Transcript SHAMPOOS, Tattoos, BBQues…

SHAMPOOS, Tattoos, BBQues…
what’s new in infectious diseases? 2016
Barb Bancroft, RN, MSN
Chicago, IL 60657
Quiz
• The average person, during a single 24-hour period, deposits in his or her
underwear an amount of fecal bacteria equal to:
a) the weight of a quarter of a peanut
b) the weight of Milk Dud
c) the weight of a chocolate chip cookie
d) the weight of a Oscar Meyer wiener
QUIZ
• If you had to make a choice, which of the following would you lick?
a) the kitchen cutting board
b) the top of your desk at work
c) the top of the toilet seat at home
d) your underwear
QUIZ
• Which stall in the ladies room is contaminated with the most
bacteria?
a) the stall nearest the door
b) the middle stall
c) the stall at the end of the row
• How long does herpes simplex virus live on a toilet seat? 45 minutes
• “Hey Nurse, can I get …”
The 1st most important fundamental aspect of infectious
disease prevention and control…
• Hand sanitizers help in a pinch…make sure they contain at least 6080 percent alcohol; kill germs they come in contact with but they
don’t cut through the layers of dirt that can hide germs
• Use plain ol’ soap and water for certain bugs (it’s not that alcohol
doesn’t work it’s just that soap and water work better)
• Norovirus and Clostridium difficile
Hand washing
• Healthcare professionals (HCPs) clean their hands less than half of the
time they should. They say most health workers performing direct
patient care activities need to wash their hands up to 100 times per
12-hour shift. But many HCP’s say they can’t possibly sing “Happy
Birthday to You” 200 times in a 12-hour shift. (That’s a joke based on
the age-old advice: For clean hands, scrub with soap and water for as
long as it takes to sing “Happy Birthday” TWICE). Not to mention the
fact it would drive any self-respecting HCP up the wall. (Association
for Professionals in Infection Control and Epidemiology's conference
this weekend in Charlotte, NC. June 17-19, 2016)
Hand washing
• Compliance is higher with alcohol-based hand gels — which kill microbes
with a combination of alcohol and friction — perhaps because a squirt of
gel is easier to apply. Is it ok just to “squirt and go”? Finally, a scientific
answer to that question: To kill most bacteria on the hands with alcoholbased hand gels, you need to rub for at least 10 to 30 seconds—30 seconds
being ideal*. After 45 seconds, you’re not doing much more good.
• (*The concentration of bacteria plunges after 10 and 15 seconds of friction,
and then drop slightly more after 30 seconds.)
• (Daniela Pires, June 18 at ASM Microbe Meeting 2016, the American
Society for Microbiology and the Interscience Conference on Antimicrobial
Agents and Chemotherapy)
Hand-washing
• The number of germs on your fingertips doubles after using the toilet
especially on the hand that wipes or holds 
• Should you shake hands with a man who has just exited the men’s
room?
• Gender differences—did you wash your hands?
Transmitting pathogens
• 80% of all infections are transmitted via airborne particles or direct
contact or both—the number ONE contact is via touch
• SHAKING HANDS is no longer acceptable…Handshakes transmit ~ 10
times more bacteria than fist bumps and about two times more than
the high fives. The longest, firmest shakes transmitted the most.
• The fist bump or high-five are the preferred methods of greeting
today
• July 28, 2014 American Journal of Infection Control.
Pathogens can live on inanimate objects for
periods of time
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How long does the flu virus live on a doorknob? 24-48 hours
How long does the cold virus live in a hotel room? 18-24 hours
How long does TB live in sputum? 2 months
How long does MRSA live on a keyboard? 24 hours
Are you a frequent flyer? MRSA can live for 168 hours (7 days) on the seat
pocket of an airline
How long does E.Coli O157:H7 live on a stainless steel countertop? 60 days
How about VRE on the curtain separating the two beds in patient’s rooms?
How far?
• Toilets and spraying toilet water throughout the bathroom— “toilet
aerosolization”…right????
• Putting the top down doesn’t help that much…
• The open space between the toilet top and the seat (12 mm), as well
as the seat and the toilet bowl (15 mm) leaves lots of room to
aerosolize toilet contents
• SARS, Norovirus, flu, C. diff, Hepatitis A and B are all transmitted via
feces
Toilet bowl aerosolization
• How many flushes?
• David Johnson, University of Oklahoma, environmental health
professional: After flushing toilets in a lab setting, Johnson found that
colonic bacteria are still there—potentially launching from the bowl
even after 24 flushes
• How far? Up to 20 feet…
• How far is YOUR toothbrush from the toilet?
The 2nd most important fundamental aspect of preventing
infectious diseases:
• Vaccinations/immunizations
• Vaccinations/Immunizations
• Vaccinations/Immunizations
FYI:
• When the current childhood immunization schedule is followed, it is
estimated that 42,000 deaths and 20 million cases of disease are
prevented annually.
• (CDC. Ten great public health achievements—United States, 2001-2010. MMWR
Morb Mortal Wkly Rep. 2011;60(19):619-623)
• Vaccine use annually derives a net savings of nearly $14 billion in
direct costs and $69 billion in total societal costs in the U.S. annually
To develop immunity you either immunize or
you…
Immunization historical highlights
• Chinese—first inoculations in the 10th century BC against smallpox; snorted scabs
of survivors
• Fast forward to 1796—Dr. Edward Jenner knew that milkmaids who survived
cowpox (“vacca = cow”) were protected against the smallpox
• the name for cowpox was “vaccinia” –hence the origin of the term “vaccine”
• Jenner inoculated an 8-year-old son of his gardener, James Phipps, with cowpox
and 6 weeks later gave him a series of stronger doses of smallpox to see if he was
protected from the disease
• The outcome? Indeed he was protected…
Jenner’s prediction? “Within 10 years…”
It wasn’t until 1977 (180 years later) that smallpox was
completely eradicated (Somalia was the last country to report a
smallpox case)
• The 1960s and early 1970s--the World Health Organization sent out
teams around the world to areas that reported cases of small pox
• Vaccinated the families and communities in the immediate vicinity of
the index case (ring immunity)
• Led to herd immunity in every country
• The last case in the U.S. was 1949
WHO and “Herd” immunity
• WHO and “herd” immunity (the population immunity level needed to
interrupt transmission)
• In other words, if you vaccinate enough people in a community the
virus/pathogen can’t spread
• The herd-immunity threshold for measles is 92-95% to prevent
sustained spread of the virus;
• Currently only 91% of kids in the U.S. are vaccinated against the
measles
Herd Immunity--% of population that needs
to be vaccinated to protect the “herd”
• Measles 92-95% (as mentioned)
• Pertussis 92-94%
• Diphtheria 83-86%
• Rubella 83-86%
• Smallpox 80-86%
• Mumps 75-86%
• Influenza 33-34%
The flu vaccine—herd immunity--vaccinate
kids, protect Gramma and Grandpa
• Immunizing 20% of children in a community is more effective at protecting
the over-65 population than immunizing 90% of the elderly. So why are we
targeting the elderly for vaccines?
• Another study suggests that immunizing 70% percent of school children
may protect an entire community from the flu.
• Children are referred to as “super-spreaders”—in other words, they “shed”
more of the virus for longer periods of time than adults do.
• Hence, keep kids away from grandma and grandpa if they haven’t had their
flu vaccine yet.
• (Ryan KA. Target the Super-Spreaders, Scientific American October 2012)
The continuing belief that vaccines cause autism
simply isn’t true…
• Young Americans who do not remember when childhood illnesses
were rampant are the most likely to be skeptical of vaccines.
