Transcript Le papillomavirus humain et le vaccin contre le PVH en 2006

They're back:
Old diseases, new again
François Boucher
MD, FRCPC
The Evolution and Eradication of
Infectious Diseases
T. Aidan Cockburn, a widely respected physician and
anthropologist:
“We can look forward with confidence to a
considerable degree of freedom from infectious
diseases at a time not too far in the future. Indeed .
. . it seems reasonable to anticipate that within some
measurable time . . . all the major infections will
have disappeared.”
Cockburn, T. A. (1963).
The evolution and eradication of infectious diseases.
Baltimore, MD: Johns Hopkins Press.
Infectious disease spread and containment is again a
major public health issue worldwide, due to such
factors as:
•International travel;
•Climate change;
•Drug-resistant pathogens;
•Entirely new diseases;
•…vaccine refusal…
Infectious disease is the No. 2 cause of death
worldwide (after cardiovascular disease), and the
No. 1 cause of death in persons age 50 and under
Objectives
After this presentation, participants will be able to:
• Identify re-emerging infectious diseases and at-risk
populations.
• Diagnose, and report infectious diseases to public
health.
• Communicate with families on the management of
close contacts.
…New again?
• Measles
• Pertussis
• Cellulitis and pneumonia: MRSA
• Invasive GAS infections
• Invasive Hib infections
• Meningococcemia
• Tuberculosis
• …etc
Physician’s role in the control of
contagious diseases
• Complete the appropriate diagnostic procedures
• Manage the patient’s condition
• Ensure proper isolation measures
• Report to Public Health authorities
• Provide immediate contacts with appropriate
prophylaxis if required
• Usually: direct home contacts
Public Health role in the control of
contagious diseases
• Reporting & keeping count…
• Epidemiologic surveillance
• Supporting physician responsible for the patient
• Accurate diagnostic definition
• Outbreak investigation
• Provide necessary preventative measures if
required
Bacterial meningitis
Etiologie de la méningite bactérienne
aigue – USA 1998-2007
Thigpen MC et al. NEJM 2011; 364:2016-25
Hib meningitis & invasive disease:
Clinical presentation
• Meningitis: Also H. influenzae types a, e, f
• Epiglottitis
• Septic arthritis
• Cellulitis (usually involving the face, head or neck)
• Pneumonia
• Osteomyelitis and pericarditis are less common
forms of invasive disease
AAP Red Book 2009
Hib meningitis & invasive disease:
Definition of close contact
• People residing with the index patient
• Nonresidents who spent four or more hours with
the index case for at least five of the seven days
preceding the day of hospital admission of the
index case
AAP Red Book 2009
Hib meningitis & invasive disease:
Management of contacts
• Chemoprophylaxis is recommended for all
household and child care centre contacts in the
following circumstances:
• Household with at least one contact younger
than four years of age who is unimmunized or
incompletely immunized
• Household with an immunocompromized child,
regardless of that child's immunization status.
Manitoba Communicable Disease Control Branch. October 2007
AAP Red Book 2009
Hib meningitis & invasive disease:
Management of contacts
• Chemoprophylaxis is recommended for all
household and child care centre contacts in the
following circumstances:
• Nursery school or child care centre when one
case of Hib invasive disease has occurred, for
incompletely or unimmunized children younger
than four years of age only;
• Nursery school or child care centre, regardless
of age and immunization status, when two or
more cases of Hib invasive disease have
occurred within 60 days
Manitoba Communicable Disease Control Branch. October 2007
AAP Red Book 2009
Hib meningitis & invasive disease:
Management of contacts
• Chemoprophylaxis is also recommended for:
• The case, if younger than 2 years of age or a
member of a household with a susceptible
contact, and who had been treated with a
regimen other than cefotaxime sodium or
ceftriaxone sodium. Chemoprophylaxis usually
is provided just before discharge from hospital
Manitoba Communicable Disease Control Branch. October 2007
BC CDC. September 2005
AAP Red Book 2009
Hib meningitis & invasive disease:
Antibiotic prophylaxis
Rifampin dosage
• Adults: 600 mg orally once daily for four days
• Children: 20 mg/kg (maximum 600 mg) orally
once daily for four days
• Infants younger than one month: 10 mg/kg
orally once daily for four days
• Rifampin should be given to contacts within seven
days after the index patient is hospitalized in order
to be effective in preventing secondary cases
AAP Red Book 2009
Hib meningitis & invasive disease:
Management of contacts
• Chemoprophylaxis of contacts is not routinely
recommended for the other serotypes of H.
influenzae
• Children who have not been appropriately
immunized for age should receive any required
immunizations.
