The Epi Team’s Diary

1. The Epi Team’s Diary A sequel to Bridget Jones’ Diary

2. Meningococcal Meningitis

3. Report • On the morning of August 16, 2003, the Executive Director of the Green River District Health Department received a call from the local hospital regarding a case of Meningococcal Meningitis. • She activated the Epi Rapid Response Team. • Our Medical Director discussed this case with DPH and decided to medicate all contacts of the case.

4. History • The case was a 16 year old male who attended high school. • He presented with the following signs and symptoms: • Nausea a day before admission • Vomiting • Body ache • Fever 103.1 F

5. History • Non blanching petechial rash all over his body including face, palm and soles. • Patient was alert, awake, oriented, no neck stiffness. • Patient was initially diagnosed as having Rocky Mountain Spotted Fever and put on Doxycycline. • Blood Culture reveled it to be a case of Meningococcal Meningitis.

6. Contacts • A contact was defined as one who had been within arm’s length of the case, and one who had prolonged contact with the patient (30 minutes or more) over the past week. • Our nurses identified and medicated contacts over the next two days.

7. Covering all bases • Other Healthcare facilities were advised of the case and the need to medicate contacts. • 50 contacts were given Ciprofloxacin or Rifampin at the Health Department, 10 others were given prophylactic medication elsewhere (ER Dept., Urgent care facilities). • House calls had to be made to medicate many of the school children.

8. Meningococcal Meningitis • Is inflammation of the meninges- meningitis, caused by the bacteria Nesseria meningitidis. • In the US, since the late 1990s, Neisseria meningitidis and Streptococcus pneumoniae are the most common agents of bacterial meningitis. • Haemophilus influenzae meningitis has been largely eliminated in the US since the advent and widespread use of vaccine.

9. Meningococcal Meningitis • Less common bacterial causes of Meningitis, such as Staphylococci, enteric bacteria, group B streptococci and Listeria, occur in sub-populations like the immunocompromised, neonates, or head trauma patients. • Patients with Meningococcal Meningitis present with sudden onset of fever, intense headache, nausea, vomiting, stiff neck and, frequently, a petechial rash with pink macules or, very rarely, vesicles. Delirium and coma often appear. • Case fatality rate is between 5% and 15%.

10. Pathogenesis • A certain percent of the population are asymptomatic carriers of this bacteria in their nasopharynx. • A small minority of persons will progress to invasive disease. This can take the form of one or more of the following; - Bacteremia - Sepsis - Meningitis - Pneumonia

11. Diagnosis • Isolation of the organism from CSF or blood.

12. Occurrence • Infections can occur through the year, but are more common in late winter to early spring. Mode of Transmission • By direct contact- respiratory droplets from nose and throat of infected people. • Infection usually causes subclinical infection, severe systemic infection is rare. • Carrier prevalence can be as high as 25%.

13. Discussion • The Hospital Staff said they had difficulty contacting the Health Department to notify them of the case. • They were given a list of Epi Rapid Response Team with the Emergency Contact phone numbers. A new notification system with a dedicated toll-free number has been installed this month.

14. Discussion • The press was very insistent that there was a second case of meningitis and that this child was still in school. The press called our Medical Director numerous times regarding this and then called the Epidemiologist with the same question the next day. • We called the school and DPH and the hospital to ascertain that there was no second case. • Some good did come of this experience, the School and the Health Department worked well together. The school principal was commended for her pro-active role.

15. Blastomycosis

16. History • One of the ICNs called on May 4, 2004, about a case of Blastomycosis. She requested our help in investigating exposure & helping the family understand the disease. • The case was a 26 year old male residing in one of our more rural counties.

17. History • Patient first presented with a complaint of pelvic pain (treated for “pulled muscle” at this time). • Later presented with shortness of breath, fever, chills & productive cough (treated for pneumonia). • Other complaints included an episode of bloody urine, “knot” in lower stomach. • In April 2004, he was diagnosed with multiple fractures of the pelvic bone, and then surgeons encountered a “pus” pocket during surgery. Culture showed Blastomycosis.

18. Blastomycosis • Blastomycosis in an uncommon fungal infection caused by Blastomyces dermatitidis. Not a reportable condition. Occurrence • This disease is considered endemic in south-eastern, south-central, and mid-western US. • In endemic areas, incidence is about 1-2 cases per 100,000 population. • Common in dogs, and also noted in cats, horses, etc. • Disease in dogs may serve as an indicator of disease in humans because of shared environment. • Common reservoirs include moist soil with high organic content along waterways, in wooded areas, undisturbed places (sheds, porches).

