Transcript document

Adolescents and Infections: How
Are They Different and Why Are
They At Risk
Lawrence J. D’Angelo, MD, NPH
Professor of Pediatrics, Medicine, Epidemiology, and Prevention
and Community Health
George Washington University
Division Chief, Adolescent and Young Adult Medicine
Children’s National Medical Center
Adolescents and Infections: How are they
different and why are they at risk?
Learning Objectives
1) Understand some of the basic physiologic
differences in adolescents and how these
differences predispose to infections;
2) Understand social and psychological issues that
predispose to infections;
3) Review some of the infections unique to adolescents
4) Understand the preventive measures that can
protect teens.
ADOLESCENT POPULATION
OF THE UNITED STATES 1980 - 2010
YEAR
AGES
10 – 14
AGES
15 -19
TOTAL
% OF TOTAL
POPULATION
1980
18,237
21,158
39,395
17.3
1985
17,102
18,587
35,689
14.8
1990
16,793
16,969
33,762
13.5
1995
18,772
17,470
36,242
13.5
2000
19,518
18,794
38,312
14.3
2005
20,857
21,038
41,913
14.1
2010
19,908
21,668
41,576
13.9
National Adolescent Health Information Center. (2008). Fact Sheet on
Demographics: Adolescents and Young Adults. San Francisco, CA
National Adolescent Health Information Center. (2006). Fact Sheet on Mortality:
Adolescents and Young Adults. San Francisco, CA
Adolescence Is…………….
“a time of storm and stress” (G. Stanley Hall)
“inconsistent and unpredictable” (Anna
Freud)
“an abstraction limited by the boundaries of
the minority group concept” (Eugene Brody)
“the confluence of all the great physical and
psychosocial changes” (A Really Great
Adolescent Medicine specialist)
“the time your tail falls off” (Kermit the Frog)
How Are Adolescents Defined?
Law - “Minors” are < 18 years of age
NIH - 12 to 18 years
NCHS/CDC - 10 to 20 years
AAP - 12 to 21 years
WHO - 10 to 25 years (youth)
Erikson - “Achievement of an identity”
ATN - 12 to 25 years
Unfortunately, Society Perceive
the Health Problems of
Adolescents as:
SEX
DRUGS
ROCK ‘N ROLL
No one thinks about
infections in adolescents,
accept in these contexts
What puts adolescents “at risk”
of inctions and infectious
diseases?
1) Their changing anatomy and
physiology
2) Their changing social milieu
3) Their changing behavior
What specific “anatomic and
physiologic” aspects can increase
infectious risk in adolescents?
•An ever changing and “inexperienced”
immune system
•An Immature genital tract
•An immature skeletal system
•An immature “central nervous system”
Case Presentation #1
14yo F with acute onset of lower and epigastric
abdominal pain
Nausea, 8 episodes of vomiting, occasionally bloodtinged but now bilious
ROSS
+fever 101.6, decreased PO intake, +sore throat,
+headache for the past 24 hours
+menses for last 4 days with cramps
DENIES URI sxs, cough, CP, diarrhea, dysuria or
hematuria, myalgias, arthralgias, rash
DENIES new foods, sexual activity, drug/alcohol use,
recent insect bites
Case #1 - Continued
PMHx: scoliosis
Surg Hx: posterior spinal fusion Oct 07
FHx: non contributory
Allergies: PCN
Meds: none
Social: Lives in New Mexico, here on school trip
Case #1 – Physical Exam
T 39.3
P 132
R 31
BP 69/29
GEN: uncomfortable, wretching
HEENT: NC/AT, PERRL, EOMI, conjunctival injection TMs
intact, MM tacky, erythematous lips
Neck: supple, no LAD
CV: Tachycardic with gallop cadence, II/VI SEM along LSB, cap refill
2 seconds, pulses 2+
Lungs: Clear to Auscultation
Abd: Scaphoid, diffusely tender to palpation, no
rebound, BS+
Skin: “flushed”, diffusely erythematous without petecchiae
Ext:
NL ROM, no swelling, no edema
Neuro: Alert, Oriented, CNs intact, 5/5 strength, NL
sensation, 2+ DTR, NL coordination, NL gait
GU / bimanual: Blood in vaginal vault; + CMT + adnexal tenderness
Case #1 – Laboratory Findings
CBC – Hgb 13.9 gm/dl; Hct 39.7%; WBC 18,900/mm3
Plt CT 83,500
Sed Rate – 67mm/hr
CMP – Na 139; K 4.2; Cl 104; CO2 ; BUN 29; Cr 3.4;
AST 48; ALT119; TBili 0.8; Alk Phos 114; CA 8.9
CPK 6426
Lipase – 67; Amylase 89
Case #1 – Question
What additional “piece of the history” will
you now seek?
