Wrap up

OCID Fort RileyFeb 25-27, 2014

What do you do with a patient who needs YF vaccine but has an allergy to egg?

• Egg protein is present in higher amounts in yellow fever and influenza vaccines and could, in theory, cause reactions in recipients with egg allergy.

• Chicken proteins other than those found in chicken egg might be present in yellow fever vaccine and could be responsible for reactions in recipients with chicken allergy.

What do you do with a patient who needs YF vaccine but has an allergy to egg?

• Do they really have an egg allergy?– History: most egg allergies are out-grown.– Baked versus raw or scrambled egg.– Skin prick and serum IgE testing to egg are available.

• Will they likely react to the vaccine?– Skin prick and intradermal testing can be performed.– If positive, administer vaccine in graded doses under

close monitoring:

What do you do with a patient who needs YF vaccine but has an allergy to egg?

• If skin prick testing to egg or vaccine is positive, weigh the risks and benefit.

• Giving vaccine in graded doses usually works.

What do you do with a patient who needs YF vaccine but has an allergy to egg?

• The test dose alone induces a protective antibody level.

How long after YF vaccination is it safe to breastfeed?

Cases of YF transmission to infants via breast-feeding

• Brazil, 2009, 23 day-old infant develops encephalitis, vaccine strain YF virus in CSF.

• Alberta, 2011, 5-week old infant develops seizures, serology for YF positive.

Cases of YF transmission to infants via breast-feeding

• Onset of viremia can occur between four and ten days after primary vaccination, lasting up to five days.

• Additional data are needed on the duration of excretion of vaccine virus in breast milk to guide recommendations for temporary suspension of breastfeeding after vaccination.

• Travelers who are breastfeeding should be strongly encouraged to either adjust their itinerary to reduce or eliminate their risk of exposure (i.e., to avoid the need for vaccination altogether) or postpone their trip until they are no longer breastfeeding and their infant is old enough to be vaccinated with low risk of adverse events.

Important African ArbovirusesVirus Reservoir Vector Clinical

syndromeStructural family

Chikungunya Primates Aedes Fever, Arthritis alphavirus

O’nyong-nyong Unknown Anopheles Fever, Arthritis alphavirus

Crimean-Congo HF Livestock Hyalomma ticks Fever, HF bunyavirus

Rift Valley Fever Livestock Aedes, Culex Fever, retinitis bunyavirus

Dengue Humans Aedes Fever, HF flavivirus

West Nile Birds mosquitoes Encephalitis flavivirus

Yellow Fever Humans Aedes Fever, HF flavivirus

Zika Primates Aedes Fever, rash flavivirus

Which arbovirus is associated with:

• Nosocomial transmission?– Crimean-Congo Hemorrhagic Fever

• Sexual transmission?– Zika virus

• A licensed vaccine available in the US?– Yellow fever

• Chronic arthritis?– Chikungunya

Evaluation of the febrile patientGeneral approach

• Careful history and serial physical examination• Appropriate/directed laboratory tests

– Malaria• Serial thick and thin smears• Rapid diagnostic tests (e.g., BinaxNOW- P. falciparum

Sensitivity/Specificity– 99.7% / 94.2%)– CBC with diff – Liver associated enzymes

• Appropriate/directed radiographic studies• Speed of evaluation contingent upon

– Tempo of illness– Differential diagnosis– Immune status of patient

Evaluation of the febrile patientGeneral approach

• Develop a management plan– Differential diagnosis– Clinical data

• Consider empirical therapies– Malaria- must not miss malaria!– Meningococcal– Rickettsial/leptospirosis– Lassa fever

• Must recognize diseases that require special precautions– Hemorrhagic fevers (S, D, C, +/- Airborne)– Meningococcal (Droplet)– Tuberculosis (Airborne)

Top 5 Illnesses in returning travelers

Rickettsial Take Home Points• Rickettsial infections are:

– More common than you think-increasing incidence– Potentially fatal– Have non-specific clinical presentations– Look for clues of rash, eschar, palm and sole

involvement– Fever, headache, +/- myalgias, +/- rash– Low WBC, low PLTS, elevated AST/ALT– Often require treatment prior to conclusive diagnosis– Respond to tetracyclines (Doxycycline)-even kidsNo one dies of an infectious disease where a

Rickettsia may be involved without Doxycycline!

