VIRAL HEMMORHAGIC FEVERS

Transcription

1 VIRAL HEMMORHAGIC FEVERS ALL SUSPECT CASES OF TULAREMIA MUST BE REPORTED IMMEDIATELY TO THE HEALTH AND HUMAN SERVICES COMMUNICABLE DISEASE CONTROL: During business hurs: (916) After hurs (Health Officer On call): (916) Etilgic Agents: Arenaviradae (Lassa, Junin, Machup, Guanarit, and Sabia), Filviradae (Marburg and Ebla), Bunyaviradae (Cng-Crimean hemmrhagic fever virus and hantaviruses)and Flaviradae (yellw fever and Dengue) can all cause viral hemmrhagic fever (VHF) Epidemilgy: Highly infectius after aerslizatin Infectius dse can be as lw as 1-10 rganisms Risk f persn-t-persn transmissin depends n virus Clinical: Incubatin perid is 4 21 days, depending n virus Clinical presentatin wuld vary by viral agent; hwever, dminant clinical features f all are a cnsequence f micrvascular damage and changes in vascular permeability. Fever, myalgia, and prstratin may evlve t shck, generalized mucus membrane hemmrhage, and neurlgic, hematpietic, r pulmnary invlvement. Labratry Diagnsis: Viral islatin shuld be handled in a Bisafety Level 3 r 4 facility and may take 3 10 days ELISA r reverse transcriptase PCR available fr mst VHF viruses Cntact the Sacrament Cunty Public Health Labratry fr assistance. Patient Islatin: Islatin rm with cntact precautins. Treatment: Prphylaxis: Ribavirin (30 mg/kg IV x 1, then 15 mg/kg IV q 6 h x 4 days, 7.5 mg/kg IV q 8 x 6 days) may be helpful fr Cng-Crimean hemmrhagic fever r arenaviruses Licensed vaccine available nly fr yellw fever

2 SACRAMENTO COUNTY HEALTH AND HUMAN SERVICES COMMUNICABLE DISEASE CONTROL Medical Treatment and Respnse t Suspected Q-Fever: Infrmatin fr Health Care Prviders During Bilgic Emergencies I. Key Summary Pints II. Intrductin/Epidemilgy III. Significance as a Ptential Biterrrism Agent IV. Clinical Manifestatins V. Labratry Diagnsis VI. Handling Labratry Specimens VII. Treatment VIII. Islatin f Patients IX. Dispsal f Infectius Waste X. Autpsy and Handling f Crpses XI. Management f Expsed Persns XII. Reprting During Business Hurs After Business Hurs XIII. References ALL SUSPECT CASES OF Q FEVER MUST BE REPORTED IMMEDIATELY TO THE SACRAMENTO COUNTY HEALTH AND HUMAN SERVICES, COMMUNICABLE DISEASE CONTROL: During Business Hurs: (916) After Hurs (Nights, Weekends and Hlidays): Health Officer On call, at (916)

3 I. KEY SUMMARY POINTS Epidemilgy: Cxiella burnettii is highly infectius by the aersl rute Q Fever is rarely transmitted frm persn t persn Clinical: Incubatin perid is days Acute infectin may be asymptmatic r a self-limited febrile illness Chest x-ray evidence f pneumnia is present in up t 50% f cases Mrtality rate is less than 2% Cntact the Sacrament Cunty Public Health Labratry at (530) fr assistance. Diagnsis: Requires serlgic cnfirmatin (IFA r ELISA) Islatin f rganism is nt recmmended due t significant hazards frm handling bacterial cultures in the labratry Treatment: Illness usually reslves withut treatment Tetracyclines are the antibitics f chice fr mre severe illnesses Prphylaxis: Tetracycline antibitics are very effective if administered 8 t 12 days AFTER expsure Starting prphylaxis immediately after expsure can delay symptm nset but des nt prevent illness Patient Islatin: Universal precautins. Patients d nt require islatin rms

