Archive for the 'Infectious Diseases' category

It is never just a cold

Apr 06 2015 :: Published in Infectious Diseases

By Stephanie Chester, Manager, Influenza Program, APHL

“Oh, it’s just a cold,” seems to be a common phrase heard in office spaces and schools alike during the winter months. But is it just a cold? Are we belittling our coughs and sneezing by grouping them under one tiny umbrella term? While the common cold is, in fact, common it is by no means simple. Your sniffles are never just a cold.

It is never just a cold | www.APHLblog.org

So how common is the cold? The viruses behind the common cold impact all of us at an average of two to three illnesses per year for adults and six to eight illnesses per year for young kids. And despite there being a cold season, these viruses are not actually confined to the winter months. There are differing theories on why people seem to catch colds more frequently during the winter but most agree that the viruses transmit more readily when people are clustered together in schools and offices.  “Environmental conditions may be a factor in which cold viruses are circulating,” said Kirsten St. George, MAppSc, PhD, chief of viral diseases at The Wadsworth Center, the New York State Department of Health’s public health laboratory . “It is not well understood, but certain viruses seem more stable in specific temperature and humidity conditions.”

There are more than two hundred viruses behind the common cold, and there may be many more still that have not been identified. Rhinoviruses are the traditional cause of the common cold, but there are at least 100 rhinovirus serotypes (distinct variations of the virus). A close relative of rhinoviruses are the enteroviruses which you probably heard about with the fall 2014 enterovirus D68 outbreaks; in a normal year they typically cause mild respiratory illness. Other cold causing viruses include human parainfluenza viruses and human metapneumoviruses.

There is a veritable alphabet soup of virus names – but why does the specific virus matter to us if they all just cause a cold?

As you can probably imagine, the fact that there are hundreds of cold-causing viruses, each with several different strains and serotypes, creates many challenges for scientists, healthcare providers and public health practitioners. For starters, it makes it nearly impossible to predict which viruses will be dominant in a given season. “There may be a swell of dominance for one virus, but then it will fade and another will take its place,” explained Dr. St. George.

So if we can’t predict it, why don’t we just prevent it? Why is there not a vaccine for the common cold much like there is for influenza? Again, the sheer volume of viruses and their ability to change and evolve over time is a huge hindrance to this process. To create an effective flu vaccine, said Dr. St. George, researchers must change the vaccine composition annually, or nearly annually, to keep pace with the variants of the virus in circulation. In contrast, she said, “With the cold, there are a myriad of types within a single group, dozens of types circulating all of the time.” This diversity would make the creation of a vaccine very expensive and difficult. It is more likely that researchers will focus on ways to stimulate the immune system to respond more productively to infection and on medications to relieve symptoms.

One area where science is making progress is in the diagnostics and surveillance of the common cold and other respiratory viruses with the advent of new molecular tests. “A lot of these viruses were difficult to identify with classical virology laboratory methods such as culture,” said Dr. St. George. “They just don’t always grow well – or at all – in culture. With new technology, especially the commercially available molecular kits, they are readily detectable.” This advance may not save us from the coughing and congestion, but it provides researchers, physicians and public health practitioners with improved data about what is circulating and causing severe illness. And that information has a multitude of benefits!

For starters, data from these tests may ultimately help researchers and physicians learn if certain demographics or risk factors increase a person’s chance of more severe illness. This may allow for prevention and mitigation strategies, or may lead to a physician being more aggressive with treatment and supportive therapy. Though, as Dr. St. George explained, serious reactions are not limited to those higher risk populations such as those with underlying health conditions. “We have seen very severe manifestations in otherwise healthy people who ended up in intensive care.” Even still, understanding if it is the virus or the host that predisposes a person to more severe illness is incredibly helpful.

Additionally, school officials may decide to cancel classes (or not) if they know the current outbreak of sniffles and coughs is caused by a more troublesome virus. Hospitals can use this data to cluster and isolate patients when needed so respiratory outbreaks don’t spread throughout the entire facility.

While understanding the different viruses that cause the common cold is valuable to public health, we also keep a close eye on how cold treatment may be contributing to a larger health concern: antibiotic resistance. Antibiotics are overprescribed for many things including the common cold. Cold viruses do not respond to antibiotics because they are viruses; antibiotics are only effective for bacterial infections. “Often the thought process is that when you get sick, you should go to the doctor, get some antibiotics and get better,” said Lisa McHugh, MPH, influenza surveillance coordinator and supervisor for the regional epidemiology program at the New Jersey Department of Health. “There is not a clear understanding [among the public] of the difference between bacteriology and virology, and what the standard treatments are for each.” She went on to emphasize that it is critical for the public to understand the difference and that antibiotics are not be the remedy for every ailment. Dr. St. George agreed. “Clinical judgment is important. People need to trust their doctors. They are pretty good at telling when your illness is viral. We are in a time where we need to look carefully at antibiotic use and keep them in reserve.”

Next time you hear someone say, “Oh, it’s just a cold,” you can let them know they may actually be sick from one of hundreds of viruses. Regardless of which one (or several) has struck your family this year, remember to cover your coughs and sneezes with your elbow, wash your hands and stay home when necessary to prevent sharing your virus with others. While scientists work to broaden their understanding of this complex group of viruses, we can help make the common cold a little less common.

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The Tenacity of Tuberculosis: MDR-TB

Mar 24 2015 :: Published in Infectious Diseases

By William A. Murtaugh, MPH, Specialist, TB Program, APHL

“Suddenly she stopped, clutched her throat and a wave of crimson blood ran down her breast… It rendered her even more ethereal.” ~ Edgar Allan Poe describes his wife dying of tuberculosis.

Disturbing, sensational and oddly romanticized — these were the days of tuberculosis past. So what has become of its future?

