1. Current Culture of Infectious Diseases
November 11, 2016

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• Newsworthy Diseases
− Ebola
− Measles
− Pertussis
− Zika
− MDROs
• Vaccine Updates
− HPV
− Influenza
Current Culture of Infectious Diseases

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• Direct
− Contact with contagious person or animal
• Indirect
− Contact with something contagious person or animal touched
• Vehicle
− Droplet / Airborne
− Foodborne
− Waterborne
• Vector Borne
− Insects
HOW DISEASES SPREAD

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DIRECT CONTACT
http://barfblog.com/wp-content/uploads/2015/09/handwashing.sep_.12.jpg
https://c1.staticflickr.com/1/95/258394782_e8cd5c84b9.jpg

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INDRIECT TRANSMISSION
http://www.callahead.com/portable-toilets/aqua-head-portable-restroom/aqua-
portable-toilet-ny-7.jpg
http://image.cdn.ispot.tv/ad/7K9L/clorox-disinfecting-wipes-toilet-plunger-large-4.jpg

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DROPLET/AIRBORNE
http://d3819ii77zvwic.cloudfront.net/wp-content/uploads/2014/04/sneeze-1024x557.jpg

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FOOD/WATER BORNE
http://gislerc.weebly.com/uploads/1/3/6/8/13681337/2531847.jpg?1347540139
http://www.ehealthzine.com/wp-content/uploads/2013/05/hepatitis-a-symptoms.jpg
https://blog.itriagehealth.com/frozen-fruit-mix-suspected-hepatitis-outbreak/

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FECAL ORAL ROUTE BYPASS THE HANDS
http://barfblog.com/wp-content/uploads/2012/01/dog_vomit(5).jpg
…or not.

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VIRAL SPREAD – VECTOR
https://www.vectorbase.org/sites/default/files/ftp/a_ae
gypti_0.png
http://albany.mosquitosquad.com/albanys-tick-identification-disease-control/
https://farmersbranchtx.gov/images/pages/N713/Femal
e%20Culex%20Quinque%20laying%20eggs.jpg

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Best line:
“Blogs are nothing but graffiti with punctuation”

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R “Naught” Contagiousness Factor

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Recent Outbreaks

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Ebola Virus Disease
• Identified in 1976
• Only outbreaks have been in Africa
• US international travel case first ever
• Largest Ebola outbreak in history
• West African high case fatality rate of 50-90% largely due to
lack of basics like water and ICU care

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• Not in air, water or food
• Infectious only when the individual is ill, not before
• Spread when virus in stool, urine, vomit, semen, breast milk,
saliva, sweat, blood enter through open skin, in eyes, nose or
mouth or needle stick.
• Incubation period is generally a week (2-21 days)
• No antivirals for treatment or vaccines for prevention
Ebola Transmission

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Clinical Look-alikes. Carefully assess
• Malaria
• Dengue
• Rickettsial disease
• Shigellosis
• Typhoid fever
• Pneumonia
• Meningococcemia
• Potential for co-infection
• Malaria parasite in RBC
• Photo by Albert Bonniers Forlag, National Geographic

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Symptoms
• Fever
• Severe headache
• Muscle Pain
• Weakness
• Diarrhea
• Vomiting
• Abdominal pain
• Bruising, bleeding,
hemorrhage

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Progression

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West Africa

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Level 1 PPE

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Level 2 PPE: Care of Ebola case
New CDC guidance. No Skin Showing

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Discharge to Home
Photo: White house EPA/Olivier Douliery Nebraska AP Photo Nati Harnik

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Screening and Control

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• 2011- Minnesota had the
largest outbreak in the
country
• 2013
− 11 Outbreaks, 3 with > 20
cases.
• 2014
− 23 Outbreaks
 383 cases in Amish
communities in Ohio
• 2015
− 4 outbreaks
 Over 200 Cases
through Mid-March
Measles

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Measles Cases in US

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Historical Significance of Recent Cases

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Historical Significance of Recent Cases

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• Early November
− Typhoon Haiyan (Yolanda in Philippines)
 Deadliest in Modern History
o 6300 dead
Philippines 2013

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• 2014 WHO Measles Report (As of 2/19/2015)
− 58,010 suspected
− 21,420 confirmed
− 110 deaths
• 25 US travelers became ill
− Most were unvaccinated
Philippines

