““Strange Germs, New Strange Germs, New Plagues, Weird Bacteria, Plagues, Weird Bacteria,

Oh My!Oh My!Michelle A. Barron, M.D.Michelle A. Barron, M.D.

Associate Professor of MedicineAssociate Professor of MedicineUniversity of Colorado DenverUniversity of Colorado DenverDivision of Infectious DiseasesDivision of Infectious Diseases

Medical Director, Infection Prevention and Medical Director, Infection Prevention and Control – University of Colorado HospitalControl – University of Colorado Hospital

ObjectivesObjectivesDiscuss new and not so new bacterial infections Discuss new and not so new bacterial infections (MRSA), viral infections (seasonal influenza, (MRSA), viral infections (seasonal influenza, avian influenza, the H1N1 pandemic, SARS, avian influenza, the H1N1 pandemic, SARS, West Nile Virus, Hantavirus), and TuberculosisWest Nile Virus, Hantavirus), and Tuberculosis– What are they?What are they?– How are they transmitted?How are they transmitted?– How do you know if you have it?How do you know if you have it?– What do you do if you do get it?What do you do if you do get it?Discuss ways to prevent infectionsDiscuss ways to prevent infections– Hand HygieneHand Hygiene– ImmunizationsImmunizations

““[it] is time to close the book on infectious [it] is time to close the book on infectious diseases and declare the war against diseases and declare the war against

pestilence won…” pestilence won…”

Attributed to:Attributed to:US Surgeon General William H. StewartUS Surgeon General William H. Stewart

1967 1967

The Antibiotic Era: An The Antibiotic Era: An Evolutionary PerspectiveEvolutionary Perspective

What is What is Staphylococcus aureusStaphylococcus aureus??

Often referred to Often referred to as “staph”as “staph”Bacteria that is Bacteria that is commonly carried commonly carried on the skin or nose on the skin or nose of healthy peopleof healthy people

Epidemiology of Epidemiology of S aureusS aureusPredominant reservoir of organisms = human Predominant reservoir of organisms = human beingsbeings

Approximately 15% – 35% of healthy people Approximately 15% – 35% of healthy people harbor harbor S. aureusS. aureus in their nose or throat at any in their nose or throat at any given pointgiven point

People can become carriers of Staph without People can become carriers of Staph without having an infection (colonization)having an infection (colonization):: – 30% prolonged, 50% intermittent, 20% never30% prolonged, 50% intermittent, 20% never– Vaginal carriage in Vaginal carriage in ~~10% of premenopausal women10% of premenopausal women– Rectal and perineal carriage also occurRectal and perineal carriage also occur

Sheagren. N Engl J Med. 1984;310:1368-1373.Rimland et al. J Clin Microbiol. 1986;24:137-138.

Centers for Disease Control (CDC). MMWR Morb Mortal Wkly Rep. 1982;31:605-607.

What is Methicillin Resistant What is Methicillin Resistant Staphylococcus aureusStaphylococcus aureus (MRSA)? (MRSA)?Some Staph bacteria are resistant to Some Staph bacteria are resistant to antibioticsantibioticsMRSA is a type of Staph that is resistant MRSA is a type of Staph that is resistant to antibiotics called beta-lactamsto antibiotics called beta-lactamsBeta-lactam antibiotics include antibiotics Beta-lactam antibiotics include antibiotics such as methicillin, amoxicillin, and such as methicillin, amoxicillin, and penicillinpenicillinApproximately 1% of the population is Approximately 1% of the population is colonized with MRSAcolonized with MRSA

Epidemiology of MRSAEpidemiology of MRSA

Organism usually spread by direct person-to-Organism usually spread by direct person-to-person contactperson contact

Spread from inanimate objects is rare, but has Spread from inanimate objects is rare, but has been documented, such as outbreaks among been documented, such as outbreaks among football players, river raft guides, etc.football players, river raft guides, etc.

Patients with MRSA infections may have high Patients with MRSA infections may have high prevalence (60%) of gut colonization or carriageprevalence (60%) of gut colonization or carriage

Common denominatorCommon denominator:: repeated trauma in repeated trauma in defined area defined area

Who Gets Staph Infections?Who Gets Staph Infections?

