Download Burkholderia Pseudomallei (Melioidosis)

COMMUNICABLE DISEASE MANUAL POLICIES / PROCEDURES
BURKHOLDERIA PSEUDOMALLEI
(MELIOIDOSIS)
WHITMORE DISEASE
OBJECTIVE:
Control and management of Burkholderia pseudomallei; to be able to identify
its use as a bioterrorism agent.
DESCRIPTION:
Melioidosis, also called Whitmore’s disease, is an infectious disease caused by
the bacterium Burkholderia pseudomallei.
Melioidosis is clinically and
pathologically similar to glanders disease, but the ecology and epidemiology of
melioidosis are different from glanders. Melioidosis is predominately a disease
of tropical climates, especially in Southeast Asia where it is endemic. The
bacteria causing melioidosis are found in contaminated water and soil and are
spread to humans and animals through direct contact with the contaminated
source. Glanders is contracted by humans from infected domestic animals.
Burkholderia pseudomallei is an organism that has been considered as a
potential agent for biological warfare and biological terrorism as it is moderately
easy to disseminate and has low morbidity rates, although the case fatality rate
among overt cases is high. Control measures include rapid identification (and
control) of the point source. The value of prophylactic medication is unproven,
but may be efficacious to control spread of the disease. There is no vaccine for
melioidosis.
Melioidosis is endemic in Southeast Asia, with the greatest concentration of
cases reported in Vietnam, Cambodia, Laos, Thailand, Malaysia, Myanmar
(Burma), and northern Australia. Additionally, it is seen in the South Pacific,
Africa, India, and the Middle East. In these endemic countries, Burkholderia
pseudomallei often is acquired early in life, with the highest seroconversion
rates between 6 and 42 months of age. Symptomatic infection can occur as
early as 1 year of age. Risk factors for disease include diabetes mellitus and
renal insufficiency. In many of these countries, Burkholderia pseudomallei is so
prevalent that it is a common contaminate found on laboratory cultures.
Moreover, it has been a common pathogen isolated from troops of all
nationalities that have served in areas with endemic disease. A few isolated
cases of melioidosis have occurred in the Western Hemisphere in Mexico,
Panama, Ecuador, Haiti, Brazil, Peru, Guyana, and in the states of Hawaii and
Georgia. In the United States, confirmed cases range from none to five each
year and occur among travelers and immigrants.
Besides humans, many animal species are susceptible to melioidosis. These
include sheep, goats, horses, swine, cattle, dogs and cats. Transmission
occurs by direct contact with contaminated soil and surface waters. In
Southeast Asia, the organism has been repeatedly isolated from agriculture
fields, with infection occurring primarily during the rainy season. Humans and
animals are believed to acquire the infection by inhalation of dust, ingestion of
contaminated water, and contact with contaminated soil, especially through
skin abrasions, and for military troops, by contamination of war wounds.
Person-to-person transmission can occur by blood and body fluid contact with
an infected person. There is one report of transmission to a sister with
diabetes who was the caretaker for her brother who had chronic melioidosis.
Two documented cases of sexual transmission have been reported.
Transmission in both cases was preceded by a clinical history of chronic
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prostatitis in the source patient, due to melioidosis.
infections can occur if procedures produce aerosols.
Laboratory acquired
Illness from melioidosis can be categorized as acute or localized infection,
acute pulmonary infection, acute bloodstream infection, and chronic
suppurative infection. Inapparent infections are also possible. The incubation
period (time between exposure and appearance of clinical symptoms) is not
clearly defined, but may range from 2 days to many years.
Acute, localized infection: This form of infection often results in ulcer,nodule,
or skin abscess. This results from inoculation through a break in the skin. The
acute form of melioidosis may or may not produce fever and general muscle
aches.
Pulmonary infection: This form of the disease can produce a clinical picture
of mild bronchitis to severe pneumonia. The onset of pulmonary melioidosis is
typically accompanied by a high fever, headache, anorexia, and general muscle
soreness. Chest pain is common, but a nonproductive or productive cough
with normal sputum is the hallmark of this form of melioidosis.
Acute bloodstream infection: Patients with underlying illness such as HIV,
renal failure, and diabetes are affected by this type of the disease, which
usually results in septic shock. The symptoms of the bloodstream infection
vary depending on the site of original infection, but they generally include
respiratory distress, severe headache, fever, diarrhea, development of pusfilled lesions on the skin, muscle tenderness, and disorientation. This is
typically an infection of short duration, and abscesses will be found throughout
the body.
Chronic suppurative infection: Chronic melioidosis is an infection that
involves abscesses in the organs of the body. These typically include joints,
viscera, lymph nodes, skin, brain, liver, lung, bones, and spleen.
Disease in humans is uncommon even among people in endemic areas who
have close contact with soil or water containing the infectious agent.
Approximately two-thirds of cases have a predisposing medical condition such
as diabetes, cirrhosis, alcoholism or renal failure, which may precipitate disease
or recrudescence in asymptomatic infected individuals.
