Pulsimeter

Protecting the blood supply from West Nile virus—BC update, 2006

Since July 2003, Canadian Blood Services (CBS) has tested every donation for West Nile virus (WNV) using an investigational WNV nucleic acid test (WNV-NAT). During 2005, as in previous years, there were no confirmed positive WNV donations in British Columbia. Nationally, CBS detected WNV in 15 asymptomatic donors (at the time of collection) during 2005, representing 6.3% of the 239 cases of WNV infection reported to Health Canada last year. This proportion of WNV-positive blood donors among reported cases is significantly biased by the fact that CBS tests all donors whereas only symptomatic, test-positive WNV cases would otherwise be reported to public health. Seven positive donors were detected in Ontario, four in Saskatchewan, and two each in Manitoba and Alberta. Monitoring of out-of-province WNV activity is relevant to blood safety in BC because blood products from other provinces—particularly Alberta and Saskatchewan—are routinely imported. Across Canada, positive donors were detected between 26 July and 29 September 2005, consistent with previous years’ experience that mid-to-late summer is the period of highest WNV risk to the blood supply.[1,2] As in the previous 2 years, no case of transfusion-transmitted (TT)-WNV was reported in Canada in 2005.

Minipool and single-unit WNV testing of donors

CBS routinely performs WNV-NAT in minipools (MP) of six specimens. Single-unit (SU) WNV-NAT is selectively used during WNV season since SU testing is more sensitive than MP testing in detecting early, seronegative, viremic infections that pose the highest risk of TT-WNV.[3] During 2005, CBS made SU testing available for the 11-week period between 24 July and 9 October and employed SU testing for approximately 8% of all donations over this period, although no SU testing was performed on BC donations. 

For the 2005 WNV season, the criteria used by CBS for implementing SU testing were either a positive-donor test result or an incidence of public health-reported WNV in a health region over a 2-week period exceeding either 1:1000 in rural areas or 1:2500 in urban settings. SU testing was implemented for a 2-week period for all donor clinics in the affected region and was discontinued if neither criterion was met during that time. In its ongoing daily review of SU test deployment, CBS undertook ongoing risk assessments for each health region in each province, using the most current available human WNV surveillance data. CBS was also able to implement SU testing for blood collections from clinics in an affected region within hours of a positive-donor test result; therefore, no donor clinics were cancelled. 

Of the 15 positive donations detected by CBS in 2005, 9 were detected by MP testing and 6 by SU testing; 14 of 15 were seronegative donations and hence more likely to have been infectious. Subsequent laboratory follow-up revealed that only 1 of the 6 units detected by SU testing would not have been identified through MP testing. This is consistent with other recently published data that indicate that MP testing is very effective at interdicting potentially infectious WNV donations.[4]

Fresh frozen plasma not stockpiled

Based on previous experience, it was determined that national requirements for fresh frozen plasma (FFP) could be met using FFP collected from areas at low risk for WNV. Consequently, for 2005, there was no stockpiling of FFP that had been collected prior to mosquito season.

Integrated WNV surveillance

In BC, CBS, the BC Centre for Disease Control (BCCDC), and BC Ministry of Health (MOH) continued their close cooperation in WNV planning, preparation, and surveillance. Between 1 June and 31 October, BCCDC provided daily reports to CBS (BC and Yukon Centre) on WNV test requests. This enabled rapid identification of donors who might recently have donated potentially WNV-infectious blood. A product recall could then be carried out quickly, and donors could be deferred for a 56-day period to prevent those affected from donating while potentially infectious.

Over this period, CBS received 427 reports of which 23 (5.4%) were donors. Three of the 23 donors had recently donated blood and a recall of in-date products was carried out. Of particular interest was a donor whose last donation was made in Hamilton, who subsequently became ill and was tested in BC. The Hamilton blood centre was immediately informed and was able to follow up with hospital customers. 

Anonymized data linkage project

The aim of this project, using WNV as a sentinel blood-borne pathogen, is to demonstrate that timely, accurate, secure data linkage can be made between the BCCDC laboratory and CBS donor databases to identify potential hazards to blood safety while simultaneously protecting patient confidentiality. During 2005, the ADL matching algorithm was tuned to optimize its sensitivity and specificity, using retrospective WNV test data from BCCDC and matching this with the national CBS donor database. Interestingly, the ADL process retrospectively identified one match that was not initially made by manual checking (due to discordant date of birth records between databases), exemplifying the potential benefits of the data linkage envisioned in the project. For 2006, ADL matching will be performed in “real time” on a daily basis to further validate the process.

