Download Neonatal Herpes

Hot Topics in Infectious Diseases
Penelope H. Dennehy, MD
Director,
Division of Pediatric Infectious Diseases
Hasbro Children’s Hospital
Professor and Vice Chair for Academic Affairs
Department of Pediatrics
Alpert Medical School of Brown University
Disclosure Information
• I do not have financial relationship(s) with the
manufacturers(s) of any commercial product(s) and/or
provider of commercial service(s) discussed in this CME
activity.
• I do not intend to discuss an unapproved/investigative use of
a commercial product/device in my presentation.
• I acknowledge that today’s activity is certified for CME credit
and thus cannot be promotional. I will give a balanced
presentation using the best available evidence to support my
conclusions and recommendations.
Objectives
• To discuss challenging issues and cases
in infectious diseases representing the
hot topics in infectious diseases for 2017
Case 1
• A mother calls you about her 18-year-old daughter,
who is a student at a college where several students
have been diagnosed with mumps
• The mother does not know the immunization status
of the infected individuals but states that her
daughter is up to date on all her immunizations and,
to the best of her knowledge, has received two
doses of MMR
• Her daughter has been asymptomatic, with no fever
or other systemic complaint
Case 1
Of the following, the MOST appropriate action is to:
A.
B.
C.
D.
E.
administer a dose of mumps immune globulin to her
daughter
confirm that her daughter has received two doses of
MMR vaccine
have her daughter stay out of classes for 9 days to
observe for the development of symptoms
vaccinate her daughter immediately with a
monovalent mumps vaccine to prevent infection
from this exposure
vaccinate her daughter immediately with another
dose of MMR to prevent infection from this exposure
Mumps Cases by Year
Mumps Cases in the United States
Mumps Vaccine
• MMR vaccine
– routinely administered to children at 12 to 15
months, with a second dose given at 4 to 6
years
• Monovalent mumps vaccine is not available
• Mumps vaccine effectiveness
– 78% for one dose
– 88% for two doses
Mumps in Vaccinated People
• In highly vaccinated communities, the
proportion of cases that occur among
people who have been vaccinated may
be high
• People who have not been vaccinated
against mumps usually have a much
greater mumps attack rate than those
who have been fully vaccinated
Management of a Mumps Exposure
• Ensure that the exposed person has received
the recommended number of doses of MMR
vaccine
– If the individual has not received two doses, a
second dose of MMR should be administered
ASAP
• Mumps vaccine is not effective in preventing
infection after exposure
• Immune globulin and mumps IG are not
effective for post-exposure prophylaxis
– Mumps IG no longer is available in the United
States
Management of a Mumps Exposure
• Exclusion from school after exposure
– Fully immunized persons do not need to be excluded
– Students who are not fully immunized are excluded
until they are immunized, then can be readmitted
immediately
– Students who refuse mumps vaccination should be
excluded from school for at least 26 days after the
onset of parotitis in the last person who has mumps in
the affected school
– Persons who have mumps are excluded from school
for 9 days from the onset of their parotid swelling
Mumps Outbreak Recommendations
• Should you offer a third dose of MMR to persons
who have two prior documented doses of MMR?
– Consult with the local health department
– Currently, data are insufficient to recommend for or
against the routine use of a third dose of MMR vaccine
– CDC has issued guidance for use of a third dose in
specifically identified target populations along with
criteria for public health departments to consider in
decision making.
– This information can be found at
www.cdc.gov/vaccines/pubs/surv-manual/chpt09mumps.html.
Case 2
• A 33-year old female is in the obstetric
clinic for her 18th week check-up. She
has no complaints.
• She just got back from Brazil where
she spent 3 weeks with her family.
• She has not felt any fetal movements
and a routine ultrasound reveals a
moderate amount of microcephaly.
Case 2
• Which of the following may be
related to the fetal pathology?
A.
B.
C.
D.
E.
Chikungunya
Dengue
Yellow Fever
Zika virus
All of the above
Case 2
• Which system is most often involved
with congenital birth defects caused
by the Zika virus infection?
A.
B.
C.
D.
E.
Cardiovascular system
Central nervous system
Joints
Reproductive system
Skin
Zika Virus
Zika virus (Zika)
 Single stranded RNA virus
 Genus Flavivirus, family
Flaviviridae
 Closely related to dengue, yellow
fever, Japanese encephalitis, and
West Nile viruses
 Primarily transmitted through the
bite of an infected Aedes species
mosquito (Ae. aegypti and Ae.
albopictus).
