Clark County Medical Society

County Line

Newsletter XII January 2001

OUTBREAK INVESTIGATION – CLARK COUNTY HEALTH DISTRICT

2001 Charity Gala January 27

The 2001 CCMS Charity Gala will be held on January 27 at the Four Seasons Las Vegas. This year, the gala will benefit the Clark County Medical Society Scholarship Fund. CCMS Scholarships are given annually to local medical and nursing school students. There will be a silent auction beginning at 6:00 and dinner at 7:30.

Entertainment will begin at 7:30 and continue until midnight. Several local physicians will be performing and DJs from PMI DJs will keep the party going between performers. You won’ want to miss this unique opportunity to enjoy the talents of some of Las Vegas’ very own doctors.Contact the Clark County Medical Society at 739-9989 for reservations or more information by January 19, 2001.

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Industry/Member News

· The National Kidney Foundation of Nevada recently honored Allan Stipe, president and CEO of Sunrise Hospital and Medical Center and Sunrise Children’s Hospital for his civic leadership and philanthropic contributions throughout the community. According to Sunrise Hospital, its Renal Transplant Unit is Nevada’s only continuously operating facility of its kind in Nevada. More than 300 living and cadaver kidney transplants have been performed since 1990.

· Alice M. Chernich, RN, MSN has been named manager of the Neonatal Intensive Care Unit (NICU) at Sunrise Hospital and Medical Center. She brings more than two decades of administrative and leadership experience in the technological advancement of neonatal and pediatric care medicine to the post. The NICU is one of the leading neonatal facilities in the southwestern United States. The neonatal medical staff includes six neonatologists and 120 specially trained neonatal nurses.

· Researchers at University Medical Center are releasing information on a new procedure that is giving people infected with the AIDS virus new choices about having HIV-free children. The procedure is a unique blend of medication and a special Caesarean section. Using this procedure, UMC researchers state that so far more than 20 babies have been delivered to HIV positive parents with zero infected children.

· Sunrise Hospital and Medical Center has named Sherri Clagg, a 24-year veteran of the healthcare industry, who specializes in critical care, trauma and neurology, manger of its new Gamma Knife Center®. The Gamma Knife is a $3.5 million stereotactic radiosurgery tool that is used to target and destroy brain tumors, vascular lesions and blood vessel abnormalities, and is one of only 64 in the United States.

· Marion Hancock has been named manager of Child and Family Services and the SCAn (Suspected Child Abuse and Neglect) Program, at Sunrise Hospital and Medical Center. She will oversee a staff of six child life specialists and two pediatric social workers who focus on the emotional and developmental needs of hospitalized children and assist their families in accessing community resources and needed support services.

· University Medical Center announced the opening of the Jean Medical Center, 23120 Las Vegas Blvd. South on December 7. According to UMC, this will be the first ever medical facility of its kind for he residents of Southern Clark County. The Jean Medical Center will serve the communities of Jean, Good Springs, Sandy Valley, Sloan, and Primm. This is the first and only place for medical service in a 20-30 mile radius.

· Upon learning a donation to 71 children at Ruby Thomas Elementary School had fallen through at the last minute, Sunrise Children’s Hospital pitched in and fulfilled the promise made by a local retailer. Through the Clark county School District’s Community School Partnership Program, Sunrise’s Center for Health Families learned of the school’s dilemma. Within 48 hours, toys for the school’s 71 hearing impaired children were purchased, wrapped and delivered to the school.

· At the annual March of Dimes Nurse of the Year awards held recently, Valley Hospital’s Chief Nurse Executive, Michele Nichols, RN, BSN, MA, was awarded the designation of Distinguished Nurse of the Year for the year 2000. Valley Hospital nurses Linda Annarino, Kasey Danyow and Rick Wilber were also recipients of awards at the event.

· A new piece of technology that will allow physicians to more quickly and accurately diagnose and treat strokes, aneurysm, and heart attacks has been installed at University Medical Center. The Siemens Bi-Plane Digital Neurostar allows a physician to monitor a patient during an angiography procedure from two angles. With the Neurostar, a physician can watch in real time as a solution goes through the chest, brain, or anywhere in the body to find a blockage. This equipment will cut the time of the procedure by over half.

· The Nevada Childhood Cancer Foundation recently recognized ten-year-old Leah Marley and her father Tony for their bicycle trip across the United States to raise awareness and money for pediatric cancer. They raised more than $8,000. Leah’s mother, DR. EDITH MARLEY, is Nevada’s only pediatric pathologist.

· DR. WILLIAM ZAMBONI, chief of surgery at the University of Nevada School of Medicine has received the Rudolf W. Gunnerman Silver State Award for Excellence in Science and Technology to advance his medical research. Dr. Zamboni heads one of four U. S. research centers studying healing in hyperbaric chambers.