Staph infections, including MRSA, occur Staph infections, including MRSA, occur frequently in persons in hospitals and frequently in persons in hospitals and healthcare facilitieshealthcare facilitiesPeople with diabetes, HIV or AIDS, and People with diabetes, HIV or AIDS, and chronic kidney failure on dialysis may be chronic kidney failure on dialysis may be colonized with Staph more frequently than colonized with Staph more frequently than othersothersIncreasing number of otherwise healthy Increasing number of otherwise healthy people are being reported as having people are being reported as having MRSA infectionsMRSA infections

What is Community Associated What is Community Associated MRSA (CA-MRSA)?MRSA (CA-MRSA)?

MRSA infections that are acquired by MRSA infections that are acquired by persons who have not been recently persons who have not been recently hospitalized (within the past year)hospitalized (within the past year)Staph or MRSA infections in the Staph or MRSA infections in the community generally occur in otherwise community generally occur in otherwise healthy peoplehealthy peopleA study in 2003, suggests that 12% of A study in 2003, suggests that 12% of MRSA infections are community MRSA infections are community associated but this varies by geographic associated but this varies by geographic region and populationregion and population

Nosocomial infection

Community-acquired infection

Methicillin-resistant S aureus

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Nosocomial infection

Community-acquired infection

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Community-acquired infection

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Epidemiology of HA- and Epidemiology of HA- and CA-MRSA InfectionsCA-MRSA Infections

1. McDonald LC. Clin Infect Dis. 2006;42:S65-S71. 2. Naimi TS, et al. JAMA. 2003;290:2976-2984.

Infections associated with CA-MRSA (n = 131)2

Infections associated with HA-MRSA (n = 937)2

Skin/Soft tissue 75%

Otitis media/externa7%

Respiratory tract 6%

Bloodstream 4%

Urinary tract 1%

Other 8%

Skin/Soft tissue 75%

Otitis media/externa7%

Respiratory tract 6%

Bloodstream 4%

Urinary tract 1%

Other 8%

Skin/Soft tissue 37%

Otitis media/externa 1%

Respiratory tract 22%

Bloodstream 9%

Urinary tract 20%

Other 12%

Skin/Soft tissue 37%

Otitis media/externa 1%

Respiratory tract 22%

Bloodstream 9%

Urinary tract 20%

Other 12%

Prevalence of MRSA increasing in hospitals and in the community1

Risk Factors for Colonization or Risk Factors for Colonization or Infection with MRSAInfection with MRSA

History of injecting drug useHistory of injecting drug useHomelessnessHomelessnessUnderlying dermatologic diseaseUnderlying dermatologic diseasePrior steroid therapyPrior steroid therapyPrior antibiotic therapyPrior antibiotic therapyPresence of a central venous catheterPresence of a central venous catheterProlonged hospital staysProlonged hospital stays

Onorato, M, et al. ICHE. 1999. 20 (1):26-30.Miller, M, et al. Eur J Clin Micro Infect Dis 2003. 22:463-69.

CA-MRSA Infections Among Competitive CA-MRSA Infections Among Competitive Sports Participants, 2000 – 2003Sports Participants, 2000 – 2003

Outbreaks of skin and soft tissue infections Outbreaks of skin and soft tissue infections (SSTIs) due to CA-MRSA reported from (SSTIs) due to CA-MRSA reported from Colorado, Indiana, Pennsylvania, and Los Colorado, Indiana, Pennsylvania, and Los Angeles County from 2000 to 2003Angeles County from 2000 to 2003

Sports involved included fencing, wrestling, Sports involved included fencing, wrestling, and footballand football

Centers for Disease Control and Prevention (CDC). MMWR Morb Mortal Wkly Rep. 2003;52:793-795.

Clinical SyndromesClinical Syndromes

Prevention of MRSAPrevention of MRSAAdequate coverage of abrasions or draining Adequate coverage of abrasions or draining lesionslesionsLimiting inappropriate antimicrobials useLimiting inappropriate antimicrobials useUse of Infection prevention practices (e.g. Use of Infection prevention practices (e.g. washing hands or using alcohol based gels)washing hands or using alcohol based gels)Advice for people who live with you:Advice for people who live with you:– Good hygiene – hot showers, use of antimicrobial Good hygiene – hot showers, use of antimicrobial

soaps, and disinfectantssoaps, and disinfectants– Avoid sharing towels, razors, or clothingAvoid sharing towels, razors, or clothing

Tacconelli, E., et al. JAC. 2004. 53:474-9.Zetola, N., et al. Lancet. 2005. 5:275-86.Kowalski, TJ, et al. Mayo Clin Proc. 2005. 80(9):1201-8.

