Duke University Medical Center November 2, 2019 1 Sy Symptoms, t - - PowerPoint PPT Presentation

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

Outcom tcome Tota

• tal P

Pati tients, 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

• the

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!

4

Herring et al. Pediatric WNV-Associated Neuroinvasive Disease: A Review of the

• Literature. Pediatric Neurology 2018.07.019

 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

• mati

tic b c but s t still i infecti ctiou

• us

 Sexu

exually t tra rans nsmitted ed

• Men should a

d abs bstain o

• r use c

condo doms f for a at least st 3 3 months

• Women, 2

, 2 months

5

Source: Centers for Disease Control

 Impo

portant t to rem remem ember er t the he beha behavior o

• f

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

• f

cases ses

▪ Usu

sually ly no a asso ssociated sy symptoms

9

Smith RP et al. Ann Intern Med

Tra rans nsmission o

• ccur

urs w wit ithin 1 n 15 minu inutes es o

• f

attachm hment nt

11

Anaplasmosis (HGA) Ehrlichiosis (HME)

MMWR Recommendations and Reports / May 13, 2016 / 65(2);1–44

12

Lone Star Tick Blacklegged Tick

 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 ho hour urs r requi uired f for in inje jectio ion o

• f bacteria

eria

14

American Dog Tick

 Sym

ympto tom o

• nse

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

 FI

FIVE VE s sta tates a acco count nt f for 60%+ of 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%

• f

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

• ms 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

• ms:
• Hives or
• r sk

skin r rash sh

• Nausea, s

stom

• mach c

cramps ps, i indi dige gesti tion

• n, v

vomiti ting, g, diarrhea

• Stu

tuffy/runny n nose

• se, sn

sneezing

• Bron
• nchospa

pasm

• Head

Headaches

• Anaphyla

laxis is

19

What

at TO TO DO

• REM

REMOV OVE t the t e tick ck ASAP

Time i is s of t the e esse ssence

• 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

• hol to kill

to kill it it What t NOT OT to do… to do…

 Burn it (gasoline,

kerosene)

 Smother it (petroleum

jelly)

 Poison it (fingernail polish)  Annihilate it (hot match

tip)

 Crush it  Use Dove soap

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

KEY EY M MES ESSAGE: FOLLOW AAP/CD

/CDC G C GUIDELINES A AND 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

• ing in

insid ide

 Ny

Nymphs emerge rge in in early rly Spring…th they’re on

• ne of
• f th

the mos

• st

t dange gero rous lif life-form rms—hard to to spot,

• t,

ca can be in infect cted vert rtica ically lly (fro rom moth

• ther)

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
• ok f

for

• r 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
• re is

isn’t B t BETT TTER, R, it’s it’s LON LONGER

 Durati

ation

• n o
• f efficacy

acy i is compar arab able e at at comp comparable con conce centratio ions f for

• r

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

• f 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

• f age in con
• ncentrati

tion

• ns 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

 Apply

pply s spa pari ringly t to expo exposed s d skin in, s smooth

• n

n lik like s e suns unscreen en o

• r

r bo body dy lo lotion

 CDC

DC a and nd othe her exper r experts: Us Use a a 25% or r hig highe her pro produ duct f for r Aedes edes spec pecies es (c (carr rry Zik ika, deng dengue, e, c chik hikung ngunya)

 Apply

pply s spa pari ringly t to clo lothi hing o

• r

r under under clo lothing if if m mosqu quitoes es c can n bit bite t e thro hrough h fabric ric

 Repellent

lent w washes es off w with p h perspira piration/ n/ swim imming ing/ra rain, in, s so reapply ply a as needed

29

 Appl

pply to expo xposed ski kin n AND D clothing, sho hoes, socks ks, p pant nts

 Use perme

rmethri rin-treated d clothi hing ng –KILLS LLS on contact

 CDC an

and oth

• ther experts: Use a

a 20% % or

• r higher

er conce centra ratio ion for r ticks

• LOWER

R conce centra ratio ions don’t work well ll or very ry long g

 A

A 25% 25% concentration DEET T pro roduct ma may la last 5-6 hours for mosqui quitoes BUT 3-4 4 for r tick cks, so R REAP APPLY LY

 Dress appro

ropria riately ly—long pa pant nts tuc ucked int nto socks. s.

