Libby Carver, DNP, FNP-BC, CNE Duke University Medical Center November 2, 2019 1
Sy Symptoms, t treatm tments nts Preve venti ntion s n strategi tegies ◦ EP EPA-re regi gistere red re repelle llents ◦ Saf afety and and efficacy inf nformation ◦ Pro roper r applica icatio ion ◦ Ur Urban legends ds Mes Messages that that wo work He Helping ng s spec ecial a aud udienc nces 2
Tota otal P Pati tients, Outcom tcome n (%) [9 (%) [95% C % CI] I] Symptom † Fatigue 94 (96 [90-99]) Fever 79 (81 [72-87]) Headache 70 (71 [62-79]) Muscle pain or aches 61 (62 [52-71]) Muscle weakness 60 (61 [51-70]) Rash 56 (57 [47-66]) Neck pain or stiffness 54 (55 [45-65]) Difficulty concentrating 52 (53 [43-63]) Joint pain or aches 36 (37 [28-47]) Vomiting 27 (28 [20-37]) Diarrhea 26 (27 [19-36]) Sensitivity to light 21 (21 [14-31])
34% of c cases es repo reported ed to C CDC DC in k in kids ids are re neuro neuroinvasive (N=2397 97 1999 1999-2016 016) ◦ Sam ame inc incidence as in as in all all o othe her ag age g gro roups Adult dults pres presen ent w wit ith enc h enceph ephalitis, k kids ids wit ith m h menin eningitis in in the he more s re sev evere ere c cases es Fatality ra rate in e in olde lder a r adul dults is is 14%...1% in in childre ldren Mo More re cases es in in kids ids t tha han for a r all a ll ages es for r SLE, E, LAC AC, EEE, EEE, a and W WEE EE combine ined! d! Herring et al. Pediatric WNV-Associated Neuroinvasive Disease: A Review of the Literature. Pediatric Neurology 2018.07.019 4
No c cure ure Tra ravel el-re rela lated Every eryone ret returning ng f fro rom endem endemic area reas needs needs to us use repel e repellen ent to prev preven ent infec ecting ing l local m l mosquit uitoes ◦ Asym ymptom omati tic b c but s t still i infecti ctiou ous Sexu exually t tra rans nsmitted ed ◦ Men should a d abs bstain o or use c condo doms f for a at least st 3 3 months ◦ Women, 2 , 2 months Source: Centers for Disease Control 5
Impo portant t to rem remem ember er t the he beha behavior o of the he mosqu quito t tha hat t tra rans nsmits it it ◦ Da Day tim ime bit e biter er ◦ Knees Knees t to ank nkle les Liv Lives es in in urba urban s n set ettings Dif Difficult t to repel repel AGGRESSIVE peo peopl ple bit e biter 6
Lyme disease Anaplasmosis B. miyamotoi disease (a form of relapsing fever), Babesiosis Powassan virus disease (related to WNV) (transmits in 15 minutes of attachment) 7
Found in 13 states – Virginia to Minnesota Not a factor in Texas A concern for students who travel elsewhere 8
▪ Tra ransmiss ssion t tim ime 24-36 h 36 hour urs a after er attachm chmen ent ▪ Onset 7 et 7-14 d 14 days a after er attachm chmen ent ▪ Bu Bull’s ey eye ▪ Pain inle less, doesn’t n’t itch ▪ Ide dent ntified in n 60 60-80% 80% of of cases ses ▪ Usu sually ly no a asso ssociated sy symptoms 9
Smith RP et al. Ann Intern Med
Tra rans nsmission o occur urs w wit ithin 1 n 15 minu inutes es o of attachm hment nt 11
Blacklegged Tick Lone Star Tick Anaplasmosis (HGA) Ehrlichiosis (HME) MMWR Recommendations and Reports / May 13, 2016 / 65(2);1–44 12
Rocky Mo Mount untain Spo potted ed F Fev ever er R. pa park rker eri Pa Pacif ific C Coast tic ick f fev ever er Ri Rick ckettsial al po pox Incidence of SFR by County, 2000-2013 13
>5 >50% rec ecall p prior ti tick ck encounter unter Tick a attachm chment ent >6 hour ho urs r requi uired f for in inje jectio ion o of bacteria eria American Dog Tick 14
Sym ympto tom o onse nset 7 7 day ays ( (rang nge, 2-14 d day ays) a after ter ti tick b bite te Reported thr through ghout the the l lowe wer 48 for 60% + of FI FIVE VE s sta tates a acco count nt f all c ll cases es NC, C, OK, A K, AR, T , TN, , MO 15
Chil hildren en < <10 yea ears rs =6% o 6% of RM f RMSF F dia diagnoses es, but but 22% 22% of f RM RMSF d F deat aths “If y you u do don’ n’t t trea reat by by Da Day 5, t they hey are re DE DEAD D by by Da Day 8 8”— CDC DC MD MD Before re a antib ibio iotic ics, fat fatality r rat ate was as 80% 80% fo for al all cas cases 17
