Transcript SHAMPOOS, TATTOOS, AND BARBEQUES—What’s new in the …

SHAMPOOS, TATTOOS, AND
BARBEQUES—What’s new in the world of
infectious diseases?
“Flies spread disease, keep yours zipped.”
---Anonymous
Quiz
• The average person, during a single 24hour period, deposits in his or her
underwear an amount of fecal bacteria
equal to:
a) the weight of a quarter of a peanut
b) the weight of Milk Dud
c) the weight of a chocolate chip
cookie
d) the weight of a Oscar Meyer wiener
QUIZ
• If you had to make a choice, which of the
following would you lick?
a) the kitchen cutting board
b) the top of your desk at work
c) the top of the toilet seat
d) your underwear
QUIZ
• Which stall in the ladies room is
contaminated with the most bacteria?
a) the stall nearest the door
b) the middle stall
c) the stall at the end of the row
QUIZ
• A Florida middle-school science student
found that ___ percent of her local fastfood restaurants had more bacteria in their
soft-drink ice than in the water from their
toilets. Yuck. (March 3, 2006—The Week)
a) 10%
b) 30%
c) 50%
d) 70%
The 2 most important fundamental aspects
of infectious disease prevention and
control…
• Hand washing
• Vaccination
• Should you shake hands with a man who
has just exited the men’s room?
Handwashing
• Use of alcohol-based gels for hand
washing
• C. difficile and soap and water (Canada;
quinolones)
• Screensavers and compliance
Cruisin’
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Noroviruses
Diarrhea-associated illness on cruise ships
In the community
In nursing homes
Use soap and water NOT alcohol-based
hand washes
How long?
• How long should you wash your hands to remove 99.9%
of the pathogens?_____
• How long should you wash your hands to remove 95% of
the pathogens?_____
• How long should you wash your hands to remove
coliform bacteria?____
• How long do we have to talk about washing our hands?
How long?
• How long does the flu virus live on a
doorknob?
• How long does the cold virus live in a hotel
room?
• How long does TB live in sputum?
• How long does MRSA live on a keyboard?
• How long can Legionella pneumoniae live
on a showerhead? When is the last time
you cleaned your showerhead?
How long?
• How long does herpes simplex live on a toilet
seat?
• “Hey Nurse, can I get …”
• How long does E.Coli O157:H7 live on a
stainless steel countertop?
• How long does the SARS virus live in diarrhea?
The 2nd most important fundamental
aspect of preventing infectious diseases:
• Vaccinate
• Vaccinate
• Vaccinate
Vaccines…
• Kids receive a plethora of vaccines prior to
the age of 2 to prevent a myriad of
childhood diseases…
To develop immunity you either
vaccinate or you…
• Suffer the infection
What’s on the horizon in the world of
vaccines? Using foods as vaccines…
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Potatoes
Tomatoes
Bananas
Spinach
Rice capsules
Or using shampoos as
vaccines…
Vaccine miracles…meningitis
• H. flu meningitis—what are the numbers? 40-100
cases/100,000 of invasive H. flu in 1989; vaccine in
1990—
• 0.2 cases/100,000 today
• Reduction of 99.8%
• Strep pneumoniae meningitis—what are the numbers?
77% decline in kids; 60% decline in adults
• Lumbar punctures in kids—before, during, after…too
many…
• And the story continues…
Let’s look at the numbers
• Declines of greater than 99% in cases of diphtheria (100&), measles
(99.9%), polio (100%), rubella (99.9%), smallpox (100%), and
invasive HiB infection (99.8%).
• Reductions of greater than 90% in mumps (95.9%), tetanus (92.9%),
pertussis (92.2%).
• Notable reductions in HAV (87.0%), HBV (80.1%), varicella (85%),
invasive pneumococcal disease (34.1%).
• Reductions in mortality have been comparable to or greater than
reductions in morbidity for all these illnesses, with the exception of
invasive pneumococcal disease (25.4%)
(Roush SW et al. Historical comparisons of morbidity and mortality for
vaccine-preventable diseases in the United States. JAMA 2007 Nov
14; 298:2155.
