“bugs are bringing bugs”€¦ · mosquito and tick-borne diseases greenville postgraduate...
TRANSCRIPT
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“Bugs are Bringing Bugs” Mosquito and Tick-borne Diseases
Greenville Postgraduate Seminar
April 11, 2014
Eric Brenner, MD Email: [email protected]
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Mosquito Tick Louse Flea Fly
Virus
Arboviruses
WNV Yellow Fever
Dengue EEE WEE SLE LACV
Chikungunya
Powassan (POW)
TBE (Tick borne
encephalitis)
Bacteria
Lyme Disease
RMSF
Anaplasmosis
Ehrlichiosis TBRF
Tularemia
Typhus
LBRFPlague
Trachoma
Tularemia
Protozoa Malaria Babesiosis Leishmaniasis
Metazoa Dog heartworm Onchocerciasis
(*) Examples only, thus not a complete list
Examples of Vector-borne Diseases (*)
Vector
Typ
e o
f P
ath
oge
n
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Hence, in SC had fatal “bubonic”, “septicemic” and “pneumonic” plague… acquired not abroad, but in New Mexico!
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Another SC Case Presentation
• 36 yo male c/o fever x 4 days with chills, headache and
general malaise. No special “cyclical fever pattern” noted.
• Pt. had just returned from overseas tour as a Peace Corps
Volunteer
• Had been working in Malawi (East Africa) for 9 months.
• PMH: no significant past or present co-morbidities
• Medications: Had been taking weekly mefloquine for anti-
malarial prophylaxis x 8 months. DC’ed meds just in last
few weeks prior to departure home.
• Other travel history: Thailand, Malaysia, Honduras,
Nicaragua within the last 6-7 years.
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Physical Exam
• Healthy-looking patient, afebrile
• Ox3. No nucal rigidity or neuro deficits
• No pallor
• No organomegaly
• No petechiae or muco-cutaneous stigmata of endocarditis or HIV
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What is the Presumptive / Working Diagnosis?
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Medical Decision Priorities
• Malaria until proven otherwise
• How to confirm diagnosis – Blood smear (traditional!)
– Rapid blood tests (newer… but are they available?)
• What species?
• Parasitemia level?
• Cerebral malaria? Other complications?
• Labs to check for complications (Hb, glucose, creatinine, LFTs…)
• IV vs. po treatment
• Is hospitalization required?
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“Ring-form” trophozoites Banana-shaped gametocytes
Morphology confirms infection due to Plasmodium falciparum
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What does one need to know about malaria Rx?
1. On the tropical medicine board exam?
2. In every day front-line primary care practice?
• Nuances, doses, options for routes of administration of all the antimalarials as might be used singly or in combination
• CDC clinicians on-call 24/7 to provide advice to clinicians re malaria Dx/Rx.
• Malaria Hotline 770-488-7788 (or toll free 855-856-4713) M-F 9-5.
• Off-hours, weekends, and holidays => 770-488-7100 and ask for malaria clinician on-call.
Or more simply: Daytime main CDC Number: 404-639-3311 Nights/weekends: 404-639-2888
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Malaria Perspectives
• Malaria (and YF) common in SC in colonial days
• Endemic local transmission now eliminated, though the insect vectors remain (Anopheles for malaria; Aedes for YF)
• Cases now thus seen only in: 1. Internationals arriving from endemic countries
2. Americans who have travelled to malarious areas and fail to take proper anti-malarials
3. VFRs (“Visiting Friends and Relatives”): i.e. Internationals going “home” on vacation who do not take prophylaxis and who – for several reasons -- are at high risk of disease!
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SC VBDs in Perspective (2004-2013)
RMSF
Lyme
Disease Babesiosis Malaria Dengue
WN
Fever
WNV -
Neuro-
invasive EEE
2004 68 6 10 1 2 1
2005 50 12 12 2 4 1
2006 47 18 9 1 1
2007 65 34 8 3 2 2
2008 58 33 8 1 2
2009 23 47 7 2 3
2010 18 28 6 16 1
2011 40 40 8 2 1
2012 68 42 9 2 19 10
2013 56 26 1 10 9 6
Total 493 286 1 87 37 37 18 2
Tick-borne Mosquito-borne
Year
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Why is this a good time to think about “vector-borne diseases”?
• Just getting into lovely spring & summer weather
– Outdoor activities
– Summer holidays
– Hikes and woods
– Mosquito & tick season!
• April 7: WHO’s World Health Day this year focuses on vector-borne diseases under the theme: “Small bite, big threat”
• Theme echoed world-wide… e.g. at PAHO, CDC etc.
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www.who.int/campaigns/world-health-day/2014/en/
(www.who.int)
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WHO World Health Day 2014 Posters re Vector-borne
Diseases
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CDC world Health Day Flyer
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www.cidrap.umn.edu
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www.cdc.gov/ticks
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www.cdc.gov/ticks
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Reported Lyme Disease Cases 2012 (CDC)
We have Ixodes scapularis ticks in Connecticut AND in South Carolina…. So, why the difference in incidence in Lyme Disease?
??