NOT b bac acte terial al ◦ Path athogen as as yet t unk unknown Sam Same sy symptom oms as as Ly Lyme Also c lso calle alled Maste Masters’ D Dise iseas ase Lon Lone Star Star tic ticks 18
Galac actos tose-al alpha 1 a 1,3-gala lacto tose (a (alp lpha g gal) l) pre resent in t in tick tick saliv aliva a and re red me meat at Rea eaction t to meat eat c consumption Symp mptom oms: ◦ Hives or or sk skin r rash sh ◦ Nausea, s stom omach c cramps ps, i indi dige gesti tion on, v vomiti ting, g, diarrhea ◦ Stu tuffy/runny n nose ose, sn sneezing ◦ Bron onchospa pasm ◦ Head Headaches ◦ Anaphyla laxis is 19
What t NOT OT to do… to do… Burn it (gasoline, kerosene) Smother it (petroleum jelly) Poison it (fingernail polish) What at TO TO DO Annihilate it (hot match tip) REM REMOV OVE t the t e tick ck ASAP Crush it Time i is s of t the e esse ssence Use Dove soap Cl Clean ean wound ar area w ea with s soap ap an and wat ater er, an antisep eptic Put th the tic tick in in a alc lcoh ohol to kill to kill it it 20
If f the c chil ild is is sy symptomatic, D DO NO NOT w wait it fo for t r test st re resu sult lts Doxy xycy cycl cline i ne is AAP’s a and CDC’ C’s reco commend endation Na National su surve rvey 2 2012 ◦ 35% 35% of p pro rovid iders rs would ld not giv give t to patie ients younge ger r than 8 8 years rs old ld due to co conce cern rn for r dental co colo lora ratio ion ESSAGE : FOLLOW AAP/CD /CDC G C GUIDELINES A AND KEY EY M MES GIVE D DOXYCY CYCL CLINE REGARDLESS OF TH OF THE P PATI ATIENT’S AG AGE 21
USE SE RE REPELLENT AL T ALWAY WAYS Let et cl clothing g be e a a bar arrier Use p permethrin tre treatme ment on t on cloth clothin ing Do a a tick ch chec eck- before g goin oing in insid ide Ny Nymphs emerge rge in in early rly Spring…th they’re on one of of th the mos ost t dange gero rous lif life-form rms—hard to to spot, ot, ca can be in infect cted vert rtica ically lly (fro rom moth other) 22
Wh When co comin ing in insid ide, put clo clothin ing in into the dry ryer r on high igh for r 20 20 mi minu nutes Do a a t tick ick-check whe when yo you’ u’re in n the he sh shower er ◦ Ch Check eck al all nooks an and cr cran annies ◦ Loo ook f for or mov moving f fre reckles Estimated d disease se transm smissi ssion n tim ime 24 24-36 h 36 hours rs ◦ ex excep cept P Powassan 15 15 minutes ◦ Ro Rock cky M Mountai ain F Fev ever er 6 6 hours 23
Alw lways us use e a repell repellent w wit ith a an n EPA PA- registere ered a d active e ingre redient dient ◦ Tes ested f d for r sa safety a ty and effi fficacy cy ◦ Tes ested f d for specif ific ic v vectors rs 24
The h e high gher t the co e conce centration t the e LONG NGER R the r e rep epellent h hel elps p protect More ore is isn’t B t BETT TTER, R, it’s it’s LON LONGER ◦ Durati ation on o of efficacy acy i is compar arab able e at at comp comparable con conce centratio ions f for or the E e EPA PA-regi egistered a ed actives ◦ 5% pic icarid ridin in la last sts s an n ho hour ur -- --same e FOR DEE DEET-base sed p products Pic Pick the c he conc ncentra ration t tha hat matches es y your t ur tim ime o of expo exposure Pro Protection t tim imes es a are re SHORTER ER for t r tic icks t tha han m n mosqu quitoes 25
CD CDC/ C/Am. Aca cademy of Pedia iatri rics cs • Use DEET, EET, pica icarid ridin in, IR3535 R3535 on kid ids as young g as 2 2 MONTHS NTHS of of age in con oncentrati tion ons up to to 30% 30% EPA has has NO ag age limi mitations on n any any of the he re regis gistere red act ctiv ives • EX EXCEP CEPT T Oil il of Le Lemon Eu Euca caly lyptus-childr dren mus must be be 3 yea ears of ag age Adul dults appl apply to the heir own wn hand hands, smo moothing re repelle llent evenly ly on ch child ild’s exposed skin in • Avoid id fin inge gers in in very ry young g ch child ildre ren • Keeps repe pellent out ut of eye yes and and mo mout uths 26
WRONG! 27
OVER ER APPLICA CATI TION N IS NOT NEEDE EDED… D…APPLY SPARI RING NGLY 28
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