A)
B)
C)
D)
Do you have pets?
Have you received the “meningitis shot”?
What type of catamenial (feminine hygiene)
products do you use?
Have you had any tick bites?
Case #1 – My Answer
What additional “piece of the history” will
you now seek?
A)
B)
C)
D)
Do you have pets?
Have you received the “meningitis shot”?
What type of catamenial (feminine
hygiene) products do you use?
Have you had any tick bites?
Staphylococcal Toxic Shock Syndrome: Definition
5/6 Criteria = Probable
*6/6 Criteria = Definite





Fever >38.9C (102 F)
Rash: Diffuse macular erythroderma
**Desquamation – late (1-2 weeks later)
Hypotension - systolic <90 mm Hg adult or <5% for age or orthostasis
Multi-organ system involvement- at least 3 of:
-1. Mucus membrane hyperemia : conjunctival, oropharyngeal or vaginal
-2. Renal: BUN, Cr >2X nl OR >5 WBC/hpf on urinalysis
-3. Hepatic: bili, AST, or ALT >2X nl
-4. Gastrointestinal: vomiting/diarrhea at onset
-5. Hematologic: Platelets <100K
-6. CNS: Disorientation, altered LOC without focal neuro signs in absence of fever, hypotens
7. Muscular: severe myalgia, CPK >2X nl
 Exclusion of other causes:
-Blood, throat, CSF cultures negative
- blood MAY be positive for Staph aureus (only 5% of time)
-Consider RMSF, Leptospirosis, Measles
TSS: Macular Erythroderm
Why Teens and Toxic Shock Syndrome?
Fact: In the 1980 TSS “outbreak”, 36% of the cases occurred
in individuals ages 15-19 years
Reasons? 1) While 95% of adults have antibody to TSST-1,
only 50% of 13 year olds do. (Immature Immune System)
2) The endocervix of most teens ages 12-15 years
is still lined with columnar epithelial cells and these persist in
many adolescents until age 20 years. (Immature Genital
Tract)
3) Young adolescents are less skilled at using
intravaginal catamenial products. (Less “Life Experience”)
4) Relatively lighter menstrual flow means fewer
tampon changes and overnight use is often greater than 8
hours.
Other infections where stage of
adolescent development is a “cofactor”
Infectious Mononucleosis
All STIs and Pelvic Inflammatory Disease (PID)
in particular
Osteomyelitis
Sinusitis
Lemierre’s Syndrome
Case Presentation #2
18 yo college freshman with 12 hours of fever (103.8 F),
sore throat, weakness, neck pain and headache.
Seen in student health center and transferred to your
emergency room
ROSS; Patient noted macular papular eruption shortly
before going to student health center
Hx: No significant history; has a “girlfriend” but denies
sexual activity; no animal contact; no history of tick bite
Case #2 – Physical Exam
T 38.7
P 118
R 31
BP 100/59
GEN: uncomfortable, aggitated
HEENT: Photophobia, PERRL, EOMI, conjunctival injection; TMs
intact, MM tacky, erythematous lips
Neck: Moderately stiff, + Brudzinski, + Kerig
CV: Tachycardic, with no murmurs or gallop
Lungs: Clear to Auscultation
Abd: Scaphoid, non-tender to palpation, BS+
Skin: Red papular lesions on lower extremities with surrounding
petecchiae
Ext:
NL ROM, no swelling, no edema
Neuro: Lethargic, Oriented, CNs intact, 5/5 strength, NL
sensation, 2+ DTR,
Case #2 – Question
Based on the history and findings to date,
what test do you want to do first?
