They re Here. Communicable Tropical Disease. Greg Mennie, PA C, MSED

Transcription

1 They re Here Communicable Tropical Disease Greg Mennie, PA C, MSED Objectives 1. Develop a basic understanding of disease transmission and chain of infection 2. Develop an overview of the current epidemiology patterns in Washington State and the US for various tropical diseases. 3. Evaluate the potential risks for tropical disease transmission in the US. 4. Know the common signs and symptoms of the more common tropical diseases seen in the US. 5. Have a basic understanding of the treatment for the more common tropical diseases seen in the US. 6. Develop a counseling strategy for prevention and maintenance of the more common tropical diseases seen in the US.

2 Patient 1 28 yo female comes to the clinic, 3 days not feeling well. Mild body aches, felt feverish for the last few days, had 101 temperature yesterday no fever today, feels a little better, mild headache no other sxs.

3 52% passport holders Borders 1 country 3 states 250 million visitors annually 11 Major Airports Multiple Military Installations Clues Travel Exposure to someone who has traveled Location Bites Atypical symptoms Rash Vector vs Host Vector Any Agent that carries and transmits an infectious pathogen from host to host Mosquito Triatome Snail Tick Reservoir habitat for the infectious agent Host

4 CDC Little Flies 3500 species 3 of the top killers Aedes Culex Anopheles Mosquito Aedes Unpleasant Dengue, Chikungunya, Zika Yellow Fever and Lymphatic Filariasis Ladies Bite during the day Resistance to Insecticides Bottle cap breeder Highly Invasive Northern Africa

5 Dengue Break Bone Fever Four closely related dengue viruses (DENV 1, 2, 3, and 4). Acute high fever 3 14 days after mosquito bite (aedes) and 2 of the following: Frontal headache, retro orbital pain, algias, rash, dec. WBC Mild bleeding (gums, epistaxis, sub conjunctival, bruising) Rash Anorexia and nausea No symptoms or minimal symptoms > children no previous history of infection Dengue Hemorrhagic Fever (DHF) Day 3-7 with decreasing fever but pt. feels worse (vomiting and severe abdominal pain) hemorrhagic manifestations, or change in mental status (irritability, confusion) Early signs of shock Dengue and Chikungunya 2015 Washington State doubled case load brought home by travelers to Hawaii, Mexico and other vacation spots. Chikungunya Virus Symptoms begin 3 7 days after mosquito bite > symptoms - fever and joint pain x 1 week Other symptoms - headache, muscle pain, joint swelling, or rash High-risk newborns infected around the time of birth 65 y.o Co morbid conditions - high blood pressure, diabetes, or heart disease Likely protected from future infections Rarely fatal

6 Chikungunya Prior to 2006 rarely identified in U.S. travelers people per year in the United States Late 2013 first local transmission of chikungunya virus in the Americas was identified in Caribbean countries and territories. Beginning in 2014 Disease cases reported among U.S. travelers returning from affected areas in the Americas and local transmission was identified in Florida, Puerto Rico, and the U.S. Virgin Islands June cases of dengue fever 3 cases of chikungunya cases of dengue fever 57 cases of chikungunya 2 yellow zones in the US 1 st US case in Brownsville Texas Miami Dade Florida

7 Zika Locally acquired mosquito-borne cases reported: 219 Travel-associated cases reported: 4,710 Laboratory acquired cases reported: 1 Total: 4,930 Sexually transmitted: 40 Jan 2017 Guillain-Barré syndrome: 13 Zika Single strand RNA Virus Discovered in 1947 New to the Western Hemisphere? 2013 > symptoms fever ~(<102 ) Pruritic pink rash, Scleral injection/conjunctivitis, Photophobia, headaches, arthralgias Outbreak in brazil 2015 US no immunity = rapid spread Association with GBS Small percentage of Zika oa #t=article infected individuals get GBS Zika virus transmission Blood Semen Possibly 6 months in Semen Vaginal fluids Urine Saliva? Breast milk Zika and Breastfeeding Transmission of Zika virus through breast milk has not been documented. Therefore CDC and WHO note benefits of breastfeeding outweigh theoretical

