Emerging Infections In The Pacific Northwest Scott Lindquist MD MPH What’s New In Medicine September 8th, 2017

The Fearsome Three of 2017 Legionella Mumps Hantavirus

Emerging Pathogens http://www.aqtsolutions.com/map-of-scheduled-airline-traffic-around-the-world/

Legionella Gram negative bacteria commonly associated with water Causes Legionnaires’ Disease (pneumonia) and Pontiac Fever (mild flu-like illness) Basic background

Legionnaires’ Disease Most commonly affects people who are older and who have underlying health conditions, but can affect young, previously healthy people too 10-30% of cases die Named after Legionnaires’ convention in PA in 1976, in which Legionella from a decorative fountain was responsible for 34 deaths Basic background

Legionnaires’ Disease Pneumonia caused by breathing in water contaminated with Legionella bacteria Image courtesy CDC

About Legionella Ideal growth occurs at 90 F-108 F Often associated with biofilms In the natural environment, Legionella can live within amoebae Upon inhalation, the bacteria can infect alveolar macrophages Main point is the biofilm association and that the bacteria grows well in warm water. Hartmannella vermiformis amoeba (orange) entrapping a Legionella bacterium (green), image courtesy CDC

Most Likely Sources of Infection Showers (inhale mist contaminated with Legionella)

Hot tubs Perfect temperature for Legionella replication; biofilms can collect in the jets and break off intermittently; bubbling action provides opportunity to inhale mist

CPAP Machines If improperly maintained, can accumulate biofilm. Need to follow manufacturer instructions re: what type of water to use and how to clean! There have been some cases definitively linked to contaminated CPAP machines.

Decorative fountains Generate fine mist that can be inhaled. Fountains with lights (heat sources!) that warm the water can be particularly problematic.

Cooling Towers Many large buildings have cooling towers for A/C purposes

Cooling towers Circled area is key. Warm moist air that has had a chance to be contaminated.

Biofilm and Scale Inside Pipes Biofilm can accumulate in pipes. Pitting and scaling of pipes mean there are nice niches for biofilms Pipes can have scaling and pitting that provide a niche for biofilm (and Legionella)

Legionnaires’ Disease on the Rise Nationally Courtesy: Garrison LE, Kunz JM, Cooley LA, et al. Vital Signs: Deficiencies in environmental control identified in outbreaks of Legionnaires’ disease - North America, 2000–2014MMWR Morb Mortal Wkly Rep. ePub: 7 June 2016.

Legionnaires’ Disease Cases Reported to WA DOH by Year of Onset

Testing for Legionnaires’ Should Occur For Patients who have failed outpatient antibiotic therapy for community-acquired pneumonia Patients with severe pneumonia, in particular those requiring intensive care Immunocompromised patients with pneumonia Patients with pneumonia in the setting of a Legionnaires’ disease outbreak Patients with a travel history within 2 weeks before the onset of illness Patients suspected of having healthcare-associated pneumonia Key slide for this audience—who to test Courtesy CDC

Case 1 65 year old female who is healthy and active, develops a cough lasting several days. She is evaluated by her provider and is started on azithromycin for bronchitis. Her cough worsens and she is hospitalized with an oxygen requirement. Non smoker No fever

Chest Radiograph

Case 1 cont’d What diagnostics to order? Coccidiomycosis antibody or culture Flu test (rapid) Legionella culture or urine antigen Sputum for gram stain and culture Mycoplasma serology

Case 1 cont’d What diagnostics to order? Coccidiomycosis antibody or culture Flu test (rapid) Legionella culture or urine antigen Sputum for gram stain and culture Mycoplasma serology

What Questions Do You Want Answered? A) Travel History B) Hospitalizations C) Exposure to water towers D) Exposure to water E) Ill contacts F) CPAP use

What Questions Do You Want Answered? A) Travel History B) Hospitalizations C) Exposure to water towers D) Exposure to water E) Ill contacts F) CPAP use G) All of the above

Results Coccidioidomycosis antibody negative Rapid flu negative Legionella urine antigen positive Sputum sample positive for mixed flora (strep pneumo and H. influnzae) Mycoplasma negative No travel or hospitalizations Hot tub at local gym

Results Hot tub at local gym test positive for legionella type 1 species. We can not match this to the patient as no culture was obtained from the patient. Unclear where she was picked up her legionella.

