January 2010 Selected Zoonotic Diseases Conference Call

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January 2010 Selected Zoonotic Diseases Conference Call

  1. 1. National Center for Emerging and Zoonotic Infectious Diseases (proposed)<br />1<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  2. 2. Shauna L. Mettee, MSN, MPH<br />EIS Officer, Enteric Diseases Epidemiology Branch, CDC<br />404-639-5277 smettee@cdc.gov<br />Human Salmonella Associated with Aquatic Frogs<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  3. 3. It’s Not Easy Being Green–A Multistate Outbreak of Human Salmonella Typhimurium Infections Associated with Aquatic Frogs–United States, 2009<br />Shauna L. Mettee, RN, MSN, MPH<br />LTJG, United States Public Health Service<br />Epidemic Intelligence Officer<br />Outbreak Response and Prevention Branch<br />Division of Foodborne, Bacterial and Mycotic Diseases <br />National Center for Zoonotic, Vector-borne and Enteric Diseases <br />Centers for Disease Control and Prevention<br />*All results are preliminary and subject to change* <br />
  4. 4. Infections with the outbreak strain of Salmonella Typhimurium, by week of illness onset (n=83 for whom information was reported as of 12/31/09)*<br />No. of cases<br />Illnesses that began during this time may not yet be reported<br />Week of Illness Onset<br />*Some illness onset dates have been estimated from other reported information<br />(Estimated onset dates range 4/9 – 12/11; Reported onset dates (n=48) range 5/24 – 11/30)<br />
  5. 5. Case Counts by States reporting Salmonella Typhimurium cases in cluster 0909MAJPX-1, as of Thursday, December 31, 2009<br />WA<br />7<br />MN<br />1<br />MA<br />3<br />NY<br />2<br />WI<br />1<br />ID<br />1<br />SD<br />3<br />MI<br />4<br />PA<br />4<br />NE<br />1<br />OH<br />2<br />IN<br />1<br />NV<br />1<br />IL<br />5<br />UT<br />14<br />VA<br />3<br />CO<br />4<br />CA<br />5<br />MO<br />4<br />KY<br />1<br />NJ<br />2<br />TN<br />2<br />AZ<br />1<br />MD<br />3<br />NM<br />1<br />GA<br />1<br />AL<br />1<br />MS<br />1<br />LA<br />1<br />TX<br />4<br />FL<br />1<br />1-2 Cases<br />3-4 Cases <br />More than 4 Cases <br />
  6. 6. Demographics for cases of Salmonella Typhimurium cases in cluster 0909MAJPX-1, as of Thursday, December 31, 2009<br />
  7. 7. Results of Matched Case-Control Study<br />Among 19 cases and 31 controls, illness was significantly associated with exposure to frogs (63% cases vs 3% controls, mOR=24.4, CI=4.0-infinity). <br />Among 6 case-patients who knew the frog type, all reported African Dwarf Frogs. <br />
  8. 8. Results of Environmental Sampling<br />Environmental samples from aquariums containing African Dwarf Frogs in 4 patients’ homes yielded Salmonella Typhimurium isolates matching the outbreak strain. (CO, UT, OH, NM)<br />Common breeder in California identified during traceback investigation<br />Environmental samples from breeder’s facility yielded outbreak strain<br />
  9. 9. African Dwarf Frogs<br />
  10. 10. Historical Case Investigation <br />Asking states to interview historical cases from Jan 1, 2008 - present with revised case questionnaire. <br />PLEASE CONTACT <br />Shauna Mettee at 404-639-5277 or smettee@cdc.gov to obtain case questionnaire<br />
  11. 11. For more information<br />CDC Web Update<br />http://www.cdc.gov/salmonella/typh1209/index.html<br />MMWR – Jan 8, 2009<br />Multistate Outbreak of Human Salmonella Typhimurium Infections Associated with Aquatic Frogs — United States, 2009<br />Contact: Shauna Mettee, smettee@cdc.gov<br />
  12. 12. Acknowledgments<br />CDC<br />Samir Sodha, Casey Barton Behravesh, Linda Capewell, Gwen Ewald, Nancy Garrett, Brenda Le, Leslie Hausman, Ian Williams<br />State and Local Health Departments: <br />Alabama, Arizona, California, Colorado, Florida, Georgia, Idaho, Indiana, Illinois, Kentucky, Louisiana, Massachusetts, Maryland, Michigan, Minnesota, Missouri, Mississippi, Nebraska, Nevada, New Jersey, New Mexico, New York, Ohio, Pennsylvania, South Dakota, Tennessee, Texas, Utah, Virginia, Washington, and Wisconsin<br />
