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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 D:\769847135.docPage 1 of 5 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. D:\769847135.docPage 2 of 5 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. D:\769847135.docPage 3 of 5 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. D:\769847135.docPage 4 of 5 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: D:\769847135.docPage 5 of 5 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