SHAMPOOS, TATTOOS, AND BARBEQUES-What's new in the world of infecBous diseases? - "Flies spread disease, keep yours zipped." Anonymous
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SHAMPOOS, TATTOOS, AND BARBEQUES—What’s
new in the world of infecBous diseases?
“Flies spread disease, keep yours zipped.” ‐‐‐
AnonymousThe 2 most important fundamental aspects of infecBous disease prevenBon and control… • Hand washing • VaccinaBon • Should you shake hands with a man who has just exited the men’s room?
The 2 most important fundamental aspects of infecBous disease prevenBon and control… • Hand washing (20 seconds) • VaccinaBon • 5 seconds to un‐coat the flu virus; 9.5 seconds to get rid of the enteric bacteria from your rear‐end • Alcohol –based gels
Alcohol based gels vs. soap and water
• Use of plain ol’ soap and water for certain bugs such as:
Clostridium difficile (difficult to culture, hence, difficile)
• major cause of anBbioBc‐associated diarrhea
• New strain (2003) produces more toxin and causes more severe
outbreaks
• Major risk factor? Use of the fluoroquinolones (the anBbioBcs
with the last name “floxacin”
• Other anBbioBcs? Clindamycin, Amox/Ampicillin, 2nd/3rd
generaBon cephalosporins
• Treatment? More anBbioBcs (Metronidazole/vancomycin), f
• fecal transplants
• fecal cloudSoap and water and the noroviruses • Diarrhea + vomiBng (shuking)‐associated illness— median duraBon of S & S = 23 hours; start shedding virus before symptoms occur and shed virus for 4 days aher symptoms subside (can shed virus up to 4 to 8 weeks aher illness • In the community (buffet restaurants, delis); in nursing homes; on cruise ships (Atmar RL et al. Norwalk virus shedding aher experimental human infecBon. Emerg Infect Dis 2008 Oct: 14:1553)
The 2nd most important fundamental aspect of
preven5ng infec5ous diseases:
• Vaccinate
• Vaccinate
• VaccinateVaccines… • Kids receive a plethora of vaccines prior to the age of 2 to prevent a myriad of childhood diseases… • (28 doses to be exact if they get the complete schedule of immunizaBons recommended by the CDC) • To develop immunity you either vaccinate or you… • Suffer the infecBon
What vaccines do you need as an
adult?
• Annual flu vaccinaBon
• Why every year? Because the flu virus changes
its appearance every yearAnBgenic drih vs. anBgenic shih
2006 2007
AnBgenic shih
AnBgenic drihSwine flu (H1N1) – the “oink” • “Swine flu”—outbreak in Southern California and San Antonio, Texas (week of April 22, 2009); first case of this outbreak was in a 6‐ year‐old child in Mexico • Kids with chronic diseases; college kids • Pregnant moms (more than 4x as likely to be hospitalized as were people in the nonpregnant general populaBon)
Flu vaccine • One other reason to get the flu vaccine as an adult: • **Flu vaccine and the prevenBon of acute coronary syndromes and stroke
What other immunizaBons do you need as
an adult?
• Td (tetanus toxoid, reduced diphtheria toxoid) – every 10
years
• Why every 10 years? The diphtheria porBon wears off in 11
years; the tetanus doesn’t wear off for 19 years…but, since
they are given together is beter to err on the safe side and
give it every 10
• What are the two most common causes for tetanus (lockjaw)
in the older individual?
• Tdap (Td + and acellular pertussis)Boostrix (ages 10‐18) and
Adacel (ages 11 to 64)— one Bme booster (an over 65 if
you’re taking care of infants)Why do we need a pertussis booster? • Pertussis “whooping cough” (Bordetella pertussis)— introduced in the 1940s; average of 175,000 cases per year; 1980‐1990 an average of 2,900 cases per year • On the rise—9,771 cases in 2002; over a million cases reported in 2007; 3x that many… • Known as the “100‐day” cough • immunity waning (wears off aher 5‐10 years); kids not geung vaccinated because of the “fear” of auBsm, parental denial of conBnuing risks of infecBous diseases • Adults do not realize that they can give pertussis to an infant that has not been fully immunized (this includes parents and grandparents)
What other vaccines do you need as an
adult?