  13. 13. Julia Murphy, DVM, MS, DACVPM <br />Virginia Department of Health,<br />804-864-8113 Julia.murphy@vdh.virginia.gov<br />Kim Mitchell, MPH<br />Maryland Department of Health and Mental Hygiene, Center for Zoonotic and Vector-borne Diseases<br />410-767-6618 kmitchell@dhmh.state.md.us<br />Peter Troell, MD, MPH<br />Fairfax County Health Department 703-246-2411 peter.troell@fairfaxcounty.gov <br />Human Rabies Case in Virginia<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  14. 14. Human Rabies, Virginia 2009<br />Julia Murphy, DVM, MS, DACVPM<br />State Public Health Veterinarian<br />Virginia Department of Health<br />
  15. 15. Patient Background<br />42 y.o. male with no significant past medical history<br />Physician involved primarily in teaching and research<br />Symptom onset October 23, 2009<br />Hot and cold flashes at work<br />October 24<br />Leg pain and backaches <br />Spontaneous ejaculation<br />Urinary incontinence<br />
  16. 16. Patient Background<br />Presented to local ED on October 26<br />MRI of lumbar spine<br />Discharged and referred to PCP<br />Evidence of hydrophobia<br />Gagging while drinking and showering<br />October 27 returned to same ED for evaluation of neurologic disorder / rabies<br />Anxious and exhibited “bizarre” behavior<br />Admitted<br />
  17. 17. Hospitalization<br />Agitated<br />Required antipsychotic and 4 point restraints<br />Cardiac arrest requiring intubation<br />Frothing at mouth and spitting<br />Multiple seizures<br />
  18. 18. Hospitalization<br />Rabies ante-mortem sampling<br />Sent to CDC 10/29 early a.m.<br />Rabies antigen detected in neck biopsy, 10/29 p.m.<br />Sequenced as Indian canine virus, 10/30<br />
  19. 19. Hospitalization<br />Milwaukee protocol initiated<br />Induced coma<br />Samples sent daily to CDC to monitor viral load and antibody levels<br />Frequent consultation with Dr. Willoughby<br />Normal blood and intracranial pressures became increasingly difficult to maintain<br />
  20. 20. Hospitalization<br />Transcutaneous pacer, continuous renal dialysis and continual CSF draining required by November 12 <br />Patient died November 20, 2009 after 24 days of hospitalization<br />Postmortem performed by hospital and samples sent to CDC<br />
  21. 21. Possible Rabies Exposures<br />Travel to India July 3 – August 7, 2009<br />Father-in-law reported patient experienced scratch or bite from unknown dog while jogging<br />No post-exposure prophylaxis pursued <br />Sequence consistent with Indian canine virus<br />Potential bat exposure<br />Rabid bat in his workplace, but not in his building<br />
  22. 22. Public Health Investigation<br />Potential exposure to others<br />Hospital staff<br />Wife and 2 children and family members<br />Friends of the family<br />Workplace exposures involving 3 clinical facilities<br />2 in Maryland<br />1 in Washington, DC<br />Infectious period: October 8 forward<br />
  23. 23. Public Health Investigation<br />Two survey tools created<br />Healthcare workers<br />Coworkers, friends, family<br />VDH, Fairfax Health District, MD DHMH and DCDOH conducted exposure assessments <br />
  24. 24. Surveys<br />Healthcare worker survey<br />Contact with infectious materials<br />Types of procedures performed<br />PPE worn when performing procedures<br />Household and coworker survey<br />Contact with infectious materials<br />Activities shared with patient<br />