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• Now over 200 cases
confirmed
− 110+ CA residents
− Additional cases linked to
Disneyland in:
 AZ, CO, NE, OR, UT, WA
 Mexico, Canada
Disneyland Outbreak

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• Rubeola
− “English,” “Hard,” “Red,” “7-day” measles—what we are talking
about today
• Rubella
− “German,” “3-day” measles
− Different Order
Measles - Background

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• Rubeola
− “English,” “Hard,” “Red,” “7-day” measles
• Rubella
− “German,” “3-day” measles
− Different Order
• Closely Related to
− Parainfluenza, Mumps (same subfamily)
− RSV (same family)
• Attaches easily to respiratory tract surfaces
• Infection spreads beyond respiratory tract
− Parainfluenza and RSV do not invade further
Measles - Background

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• History of Illness
− Early illness lasts several days
− Looks like other viral infections
• FEVER (usually high)
• Develop the 3 C’s
− CONJUNCTIVITIS
(watery, typically non-purulent)
− CORYZA (rhinitis)
− COUGH (non-specific, “croupy”)
• RASH
 May last a week or more
Triage Considerations

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• Starts at hairline and spreads across face to trunk
− Like “a bucket of virus poured over the head”
• Lasts 4-6 days or more
• Clears in same order
• Patient is most contagious
− 4 days before rash appears
− 4 days after rash appears
Measles Rash

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Rash

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• Measles virus is Airborne
− Spreads through the air on tiny droplets
• Highly Infectious
− 9 out of 10 susceptible people will develop illness
• Highly Contagious
− Spreads easily
− Exposure can occur 2 hours after patient left room
Measles is Contagious…
http://graphics.thomsonreuters.com/15/measles/index.html

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• MMR Vaccine > 97% effective
− With 2 doses (> 93% with 1)
• Herd Immunity protects
− Infants < 12 months of age
− Immunocompromized
− < 3% vaccine “non-responders”
• Health Care Workers
− Protected by vaccination
− Recommendation for N95 use
− If unable to fit test staff
 have patient AND staff wear masks
…but Preventable

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• Droplet Transmission
• “100 day” cough
• Worse at night
• May have vomiting
• Face/lips may look blue due to
lack of oxygen
Pertussis

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Pertussis
http://www.immunize.org/photos/pertussis-photos.asp

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• Vaccine preventable
• More cases – Why?
− Acellular vaccine
 Not as long-lasting
− Anti-vaccine
 Under-immunized
clusters
− Bacteria mutating
 Pertactin component
absent
Pertussis
http://www.health.state.mn.us/divs/idepc/diseases/pertussis/stats/casesbyweek.pd

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• Mild Illness
− Fever
− Rash
− Headache
− Red eyes
• Sick for 2-7 days
• 20% of infected people become ill
− Complex to control
ZIKA - SYMPTOMS
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ZIKA OCTOBER 2015
• Brazil
− Increase in birth
defect reports

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• French Polynesia
− Reviewed 2013 data
 Smaller outbreak
• WHO Issued Alert 1/28/2016
− Increase in babies with abnormally small heads
 Microcephaly
− Possible increase in conditions where immune cells attack nerves
 Guillain-Barré syndrome (GBS)
− Improve system for monitoring for disease and symptoms
ZIKA WHO ALERT

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MICROCEPHALY – CLOSER LOOK
http://4.bp.blogspot.com/-C7ahJJT_t-
I/VqPK67vlu0I/AAAAAAAADe8/DYJzQjJ1jWg/s640/_
87830204_microcephaly.png
http://www.cdc.gov/ncbddd/birthdefects/images/microcephaly-comparison-
triple-450px.jpg
• Difficult to diagnose
• Measurements differ
− Duration of pregnancy
− Gender
− Race
− Ethinicity
• No cure

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MICROCEPHALY - IMAGES
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cdn.com/uploads/chorus_asset/file/5972795/Screen_Shot_2016-01-28_at_2.08.51_PM.0.png
http://static01.nyt.com/images/2015/12/30/wo
rld/31BRAZIL-web2/31BRAZIL-web2-
facebookJumbo.jpg
https://qzprod.files.wordpress.com/20
16/01/ap_521357789523.jpg?quality
=80&strip=all&w=2000
http://www.globalpost.com/sites/def
ault/files/styles/w768/public/photos/
201602/rtx2693b_2016-2-
11.jpg?itok=eoR5Z6Vg

