Seven BIG reasons to stay briefed on infectious diseases
Transcript of Seven BIG reasons to stay briefed on infectious diseases
Seven BIG reasons to stay briefed on infectious diseases
Patricia Huston, MD, CCFP, MPH
Michel Deilgat, CD, MD, MPA, MEd, CCPE
Family Medicine Forum
November 11, 2017
DISCLOSURES
Dr. Michel Deilgat
COIs: NONENo competing financial interests exist
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DISCLOSURES
Dr. Patricia Huston
In the spirit of transparency here are my biases:
I think CCDR is a great way to stay briefed on IDs
and St. Andrews-by-the-Sea in NB is one of my favourite places on earth:
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Our objective for today:
To inspire, motivate and regale you regarding 7 current ID topics: - Give some facts and identify some federal and other resources/tools
- Pose some reflective questions
In order to advance your CanMED competencies and enjoy an hour together.
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Reason #1: Infectious diseases are evolving
WHY?
1. Globalization
• Over 20% of the
population in Canada
mother tongue
non-English/French
(2016 Census)
• People travel
2. Climate change…
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Resources: TRAVEL.GC.CA
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Resources: CATMAT statements
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#1 Infectious diseases are evolving…
Q: Have you seen
the health effects of
globalization and
climate change?
• What are the implications
for practice?
• Any tips or insights?
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Reason #2: To avoid the risk of totally drug-
resistant infections
Last year at the United Nations Annual Assembly a resolution was passed
identifying
ANTIMICROBIAL RESISTANCE
as a GLOBAL HEALTH SECURITY ISSUE
- All countries committed to
working on this.
- We face a dystopic situation
of running out of treatment
options…
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Reason #2: Risk totally drug resistant
gonorrhea
The situation is NOT pretty:
• Gonorrhea is the second most
common STI in Canada
• Much like the rest of the world,
its incidence has been steadily
rising
• Over the years gonorrhea has
become resistant to
– Tetracyclines
– Sulfonamides
– Trimethoprim combinations,
– Quinolones
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Reason #2: Totally drug resistant infections…
Nasty complications:
• Several-fold increase in HIV
transmission
• Pelvic inflammatory disease
– Acute/chronic lower
abdominal pain
– Ectopic pregnancy
– Spontaneous abortion
– Infertility
Current recommendation:
Combination therapy
• Azithro + either
Ceftriaxone or Cefixime
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Reason #2 Why risk of total resistance?
• We are seeing rising rates of resistance to the last two
effective antibiotics.
• US CDC reported that between 2013 and 2014,
– Resistance to azithromycin rose from 0.6% to 2.5%, while
– Resistance to ceftriaxone rose from 0.4% to 0.8%.*
• CURRENT RATES ARE LOW
– Similar situation in Canada
The trend is concerning
* Kirkcaldy RD et al. N gonorrhoeae antimicrobial susceptibility surveillance. MMWR 2016:65(7):1-19.
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Reason #2: Risk of totally resistant gonorrhea
In a recent online survey
…. only 20% of clinicians indicated they would prescribe a
cephalosporin and azithromycin as first-line therapy for gonococcal
pharyngeal infection.*
• This was a convenience sample
• Suggests not all clinicians are aware of the need for combination therapy.
Q: What are the implications for practice?
TIPS?
* Ha S et al. What are Canadian primary care physicians prescribing for the treatment of gonorrhea?
CCDR 2017;43(2):33-7.
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Resources
STI treatment app
-- from the Public Health Agency of Canada
-- can be downloaded for free for Apple
or Android devices
-- puts all the latest treatment guidance
at your fingertips.
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Reason #3: Lyme disease is expanding its reach
in Canada
• Lyme disease is the most
common vector-borne
illness in North America
• (US) Reported cases of
LD have increased from
approx. 10,000 cases
annually in 1991 to >
25,000 cases in 2014
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Reason #3: Lyme disease is expanding its reach
in Canada
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Reason #3 - Facts about Lyme Disease
1) LD is a treatable multisystem illness
2) LD is predominantly a clinical diagnosis
3) Both underdiagnosis and overdiagnosis:
- Nonspecific symptoms, and
- Shortcomings of available serologic tests
Primary physicians need to be skilled in the clinical recognition of early
localized, early disseminated and late disseminated disease (clinically capable
of differenting from other acute, subacute, and chronic neurologic and
muscoloskeletal conditions)
Also….
