Managing Communicable Disease on Center John Kulig, MD, MPH Lead Medical Specialist, Job Corps February 4, 2015.

Managing Communicable Disease on Center

John Kulig, MD, MPH

Lead Medical Specialist, Job Corps

February 4, 2015

Goal

• Among the most common outbreaks of infectious disease on Job Corps centers are influenza (flu), pertussis (whooping cough) and varicella (chickenpox).  This webinar will address prevention, diagnosis, treatment and isolation of students and staff with these three common infections.

Objectives

1. Review the prevalence, demographics and morbidity associated with influenza, pertussis, and varicella infection in the United States.

2. Describe the clinical presentation, diagnosis, treatment and isolation of students with influenza, pertussis, or varicella infection on center.

3. Explain Job Corps policy for the prevention of infection and management of students with communicable disease on center.

Influenza

Influenza clinical presentation

Symptoms• Cough• Sore throat• Runny or stuffy

nose• Muscle or body

aches• Headaches• Fatigue

Signs• Fever• Chills

Less commonly:• Vomiting • Diarrhea• Joint pain

Influenza complications

• pneumonia • bronchitis • sinus infection• ear infection• asthma exacerbation• cardiac - myocarditis• muscular – myositis, rhabdomyolysis• neurologic - Guillain-Barre, seizures,

encephalitis, meningitis, Reye syndrome

Influenza diagnosis

• Rapid influenza diagnostic tests (RIDTs) are immunoassays that can identify the presence of influenza A and B viral nucleoprotein antigens in respiratory specimens, and display the result in a qualitative way (positive or negative)

• Viral culture (3-10 days)• Immunofluorescent antibody staining

Influenza treatment• Randomized, controlled trials conducted primarily

among persons with mild illness in outpatient settings have demonstrated that oseltamivir or zanamivir can reduce the duration of uncomplicated influenza A and B illness by approximately one day when administered within 48 hours of illness onset compared with placebo

• Oseltamivir (Tamiflu®) 75 mg po twice daily

x 5 days• Zanamivir (Relenza®) 10 mg (two 5-mg

inhalations) twice daily x 5 days• Once daily dosing for chemoprophylaxis

Controlling the spread of influenza on center

• Cover your nose and mouth with a tissue when you cough or sneeze. Throw the tissue in the trash after use.

• Wash your hands often with soap and water, especially after you cough or sneeze. Alcohol-based hand cleaners are also effective.

• Avoid touching your eyes, nose, or mouth. Germs spread that way.

Job Corps policy

• Job Corps centers should offer seasonal influenza vaccine on a voluntary basis to all students, not just to students with health conditions placing them at higher risk of medical complications.

Job Corps policy

• One dose of seasonal flu vaccine should be administered as early as September when available.

• Influenza vaccine should remain available on center throughout the flu season for new students and for students who may initially decline to be immunized.

Seasonal influenza vaccine

• The seasonal influenza vaccine protects against the flu strains that research indicates will cause the most illness during the flu season.

• The 2014-2015 influenza vaccine contains either three or four influenza virus strains: – A/California/7/2009 (H1N1)-like virus

– A/Texas/50/2012 (H3N2)-like virus

– B/Massachusetts/2/2012-like (Yamagata lineage) virus

– B/Brisbane/60/2008-like (Victoria lineage) virus – quadrivalent vaccines only

Influenza 2014-2015• Getting flu vaccine this season reduced a

person’s risk of having to go to the doctor because of flu by 23 percent among people of all ages.

• Since CDC began conducting annual flu vaccine effectiveness studies in 2004–2005, overall estimates for each season have ranged from 10%-60% effectiveness in preventing medical visits associated with seasonal influenza illness.

• Flu viruses change constantly and the drifted H3N2 viruses did not appear until after the vaccine composition for the Northern Hemisphere had been chosen.

Influenza 2014-2015• CDC recommends that people get a flu vaccine

even during seasons when drifted viruses are circulating because vaccination can still prevent some infections and can reduce hospitalization and death.