• 21% of adults under 30 believe the disproven theory that childhood
vaccinations can cause autism, compared with just 11% of adults
between ages 45 and 64 and 3% of Americans 65 and older (YouGov. The
Week February 13, 2015)
• Madsen KM Et al. A population-based study of measles, mumps, and rubella
vaccination and autism. N Engl J Med 2002 Nov 7;347:1477-82.
• Lancet 2004;364:9438
Vaccines…
• The term “conscientious objector” came from people
objecting to the smallpox vaccine over 200 years ago (since it
came from cowpox they thought they would turn into a
cow…)
• The “antivaxxers” simply won’t even consider statistics when
discussing the benefits of vaccines
If they would, they would hear of HUGE success
stories—H. flu for example
• What are the numbers? 40-100 cases/100,000 of invasive
H. flu meningitis in 1989; vaccine in 1990—
• 1.4 cases/100,000 today (and those cases are in
unvaccinated kids—immigrants or from children whose
parents deny the benefits of vaccines)
• Lumbar punctures in kids—before, during, after…too
many…
Vaccines…
• Kids receive a plethora of vaccines (~23-28) prior to the age
of 2 to prevent a myriad of childhood diseases…
• “But you told me…”
Future perspectives with vaccinations?
Shampoos as vaccines…
And even better, Nano-bandaids for
vaccines!!
More on vaccines…kids AND adults
• Td (tetanus toxoid, reduced diphtheria toxoid) – every 10 years—
WHY? Tetanus (LOCKJAW) antibodies last 19 years, diphtheria, 11
years
• Geriatric activities?
Why do we need a pertussis booster? Tdap
• Vaccine was introduced in the 1940s; average of 175,000 cases per
year; From 1980-1990 there was an average of 2,900 cases per year
• Fast forward to 2012? 48,227 cases with 20 deaths (most under the
age of 3 months; the most cases since 1955; numbers down in 2013,
but pertussis was back with a vengeance in 2014—10,000 cases in
California alone)
Tdap – the vaccine IS SAFE during pregnancy
• Tdap (Td + and acellular pertussis)
• Boostrix (ages 10-18) and Adacel (ages 11 to 64)— one time booster
(over 65 if taking care of infants)
Why? Pertussis in infants is deadly…
• 50% under age 1 w/ pertussis are hospitalized
• 1-2 per 100 hospitalized infants die*
• Infection in infants can manifest as apnea, with or without cough
• *has been misdiagnosed as SIDS
Pertussis
• On the rise since the vaccine was changed from the whole vaccine
(DTwP) to the acellular (DTaP in 1996)—immunity to DTaP doesn’t
seem to be lasting as long as with DTwP); the DTaP wanes after ~5
years (5 doses of DTaP recommended –final dose @4-6; Booster of
DTaP at 11-12 y.o.)
• PLUS…kids not getting vaccinated because of the “fear” of autism and
parental denial of continuing risks of infectious diseases
(Dworkin MS. Pertussis and its comeback—in persons of all ages.
Patient Care 2005 Oct; 43-7)(CDC.gov accessed 9/29/14)N Engl J Med
2015;372(8):765-72.
It’s baaaaack…the Measles (rubeola) has
returned….
• One of the most contagious of the vaccine-preventable diseases,
• The average person with measles is capable of infecting 12 to 18
other people if all his or her contacts are susceptible.
• Who’s susceptible? Kids who are too young to be vaccinated, people
with legitimate contraindications to vaccination (such as severe
immunodeficiency), and/or the few people who remain unprotected
against the disease despite being vaccinated (approximately 6%).
• In 2014 alone, there were at least 48 U.S. importations of measles
from more than 30 countries—most notably, the Philippines, which
was the source of 22 of the 48 importations.
Measles vaccine
• The first live attenuated measles vaccine was released in 1963.
Current vaccines are highly effective—about 94% for a single dose, if
it’s administered in the second year of life. With two doses
administered on or after the first birthday and at least one day apart,
almost all immunocompetent children are protected against measles
for life.
• Greater than 95% protection
In addition to ONE Tdap booster, what other
vaccines do you need as an adult?
• Traveling to certain foreign countries? Hepatitis A vaccine and other
vaccines for specific countries (check the CDC recommendations) at
least 6 weeks before you travel
• Pneumococcal vaccine after age 65 (earlier if no spleen, sickle cell
anemia, CRF, COPD)— actually 2 vaccines now—PCV13 (Prevnar 13
+ Pneumovax (PPSV23)—but not at the same visit
• Zostavax for the prevention of shingles
• Flu vaccine every year
Why should all pregnant women get the flu
vaccine?
• critical period of brain development is the migration of neurons in the
correct direction and the right orientation
• If this is interrupted in any way, the neurons may not “migrate” as
they should or not be placed in the right orientation
• This critical period of development appears to be related to the prenatal origins of schizophrenia; interference with this migration
pattern plays a role in the development of schizophrenia in a
genetically-predisposed individual
• Major risk for schizophrenia? Maternal infections during pregnancy in
a genetically –predisposed individual
Let’s go back to the “shingles” vaccine-Zostavax (2006)
• Zostavax after age 50 to prevent shingles (14x stronger than Varivax—the
kids version for chickenpox)
• With aging population, the absolute # of herpes zoster cases is increasing
dramatically; Why?
• Because the type of immunity that keeps latent herpes in a “latent” state
wanes with aging—this type of immunity is called cell-mediated immunity;
killer T cells are responsible for CMI and their action decreases with age
• Lifetime incidence is 10-20% with greater than 50% of cases in people over
85
• The vaccine is NOT perfect (only 51% protection), but it’s better than
nothing! Vaccines also reduce the risk of post-herpetic neuralgia even if
you get shingles after getting the vaccine (which is a mild case if you do)
• A newer “shingles” vaccine is coming!! 94% effective in clinical trials
FYI: Percent of individuals with shingles, by age
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10—0.5%
20—1.3%
30—2.7%
40—4.8%
50—7.5%
60—11.9%
70—19.7%
80—31.8%
90—46.1%
Donahue JG, et al. Archives of Internal Medicine, 1995.
The flu …avian flu, swine flu, human flu, “stomach flu”
• Understanding the flu virus
• The H and the N designation (two surface glycoproteins known as…)
Understanding the flu virus antigens
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Hemagglutinin—necessary for the virus to attach to respiratory membranes
Neuraminidase—enzyme drills a hole for the virus to penetrate and release
virus from infected cells
H3N2, H1N1, H1N2, H5N1, etc.
The most common strain this year is influenza A strains H3N2—H1N1 viruses
—the vaccine contains both strains + a couple of Influenza B strains—vaccine is
??? % effective (not sure yet)
Oseltamivir (Tamiflu) and zanamivir (Relenza) are neuraminidase inhibitors
(Oseltamivir)—patients less than 2 or older than 65; PG, COPD, CHF; try to start
within 48 hours or up to 5 days for severe or hospitalized patients (Prescriber’s
Letter Feb 2015)
Why do all of the flu viruses come from China? Well, they don’t all
come from China but it’s the ”perfect storm” for mixing viruses
• Migratory water fowl (millions of birds)
• Migratory birds as the natural host for the flu virus
• “Avian flu”
Millions of pigs…
• Add the mixing vat (pigs)
• Pigs as the natural host for the flu virus
• “swine flu”
3 reasons…
• Billions of people in China
• Triple resortment of flu viruses found in pigs with genes from bird,
swine, and human
Antigenic drift vs. antigenic shift
• How does the flu virus change it’s appearance each year?