Why do we worry about Zika Virus?
• Many people infected with Zika virus
won’t have symptoms or will only
have mild symptoms.
• Zika virus infection during
pregnancy can cause microcephaly
and other severe brain defects.
Where has Zika been found?
http://www.cdc.gov/zika/geo/index.html
Zika in the United States
• Zika Virus Disease Cases*
– 5,359
• Pregnant Women with Any Lab Evidence
of Zika Virus Infection#
– 1,963
*Source: ArboNET data as of June 28, 2017
https://www.cdc.gov/zika/reporting/case-counts.html
#Source: Pregnancy Registries as of June 13, 2017
https://www.cdc.gov/zika/geo/pregwomen-uscases.html
Zika in the United States
• Local mosquito-borne spread of
Zika virus has been identified in
Miami-Dade County, Florida, and
Brownsville, Texas
– Pregnant women should
consider postponing travel to
Brownsville, Texas (currently a
yellow area)
– CDC lifted the yellow area
designation for Miami-Dade
County on 6/2/17
Brownsville, Texas
Miami-Dade County, Florida
How is Zika spread?
• Zika can be spread through
–
–
–
–
Mosquito bites
From a pregnant woman to her fetus
Sex with an infected person
Laboratory exposure
• Zika may be spread through blood
transfusion.
• No reports of infants getting Zika through
breastfeeding.
What are the symptoms of Zika?
• For people with
symptoms, the most
common symptoms
of Zika are
–
–
–
–
–
–
Fever
Rash
Headache
Joint pain
Conjunctivitis (red eyes)
Muscle pain
How can Zika affect pregnancies?
• Zika virus can be transmitted
during all trimesters of pregnancy
• Mother may transmit even if she
is asymptomatic
• Most recent data from the Zika
Pregnancy Registries suggest
transmission rate is about 5%
overall
Shapiro-Mendoza CK, et al. Pregnancy Outcomes After Maternal Zika Virus
Infection During Pregnancy — U.S. Territories, January 1, 2016–April 25, 2017.
MMWR 2017;66:615-621.
How can Zika affect pregnancies?
• Infection during pregnancy can cause
damage to the brain, microcephaly,
and congenital Zika syndrome
• Linked to other problems, such as
miscarriage, stillbirth, and birth defects
• No evidence that past infection will
affect future pregnancies once the
virus has cleared the body
Congenital Zika Syndrome
Distinct pattern of birth defects in fetuses and infants of women infected
during pregnancy
Associated with 5 types of birth defects not seen or rarely seen with other
infections during pregnancy
•
severe microcephaly (>3 SD below the
mean) with findings consistent with fetal
brain disruption sequence including
–
•
–
–
–
partially collapsed skull, overlapping cranial
sutures
prominent occipital bone
redundant scalp skin
neurologic impairment
–
–
–
–
–
–
–
cerebral cortex thinning
abnormal gyral patterns
increased fluid spaces
subcortical calcifications
corpus callosum anomalies
reduced white matter
cerebellar vermis hypoplasia
brain anomalies including
•
ocular findings such as
–
–
–
•
•
–
–
macular scarring
focal pigmentary retinal mottling
structural anomalies (microphthalmia,
coloboma, cataracts, and posterior anomalies)
chorioretinal atrophy
optic nerve hypoplasia/atrophy
–
–
unilateral or bilateral clubfoot
arthrogryposis multiplex congenita
–
pronounced early hypertonia/spasticity with
extrapyramidal symptoms
motor disabilities
cognitive disabilities
Hypotonia
irritability/excessive crying
Tremors
swallowing dysfunction
vision impairment
hearing impairment
epilepsy
congenital contractures, including
neurological impairments such as
–
–
–
–
–
–
–
–
–
Assessing pregnant women for possible Zika
exposure
• At each prenatal care visit, all pregnant women
should be asked if they
– Traveled to or live in an area with risk of Zika
– Had sex without a condom with a partner who lives in
or traveled to an area with risk of Zika
How is Zika diagnosed?
