emerging infectious diseases 2016: menace of the...
TRANSCRIPT
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Emerging Infectious Diseases 2016:
Menace of the Mosquito
Infectious Diseases & Emergency Medicine Washington University School of Medicine No disclosures
October 13, 2016
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Define what is an emerging infectious disease, how they come about, and why they matter in prehospital care. Update providers on current clinical knowledge & approach to Chikungunya and Zika virus infection.
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Zoonoses
SARS coronavirus (civet, bat)
Nipah virus (bat)
Avian influenza (poultry)
2009 H1N1 influenza (pig)
MERS coronavirus (camel)
Ebola virus (bat, monkey)
Vector-borne diseases West Nile virus (mosquito)
Chikungunya virus (mosquito)
Zika virus (mosquito)
(Can also be zoonoses)
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• War • Famine • Poverty & social inequality • Lack of political will
• Climate & weather • Economic development
Intent to harm
Changing ecosystem
Cohen. Nature 2000;406:762.
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2015: U.S. & foreign air carriers transported 196.3 million passengers between the U.S. & the rest of the world
Europe: 56.3 million
C. America: 33.7 million
Asia: 28.8 million
www.transportation.gov
U.S.
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Arbovirus Alphavirus
Single-stranded RNA Vector-borne Swahili/Makonde: “to walk bent over”
Incapacitating arthralgias Can look like dengue
Traditionally a tropical disease
http://phil.cdc.gov/
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Excluding countries/territories w/ only imported cases
As of April 22, 2016 http://www.cdc.gov/chikungunya
• Endemic to parts of W. Africa • 2005-6: Réunion Island • 2007: Italy • 2013: Caribbean (St. Martin)
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2013 – present
http://www.paho.org/chikungunya
Local transmission: • Late 2013:
Caribbean • Early 2014:
Florida, Puerto Rico, U.S. Virgin Islands
• Since 2014: 45 countries/ territories
• >1.7 million suspected cases reported
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2006-2013: 28 cases/yr 2014: 2,799 cases
http://www.cdc.gov/chikungunya
Florida (2014): 11 locally-transmitted cases
2014
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http://www.cdc.gov/chikungunya
2016
93 cases (CONUS), 137 (P.R.) As of October 11, 2016
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• Asian tiger mosquito • Mostly outdoors (garden) • Aggressive biter
• Yellow fever mosquito • Indoors & outdoors • Sneaky biter
http://www.cdc.gov/chikungunya
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Life cycle Infected pts spread virus via travel
Europe: Indian Ocean islands, India, Malaysia N. America: Caribbean, S. America
Competent vectors + seasonal synchrony = local transmission Nosocomial transmission: blood, corneal grafts Vertical transmission (mother-fetus):
Reunion Island epidemic (48.7%)
Curr Opin Virol 2011;1(4):310-7.
Monkeys, rodents, birds, other vertebrates Human (epidemics)
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Incubation period: 2-4 d (range 1-14) Fever Polyarthralgias (2-5 d after onset of fever)
Intense, disabling Often ≥ 10 joint groups Often symmetrical Distal > proximal
Polyarthralgia (96%) %
Ankle 66.2
Knee 60.9
Metacarpophalangeal joints 49.6
Metatarsal joints 41.0
Shoulder 36.4
Elbow 31.7
Wrist 29.1
Sternoclavicular joints 15.0
Hip 7.2
157 pts, Réunion Island (2005-6) Clin Infect Dis 2007;44:1401-7
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Maculopapular rash (50%; ≥3d after onset of fever)
Pruritus, bullous dermatitis (children)
Headache, conjunctivitis, myalgias, N/V Swollen joints (ankle, MTP, wrist, MCP)
Lymphopenia, thrombocytopenia, elevated liver enzymes Symptoms typically resolve within 7-10 d Rarely life-threatening (<0.1%)
Meningoencephalitis Cardiovascular, respiratory, renal failure
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J Am Acad Dermatol 2008;58:308-16.