1) Controversial disease between (advocacy groups/patients and main
stream medicine (FM, ID…)
2) Canada – Federal Framework on Lyme Disease Act (Assented to 16th
December 2014 – last reviewed April 25, 2017)
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Natural history of untreated Lyme disease
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Reason #3: LD
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Note on interpretation of Lyme disease
serological assays (NML, 2017)
Enhancing existing
Lyme disease
reporting to include
specific band
information
Interpreting the
results
(Hand-outs)Reply to: [email protected]
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Reason #3: LD Tx – IDSA Guidelines
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Reason #3 – LD: Best Treatment is PREVENTION
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Reason #3: LD challenges
MANY ISSUES:
- Making a diagnosis / investigation / treatment
- Lab results from private labs in the US or from « Lyme
literate doctors » and other experts in Lyme treatment
Q: What is needed to increase
confidence/accuracy in diagnosing and treating
LD?
TIPS?
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Reason #3 – LD Resources
Federal LD Framework
• Enhanced surveillance
• Education & Awareness
• Guidelines and Best
Practices (note: IDSA Spring
2018- new guidelines)
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Reason #4: Be part of the plan for the global
elimination of HIV
In 2014, the United Nations AIDs organization released its global
strategy to eliminate HIV. It called upon countries to meet the 90-90-
90 targets by 2020:
• 90% of people living with HIV diagnosed
• 90% of diagnosed people on antiretroviral treatment
• 90% of people on treatment with fully suppressed viral load
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Reason #4
Are we meeting the global targets in Canada?
- Are 90% of people living with HIV diagnosed?
- No. An estimated 21% of people living with HIV are undiagnosed*
Public Health Agency of Canada. Summary: Estimates of HIV incidence, prevalence and proportion
undiagnosed in Canada, 2014 https://www.canada.ca/en/public-health/services/ publications/diseases-
conditions/summary-estimates-hiv- incidence-prevalence-proportion-undiagnosed-canada-2014. html
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Reason #4: HIV can be eliminated
What can we do? ROUTINE SCREENING AND TESTING.
• Normalize it.
• Offer providing information on risk factors, then offer testing to every
adult (and minors at risk).
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Reason #4: HIV can be eliminated
And there is good news : PrEP
- Pre-exposure prophylaxis
- Recently approved by Health
Canada when used in conjunction
with other safe sex/IDU practices
- Now available in generics
- Some provinces have started
to include them on the formulary
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Reason #4: HIV can be eliminated…
Q: Why do you think family physicians often do not
routinely offer HIV screening tests to their patients?
TIPS?
Resources:
CATIE.ca
Also see:
Dec 2017 issue CCDR
Spoiler alert: HIV
in 2016 >10% higher
than 2015.
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Reason #5: Emerging infections can come …
and go!
Good news on Zika virus
1. The Pan American Health Organization (PAHO) has reported a large drop
in the number of Zika cases in the Caribbean…
2. Overall transmission of the virus in the Western hemisphere declined in
2017
3. Decrease in the intensity of Zika virus transmission = concomittant
reduction in # of travel-related Zika cases reported
4. Reporting to PHAC began in March 2016 – As of August 31, 2017 there
has been 529 lab confirmed cases of ZV in Canada
- 103 cases reported in 2017
5. Although the # of cases decline – the testing rates remain relatively high
especially for pregnant women
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Reason #5: Emerging infections can come …
and go!
Zika FACTS • First identified in 1947 Uganda
• Vectors : MOSQUITOES
Aedes aegypti and Ae. albopictus
• Sx: mild fever, skin rash,
conjunctivitis, muscle and joint
pain, malaise or headache,
symptoms normally last for 2-7
days
• Microcephaly in babies and
Guillain-Barré syndrome
• Can be sexually transmitted
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Reason #5 –Zika virus is declining… but
• 99% of reported cases
acquired while travelling
to affected region
• 4 cases sexually
transmitted– no history of travelling to an
affected region within the 2
weeks prior to symptoms
onset
• 2 cases are newborns
who acquired infections in
utero
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Reason #5 – ZIKA Canadian Paediatric
Surveillance Program (CPS) – 2 Special Studies
Severe Microcephaly
(SM) Study
June 1, 2016 to
May 31, 2018
1 x case (meeting the
inclusion criterion for both
studies)
Congenital Zika
Syndrome (CZS)
Study
March 1, 2017 to
February 28, 2019
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Reason #5 – RESOURCES: CATMAT’s Zika virus
recommendations
http://healthycanadians.gc.ca/publications/diseases-conditions-maladies-affections/committee-statement-
treatment-prevention-zika-declaration-comite-traitement-prevention/index-
eng.php?_ga=2.246116484.1655599020.1509985632-330767322.1490794154
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Reason #5: Zika cases are declining BUT …
When travelling to affected countries, Zika is still a risk for
those who do not have antibodies…
Zika persistence (median detection rates) (Source: IDSA)
urine (11 days); serum (2 weeks); and semen (6 weeks)
Bottom line: Important to DISCUSS WITH ALL WOMEN WHO
- ARE PREGNANT (or are planning to get pregnant)
- ARE PLANNING TO TRAVEL to affected countries
(E.G. CARIBBEAN, MEXICO ETC)
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Reason #5: ZIKA cases are declining but…
Q: What are the implications for YOUR practice?
