Avian Influenza H5N1 Emerging Infectious Diseases • Endemic in domestic poultry in certain areas 2008 • Sporadic human infection from direct contact with infected poultry and/or wild birds • Person-to-person spread of H5N1 virus from has been very rare, limited and unsustained William E. Maher, MD Ohio State University Medical Center • No evidence of changes to H5N1 to increased transmissibility to or among humans, but infection seen in some mammals Emerging Infectious Avian Influenza H5N1 Diseases - Global View • Update on Avian Influenza A/H5N1 • H5N1 resistant to amantadine and rimantidine, but sensitive to Oseltamivir and • Upsetting the balance Zanamivir • Things that shouldn’t be there • Some Oseltamivir resistant strains reported • No available vaccine, work in progress • Things we weren’t aware of • Unanticipated (but maybe not unexpected) changes 1
Malaria Epidemiologic Findings in Dominican Republic Human H5N1 Cases • 1999-2000 outbreak, Hurricanes Mitch and George • Thailand, 2004: limited spread in a family from prolonged and very close contact. No transmission beyond one person. • 2004, Hurricane Jeanne, Punta Cana • Vietnam, 2004: fatal case presented with fever, diarrhea and • Heavy rains and flooding, increased mosquitoes seizures, and was initially diagnosed as encephalitis. • Vietnam, 2005: Infection via ingestion of raw duck blood. • Malaria-infected migrant workers • Azerbaijan, 2006 : teenagers infected by contact with wild dead • 3,000 malaria cases reported in 1999 birds (swans) removing feathers from the birds. • 1,500-2,500 malaria cases now reported annually • Indonesia, 2006: 8 people in one family were affected, with 7 deaths. No further spread outside of the exposed family was • Europeans in Punta Cana All inclusive resorts, documented or suspected. never left the grounds • Vietnam, 2006: high viral concentration and elevated inflammatory cytokine levels in fatal cases. Inflammatory • CDC recommend chloroquine prophylaxis for response appears to be implicated in the pathogenesis travelers to La Altagracia and Duarte provinces. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO 2003 2004 2005 2006 2007 2008 Total Country Malaria risk area in deaths cases deaths cases death death deaths cases death cases death cases cases cases s s s s Dominican Republic: Azerbaijan 0 0 0 0 0 0 8 5 0 0 0 0 8 5 Cambodia 0 0 0 0 4 4 2 2 1 1 0 0 7 7 Rural, with highest risk China 1 1 0 0 8 5 13 8 5 3 3 3 30 20 in provinces bordering Djibouti 0 0 0 0 0 0 1 0 0 0 0 0 1 0 Egypt 0 0 0 0 0 0 18 10 25 9 7 3 50 22 Haiti. In addition, risk in Indonesia 0 0 0 0 20 13 55 45 42 37 16 13 133 108 Iraq 0 0 0 0 0 0 3 2 0 0 0 0 3 2 all areas of La Lao People's Altagracia Province, 0 0 0 0 0 0 0 0 2 2 0 0 2 2 Democratic Republic including resort areas. Myanmar 0 0 0 0 0 0 0 0 1 0 0 0 1 0 Nigeria 0 0 0 0 0 0 0 0 1 1 0 0 1 1 Pakistan 0 0 0 0 0 0 0 0 3 1 0 0 3 1 Thailand 0 0 17 12 5 2 3 3 0 0 0 0 25 17 Turkey 0 0 0 0 0 0 12 4 0 0 0 0 12 4 Viet Nam 3 3 29 20 61 19 0 0 8 5 5 5 106 52 Total 4 4 46 32 98 43 115 79 88 59 31 24 382 241 2
Malaria in Kingston, Jamaica • Fall 2006, confirmed malaria cases, Kingston, Jamaica where Malaria Great Exuma transmission does not normally occur • Ant malarial drugs recommended. • February 29, 2008 CDC removed temporary recommendation for malaria preventive medication (prophylaxis) for travel to Kingston Jamaica. • Kingston continues to experience rare cases of malaria, but the risk to travelers appears to be minimal. Recommendations for Celebrities Who Own Travelers to Great Exuma Islands in the Exumas • Repeated instances of chloroquine-sensitive Plasmodium falciparum malaria occurring in • Nicolas Cage travelers to the island of Great Exuma • Ongoing, low-level risk of malaria for people • Faith Hill and Tim McGraw traveling to the island. • CDC recommends that travelers to Great Exuma, Bahamas take chloroquine malaria preventive • David Copperfield medication (prophylaxis) • There is currently no known risk of malaria on • Johnny Depp other islands of the Bahamas; therefore, prophylaxis is not necessary for those islands 3
