* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
Download Pediatric Pathogens and Impact on the Adult Population
Influenza A virus wikipedia , lookup
Onchocerciasis wikipedia , lookup
Chagas disease wikipedia , lookup
Meningococcal disease wikipedia , lookup
Carbapenem-resistant enterobacteriaceae wikipedia , lookup
Sexually transmitted infection wikipedia , lookup
Gastroenteritis wikipedia , lookup
Herpes simplex virus wikipedia , lookup
African trypanosomiasis wikipedia , lookup
Sarcocystis wikipedia , lookup
Leptospirosis wikipedia , lookup
Dirofilaria immitis wikipedia , lookup
Eradication of infectious diseases wikipedia , lookup
West Nile fever wikipedia , lookup
Trichinosis wikipedia , lookup
Neisseria meningitidis wikipedia , lookup
Hepatitis C wikipedia , lookup
Human cytomegalovirus wikipedia , lookup
Schistosomiasis wikipedia , lookup
Henipavirus wikipedia , lookup
Marburg virus disease wikipedia , lookup
Neonatal infection wikipedia , lookup
Hepatitis B wikipedia , lookup
Coccidioidomycosis wikipedia , lookup
Oesophagostomum wikipedia , lookup
Lymphocytic choriomeningitis wikipedia , lookup
Whooping cough wikipedia , lookup
Pediatric Pathogens and Impact on the Adult Population APRIL KILGORE, MD, FAAP ASSISTANT PROFESSOR OF PEDIATRICS PEDIATRIC INFECTIOUS DISEASE MARSHALL UNIVERSITY SCHOOL OF MEDICINE Disclosure My presentation does not include discussion of any commercial products or services I will not be discussing investigational products or unlabeled uses I have no financial interests or relationships with manufacturers or commercial products Objectives Participants will understand the changing epidemiology of childhood infectious disease including Respiratory syncytial virus (RSV), Human metapneumovirus (hMPV), and Bordatella pertussis Participants will recognize the impact of these diseases on the adult population and the implications for clinical care/management Participants will know the infection control related issues for patients in the hospital/chronic care setting Respiratory Syncytial Virus Background Respiratory syncytial virus (RSV) first discovered in 1956 as respiratory pathogen in chimpanzees 1957 identified as cause of epidemic bronchiolitis in infants Long believed to be primarily a pediatric pathogen, however increasingly recognized as important pathogen in adults Evidence indicates second to influenza as cause of serious viral respiratory disease in adults Virology RNA virus of the family Paramyxoviridae Viral structure consists of a nucleocapsid core surrounded by lipid layer 3 glycoproteins embedded in lipid layer: G, F, SH Human RSV classified two major groups, A and B Each contain subgroups based on antigenic differences in G protein Virion varies in size and shape 120-300nm http://phil.cdc.gov/PHIL_Images/092020 02/00006/PHIL_2175_lores.jpg Epidemiology Yearly epidemics of respiratory illnesses during winter months in temperate climates Epidemic curve usually broader than influenza with longer periods of activity Primary infection almost universal by 2 years of age http://www.cdc.gov/surveillance/nrevss/rsv/natltrend.html Epidemiology: CommunityDwelling Adults Early estimates limited by diagnostic tools Reverse transcriptase polymerase chain reaction (RT-PCR) has allowed more accurate estimates of disease Zambon et al examined adults > 45 years visiting GP during winter for respiratory illness RSV identified in 10-22% of subjects Influenza identified in 13-42% Epidemiology: CommunityDwelling Adults 2001 prospective study Rochester, NY of elderly and high risk adults over 4 winter seasons 6 RSV infection confirmed in 3-7% of healthy elderly enrollees & 4-10% of high risk adults (chronic cardiopulmonary conditions) 89% were symptomatic Illness in 17-29% prompted office visits Among high risk patients, 9% visited the ED, 16% were hospitalized and 4% died Epidemiology: Adults and Hospitalizations 2007 study examined hospitalizations for influenza and RSV among adult population in large HMO14 Indirect measure utilizing discharge diagnosis and ICD-9 codes for “pneumonia and influenza” Influenza and RSV associated