Influenza

What is Influenza?What is Influenza?Contagious respiratory illness caused by the influenza virus – Influenza A, B and C

subtypes: H1N1, H5N1, H3N2, pandemic H1N1, etc.Causes mild to severe illness and can lead to deathYearly, 5-20% of the population will become infected influenza > 200,000 are hospitalized annually with severe complications from influenza About 36,000 die annually from flu-related illness

How is it spread ?Spread is usually person to person via large virus-laden droplets when

coughing/sneezing, poor hand hygiene compliance, poor compliance with respiratory etiquette

What is the period of infectivity period?Infectivity is one day prior to symptom onset and up to 5 days after onset.

Children and those with weakened immune systems may be infectious for 10 days or more after onset of symptoms.

Viral Shedding and TransmissionViral Shedding and Transmission

30-50% of seasonal influenza infections may not 30-50% of seasonal influenza infections may not result in illnessresult in illnessViral shedding in healthy adults with influenza Viral shedding in healthy adults with influenza occurs 24-48 hours prior to onset of illnessoccurs 24-48 hours prior to onset of illnessTiters of infectious virus peak during 1Titers of infectious virus peak during 1stst 24-72 24-72 hrs of illnesshrs of illness– Undetectable titers by day 5 of illnessUndetectable titers by day 5 of illness

Children may have asymptomatic viral shedding Children may have asymptomatic viral shedding 3-6 days before illness onset3-6 days before illness onset– Median duration of virus detection is 7-8d after illness Median duration of virus detection is 7-8d after illness

resolvesresolves

Clinical Features - AdultsClinical Features - Adults

Incubation period of 1-5 days Incubation period of 1-5 days Abrupt onset of severe headache, chills, and non-Abrupt onset of severe headache, chills, and non-productive coughproductive coughAlso prominent muscle aches accompanied by high Also prominent muscle aches accompanied by high feversfevers– Fever peaks on the first day and may decrease over Fever peaks on the first day and may decrease over

the next 72 hoursthe next 72 hoursDecreased energy and appetite are universal Decreased energy and appetite are universal Mild-moderate cases usually resolve in 7 daysMild-moderate cases usually resolve in 7 daysWeakness, cough, and lack of energy may persist for Weakness, cough, and lack of energy may persist for weeks after clinical resolutionweeks after clinical resolution

Avian influenza A (H5N1)Avian influenza A (H5N1)December 2003December 2003 19,000 of 24,000 chickens on a farm in Korea die in a week19,000 of 24,000 chickens on a farm in Korea die in a week Epidemic of the highly pathogenic avian influenza H5N1 strain found as Epidemic of the highly pathogenic avian influenza H5N1 strain found as

the cause of the poultry deathsthe cause of the poultry deaths More than 1.3 million chickens and ducks have died or been destroyedMore than 1.3 million chickens and ducks have died or been destroyed

January 2004January 2004 Outbreak of severe respiratory illness in 12 previously healthy children Outbreak of severe respiratory illness in 12 previously healthy children

and 1 adult hospitalized in Viet Nam reported to WHO – 8 cases are and 1 adult hospitalized in Viet Nam reported to WHO – 8 cases are fatalfatal

Test on samples from two of the fatal cases confirm infection with H5N1 Test on samples from two of the fatal cases confirm infection with H5N1 avian influenza virus strainavian influenza virus strain

February 2004 February 2004 – 34 human cases with 23 deaths reported in Thailand and Vietnam34 human cases with 23 deaths reported in Thailand and Vietnam

WHO. 2004

Avian influenza A (H5N1)Avian influenza A (H5N1)August/September/October 2004 August/September/October 2004 – 4 human deaths from avian influenza H5 infection reported in Vietnam; 4 4 human deaths from avian influenza H5 infection reported in Vietnam; 4

fatal cases in Thailandfatal cases in Thailand– 1 case of possible human-to-human transmission reported1 case of possible human-to-human transmission reported

December 2004December 2004 Resurgence of poultry outbreaks and human cases reported in Resurgence of poultry outbreaks and human cases reported in