Vaccines to prevent diseases…
• Gardisil to prevent cervical cancer (HPV 16, 18)
and warts caused by HPV-6 and11; new info on
HPV-16 and oral cancers
• When will boys get the HPV vaccine?
• Vaccines to prevent heart attacks
• Vaccines to prevent amyloid plaque formation in
the brain (in clinical trials)
• Vaccines to prevent UTIs, STDs (Chlamydia)
Do vaccines trigger chronic
disease?
• MS? NO…
• Autism? NO…
• Crohn’s disease? NO…
• Don’t believe everything you read on the Internet…
• Ethyl mercury vs. methyl mercury
• Madsen KM Et al. A population-based study of measles, mumps,
and rubella vaccination and autism. N Engl J Med 2002 Nov
7;347:1477-82.
• Lancet 2004;364:9438
What vaccines do you need as an
adult
• Tdap (tetanus toxoid, reduced diphtheria toxoid,
and acellular pertussis)Boostrix (ages 11-18)
and Adacel (ages 11 to 64)—every 10 years
• Pertussis “whooping cough”—introduced in the
1940s; average of 175,000 cases per year;
1980-1990 an average of 2,900 cases per year
• On the rise—9,771 cases in 2002
• The “100-day” cough
• Immunity waning, kids not getting vaccinated
because of the “fear” of autism, parental denial
of continuing risks of infectious diseases
What vaccines do you need as an
adult?
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Flu every year
Hepatitis B (x3)(if you haven’t had it as a child)
Pneumococcal vaccine after age 50
Zostavax after age 60 to prevent shingles (14x
stronger than Varivax—the kids version)
Parvovirus B19--1975
• “Fifth disease” in kids
“slapped cheek”
• Migratory arthritis
• Fetal wastage during
pregnancy
• Aplastic crisis in patients with hemolytic
anemia
Staphyloccocal TSS--1981
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The tampon wars
Who won? Proctor and Gamble and RELY
Super, dooper, dooper absorbent tampons
39 deaths; hundreds ill
You could get it in, but ya’ couldn’t get it out!
Lyme disease--1982
• Tick-borne--spirochete—Borrelia burgdorferi
• 24-36 hours for the spirochete to make it’s way
from the stomach of the tick to the salivary gland
of the tick and into the host
• Bull’s eye lesion
• Arthritis
• Neuritis
• Doxycycline
“Tickacillin”
Helicobacter pylori—1983
• Dr. Barry Marshall and
Dr. Robin Warren and the tale of H. pylori
• Antibiotics to RX
• Antibodies will last for at least 3 years in the
blood so that re-infection will be picked up by
breath test or stool antigens for H. pylori
• Or endoscopy (if you have insurance)
H. pylori
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How do we get it?
Is it “normal flora”?
Common housefly may be a vector…
Municipal water systems
Kissing your “shweethaht” in the mornin’
(reflux)--???
Human Immunodeficiency Virus-1983
• What do we know?
• 2 receptors are necessary for the HIV
virus to enter the T4 lymphocyte
• Natural immunity
• Worldwide 33 million
• 67% in Sub-Saharan Africa with 3/4th of
deaths for 2003
• New drugs, no vaccine
GABHS mutations--1985
• Group A Beta Hemolytic strep, new strains
• M1, M3, M18
• Resurgence of Rheumatic Heart disease,
necrotizing fasciitis, Streptococcal TSS
Hepatitis C virus--1989
• Blood transfusions prior to 1992 (1 in every
3,000 units prior to 1992)
• Hemodialysis patients
• IV drug use
• Sexual transmission with multiple partners
• Vietnam veterans
• Intranasal cocaine use
• Tattoos, piercings
Guys tattoos…
• Out there…
• Everywhere…
• Showin’ them off
Kaposi’s sarcoma…1995
• The 8th member of
the Herpes “family”—
HHV-8
• STD
• It is NOT an AIDS
defining illness as it
can be transmitted
without having HIV
Avian Flu (H5N)--1997
• 1997 strain from birds hops to humans—6 people die in
Hong Kong
• 2003—the strain re-emerges, killing one man in Hong
Kong
• 2005—SE Asia, west to Europe, Turkey, Africa; infected
more than 130 people, killing more than 65
• Bird to person; person to person…
• Deep lung tissues—hard to spread via respiratory route
• The Center for Disease Control has released a list of the
symptoms of bird flu. If you experience any of the
following, please seek medical treatment immediately.