· At the Annual CCMS Alliance Holiday Luncheon, the Clark County Medical Society donated over $200 worth of toys. Donated toys were given to the Shade Tree Shelter.

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OUTBREAK INVESTIGATION – CLARK COUNTY HEALTH DISTRICT

Salmonella D Enteritidis

On August 22, 2000, two independent sources, one from Washington State and one from Utah reported hospitalizations of 4 persons suffering from severe gastroenteritis after consuming food at a Clark County Resort. The two initial reports indicated that at least six individuals were ill. A third report of severe gastroenteritis requiring hospitalization was received from a Clark County physician on August 23, 2000. This patient also had a history of eating at the same resort. Subsequent laboratory results from the hospitalized patients indicated that the causative agent was Salmonella D enteriditis.

An in-depth epidemiological investigation was carried out in order to determine links between the cases, possible source(s) of the illnesses and the scope of the outbreak.

The Office of Epidemiology at Clark County Health District conducted a case-control study, as outlined below.

EPIDEMIOLOGICAL INVESTIGATION METHODS

Case Definition:

A case was defined as a person that became ill with diarrhea and/or vomiting between August 15, 2000 and August 18, 2000 and that ate at the breakfast buffet at the resort on August 15, 2000.

Nine cases had laboratory-confirmed -Salmonella D enteriditis, and the other seven cases in the study had clinically compatible symptomatology. (There were an additional 11 patrons that had laboratory-confirmed salmonellosis, but did not fit the case definition because they ate at the resort after August 15, and/or became ill after August 18, 2000).

Control Definition:

A control was defined as person that ate at the breakfast buffet at the resort on August 15, 2000, and did not experience any subsequent illness.

Case Finding:

The initial cases were identified through the Clark County Health District’s passive reporting system, however in order to determine the scope of the outbreak and obtain cases and controls in sufficient numbers to allow a case/control study, four methods of case finding were employed:

1. Security reports of ill patrons were obtained from the resort.

2. As cases were identified and interviewed, information on additional cases and controls was elicited.

3. The State of Nevada Health Division requested that other State Health Divisions refer gastroenteritis cases with a history of travel to the Clark County resort, to the State of Nevada Health Division, Communicable Diseases Department.

4. The main medical center near the resort was asked to refer any patients with gastroenteritis and a history of eating at the resort to the Clark County Health District for testing and follow-up.

Questionnaire:

A questionnaire was constructed, using buffet menus provided by the food and beverage office at the resort. The questionnaire, which was administered via telephone interviews listed all 22 food items served on the breakfast buffet and also covered clinical histories.

Analysis:

The software package Epi-Info 6 was used to statistically analyze the data collected on the questionnaire.

Laboratory Studies:

Salmonellosis was confirmed through laboratory testing of stool specimens. The majority of the cases in this outbreak were not residents of Clark County, Nevada. For out-of-state cases, the State Health Division in the case’s state of residence provided the laboratory testing.

Isolates from two of the cases identified in Clark County were sent to the Centers for Disease Control and Prevention (CDC) for phage-typing.

One hundred seventeen stool samples from food handlers employed at the resort were tested for Salmonella species.

RESULTS

Scope:

The investigators identified a total of 35 individuals who experienced illness and had eaten at least one meal at the resort between August 15 and 30, 2000. Of the ill persons, two were from Arizona, seven from California, six from Nevada, eighteen from Utah and two from Washington State. Seven individuals experienced symptoms severe enough to require hospitalization. All seven had laboratory-confirmed salmonellosis. An additional six patrons sought medical attention for their symptoms.

The epidemiological curve for this outbreak shows a peak on August 16, 2000, which is an indication of a point source outbreak. The median incubation period was 26 hours, and the range was 15 to 77 hours.

Sixteen ill patrons fit the case definition and 22 controls were interviewed. Of the 22 food items, two were statistically significant. The food item "Shell Eggs" was a combination of all fresh egg breakfast items i.e., French toast, omelets, and Eggs Benedict. Consequently, there was an overlap in the analysis between shell eggs and Eggs Benedict. The scrambled eggs served on the buffet were made entirely of liquid pasteurized eggs and therefore were not included in the shell egg analysis.

Laboratory Results:

The laboratory-confirmed pathogen in the outbreak was Salmonella D enteriditis. The two isolates sent to CDC for phage typing were both phage-type 4. None of the resort employees tested positive for pathogen.

DISCUSSION

The epidemiological curve suggests that this was a point source outbreak resulting from consuming food contaminated with Salmonella D enteriditis on or before August 15, 2000. The meal that the majority of cases had in common was the breakfast buffet served on August 15, 2000, at the resort. Therefore, the epidemiological investigation focused on this meal.

