Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

   Diseases of
    Absence
                    Meg Fisher, MD
                      Medical Director,
                      The Unterberg
                      Children’s Hospital
                    Long Branch, NJ

      Disclosures
• I have no disclosures
• I do not intend to mention
  off label uses of drugs
• I have way too many slides so
  we will be moving quickly

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

              Objectives
• Decide when a child should be sent
  home from school and when that
  child can return to school
• Decide which children can stay at
  school

    Reasons for Absence
• Child is a risk to others: contagious
• Child unable to participate
• Child is at risk: needs medical
  attention
  • Possible serious infection
  • Dehydration
  •Injury

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

        When to Return
• Child no longer contagious
• Child able to participate
• No need for acute medical attention

         Case 1 - September
• A 10 year old who just returned from
  a trip to Ireland develops fever
• He appears ill – you send him home
• The next day he has a runny nose
  and he starts coughing
• He has bilateral conjunctivitis
What should you be worried about?

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

             Concerns
a)   Pneumonia
b)   Kawasaki disease
c)   Adenovirus
d)   Blarney stone fever
e)   Measles

           My Thoughts
a) Pneumonia – possible but why
   conjunctivitis
b) Kawasaki disease – too old, cough
c) Adenovirus - possible
d) Blarney stone fever – I made that up
e) Measles – you bet, check for Koplik
   spots today, rash tomorrow

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

                            Measles
 • RNA virus: family Paramyxoviridae,
   genus Morbillivirus
 • Transmitted by droplets and air
 • Extremely contagious
 • Incubation period 8 to 12 days
 • Contagious 4 days prior to 4 days
   after the rash appears
                                           2018 Red Book. Measles

            Measles in the US
• 1st Vaccine
  licensed
  1963
• About 95%
  effective
• US measles
  free since
  2000
www.cdc.gov/measles/cases-outbreaks.html

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

      Measles in the US
•   2014: over 600 cases, 23 outbreaks
•   2018: 137 cases, 11 outbreaks so far*
•   US travelers bring measles home
•   Travelers to US bring measles along
•   Secondary spread to unimmunized
    contacts
    *as of 9/8/18     www.cdc.gov/measles/index.html

           Clinical Illness
• Fever, cough, conjunctivitis
• Day 2 to 3 of fever, Koplik spots appear
• One to 3 days later, rash appears on
  the face, maculopapular to confluent
• Rash spreads and then fads over days
                                                 Photos from

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

Fever, Cough, Conjunctivitis

               Photos from

       Koplik spots

                             Photos from

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

         Confluent Rash

                                      Photos from

          Complications
• Otitis media
• Respiratory: pneumonia (viral
  and bacterial); laryngotracheitis
• Encephalitis
• Subacute sclerosing panencephalitis:
  years later

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

                       Diagnosis
 • Clinical
 • Confirm with serology: IgG and IgM
 • Virus isolation: nasopharyngeal swab,
   urine
 • Report all suspected cases:
   local health department –
   if not available, call the state

www.cdc.gov/measles/index.html      2018 Red Book. Measles

                        Treatment
 • Isolate the patient: air and droplet
 • Report the case
 • Vitamin A: Once daily for two days
   200,000 IU age > 12 mo; 100,000 IU
   6-11 mo; 50,000 IU < 6 mo
 • Ribavirin: in vitro, not approved
www.cdc.gov/measles/index.html      2018 Red Book. Measles

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Diseases of Absence - Disclosures I have no disclosures I do not intend to mention - njaap
10/18/2018

                               Prevention
 •   Measles vaccines: MMR and MMRV
 •   Routine: 12-15 mo, 4-6 yr
 •   Post-exposure: within 72 hours
 •   Immunoglobulin 0.25 ml/kg (max 15)
 •   Travelers/outbreaks: MMR for ages 6 to
     12 mo; child: give 2nd dose at age 12-15
     months and 3rd dose at 4-6 years
        www.cdc.gov/measles/index.html   2018 Red Book. Measles

         Infection Control
• Staff: all should be immune
• Proof of immunity: 2 doses of vaccine or
  seropositive
• NOTE: no need for serology if 2 doses given
• Born 1957 and later: 2 doses; seropositive
• Born before 1957: generally considered
  immune but serology recommended if not
  immunized; vaccine if negative
  www.cdc.gov/measles/index.html                2018 Red Book. Measles

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10/18/2018

       Infection Control
• Triage is essential
• When possible, make the diagnosis outside
  of your office: car or hospital
• If the child is in your office, put into a room
• Mask on the child if possible
• The area is considered contaminated for 2
  hours after the patient leaves
• Air in offices often re-circulated