Know the symptoms of bird flu…
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1) High fever
2) Congestion
3) Nausea
4) Fatigue
5) Aching in the joints
6) And…an irresistible urge to s#!t on
someone’s windshield.
West Nile Virus…1998-1999
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Mosquito-borne illness
Hitching a ride form Africa to NYC (Queens)
Has since spread throughout the U.S.
“Where the crow flies and dies…” and the blue jays, and
the red, red robins…
3-15 day incubation period
Polio-type picture, encephalitis
Other modes of transmission? Blood transfusions?
(blood screened on pooled samples from 6-16 donors
since 2003) (23 cases in 2002 to 0 in 2005; 2 cases in
2006)(MMWR 2007 Feb 2;56:76-9)
Breast milk?
SARS--2003
• What do we know?
• Mutation of the
corona virus
• Most contagious around the 10th day
during hospitalization
• Explains the high rate of SARS in HCWs
• Hong Kong tourism slogan
8 TRENDS IN INFECTIOUS
DISEASES
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Everything global—warming, travel, economics
Increased food-borne illnesses
Zoonoses
Increased population of immunocompromised
patients
Sexual promiscuity
Healthcare-associated infections (HAIs)
Infectious disease and chronic inflammation
Bioterrorism
Global warming and
mosquitoes…
• Carry over 100 diseases
• With global warming they are moving
further away from the equator
• Malaria (“mal aria”)—bad air
• Dengue fever—”breakbone” fever
Global travel
• When in Rome,
don’t do as the
Romans do!!
Water in cocktails?
Water to plump up vegetables at roadside
vendors?
Ice in drinks?
Ice on the airplane coming home?
Splurge for bottled water!
Multidrug resistant TB (MDR-TB)…
• TB on airplanes
• Countries with the highest rate of MDR-TB and
immigration to the US (Russia, Romania,
Mexico)
• Elderly, prison population, HIV+, homeless
(shelters vs. street living)
• Extensive Drug Resistant TB (XDR-TB)
• “If you have consumption…go up on the
mountain…”
• Vitamin D and the immune system
Global economics…
• 1985—Houston, Texas ordered used tires from
SE Asia
• What were they thinking?
• The tires were delivered right along with the
Asian tiger mosquito (Aedes Aegypti)
• Caused an outbreak of Dengue (breakbone)
fever in SE Texas and LA in 1985
• Other issues in global economics brings us to
another emerging trend in infectious diseases—
Food-borne illnesses…
• 1990 only 13 food-borne illnesses to worry
about
• Today there are 8 x that many
• Why?
• Distribution around the world
• Centralization of food processing plants
Food-borne illness…
• Guillain-Barré syndrome and under-cooked
chicken—Campylobacter jejuni
• How long after the exposure will I see
symptoms?
• What temperature should I cook my chicken to?
• White meat?
• Dark meat?