The Tenacity of TB: How multi-drug resistant tuberculosis will determine global progress in TB elimination | www.APHLblog.org

While recent news stories about en vogue infectious diseases are no less sensational, TB has certainly lost its status at the water cooler. It is far from having the mystique of a zombie apocalypse; it’s not wrapped up in a passionate human rights movement like HIV/AIDS; it doesn’t have the exotic novelty of Ebola; and it hardly provokes the Thought Police like vaccine preventable diseases. With a low burden of disease in the US and case rates continuing to decline annually, TB has all but faded from public consciousness.

But what TB has lost in zeitgeist influence, it has made up for in tenacity. For every major advancement in treatment and control, M. tuberculosis has capitalized on weaknesses and dared the public health system to rest on its laurels. As a result, the US, a country with relatively robust TB control programs, has not achieved TB elimination. Globally, large disparities in resources and infrastructure remain and TB is the second largest cause of mortality of any single pathogen behind HIV.

In the US, TB often persists in marginalized and invisible populations such as homeless or foreign-born communities. With few exceptions, cases of TB are still reported by every state. Occasionally, rare outbreaks breach the imaginary safety bubble of larger communities. It is vital to recognize that our current system is neither infallible nor exclusive of the global TB fight. The TB of today poses a challenge that could take the hot air from the lungs of the most bumptious pathogen pundit. That threat, and this year’s topic for World TB Day, is multi-drug resistant tuberculosis (MDR-TB).

Multi-drug resistant tuberculosis is defined as active disease from infection by M. tuberculosis strains that are resistant to at least rifampin and isoniazid, two of the four drugs in first line drug therapy (collectively and colloquially known by the acronym “RIPE”). The reasons that TB strains develop drug resistance are complicated and derive from a variety of biological and man-made influences. The major concern with MDR-TB is that it renders inadequate an already limited number of drugs, with only prolonged, less effective and more toxic treatment options remaining.

The story of MDR-TB has its roots right here on, or rather in, our soil. Streptomycin, the first drug to treat TB, is an antibiotic produced by bacteria found in the soil, and is a Nobel Prize winning discovery by Selman Waksman of Rutgers University. While blindingly obvious, drug resistance can’t develop without one key component…drugs. But drug resistant TB was unheard of prior to the discovery of streptomycin in 1943. Not to be outdone, M. tuberculosis showed that it could quickly develop resistance. Through the next 20 years this TB tit-for-tat went on with each newly developed drug until a regimen of combination therapy, the RIPE panel of drugs, provided the TKO and is still the primary arsenal used today. This drug regimen was lengthy with harsh side effects, but it was nonetheless effective. US case rates began to decline through the 1970s. However, the silver bullet of antituberculosis drug discovery was a silver lining that encircled a menacing storm cloud of emerging drug resistant TB.

Optimism in new treatment regimens gave way to the reality that global scale-up of effective treatment programs was a long term investment and expensive. Funders wanted the most bang for their buck, and TB didn’t fit the bill. Consequently, global political will eroded and only wealthy countries, like the US, made significant strides toward TB elimination. Low resource, high burden countries faced limited access to antituberculosis drug supplies and deficient healthcare infrastructure. This contributed to the improper use of drugs that consequently encouraged the emergence of resistant TB strains and subsequent outbreaks of multi-drug resistant TB. These factors led to treatment failure and widespread transmission, and paved a road for outbreaks of multi-drug resistant TB.

Not until the 1990s, when TB remained the single largest cause of death from an infectious disease, were advances made in public health economics that supported investment in TB treatment efforts. The World Health Organization implemented a strategy that is the foundation of today’s approach: Directly Observed Therapy short-course (DOTS). DOTS strategy, as the name indicates, involves a high level of accountability for treatment adherence. Unfortunately, drug resistant strains of M. tuberculosis cannot be determined through direct observation or even under a microscope. MDR-TB patients were failed by the original DOTS strategy because it did not include a significant laboratory component to detect drug resistance. This weakness, coupled with comorbidity associated with a mounting HIV epidemic, gave rise to numerous MDR-TB outbreaks here in the US.

Traditional methods for TB drug susceptibility testing in the laboratory greatly improve the ability to properly treat and control MDR-TB, but require weeks of precious time and expertise. This often limits their utility. The Centers for Disease Control and Prevention Division of TB Elimination, in conjunction with APHL and state and local public health laboratory systems in the US, continue to play an important role in maintaining expertise amid overall declining rates of TB. Great strides have been made in the past decade in development and implementation of technologies that can inform treatment decisions within 24 hours and in greater detail than was ever thought possible.

With a bolster to the domestic diagnostic infrastructure, MDR-TB cases are able to be detected and remain rare (95 cases in 2013). But MDR-TB is showing little sign of significant decrease and, as of 2013, nearly 90% of cases were foreign-born. While barely registering in headlines, MDR-TB is nevertheless the next major obstacle to tuberculosis control. Its path will determine global progress toward TB elimination.

Check out APHL’s webinars related to TB:

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University of Oregon outbreak highlights collaboration between public health and clinical care

Mar 12 2015 :: Published in Infectious Diseases

By Michelle Forman, senior specialist, media, APHL

University of Oregon outbreak highlights collaboration between public health and clinical care | www.APHLblog.org

In mid-January, a University of Oregon student was diagnosed with Neisseria meningitidis serogroup B, a rare but serious disease. Within one month, three additional students were diagnosed with the same disease, one of whom died. “I was the first assistant on that autopsy,” said Patrick F. Luedtke MD, MPH, senior public health officer and medical director of the Lane County Department of Health & Human Services Community & Behavioral Health clinics. (He’s also a past APHL president.) “The bacteria were everywhere. Neisseria meningitidis takes over the body and wins every battle.”

College campuses like the University of Oregon are perfect breeding grounds for meningococcal disease. Young adults ages 16-21 have higher rates than others, and it is transmitted through close or lengthy contact such as living in close quarters or kissing. So, yeah… meningococcal disease can make its way across a college campus if it isn’t stopped quickly. In fact, there were similar outbreaks at Princeton University and at University of California, Santa Barbara in 2013.

