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

2. The Fearsome Three of 2017
Legionella
Mumps
Hantavirus

3. Emerging Pathogens

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

5. 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

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

7. 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

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

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

10. 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.

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

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

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

14. 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)

15. 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.

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

17. 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

18. 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

19. Chest Radiograph

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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.

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

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

28. Mumps Virus

29. 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

30. 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)

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

32. 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

33. 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

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

35. Mumps reporting baseline and epidemic threshold Washington State

37. Confirmed and probable cases
WA State mumps outbreak cases by age group October 2016 through June
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

38. 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

39. 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

40. 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

45. 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)

48. Hantavirus Cases in Washington State

49. 47 reported cases; 38 in state, 3 OOS, 6 unk

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