A)
B)
C)
D)
CBC and platelet count
Complete metabolic panel
CT scan
Lumbar Puncture
Case #2 –My Answer
Based on the history and findings to date,
what test do you want to do first?
A)
B)
C)
D)
CBC and platelet count
Complete metabolic panel
CT scan
Lumbar Puncture
Meningococcal Disease1
Meningitis
Fever and headache
(flu-like symptoms)
Stiff neck
Nausea
Altered mental status
Seizures
Occurs in ~30% of
cases;
3% to 10% fatality rate
© The Meningitis Trust. www.meningitis-trust.org.
Meningococcemia
Rash
Vascular damage
Disseminated
intravascular
coagulation
Multi-organ failure
Shock
Death can occur in 24 hours
Occurs in 10% to 30% of cases;
up to 40% fatality rate
Reference: 1. Munford RS. Meningococcal infections. In: Braunwald E, Fauci AS, Kasper DL, et al, eds. Harrison’s
Principles of Internal Medicine. 15th ed. New York, NY: McGraw-Hill Professional Publishing; 2001:927-931.
Meningococcal Disease:
Adolescents and Young Adults at Risk
2
ABCs a
b
NETSS
1.5
1
0.5
a
0
b
29
27
25
23
21
19
17
15
ABCs = Active Bacterial Core
Surveillance System.
13
11
Rate per 100,000
2.5
NETSS = National Electronic
Telecommunications System for
Surveillance.
Age (yrs)
Rate of invasive disease in 17- to 20-year-olds is twice that of US population1
Carriage rates suggest that adolescents, young adults are most common source of
transmission to the community2
Majority of cases are potentially vaccine-preventable3
References: 1. CDC. Meningococcal disease. In: Atkinson W, Wolfe S, Hamborsky J, McIntyre L, eds. Epidemiology
and Prevention of Vaccine-Preventable Diseases. (The Pink Book). 11th ed. Washington DC: Public Health
Foundation; 2009:177-188. 2. Pelton SI. Pediatr Infect Dis J. 2009;28(4):329-332.
3. Harrison LH, et al. JAMA. 2001;286(6):694-699.
Age-Specific Fatalities From Meningococcal Disease, US,
1997–2002
299
Deaths
300
200
156
158
155
106
102
121
100
61
63
67
55-64
65-74
75-84
53
0
<1
1-4
5-14
15-24
25-34
35-44
45-54
Age Group (years)
CDC. National Vital Statistics Reports. 2003;52:30; 2004;53:29.
85+
Rates of Meningococcal Disease in
Young Adults, US, 9/1/98 - 6/30/99
Groups
All 18-23 year olds
# Cases
Population
Rates/100,000
304
22,070,535
1.4
College Students
90
14,897,268
0.6
Undergraduates
87
12,771,228
0.7
Freshmen Students
40
2,285,001
1.9
Dormitory Residents
45
2,085,618
2.3
Freshmen Living in
Dormitories
27
591,587
5.1
Centers for Disease Control and Prevention. Prevention and control of meningococcal disease and Meningococcal disease and
college students: Recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR. 2000;49(RR-7);120.
Updated in: Bruce MG et al [CDC]. Risk Factors for Meningococcal Disease in College Students. JAMA. 2001;286:688-693
Common factors of Adolescent “Social
Milieu” that are “Risk Factors” for
Meningococcal Disease
Risk Factor
Relative Risk
Dormitory living
10.7
Cigarette smoking
7.8
Bar patronage
16.7
Alcohol consumption (>15
drinks*/week)
3.8
*With one drink defined as 2 oz (60 mL) of liquor, 5 oz of wine, or 12 oz of beer
Bruyere HJ, Culver B. Pharm Times. 1998;90; McGee ZA, Baringer R. In: Mandell GL, Douglas RG Jr, Bennett JE, eds. Principles and
Practices of Infectious Diseases. 3rd Edition. New York, NY, Churchill Livingston; Imrey PB, et al.
