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I D U

M D H, MD, PD

A 10, 2015

O H H

T P • Ebola

• Influenza overview

• Seasonal influenza (former ‘swine flu’, and others)

• H5N1 influenza and H7N9 influenza

• Enterovirus

• Measles

• MERS-coronavirus

• Chikungunya and Dengue

• Bacterial updates

EBOLA

•   F

 –   RNA,

•   I ,

•   N

•   O ,

(, , ,

)

•   G ,

•   E

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T

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A 2 U

• Over 10,000 deaths

• Most in Liberia

• Sierra Leone experienced its fourth consecutive week of decreasing

new cases.

• Liberia reported no new confirmed cases in the week up to March29. Last fatality from case March 27th

• Guinea has seen an increase in the week up to March 29

• Guinea has declared a 45-day state of health emergency in five

prefectures.

 – Conakry (capital) restriction of movement in areas of transmission

 – the temporary closure and quarantine of private facilities where Ebola

cases have been detected, and

 – limitation of burial participation to close relatives only

L

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T• Supportive intensive care

• Treat and test for Malaria

• Personal protective gear

• Dialysis (24 days)

• intubated (12 days on ventilator)

• Sti ll recovering

• Doesn’t remember 3 weeks of stay

• Just spoke at Vanderbilt on April 8th

Treatments on horizon

• Antibody cocktails

• Immune serum

• Fav ip ravi r

• Vaccine trials have started

I

• Orthomixoviridae-RNA virus

• Incubation can be very short (1-4), within 2 days

• Can appear as common cold early, fevers, headache, body aches – Some people can be relative asymptomatic – Resolves after 3-7 days – High fevers, febrile seizures and sepsis like reported in 6% of peds patients

• Infectious 1 day prior, 7 days after becoming sick – Children may shed longer

• Each year 5-20% of individuals in the world infected

• Prior to vaccination, used to kill 250K-500K persons per year – Spanish flu pandemic circa 1918 killed est. 50 million persons worldwide

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P P, 2004.

 (12 S): S827.

A

S

I B

• Does not undergo major shifts

• Consider ‘endemic’ in humans

• Peak is later in the season

• In adults can be sometimes more severethan A

P

•   V > 6

•   S 24 T>100 F 37.8 C  –  C 7

•   I /: P

•   H:

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H5N1

"H5N1 G S"

O . L P D

C

://..//F:H5N1GS.#//

F:H5N1GS.

•   N H5N1 US A

•   >600 2003 –   15 ( ) –   I, V E –   60%

•   C  –   E  –   C A >40 –   S

•   E  –   B, C, E, I, I, V –   S

•    –   M

H5N2

•  C

•   I US H5N2 H5N8

•  N

H7N9

• Winter/Spring 2013-132 human cases confirmed

 – 44 deaths, 27% case fatality rate

Reports restarted in late fall of 2013, ongoing studies, seemingly sporadic, no human to

human spread

1st report outside of China, Malaysia Feb 12, 2014

• 2 Canadian travellers to China (March 2015)

• CDC advises against poultry contact in China including markets

• flu-like symptoms including fever and cough and progressed quickly to

severe pneumonia, acute respiratory distress syndrome (ARDS) and multi-

organ failure

• Consider: Symptoms in recent travel, within 10 days

T

•   D S, ,  –  S

•  K

•   A 23

•   C

 –  A •   T, N,

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•   R  –   S ,

•   RB  –   C H7N2, H5N2, H1N1 (), H5N1

•   H, •   M

•   V

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I H

•   S •   D R

•   C RTPCR :

 –   I N HIGH

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•   M

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•   FQ –  249 , ,

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•   D 21, 2012 FDA 2 •   100,000  –   HO : 78%

562 000 2000 122 000 2012.

•   C 30%, .US 0.3% .

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F G A, MD

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C M

F H F, MD

K S

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F H F, MD

D M E

F H F, MD

M R

F H F, MD

E C R

F H F, MD

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178 : 4 D D 28, 2014

D D 28, 2014

•   O : 49 , 51 , 8 >1 .

(47 ) 87% .

 –   M ,

 –   I ,

•   T

.