hospitalization rates per 10,000 person-periods Risk Group Age (years) Viral period Pneumonia and Influenza Low 65+ Any Flu 18.7 (10.2-27.1) Low 65+ RSV only 5.1 (0.7-9.5) High 65+ Any Flu 55.6 (41-70.2) High 65+ RSV only 23.4 (13.9-32.9) Adapted from Mullooly et al. Influenza and RSV associated hospitalizations among adults. Vaccine 2007;25:846-855 Epidemiology: Community Acquired Pneumonia Estimates of RSV contribution vary widely Falsey et al. conducted large study of hospitalized adults with pneumonia Utilized RT-PCR for diagnosis RSV identified in 4.4% of cases 3rd most common identified pathogen after S. penumoniae (6%) , and Influenza (5%) Composite data from the past 30 years indicate RSV accounts for 2-5% OF CAP throughout the year 5-15% during winter months Epidemiology: Long-Term Care Facilities First outbreaks in nursing homes in 1970s Surveillance studies estimate5 Infection rates 1-18% Pneumonia rates 0-33% Death 0-5% of those infected Clustering of cases suggests nosocomial spread by healthcare workers Other closed populations at risk- senior day care centers 7 10% of acute respiratory tract infections in participants 5% of day care staff Clinical Manifestations: Adults No clinically distinct illness in adults Characterized by nasal congestion and cough Ranges from mild URI to severe respiratory disease Relative Frequencies of Symptoms with RSV and Influenza Symptom RSV Influenza Rhinorrhea ++++ ++ Wheezing ++++ ++ Dyspnea +++ ++ Sputum production +++ ++ Fever + ++++ Myalgias + ++++ GI symptoms 0 ++ Adapted from Falsey, Ann. Respiratory Syncytial Virus infection in Adults. Seminars in Respiratory and Critical Care Medicine; 28(2)2007:171-181 Diagnosis Diagnosis on clinical grounds difficult in adults Four methods diagnosis Viral culture Sensitivity 20-45% Enzyme immune assay (rapid tests) Sensitivity 50-90% Varies on prevalence of RSV in community RT-PCR Most sensitive and specific method available Detects 30% more infections than viral isolation techniques Serology Limited by pre-existing antibodies and need for acute and convalescent Treatment Symptomatic supportive care Fluids, oxygen, and antipyretics mainstay of care No FDA approved anti-viral medications for adults Published reports of ribiviran use in elderly patients with severe disease Infection Control From Tang J, Nicolle A, Pantelic J, Jiang M, Sekhr C, Cheong D, Tham K (2011). "Qualitative Real-Time Schlieren and Shadowgraph Imaging of Human Exhaled Airflows: An Aid to Aerosol Infection Control Infection Control Viral shedding in infants up to 21 days Shedding in young adults averages 3-6 days with range 1-12 days Shedding in older adults not well studied Presumably shorter in healthy adults Longer in patients with COPD Spread via contact with contaminated secretions via large droplets or fomites Can survive on surfaces for many hours Infection Control Infection control practices1,20 Hand washing key to prevention Contact isolation with use of gown and gloves recommended Mask use per standard precautions Patients with known infection single room or cohorted HAI1,20 During community outbreaks can consider Screening of symptomatic patients Cohorting of infected patients and staff Excluding visitors with current or recent respiratory tract infections Excluding staff with respiratory tract illness from caring for susceptible patients Emphasizing contact precautions and hand hygiene Limiting sibling visitation Infection Control When can they come out of isolation? Immunocompromised adult and pediatric patients Official guidelines warn of extended shedding but give no duration recommendations What have we done to address this? If prolonged hospitalization and primary team wishes to discontinue PCR, isolation can be discontinued when patient has been asymptomatic for at least 5 days AND respiratory PCR is negative Human Metapneumovirus (hMPV) Background 2001 first described as respiratory pathogen by van den Hoogen and colleagues in the Netherlands Identified in specimens collected over a 20 year period from patients with respiratory tract disease during the winter months The then unidentified