Laura Christie, MD Carol Glaser, MD, DVM · Laura Christie, MD Carol Glaser, MD, DVM California...
Transcript of Laura Christie, MD Carol Glaser, MD, DVM · Laura Christie, MD Carol Glaser, MD, DVM California...
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Zoonoses diseases
Laura Christie, MD
Carol Glaser, MD, DVM
California Department of Public Health
Viral and Rickettsial Disease Laboratory
Richmond, CA, USA
Prepared as part of an education project of the
Global Health Education Consortium
and collaborating partners
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Zoonoses
• Diseases transmitted from animals to humans
• > 250 zoonoses have been described
• Pathogens include viruses, rickettsia, bacteria, fungi, parasites
– Some rare – e.g. rabies
– Some common – e.g. Salmonella
• Some are very serious (rabies), others are less serious (cat scratch disease)
• Several different means of transmission (direct, indirect, vector-borne)
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Zoonoses, direct mechanisms of transmission:
• Direct contact by bite/scratch (e.g. rabies, cat-
scratch fever, rat-bite fever)
• Direct contact by handling of animal (e.g.
salmonellosis, avian flu, anthrax, tinea corpora)
• Direct infection by ingestion of animal products (e.g.
paragonamiasis, Creutzfeldt-Jakob disease,
cystercercosis)
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Zoonoses, indirect mechanisms of transmission:
• Indirect infection by ingestion in contaminated
water or food (e.g. giardiasis, salmonellosis)
• Indirect infection by inhalation of contaminated
fluids such as feces, placenta/amniotic fluids,
urine, milk, etc. (e.g. brucellosis, Hanta virus,
psittacosis)
• Indirect infection by exposure to contaminated soil
or water (e.g. schistosomiasis, leptospirosis)
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Zoonoses, vector-borne mechanisms of transmission:
• Vector-borne diseases (insect borne):
– Mosquito-borne infections (arboviruses):
Japanese encephalitis, dengue, malaria
– Tick-borne infections: Lyme disease,
ehrlichiosis, rickettsioses, babesiosis
– Fleas: plague, endemic typhus
– Flies: onchocerciasis, African trypanosomiasis,
leishmaniasis
– Lice: epidemic typhus
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Common routes for potential transmission of infectious diseases
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Module Outline:
• Different types of zoonoses will be discussed in this module:
– Rabies: viral, transmitted via bite or scratch
– Japanese encephalitis: viral, transmitted by mosquito bite
– Arenavirus: viral, transmitted by aerosolized rodent body fluids
– Salmonella: bacterial, transmitted by contamination of food products or direct contact with animal host
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Rabies
Infection from bite or scratch
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Rabies epidemiology:
• Develops from a bite, scratch or other contact with saliva from a rabid animal
• Rabies is rare or non-existent in parts of the developed world (US, Western Europe, Australia)
– Reservoir typically wild animals (e.g. raccoons, skunks, bats)
– Rates ~3-5 cases per year in the US
– Compare with 50-100,000 cases per year worldwide
• Rabies is more common in developing countries
– Reservoir typically domestic animals (e.g. dogs and cats) which aren’t vaccinated
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WHO, World: Total number of rabies human deaths , 2003
WHO, World: Total number of rabies human deaths , 2003 Page 10
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Rabies pathogenesis:
• Rabies is introduced via a bite or other contact into
skin and muscle tissue
• The virus then travels through axons of peripheral
nerves towards the central nervous system (CNS)
• Upon reaching the CNS, the virus then spreads
outwards again along nerve fibers to the skin,
cornea, salivary glands, etc.