Am J Epidemiol. 1996;143:624; Imrey PB, et al. J Clin Microbiol. 1995;33:3133
Meningococcal Vaccines
1) Meningococcal capsular polysaccharide vaccine (MPSV4)
2) Meningococcal conjugate vaccines (MCV4) (Menactra and
Menveo)
Preferred vaccine, replacing MPSV4 for most patients
Provides longer lasting immunity than MPSV4
Provides herd immunity by reducing nasopharyngeal carriage
Recent data showed breakthrough cases and titer decreases
Later vaccine may cause quicker response with higher titer
No conclusive data on “boostering” with vaccine not
originally administered as primary
ACIP Recommendations for Use of Meningococcal
Conjugate Vaccine in Adolescents
Adolescents at their 11- to 12-year health-care visit, with a booster dose at 16
years of age1
If primary dose not given until 13-15 years of age, then booster dose at 1618 years of age1
Adolescents 11-18 years of age who were not vaccinated previously2
Previously unvaccinated college freshmen living in dormitories3
Adolescents 11-18 years of age with human immuno-deficiency virus (HIV)
infection1
Two-dose primary series, 2 months apart
Booster doses: same as for other adolescents
Reference: 1. CDC. MMWR. 2011;60(3):72-76. 2. CDC. MMWR. 2007;56(31):794-795. 3. CDC. MMWR.
2005;54(RR-7):1-21.
ACIP: Meningococcal Vaccination of
High-risk Persons 2-55 Years of Age1
Persons with persistent complement component deficiencies
or functional or anatomic asplenia
Primary series: 2 doses, 2 months apart
Booster dose every 5 years (give first booster at earliest
opportunity if a 1-dose primary series was given)
Persons at prolonged increased risk for exposure
Microbiologists working with N meningitidis; travelers to
countries where meningococcal disease is hyperendemic
or epidemic
If first vaccinated at 2-6 years of age, revaccinate after 3
years
If first vaccinated at 7 years of age or older, revaccinate
after 5 years if the person remains at increased risk
Reference: 1. CDC. MMWR. 2011;60(3):72-76.
Other infections where the “Social Milieu”
is a “risk factor” for adolescents
Pertussis
Influenza
Mycoplasma pneumonia
Hepatitis A
Cellulitis, skin eruptions (herpes, MRSA)
Reported Cases of Pertussis Are Highest
Among Adolescents and Adults
1990-19931
1994-19961
1997-20002
2001-20033
2004-20053
2006-20093
Average Cases Per Year
9000
8000
7000
6000
5000
4000
3000
2000
1000
0
<1 yr
1-4 yrs
5-9 yrs
10-19 yrs
20+ yrs
Age Group
References: 1. Güris D, et al. Clin Infect Dis. 1999;28(6):1230-1237. 2. CDC. MMWR. 2002;51(4):73-76.
