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Emerging Infections Update: 2011 Ruth Lynfield, MD Minnesota Department of Health.

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Presentation on theme: "Emerging Infections Update: 2011 Ruth Lynfield, MD Minnesota Department of Health."— Presentation transcript:

1 Emerging Infections Update: 2011 Ruth Lynfield, MD Minnesota Department of Health

2 Emerging Infections Infectious agents evolve –Ability to infect new hosts/new populations/new modes of transmission, new geographic/ecological ranges, resistance to therapeutic agents Re-emerging infectious diseases –Recurrence of previously controlled infectious diseases

3 Case 1 10-year-old male from rural Cass County (wooded farm) presented in June with difficulty speaking and swallowing, headache, confusion, and subjective fever for 1 day –Flaccid symmetrical bulbar paralysis on exam 1 week prior had a generalized urticarial rash, followed by a sore throat 2 days later 1 week prior to the development of rash parents noted an engorged tick (unknown type) attached to his body

4 CSF sample PCR positive for Powassan virus; of the deer tick lineage Ixodes scapularis Tick-Borne Disease New to Minnesota, 2008 (cont.) Western-most case identified in United States

5 Powassan Virus Tick-Borne flavivirus first isolated in 1958 from a case of encephalitis in Powassan, Ontario Incubation period usually 1-2 weeks –Acute onset of muscle weakness and confusion Patients (particularly adults) often left with sequelae 31 human cases reported in Canada and northeastern United States, 1958-2001

6 MN Powassan Virus Cases, 2008-2011 12 cases Exposures May – October Median age: 56 years (10-70 y); 92% male; 50% previously healthy 100% fever, headache; 67% (8) confusion or delirium; 50% (6) rash; 50% (6) muscle weakness 58% (7) required ICU care; 1 fatality 42% (5) had known persistent symptoms including weakness, dizziness, speech abnormalities, intense fatigue and difficulty concentrating 67% (8) had known tick bite; others tick exposed or lived in geographic area where there are ticks

7 Human Ehrlichiosis due to Novel Ehrlichia: Ehrlichia muris-Like Agent 2009-2010: Mayo Medical Lab detected Ehrlichia muris-like agent (EML) in 14 Minnesota and Wisconsin patients Patients had illnesses suggestive of anaplasmosis or ehrlichiosis EML infection with cross-reactivity to E. chaffeensis could explain some Midwestern cases with positive E. chaffeensis serology EML also identified in I. scapularis and Peromyscus mice by PCR

8 Minnesota 2010 Tick-borne Disease Disease Lyme disease Human anaplasmosis (HA) Babesiosis Human ehrlichiosis (HE) HA/HE undetermined HE-EML agent Powassan disease Rocky-Mountain spotted fever No. of Cases 1,293 720** 56** 12** 11 4 3 2** ** Includes confirmed and probable case totals

9 Reported Tick-Borne Disease Cases, Minnesota, 1986-2010 (n = 14,921)

10 Minnesota Biomes Coniferous and mixed forest Tallgrass Aspen Parkland Prairie grassland Deciduous forest Minneapolis-St. Paul Metropolitan Area

11 Distribution of Lyme Disease Cases by County of Residence, MN, 1996-2010 Incidence Rate (cases/100,000 person-years) No Cases >0.0-10.0 >10.0-100.0 >100.0-160.0 2006-20102001-20051996-2000

12 Timeline of Autochthonous Vector-Borne Diseases of Humans, Minnesota Malaria Babesiosis Anaplasmosis La Crosse encephalitis West Nile virus Lyme disease 1850 2000 1920 POW 1900 196019401980 2010 Western equine encephalitis EEE equine outbreakRMSF Fatality Mosquito-Borne Tick-Borne EML

13 Case 2 Woman in her 50s with a history of depression, had fatigue, insomnia, achy joints, memory loss and confusion x 5 years with worsening of symptoms x 2 years

14 Case 2 (cont.) Serological testing –Indeterminate IFA for Lyme –Lyme IgM Western blot + (2/3 bands; 2 or more considered positive) –Lyme IgG Western blot – (3/10 bands; 5 or more considered positive)

