Hot Topics in Infectious Diseases:

Enteric Infections in the Arctic

Tobey Audcent MD, FRCPC Department of Pediatrics Children’s Hospital of Eastern Ontario

6th International Meeting on Indigenous Child Health

March 21, 2015

Faculty/Presenter Disclosure

Tobey Audcent has no relevant financial relationships

with the manufacturer(s) of commercial services

discussed in this CME activity

AND

Tobey Audcent does not intend to discuss an

unapproved/investigative use of a commercial

product/device in my presentation

Acknowledgements

Thanks to: with permission

• Dr. David Goldfarb slides and data (ID/Micro,

BC Children’s Hospital)

• Dr. Cedric Yansouni (ID/Micro, McGill

University) for data from Nunavik

• Dr. Sherilee Harper (Guelph University) for

Iqaluit and Rigolet data

Session Objectives:

1. Review the contribution of chronic enteropathy to

childhood development

2. Describe an overview of enteric infections in the Arctic

3. Discuss cryptosporidium as an emerging childhood

enteric infection in the Arctic

Hot Infection Topics

Tuberculosis

Sexually Transmitted Infections

Diarrhoea

Global Burden of Diarrheal

Disease Diarrhea kills 2,195 children every day—more than

AIDS, malaria, and measles combined

Lancet. 2012;379(9832):2151-61

2nd leading cause

of child death

Environmental Enteropathy:

Unifying Mechanism

Nutr Rev. 2008 September; 66(9): 487–505 [15]

PLoS Negl Trop Dis 7(4): e2125. doi:10.1371/journal.pntd.0002125

With permission D Goldfarb from: Guerrant R, Ped Academic Soc Mtg, April 30 2012

Arctic Communities: More

Diarrhea ?

Among American Indian (AI) and Alaskan Native (AN)

children:

diarrhea-associated hospitalization ~2X general U.S.

262.6 vs. 154.7 per 10,000 population

diarrhea-associated outpatient visits also higher than

general U.S.

2,255.4 vs. 1,647.9 per 10,000 population

Singlelton RJ et al; Pediatr Infect Dis J. 2007;26(11):1006-13.

Arctic Communities:

Emerging Data Acute gastrointestinal illness in two Inuit

communities: burden of illness in Rigolet and Iqualuit,

Canada. SL Harper et al. Epidemiol Infect. 2015

Lived experience of acute gastrointestinal illness in

Rigolet, Nunatsiavut: “Just suffer through it”. SL

Harper et al. Social Sci and Med. 2015

Nanolitre real-time PCR detection of bacterial,

parasitic and viral agents from patients with diarrhoea

in Nunavut, Canada. DM Goldfarb et al. Int J

Circumpolar Health. 2013.

AGI in Arctic Communities

Data from Dr. Sheri Harper, University of Guelph

Changes in Diagnostic Methods?

Multiplex PCR

Bacteria

Virus

Parasite

No Pathogen

Conventional Testing

Bacteria

No Pathogen

with permission Goldfarb DM et al; Int J Circumpolar Health. 2013;72:19903.

Molecular Testing old specimens, new tools

with permission Goldfarb et al; Int J Circumpolar Health

2013;72:19903.

Cryptosporidium: New Kid on

the Map

Spring 2013: Crypto retrospectively found to be

leading stool pathogen

July 2013: first observed Crypto outbreak in Arctic

July 2014: new outbreak

With permission, D Goldfarb

Crypto-whaaa? Oocyst forming coccidian protozoa

Fecal-oral transmission, no intermediate maturation cycle

Causes frequent non-bloody watery diarrhea +/- abdo cramps, fatigue, fever, wt. loss, vomiting , anorexia

Self limited in immune competent hosts, incubation 3-14 days, illness usually lasts 6-14 days, continue to shed oocysts for 2 weeks

Extensive waterborne disease outbreaks associated with contaminated drinking and recreational water (oocysts are chlorine tolerant) and in low resource settings and transmission from livestock and animals such as petting zoos (C. Parvum)

Red Book. 29th Ed. 2012.

Sources:

Not the Petting Zoo or the Pool!

Giardia duodenalis and Cryptosporidium Spp . in

the Intestinal Contents of Ringed Seals (Phoca

Hispida) and Bearded Seals (Erignathus Barbatus)

in Nunavik, Quebec, Canada Region. J Parasitology.

Dixon et al.2008;94(5):1161–3.

Molecular characterization of Cryptosporidium sp

isolated from northern Alaskan Caribou (Rangifer

tarandus). J Parasitology. Siefker et al 2002;88:213-

216.

Detection & Treatment Might not be detected on routine O & P of stools

intermittent shedding- need 3 stools on 3 separate days

small size of oocysts (4-6 um)

concentration techniques + modified AF stain

specific DFA gold standard, emerging role for flocked

swabs/molecular testing

No treatment in immune-competent

Crypto in Canada

Thomas MK et al. Foodborne Pathogens and Dis. 2013; 10(7) 639-48

Crypto in the Arctic

SL Harper et al. Epidemiol Infect. 2015

Crypto in kids?

With permission. C. Yansouni

Crypto: QGH vs. the world?

QGH detection

rate

Slide with permission D Goldfarb. Graphic from Shirley DT et al., Curr Opin

Infect Dis 2012, 25:555–563

Practical Implications:

Diagnosis

Gamma – dynacare is doing acid fast staining on all O and P samples

So what? It’s Self-Limiting • Villous blunting

• Can have lasting effects in children, including

• increased diarrheal burden months after infection

• linear growth failure

• cognitive impairment

• Developmental delays has also been found in children with apparently asymptomatic infections

• May remain carrier for months

• No effective treatment (prevention is key)

Guerrant et al (Eds); Tropical Infectious Diseases (2nd Ed)

Practical Implications:

Infection Control

Infection Control (daycare exclusion, handwashing,

animal handling, water ingestion)

Most healthy individuals with acute diarrhea will only need

supportive care

Survey: Health Behaviours

Survey: Health Beliefs

Practical Implications:

Treatment Nitazoxanide is only FDA approved medication (is Health Canada special access)

RCT -Diarrhea was resolved in 80% of adults and children within 7 days of being randomized to receive a 3-day course of nitazoxanide compared with only 41% of those randomized to placebo

Indicated in:

immunocompromised

Chronic disease, particularly with growth failure

Rossignol JF, et al. J Infect Dis 2001; 184:103–106.

Research Questions: 1. What is the incidence and prevalence of (i) intestinal

infections and of (ii) diarrhea in Arctic communities?

2. What are the main infectious causes?

3. Are children being affected by repeated or chronic infections (Growth? Development?)

4. How can enteric infections be prevented in these communities?

Nunavut Gastroenteritis Study

You may have a patient eligible for the…. .

Child under 5 years old?

Has Gastroenteritis?

Pick up the study pack for details

If you have any questions please contact Dr. David Goldfarb

(goldfarb@mcmaster.ca) or Dr. Amber Miners (aminers@gov.nu.ca)

If they are eligible and consent obtained,

collect a swab sample to send to the lab

Take Home Points

1. Diarrhoeal disease is an important, multifactorial, and underappreciated contributor to child health.

2. The burden of disease is higher in Arctic communities, unique prevention challenges.

3. Cryptosporidium is an emerging pathogen, diagnostic challenges, need more data.

4. There is a role for treatment of this pathogen in children with chronic disease.

Questions?

Clyde River, Nunavut. Image courtesy of T Audcent