EQUIPMENT:
MDSS User Manual and Disease specific form found in MDSS.. MDCH
website
at
www.michigan.gov/cdinfo
and
CDC
website
at
www.cdc.gov/diseasesconditions/az/a.html.
POLICY:
Legal Responsibility: Michigan’s communicable disease rules of Act No. 368 of
the Public Acts of 1978, as amended, being 333.5111 of the Michigan
Compiled Laws. Notify MDCH immediately via phone and fax if suspect or
confirmed case and follow-up within 24 hours post referral. ENTER INTO
MDSS WITHIN 24 HOURS OF RECEIPT OF REFERRAL.
PROCEDURE:
A.
Case Investigation
1.
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Referral received per phone call, laboratory results, or
automatically through MDSS.
2.
Document all case investigation proceedings.
3.
Contact MD and/or client to start process of completing disease
specific form in MDSS.
4.
Immediately notify CD Supervisor, Medical Director and
Health Officer for confirmed or suspected cases. Call
MDCH at 517-335-8165 and Regional Epidemiologist. Nurse
to Fax Notification of Serious Communicable Disease form
to MDCH for confirmed or suspected cases.
B.
Diagnosis-- Laboratory Criteria
1.
CONFIRMED: Diagnosis --by isolating B. pseudomallei from
clinical specimen of a case of severe febrile illness. A culture of
the organism may be done by blood, sputum, urine, pus, throat
swab, or swabs from organ abscesses or wounds.
2.
PROBABLE: -- Evidence of a four fold or greater rise in B
pseudomallei antibody titer by IHA between acute-and
convalescent- phase serum specimens obtained greater than or
equal to 2 weeks apart..---OR-- Evidence of B. pseudomallei
DNA (for example, by LRN- validated polymerase chainreaction)
in a clinical specimen collected from a normally sterile site
(blood) or lesion of other affected tissue (abscesses, wounds.)
3.
The possibility of melioidosis must be kept in mind in any
unexplained suppurative diseases, especially cavitating
pulmonary disease, in patients living in or returned from endemic
areas; as disease may manifest symptoms as long as 25 years
after exposure.
4.
Contact MDCH Laboratory at 517-335-8067 prior to obtaining or
sending cultures for suspect cases. Notify MDCH Infectious
Disease Section at 517-335-8165 of potential case.
5.
States and territories should also notify the CDC’s Bacterial
Special Pathogens Branch of such cases by calling 404-6391711 or e-mailing— [email protected]
.
C.
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Control Measures
1.
There is no vaccine for melioidosis.
2.
Prevention of the infection in endemic-disease areas can be
difficult since contact with contaminated soil is so common.
3.
Persons with diabetes and skin lesions should avoid contact with
soil and standing water in these areas.
4.
Wearing boots during agricultural work can prevent infection
through the feet and lower legs.
5.
In health care settings, using universal respiratory, contact,
blood and body fluid precautions can prevent transmission.
6.
Safe disposal and handling of sinus drainage, sputum and
wound discharges.
7.
Educating families and patients about hand hygiene and
appropriate personal hygiene is recommended to prevent
spread.
8.
Remind patient and family Burkholderia pseudomallei are
waterborne and soil borne organisms that can survive for
prolonged periods of time when kept moist. Good hygiene and
careful handling and disposal of discharges are a must to
prevent spread within the family.
9.
The most effective treatment is IV ceftazidime or imipenem for at
least 10 days, followed by a 4-drug combination of doxycycline,
trimethoprim-sulfamethoxazole
(for
20
weeks)
and
chloramphenicol (for the first 8 weeks). The infection may be
slow to respond to treatment and even with 20 weeks of
treatment, 10% relapse. Treatment for an inadequate length of
time leads to a high probability of relapse. Abscesses should be
drained if possible.
10.
Although bloodstream infection with melioidosis can be fatal, the
other types of the disease are nonfatal. The type of infection
and the course of treatment can predict any long-term sequelae.
D.
MDSS Case Reporting
Case Classification:
Confirmed: A case that is laboratory confirmed, with or without
clinical evidence.
Probable: A case that meets the case clinical definition, one or
more of the probable lab criteria, and one of the following
epidemiological findings:
History of travel to a melioidosis-endemic region, OR
Known exposure to B. pseudomallei as a result of
intentional release or occupational risk (lab exposure)
1.
2.
3.
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Complete case investigation using disease specific form in
MDSS.
Notify CD Supervisor that the case report is ready for review.
PHN will be notified if corrections are needed prior to closing
case in MDSS.
CD Supervisor reviews case for completeness and closes MDSS
case report.
RESOURCES:
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Current Red Book
Current Control of Communicable Diseases Manual
Current disease specific “Fact Sheet”
Websites: www.cdc.gov/diseasesconditions/az/a.html
www.michigan.gov/cdinfo