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Rabies clinical symptoms:
• Incubation period ranges from a few days to > 1
year
– Most cases present between 2 and 16 weeks
• Initial symptoms are nonspecific:
– Fever, malaise, fatigue, anxiety, headache
– Half of patients have pain, itching or
paresthesias at site of the bite
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Rabies clinical symptoms:
• One of two clinical syndromes then develops:
– Furious (encephalopathic) rabies
– Dumb (paralytic) rabies
• Mortality is 100% once clinical symptoms
appear
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Rabies diagnosis:
• Always consider in case of acute onset, rapidly
progressive encephalitis
• Diagnosis before death is difficult, but possible
– Need multiple specimen types and multiple
assays
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Rabies prevention - Pre-exposure prophylaxis:
• Vaccination can prevent disease when given
BEFORE contact
• People at high risk of exposure can undergo a 3-
shot vaccination series
• Ex: veterinarians, wilderness occupations, rabies
laboratory personal, visitors to endemic countries
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Rabies prevention – Post-exposure prophylaxis (PEP)
• Vaccination can prevent disease when given AFTER
contact with a rabid animal
– If animal available for observation, can watch animal
for 10 days and hold off on prophylaxis
• ALWAYS wash wound thoroughly with soap and water
• PEP has 2 components – vaccine and immunoglobulin
– Day 0 - rabies immunoglobulin (RIG)
– Days 0, 3, 7, 14, and 28 – vaccine
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Japanese Encephalitis virus
Infection from insect vector
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Japanese Encephalitis (JE):
• One of leading causes of encephalitis world-wide
• Estimated 50,000 cases/year with 15,000
deaths/year
• Found mostly in Asia, now spreading to Australia,
India, Pakistan
• Transmitted by mosquito vector from pigs and
birds
• Member of the flavivirus family
– Includes West Nile virus, St. Louis encephalitis
virus, Dengue fever virus
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JE pathogenesis:
• After transmission by mosquito, virus multiplies
locally and in lymph nodes
• Transient viremia with invasion of central nervous
system
• Virus targets neuronal cells
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JE clinical features:
• Incubation period 1-14 days
• Infection most commonly asymptomatic
– Estimated asymptomatic:symptomatic infection ratio
varies from 25:1 to 1000:1
• Onset of symptomatic disease can be abrupt, acute,
subacute or gradual
• Course of symptomatic disease:
– Prodromal stage
– Encephalitis stage
– Late stage with recovery or neurologic sequelae
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JE prodromal stage:
• Characterized by flu-like symptoms:
– High grade fever ± rigors, headache, malaise,
nausea, vomiting
– Nonspecific
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JE encephalitis stage:
• Develops by day 3-5 of illness
• Characterized by:
– Altered sensorium, seizures, neck stiffness,
muscle rigidity, mask-like facies, abnormal
movements
• Mortality varies from 8-72% but typically
averages 25-30%
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JE late stage:
• Regain function over several weeks
• ~1/3 recover completely
• Residual sequelae include:
– Impaired speech, aphasia, paresis
– Neurocognitive deficits
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JE diagnosis:
• Diagnosis based on one of the following:
– Serologic testing
– Isolation of virus from tissue, blood, CSF or
other fluid
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JE management:
• Supportive therapy, no specific antiviral therapy
available
• Aggressive management of intracranial pressure,
seizures, and fluid balance
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JE prevention:
• Vector control (mosquitoes)
• Prevention of mosquito bites
• Separation of animals which carry virus
(e.g. pigs) from human habitations
• Human vaccines
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Arenaviruses
Infection from inhalation of dried
animal secretions or direct
contact
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Lassa Fever
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Arenaviruses classification:
Classified into Old World and New World viruses
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Arenaviruses classification:
• Old World viruses:
– Lassa fever virus which causes Lassa fever (Africa)
– Lymphocytic choriomeningitis virus (LCMV, worldwide)
• New World viruses (North and South America)
– Junin virus (Argentine hemorrhagic fever)
– Machupo virus (Bolivian hemorrhagic fever)
– Sabia (Brazilian hemorrhagic fever)
– Guanarito (Venezuelan hemorrhagic fever)
– Whitewater Arroyo (found in North America)
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Arenavirus distribution:
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Arenaviruses epidemiology:
• Most arenaviruses are found in a limited geographic
distribution corresponding to the range of the
specific reservoir rodent
• Thought to be transmitted by inhalation of
aerosolized animal body fluids (e.g. feces, urine)
The multimammate rat (Mastomys natalensis) appears
to be the natural reservoir for Lassa virus
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Arenaviruses pathogenesis:
• Virus enters through mucous membranes (respiratory, GI or reproductive tracts) or non-intact skin
• Virus reproduces in reticuloendothelial system, then enters blood stream
• Causes endothelial cell damage, leading to capillary leakage and increased vascular permeability
• Exception: Lymphocytic choriomeningitis virus (LCMV) causes acute CNS disease by a cellular immune response
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Arenaviruses clinical features:
• Clinical illness ranges from subclinical infection to
shock and death
• Clinical illness generally falls into 2 stages:
– Prodrome with non-specific signs/symptoms
– Severe illness, can lead to death
• CNS disease