Vietnam.Vietnam. Suggested transmission to at least two persons through Suggested transmission to at least two persons through

consumption of uncooked duck bloodconsumption of uncooked duck blood February 2, 2005February 2, 2005

The first of 4 human cases of H5N1 infection from Cambodia The first of 4 human cases of H5N1 infection from Cambodia was reportedwas reported

July 21, 2005July 21, 2005 First human case of H5N1 in Indonesia was reportedFirst human case of H5N1 in Indonesia was reported Indonesia has continued to report human cases in August, Indonesia has continued to report human cases in August,

September, and October 2005September, and October 2005 January 2006January 2006

Two cases of avian influenza in TurkeyTwo cases of avian influenza in Turkey WHO. 2004

Pandemic Potential of H5N1Pandemic Potential of H5N1Pros:Pros:Novel virus (Avian origin, similar to 1918 flu)Novel virus (Avian origin, similar to 1918 flu)Highly infectiousHighly infectiousNo vaccine availabilityNo vaccine availabilitySpread easily between sick poultry and humansSpread easily between sick poultry and humansMigrating birds can serve as potential world-Migrating birds can serve as potential world-

wide vectorwide vector

Cons:Cons:Mass culling of infected birds, limiting spreadMass culling of infected birds, limiting spreadLimited human to human spreadLimited human to human spread

Just When You Thought It Was Safe…Just When You Thought It Was Safe…

January 24, 2012January 24, 2012Ministry of China Ministry of China notified WHO of a notified WHO of a human case of H5N1 human case of H5N1 infection in a 39 year infection in a 39 year old male who was old male who was hospitalized and hospitalized and subsequently died.subsequently died.Investigation into Investigation into source of infection on-source of infection on-going.going.No other cases so far…No other cases so far…

Pandemic H1N1 Influenza – Pandemic H1N1 Influenza – April 23, 2009April 23, 2009

CDC dispatch:CDC dispatch:Human cases of Human cases of swine influenza A swine influenza A (H1N1) virus (H1N1) virus infection have been infection have been identified in San identified in San Diego County and Diego County and Imperial County, Imperial County, California as well California as well as in San Antonio, as in San Antonio, Texas.Texas.

May 3, 2009 – WHO May 3, 2009 – WHO

What Are the Differences Between What Are the Differences Between Seasonal and pandemic H1N1 Influenza?Seasonal and pandemic H1N1 Influenza?

Seasonal InfluenzaSeasonal InfluenzaInfluenza strains A and BInfluenza strains A and BSpread via dropletsSpread via dropletsSigns/symptoms:Signs/symptoms:– Fever, cough, sore throat, Fever, cough, sore throat,

runny nose, body aches, runny nose, body aches, headaches, chills and fatigueheadaches, chills and fatigue

– Vomiting and diarrhea more Vomiting and diarrhea more common in childrencommon in children

Risk for complications: Risk for complications: – >65 yo, asthma, diabetes, >65 yo, asthma, diabetes,

suppressed immune suppressed immune systems, heart disease, systems, heart disease, kidney disease, and kidney disease, and pregnancypregnancy

Pandemic H1N1 InfluenzaPandemic H1N1 InfluenzaInfluenza A strain onlyInfluenza A strain onlySpread via dropletsSpread via dropletsSigns/symptoms:Signs/symptoms:– Fever, cough, sore throat, Fever, cough, sore throat,

runny nose, body aches, runny nose, body aches, headaches, chills and fatigueheadaches, chills and fatigue

– Vomiting and diarrhea in all age Vomiting and diarrhea in all age groupsgroups

Risk for complications:Risk for complications: – Asthma, diabetes, suppressed Asthma, diabetes, suppressed

immune systems, heart immune systems, heart disease, kidney disease, and disease, kidney disease, and pregnancypregnancy

– Elderly not at higher risk for Elderly not at higher risk for infection infection

67 of the 147 deaths in 2008-2009 were due to H1N1;29 have occurred since August 30, 2009

Prevention and Good Health HabitsPrevention and Good Health HabitsVaccination is the key prevention strategyVaccination is the key prevention strategyStay home when you are sickStay home when you are sickAvoid direct contact with people that are Avoid direct contact with people that are coughing or sneezingcoughing or sneezingCover your mouth when you cough or Cover your mouth when you cough or sneezesneezeWash your hands frequently or use Wash your hands frequently or use antibacterial gels frequentlyantibacterial gels frequently