isolates caused cytopathic effects largely indistinguishable from RSV Serologic studies show high rate of antibodies in populations worldwide and evidence circulating dating back to 1958 Virology RNA virus of the Paramyxoviridae family with lipid bilayer envelope of host cell origin Genetically related to avian pneumovirus (AVP) aka turkey rhinotracheitis virus Causes URI in turkeys and other avian species Suggestive of origination from bird species Epidemiology Predominantly in winter months in temperate climates May exhibit yearly variation 2 Major genotypes that often co-circulate Almost all children infected by 5 years of age Older age at primary infection than RSV http://www.cdc.gov/surveillance/nrevss/hmpv/natltrend.html Epidemiology: CommunityDwelling Adults Less well studied than epidemiology of RSV Estimates of symptomatic infection generally < 5%8 2001 study in the Netherlands hMPV infection rate 3% in adults with symptomatic respiratory illnesses16 2003 two year prospective study in Rochester NY9 Cohorts of young and older adults studied 4.5% of illnesses associated with hMPV infection Significant yearly variation with rates of 1.5% and 7% during years 1 and 2 of the study period respectively High risk adults had more severe disease and more hospitalizations Epidemiology: Long Term Care Facilities Multiple reports in the literature of outbreaks June-July 2006 outbreak in Sacramento California in 148 bed facility13 26 residents and 13 staff with acute respiratory illness 31% ill residents developed pneumonia and 5 % hospitalized RT-PCR confirmed hMPV in 5 of 14 specimens and no other cause identified Epidemiology: Long Term Care Facilities January-February 2006 outbreak of severe disease in facility in Canada 2 27% of residents developed respiratory or constitutional symptoms Attack rate on most affected ward 72% Fatality rate 50% among confirmed cases (3/6) and 9.4% among possible cases (9/96) Spring Summer 2011 outbreak in facility in Oregon11 Attack rate 36% among residents 3 health care workers affected Fatality rate of confirmed and possible cases 31% Clinical Manifestations Vary based on age and health status Clinical symptoms indistinct from other viral respiratory infections Patients requiring hospitalization typically elderly with chronic cardiac or lung disease Clinical characteristics of young versus older adults with hMPV Clinical Feature Elderly (n=13) Young (n=11) Hoarseness 46% 91% Dyspnea 69% 9% Wheezing 62% 9% Length of stay 17.4 ± 9.4 8.5 ± 3.4 Adapted from Falsey, Ann et al. Human metapneumovirus infections in young and elderly adults. JID 2003;187(1-March):785-790 Clinical Manifestations Evidence of role in COPD exacerbations, pneumonia in immunosuppressed patients, and severe illness with ARDS Most common diagnoses of patients admitted with hMPV are exacerbation of COPD, bronchitis, and pneumonia8 Diagnosis Serology Viral culture Difficult to perform and can take up to three weeks to see cytopathic effects Immunofluorescence Limited by pre-existing antibodies and need for acute and convalescent testing Rapid testing available Sensitivity approaches that of RT-PCR RT-PCR Testing modality with greatest sensitivity and specificity Treatment Symptomatic supportive care Fluids, oxygen, and antipyretics mainstay of care No FDA approved anti-viral medications Susceptible in vitro to Ribavirin but no controlled clinical data to assess benefit Infection Control Route of transmission not established Likely similar to RSV since closely related and similar epidemiology Infection probably through direct or close contact with contaminated secretions Infection control practices1,20 Contact precautions for duration of illness Masks according to standard precautions Patients with known infection single room or cohorted HAI Problematic as symptoms in staff and patients may be mild Emphasis on hand hygiene and adherence to contact precautions Bordatella pertussis Background “The lung is so irritated that, in its attempt by every effort to cast forth the cause of the trouble, it can neither admit breath nor easily give it forth again. The sick person