TIPS?
RESOURCE:
WHO ZIKA
MAP
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Reason #6: TB still lurks…
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One quarter of the
world’s population
has latent tuberculosis
infection (LTBI)
Reason #6: TB elimination is in our grasp
Canada has one of the lowest TB rates in the world, but it
is not zero.
INDIGENOUS
- Rates in Nunavut comparable
to highly endemic countries
IMMIGRANTS
- Often have latent TB
HOMELESS with IDU also at risk
- Recent 13-year
outbreak in Montreal
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Reason #6: Elimination of TB
There is good news:
1. A better test (than Mantoux): IGRA
- Interferon gamma release assay – a blood test.
- Results available within 24 hours
- If positive can be Active/Latent TB or post treatment
2. A better treatment under investigation: 3HP
- INH + Rifapentine: 12 doses ONLY - weekly treatment
- Much better adherence.
- Currently only under Special Access Programme
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Reason #4: TB - But really - what does this have
to do with family physicians?
Need a high index of suspicion…
CBC NEWS headline: March 23, 2017
“She was my only girl”: Nunavut
teen’s death sheds light on
failures in fighting TB”
- Young teenager with a cold
- It worsened… she began to get SOB
- Then had headache and weakness
- Got medivac’d - Dx: Pneumonia
- Lost conciousness and died
- Dx: TB MENINGITIS
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Reason #6: The focus of global elimination
is managing LTBI
• One important role family physicians can play is
identifying people with LTBI who:
– Are at high risk of re-activation
• Patients with chronic renal failure on hemodialysis
• Transplant patients on immune suppressants
• Patients with silicosis
– Are at moderate risk of reactivation
• Patients on TNF alpha inhibitors (not uncommon!)
• Glucocorticoids
• Diabetes
– Have started to turn into active TB
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Reason #6: We could eliminate TB…
Q: Is the coordination
between clinical care and
public health optimal
for the management of TB?
TIPS?
Resources:
Canadian TB Standards
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Reason #7: To be better prepared to deal with
another “SARS” or influenza pandemic
• Nationally, we are now better prepared than ever – but
clinicians need to be “plugged in”…
•
• And know how to reach
your
• your LOCAL MEDICAL
OFFICER OF HEALTH
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Reason #7: To be ready for an OUTBREAK
Q: Do you think there
will be another infectious
disease emergency over
your professional lifetime?
Tips?
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Reason #7: To be ready for an OUTBREAK
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Reason #7: OK some good news on preparedness
CCDR - A resource for ID info and outbreak preparedness
for BOTH CLINICIANS and PUBLIC HEALTH
NEW -- LAST 3 YEARS (actually revitalized...)
- NOW ON PUBMED
It has rapidly become THE #1 RESOURCE FOR THE
LATEST ID INFORMATION IN CANADA.
- This is based on a recent readership survey
SIGN UP FOR FREE and receive the monthly Table of Contents with
hyperlinks in your email
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7 BIG reasons to be briefed on infectious diseases
1. Emerging infectious diseases are evolving and are only a
plane ride away
2. If we are not careful, totally antibiotic-resistant diseases
could occur
3. Lyme disease is expanding its reach in Canada
4. HIV could be eliminated: Start screening
5. Zika virus (and microcephaly) is still a risk for pregnant
women who travel.
6. TB is a totally curable disease and still lurks in Canada –
keep a high index of suspicion.
7. You want to be prepared for the next outbreak - know how
to contact your local MOH and subscribe to CCDR!
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Questions?
Feel free to contact us:
We hope we have inspired, motivated and regaled you…
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THANK YOU for your interest
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