4 ALL SUSPECT CASES OF Q FEVER MUST BE REPORTED IMMEDIATELY TOTHE SACRAMENTO COUNTY HEALTH AND HUMAN SERVICES, COMMUNICABLE DISEASE CONTROL: During Business Hurs: (916) After Hurs (Nights, Weekends and Hlidays): Health Officer On call, at (916) II. Intrductin/Epidemilgy Q fever is a zntic disease caused by Cxiella burnetii, a rickettsia-like rganism. C. burnetii is unable t replicate utside hst cells, but there is a spre-like frm f the rganism that is extremely resistant t heat, dessicatin and many standard antiseptic cmpunds. The rganism can persist in the envirnment fr lng perids under harsh cnditins. Despite the inherent resilience f C. burnetii and its ease in transmissibility, generally by inhaled aersls, the acute clinical disease f Q fever is usually benign, althugh temprarily incapacitating. Cxiella burnetii is extremely infectius. Humans have been infected mst cmmnly by cntact with dmestic livestck, particularly gats, cattle and sheep but husehld pets, ntably cats, have als been assciated with infectin. The risk is highest when humans are expsed t these animals at parturitin, presumably via aerslizatin f the rganism frm the uterus during birthing. Cxiella rganisms can persist in the lcal envirnment, and prduce infectin, fr weeks r mnths after cntaminatin. Q fever has VERY RARELY been transmitted frm persn-t-persn (specifically, transmissin has ccurred t attendants during autpsies and frm an infected patient t the attending bstetrician during delivery). Persns expsed t an aersl f Cxiella burnetii d nt present a risk fr secndary transmissin t thers r fr reaerslizatin f the rganism. III. Significance as a Ptential Biterrrist Agent The spre-like frm f the rganism is resistant t heat and dessicatin, and can persist in the envirnment fr lng perids f time. Highly infectius when aerslized and inhaled; a single rganism may cause clinical illness

5 Aerslized Cxiella burnetii can result in an incapacitating respiratry illness; hwever, severe illness and fatalities are rare. IV. Clinical Manifestatins During an act f biterrrism, release f an aersl will be the mst likely rute f transmissin. A. Acute Q Fever Incubatin perid days, duratin f the incubatin perid is inversely crrelated with the size f the inculum. Symptms - Acute disease is nt clinically distinct, and illness resembles viral respiratry infectins r atypical pneumnias. Can be divided int 3 main categries: (1) asymptmatic infectin (sercnversin) - ccurs in up t 50% f expsed persns, (2) self-limited febrile flu-like illness withut pneumnia lasting 2 t 14 days and (3) pneumnia. Hepatitis, mening-encephalitis, mycarditis, and pericarditis may be present acutely but are relatively uncmmn. Symptmatic patients exhibit any cmbinatin f the fllwing (in rder f decreasing frequency f appearance): SYMPTOM RELATIVE FREQUENCY (%) fever (present in all symptmatic patients) chills, rigrs severe headache, retrrbital pain (may be a useful clue t diagnsis) fatigue, anrexia, weight lss cugh myalgia pleuritic chest pain nausea, vmiting diarrhea 5-20 neck stiffness 5-7 Pneumnia -Chest x-ray evidence f pneumnia may be present in up t 50% f patients. There are three pssible presentatins: (a) atypical pneumnia (dry nnprductive cugh) (b) rapidly prgressive pneumnia (ften mimicking Leginnaire's disease), r (c) pneumnia with fever but n pulmnary symptms [mst cmmn clinical scenari fr acute Q fever]. Radigraphic findings: Variable;

6 may have pleural-based pacities, multiple runded pacities, abut 35% have pleural effusin, hilar adenpathy is uncmmn. Duratin - 2 days - 2 weeks Mrtality - Lw, estimated t be abut 2% (usually in patients with c-mrbid cnditins) B. Chrnic Q Fever Chrnic infectin due t Q fever is uncmmn, ccurring in less than 1% f acute infectins. Endcarditis is the usual manifestatin f Q fever but a wide array f syndrmes have been described including: infectin f vascular grafts, stemyelitis, infectius arthritis, chrnic hepatitis, pseudtumr f the lung, chrnic pulmnary fibrsis, infectin during pregnancy with miscarriage and prlnged fever. Incubatin perid - varies, can be mnths t several years Symptms - Variable depending n specific clinical syndrme. Mst ften diagnsed in patients with either a cardivascular abnrmality ( valvulpathy, prsthesis r aneurysm) r an underlying immuncmprmised state (i.e., HIV infectin r cancer). Labratry Diagnsis ALL SUSPECT CASES OF Q FEVER MUST BE REPORTED IMMEDIATELY TOTHE SACRAMENTO COUNTY HEALTH AND HUMAN SERVICES, COMMUNICABLE DISEASE CONTROL: During Business Hurs: (916) After Hurs (Nights, Weekends and Hlidays): Health Officer On call, at (916) The diagnsis f Q Fever requires a high index f suspicin since the disease ften presents with nnspecific symptms which can be difficult t distinguish frm viral illnesses r atypical pneumnia. The diagnsis is generally cnfirmed serlgically; mst labratries are nt equipped t islate Cxiella burnetii and islatin f the rganism is nt recmmended due t the significant hazards frm handling bacterial cultures in the labratry.