• BUY an instant read thermometer TODAY…
Food-borne illness…
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Undercooked chicken, eggs and …
Cantaloupe from Honduras
Peanut butter
Salmonella
Pasteurized eggs for “seizure” salad
(Caesar salad)
• No more sunny-side up, especially for
high-risk patients
The Hamburger Bug
E. Coli O157:H7
• Mid-70’s, mutation in Venezuela
• Shigella + E. Coli exchanged genes in a cow’s bowel
• Moved up through Central America into Southern Texas
in the early ’80’s (1982 first identified)
• 3rd most deadly toxin in the world
• 10-100 pathogens to make you ill or kill you—
enterohemorrhagic diarrhea
• #1 cause of acute renal failure in kids
• 1993-Seattle-Tacoma deadly outbreak at Jack-in-the-Box
restaurants
• Mickey D’s—30 outbreaks per year
• Supportive Treatment
The Hamburger Bug
E. Coli O157:H7
• COOK your burgers to 160º F
• Hamburgers are pretty safe these days—
well, as safe as the 16 y.o. pimply kid
talking on his cell phone, flippin’ the
burgers
• Biggest concern is produce—lettuce,
spinach
The green leafys…
• Between 1986 and 1995, Americans ate
17 percent more leafy greens than in the
previous decade, yet food poisoning from
those leafy greens rose more than 60
percent. In the subsequent decade (19962006) food poisonings rose 39 percent
compared to a 9 percent rise in
consumption (CDC, Atlanta, March 2008
Conference on Emerging Infectious
Diseases)
How about a hot dog?
• Listeria
monocytogenes
• Hot dogs, bologna, deli meats
• Also soft cheeses, brie,
feta, camembert
• The very young, the very old and the…
No, thanks, I’ll have the salmon
sushi…
• Oh no you won’t…1 in
10 salmon “sushi’s)
have parasites…
Pets and zoonoses
• Can your pet make
you sick?
• Cuddly puppies and
Campylobacter jejuni
Zoonoses…
• Kitty litter and
toxoplasmosis
What about feline
leukemia, feline AIDS,
and feline distemper?
NO…
The reptiles and Salmonella
• Snakes
• Turtles
• Iguanas
Zoonoses
• MRSA from dogs, cats and other pets.
Patients with MRSA can pass the infection to
their animals through normal daily contact,
which in turn, passes it right back to the person,
leading to human reinfection
• All carriers in the household should be tested for
and treated in order to eradicate this vicious
cycle of reinfection. Dogs that visit health care
facilities to boost the morale of patients may also
be bringing MRSA directly to the patients.
(Enoch DA)
Zoonoses
• MRSA: From pigs to people. A new MRSA
strain, NT-MRSA (non-typeable) emerged in
2003 in the Netherlands. Several infections were
identified with this strain in 2004 and 2005,
seemingly linked to pig farms. After further
investigation, the presence of NT-MRSA was
significantly associated with contact with pigs
and cattle.
(van Loo I et al)
Increased population of
immunocompromised patients…
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Diabetics
HIV+
Cancer patients
Transplant patients
The elderly
Sexual promiscuity…
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HIV
HPV
HSV
HBV
HCV* (less than 5%)
H_V
Chlamydia and GC
Sexual promiscuity…
• Immature vagina
including an alkaline pH
in teenagers
• Know your partner
• Do condoms protect from STDs? YES
• But not the “natural feel” condoms
Does circumcision protect?
• To circumcise or not to circumcise—that is
the question…
• YES
• (Auvert B. PLoS Medicine, November 2005; Science
News 10/29/05, Vol. 168)
The pH of body fluids is
protective
• Stomach—pH 2
• Vaginal—pH 4.5
• Urine—pH 4
• Semen—pH 7
When our ovaries die…
• Increased risk of vaginal infections and
urinary tract infections
• Fastest rising group with STDs is the
elderly!
• 300% increase in the past 10
years…WHY?
the Pfizer Riser (Viagra)… and
friends
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November 1, 1998
Before 11/1/98?
After 11/1/98?
Levitra, Cialis
One last note on STDs…
• A high risk group
• Long-haul truckers play a significant role in the
transmission of disease in Africa and maybe
here in the U.S.
• Some stats: 1/3 have frequent sex with
prostitutes on the road and greater than 80%
don’t use condoms
• Why? “Because condoms don’t protect you and
AIDS is only a disease found in gay men.”
Whoa.
Healthcare-associated infections
• MRSA
• MRSA in the community
About 2.3 million people in the U.S. carry
methicillin-resistant Staphylococcus aureus
(MRSA) in their nasal passages. MRSA
prevalence is highest among females and
individuals older than age 60.
