“Strange Germs, New Plagues, Weird Bacteria, Oh My!

1. “Strange Germs, New Plagues, Weird Bacteria, Oh My! Michelle A. Barron, M.D. Associate Professor of Medicine University of Colorado Denver Division of Infectious Diseases Medical Director, Infection Prevention and Control – University of Colorado Hospital

2. Objectives • Discuss new and not so new bacterial infections (MRSA), viral infections (seasonal influenza, avian influenza, the H1N1 pandemic, SARS, West Nile Virus, Hantavirus), and Tuberculosis • What are they? • How are they transmitted? • How do you know if you have it? • What do you do if you do get it? • Discuss ways to prevent infections • Hand Hygiene • Immunizations

3. “[it] is time to close the book on infectious diseases and declare the war against pestilence won…” Attributed to: US Surgeon General William H. Stewart 1967

5. The Antibiotic Era: An Evolutionary Perspective

6. What is Staphylococcus aureus? • Often referred to as “staph” • Bacteria that is commonly carried on the skin or nose of healthy people

7. Epidemiology of S aureus • Predominant reservoir of organisms = human beings • Approximately 15% – 35% of healthy people harbor S. aureus in their nose or throat at any given point • People can become carriers of Staph without having an infection (colonization): • 30% prolonged, 50% intermittent, 20% never • Vaginal carriage in ~10% of premenopausal women • Rectal and perineal carriage also occur Sheagren. N Engl J Med. 1984;310:1368-1373. Rimland et al. J Clin Microbiol. 1986;24:137-138. Centers for Disease Control (CDC). MMWR Morb Mortal Wkly Rep. 1982;31:605-607.

8. What is Methicillin Resistant Staphylococcus aureus (MRSA)? • Some Staph bacteria are resistant to antibiotics • MRSA is a type of Staph that is resistant to antibiotics called beta-lactams • Beta-lactam antibiotics include antibiotics such as methicillin, amoxicillin, and penicillin • Approximately 1% of the population is colonized with MRSA

9. Epidemiology of MRSA • Organism usually spread by direct person-to-person contact • Spread from inanimate objects is rare, but has been documented, such as outbreaks among football players, river raft guides, etc. • Patients with MRSA infections may have high prevalence (60%) of gut colonization or carriage • Common denominator: repeated trauma in defined area

10. Who Gets Staph Infections? • Staph infections, including MRSA, occur frequently in persons in hospitals and healthcare facilities • People with diabetes, HIV or AIDS, and chronic kidney failure on dialysis may be colonized with Staph more frequently than others • Increasing number of otherwise healthy people are being reported as having MRSA infections

11. What is Community Associated MRSA (CA-MRSA)? • MRSA infections that are acquired by persons who have not been recently hospitalized (within the past year) • Staph or MRSA infections in the community generally occur in otherwise healthy people • A study in 2003, suggests that 12% of MRSA infections are community associated but this varies by geographic region and population

12. Epidemiology of HA- and CA-MRSA Infections Infections associated with CA-MRSA (n = 131)2 Prevalence of MRSA increasing in hospitals and in the community1 Infections associated with HA-MRSA (n = 937)2 1. McDonald LC. Clin Infect Dis. 2006;42:S65-S71. 2. Naimi TS, et al. JAMA. 2003;290:2976-2984.

13. Risk Factors for Colonization or Infection with MRSA • History of injecting drug use • Homelessness • Underlying dermatologic disease • Prior steroid therapy • Prior antibiotic therapy • Presence of a central venous catheter • Prolonged hospital stays Onorato, M, et al. ICHE. 1999. 20 (1):26-30. Miller, M, et al. Eur J Clin Micro Infect Dis 2003. 22:463-69.

14. CA-MRSA Infections Among Competitive Sports Participants, 2000 – 2003 • Outbreaks of skin and soft tissue infections (SSTIs) due to CA-MRSA reported from Colorado, Indiana, Pennsylvania, and Los Angeles County from 2000 to 2003 • Sports involved included fencing, wrestling, and football Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2003;52:793-795.

15. Clinical Syndromes

16. Prevention of MRSA • Adequate coverage of abrasions or draining lesions • Limiting inappropriate antimicrobials use • Use of Infection prevention practices (e.g. washing hands or using alcohol based gels) • Advice for people who live with you: • Good hygiene – hot showers, use of antimicrobial soaps, and disinfectants • Avoid sharing towels, razors, or clothing Tacconelli, E., et al. JAC. 2004. 53:474-9. Zetola, N., et al. Lancet. 2005. 5:275-86. Kowalski, TJ, et al. Mayo Clin Proc. 2005. 80(9):1201-8.