Lancet Infect Dis 2007;7:319-27.
Lancet Infect Dis 2007;7:319-27.
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Chronic sequelae Polyarthralgias (previously affected joints) Polyarthritis Tenosynovitis
Wrist, hand, ankle Carpal tunnel syndrome
New-onset Raynaud phenomena
Chikungunya: “that which bends up”
Polyarthritis of hands & tenosynovitis of wrists Indian J Dermatol 2010;55(1):54-63.
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Clinical features Chikungunya Dengue Fever (>38.9°C) +++ ++ Myalgias + ++ Arthralgias +++ +/– Headache ++ ++ Rash ++ + Bleeding dyscrasias +/– ++ Shock – +/– Leukopenia ++ +++ Neutropenia + +++ Lymphopenia +++ ++ Thrombocytopenia + +++
Dengue
Clin Infect Dis 2009;49:942-8
Retro-orbital
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Malaria Typhoid fever Rickettsial infection Leptospirosis Other Alphaviruses (e.g., Ross River, O’nyong nyong)
Measles, Rubella, EBV Meningococcemia Seronegative rheumatoid arthritis
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Viral DNA in blood RT-PCR (first 5-8 days)
Antibodies to CHIKV in blood IgM ELISA (D5 → D90) IgG ELISA (D14 → years)
Isolation of virus in culture Testing via local/state health dept, CDC
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Supportive care Rest, fluids, antipyretics NSAIDs, other analgesics
No effective antivirals Ribavirin & interferon-α (in vitro activity against replication)
Infection → long-standing protective immunity
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Fevers, polyarthralgias (distal joints), rash Rarely life-threatening
Unlike dengue! Arthralgias can persist A. aegypticus & albopictus mosquito
CHIKV
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Flavivirus Dengue virus Yellow fever virus West Nile virus
Enveloped Single-stranded, positive-sense RNA Vector-borne
Arthropod (arbovirus) Aedes mosquito
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Isolated in 1947 Rhesus monkey Zika Forest (Uganda)
Confined to Africa & Asia for 60 years
Sporadic cases (14 reported) Seroprevalence
First documented outbreak (2007)
Yap State (Micronesia)
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(2007) Rash, fever, conjunctivitis, arthralgia 185 cases
49 confirmed (RNA, neutralizing antibody response)
59 probable (IgM by ELISA)
No admissions or deaths
Overall attack rate: 14.6 per 1,000 residents
Duffy et al. N Engl J Med 2009;360:2536.
Population (2000): 7,391
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(2007-14)
Yap (2007) Est. 5,400 cases (73% population; >900 illnesses)
French Polynesia (2013-14) Est. 28,000 cases
(11% population)
New Caledonia (2014) 114 cases Easter Island (2014)
>50 confirmed cases
Imported cases: • Asia • Australia • Europe • U.S.
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Brazil May 2015: 1st local case September 2015: microcephaly (northeast areas) Early est. 440,000 – 1,300,000 suspected cases
(2015 – present)
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Mid July 2015
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Late October 2015
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February 2016
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February 1, 2016: WHO: Public Health Emergency of International Concern (PHEIC)
February 3, 2016: CDC: Emergency Operations Center – Level 1
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www.cdc.gov/zika
Travel-associated: 3,712 Locally-acquired: 105
As of 10/5/2016
U.S. territories: Travel-associated: 83 Locally-acquired: 24,118
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Local transmission since mid-July 2016
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Vector: Aedes spp. A. aegypti A. albopictus A. africanus A. hensilli & others
Non-vector: (blood, urine, semen, saliva, CSF, amniotic fluid, breast milk)
Sexual transmission Vertical transmission (intrauterine/intrapartum) Blood transfusion Not yet tied to breastfeeding
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Yap (2007) Macular/papular rash 90% Fever (usually low-grade) 65% Arthritis/arthralgia (hands/feet) 65% Non-purulent conjunctivitis 55% Myalgia 48% Headache 45% Retro-orbital pain 39% Edema 19% Vomiting 10%
Incubation period: 2-14 days after bite Up to 80% cases are asymptomatic Mild, self-limited illness (2-7 days)
Pregnancy not associated w/ ↑risk or severity
Severe disease uncommon
Low case fatality
Duffy et al. N Engl J Med 2009;360:2536.