• Post-exposure Hib immunization is not known to
decrease the risk of transmission. Rather, the
situation presents an opportunity for completion of
Hib immunization of contacts.
Manitoba Communicable Disease Control Branch. October 2007
BC CDC. September 2005
AAP Red Book 2009
Hib meningitis & invasive disease:
Management of contacts
• Chemoprophylaxis is not recommended for:
• Household contacts of index cases of invasive
Hib infection when the contacts are completely
immunized against Hib
• Nursery school and child care contacts of one
index case, especially those older than two
years of age.
• Pregnant women as safety has not been
determined.
Manitoba Communicable Disease Control Branch. October 2007
AAP Red Book 2009
Invasive meningococcal disease
Invasive meningococcal disease
Case definition
• Confirmed case
• Invasive disease with laboratory confirmation of
infection:
• isolation of N. meningitidis from a normally
sterile site (blood, CSF, joint, pleural or
pericardial fluid); OR
• demonstration of N. meningitidis DNA by
appropriately validated nucleic acid test
(NAT) from a normally sterile site.
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151.
Invasive meningococcal disease
Case definition
• Probable case
• Invasive disease with purpura fulminans or
petechiae and no other apparent cause:
• with demonstration of N. meningitidis antigen
in theCSF;OR
• in the absence of isolation of N. meningitidis
or demonstration of DNA by appropriately
validated NAT from a normally sterile site.
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151.
Invasive meningococcal disease
Definition of close contact: Group 1
Ongoing exposure…
•Household contacts of a case (the attack rate for
household contacts is 500 to 800 times the rate for
the general population)
•Persons who share sleeping arrangements with the
case
•Persons who have direct contamination of their
nose or mouth with the oral/nasal secretions of a
case (e.g. kissing on themouth, shared cigarettes,
shared drinking bottles)
•Children and staff in child care and nursery school
facilities
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151
AAP Red Book 2009
Invasive meningococcal disease
Definition of close contact: Group 2
• Transient exposure…
• Health care workers (HCWs) who have had
intensive unprotected contact (withoutwearing
amask) with infected patients (e.g. intubating,
resuscitating or closely examining the oropharynx)
• Airline passengers sitting immediately on either
side of the case (but not across the aisle)when the
total time spent aboard the aircraft was at least 8
hours
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151.
Invasive meningococcal disease
Antibiotic prophylaxis
Drug
Dosage
Comments
Ciprofloxacin
Adults ≥ 18 years of age: 500 mg x
single dose PO
Preferred regimen for adults because of demonstrated
safety in this age group, lower cost, single dose and
absence of red discoloration of body fluids.
Contraindicated during pregnancy and lactation. Only
approved for persons > 18 years of age.
Rifampin
Adults: 600 mg PO q 12h x 4 doses
Children ≥ 1 month of age: 10 mg/kg
(maximum 600 mg) per dose PO q 12h
x 4 doses
Infants < 1 month of age:
5 mg/kg per dose PO q 12h x 4 doses
Preferred regimen for children. Contraindicated in
pregnancy. Urine and tears may be stained red. Advise
against wearing soft contact lenses as these can also
be stained. Can reduce effectiveness of oral
contraceptives. Advise use of alternative/additional
contraceptive measures.
Ceftriaxone
Adults and adolescents ≥ 12 years:
250 mg IM x 1 dose
Children < 12 years:
125 mg IM x 1 dose
Recommended drug for pregnant women. Dilute in 1%
lidocaine to reduce pain at injection site.
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151.
Invasive meningococcal disease
Antibiotic prophylaxis
• Chemoprophylaxis should be administered as soon
as possible and preferably within 24 hours of case
identification, but is still recommended for up to 10
days after the last contact with an infectious case
• Close contacts should be alerted to the signs and
symptoms of meningococcal disease and be
advised to seek medical attention immediately
should they develop febrile illness or any other
clinical presentation consistent with IMD
Supplement: Guidelines for the Prevention and Control
of Meningococcal Disease. CCDR 2005;3151.
Invasive meningococcal disease
Immunization of close contacts
• Vaccination is not generally indicated for contacts
of cases of disease in which the serogroup has not
been determined.
• Group 1 contacts: Immunoprophylaxis should be
considered when the case’s serotype is known and
vaccine preventable and the contact has not
previously been immunized against that serotype.