19. Pathogenesis • Subpopulations at increased risk include woodsmen, campers, hunters in endemic areas. • Disease is transmitted when fungal spores are inhaled. • Incubation period: few weeks to months, median about 45 days. • Pulmonary disease can be acute or chronic. Pulmonary infections can be asymptomatic in 50% of the cases. • Secondary sites like skin, bone, genitourinary tract, meninges, brain, etc., may also become involved. • Does not spread from human-to-human or animal-to-human.

20. Diagnosis • Direct microscopic examination of unstained smears of sputum and material from lesion shows broad based budding forms - dumbbell shaped. • Can be isolated by culture. • Serologic tests are not useful.

21. Measures • Mortality rate is about 5%. • Treated using Antifungals. • Disinfection of sputum, discharges, and contaminated clothing. • Investigation of contacts and source of infection is not advised unless clusters seen.

22. Our Investigation • Epi Team Members interviewed the patient and a survey of his residence was done. • Patient said he had torn down an existing porch about 6 months before the onset of disease. • History did not indicate extensive outdoor activity, some sporadic fishing. • Dr. Pass who heads an Environmental Lab at Morehead was consulted and he indicated that exposure would be very difficult to pinpoint, as it was most likely an outdoor source.

23. Recommendations • Dr. Pass instructed that remnants of the porch be disposed of appropriately. Patient was asked to douse the pile of wood with bleach solution and to then set fire to it. • He was asked not to set fire to it without dousing it with bleach, or bury it. • Environmental samples were not collected or tested as it was not economically feasible to do so. • It was advised that the Patient’s children also be tested for this disease.

24. We meet our quota for the year ? • Second case of Blastomycosis Pneumonia was reported in August 2004 from another county. • Patient is a 32 year old female. • History indicated that she is asthmatic and takes inhalants, steroids to control her asthma. • Could this have predisposed her? • Inspection of her residence did not indicate exposure, history does not indicate outdoor activity.

25. Tularemia

26. History • In July, a case of Tularemia (Pneumonia) was reported in a 65 year old male. • Patient presented with joint aches, neck stiffness, cough, haemoptysis. • Patient was diagnosed with Tularemia and treated accordingly by the local hospital.

27. Tularemia • Tularemia is an infectious disease caused by the bacteria, Francisella tularensis. • Category A agent - potential use in Bioterrorism. Mode of Transmission • Reservoirs of Infection - Rabbits, hares, beavers, opossums, sheep, cats, hard ticks. • Spread by the bite of wood ticks, deer ticks, lone star ticks, deer flies, handling or ingesting insufficiently cooked meat of infected animals, drinking contaminated water and inhalation of contaminated dust/hay. Can also be spread from the bite of an animal whose mouth was contaminated from eating an infected animal. Animals can shed this organism in their feces.

28. Pathogenesis • Depending on the route of exposure, the disease can present as pneumonia (if inhaled), ulceroglandular form (ulcer at the site of introduction, eg: Tick Bite), oropharyngeal form (when ingested), typhoidal type (septicemia), oculoglandular type (through conjunctival sac), blood borne infection can localize in lungs and pleural spaces to cause pleuropulmonary form. • Incubation is about 1-21 days, usually 3-5 days. Occurrence • Occurrence of about 120 cases annually. • Not directly transmitted from person-to-person.

29. Diagnosis • Increase in specific serum antibodies. • Fluorescent Antibody test on ulcer exudate, lymph node aspirate, etc., yields rapid results. • Culture.

30. Route of Exposure • Patient’s history did not indicate any outdoor activity or tick bites. • He indicated that he had cleaned possum feces on his property about 3 weeks before he was diagnosed with the disease. He did not wear gloves or a mask while cleaning. The hypothesis is that he must have aerosolized and thus inhaled the organism during this act.

31. Never a dull moment….. • My physician said that Lyme Disease is a Sexually Transmitted Disease, and that my husband transmitted it to me? • I chewed on a Ban-Aid while eating Chinese Food, should I take some Antibiotics? • More staid questions like: High Mercury level in a farmer, what could be the possible route of exposure?

32. References • Centers for Disease Control & Prevention Website www.cdc.gov • Kentucky Department of Public Health Website http://chs.ky.gov/publichealth/ • Control of Communicable Diseases Manual. • Emedicine website: www.emedicine.com • Pictures from Google Images: http://images.google.com.