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Suicide, Hepatitis C & Influenza vaccination

Today’s topics:

  • Suicide
  • Hepatitis
  • Influenza vaccination

 

Suicide

Action requested: Screen patients for suicidal potential.

Background & Recommendations

Suicide at any age is tragic, but a significant increase in suicides among young people is particularly worrisome.  This past school year (September 2014 through May 2015), thirteen Snohomish County residents ages 12-19 years committed suicide.   Ten were male.  Seven used handguns; the rest hung themselves.  They lived across the county.  Reviews of these deaths revealed common themes, including pressure to perform in school and the community and feelings of low self-worth.  Bullying may also have played a role in some suicides.

These suicides are consistent with data from the local Healthy Youth Survey (HYS), conducted in middle and high schools throughout the county.  Students report significant depression, suicidal ideation and attempts, and a need for adults to whom they can turn for help.

Following an intensive community health assessment, the Public Health Advisory Council (citizens appointed to advise the Board of Health) identified suicide as a priority for action.  A community health improvement plan has called out specific strategies for schools, the medical community, and the public at large:

 

  1. Schools should implement a behavioral health curriculum that addresses suicide prevention and the need to intervene when youth experience depression, self-injury, and bullying
  2. A community awareness campaign should be conducted aimed at educating residents to seek help when they or family members are overwhelmed by depression and/or suicidal thoughts.
  3. County residents should be trained in mental health first aid, especially those who may come in contact with high priority populations of youth, older males, Native Americans, and persons who have suffered from abuse.
  4. Hospitals should include suicide crisis line and other resource information in all discharge instructions for patients admitted for a suicide attempt.
  5. During wellness visits, primary care providers should screen patients for depression.  (Note that more than 60% of high school students report having seen a doctor for a checkup in the last 12 months, so this is a real opportunity to potentially identify young people at risk for suicide.)

Screening tools such as the Patient Health Questionnaire 2 or 9 (PHQ2 or PHQ 9) are embedded in many electronic health records and are accessible online as well.  I urge providers to use these tools.  Note that tools may not have been validated for all populations.  Please work with mental health experts with whom you have contact to identify screening and referral strategies for your clinic population.

For more information about screening tools you might use, see http://www.cqaimh.org/pdf/tool_phq2.pdf and http://impact-uw.org/tools/phq9.html.

 

Hepatitis C

Action requested: Test for hepatitis C.

Background & Recommendations

A leading cause of liver failure and the leading cause of liver transplants, hepatitis C (HCV)  is a significant public health problem.  The number of chronic HCV cases reported to the Health District has increased annually, from 613 in 2011 to 823 in 2014.  Treatment is a key strategy to not only improve the health of those who are infected, but also to reduce transmission.  The Centers for Disease Control & Prevention recommends testing for anyone at increased risk, including:

  • Persons born from 1945 through 1965
  • Persons who have ever injected illegal drugs, including those who injected only once many years ago
  • Recipients of clotting factor concentrates made before 1987
  • Recipients of blood transfusions or solid organ transplants before July 1992
  • Patients who have ever received long-term hemodialysis treatment
    • Persons with known exposures to HCV, such as health care workers after needle sticks involving HCV-positive blood and recipients of blood or organs from a donor who later tested HCV-positive
  • All persons with HIV infection
  • Patients with signs or symptoms of liver disease (e.g., abnormal liver enzyme tests)
  • Children born to HCV-positive mothers (to avoid detecting maternal antibody, these children should not be tested before age 18 months)

HCV-positive persons should be evaluated (by referral or consultation, if appropriate) for presence of chronic liver disease, including assessment of liver function tests, evaluation for severity of liver disease and possible treatment, and determination of the need for Hepatitis A and Hepatitis B (HBV) vaccination.

For more information about hepatitis C, see http://www.cdc.gov/hepatitis/HCV/index.htm.

 

Influenza vaccination

Action requested: Be aware of current recommendations for influenza vaccination.

Background & Recommendations

Influenza has circulated in the community throughout the summer.  The Health District has had reports of influenza A at two long term care facilities, resulting in at least two hospitalizations.  With the next influenza season within sight, providers should be aware of CDC’s updated recommendations for influenza vaccination:

  1. All persons aged ≥6 months should receive influenza vaccine annually. Influenza vaccination should not be delayed to procure a specific vaccine preparation if an appropriate one is already available.
  2. For healthy children aged 2 through 8 years who have no contraindications or precautions, either live attenuated influenza vaccine (LAIV) or inactivated influenza vaccine (IIV) is an appropriate option. No preference is expressed for LAIV or IIV for any person aged 2 through 49 years for whom either vaccine is appropriate. An age-appropriate formulation of vaccine should be used.
  3. LAIV should not be used in the following populations:
    • Persons aged <2 years or >49 years;
    • Persons with contraindications listed in the package insert:
      • Children aged 2 through 17 years who are receiving aspirin or aspirin-containing products;
      • Persons who have experienced severe allergic reactions to the vaccine or any of its components, or to a previous dose of any influenza vaccine;
    • Pregnant women;
    • Immunocompromised persons and persons who care for severely immunosuppressed persons who require a protective environment;
    • Persons with a history of egg allergy;
    • Children aged 2 through 4 years who have asthma or who have had a wheezing episode noted in the medical record within the past 12 months, or for whom parents report that a health care provider stated that they had wheezing or asthma within the last 12 months (Table, footnote). For persons aged ≥5 years with asthma, recommendations are described in item 4 of this list;
    • Persons who have taken influenza antiviral medications within the previous 48 hours.
  4. LAIV should be used with caution in persons with asthma and persons with other underlying medical conditions that might predispose them to complications after wild-type influenza virus infection (e.g., chronic pulmonary, cardiovascular [except isolated hypertension], renal, hepatic, neurologic, hematologic, or metabolic disorders [including diabetes mellitus]).
  5. As in prior years, no preference is expressed for high dose vaccine in persons aged 65 and older.

For more detail about current recommendations, see http://www.cdc.gov/mmwr/preview/mmwrhtml/mm6430a3.htm?s_cid=mm6430a3_w#Tab.

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