New for 2006 WNV season

A similar blood donor screening strategy is planned for 2006, except that SU testing will continue for 1 week only (instead of 2 weeks as in 2005) in a region following a single reported positive donor. The rationale is that surveillance experience indicates that subsequent cases are identified either through donor screening or public health testing in the week following an initial positive donor in regions that are experiencing sustained high WNV activity. 

In addition, Health Canada has approved a submission by Hema Quebec for “seasonal” WNV testing; i.e., discontinuing routine donor WNV testing during the cold winter months and during this time, requiring testing of only those donors who have traveled outside Canada. CBS is examining the utility of a similar approach.

Protecting your patients from TT-WNV

Physicians are reminded of the need to ensure that their patients are aware of the risk of WNV transmission through transfusion. During the WNV season, this warning should be part of the informed consent for transfusion. During summer and fall in particular, TT-WNV should be considered in patients who present with signs and symptoms of WNV infection within 4 weeks of receiving a blood product. Suspect cases of TT-WNV should be reported to CBS by phone at 604 876-7219 or by fax at 604 879-6669 as well as to your local medical health officer. Physicians should routinely question patients who may have WNV infection about recent blood donation, and patients who have donated in the previous 8 weeks should be reported to CBS so that in-date components can be withdrawn. 

—Mark Bigham, MD
—Gershon Growe, MD
Canadian Blood Services
BC & Yukon Centre, Vancouver

 

Looking for more information? For questions about WNV-related  transfusion practice, visit the TraQ Program web site at www.traqprogram.ca/WNV-contingencies.asp

Book reviews

A Physician’s Guide to Return to Work. By James Talmage, MD and Mark Melhorn, MD. Chicago: American Medical Association Press, 2005. ISBN 1-57947-628-7. Paperback, 356 pages. $70.

A frustration in clinical practice can be assessing fitness to work and the related interaction between physicians, patients, and their insurance companies. The disability forms may ask questions the physician feels inadequate to answer. The physician is placed in an unwanted role of disability manager and is the one who has to deal with the stressed claimant if insurance benefits are denied. Physicians can become frustrated with their patients when there is a lack of objective findings, despite the ongoing pain reported by their patients.

This book, edited by Talmage and Melhorn with chapters written by numerous contributors, provides a useful framework in both assessing and managing disability. There are chapters on cardiovascular, musculoskeletal, neurological, and psychiatric disease. There is also a section on fibromyalgia and chronic fatigue syndrome.

The concepts of capacity, tolerance, and restrictions are introduced. Capacity refers to concepts such as strength, flexibility, and endurance that are measurable with a fair degree of precision. Tolerance refers to reported subjective limitations (pain and/or fatigue). A patient may have the ability to perform a certain task but reports being unable to do it comfortably. Tolerance may, in part, be dependent on such issues as job satisfaction, financial remuneration, and other non-medical incentives or disincentives. Restrictions refer to things a patient can do but should not do due to possible harm to her- or himself or others, such as a person with poorly controlled epilepsy driving a bus.

There are a number of chapters that offer practical advice on assessing functional impairment related to various common medical conditions.

Our role as physicians is to define the medical impairments of our patients. It is up to the insurer and employer to decide if the reported impairments can be accommodated or if the worker is disabled.

While the reader is unlikely to agree with everything in it, the book does present an excellent guide to assessing impairment related to many common medical problems. It provides practical advice and is helpful in decreasing the amount of speculation, uncertainty, and frustration in assessing medical impairment. It may allow you to sleep better at night rather than worrying about what you did or did not write on your patient’s disability application. 

Given the amount of time that the average attending physician spends completing disability forms, a guide like this is long overdue.

—John Sehmer, MD
Vancouver

 

Fit to Deliver: An Innovative Prenatal and Postpartum Fitness Program.  By Karen Nordahl, MD, Carl Petersen BPE, BSc(PT), and Renee Jeffreys, MSc. Vancouver: Hartley & Marks Publishers Inc., 2005. ISBN 0-88179-208-X. Paperback,163 pages. $24.95.

This book is written by a physician, a physical therapist, and an exercise physiologist. The stated goal of the book is to “give women the ability to modify their existing fitness program (or, for those new to exercise, to start a program) and to go one step further by offering state-of-the-art training techniques to better prepare for delivery and the postpartum period.”