Meningococcal disease is rare, but if a person gets it they are likely to become very sick. Once it is suspected, clinical laboratories can do a test to confirm meningococcal disease and doctors can quickly begin antibiotic treatment. (Oftentimes prophylactic antibiotic treatment is given anyone who had close contact with the sick individual.) But even with quick and proper treatment, approximately 20% of people will have long-term disabilities and 10-15% of people die. The best way to prevent severe illness is to prevent illness all together – decrease the number of people who can get meningococcal disease in the first place – with vaccines. Here’s the kicker, though… Kids in the US receive a quadrivalent meningococcal vaccine at age 11. However, that vaccine only protects kids from serogroup A, C, Y or W-135. What about B, the serogroup found at the University of Oregon?

In October 2014, the FDA approved the first ever N. meningitidis serogroup B vaccine for use in people 10-25 years of age as a three-dose series. In January 2015, the FDA approved another N. meningitidis serogroup B vaccine for use in the same age group as a two-dose series. Neither vaccine has been recommended for routine use yet, but it has been recommended for controlling outbreaks like the one at the University of Oregon. In order to implement a massive campaign to vaccinate all 22,000 students, CDC needed to know that there had been at least three confirmed serogroup B cases within a three month period. The clinical test that confirmed meningococcal disease in each of the four patients wasn’t enough, though. Not only are clinical laboratories often without the capabilities to serotype meningococcal disease, the serogroup doesn’t affect clinical care. Whether the meningococcal disease was serogroup A, B, C, Y or W-135 didn’t change how they cared for the sick individuals. Further testing was needed to show that all four cases had the exact same strain of serogroup B meningococcal disease.

That was a task for the Oregon State Public Health Laboratory; in an outbreak, it is the public health laboratory’s role to show cases are truly linked. As each case was determined to be meningococcal disease, the public health laboratory was contacted and serotyping began. While the public health lab’s confirmation that the patients were sick with group B meningococcal disease was enough information for CDC to green-light the vaccination effort, the Oregon State Public Health Laboratory dug even deeper. With Neisseria meningitidis cases such as the ones at the university, the Oregon state lab routinely uses pulsed-field gel electrophoresis (PFGE) to isolate the DNA fingerprint of each strain to show that everyone got the disease from the same source. That information could help epidemiologists identify the index case. “Using PFGE to fingerprint meningococcus is considered very risky, and it is very expensive, so many laboratories don’t do it,” explained Robert Vega, general microbiology manager at the Oregon state lab. “The risk associated with this is very real to us. Our staff is vaccinated against groups A, B, C, Y and W-135; we are well equipped and I have highly proficient staff.”

Once it was confirmed that the cases were group B meningococcal disease, CDC approved the Lane County Health Department and the University of Oregon to implement a massive effort to quickly vaccinate 22,000 students. The vaccination effort began on March 2 and within one week over 10,000 students had received the first dose of the vaccination. “We still have more students to reach, but we are working hard to make sure everyone is vaccinated,” said Dr. Luedtke. Quick treatment from clinical care providers and fast, accurate testing by the public health lab will hopefully mean that this is the beginning of the end of this outbreak.

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For Global Handwashing Day, the ABCs of Washing Your Hands

Oct 15 2014 :: Published in Infectious Diseases

Did you know that today, October 15, is Global Handwashing Day? It’s true! Even without a designated day, proper hand washing should always be a priority.

Why is hand washing so important?

  • It is estimated that washing hands with soap and water could reduce diarrheal disease-associated deaths by up to 50%. (CDC)
  • Researchers in London estimate that if everyone routinely washed their hands, a million deaths a year could be prevented. (CDC)
  • Handwashing can reduce the risk of respiratory infections by 16%. (CDC)
  • Handwashing with soap at critical times could help reduce school absenteeism by around 42 percent. (PPPHW)
  • When hand hygiene compliance in health facilities increases from less than 60% to 90%, there can be a 24% reduction in MRSA acquisition. (WHO)

What exactly is proper hand washing? It’s important to wet your hands with clean water and use soap. Rub your hands together and be sure to get every bit of your hand. Keep scrubbing for 20 seconds! We asked a few of APHL’s most special partners to demonstrate proper hand washing including a fun way to know you’ve been scrubbing for 20 seconds. Check out the video below and be sure to pass the message along!

 

ABCs of Good Handwashing from APHL on Vimeo.

 

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Enterovirus D68 Testing, Surveillance and Prevention: What We’re Telling Our Friends

Sep 11 2014 :: Published in Infectious Diseases

By Laura Iwig, MPH, Senior Specialist, Infectious Disease Program, Stephanie Chester, MS, Influenza Program and Kelly Wroblewski, MPH, MT (ASCP), Infectious Disease Program, APHL

Fall brings the start of many things every year – school, of course, but also respiratory virus season. And this year as both kick-off we’re faced with an outbreak of a virus that is new to many, enterovirus D68 (EV-D68). Terrifying headlines have loaded up our Facebook newsfeeds, so we’re here to straighten things out a bit. When our friends and family ask us about EV-D68, this is what we tell them.

Enterovirus D68 Testing, Surveillance and Prevention: What We’re Telling Our Friends | www.aphlblog.org

First of all, there are many enteroviruses and D68 is just one type. What makes EV-D68 unique is that it is causing severe illness in some people, particularly children which is always cause for concern. Keep in mind that while there are severe cases being reported, there very likely are also less severe cases of EV-D68 with typical cold-like symptoms going unreported. The number of severe cases is not necessarily the full picture. Despite there being no vaccine or specific treatment for EV-D68, it typically resolves itself without any complications.

We know this all sounds kind of scary especially when news reports are focusing on the most severe cases. But it is important to understand that the clinical and public health communities are well-equipped to deal with enterovirus outbreaks and actually respond to similar outbreaks on a routine basis. We and our partners are prepared.