7 Serlgy Several assays are available; antibdy detectin by indirect flurescent antibdy (IFA) r ELISA are used mst cmmnly and appear t be the mst sensitive. Significant IgM antibdy des nt appear until 2-3 weeks int illness and may persist fr years. Acute and cnvalescent (2-3 mnths after nset f illness) antibdy titres shw a fur-fld rise. In acute Q fever, antibdies t phase II antigens are higher than thse t phase I antigens, in chrnic Q fever the reverse ccurs. Antibdies f the IgM type are usually bserved fr the first 6-12 mnths after infectin, with IgG persisting afterward. Cntact the Sacrament Cunty Public Health Labratry at (916) fr assistance. V. Handling Labratry Specimens Labratry staff handling specimens frm persns wh might have Q fever must wear surgical glves, prtective gwns, and she cvers. Labratry tests, such as serlgical examinatins and staining f tissue impressin smears, can be perfrmed in Bilgical Safety Level 2 cabinets; althugh nt recmmended, bld cultures shuld be maintained in a clsed system. Every effrt shuld be made t avid splashing r creating an aersl. Bisafety Level 3 practices and facilities shuld be used fr inculatin, incubatin and harvesting f cell cultures and the manipulatin f infected tissues. Accidental spills f ptentially cntaminated material shuld be decntaminated immediately by cvering liberally with a disinfectant slutin (0.05% hypchlrite, 5% perxide, r 1:100 slutin f Lysl). All bihazardus waste shuld be decntaminated by autclaving. Cntaminated equipment r instruments may be decntaminated with a hypchlrite slutin, hydrgen perxide, peracetic acid, 1% glutaraldehyde slutin, frmaldehyde, ethylene xide, cpper irradiatin, r ther O.S.H.A. apprved slutins, r by autclaving r biling fr 10 minutes. VI. Treatment A. Acute Q Fever Pneumnia usually reslves withut treatment in 15 days; therefre, in the event f a biterrrist attack, therapy may nly be required fr persns with mre severe illness. Several antibitics have been evaluated as therapeutic agents fr acute Q fever -- tetracyclines have been shwn t shrten the duratin f illness and are cnsidered the drug f chice, particularly fr severe infectin:

8 Adult dsages: Dxycycline 100 mg every 12 hurs p r IV fr days r tetracycline 500 mg p every 6 hurs fr days. (NOTE: Fr milder illnesses, 5-7 days f therapy may be sufficient) Alternatives: Quinlnes, chlramphenicl, trimethrprim-sulfamethxazle are als prbably effective. Studies f erythrmycin (500 mg - 1 gram every 6 hurs p.. r IV) have shwn cnflicting results, and erythrmycin is prbably nt preferred fr cases f severe pneumnia. Azithrmycin appears t be anther ptin but little clinical infrmatin is available. Beta-lactam antibitics are generally ineffective. Pediatric dsages: Fr mre severe illnesses, when benefits utweigh the risks, cnsider use f dxycycline (r c-trimxazle r chlramphenicl). If > r = 8 years f age: Dxycycline: If > 45 kg mg IV r p every 12 hurs If < 45 kg mg/kg IV r p every 12 hurs If < 8 years f age: C-trimxazle 4 mg/kg IV r rally every 12 hurs Chlramphenicl 25 mg/kg rally every 12 hurs Newbrns up t age 2 Ciprflxacin mg/kg rally twice daily, mnths: d nt exceed 1 gram/day. Pregnant Wmen Pst-Expsure Prphylaxis - C-trimxazle [1 DS tablet rally twice daily], is the preferred antibitic, except at term, when the risk f kernicteris is greatest -- use flurquinlnes [ciprflxacin 500 mg rally twice daily] B. Chrnic Q Fever Endcarditis requires cmbinatin therapy, usually with dxycycline plus rifampin r pssibly a quinlne plus rifampin. The duratin f therapy is fr years and a valve replacement is ften necessary.

