.g., methamphetamine and prescription stimulants), have increased steadily since 2014, both with and without co-involved opioids. The effect of stimulants on the human body and brain can vary by how frequently they are used, how strong they are, how they are consumed, and the amount consumed. People experiencing stimulant overdose are often awake and may be breathing quickly. They may need assistance in reducing overheating and overstimulation.

The impact of the indictment on the telehealth company’s patients is unknown at the time of this HAN’s release. However, some or all patients who have been accessing treatment or prescriptions for ADHD through the telehealth company might find they need to or want to find a new healthcare provider. They might also have difficulty filling a stimulant prescription. Some patients might try to seek medication outside the regulated healthcare system. Counterfeit pills that look like prescription stimulant medications, such as Adderall®, might contain illegally made fentanyl or other dangerous substances, thus increasing the risk of nonfatal and fatal overdose. Recently, the Drug Enforcement Administration (DEA) reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of illegally made fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and 100 times stronger than morphine.

Signs of an opioid overdose include—

• Unconsciousness or inability to awaken

• Slow or shallow breathing or difficulty breathing such as choking sounds or gurgling/snoring noise from a person who cannot be awakened

• Discolored skin (especially in nails or lips)

• Small, constricted "pinpoint pupils" that don't react to light

A person who has been misusing prescription stimulants might seek out illegal drugs they believe can provide them with the same effects as the prescription. Transitioning to using illegal drug products is extremely dangerous. Unlike prescriptions, which have clearly labeled ingredients, quantities, and other safety information, illegal drug products are less predictable and might contain unexpected substances, unknown quantities, or potencies.

Recommendations for Public Health Professionals

• Communicate to partner organizations and agencies about this disruption and the potential associated overdose risk among affected patients.
• Support patients affected by a disruption in identifying new clinicians and legal sources of medications.
• Communicate risks of replacing prescription stimulant medications with drugs or pills obtained illegally, including pills received from family, friends, or acquaintances).
• Increase risk communication about the prevalence and danger of counterfeit pills that look like prescription medications. Communicate that 7 out of every 10 pills seized by DEA from the illegal drug market contain a lethal dose of fentanyl.
• Increase risk communication, harm reduction and other overdose prevention efforts (i.e., provision of naloxone) directed at adults primarily ages 18 through 50 years, as they represent the population most served by the indicted company and most at risk for overdose.
• Increase risk communication, harm reduction, and other overdose prevention efforts (i.e., provision of naloxone) directed at college students and at places where young adults study or work due to risks of stimulant misuse.
• Disseminate resources to help clinicians care for patients with ADHD or other health conditions treated with prescription stimulants.

Recommendations for Clinicians

• Help patients who have lost healthcare access to find new licensed clinicians and pharmacies.
• Avoid stigmatizing patients affected by a disruption in care.
• Educate all patients about the health risks of using drugs or medications obtained from sources other than licensed clinicians and pharmacies, including family, friends, and social media contacts. Communicate to patients that 7 out of every 10 pills seized by DEA from the illegal drug market contain a lethal dose of fentanyl.
• As a safety precaution, in case a patient obtains medication outside the regulated healthcare system, prescribe naloxone and overdose prevention education to any patient who has difficulty accessing their stimulant medication or tell patients where they, their caregivers, or families, can access naloxone. Naloxone, for example Narcan®, can reverse the effects of an opioid overdose and can be given to any person showing signs of an opioid overdose (e.g., unconscious or unable to be awakened; slow or shallow breathing or difficulty breathing).
• Ensure that patients requesting care continuity for ADHD receive appropriate assessments and best-practice treatments.
• Discuss with patients, their caregivers, and families the possibility of difficulty filling a prescription due to current drug shortages and work with them to ensure they are able to fill prescriptions.
• Offer other FDA-approved treatment options for ADHD if a prescribed medication is unavailable when needed or facilitate a rapid referral to a clinician who can provide such treatment.
• If you believe a patient might have a stimulant use disorder or needs immediate mental health support, provide referrals and information about how to access treatment services, including hotlines: #988 or 1-800-662-HELP (4357).
• Contact Poison Control (call 1-800-222-1222 or use the webPOISONCONTROL tool) for help with a poisoning emergency or for questions related to an unknown substance.

Recommendations for Pharmacists and Pharmacies

• Avoid stigmatizing patients affected by a disruption in care.
• Recognize that the indictment should not result in universal refusals to fill prescriptions from telehealth providers, and that telehealth provides access to needed care for many Americans.
• Recognize that Schedule II–V controlled substances can be prescribed via telehealth without an in-person visit until December 31, 2024, under current regulations.
• If your pharmacy does not have a particular prescription medication available to dispense, you may electronically transfer a Schedule II prescription according to federal regulations.
• Discuss with patients the possibility that they might have difficulty filling a prescription due to medication shortages, and share resources below on finding a provider to identify alternative treatment options if needed.
• Discuss with patients the risks associated with obtaining medications from anyone other than a licensed pharmacist due to the prevalence of counterfeit pills that look like their medication but could contain other dangerous substances. Recently, DEA reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of fentanyl.
• If your state has a statewide standing order or protocol order for naloxone, dispense it, or let patients know where they can purchase it over the counter (i.e., without a prescription).

Recommendations for Affected Patients
For ADHD treatment

• If you are running low on your current prescription, schedule an appointment with your existing or new healthcare provider as soon as possible.
• Contact your primary care doctor if you can no longer access your previous healthcare provider for assistance obtaining ongoing prescriptions. If you do not have a primary care doctor, call the number on the back of your insurance card, and ask for assistance finding a healthcare provider near you. Resources like Find a Health Center (hrsa.gov) can identify federally funded health clinics in your area and the organization Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) can identify an ADHD specialist.
• Talk with your healthcare provider and pharmacist if you cannot find a pharmacy that has your medication.