seems to swell up, and, as if about to strangle, holds his breath clinging in the midst of his jaws. …” DeBaillou describing the first documented whooping cough epidemic in 1578 In 1679 Syndenham named the illness pertussis which means violent cough In 1900 Bordet and Gengou discovered the organism which causes whooping cough and by 1906 they had developed media to support culture and detailed morphology and virulence Pertussis is caused by a fastidious, strictly aerobic gram negative coccobacillus Epidemiology Humans are the only known hosts of B. pertussis Transmission occurs by close contact with cases via aerosolized droplets Cases occur year round with peaks in late summer/autumn In immune-naïve population, it is estimated a primary case will result in 17 secondary cases18 In households up to 80% of immunized contacts of symptomatic cases acquire infection 4 Mild or unrecognized atypical disease to classic pertussis Epidemiology Prior to routine vaccination large burden of disease and high mortality rates in infants The first whole-cell vaccine introduced in 1940s Very successful and resulted in tremendous decrease in disease incidence In pre-vaccine era, natural infection(s) resulted in boosted immune response Since routine vaccination and reduction in natural disease, now see waning immunity over time Result is increase in cases in people > 10 years of age Waning maternal immunity and transplacental antibody Increase in pertussis in very young infants Epidemiology Currently approximately 50% of cases reported are in adults and adolescents4 Reservoir of infection for infants who are unimmunized or partially immunized Based on epidemiologic studies, most infants infected by adolescents or adults in the household Highest rates of mortality among infants and elderly4,17 Case fatality rates approximately 1% in infants < 2 months and <0.5% in infants 2-11 months17 Recent studies have highlighted risk in elderly17 Older patients with longer hospitalizations for pertussis Although pertussis related deaths rare in adults, most in persons > 50 years of age and majority > 65 Clinical Manifestations: 3 Stages Classic Disease Catarrhal Nonspecific sings and symptoms following 7-10 day incubation period Often mistaken for viral URI Paryoxysmal Typically starts second week of illness Hallmark coughing spells Cough paroxysm low lung volumes Post-tussive emesis and syncope reported vigorous inspiration Convalescent Slow transition after 2-3 months of paroxysmal stage Persistent cough that is less frequent and less severe Clinical Manifestations Adults and adolescents with prior infection/immunization highly variable presentation Often mild and atypical Most common symptom is a persistent cough Frequently pertussis not suspected by clinician and therefore not diagnosed Pertussis estimated to be the cause in 12-32% of adolescents and adults with prolonged cough (> 3 weeks)4 Laboratory Diagnosis Culture B. pertussis fastidious and requires special culture media resulting in false negatives Delay in transport and plating, as well as duration of illness at time of collection, and prior antibiotics contribute to high rate false negatives Sensitivity only 30-60% PCR Able to detect small number of organisms Unaffected by prior antibiotics Used more frequently due to better sensitivity and specificity Challenges in testing Must obtain specimen from ciliated respiratory epithelium of posterior nasopharynx Cotton swabs toxic to organism and calcium alginate interfere with PCR, so dacron swabs preferred Treatment If considering testing then should also consider treating Treatment during catarrhal phase may decrease duration of illness Treatment at later stages does not affect duration of illness but reduces shedding and spread Macrolides preferred and usually eradicate B. pertussis in 5 days Infection Control Considerations Untreated may remain contagious for > 1 month Post exposure prophylaxis 1 Household and close contacts If unimmunized or under immunized: age appropriate vaccine and chemoprophylaxis If immunized but in household with high risk individual : chemoprophylaxis