9 VII. Islatin f Patients Q fever is nt transmissible frm persn-t-persn. Standard precautins shuld be fllwed fr all patients. Respiratry islatin rms are nt required. VIII. Dispsal f Infectius Waste Use f tracking frms, cntainment, strage, packaging, treatment and dispsal methds shuld be based upn the same rules as all ther regulated medical wastes. IX. Autpsy and Handling f Crpses All pstmrtem prcedures are t be perfrmed using Respiratry Precautins. Effrts shuld be made t avid aerslizatin. All persns perfrming r assisting in pstmrtem prcedures must wear mandated P.P.E. (persnal prtective equipment) as delineated by O.S.H.A. guidelines. Instruments shuld be autclaved r sterilized with a 10% bleach slutin r ther slutins apprved by O.S.H.A. Surfaces cntaminated during pstmrtem prcedures shuld be decntaminated with an apprpriate chemical germicide such as 10% hypchlrite r 5% phenl (carblic acid). X. Management f Expsed Persns An expsed persn is defined as a persn wh has been expsed t the release f a Cxiella burnetii cntaining aersl. Pst-expsure prphylaxis: Antibitic prphylaxis is very effective and will prevent clinical disease if administered 8-12 days AFTER expsure (dxycycline 100 mg p every 12 hurs r tetracycline 500 mg p every 6 hurs) fr 5 days. Starting prphylaxis immediately after expsure can delay nset f disease but nt prevent symptms frm ccurring.

10 Pediatric Pst-Expsure Prphylaxis with Dxycycline: If > r = 8 years f age: If > 45 kg mg rally every 12 hurs fr 5 days If < 45 kg mg/kg rally every 12 hurs fr 5 days If < 8 years f age: C-trimxazle 4 mg/kg rally every 12 hurs fr 5 days Chlramphenicl 25 mg/kg rally every 12 hurs fr 5 days Newbrns up t age 2 Ciprflxacin mg/kg rally twice daily mnths: fr 5 days, d nt exceed 1 gram/day XI. Reprting t the Health Department Cnfirmed r suspect Q Fever cases must be reprted immediately t the Sacrament Cunty Health and Human Services Cmmunicable Disease Cntrl: During business hurs Sacrament Cunty Health and Human Services Cmmunicable Disease Cntrl at (916) After business hurs Sacrament Cunty Health Officer On call, at (916)

11 XII. References Byrne WR. Q Fever. In: Sidell FR, Takafuji ET, Franz DR, eds. Medical Aspects f Chemical and Bilgical Warfare. Washingtn, D.C.:Office f the Surgen General, 1997: Fleming DO, Richardsn JH, Tulis JJ, Vesley D, eds. Labratry Safety Principles and Practices. 2nd ed. Washingtn, DC: American Sciety fr Micrbilgy;1995:324. Marrie TJ. Cxiella burnetii (Q Fever) In: Mandell GL, Bennett JE, Dlin R, eds. Principles and Practice f Infectius Diseases 4th ed. New Yrk: Churchill Livingstne;1995: Rault D, Marrie T. Q Fever. Clin Infect Diseases 1995;20: Rault D. Treatment f Q Fever. Antimicrb Agents Chemther 1993;37: Turnbull PCB, Kramer JM. Bacillus. In: Balws A, Haulser WJ, Herrman KL, Shadmy HJ, eds. Manual f Clinical Micrbilgy 5th ed. Washingtn, DC: American Sciety fr Micrbilgy; 1991: Octber 2001 Used with permissin and adapted frm the New Yrk City Department f Health/Bureau f Cmmunicable Diseases