François Boucher MD, FRCPC They're back: Old diseases, new again.

François Boucher MD, FRCPC

They're back:Old diseases, new again

The Evolution and Eradication of Infectious Diseases

T. Aidan Cockburn, a widely respected physician and anthropologist:

“We can look forward with confidence to a considerable degree of freedom from infectious diseases at a time not too far in the future. Indeed . . . it seems reasonable to anticipate that within some measurable time . . . all the major infections will have disappeared.”

Cockburn, T. A. (1963).The evolution and eradication of infectious diseases.

Baltimore, MD: Johns Hopkins Press.

Infectious disease spread and containment is again a major public health issue worldwide, due to such factors as:

•International travel;

•Climate change;

•Drug-resistant pathogens;

•Entirely new diseases;

•…vaccine refusal…

Infectious disease is the No. 2 cause of death worldwide (after cardiovascular disease), and the No. 1 cause of death in persons age 50 and under

Objectives

After this presentation, participants will be able to:

• Identify re-emerging infectious diseases and at-risk populations.

• Diagnose, and report infectious diseases to public health.

• Communicate with families on the management of close contacts.

…New again?

•Measles

•Pertussis

•Cellulitis and pneumonia: MRSA

•Invasive GAS infections

•Invasive Hib infections

•Meningococcemia

•Tuberculosis

•…etc

Physician’s role in the control of contagious diseases

•Complete the appropriate diagnostic procedures

•Manage the patient’s condition

•Ensure proper isolation measures

•Report to Public Health authorities

•Provide immediate contacts with appropriate prophylaxis if required

• Usually: direct home contacts

Public Health role in the control of contagious diseases

•Reporting & keeping count…

•Epidemiologic surveillance

•Supporting physician responsible for the patient

•Accurate diagnostic definition

•Outbreak investigation

•Provide necessary preventative measures if required

Bacterial meningitis

Etiologie de la méningite bactérienne aigue – USA 1998-2007

Thigpen MC et al. NEJM 2011; 364:2016-25

Hib meningitis & invasive disease:Clinical presentation

•Meningitis: Also H. influenzae types a, e, f

•Epiglottitis

•Septic arthritis

•Cellulitis (usually involving the face, head or neck)

•Pneumonia

•Osteomyelitis and pericarditis are less common forms of invasive disease

AAP Red Book 2009

Hib meningitis & invasive disease:Definition of close contact

•People residing with the index patient

•Nonresidents who spent four or more hours with the index case for at least five of the seven days preceding the day of hospital admission of the index case

AAP Red Book 2009

Hib meningitis & invasive disease:Management of contacts

•Chemoprophylaxis is recommended for all household and child care centre contacts in the following circumstances:

• Household with at least one contact younger than four years of age who is unimmunized or incompletely immunized

• Household with an immunocompromized child, regardless of that child's immunization status.

Manitoba Communicable Disease Control Branch. October 2007AAP Red Book 2009


•Chemoprophylaxis is recommended for all household and child care centre contacts in the following circumstances:

• Nursery school or child care centre when one case of Hib invasive disease has occurred, for incompletely or unimmunized children younger than four years of age only;

• Nursery school or child care centre, regardless of age and immunization status, when two or more cases of Hib invasive disease have occurred within 60 days



•Chemoprophylaxis is also recommended for:

• The case, if younger than 2 years of age or a member of a household with a susceptible contact, and who had been treated with a regimen other than cefotaxime sodium or ceftriaxone sodium. Chemoprophylaxis usually is provided just before discharge from hospital

Manitoba Communicable Disease Control Branch. October 2007BC CDC. September 2005

AAP Red Book 2009

Hib meningitis & invasive disease:Antibiotic prophylaxis

Rifampin dosage

• Adults: 600 mg orally once daily for four days

• Children: 20 mg/kg (maximum 600 mg) orally once daily for four days

• Infants younger than one month: 10 mg/kg orally once daily for four days

•Rifampin should be given to contacts within seven days after the index patient is hospitalized in order to be effective in preventing secondary cases

AAP Red Book 2009


•Chemoprophylaxis of contacts is not routinely recommended for the other serotypes of H. influenzae

•Children who have not been appropriately immunized for age should receive any required immunizations.

•Post-exposure Hib immunization is not known to decrease the risk of transmission. Rather, the situation presents an opportunity for completion of Hib immunization of contacts.