Clinical, commercial and public health laboratories are conducting testing to determine if severe cases and/or outbreaks are being caused by an enterovirus or closely related rhinovirus. (Not specifically D68 – we’ll get to that below.) Many of these labs utilize rapid molecular methods to detect a wide array of respiratory pathogens, including enteroviruses.

If testing confirms that you do have an enterovirus and if you have severe symptoms, CDC is conducting additional testing to determine which type of enterovirus you may have. For the public, the value in differentiating EV-D68 from other related viruses is to provide real-time information to your doctor to help recognize symptoms associated with severe cases, identify them and get them early supportive treatment. For example, if your child has an underlying condition such as asthma and comes down with a cold that starts to become severe, his doctor might want to be more proactive in supportive care if they have learned from public health officials that EV-D68 was detected in your community. Knowing that it is EV-D68 is in the community or even a specific school can impact public health infection control measures and raise awareness for patients and parents to be more proactive about intervention if their child does get sick.

There is also significant value to the scientific and public health communities in determining if enterovirus cases and outbreaks are caused by EV-D68. Historically, this particular type of enterovirus has been rarely reported so we are still learning how easily it transmits, who is at risk for severe illness and how widespread the virus may be. In fact, some scientists are wondering if EV-D68 is truly as rare as many think or if our testing capabilities have improved allowing us to detect more cases. Science is a never ending process of information gathering. While most actions won’t be any different from other respiratory outbreaks if even if epidemiological and laboratory surveillance activities detect EV-D68, these investigations may change how we deal with outbreaks like these in the future making us more prepared.

What can you do to protect yourself and your family?

  • Wash your hands frequently with soap and water! Alcohol based hand sanitizers do not work against enteroviruses.
  • Avoid close contact with those who are sick.
  • Clean and disinfect surfaces, especially those touched by those who are ill. The virus can be easily killed on surfaces.

For now, we are reassuring our friends and family that the clinical and public health communities are prepared and are responding to this outbreak. That gives us peace of mind and hopefully it will do the same for you.

 

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In US, Massive Effort to Detect and Respond to Ebola Already Underway

By Tyler Wolford, MS, Specialist, Laboratory Response Network, APHL

Our curiosity and fears have been running wild since the 2014 Ebola* outbreak in West Africa hit headlines. Scenes from Outbreak, the 1995 box office hit that focused on a fictional outbreak of an Ebola-like virus in Zaire, begin running through our minds. We need to stray from these dramatizations and focus on the facts. Movies are supposed to build suspense and fear, but real life outbreaks don’t happen like they do in the movies. This isn’t Hollywood.

In US, Massive Effort to Detect and Respond to Ebola Already Underway | www.aphlblog.orgThe most common question on the minds of people around the United States: Are we fighting Ebola well enough to keep it from coming to my community?

The truth with many emerging infectious diseases including Ebola, is that the only way to fight it is to be prepared to respond. In the United States, we’re doing just that.

Although the Ebola-Zaire virus circulating in West Africa has not arrived in the United States, a massive effort is underway to detect and control any isolated cases of the disease should they occur in this country. The Centers for Disease Control and Prevention (CDC), the United States Department of Defense (DoD), pharmaceutical companies, public health laboratories and many more are all working domestically and abroad to minimize the potential threat. The DoD has long been studying Ebola virus and successfully developed a test to detect the Zaire strain. On August 5, 2014, the DoD Ebola detection test received emergency use authorization (EUA) by the Food and Drug Administration (FDA) to be used in this extreme circumstance. (An EUA expedites the FDA approval process for unapproved medical devices that could benefit response efforts when no adequate alternatives exist.) After the EUA was issued, CDC worked quickly to deploy the test to select public health laboratories across the United States. As the supply of test kits increases, CDC will look to expand the number of laboratories qualified to detect the Ebola-Zaire virus.

The public health laboratories receiving the Ebola detection assay are part of the Laboratory Response Network (LRN), a specialized network of laboratories that are capable of responding to biological, chemical, radiological and other emerging threats. This preparedness and response effort is not unique to Ebola. Most recently, the LRN has been leveraged to respond to emerging infectious diseases like Middle East Respiratory Syndrome – Coronavirus. The LRN provides a strong infrastructure of trained personnel, clear communication lines, and advanced technology to launch an effective response to emerging infectious disease.

The race to contain Ebola is on since the World Health Organization (WHO) declared the Ebola outbreak a Public Health Emergency of International Concern (PHEIC) in early August 2014. Moreover, the CDC has activated its Emergency Operations Center at the highest response level to help with the outbreak. As Dr. Tom Frieden, CDC director, said in a press conference this week, “We know how it spreads. We know how to stop it from spreading. The challenge is to do that everywhere that’s needed. In order to do that effectively, speed is key.”

While we all are concerned for the health and safety of the people in the most affected nations, we can find some comfort in knowing that a coordinated effort of qualified scientists, doctors, public health officials and organizations is underway to minimize the threat of outbreak in the US.

*Did you know there are five known strains of Ebola virus? The most dangerous one, Ebola-Zaire, is responsible for the outbreak in West Africa. The virus spreads person to person through direct contact with blood and other bodily fluids; despite what you may have read in fear-mongering articles, the spread of the virus through the air has never been documented. Once inside the host, the virus works by weakening the immune system and starving the host organs to the point of failure.

 

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Vector-borne disease vs chemicals in bug spray: Weighing the risks

Aug 18 2014 :: Published in Environmental Health, Infectious Diseases

By Michelle M. Forman, senior media specialist, APHL

Vector-borne disease vs chemicals in bug spray: Weighing the risks | www.aphl.orgWith hot and humid weather comes news of diseases spread by mosquitos and ticks, while we also hear of concerns around the bug sprays we’re supposed to use to protect ourselves. What exactly are people supposed to do? Which pieces of information should you believe? How are you to decide the best way to protect yourself and our family from bites, disease AND harmful chemicals all at the same time? At this point, locking yourself inside until winter might seem like the only option.

