4.4.2016 1
Controlling and treating infectious diseases in primary care
Topi Turunen, M.D.
Controlling and treating infectious diseases in primary care / Turunen
Disclosure
• National Institute for Health and Welfare (2/2016–)
• City of Lohja, HUCH hospitals Peijas & Lohja (–1/2016)
• No financial conflicts of interest
• Project coordinator / PSR-Finland (Strenghening Youth Friendly Health Services Through Community-Based Interventions in Rural India -hanke)
4.4.2016 Tartuntatautikurssi 2016 2
Content
Infection control in primary care
• Surveillance
• Diseases to report
• Vaccination schedule
Common infections in primary care
• Common respiratory tract, urinary, cutaneous etc. infections
• Some less common infections
• Practical issues
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4.4.2016 4
Infection control in primary care
Topi Turunen, M.D.
Controlling and treating infectious diseases in primary care / Turunen
Communicable Disease Act of 1986
• In English: http://www.finlex.fi/en/laki/kaannokset/1986/en19860583.pdf
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Surveillance systems
• National Infectious Disease Register
– Founded 1995
– Operation based on the Communicable Diseases Act
• Doctors required to report 1) generally hazardous communicable diseases, 2) some other diseases (~30)
• Laboratories required to report 1) all positive blood- or CSF findings, 2) some other diseases (~70)
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National Infectious Disease Register
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Doctor
National Infectious
Disease Register
reminder
Laboratory
Population
register
12.9.2014 8
www.tartuntatautirekisteri.fi/tilastot
12.9.2014 9
What to report pt 1 – Generally hazardous diseases
• Hepatitis A
• Smallpox
• Yellow fever
• EHEC E. coli
• H5N1 Influenza
• Cholera
• Syphilis
• Diphteria
• Typhoid fever
• Paratyphoid fever
• Meningococcal disease
• Polio
• Plague
• Anthrax
• Salmonella*
• SARS
• Tuberculosis
• Hemorrhagic fevers
* No need for doctor’s report
What is ”generally hazardous”?
• Defined by the Communicable Diseases Act:
1. it is easily communicable or spreads rapidly;
2. it is dangerous; and
3. its spread can be prevented by measures aimed at persons who have such a disease or are justifiably suspected of having such a disease.
• The attending physician is primarily responsible for referring a patient (and others who may have caught it) to examinations and treatment
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What does it matter?
• To prevent the spread of a generally hazardous disease, the following is possible…
– Compulsory physical examination and treatment
– Quarantine for a fixed period
– Ordering a person be absent from their gainful employment
– Obligation to report the manner, date and place of infection, and from whom it may have been caught
– Employer may demand a reliable account of not having a certain generally hazardous disease (TB, Salmonella)
– The police must provide executive assistance if needed.
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12.9.2014 12
What to report pt 2 – other notifiable diseases
• Botulism
• CJD*
• Echinococcosis
• Haemophilus influenzae (only sepsis / meningitis)
• Hepatitis B
• Hepatitis C
• Pertussis
• HIV
• Chlamydia*
• Legionella
• Listeria
• Malaria
• Other mycobacteria than TB*
• Tick-born encephalitis*
• Rabies (incl. suspicion)
• Chancroid / LGV
• Mumps
• Gonorrhea
• Measles
• Rubella
* No need for doctor’s report
What is ”notifiable”
• Defined by the Communicable Diseases Act:
1. its monitoring presupposes information from a physician;
2. free of charge treatment for the patient is necessary to break the chain of infection; or
3. it is question of a disease that is preventable by a general vaccination programme.
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National Immunization Programme (NIP)
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• Vaccines given at child welfare clinics, schools, the military…
• Vaccines are voluntary
• Vaccines belonging to NIP are free of charge
Children and adolescents
• RV = rotavirus
• DTaP = diphteria, tetanus, acellular pertussis
• IPV = inactivated polio vaccine
• Hib = Hemophilus influenzae type B
• PCV = pneumococcal conjugate vaccine
• MMR = measles, mumps, rubella
• HPV = human papilloma virus
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Rotavirus (RV) 2 mo
DTaP-IPV-Hib +RV +
PCV 3 mo
DTaP-IPV-Hib + RV
+ PCV 5 mo
DTaP-IPV-Hib + PCV 12 mo
MMR 12–18 mo
Seasonal influenza 6–35 mo (annually)
DTaP-IPV 4 y
MMR 6 y
HPV girls 11–12 y (catch
up 13–15 y)
dtap 14–15 y
Adults
• dT = diphteria, tetanus
• MMR = measles, mumps, rubella
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dT-booster every 10th yrs
Polio
if travelling to
endemic country or
other countries with
the known risk of
wild polioviruses and
the last booster has
been given over 5
yrs ago
MMR
one or two doses if
not properly
protected previously
by vaccinations or
actually by the
disease in
childhood.