• Also, the flu vaccine is designed to protect against three or four influenza viruses and some of these other viruses may circulate later in the season.

• Flu activity so far this season has been similar to the 2012–2013 flu season, a “moderately severe” flu season with H3N2 viruses predominating.

Influenza 2014-2015• Antiviral medications are a valuable second

line of defense, but are not a substitute for influenza immunization.

• Antiviral treatment should not be delayed while waiting for a definitive influenza test result.

• Early therapy provides the best outcomes, as the benefit of antiviral treatment is greatest when initiated within 48 hours of symptom onset.

• Antiviral treatment should be offered to students at high risk.

High-risk medical conditions

• asthma • diabetes • heart disease• immunosuppression • kidney disease • neurocognitive disorders• neuromuscular disorders • pregnancy

Center health staff

• Influenza vaccination is strongly encouraged for all center health staff members, who could potentially transmit infection to students.

• Increased absenteeism among health staff could also reduce the capacity of a center to respond to increased demand for care in the event of an influenza outbreak on center.

Medical leaves for influenza

• Public health recommendations encourage symptomatic treatment at home and discourage visits to a physician’s office to obtain documentation and clearance for return to school or work.

• For Job Corps students, medical leaves for influenza will not require third party verification.

Return to class or work

• Patients can shed influenza virus 1 day before symptoms appear and up to 5 days after onset of illness.

• Students with influenza should not return to class or to work until fever has resolved without medication, and 5 days have passed since onset of symptoms.

Pertussis

9,935 cases26.0/100,000

Pertussis

• Pertussis, a respiratory illness commonly known as whooping cough, is a very contagious disease caused by Bordetella pertussis. These bacteria attach to the cilia (tiny, hair-like extensions) that line part of the upper respiratory system and release toxins, which damage the cilia and cause inflammation.

• Known in China as the “100 day cough.”

Pertussis

• Pertussis is only found in humans and is spread from person to person by coughing or sneezing while in close contact with others, who then breathe in the pertussis bacteria.

• Symptoms of pertussis usually develop within 5–10 days after being exposed, but sometimes not for as long as 3 weeks.

• Waning immunity associated with use of acellular pertussis vaccine (Dtap/Tdap).

• Cyclical peaks every 3-5 years in US.

Pertussis clinical presentation

Symptoms• Runny nose• Sneezing• Mild cough• Paroxysmal cough• Chronic cough• Fatigue

Signs• Low-grade fever• Apnea in infants• Post-tussive

whoop *• Post-tussive

vomiting

* http://www.cdc.gov/pertussis/about/signs-symptoms.html

Pertussis complications

• Pneumonia (2%)

• Weight loss (33%)

• Urinary incontinence (28%)

• Syncope (6%)

• Rib fractures from severe coughing (4%)

• Other complications include anorexia, dehydration, epistaxis, hernias and otitis media

• More severe complications include encephalopathy, pneumothorax, rectal prolapse, subdural hematomas and seizures

Pertussis diagnosis

• Culture – up to two weeks• Polymerase chain reaction (PCR)• Serology

Pertussis treatment

• Azithromycin 500 mg orally on the first day, then 250 mg once daily on days 2-5

• Clarithromycin 500 mg twice daily for 7 days

• Erythromycin 2 g/day orally divided into 4 doses/day for 14 days

• Trimethoprim-sulfamethoxazole 320 mg TMP/1600 mg SMX per day orally divided into 2 doses/day for 14 days

Varicella

* In thousands.In four states (Illinois, Michigan, Texas, and West Virginia), the number of cases reported in 2011 was 16% lower than 2010 and 94% less than the number reported during the pre-vaccine years 1993–1995.

Varicella/Chickenpox

• Caused by the varicella-zoster virus (VZV)• Virus spreads in the air when an infected

person coughs or sneezes. • Also spread by touching or breathing in the

virus particles that come from chickenpox or shingles blisters

• A person with chickenpox can spread the disease from 1 to 2 days before they get the rash until all their chickenpox blisters have formed scabs.

