Transcript Zahn SchoolNursePresentationAug2013

Communicable Disease
Update
Matt Zahn, MD
Medical Director
Epidemiology
Orange County Health Care Agency
August 14, 2013
Hepatitis A Outbreak and Townsend
Frozen Berry Blend
• As of August 1, 2013, 158 confirmed cases
• 9 states affected: Arizona (23), California (77),
Colorado (28), Hawaii (8), New Mexico (9),
Nevada (6), Utah (3), and Wisconsin (2), New
Hampshire
• 10 cases in Orange County
• All ill people who reported eating this product
purchased it from Costco markets
• Product was also sold at Harris Teeter stores
– No cases associated with these stores thus far
Epidemiology of Those Ill
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55% are women
Ages range 1 – 84 years;
57% between 40 – 64 years of age.
11 children age 18 ill
– None were previously vaccinated.
• Illness onset dates range from 3/31/2013 –
7/14/2013
• 69 (44%) hospitalized
• No deaths
Hepatitis A in
Children
• 30% of children under 6 are symptomatic
•These children are still infectious!
•Children can be the source of outbreaks
• Older children and adults have symptoms
70% of the time
• Rate of disease low because of
asymptomatic children, but also high
immunization rates
FDA and CDC Investigation
• Vehicle for hepatitis A appears to be a common
shipment of pomegranate seeds from Goknur
Foodstuffs Import Export Trading in Turkey
• Viral genotype is 1B
• FDA will detain shipments of pomegranate seeds
from Goknur
• These pomegranate seeds are used in:
– Townsend Farms brand Organic Antioxidant Blend sold by
Costco stores
– Organic Antioxidant Berry Blend sold by Harris Teeter
– Woodstock Frozen Organic Pomegranate Kernels from
Scenic Food Company
– All products recalled
California Department of Public Health Post
Exposure Prophylaxis Recommendations
• Prophylaxis recommended for exposure within
last two weeks
• Considered for all persons who consumed
product
• Single-antigen Hepatitis A Vaccine is
recommended
People who should receive IG for PEP
The following are at increased risk of severe HAV infection
or may have a decreased immune response to vaccine:
• Persons with chronic liver disease (e.g., cirrhosis)
• Immunocompromised persons, including persons:
– With HIV/AIDS;
– Undergoing hemodialysis;
– Have received solid organ, bone marrow or stem cell
transplants;
– Receive high dose steroids (>2mg/kg/day), chemotherapy, or
immunomodulators and/or biologic medications
• Vaccine may be given in addition to IG to potentially
provide longer-term protection, but vaccine response may
be limited.
HCA Response
• Provide education and advice
• Vaccinate or give immune globulin to persons
who have consumed the product within the last
two weeks
• Environmental Health assured product is pulled
from local stores
• Work with Costco to assure that accurate
message is disseminated
• Follow up on cases, including prophylaxis for
their close contacts
Avian Influenza A (H7N9)
• On March 30, 2013, three patients in China
with fatal cases of rapid, progressive
pneumonia were confirmed to be infected
with influenza A H7N9
• Virus had not been detected in humans or
animals previously
Geographical Location
Confirmed human cases of avian influenza A(H7N9) reported to WHO
Epidemiological Curve of Confirmed Cases
of Avian Influenza A(H7N9) Reported to
WHO, by Day, 2013
N= 122 confirmed cases for whom date of onset is known
Feb
Mar
Apr
Date of Onset
May
Avian Influenza A (H7N9)
As of May 30, 2013:
• WHO reported 132 laboratory-confirmed
cases
• 43 deaths
• Most patients had severe respiratory illness
• Some mild illness in human cases was
seen
Influenza A
Nat Struc & Mol Bio 16, 233 - 234 (2009)
Ppdictionary.com
Antigenic Drift


Point mutations in
HA or NA
Generally results in
relatively small
changes in virus
www.influenzacentre.org