Manitoba Communicable Disease Control Branch. October 2007BC CDC. September 2005

AAP Red Book 2009


•Chemoprophylaxis is not recommended for:

• Household contacts of index cases of invasive Hib infection when the contacts are completely immunized against Hib

• Nursery school and child care contacts of one index case, especially those older than two years of age.

• Pregnant women as safety has not been determined.


Invasive meningococcal disease

Invasive meningococcal diseaseCase definition

•Confirmed case

• Invasive disease with laboratory confirmation of infection:

• isolation of N. meningitidis from a normally sterile site (blood, CSF, joint, pleural or pericardial fluid); OR

• demonstration of N. meningitidis DNA by appropriately validated nucleic acid test (NAT) from a normally sterile site.

Supplement: Guidelines for the Prevention and Controlof Meningococcal Disease. CCDR 2005;3151.

Invasive meningococcal diseaseCase definition

•Probable case

• Invasive disease with purpura fulminans or petechiae and no other apparent cause:

•with demonstration of N. meningitidis antigen in theCSF;OR

• in the absence of isolation of N. meningitidis or demonstration of DNA by appropriately validated NAT from a normally sterile site.


Invasive meningococcal diseaseDefinition of close contact: Group 1

Ongoing exposure…

•Household contacts of a case (the attack rate for household contacts is 500 to 800 times the rate for the general population)

•Persons who share sleeping arrangements with the case

•Persons who have direct contamination of their nose or mouth with the oral/nasal secretions of a case (e.g. kissing on themouth, shared cigarettes, shared drinking bottles)

•Children and staff in child care and nursery school facilities

Supplement: Guidelines for the Prevention and Controlof Meningococcal Disease. CCDR 2005;3151

AAP Red Book 2009

Invasive meningococcal diseaseDefinition of close contact: Group 2

•Transient exposure…

•Health care workers (HCWs) who have had intensive unprotected contact (withoutwearing amask) with infected patients (e.g. intubating, resuscitating or closely examining the oropharynx)

•Airline passengers sitting immediately on either side of the case (but not across the aisle)when the total time spent aboard the aircraft was at least 8 hours


Invasive meningococcal diseaseAntibiotic prophylaxis

Drug Dosage Comments

Ciprofloxacin Adults ≥ 18 years of age: 500 mg x single dose PO

Preferred regimen for adults because of demonstrated safety in this age group, lower cost, single dose and absence of red discoloration of body fluids. Contraindicated during pregnancy and lactation. Only approved for persons > 18 years of age.

Rifampin Adults: 600 mg PO q 12h x 4 doses Children ≥ 1 month of age: 10 mg/kg (maximum 600 mg) per dose PO q 12h x 4 doses Infants < 1 month of age: 5 mg/kg per dose PO q 12h x 4 doses

Preferred regimen for children. Contraindicated in pregnancy. Urine and tears may be stained red. Advise against wearing soft contact lenses as these can also be stained. Can reduce effectiveness of oral contraceptives. Advise use of alternative/additional contraceptive measures.

Ceftriaxone Adults and adolescents ≥ 12 years: 250 mg IM x 1 dose Children < 12 years: 125 mg IM x 1 dose

Recommended drug for pregnant women. Dilute in 1% lidocaine to reduce pain at injection site.


Invasive meningococcal diseaseAntibiotic prophylaxis


•Chemoprophylaxis should be administered as soon as possible and preferably within 24 hours of case identification, but is still recommended for up to 10 days after the last contact with an infectious case

•Close contacts should be alerted to the signs and symptoms of meningococcal disease and be advised to seek medical attention immediately should they develop febrile illness or any other clinical presentation consistent with IMD

Invasive meningococcal diseaseImmunization of close contacts

•Vaccination is not generally indicated for contacts of cases of disease in which the serogroup has not been determined.