Monitor closely for symptoms 21 days after last contact and evaluate and treat when appropriate Child care Prophylaxis for household and close contacts Providers and exposed children observed for 21 days after last contact Children and providers with confirmed pertussis excluded until completed 5 days of antimicrobial therapy or 21 days if untreated Infection Control Considerations Post exposure prophylaxis1 Schools Students and staff with pertussis excluded until completed 5 days antimicrobial therapy or 21 days from onset of symptoms if untreated Immunization given Consider status reviewed and age appropriate vaccines excluding persons with cough illness pending eval by physician Infection Control Considerations Post exposure prophylaxis1 Health Tdap Care Settings may not preclude need for antimicrobial prophylaxis Antimicrobial prophylaxis recommended for ALL health care workers (HCW) regardless of immunization status who have unprotected exposure to pertussis AND are likely to have contact with high risk patient Other HCW should receive antimicrobial prophylaxis or be monitored for 21 days and treated at first sign symptoms Patients and caregivers who are close contacts or high risk contacts of patient or HCW with pertussis should receive antimicrobial prophylaxis and if appropriate, vaccination HCW with suspected pertussis or cough illness within 21 days of exposure should be excluded pending 5 days of antimicrobial therapy or 21 days if refuse treatment Infection Control Considerations Isolation1,20 Droplet precautions for until patient has completed 5 days of effective therapy If appropriate therapy not given then droplet precautions until 3 weeks after onset of cough Measles Background Recorded epidemics of measles date back to the 10th century Repeated epidemics have occurred throughout the ages in Europe, Asian, and ultimately America The first live attenuated measles vaccine licensed for use in 1963 2001 Measles declared eradicated from the US with the only cases imported Virology Large RNA virus of the family Paramyxoviridae Virion composed of outer lipoprotein envelope and internal nucleocapsid Labile and inactivated rapidly by heat, UV light, and lipid solvents •Photo Credit: Cynthia S. Goldsmith •Content Providers(s): CDC/ Courtesy of Cynthi S. Goldsmith; William Bellini, Ph.D. Epidemiology Although declared eradicated in 2001, importation of cases continues15 From 2001-2012 median number of cases annually in US was 60 This year to date 159 cases have been reported in 16 states 82% cases unimmunized and 9% unknown immunization status Of those unimmunized, 79% had philosophical objections and 13% were infants too young to be immunized http://www.cdc.gov/mmwr/preview/mm wrhtml/mm6236a2.htm#fig2 Epidemiology 2013 outbreaks15 11% required hospitalization 4 patients diagnosed with pneumonia No deaths reported Source of outbreaks continues to be WHO European Region http://www.cdc.gov/mmwr/preview/mmwrhtml/mm 6236a2.htm#fig2 Clinical Manifestations Prodrome Onset characterized by fever, cough, coryza, conjunctivitis Koplik spots, bluish white spots on bright red mucosal surface, usually appear on approximately day 10 and are pathognomonic Exanthem stage Characteristic rash appears on day 14 after exposure Rash starts on hairline and spreads from head to feet in centrifugal manner Exanthem begins to clear on day 3-4 of rash and typically lasts 6-7 days Clinical Manifestations: Complications Pneumonia10 Very common and reported in 50-75% Young infants have clinical picture of bronchiolitis Clinical course can progress to severe pulmonary disease and ARDS Encephalitis10 0.5 to 1 per 1000 cases 20-40% of patients with encephalitis have evidence of brain damage Subacute Sclerosing Panencephalitis (SSPE)10 Rare, incidence in pre-vaccine era after infection with wild type measles 1 case per 100,000 population Stage 1 progressive psychointellectual disturbances Stage 2 convulsive and motor disorders Stage 3 pre-terminal stage with rapid decrease in cortical activity ultimately progression to vegetative state Progression over months to years Laboratory Diagnosis