15 Case 2 (cont.) Rx with 5 weeks of doxycycline –Felt better on therapy; worsened off therapy Rx cefuroxime and telithromycin x 2-4 months

16 Case 2 (cont.) Developed diarrhea 5 weeks into course

17 Case 2 (cont.) Started on metronidazole Developed ascites and severe abdominal pain 2 days later Cardiac arrest while undergoing emergency colectomy Pseudomembranes found in colon Stool positive for C. difficile toxinotype III, binary toxin positive, containing 36-bp tcdC deletion


19 Case 3 7 yo previously well Developed headache and abdominal pain, followed one day later by fever Evaluated and given IM penicillin for possible strep throat Developed seizures next day and admitted to ICU CSF: 8,150 WBC/mm3 (90% PMN), 800 RBC/mm3, TP 461 mg/dL, glucose < 20 mg/dL

20 Wright’s Stain of Cerebrospinal Fluid

21 Naegleria fowleri Thermophilic, free-living ameba Fresh water Proliferates above 30º C (86º F) Can migrate up olfactory nerve to brain Primary amebic meningoencephalitis (PAM) 111 cases in U.S. 1962–2008 1 survived

22 Naegleria fowleri Thermophilic, free-living ameba Fresh water Proliferates above 30º C (86º F) Can migrate up olfactory nerve to brain Primary amebic meningoencephalitis (PAM) 111 cases in U.S. 1962–2008 1 survived 2010: cases in AK, TX; 2011: LA, FL, VA

23 N. fowleri cultured and confirmed by real- time PCR from CSF

24 6912151621 Illness Onset Death Lake A Lake B River Timeline of Swimming Exposures and Illness Date August 2010 7d 5d Lake A Typical incubation

25 Lake A Organic Matter and Algal Bloom

26 Environmental Testing N. fowleri cultured from Lake A water and sediment N. fowleri not found at other 2 swimming sites N. fowleri from Lake A water and CSF were genotype 3

27 Precipitation Maximum Daily Temperature ( ° C) Date – August, 2010 Centimeters Ambient Temperature and Precipitation near Lake A, August 1-15, 2010 6 4 2 8 Lake A ≥30 ° C (86 ° F) on 6 of 15 days Maximum Daily Temperature

28 * Epidemiol. Infect. 2010; 138:968-975 Primary Amebic Meningoencephalitis Cases MN

29 Case 4 23 month old male with temp to 102  F x 2 days, runny nose and cough x 2 days Decreased activity No childcare, no travel Mother is a nurse in a long-term care facility PE significant for mild conjunctival erythema

30 Case 4 (cont.) Small white spots observed on oral mucosa Developed vomiting over next day and a rash on face


32 Measles Epidemiology in the U.S. Before introduction of vaccine (1963) approximately 3-4 million cases and 500 deaths annually; 90% prior to age 15 years 1989, 2 nd dose recommendation 1998, ACIP and AAP recommendation of 2 doses for school entry Fewer than 150 cases reported each year 1997- 2010 in US (37-140/year) Globally 164,000 deaths per WHO in 2008

33 92%

34 Dec 1999-July 2000, Dublin National immunization rates 79% and < 70% in North Dublin 111 children hospitalized Pneumonia 47%, tracheitis 32% 13 children ICU, 7 ventilated 3 deaths Resurgence of Measles in UK

35 Resurgence of Measles Rise in measles 'very worrying' Friday, 6 February 2009 Measles cases in England and Wales rose by 36% in 2008, figures show. Confirmed cases increased from 990 in 2007 to 1,348 last year - the highest figure since the monitoring scheme was introduced in 1995. Health Protection Agency experts said most of the cases had been in children not fully vaccinated with combined MMR and so could have been prevented. Immunisation expert Dr Mary Ramsay said the rise was "very worrying", adding measles "should not be taken lightly". More than 600 of the 2008 measles cases occurred in London, where uptake of the vaccine for MMR - measles, mumps and rubella - is particularly low. Public confidence in the triple MMR vaccine dipped following research - since discredited - which raised the possibility that the jab may be linked to an increased risk of autism. It led to some parents opting to pay privately for single vaccines. Across the UK, 84.5% of two year olds have been immunised with their first dose of MMR. But by age five, when children are recommended to have a second dose, the latest uptake figures are 77.9%. “ There are still many children out there who were not vaccinated as toddlers over the past decade and remain unprotected ” Dr Mary Ramsay, Health Protection Agency Since 2005, the number of cases of measles has been rising year on year. There have also been sporadic outbreaks of mumps in recent years. t