8 Clinical Management Diagnosis CDC Zika IgM Antibody Capture Enzyme Linked Immunosorbent Assay (Zika MAC ELISA) then confirmatory test No vaccine or specific antiviral treatment Treat the symptoms Rest, Drink fluids Symptom meds (tylenol) Avoid aspirin and NSAIDS until dengue can be Pre Pregnancy Counseling CDC Zika US pregnancy exposure rate completed pregnancies with or without birth defects include those that ended in a live birth, miscarriage, stillbirth, or termination 37 Liveborn with defects 5 Pregnancy losses with defects Jan 2017

9 Confirmed or Suspected Exposure Serial ultrasounds Q 3 4 weeks to assess fetal anatomy and growth Amniocentesis Individualized for pregnant women with confirmed recent Zika virus Can be considered for pregnant women with presumptive recent Zika virus Congenital Zika Syndrome Severe microcephaly 13% estimated risk of microcephaly due to Zika virus infection in 1st trimester Thin cerebral cortices with subcortical calcifications Eye anomalies macular scarring focal pigmentary retinal mottling Congenital contractures or limited range of joint motion Marked early hypertonia Normal head circumference at birth brain abnormalities consistent with congenital Zika syndrome Prevention Prevent Mosquito Bites Wear long sleeved shirts and long pants Stay and sleep in places with air conditioning or that use window and door screens Insect repellents DEET, picaridin, IR3535, oil of lemon eucalyptus, paramenthanediol, or 2 undecanone not under age of 2 months Clear standing water sources

10 cases of Zika cases of Zika Total infections: 555 New infections reported June 2017: 4 Locally acquired infections: 0 Sexual transmission: 8 Pregnant women: 127 Completed pregnancies: 100 Liveborn infants with birth defects: 6 Pregnancy losses with birth defects: 0 Triatomine Bug 11 different species 28 states >Texas, New Mexico, and Arizona 50% of infected with Trypanosoma Cruzi It all starts with Poop Triatomine bug bite and poops near bite (or in your eye) offering exposure of Trypanosoma cruzi. Congenital Blood transfusion Contaminated food or drink (rare)

11 Chagas (American Trympanosomiasis) > 300,000 persons in the U.S. infected Unknown number of congenital or vector borne transmission of T. cruzi in the United States Cogenital T. cruzi infection ~ neonates annually Chagasic cardiomyopathy ~30,000 45,000 persons > latin american immigrants 8 million people» Mexico, Central America, and South America Bern CM, Montgomery SP. An estimate of the burden of Chagas disease in the United States. Clin Infect Dis. 2009;49:e Traina MI, Kirchoff LV, Khamag H, Padilla Garcia E, Meymandi S. Atlanta, GA: Community-based study of Prevalence of Chagas Disease in Los Angeles County. 59th Annual Meeting American Society of Tropical Medicine and Hygiene 2 phases Acute phase lasts 6 8 weeks > asymptomatic or non specific symptoms Fever, fatigue, body aches, headache, rash, loss of appetite, diarrhea, and vomiting Hepatosplenomegaly, lymphadenopathy infants > risk for severe manifestations (acute myocarditis or meningoencephalitis) Chronic phase > Indeterminate form Asymptomatic Determinate form 20 30% years to decades Cardiac Rassi A, Jr, Rassi A, Marin-Neto JA. Chagas disease. Lancet. 2010;375: > Arrhythmias, heart block, heart failure Machado FS, Jelicks LA, Kirchhoff LV, Shirani J, Nagajyothi F, Mukherjee S, Nelson R, Coyle CM, Spray DC, de Carvalho AC, Guan F, Prado CM, Lisanti MP, Weiss LM, <stroke, Montgomery and sudden SP, Tanowitz death HB. Chagas heart disease: report on recent developments. Cardiol Rev. 2012;20:53 65 GI Clinical Signs 50% Romaña's sign edema of the upper and lower eyelids chemosis of the conjunctiva enlargement of the preauricular lymph nodes 25% Chagoma nodular or ulcerative skin lesion regional lymph node enlargement

