Transcript Survival of the Species - Northeast Iowa Family Practice Center

Emerging Diseases:
Iowa and the World
Patricia Quinlisk, MD, MPH, D.Sc.(Hon)
Medical Director/State Epidemiologist
Iowa Department of Public Health
Good News from Public Health
• Rubella eradicated from the Americas (last
large outbreak in Iowa in 1999)
• Highly pathogenic avian influenza H5
infections have been reported in Iowa
poultry - BUT NOT IN HUMANS.
• Most Iowa schools have vaccinated
children rates of over 95%, and almost all
are over 90%
• But still need work on………
Ebola
(emerging)
Chikungunya
(emerging)
Chikungunya
• Mosquito borne
– illness starts 3-7 days after mosquito
bite
• 72%–97% have symptoms when infected
– Fever, joint pain (often multiple joints
in hands and feet), headache, muscle
pain, rash, conjunctivitis, nausea and
vomiting
• Fatality rare, but can occur in older
adults.
• No specific treatment, supportive care.
Chikungunya Epidemiology
Chikungunya Epidemiology
Measles
(re-emerging)
History of Measles
• First description in the 9th century
• First reportable in the US in 1912, and 6,000 measles
related deaths were reported in the first decade.
• 1963 first vaccine licensed for use in the US, improved
vaccine developed in 1968
• In 1978 goal to eliminate measles from US by 1982
• 1989 ACIP recommends 2 doses of MMR
• In Iowa, one dose required for school 1977, two in
1991
• Measles declared eliminated from U.S. in 2000
• Since then measles imported into U.S. from other
countries – many from Europe
• The cases / year range from a low of 37 people in 2004
to a high of 644 people in 2014
Reported Cases of Measles in Iowa:
Selected Years
•
•
•
•
•
•
•
•
•
1935
1958
1965
1971
1986
2004
2009
2011
2015
- 21,432
- 12,732
- 5,618
- 2,717
- 134
3
1
1
0 (so far!)
Immunity Assumptions
• Persons who started school in Iowa after 1991
(who received required vaccines) have received 2
MMR vaccines
• Persons who started school in Iowa between 1977
and 1991 (who received required vaccines)have
received one dose of measles vaccine
• Persons born before 1957 probably had measles
disease and are immune
• Persons born after 1957 but before 1972 (started
school before 1977) may be susceptible to
measles
Why the resurgence in the US?
Measles in 2015
As of April 17, 2015
• 162 cases in US in 2015
• 19 states: AZ (7), CA (103),
CO (1), DC (2), DE (1), FL
(1), GA (1), IL (15), MI (1),
MN (1), NE (2), NJ (1), NY
(3), NV (9), OK (1), PA (1),
SD (2) TX (1), UT (2), WA
(7). None in Iowa.
• 147 cases trace back to
Disneyland Parks & Resorts
Measles Virus Transmission
• One of most contagious of all infectious
diseases
• Infectious Period: 4 days before to 4 days
after the rash appears
• 90% of susceptible persons with close
contact to a measles patient will develop
illness
• Airborne, infectious on surfaces and in air
for more than 2 hours
Complications
• 1/10 cases have ear infections - can lead to
hearing loss
• 15% are hospitalized
• 1/20 cases develop pneumonia
• 1 / 1,000 cases develop acute encephalitis,
often resulting in permanent brain damage
• 1-2 / 1,000 children with measles will die from
respiratory and neurologic complications
• Subacute sclerosing panencephalitis, a rare fatal
complication can develop 7 to 10 years later
Measles In Central Iowa, Summer 2011
• Unvaccinated person flies into Iowa from New Delhi,
India
• Next day – symptoms begin: rash, fever, conjunctivitis,
coryza
• Two days later seeks medical care – measles suspected
by HCP
• Patient sent to medical center for blood draw
• No precautions taken to protect other patients or
health care practitioners
• Blood sent to out of state reference lab
Measles In Central Iowa, 2011, Con’t
• Nine days later, lab result comes back IgM
positive
• Public health notified at that point
• Too late to protect anyone with vaccine or IG
(need to give within 3 or 6 days respectively)
• Voluntary home quarantine begun for family
• Public notified of potential exposures
• Hundreds of people potentially exposed
Measles in Central Iowa,
Follow up Investigation
• Contacted all those on flight (IDPH did Iowa flight, CDC
coordinated with states for passengers of the India to US
flight)
• Contacted all those at Clinic (23 patients plus thier