17. Influenza

18. What is Influenza? • Contagious respiratory illness caused by the influenza virus • Influenza A, B and C • subtypes: H1N1, H5N1, H3N2, pandemic H1N1, etc. • Causes mild to severe illness and can lead to death • Yearly, 5-20% of the population will become infected influenza • > 200,000 are hospitalized annually with severe complications from influenza • About 36,000 die annually from flu-related illness

19. How is it spread ? Spread is usually person to person via large virus-laden droplets when coughing/sneezing, poor hand hygiene compliance, poor compliance with respiratory etiquette What is the period of infectivity period? Infectivity is one day prior to symptom onset and up to 5 days after onset. Children and those with weakened immune systems may be infectious for 10 days or more after onset of symptoms.

20. Viral Shedding and Transmission • 30-50% of seasonal influenza infections may not result in illness • Viral shedding in healthy adults with influenza occurs 24-48 hours prior to onset of illness • Titers of infectious virus peak during 1st 24-72 hrs of illness • Undetectable titers by day 5 of illness • Children may have asymptomatic viral shedding 3-6 days before illness onset • Median duration of virus detection is 7-8d after illness resolves

21. Clinical Features - Adults • Incubation period of 1-5 days • Abrupt onset of severe headache, chills, and non-productive cough • Also prominent muscle aches accompanied by high fevers • Fever peaks on the first day and may decrease over the next 72 hours • Decreased energy and appetite are universal • Mild-moderate cases usually resolve in 7 days • Weakness, cough, and lack of energy may persist for weeks after clinical resolution

22. Avian influenza A (H5N1) • December 2003 • 19,000 of 24,000 chickens on a farm in Korea die in a week • Epidemic of the highly pathogenic avian influenza H5N1 strain found as the cause of the poultry deaths • More than 1.3 million chickens and ducks have died or been destroyed • January 2004 • Outbreak of severe respiratory illness in 12 previously healthy children and 1 adult hospitalized in Viet Nam reported to WHO – 8 cases are fatal • Test on samples from two of the fatal cases confirm infection with H5N1 avian influenza virus strain • February 2004 • 34 human cases with 23 deaths reported in Thailand and Vietnam WHO. 2004

23. Avian influenza A (H5N1) • August/September/October 2004 • 4 human deaths from avian influenza H5 infection reported in Vietnam; 4 fatal cases in Thailand • 1 case of possible human-to-human transmission reported • December 2004 • Resurgence of poultry outbreaks and human cases reported in Vietnam. • Suggested transmission to at least two persons through consumption of uncooked duck blood • February 2, 2005 • The first of 4 human cases of H5N1 infection from Cambodia was reported • July 21, 2005 • First human case of H5N1 in Indonesia was reported • Indonesia has continued to report human cases in August, September, and October 2005 • January 2006 • Two cases of avian influenza in Turkey WHO. 2004

24. Pandemic Potential of H5N1 • Pros: • Novel virus (Avian origin, similar to 1918 flu) • Highly infectious • No vaccine availability • Spread easily between sick poultry and humans • Migrating birds can serve as potential world-wide vector • Cons: • Mass culling of infected birds, limiting spread • Limited human to human spread

25. Just When You Thought It Was Safe… • January 24, 2012 • Ministry of China notified WHO of a human case of H5N1 infection in a 39 year old male who was hospitalized and subsequently died. • Investigation into source of infection on-going. • No other cases so far…

26. Pandemic H1N1 Influenza – April 23, 2009 CDC dispatch: • Human cases of swine influenza A (H1N1) virus infection have been identified in San Diego County and Imperial County, California as well as in San Antonio, Texas.

27. May 3, 2009 – WHO

28. Seasonal Influenza Influenza strains A and B Spread via droplets Signs/symptoms: Fever, cough, sore throat, runny nose, body aches, headaches, chills and fatigue Vomiting and diarrhea more common in children Risk for complications: >65 yo, asthma, diabetes, suppressed immune systems, heart disease, kidney disease, and pregnancy Pandemic H1N1 Influenza Influenza A strain only Spread via droplets Signs/symptoms: Fever, cough, sore throat, runny nose, body aches, headaches, chills and fatigue Vomiting and diarrhea in all age groups Risk for complications: Asthma, diabetes, suppressed immune systems, heart disease, kidney disease, and pregnancy Elderly not at higher risk for infection What Are the Differences Between Seasonal and pandemic H1N1 Influenza?

