Emerging Pathogen Threats Michael Olesen

Clinical Considerations - Evaluation MRSA belongs in the differential diagnosis of skin and soft tissue infections (SSTI s) compatible with S. aureus infection:

MRSA Surveillance Areas

Prevalence (%) S. aureus Nasal Colonization National Health and Nutrition Examination Survey 2001-02 50 45 40 S. aureus: 32.4% = 89.4 M people 35 30 25 20 15 10 5 0 1--5 6--11 12--19 20--29 30--39 40--49 50--59 60--69 70+ Age (years) Male Female MRSA: 0.8% = 2.3 M people MRSA colonization associated with age >= 60 years & being female

Percent Resistance Methicillin-Resistant Staphylococcus aureus (MRSA) Among Intensive Care Unit Patients, 1995-2004 70 60 50 40 30 20 10 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Source: National Nosocomial Infections Surveillance (NNIS) System

Percent Resistance Vancomycin-Resistant Enterococci (VRE) Among Intensive Care Unit Patients,1995-2004 35 30 25 20 15 10 5 0 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 Year Source: National Nosocomial Infections Surveillance (NNIS) System

Percent Resistance Fluoroquinolone-Resistant Pseudomonas aeruginosa Among Intensive Care Unit Patients, 1995-2004 40 35 30 25 20 15 10 5 0 1995 1996 1997 1998 1999 2000 Year 2001 2002 2003 Source: National Nosocomial Infections Surveillance (NNIS) System 2004

Tuberculosis

No. of Cases 30,000 Reported TB Cases United States, 1982 2010* 25,000 20,000 15,000 10,000 5,000 0 *Updated as of July 21, 2011 Year

TB Case Rates,* United States, 2010 D.C. *Cases per 100,000. < 3.6 (2010 national average) >3.6

Percentage of TB Cases Among Foreign-born Persons, United States* 2000 2010 DC DC *Updated as of July 21, 2011 >50% 25% 49% <25%

Available data on anti-tb drug resistance, 2010 Nationwide surveillance data Subnational surveillance data Nationwide recent survey data (since 2000) Subnational and/or old survey data (before 2000) No data available The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2011. All rights reserved

Proportions of MDR among previously treated TB cases, 1994-2010 0-<6 6-<12 12-<30 30-<50 >50 No data available Subnational data only The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2011. All rights reserved

Proportions of MDR among new TB cases, 1994-2010 0-<3 3-<6 6-<12 12-<18 >18 No data available Subnational data only The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2011. All rights reserved

Estimated absolute number of MDR-TB cases, 2009 0-<4,000 4,000-<10,000 10,000-<40,000 approximately 100,000 The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2011. All rights reserved

Countries that had reported at least one XDR-TB case by end 2010 Argentina Bhutan France Kazakhstan Nepal Republic of Moldova Togo Armenia Cambodia Georgia Kenya Netherlands Romania Tunisia Australia Canada Germany Kyrgyzstan Norway Russian Federation Ukraine Austria Chile Greece Latvia Pakistan Slovenia United Arab Emirates Azerbaijan China India Lesotho Peru South Africa United Kingdom Bangladesh Colombia Iran (Islamic Rep. of) Lithuania Philippines Spain United States of America Belgium Czech Republic Ireland Mexico Poland Swaziland Uzbekistan Botswana Ecuador Israel Mozambique Portugal Sweden Viet Nam Brazil Egypt Italy Myanmar Qatar Tajikistan Burkina Faso Estonia Japan Namibia Republic of Korea Thailand The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. WHO 2011. All rights reserved

Emerging Diseases XDRTB

XDR TB Andrew Speaker

TDR TB

Consumer product antibacterials

Animal Husbandry Institute of Medicine. 1990. Human health risks with the subtherapeutic use of penicillin or tetracyclines in animal feeds. National Academy Press, Washington, D.C.

Animal Husbandry 80% of abx used in animals are to promote growth (15-17 million lbs. annually in US) 30x more animals receive abx than humans Animals produce 5-400x more feces Vector transmission Fertilizer Tetracycline dosage change over time 1950s: 5-10 ppm Today: 50-200 ppm (10-20x increase)

Recommended Reading

The Cost of HAI 5.4 excess days of hospitalization per infection Am J Med Qual. 2009 Jan-Feb;24(1):71-3.

Infection Prevention and Health Care Finance Effect on the Bottom Line Profit Reimbursement $0 Time (LOS) Loss

Infection Prevention and Health Care Finance Effect on the Bottom Line Profit Reimbursement $0 Time (LOS) Loss HAI

The Cost of HAI 5.4 excess days of hospitalization per infection $12,197-15,275 per infection Am J Med Qual. 2009 Jan-Feb;24(1):71-3.

Calculation of estimates of healthcare-associated infections in U.S. hospitals among adults and children outside of intensive care units, 2002 263,810 274,098-967 -21-28,725 244,385 TOTAL HRN WBN Non-newborn ICU = SSI SSI 20% Other 22% BSI 11% 133,368 129,519 PNEU 11% UTI 36% 424,060 HRN = high risk newborns WBN -= well-baby nurseries ICU = intensive care unit SSI = surgical site infections BSI bloodstream infections UTI = urinary infections PNEU = pneumonia Klevens, Edwards, Richards, et al. Pub Health Rep 2007;122:160-6

Costs by Type of Infection VAP: $25,072 BSI: $23,242 SSI: $10,478 MRSA: $5,980 MRSA SSI: $61,681 Anderson, DJ, Kirkland, KB, Kanafani, ZA, Engemann, JJ, Thacker P, Kaye, KS, Sexton, DJ. Cost of Healthcare-Associated Infections (HAI) and Hospital Budgets for Infection Control and Prevention (IC): Just a Drop in the Ocean? 17th Annual Society for Healthcare Epidemiology in America meeting, Baltimore, MD, April, 2007 Anderson DJ, Kaye KS, Chen LF, et al. Clinical and financial outcomes due to methicillin resistant Staphylococcus aureus surgical site infection: a multi-center matched outcomes study. PLoS ONE. 2009;4(12):e8305.