•
•
A blood or urine test can confirm a Zika infection
CDC has algorithms for testing pregnant women and infants
–
–
•
•
–
For pregnant women: https://www.cdc.gov/zika/pdfs/testing_algorithm.pdf
At time of birth: https://www.cdc.gov/zika/hc-providers/test-specimens-attime-of-birth.html
For infants: https://www.cdc.gov/mmwr/volumes/65/wr/mm6533e2.htm
Healthcare providers should work closely with the state, local, or
territorial health department to ensure that the appropriate test
is ordered and interpreted correctly
CDC maintains a 24/7 Zika consultation service for HCPs caring
for pregnant women
– To contact the service, call 770-488-7100 and ask for the Zika
Pregnancy Hotline
Who should be tested for Zika?
• All pregnant women (regardless of symptoms) who
– Live in or recently traveled to an area with risk of Zika that
has a CDC Zika travel notice, or
– Had unprotected sex with a partner who lives in or traveled
to an area with risk of Zika that has a CDC Zika travel notice
• Pregnant women who live in or recently traveled to an
area with risk of Zika but without a CDC Zika travel
notice
– If they develop symptoms of Zika, or
– If their fetus has abnormalities on an ultrasound that may
be related to Zika infection
Testing babies for Zika
CDC recommends laboratory testing for
• All infants born to mothers with laboratory
evidence of Zika virus infection during
pregnancy
• Infants who have abnormal clinical or
neuroimaging findings suggestive of
congenital Zika syndrome and a mother with a
possible exposure to Zika virus, regardless of
maternal Zika virus testing results
Reporting of Zika in the United States
•
•
•
Healthcare providers should
report cases to their local,
state, or territorial health
department.
State and territorial health
departments are encouraged to
report confirmed cases to CDC
through ArboNET, the national
surveillance system for
arboviral diseases.
Pregnant women with any lab
evidence of possible Zika virus
infection should be reported to
the US Zika Pregnancy
Registry.
For the most recent case counts, visit
https://www.cdc.gov/zika/geo/unitedstates.html.
Zika Pregnancy Registries
US Zika Pregnancy Registry
• CDC established the US Zika
Pregnancy Registry to collect
information and learn more about
pregnant women in the US with Zika
and their infants.
• Data will be used to
– Update recommendations for clinical
care
– Plan for services for pregnant women
and families affected by Zika
– Improve prevention of Zika infection
during pregnancy
• Zika Active Pregnancy Surveillance
System is used in Puerto Rico.
https://www.cdc.gov/zika/hc-providers/registry.html
https://www.cdc.gov/zika/public-health-partners/zapss.html
Suggested Readings - Zika
• General information about zika
virus: http://www.cdc.gov/zika
http://www.paho.org/hq/index.php?option=com_content&vi
ew=article&id=11585&Itemid=41688&lang=en
• Zika information for clinicians: http://www.cdc.gov/zika/hcproviders/index.html
• Travel notices related to zika
virus: http://wwwnc.cdc.gov/travel/page/zika-travelinformation
• For information on where Zika virus is found:
http://www.cdc.gov/zika/geo/index.html.
• Information about zika for travelers and travel health
providers: http://wwwnc.cdc.gov/travel/yellowbook/2016/i
nfectious-diseases-related-to-travel/zika
Case 3
• A previously healthy 10 year old girl presents
to your office for her routine health
maintenance visit in October 2017.
• What influenza vaccine should she be given?
A.
B.
C.
D.
E.
Trivalent IIV
Quadrivalent IIV
Quadrivalent LAIV
Either A or B
Either A, B or C
Influenza Vaccine Recommendations
for 2017-2018
Influenza 2016-2017 Season
•
•
•
•
As of early November 2016,
only 37% of children aged 6
months–17 years had
received vaccine
Only 47% of pregnant
women had been vaccinated
by early November 2016
During the current flu
season, 101 children died
Vaccine effectiveness was
53% in children 6 mos to 8
years and 23% in older
children
Flannery B, et al. Interim Estimates of 2016–17 Seasonal Influenza Vaccine
Effectiveness — United States, February 2017. MMWR 2017;66:167–171.
Influenza 2016-2017 Season
• Overall, flu activity
was moderate, with
peak incidence in
mid-February
• Influenza A (H3N2)
viruses predominated
overall, since late
March, influenza B
viruses have been
reported more
frequently than A
viruses.