29. 67 of the 147 deaths in 2008-2009 were due to H1N1; 29 have occurred since August 30, 2009

30. Prevention and Good Health Habits • Vaccination is the key prevention strategy • Stay home when you are sick • Avoid direct contact with people that are coughing or sneezing • Cover your mouth when you cough or sneeze • Wash your hands frequently or use antibacterial gels frequently

31. Severe Acute Respiratory Syndrome

32. SARS • First reported in Nov 2002 in China • Spread worldwide by Feb-Mar 2003 • Contained by July 2003 • Worldwide: • 8098 probable cases • 21% healthcare workers • 774 deaths (case/fatality ratio 9.6%) • United States: • 164 total cases • 137 suspect, 19 probable, and 8 confirmed • No deaths Source: WHO; CDC

33. SARS Transmission • Most important • Close personal contact • Large droplet nuclei • Airborne spread • Role of aerosol-generating procedures (intubation, suctioning, nebulization, bronchoscopy) • ? point in disease • Potential role of fomites • Fecal spread implicated in one outbreak Source: www.cdc.gov

34. Summary of Clinical Manifestations • Week 1: Febrile prodrome • Fever, myalgia, headache, sore throat, cough • 5-10% diarrhea • CXR may be normal • Week 2: Respiratory phase • Rapid progression SOB, cough, hypoxia; ARDS in 10-20% usually by day 7-8 • Radiographic progression • Exam may be unremarkable • Week 3: Resolution vs Death vs Chronic Disease • Resolution of Sx from ~ day 11-14

35. Real Life Occupational Exposure SARS (Toronto experience) SGH Mr. T Index Case (Mother) (Son) Friday, March 7, 2003 Slide provided courtesy of Allison McGeer, MD

36. Night of March 7th: Observation Unit ER SGH Mr T Mr P Mr D Slide provided courtesy of Allison McGeer, MD

37. Mr. P’s wife Mr. P Mr. D Index Case (Mother) Mr T (Son) Slide provided courtesy of Allison McGeer, MD

38. Mr. P’s wife Mr. P 24 persons 9 persons Mr. D Index Case (Mother) Mr T (Son) Mr. R ? Slide provided courtesy of Allison McGeer, MD

39. Mr. P’s wife Mr. P 24 persons 9 persons Mr. D Index Case (Mother) Mr T (Son) 21 persons Mr. R ? Slide provided courtesy of Allison McGeer, MD

40. Mr. P’s wife Mr. P 24 persons 9 persons Mr. D 21 persons Index Case (Mother) Mr T (Son) 15persons Mr. R ? Slide provided courtesy of Allison McGeer, MD

41. Current Status of SARS: Will it Return? • July 2003 • 3 recent cases reported in China • Lab-acquired case in Singapore • April 2004 • 9 cases of SARS in China • 1 person died • No further cases since 4/29/04

42. West Nile Virus

43. West Nile Virus • What is it? • A potentially serious illness that affects the central nervous system. • Can cause inflammation of the brain (encephalitis) or around the brain (menigitis) and can also cause polio-like paralysis. • How is it spread? • Typically by the bite of an infected mosquito. • Mosquitoes become infected by feeding on birds with the virus.

44. West Nile Virus • What are the signs and symptos of infection? • About 20% of patients will have a “flu-like illness” • Fever, malaise, anorexia, nausea, vomiting, headache, muscle pain, occasional rash • 1 in 150 infections will be severe • Fever, weakness, gastrointestinal symptoms, change in mental status Higher risk in individuals over age 50 years old

45. West Nile Virus • How can it be prevented? • Apply insect repellent when you are going to be outdoors. Even if you don’t notice mosquitoes there is a good chance that they are around. • When weather permits, wear long-sleeved shirts and long pants whenever you are outdoors. • Place mosquito netting over infant carriers when you are outdoors with infants. • Consider staying indoors at dawn, dusk, and in the early evening, which are peak mosquito biting times. • Install or repair window and door screens so that mosquitoes cannot get indoors. • Drain sources of standing water

46. Hantavirus

47. Hantavirus Pulmonary Syndrome • What is Hantavirus pulmonary syndrome? • A serious, often deadly disease caused by the Sin Nombre virus. • How is it transmitted? • The virus is carried by rodents and passed on to humans through rodent urine, saliva, and droppings. • The deer mouse is the primary carrier of the virus. • It is not spread person to person.

48. Confirmed Cases of Hantavirus by State from 1993-2011

49. Hantavirus Pulmonary Syndrome (HPS) • What are the symptoms of HPS? • First symptoms are generally flu-like • Fever, headache, abdominal pain, back pain and joint pain • Main symptom is increasing shortness of breath • What is the treatment? • Mainly supportive. Key is getting to the hospital right away.

50. Hantavirus Pulmonary Syndrome • How can you prevent getting infected? • Open up and air out unused or abandoned cabins before occupying the building. • If you’re sleep outdoors, check campsites for rodent dropping and burrows. • D not disturb rodents, burrows, or dens. • Avoid sleeping near woodpiles or gargbage • Avoid sleeping on bare ground; use a mat or elevated cot if available • Store food in rodent-proof containers and discard, bury, or burn all garbage.