Not to worry. The important thing is to consider whether the risks associated with each vector-borne disease are more or less worrisome than the risks associated with the chemicals found in bug sprays. Here is our breakdown of those risks.

While vector-borne diseases refer to illnesses transmitted by many tours of insects, we’re going to focus on mosquitoes and ticks here.

Note the severity of each vector-borne disease and impacts of applications described below may differ based on individual conditions such as age, predetermined health status, access to healthcare, etc. If you have any questions or concerns, please speak with your physician.

Mosquito-Borne Diseases

West Nile virus (WNV)WNV is found in all 48 contiguous states. The number of cases annually varies. 2012 was the deadliest year with 286 deaths.

  • The bad news: Those who show symptoms will typically have headache, body aches, joint pain, vomiting, diarrhea and/or rash within about a week of the infectious bite. In some cases, fatigue and weakness can last for months. In more severe cases, people can even develop neurologic conditions like encephalitis or meningitis. About 10% of those people will die. There are no medications or treatments for WNV aside from pain medication to reduce fever or relieve some of the symptoms. Those experiencing the most severe symptoms may be hospitalized.
  • The good news: Not every person bitten by an infected mosquito will show symptoms.

Eastern equine encephalitis virus (EEEV) – In the United States, an average of six human cases of EEE are reported annually. Cases mostly occur in the Atlantic and Gulf Coast states, although there have been some cases in the Great Lakes region as well.

  • The bad news:  EEE can be very serious. Severe cases will experience headache, high fever, chills and vomiting which could progress into disorientation, seizures, encephalitis and coma. Approximately one-third of patients who develop EEE die, and many of those who survive have mild to severe brain damage. Some of the long-term effects can cause death years later. There is no specific antiviral treatment for EEE; people showing symptoms should see their healthcare provider who can determine if supportive treatment is necessary and available.
  • The good news: Most cases will not show any symptoms, and only about 4-5% of EEEV cases become EEE.

Chikungunya – While there have only been four reported cases of locally acquired chikungunya in the US, experts are concerned because the disease spreads so rapidly. Chikungunya first reached the Caribbean in December 2013 and by March 2014 there were 15,000 reported cases.Chikungunya has now been identified in nearly 40 countries in Asia, Africa, Europe and, most recently, the Americas.

  • The bad news:  Nearly everyone who is bitten by an infected mosquito will develop fever and joint pain; other symptoms may also include headache, muscle pain, joint swelling or rash. The joint pain is often very debilitating, but usually lasts for a few days or possibly weeks. In some cases joint pain may continue for months or years. There have been some reports of lasting gastrointestinal, eye, neurological and heart complications. There is no treatment for chikungunya aside from over the counter pain medication to reduce discomfort.
  • The good news: Most people fully recover.

Dengue virus – According to CDC, there are over 100 million cases of dengue worldwide each year. It is a leading cause of death in many tropical areas of the world. While it is not typically found in the continental US, dengue is endemic in Puerto Rico and many parts of Latin America, Southeast Asia and the Pacific Islands where Americans vacation.

  • The bad news: Typical symptoms include high fever, severe headache, severe pain behind the eyes, joint pain, muscle and bone pain, rash, and mild bleeding (e.g., nose or gums bleed, easy bruising). Dengue hemorrhagic fever, a more severe form of dengue virus, is characterized by a fever that lasts from 2 to 7 days. It can be fatal if unrecognized and not properly treated in a timely manner.
  • The good news: Early detection and treatment will lower the rate of fatality to below 1%.

Tick-Borne Diseases

Lyme – According to CDC, Lyme disease is the most commonly reported vector-borne illness in the United States with over 20,000 cases annually. However it does not occur nationwide, but tends to be heavily concentrated in the northeast and upper Midwest.

  • The bad news: Bulls-eye rash occurs in 70-80% of infected people. Other symptoms include fatigue, chills, fever, headache, muscle and joint aches, and swollen lymph nodes. 10-20% of cases treated with antibiotics have muscle and joint pains, cognitive defects, sleep disturbance, or fatigue that lasts months or even years. In extremely rare cases (1% of cases), Lyme disease bacteria can enter the heart tissue causing Lyme carditis which can be fatal.
  • The good news: Patients can be treated with antibiotics and the prognosis is best when treatment begins early.

Rocky Mountain Spotted Fever – Spread through the bite of an infected tick, Rocky Mountain Spotted Fever occurs throughout the US.

  • The bad news: Symptoms typically begin with a sudden fever and headache, but many patients will eventually develop a rash, stomach pain, nausea, fatigue or muscle aches. (Not all cases develop every symptom.)  Severe cases can lead to life-long complications such as neurological problems and internal organ damage.  In extremely rare cases (less than 1% of cases), Rocky Mountain Spotted Fever can be fatal. Diagnosis can be difficult as the symptoms can resemble other conditions, and diagnostic tests looking for antibodies are often negative within the first 7-10 days. Treatment is most successful if started in the first five days.
  • The good news: While the number of cases has been higher than usual, the fatality rate is at an all-time low.

Bug Spray – These chemicals have been determined to be the most effective in preventing mosquito and tick bites:

DEET

  • The bad news: DEET has been linked to various health risks such as skin irritation, eye irritation and even neurological damage. But those cases are very rare, and many studies have found the connection between DEET and serious health risks to be inconclusive.
  • The good news: DEET is widely regarded as the most effective chemical in personal bug repellant. The stuff works! Better yet, using DEET with caution appears to significantly limit any serve risks; in fact, many now feel that DEET is safer than once believed. By using lower concentrations (10-30% for children), only using when it is necessary and following the instructions on the label the benefits of DEET far outweigh any risks.

Picaridin

  • The bad news: Picaridin has not been as effective for as long a period of time as DEET in some studies. It also does not protect against all species of mosquitoes. Picaridin is also a relative new kid on the block, so surveillance data is still lacking.
  • The good news: Picaridin is structurally made from the chemicals in pepper, so it is more natural than DEET. It is less likely to irritate skin, doesn’t have the same strong odor as DEET and seems to have a safer profile than DEET.