UNCLASSIFIED/FOUO 18

Summary: Management and Treatment of Animal Bites

Cultures- Gram stain, aerobic, and anaerobic cultures

Irrigation- Normal saline; copious high-pressure

Debridement- remove necrotic tissue and any foreign bodies

Imaging- Plain radiographs to rule out foreign body- CT/MRI if concern for osteomyelitis

Wound closure - not usually indicated

UNCLASSIFIED/FOUO 19

Management and Treatment of Animal Bites

Antimicrobial therapy:- Prophylactic antibiotics in selected cases –Augmentin preferred- Coverage based on patient type and specific animal involved

Hospitalization Indications: - fever, sepsis, spreading cellulitis, substantial edema or crush injury, loss of function, immunocompromised status, or noncompliance

Immunizations:- Tetanus booster and/or immune globulin- ? Rabies vaccine and/or immune globulin

Take Home Points

• Mosquito borne illness-PPE– Not spread person-to-person

• First infection can be a real bad experience• Second infection can be deadly• No antiviral treatment• No vaccine (yet)• Supportive care/fluids

1. Malaria2. Dengue4. Leishmaniasis13. CCHF16. Chikungunya18. Plague19. Rickettsioses20. Viral enceph23. TBE24. Rift Valley fever27. Other arboviruses

Pediatric Tropical medicine issues • US Military has been involved in multiple medical engagements in recent years• -Haiti, Indonesia, AFRICOM MEDCAP missions, PRTs in Afghanistan, etc.• Women and Children are the largest vulnerable populations in most cases• Important to differentiate between humanitarian emergencies and chronic or

endemic disease.• During humanitarian emergencies, trauma and/or preventative medicine efforts

typically take priority.

– ATLS and surgical intervention when needed– Clean water– Food– Cooking equipment– Clothing and Shelter– Medical surveillance for outbreaks

– Examples of humanitarian emergencies can be natural disasters (Earthquakes, Flooding, etc) Can be from civil war resulting in large numbers of displaced citizens (Refugee camps), or can be from severe drought/famine.

Major Pediatric Mortality in Humanitarian Emergencies

• Diarrheal illness• Measles• ARD• Malaria• Malnutrition

23Communicable Disease

Medical Civic Actions Programs -MEDCAPS or Civil-Military Operations

Not Related to a Humanitarian Crisis

• Popular among Commanders• Advantages:

– Good way to collect demographic data and collect intelligence on the community-often coordinated with SOF exercises.

– Tool to win “Hearts and Minds”.– Allows interaction with the community.– The majority of the people seen will be women and children.

• Disadvantages:– May undercut the local medical personnel– Decreases reliance of the community on their own

resources– Many conditions are chronic, and a 15-30 day supply

of medications will not cure these individuals.– In some cases, like TB, short term therapy may make

things worse.– People may turn around and sell the medications,

instead of administering them.

Alternatives

• Partner with local medical personnel/healers.• Provide medical support/supplies to the local ‘clinic’.• Support Ministry of Health policies• Engage in educational and preventative medicine

programs with the local medical personnel and the community.– Typically topics like

• Womens health• Management of severe diarrheal disease • Childhood illnesses• Immunizations

WHO Efforts• Integrated Management of Childhood Illnesses: ICMI• Being taught to local providers• Designed to address most common childhood issues• Limited Resource Environments

• ICMI Handbook:• Algorithms for diagnosis and treatment of children

• WHO Manual for the Healthcare of Children in Humanitarian Emergencies

• Can be downloaded from the internet

Preventative Medicine

• Prevention efforts typically provide more bang for the buck

• Vaccination programs, Mass Drug Administration Programs

• Vector control Programs

• Tend to produce lasting effects• Help to build community capabilities

Prevention of Disease

• Identify illness patterns - surveillance• Interrupt transmission

– mostly environmental health measures– Vector control efforts (spraying,

bednets, etc)

• Reduce susceptibility of individuals – vaccines and chemoprophylaxis– improved nutrition

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Water / Sanitation• Point-of-use treatment and filtration-water buffaloes• Household water treatment and safe storage

– Boiling, Solar disinfection, filtration/disinfection– Cloth filtration with one of the above (48% risk)▼

• Strengthen municipal water systems/wells• Sanitation tools

– Systematic handwashing with soap (47% risk reduction)– Improve sewage systems and latrines

• Pit latrines, above ground tanksWater monitoring (early detection)

Questions?

• Questions now:– Arthur Lyons– Jennifer Caci– Paul Keiser– Richard Ruck– Ramiro Gutierrez

• Questions while deployed:– id.consult@us.army.mil