To prevent overdose and other harms

• Only take medications prescribed to you by a licensed healthcare provider and dispensed by a licensed pharmacy.
• Never illegally purchase or obtain pills. Recently, DEA reported that laboratory testing indicates 7 out of every 10 pills seized from the illegal drug market contain a lethal dose of fentanyl. Pills obtained from family, friends, or social media contacts and not prescribed to you could contain deadly levels of illegally made fentanyl, and you wouldn’t be able to see it, smell it, or taste it.
• Never purchase or obtain illegal stimulants, such as cocaine, methamphetamine, or ecstasy. Substances might not be what they seem and could contain lethal doses of fentanyl or additional dangerous substances.
• Carry naloxone, a life-saving opioid overdose reversal drug. Naloxone should be given immediately in response to any unconscious person suspected of overdosing. Signs of an opioid overdose include—
  • Unconsciousness or inability to awaken
  • Slow or shallow breathing or difficulty breathing such as choking sounds or gurgling/snoring noise from a person who cannot be awakened
  • Discolored skin (especially in nails or lips)
  • Small, constricted "pinpoint pupils" that don't react to light
• Never use illegally obtained pills or other substances.
• If someone is planning to use illegally obtained pills or other substances, test them first with fentanyl test strips, and make sure there is always someone else nearby who can help in case of emergency.
• In case of a poisoning emergency, call 911 and seek medical attention immediately.
• For questions about an unknown substance, contact Poison Control (call 1-800-222-1222 or use the webPOISONCONTROL tool).

For stimulant use disorder treatment

• Call or text #988 or 1-800-662-HELP (4357) if you believe you, a family member, or loved one might have a stimulant use disorder or are experiencing psychological distress.

For More Information
ADHD Symptoms, Diagnosis, and Treatment

• Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC
• Improving the Lives of People Affected by ADHD | Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD)
• Adult ADHD Toolkit | American Academy of Family Physicians (AAFP)

Stimulants or Stimulant Use Disorders

• Stimulant Overdose | Overdose Prevention | CDC
• Treatment of Stimulant Use Disorders | Substance Abuse and Mental Health Services Administration (SAMHSA)

Counterfeit Pills

• Counterfeit Pills Factsheet | Department of Justice/Drug Enforcement Administration (DEA)
• Northern District of Iowa | United States Attorney and the Federal Bureau of Investigation Warn Iowans about the Dangers of Counterfeit Adderall Pills | U.S. Department of Justice
• Drug Overdose Deaths with Evidence of Counterfeit Pill Use — United States, July 2019–December 2021 | CDC

References

1. Baker EA, Miracle TL. College prescription drug study key findings report. College of Pharmacy, The Ohio State University: Columbus, Ohio, 2022. https://www.campusdrugprevention.gov/sites/default/files/2022-06/CPDS_Multi_Institutional_Key_Findings_2022.pdf
2. Ahmad FB, Anderson RN, Cisewski JA, Rossen LM, Warner M, Sutton P. County-level provisional drug overdose death counts. National Center for Health Statistics. Accessed May 28, 2024. https://www.cdc.gov/nchs/nvss/vsrr/prov-county-drug-overdose.htm
3. Centers for Disease Control and Prevention. A Stimulant Guide: Answers to Emerging Questions about Stimulants in the Context of the Overdose Epidemic in the United States. 2022. https://www.cdc.gov/overdose-prevention/media/pdfs/2024/03/CDC-Stimulant-Guide.pdf
4. Chang Z, Ghirardi L, Quinn PD, Asherson P, D’Onofrio BM, Larsson H. Risks and benefits of attention-deficit/hyperactivity disorder medication on behavioral and neuropsychiatric outcomes: A qualitative review of pharmacoepidemiology studies using linked prescription databases. Biol Psychiatry 2019;86(5):335–343. DOI: 10.1016/j.biopsych.2019.04.009
5. Danielson ML, Bohm MK, Newsome K, et al. Trends in stimulant prescription fills among commercially insured children and adults — United States, 2016–2021. MMWR Morb Mortal Wkly Rep 2023;72:327–332. DOI: 10.15585/mmwr.mm7213a1
6. French B, Daley D, Groom M, Cassidy S. Risks associated with undiagnosed ADHD and/or autism: A mixed-method systematic review. J Atten Disord 2023;27(12):1393–1410. DOI: 10.1177/10870547231176862
7. Faraone SV, Banaschewski T, Coghill D, et al. The World Federation of ADHD international consensus statement: 208 evidence-based conclusions about the disorder. Neurosci Biobehav Rev 2021;128:789–818. DOI: 10.1016/j.neubiorev.2021.01.022
8. National Institute on Drug Abuse. What is the scope of prescription drug misuse in the United States? December 14, 2023. https://nida.nih.gov/publications/research-reports/misuse-prescription-drugs/what-scope-prescription-drug-misuse
9. O’Donnell J, Tanz LJ, Miller KD, et al. Drug overdose deaths with evidence of counterfeit pill use — United States, July 2019–December 2021. MMWR Morb Mortal Wkly Rep 2023;72(35):949–956. DOI: 10.15585/mmwr.mm7235a3
10. Shaw M, Hodgkins P, Caci H, et al. A systematic review and analysis of long-term outcomes in attention deficit hyperactivity disorder: Effects of treatment and non-treatment. BMC Med 2012;10:99DOI: 10.1186/1741-7015-10-99
11. Stevens JR, Wilens TE, Stern TA. Using stimulants for attention-deficit/hyperactivity disorder: Clinical approaches and challenges. Prim Care Companion CNS Disord. 2013;15(2):PCC.12f01472. DOI:10.4088/PCC.12f01472 

Severe Illness Potentially Associated withConsuming Diamond Shruumz BrandChocolate Bars, Cones, and Gummies

Download the CDC advisory

Summary
The Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), America’s Poison Centers ,and state and local partners are investigating reports of severe acute illnesses potentially associated with consumingDiamond Shruumz brand chocolate bars, cones, and gummies marketed as containing a proprietary blend of mushroom. As of June 11, 2024, 12 total illnesses and 10 hospitalizations have been reported in eight U.S. states with ongoing effortsto identify other potential cases. The cause of the reported illnesses is not known at this time. Individuals should not eat, sell, or serve any flavors of Diamond Shruumz brand chocolate bars, cones, or gummies, and should discard products that have been purchased. CDC and FDA are working to determine whether other products from this company are associated with adverse health effects.