Statistical analysis indicated a strong association between illness and Eggs Benedict and/or shell eggs. The statistical significance of the shell eggs is partly due to the overlap with Eggs Benedict, since of the sixteen persons consuming shell eggs, thirteen consumed them in the form of Eggs Benedict. Of the 16 cases, 100% had consumed fresh shell eggs at the breakfast buffet in some form. Of the 22 controls, 18 had not eaten shell eggs. None of the other menu items served at the breakfast buffet on August 15, 2000 was statistically implicated.

Salmonella D enteriditis has been associated with raw and undercooked eggs and foods containing eggs. When eggs with soft or runny yolks are prepared (such as those in Eggs Benedict), generally, the temperature reached in the cooking process is insufficient to kill Salmonella bacteria (if present). Fresh shell eggs were also used for the hollandaise sauce on the Eggs Benedict. Hollandaise sauce prepared with fresh egg yolk, using traditional methods, generally does not reach kill temperatures.

Because eggs were implicated in this outbreak, the resort requested that the purveyor retrieve the eggs from the resort on August 26, 2000. The resort changed egg suppliers on the same date. It is possible that eggs from the source that was present on August 15 were still in use until August 26.

Twelve patrons (who were not included in the case/control study) became ill after August 18, 2000. Their illnesses do not appear to be directly associated with the buffet breakfast meal served on August 15, and may represent illnesses that were propagated through secondary transmission or by consuming other meals containing eggs or otherwise contaminated with Salmonella.

Tests on stool specimens from food handlers at the resort were negative for the implicated pathogen. Since the tests were done two weeks after the initial point source outbreak, it is unknown if there had been any employees infected with Salmonella D enteriditis prior to the testing date.

The Environmental Health Division at the Clark County Health District initiated a trace-back of the eggs. A source in another state was identified. Once the case/control study was completed, and eggs were implicated, the Food and Drug Administration (FDA) was able to complete the trace-back. In October, FDA teams collected environmental samples from five hen houses at a farm initially identified by the Environmental Health Division. Four of the five hen house environments were positive for Salmonella D enteriditis. The farm has retained the services of a veterinarian to assist them through egg sampling, diversion, depopulation and clean up. For most of this year, the state where the farm is located had been experiencing higher than usual numbers of Salmonella D enteriditis cases, but had not identified any common sources among their cases. The isolates that this state submitted to CDC for analysis were also phage-type 4.

CONCLUSION

Salmonellosis is a nationally reportable illness. Health authorities in every state are mandated to contact all salmonellosis cases to obtain a history and document travel and possible sources of the illness. When the illness is associated with travel to another area, the health authority with jurisdiction for that area is notified. The Clark County Salmonella D enteriditis outbreak may never have been recognized had the initial cases not been tested and reported to Clark County Health District in such a timely manner. The investigation was initiated as a consequence of identifying a cluster of salmonellosis cases having an association with a resort located here. Identification of the source and halting distribution of the eggs may have prevented many other illnesses in Clark County and in other areas where these eggs were distributed.

Las Vegas is a major tourist destination and foodborne illness outbreaks in Clark County frequently involve individuals from other states. Clark County Health District relies on reports of laboratory- confirmed illness as well as inter-agency cooperation to identify and investigate outbreaks. Subsequent implementation of appropriate and timely interventions and preventative measures can protect the health of local citizens and visitors to Clark County.

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Referral Tallies

The following referrals were provided to CCMS members in the third quarter of 2000:

Specialty	Referrals
Allergy	3
Anesthesiology	2
Cardiology	8
Card. Vascular Surgery	3
Colon & Rectal Surgery	0
Dermatology	13
Diagnostic Radiology	0
Ear, Nose & Throat	3
Endocrinology	7
Family Practice	19
Gastroenterology	3
General Surgery	1
Genetics	0
Geriatrics	1
Gynecology	0
Hematology	0
Infectious Medicine	0
Internal Medicine	13
Nephrology	1
Nuerology	6
Neurosurgery	4
Ob-Gyn	9
Oncologist	8
Ophthalmology	3
Orthopaedic Surgery	11
Pain Mgmt.	3
Pathology	1
Pediatrics	5
Ped. Neuro.	0
Ped. Psychiatry	0
Ped. Surgery	0
Plastic Surgery	8
Psychiatry	12
Pulmonology	2
Radiology	1
Rheumatology	1
Urology	3
Vascular Surgery	2
Other	1
Totals	157

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January CMEs

UMC Continuing Medical Education Program For additional information please call 383-2604

January 9

PI/UM Comm 12:00 noon - E&F (North Auditorium)