family members)
• Public announcement of exposure at the medical center
and airport
• 15 people exposed and not vaccinated, so go into home
quarantine (some tested for IgG and released when
positive)
• No more cases occurred – very lucky most vaccinated
MMR Recommendations for Kids
• School age children- requires 2 doses MMR
–1st dose at 12 months of age
–2nd dose usually given 4-6 years of age
• Can give 1st dose at 6 months in outbreaks
–But will NOT count as a required dose, thus
will need 2 more doses
• Can give 2cd dose 28 days after 1st dose
–(child does not need to be 4-6 years of age)
MMR Recommendations for Adults
• All adults born on or after 1957 should
receive at least 1 dose of MMR, or have lab
confirmation of disease or immunity
(positive IgG on serology)
–If HCW, travel internationally or student in
post-secondary institution -need 2 doses
• If born before 1957 were likely infected with
measles and therefore have presumptive
immunity
–If HCW or travel internationally need 2
doses
MMR Recommendations for
Healthcare Providers
• ALL healthcare providers (REGARDLESS
OF AGE) should have 2 documented
doses of MMR, proof of immunity, or
laboratory confirmation of disease
QUARANTINE
Effective Dates
From: ____________ Through: _______________
Due To Communicable Disease (___________________)
No one shall enter or leave these premises without authorization by The Iowa
Department Of Public Health or The ____________________County Board Of
Health. Any individual entering a quarantine premises with or without authorization
of the health department or County Board Of Health may be isolated or quarantined.
Pursuant to Iowa Code section 135.38, any individual who knowingly violates a lawful
department order for isolation or quarantine, whether written or oral, shall be guilty
of a simple misdemeanor. The court ordered sentence may include a fine up to $500
and imprisonment not to exceed 30 days. No person other than an authorized
employee of The Iowa Department Of Public Health or county health department
shall alter, destroy, or remove this notice. Address inquiries to The Iowa
Department Of Public Health at 1-800-362-2736.
IOWA CODE 139A.5
Iowa Department of Public Health
321 East 12th Street
Des Moines, IA 50319-0075
Influenza (just won’t go away)
Weekly Influenza Report
• Posted every Friday
at IDPH website
www.idph.state.ia.us/I
dphArchive/Archive.as
px?channel=FluReports
Crazy Emerging Issues (1)
• Vet was bitten by stray cat
• Subsequently developed
lesion and hospitalized
• Culture grew Tularemia
• 3 other vets at clinic started on prophylaxis
because of potential exposure
• Cat still alive at that point because of Rabies
quarantine
• What happened next???? (Note: Tularemia is
endemic in Iowa – primarily rabbits)
Cat
Declared
a
CDC
declared
the
cat to be
Terrorist
aThreat!
TERRORIST
THREAT!!!!
What was done with “Terrorist” Cat?
• CDC required cat to be autoclaved
• Transporter of cat from clinic to public health
lab required to have appropriate FBI clearance
• Special papers required for vet clinic to
“release” cat carcass to FBI cleared transporter
• Cat autoclaved at SHL
• Tularemia endemic in Iowa and often found in
rabbits, ticks, etc. and occasionally in cats
Crazy Emerging Issues (2)
A woman in Iowa
bought a pill
containing this
parasite off the
internet to help her
lose weight.
Became worried
and contacted her
doctor.
(Media calls Galore!)
She had bought a
Taenia tapeworm head
and swallowed it.
On the internet you can illegally buy a pill
containing Taenia saginata (scolex or head). This
can developed into a 30 foot long, one inch wide
worm – causing malabsorption and anorexia.
Meanwhile, segments of the worm – sometimes
feet long - are passed.
Woman was given anti-helmith drug.
The
Human
Microbiome
(emerging
issue)
Disrupted Microbiome
• Associated with:
–
–
–
–
–
–
–
–
Malnutrition and obesity
Diabetes (both type 1 and type 2)
Atherosclerosis and heart disease
Multiple sclerosis
Asthma and eczema,
Liver disease
Bowel cancer
Autism
• Obscure how these associations work, but may
be bacterial molecules impact/regulate human
cell activities
• Could balancing the microbiome then prevent,
improve or cure these diseases?