•Group 1 contacts: Immunoprophylaxis should be considered when the case’s serotype is known and vaccine preventable and the contact has not previously been immunized against that serotype. When indicated, immunoprophylaxis should be carried out as soon as possible after the exposure

•For group 2 contacts: Chemoprophylaxis is recommended. Immunoprophylaxis is not recommended as there will not be ongoing exposure to the case

Manitoba Communicable Disease Control Branch. June 2011

Group A streptococcalinvasive disease

GAS invasive disease:prevention of secondary cases

•Ontario Group A Streptococcal Study: Attack rate among household contacts: 2.94 per 1,000

•US Active Bacterial Core Surveillance (ABCs)/Emerging Infections Program network: 0.66 per 1,000

•Limitations:

• Household contacts and attending physicians were not asked about use of chemoprophylaxis;

• These attack rates are based on extremely small numbers of subsequent cases and therefore may be unstable

Supplement: Guidelines for the Prevention and ControlOf Invasive GAS Disease. CCDR 2006;3252.


•Approximately 300 close contacts of an invasive GAS case would need to receive chemoprophylaxis to prevent one secondary case;

•There would be an average of 10 contacts per case;

•Retail cost of $30 per person for antibiotics;

•Approximately 3 hours of public health nurse follow-up time per case, at $50 per hour;

•The cost-effectiveness has been estimated to be $13,500 CAD in direct health care costs per secondary case prevented.



•Chemoprophylaxis is indicated only for contacts at the highest risk of acquisition of the organism and of subsequent severe disease



•Chemoprophylaxis should only be offered

• To close contacts of a confirmed severe case, that is, a case of STSS, soft-tissue necrosis (including NF,myositisorgangrene),meningitis, GAS pneumonia, other life-threatening conditions or a confirmed case resulting in death; AND

• If close contacts have been exposed to the case during the period from 7 days prior to onset of symptoms in the case to 24 hours after the case's initiation of antimicrobial therapy



•Chemoprophylaxis of close contacts should be administered as soon as possible and preferably within 24 hours of case identification but is still recommended for up to 7 days after the last contact with an infectious case.

•Close contacts of all confirmed cases (i.e. regardless of whether the case is a severe one) should be alerted to signs and symptoms of invasive GAS disease and be advised to seek medical attention immediately should they develop febrile illness or any other clinical manifestations of GAS infection within 30 days of diagnosis in the index case.


GAS invasive disease:Antibiotic prophylaxis

Drug Dosage

1st gen cephalosporin (Keflex, Cefadroxil)

25-50 mg/kg/d, Max 1 g/day in 2 to 4 divided doses × 10 days

Erythromycin Children: 5 to 7.5 mg/kg q6h or 10 to 15 mg/kg q12h (base) × 10 days (not to exceed maximum of adult dose) Adults: 500 mg q12h (base) × 10 days

Clarithromycin Children: 15 mg/kg/d in divided q12h, to a maximum of 250 mg po bid × 10 daysAdults: 250 mg po bid × 10 days

Clindamycin Children: 8 to 16 mg/kg/d divided into 3 or 4 equal doses × 10 days (not to exceed maximum of adult dose) Adults: 150 mg q6h × 10 days


Measles – Quebec 2011

Epidemiologic context

•Major outbreaks in Europe

• Many importations (notably from France)

•First cases in January 2011

• Transmissions in daycare centers and health care settings

•Since April: sustained local transmission

•Since last May: 3 importations (Middle East, France, Great Britain)

•Worst epidemic in the Americas since 2002

Measles epidemic, France

• Since 2008

• >21 000 cases

• 4 000 hospitalizations

• 10 deaths• January-July 2011: close to 14 500

cases, of which

• 15 had neurologic complications

• 639 pulmonary complications

• 6 deceased

Bulletin épidémiologique hebdomadaire del’Institut de veille sanitaire du 20 septembre 2011.

Distribution des cas de rougeole selon la date de début du rash et la région de résidence, Québec, 2011 (n= 708 cas)

Au total, 709 cas ont été rapportés en date du 31 août 2011 (12h00) dont 1 cas confirmé pour lequel la date de début du rash n’est pas documentée. Pour la semaine débutant le 28 août 2011, il s’agit des données cumulées jusqu'au 31 août, 12h00.Source : BSV, DPSP, MSSS au 31 août 2011, 12h00.