Background
CDC and FDA have received reports of severe acute illnesses and other adverse effects following consumption of DiamondShruumz brand chocolate bars, cones, and gummies reported to multiple poison control centers across the United States. These products are distributed online and at retailers including those that that sell hemp-derived (e.g., cannabidiol [CBD],delta-8 tetrahydrocannabinol [THC]) and smoke/vape products nationwide.

Products containing psychoactive compounds such as cannabis or mushroom extracts are increasing in availability. These“edibles” are often sold as gummy candies, chocolate, or other snack foods. They might contain undisclosed ingredients,including illicit substances, other adulterants, or potentially harmful contaminants that are not approved for use in food. Mushroom-containing products have been marketed for promoting health or for achieving nonspecific physical or psychoactive effects. Examples of health claims have included improving focus and increasing energy. Advertising for these products has also implied that consumption would lead to feelings of euphoria, hallucinations, or psychedelic effects. Common terms used in marketing include “microdosing,” “adaptogens” (substances to help the body adapt to stress),“nootropics” (substances that enhance memory or cognitive function), or “functional mushrooms.”

Adverse effects reported to U.S. poison centers in 12 patients who sought medical attention after consuming Diamond Shruumz brand chocolate bars, cones, or gummies as of June 11, 2024, include central nervous system depression withsedation, seizures, muscle rigidity, clonus, tremor, abnormal heart rate (bradycardia or tachycardia), abnormal blood pressure (hypotension or hypertension), gastrointestinal effects (nausea, vomiting, or abdominal pain), skin flushing, diaphoresis, and metabolic acidosis with increased anion gap. Ten patients were hospitalized, and several patients required intubation, mechanical ventilation, and admission to an intensive care unit. None have died.

CDC, FDA, and America’s Poison Centers are continuing to monitor cases of illness reported to poison centersnationwide. Any suspected cases or adverse effects after consuming any Diamond Shruumz brand products should bereported to the Poison Help Line (1-800-222-1222).

Recommendations for Clinicians

• Counsel patients, caregivers, and guardians not to purchase, consume, or serve Diamond Shruumz brand chocolate bars, cones, or gummies.
• Counsel patients, caregivers, and guardians to avoid consuming mushroom-containing edible products claiming toproduce neurologic, cognitive, or psychoactive effects.
• Be aware that “edibles” or food-like products marketed with nonspecific health benefits or implied psychoactive effects might contain undisclosed, misformulated, or unapproved ingredients that can cause severe adverse health effects.
• Have a high index of suspicion for severe illness in any patient who recently consumed any of these products presenting to a healthcare facility with any adverse effects. Symptoms might include, but are not limited to, central nervous system depression with sedation, seizures, muscle rigidity, clonus, tremor, abnormal heart rate (bradycardia ortachycardia), abnormal blood pressure (hypotension or hypertension), gastrointestinal effects (nausea, vomiting, orabdominal pain), skin flushing, diaphoresis, and metabolic acidosis with increased anion gap.
• Obtain early consultation with a medical toxicologist with expertise in managing patients with acute unknowningestions. Contact your local poison center (1-800-222-1222) for advice on medical management of these patients.
  • Managing symptoms from an unknown exposure primarily involves supportive care and consultation with apoison center or toxicologist. Common treatments include IV fluid hydration, supplemental oxygen, and ventilatory support for respiratory failure. Benzodiazepines might be indicated as first-line medications to treat seizures, muscle rigidity, or agitation.
  • Consider the possibility of concomitant ingestion of other drugs or medications and be aware that other specific antidotes (e.g., naloxone) might be indicated.
  • Consider routine diagnostic testing if indicated based on the patient’s clinical presentation. Examples might include, but are not limited to, a comprehensive metabolic panel (CMP), including serum electrolytes, liver enzymes and BUN/creatinine; complete blood count; arterial blood gas; urinalysis; and urine drug screen.
  • Consider consulting a neurologist for evaluation and further diagnostic workup such as electroencephalogram(EEG) or imaging studies if there is any concern for status epilepticus. [4]
  • Consider retaining urine and blood samples for further testing. Urine drug screens commonly used in healthcare facilities usually only detect a limited number of compounds. Decisions to perform further testing may be based on discussions and coordination with a poison center or local health authorities. Contact your local public health authority or regional poison center to report cases of illness after consuming mushroom-containing chocolate or other similar edible products.

Recommendations for Public Health Practitioners

• Be aware that cases of severe illness have been reported following consumption of Diamond Shruumz brand chocolate bars, cones, and gummies. Educate the public about the risks of eating mushroom-containing edible products marketed with claims of nonspecific physical effects, health benefits, or implied psychoactive effects. Such products might contain potentially harmfulundisclosed, misformulated, or unapproved ingredients.
• Coordinate with your local poison center (1-800-222-1222) and other relevant stakeholders to discuss any suspectedcases of illness due to these products within your jurisdiction and establish preferred processes to collect informationon suspected cases.

Recommendations for the Public

• Do not buy, eat, sell, or serve Diamond Shruumz brand chocolate bars, cones, or gummies. Discard and destroy anyproduct that has been purchased.
• Do not consume chocolate, gummies, snack foods, or other edible products claiming to produce feelings of euphoria,hallucinations, or psychedelic effects. They might contain undisclosed ingredients that might be linked to severe illness.
• Store edibles and other products that contain mushrooms, THC, or CBD safely away from children. Children may mistake some edibles for candy.
• Seek immediate medical attention or call the Poison Help Line (1-800-222-1222) for advice if you have consumed a product and are having symptoms. Signs and symptoms may include gastrointestinal effects (nausea, vomiting, abdominal pain), hallucinations, uncontrolled movements, fast or slow heart rate, high or low blood pressure, coughing, choking, excessive sweating or secretions, and flushed skin. Other severe adverse effects have been reported, including seizures, decreased level of consciousness, and respiratory failure.
• Consumers are also encouraged to report adverse events related to these products to FDA MedWatch