HA-MRSA
• Discovered in the 19th century, Staphylococcus aureus
was shown to be susceptible to penicillin in the mid-20th
century.
• Methicillin-resistant S aureus (MRSA) strains developed
not long after the introduction of the antibiotic methicillin
itself in the mid 1960s. Hospital-acquired MRSA (HAMRSA) has been a dominant heath care associated
infection in hospitals for several decades.
• Although methicillin is no longer available as an
antibiotic, the acronym MRSA has survived and signifies
those strains of S aureus resistant to all beta-lactam
drugs (penicillins, cephalosporins, and carbapenems).
HA-MRSA
• MRSA is on the rise in the U.S. w/ a prevalence of 4.6
known cases per 100 patients. (true prevalence of MRSA
was probably far greater than this estimate as only 30%
of hospitals responded to survey)
• The primary sites of infection are skin/soft tissue (28%),
lung (17%), bloodstream (13%), urinary tract (10%), and
surgical site (8%). Approximately 70% are believed to be
healthcare-associated (acquired during hospitalization)
and most cases occurred outside the ICU.
• HA-MRSA targets the hospitalized vulnerable patients
(the elderly, the nursing home patient, mechanical
ventilation, stay in an ICU, long hospitalization, current or
recent hospitalization, catheterization)
CA-MRSA
• Beginning in the 1990s, and accelerating
at the speed of light, a new strain of
MRSA, which has its onset in the
community, not in the hospital, is wreaking
havoc in the primary care setting,
emergency rooms, prisons, day care
centers, and high school gyms and locker
rooms. This new strain, dubbed CA-MRSA
(community-acquired MRSA) is
significantly different
CA-MRSA
• CA-MRSA targets patients of any age, including the
young and healthy, throughout the community. The
primary risk factor for CA-MRSA is the combination of
exposure to the pathogen and the opportunity to invade
through the skin. A frank cut or abrasion is a perfect
entry point, but is not absolutely necessary. Exposure
can begin with the person’s own nose and skin, typical
sites for CA-MRSA colonization. Up to half of the U.S.
population may be colonized asymptomatically with S
aureus, while a smaller percentage (from 1%-10%) is
colonized with MRSA.
• Transmission is fairly easy with CA-MRSA.
Environments are more likely to have skinto-skin contact and athletes and active
children are at risk because of potential
abrasions and cuts. Combining such an
injury with the sharing of a colonized or
infected team member’s towel is an
example of how infection can not only be
contracted but spread. Family members of
infected persons are also at risk.
Diagnosis—new tests
• Spectra MRSA—nasal test with results
within 24 hours; + predictive value of 98%
• MRSA rapid blood test—2 hours (vs. 2
days) for MRSA or other staph strains;
100% predictive for MRSA, 98% for other
strains
(BD GeneOhm StaphSR Assay)
• MRSA-related skin abscesses are treated
by incising and draining the abscess
followed by antibiotic therapy.
• TMP/SMX (trimethoprim/sulfa; Bactrim;
Septra) twice a day and clindamycin
(Cleocin) four times a day are appropriate.
• Eradicate nasal colonization with Rifampin
300 mg twice and day and bactroban
nasal ointment twice a day.
• Other drugs used to treat MRSA include
vancomycin (Vancocin), Linezolid (Zyvox),
daptomycin (Cubicin), and quinupristindalfopristin (Synercid). Just as an
FYI…Vancomycin costs approximately $29.00 a
day; Linezolid (Zyvox) costs about $155 per day;
daptomycin (Cubicin) coasts in the
neighborhood of $120 per day; and,
quinupristin/dalfopristin (Synercid) cha-chings in
at a mere $265 per day. Yikes on the Synercid.
• .
• Educate the patient! MRSA is almost always transmitted
by direct physical contact; however, known MRSA
transmissions have occurred via towels, sheets, wound
dressings, clothes, workout areas, sports equipment,
and Fido and Fluffy.
