The Infectious Disease Smorgasbord: Hot ID Topics for Health Units

Transcription

1 The Infectious Disease Smorgasbord: Hot ID Topics for Health Units Gregory J. Martin MD Tropical Medicine Infectious Diseases US Department of State Washington, DC

2 The Infectious Diseases Smorgasbord Hot ID topics for Health Units: - Influenza - Chikungunya - Ebolavirus Disease - Malaria update - HIV PEP and PrEP - Meningococcal vaccines and new recs - PCR in the Health Unit: Biofire/FilmArray

3 Influenza 2015 Well publicized poor match between the Northern Hemisphere vaccine and the circulating H3N2 has been associated with a robust, early flu season First time in 3 years that the Northern and Southern Hemisphere vaccines are different: * Northern Hemisphere Influenza season vaccine components A/California/7/2009 (H1N1)pdm09-like virus A/Texas/50/2012 (H3N2)-like virus B/Massachusetts/2/2012-like virus B/Brisbane/60/2008-like virus (only in quadrivalent vaccines) * Southern Hemisphere 2015 Influenza season vaccine components A/California/7/2009 (H1N1)pdm09-like virus; A/Switzerland/ /2013 (H3N2)-like virus (A/South Australia/55/2014, A/Norway/466/2014, A/Stockholm/6/2014) B/Phuket/3073/2013-like virus. B/Brisbane/60/2008-like virus. (only in quadrivalent vaccines)

4 So what do we do about flu immunizations? These are my personal opinions NOT CDC recs If staff received the Northern Hemisphere flu vaccine they are protected against some of the circulating strains and if infected with the new strain are less likely to have severe disease. If you are in the Southern Hemisphere consider offering an approved Southern Hemisphere influenza vaccine: Strongly recommended for those who did not receive a Northern Hemisphere flu vaccine earlier Should be encouraged for those with chronic respiratory disease or other immunocompromising conditions, including age >65 y May be offered to those who received the Northern Hemisphere flu vaccine and want added protection but should not be required

5 Neuraminidase Inhibitors Underutilized in HUs? CDC has tested 139 influenza A and B isolates for resistance this season and 100% were sensitive to both oseltamivir (Tamiflu) and zanamivir (Relenza). In Oct 2014 FDA approved peramavir (Rapivab) for IV Single dose of 600 mg IV These antivirals are really only effective if initiated within 48 hours of symptom onset.

6 Makonde for that which bends up An alphavirus NOT related to dengue but gives a dengue like illness with prominent joint pain, may last weeks Neonates exposed intrapartum may develop severe or fatal dz African origin but now widespread in Asia and newly popping up in the Caribbean Incubation for 3-7 days post mosquito bite No treatment Chikungunya Avoid mosquito bites with topical repellants and permethrin Diminish breeding of mosquitoes Essentially identical efforts as should be used for dengue prevention

7 Chikungunya Rarely fatal but you may feel like dying! Tally of chikungunya cases in the Americas now exceeds a million cases. The continental US tally of locally acquired chikungunya cases is 11 - additional travel-related cases. Puerto Rico has 25,000 suspected autochthonous cases and the US Virgin Islands > attributed deaths in the Americas The French have seen significant numbers with prolonged joint complaints - 80% at 3 m - 57% at 15 m - 5% chronic

8 Chikungunya vaccine development Like Ebola, will move much faster as the US is affected Experimental Vaccine for Chikungunya passes first test

9 Ebolavirus Disease (EVD) DoS MED s 2014 Virus of the Year is Still Performing Cases Deaths Total: Sierra Leone: Liberia: Guinea: Nigeria: 20 8 Mali: 8 6 US: 4 1 Spain: 1 1 Senegal: 1 0 UK: 1 0 Data from CDC 22 Jan

10 Malaria Update Recs from the Malaria ALDAC 2013 Increase use of Personal Protective Measures: Topical Repellant Formulations approved by CDC available from post Permethrin available for tents, clothing, etc Impregnated bednets provided by post Screened enclosures Optimize adherence with chemoprophylaxis Preferable to have all meds available at HU without charge or inconvenience to the patient Clarifying malaria risk at posts prior to bidding Require Acknowledgement of Malaria Risk to be signed Establishing reporting to leadership of malaria cases