•   28 37 (67%)

•  

•   24 1 MMR

 NS . NC 87%

  N   89%

Data from National Immunization Survey 

MMR Immunization Rates

Data from Kindergarten Entrance SurveyErie County Suburban Public Schools 

•  K 2 MMR96% 98%

From Gale Burstein and Mary Walawander

M T/T

•   T IM, IG

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•   V A  –   1 2

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 –  N 4 .

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F G A, MD

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P E P

• Susceptible person should be offered prophylaxis or be

excluded from school or work from 5-21 days after exposure

• MMR can be given up to 3 days after exposure.

• Intramuscular immune globulin (our pharmacy can get this)-

can be given up to 6 days after exposure, especially valuable

for household contacts, immuno-compromised and pregnant

persons.

• Can vaccinated down to 6 months of age in outbreaks

T ? O

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SARS MERS C

•  C

•  SARS

•  MERS

://..///.

•   SARS –   8098  –  774

 –   I US 192 ,  –   T

 –   P 99.8% SARS ()

 –   S (CH )

•   MERS –   O

 –   H  –   A , NEJM 2014

 –   P

 –   L

 –   H ,

 –   2 US (F, I) E

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MERSP (PUI)

•   A ( >38 100.4)

•   AND /ARDS

•   AND A P MERS

•   AND 14

•   AND /

•   REPORT

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•   H  –  H ,

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E• Polio still persists but also Over 100 non-polio enteroviruses

• Outbreak of Enterovirus D68 last year

 – significant respiratory symptoms particularly asthmatics – From mid-August 2014 to January 15, 2015 confirmed a total of 1,153 people in 49

states with respiratory illness caused by EV-D68

• Also, happened to be 90 cases of acute flaccid paralysis (acute flaccidmyelitis) in children in this time

 – 2 of 23 cases in California had CSF + for enterovirus D68

• Enteroviruses can cause acute flaccid paralysis (acute flaccid myelitis)

 – Similar to Polio, West Nile

• Overall, unclear if D68 is the cause of current 90 cases

• We had one case of AFP here, was an enterovirus, but not was not D68

P

..

2013

P

PP: S

• Fevers in recent travelers to Sierra Leone, Liberia, Guinea (21

days afebrile should be clear)

• Respiratory symptoms, travel from Arabian peninsula within 2

weeks- high concern

• H7N9; H5N1 – Very recent travel from SE Asia

 – Poultry contact (person-to-person described)

• Initial negative tests need follow-up if high clinical suspicion-

send backup cultures or PCR (generally to CDC)

• Good handwashing and infection control for suspected cases

 – AIRBORNE if worried about MERS and MEASLES

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D F• Benjamin Rush in 1789 described an

epidemic of a disease he called biliousremitting fever

 – mid-August through September 1780 in

Philadelphia – Delaware River waterfront

 – Later ‘breakbonefever’ due to severe rigors

• 4-7 days after mosquito bite symptoms develop

 – Retro-orbital headache classic

 – muscle/bone pain more typical, lest arthritisalthough general soreness can be confusing

 – Rash

 – 2-7 days of fever

• Capillary leak near end of fever- CRITICAL timeperiod

• Hemoglobin/Hematocrit will rise at this time

• Current Epidemic in Guangdong province,China

• Treatments should avoid aspirin/ibuprofen andfluid overload

C

R

A S

C I

F P

K

S

..

C

• Cases in 44 countries in

Americas, >1.2 million

infections worldwide

• Humans are the primaryamplifying host for

chikungunya virus, and

most infected persons

develop symptomatic

disease

• Mortality is rare and

occurs mostly in older

adults.

..

C

• The most common clinical findings are acute onset of fever andpolyarthralgia.

 – Joint pains are usually bilateral and symmetric

 – can be severe and debilitating

 – Usually recover within a week

 – Polyarthralgia can last months at times• Chikungunya vsDengue

 – Chikungunya-high fever, severe arthralgia, arthritis, rash, and lymphopenia

 – Dengue virus: neutropenia, thrombocytopenia, hemorrhage, shock, and death.

• Laboratory diagnosis:

 – IgG and IgMantibodies

 – Serum PCR

 – Viral culture from serum

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CAP R G 2011

•   2011 PIDS IDSA 3

•   B, /PCN G

•   , ( ) (P 10,000)

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•   R :