3. CDC. Pertussis Surveillance Reports, 2001-2009.
Case Presentation #3
17yo F with 3 days of increasing right upper quadrant
pain
Nausea with 2 episodes of vomiting; preceded by lower
abdominal pain 5 days prior
ROSS
Decreased PO intake for past 24 hours; LMP concluded
1 day prior to onset of symptoms
DENIES diarrhea, fatty food intolerance, dysuria or
hematuria
DENIES new foods, drug use, or alcohol use
Case #3 - Continued
PMHx: History of “gonorrhea” 10 months ago, rxed
with “pills”
FHx: no history of gall bladder disease
Allergies: Shellfish, nuts
Meds: Oral Contraceptives
Social: Sexually active (sexual debut age 14), 2
partners in past 6 months, 5 lifetime
Case #3 – Physical Exam
T 36.7
P78
R 14
BP 110/66 BMI 31
GEN: No distress
HEENT: Unremarkable
Neck: Supple; no abnormalities
CV: Normal rate and rhythm with no murmurs or gallop
Lungs: Clear to Auscultation
Abd: Scaphoid, Moderate RUQ tenderness worse with
inspiration, neither liver or spleen palpated; BS+
Pelvic: No ext lesions; moderate white dc from os;
minimal CMT and “1+” adnexal tenderness
Skin: No rashes or lesions
Ext: NL ROM, no swelling, no edema
Neuro: Alert, Oriented
Case #3 – Laboratory Findings
CBC – Hgb 13.9 gm/dl; Hct 39.7%; WBC 6900/mm3
Sed Rate – 67mm/hr
CMP – Na 139; K 4.2; Cl 104; CO2 ; BUN 19; Cr 1.0;
AST 48; ALT119; TBili 0.8; Alk Phos 114; CA 8.9
Lipase – 67; Amylase 89
Wet Prep – pH 5.5, + clue cells, + “wiff” test, moderate
WBCs
Case #3 – Question
The most likely etiology of this illness is:
A)
B)
C)
D)
Gram negative bacteria (Gall Bladder
Disease)
Neisseria Gonorrhoea
Chlamydia trachomatis
Streptococcus pneumoniae
Case #3 – My Answer
The most likely etiology of this illness is:
A) Gram negative bacteria (Gall
Bladder Disease)
B) Neisseria Gonorrhoea
C) Chlamydia trachomatis*
D) Streptococcus pneumoniae
* Causing Fitz-Hugh Curtis Syndrome
Chlamydia—Rates by State, United States and Outlying Areas,
2009
327
309
305
272
303
252
Guam
352
372
375
472
457
369
469
225
405
399
400
346
313
305
386
375
413
478
341
435
420
199
311
438
503
398
595
626
556
411
753
Puerto Rico
185
191
160
297
344
346
276
540
422
1,107
445
478
803
468
VT
NH
MA
RI
CT
NJ
DE
MD
DC
185
Virgin
Islands
444
398
Rate per 100,000
population
<300.0
(n = 10)
300.1–400.0
(n = 21)
>400.0
(n = 23)
NOTE: The total rate of chlamydia for the United States and outlying areas
(Guam, Puerto Rico, and Virgin Islands) was 406.3 per 100,000 population.
Chlamydia—Rates by Age and Sex, United States, 2009
Men
3,800
Rate (per 100,000 population)
3,040
2,280
1,520
760
0
13.8
760
Age 0
10–14
127.9
Women
1,520
15–19
735.5
1,234.0
30–34
286.0
141.3
81.9
511.7
35–39
40–44
205.8
88.4
36.0
45–54
32.0
11.0
55–64
9.1
2.9
219.8
65+
Total
3,800
3,273.9
25–29
573.3
3,040
3,329.3
20–24
1,120.6
2,280
2.1
593.4
Gonorrhea—Rates by State, United States and
Outlying Areas, 2009
34.9
8.3
23.5
29.4
7.2
Guam
33.5
44.1
92.4
42.8
77.2
57.2
50.0
81.4
55.2
154.7
12.5
63.2
54.5
89.4
128.3
139.2
107.2
89.6
109.8
156.2
160.8
120.4
204.0
49.0
26.2 100.3
Puerto Rico
5.8
8.0
8.6
30.4
30.6
73.1
54.8
111.2
113.5
432.7
150.4
127.5
246.4
144.3
87.2
147.0
13.9
66.4
VT
NH
MA
RI
CT
NJ
DE
MD
DC
10.9
185.7
141.3
113.9
Virgin
Islands
104.7
Rate per 100,000
population
<19.0
(n = 8)
19.1–100.0
(n = 24)
>100.0
(n = 22)
NOTE: The total rate of gonorrhea for the United States and outlying areas
(Guam, Puerto Rico, and Virgin Islands) was 97.8 per 100,000 population.