• It takes from 10 to 21 days after exposure to a person with chickenpox or shingles for someone to develop chickenpox.

Varicella clinical presentation

Symptoms• Fatigue• Nausea• Anorexia• Headache• Myalgia

Signs• High fever• Rash – “dew drop

on rose petal”• Crops of lesions

in all stages of development

Varicella complications• Dehydration• Pneumonia• Thrombocytopenia/purpura• Infection or inflammation of the brain

(encephalitis, cerebellar ataxia)• Bacterial infections of the skin and soft tissues

including Group A streptococcal infections• Blood stream infections (sepsis)• Toxic shock syndrome• Bone infections• Joint infections• Shingles (zoster) - late

Varicella diagnosis

• PCR to detect VZV in skin lesions is the most sensitive method for confirming a diagnosis of varicella

• IgM testing is considerably less sensitive • Paired acute and convalescent sera showing a

four-fold rise in IgG antibodies have excellent specificity

• A single positive IgG ELISA result indicates that a person has antibodies to VZV either from current or past varicella disease or vaccination

Varicella treatment

• Antiviral medications are recommended for people with chickenpox who are more likely to develop serious disease including:– otherwise healthy people older than 12 years of age– people with chronic skin or lung disease– people receiving steroid therapy– some groups of pregnant women

• Antiviral medication for treatment of chickenpox – acyclovir 800 mg orally four times a day for 5 days– Varicella-zoster immune globulin (VariZIG) is indicated for use

in highly susceptible, VZV-exposed immunocompromised or immunosuppressed patients

• Avoid using aspirin for symptomatic treatment (Reye risk)

Prevention

• Vaccination:– Influenza vaccine – annual due to

antigenic drift/shift (IIV vs LAIV)– Tetanus-diphtheria-acellular pertussis

(Tdap) vaccine – single dose except in pregnancy– waning immunity

– Varicella vaccine – two doses at least 4 weeks apart

Vaccine purchase

• Centers should first contact their state and/or local health departments to inquire if vaccine are available for administration on center.

• Vaccines for Children (VFC) provides free vaccines for students less than age19 years

• If not, vaccines can be purchased from the HHS Supply Service Center in Perry Point, Maryland, or from private vendors.

Planning

• Job Corps centers are encouraged to review their communicable disease plans to prepare for the potential of outbreaks on center.

• Center health staff are also strongly encouraged to contact their state and/or local health department to obtain the latest information about vaccine availability and recommendations for testing, treatment and prophylaxis in response to outbreaks among students.

Controlling the spread of communicable disease on center• Try to avoid close contact with sick

people.

• Encourage residential students to report to the Wellness Center if they become ill.

• Sick nonresidential students and center staff should be encouraged to stay home and limit contact with others.

Isolation procedures for communicable disease on center

• Use isolation room in HWC for individuals

• Consider cohorting in dorm rooms for epidemics – provide “room service”

• Doors closed – limit visitors• Use personal protective equipment and

respiratory/contact precautions as indicated, including masks for students

Communicable disease on center

• Residential students may be transported home by a family member, center staff member or treated on center.

• Public transportation should not be used for students exhibiting symptoms of a communicable disease.

Epidemic infections on center

• Centers should continue to use the Significant Incident Report (SIR) system to keep the National and Regional Offices of Job Corps informed about epidemic infections on center.

• For the purpose of reporting, epidemic infections will be defined by Job Corps as cases affecting 10% or more of on-board strength (OBS).

Clinical alert – Recognition of measles

Maculopapular rash spreads from head to trunk to lower limbs Fever to 105o F with malaise The three Cs: cough, coryza, conjunctivitis Pathognomonic enanthema (Koplik spots) Incubation period 7-21 days – averages 14 days Contagious period 4 days before and 4 days after onset of rash

Resources

• For the most current information for clinicians, visit the following CDC websites: – http://www.cdc.gov/flu/professionals/

index.htm - influenza– http://www.cdc.gov/pertussis/clinical/

index.html - pertussis– http://www.cdc.gov/chickenpox/hcp/

index.html - varicella