Specific risk groups
BCG children under 7 yrs*
PCV + PPV children under 5 yrs of
old**
Seasonal influenza
all at medical risk for
severe influenza
all 65 y or older
all pregnant
part of HP´s and Social
Workers
conscripts (the Finnish
Defense Forces)
relatives or close
persons of those who
are at higher risk to
have a severe
influenza.
• BCG = Bacillus Calmette-Guérin
• PCV = pneumococcal conjugate vaccine
• PPV = pneumococcal polysaccharide vaccine
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*BCG-vaccinations only for children at
high risk
**Pneumococcal conjugate and
Pneumococcal Polysaccharide
vaccinations since 2010
Hepatitis A and B Some risk groups
Tick Borne
Encephalitis, TBE***
3 yrs and older living in
Åland (an island near
south-western coast)
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Common infections in primary care
Topi Turunen, M.D.
Controlling and treating infectious diseases in primary care / Turunen
Upper respiratory infections
• Most are caused by viruses
• But check for possible bacterial infection
– Sinusitis
– Tonsillitis
– Otitis media
– Pneumonia
– …
• Even benign infections may lead to worsening of underlying disorders: asthma, COPD…
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Viral upper respiratory infections
• Often managed by nurses, no need for doctor’s appointment
• No need for specific diagnostics
• Self-limiting, no antibiotics
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Flunssa
Acute maxillary sinusitis
• Develops after viral URI in 0,5–5 % – usually takes at least 10 days
• Facial or dental pain, postnasal discharge
• Before antibiotics, diagnose with ultrasound, x-ray (or needle puncture – quite rare nowadays)
• 1st-line treatment: amoxicillin/penicillin
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Poskiontelontulehdus
Tonsillitis
• Inflammation of pharyngeal tonsils: fever, sore throat, odynophagia, tender cervical lymph nodes
• Viral or bacterial – test before treating! If streptococcal, 1st-line treatment is penicillin
• Complication: peritonsillar abscess (severe pain, trismus, drroling etc.) – refer to ENT
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Nielutulehdus / angiina
Mononucleosis
• Caused by Epstein-Barr virus, very common
• Often asymptomatic in early childhood, or: fever, sore throat, lymphadenopathy, splenomegaly, hepatitis
• Diagnosis by FBC, rapid test, antibodies (n.b.: can coexist with streptococcal tonsillitis)
• Warn about the possibility of splenic rupture
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Mononukleoosi / ”pusutauti”
Acute otitis media
• Common follow-up of viral infections
• Fever, ear pain, difficulty hearing, irritability, loss of appetite, vomiting…
• Diagnosis by pneumatic otoscopy – note the color, position, mobility, and possible perforation
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Korvatulehdus
• Most AOMs resolve by themselves; ”1st-line treatment” is paracetamol
• Discuss other treatment options with family
a) Amoxicillin right away (e.g. if <2 years, both ears affected, perforation)
b) Prescribe amoxicillin ”just in case” but suggest they wait for 2–3 days
c) New checkup after a few days
• Paracentesis performed very rarely
• Checkup after 1 month until effusion gone or consult ENT
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Influenza
• Epidemic every winter
• Vaccinations given in Oct-Nov for free:
– Over 65-yr-olds
– Pregnant women
– Children aged 6–35 months
– Social & healthcare workers
– Conscripts
– Serious medical condition
– …and their relatives / close ones.
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Influenssa
• After 2-3 days: high fever, chills, headache, muscle pains, cough…
• Diagnosis on clinical grounds (mostly) or by rapid test
• Treatment: supportive (oseltamivir / tsanamivir can be considered if symptoms for <48 h)
• Complications: pneumonia, sinusitis
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Pneumonia
• Cough, high fever, dyspnea, chest pain
• Elderly may present with atypical symptoms, e.g. only confusion, no cough or fever
• Auscultate lungs, note respiratory rate & take X-ray
• Note: pneumococcal vaccine is in NIP for children and also recommended to the elderly and people with underlying medical conditions
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Keuhkokuume
• Consider hospital care, if
– Notable changes in vital signs (RR, HR, temp)
– B-leuk <3 or >15 x 10E9
– Underlying illness
– Large infiltrate in X-ray
– Condition seems bad otherwise.
• 1st-line treatment
– At home: amoxicillin (consider macrolide or doxycycline if Chl. pneumoniae or M. pneumoniae suspected)
– In hospital: cefuroxime or penicillin i.v.
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Some other viral diseases of children
• Difficulty breathing in
– Laryngitis / croup
– Laryngotracheitis
– Bacterial tracheitis
– (Epiglottitis)
• Difficulty breathing out
– Obstructive bronchitis
– Bronchiolitis
• Remember also: asthma, foreign object
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Laryngitis / croup
• Caused by viruses. Common in 6 – 23 month-olds: hoarse voice, ”barking” cough, coldlike symptoms, stridor, respiratory distress
• Treatment: Cool air, consider p.o. corticosteroids, inhaled adrenaline
• Outpatient care usually sufficient, consider monitoring at hospital if severe difficulty breathing, bacterial pneumonia/tracheitis suspected etc.