2014
2015
Antigenic drift
Antigenic shift
Shifts and pandemics
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Only 6 pandemics in 300 years!
But when you hear the word “pandemic”—it’s nasty
H1N1 (Spanish flu—1917-1918)--pandemic
H5N1 (Avian flu virus)—has not yet adapted to replicate easily in humans;
person-to-person transmission is rare
Swine flu (H1N1) – the “oink”
• “Swine flu”—outbreak in Southern California and San Antonio,
Texas (week of April 22, 2009); first case of this outbreak was in a
6-year-old child in Mexico
• Kids with chronic diseases;
• Pregnant moms (more than 4x as likely to be hospitalized)
• Pandemic declared “over” in August 2010
Jamieson DJ et al. H1N1 2009 influenza virus infection during pregnancy in the USA. Lancet 2009
Aug 8; 374-451.
Cardiovascular benefit of the flu vaccine
• Getting the flu shot within the previous year was associated with a 19
percent lower rate of first-time heart attack among people 40 and
over. Vaccination obtained during the early part of flu season,
September through mid-November were more protective than later
inoculations.
• WHY? The flu causes systemic inflammation…inflammation is a trigger
for atherosclerotis plaque rupture (fissuring) and subsequent
thrombosis formation
• Canadian Medical Association Journal, online September 20, 2010.
Fluzone—Higher dose for > 65 patients
• 24.2% more effective than
traditional flu vaccine
• The vaccine may cause “flu-like”
symptoms due to immune
stimulation—headache,
myalgias, fever, malaise for 24
hours
• “Barb, I got the flu from that
damn vaccine…”
• No you didn’t...
So, what do you do when the avian flu “lands” in your back yard?
Don’t panic…
Know the symptoms of bird flu…
• The Center for Disease Control has released a list of the symptoms of
bird flu. If you experience any of the following, please seek medical
treatment immediately:
Bird flu
• 1) High fever
• 2) Congestion
• 3) Nausea
• 4) Fatigue
• 5) Aching in the joints
• 6) An irresistible urge to s#!t on someone’s windshield.
“Can I get paralyzed from the swine flu
vaccine?”
• In 1976? YES…1 extra case of Guillain-Barré syndrome (GBS) /100,000
people who received the swine flu vaccine in 1976
• Today? 0.46 per 1,000,000 vaccines; Only 3000-6000 cases in U.S./
year (300-600 in Canada) regardless of whether or not you received
the flu vaccine
• What is Guillain-Barré syndrome (GBS)? —ascending paralysis is the
usual pattern of GBS, starting with demyelination of the longest
peripheral nerves first; the bulbar presentation is rare, but starts in
CN IX and X (glossopharyngeal & vagus) with swallowing problems
The two major causes of GBS today:
1) ZIKA virus (In Brazil, with the ongoing ZIKA epidemic, the incidence
of Guillain-Barre Syndrome is 7.5 cases per 100,000 cases per year
the usual one to two cases per 100,000 cases per year)
2) Campylobacter jejuni -- found in UNDERCOOKED CHICKEN and
turkey!
• Studies in developed countries have shown antecedent
Campylobacter infections in 20-50% of patients presenting with GBS
• STEP away from the undercooked chicken at the picnic table…(more
later on cooking the chicken to kill the bacteria…)
What vaccines do you need as a pre-teen and
teenager?
• Meningococcal vaccine
• Tdap
• HPV
The newest HPV vaccine is better than ever!!!
• Need to administer 9vHPV w/ Tdap and meningococcal vaccines at age 1112
• HPV-9v (HPV types 6, 11 (warts), 16 (most oncogenic) + 18, 31, 33, 45, 52,
58 (all oncogenic)) (Joura EA, et al. NEJM 2015, Feb.19)
• The 9-valent vaccine (as compared to the old Gardasil-4 (quadrivalent
vaccine targeting only HPV-6, 11, 16, 18) targets an additional 15-20% of
cervical cancers and an additional 5 to 20% of other HPV-related cancers
(>90% of HPV cancers)
HPV-induced Cancer--U.S. Numbers—2015
TOTAL HPV-related cancers—33,200 -- 20,600 (F); 12,600 (M)
• Cervical cancer – 11,422 (3,939 deaths) (~91% HPV-induced)
• Vulvar -- 3,168 (~69% HPV-induced)
• Vaginal – 735 (~75% HPV-induced)
• Penile -- 1,048 (~63% HPV-induced)
• Anal –4,370 per year of which 2,821 (F); 1549 (M) (~91% HPVinduced)
• Oropharyngeal – 12,417 -- 9,974 in males; 2,443 females (~72% HPVinduced)
The HPV vaccine
• Why should I have my daughter get the HPV vaccine? She tells me…
HPV and head and neck cancer
• So, you think oral sex is “less risky” than usual method? People who perform
oral sex on more than five partners in their lifetime have a 250 percent higher risk
of developing throat cancer. Pharyngeal infections with HPV increase the risk of
throat cancer by 32-fold. (N Engl J Med, May 6, 2007)
Oral HPV cancers are rising faster than
cervical…
• It is estimated that by 2020, HPV will cause more oropharyngeal
cancers than cervical cancers in the U.S.
• 90% of men and women under age 30 report having given or received
oral sex
• 1 in 5 ninth-grade girls have provided oral sex (Orenstein P. Girls and Sex:
Navigating the Complicated New Landscape, March 29, 2016)
• Indiana U. Center for Sexual Health Promotion 2010
HPV vaccines
• To get the greatest protection from HPV you need to vaccinate girls
and boys BEFORE they become sexually active—keep repeating
this…to yourself and your patients, to families…
• One reason for the age 11-12 recommendation, but the other reason
is the IMMUNE system responds beautifully to the vaccine at this
age…
What else is going on behind closed doors?
• 40% of women under age 25 have engaged in anal sex;
• 7% of men and women identified themselves as other than
heterosexual;
• 14% said they had experimented with same sex partners
• Indiana U. Center for Sexual Health Promotion 2010
Can Gardasil-9 prevent other cancers caused by
HPV? YES…
• Squamous cell carcinoma of the rectum (MSM {men having sex
with men} + heterosexuals)—the vaccine is FDA approved for
preventing anal HPV infection and cancer
• In MSM, those that are HIV negative are 20 times more likely to
develop anal cancer than the general population. HIV positive MSM
are 40 times more likely.
Parents and PCPs (primary care providers) can
share the blame…
• What parent, even one with an IQ just slightly above room
temperature, wouldn’t want to PREVENT cancer in their children?
• HOWEVER, let’s NOT blame everything on parents…
• A 2014 systematic review showed that a lack of a health care
professional’s recommendation was one of the top 3 reasons
children did not get the HPV vaccine…Say WHAAAAAAAAT???
• (Holman DM, et al. Barriers to human papillomavirus vaccination
among US adolescents: a systematic review of the literature. JAMA
Pediatr. 2014;168(1):76-82.
It’s time to teach PCPs how to approach
parents…
• Presumptive approach (strong recommendation) vs. participatory approach (wimpy
recommendation)
• Presumptive… “We have to do some shots,” rather than
• Participatory ... “What do you want to do about shots?”
• THINK OF RAISING TODDLERS...you don’t ASK them if they want to go to bed!