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Southern Tick-Associated Rash Illness (STARI)
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Reported Cases of Rocky Mountain Spotted Fever (RMSF) 2012
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Ehrlichia Chaffeensis- 2012
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Anaplasma phagocytophilium-2012
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Distribution of Key Tickborne Diseases, 2012 (CDC)
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Lyme Disease • Caused by spirochete Borrelia burgdorferi
• Caused by Ixodes ticks
• ~30,000 cases reported annually in US
• Studies about to appear suggest actual number of annual infections may be closer to ~300,000 (!!) – BUT… this “jump” largely indicative of under-
reporting and NOT of increase
– Main geographic foci not greatly changing (though there has been a gradual “southward extension” from previous mainly New England hyper-endemic focus
– This “revised estimate” based on surveys of “medical visit coding”, “laboratory test results” and other “indirect counting & extrapolation” methods
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Life Cycle of Ixodes Scapularis (CDC)
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Primary Dis. Transmitted • Lyme disease • Anaplasmosis • Babesiosis • Powassan disease • STARI • Ehrlichiosis • Tularemia • RMSF
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Erythema Migrans (EM)
• Seen in ~ 70-80% of cases • ~1-2 weeks after tick bite • Expands over days • Rarely painful • Distinguish from allergic
reaction ?
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Atypical EM Presentations
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Disseminated and Late Lyme Disease Facial Palsy • Summer months • May be bilateral • +/- CSF pleocytosis
Arthritis • Intermittent • Oligoarticular • Swelling >> pain
Late-stage neurologic • Peripheral neuropathy • Encephelopathy
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(MMWR Dec 13, 2013)
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(MMWR Aug 16, 2013)
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(JSCMA June 2013)
Comparison: In one case deaths from cardiac complications of unrecognized tick-bites… whereas here we have rabies death following an unrecognized bat bite
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Sensitivity of Two-Tiered Serologic testing (*)
Lyme Diseae Stage Sensitivity (%)
EM rash (acute) 38
EM rash (convalescent) 67
Early Neurologic 87
Late Neurologic 100
Arthritis 97
(*) Specificity of two-tiered testing generally >95
Bottom Line: • Two-tiered testing performs well in late stages of disease • Testing of EM patients not generally necessary (?!)
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Possible “red flags” for “alternate labs” (CDC)
• Tests offered are not FDA approved
• Laboratory claims to “specialize” in Lyme and other tick-bone disease testing
• Do not accept insurance => patient pays out of pocket (e.g. $500 - $1000 ++)
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http://en.wikipedia.org/wiki/Mosquito-borne_disease
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The Nile
River Basin Uganda: West
Nile District
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NY Times Sept 4, 1999
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NY Times Sept 8, 1999
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NY Times Sept 25, 1999
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Unusual Encephalitis Cluster
in Northern Queens, 1999
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NYT April 8,
2013
What does this
story about a single
(just 1!) case of polio in
Baghdad have to do with WNV?
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• 44% Participation among households selected by cluster
sampling
• Estimated seroprevalence : 2.6% (95% CI: 1.2 – 4.1%)
• 20% of seropositive individuals reported febrile illness.
Primary symptoms included:
- Myalgias (100%) - Fatigue (87%)
- Headache (89%) - Arthralgias (76%)
• Overall “neuroinvasive infection to “asymptomatic
infection” ratio ~ 1:200-300.
Household-based Serosurvey Conducted in 2x2
Mile area in Northern Queens in Persons 5+ y.o.
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A “natural history pyramid” with essentially the same shape and compartment proportions as we find in polio (!!)… with similar consequences about how we may consider what is “really happening” when we have even one person with polio paralysis or WNV neuro-invasive disease.
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• Migrating viremic bird?
• Imported viremic bird (legally or illegally)?
• Viremic human traveler?
• Imported mosquitoes (airplane or ship)?
• Intentional release?
Potential Sources of Introduction
of WNV into NYC (?)
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• Need to always remain open-minded to the possibility
of the unexpected
• Importance of strong relationships between the medical
community and public health.
• Need to engage nontraditional public health partners
(e.g., veterinarians, wildlife experts)
• Unusual events in animals/birds may be an early
warning for human disease outbreaks
• Newly introduced West Nile virus may become
endemic in the US
West Nile Outbreak 1999:Lessons Learned / Conclusions
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Countries with reported local transmission of Chikungunya virus (as of 2-10-2014)
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www.cdc.gov/chikungunya/geo/americas.html
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Chickungunya Virus - 1
• Single stranded RNA virus
• Related to Mayaro, O’nyong-nyong and Ross River viruses
• Predominantly spread by Aedes aegypti and Aedes albopictus (same vectors as for Dengue!)
• Aggressive daytime biters
• Most (~72-97%) infected develop symptoms: typically abrupt fever >39.0C + often severe polyarthralgia
• Also variable: headache, myalgia, conjunctivitis, NV, maculopapular rash
• Risk factors for hospitalization or atypical disease: neonates, older age, underlying conditions
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Chickungunya Virus - 2
• Dx assays (e.g. through DHEC and CDC)
– Viral culture (<= 3days)
– RT-PCR <=8days)
– IgM Ab >= 4 days
• Treatment
– No specific antiviral
– Supportive care / rest /fluids / NSAIDS
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Some Final Thoughts and Questions?
• Will range of Chickungunya transmission extend up from Caribbean to Florida (where Dengue is already established, and thence (also with Dengue) up the SE Coast where Aedes mosquitoes are already present!
• Might these new virus go “coast to coast” in a few years…. Just as did WNV?
• Will society be willing to invest in government run community-wide mosquito control programs -- or leave backyard spraying to the private sector?
• What consequences of emerging VBDs for front-line medical practice?
• Will global warming extend the “eco-range” of various mosquito (and other) vectors, and hence radically change the epidemiology and distribution of VBDs!?