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• Advised pregnant women
− No travel to countries with Zika transmission
• Sexual Contact
− Abstain from sexual activity 6 months after travel
− If pregnant – no sexual activity for duration of
pregnancy
• All other should take precautions to avoid bites
− Bug Spray
− Bed Nets
− Repellent Clothes
− Screens
CDC – TRAVEL WARNING
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• Better drainage
− No water = no eggs
• Insecticides
− Sprayed in and around homes
• Larvicides
− Treatments in standing water
• GMO
− Dead-end mosquitoes
MOSQUITO CONTROL
https://c.o0bg.com/rf/image_960w/Boston/2011-
2020/2016/02/17/BostonGlobe.com/Foreign/Images/05164725.jpg
http://www.circleofblue.org/watern
ews/2016/science-
tech/health/water-a-key-factor-in-
zika-virus-spread/
http://www.oxitec.com/oxitec-video/more-on-the-science-how-does-oxitec-
make-genetically-modified-mosquitoes/

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• Multi-Drug Resistant Organisms
− C. difficilie
− MRSA
− CRE
MDROs
https://www.cdc.gov/mrsa/community/photos/photo-mrsa-13.html
https://www.cdph.ca.gov/programs/hai/PublishingImages/CREthreatInfographicCDC.png

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• Clostridium difficile
• Bacterial infection causes symptoms including severe diarrhea
C. diff
http://www.health.state.mn.us/divs/idepc/diseases/cdiff/cdistat2014.pdf

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• Treatment advances
• Fecal transplant
− If disease persists after several rounds of traditional therapy
C. diff

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• Methicillin-resistant Staphylococcus aureus
− 1961: 1 year after methicillin introduced
• Most often spread by contaminated hands
− Wash ‘em Proud
MRSA
http://www.health.state.mn.us/divs/idepc/dtopics/invbacterial/invbacrpt14.pdf

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• Carbapenem-resistant Enterobacteriaceae
− Recent outbreaks associated with medical devices
 Duodenoscopes
CRE
https://www.cdc.gov/hai/settings/lab/lab-duodenoscope-sampling.html

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Vaccine Updates

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• AAP Immunization
Schedule
Vaccination Schedule 1983
http://www.cdc.gov/vaccines/schedules/images/schedule1983s.jpg

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Vaccination Schedules - 2016
• Birth to 18
years

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• 1st of 3
pages
Vaccination Schedule – 2016 Footnotes

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• Human Papillomavirus
• Gardasil 9
− 9 valent vaccine
− Protective against 90% of cancers
 Cervical, vaginal, vluvar
 Penile
 Anal
 Oropharengyal
HPV Vaccine
http://media1.s-
nbcnews.com/j/newscms/2016_02/936821/rory-
joey-feek-today-160115-
01_ce3b251039419854a449c84b22241a60.today-
inline-large.jpg

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HPV Vaccine Coverage
https://www.cdc.gov/mmwr/volumes/65/wr/mm6533a4.htm?s_cid=mm6533a4_w#F1_down

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• Most effective when
− Given before exposure
− Provided earlier than later
 11-12 yrs of age
• New Schedule (starting 10/19/16)
− 3 dose schedule
 For immunocompromized
 Series start older than 14 years of age
− 2 dose
 1st dose given before 15th birthday
 2nd dose given 6-12 months later
HPV Vaccine Schedule

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• If you had chickenpox…
− You already have the virus
• Zoster virus case
− Painful rash
− Scabs over after a week
− 2-4 weeks to fully heal
• Vaccine advised for
− All people aged 60+
− Even if you’ve already had shingles
Shingles Vaccine

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• Unintended
consequences
Pneumococcal Vaccine(s)

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• Starting 2014:
• Adults 65yrs old +
− 1 dose of PCV13
− 1 dose of PPSV23 1 year later
Pneumococcal Vaccine(s)

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• Children’s Infection Prevention Team
− Patsy Stinchfield
− Wendy Berg
− Jennifer Boe
− Martina Korinek
− Julie LeBlanc
− Caramae Steinwand
− Adriene Thronton
• Minnesota Department of Health
Special Thanks

64. Thank you
Joseph Kurland, MPH
Vaccine Specialist / Infection Preventionist
Joseph.Kurland@childrensmn.org
Twitter: @InfectiousJK