Pediatric and Adolescent Infectious Disease Concerns

Transcription

1 Pediatric and Adolescent Infectious Disease Concerns Sean P. Elliott, MD Professor of Pediatrics Associate Chair of Education, Department of Pediatrics University of Arizona College of Medicine Tucson, AZ

2 Objectives Learn the clinical presentations of vaccine preventable infections measles, meningitis, and pertussis. Apply appropriate infection prevention anticipatory guidance for the ambulatory setting Identify appropriate vaccination strategy for college-bound patients

3 Conflict of Interest Disclosure I have no relevant financial relationships with the manufacturer(s) of any commercial product(s) and/or provider of commercial services discussed in this presentation. I do not intend to discuss an unapproved or investigative use of a commercial product or device in my presentation.

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6 Measles Epidemic viral disease 1 st U.S. description Pre-vaccine U.S.: 315/100,000 Post-vaccine U.S.: <1/100,000 World-wide prevalence Clusters/mini-outbreaks

7 Measles Large RNA virus Cultures easiest in human/monkey kidney cells Syncytial formation = giant cells Antigen expressed at cell surface by 30 hours

8 Measles Disease of childhood? 1964: <10% pts > 10 years old 1991: 40% pts > 10 years old 2005: 75% pts > 10 years old Winter-Spring disease (March/April) Male = Female incidence HIGHLY contagious: Respiratory droplet No asymptomatic contagious carriers

9 Measles - Clinical Incubation period: 8-12 days Prodromal period: 2-4 days Fever + URTI ( cold ) Clinical measles (2-4 days): 3 C s: cough, coryza, conjunctivitis Cough brassy, troublesome Coryza copious Conjunctivitis ++ lacrimation

10 Measles - Clinical Koplik spots: Day 10 +/- 1 after exposure Buccal mucosa opposite lower molars Whitish, 1-2 mm Exanthem: Day 14 after exposure Begins at ears, forehead Spreads downwards to feet Maculopapular morbilliform

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12 Measles - complications Pneumonia 55%: diffuse, fluffy infiltrates 74%: hilar adenopathy Laryngitis and AOM Cardiac: ECG abnormalities Neurologic: encephalitis SSPE Atypical Measles

13 Vaccine preventable infections Bacteria: Diphtheria Tetanus Pertussis Hib Pneumococcus Meningococcus

14 Pertussis Fastidious gram-negative bacteria Outbreaks first described in 16th century Bordetella pertussis first isolated in 1906 Prevaccine: >200,000 cases reported/year Postvaccine: >98% reduction Estimated >300,000 deaths/year worldwide 2014: US: 28,660 cases (9.1/100,000); 18% AZ: 464 cases (7.0/100,000)

15 Pertussis Humans only hosts of B. pertussis Transmission person-person by respiratory droplet Highly communicable (70-100% secondary attack rates) Most contagious during catarrhal stage, up to 3 weeks after onset of paroxysms

16 Pertussis - Clinical Incubation: 5-10 days (up to 21 days) Insidious onset, similar to minor URTI Minimal fever during course Catarrhal stage: 1-2 weeks Paroxysmal stage: 1-6 weeks Convalescence: Weeks to months Chronic cough in adolescents, adults

17 Pertussis - Control Isolation: Droplet precautions for 5 days after initiation of therapy 3 weeks after onset of paroxysms Immunization: DTaP now preferred for primary series; Tdap for > 11 y.o. Tdap for incompletely immunized > 7 y.o.

18 Pertussis - Control Prophylaxis: Pertussis immunity is not absolute/may not prevent disease; limited duration Patients with mild disease can transmit Erythromycin mg/kg/day X 14 days ALL household and close contacts Return to school 5 days after initiation Alternatives (other macrolides, T/S)

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20 Meningitis Three most common Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae type b (Hib) Steady decline in Hib meningitis-1984 Seasonal pattern

21 Meningitis - clinical Often nonspecific, flu-like Fever, irritability, nausea, vomiting, diarrhea Progressive irritability, lethargy; anorexia, respiratory distress (neonate) Headache, neck pain/nuchal rigidity, photophobia (child)

22 Meningitis - clinical Exam nonspecific Nuchal rigidity Bulging fontanelle Meningeal irritation (12-18 months +)

23 Meningitis- clinical WBC >1000/mm 3 (mostly PMNs) Glucose: <40 mg/dl serum glucose Protein mg/dl ( )

24 Meningitis - clinical GBBS, E. coli H. influenzae, S. pneumoniae, N. meningitidis Control measures: Isolation Prophylaxis

25 Cases per 100,000 persons Incidence of Invasive Pneumococcal Disease in Children yrs yrs Age group (months)

26 Streptococcus pneumoniae 7-valent pneumococcal conjugate vaccine Significant reduction in disease Serotype replacement antibiotic resistance (type 19A)

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28 Importance of Herd Immunity: Rates of PCV7- type Invasive Pneumococcal Disease among Adults, U.S., 1998/ Cases per 100, vs. baseline >80: -90% (-93,-86) 65-79: -88% (-91,-83) 50-64: -84% (-87,-79) 18-49: -88% (-91,-86) Pilishvili, IDSA 2007 Year

29 Streptococcus pneumoniae 13-valent pneumococcal conjugate vaccine 2010 Significant reduction in remaining disease: AOM Pneumonia Meningitis Sepsis Significant reduction antibiotic resistance

30 Penicillin Resistance

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32 Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study Lancet:

33 Infection Prevention 1 Care Prevention (especially with athletes): NO sharing of equipment, towels, clothes, personal items Regular cleaning of shared equipment Frequent laundering uniforms Cover all wounds No body shaving Rigorous skin hygiene

34 Infection Prevention: Decolonization Decolonization protocol: Appropriate Rx of active lesions Intranasal mupirocin TID X 7 days Chlorhexidine gluconate soap OR bleach baths X 7 days Hypoallergenic skin care regimen Who? When? How effective? Loeb, Cochrane Database of Systemic Reviews 2009

35 Infection Prevention: Common Viruses Exclude staff with respiratory illness RSV: Contact precautions Croup: Contact and Respiratory precautions Influenza: Respiratory precautions Adenovirus: Contact and Respiratory precautions Enterovirus: Contact (GI)

36 Pediatric Vaccinations

37 Arizona vaccine requirements HBV (grades K-12) HAV (Maricopa only) DTaP (primary series) Tdap (grades 6-8) IPV Hib MMR (grades K-12) Varicella (grades K-12) Recommended: PCV7 PPV23 Rotavirus Influenza HAV (non-maricopa) HPV MCV4 (grades 6/7-12)

38 Arizona vaccine requirements UA: MMR (MCV4 & MCV-b) ASU: Req.: MMR Rec.: MCV4 & Tdap NAU: Measles Grand Canyon University: Req.: MMR Rec.: Tdap, MCV4, HPV, HBV

39 Questions?