IR3535

  • The bad news: Concentrations of less than 10% were considered ineffective. IR3535 can be very irritating to the eyes, and has been shown to damage plastics.
  • The good news: IR3535 has been used in Europe for over 20 years. It has a safer profile than its competitors.

Oil of lemon eucalyptus and para-menthane-diol (PMD – synthetic concentration of lemon eucalyptus oil)

  • The bad news: Oil of lemon eucalyptus enhanced with PMD is not recommended for children under the age of 3. It can be irritating to the lungs and cause possible allergic reactions. Protection time seems to be less than DEET.
  • The good news: Higher concentrations seem to be as effective as 15-20% DEET. While lower concentrations will reduce the risk of allergic reaction and lung irritation, they are considerably less effective in repelling mosquitoes and ticks. For those insisting on a botanical bug spray, this is considered the best option.

So what’s the answer to our initial questions? Well, it isn’t really that easy. There is no one right answer for every person in every situation. Vector-borne diseases present a serious health risk that should be avoided. DEET is the most effective chemical for repelling insects available, and studies have shown that risk is low and effectiveness is still high when using concentrations under 30%. The other chemicals listed above may also be reasonable options for you and your family.

Our recommendation: The benefits associated with the chemicals far outweigh the risks. Wearing long pants and sleeves, wearing a hat and eliminating standing water will also help decrease the risk of mosquitoes and ticks. But the best way to avoid vector-borne diseases is to use bug spray when you are in an area with a high number of mosquitoes and ticks.

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MERS-CoV: Why We Are Not Panicking

By Tyler Wolford, Specialist, Laboratory Response NetworkPublic Health Preparedness and Response Program; and Stephanie Chester, Senior Specialist, Influenza Program, Infectious Disease Program, APHL

MERS-CoV: Why We Are Not Panicking | www.aphlblog.orgBy now you have probably heard that CDC has confirmed two cases of Middle East Respiratory Syndrome (MERS-CoV) infection in the US. Both were imported from Saudi Arabia; travelers became sick on their journey and sought care here in the US. This is the kind of stuff that typically gets us, infectious disease and preparedness folks, amped up, reaching for coffee and telling our loved ones we might be working late. We know that MERS-CoV is a serious infection – as of mid-May 2014, there have been 536 laboratory-confirmed cases and 145 deaths of MERS-CoV. However, the laboratory community is accustomed to responding to these situations—and that’s good news for public health. We have written, tested and rewritten preparedness plans, policies and procedures for dealing with novel and/or unexpected events and pathogens. We have dealt with white powders (more times than we can count), influenza A(H3N2)v, re-emerging vaccine preventable diseases and many other threats. In addition, we were given a lengthy (roughly two-year) heads-up with MERS-CoV. And while we know not to expect this luxury every time (we’re looking at you, 2009 H1N1 pandemic), the lead time meant that CDC, public health laboratories, health departments and clinicians were alerted and prepared well before the first US two cases occurred. Efforts by CDC and the public health labs ensured that, when the first cases arrived, they could be rapidly identified so proper precautions and epidemiologic investigations could begin. What are the reasons for our relative calmness despite the arrival of MERS-CoV on our shores? We were – and still are – prepared as the case count mounted on the other side of the Atlantic. Here are the specifics:

  • Planning. MERS-CoV was first reported in 2012 in Saudi Arabia. Once transmission became sustained in the Middle East, public health officials knew it was likely that a case would arrive in the US: we just didn’t know when. We had time to plan our response.
  • An approved test. CDC rapidly developed a real-time reverse transcriptase polymerase chain reaction (rRT-PCR) test which was granted emergency use authorization (EUA) by the FDA on June 5, 2013, and deployed the same month to 44 state public health laboratories and one local public health laboratory.
  • Infrastructure. The Laboratory Response Network (LRN) provided critical infrastructure for rapid distribution of the MERS-CoV test to public health laboratories across the US.
  • Training. Once laboratories received the test, they trained their staff and completed proficiency testing to demonstrate that they were trained and ready to perform testing should the need arise.
  • Experience. With health departments and physicians on alert, over 150 patients with MERS associated symptoms have been tested using the CDC assay. All were found to be negative.  This testing provided valuable opportunities for laboratories to familiarize themselves with the test.
  • Communication. CDC, APHL and other partner organizations have maintained timely communications with states, and others partners to keep everyone abreast of the current situation.
  • Dedication. Our public health labs are full of amazing scientists who are willing to spend countless hours, seven days a week to ensure rapid test results.

So if we aren’t panicking now that we have MERS-CoV cases in the US, what are we doing? We’re sprinting to keep pace with MERS-CoV and so far we have performed well, managing every step in the process with precision.

  • Indiana promptly notified CDC of a presumptive positive MERS-CoV infection and CDC rapidly confirmed this result.
  • CDC and Indiana started epidemiologic investigations and tested samples from close contacts of the infected patient.
  • APHL and CDC began communications immediately after the first case was confirmed.
  • APHL, in collaboration with CDC, held a laboratory alert call on May 6, 2014, to provide state and local public health labs with a situational update and to review laboratory testing guidance.
  • Currently CDC is distributing new proficiency testing panels so labs can refresh their competency on the CDC MERS-CoV test.

MERS-CoV is a serious threat that deserves the highest level of preparedness and attention.  Fortunately for the American public, we in the public health system are poised to handle MERS-CoV and other health threats whenever, wherever and however they enter our country. This is why we aren’t panicking, but it’s also why public health requires steady support.  Pathogens have no regard for budgets, funding cycles or economic trends. They won’t wait, and neither can we.