OB/GYN Comm. 12:30 p.m. - Rooms A& B

January 11

Ortho Trauma 7:30 a.m. - 4N Conference Room

Tumor Board 12:00 noon - South Auditorium

January 12

Medical Grand Rounds 7:30 a.m. - South Auditorium

January 16

P & T Comm. 12:00 noon - Rooms C & D

January 17

Surgery Comm. 7:00 a.m. - Rooms A & B

IRB Comm. 7:30 a.m. - Rooms C & D

January 18

Credentials Comm. 7:30 a.m. - Rooms A,B,C,D

Orthopaedic Trauma 7:30 a.m. - 4N Conference Room

Tumor Board 12:00 noon - South Auditorium

Ambulatory Care 5:00 p.m. - Rooms G&H

January 19

Medical Grand Rounds 7:30 a.m. - South Auditorium

January 23

Medical Grand Rounds 8:00 a.m. Rooms G&H

Infection Control 12:00 noon - Rooms C&D

January 24

Burn Care 12:00 noon - Burn Care Conf. Room

Hand Surgery 5:30 p.m. - Rooms C&D

January 25

Ortho Trauma 7:30 a.m. - 4North Conf. Room

Peds Closed Peer Review 7:30 a.m. - Rooms E&F

Peds Dept. 8:00 a.m. - Rooms E&F

Tumor Board 12:00 noon - South Auditorium

January 26

Medical Grand Rounds 7:30 a.m. - South Auditorium

Cancer Control 12:30 p.m. - Rooms A&B

January 31

Family Practice 7:30 a.m. - Rooms A&B

Valley Hospital CME Program

January 9

Latex Sensitivity 12:00 noon - Hosp. Conf. Room

January 23

GERD and PPI’s 12:00 noon - Hosp. Conf. Room

January 11

MGMA Meeting. 8 a.m. Sunrise Hospital Auditorium. Speaker Tina Landskroener, CPC, Proactive Health Care Services, Inc. Call Cheryl 732-0072.

January 13

2001 Diabetes Symposium. Sponsored by the American Diabetes Association. FAX (916) 363-4798.

January 19-21

Ob/Gyn Ultrasound. Setting Standards for Practice in 2001.Atlanta, Georgia. Contact: 1-888-639-0817.

January 24

NV State Society of Medical Assistants Quarterly Meeting. Topics: Diabetes, Osteoporosis, Endocrinologist. Contact 387-8868.

May 5-8

Academy of Correctional Health Professionals. Clinical Updates in Correctional Health Care, 6th Annual Spring Educational Conference. Alexis Park Resort. Call 773-880-1460 or www.ncchc.org.

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Classified Advertising

· MEDICAL OFFICE SPACE TO SUB-LEASE. New office building in prime Northwest location, close to Mountainview Hospital on Tenaya, has space for share with dermatology practice, 3-5 exam rooms available for sub-lease either full or part-time. Beautiful, large waiting room and reception area are fully furnished. Call Pamela Ashworth at 367-8458.

· WANTED: Part-time Nevada licensed Family Practice and/or Internal Medicine MD or DO. Flexible hours (mornings or afternoons), stress free work environment and competitive salary. Fax CV to 431-6195 .

· BLDG. FOR LEASE/SALE up to 7,000 sq. ft. 2905 W. Charleston, close to UMC, Valley Hospital and Freeways. Can lease smaller space. Also available bldg. next door for right person. Excellent sign visibility, one story, ample parking. Call 804-4736 leave message or cell 232-3344.

· OFFICE SPACE: Excellent space for medical office for sublease of part time use. XRay available.2400 sqft. excellent incentives. 6380 W. Flamingo, call 896-1710.

· NEW PHYSICIAN Joining Your Practice, going solo or just new in town? TRM Consulting specializes in physician credentialing. We handle all aspects of credentialing and recredentialing for physicians and medical professionals. If interested please contact Tanya @ 614-9704.

· OB/GYN established practice for sale. Call 384-7756.

· PHYSICIANS NEEDED: Las Vegas fastest growing Primary & Urgent Care, JCAHO accredited facilities is actively seeking Board Certified or Board Eligible Family Practitioner or Internal Medicine physicians to join our medical team. FAX CV to 255-0846 or call 255-9300.

· MEDICAL OFFICE FOR PART TIME LEASE. Beautiful, modern office available for part time lease. Fully equipped for Ob/Gyn practice, 7 exam rooms, operating room and large, private office. Call Cindy at 733-7850.

· ST. ROSE SIENA CAMPUS TIME SHARE. Prime location of I-215 and Eastern next to new St. Rose Siena Campus. Half-day per week basis, 1,200 sq.ft. office with 3 exam rooms and consultation office. Interested parties call Ellen at 454-6226.

· ANTHEM/SEVEN HILLS - Space available by the hour, day, week, etc. We have patients to refer to you. Also, case by case consulting arraignment available. Call Dr. Gary Solomon 480-7702.

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Contents

2001 Charity Gala January 27

Industry/Member News

OUTBREAK INVESTIGATION – CLARK COUNTY HEALTH DISTRICT

Referral Tallies

January CMEs

Classified Advertising