For More Information

• Investigation of Illnesses: Diamond Shruumz-Brand Chocolate Bars, Cones, & Gummies (June 2024) | FDA
• MedWatch: The FDA Safety Information and Adverse Event Reporting Program | FDA
• America’s Poison Centers
• American College of Medical Toxicology
• Pediatric Environmental Health Specialty Units

References

1. Ogozalek S. Mood-Altering Mushroom Sales Bloom Despite Safety Concerns. Tampa Bay Times . 2023. https://kffhealthnews.org/news/article/mood-altering-mushroom-sales-bloom-despite-safety-concerns
2. Barrus DG, Giombi K, Cates SC, Gourdet CK, Peiper NC, Novak SP, et al. Tasty THC: Promises and Challenges ofCannabis Edibles. RTI Press . 2016. No. OP-0035-1611. https://doi.org/10.3768/rtipress.2016.op.0035.1611
3. Huff JS, Melnick ER, Tomaszewski CA, Thiessen MEW, Jagoda AS, Fesmire FM, et al. Clinical Policy: Critical Issues inthe Evaluation and Management of Adult Patients Presenting to the Emergency Department with Seizures . Ann EmergMed . 2014. 63(4): 437-47.e15. https://doi.org/10.1016/j.annemergmed.2014.01.018
4. Santillanes G, Luc Q. Emergency Department Management of Seizures in Pediatric Patients. EB Medicine Pediatr EmergMed Pract . 2015. 12(3): p. 1-25. https://www.ebmedicine.net/topics/neurologic/pediatric-seizures TM

Key Points

• Measles is one of the most contagious diseases. MMR vaccine provides the best protection.
• Isolate infected patients for 4 days after they develop a rash and follow airborne precautions in
• healthcare settings.
• Report suspected measles cases to your local health department. During business hours:
  • Jodi Caruthers (417) 864-1582
  • Mariah Inman (417) 864-1698
• 24/7: DHSS Emergency Response Center: (800) 392-0272
• Laboratory confirmation is essential for all sporadic measles cases and all outbreaks.

Clinical Features

Healthcare providers (HCP) should consider measles in patients presenting with the following symptoms, particularly those who have traveled abroad or had contact with known measles cases:

• Fever ≥101°F (38.3°C) AND
• Generalized maculopapular rash lasting ≥3 days AND
  • Rash usually begins at the hairline/scalp and progresses down the body
• Cough, runny nose, or conjunctivitis OR Koplik spots (bluish-white specks or a red-rose background appearing on the buccal and labial mucosa usually opposite the molars).

The rash usually appears about 14 days after a person is exposed. The rash spreads from the head to the trunk to the lower extremities. Patients are considered to be contagious from 4 days before to 4 days after the rash appears. Sometimes immunocompromised patients do not develop the rash.

Measles is one of the most contagious of all infectious diseases. Up to 9 out of 10 susceptible people with close contact to a measles patient will develop measles. The virus is transmitted by:

• Direct contact with infectious droplets.
• Airborne spread when an infected person breathes, coughs, or sneezes.

Measles virus can remain infectious in the air for up to 2 hours after an infected person leaves an area.

Infection Prevention

Upon arrival to a healthcare setting: Persons with signs or symptoms of measles should be identified, provided a facemask to wear, and separated from other patients prior to or as soon as possible after entry into a facility.• Adhere to Standard and Airborne Precautions when caring for patients with known or suspected measles.

• Immediately place patients with known or suspected measles in an airborne infection isolation room (AIIR).
• HCP should use respiratory protection (i.e., a respirator) that is at least as protective as a fit-tested,NIOSH-certified disposable N95 filtering facepiece respirator, regardless of presumptive evidence of immunity, upon entry to the room or care area of a patient with known or suspected measles.
• HCP without acceptable presumptive evidence of measles immunity should not enter a known or suspected measles patient's room if HCP with presumptive evidence of immunity are available.

Laboratory Testing

Measles testing should be performed for patients who:

• Meet the clinical case definition for measles (generalized maculopapular rash; and fever ≥101̊F; and cough, coryza, or conjunctivitis) AND
• Within the 21 days prior to symptom onset, had an elevated risk of exposure to measles including:
  • Had a known exposure to measles, or
  • Traveled internationally or to an area with known measles cases, or
  • Had contact with someone with a febrile rash illness, particularly if those individuals had traveled internationally or to an area with known measles cases.

Testing for measles is available through the Missouri State Public Health Laboratory and the CDC with prior authorization. Providers pursuing measles testing should collect specimens for both PCR testing (either a nasopharyngeal or throat swab) and serology (IgM, IgG). Measles testing to be performed by the MSPHL should go through the Virology Unit, phone # (573) 751-3334 before submission.

NOTE: Clinical specimens or isolates positive for measles performed by commercial clinical laboratories are to be submitted to the MSPHL for epidemiological or confirmation purposes.

Vaccination

Children

CDC recommends children should routinely get 2 doses of MMR vaccine:

• First dose at age 12 through 15 months
• Second dose at age 4 through 6 years (before school entry)

Adults

Adults and teens should be up to date on MMR vaccinations with either 1 or 2 doses (depending on risk factors); unless they have other presumptive evidence of immunity to measles, mumps, and rubella.

MMR efficacy against measles

Two doses of measles vaccine are 97% (range: 67% to 100%) effective at preventing measles.

One dose is 93% (range: 39% to 100%) effective at preventing measles.

ACIP recommends that people who don't have presumptive evidence of immunity to measles, mumps, and rubella should get vaccinated against these diseases.

Presumptive evidence of immunity can be established in any of the following ways:

• Written documentation of adequate vaccines for measles, mumps, and rubella
• Laboratory evidence of immunity
• Laboratory confirmation of disease
• Birth before 1957

Travel

• Measles cases in the United States originate from unvaccinated international travelers.
• You should be vaccinated against measles at least 2 weeks before international travel.
• Call your doctor immediately if you think you or your child have been exposed to measles.

Infants under 12 months old who are traveling:

• Get an early dose at 6 through 11 months.
• Follow the recommended schedule and get:
  • Another dose at 12 through 15 months.
  • A final dose at 4 through 6 years.