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Zanluca et al. Mem Inst Oswaldo Cruz 2015;110(4):569.
http://exanthem.dermnetnz.org/viral/zika.html
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Guillain-Barre syndrome (French Polynesia, S. America)
Progressive, mostly symmetric muscle weakness Absent/depressed deep tendon reflexes Mild to complete paralysis (extremity, face, respiratory, bulbar); death (rare)
San Salvador, El Salvador
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Head circumference ≥2 S.D. below mean
Sex, gest. age at birth Highest risk if infected during 1st trimester
Bahia, Brazil: 0.88-13.2% Associated findings:
Brain calcifications Ventricular enlargement Macular & optic nerve lesions
Johansson et al. N Engl J Med 2016;375:1.
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Dengue Chikungunya Malaria Leptospirosis Rickettsia Group A Strep Measles Parvovirus Rubella Other viruses
Clinical feature DENV CHIKV ZIKV Fever ++++ +++ +++
Myalgia/arthralgia +++ ++++ ++
Edema of extremities 0 0 ++
Maculopapular rash ++ ++ +++
Retro-orbital pain ++ + ++
Conjunctivitis + +++
Lymphadenopathy ++ ++ +
Hepatomegaly +++ 0
Leukopenia/ thrombocytopenia
+++ +++ 0
Hemorrhage + 0 0 Ioos et al. Med Mal Infect 2014;44:302.
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ZIKV
Viral DNA in serum/urine RT-PCR (first 3-7 days)
Antibodies to ZIKV IgM Neutralizing antibody titers (≥4-fold higher than DENV titers) Detectable ≥4 days of symptoms
Cross-reactivity w/ other flaviviruses (e.g., DENV, CHIKV, YFV, WNV)
Testing via local/state health dept, CDC https://health.mo.gov/living/healthcondiseases/communicable/zika.php
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Supportive care Rest Fluids Fever/pain control (acetaminophen)
Avoid ASA/NSAIDs until DENV ruled out due to bleeding risk
No antivirals No vaccine After infection → immunity
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Primarily mosquitoes Incubation: 2-14 days Fever, rash, arthralgias
Self-limited Assoc w/ microcephaly Symptoms & travel history should guide testing Guidelines still evolving!
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Approach & Prevention
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Identify: Testing for Chikungunya:
Acute infection Test for Zika:
Acute infection (≥1 symptom) + exposure (travel, sex) within 14 days of symptom onset Asymptomatic pregnant woman + exposure within the past 12 weeks
Isolate?: Not necessary!! Inform: Notify local/state health dept PPE: Standard precautions only
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Avoid travel to areas w/ active transmission Minimize mosquito exposure
Insect repellants (DEET, picardin, ELO/PMD, IR3535)
Sunscreen, then repellent DEET can ↓SPF by 30%
Long sleeves & pants Permethrin-treated
Bed nets Screens, AC – stay indoors
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Protect infected pts from mosquitoes (1-3 wks!) to ↓ local transmission Vector control
Eliminate breeding sites Containers are ideal larval habitats Empty standing water
Larvicides The future
Vaccine???
www.paho.org
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Reduce risk for sexual transmission If exposed, avoid unprotected sex & unintended pregnancy:
Men: minimum 6 months Women: minimum 8 weeks
Pregnant women w/ male partners who have or are at risk for ZIKV infection
Condoms or abstinence for the duration of the pregnancy
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Tale of 2 emerging mosquito-borne illnesses: Chikungunya & Zika Virus
Understand & mitigate exposure: Geography matters – get a brief travel history!
CDC, WHO, ProMED mail Know when & how the disease is transmitted
Hosts, vectors Refer for testing when indicated
Prevention is key!