11 Malaria Update Where we are in DoS since the Malaria ALDAC DoS Total Malaria cases (24 confirmed) Post provides: Atovaquone/proguanil (Malarone) 42% 54% Topical repellants DEET (20-35%) Picaridin 20% Oil of Lemon Eucalyptus IR % 56% 4% % 84% 9% 0 0 Permethrin for clothing/fabric/furniture 29% 42% Treated Bednets Permanet 3.0 Other treated net 56% 28% 28% 100% 67% 39%

12 HIV PEP and PrEP Well tolerated regimens and more people on ARVs Tenofovir/emtricitabine (Truvada) 300/200 mg po qd ($1300/month) plus Raltegravir (Isentress) 400 mg po bid ($1200/month) Dolutegravir (Tivicay) 50 mg po qd ($1200/month) or All three of these drugs are exceptionally well tolerated; if dolutegravir is used require once daily dosing with a total of only 2 pills. Occupational exposures require urgent medical evaluation. Initiate occupational PEP as soon as possible, ideally within 2 hours of exposure. A first dose of PEP should be offered while evaluation is underway. Do not delay for info about the source patient or the exposed worker's baseline HIV. Updated US Public Health Service Guidelines for the Management of Occupational Exposures to HIV and Recommendations for Postexposure Prophylaxis. Infec Control Hospital Epi, Sep 2013; 34:

13 HIV Pre Exposure Prophylaxis (PrEP) Marked reduction in HIV transmission but when should it be used? Use of emtricitibine/tenofovir (Truvada) one tablet daily has been approved by the FDA for prevention of HIV infection in those at high risk and is covered by most insurance plans. Although this is effective there are concerns regarding: Not using condoms and increasing other STIs Side effects uncommon but need to check renal function initially High cost (~$ per month), although cheaper in some countries Discuss with patient requesting and have them ensure that their insurance will cover this. This should NOT be purchased and dispensed by the HU but can be Rx thru the mail order pharmacy Do not use emergency PEP drugs for PrEP! If patients request this they generally perceive they have risk and PrEP should probably be Rx. Preexposure Prophylaxis for the Prevention of HIV Infection in the United States 2014 Clinical Practice Guideline. US Public Health Service

14 Meningococcal Quadrivalent vaccines Could it get any more confusing? YES! MenACWY-CRM = Menveo, 2m to 55y. Oligosaccharide conjugate A,C, Y, W m at series start: 4 doses at 2m, 4m, 6m, and 12 m 7-23 m at series start: 2 doses >3m apart; give 2nd dose at >2 y 2-10 y: 2 doses, may give 2nd dose >2m after 1st dose in pts 2-5 y if continued risk >11 y: first dose y, then 2 nd at 16 y >18-55 y: one dose repeat dose every 5 years for continued risk Preferred for immunosuppressed, asplenic, etc MenACWY-D = Menactra >9m. Polysaccharide conjugate A,C, Y, W m at series start: 2 doses 3 m apart 2-18 y: 1 st dose at y, then 2 nd at 16 y; if 1st dose given at y, give 2nd at y >18 y: one dose, repeat dose every 5 years if needed Preferred for immunosuppressed, asplenic, etc MPSV4 = Menomune, >2 y. Polysaccharide A,C, Y, W-135 Over age 2 and repeated every 5 years for those at continued risk Preferred for >55y who have not received MenACWY. Many travelers.

15 Ever more meningococcal vaccines! Six serotypes Neisseria meningitidis circulating: A, B, C, Y, W-135 and X US polysaccharide and conjugate vaccines cover A, C, Y and W-135 New vaccine covers B US FDA approved Oct 2014 There are not clear US recs for use of the new mening B vaccine use except in outbreak settings US vaccine FDA approved for use in yo Doses at 0, 2 and 6 months Some countries require mening B for school aged children CDC. Recs of the ACIP on meningococcal vaccine. MMWR. 2014;63:

