2/4/2014 Em erging Issues in Ped ia tric Infections w ith em p ha sis on Vaccine-Preventable Illnesses CA R O L G L A S ER , D V M , M P V M , M D DEPARTMENT OF PEDIATRICS DIVISION OF PEDIATRIC INFECTIOUS DISEASES UNIVERSITY OF CALIFORNIA, SAN FRANCISCO I have nothing to disclose Em erging Issues in Ped ia tric Infections rela ted to Va ccine-p rev enta b le d isea ses (VPD) Why I choose this topic Resurgence of VPD due to failure to immunize and what it means to United States Measles (mainly a problem in Europe but spill over has led to problems / issue here) Impact on others The Pertussis Problem Is this due to failure to immunize? Mumps Why are we still seeing cases? Other vaccine-preventable illness and/ or illnesses that look like VPD http://www.npr.org/blogs/health/2014/01/25/265750719/h ow-vaccine-fears-fueled-the-resurgence-of-preventable-diseases About vaccines Childhood rates have plummeted in Europe following 1998 study that falsely claimed MMR was linked to autism Although results of 1998 study have been shown to be false, fears about vaccine safety have remained What is the current impact? 1
2/4/2014 Case Case 1 3 year old female with fever and runny nose followed by a rash 3 days later On exam child is irritable and coughs frequently. Eyes are red and erythematous MP rash whole body, most pronounced on trunk. No palmar erythema, no puffy hands/ feet Labs CRP =2, ESR=36 CBC unremarkable AST slight increase, ALT normal U/ A with pyuria Case Case Past Medical history: -incomplete immunizations (no MMR) -6 older siblings, “incomplete” vaccinations -no prior medical problems No animal contact Just returned home from Philippines Diagnosis Background Rash illness, historically childhood infection with 2- Blood and Respiratory samples taken 4 year epidemic cycle; most cases in winter / spring Positive Measles IgM Complications may include otitis media, Positive Measles PCR pneumonia, encephalitis, miscarriage, and death Airborne spread - probably the most infectious Diagnosis : Measles communicable disease; R 0 =15-17 Two doses of MMR vaccine offer >99% protection from disease; however, requires very high population immunity to interrupt transmission (92- 95%) 2
2/4/2014 Epidemiology Epidemiology Highly contagious viral illness – 90% of susceptible Currently, most U.S. measles cases are related to persons who are exposed to measles will become ill international travel or contact with ill travelers Measles is transmitted via the airborne route Measles is still endemic in Europe with large Measles patients are infectious 4 days prior to rash outbreaks in 2010-2011; >15,000 cases in France onset and 4 days after rash onset in 2011 {Romania, Ireland, the UK, France, Italy, No endemic transmission in the U.S. at this time – and Spain] declared eliminated in 2000 Ongoing transmission in India, the Philippines and R0 = 12-18 Ethiopia, among other countries 139,300 deaths from measles were reported in 2010 globally Measles cases in the U.S., 2013 Imported cases of Measles in U.S., 2001-2013 Unvaccinated U.S. resident-Measles 3
2/4/2014 Clinical Features Measles Clinical Features Rash Prodrome – onset 8 to 12 days after exposure 2-4 days after prodrome, 14 days after exposure (range=7-21 days) Maculopapular, becomes confluent Stepwise increase in fever to 101º F or higher Begins on face and head Cough, coryza, conjunctivitis Persists 5-6 days Koplik spots (rash on mucous membranes) Fades in order of appearance Measles complications Condition Percent reported Diarrhea 8 Otitis Media 7 Pneumonia 6 Encephalitis 0.1 Hospitalization 18 Death 0.2 Based on 1986-1992 Surveillance data Case 2 Choosing Not to Vaccinate I S I T R E A L L Y A P E R S O N A L D E C I S I O N ? W H A T I S T H E I M P A C T O N O T H E R S ? 4
