Vaccines: Responding to Terrors Old & New

Transcription

1 Vaccines: Responding to Terrors Old & New G. Blackburn DO, MACOI Bryan Martin DO, FACOI Annual WVOMA CME Conference White Sulphur Springs, WV November, 2017

2 Disclosures: none

3 Our Goal: To talk about vaccines in such a way that you will find our presentations both interesting and informative

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7 Who here has ever seen a case of rabies within the continental U.S.?

8 How many people would you guess die each year (worldwide) from rabies?

9 55,000

10 In the U.S... What animal is responsible for most cases of human rabies? What is the most common exposure history associated w/ human rabies?

11 In the U.S., what domestic animal is most commonly infected w/ rabies? What is the incubation period for human rabies?

12 In the U.S... only average 2 deaths/yr, but 40,000 exposures

13 Who here has ever seen a case of tetanus within the continental U.S.?

14 How many people would you guess die each year (worldwide) from tetanus?

15 Over 200,000 cases - 59,000 deaths

16 Who would you guess is at greatest risk for tetanus in this country?

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18 Who here has ever seen a case of measles within the continental U.S.?

19 Ro = 12-18

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21 How many people would you guess die each year (worldwide) from measles?

22 between ,000 (mostly children)

23 Who gets measles in this country and where does it come from?

24 Ro

25 Who here has ever seen a case of acute hepatitis A within the continental U.S.? If so, were they hospitalized?

26 How many people would you guess die each year (worldwide) from acute hepatitis A?

27 11,000

28 What is the incidence of acute hepatitis A each year in the U.S.? How many die?

29 1400 cases; 67 deaths 21 of these > 75 y.o.

30 What do all of these have in common, and why have you never seen a case?

31 They are all nearly 100% preventable by immunization

32 The same could be said of polio, rubella, diphtheria, hepatitis B, and smallpox

33 Summary I Vaccines work In order for a vaccine to work, it must first be given!

34 Hepatitis A Update(?) RNA virus spread by fecal/oral transmission (e.g., food handlers), including contaminated food/water Back in the day. Greatest risk for U.S. citizens : international travel (1/2 of cases) Incubation period: ~30days (range days) Dx: IgM anti-hav ab Contagiousness: from incubation period until 1 week after jaundice appears

35 Hepatitis A Update (?) Generally taught to be self-limited (only occasional need for hospitalization and only infrequent mortality, usually in those over 40 yo) Tx: supportive Prevention: vaccine Passive immunization w/ immune globulin w/in 2 weeks of exposure?

36 Hepatitis A

37 The Saint Elsewhere Hepatitis A experience (Spring, 2017): transmission issues isolation issues My first reaction: thank goodness it s their problem and not ours!!

38 Health officials continue to investigate ongoing hepatitis A outbreak in Southeast Michigan LANSING, Mich. The Michigan Department of Health and Human Services (MDHHS) and local public health officials are continuing to investigate an outbreak of hepatitis A cases in the city of Detroit, and Macomb, Oakland, Wayne, and St. Clair counties. From August 1, 2016 to June 26, 2017, there have been nearly 190 cases of confirmed hepatitis A including ten deaths reported to public health authorities in these jurisdictions. This represents a ten-fold increase during the same time last year. Ages of the cases range from 21 to 86 years, with an average age of 44 years. Twothirds of the cases (66 percent) are men, and nearly nine out of ten (87 percent) have been hospitalized. While no common source of the outbreak such as contaminated food or water has been identified, transmission does appear to be person-to-person through illicit drug use, sexual activity, and close contact among household members. The ongoing hepatitis A outbreak presents a significant public health threat to vulnerable community members within Southeast Michigan. Nearly half of the cases (47 percent) have a history of substance abuse, 20 percent are co-infected with hepatitis C, and six more recent cases have been incarcerated. Hepatitis A is a vaccine-preventable disease, said Dr. Eden Wells, chief medical executive for MDHHS. And while the hepatitis A vaccine is recommended as part of the routine childhood vaccination schedule, most adults have not been vaccinated against the hepatitis A virus and may be susceptible to the illness. July 12, 2017