The authors suggest that the first two chapters of the book be read prior to other chapters. In these first two chapters, the benefits of exercise for both the mother and the baby are outlined, as well as the absolute and relative contraindications to aerobic exercise during pregnancy. The authors then go on to outline a detailed program of exercise based on building core strength.

There are chapters on warm-up, cool-down, and stretching routines, cardiovascular training (including a walk-run program much like that proposed for Sun Run training in Vancouver), resistance training, balance training, relaxation techniques, and guidelines for adapting these approaches to the postpartum period.

The authors make claims that would entice any woman into their fit-to-deliver program. For example, they say that with a moderate exercise program, women have a reduced time in the “active stage” of labor and children have greater neuro-developmental scores in oral language and motor areas when tested at age 5. Although there are general references at the end of the book, specific references for facts such as these are not provided.

The book is nicely laid out. Pencil drawings of parts of the body and various muscles are clear and aid in the reader’s understanding of the purpose of each exercise. There are photographs of pregnant women demonstrating the various exercises, and on every second page, there is a “Tips from the Team” box, which emphasizes the interdisciplinary approach this book takes.

There are aspects of the book that reflect the upper middle class experiences of the authors. They recommend that every woman work with a qualified fitness professional during the pregnancy and suggest that women invest in good exercise clothing.

The program requires time and discipline. However, because of the clarity of its presentation and the range of exercise options not often seen in pregnancy exercise books, I do recommend this book.

—Elaine Carty, MSN
Professor and Director
UBC Midwifery Program

VGH photo history released

Canadian heritage consultant Donald Luxton has compiled a photographic collection illustrating the 100-year history of Vancouver General Hospital. Accompanied by a brief but entertaining written history, these photographs document not only the hospital’s buildings and medical machinery but also moments in the lives of the physicians, nurses, cleaners, cooks, and ambulance drivers who have made VGH tick for the past century. From its early days as a tent for injured and sick workers on the Canadian Pacific Railroad to its development into a teaching and research centre of the highest quality, the history of VGH is beautifully presented.

To order a copy, which is $35, contact the Heather Heritage Society, 4380 Locarno Crescent, BC  V6R 1G3, tel/fax: 604 224-3607, e-mail: m.ford@telus.net.

 Identity theft insurance--new membership benefit

BCMA membership now includes identity theft insurance coverage for all members and their spouses.

Identity theft refers to all types of crimes where someone wrongfully obtains and uses another person’s identifying information for the purpose of fraud or other criminal activity.

Identity thieves target individuals who have a good credit rating or potential for good credit, such as physicians. The two distinct results of identity theft are direct financial loss and indirect costs such as a damaged credit rating and reputation.

Identity theft has become one of the fastest-growing crimes in North America. Canadian credit bureaus indicate that they receive approximately 1400 to 1800 identity theft complaints a month. According to the Identity Theft Resource Centre, it takes an individual almost 600 hours and $1400 in out-of-pocket expenses to restore their identity.

Your insurance covers such losses as:

•           Wages
•           Notary and certified mail charges
•           Fees to reapply for loans
•           Long-distance telephone charges
•           Legal fees

Reduce your exposure to identity theft

Here are some tips to help you prevent identity theft:

• Guard your social insurance number (SIN). Never put your SIN on cheques, do not use your SIN or any part of it as a password, and only give it out when you believe it to be absolutely necessary.

• For all accounts, create passwords and PINs that are difficult to guess and change them periodically.

• Consider buying a shredder to adequately destroy personal financial documents that you are throwing out.

• Never give out any confidential information (account numbers, passwords) over the phone to an unsolicited caller who is stating that they represent your financial institution or similar creditor.

• Review credit card and bank account statements as soon as you receive them to determine whether there are any unauthorized charges.

• Do not carry your social insurance card, birth certificate, or passport with you unless absolutely necessary.

• If you are denied credit, find out why.

• Be alert to red flags. If you ever receive a call from a merchant, creditor, or collection agency in what seems to be a case of mistaken identity, find out exactly who they are and why they are calling you.

• Watch for people standing near you at retail stores, restaurants, grocery stores, etc. who have a cell phone in hand. With the new camera cell phones, they can take a picture of your credit card.

E-mail and phishing identity theft prevention tips

“Phishing” is when criminals lure people to surprisingly realistic web sites that they have created to trick people into disclosing their account numbers, passwords, social insurance numbers, or other sensitive information.

• Don’t trust e-mail headers; they can be forged easily.