Children over 12 months old:

• Get first dose immediately.
• Get second dose 28 days after first dose.

Teens & adults with no evidence of immunity*:

• Get first dose immediately.
• Get second dose 28 days after first dose.

*Acceptable evidence of immunity against measles includes at least one of the following:

• Written documentation of adequate vaccination
• Laboratory evidence of immunity
• Laboratory confirmation of measles
• Birth in the United States before 1957

Resources

For Healthcare Professionals – Clinical Overview of Measles

Interim Measles Infection Prevention Recommendations in Healthcare Settings | CDC

Measles Infection Control in Healthcare Personnel | CDC

Acceptable Presumptive Evidence of Immunity to Measles | MMWR

ACIP Recommendations: Measles, Mumps and Rubella (MMR) Vaccine

Measles – Manual for the Surveillance of Vaccine-Preventable Diseases | CDC

Plan for Travel – Measles | CDC

Laboratory Testing for Measles | CDC

Measles Serology Testing | CDC

CDC Measles Resources

Global Measles Outbreaks | CDC

In August 2023, Missouri Revised Statutes 701.340-349 were updated to simplify testing schedules.

What are the testing requirements?

• The parents of all children ≤3 will be provided education on lead hazards by
  their medical provider
• The parents of all children ≤3 will be given the option to test annually
• Every child ≤72 months shall be screened using a lead risk questionnaire
  and will be offered testing if they are determined to be at high risk for exposure.

Children with elevated lead levels (above 3.5 mcg/dL) will be offered lead case management services at no cost by the Health Department’s NEST Partnership or their Medicaid managed care provider. This includes an assessment by a nurse and the Lead Risk Assessor to ask questions, assess the home and offer any tips or suggestions to get their level down before it becomes more of an issue.

More resources:

• SGCHD Lead Poisoning Prevention Information
• CDC National Lead Poisoning Prevention Week Resources
• Lead testing information for providers
• Recommended actions form
• MODHSS Healthy Children and Youth Lead Risk Assessment Guide

As the weather continues to warm and people spend more time outdoors, tick bites are becoming more common. With this nuisance comes the potential for tick-borne illnesses. Springfield-Greene County Health is anticipating a spike in one of these illnesses, alpha-gal syndrome (AGS), due to the prevalence of the lone star tick in this region.

AGS is caused when a lone star tick that has fed on other mammals bites a person and transfers the alpha-gal carbohydrate into their bloodstream. This can lead to the person bitten developing an allergy to red meat, which is why AGS is sometimes referred to as Mammalian Meat Allergy (MMA).

People with AGS usually see signs of an allergic reaction 2 to 8 hours after eating red meat, organ meat and other products made from mammals such as gelatins and dairy products. Symptoms of a reaction caused by AGS include:

• Hives, itching or itchy, scaly skin.
• Swelling of the lips, face, tongue, throat or other body parts.
• Wheezing or shortness of breath.
• Stomach pain, diarrhea, upset stomach or vomiting.

There is no treatment for AGS and it can last between 8 months and 5 years. People who contract AGS are advised to avoid additional tick bites and stop eating red meat. Further tick bites can lead to complications or more severe reactions.

While the Health Department does not know precisely how many cases occur in Greene County annually since AGS is not a reportable disease, the estimated number of cases of AGS is 32% higher in the Midwest than in other parts of the United States. Additionally, the lone star tick can also transmit other diseases like ehrilchia, Rocky Mountain Spotted Fever, heartland virus, southern tick-associated rash illness, bourbon virus and tularemia.

Ticks are most commonly found in wooded, bushy areas and areas with long grass. The Health Department encourages people to spend time outdoors this summer, since getting out and enjoying our regions trails, parks, lakes, rivers, and other natural amenities is good for both your physical and mental health. When you are spending time outdoors, you can take steps to prevent tick bites and the resulting tick-borne illnesses:

• Use an EPA-registered insect repellent containing DEET, picaridin, IR3535, Oil of Lemon Eucalyptus (OLE), para-menthane-diol (PMD), or 2-undecanone.
• Wear long pants and tuck them into your socks.
• Always wear shoes that cover your feet completely.
• Stick to established and maintained trails.
• Keep pets on a leash and don’t let them wander into tall grass or bushy areas.

 

Once you return indoors, check yourself, children and pets for ticks and remove any that have bitten immediately. For more information on preventing tick-borne illnesses, visit the Health Departments Bug-Related Illnesses webpage. More information about Alpha-Gal Syndrome can be found on the Centers for Disease Control and Prevention website.

 

Diagnosis

Confirmed laboratory evidence:

• Serum or plasma immunoglobulin E (IgE) specific to alpha-gal > 0.1IU/mL or > 0.1 kU/L. Higher levels of IgE does not correlate with severity of symptoms but does correlate with manifestation of symptoms. Primary location for testing in the U.S.:

Viracore Secure
1001 NW Technology Drive
Lee’s Summit, MO 64086
(800) 305-5198

Presumptive laboratory evidence:

• An allergy skin test that demonstrates sensitivity or one or more mammalian meats or other mammalian-derived product.

Clinical Criteria:

• Acute onset of any one or more of the following allergic and/or gastrointestinal symptoms that occur 2 – 10 hours after ingestion of pork, beef, lamb, any other mammalian meat, or any mammalian-derived product. OR within 2 hours after intramuscular, intravenous, or subcutaneous administration of alpha-gal-containing vaccination or medication:
  
  • Abdominal pain
  • Nausea
  • Diarrhea
  • Vomiting
  • Heartburn/indigestion
  • Hives
  • Itching
  • Anaphylaxis as diagnosed by provider.
  • Swelling of one or more of the following: lips, tongue, throat, face, eyelids, or other associated structures.
  • Shortness of breath.
  • Cough
  • Wheezing
  • Acute episode of hypertension 
  • AND The absence of a clear alternative diagnosis.

Treatment
There is no specific medical treatment for AGS. Recommendations for recovery include avoidance of further tick bites and no red meat consumption. If followed, desensitization may occur between 8 months and 5 years.