• Hemorrhagic fever
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Arenaviruses clinical features:
• Prodrome (may be only symptoms that develop):
– Typically: fever, headache, malaise, myalgias
– May include GI symptoms, pharyngitis, cough,
joint pain
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Lassa fever:
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Arenaviruses clinical features:
• Severe illness:
– Ex: Lymphocytic choriomeningitis virus:
• 10-20% of patients develop neurological disease,
including meningitis, encephalitis
– Ex: Lassa virus/South American viruses:
• Cause hemorrhagic fever
• <10% of patients have severe illness, but case
fatality is high (15-25%)
• Initially retrosternal chest pain, back pain, GI illness,
hepatitis
• Followed by hypovolemic shock
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Arenaviruses clinical features:
• Specific features:
– Lassa virus:
• Infection in pregnancy linked to abortion, 30%
fatality for women infected in 3rd trimester
• “swollen baby syndrome” = edema,
abdominal distention, bleeding, frequently
fatal
• Hearing loss seen in 20% of patients
– Argentine hemorrhagic fever:
• Flushing of head/torso, petechiae,
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Arenaviruses clinical features:
• Specific features:
– Venezuelan hemorrhagic fever:
• Vomiting, abdominal pain, diarrhea,
convulsions, hemorrhagic findings
– Bolivian hemorrhagic fever
• Similar to Argentine and Venezuelan
hemorrhagic fevers
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Arenaviruses diagnosis:
• Nonspecific signs and laboratory abnormalities
combined WITH a travel history to endemic area
• Contact with rodents is suggestive of
arenaviruses
• Requires specific laboratory testing for
confirmation
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Arenaviruses management:
• Treatment is mainly supportive care
– Managing electrolyte and fluid balance is key
– Limit invasive procedures to avoid bleeding
– Isolation precautions to limit spread
• Mortality varies from 15-30%
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Arenaviruses prevention:
• Vaccines available for a few viruses
• Rodent control key to prevention of arenaviruses
– Reduce rodent habitats near human habitation
– Limit opportunities for rodents to live with humans
(reduce available food, trapping, etc.)
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Non-typhoidal Salmonella
Contact with animal or human feces, contaminated animal derived food products, contaminated water
or produce, pets
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Salmonella nomenclature:
• Salmonella is a gram negative rod
• Salmonella typhi and S. paratyphi infect only humans and
are usually spread by contaminated food or water
– S. typhi is NOT a zoonosis
– Is the cause of “Typhoid fever”
• Other species of Salmonella which infect humans as well
as other animals are called “nontyphoidal” Salmonella
– Can be spread by contact with animals or contaminated
food or water
• This section will discuss nontyphoidal Salmonella only
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Salmonella epidemiology:
• Incidence had been rising worldwide, especially in
developed countries via poultry production
systems
• Rise in antibiotic-resistant Salmonella worldwide in
the last 5-10 years (ampicillin, ceftriaxone,
ciprofloxacin)
• Peak in infection in children <4 years, especially
neonates
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Salmonella epidemiology:
• Non-typhoidal Salmonella can colonize the digestive
tracts of many animals (mammals, birds, reptiles,
insects) including pets, rodents and farm animals
• >95% of cases of Salmonella infections are food-
borne, typically from animal products
– Common sources: chickens, eggs; Less common:
ground beef, cheese, ice cream
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Salmonella epidemiology:
• 3-5% of cases result from contact
with exotic pets (e.g. reptiles,
rodents)
– 90% of reptiles may be
asymptomatic carriers
• Non-typhoidal Salmonella in human
or animal feces can also enter water
supplies, contaminating produce
(melons, tomatoes, sprouts)
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Salmonella pathogenesis:
• Amount of Salmonella ingested (dose) directly correlated with duration of incubation and severity of illness
• Once in the small intestine:
– Salmonella multiply within the lumen
– Penetrate the wall of the intestine
– Remain in intestinal wall in diarrheal disease, where they release toxins resulting in secretory diarrhea
– In invasive disease, enters the blood stream (rare)
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Salmonella clinical symptoms:
• 3 main syndromes of nontyphoidal Salmonella:
– Asymptomatic
– Gastroenteritis
– Bacteremia (which may lead to metastatic
disease)
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Salmonella diagnosis:
• Stool culture best means of diagnosis in acute
gastroenteritis
• Blood culture most helpful in bacteremia
• Focal sites of infection (abscesses, meningitis,
etc.) require culture from that site
• Culture important in invasive disease to determine
antimicrobial susceptibility
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Salmonella treatment:
• Symptomatic treatment for dehydration should be
given in ALL patients
• Acute gastroenteritis in healthy child or adult does
NOT require antibiotics
– Why? Antibiotics can prolong carrier state and
longer period of asymptomatic shedding (inhibit
growth of normal flora)
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Salmonella treatment:
• Patients with risk of invasive disease (neonates and infants <1year, elderly, immunocompromised) should be treated with antibiotics, guided by susceptibility testing
– Empiric treatment generally 3rd generation cephalosporin or fluorquinolone but resistance is increasing
• Patients with invasive disease should be treated with antibiotics and drainage/surgery if needed
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Salmonella outcome:
• Complete recovery typical in healthy children with
Salmonella gastroenteritis.