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Laryngiitti
Obstructive bronchitis / bronchiolitis
• Caused by viruses (e.g. RSV)
• Dyspnea (breathing out difficult), may have expiratory wheeze
• Treat with salbutamol
• Under-1-yr-olds often need hospital care
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Bronkioliitti
Conjunctivitis
• Redness, itching, discharge – could be any inflammatory condition of the conjunctiva – but if purulent discharge, most likely bacterial or viral origin
• If any of the following, consider iritis, ceratitis, episcleritis or glaucoma instead – consult eye specialist
– Severe pain
– Light sensitivity
– Worsened vision
– Cornea or pupilla looks odd
• Cloramphenicol of fucidic acid drops/ointment
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Sidekalvotulehdus
Erysipelas / cellulitis
• Bacterial infection of the skin
• Fever, redness, CRP & leuk ↑
• Often needs hospital care, 1st-line drug i.v. penicillin or e.g. cefuroxime (if staphylococcus suspected)
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Ruusu / selluliitti
Urinary tract infections: Cystitis
• Dysuria, urinary frequency, lower abdominal discomfort, bloody urine
• Lab tests usually not required if pt is a woman aged 18-65 and symptoms typical: just treat.
– Urine dipsticks and culture widely available in health centers.
• Unsymptomatic bacteriuria is not treated - except with pregnant women
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Virtsatieinfektio
• Treatment: nitrofurantoin, pivmecillinam or trimethoprim-sulfamethoxazole, 3 days usually enough
• UTI in males often involves prostate: do prostate exam, check PSA, treat with trimethoprim or ciprofloxacin for 7-14 days
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Urinary tract infections: Pyelonephritis
• Fever, flank/back pain +/- lower UTI symptoms, CRP ↑
• P.o. fluorocinolones effective, e.g. ciprofloxacin for 7 days
• If hospital care required, e.g. i.v. cefuroxime or p.o. ciprofloxacin
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Pyelonefriitti
Chickenpox
• Very common, benign infection in childhood, morbidity increased in adults and the immunocompromised, risk for fetal malformations in pregnancy
• Vesicular rash, possibly fever, malaise
• Treatment:
– Healthy children <13 years: usually none required
– Others: acyclovir (p.o. or i.v.)
• If immunocompromized person / pregnant woman exposed to VZV, consult internist/gynaecologist
•
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Vesirokko
Ticks
• Ixodes ricinus (and to some degree, I. persulcatus) widespread in Finland
• Bite humans and animals e.g. during walks in tall grass
• Can carry
1. Lyme disease
2. Tick-borne encephalitis
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Punkki
Lyme disease
• Caused by Borrelia sp. bacterium
• Early sign: erythema migrans rash
– No testing needed – treat with amoxicillin/doxycycline
• Late signs: lymphocytoma, arthritis, meningitis, facial paralysis, other neurological symptoms
• Removing the tick within 24 h is likely to prevent Lyme disease (but not TBE)
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Borrelioosi
Tick-born encephalitis
• Often asymptomatic, or
– After 1 week: fever, malaise
– After 1–2 more weeks: encephalitis, fever, headache, light sensitivity, neurological symptoms
• Can be confirmed serologically
• A vaccine exists
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Puutiaisaivokuume
Epidemic nephropathy
• Caused by Puumala virus (a hantavirus) in mostly Eastern and Central Finland, contracted from moles
• After 2–4 weeks, fever, headache, muscle pains, decreased or increased urination, proteinuria, hematuria, visual disturbance, vomiting, …
• FBC, CRP, creatinine, antibodies
• Treatment symptomatic
– Fluids, paracetamol
– Some may require dialysis
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Myyräkuume
Underlying conditions
• Many infections can cause complications in people with
– Diabetes
– Asthma, COPD
– Alcoholism
– Corticosteroid or other immunosuppressive medication
– …
• …all of these are quite common in Finland!
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Perussairaudet
A word on antibiotics
• In Finland, 80 % prescribed for respiratory infections
• Do have side effects
– Diarrhoea, C. difficile infections, UTIs
– Autoimmune conditions?
– Antibiotic resistance
– Cost
• Indicated in certain cases: even then, a narrow-spectrum drug (e.g. penicillin or amoxicillin) is often enough
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Antibiootit
Most practices are equipped by…
• Bedside tests
– CRP
– Streptococcus A (rapid test / culture)
– Mononucleosis (rapid test)
– Influenza (rapid test)
– Urine dipsticks
• Otoscope, nose speculae
• Indirect laryngoscopy mirrors
• Tympanometer
• Sinus ultrasound
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When in doubt…
• The Lääkärin tietokannat database
• The Käypä hoito guidelines
• Every municipality has “a physician in charge of communicable diseases” – ask them!
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