Antigenic Shift
• Reassortment of gene
segments
• Leads to novel and
potentially pandemic
strains
www.influenzacentre.org
Influenza in Avian Populations
• All 16 HA and all 9 NA subtypes of influenza A
virus are detected in wild water birds
• H17N10 is found in bats
• Most infections are mild or asymptomatic in
avian species
• Outbreaks in wild birds and poultry have been
associated with avian influenza H5 subtypes
• Outbreaks in poultry have been associated with
H7 subtypes
Hosts for Influenza A
• Human infections are generally confined to H1, H2,
and H3 subtypes
– These subtypes have affinity for host cell receptors
containing α-2,6-linked sialic acid
• Direct transmission of influenza from domestic
poultry to people found with H5N1, H7N2, H7N3,
H7N7, H9N2, and H10N7 subtypes
• Resulting human infections were generally mild
• H5N1 subtype notably has caused severe disease
Avian Influenza A (H7N9)
Origination
• Virus arose from multiple
reassortment events
• Four or more influenza A viruses
appear to have contributed
genetically
• H7 gene is genetically close to
sequences isolated from ducks in
Zhejiang province
• N9 gene is similar to genes from
H7N9 viruses found in wild ducks
in South Korea
• The six internal genes are similar
to H9N2 viruses isolated from
poultry and ducks in China
www.thelancet.com Vol 381 June 1, 2013
H7N9 Characteristics of 111
Patients
Characteristic
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Median age, years
≥65 yo
≤14 yo
Male
Preexisting Condition
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Hypertension
Diabetes
Immunosuppression
Pregnancy
• Exp. poultry prev. 14 days
Number (%)
61(3-88)
47(42.3)
2 (1.8)
92 (65)
68 (61)
51 (45.9)
18 (16.2)
10 (9.0)
2 (1.8)
62 (55.9)
n engl j med 368;24 nejm.org june 13, 2013
H7N9 Symptoms
Characteristic
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Fever
Maximal temperature
Fatigue
Conjunctivitis
Cough
Sputum production
Hemoptysis
Shortness of breath
Diarrhea or vomiting
No. (%)
111 (100.0)
°C 39.2±0.8
40 (36.0)
0 (0)
100 (90)
62 (55.9)
27 (24.3)
62 (55.9)
15 (13.5)
n engl j med 368;24 nejm.org june 13, 2013
H7N9 Complications
Complication
No. (%)
• Pneumonia
• Acute respiratory distress
syndrome
• Shock
• Acute kidney injury
• Rhabdomyolysis
108 (97.3)
79 (71.2)
29 (26.1)
18 (16.2)
11 (9.9)
n engl j med 368;24 nejm.org june 13, 2013
Outcome of H7N9 Infection
• 109 of 111 hospitalized
• Antivirals initiated in 108 patients
– Median of 7 days after the onset of illness
• 30 (27.0%) died, most from refractory
hypoxemia
n engl j med 368;24 nejm.org june 13, 2013
H7N9 and Mild Disease
• Serology survey of 20,000 Chinese persons
with influenza symptoms found only 6 cases of
H7N9
• Survey of over 3000 contacts of cases found no
evidence of disease
• Mild disease seems to be unusual
• Minimal human-to-human transmission seems
to have occurred
• No sustained human-to-human transmission
has occurred
EID Volume 19, Number 8—August 2013
Influenza A H7N9 Testing Criteria:
Clinical Illness Criteria
• Patients with new-onset severe acute respiratory infection requiring hospitalization
AND
• Patients for whom no alternative infectious etiology is identified
Exposure Criteria
• Recent travel (within ≤ 10 days of illness onset) to a country where human cases
of H7N9 have been detected
OR
• Recent close contact (within ≤ 10 days of illness onset) with a confirmed case of
human infection with H7N9 virus
Avian Influenza A (H7N9) Testing
• PCR is test of choice for influenza viruses,
including avian influenza A (H7N9)
• With H7N9, initial PCR testing will indicate:
– Positive for influenza A
– Negative for H1pdm09
– Negative for H3
– Follow up testing for H7N9 will occur at that point
• OCHCA can facilitate this testing
Antiviral Treatment Recommendations for