39 From: Michigan Health Alert Network Subject: ONGOING HEPATITIS A OUTBREAK IN SE MI Date: July 18, 2017 at 11:58:34 AM EDT Dear Southeast Michigan Healthcare Community Members, We are facing a large, ongoing hepatitis A outbreak in Southeast Michigan and need your help. Since August 2016, there have been over 200 cases of hepatitis A, 10 associated deaths, and several more cases of fulminant liver failure requiring transplantation. To end this outbreak, we must work together to increase hepatitis A vaccination of the most vulnerable individuals, including: History of injection and non-injection drug use Homelessness or in transient housing History of trading sexual practices for drugs or money Chronic liver disease (hepatitis B, C) MSM Anyone who requests vaccination regardless of risk factors endorsed Please also ensure that staff members who provide direct patient care are vaccinated. Sincerely, Detroit Health Department Macomb County Health Department Oakland County Health Division St. Clair County Health Department Wayne County Department of Health, Veterans, and Community Wellness MDHHS

40 Why has this infection exploded in these populations? More contagious? More virulent? Or..has the number of infected individuals simply crossed a critical threshold for continued transmission? Why the high number of hospitalizations? Deaths? Transplantations? Virulence?

41 The nightmare begins. Monday, 8/14 9:45 a.m. - Hey, Blackburn.guess what? Impromptu meeting w/ Administration and Senior Management to determine how big a concern and what to do about it Immediate call to local County Health Dept. - the start of long, daily discussions throughout the week By late afternoon, est. 100 pts at some risk

42 The BH-FH experience: Tuesday, 8/15 8:21 a.m. - Hey, Blackburn.you re not going to believe this. Additional 100 pts determined to be at risk No pts identified consistent w/ patient to HCW transmission. (Also zero reason to suspect link to IDVA or gay community) Potentially exposed patients contacted and offered hepatitis A vaccine

43 The BH-FH experience: Friday, 8/17 Completion of immunization efforts Total of 136 doses dispensed by pharmacy One physician refused!!!!!

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45 But it doesn t end there.. Week of 8/21-8/28/25 Ongoing investigation by local CHD regarding Farmington Hills outbreak, all of whom appear to have become ill (and therefore presumed to have been exposed) at approximately the same time

46 The BH-FH experience: Week of 8/21-8/28/25 Additional case seen at BH-FH, with several family members ill, one requiring a liver transplant. They report having eaten at the same restaurant as our two HCWs!! (Ultimately inaccurate) hx provided by family almost leads to (inappropriate and disasterous) closure of a local restaurant

47 The BH-FH experience: Week of 8/21-8/28/25 and continuing Source unknown, though several restaurants were under intense investigation Unknown at this point if the FH outbreak is the same strain as is being seen in the IVDA and/or gay community elsewhere in southeastern Michigan Unknown if this strain is uniquely different in terms of virulence or transmissibility

48 As of 8/31: 12 cases locally- all presumably exposed at approximately the same time; none since No common source determined No restaurants/food items/food handlers incriminated

49 From Michigan Health Alert Network - Oct. 19, 2017 public health officials continue to investigate a large hepatitis A outbreak in southeastern Michigan..the importance of handwashing and vaccination. There has been a recent concerning increase in confirmed hepatitis A cases among men who have sex with men (MSM). Since August 1, 2016, 431 confirmed cases. have been reported. Primary cases range in age from 20 to 87 years with median age of 42 years. The majority are male (63.0%) and have been hospitalized (85.7%). Seventeen deaths are associated with the outbreak. Fortyseven percent of cases reported illicit drug use, 27% of cases were coinfected with hepatitis C, and 3.5% co-infected with hepatitis B. Six percent report recent incarceration, and 7.4% percent of men reported having sex with men.

50 From Michigan Health Alert Network - Oct. 19, no single source has been identified. From August 1, 2016 to October 1, 2017, there were 10 (4.3%) hepatitis A cases among MSM. Since October 1st, 9 additional hepatitis A cases identifying as MSM, representing a 90% increase over three weeks. Among the MSM hepatitis A population, 18 (94.7%) cases have been hospitalized and there has been 1 death. The median age of these men is 39 years (range years). Eight (42.1%) cases report substance abuse alone, 10 (52.6%) cases report neither substance abuse nor homelessness, and 1 (5.3%) case reports substance abuse and homelessness. Three (15.8%) cases are co-infected with hepatitis C, and 3 (15.8) cases were employed as food workers. Men who have sex with men are at greater risk of acquiring hepatitis A, and hepatitis A vaccination is indicated for MSM. Despite this guidance, hepatitis A vaccination coverage among MSM in the United States remains low, estimated at 15-35%. There are currently multiple hepatitis A outbreaks among MSM both in the United States and Western European countries.

51 Summary II Get vaccinated - and that includes the hepatitis A vaccine! Do the same for your patients You think these kind of outbreaks don t happen where you live or practice? Wash your hands