36 February 2, 2010

37 Measles outbreaks spread across Europe Copenhagen, 20 April 2011 Thirty countries in WHO’s European Region have reported a marked increase in measles cases, with 6500 so far in 2011. Epidemiological investigations and genotyping by laboratories confirm exportation of the virus among several countries in the Region and to other regions of the world. Outbreaks and the further spread of measles are likely to continue so long as people remain unimmunized or do not get immunized on time according to the routine immunization schedule. France faces the largest outbreak, with 4937 measles cases officially reported from January to March 2011, a figure almost equal to the total of 5090 cases reported for whole of 2010.

38 Measles in France Outbreak since January 2008 14,000 cases from January through June 2011 –6 deaths –15 neurological complications –615 severe pneumonia Surveillance Report July 13, 2011




42 Comparison of 24 Month Old Children Born in Minnesota of Somali Descent and Non-Somali Descent; MMR vs. Varicella Vaccinations in Hennepin County, Minnesota Year of Birth Percent Vaccinated n= 645 Somali, 13,565 Non-Somali n= 685 Somali, 11,947 Non-Somali n= 719 Somali, 14,197 Non-Somali n= 705 Somali, 14,509 Non-Somali n= 739 Somali, 14,323 Non-Somali n= 321 Somali, 7,176 Non-Somali

43 MN Measles Outbreak; February- April 2011 On March 2, measles confirmed in a 9 month old infant Index case 30 month old, US born, returning traveler from Kenya – Rash onset on February 15 (genotype B3) 23 confirmed cases 19 linked to the 30 month old (20 total) age 4 months to 51 years old One case in a 34 y.o. who acquired infection in Florida (unknown vaccination status) (genotype D4) One case in 27 y.o. who acquired infection in India (vaccinated with 2 doses) (genotype D8) One child with unknown exposure, with secondary case (daycare exposure)

44 Measles Genotypes Distribution of measles genotypes associated with endemic transmission in various areas of the world based on information available in 2002. JID 2003; 187 (supp 1) Rota and Bellini

45 Measles Cases Vaccination status: Unvaccinated –7 cases too young to receive vaccine –9 were of age but were not vaccinated Vaccinated –1 had received at least 1 MMR –1 had received 2 MMR –1 received MMR earlier than recommended age (11 mo) 4 unknown vaccine status 14 hospitalizations, no deaths: 3 pneumonia, 1 croup, 8 otitis media, many with dehydration

46 Exposure Settings for Outbreak Cases Index case acquired infection in Kenya Household (4 cases exposed) Healthcare (3 cases exposed in E.D.) Congregate living for the homeless (8 cases exposed) Drop in Daycare (3 cases exposed) One unknown exposure with secondary daycare exposure with B3 genotype

47 Measles Cases August, 2011 12 month old returned from Kenya (not Somali) –Prolonged course in ICU (intubated, measles pneumonia) 15 month cousin (brief hospitalization for dehydration, pneumonia) 43 yo exposed in waiting room 12 and 15 month- no MMR 43 yo unknown if vaccinated, but was measles- IgG negative when presented with symptoms

48 Community health workers immunize children under the age of five against polio and measles, and give them vitamin A and de-worming tablets, in a house-to-house campaign in the town of Liboi, north-eastern Kenya.

49 Acknowledgements Clinicians, ICPs, and Microbiologists in Minnesota Local Public Health Epidemiologists, Laboratorians and Student Workers at the Minnesota Department of Health CDC

50 Questions?

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