Hot Topics in Infectious Diseases: Enteric Infections in the Arctic

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1 Hot Topics in Infectious Diseases: Enteric Infections in the Arctic Tobey Audcent MD, FRCPC Department of Pediatrics Children s Hospital of Eastern Ontario 6 th International Meeting on Indigenous Child Health March 21, 2015

2 Faculty/Presenter Disclosure Tobey Audcent has no relevant financial relationships with the manufacturer(s) of commercial services discussed in this CME activity AND Tobey Audcent does not intend to discuss an unapproved/investigative use of a commercial product/device in my presentation

3 Acknowledgements Thanks to: with permission Dr. David Goldfarb slides and data (ID/Micro, BC Children s Hospital) Dr. Cedric Yansouni (ID/Micro, McGill University) for data from Nunavik Dr. Sherilee Harper (Guelph University) for Iqaluit and Rigolet data

4 Session Objectives: 1. Review the contribution of chronic enteropathy to childhood development 2. Describe an overview of enteric infections in the Arctic 3. Discuss cryptosporidium as an emerging childhood enteric infection in the Arctic

5 Hot Infection Topics Tuberculosis Sexually Transmitted Infections

6 Diarrhoea

7 Global Burden of Diarrheal Disease Diarrhea kills 2,195 children every day more than AIDS, malaria, and measles combined 2 nd leading cause of child death Lancet. 2012;379(9832):

8 Environmental Enteropathy: Unifying Mechanism Nutr Rev September; 66(9): [15] PLoS Negl Trop Dis 7(4): e2125. doi: /journal.pntd

9 With permission D Goldfarb from: Guerrant R, Ped Academic Soc Mtg, April

10 Arctic Communities: More Diarrhea? Among American Indian (AI) and Alaskan Native (AN) children: diarrhea-associated hospitalization ~2X general U.S vs per 10,000 population diarrhea-associated outpatient visits also higher than general U.S. 2,255.4 vs. 1,647.9 per 10,000 population Singlelton RJ et al; Pediatr Infect Dis J. 2007;26(11):

11 Arctic Communities: Emerging Data Acute gastrointestinal illness in two Inuit communities: burden of illness in Rigolet and Iqualuit, Canada. SL Harper et al. Epidemiol Infect Lived experience of acute gastrointestinal illness in Rigolet, Nunatsiavut: Just suffer through it. SL Harper et al. Social Sci and Med Nanolitre real-time PCR detection of bacterial, parasitic and viral agents from patients with diarrhoea in Nunavut, Canada. DM Goldfarb et al. Int J Circumpolar Health

12 AGI in Arctic Communities Data from Dr. Sheri Harper, University of Guelph

13 Changes in Diagnostic Methods? Conventional Testing Multiplex PCR Bacteria Bacteria No Pathogen Virus Parasite No Pathogen with permission Goldfarb DM et al; Int J Circumpolar Health. 2013;72:19903.

14 Molecular Testing old specimens, new tools with permission Goldfarb et al; Int J Circumpolar Health 2013;72:19903.

15 Cryptosporidium: New Kid on the Map Spring 2013: Crypto retrospectively found to be leading stool pathogen July 2013: first observed Crypto outbreak in Arctic July 2014: new outbreak With permission, D Goldfarb

16 Crypto-whaaa? Oocyst forming coccidian protozoa Fecal-oral transmission, no intermediate maturation cycle Causes frequent non-bloody watery diarrhea +/- abdo cramps, fatigue, fever, wt. loss, vomiting, anorexia Self limited in immune competent hosts, incubation 3-14 days, illness usually lasts 6-14 days, continue to shed oocysts for 2 weeks Extensive waterborne disease outbreaks associated with contaminated drinking and recreational water (oocysts are chlorine tolerant) and in low resource settings and transmission from livestock and animals such as petting zoos (C. Parvum) Red Book. 29 th Ed

17 Sources: Not the Petting Zoo or the Pool! Giardia duodenalis and Cryptosporidium Spp. in the Intestinal Contents of Ringed Seals (Phoca Hispida) and Bearded Seals (Erignathus Barbatus) in Nunavik, Quebec, Canada Region. J Parasitology. Dixon et al.2008;94(5): Molecular characterization of Cryptosporidium sp isolated from northern Alaskan Caribou (Rangifer tarandus). J Parasitology. Siefker et al 2002;88:

18 Detection & Treatment Might not be detected on routine O & P of stools intermittent shedding- need 3 stools on 3 separate days small size of oocysts (4-6 um) concentration techniques + modified AF stain specific DFA gold standard, emerging role for flocked swabs/molecular testing No treatment in immune-competent

19 Crypto in Canada Thomas MK et al. Foodborne Pathogens and Dis. 2013; 10(7)

20 Crypto in the Arctic SL Harper et al. Epidemiol Infect. 2015

21 Crypto in kids? With permission. C. Yansouni

22 Crypto: QGH vs. the world? QGH detection rate Slide with permission D Goldfarb. Graphic from Shirley DT et al., Curr Opin Infect Dis 2012, 25:

23 Practical Implications: Diagnosis Gamma dynacare is doing acid fast staining on all O and P samples

24 So what? It s Self-Limiting Villous blunting Can have lasting effects in children, including increased diarrheal burden months after infection linear growth failure cognitive impairment Developmental delays has also been found in children with apparently asymptomatic infections May remain carrier for months No effective treatment (prevention is key) Guerrant et al (Eds); Tropical Infectious Diseases (2 nd Ed)

25 Practical Implications: Infection Control Infection Control (daycare exclusion, handwashing, animal handling, water ingestion) Most healthy individuals with acute diarrhea will only need supportive care

26 Survey: Health Behaviours

27 Survey: Health Beliefs

28 Practical Implications: Treatment Nitazoxanide is only FDA approved medication (is Health Canada special access) RCT -Diarrhea was resolved in 80% of adults and children within 7 days of being randomized to receive a 3-day course of nitazoxanide compared with only 41% of those randomized to placebo Indicated in: immunocompromised Chronic disease, particularly with growth failure Rossignol JF, et al. J Infect Dis 2001; 184:

29 Research Questions: 1. What is the incidence and prevalence of (i) intestinal infections and of (ii) diarrhea in Arctic communities? 2. What are the main infectious causes? 3. Are children being affected by repeated or chronic infections (Growth? Development?) 4. How can enteric infections be prevented in these communities?

30 Child under 5 years old? Has Gastroenteritis? You may have a patient eligible for the.. Nunavut Gastroenteritis Study Pick up the study pack for details If they are eligible and consent obtained, collect a swab sample to send to the lab If you have any questions please contact Dr. David Goldfarb (goldfarb@mcmaster.ca) or Dr. Amber Miners (aminers@gov.nu.ca)

31 Take Home Points 1. Diarrhoeal disease is an important, multifactorial, and underappreciated contributor to child health. 2. The burden of disease is higher in Arctic communities, unique prevention challenges. 3. Cryptosporidium is an emerging pathogen, diagnostic challenges, need more data. 4. There is a role for treatment of this pathogen in children with chronic disease.

32 Questions? Clyde River, Nunavut. Image courtesy of T Audcent

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