The solution of the problem of congenital infections as a method to reduce infantile mortality

Transcription

1 The solution of the problem of congenital infections as a method to reduce infantile mortality Valeriy V. Vasilyev Professor of the Chair of Infection diseases at North-Western State University n. a. I.I. Mechnikov, Saint Petersburg

2 Mortality: CI s outcomes - Toxoplasmosis 12 % - HSV infection up to 90 % - Enteroviruses around 80 % - Parvovirus B19V to 25 % - CRS (SASPE) 100 % Nonfatal outcomes: Severe malformations Multiple organic pathology Disability Unapparent CI: Relapse of infection (toxoplasmic eye lesions in adolescents)

3 CI s burden «The estimated disease burden of congenital toxoplasmosis in the Netherlands is similar to that for salmonellosis» (Havelaar A. A H. et al. Clin. Infect. Dis. 2007) «A total of 777 congenital CMV-associated deaths occurred over the 17-year study period resulting in 56,355 years of age- adjusted years of potential life lost. 71.7% of congenital CMV-associated deaths occurred in age less than 1 year» (Bristow B.N. et al. PLoS Negl. Trop. Dis. 2011)

4 CI s economics Direct medical costs for 45 cases of CRS (occurred during two years in Brasil) were US dollars in the first year of follow-up. Indirect costs are 2-4 times higher direct ones. (Lanzieri T.M. T. et al. Pediatr Infect Dis J. J 2004) One case costs about US dollars (in 2003) in the FIRST year About 400 cases of CRS in RF annually (in «Epidemiological surveillance of congenital rubella» PD # ) Estimated DMC for expected cases of CRS in RF: 400 x = US$ (about( rubles) in the FIRST year!!!

5 Treatment in infants It is very difficult because of: Non-specific manifestations of CI Limited spectrum of agent-specific medicines Severity of pathology already persisting at the birth (often( acute phase ends already in uterus!) Very high cost (intensive care, follow-up and so on)

6 To treat or to prevent? Anti-Rubella vaccination for one woman costs about 350 rubles About 20% of pregnant women (PW) are negative for Ig G About pregnancies occur in our city annually: PW are at risk of Rubella infection To vaccinate them = rubles. ONLY ONE TIME and FOREVER!

7 Only two of many aspects in CIs prophylaxis Basic information for women Specialist s competency

8 Basic information for women THEY NEED TO BE MUCH MORE INFORMED THAN NOW!!! Family School,, college, university Each visit to maternity welfare clinics (wallpapers not only about contraception and child nutrition, but CIs and its prevention) from the first one Mass-media!!!

9 Specialist s competency (present time) The greater part of physicians DO need modern knowledge and practice in ID and CIs

10 Recommended CI s risk estimation before pregnancy (the first step = to get maximum primary information) Anamnesis and clinical data First visit Other medical records and data Sexual life, social status STD? If YES, when? What was the control? Rubella? When? Confirmed or not? Did you have such diagnoses as toxoplasmosis, CMV and others? HSV? What about partners, child s father? Physical exam s data Certificate of vaccinations Does vaccination comply with National schedule? Extra-vaccinations? Tested for HIV? When? Results? Syphilis? When? Results? Hepatites? When? Results? Something else How we have to use that information in order to estimate risks of CIs?

11 The second step = primary tests (routine and additional) Routine tests (rubella, HB, HC, HIV, syphilis serum, vaginal and cervical smears) Additional tests More than one smear At least 3 times Microcsopy PCR Immunohistochemical analyses Early beginning of sexual life, combined with low social status and income; many partners; unprotected sex; STD in anamnesis At least: serum toxoplasma, HSV, CMV, parvovirus B19V. Ig G, Ig M quantitative analyses only! If toxoplasmic Ig G was present no test HSV, CMV PCR (blood and smears) If HSV infection is relapsing If there wasn t any tests for CI recently If there are pets or children (day care centre) at home Specialists HIV infected HBV, HCV infected Syphilis was documented

12 Dynamics of anti-toxoplasmic Ig (type 1) % экстинции; МЕ/мл Ig M-tox Ig G-tox cut-off Ig M до 8 недель 9-16 недель недель недели недели недели позже 52 недели От начала заболевания

13 The third step = primary risk s estimation after primary tests results Routine tests (rubella, HB, HC, HIV, syphilis serum, vaginal and cervical smear) HIV, HBV, HBC, syphilis positive Specialists Information: Risk of acute infections How to prevent Re-testing after consumption Additional tests No signs of infections, antibodies are absent HIV, HBV, HBC, syphilis, OSTD negative Repeat tests after consumption NO risk! Toxoplasmic Ig G + Ig M - negative Rubella negative Rubella positive STD positive Vaccinate AFAP! Only Ig G NO risk Ig M re-test To treat and control Treatment, control Delay of pregnancy Risk of CIs is low Signs of acute or Signs of acute or relapsed other relapsed infections infections Latent infections at present time

14 Further activities If woman is well-examined, well-treated and well- controlled and so has no (or low) risks of CIs before consumption, we may use only routine examinations during pregnancy In other cases see steps 1 and 2, at first, then next picture

15 The third step for pregnant women Routine tests (rubella, HB, HC, HIV, syphilis serum, vaginal and cervical smear) HIV, HBV, HBC, syphilis positive Specialists Information: Risk of acute infections How to prevent Monitoring Additional tests No signs of infections, antibodies are absent HIV, HBV, HBC, syphilis, STD negative Repeat tests as recommended NO risk? Toxoplasmic Ig G + Ig M - negative Rubella negative Rubella positive Avoid exposure Monitoring Only Ig G NO risk If Ig M: re-test, Repeat estimation Monitoring? To treat and control Risk of CIs is low? Monitoring is expensive Signs of acute or Signs of acute or relapsed other relapsed infections infections Latent infections at present time STD positive To treat and control Is that simply and easy?

16 Clinical case 28 y.o. immunocompetent woman. First exam at 8 th week of gestation: specific Ig M to T. gondii - positive, «high» levels of Ig G. Tests were repeated EVERY week (Ig M positive,, Ig G at the same levels). Quantitative Q test for Ig M was never conducted. Ig G avidity was less than 30%. PCR negative (blood, 3 times). There were not antibodies 3 years before. Spiramycine from 12 th week,, the advice to cease pregnancy (3 times). Exam in RSI of children s infections at 15 weeks of gestation: quantitative test for Ig M positive (1, 95; cut-off = 0,85), Ig G = 98 IU/ml (cut-off -= 4). Ig G avidity = 42 %. No signs of acute toxoplasmosis. Fetus USE normal. Conclusion: acute acquired toxoplasmosis with exposure at early pregnancy WITHOUT vertical transmission. Unfortunately, patient had received this information too late (returning to home city, woman had visited specialists, which really forced her to cease pregnancy ) Those specialists don t know,, that the vertical transmission s risk T. gondii- infection in first trimester is around 6%, but if occurs it will be abortion in 99,999 % of cases before 2 nd trimester.. Woman had normal pregnancy up to 16 th week

17 Improving specialists competency Training under control of specialists in ID!!! How? The Chair of Infectious Diseases of Northern- West State Medical University n. a. I.I. Mechnikov (Saint-Petersburg, RF) offers short-term (two weeks) theoretical and practice training in CI from For all specialists!

18 Possible key directions toward better CIs prevention More information for women (motivate to be examined before pregnancy) Education for all specialists who have bearing on this situation Expanding spectrum of tests (social insurance) More real dates and recommendations for motoring during pregnancy Use modern methods (quantitative analyses only)

19 Thank you very much for attention!