30

 Ap

Apply su sunsc screen een first, th then en repel ellen ent

 Rea

eapply su sunsc scree een of

• ften

ten

 Rea

eapply rep epellen ent when en bugs gs retu eturn

31

 Causes

es s seizures

• Extens

nsive i ind ndepend ndent nt m meta-an anal alysi sis s and o

• ther

er reviews s ews show w this i s is not t true

 Hi

High gher co conce centrations ar are e more e dangerous

• No relat

ationship b bet etwee een ad adverse ev e even ents an and concen entrat ation w when en u used ed a according t to d direc ections

 Child

ildren are are a at t gre reater ris risk

• Ser

erious ad adverse ev even ents ar are ex e exceed edingly r rare, associat ated ed w with mis-use an and N NOT r rel elated t to ag age e

 Causes

es d death ath

• Ingesti

tion

• n o
• f s

subs bsta tanti tial amounts ts

 Label d

l dire irecti tion

• ns a

are re “s “scar ary” (w ” (was ash, e etc.) tc.)

• SAME

SAME d dir irections o

• n all

ll EP EPA-reg egist ster ered ed r repel ellen ents

32

 “Repel

epellen ent” m may no not be be a familiar pro produ duct

 Thin

hink it it is is RAID D

• Spray it

it at at mo mosquitoes, o

• n sc

n screens, in t in the he air air— but ut no not o

• n t

n the heir ski skin

 Us

Use it e it AF AFTER ER a mos

• squito b

bite te to to stop top th the it

• itch. (I

(It do does esn’ n’t)

 Spra

pray a a fog aro roun und t them hemsel elves es a and nd other hers

 Afra

raid t to us use repel e repellen ent

33

 Use a con

• ncentrati

tion

• n to

to matc tch you

• ur ti

time of

• f

exposure re (5% 5%=60 =60 min inutes, 30% 30%=8 =8 hours rs)

 25%

25%+

+ conc

ncentrat ation (on n expo posed skin n and and clo clothin ing g for r Aed Aedes (Zi (Zika-ca carr rrie iers rs) pro rotect ctio ion

 Us

Use permethrin only ly on clo clothin ing

 Dr

Dress appr appropriat ately

 Pro

rotect ction tim imes VA VARY RY via ia pers rspira iration, humid idit ity, win ind co condit itio ions, other r varia riable les THERE THERE ARE NO RE NO CU CURES RES –PRO ROTECTI TECTION N IS CRU CRUCI CIAL

34

 Put tic

t ticks in in alcoh alcohol

• l to

to kill th ill them m (h (hand s san anit itiz izer work

• rks)

 If you

• u re

remov moved a a tick tick an and th the h head re rema mains, don’ n’t p panic

• The body

body i is s th the pa part th that really m matt tters

 Use a

an an anti tibio ioti tic oin

• intm

tment/spray on

• n th

the b bite ite a are rea

 For s

• r some
• me tick

tick-borne d e disea eases es, t there a are n e no cures es –prote tecti tion

• n is

is th the O ONLY op Y optio tion

 If bitten by

by a a tick a and nd y you ha u have N NO sy symptoms, th there is is no

• need to

to see a a healt lthcare p prof rofessio ional an and n no

• need f

for an

• r antib

tibiot

• tic

ics

• Many fearful o
• f L

Lyme d e disease d sease do s so a anyway way

35

 Children m

en may presen ent differ erent ent s sympto toms tha than a adul dults to the to the sa same dise isease se

 Bact

cter erial i infec ections ns r respond nd t to doxy xy

 Some i

e infecti ections ns ( (Ehr hrlich chiosis and o

• ther

hers) ) can be f fatal q quick ckly w witho thout ut prompt treatm tment ent RMS MSF—”If yo you d don’t ’t treat at b by y day 5 ay 5, , the pat atient may may be d dead ad by y day 8 ay 8”

36

 CDC.go

gov

 800-789

789-33 3300 00 info@deet eeted educa cationp nprogram.org

 Tic

ick E Enc ncounter er (Univ (University o

• f Rho

hode de Island) d) - In n dept depth inf h information a n abo bout ut ticks s https://tickencounter.org/

 Repell

epellent Pro Produc ducts – Americ erican Mo n Mosqu quito Contr trol

• l Asso

Associati tion

• n

https://www.mosquito.org/general/cust

• m.asp?page=repellents

37