• Presumptive approach dramatically decreases resistance to vaccine
recommendations. In one study, 83% of parents resisted the participatory approach vs.
only 26% with a presumptive approach, both in vaccine-hesitant parents and in the
overall study population
• Educate your staff about vaccinations and vaccination programs for ALL vaccines—
mandate follow-up procedures; use social media for kids…text, Instagram, emails…
Opal DJ et al. The relationship between pareent attitudes about childhood vaccines survey scores and
future child immunization status and validation study JAMA Pediatr. 2013;167(11):1065-1071.
Emerging pathogens—past 30 years
• What we perceive as new or “emerging” pathogens are generally not
brand new pathogens, but are rather existing pathogens that have
found us through changes in the environment (deforestation, working
in caves, travel, overcrowding, natural disasters, changes in human
ecology (immunosuppression, antibiotics, aging).
Lyme Disease & other tick-borne illnesses -1982
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Tick-borne diseases
Lyme disease (1982) (over 300,000 cases in the U.S. per year)
Rocky Mountain Spotted Fever
Babesiosis
Ehrlichiosis
Anaplasmosis
Tularemia
• Sing-Behl D, La Rosa SP, Tomecki KJ. Tick-borne infections. Dermatol Clin. 2003:21:237-244.
Lyme disease (1982)
• Deer tick—Ixodidae carries the bacteria
• Spirochete—Borrelia burgdorferi
• 24-36 hours for the spirochete to make it’s way from the stomach
of the tick to the salivary gland of the tick and into the host
• erythema chronicum migrans—erythematous oval plaque with a
pale center
• Monoarticular arthritis
• Bell’s palsy—CN VII
• AV block
Lyme Disease
• Occupation? Outdoor exposure? Geographic area? Camping? New
Hampshire (75.9), Maine (66.6), Vermont (61.7), Delaware (55.3),
Massachusetts (51.1), Connecticut (46.0), Pennsylvania (32.5), New
Jersey (30.8), Wisconsin (23.9), Maryland (18.9); Time of year? May
through October
• Treatment? “tickacillin”--doxycycline
Human Immunodeficiency Virus– (named in 1983)
• Worldwide 37 million people are living with AIDS today; 17 million don’t know
they have it; 5500 new cases per day in the world in 2014
• 67% in Sub-Saharan Africa
• 1st documented case—1959 in a sailor from England that traveled to sub-Sahara
Africa
• HIV-1 group M subtype B entered Haiti in 1966 and U.S. in 1969 (young male
prostitute in St. Louis was the first documented case—but not documented until
the mid-80s)
• First big report of HIV patients in U.S.—1981 in Southern California
Wild chimpanzees
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Entered human population by cross- species transmission of virus found in wild
chimpanzees in central Africa somewhere between 1900 and 1930
Eating wild animals (bushmeat), especially chimpanzee meat? Exposure to
blood?
No cities with more than 10,000 people existed in Africa prior to 1910;
Increased populations moving to cities may have facilitated the establishment
and early spread of HIV in Africa after 1910
Influx of workers for harvesting rubber for bicycles, moving workers around
Africa; coincided with a sleeping sickness outbreak; HCWs treated sleeping
sickness patients with reusable needles and syringes—HIV numbers exploded
(Worobey M et al. Direct evidence of extensive diversity of HIV-1 in Kinshasha by 1960. Nature 2008 Oct
2; 455:661)
In today’s world?
• Who’s at risk? MSM, IV drug use, multiple partners, the
absence of barrier protection
• Blood transfusions in North America? Risk is negligible…
• Scandinavian background reduces the risk due to genetic
predisposition to a deletion mutation for the CCR5
receptor needed for the virus to enter the CD4+ cells
• Is AIDS a chronic disease? If a 20-year-old acquires HIV
today (in North America), his life expectancy, with
antiretroviral drugs), is another 46 years
HIV Prevention?
• Mother-to-child transmission—15-45% without retroviral drugs;
reduced to less than 5% with pre-and postnatal retroviral drugs
• Early treatment of babies with HIV infections decreases infant
mortality by 76% and HIV progression by 75%
• Vaginal gel for protection?
• Drugs for prevention in high-risk individuals—PReP (pre-exposure
prophylaxis) – the drug known as Truvada (emtricitabine/tenofovir)—if
taken consistently as prescribed risk reduction is 92%
Helicobacter pylori—1983
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Dr. Barry Marshall and Dr. Robin Warren and the tale of H. pylori
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Fecal - oral transmission; Contaminated water systems; Humans are the only host
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Severe gastritis with ulceration—gastric, duodenal
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OLD TREATMENT: 2 ounces of milk alternating with 2 ounces of Maalox every two
hours
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Pepto Bismol was also popular--and it actually helped
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Triple therapy—omeprazole, amoxicillin, clarithromycin (OAC);--increasing antibiotic
resistance; switching to bismuth-based quadruple therapy—bismuth, metronidazole,
tetracycline, PPI)
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Re-infection can be picked up by breath test or stool antigen test for H. pylori; Or
endoscopy with biopsy
GABHS mutations--1985
• Group A Beta Hemolytic strep, new strains emerged in SLC, Utah in
the mid 80s—M strains types 1, 3, 5, 6, 12, 18, 19, and 24) strep
pharyngitis
• M49 assoc. with PSGN
• Rheumatic Heart disease, necrotizing fasciitis, Streptococcal TSS
Digression: Staphyloccocal TSS--1981
• The tampon wars
• Who won? Proctor and Gamble and RELY
• Super, dooper, dooper absorbent tampons
• 39 deaths; hundreds ill
• You could get it in, but ya’ couldn’t get it out!
Hepatitis C—1989—scope of the problem
• HCV is the most common chronic blood-borne infection and accounts for
almost half of all individuals with chronic liver disease
• Worldwide 180 million cases
• Prior to 1989 it was called non-A, non-B hepatitis
• 3.5 million Americans with HCV; 50% diagnosed;
• HIGH RISK GROUP: The Department of Veterans Affairs has reported that
although 65,000 US veterans have been treated for hepatitis C, some
87,000 are still untreated and 20,000 are undiagnosed
• GOOD NEWS: # of new cases is decreasing
• Why? Decreased blood transfusions and widespread testing of blood
(available since 1992)
Hepatitis C virus
• BAD NEWS: Cirrhosis eventually occurs (5 to 20+ years after acute
infection) in 20-30% of individuals with chronic active HCV infections
• Hepatocellular carcinoma occurs in about 3% of the population
infected with hepatitis C
• Where’s the HCV vaccine? The virus has developed multiple strategies
to evade endogenous antiviral immunity; also has genomic instability
and antigenic variability—a fancy way of saying it’s a moving target
and very difficult to make a vaccine against
• It took 12 years to make the hepatitis B vaccine—and it doesn’t and
hasn’t, changed its appearance since it was discovered in Australia
HCV can be transmitted through:
• Transfusions and organ transplants prior to 1992
• IV drug use
• Intranasal cocaine use
• Sharing personal items with an infected person (e.g. razors, shavers,
and toothbrushes)
• High-risk sexual activity
• Clotting factors prior to 1987
• Occupational exposures
• Using contaminated needles and equipment
HCV can be transmitted through:
• Tattooing (contaminated ink) and body piercing (needles)
• Although there are no KNOWN cases transmitted through tattooing
and piercing, it’s theoretically possible
Updated guidelines (CDC)—testing for HCV
infections
• More than 75% of patients with HCV are baby boomers—born
between 1945 and 1965
• This group accounts for 73% of HCV mortality, and 35% of
undiagnosed “baby boomers” have already progressed to advanced
stages of liver disease
• A one-time test for HCV is recommended without prior ascertainment
of risk
Major game-changer—the new oral drugs for
HCV
• 4-drug combination – Viekira Pak -- 4 tablets per day x 12
weeks…$83,320
• Harvoni (2 drugs combined) – 1 tablet per day x 12 weeks … $94,500
• More are coming out…cheaper (half price--)
• EPCLUSA—treats all 6 genotypes vs. Harvoni (genotype 1,4) and
Viekira Pak (genotype 1)
West Nile Virus…1998-1999
•
•
•
•
•
•
•
•
•
Mosquito-borne illness
Hitching a ride form Africa to NYC (Queens)
Has since spread throughout the U.S.