2/4/2014 Case 2 Case 2 Previously healthy, Hispanic male Ultimately diagnosed with Bordetella pertussis (w hooping cough) 6 weeks of life Several family illness with cold illness in last few Developed upper respiratory tract symptoms Seen in clinic for ‘stuffy nose” and told to use nasal saline weeks drops During next 8 days had 2 additional visits to PMD and then in ER 2 nd ER visit Admitted to floor and within a few hours transferred to PICU with pulmonary HTN Died the following day: Pulmonary HTN and CBC WBC >130,000 Background Pertussis (whooping cough) Caused by Bordetella pertussis, a gram negative, fastidious, Humans are the only host pleomorphic bacillus Close contacts: aerosolized droplets Primarily a toxin-mediated disease; bacteria attach to cilia of Incubation period ~ 7-10 days [5-21] respiratory epithelial cells Occurs year-round but some seasonal peaks in late Most severe disease and death occurs in infants <4 months of age summer-fall Highly infectious during catarrhal phase and first two weeks of cough Neither infection or Immunization confers life-long R0 estimated to be 15-17 (similar to measles) immunity Has been described in writings as early as 14 th c. and first isolated by Bordet and Gengou in 1906 Epidemiology U.S. Pertussis Cases: 1922-2011* Prior to vaccine, >200,000 cases/ year, used to be most common childhood illness DTP Still major problem in developing countries, (among the 10 leading causes of childhood mortality) Outbreaks in the US have “ballooned” in regions across the US “breaking records” Tdap DTaP CA experience pertussis epidemic in 2010; incidence declined in 2011-2012 but is now increasing again in 2013, not clear what 2014 will bring… Nearly all other states experienced peaks in disease *2011 data have not been finalized and are subject to change. 2011 data were accessed on July 5, 2012. incidence in 2011-2012 SOURCE: CDC, National Notifiable Diseases Surveillance System and Supplemental Pertussis Surveillance System and 1922-1949, passive reports to the Public Health Service 5
2/4/2014 Only vaccine-preventable disease in the US increasing… Europe also experiencing increase Clinical Stages of Disease in Weeks (outside neonatal period) 3 stages: catarrhal, paroxysmal, and convalescence Classical presentation Communicable Period coryza; no pharyngitis paroxysmal cough, posttussive vomiting & “whoop” Paroxysmal Stage Convalescent Incubation Period no systemic illness, no fever, no pharyngitis Stage Catarrhal Stage Cough often quite prolonged and severe -3 0 2 8 12 Adults with pertussis often report sweating episodes Symptom Onset and feeling as if they’re choking on something 6
2/4/2014 Pertussis in Young Infants Child with broken blood vessels in eyes, bruising on face (2 0 cough) (< 6 month) Infant initially looks deceptively well; coryza, no or minimal fever, mild or no apparent cough Later: Gagging, gasping Bradycardia or Apneic episodes Cyanosis (parents may report red or purple face) Post-tussive emesis Infants can develop very high lymphocytosis Adenovirus or RSV co-infection can occur Other complications in infants Mechanism for pathogenesis pulmonary hypertension in infants Pneumonia Seizures Respiratory distress Pneumonia Encephalopathy Death Paddock C, Clin Infect Dis, 2008 Exchange transfusion as management for Pertussis Diagnostics infants with pertussis Background reports Culture: considered gold standard and very specific but insensitive, not timely 6 reports; 13 infants ET 11/ 13 survived PCR: increased sensitivity > culture, more rapid 5 were in cardiogenic shock but not organ failure before ET (Ct cut off values are important; contamination of NP swabs 2 fatalities with pertussis vaccine DNA can lead to false positives* ) Both were in renal failure BEFORE ET initiated Serology: useful for adolescents & adults in the later stages of the disease. Is not considered valid laboratory confirmation for surveillance purposes *See: http:/ / www.cdc.gov/ pertussis/ clinical/ diagnostic-testing/ diagnosis-pcr-bestpractices.html 7
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