Severe Acute Respiratory Syndrome

SARSSARSFirst reported in Nov 2002 in ChinaSpread worldwide by Feb-Mar 2003Contained by July 2003Worldwide:– 8098 probable cases

21% healthcare workers– 774 deaths (case/fatality ratio 9.6%)

United States:– 164 total cases– 137 suspect, 19 probable, and 8 confirmed– No deaths Source: WHO; CDC

SARS TransmissionSARS TransmissionMost important– Close personal contact– Large droplet nuclei

Airborne spread – Role of aerosol-generating procedures

(intubation, suctioning, nebulization, bronchoscopy)

– ? point in disease

Potential role of fomites Fecal spread implicated in one outbreak

Source: www.cdc.gov

Summary of Clinical ManifestationsSummary of Clinical ManifestationsWeek 1: Febrile prodromeWeek 1: Febrile prodrome– Fever, myalgia, headache, sore throat, cough Fever, myalgia, headache, sore throat, cough – 5-10% diarrhea5-10% diarrhea– CXR may be normalCXR may be normal

Week 2: Respiratory phase Week 2: Respiratory phase – Rapid progression SOB, cough, hypoxia; ARDS in 10-20% Rapid progression SOB, cough, hypoxia; ARDS in 10-20%

usually by day 7-8usually by day 7-8– Radiographic progressionRadiographic progression– Exam may be unremarkableExam may be unremarkable

Week 3: Resolution vs Death vs Chronic DiseaseWeek 3: Resolution vs Death vs Chronic Disease– Resolution of Sx from ~ day 11-14Resolution of Sx from ~ day 11-14

Index Case(Mother)

Mr. T(Son)

SGH

Real Life Occupational Exposure SARS (Toronto experience)

Friday, March 7, 2003Slide provided courtesy of Allison McGeer, MD

Mr T

Mr D

Mr P

Night of March 7th:

Observation Unit ER SGH

Slide provided courtesy of Allison McGeer, MD

Index Case

(Mother)

Mr T(Son)

Mr. D

Mr. PMr. P’s

wife

Slide provided courtesy of Allison McGeer, MD

Mr. D

Mr. P

Mr. P’swife

Mr. R?

24 persons

9 persons

Slide provided courtesy of Allison McGeer, MD

Index Case(Mother)

Mr T(Son)

Mr. D

Mr. PMr. P’s

wife

Mr. R?

24 persons

9 persons

21 persons

Slide provided courtesy of Allison McGeer, MD

Index Case(Mother)

Mr T(Son)

Mr. D

Mr. P

Mr. P’swife

Mr. R?

24 persons

9 persons

21 persons

15 persons

Slide provided courtesy of Allison McGeer, MD

Index Case(Mother)

Mr T(Son)

July 2003 July 2003 – 3 recent cases reported in China3 recent cases reported in China– Lab-acquired case in SingaporeLab-acquired case in Singapore

April 2004April 2004– 9 cases of SARS in China9 cases of SARS in China

1 person died1 person died– No further cases since 4/29/04No further cases since 4/29/04

Current Status of SARS: Will it Return?Current Status of SARS: Will it Return?

West Nile VirusWest Nile Virus

West Nile VirusWest Nile Virus

What is it? What is it? – A potentially serious illness that affects the A potentially serious illness that affects the

central nervous system.central nervous system.Can cause inflammation of the brain (encephalitis) Can cause inflammation of the brain (encephalitis) or around the brain (menigitis) and can also cause or around the brain (menigitis) and can also cause polio-like paralysis.polio-like paralysis.

How is it spread?How is it spread?– Typically by the bite of an infected mosquito.Typically by the bite of an infected mosquito.– Mosquitoes become infected by feeding on Mosquitoes become infected by feeding on

birds with the virus.birds with the virus.

West Nile VirusWest Nile Virus

What are the signs and symptos of What are the signs and symptos of infection?infection?– About 20% of patients will have a “flu-like About 20% of patients will have a “flu-like

illness”illness”Fever, malaise, anorexia, nausea, vomiting, Fever, malaise, anorexia, nausea, vomiting, headache, muscle pain, occasional rashheadache, muscle pain, occasional rash

– 1 in 150 infections will be severe1 in 150 infections will be severeFever, weakness, gastrointestinal symptoms, Fever, weakness, gastrointestinal symptoms, change in mental status Higher risk in individuals change in mental status Higher risk in individuals over age 50 years oldover age 50 years old

West Nile VirusWest Nile VirusHow can it be prevented?How can it be prevented?– Apply insect repellent when you are going to be Apply insect repellent when you are going to be

outdoors. Even if you don’t notice mosquitoes there is outdoors. Even if you don’t notice mosquitoes there is a good chance that they are around. a good chance that they are around.

