Zoonosi respiratoria

DR. JORDI ROIGPneumologia

Time present & time past

are both perhaps

present in time future.

And time future

is contained in time past.

T. S. Eliot

The Four Quartets

1936

HIV / AIDS ES UNA ZOONOSI:

malaltia transmisible

d’animals a l’home en

condicions naturals

HEMORRAGIA ALVEOLAR: PERLS

Història dels Virus de la Grip “mutants”

Spanish Flu - 1918-19; pigs

– influenza A - 20-50 million deaths - WWI

Asian Flu - 1957-58; ducks/pigs China

– influenza A - 1 million deaths

Swine flu - 1976 - pigs

– influenza A, 40 million vaccinated, 1 death

Avian Flu - 1997-99 - chickens Hong Kong

– killed 6 (H5N1); 1.5 million chickens killed

Altres Virus “mutants”

Ebola - 1976 – monos a l’ Africa– 900 morts per sagnat

HIV - 1980-81- African chimps & monos – 40 million infectats; 25 million morts

Nipah virus - 1998-’99 – ratpenats a porcs - Asia– 100 morts en treballadors del porc

– no transmissió de persona a persona

SARS virus – 2003 – font animal ?

Forma de Transmissió: Associada directament

amb Aviram i Animals - China - Time

Contacte Directe amb Animals Infectats

Caça & carnisseries

Influenza Epidemics

Antigenic drift

Neurominidase

Hemagglutinin

New strains each yr

Animal reservoirs

New vaccines

formulated

Highly contagious

Epidèmia de Grip Espanyola

“Soldiers returning from the Great War

haven’t come back alone. They have

brought back a horror that will surpass the

battlefields of Europe with its deadliness.”

“Rather than threaten the very young and

the very old, this flu singles out those

between the ages of 15 and 35.”

Epidèmia de Grip Espanyola

“Spanish flu kills quickly &

inexplicably, sometime within hours.

Healthy young go to bed & never wake

up…..”

“Panic sets in. Services began to falter

as employees succumbed to the virus

or refuse to come to work. Doctors and

nurses are helpless to stem the tide….”

Epidèmia de Grip Espanyola

“In October of 1918 in NYC, a steam

shovel is used to dig trenches to

temporarily bury the bodies of the

Spanish Flu victims.”

“By the spring of 1919, it is a fading

nightmare that has left almost

50 million dead worldwide, more than

all of the casualties of the Great War.”

Transmissió Animals a Humans

Reservoris

Animal Virus

Grip Asiàtica

Anecs - Porcs

‘57-’58

Ebola

Micos

‘76

Grip porcina

Porcs

‘76

HIV

Micos

‘80-’81

Grip Aviar

Pollastres

‘97-’99

Nipah

Porcs

‘98-’99

SARS

??

2003

Grip Espanyola

Porcs

’18-’19

Armes Biològiques

Anthrax*

– spores

Smallpox*

– virus & vaccine

Plague*

– bacterial aerosol

Viruses:

– Hemorrhagic fevers

– Ebola virus

Q fever

Bacteria:

– Tularemia

– Botulinum toxin

Key Points

For all of the biological agents known to have

potential for use in bioterrorism:

– occur as natural infections

– management involves procedures similar to those

already used to manage other critically ill patients

– most are not transmitted person to person

– for the exceptions, established hospital

precaution procedures can prevent transmission:

smallpox (contact + droplet or airborne precautions)

plague pneumonia (droplet precautions)

hemorrhagic fever viruses (contact + airborne)

Anthrax

Spore outside host & bacillus in host

Spores may survive for years in soil

Organism present worldwide in soil

Host: herbivores - cattle, goats, buffalo

Disease in cattle prevented by vaccine

Not spread person to person

Anthrax Presentations

Cutaneous

Gastrointestinal

Inhalation

Anthrax Toxin = Virulence

Spores on skin, ingested or inhaled

Spores germinate to bacilli; capsule

Bacilli produce toxin (3 proteins):

– PA = protective antigen - binds host cells

(ATR)

– EF = edema factor inhibits phagocytosis

– LF = lethal factor kill macrophages, TNF

Vaccine (PA): induces antibodies to PA

Dixon, NEJM, 1999:341:815

Inhaled B. anthracis

Disease requires 8,000 - 50,000 spores

Incubation period = 1 - 5 days

Sx: fever, malaise, dry cough, SOB, sepsis

Dx: blood: Gram-stain, Ag & AB

Rx cipro, doxy, Pen G + streptomycin

Prophylaxis: cipro or doxy x 4 wks

Vaccine: 0, 2, 4 wks, 6, 12 &18 mo

Anthrax in Tissue

Lessons from Anthrax: USA

Difficult to produce small spores

Need to improve diagnostic tests

Better vaccines are needed

New antitoxin treatments of interest

Clinicians should be vigilant

Public health improvement

TABLE 1. Symptoms and signs of inhalational anthrax, laboratory-confirmed influenza, and influenza-like illness (ILI) from other causes