• Pneumococcal vaccine at age 65; chronic
illness necessitates the vaccine at an earlier
age—asthma, COPD, funcBonal or anatomic
asplenia, CKD, DM; vaccine before 65? Need a
2nd one aher 5 years
• Influenza and pneumonia represent the fihh
leading cause of death in the elderlyThe HPV vaccine for adolescents and
young adults
• Gardasil to prevent cervical cancer (HPV 16, 18) and genital
warts (HPV‐6 and11); cervical cancer is the number 2 cause
of death in women worldwide (273,000 women died
worldwide, 6500 in U.S. in 2002)
• By the way there are over 100 types of HPV, 30 of which
invade mucus membranes
• BTW #2, roughly three quarters of U.S. adults have had at
least one HPV infecBon
• Vaccinate girls between 9 and 26; has just been approved
for boys same age
• Is it 100% effecBve? HPV naïve, yes; already + HPV with
above types? Not effecBve…
• Why should I have my daughter get the HPV vaccine? She
tells me…HPV and head and neck cancer • So, you think oral sex is “less risky” than usual method? People who perform oral sex on more than five partners in their lifeBme have a 250 percent higher risk of developing throat cancer. (N Engl J Med, May 6, 2007) • .
Do immunizaBons trigger chronic disease? • MS? NO… • AuBsm? NO… • Crohn’s disease? NO… • Madsen KM Et al. A popula@on‐based study of measles, mumps, and rubella vaccina@on and au@sm. N Engl J Med 2002 Nov 7;347:1477‐82. • Lancet 2004;364:9438
Helicobacter pylori—1983 • Dr. Barry Marshall and Dr. Robin Warren and the tale of H. pylori • 100% of duodenal ulcers are caused by H. pylori; 70% of gastric (stomach) ulcers • The other 30% of stomach ulcers are caused by NSAIDS • AnBbioBcs and a PPI + bismuth preparaBon for the treatment of H. pylori
Human Immunodeficiency Virus‐‐1983 • Worldwide 33 million • 67% in Sub‐Saharan Africa with 3/4th of deaths for 2003 • 1.1 million in U.S; 233,000 are clueless (46% B; 35% C, 18% H) • 1st documented case—1959 in a sailor from England that traveled to sub‐Sahara Africa • HIV‐1 group M subtype B entered HaiB in 1966 and U.S. in 1969 (young male prosBtute in St. Louis) • First big report of HIV paBents in U.S.‐‐1981
Wild chimpanzees • Entered human populaBon by cross‐ species transmission of virus found in wild chimpanzees in central Africa somewhere between 1884 and 1924 • EaBng chimpanzee meat? FighBng? • No sites with more than 10,000 people existed in Africa prior to 1910 • Rise in ciBes may have facilitated the establishment and early spread of HIV in Africa (Worobey M et al. Direct evidence of extensive diversity of HIV‐1 in Kinshasha by 1960. Nature 2008 Oct 2; 455:661)
Natural immunity? • Who’s at risk? MSM, IV drug use, mulBple partners, the absence of barrier protecBon • Scandanavian background reduces the risk due to geneBc predisposiBon to a deleBon mutaBon for the CCR5 receptor needed for the virus to enter the CD4+ cells • Mediterranean vs. central African • PrevenBon with anB‐retroviral drugs? • Do condoms protect?
But the “natural feel” condoms don’t
protect
“You want to do what
with my intesBnes?
Trojan “cling‐Bghts”….Does circumcision protect? • YES ‐‐ reduced acquisiBon of HIV by 50 to 60% • Decreases prevalence of HPV by 35%, reduced HSV‐2 acquisiBon by 25%, • Golden MR, Wasserheit JN. PrevenBon of viral sexually transmited infecBons—Foreskin at the forefront. N Engl J Med 2009 March 26;360:1349‐1351.
GABHS mutaBons‐‐1985 • Group A Beta HemolyBc strep, new strains emerged in SLC, Utah in the mid 80s—M strains • Resurgence of RheumaBc Heart disease, necro5zing fascii5s, Streptococcal TSS • Oral steroids (60 mg Predisone) for severe sore throat • Penicillin is sBll the drug of choice • #1 cause of cardiac valve replacement under 60 y.o.
Digression: Staphyloccocal TSS‐‐1981 • The tampon wars • Who won? Proctor and Gamble and RELY • Super, dooper, dooper absorbent tampons • 39 deaths; hundreds ill • You could get it in, but ya’ couldn’t get it out!
HepaBBs C virus‐‐1989 IDENTIFY HIGH RISK GROUPS—primary factors • Baby boomers • IV drug user (even 1 Bme experimental drug use in college) • Blood transfusions prior to July1992 —or organ transplant recipients • Persons who have ever received hemodialysis • Hemophiliacs who received cloung factor concentrates prior to 1987
HepaBBs C high risk factors • HCW aher a needle sBck injury or mucosal exposure to HCV‐posiBve blood • Current sexual partners of HCV‐infected persons
HepaBBs C virus—secondary risk factors—the need for
screening is uncertain
• Sexual transmission with mulBple partners—
what does mulBple mean?
• Intranasal cocaine use
• Tatoos (prison applied?)