Most recent big outbreak in Texas, Miss, Louisiana, Oklahoma, Illinois (2012)
“Where the crow flies and dies…” and the blue jays and the red, red robins
3-15 day incubation period; 20% w/flu-like sx
1 in 150 develop encephalitis
Blood transfusions—pooled samples for testing (6 to 16 samples)(23 cases in
2002; 0 cases in 2005; 2 cases in 2006)
(MMWR 2007 Feb 2; 56:76-9)
SARS--2003
• What do we know? Mutation of the corona virus
• SARS, originated in horseshoe bats sold as food in open air markets in
the Guangdong province of southern China; infected person traveled
to Hong Kong and stayed in a hotel
• 2nd outbreak via toilet aerosolization—one patient with severe
diarrhea infected 321 people, killing 40—from his own toilet in an
apartment complex in Hong Kong; faulty plumbing or fan system,
spreading the virus-laced droplets through the air (hand-washing is
worthless against this airborne virus)
• 1700 people, 774 deaths, 25 countries, 40 billion dollars
• Hong Kong tourism slogan
MERS-CoV (Middle East Respiratory
Syndrome)--2012
• Another mutation of the corona virus
• First reported in Saudi Arabia
• Carried by bats and camels—another airborne virus
• Infects the non-ciliated epithelial cells of the lungs (vs. flu and SARS)
• Latest outbreak in South Korea (Summer 2016)
Ebola Viral Disease -- 2014
• First Ebola outbreak in 1976
• Mid-November 2014: 15,000 infected with 5,000 dead
• “Patient zero” for the current Ebola outbreak in West Africa.
Scientists have found that the most likely source (ie, patient zero) of
the current outbreak is a two-year-old boy, Emile Ouamouno, playing
in Guinea (close to Sierra Leone and Liberia)in a tree full of a colony of
the bat species Mops condylurus, a mouse-size bat well-known to be
a carrier of the Ebola virus.
Fast Facts about Ebola Virus
• The virus can incubate for 21 days; it is not airborne; direct exposure to
body fluids (survives for 7 days postmortem) Studies have shown that
Ebola virus can be isolated from semen up to 82 days after symptom
onset
• The usual “flu-like” symptoms (muscle aches and pains, headache, fever),
are followed by vomiting and diarrhea and dehydration; symptoms mimic
many other diseases found in Africa so the early diagnosis is difficult. The
virus can trigger the immune system to “overreact”—releasing a
“cytokine storm” that results in damage to the vascular system resulting
in the leakage of blood and fluids into the tissues. This results in
hypovolemic shock and the hemorrhagic form of the disease.
• The hemorrhagic form of the disease consists in internal and external
hemorrhaging – increasing the risk of spreading the deadly virus to
people who come in close contact with the patient.
• Long term sequelae—ocular (eye pain, blurred vision), hearing loss,
insomnia, arthralgias, memory loss
Zika virus—2015-2016
• The virus was named after the region where it was found — in the Zika
Forest of Uganda — in 1947.
• Brazil experienced a major outbreak of Zika virus starting in May 2015, with
infections estimated in the hundreds of thousands.
• Increased rate of miscarriages and an epidemic of babies with
microcephaly (usually 150 cases per year, but last year over 6000 cases)
• Microcephaly—critical period for head growth is the 2nd trimester; the
virus infects the neuronal stem cells that migrate out to form a normal size
head and brain during the second trimester
• Increased numbers of cases of Guillain-Barré appear to be caused by Zika
• Joint disease—arthrogryposis may be linked to ZIKA as well
ZIKA in the U.S.
• Florida has been hardest hit
• First case of a ZIKA-related death of a baby in Texas this summer—
born with microcephaly (mom had traveled to Latin America during
her pregnancy)
• Currently over 1,000 pregnant women with ZIKA in the U.S.
• the risk of an infected woman giving birth to a child with birth defects
is around 1-15%
7 TRENDS IN INFECTIOUS DISEASES
• Everything global—warming, travel, economics
• Increased number of food-borne illnesses
• Zoonoses—animals to humans--3/4th of emerging diseases are
zoonotic—begin in animals and via a genetic mutation are capable of
jumping the species barrier to humans
• Increased population of immunocompromised patients
• Sexually transmitted infections (STIs) continue to flourish
• Overuse, misuse, and abuse of antibiotics
• Bioterrorism
Global warming and mosquitoes…
•
•
•
•
•
•
Carry at least 35 diseases—West Nile virus, dengue fever, malaria, yellow fever,
ZIKA
With global warming they are moving further away from the equator
Malaria (“mal aria”)—bad air—1,000,000 deaths worldwide per year
*If a patient has traveled to an endemic area for malaria and they present with
a fever of unknown origin, anemia and a big spleen—consider malaria for up to
one year after their trip
Epidemic right now in Venezuela
Increased mosquito populations in U.S. due recession (no spraying) and
foreclosures!
Why do mosquitoes suck?
• What is it about YOU that they like?
• Smelly breath
• Smelly feet
• Dawn and dusk
• Cemeteries
Global travel
• Pathogens can move at the speed of an international flight
• Top U.S. airports for disease transmission (in order)
• JFK, LAX, Honolulu, San Fran, Newark, Chicago, Dulles (Washington
DC), Atlanta
• Even the most remote spots in the world are less than 24 hours away
from cities with millions and millions of people
Let’s continue on airline travel for a moment…
• Air travel is one of the major reasons why we can jet set around the
world so quickly…but it’s also why infectious diseases can jet set
around the world so quickly with us…
• SARS was able to reach 29 countries in seven months (including
Canada) after it reared its ugly head in China/Hong Kong in 2002.
• Ebola from Liberia—1st U.S. case was Thomas Eric Duncan—flying
from Liberia through Belgium to U.S. via Dulles International Airport
• Patient zero brought the measles with him from the Philippines to
Disneyland…
Global travel and traveler's diarrhea…Don’t
drink the water…
• Usually caused by coliform bacteria
• Also salmonella typhi in contaminated water systems
• New Delhi belly
• Montezuma’s revenge
• The Tahitian Two-Step
• The Romanian Rumba
Traveler’s diarrhea
• 30-70% of all international travelers from North America usually
return TO the North America with diarrhea
• Prophylactic antibiotics? Not advised unless patients are
immunocompromised
Don’t drink the water!
• Water in cocktails? Ice in drinks? Ice on the airplane coming home?
(P.S. Don’t ever drink the water from the faucets in airplane
bathrooms)
• Water to plump up vegetables at roadside vendors?
• Splurge for bottled water!