Additional tick bites will reactivate allergic reactions or cause more severe reactions.
Reptiles, poultry, and seafood do not have alpha-gal, and therefore can be ingested.

Case Classification

• Suspect: Meets confirmatory laboratory evidence with no clinical information.
• Probable: Meets clinical criteria AND presumptive laboratory evidence.
• Confirmed: Meets clinical criteria AND confirmatory laboratory evidence.

For more information: CDC case definition website

Revive was created in response to the growing epidemic of drug overdose deaths impacting our community, and provides resources and lifesaving guidance to people in both English and Spanish who use illicit substances, their loved ones, service providers and other people in the community who might encounter someone experiencing an overdose.

The goal of Revive is to prevent a drug overdose from becoming an overdose death. Overdoses from opioids, including fentanyl, can be reversed using the life-saving medication naloxone. Revive allows people to find naloxone to carry with them and guides them through its proper use if the need arises. The app will provide written, verbal and visual step-by-step guidance to those responding to a drug overdose. It asks a few questions to provide the best information, then walks the user through how to administer naloxone, conduct CPR and position the person so they can remain safe until emergency services arrives. Revive also reassures the person responding that, under Missouri’s Good Samaritan Law, they will not be arrested for minor offenses including drug possession if they call 911 to help someone who is experiencing a medical emergency.

In addition to rescue guidance, Revive provides information on recognizing the signs of an overdose, maps of community resources like drug disposal sites and treatment services and information for those who have experienced a drug overdose.

Revive can be accessed and downloaded for free by going to Revive417.com or through the Apple and Google Play stores on your mobile device.

Health care providers should consider the presence of xylazine when managing drug overdose, especially when naloxone administration is ineffective.

 

From: Paula F. Nickelson, Acting Director, Missouri Department of Health and Senior Services

 

Subject: Xylazine-Involved Fatal Drug Overdoses in Missouri, 2019-2022

 

DOWNLOAD THE ALERT

 

Xylazine is used in veterinary medicine as a sedative and muscle relaxant, but it is not approved by the Food and Drug Administration (FDA) for use in humans. Persons who use xylazine-adulterated opioids are at high-risk for fatal overdose. The White House Office of National Drug Control Policy declared xylazine and the use of fentanyl adulterated or associated with xylazine (FAAX) an emerging threat on April 12, 2023. Missouri DHSS detected a sharp increase in xylazine involved deaths in Missouri from 39 deaths in 2021 to 109 deaths in 2022, a 180% increase. Nearly two thirds (65%) of those deaths occurred in adults between 25 and 44 years of age. For all xylazine-involved deaths in 2019-2022, synthetic opioids were also found in 99.4% of these deaths. Increased surveillance and public education, as well as expanded postmortem testing for xylazine is needed, especially in Missouri jurisdictions with a high prevalence of fentanyl use.

 

Xylazine is an α-2 agonist similar to clonidine, lofexidine, and dexmedetomidine. It is used in veterinary practice as a sedative and analgesic. Xylazine is not FDA approved for human use and is not controlled under the federal Controlled Substances Act (CSA). This non-opioid agent is increasingly being found in combination with opioids such as fentanyl. Xylazine is known as “tranq” or “tranq dope” in the illicit drug market. The drug’s reported duration of effect is longer than that of fentanyl; therefore, it may enhance the euphoria and analgesia induced by fentanyl and reduces the frequency of injections. Recreational use of xylazine can occur via oral ingestion, smoking, snorting, or intramuscular, subcutaneous, or intravenous injection (most common). When used in combination with an opioid, such as heroin or fentanyl, xylazine may worsen respiratory depression during the drug overdose.

 

Xylazine was found in over 90% of illicit drug samples tested in Philadelphia in 2021 (1). As of March 2023, fentanyl mixed with xylazine had been found in drug seizures in 48 states (2). According to the CDC, the estimated number of drug-poisoning deaths in the United States involving xylazine went from 260 in 2018 to 3480 in 2021, a 1238% increase (2). The analysis published in MMWR found that among 45,676 overdose deaths reported from 38 states and the District of Columbia in 2019, xylazine was detected in 1.8% of the deaths, and xylazine was listed as a cause of death in 64.3% of deaths in which it was detected (3). In a Cook County, IL study, fentanyl or fentanyl analogs were detected on forensic testing in most xylazine-involved deaths (99.2%). Other common co-occurring substances included diphenhydramine (79.7%), cocaine (41.1%), and quinine (37.3%) (4). Many coroners and medical examiners may not include xylazine in their routine toxicology testing which would leave it largely undetected when investigating cause of death.

 

Xylazine Involved Deaths in Missouri
A sharp increases in xylazine-associated deaths were observed in Missouri in 2021 and 2022. Among death cases, 73% were males. Nearly two third (65%) of xylazine involved deaths occurred in adults between 25 and 44 years of age. Four adjacent Missouri jurisdictions (St Louis City, St Louis, St Charles, and Jefferson counties) comprise 86% of death cases during the 2019-2022 time period. It is likely that better availability of xylazine testing in the St Louis metropolitan area is contributing to those jurisdictions being overrepresented. For all xylazine-involved deaths in 2019-2022, synthetic opioids were also found in 99.4% of these deaths. Improved availability of xylazine testing in the recent years could be contributing to the sharp increase of xylazine associated death reports in 2021 and 2022.

 

Clinical Information
As a centrally acting α2 -agonist medication, xylazine inhibits the release of norepinephrine and epinephrine. The effects on the central nervous system include sedation, analgesia, and euphoria. Reduced sympathetic outflow from the central nervous system causes decreased peripheral vascular resistance, heart rate, and blood pressure. All routes of exposure to xylazine have been associated with drowsiness or coma, and in rare instances, apnea and death. Xylazine also causes decreased sensitivity to pain, respiratory depression, bradycardia (low heart rate), hypotension (low blood pressure), and potentially hypothermia. After taking xylazine with an opioid, a person may experience bradycardia and hypotension not explained by heroin or fentanyl alone. Respiratory depression reported in people using xylazine is likely due to the drug increasing the risk of opioid-induced respiratory depression. Xylazine can cause severe circulatory changes with peripheral vasoconstriction leading to poor tissue perfusion, skin ulceration, and necrosis. People who inject drugs containing xylazine can develop severe skin wounds and patches of dead and rotting tissue that easily become infected and, if left untreated, may lead to amputation . These wounds can develop in areas of the body away from the injection site and may become life-threatening. Soft tissue infections at injection sites and loss of digits have been reported as well. Because xylazine’s duration of effect is longer than that of fentanyl or heroin, repeated intake may allow xylazine levels to accumulate.

