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
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
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.
Measles Epidemic viral disease 1 st U.S. description - 1657 Pre-vaccine U.S.: 315/100,000 Post-vaccine U.S.: <1/100,000 World-wide prevalence Clusters/mini-outbreaks
Measles Large RNA virus Cultures easiest in human/monkey kidney cells Syncytial formation = giant cells Antigen expressed at cell surface by 30 hours
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
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
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
Measles - complications Pneumonia 55%: diffuse, fluffy infiltrates 74%: hilar adenopathy Laryngitis and AOM Cardiac: ECG abnormalities Neurologic: encephalitis SSPE Atypical Measles
Vaccine preventable infections Bacteria: Diphtheria Tetanus Pertussis Hib Pneumococcus Meningococcus
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)
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
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
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.
Pertussis - Control Prophylaxis: Pertussis immunity is not absolute/may not prevent disease; limited duration Patients with mild disease can transmit Erythromycin 40-50 mg/kg/day X 14 days ALL household and close contacts Return to school 5 days after initiation Alternatives (other macrolides, T/S)
Meningitis Three most common Streptococcus pneumoniae Neisseria meningitidis Haemophilus influenzae type b (Hib) Steady decline in Hib meningitis-1984 Seasonal pattern
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)
Meningitis - clinical Exam nonspecific Nuchal rigidity Bulging fontanelle Meningeal irritation (12-18 months +)
Meningitis- clinical WBC >1000/mm 3 (mostly PMNs) Glucose: <40 mg/dl 0.3 0.5 serum glucose Protein 100-500 mg/dl (30-1000)
Meningitis - clinical GBBS, E. coli H. influenzae, S. pneumoniae, N. meningitidis Control measures: Isolation Prophylaxis
Cases per 100,000 persons Incidence of Invasive Pneumococcal Disease in Children 250 200 150 100 50 0 0 5 6 11 12 17 18 23 24 35 36 47 48 59 5 9 yrs 10 19 yrs Age group (months) http://www.cdc.gov/ncidod/dbmd/abcs
Streptococcus pneumoniae 7-valent pneumococcal conjugate vaccine Significant reduction in disease Serotype replacement antibiotic resistance (type 19A)
Importance of Herd Immunity: Rates of PCV7- type Invasive Pneumococcal Disease among Adults, U.S., 1998/99-2006 Cases per 100,000 120 100 80 60 40 20 2006 vs. baseline >80: -90% (-93,-86) 65-79: -88% (-91,-83) 50-64: -84% (-87,-79) 18-49: -88% (-91,-86) 0 1998 1999 2000 2001 2002 2003 2004 2005 2006 Pilishvili, IDSA 2007 Year
Streptococcus pneumoniae 13-valent pneumococcal conjugate vaccine 2010 Significant reduction in remaining disease: AOM Pneumonia Meningitis Sepsis Significant reduction antibiotic resistance
Penicillin Resistance 2003-2012
Epidemiology of bacterial meningitis in the USA from 1997 to 2010: a population-based observational study Lancet: http://dx.doi.org/10.1016/s1473-3099(14)70805-9
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
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
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)
Pediatric Vaccinations
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)
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
Questions?