Global economics
•
•
•
•
•
•
1985--Houston Texas ordered 70,000 used tires from southeast ASIA
What were they thinking? They could have just called Little Rock, Arkansas…
The tires were delivered right along with the Asian tiger mosquito (Aedes
Aegypti)
Caused an outbreak of Dengue (breakbone) fever in SE Texas and LA in 1985
The Aedes Aegypti has been found as far north as Peoria IL/New York/New
Jersey
Other issues in global economics brings us to two other emerging trends in
infectious diseases
Food-borne illnesses…
• We want our peaches, raspberries, mangoes, and lettuce year-round
• We get 40% of our produce from other countries…Mexico, Chile,
Guatemala, Costa Rica, Honduras…and most of the countries don’t
have food safety as their first concern (exception, Costa Rica)
• And there’s no tag on the fresh fruit that says…
• But…let’s not blame all of our foodborne illnesses on produce
imported from other countries…
We’re also eating out more often…
• ≥40% of our food dollars are spent outside the home
• So we’re at the mercy of the inexperienced food handler who comes
to work “sick”
• Or the waiter who doesn’t wash his/her hands after using the
restroom
Centralization of food processing plants
• Not too many families today run outside to the back barnyard for
their chicken dinner
• “Factory farms” housing thousands of animals jammed together
• Thousands of baby chickens contaminated with C. jejuni—shrinkwrapped right along with the chicken for the grocery shelf
• Cattle feedlots full of manure, so when it’s time to slaughter, the cows
are covered with feces
• Feces carries E. Coli O157:H7 (STEC)
• When the beef is processed into ground beef, the chances of
contamination rise significantly
Top 5 acquired foodborne pathogens
accounting for 91% of the cases
• Norovirus
• Salmonella (nontyphoidal)
• Clostridium perfringens
• Campylobacter spp
• Staphylococcus aureus
TOTAL
58%
11%
10%
9%
3%
91%
The “vacation of a lifetime”--Norovirus
• Cruise ships (buffets/food handlers), nursing homes (food
handlers), restaurants (food handlers)
• Exposure to a few as 18 norovirus particles can lead to infection,
compared with at least 1000 flu virus particles needed for infection.
• In theory, one batch of vomit contains enough viruses to infect 3
million people.
Noroviruses—clinical signs and symptoms
• Diarrhea + vomiting (shuking)-associated illness—median duration
of S & S = 23 hours; start shedding virus before symptoms occur
and shed virus for 4 days after symptoms subside (hence, the rapid
spread of infection); can shed virus up to 4 to 8 weeks after illness
• Stay home for 3-4 days after the norovirus symptoms subside,
especially if you handle food or work in healthcare. You are still
shedding billions of virus particles in those three to four days and
you can infect co-workers and contaminate food. (Jones D. The
Mark of Noro. New Scientist 2013 March;42-45)
• (Journal of Medical Virology, vol 80, p. 1468)
The “inoculum”
As mentioned, it only takes 18 noroviruses to give you a significant
case of gastroenteritis.
Compare that to:
10,000 to 100 million for Salmonella
100 million for Vibrio cholera
1 billion for Listeria monocytogenes
10-100 for Shigella
10-100 for E. Coli O157:H7
Stay away from salad bars…
• Bioterrorism and salad bars in The Dalles, Oregon
• Salmonella typhimurium and Nurse “Mengele”
• What was her first suggestion?
E. Coli O157:H7 and other shiga-toxin
producing E. Coli
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•
•
•
•
•
Mid-70’s, mutation in Venezuela
Shigella + E. Coli exchanged genes in a cow’s bowel
STEC (shiga-toxin producing E. Coli –other strains, too
Moved up through Central America into Southern Texas in the early ’80’s (1982
first identified)
The leading culprit in 2006 for food-borne illness
Last big outbreak in Germany with contaminated sprouts
Last big outbreak? Bean sprouts from an
organic farm in Northern Germany
• May-July 2011
• 752 Europeans developed kidney failure due to a virulent strain of E.
Coli
• 3,768 people were infected
• 44 deaths
• 30 outbreaks of foodborne illness associated with bean sprouts since
1996
• Children, pregnant moms and the elderly should avoid all raw sprouts
E. Coli O157:H7--10-100 pathogens to make you ill
or kill you—enterohemorrhagic diarrhea
•
Shigatoxin is the 3rd most deadly toxin in the world
•
#1 cause of acute Renal Failure in Kids (and O111 strain in young adults and adults)—
HUS (hemolytic uremic syndrome)
•
73 Jack in the Box restaurants--1993 Seattle-Tacoma (+ 5 other states) deadly
outbreak at the Jack-in-the-Box restaurants--Health inspectors traced the
contamination to the restaurants' "Monster Burger" sandwich which had been on a
special promotion (using the slogan So good it's scary!) and sold at a discounted price
•
far and away the most infamous food poison outbreak in contemporary history."
•
732 people, 171 required hospitalization, 38 with severe kidney disease, 21 required
dialysis, 4 children died
•
Supportive Treatment
E. Coli O157:H7
• COOK your burgers to internal 155° F (68 ° C)
• Hamburgers are pretty safe these days…well, as safe as the
pimply kid talking on his cell phone, flippin’ burgers
How about a hot dog?
•
•
•
•
•
Listeria monocytogenes is the third leading cause of fatal foodborne infection
in North America.
What are the most common sources? Ready-to-eat (RTE) foods are the prime
source; hummus and eating melon at commercial restaurants have also caused
outbreaks
Thrives in an anaerobic environment such as vacuum packs in the deli
department; vacuum packs are used to keep contaminants OUT, but can just as
easily trap a few in…like Listeria
The very young, the very old and the very pregnant—highest risk
2016-- packaged salads produced at the Dole processing facility in Springfield,
Ohio (US and Canada)
Never mind the hot dog, I’ll take the pork…
• Organic pigs vs. antibiotic-treated pigs
• Traces of Salmonella in 39% of pigs raised in the standard
indoor pens and routinely given antibiotics, but in 54% of
the organic pigs raised without drugs (also found
Toxoplasma and Trichinella in organic pigs)
• Foodborne Pathogens and Disease 2008 (5); 199)
Pets and zoonoses
• Diseases from animals to humans
• Can your pet make you sick?
• Cuddly puppies and
Campylobacter jejuni
Toxoplasmosis gondii
• Single celled parasite—contact with cats, cat feces, raw or
undercooked meat (pork, lamb, venison)
• Of all mammals, the parasite can only reproduce in the feline
gastrointestinal tract, so the parasite relies on the cat to eat infected
mice.
• The parasite makes the brains of mice change—not afraid of
cats and CHOMP!
Should you get rid of the cat?
• Don’t kill the cat, just have someone else change the litter box, AND…
• WASH your hands after petting the cat (hand contamination and meat
ingestion are the two biggest offenders in terms of transmission)
• Toxoplasmosis is contracted primarily through eating contaminated
meat in today’s world
Pets and Salmonella
•
•
•
Hamsters, hedgehogs, iguanas, turtles, lizards, and other exotic pets harbor
salmonella as well as other potentially harmful bacteria
Do not consider NON-traditional pets for kids under 5—Salmonella sepsis
Centers for Disease Control and Prevention (CDC). Multistate outbreak of
human Salmonella infections associated with exposure to turtles – United
States, 2007-2008. MMWR Morb Mortal Wkly Rep 2008 Jan 25;57:69
Increased population of immunocompromised
patients…
• Diabetics
• HIV+
• Cancer patients
• Transplant patients
• Patients on corticosteroids
• The elderly
Sexually transmitted infections
•
•
•
•
“Five minutes with Venus gives you a lifetime with Mercury.”
Side effects of mercury—worse than the disease! Drooling, hair loss, and
dementia
Gabriel Fallopius
Causes of syphilis—from doorknobs to horse’s hineys, to the wearing of linen
shirts
Sexually transmitted infections…
•
•
•
•
•
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•
•
HIV
HPV
HSV
HBV
HCV* (less than 5%)
Chlamydia and GC
Syphilis
Trich or Treat?
