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Naegleria Fowleri : The Danger in Your Swimming Hole Nancy Wilson, MPH student Walden University

Naegleria Fowleri : The Danger in Your Swimming Hole Nancy Wilson, MPH student Walden University PUBH 6165-4, Environmental Health Dr. Raymond Thron Summer 2014. What is Naegleria fowleri ? What is primary amebic meningoencephalitis? How is a person infected?

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Naegleria Fowleri : The Danger in Your Swimming Hole Nancy Wilson, MPH student Walden University

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  1. Naegleria Fowleri: The Danger in Your Swimming Hole Nancy Wilson, MPH student Walden University PUBH 6165-4, Environmental Health Dr. Raymond Thron Summer 2014

  2. What is Naegleria fowleri? What is primary amebic meningoencephalitis? How is a person infected? How can infection be prevented? Learning Objectives

  3. What is Naegleria fowleri? • Thermophilic, free-living ameba • Found in warm fresh water • Lakes, ponds, rivers, hot springs • Feeds on bacteria • Image credit: Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Kemble, S. K., Lynfield, R., DeVries, A. S., Drehner, D. M., Pomputius III, W. F., Beach, M. J.,...Danila, R. (2012). Fatal Naegleria fowleri infection acquired in Minnesota: Possible expanded range of a deadly thermophilic organism. Clinical Infectious Diseases, 54(6), 805-809. doi:10.1093/cid/cir961

  4. How are people infected? • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  5. Where can N. fowleri be found? • Every continent except Antarctica (Painter, Pfau, Brady, & McFarland, 2013) • In the U.S., more frequently in southern states (Yoder et al., 2012) • In ponds, lakes, rivers, and hot springs (Painter et al., 2013) • In drinking water • Not regulated (Yoder et al., 2012). Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162 Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

  6. Reported U.S. Cases, 1962-2013 • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  7. Why should we pay attention? • Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C. (2014). Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834

  8. What is PAM? • Primary • Amebic • Meningoencephalitis Meningo + encephal + itis membranes + brain + inflammation • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  9. The Symptoms of PAM • Headache • Fever • Nausea/vomiting • Stiff neck • Altered mental status • Seizures Yousuf, F. A., Siddiqui, R., Subhani, F., & Khan, N. A. (2013). Status of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan. Journal of Water & Health, 11(2), 371-375. doi:10.2166/wh.2013.112 Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  10. How quickly does PAM progress? • Symptoms start 1-7 days after infection (median is 5 days) • Death occurs an average of 10 days after infection, or 1-12 days (median 5.3 days) after initial symptoms • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162

  11. Who is at risk? • Children and young adults • Males • Freshwater swimmers • Those who play, swim, or bathe in fresh water in July or August • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  12. Are people only at risk when swimming? • Short answer: No. • Nasal exposure to infected drinking water • Shower or bath • Slip-n-slide • Nasal irrigation or rinsing • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  13. How is PAM diagnosed? • Laboratory tests • Direct visualization • Antigen detection • Polymerase chain reaction (PCR) • Ameba culture • Environmental detection • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  14. What treatment is available? • Miltefosine, breast cancer drug • Successful usage in 2013 (CDC, 2013) • Amphotericin B, confirmed clinical efficacy • In combination with fluconazole, rifampicin, sulfadiazine, dexamethasone, or other drugs (Sood, Chauhan, Chandel, & Jaryal, 2014) • Early treatment is best! • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C. (2014). Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834

  15. How can infection be prevented? • Avoid activities in freshwater when there is a high water temperature (Yoder et all., 2012) • Avoid getting water up the nose • Use nose clips (Yoder et al., 2012) • Avoid head submersion (CDC, 2013) • Avoid stirring up sediment during water-related activities (Yoder et al., 2012) • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

  16. How can infection be prevented? • Use sterile, distilled, filtered, or previously boiled water for nasal irrigation (Yoder et al., 2012) • Do not allow bathing water to go up in nose (CDC, 2013) • Avoid the use of slip-n-slides (CDC, 2013) • Do not allow children to play unsupervised with hoses or sprinklers (CDC, 2013) • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

  17. What should I do if I suspect Naegleria fowleri infection? • Go to the hospital immediately and report possible exposure • CDC Emergency Operations Center is available for consult on any suspected infection case • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

  18. Points to Remember • Be wary of warm freshwater! • Protect your nose! • It is better to be safe than sorry! • Early is best!

  19. References • Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html • Kemble, S. K., Lynfield, R., DeVries, A. S., Drehner, D. M., Pomputius III, W. F., Beach, M. J.,...Danila, R. (2012). Fatal Naegleria fowleri infection acquired in Minnesota: Possible expanded range of a deadly thermophilic organism. Clinical Infectious Diseases, 54(6), 805-809. doi:10.1093/cid/cir961 • Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162

  20. References • Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C. (2014). Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834 • Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85. • Yousuf, F. A., Siddiqui, R., Subhani, F., & Khan, N. A. (2013). Status of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan. Journal of Water & Health, 11(2), 371-375. doi:10.2166/wh.2013.112

  21. Thank You! Any Questions?

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