Viral culture PCR Can be performed on throat swab specimens Serology Acute and convalescent titers Single positive IgM suggests diagnosis Treatment Supportive care for typical measles Vitamin A supplements recommended in certain situations 1,10 Reduced morbidity in Vitamin A deficient children Enhanced IgG and total lymphocyte numbers Children 6 months to 2 years who require hospitalization Children > 6 months with suspected vitamin A deficiency Infection Control Considerations Transmitted by direct contact with infectious droplets or airborne spread Airborne transmission precautions indicated for 4 days after onset of rash in healthy children and duration of illness in immunosuppressed 1,20 Negative airflow room with 6-12 changes per hour Susceptible HCW should not enter patient rooms If susceptible persons must enter then N-95 mask should be worn People with documented immunity do not need to wear a mask Infection Control Considerations Vaccination recommended for all people who work or volunteer at health care facilities and who may be in contact with patients with measles1 Adequate evidence of immunity 1 Documentation of 2 doses live-virus measles vaccine Laboratory evidence of immunity or confirmation of disease Birth before 1957 References 1. 2. 3. 4. 5. 6. 7. American Academy of Pediatrics. RedBook: The report of the committee on infectious diseases 2012 Boivin, G. et al. An outbreak of severe respiratory tract infection due to human metapneumovirus in a long-term care facility. CID 2007;44(1-May): 1152-1158 Caram et al. Respiratory Syncytial Virus outbreak in a long-term care facility detected using reverse transcriptase polymerase chain reaction: an argument for real-time detection methods. J Am Geriatric Soc 2009;57:482-485 Cornia, P et al. Does this coughing adolescent or adult patient have pertussis? JAMA 2010;304(8):890-896 Falsey, Ann. Respiratory Syncytial Virus infection in Adults. Seminars in Respiratory and Critical Care Medicine; 28(2)2007:171-181 Falsey AR. Et al. Respiratory syncytial virus infection in elderly and high-risk adults. N Engl J Med 2005;28:1749-1759 Falsey AR et al. Acute respiratory tract infection in daycare centers for older persons. J Am Geriatr Soc 1995;45:30-36 References 8. 9. 10. 11. 12. 13. 14. 15. Falsey, Ann. Human metapneumovirus infection in adults. The Pediatric Infectious Disease Journal 2008;27(10):s80-s83 Falsey, Ann et al. Human metapneumovirus infections in young and elderly adults. JID 2003;187(1-March):785-790 Feigan and Cherry’s Textbook of Pediatric Infectious Diseases 6th edition. Saunders Elsevier Philadelphia PA 2009 Liao, R. et al. An outbreak of severe respiratory tract infection due to human metapneumovirus in a long-term care facility for the elderly in Oregon. Journal of Clinical Virology 2012;53:171-173 Liss, HP, Bernstein, J. Ribavirin aerosol in the elderly. Chest 1998;93:1239-1241 Louie, J. et al. A summer outbreak of human metapneumovirus infection in a longterm-care facility. JID 2007;196(1-September):705-708 Mullooly et al. Influenza and RSV associated hospitalizations among adults. Vaccine 2007;25:846-855 MMWR. Centers for Disease Control and Prevention. September 13, 2013 / 62(36);741743 References 16. 17. 18. 19. 20. 21. Osterhaus A, Fouchier R. Human metapneumovirus in the community. Lancet 2003;111:1407-1410 Ridda, I. et al. The importance of pertussis in older adults: A growing case for reviewing vaccination strategy in the elderly. Vaccine 2012; 30: 6745-6752 Schellekens, J. Et al. Pertussis sources of infection and routes of transmission in the vaccination era. Pediatr Infect Dis J 2005;24: S19-S24 Senzilet, L et al. Pertussis is a frequent cause of prolonged cough illness in adults and adolescents. CID 2001;32(15 June): 1691-1697 Siegel, J et al. 2007 guideline for isolation precautions: preventing transmission of infectious agents in healthcare settings. The Healthcare Infection Control Practices Advisory Committee Zambon et al. Contribution of influenza and respiratory syncytial virus to community cases of influenza-like illness: an observational study. Lancet 2001;358:1410-1416