The Cost of HAI 5.4 excess days of hospitalization per infection $12,197-15,275 per infection 98,987 deaths Am J Med Qual. 2009 Jan-Feb;24(1):71-3.

Outbreaks of MRSA in the Community Often first detected as clusters of abscesses or spider bites Various settings Sports participants Inmates in correctional facilities Military recruits Daycare attendees Native Americans / Alaskan Natives Men who have sex with men Tattoo recipients Hurricane evacuees in shelters

US Yellow Fever Outbreaks, c. 1800-1900 Philadelphia; August-November 1793; approximately 5,000 dead New York City; July-October 1795; 730 dead Boston, New York City and Philadelphia; Summer 1798; more than 5,000 dead Baltimore; Summer 1800; 1,200 dead New Orleans; Summer 1853; 8000 or more dead Norfolk; June-Oct 1855; 2,000 dead Mississippi Valley; May-Oct 1878; 20,000 dead Cuba; Summer 1898; hundreds dead. New Orleans; May-October 1905; more than 900 dead

Walter Reed (1851-1902) Spread through mosquito vector instead of contact transmission Led to the ability to complete the Panama Canal

1870

MMWR 58(SS02);1-16

Emerging Diseases Pandemic Influenza

J Infect Dis. 2012 Feb 7 Influenza and COD

Recent Research Controversy 62

Camp Devens, Mass., Surgical Ward No 16 (Base Hospital) 9/29/1918 These men start with what appears to be an ordinary attack of LaGrippe or Influenza, and when brought to the hospital they very rapidly develop the most viscous type of Pneumonia that has ever been seen. Two hours after admission they have the Mahogany spots over the cheek bones, and a few hours later you can begin to see the cyanosis extending from their ears and spreading all over the face, until it is hard to distinguish the coloured men from the white. It is only a matter of a few hours then until death comes, and it is simply a struggle for air until they suffocate. It is horrible. One can stand it to see one, two or twenty men die, but to see these poor devils dropping like flies sort of gets on your nerves. We have been averaging about 100 deaths per day, and still keeping it up. There is no doubt in my mind that there is a new mixed infection here... they all mean but one thing here pneumonia and that means in about all cases death.

Presentation in chickens

What does 300M deaths mean? 250,000 deaths from the December 26, 2004 tsunami Imagine a tsunami of that scale EVERY HOUR for a six week period

Role of Antibiotic Resistance 1918-1919, 50% deaths due to 2 PN 1968-1969 33% mortality rate from 2 PN Will MRSA pneumonia, play a role in the next pandemic? MRSA attaches easier to cells infected with influenza Agwu, A., K. M. Brady, et al. (2007). "Cholera-like diarrhea and shock associated with community-acquired methicillin-resistant Staphylococcus aureus (USA400 clone) pneumonia." Pediatr Infect Dis J 26(3): 271-3. (2007). "Severe methicillin-resistant Staphylococcus aureus community-acquired pneumonia associated with influenza--louisiana and Georgia, December 2006-January 2007." MMWR Morb Mortal Wkly Rep 56(14): 325-9.

Immune Systems - 1918 versus today Antibiotic Resistance Immunosuppression HIV/AIDS Chemotherapy Organ transplant 25% of military/police forces in Africa are HIV+

From barbarism to civilization requires a century, from civilization to barbarism needs but a day. - Will Durant (1885-1981) Durant W. The Reformation. Simon & Schuster; 1980.

Male Female 2005 85 80 75 70 65 60 55 50 45 40 35 30 25 20 15 10 5 Population (millions) 14 12 10 8 6 4 2 0 0 2 4 6 8 10 12 14 0

Surge Capability and Surge Capacity Surge Capability the ability to manage patients requiring unusual or very specialized medical evaluation and intervention, often for uncommon medical conditions i.e., mix Surge Capacity the ability to manage increased patient care volume that otherwise would severely challenge or exceed the existing medical infrastructure i.e., numbers Barbera J, Macintyre A. Medical Surge Capacity and Capability: A System Template for Managing Medical and Health Resources during Large-Scale Emergencies. U.S. Department of Health and Human Services. Washington, D.C. August, 2004.

Surge Capability

What is surge capacity?

Military Hospital Surge Capacity Camp Devens (above near Boston) Built for 1200 Surge capacity: 2500 Census: 6000 Camp Grant (Rockford, IL) Went from census of 610 to 4102 in 6 days The base commander committed suicide

US Hospital Surge Capacity 955,768 licensed beds 707,268 staffed beds 96% of hospital beds occupied during seasonal flu During pandemic mirroring 1918 100,000,000 Americans sick 50,000,000 require care 25,000,000 s/s ARDS 12,500,000 require intubation 6,250,000 will die

National Ventilator Surge Capacity and Ethics ~105,000 in US 75,000 80,000 in use at any given time 100,000+ in use during normal flu season <6 per hospital in survey Who should get a ventilator? Osterholm, M. (2005). NEJM 352(18): 1839 Kaji, A. H. (2006). Acad Emerg Med 13(11): 1198

Can shortages happen today? Gasoline After onset of military action After Hurricane Katrina Food Will a pandemic trigger a rush to grocers in a similar manner? OTC pharmaceuticals Shelves were emptied in 1918 Clin Infect Dis 31(6): 1409-13. 80% of pharmaceuticals are produced overseas

Isolation

Extreme times call for extreme measures

Disease/Climate Interaction

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