 

People who use xylazine may develop dependence, and have severe withdrawal symptoms, such as irritability, anxiety, and dysphoria when the drug is stopped abruptly. Severe xylazine withdrawal symptoms are unlikely to be managed by medications for opioid use disorder (MOUD) (i.e., methadone, buprenorphine, or naltrexone). Limited data are available for clinical management of the xylazine withdrawal in inpatient settings. Therefore, xylazine presents new potential public health challenges associated with possible withdrawal signs and symptoms in those with xylazine-related substance use disorder.

 

Routine toxicology tests do not test for xylazine. It may therefore be under-detected and under-accounted for in overdose cases and other life-threatening events. Since xylazine is not an opioid, it does not respond to naloxone, and there is no antidote or reversal agent for xylazine. Even though naloxone is not effective in treating drug overdoses caused solely by non-opioids, such as xylazine, the administration of naloxone may be helpful in drug overdoses caused by a combination of xylazine and opioids like fentanyl and its analogues. Therefore, when a patient presents with a possible exposure to xylazine, practitioners should provide routine care for opioid intoxication, particularly the administration of naloxone, as indicated. The treatment for overdoses involving xylazine is supportive: airway maintenance, breathingand circulation support, and infusion of IV fluids. If indicated, early administration of atropine may mitigate the onset or severity of bradycardia.

Recommendations

• Public education, especially among people who use illicit drugs, regarding the possible presence of xylazine in illicit drugs and the need for emergency medical care even when naloxone is administered.
• Any individual suspected of consuming substances containing xylazine should receive counseling about the dangers of this substance and extensive advice on harm reduction.
• Because xylazine is most often mixed with opioids, the individual exposed to xylazine should also be offered access to medications for opioid use disorder (MOUD) (i.e., methadone, buprenorphine, or naltrexone) and referral to treatment to reduce opioid overdose risk.
• Health care providers should consider the presence of xylazine when managing drug overdose, especially when naloxone administration is ineffective.
• Expand postmortem testing for xylazine and co-occurring substances in opioid-related deaths.
• While routine toxicology tests do not test for xylazine, local jurisdictions may establish partnerships with toxicology laboratories that can identify xylazine in drug or biologic samples.

For questions on management of these patients, contact the Missouri Poison Center (1-800-222-1222)

 

References

1. Philadelphia Department of Public Health. Substance use Philly: xylazine. (https://www . substanceusephilly . com/ tranq).
2. Gupta R, Holtgrave DR, Ashburn MA. Xylazine - Medical and Public Health Imperatives. N Engl J Med. 2023 Apr 26. doi: 10.1056/NEJMp2303120. Epub ahead of print. PMID: 37099338.
3. Kariisa M, Patel P, Smith H, Bitting J. Notes from the Field: Xylazine Detection and Involvement in Drug Overdose Deaths - United States, 2019. MMWR Morb Mortal Wkly Rep. 2021 Sep 17;70(37):1300-1302. doi: 10.15585/mmwr.mm7037a4. PMID: 34529640; PMCID: PMC8445380.
4. Chhabra N, Mir M, Hua MJ, Berg S, Nowinski-Konchak J, Aks S, Arunkumar P, Hinami K. Notes From the Field: Xylazine-Related Deaths - Cook County, Illinois, 2017-2021. MMWR Morb Mortal Wkly Rep. 2022 Apr 1;71(13):503-504. doi: 10.15585/mmwr.mm7113a3. Erratum in: MMWR Morb Mortal Wkly Rep. 2022 May 06;71(18):641. PMID: 35358161; PMCID: PMC8979597.

Disease Intervention Specialist (DIS)
Springfield-Greene County Health implemented a new DIS program earlier this year. Previously, the Missouri Department of Health and Senior Services (DHSS) was responsible for tracking all cases of Syphilis and HIV in southwest Missouri. In addition to two new DIS team members, the program includes a Community Health Advocate to assist with education and outreach activities. DHSS implemented approximately 10 DIS staff members throughout Missouri, two of which work for Springfield-Greene County Health focusing strictly on cases in Greene County.

The state of syphilis
Springfield-Greene County Health is making efforts to combat the rise of sexually transmitted infections (STIs), like syphilis and HIV, in our community. Syphilis cases continue to rise locally and throughout the state of Missouri. DHSS reports that Missouri has seen a 259% increase in syphilis infections from 2015 to 2021. Rates of congenital syphilis have also drastically increased—there were four cases in 2015 compared to 66 cases in 2021. Currently, Missouri is investigating over 2,500 cases of syphilis. This number does not yet reflect the final case count for 2023.
Of the 2,500 Missouri cases, Greene County DIS (DHSS and SGCHD) is currently investigating over 500 cases of syphilis. There are 13 congenital syphilis cases currently being investigated in Greene County.

Testing recommendations
The CDC recommends all sexually active patients be tested at least once a year for chlamydia, gonorrhea and syphilis. The following cases outline recommendations for more frequent testing:

• Any patient who has three or more partners in a year should be tested quarterly.
• Pregnant patients should be tested three times during pregnancy to reduce the risk of congenital syphilis; test for syphilis at the first prenatal visit, at third trimester (28 weeks) and again at delivery.