• Piercings
• Receipt of injecBon in a developing worldGuys tatoos… • Out there… • Everywhere… • Showin’ them off • Gals are a bit more subtle…(tramp stamp) • No vaccine yet; drugs to treat
8TRENDS IN INFECTIOUS DISEASES
• Everything global‐‐warming, travel, economics
• Increased food‐borne illnesses
• Zoonoses
• Increased populaBon of immunocompromised
paBents
• Sexual promiscuity
• Overuse, misuse, and abuse of anBbioBcs
• InfecBous disease and chronic inflammaBon
• BioterrorismGlobal warming and mosquitoes… • Carry at least 35 diseases • With global warming they are moving further away from the equator • Malaria (“mal aria”)—bad air—1,000,000 deaths worldwide per year • *If a paBent has traveled to an endemic area for malaria and they present with a fever of unknown origin, anemia and a big spleen—consider malaria for up to one year aher their trip • Increased mosquito populaBons in U.S. due to foreclosures! • West Nile Virus and cemeteries
Global economics • 1985‐‐Houston Texas ordered 70,000 used Bres from SE Asia • What were they thinking? • The Bres were delivered right along with the Asian Bger mosquito (Aedes Aegyp@) • Caused an outbreak of Dengue (breakbone) fever in SE Texas and LA in 1985; new outbreak in Key West this past year • The Aedes Aegyp@ has been found as far north as Peoria IL • Other issues in global economics brings us to another emerging trend in infecBous diseases
Food‐borne illnesses… • 1990 only 13 food‐borne illnesses to worry about • Today there are 8 x that many • Why? • DistribuBon around the world • CentralizaBon of processing plants • The top 3 food‐borne illnesses plus a few extra…
Food‐borne illness…Salmonella • Undercooked chicken, eggs , eggs, and eggs … • Peanut Buter outbreaks in 2007, 2009 • Pasteurized eggs for “seizure” salad (Caesar salad) • No more sunny‐side up, especially for high‐ risk paBents
E. Coli O157:H7 • 3rd most deadly toxin in the world • 10‐100 pathogens to make you ill or kill you— enterohemorrhagic diarrhea • #1 cause of acute Renal Failure in Kids • 1993 Seatle‐Tacoma deadly outbreak at the Jack‐in‐the‐Box restaurants • Mickey D’s—30 outbreaks per year • SupporBve Treatment
How about a hot dog? • Listeria monocytogenes • Hot dogs, bologna, deli meats • Also soh cheeses, brie, feta, camembert • Thrives in an anaerobic environment such as vacuum packs in the deli department; vacuum packs are used to keep contaminants OUT, but can just as easily trap a few in…like Listeria • The very young, the very old and the…very pregnant! •
No, thanks, I’ll have the salmon sushi… • Oh no you won’t…1 in 10 salmon “sushi’s” has parasites…
Where does all of our produce come
from?
• Everywhere!
• Enjoy raspberries from Guatamala
• Cantaloupe from Honduras
• Scallions from MexicoPets and zoonoses • Diseases from animals to humans • Can your pet make you sick? • Cuddly puppies and Campylobacter jejuni
Zoonoses… • Kity liter and toxoplasmosis • Actually most cases of toxoplasmosis today are from undercooked meat • What about feline leukemia, feline AIDS, and feline distemper? NO…
Pets and Salmonella • Hamsters, hedgehogs, iguanas, turtles, lizards and other exoBc pets harbor salmonella as well as other potenBally harmful bacteria • Do not consider non‐tradiBonal pets for kids under age 5 • (Dr. Larry Pickering, CDC and American Academy of Pediatrics)
Increased populaBon of
immunocompromised paBents…
• DiabeBcs—25 million in U.S.
• HIV+‐‐approx. 1 million in U.S.
• Cancer paBents
• Transplant paBents
• The elderlySexual promiscuity • “Five minutes with Venus gives you a life@me with Mercury.” • Side effects of mercury—worse than the disease! Drooling, hair loss, and demenBa • Gabriel Fallopius • Causes of syphilis—from doorknobs to horse’s hineys, to the wearing of linen shirts
Sexual promiscuity…
• HIV Contact tracing…
• HPV
• HSV
• HBV
• HCV* (less than 5% through
sexual contact with
monogamous relaBonship)
• H_V
• Chlamydia and GC
• Syphilis
• Trich or treat?One last note on STDs… • A high risk group • Long‐haul truckers play a significant role in the transmission of disease in Africa and maybe here in the U.S. • Some stats: 1/3 have frequent sex with prosBtutes on the road and greater than 80% don’t use condoms • Why? “Because condoms don’t protect you and AIDS is only a disease found in gay men.” Whoa.
InfecBous disease and chronic
inflammaBon…
• C. pneumoniae and atherosclerosis
• CMV? H. pylori?