Contact tracing
Expedited partner therapy
ZIKA…more information
• Up until this point, health officials have advised men to use condoms
or practice abstinence for six months after being infected with Zika
virus, based on the assumption that the longest the virus could be
detected in semen was 93 days after infection. Aug 11, 2016
• BUT WAIT!! ZIKA (found semen for 188 days after the above
report—Eurosurveillance, European CDC, August 16, 2016)
• Can transmit even if not symptomatic with the infection—before,
during and after the mosquito bite
Do condoms protect?
But not the “natural feel” condoms
“You want to do what
with my intestines?
Speaking of condoms…the OLYMPICS
• 2016 Summer Olympics, Rio: “About 450,000 condoms will be
distributed during the Rio de Janeiro Olympics, three times more than
for the London Games four years ago, the International Olympic
Committee says. Part of the reason was because 100,000 female
condoms will be available for the first time, along with 350,000
condoms for men. About 175,000 packets of lubricant are also being
supplied.” —Associated Press, May 21, 2016
• WHOA!! They are certainly Olympians in every way…
• First condoms distributed in 1988, Seoul, Korea #8500
GOLD, SILVER, BRONZE and LATEX!!…from the first
condom distribution to the current Brazil Olympics
• 1988 Seoul Korea 8500
• 1992 Albertville
30,000
• 1992 Barcelona
90,000
• 1994 Lillehammer 40,000
• 1996 Atlanta
15,000 “They were ordered just in case the
athletes happen to be in the mood…” Shirley Jenkins, a nurse at the
Olympic Village
• 1998 Nagano
36,000
• 2000 Sydney
90,000 (originally ordered 70,000, had to order
another 20,000 STAT
Through the years…
• 2008 Beijing
100,000 (Condoms with Olympic Motto—
Faster, Higher, Stronger)
• 2010 Vancouver
100,000
• 2012 London
150,000
• 2014 Sochi, Russia 100,000
• 2016 Rio
450,000 including 100,000 female condoms
Does circumcision protect?
• To circumcise or not to circumcise—that is
•
the question…
• YES
• Decreases prevalence of HPV by 35%, reduced HSV-2
acquisition by 25%, reduced acquisition of HIV by 50 to
60%
•
Golden MR, Wasserheit JN. Prevention of viral sexually transmitted
infections—Foreskin at the forefront. N Engl J Med 2009 March 26;360:13491351.
Baby Boomers Gone Wild!!
• One of the fastest rising group for STIs is the over 65 group
• Incidence of syphilis is up 52%, Chlamydia up 32%; most prevalent in
retirement communities—Arizona reported a 87% rise in STDs from
2005-2009; Central Florida 71% rise, Southern Florida 60% rise…
• WHY?
MORE SEX! the Pfizer Riser (sildenafil/Viagra)…
and friends
•
•
•
•
November 1, 1998
Before 11/1/98
After 11/1/98
Vardenafil/Levitra, tadalafil/Cialis
• Medicare now offers free STD screening for Seniors but only 5% have taken
advantage…
Historical highlight
• According to Emory University economist, Andrew Francis, the sexual
revolution did NOT start as soon as the birth control pill was released
in 1960
• He realized that the sexual revolution started approximately 15 years
earlier prior to the introduction of birth control pills when penicillin
became the treatment of choice for syphilis in the mid-1940s. Up to
then, fear of syphilis was universal, because it was considered a fatal
sexually transmitted disease. Penicillin cut the infection rates by 95
percent, removing the danger of the deadly disease and the back seat
of a ’57 Chevy became a ‘hotseat’ of sexual activity.
Hospital-acquired/Treatment-acquired
infections
• The over-use, misuse, and abuse of antibiotics resulting in antibiotic
resistant bugs and clinical disease
• MRSA—(1962)
• C. difficile
• VRE (vancomycin resistant enterococci)
• CRE (carbepenem resistant enterococci)
Procedure-related infections
• Hepatitis C outbreaks from endoscopies
• CRE (Carbepenam resistant enterbacteria)outbreak at UCLA (2015)
from endoscope for ERCP
• Corneal transplants and Creutzfeldt-Jakob disease
• Pituitary extract and Creutzfeldt-Jakob disease
Estimated risks of TTIs
• Hepatitis A—practically NON-existent
• Hepatitis B – Very low risk—9 cases per 3.7 million donations) (NEJM
2011; Jan 20: 364:236)
• Hepatitis C – 1/2,000,000 today (in 1967 it was 1/3000)
• HIV – 1 / 1,000,000 to 1 / 4,000,000 depending on where the
donations are (in 1985 it was 1/16,000)
• (National Institutes of Health, 2016)
Antibiotic associated diarrhea--Clostridium difficile
(1935)
• Difficult to culture, ie. difficile
• Clostridium difficile infection is the ninth leading cause of
gastrointestinal deaths in the U.S.
• CDI risk 7-10 fold higher during antibiotic Tx and the 1st
month after cessation of treatment; nearly 3-fold higher for
next 2 months
• Greatest risk—2nd and 3rd generation cephalosporins,
quinolones, clindamycin, amoxicillin, ampicillin
•
(Hensgens M, et al. Time interval of increased risk for CDI after exposure to
antibiotics; J antimicrob chemother 2012 Mar; 67:742
Other risk factors
• Increased exposure to CD patients (OR, 13.0)--“fecal cloud”
• All patients with C. diff should be ISOLATED
• High incidence among patients admitted to a room with previous CD
patient
CDI
• Diarrhea*—watery, profuse, nonbloody 10-15x per day; smells like
horse manure;
• Fever and crampy abdominal pain are usually present
• Anorexia, nausea, malaise (no vomiting)
• Lab—WBC (30,000 to 40000 w/ left shift; fecal leukocytes with C.
diff toxin)
• *DO NOT send a well-formed stool to the lab for a C. diff test—the
lab will throw it back at you…
A few more notes on C. diff
• Treatment—metronidazole (Flagyl) for mild to moderate symptoms;
vancomycin for severe symptoms; first reoccurence? Same regimen;
second reoccurence? Vancomycin (oral) use the IV form and make it into
a slurry)
• Mean time for diarrhea to stop? 2-4 days
• Fidaxomicin (Dificid) –narrow spectrum AB for C. diff ($2800 for 10 day
treatment)
• Use plain ol’ soap and water for C. diff (it’s not that alcohol doesn’t work
it’s just that soap and water work better)
• Do probiotics prevent C. diff? No consistent benefit
• Fecal transplants in chronic C. diff—changing the microbiome to a
healthier one
• OpenBiome (MIT or Harvard students as donors)— “Now that’s some
smart…”
Fecal transplants for patients with
C. difficile
• Changing the microbiome with a fecal transplant appears to be the
most efficacious treatment
• 93% cure rate with first transplant
• MIT and Harvard graduate student have a donor bank set up
Methicillin Resistant Staphylococcus Aureus
• Signifies those strains of S aureus resistant to all beta-lactam drugs
(penicillins, cephalosporins, and carbapenems).
• The primary sites of infection are skin/soft tissue (28%), lung (17%),
bloodstream (13%), urinary tract (10%), and surgical site (8%).