When indicated, immunoprophylaxis should be
carried out as soon as possible after the exposure
• For group 2 contacts: Chemoprophylaxis is
recommended. Immunoprophylaxis is not
recommended as there will not be ongoing
exposure to the case
Manitoba Communicable Disease Control Branch. June 2011
Group A streptococcal
invasive disease
GAS invasive disease:
prevention of secondary cases
• Ontario Group A Streptococcal Study: Attack rate
among household contacts: 2.94 per 1,000
• US Active Bacterial Core Surveillance
(ABCs)/Emerging Infections Program network: 0.66
per 1,000
• Limitations:
• Household contacts and attending physicians
were not asked about use of chemoprophylaxis;
• These attack rates are based on extremely
small numbers of subsequent cases and
therefore may be unstable
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
GAS invasive disease:
prevention of secondary cases
• Approximately 300 close contacts of an invasive
GAS case would need to receive chemoprophylaxis
to prevent one secondary case;
• There would be an average of 10 contacts per
case;
• Retail cost of $30 per person for antibiotics;
• Approximately 3 hours of public health nurse
follow-up time per case, at $50 per hour;
• The cost-effectiveness has been estimated to be
$13,500 CAD in direct health care costs per
secondary case prevented.
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
GAS invasive disease:
prevention of secondary cases
• Chemoprophylaxis is indicated only for contacts at
the highest risk of acquisition of the organism and
of subsequent severe disease
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
GAS invasive disease:
prevention of secondary cases
• Chemoprophylaxis should only be offered
• To close contacts of a confirmed severe case,
that is, a case of STSS, soft-tissue necrosis
(including NF,myositisorgangrene),meningitis,
GAS pneumonia, other life-threatening
conditions or a confirmed case resulting in
death; AND
• If close contacts have been exposed to the case
during the period from 7 days prior to onset of
symptoms in the case to 24 hours after the
case's initiation of antimicrobial therapy
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
GAS invasive disease:
prevention of secondary cases
• Chemoprophylaxis of close contacts should be
administered as soon as possible and preferably
within 24 hours of case identification but is still
recommended for up to 7 days after the last
contact with an infectious case.
• Close contacts of all confirmed cases (i.e.
regardless of whether the case is a severe one)
should be alerted to signs and symptoms of
invasive GAS disease and be advised to seek
medical attention immediately should they develop
febrile illness or any other clinical manifestations of
GAS infection within 30 days of diagnosis in the
index case.
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
GAS invasive disease:
Antibiotic prophylaxis
Drug
Dosage
1st gen cephalosporin
(Keflex, Cefadroxil)
25-50 mg/kg/d, Max 1 g/day in 2 to 4 divided doses ×
10 days
Erythromycin
Children: 5 to 7.5 mg/kg q6h or 10 to 15 mg/kg q12h
(base) × 10 days (not to exceed maximum of adult
dose) Adults: 500 mg q12h (base) × 10 days
Clarithromycin
Children: 15 mg/kg/d in divided q12h, to a maximum of
250 mg po bid × 10 days
Adults: 250 mg po bid × 10 days
Clindamycin
Children: 8 to 16 mg/kg/d divided into 3 or 4 equal
doses × 10 days (not to exceed maximum of adult
dose) Adults: 150 mg q6h × 10 days
Supplement: Guidelines for the Prevention and Control
Of Invasive GAS Disease. CCDR 2006;3252.
Measles – Quebec 2011
Epidemiologic context
• Major outbreaks in Europe
• Many importations (notably from France)
• First cases in January 2011
• Transmissions in daycare centers and health
care settings
• Since April: sustained local transmission
• Since last May: 3 importations (Middle East,
France, Great Britain)
• Worst epidemic in the Americas since 2002
Measles epidemic, France
• Since 2008
• >21 000 cases
• 4 000 hospitalizations
• 10 deaths
• January-July 2011: close to 14 500
cases, of which
• 15 had neurologic
complications
• 639 pulmonary complications
• 6 deceased
Bulletin épidémiologique hebdomadaire de
l’Institut de veille sanitaire du 20 septembre 2011.