  25. 25. Results<br />Hospital: Fairfax County HD (FHD) assessed 70 of 70 potentially exposed individuals<br />24 pursued PEP<br />17 met criteria for non-bite exposure<br />7 did not meet criteria but pursued PEP <br />Family: FHD assessed all family identified as having contact with the patient during the infectious period (n=6)<br />3 immediate and 3 additional family members<br />All pursued PEP<br />
  26. 26. Results<br />DC: 34 of 40 contacts at patient’s worksite assessed<br />2 close friends pursued PEP<br />MD: 63 of 63 contacts at patient’s worksites assessed<br />Facility 1: 19/19 individuals assessed<br />Facility 2: 44/44 individuals assessed<br />No PEP pursued<br />
  27. 27. PEP Summary, Human Rabies, Virginia, 2009<br />
  28. 28. Challenges and Lessons Learned<br />Public health involvement early in the process associated with potential human rabies cases is important<br />Outreach to pathologists in regard to autopsy procedures is important<br />Good to be familiar with the legal basis for information requested as part of a public health investigation <br />
  29. 29. Acknowledgements<br />Fairfax Health District<br />Peter Troell<br />Beth Miller-Zuber<br />Bryant Bullock<br />MD Dept. of Health and Mental Hygiene<br />Katherine Feldman<br />Kim Mitchell<br />Erin Jones<br />
  30. 30. Acknowledgements<br />DC Department of Health<br />Chevelle Glymph<br />Garret Lum<br />Maria Hille<br />Florida Department of Health<br />Carina Blackmore<br />New York City Department of Health<br />Sally Slavinski<br />
  31. 31. Acknowledgements<br />CDC<br />Charles Rupprecht<br />Jesse Blanton<br />Sergio Recuenco<br />Richard Franka<br />
  32. 32. Jennifer House, DVM, MPH Indiana State Department of Health<br />317-233-7272 jhouse@isdh.in.gov <br />John Poe, DVM, MPH Kentucky Department for Public Health<br />502-564-3418<br />john.poe@ky.gov<br />Human Rabies – A Joint Investigation with CDC, Indiana and Kentucky<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  33. 33. Human Rabies – A Joint Investigation with CDC, Indiana and Kentucky<br />Jennifer House, DVM, MPH <br />Indiana State Department of Health<br />John Poe, DVM, MPH <br />Kentucky Department for Public Health<br />Indiana Logo<br />
  34. 34. Case Report<br />43 year old white male<br />No history of previous severe illness<br />Resident of Southern Indiana<br />Died in a Kentucky hospital<br />
  35. 35. October 2009<br />PCP:<br />Muscle fasc., signs of sepsis<br />Admitted to Local Hospital-Placed on Resp Support<br />ED:<br />Chest pain, spasms in back, and chills<br />Left hospital against medical advice<br />Employee HCP:<br />Fever, Chills, Chest pain, arm numbness<br />Employee HCP:<br />Fever & Cough<br />Condition continues to deteriorate<br />Patient has minor arm pain attributed to previous car accident but otherwise seems fine<br />Transferred to tertiary care facility in KY<br />ED:<br />Chest Pain<br />Mechanical Ventilation<br />Mechanical Ventilation<br />Patient died after being removed from life support<br />Mechanical Ventilation<br />Autopsy performed <br />
  36. 36. Investigation<br />Family, friends, co-workers interviewed for history and exposure to patient<br />No history of animal bites<br />Told neighbor he ‘saw’ a bat (end of July)<br />Did not mention a bite<br />Worked as a mechanic/welder<br />May not have recognized a bite or unaware of the importance of being bitten<br />
  37. 37. Investigation cont…<br />Use standardized form<br />One for family/friends/co-workers<br />Different form for HCP<br />Asked specific questions about potential saliva exposures<br />Included a one page summary of risks and non-risks specific to exposures to human cases<br />Also provided handouts and brochures on rabies virus<br />
  38. 38. Rabies Post-Exposure Prophylaxis<br />159 close contacts- 100% counseled<br />147 individually interviewed- 92.5%<br />23 identified that MAY have been exposed to saliva <br />18 started/completed PEP<br />
  39. 39.
