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Sara Podczervinski, RN, MPH, CIC, FAPIC
Washington State Department of Health
Healthcare Associated Infections Program
April 18, 2017
Vancouver, WA
Definitions
Types of emerging infections
Prioritization of pathogens
Transmission
Lots of maps
Some trivia
Resources
THE PLAN
UNKNOWN
CASE IDENTIFICATION
One afternoon in March 1999 during the third month of my infectious diseases fellowship program in a public hospital in Singapore, an emergency room doctor who sounded very alarmed beeped me. He had just seen two consecutive patients with fever and confusion and was admitting a third, all of whom were abattoir workers. One of them needed to be intubated. The same afternoon saw another two workers from the same abattoir with similar symptoms. Later it was learned that a further six abattoir workers had presented to other hospitals the same week, one of whom died after a rapid neurological deterioration. So what was this outbreak of encephalitis involving abattoir workers?
Asok Kurup, MBBS
Singapore
http://journals.lww.com/infectdis/Fulltext/2002/02000/From_Bats_to_Pigs_to_Man__the_Story_of_Nipah_Virus.3.aspx
NIPAH VIRUS
Member of the family Paramyxoviridae.
Initially isolated and identified in 1999
Outbreak of encephalitis and respiratory illness in Malaysia and Singapore.
Over 100 deaths reported
Incubation: 5 to 14 days
Symptoms: Fever, headache, drowsiness, confusion, encephalitis, coma in 24-48 hours, respiratory illness
Mortality Rate: 40%
Treatment: Limited to supportive care
NIPAH VIRUS
NIPAH VIRUS
NIPAH VIRUS
EMERGING PATHOGEN
New to a population
New to a geographical region
Increased Rapidly
RE-EMERGING PATHOGEN
Infectious agents that have been known for some time, had fallen to such low levels that they were no longer considered public health problems & are now showing upward trends in incidence or prevalence worldwide
What Major disease did Europeans catch in the Americas and bring back to Europe
o Smallpox
o Scarlet Fever
o Syphilis
o Malaria
What Major disease did Europeans catch in the Americas and bring back to Europe
o Smallpox
o Scarlet Fever
o Syphilis
o Malaria
BEST GUESS
1. Human transmissibility
2. Severity or case fatality rate
3. Spillover potential
4. Evolutionary potential
5. Available countermeasures
6. Difficulty of detection or control
7. Public health context of the affected area(s)
8. Potential scope of outbreak
9. Potential societal impacts
Emerging Pathogens - Factors
World Health Organization. Workshop on Prioritization of Pathogens, 12/2015.
1. Crimean-Congo haemorrhagic fever
2. Filovirus diseases (i.e. EVD & Marburg)
3. Highly pathogenic emerging Coronaviruses relevant to humans (MERS Co-V & SARS)
4. Lassa Fever
5. Nipah
6. Rift Valley Fever
7. New disease – aka Andromeda Strain
World Health Organization. Workshop on Prioritization of Pathogens, 12/2015.
Emerging Pathogens – Top 7
Emerging pathogens – Know the BasicsInfection Transmission Countries Type Illness
Crimean-Congo
haemorrhagic fever
Ticks, contact with infected
animal blood or tissue
Over 30 countries in
Africa and Eurasia
Flu-like illness,
hemorrhage
Filovirus diseases Direct contact with infected
fluids
Uganda, DR Congo,
Sierra Leone
Hemorrhagic fever
Emerging
Coronaviruses
Airborne and direct contact Saudi Arabia, Iran,
Jordan, Korea
Respiratory illness
Lassa Fever Direct contact and ingestion Nigeria and West Africa Flu-like illness
Rift Valley Fever Mosquitoes, direct contact with
infected animal fluids
Kenya, Somalia, Saudi
Arabia,Yemen
Flu-like illness
Nipah Direct contact with infected
bats, pigs, people
Malaysia, Singapore,
India, Bangladesh
Neurologic illness,
sometimes respiratory
Emerging pathogens –Mechanisms of TransmissionContact/Fomites Droplet Airborne
Ebola Ebola? Variola
Marburg Marburg? XDR-TB
Lassa Nipah SARS?
Other VHF Hendra? MERS?
Variola Influenza
Monkeypox Plague
Monkeypox
Emerging pathogens – Transmissibility
“…The human virus bomb explodes…The victim has “crashed and bled out.”…He becomes dizzy and utterly weak, and his spine goes limp and nerveless and he loses all sense of balance….He leans over, head on his knees, and brings up an incredible quantity of blood from his stomach and spills it onto the floor with a gasping groan. He loses consciousness and pitches forward onto the floor…”
VIRAL HEMORRHAGIC FEVERS (VHF)
• Yellow Fever, Rift Valley, Crimean-Congo
Jaundice
• Hantaviruses, Yellow Fever
Renal Failure
• Dengue, Filoviruses, Lassa
Rash
• New World Arenaviruses, Filoviruses, Yellow Fever, Omsk, KyansanurForest
Encephalopathy
THE LETHAL VHFs – Mortality Rates
Ebola Zaire 65%
Lassa Fever 15-20% of
hospitalized
Marburg
25-90%
Crimean-Congo
3-30%
Rift Valley 50% with
hemorrhagic form
Orthopoxviruses – smallpox and monkeypox
Highly Pathogenic Avian Influenza
Other novel and pathogenic influenza viruses
Pneumonic plague
XDR-TB
Coronaviruses
Severe Acute Respiratory Syndrome (SARS)
Middle East Respiratory Syndrome (MERS)
229E
NL63
OC43
HKU1
SARS
MERS
Causes of Common Cold
First detected 2012
Not seen in humans before
1841 Cases, 652 deaths (35% mortality)
80% Cases from Saudi Arabia
In May 2015 – South Korea 40 cases/4 deaths
Source: National Ebola Training
and Education Center
Risk Factors for Novel influenza or highly pathogenic avian influenza (HPAI)
Pigs harbor human strains
Pigs harbor avian strains
Pigs serve as “mixing vessels”
Antigenic shift occurs in the pig
The fear: A new virus with human affinity and avian mortality
Source: National Ebola Training and Education Center
ANOTHER SUPERBUG EMERGES –This Time it’s a Fungus
Candida auris discovered in 2009 in Japan
1st infection found in the ear (“auris”)
Subsequent have caused bloodstream infections
Mortality ~60%
Median time from admission to infection: 19Days
Source: Centers for Disease Control and Prevention, 2016
Source: Centers for Disease Control and Prevention, 2016
C. auris outbreak in UK hospital
9 C. auris bloodstream infections
>40 people colonized
CLEAR patient to patient transmission
What did the hospital do?
Contact precautions
Screening for colonization
Chlorhexidine bathing
Cleaning room with bleach 3X a day and terminal cleaning with higher concentration bleach
Eventually closed unit
Source: Centers for Disease Control and Prevention, 2016
Is C. auris in the US?
Data from February 2017
Stay up-to-date through ProMED mail
And then this happened!
Nation RL and Jian L, Colistin in the 21st Century, Curr Opin Infect Dis 2010
In November 2015, mcr -1—a gene that can make bacteria resistant
to colistin was reported in China.
Source: https://gis.cdc.gov/grasp/PSA/
Early
Identification
Clear
CommunicationCautionary
Prevention
EMERGING PATHOGENS – themes in response
Awareness Collaborative
Astute
Healthcare
Workers
http://netec.org/