Distribution des cas de rougeole selon
la date de début du rash et la région de
résidence, Québec, 2011 (n= 708 cas)
100
Autres RSS
Nombre de cas
80
60
RSS 16
RSS 03
RSS 04
40
20
0
2 9 16 23 30 6 13 20 27 6 13 20 27 3 10 17 24 1er 8 15 22 29 5 12 19 26 3 10 17 24 31 7 14 21 28
jan jan jan jan jan fév fév fév fév marsmarsmarsmars avril avril avril avril mai mai mai mai mai juin juin juin juin juil juil juil juil juil aoû aoû aoû aoû*
Date de début du rash - semaine débutant le
Au total, 709 cas ont été rapportés en date du 31 août 2011 (12h00) dont 1 cas confirmé pour lequel la date de début du rash
n’est pas documentée. Pour la semaine débutant le 28 août 2011, il s’agit des données cumulées jusqu'au 31 août, 12h00.
Source : BSV, DPSP, MSSS au 31 août 2011, 12h00.
Measles outbreak – Québec 2011
To August 31, 2011
• 747 cases (709 confirmed, 38 suspect)
• 10 health regions affected
• Mauricie and Centre-du-Québec (71 %)
• Montérégie (20 %)
• Confirmation
• 254 laboratory-confirmed (36 %)
• 394 epidemiologic link(56 %)
• 61 clinical cases (9 %)
Distribution des cas de rougeole selon
date début du rash et le type
d’acquisition, Québec, 2011 (n= 708 cas)
100
Histoire voyage hors Qc
Nombre de cas
80
Source non documentée
Milieu de soins suspecté
60
Communautaire autres
Milieu scolaire
40
20
0
2 9 16 23 30 6 13 20 27 6 13 20 27 3 10 17 24 1er 8 15 22 29 5 12 19 26 3 10 17 24 31 7 14 21 28
jan jan jan jan jan fév fév fév fév marsmarsmarsmars avr avr avr avr mai mai mai mai mai juin juin juin juin juil juil juil juil juil août aoû aoû aoû*
Date de début du rash - semaine débutant le
Au total, 709 cas ont été rapportés en date du 31 août 2011 (12h00) dont 1 cas confirmé pour lequel la date de début du rash
n’est pas documentée. Pour la semaine débutant le 28 août 2011, il s’agit des données cumulées jusqu'au 31 août, 12h00.
Source : BSV, DPSP, MSSS au 31 août 2011, 12h00.
Transmission
• 2% cases acquired during travel
• 43% school acquisitions
• 21% unknown source
• 18 cases acquired in healthcare settings
• 11.5% hospitalized
Distribution of measles cases according
to age and immunization status,
Québec, 2011
Vaccinés
300
Incomplets pour l'âge
Nombre de cas
250
200
Non vaccinés
1
ère
dose RRO
12 mois
150
2e dose RRO
18 mois
100
50
0
< 1 an
12-17
mois
18-23
mois
2-4 ans
5-9 ans
10-14
ans
15-19
ans
Groupe d'âges
20-29
ans
30-39
ans
40-49
ans
50 ans +
Measles
Prevention of secondary cases
• Define what is a contact…
• …most everyone around the index case…
• Contact during the 4 days prior to 4 days after
rash appeared
• Define who is susceptible
• Depends on age and number of vaccine doses
received – ask for help…
La Rougeole: Protocole d’intervention. Mise à jpour 2003.
Québec, MSSS 2003
Measles
Prevention of secondary cases
• Intervention
• Need help of Public Health & local ID specialist
• Quarantine
• Susceptible contacts should be quarantined in
their home until 21 days after the onset of rash
in the last measles case
La Rougeole: Protocole d’intervention. Mise à jpour 2003.
Québec, MSSS 2003
Measles
Prevention of secondary cases
• Vaccination
• Within 72 hours of exposure in unimmunized
persons
• Once vaccinated, a person may come out of
quarantine immediately
• If immunization status is unknown: vaccination
in an already immune person is not harmful.
La Rougeole: Protocole d’intervention. Mise à jpour 2003.
Québec, MSSS 2003
Measles
Prevention of secondary cases
• Immunoglobulins
• for persons that are immunocompromised,
pregnant, or infants less than 1 year of age.
• IG should be administered within 7 days of
exposure, preferably within 72 hours.
• The recommended dose of IG is 0.25 ml/kg,
with a maximum dose of 15 ml.
La Rougeole: Protocole d’intervention. Mise à jpour 2003.
Québec, MSSS 2003
Control of other communicable
diseases…
• http://www.bccdc.ca/dis-cond/commmanual/CDManualChap1.htm
• http://www.gov.mb.ca/health/publichealth/cdc/pro
tocol/index.html
• http://www.oahpp.ca/resources/index.html
• http://www.inspq.qc.ca/domaines/index.asp?Dom=
60
Merci!
François Boucher
MD, FRCPC