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Testing for MERS-CoV: The Indiana Lab’s Story

May 08 2014 :: Published in Infectious Diseases, Member News

By Lixia Liu, Deputy Director, Indiana State Department of Health Laboratories

Stephanie Dearth is a cheerful young supervisor with blond hair and black-framed eye glasses.  This was her third week as the supervisor of the virology laboratory at the Indiana State Department of Health Laboratories (ISDHL). When she arrived at work on Wednesday, April 30, she felt lighter as she had submitted her portion of a grant application the day before. She thought she might be able to catch up on her many tasks that had been put on hold. She took a sip of her coffee and walked to the laboratory.

Stephanie put her things away and went to her desk inside the laboratory. Between responding to her emails, discussing training plans for the new hire in her area and preparing for an upcoming CLIA inspection, the day went by quickly. She finally sat down at her desk after many trips to the lab bench; the voicemail light was blinking on her phone.

Testing for MERS-CoV: The Indiana Lab’s Story | www.aphlblog.org

Stephanie listened to the message. It was from Community Hospital in Munster requesting MERS-CoV testing. Recognizing the urgency of the request, she returned the call immediately and then sent an email to alert the ISDH respiratory epidemiologist about the request. Within an hour, the epidemiologist authorized the MERS-CoV test request from Community Hospital and held a teleconference with the ISDH (laboratory and epidemiology), CDC and the hospital. The specimens were scheduled to be delivered to the laboratory for testing the next morning.

When she told me the news I had goose bumps. I realized this may be the first MERS-CoV case in the United States. The weight of the situation was also felt by Dr. Omar Perez, the director of clinical microbiology. Stephanie, Omar and I stayed after the teleconference and discussed the plan for the next day.  Although the MERS-CoV assay was in place, the last MERS-CoV run was performed more than a year ago when the assay was first validated. To be cautious, the team decided to use BSL-3 practice for the entire process. We also agreed that the most experienced senior microbiologist, Jamie Yeadon-Fagbohun, would be the best choice to run the test. Jamie, who was known for her high quality work, had over five years of experience at the ISDHL. She worked on the response to the H1N1 pandemic, the discovery of novel H3N2v and many other high-profile outbreak investigations. She had worked under pressure before, but nothing like this.

The next morning I updated Dr. Judith Lovchik, ISDH assistant commissioner of public health protection and laboratory services, on the testing plan and discussed the testing approaches.  Meanwhile on the clinical microbiology floor, Stephanie, Omar and Jamie were detailing the testing plan.  The same conclusion was reached by all: time was of the essence in this situation.

Immediately after the arrival of a nasopharyngeal swab and serum sample from the patient, Jamie took the specimens to the bioterrorism suite where she gowned-up, put on the respirator and began processing the specimens. She wiped all the surfaces that the specimens might come into contact with and took every precaution to prevent potential carryover. Around noon Jamie resurfaced from the BT suite, her face reddened by the pressurization in the lab and her respirator.

By 3:00 that afternoon, the test runs were completed. Despite the increased anticipation of the nation’s first possible MERS-CoV case, Jamie was not expecting positive results.  “There is no way this would happen in Indiana. After all, Indiana is only a fly-over state,” Jamie thought to herself. After carefully reviewing the test results, Stephanie and Omar came to my office. I knew the results just by the looks on their faces. They told me that the serum sample was positive for all three genetic markers detected by the screening and confirmatory tests. As much as I was prepared for a positive result, I was still shocked to hear it. I immediately called Dr. Lovchik and broke the news to her.  She was equally shocked.

The perceived pressure earlier in the day turned into real pressure that was building with every thought of the potential impact. The lab team – Jamie, Stephanie, Omar and I – met again to review the testing details such as how the samples were arranged in the run, where the controls were situated, etc. With all possible errors ruled out, the team was confident in the results and ready to share the news with the rest of the nation.

As planned, the nasopharyngeal swab and serum sample were shipped to the CDC lab on Thursday for final confirmation of the MERS-CoV results on Friday morning.

The ISDH, Community Hospital and various CDC teams reconvened to plan the response actions based on the public health lab’s test results. The response plan would be executed as soon as CDC’s confirmatory test results were made available, which was scheduled to occur around 1:30 pm on Friday.

First thing on Friday morning the lab team met to discuss the action plan for a potential surge in testing once CDC confirmed results from the first case. Each team member was assigned a task: ordering reagents and supplies, requesting laboratory information management system (LIMS) modifications for easier sample submission, identifying microbiologists from other areas for surge capacity, and others.

Testing for MERS-CoV: The Indiana Lab’s Story | www.aphlblog.org

By noon, planning slowed, and the lab team had time to comprehend what the ISDH lab’s MERS-CoV results meant. But would the results be confirmed by CDC? The wait felt like eternity. I read every email that came across my computer screen. An email from CDC with the subject line “Confirmation” finally arrived at 1:43 pm. I felt like I was about to hear a courtroom verdict. I took a deep breath and continued to read the email: “CDC confirms Indiana MERS-CoV on 5/2/2014 at 1:30 pm.”

”WE DID IT!” I shouted with great relief. I couldn’t wait to share the news with the rest of the team. While it was not good news to hear that MERS-CoV had made its way into the US, it was extremely validating to know that our team quickly and successfully accomplished the task at hand. I was very proud of my colleagues.

After the detection of the first MERS-CoV case on May 1, the ISDH laboratory brought in two additional microbiologists, Stephanie Dalenberg and Brian Pope, to help with testing. During two consecutive 13-hour days, ISDH lab microbiologists, supervisors and directors tested a total of 124 specimens from all of the patient’s direct contacts, including health care workers and household contacts. All contacts continue to be observed, and there have been no additional cases to date.

The ISDH laboratory staff’s quick response, safe testing and accurate results were critical to detecting and containing MERS-CoV. Once again, our national laboratory first responders had quietly and effectively done their job to protect the public’s health.

