EMERGING INFECTIOUS DISEASES DISCLOSURES EMERGING NONE

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1 EMERGING INFECTIOUS DISEASES DISCLOSURES NONE EMERGING INFECTIOUS DISEASES New, re-emerging, or drug-resistant infections whose incidence: threatens to increase in humans has increased within the past two decades, or threatens to increase in the near future. Institute of Medicine definition

2 Everybody knows that pestilences have a way of recurring in the world; yet somehow we find it hard to believe in ones that crash down on our heads from a blue sky. Albert Camus, The Plague, 1948 EMERGING INFECTIONS OF THE LATE 20 TH CENTURY HIV/AIDS MDR Tuberculosis MDR Malaria Hemorrhagic Dengue Fever CA-MRSA

3 CONTRIBUTING FACTORS Breakdown of public health Poverty and social inequality War and famine Bioterrorism Dam and irrigation system construction mosquito-borne diseases CONTRIBUTING FACTORS Microbial adaption Changing human susceptibility Immunocompromised hosts Climate and weather zoonotic vectors moving further from the tropics as the climate warms Change in human demographics and trade Economic development use of antibiotics to increase meat yield HEALTH-CARE ASSOCIATED Exserohilum rostratum

4 Exserohilum rostratum September 2012 several cases of fungal meningitis reported from different states CDC investigation discovery that causative organism was a rare, usually nonpathogenic brown-black mold, Exserohilum rostratum Exserohilum rostratum CDC investigation infection associated with epidural injection of methylprednisolone acetate that had been contaminated at the compounding center at which it was produced

5 Exserohilum rostratum 17,675 vials of potentially contaminated methylprednisolone acetate shipped to 76 facilities in 23 states 13,534 patients exposed 753 cases; 64 deaths ISSUES RAISED Drugs prepared at compounding pharmacies were not under FDA regulations Investigation found unsanitary conditions, including fungus in steroid solutions

6 HEALTH-CARE ASSOCIATED Exserohilum rostratum Candida auris Candida auris First described in cases reported in US as of Aug 2018 Candida auris Often multidrug-resistant Has caused outbreaks in healthcare settings

7 Candida auris Difficult to identify with standard laboratory methods COMMUNITY TRANSMISSION Measles

8 MEASLES Highly contagious One of the most communicable of the infectious diseases Distinctive disease syndrome with fever and rash MEASLES Epidemiology: Worldwide Hosts: Humans Transmission: Respiratory (droplets) Incubation period: days Period of transmissibility: contagious from 5 days before until 5 days after the onset of rash MEASLES Clinical Features: Prodrome: Malaise, fever, anorexia, conjunctivitis, and respiratory symptoms, such as cough and coryza May resemble a severe upper respiratory tract infection Disease: Rash begins on the face and proceeds down the body to involve the extremities last, including the palms and soles

9 MEASLES Clinical and diagnostic features Prodromal fever Cough, Coryza, Conjunctivitis Koplik spots Rash begins day 3-7 on face, lasts 4-7 days

10 WORLD-WIDE OUTBREAKS Sept 2018: 213 cases in Jerusalem 2018: 5-fold rise in cases in England

11 COMMUNITY TRANSMISSION Measles MDR gonorrhea GONORRHEA RATES: US,

12 N. gonorrhea THERAPY Classic therapy was penicillin Antibiotic resistance rising Penicillin resistance due to penicillinase production first seen in 1975 Now 5% in the US and up to 50% elsewhere Fluoroquinolone resistance rising Current CDC treatment recommendation: IM Ceftriaxone PLUS oral azithromycin MDR GONORRHEA Ceftriaxone-resistant GC identified in: Japan Denmark England Australia Canada MDR GONORRHEA No cases of CTX resistance reported yet in US Prevention: Public Health measures of safer sex, contact tracing

13 COMMUNITY TRANSMISSION Measles MDR gonorrhea Borrelia miyamotoi Borrelia miyamtoi Spiral-shaped bacteria: closely related to the bacteria that cause tick-borne relapsing fever (TBRF) more distantly related to the bacteria that cause Lyme disease Found in Ixodes scapularis and Ixodes pacificus (black-legged ticks) Borrelia miyamtoi First identified in 1995 Clinical: fever, chills, headache Confirmation requires serology or PCR (only at CDC) Treatment: 2-4 week course of doxycycline

14 COMMUNITY TRANSMISSION Measles MDR gonorrhea Borrelia miyamtoi Ebola EBOLA First recognized in 1976 in outbreaks in DRC (then Zaire) and Sudan From 1976 to 2013, WHO reported 1,716 confirmed cases Different species in different areas of Africa 41 EBOLA Reservoir: fruit bats Several monkey species, chimpanzees, gorillas, baboons and duikers Transmission: Blood and bodily fluids Human to human: includes sweat 42

15 43 EBOLA Largest outbreak to date began March 2014 in Guinea Guinea, Liberia and Sierra Leone alone reported 10,004 confirmed, probable and suspected deaths 44 45

16 EBOLA Incubation: 3-21 days Sudden onset of fever, myalgia, vomiting and diarrhea Rash may occur 46 EBOLA HYSTERIA Returning health care workers 47 EBOLA HYSTERIA United States Sept 30, 2014: Traveler from Liberia in Texas Initially sought treatment and diagnosis missed Returned in critical condition and died Oct 8 2 nurses who cared for him One traveled by air from Dallas to Cleveland on October 10 and from Cleveland to Dallas on October 13; diagnosed October 15

17 EBOLA Diagnosis: PCR Treatment: No specific antiviral therapy proven Supportive Care Fluids, electrolyte support Vaccine 49 EBOLA: LESSONS LEARNED Lack of preparedness at US hospitals for containing a highly contagious disease High mortality in Africa reflective of lack of ICU resources to support critically ill infected patients Scientific medicine does not always inform political decision making 50 EBOLA: IS IT OVER? No new cases in affected areas But, resultant devastation of the health care systems DRC: Outbreak began Aug cases, 135 deaths Continuing new cases seen 51

18 EBOLA: IS IT OVER? It ain t over til it s over - Yogi Berra 52 THE FUTURE New diseases will appear Old diseases will become common again Prediction is very difficult, Especially about the future. Courvalin P. EID. 11:1014, 2005

19 THANK YOU OBJECTIVES Upon completion of this program, the participant should be able to: Identify emerging infectious diseases Describe strategies to decrease the risk of emerging infectious diseases Formulate hospital-based approaches to diagnose emerging infections and protect patients and staff

20 QUESTION #1 The epidemic of Exserohilum rostratum was caused by: 1. Water damage to hospitals from a hurricane 2. Contaminated product from a compounding pharmacy 3. Contaminated air filters 4. Patient to patient spread due to poor hand hygiene by health care workers QUESTION #1: ANSWER The epidemic of Exserohilum rostratum was caused by: 2. Contaminated product from a compounding pharmacy QUESTION #2 Ebola is: 1. Likely to cause an epidemic in the United States 2. Spread primarily by mosquitos 3. Primarily treated with antiviral drugs 4. A major risk for health care workers caring for patients with Ebola

21 QUESTION #2: ANSWER Ebola is: 4. A major risk for health care workers caring for patients with Ebola