Talking to your patients about sexual health is a standard when providing medical care. It is recommended that providers take sexual history of all sexually active patients regardless of their age, sex, gender identity, sexual orientation, marital status, etc. Leading conversations about sexual history with your patients reduces stigma, invites open and honest conversations and can be instrumental in getting your patients needed resources and support. There are five Ps to guide you when having these conversations with patients: Partners, Practices, Protection from STIs, Past history of STIs, and Pregnancy intention. More information is available in the CDC’s A Guide to Taking a Sexual History.

Congenital syphilis
Pregnant women diagnosed with syphilis should be treated immediately. Treatment greater than 30 days of delivery is likely to prevent most cases of congenital syphilis. It may not prevent stillbirth or congenital syphilis in a gravely infected fetus, as evidenced by fetal syphilis on ultrasound at the time of treatment. All neonates with reactive nontreponemal tests should receive thorough follow-up examinations and testing every 2-3 months until the test becomes nonreactive.

Note: For more treatment information on congenital syphilis and syphilis in children, please see CDC STD Treatment Guidelines 

Bicillin shortage
The Food and Drug Administration (FDA) reported a shortage of Bicillin L-A® on April 26, 2023. Bicillin L-A® is the first-line recommended treatment by the CDC for syphilis and the only recommended treatment option for some individuals. Current guidance shows an estimated recovery for the Bicillin L-A® shortage in April 2024 at the earliest.

Treating Syphilis
Treatment for syphilis is dependent on diagnosis and stage of syphilis. The following are guidelines for providing treatment:

• Pregnant patients: Treatment should be administered at least 30 days prior to delivery.
  
  • Bicillin L-A 2.4 Mu IM (1-3 doses given a week apart)
  • If there is a penicillin allergy, desensitization will need to occur for mother to be considered adequately treated.
  • If patient has late latent diagnosis and misses a dose, re-treatment must occur.
• Primary, secondary, or early latent patients: Patient has visible signs/symptoms or previous reactive RPR within last 12 months.
  
  • Benzathine penicillin G 2.4 million units IM in a single dose OR
  • Doxycycline 100mg PO BID (orally twice a day) for two weeks (14 days)
• Late latent patients: Patient has no visible or reported signs/symptoms upon exam. There has been no nonreactive RPR within last 12 months.
  
  • Benzathine penicillin G 7.2 million units total administered as 3 doses of 2.4 million units IM each at 1-week intervals OR
  • Doxycycline 100mg PO BID (orally twice a day) for four weeks (28 days)
• Neurosyphilis, ocular syphilis patients:
  
  • Aqueous crystalline penicillin G 18–24 million units per day, administered as 3–4 million units IV every 4 hours or continuous infusion, for 10–14 days

Reporting syphilis/HIV cases
All cases of Syphilis and HIV should be reported as soon as possible (within one working day). Report cases using the CD1 form. The following should be included on the form:

• All demographics: name, DOB, address, phone number, ethnicity, marital status, gender identity, sexual orientation, pregnancy status if applicable, HIV status if tested
• Signs and symptoms: onset date, duration
• Diagnosis
• Treatment, if given
• Lab results
• Any supporting medical records that are easily available

Springfield-Greene County Health STI Clinic
SGCHD STI Clinic offers free STI testing and treatment four days a week. The clinic tests for chlamydia, gonorrhea, syphilis, HIV, trichomoniasis, and Mycoplasma genitalium (Mgen). To receive Mgen testing, individuals must be over the age of 18, nonpregnant, have no pregnant partners and be symptomatic at time of testing. The clinic offers free treatment for chlamydia, gonorrhea, syphilis, and trichomoniasis. All positive cases of HIV are immediately referred to APO for treatment and case management services. The clinic offers treatment for Mgen cases, however, the cost associated is dependent upon patient’s pharmacy and insurance coverage.

The STI clinic is open on Mondays and Wednesdays for walk-in testing from 8 a.m.-2 p.m. on a first come, first serve basis. We offer appointments for STI testing on Tuesdays and Thursdays from 9-10:45 a.m. and 12:15-3 p.m. The best way to schedule appointments for STI testing is on our website health.springfieldmo.gov/STI or by calling (417) 864-1684. Results for STI testing usually take 7-10 days.

Springfield-Greene County Health is encouraging caregivers to take steps to prevent infant deaths due to sudden infant death syndrome (SIDS) as a part of SIDS Awareness Month and Pregnancy and Infant Loss Awareness Month. Unfortunately, there have been several deaths in Greene County this year due to unsafe sleeping conditions.

In June 2022, the American Association of Pediatrics (AAP) published updated recommendations for reducing infant deaths in the sleep environment. Some of their recommendations include:

• Providers should endorse and model safe infant sleep guidelines from the beginning of pregnancy.
• Providers should screen for and recommend safe sleep practices at each visit for infants, up to 1 year of age.
• Provide culturally-appropriate, respectful and nonjudgmental communication when discussing safe sleep.

Local resources
Expecting parents can learn more about how to keep their baby safe and healthy through the Health Department’s NEST Partnership, which provides nurse care management. More information and an interest form can be found at nestpartnership.org

The First Birthday Program serves families in 24 counties in southwest Missouri who are in their third trimester and/or have a child who is up to 6 months old and do not have a safe sleep option. Home visitors provide safe sleep education, safe sleep kit and a pack-n-play to eligible families.

Providers can refer families or families can self-refer by visiting www.cpozarks.org/redcap or calling 417-888-2020.

Safe Kids Springfield (safekidsspringfield.org)
Safesleep.mo.gov (Missouri Safe Sleep Coalition)

Mental Health 417 is a comprehensive resource hub created by the Healthy Living Alliance of the Ozarks. We’re here to connect people in Springfield and Greene County with vital mental health information, with the goal of halting progression before it reaches a crisis.
The MentalHealth417.org website is a comprehensive and interactive resource hub for all of Greene County that includes:

• Overviews of common mental health disorders.
  
• Interactive mental health self-assessments
  
• A self-care toolbox with local ideas for managing stress and improving your mental wellbeing.
  
• Tips for starting conversations about mental health with friends, family, healthcare providers, etc.
  
• A treatment finder to help you get connected to professional mental health care.

 

SGCHD Call Center: 417-874-1211

Missouri DHSS

Missouri Hospital Association