16 The Good the Bad and the Ugly of PCR in Health Units Is the Biofire/FilmArray your new best friend or your worst enemy? First FDA approved, user friendly multiplex PCR with rapid results GI Panel Campylobacter Clostridium difficile Plesiomonas Salmonella Yersinia Vibrio spp Vibrio cholerae E.coli/Shigella EAEC EPEC ETEC STEC E. coli O157 Shigella EIEC Cryptosporidium Cyclospora Entamoeba histolytica Giardia lamblia Adenovirus F40/41 Astrovirus Norovirus GI/GII Rotavirus A Sapovirus Upper Respiratory Panel Adenovirus Coronavirus HKU1 Coronavirus NL63 Coronavirus 229E Coronavirus OC43 Human Metapneumovirus Human Rhinovirus/Enterovirus Influenza A Influenza A/H1 Influenza A/H3 Influenza A/H Influenza B Parainfluenza Virus 1 Parainfluenza Virus 2 Parainfluenza Virus 3 Parainfluenza Virus 4 Respiratory Syncytial Virus Bacterial Targets Bordetella pertussis Chlamydophila pneumoniae Mycoplasma pneumoniae BioThreat Panel Bacillus anthracis Brucella melitensis Burkholderia Clostridium botulinum Coxiella burnetii Ebola virus (Zaire) EEE virus F. tularensis Marburg virus Ricinus communis Rickettsia prowazekii Variola virus VEE virus WEE virus Yersinia pestis Orthopox virus Blood Culture ID Panel Meningoencephalitis Panel (in development) Lower Respiratory Panel (in development)

17 The dried reagents in the FilmArray pouch are reconstituted by the addition of 1 ml distilled water to the blue port (lower right of diagram), and the diluted sample is injected into the port shown in red. Rand K H et al. J. Clin. Microbiol. 2011;49:

18 Some examples for the GI Panel Age >3 BMs/24h Duration of symptoms Patient reports blood in stool Temp >100.5 F (38 C) Film Array results Antibioti cs Prescribe d If antibx given, what drug and how many days? 43 Yes 2 days No Yes Shigella Yes Levofloxacin, single day 6 Yes 3 weeks No No EAEC, Giardia Yes Tinidazole single dose 59 No 5 months No No Clostridium difficile Yes Metronidazole 10days Stool culture performed? Results? Yes, confirms Shigella Yes, no pathogens No Stool microscopy performed? Yes, no pathogens Yes, no pathogens, +WBC Yes, Blastocystis hominis - Patient 1 with Shigella could be dx and tx very quickly with single dose therapy and has a pretty definitive diagnosis - Patient 2 with EnteroAggregative E.coli and Giardia is confusing. 3 weeks of sx is most c/w Giardia and treating it is indicated. What about the EAEC? This is a common cause of peds diarrhea but it is also commonly seen without diarrhea in developing world kids. In this case I would probably NOT treat for EAEC. - Patient 3 has chronic loose stools, 1-3x/ day and abdominal cramping. His film array comes up with C. diff but clinically his illness is not c/w C. diff and is more likely IBS or another noninfectious etiology. NOT treating him may have been a more appropriate answer and sending him for colonoscopy to make sure this isn t neoplasia, inflammatory bowel disease, etc may be indicated.

19 Age Temp >100.5 F (38 C) Some examples for the Upper Respiratory Panel Cough Sputum Producing Pharyngitis Duration of symptoms Film Array results Antibx or antiviral Rx If antibx or antiviral, what drug and how many days? Respiratory culture performed? Results? Rapid flu test performed? Results 11 No Yes Yes No 18 days Rhinovirus No None No No 14 yes yes yes No 4 days Bordetella, Yes azithro x 10 d No No Rhinovirus 18 yes yes no? 3 days RSV No no No No m 32 yes yes no yes 1 day Influenza A yes oseltamivir x5d No Yes, positive 58 yes yes yes no 2 days Rhinovirus No - Yes, Pneumococcus No Patient 1: sick for 18d and PCR with rhinovirus only, was not given antibiotics. Patient 2: patient 1 s brother, sick 4d, + pertussis on PCR as well as rhinovirus, gets tx for pertussis. This explains the prolonged sx in Pt 1 who has pertussis but no longer is PCR +, rhinovirus rarely causes sx this long. Pt 1 sx were attributed to a viral infection while a pertussis outbreak was ongoing. Patient 3: diagnosed correctly with RSV early on, saved her from being empirically treated with antibx that would not have helped her and may give side-effects Patient 4: diagnosed with Influenza A but a rapid Flu test <¼ the cost also made the dx. Flu RDTs are not incredibly sensitive but are quite specific.? need for PCR Patient 5: smoker with a febrile respiratory dz. PCR+ Rhinovirus so no antibx, 2 days later septic with RML pneumonia and Pneumococcus in blood cx. FilmArray does not test for Pneumococcus. Without the PCR results he may have been appropriately started on empiric antibx.

20 Yikes! 6 pathogens in one stool!

21 10 Days later: 3 of the same and 1 more! Thanks to Holly Strain in Mexico City