• Hand hygiene is of utmost importance in decreasing the
transfer of one MRSA-infected patient to a non-MRSAinfected patient. Alcohol-based rubs are effective in
killing MRSA and they reduce the time necessary for
hand disinfection
• Should screening be performed on ALL patients entering
the hospital? Controversial—some studies say yes and
others say it doesn’t make a difference (Chaberny)
Postoperative infection prevention
• Intranasal and oropharyngeal decontamination with
chlorhexidine solutions 4x /d from hospital admission to
removal of ng tube vs placebo
• Postop nosocomial infections 19.8% vs 26.2%
• Lower RT infections 9.3% vs. 15.8%
• Bacteremias 1.9% vs. 3.6%
• Deep SSIs 1.9% vs. 5.1%
• Preventing one nosocomial infection required treating
only 16 patients
• Simple, inexpensive decontamination produces a
clinically relevant reduction in postop infection and total
hospital stay (9.5 days vs. 10.3) (Segers P)
• Clostridium difficile (new strain vs. old
strains)
• Binary toxin vs. toxin A and B
• Clostridium difficile in the community
• Metronidazole susceptibility depending on
the type of C.diff
• Stool transplants
Infectious disease and chronic
inflammation…
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C. pneumoniae and atherosclerosis
CMV? H. pylori?
Hs-CRP and vasculitis (chronic inflammation)
Drugs to reduce inflammation reduce MIs
Flu vaccine for secondary prevention
Periodontal disease and cardiovascular
disease—FLOSS YOUR TEETH
• KEEP YOUR TEETH
CV risk factor: Measure waist
size
The more fat around the middle, the higher
the risk of CV disease and chronic
inflammation
Is obesity caused by a virus?
• Ladies--35 inches or less
• Gentlemen--40 inches or less
BIOTERRORISM…
• Have a high index of suspicion if there is
“clustering” of a common disease
• Or, if there are a few cases of an
uncommon disease
• Bugs most likely to be used: Anthrax,
Yersinia pestis (bubonic plague), smallpox,
botulism…HAVE A PLAN!!!
Survey of counties in U.S.-2002
• One county in Iowa had a 3-pronged plan
of attack:
1) Call for help
2) Hope someone comes
3) Stack the bodies in the high school
gym
THANK YOU …
“Support bacteria—they’re the only culture
some people have.” Anonymous
Barb Bancroft, RN, MSN, PNP
www.barbbancroft.com
[email protected]
Bibliography
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Chaberny IF et al. Impact of routine surgical ward and intensive care unit
admission surveillance cultures on hospital-wide nosocomial methicillinresistant Staphylococcus aureus infections in a university hospital: An
interrupted time-series analysis. J Antimicrob Chemother 2008 Sep 1.
Enoch DA, et al. MRSA carriage in a pet therapy dog. J of Hosp Infect
2005;60:186-8)(Rabinowitz PM, et al. Pet-Related Infections. Am Fam Phys
2007;76(9):1314-22)
Jarvis WR et al. National prevalence of methicillin-resistant Staphylococcus
aureus in inpatients at U.S. health care facilities. Am J Infect Control 2007
Dec;35:631.
Segers P et al. Prevention of nosocomial infection in cardiac surgery by
decontamination of the nasopharynx and oropharynx with chlorhexidine
gluconate: A randomized controlled trial. JAMA 2006 Nov 22; 296:2460-6.
van Loo I et al. Emergence of methicillin-resistant Staphylococcus aureus of
animal origin in humans. Emerg Infec Dis 2007 Dec; 13:1834
Bibliography
• Bailey RC et al. Male circumcision for HIV
prevention in young men in Kisumu, Kenya: A
randomized controlled trial. Lancet 2007 Feb 24:
369:643-56.
• Gray RH et al. Male circumcision for HIV
prevention in Rakai, Uganda: A randomized
controlled trial. Lancet 2007 Feb 24: 369:657-66.
• Newel ML and Bärnighausen T. Male
circumcision to cut HIV risk in the general
population. Lancet 2007 Feb 24: 369:617-9.