– When weather permits, wear long-sleeved shirts and When weather permits, wear long-sleeved shirts and long pants whenever you are outdoors. long pants whenever you are outdoors.

– Place mosquito netting over infant carriers when you Place mosquito netting over infant carriers when you are outdoors with infants. are outdoors with infants.

– Consider staying indoors at dawn, dusk, and in the Consider staying indoors at dawn, dusk, and in the early evening, which are peak mosquito biting times. early evening, which are peak mosquito biting times.

– Install or repair window and door screens so that Install or repair window and door screens so that mosquitoes cannot get indoors. mosquitoes cannot get indoors.

– Drain sources of standing water Drain sources of standing water

HantavirusHantavirus

Hantavirus Pulmonary SyndromeHantavirus Pulmonary Syndrome

What is Hantavirus pulmonary syndrome?What is Hantavirus pulmonary syndrome?– A serious, often deadly disease caused by the A serious, often deadly disease caused by the

Sin Nombre virusSin Nombre virus..

How is it transmitted?How is it transmitted?– The virus is carried by rodents and passed on The virus is carried by rodents and passed on

to humans through rodent urine, saliva, and to humans through rodent urine, saliva, and droppings. droppings.

The deer mouse is the primary carrier of the virus.The deer mouse is the primary carrier of the virus.– It is not spread person to person.It is not spread person to person.

Confirmed Cases of Hantavirus by Confirmed Cases of Hantavirus by State from 1993-2011State from 1993-2011

                                                                      

Hantavirus Pulmonary Syndrome (HPS)Hantavirus Pulmonary Syndrome (HPS)

What are the symptoms of HPS?What are the symptoms of HPS?– First symptoms are generally flu-likeFirst symptoms are generally flu-like

Fever, headache, abdominal pain, back pain and Fever, headache, abdominal pain, back pain and joint painjoint pain

– Main symptom is increasing shortness of Main symptom is increasing shortness of breathbreath

What is the treatment?What is the treatment?– Mainly supportive. Key is getting to the Mainly supportive. Key is getting to the

hospital right away.hospital right away.

Hantavirus Pulmonary SyndromeHantavirus Pulmonary Syndrome

How can you prevent getting infected?How can you prevent getting infected?– Open up and air out unused or abandoned cabins Open up and air out unused or abandoned cabins

before occupying the building.before occupying the building.– If you’re sleep outdoors, check campsites for rodent If you’re sleep outdoors, check campsites for rodent

dropping and burrows.dropping and burrows.– D not disturb rodents, burrows, or dens.D not disturb rodents, burrows, or dens.– Avoid sleeping near woodpiles or gargbageAvoid sleeping near woodpiles or gargbage– Avoid sleeping on bare ground; use a mat or elevated Avoid sleeping on bare ground; use a mat or elevated

cot if availablecot if available– Store food in rodent-proof containers and discard, Store food in rodent-proof containers and discard,

bury, or burn all garbage.bury, or burn all garbage.

Multidrug Resistant TuberculosisMultidrug Resistant Tuberculosis

One third of the world’s One third of the world’s population are infected with population are infected with TB.TB.In 2010, a total of 8.8 million In 2010, a total of 8.8 million people worldwide became people worldwide became sick with TB disease, most of sick with TB disease, most of whom (82%) live in one of whom (82%) live in one of the 22 high burden countries the 22 high burden countries for TB.for TB.TB is a leading killer of TB is a leading killer of people living with HIV.people living with HIV.

Multidrug-Resistant TuberculosisMultidrug-Resistant Tuberculosis

What is tuberculosis (TB)?What is tuberculosis (TB)?– It is a disease caused by germs that are It is a disease caused by germs that are

spread from person to person through the air.spread from person to person through the air.– It typically affects the lung but can infect the It typically affects the lung but can infect the

brain as well as gone.brain as well as gone.