Impact of Human Gut Microbiome
• Each person’s biome is different
– Complex and abundant microbial community
– Appears that microbial activity is more important
than exactly which microbes perform that activity
(we need help digesting fat, but many different
kinds of bacteria can help us do this for us)
– Children in Malawi and rural Venezuela have
more riboflavin-producing and milk-enzyme
producing bacteria than in US children
– Pick up non-human bacteria genes to help human
bacteria, Japanese can now digest seaweed
Antibiotic Use and Impact
• One course of Cipro suppresses 1/3 gut
microbiome, most bacteria recover but not all –
some disappear – what does that mean?
• When mice and livestock are given antibiotics,
they have about 15% more body fat
• As the use of antibiotics increases from one US
state to another state, so does the incidence of
obesity (and diabetes and hypertension etc.)
Example of Complex Interaction
• Helicobacter pylori is associated with gastric ulcers and
cancer (but since very common – some good effects?)
• Antibiotics rids stomach of this bacteria
• However, with no H. pylori, levels of stomach hormones ghrelin - didn’t fall
• Falling levels of ghrelin tell body to stop eating
• Result in increases in body fat even with same diet (farmers
give antibiotics to livestock to promote weight gain and
more fat in muscle)
• People with no H. pylori, increase in asthma/hay fever, and
increase in esophageal inflammation and esophageal CA
Psychobiotic
• Live gut microbes are psychoactive
• Potential benefit to those with a variety of
psychiatric/mental illnesses?
• Secrete neurotransmitters (serotonin)
• Specific gut bacteria influence the brain as
well as nervous system
–Depression?
–Anxiety?
–Appetite?
Other Biome Issues
• Biggest dietary impact on microbiome -Fiber!
• High fiber diet changes microbiome within days
(Could this be why fruits and vegetables have
such a huge impact on health?)
• Mice with high fat diet-induced inflammatory
disease treated with high fiber with
improvement. (Easy reduction of inflammation?)
• Genetics - Could disease-causing microbes be
passed down from mother to child – explaining
certain familial disease risks for which no human
gene link found?
References for More Reading on the
Human Microbiome
• Human Microbiome in Health and Disease; Pflughoeft and Versalovic.
Annu. Rev. Pathol. Mech. Dis. 2012.7:99-122.
• Gut flora metabolism of phosphatidylcholine promotes cardiovascular
disease; Wang, et.al. Nature 472,57-63 (07 April 2011).
• The ‘hygiene hypothesis’ for autoimmune and allergic diseases; an
update. Okada, et.al. Clin. Exper. Imm., 160: 1-9 (2010)
• Diet rapidly and reproducibly alters the human gut microbiome.
David, et.al. Nature; Dec., 2013.
• Implications of the Human Microbiome Project for Epidemiology.
Foxman and Rosenthal. Am. J. Epidemiol. 2013;177(3):197-201.
• The microbiome explored: recent insights and future challenges.
Blaser, Bork, Fraser, Knight and Wang. Nature Review –Microbiology;
Vol. 11:213-217. March 2013.
Good
Articles
(but
lighter)
New York Times:
Nov 1, 2014 – by Ed Yong “There Is No ‘Healthy’ Microbiome”
Aug 14, 2014 – by CARL ZIMMER "How Bacteria May Control Our Behavior"
May 15, 2013 – by MICHAEL POLLAN - " My Best Friends Are Bacteria"
June 18, 2012 - By CARL ZIMMER - "Tending the Body’s Microbial Garden"
June 13, 2012 - By GINA KOLATA - "In Good Health? Thank Your 100 Trillion Bacteria"
Aug 29, 2013 - By CARL ZIMMER - "Human Microbiome May Be Seeded Before Birth"
Sep 15, 2014 - By CARINA STORRS - "Fighting Poisons With Bacteria"
May 22, 2014 - By JULIA SCOTT - "A Wash on the Wild Side"
The Economist:
“The human microbiome: Me, myself, us” Aug 18, 2012
“”The microbiome and health: Sniffing out hypertension.
“Malnutrition and the microbiome” Feb 2, 2013
“Heart disease and the microbiome” April 13, 2013
“Cancer and the microbiome” June 29, 2013
“Modern medicine: Microbes maketh man” Aug 18, 2012
Have a
Happy and
Healthy
Year!
Questions?