• Bacteremia with systemic involvement or
metastatic foci may have a prolonged course
• Prognosis generally poor for children with
Salmonella meningitis or endocarditis but is rare in
non-typhoidal Salmonella
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Salmonella outcome:
• Asymptomatic fecal excretion may occur for several
months after clinical resolution of gastroenteritis,
especially in young children or those treated with
antibiotics
– May allow transmission to others
• Rarely, a chronic carrier state may develop
– Defined as asymptomatic excretion of
Salmonella for >1 yr
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Salmonella prevention:
• Related to hygiene:
– Hand washing to prevent fecal-oral
contamination
– Proper hand washing and cleaning of
utensils when handling foods
(especially chicken and eggs)
– Exclusion of infected persons from
food preparation or child care
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Salmonella prevention continued:
• Related to food items:
– Fully cook potentially contaminated
food items such as chicken and
eggs
– Clean machinery and equipment
used to prepare foods
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Salmonella prevention continued:
• Related to exotic pets:
– Reptiles should not be in homes with:
• Children < 5 years
• Elderly
• Immunocompromised people
• Pregnant women
– Reptiles should not be kept in child care centers or allowed access to sites of food preparation
– Hands and other items should be washed well after contact with reptiles
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General References
1. Weiss EL. Wilderness-Acquired Zoonoses. In: Auerbach PS, ed.
Wilderness Medicine 4th ed. St. Louis, MO: Mosby, 2001.
2. Rabies world maps:
http://www.who.int/globalatlas/interactiveMapping/MainFrame2.asp
3. Glaser C. ewis P. Wong S. Pet-, animal-, and vector-borne infections.
Pediatrics in Review. 2000;21(7):219-32.
4. Romero JR. Newland JG. Diagnosis of viral encephalitides: zoonotic-
associated viruses. Pediatric Infectious Disease Journal. 2006;25(8):741-2.
5. Tiroumourougane SV. Raghava P. Srinivasan S. Japanese viral
encephalitis. Postgraduate Medical Journal. 2002;78(918):205-15.
6. Marty AM et al Viral Hemorrhagic Fevers. Clinics in Laboratory
Medicine, 2006;26:345-386.
7. Cleri DJ et al Viral Hemorrhagic Fevers: Current Status of Endemic
Disease and Strategies for Control. Infect Dis Clin N Am 2006;20:359-393.
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Page 59
8. Enria DA and Pinheiro Emerging and Re-emerging Diseases in Latin America:
Rodent-borne Emerging Viral Zoonosis – Hemorrhagic Fevers and Hantavirus
Infections in South America, Inf Dis Clin of N Am 2000;14(1)167-184.
9. Jay MT, Glaser C, Fulhorst CF Zoonosis Update: The arenaviruses JAVMA
2005;227(6):904-915.
10. Pitout JDD, Church DL Emerging gram-negative enteric infections Clinics in
Laboratory Medicine, 2004;24:605-26
11. Schlundt J, Toyofuku H, Jansen J and Herbst SA Emerging food-borne
zoonoses. Rev sci tech Off int Epiz 2004;23(2):513-533.
12. Amieva M. Important Bacterial Gastrointestinal Pathogens in Children: A
Pathogenesis Perspective. Pediatric Clinics of North America 2005;52:749-777
13. Warwick C, Lambiris AJL, Westwood D, Steedman C Reptile-related
salmonellosis. Journal of the royal society of medicine, 2001;94:124-6.
General References
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Further reading
• WHO website: http://www.who.int
• US Centers for Disease Control and Prevention:
http://www.cdc.gov
• American Academy of Pediatrics Red Book – Report
of the Committee on Infectious Diseases:
http://aapredbook.aappublications.org/
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Credits
Laura Christie, MD
Carol Glaser, MD, DVM
California Department of Public Health
Viral and Rickettsial Disease Laboratory
Richmond, CA, USA
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Acknowledgements
The Global Health Education Consortium gratefully acknowledges the support provided for developing these teaching modules from:
Margaret Kendrick Blodgett Foundation
The Josiah Macy, Jr. Foundation
Arnold P. Gold Foundation
This work is licensed under a Creative Commons Attribution-Noncommercial-No Derivative Works 3.0
United States License.