Influenza A and B
• Oseltamivir is recommended for treatment of
persons of any age
• Zanamivir is recommended for children aged 7 and
older
• Recommended duration of treatment for
uncomplicated illness is 5 days
• Longer courses of treatment should be considered
for severely ill hospitalized H7N9 patients
• Optimally treatment begun as soon as possible
and within 48 hours of illness starting
• In severe disease, starting antivirals after 48 hours
has still been associated with improved survival
H7N9 and Avian Populations
• H7N9 strain was detected from:
– Chickens
– Ducks
– Pigeons
– Live bird markets
• Initial human cases found in Zhejiang, China
when migratory birds were moving north and
transiting at the Yangtze River Delta
• No increase in poultry deaths occurred
Chinese Health Authority Response
• Aggressive follow up on contacts of cases
– Over 3000 contacts followed for symptoms
– No additional cases found
• Closing of bird markets
AAP
Avian Migratory Patterns
Avian Influenza A (H7N9)
• H7N9 infection does not lead to significant
illness in birds
– In contrast to H5N1
• Identification and control of viral spread in
avian populations will be difficult
• Recurrence of H7N9 in avian populations
is anticipated
Influenza A H3N2v
• First identified in 2010
• 12 cases identified in Indiana in 2013
– All with close contact to pigs in fair settings
• Limited human-to-human spread of this virus has
been detected
• No sustained or community spread of H3N2v has
been identified
• Sporadic infections and even localized outbreaks
among people with this virus may continue to occur
Influenza Vaccine
• Recommended each year for all persons 6
months of age and older
• Influenza vaccine for upcoming season will
contain:
– A/California/7/2009 (H1N1)pdm09-like virus
– A(H3N2) virus like A/Victoria/361/2011b
– B/Massachusetts/2/2012-like virus
– And for quadrivalent vaccine:
B/Brisbane/60/2008-like virus
Influenza A H7N9 Vaccine
• Development of influenza A H7N9 vaccine has
begun
• Potential candidate vaccine viruses have been
identified
• H7-derived candidate strains have historically
been slow-growing
• Non-egg based vaccines may provide
opportunity for quicker development of vaccine
– Recombinant DNA vaccine
– Cell culture based vaccine
Middle Eastern Respiratory Syndrome
Coronavirus
Coronaviruses and Human Disease
Five human respiratory coronaviruses have
been described:
• Causers of colds
and URIs
– 229E
– OC43
– NL63
• Causers of
Pneumonia:
– HKU1
– SARS
On September 23, 2012, WHO Announces:
The first laboratory-confirmed case of
MERS-CoV: a 60-year-old man from Bisha,
the Kingdom of Saudi Arabia, who died of
rapidly progressive community-acquired
pneumonia and acute renal failure
MERS-CoV from September, 2012Present
MERS CoV Clusters
• Multiple clusters of human cases have
occurred
– Healthcare associated events
– Family clusters
• Human to human transmission has
occurred, though no sustained community
transmission
MERS-CoV Hospital Outbreak, Saudi
Arabia
Case
Health Care Worker
Family Member
Community
Ward 1, Hospital A
Ward 2, Hospital A
Dialysis, Hospital A
ICU, Hospital A
Ward, Hospital B
Dialysis, Hospital C
ICU, Hospital D
Ward, Hospital D
NEJMoa1306742
4/8
4/15
4/22
4/29
5/6
5/13
MERS-CoV Clusters
NEJMoa1306742
Review of 47 Patients with MERS-CoV
• Cases of laboratory-confirmed MERS-CoV
reported from Saudi Arabia between Sept 1,
2012, and June 15, 2013
• 46 adults, one child
• 36 (77%) male
• 28 (60%) died
• Case-fatality rate rose with increasing age
• Two of the 47 cases were previously healthy
TheLancet.com Published Online 7/26/13
45 (46%) had underlying comorbid medical disorders
No. (%)
• Diabetes
• Hypertension
• Chronic cardiac
disease
• Chronic renal
disease
32 [68%]
16 [34%]
13 [28%]
23 [49%]
TheLancet.com Published Online 7/26/13