What is multi-drug resistant TB (MDR-What is multi-drug resistant TB (MDR-TB)?TB)?– It is TB that is resistant to at least two of the It is TB that is resistant to at least two of the

best anti-TB drugs, isoniazid and rifampicin.best anti-TB drugs, isoniazid and rifampicin.

Multidrug-Resistant TBMultidrug-Resistant TB

What is extensively drug resistant TB What is extensively drug resistant TB (XDR TB)?(XDR TB)?– It is a relatively rare type of MDR TB. It is It is a relatively rare type of MDR TB. It is

defined as TB which is resistant to multiple defined as TB which is resistant to multiple anti-TB drugs. anti-TB drugs.

– It is of particular concern in HIV patients as It is of particular concern in HIV patients as they are more likely to develop active disease they are more likely to develop active disease and have a higher risk of death.and have a higher risk of death.

Multi-Drug Resistant TBMulti-Drug Resistant TB

What are the symptoms of TB?What are the symptoms of TB?– Weight loss, fever, and night sweats.Weight loss, fever, and night sweats.– Also may include coughing and coughing up Also may include coughing and coughing up

blood.blood.

How is TB spread?How is TB spread?– TB germs are put into the air when someone TB germs are put into the air when someone

infected with TB in the lungs coughs, infected with TB in the lungs coughs, sneezes, speaks, or sings. Another person sneezes, speaks, or sings. Another person then breathes in the germs and can become then breathes in the germs and can become infected.infected.

Multidrug Resistant TBMultidrug Resistant TB

Who can get MDR-TB?Who can get MDR-TB?– Patients not taking their TB medications correctly.Patients not taking their TB medications correctly.– Patients from areas where the disease is endemic.Patients from areas where the disease is endemic.– Patients that have spent time with someone known to Patients that have spent time with someone known to

have drug-resistant TBhave drug-resistant TB

How can you prevent getting TB or MDR TB?How can you prevent getting TB or MDR TB?– Get tested for possible exposure (ppd test yearly) and Get tested for possible exposure (ppd test yearly) and

get treatment if neededget treatment if needed– If you have TB, take all of your medications as If you have TB, take all of your medications as

directed.directed.

Hand Hygiene Works!Hand Hygiene Works!

Hand contamination after patient contact (A) and Hand contamination after patient contact (A) and after washing with an alcohol based sanitizer (B)after washing with an alcohol based sanitizer (B)

NEJM. 2009

Alcohol is more effective than plain soap and water

Alcohol based hand sanitizersAlcohol based hand sanitizers– 5 log5 log1010 reduction in bacteria after 15 s application reduction in bacteria after 15 s applicationSoap and waterSoap and water– 0.6-1.1 log0.6-1.1 log1010 after 15 s application after 15 s applicationMore effective at reducing MDROs from More effective at reducing MDROs from hands than soap and waterhands than soap and waterPotential for added emoillients = comfortPotential for added emoillients = comfortDOES NOT have activity against sporesDOES NOT have activity against spores– e.g. e.g. Clostridium difficile, Bacillus anthracus, etc.Clostridium difficile, Bacillus anthracus, etc.

Preventative VaccinesPreventative Vaccines

Immunizations Available for 24 Immunizations Available for 24 Infectious Diseases*Infectious Diseases*

AnthraxAnthraxDiphtheriaDiphtheriaH. influenzaeH. influenzae infection infectionHepatitis AHepatitis AHepatitis BHepatitis BHerpes zosterHerpes zosterHuman Papillomavirus Human Papillomavirus infectioninfectionInfluenzaInfluenzaJapanese EncephalitisJapanese EncephalitisMeaslesMeaslesMeningococcal DiseaseMeningococcal DiseaseMonkeypoxMonkeypox

MumpsMumpsPertussisPertussisPneumococcal DiseasePneumococcal DiseasePolioPolioRabiesRabiesRotavirus infectionRotavirus infectionRubellaRubellaSmallpox (Vaccinia)Smallpox (Vaccinia)TetanusTetanusTuberculosis (BCG)Tuberculosis (BCG)Typhoid FeverTyphoid FeverVaricellaVaricellaYellow FeverYellow Fever

* Vaccines for Cholera, Lyme Disease, and Plague are no longer commercially available

““Chance Favors the Prepared Mind.”Chance Favors the Prepared Mind.”

Louis PasteurLouis Pasteur

Questions?Questions?