 Why Did He Get Measles?
 • He had a religious exemption from
   immunizations
 • Measles is still endemic in most of
   Europe as well as most everywhere
   other than the Western Hemisphere
 • There are rare vaccine failures: that
   is the reason for the second dose

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10/18/2018

 Take Home Messages
• Think measles: fever, cough, conjunctivitis
  and then rash
• Notify local health department stat
• Get the proper specimens: serology and
  viral culture (NP preferred)
• Get everyone protected and immunized:
  staff and patients

                Case 2
• A 15 year old boy comes to the office
  with fever, headache, and sore throat
• He says he was fine earlier in the day
• You examine him: T 101, throat OK
• You debate and decide to give an
  antipyretic
• 20 minutes later you notice a rash

                                                       12
10/18/2018

              Rashes
• Petechiae: think bad things –
  meningococcemia, low platelets
• Hives: think allergic reaction
• Maculopapular: think virus or allergy
• Erythema: think burn, infection
• Vesicles: think herpes viruses
• Photos help

               Petechiae

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10/18/2018

Purpura fulminans

       Hives

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10/18/2018

Maculopapular

  Erythema

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               Vesicles

              Case 2
• The rash is petechial – oh dear!
• Where do you send him? – ideally to
  the hospital
• What does he need? – fluids and an
  antibiotic

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10/18/2018

         Meningococcemia
• Gram negative bacteria: Neiserria
  meningiditis, types A, B, C, W135, Y
• Spread person to person by
  respiratory and saliva
• Fever, headache, vomiting, rash
• Asymptomatic carriage to rapid
  progression

 Meningococcemia
• Sepsis with purpura fulminans
• Meningococcal meningitis
• Diagnosis: culture, spinal fluid
• Treatment: fluids and antibiotics
• Outcomes: full recovery, deafness,
  loss of limbs, organ damage, death

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               Prevention
• Chemoprophylaxis: close contacts,
  follow health department advice
• Vaccines:
  • MCV4: universal, age 11-12, age 16
  • MenB: at risk >10 yr, no risk age 16-23

                   Case 3
• A 17 year old comes to the office
  complaining of jaw swelling and fever
• His temperature is 100.5. He has a
  tender swelling at the angle of the jaw
What are you worried about?

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10/18/2018

               Concerns
• Tonsillitis
• Mumps
• Dental abscess
• External otitis
• TMJ disease

               Concerns
• Tonsillitis – anterior cervical node
• Mumps – parotitis, angle of jaw
• Dental abscess – submandibular node
• External otitis – preauricular node
• TMJ disease – pain preauricular area

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10/18/2018

Lymph Nodes of the Neck

               Mumps
• RNA virus, Paramyxoviridae family, genus
  Rubulavirus
• Transmitted by saliva and respiratory
  secretions
• Incubation 16 to 18 days (range 12-25 d)
• Contagious before and during parotitis;
  (virus recovered 7 d pre to 8 d post)
                            2018 Red Book. Mumps

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10/18/2018

                                 Mumps
•    Vaccine efficacy 88% with 2 doses but…
•    Midwest outbreak 2006, college students
•    NY, NJ 2009-10 outbreak: Orthodox
•    Belmar, NJ Bar outbreak: young adults
•    NHL outbreak 2014: NJ Devils and more
•    Many infected patients had 2 doses
    Graph from Red Book Online

      Mumps: Clinical Illness
•    Salivary glands infected: Parotitis
•    Often asymptomatic
•    CNS pleocytosis common
•    Orchitis after puberty; sterility rare
•    Diagnosis: virus detection by culture or
     RT-PCR; buccal swab, saliva, CSF;
     serology – IgM tricky, increasing IgG

                                           CDC photo

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10/18/2018

                Mumps
• Differential diagnosis of parotitis:
  other viruses (cytomegalovirus,      EBV,
  influenza, parainfluenza, LCM,
  enteroviruses, HIV) and less commonly,
  bacteria (atypical mycobacteria, gram
  positive and gram negatives)
• Treatment: supportive, report the case
• Prevention: 2 doses of vaccine; consider
  third dose during outbreaks
                              2018 Red Book. Mumps

                  Some Others
• Influenza: contagious a day before
  symptoms, easily transmitted, stay
  home until afebrile without meds
• Norovirus: vomiting and diarrhea,
  spreads easily, stay home until better
• Streptococcal pharyngitis: sore
  throat, pus, nodes, ok to return after
  a dose of penicillin

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10/18/2018

    Diseases of Presence
• Lice: short legs, no jump
• Infectious mononucleosis: shed for life
• MRSA carrier: 25-40% of us
• Strep carrier: 10-15% school age
• Noninfectious colitis: if able
• Poison Ivy: allergic reaction

      Smiling is a contagious condition!

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