MERS-CoV Clinical Presentation
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Fever
Cough
Shortness of breath
Myalgia
Diarrhea
Vomiting
Abdominal pain
46 [98%]
39 [83%]
34 [72%]
15 [32%]
12 [26%]
10 [21%]
8 [17%]
TheLancet.com Published Online 7/26/13
MERS-CoV Disease Spectrum
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Multiple reports of mild disease
Initial symptoms may not be respiratory
GI illness can be prominent
Broader serologic analysis is ongoing
SARS-CoV and its Spread
• Fast spread of SARS occurred early in the
outbreak
• SARS often spread between healthcare workers
and their patients
• Mainly direct or short-range transmission
• ‘Superspreaders’ existed who generated a far
greater than average number of secondary cases
• Reasons for this are still not known for certain,
likely a combination of host and viral factors
Coronaviruses infect and cause disease in many animal species:
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Bats
Mice
Birds
Dogs
Pigs
Cattle
– Viruses tend to be specific for individual
species, but mutation occurs
Sources of Coronavirus
• SARS-CoV thought to have
originated in the Himalayan palm
civet found in south China
• MERS-CoV source still uncertain
– South African bat Neoromicia cf.
zuluensis derived CoV is closest
phylogenetically to date
– Intermediate host is considered
possible
• First cases of MERS-CoV
associated with camels, sheep,
goats exposure
MERS CoV Infectivity
• Human-to-human transmissibility of MERS
CoV appears to be low
• Sustained community transmission has not
been seen
• Close monitoring of health-care workers
and household contacts has not revealed
large numbers of secondary infections
MERS-CoV Epidemiology
• Infectious Period
– Not clearly established
– Likely to extend from the onset of fever until 10
days after fever resolves
• Incubation Period
– Available data suggest that symptoms have
occurred up to 14 days after last exposure.
MERS-CoV Clinical Case Definition
• A person with an acute respiratory infection,
which may include fever (≥ 38°C , 100.4°F)
and cough; AND
• Suspicion of pulmonary parenchymal disease;
AND
• History of travel from the Arabian Peninsula or
neighboring countries within 14 days; AND
• Not already explained by any other infection
or etiology
MERS-CoV Specimen Collection and Testing
PCR testing should be performed with samples from:
• Lower respiratory tract specimens:
• Broncheoalveolar lavage, tracheal aspirate, pleural
fluid and/or sputum
– Typically have highest yield
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Upper respiratory tract specimens
Nasopharyngeal and oropharyngeal swabs
Serum
Stool
OCHCA can arrange testing
tp://www.cdc.gov/coronavirus/mers/downloads/Interim-Guidelines-MERS-Collection-Processing-
MERS CoV Treatment
• Minimal evidence to indicate antiviral or
adjunctive therapy
• Supportive care
• Mechanical ventilation
• Some studies have shown that interferon
may have beneficial effects in the
treatment of SARS
Avian Influenza A H7N9 and
MERS CoV Infection Control
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Hand hygiene
Gown
Gloves
Respiratory protection at least as
protective as N95 respirator
• Eye protection
Current Status
• No cases of MERS-CoV or Influenza A H7N9
have been identified in the United States to date
• CDC advises travelers to China to take some
common sense precautions, like not touching
birds or other animals and washing hands often.
Poultry and poultry products should be fully
cooked.
• WHO advised that persons with chronic medical
conditions and want to go on Hajj pilgrimage
should discuss the risks with their healthcare
provider
Pertussis May be Returning…
• Increase in reports in Northern California
• Disease seems to be cycling every three to five
years
Thank you!
714-834-8180