Chikungunya Fever in Italy Chikungunya Fever in Italy • In Swahili Chikungunya: illness of the • CHIKV 1 st Isolated in Tanzania in 1953 bended walker • African countries, Indian subcontinent, SE Asia. • Fever, arthralgia, myalgia, headache and diffuse maculopapular rash. • Outbreaks: India, Comoros and La Réunion islands in the SW Indian Ocean in early 2005 • Symptoms 4–7 days after bite • During these outbreaks, travelers from • Arthralgia is often severe, persistent industrialized countries became infected with CHIKV and were still infected on returning home. • 12% of patients have chronic arthralgia 3 years after onset of illness • Aedes albopictus —a vector of CHIKV—was introduced a number of years ago and is now • Chikungunya is transmitted by Aedes aegypti widespread in Italy or A. albopictus 85% of the cases were confirmed by either serology or PCR. Lancet. 2007 Dec 1;370(9602):1805-6 Lancet. 2007 Dec 1;370(9602):1805-6 4
Chikungunya Fever in Italy • Outbreak of a tropical disease in a non- tropical area • Index case had recently traveled to an endemic area (India) to visit relatives • Vector infestation traced to imported tires from a tire retreading company that had imported used tires infested with mosquito eggs from Georgia, USA. • Other Diseases: Malaria, Yellow Fever, Dengue, ? MMWR August 10, 2007 / Vol. 56 / No. 31 Dengue in Texas Autochthonous Malaria • Dengue noted in 5 Texas border counties • Inadvertent carriage of infective since 1980. Anopheles mosquitoes by airplane, ship, baggage, or bilge water may be • Survey in Brownsville, Texas, and Matamoros, Tamaulipas, Mexico (n = 600), responsible for these occurrences. in 2004 to assess dengue seroprevalence. • Also, large populations of migrants from areas highly endemic for malaria may act • Recent dengue infection was detected in as human reservoirs for potential 2% and 7.3% of residents in Brownsville gametocyte carriers. and Matamoros, respectively. • Outbreaks of mosquito borne malaria in • Past infection was detected in 40% of areas of New Jersey, New York, and Texas Brownsville residents and 78% of Matamoros residents. 5
Norovirus • Most common cause of infectious gastroenteritis among persons of all ages • Responsible for 50% of all food-borne gastroenteritis outbreaks in the United States • Major problem cruise ships, nursing homes and hospitals • Detected in 35% of persons with sporadic gastroenteritis and in 14% of all children < 3 years old hospitalized for gastroenteritis. • Cause of chronic diarrhea among transplant patients • Diagnostic PCR available at CDC and State Health Dept. • ? Emerging due to lifestyle changes vs. better tests EID Vol 2, No. 1—January-March 1996:37-43 Outbreaks of Acute Norovirus Gastroenteritis: Settings 2006 • Short, self-limited illness Setting Number of Outbreaks • As few as 100 virus particles thought to Cruise ships 37 infectious Long-term care 37 • Stable in the environment and can survive facilities freezing and heating to 60°C (140°F). Restaurants 13 • Transmission to the oral mucosa via hand contact with materials, fomites, and Hospitals 7 environmental surfaces contaminated with feces Colleges 3 or vomitus Parties 3 • May be food borne or waterborne Other 26 • Susceptible to chlorination Total 126 6
Prevention of Norovirus Chagas Disease Transmission Trypanosoma cruzi in The USA • American trypanosomiasis • Endemic to Central and South America • Hand hygiene with alcohol-based � Romaña’s Sign hand gels; � Megacolon • Disinfect surfaces: 1:10-50 dilution � Megaesophagus chlorine bleach � Cardiomegaly. • Do not return to work or school for 24 � Reduvid Bug Vector to 72 hours after symptoms resolve • Rare Transmission � IVDA � Transfusion Photo courtesy of CDC Prevention of Norovirus Chagas Disease Transmission Range and Vector • During outbreaks Triatoma sanguisuga � Use contact precautions � Avoid sharing staff members between units or facilities with affected patients � cluster symptomatic patients � instruct visitors on hand hygiene � close affected units to new admissions and transfers Photo courtesy of CDC 7
Chagas Disease • Cases of Chagas disease reported in the United States � 3 in infants in Texas � 1 in an infant in Tennessee � 1 in a 56-year-old woman in California � 1 in Louisiana 2006 • Vector in the USA is Triatoma sanguisuga , Photograph courtesy South Florida NRC Chagas Disease Wildlife, Exotic Pets, and Emerging Zoonoses • T. cruzi has been identified in Photos courtesy of CDC � >18 species of mammals � raccoons, opossums, armadillos, foxes, skunks, dogs, wood rats, squirrels, and nonhuman primates • Lack of human cases in USA � Lack of habitat for the bugs in most US homes � a preference for animal hosts � delayed defecation of triatomines found in the US compared with those found in Latin America. ► May 22 – Child hospitalized because of festering lesions, fever, sweats, ocular discharge, and new skin lesions. 8
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