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8/19/2019 Grand Rounds 041015
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4/8/20
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
..
T
..
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
"T D
' .",
H T S A
..
H P
C D
B
S
8/19/2019 Grand Rounds 041015
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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:
8/19/2019 Grand Rounds 041015
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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,
– NPV PPV • D ,
• D H ,
R T• D (DFA)
– G – F
– H3N2 H1N1 , ( )
• 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
– I P LO
– F PIGS POULTR
• , , )
• M
• A – S >6
• FQ – 249 , ,
– N , ,,
– I (RAD) 65
Q
R T
LQ2013
T: R
• C ?
– T
• T:
–
, ,
–
– 48 .
T
• C A ( B) R ( )
• N – O
• D 21, 2012 FDA 2 • 100,000 – HO : 78%
562 000 2000 122 000 2012.
• C 30%, .US 0.3% .
• H ,
• C
F G A, MD
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C M
F H F, MD
K S
I
C
F H F, MD
D M E
F H F, MD
M R
F H F, MD
E C R
F H F, MD
8/19/2019 Grand Rounds 041015
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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
• S CDC(, )
• V A – 1 2
• P: – C/D/A: M
2 .
– N 4 .
C
P > 3
,
.
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
..
MERSP (PUI)
• A ( >38 100.4)
• AND /ARDS
• AND A P MERS
• AND 14
• AND /
• REPORT
S A?• N ,
• M ,
• H – H ,
I • A
• I , – M , , – I ,
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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)
• A ( ) – , ID
• V : / , , 4872 . P .
• R :