Top Photo: Jamie Yeadon-Fagbohun in the BSL-3 laboratory

Bottom Photo (from left to right): Dr. Lixia Liu, Dr. Omar Perez, Stephanie Dalenberg, Stephanie Dearth, Jamie Yeadon-Fagbohun, Brian Pope, and Dr. Judith Lovchik 

Photo credit: Indiana State Department of Health Laboratories staff

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TB Vanquished by Lab System in the “Malibu of the Midwest”

Mar 24 2014 :: Published in Infectious Diseases

By William Murtaugh, specialist, HIV/TB programs, Infectious Disease, APHL

“Defeat TB: Now and in the Future.”  This was the first theme of World Tuberculosis Day declared by the International Union Against Tuberculosis and Lung Disease (IUATLD) 32 years ago today in 1982, and 100 years after Dr. Robert Koch announced his discovery of the bacteria that cause tuberculosis disease (TB).

Well, the future is March 24, 2014, and TB has not yet been defeated.  But year after year,  and theme after inspiring theme,  the global public health community still proclaims a call to arms, aiming to inspire the world to take up the cause of TB elimination.

TB Vanquished by Lab System in the “Malibu of the Midwest” | www.aphlblog.org

In the United States, the burden of TB is very low relative to many parts of the world. Why then should we be concerned with Mycobacterium tuberculosis, the obligate bacillus demanding our attention today?

It is common to cite TB statistics to emphasize the disease’s impact and the progress toward its elimination. Indeed any TB expert can pull some staggering historical numbers out of his or her pocket.  But reconciling unembellished phrases like “billions infected,” “millions of new cases,” “over a million deaths,” with the experience of those of us average Americans who’s TB “exposure” is limited to news bulletins on World TB Day, is challenging. For us, World TB Day serves as a gentle nudge that the disease is still a threat, and the fight for its elimination continues. Yet while I would be remiss if I did not mention that the United States has seen 21 years of consecutive decline in annual TB cases, I must contend that TB awareness is particularly important here in the United States because of the country’s low TB burden.

Lest we take our progress for granted, repeating the mistakes of the 1980’s and 90’s, it’s important to remember the consequences when the health system falters.  But for the one day, hour or minute that we consider World TB Day, let’s recognize that our progress to date has been achieved through the quiet efforts of a public health system that functions not one day, but all year long.

A TB outbreak in April 2013 exemplifies this point. Along the shores of Lake Michigan sits Sheboygan, WI, a city whose description could be mistaken for a Garrison Keillor monologue “where all the children are above average” and so too are its TB case rates. This Midwestern community learned the hard way that the damaging effects of TB can still be very real.

Prior to 2013, Sheboygan County typically saw fewer than three TB cases per year.  Known as the “Malibu of the Midwest” for its lake surfing competition (the largest in the world in fact), Sheboygan was a place more familiar with the phrase “Hang Ten” than “MDR-TB.”  Then in mid-April, the Sheboygan County Health Department was notified of a suspected TB case that would lead to an outbreak that would engage its resources and generate national media coverage for the remainder of the year.

Before it was over, the outbreak would cross the county and spread through multiple generations of a single family, school children and healthcare workers. It would lead to a case of MDR-TB, 11 additional cases of active pulmonary TB disease and 38 latent (non-symptomatic, non-contagious) TB infections. Over $6 million in state and federal funds ($4.7 million state, $1.4 million federal) would be expended to cover costs associated with outbreak investigation, testing, treatment and prevention measures.

Because TB is uncommon in the US, doctors may not consider it as a potential diagnosis. The first (i.e., index) case in the Sheboygan outbreak sought medical care for symptoms at least eight months before receiving a diagnosis of TB. What should have been a straightforward case – in which a suspected TB patient is diagnosed, treated and transmission prevented – led to eight months of transmissions.

Once TB was finally proposed as a diagnosis, the Wisconsin State Laboratory of Hygiene (WSLH) responded quickly, performing initial screening in two days and confirming diagnosis in less than two weeks. This diagnosis kick-started the TB control system into high gear. The patient was isolated and treated, and contact investigations were initiated to find related cases.

Next the WSLH assessed the standard drug regimen to determine if it would prove effective with this patient. With assistance from the Centers for Disease Control and Prevention (CDC), the lab identified  multi-drug resistant TB (MDR-TB) a category of infection that involves resistance to multiple drug therapies, is more difficult and expensive to treat, and holds a higher risk of death — as the cause of the patient’s illness. Now the concern was, “Had other patients been exposed to MDR-TB in the past eight months?”

More specimens began arriving at the local laboratory near Sheybogan, which quickly exceeded its capacity. With the threat of an MDR-TB outbreak, a solution was needed quickly. Enter the integrated public health laboratory system!  State and local laboratories coordinated with the community hospital in Sheboygan and decided jointly that all specimens from TB suspects would go to the WSLH.

As diagnosis after diagnosis of active pulmonary TB was confirmed, the state TB Control Program wanted to know if all these cases were part of the same outbreak.  While this may seem an obvious “YES!”, not all TB is created equal. Numerous strains of TB are continually in circulation. Without identification of the specific strain, public health officials could not understand the chain of transmission, and without this information, they could not control the outbreak.

Through a CDC initiative designed to strengthen national response to TB outbreaks, state public health laboratory in Michigan performed complex testing to uniquely identify each strain of M. tuberculosis (called genotyping). They determined that the MDR-TB patient was infected with two different strains of TB, one of which was not MDR-TB.  The state laboratories confirmed that other TB strains also belonged to the outbreak. None of these strains, however, were MDR-TB and therefore were more easily treated.

Not bad for a low burden TB setting.

Sheboygan’s story reminds us that TB outbreaks can happen anywhere. Yet if an outbreak does occur in our community we can look with confidence to the response capability of the nation’s public health laboratory system. The impressive response to the outbreak in Sheboygan testifies to the expertise and commitment of  these laboratory professionals. It also epitomizes CDC’s World TB Day theme:  “Find TB. Treat TB. Working together to eliminate TB.”

To learn more about public health laboratories and TB, check out APHL’s TB page. Additional information and resources for World TB Day and related events can be found at CDC’s dedicated website.

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