Inhalational Laboratory-confirmed ILI fromSymptom/Sign anthrax (n=10) influenza other causes _____________________________________________________________________

Fever or chills 100% 83%-90% 75%-89%Fatigue/malaise 100% 75%-94% 62%-94%Cough 90% 84%-93% 72%-80%Shortness of breath 80% 6% 6%Chest discomfort orpleuritic chest pain 60% 35% 23%

Headache 50% 84%-91% 74%-89% Myalgias 50% 67%-94% 73%-94%Sore throat 20% 64%-84% 64%-84%Rhinorrhea 10% 79% 68%Nausea or vomiting 80% 12% 12%_____________________________________________________________________

Modified from MMWR November 9, 2001

Pneumonic Plague:

Yersinia pestis Pneumonia

Bacterial Aerosols in

Subways, Buildings,

or Airplanes

Plague - Y. pestis

ID/IP: 100-500 orgs; 2-3 days

Sx: fever, bloody sputum, pn, sepsis

Dx: blood, sputum GS, Ag, culture, AB

Rx: Gent + doxy

Prophylaxis: doxy, Tetracyclines

Vaccine: inactivated 0, 1 & 6 mo

Precautions: droplet

History of Bacterial Plague

AD 54 - 1st plague: Egypt, Europe, Asia,

50-60% of the population died

1346 - 2nd plague: Black Death –

20-30 million deaths - 1/3 of Europeans

1855 - 3rd plague: China & India

12 million deaths

Types of Plague: Y. pestis

Enzooic infection of rodents: flea vector

Bubonic - skin lesion (bubo) with spread

to bloodstream or flea bite with Y. pestis

Pneumonic - inhaled bacterial aerosol

or infected respiratory droplet

secretions

Prairie Dog - Y. pestis

Reservoir

Plague as a Biological Weapon

Perhaps the most serious BW

Capacity for mass production

Aerosol = pneumonic plague

High fatality rate

Secondary spread from secretions

Signs: Plague Pneumonia

IP = 2-4 days; acute onset of “flu”

Signs & symptoms: The Patient

– fever >101o F, cough, bloody/watery

sputum

– breathing rapidly

– nausea, vomiting & diarrhea

Pneumonia & shock

Rapidly progressive

Viral Hemorrhagic Fevers

Hemorrhagic fevers & Ebola, Marburg

Intestinal hemorrhage, MOF

IP = 7d; fever, N&V, malaise & headache

with raised rash over entire body

Ebola: person-to-person contact

Similar Hantavirus

No Rx: mortality = 80%-90%

Brucellosis - Brucella spp.

10-100 organisms, IP 5->60 days

Sx: fever, pn, jt, cardiac or respiratory sx

Dx: blood, BM, serology & culture

Rx: doxy + rifampin or TMP-SMX

Prophylaxis: doxy + rif x 3 wks

Vaccine: none

Precautions: standand or contact

Tularemia - F. tularensis

ID/IP: 10-50 orgs: 2-10 days

Sx: ulceroglandular, typhoidal, pneumonia

Dx: blood, sputum, culture, serology

Rx: gentam.

Prophylaxis: doxy or Tetracyclines

Vaccine: inactivated single dose

Precautions: standard

Q Fever - Coxiella burnetii

ID/IP: 1-10 orgs: 10-40 days

Sx: fever, headache, myalgia, chest pains,

neurologic, skin, LFTs, FUO

Dx: EIA or serology

Rx: Tetrac., macrolides, or quinolones

Prophylaxis: doxy or Tetrac.

Vaccine: investigational in USA

- Produced by ingestion or inhalation of one of

seven serologically distinct types of botulinum

toxin, groups A-G

- Clinical illness characterized by symmetrical

cranial neuropathies and (often) dilated pupils,

followed by symmetric descending flaccid

paralysis

- No fever or sensory abnormalities

- DTRs reduced or absent

- Differential Dx includes Guillain-Barre

syndrome, myasthenia gravis, tick paralysis

BOTULISM

- Incubation period 1-5 days

- Not transmitted person-to-person - standard

precautions in hospitalized patients

- Supportive care, possible mechanical ventilation

(2-3 months)

- Prompt administration of trivalent equine

botulinum antitoxin (types A, B and E)

- Antitoxin not known to be effective

after exposure but before symptoms

BOTULISM

Claus anamnesi

Psitacosi: ocells, esplenomegàlia

FQ: boví, citolisi hepàtica

Leptospira: rosegadors + aigüa,

conjuntivitis hemorr., ictericia

Claus anamnesi

Febre botonosa: garrapates, taca

negra, rash palmoplantar, gossos

Tularèmia: caça, conills, lesió pell

Brucella: febre sudoral àlgica, llet

ovelles i cabres no controlada

MENJADOR DE CARGOLS CRUS

MISSATGES

El que no sap el que busca no

entén el que troba

Globalització: viatges, immigrants

Història epidemiològica es bàsica

–Animals, laboral, hobbies