What To Treat The Patient With? Cefdinir Azithromycin Levofloxacin Amoxicillin/clavulanate XR

What To Treat The Patient With? Cefdinir Azithromycin Levofloxacin Amoxicillin/clavulanate XR

Mumps Virus

About Mumps Caused by the mumps virus Spread by contact with saliva from someone who is infected No specific treatment Signs and symptoms Swelling of salivary glands in one or both cheeks that starts in front of the ear and can spread down to the neck or jaw (parotitis) Fever, headache, muscle aches, tiredness, loss of appetite, hearing loss

Mumps Virus Clinical Manifestations Subclinical infection estimated at 30% pre-vaccine era Fever, inflammation of salivary glands (parotitis) Potential complications: meningoencephalitis, deafness, orchitis Severity of disease increases with age Transmission through droplets and direct contact Incubation period: 12 – 25 days Infectious period: 7 days before – 9 to 14 days after symptom onset Contact investigation period: 2 days before – 5 days after symptom onset Henle et al. (1948), Gupta et. al. (2005)

MMR Vaccine has Reduced Severity of Symptoms High 2-dose MMR coverage protects against severe complications of mumps

Symptom/Complication Number with complication Documented occurrence of complications among mumps cases in Washington State – October 30, 2016 through March 27, 2017 Symptom/Complication Number with complication Rate using only “yes/no response” denominator Orchitis 22 9.9% (males) Mastitis 3 0.7% Hearing Loss 9 2.1% Pancreatitis 1 0.2% Hospitalization 2 0.4% Meningitis Encephalitis 0% Death logged into the DOH mumps investigations linelist, only 489 cases had been entered into PHIMS by local jurisdiction investigators

Evidence of Immunity Documentation of adequate vaccination 1 dose of mumps vaccine for children in child care or preschool and adults not at high risk 2 doses of mumps vaccine for students in K-12th grade and adults at high risk: healthcare workers, international travelers Lab evidence of immunity Birth before 1957 Documentation of physician-diagnosed mumps

Reported Mumps Cases, United States, Vaccine Era, 1968-2016

Mumps reporting baseline and epidemic threshold Washington State

Confirmed and probable cases WA State mumps outbreak cases by age group October 2016 through June 2017 2017 Confirmed and probable cases   Age range N % 0-4 34 4% 5-9 104 12% 10-14 201 23% 15-19 214 24% 20-39 256 29% 40-64 80 9% 65+ 2 0% Unknown 1 Total 892

Mumps cases by vaccination status October 2016 through August 2, 2017 Category Total cases Cases with unknown vaccination status % Cases with vaccine info available No. with 2 doses No. with 1 dose N0. with 0 doses TotalUTD* % of cases with vaccine info available UTD School-aged (5-19 years) 519 36 7% 483 93% 439 28 16 91% Entire outbreak 892 233 26% 659 74% 511 83 65 575 87% *UTD: 2 doses of MMR for children (5-19), 1 dose for children ages 1-5, 1 dose for adults (20+), and excludes those with unknown immunization status

Mumps outbreak case onsets by county Oct 30, 2016 – August 2, 2017 Number of cases Benton 6 Ferry 3 Grant 45 King 312 Kitsap 2 Okanogan Pend Oreille Pierce 62 Skagit 17 Snohomish 88 Spokane 335 Stevens 1 Thurston Whatcom 4 Yakima 5 Total 892 Whatcom Pend Oreille Ferry San Juan Okanogan Skagit Stevens Island Clallam Snohomish Chelan Douglas Jefferson Kitsap Lincoln Spokane King Mason Grays Harbor Kittitas Grant Adams Whitman Thurston Pierce Pacific Franklin Lewis Garfield Yakima Benton Walla Walla Eyob Cowlitz Columbia Skamania Wahkiakum Asotin Klickitat Clark

Hantavirus Hantaviruses Bunyavirus family Primarily rodent reservoirs Human infection Inhalation of excreta Bites possible Hemorrhagic fever with renal syndrome (HFRS) Old-world hantaviruses (Seoul virus likely throughout world) Europe and Asia Hantavirus pulmonary syndrome (HPS) New-world hantaviruses Numerous pathogenic hantavirus species across North and South America

Hantavirus Pulmonary Syndrome Epidemiology 20-40 cases in the US annually, >95% exposed west of Mississippi River Persons living or working in rural areas at increased risk include: Farmers Outdoor enthusiasts (camping, hiking) Opening/cleaning unfrequented buildings (sheds, attics, summer homes etc)

Hantavirus Cases in Washington State

47 reported cases; 38 in state, 3 OOS, 6 unk

Hantavirus cases in Washington, 1994-2017* Case count Year of onset *2017 data is preliminary and partial year data only