• Drugs to reduce inflammaBon reduce acute
coronary syndromesBIOTERRORISM… • Have a high index of suspicion if there is “clustering” of a common disease • Or, if there are a few cases of an uncommon disease • Bugs most likely to be used: Anthrax, Yersinia pesBs (bubonic plague), smallpox, botulism…HAVE A PLAN!!!
Survey of counBes in U.S.‐‐2002 • One county in Iowa had a 3‐pronged plan of atack: 1) Call for help 2) Hope someone comes 3) Stack the bodies in the high school gym
THANK YOU … “Support bacteria—they’re the only culture some people have.” Anonymous Barb Bancroh, RN, MSN, PNP www.barbbancroh.com BBancr9271@aol.com
Bibliography Atmar RL et al. Norwalk virus shedding aher experimental human infecBon. Emerg Infect Dis 2008 Oct: 14:1553 Barry PM et al. Results of a program to test women for rectal chlamydia and gonorrhea. Obstet Gyn 2010 Apr; 115:753 Bartecchi CE and Schrier RW. Living Healthier and Longer: What Works, What Doesn’t. MFTP PublicaBons, 2008. Blaser MJ. The bacteria behind ulcers. Scien@fic Am 2006 (February); 104‐107. CDC. QuanBFERON‐TB Gold Test, October 2007. www.cdc.gov/tb CDC. Lyme disease—US, 2003‐2005. MMWR Morb Mortal Wkly Rpt. 2007;56(23):573‐576. .
Bibliography Creech CB, Schaffner W, Talbot TR. Healthcare‐ associated infecBons: Your role in prevenBon. Pa@ent Care/Hospital Medicine 2007 (June): 15‐23 Dale RC, et al. Incidence of anB‐brain anBbodies in children with obsessive compulsive disorder. Br J Psychiatry 2005 Oct;187:314‐9. D’Souza G et al. Oral sexual behaviors associated with prevalent oral human papillomavirus infecBon. J Infect Dis 2009;199:1263‐1269. Dworkin MS. Pertussis and its comeback—in persons of all ages. Pa@ent Care 2005 Oct; 43‐7. Heyderi LE et al. Severe herpes simplex virus type 1 infectgions aher dental procedures. www.medicinoral.com PrepublicaBon, 5/10/10
Bibliography Jamieson DJ et al. H1N1 2009 influenza virus infecBon during pregnancy in the USA. Lancet 2009 Aug 8; 374‐451. Juurlink DN, et al. Drug‐drug interacBons among elderly paBents hospitalized for drug toxicity. JAMA 2003;289:1652‐58. Kelly CP, LaMont JT. Clostridium difficile—More Difficult than ever. NEJM 2008;359(18):1932‐39. Knechel NA. Tuberculosis: Pathophysiology, Clinical Features, and Diagnosis. Cri@cal Care Nurse 2009; 29(2):34‐43. • Levine DP. Vancomycin: Understanding its past and preserving its future. Southern Medical Associa@on 2008;101(3):284‐91.
Bibliography • Marur S et al. HPV‐associated head and neck cancer: a virus‐related cancer epidemic. The Lancet Oncology 2010 (August);11(8) • McFarland LV. Meta‐analysis of probioBcs for the prevenBon of anBbioBc associated diarrhea and the treatment of Clostridium difficile disease. Am J • Parkinson E. What now? Responding to relapse in HepaBBs C. Advance for NPs 2007 (December);49‐51.
Bibliography • Roush SW et al. Historical comparisons of morbidity and mortality for vaccine‐preventable diseases in the United States. JAMA 2007 Nov 14; 298:2155. • Sing‐Behl D, La Rosa SP, Tomecki KJ. Tick‐borne infecBons. Dermatol Clin. 2003:21:237‐244. • Stone JH, Dieberg K, Aram G, et al. Human monocyBc ehrlichiosis. JAMA. 2004;292:2263‐2270. • Strangfeld A et al. Risk of herpes zoster in paBents with rheumatoid arthriBs treated with anB‐TNF alpha agents. JAMA 2009 Feb 18; 301:737.
Bibliography • Warny M et al. Toxin producBon by an emerging strain of Clostridium difficile associated with outbreaks of severe disease in North America and Europe. Lancet 2005 Sep 24;366:1079‐84. • Wenner M. Does Herpes Cause a Form of Senator Edward Kennedy’s Brain Cancer? Scien@fic American January 2009. • Wilson ME et al. Fever in returned travelers: Results from GeoSenBnel Surveillance Network. Clin Infect Dis 2007 June 15;44:1560‐8 • Zetola NM, Klausner JD. Syphilis and HIV infecBon: An Update. CID 2007:44(1 May); 1222‐1228.
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