• Avoid filling out forms in e-mail messages.

• If you want to do business online, don’t click on links in an unsolicited e-mail. Go to the company’s web site yourself and fill out information there.

• Be wary of any e-mail message asking you to verify or re-enter account information that you have already given to an organization you do business with.

• If there is any reason to doubt the authenticity of an e-mail message from a company you do business with, do not click on any link or button in the message. Instead, type the Internet address of the company into your browser, log in as you usually do, and examine your account information.

• Look for the padlock icon on the bottom of the browser window that indicates that the site is using security features meant to protect confidential information. If a site is asking for personal information and is not using this security method, it is suspect. However, the padlock in itself is no assurance that a site is legitimate.

• Phone a company to ask if an e-mail is legitimate. Let any organization being impersonated know of the scam.

• If you have any reason to suspect that you have inadvertently provided information to a phisher, contact your bank and credit card companies immediately. Also, change any online passwords that you may have revealed to the phishers.

• If you get an e-mail that warns you, with little or no notice, that an account of yours will be shut down unless you reconfirm your billing information, do not reply or click on the link in the e-mail. Instead, contact the company cited in the e-mail using a telephone number or web site address you know to be genuine.

Identity theft coverage is now automatically included as a BCMA membership benefit for all members and their spouses. For general information or if you have questions regarding identity theft coverage please contact the BCMA Insurance Department staff at 604 736-5551 or 1 800 665-2262 outside the Lower Mainland.

—Christiane AhPin
Director, BCMA 
Corporate Affairs

2006 Health Promotion Award recipients

The Excellence in Health Promotion Award, sponsored by the BCMA Council on Health Promotion, was presented to two candidates at the BCMA awards ceremony on 10 June 2006.

The BCAA Traffic and Safety Foundation was awarded for their Mature Drivers Program, which works to ensure seniors remain safe and proficient on the road. The program respects seniors’ strong need for empowerment and independence, while recognizing that mobility plays a significant role in their lives, lifestyle, and well-being.

The other recipient is SportMedBC for their InTraining Walk/Run program. Developed in 1996, this program promotes health and fitness for all British Columbians interested in adopting a more active lifestyle. Now in its 11th year, the program helps more than 4000 participants safely and comfortably reach their running and walking goals each year.

Once again, the Council on Health Promotion was impressed by the quality of nominations for this award and encouraged by the variety of health promotion projects striving to improve the health and safety of British Columbians.

 BCPA online listings

There are over 5000 British Columbians living with a spinal cord injury and an average of 200 spinal cord traumas in the province each year. The BC Paraplegic Association (BCPA) provides support to these British Columbians and many others with physical disabilities. Through its web site, the BCPA provides people with physical disabilities, their caregivers, and family members with easy access to a searchable online database of wheelchair-accessible service providers and other community information. The web site and resource directory are located at www.bcpara.org and are visited by over 1600 people every month. If you are interested in having your wheelchair-accessible practice listed, contact the association at 604 326-1276 or e-mail marketing@bcpara.org for pricing.

Dementia simulation program

Providence Health Care has partnered with the Alzheimer Society of BC to participate in the Alzheimer Society’s new program, Making the Connection--The Dementia Experience. The first of its kind in BC, this program offers a simulated dementia experience in which the senses are artificially altered through various techniques. It offers professional caregivers a chance to walk in the shoes of a person who has dementia and helps participants understand what a person with dementia feels, hears, and sees. The program is completed with a debriefing and an education workshop.

The Alzheimer Society developed the two-part course to give professional caregivers insight and skills to help inspire change in the way they provide care to people with dementia.

About 600 people, including 525 staff from Providence, have completed the program since its launch.
For more information, call 604 681-6530 or e-mail adevries@alzheimerbc.org.

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References

1. Cameron C, Reeves J, Antonishyn N, et al. West Nile virus in Canadian blood donors. Transfusion 2005;45:487-491.
2. Stramer SL, Fang CT, Foster GA, et al. West Nile virus among blood donors in the United States, 2003 and 2004. N Engl J Med 2005;353:451-459.
3. Busch MP, Tobler LH, Tobler J, et al. Analytical and clinical sensitivity of West Nile virus RNA screening and supplemental assays available in 2003. Transfusion 2005;45:492-499.
4. Busch MP, Caglioti S, Roberson EF, et al. Screening the blood supply for West Nile virus RNA by nucleic acid amplification testing. New Engl J Med 2005;353:460-467.