Influenza Vaccine Recommendations
for 2017-2018
• Core requirements for influenza
immunization would remain the
same for the 2017-18 flu season,
under a recommendation approved
by the Advisory Committee on
Immunization Practices (ACIP) at
the June meeting
Influenza Vaccines for the 2017-2018
Season
• 2017–18 trivalent vaccines contain:
– an A/Michigan/45/2015 (H1N1) pdm09-like virus
– an A/Hong Kong/4801/2014 (H3N2)-like virus
– a B/Brisbane/60/2008-like virus (B/Victoria lineage)
• 2017-2018 quadrivalent vaccines have two
influenza B viruses and contain:
– the viruses recommended for the trivalent vaccines
– a B/Phuket/3073/2013-like virus (B/Yamagata
lineage)
Influenza Vaccine Recommendations
for 2017-2018
• ACIP also recommended allowing any
licensed, recommended and age-appropriate
trivalent or quadrivalent inactivated influenza
vaccine (IIV) or recombinant influenza vaccine
(RIV) for pregnant women.
– The previous recommendation specified use of
IIV for pregnant women.
• Afluria (IIV3) now is indicated for people 5
years and older (down from 9 years and
older).
Influenza Vaccine Recommendations
for 2017-2018
• ACIP reiterated that the quadrivalent live
attenuated influenza vaccine (LAIV4) not be
used in any setting during the upcoming flu
season
• In 2016 it was reported that in all pediatric
age groups LAIV did not have any statistically
significant benefit in preventing influenza
during the 3 previous flu seasons
• Additional data on LAIV4 is expected in
October 2017
Prior Recommendations for Choice of
Influenza Vaccine
• Annual influenza vaccination for everyone
ages 6 months and older has been
recommended since 2011-2012 season
• During 2014-2015 season
– CDC/ACIP had a preferential recommendation for
LAIV for young children
– AAP had no preference
• During the 2015-2016 season
– CDC and AAP recommended influenza vaccination
without any preference for vaccine
Performance of Influenza Vaccine
• Can range widely from season to season
• Can be affected by a number of factors
including:
– characteristics of the person being vaccinated
– the similarity between vaccine viruses and
circulating viruses
– which vaccine is used
• While the protection offered by flu vaccines
can vary, overall VE estimate was 48%
against flu last season
LAIV Vaccine Effectiveness
• LAIV contains live, weakened influenza
viruses
• In general, vaccines containing live viruses
can cause a stronger immune response than
vaccines with inactivated virus
• VE data before and soon after licensure of
LAIV suggested it was either comparable to,
or better than, IIV
LAIV Vaccine Effectiveness
In late May 2016, preliminary VE data on LAIV in
children 2 through 17 years during 2015-2016 season
became available from the U.S. Influenza Vaccine
Effectiveness Network
Vaccine
VE against any flu
virus
95% CI
LAIV
3%
-49 to 37%
IIV
63%
52 to 72%
Other non-CDC studies support the conclusion that LAIV
worked less well than IIV during the 2015-2016 season
LAIV Vaccine Effectiveness
The data from 2015-2016 follows two previous seasons
showing poor and/or lower than expected VE for LAIV in
children 2 through 8 years
2013-2014
Vaccine
LAIV
IIV
VE against influenza A
(H1N1)
0
63%
2014-2015
Vaccine
VE against influenza A
H3N2
LAIV
-23% (95% CI -90 to 21%)
IIV
15% (95% CI -20 to 40%)
The reason for the poor performance of LAIV is not known and is
being investigated
Influenza Vaccine Recommendations
for 2017-2018
• The CDC director will review ACIP’s
recommendations. Those that are approved will
be published as official recommendations in the
Morbidity and Mortality Weekly Report.
• The AAP will review the CDC’s changes and
make official policy recommendations of its own.
Suggested Reading
• Centers for Disease Control and Prevention.
Vaccine effectiveness - How well does the flu
vaccine work?
• CDC’s seasonal influenza web page for
health professionals,
www.cdc.gov/flu/professionals/index.htm
Post-Test Questions
Question 1
• You are caring for a college student
who is exposed to mumps on campus.
The student received 2 prior doses of
MMR at 12 months and 6 years of age.
• You should administer a 3rd dose of
MMR as soon as possible
A. True
B. False
Question 2
• Zika is transmitted only during the
first trimester of pregnancy
A. True
B. False
Question 3
• An asymptomatically infected
mother can not transmit Zika virus
to her fetus
A. True
B. False
Question 4
• Zika can be diagnosed with either
blood or urine tests.
A. True
B. False
Question 5
• LAIV is recommended for use
during the 2017-2018 influenza
season.
A. True
B. False