  40. 40.
  41. 41. Normal Human Brain – <br />Ventral View<br />Patient X 10.25.2009<br />
  42. 42. Negri bodies<br />in neuron:<br />hematoxylin and eosin stain<br />IHC stain for rabies virus<br />
  43. 43. Kentucky-Indiana 2009, rabies autopsy<br />
  44. 44. Lessons Learned<br />Rabies diagnosis is extremely difficult to obtain<br />Rabies is not high on the list of differential diagnoses for encephalitis<br />Human encephalitides often go undiagnosed<br />Many pathologists are reluctant to perform autopsies on possible rabies cases<br />Rabies is interpreted as an “animal disease” in a primary care setting<br />Joint federal, state and local health department collaboration is critical for successful diagnosis and disease mitigation<br />
  45. 45. Mary Grace Stobierski, DVM, MPH, DACVPM Michigan Department of Community Health<br />517-335-8165 stobierskim@michigan.gov<br />Kim Signs, DVM<br />Michigan Department of Community Health<br />517-335-8165 signsk@michigan.gov<br />Human Rabies Case in Michigan<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  46. 46. William H. Wunner, PhDProfessor and Director of Outreach Education<br />and Technology Training<br />The WistarInstitute<br />215-898-3854 wunner@wistar.org<br />Overview of special collections on papers on rabies appearing in the journals Vaccine and PLoS NTD<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  47. 47. D. Craig Hooper, PhD<br />Associate Director, WHO Center for Neurovirology, Associate Professor, Departments of Cancer Biology and Neurological Surgery, Thomas Jefferson University<br />215-503-1774<br />douglas.hooper@jefferson.edu<br />The Production of Antibody by Invading B Cells Is Required for the Clearance of Rabies Virus from the Central Nervous System <br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />
  48. 48. Rabies virus clearance from the CNS requires antibody production in CNS tissues<br />D. Craig Hooper<br />Thomas Jefferson University<br />
  49. 49. Attenuated RV that spread to the CNS induce limited, therapeutic BBB permeability changes<br />BBB fails to “open” during lethal RV infections – few immune effectors reach the CNS and the virus is not cleared <br />Antibodies are the major effector in rabies immunity; how important is the BBB?<br />
  50. 50. Peak circulating rabies-specific antibody levels occur after the restoration of BBB integrity<br />
  51. 51. BBB permeability detected during rabies virus clearance is limited to fluid phase markers<br />
  52. 52. CVS-F3 clearance correlates with antibody synthesis in the CNS<br />
  53. 53. B cells in the CNS during CVS-F3 clearance <br />
  54. 54. B cells infiltrate the CNS tissues and produce antiviral antibodies in situ<br />B cells<br />(CD19)<br />Immunoglobulin<br />(anti-Ig)<br />T helper cells<br />(CD4)<br />
  55. 55. Rabies virus-specific antibodies produced by B cells infiltrating the CNS differ from those produced in the periphery<br />
  56. 56. B cell growth/differentiation/maturation factors in the RV infected CNS<br />
  57. 57. Germinal centers and Ig affinity maturation in the CNS?<br />Peanut agglutinin<br />Activation-induced cytidine deaminase (AID) <br />control<br />d10<br />d18<br />d24<br />
  58. 58. Conclusions<br />The clearance of attenuated rabies viruses from CNS tissues is associated with limited fluid phase BBB permeability <br />Serum rabies virus-specific antibody titers peak after BBB integrity has largely been restored<br />B cells enter the CNS during the response to attenuated rabies viruses<br />B cell growth/differentiation/maturation factors are produced in the CNS and B cells transiently display germinal center markers<br />Rabies virus-specific antibodies produced in the CNS may differ from those produced in periphery (isotype, specificity?)<br />Are antibodies capable of clearing rabies virus from infected CNS tissues more commonly produced in CNS tissues?<br />
  59. 59. National Center for Emerging and Zoonotic Infectious Diseases (proposed)<br />59<br />Selected Zoonotic Diseases <br />Conference Call<br />January 6, 2010<br />

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