Gonorrhea—Rates by Age and Sex, United States,
2009
Men
750
Rate (per 100,000 population)
600
450
300
150
0
5.0
Age
10–14
0
150
Women
300
568.8
20–24
407.5
555.3
25–29
238.9
229.4
30–34
145.0
60.8
40–44
33.6
11.4
2.7
92.2
106.2
35–39
85.6
47.6
22.9
45–54
8.7
55–64
2.1
65+
0.5
Total
600
25.3
15–19
250.0
450
105.7
750
Percentage of High School Students Who
Ever Had Sexual Intercourse, by Sex* and
Race/Ethnicity,† 2011
*M>F
†B > H > W
National Youth Risk Behavior Survey, 2011
Percentage of High School Students Who
Ever Had Sexual Intercourse, 1991 – 2011†
†
Decreased 1991–2001, no change 2001-2011, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2011
Percentage of High School Students Who
Had Sexual Intercourse for the First Time
Before Age 13 Years, 1991 – 2011*
* Decreased 1991–2005, no change 2005-2011, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2011
Percentage of High School Students Who Had
Sexual Intercourse with Four or More Persons
During Their Life, 1991 – 2011*
* Decreased 1991–2001, no change 2001-2011, p < 0.05.
National Youth Risk Behavior Surveys, 1991–2011
Range and Median Percentage of High School
Students Who Had Sexual Intercourse with Four or
More Persons During Their Life,
Across 38 States and 21 Cities, 2011
State and Local Youth Risk Behavior Surveys, 2011
Percentage of “Currently Sexually Active”
Students who have had 4 or more Sexual
Partners by grade
Grade
9th
10th
11th
12th
% Female
18.0
31.8
41.5
56.7
% Male
22.2
29.4
42.0
48.3
Total
20.1
30.6
41.8
52.6
Percentage of High School Students Who Used a
Condom During Last Sexual Intercourse,* by Sex† and
Race/Ethnicity,§ 2011
* Among the 33.7% of students nationwide who were currently sexually active.
†M>F
§ B>H
National Youth Risk Behavior Survey, 2011
Percentage of High School Students Who
Used a Condom During Last Sexual
Intercourse,* 1991 – 2007
100
Percent
80
60
52.8
54.4
1993
1995
56.8
58.0
57.9
1997
1999
2001
63.0
62.8
61.5
2003
2005
2007
1
46.2
40
20
0
1991
* Among students who had sexual intercourse with at least one person during the 3 months before the survey.
1 Increased 1991-2003, no change 2003-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
Percentage of High School Students Who
Were Ever Taught in School about AIDS or
HIV Infection, 1991 – 2007
100
83.3
86.1
86.3
1993
1995
91.5
90.6
89.0
87.9
87.9
89.5
1997
1999
2001
2003
2005
2007
1
Percent
80
60
40
20
0
1991
1
Increased 1991-1997, decreased 1997-2007, p < .05
National Youth Risk Behavior Surveys, 1991 – 2007
What Are Adolescents’ Risk Factors
for HIV Infection and other STDs?
•Traditional risk factors (Lack of Barrier
Protection, MSM, Injection drugs, Other high
risk sexual practices)
•“Multiple” and “Older” sexual partners
•Non-injection drug use
•Co-existent sexually transmitted disease(s)
•Resident in community with high incidence of
HIV
What Puts Adolescents at Risk of
Infections?
Who they Are (Biology)
“Where they’re At” (Sociology)
What they Do (Psychology)
What Can Health Care Providers Do
to Lower the Risks for Adolescents?
Biologic Risks – Anticipatory guidance;
Education advocacy
Social Milieu Risks – Immunization; Health
advocacy
Behavioral Risks – Endorse family values;
Encourage “connectedness”; Encourage
communication on sexual matters;
Anticipatory guidance; Community advocacy
An Anticipatory Guidance Checklist
For Biologic Risks
Appropriate Tampon Use
Appropriate Barrier Protection for Sexually
Active Teens
Appropriate education about skeletal
development
Anticipatory Guidance for Social
Interaction Risks
Provide Appropriate Immunization
Emphasize the value of Handwashing
Encourage Protective Hygiene
Limit Exposure to High Risk Environments
Anticipatory Guidance for Behavioral
Risks
Encourage teen-parent communication
Emphasize the importance of family and
family values
Encourage barrier protection use
Emphasize the risks of STIs
Encourage HPV immunization