0

20

40

60

80

100

2

jan

9

jan

16

jan

23

jan

30

jan

6

fév

13

fév

20

fév

27

fév

6

mars

13

mars

20

mars

27

mars

3

avril

10

avril

17

avril

24

avril

1er

mai

8

mai

15

mai

22

mai

29

mai

5

juin

12

juin

19

juin

26

juin

3

juil

10

juil

17

juil

24

juil

31

juil

7

aoû

14

aoû

21

aoû

28

aoû*

Date de début du rash - semaine débutant le

No

mb

re d

e c

as

Autres RSS

RSS 16

RSS 03

RSS 04

Measles outbreak – Québec 2011To August 31, 2011

• 747 cases (709 confirmed, 38 suspect)• 10 health regions affected•Mauricie and Centre-du-Québec (71 %)

•Montérégie (20 %)

• Confirmation • 254 laboratory-confirmed (36 %)

• 394 epidemiologic link(56 %)

• 61 clinical cases (9 %)

0

20

40

60

80

100

2

jan

9

jan

16

jan

23

jan

30

jan

6

fév

13

fév

20

fév

27

fév

6

mars

13

mars

20

mars

27

mars

3

avr

10

avr

17

avr

24

avr

1er

mai

8

mai

15

mai

22

mai

29

mai

5

juin

12

juin

19

juin

26

juin

3

juil

10

juil

17

juil

24

juil

31

juil

7

août

14

aoû

21

aoû

28

aoû*

Date de début du rash - semaine débutant le

No

mb

re d

e c

as

Histoire voyage hors Qc

Source non documentée

Milieu de soins suspecté

Communautaire autres

Milieu scolaire

Au total, 709 cas ont été rapportés en date du 31 août 2011 (12h00) dont 1 cas confirmé pour lequel la date de début du rash n’est pas documentée. Pour la semaine débutant le 28 août 2011, il s’agit des données cumulées jusqu'au 31 août, 12h00.Source : BSV, DPSP, MSSS au 31 août 2011, 12h00.

Distribution des cas de rougeole selon date début du rash et le type d’acquisition, Québec, 2011 (n= 708 cas)

Transmission

• 2% cases acquired during travel

• 43% school acquisitions

• 21% unknown source

• 18 cases acquired in healthcare settings

•11.5% hospitalized

Distribution of measles cases according to age and immunization status, Québec, 2011

0

50

100

150

200

250

300

< 1 an 12-17mois

18-23mois

2-4 ans 5-9 ans 10-14ans

15-19ans

20-29ans

30-39ans

40-49ans

50 ans +

Groupe d'âges

No

mb

re d

e c

as

Vaccinés

Incomplets pour l'âge

Non vaccinés

1ère dose RRO12 mois

2e dose RRO18 mois

MeaslesPrevention of secondary cases

•Define what is a contact…

•…most everyone around the index case…

• Contact during the 4 days prior to 4 days after rash appeared

•Define who is susceptible

• Depends on age and number of vaccine doses received – ask for help…

La Rougeole: Protocole d’intervention. Mise à jpour 2003.Québec, MSSS 2003


•Intervention

•Need help of Public Health & local ID specialist

•Quarantine

• Susceptible contacts should be quarantined in their home until 21 days after the onset of rash in the last measles case



•Vaccination

•Within 72 hours of exposure in unimmunized persons

• Once vaccinated, a person may come out of quarantine immediately

• If immunization status is unknown: vaccination in an already immune person is not harmful.



•Immunoglobulins

• for persons that are immunocompromised, pregnant, or infants less than 1 year of age.

• IG should be administered within 7 days of exposure, preferably within 72 hours.

• The recommended dose of IG is 0.25 ml/kg, with a maximum dose of 15 ml.


Control of other communicable diseases…

•http://www.bccdc.ca/dis-cond/comm-manual/CDManualChap1.htm

•http://www.gov.mb.ca/health/publichealth/cdc/protocol/index.html

•http://www.oahpp.ca/resources/index.html

•http://www.inspq.qc.ca/domaines/index.asp?Dom=60

http://www.bccdc.ca/dis-cond/comm-manual/CDManualChap1.htm

http://www.bccdc.ca/dis-cond/comm-manual/CDManualChap1.htm

http://www.gov.mb.ca/health/publichealth/cdc/protocol/index.html

http://www.gov.mb.ca/health/publichealth/cdc/protocol/index.html

http://www.oahpp.ca/resources/index.html

http://www.inspq.qc.ca/domaines/index.asp?Dom=60

http://www.inspq.qc.ca/domaines/index.asp?Dom=60

Merci!

François Boucher MD, FRCPC

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François Boucher MD, FRCPC They're back: Old diseases, new again.

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