The 5 C’s of MRSA
• Crowding (correctional facilities, households, dormitories, livestock
settings),
• Contact (frequent skin-to-skin in hospitals, certain sports such as
football and wrestling and sex, sharing towels in the locker room,
dormitories, veterinary clinics),
• Compromised skin (i.e., cuts or abrasions, surgical wounds),
• Contaminated items and surfaces (hospitals, daycare, schools,
correctional facilities, military barracks), and lack of
• Cleanliness (no, I don’t want to say hospitals—but perhaps
inadvertently sharing towels, correctional facilities).
Could it be bedbugs?
• Bedbugs have been shown to carry MRSA and VRE…small study but
“even tho’ this is a small study, it suggests that bedbugs may be
playing a role in the transmission of MRSA in inner-city populations
where bedbug infestations are a problem.”
• (Mark Romney, Medical Director of Infection Control and Prevention,
St. Paul’s Hospital, Vancouver, BC. Emerging Infectious Diseases, June
2016, online, CDC)
Noses, nose picking, and nasal carriage of MRSA—
20% of population has nasal colonization
• Is it a cause or is it a consequence?
• 53.6% of nose pickers with MRSA vs. 35.5% of non-nose pickers
• Conclusion of the study? Overcoming the habit of nose picking may
aid S. aureus decolonization strategies
• Wertheim HF, et al. Infect Control Hosp Epidemiol. 2006
Aug;27(8):863-7. Epub 2006 Jul 20.
Want to get rid of MRSA? Declare your
hospital a…
Digression? When do most people pick their
nose? In the car!!
During stage 3 – 4 sleep…the dreaded
nocturnal nose-picking reflex...
BIOTERRORISM…
• Have a high index of suspicion if there is “clustering” of a common disease
• Or, if there are a few cases of an uncommon disease
• Bugs most likely to be used: Anthrax, Yersinia pestis (bubonic plague), smallpox,
botulism…HAVE A PLAN!!!
Survey of counties in U.S.--2002
• One county in Iowa had a 3-pronged plan of attack:
1) Call for help
2) Hope someone comes
3) Stack the bodies in the high school gym
THANK YOU …
“Support bacteria—they’re the only culture some people have.”
Anonymous
Barb Bancroft, RN, MSN, PNP
www.barbbancroft.com
[email protected]
Bibliography
•
•
•
•
•
•
Atmar RL et al. Norwalk virus shedding after experimental human infection.
Emerg Infect Dis 2008 Oct: 14:1553
Creech CB, Schaffner W, Talbot TR. Healthcare-associated infections: Your role
in prevention. Patient Care/Hospital Medicine 2007 (June): 15-23.
Centers for Disease Control and Prevention (CDC). Multistate outbreak of
human Salmonella infections associated with exposure to turtles – United
States, 2007-2008. MMWR Morb Mortal Wkly Rep 2008 Jan 25;57:69
Barry CE, Cheung MS. New tactics against tuberculosis. Scientific Medicine,
March 2009;62-69)
D’Souza G et al. Case-control study of human papillomavirus and
oropharyngeal cancer. N Engl J Med 2007 May 10;356:1944-56.
Fox G. HiV and STDs in the elderly: a silent epidemic? Program and abstract
from the National Conference of Gerontological Nurses. 9/2003; CDC. AIDS
among persons over 50 years. http://www.cdc.gov
Bibliography
Joura EA et al. A 9-Valent HPV Vaccine against Infection and
Intraepithelial Neoplasia in Women. New Engl J Med
2015;372(8):711-723)
Delchier JC et al. Use of a combination formulation of bismuth,
metronidazole, and tetracycline with omeprazole as a rescue therapy
for eradication of Helicobacter pylori. Aliment Pharmacol Ther 2014
Jul;40:171.
Bibliography
• Golden MR, Wasserheit JN. Prevention of viral sexually
transmitted infections—Foreskin at the forefront. N Engl J Med
2009 March 26;360:1349-1351
• Kelly CP, LaMont JT. Clostridium difficile—More Difficult than ever.
NEJM 2008;359(18):1932-39.
• Reece M. National Survey of Sexual Health and Behavior, Indiana
University; Center for Sexual Health Promotion
• Surawicz CM. Reining in recurrent Clostridium difficile infection—
Who’s at risk? Gastroenterology 2009 Apr;136:1152.
• Tobian AAR et al. Male circumcision for the prevention of HSV-2
and HPV infections and syphilis. N Engl J Med 2009 Mar 26;
360:1298.
Bibliography
• Liu C, et al. Clinical Practice Guidelines by the Infectious
Diseases Society of America for the Treatment of MethicillinResistant Staphylococcus Aureus Infections in Adults and
Children. Clinical Infectious Disease 2011:52(February 1)
• Yorkgitis BK, Frain V. C. diff infection. Clinician Reviews 2011;
21(12):41-46.
• Warny M et al. Toxin production by an emerging strain of
Clostridium difficile associated with outbreaks of severe
disease in North America and Europe. Lancet 2005 Sep
24;366:1079-84
HIV Bibliography
• Auvert B, et al. Randomized, controlled intervention trial of male circumcision for
reduction of HIV infection risk: the ANRS 1265 Trial. Plos Med 2005; 2(11):e298
• Abdool K et al. Effectiveness and safety of tenovir gel, an antiretroviral
microbicide for the prevention of HIV infection in women. Science 2010;
329:1168-74.
• Bailey RC, et al. Male circumcision for HIV prevention in young men in Kisumu,
Kenya; a randomised controlled trial. Lancet 2007; 369:643-6
• Reduction in perinatal transmission of HIV infection—United States, 1985-2005.
MMWR 2006; 5592-7.
BIB for C. diff
• Dubberke ER et al. Development and validation of a Clostridium
Difficile infection risk prediction model. Infect Control Hosp Epidemiol
2011 Apr;32:360; Shaughnessy MK et al. Evaluation of hospital room
assignment and acquisition of Clostridium Difficile infection. Infect
Control Hosp Epidemiol 2011; 32:201.
• Both studies raise the issue of contamination of the hospital
environment with C. Diff spores as a – if not THE – major risk factor
for nosocomial CDI
HCV bibliography
• Yehia BR et al. HCV statistics. PLoS ONE 2014;9(7):1-7
• Kim WR et al. Am J Transplant 2014:14 (Supplement 1):69-96
• El Serag HD. Gastroenter 2012;142(6):1264-73.
• CDC Hepatitis Statistics. 2014
• Smithe BD et al. MMWR 2012:61(RR-4); USPSTF, Oct. 2013;
http://www.hcvguidelines.org)
• USDHHS.October 2013.
Vaccine schedule
• www.cdc.gov/vaccines/schedules/index.html.)
Fecal Transplants
1) You need a donor -- Any volunteer will do, but generally a close
friend, roommate, boyfriend, girlfriend, sister, brother, father or
mother
2) How much of a donation will do? A mean of 141 +/- 71 grams of
feces is usually infused.
3) The donor stool is screened for common infections before the
infusion. The recipients are typically treated with antibiotics until
24-48 hours before the infusion.
Fecal Microbiotia Transplants
4) The donor stool is homogenized into a “slurry” (fancy way of saying
tossed into a blender and hitting the “high” button). “slurry” is instilled into
the proximal colon through the biopsy port of a colonoscope, or into the
duodenum through a nasoduodenal tube.
5) Post-procedure the patient remains supine for a time and may be treated
with anti-motility agents—no sense in “expelling” the donation before it
has a chance to make itself at home.
6) Patients with chronic C. diff state that they feel better as soon as the
transplant is performed. Hallelujah. (Mattila E et al. Fecal transplantation,
through colonoscopy is effective therapy for recurrent Clostridium difficile
infection. Gastroenterology 2012 Mar;142:49)