12 Diagnosis and treatment Acute Diagnosis is based upon detection of circulating parasites Chronic IgG antibodies to T. cruzi Treatment benznidazole or nifurtimox (Weight based days) Acute Phase 90% cure if given in first year of life 70% overall cure for acute phase Indeterminate Phase Bern C, Montgomery SP, <18 Herwaldt yo. BL, et al. Evaluation and treatment of chagas disease in the United States: a systematic review. JAMA Nov (18): Chronic Phase Altcheh J, Biancardi M, Lapena A, et al. [Congenital Chagas disease: experience in the Hospital de Niños, Ricardo Gutiérrez, Buenos Aires, Argentina]. Rev Soc Bras <50 Med y.o. Trop. without advanced 38 Suppl 2:41-5. Chagas cardiomyopathy It s not uncommon for people to learn they have Chagas disease after donating blood, Meymandi and others said. In 2006, the Red Cross isolated 21 cases of Chagas in Southern California donors. In 2007, the figure more than doubled to 46. In 2008, there were 55 cases. Culex Gnat Common House Mosquito West Nile Virus Bite at Night Prefers birds

13 West Nile Arthropod borne virus (arbovirus) most commonly spread by infected mosquitoes (culex) > summer months detected in all lower 48 states Elderly > risk > Non NeuroInvasive 2 to 14 days after bite 70 80% No symptoms 20% fever, headache, body aches, joint pains, vomiting, diarrhea, or rash. Neuro invasive 1% encephalitis or meningitis headache, high fever, neck stiffness, disorientation, coma, tremors, seizures, or paralysis. 10 % mortality Treatment is supportive case cases 19 deaths USELESS Malaria gambiae ANOPHELES Canine Heartworm Slant their body Bite at night Prefer Humans quadrimaculatus

14 Malaria Approx 215 million cases yearly on the African continent The disease kills more than one million children each year in Africa alone 2,800 per day 20% of all childhood deaths in Africa 80 to 90% of malaria deaths occur in sub Saharan Africa Malaria Arthropod borne virus Anopheline mosquitoes Plasmodium species, commonly P. vivax, P. falciparum, P. ovale, and P. malariae Eliminated from the United States in the early 1950's. 1,500 2,000 cases reported yearly in the United States > travelers (Asia/Africa) Over the last 50 years 63 outbreaks of locally transmitted mosquito borne malaria have occurred Uncomplicated Symptoms Severe Bouts of fever, chills, sweats, headache, and rigors Gastrointestinal, respiratory, muscular, and neurological symptoms may occur Naïve> chance of Cerebral Malaria Anemia CDC Diagnosis Smear RDT Treatment Uncomplicated Antimalarials Malerone, Coartem, Chloroquin Severe Quinidine + Doxycycline Supportive care Blood Glucose Malaria

15 16 malaria cases 2013 in LA County Ebola Fever Severe headache Muscle pain Weakness Fatigue Diarrhea Vomiting Abdominal (stomach) pain Unexplained hemorrhage (bleeding or bruising Ebola Outbreak U.S. 2 imported cases one death September 30, 2014 First travel associated case of Ebola traveled from West Africa to Dallas, Texas Texas Health Presbyterian Hospital of Dallas deceased October 8, October 10 and 15, for Ebola 2 healthcare workers at Texas Health Presbyterian October 23, Ebola medical aid worker who volunteered in Guinea CDC

16 28,000 cases Over 11,000 deaths Ebola Outbreak Africa