Title: Emerging Infectious Disease Threats in Theatre: Risk and Mitigation Institute of Federal Health Care
1Emerging Infectious Disease Threats in Theatre
Risk and MitigationInstitute of Federal Health
Care Roundtable
Examples of Emerging Infectious Disease Threats
from the Clinicians Vantage Point
- COL Naomi Aronson
- Director, Infectious Diseases Division
- Department of Medicine
- Uniformed Services University of the Health
Sciences, Bethesda MD
The views expressed in this session are those of
the author and do not reflect the official policy
or position of the Department of the Army,
Department of Defense, or the U.S. Government
2Emerging Infectious Diseases in Theatre
Emphasis on Afghanistan
- Infectious diseases that are unusual for US
practitioners to manage - - Leishmaniasis, visceral and
cutaneous - - Malaria
- - Q fever
- Antimicrobial resistant pathogens
- - Multidrug resistant gram negative
bacteria - - Multidrug resistant tuberculosis
- Undifferentiated febrile illness with limited
diagnostic capability in theatre
3Leishmaniasis
- Visceral Leishmaniasis
- - L. donovani in Afghanistan vs L.
infantum in Iraq - - Symptom onset may be after leaving
theatre - Asymptomatic and subclinical
infection more common - Later reactivation during
immunocompromising conditions - - Rapid diagnostic test rk39
- - Treatment is expensive IV Ambisome
- - Transfusion related transmission
possible
- Kala azar Detect
- FDA cleared
- gt95 sensitivity
- Uses serum
- 10 cross reaction with
- cutaneous leishmaniasis
4Leishmaniasis
- Cutaneous Leishmaniasis
- - L. major and L. tropica in Afghanistan
- - L. tropica
- less likely to self heal, risk for
late reactivation - ? risk for viscerotropic, mucosal
involvement - no rapid speciation tool (WRAIR PCR
not optimized for species) - treatment is more difficult
Dowlati Clin Dermatol 1996. 14425-31
5Malaria
- Risk in Afghanistan
- - P. vivax and P. falciparum
- - Challenges in prophylaxis (daily, GI
upset, hypnozooites) - - P. vivax with late presentation, post
redeployment - - Rapid diagnostic test
- - Treatment newly approved CoArtem,
will it be fielded? - - Blood supply
-
- For P. vivax and parasitemiagt5,000 per µl
- - Sensitivity 93.5
- - Specificity 99.8
- For P. falciparum and parasitemiagt5,000 per µl
- - Sensitivity 99.7
- - Specificity 94.2
Kolaczinski J. Lancet. 2005. 3561507
6Q Fever
- Caused by bacteria Coxiella burnetti
- Flu-like febrile syndrome, pneumonia, hepatitis
- - less commonly
- meningoencephalitis, cholecystitis, orchitis,
peri/myocarditis - - most commonly subclinical, self
limited - Chronic Q fever about 1 cases
- - associated with cardiac valve
abnormalities - - associated with immunosuppression,
including pregnancy -
7Diagnosis and Treatment Q Fever
- FDA approved serology is IFA based
- - Phase II antibodies elevated in acute
infection - - Phase I antibodies elevated in
chronic infection - Results vary depending on assay
- - Focus Diagnostics (Send out, Quest
Laboratory) IFA - - USAFSAM IFA (uses Focus Diagnostics
kit) - - DoD Veterinary Laboratory (not for
human diagnosis) - - JBAIDS PCR (not FDA cleared)
- - CDC IFA
- - USAMRIID ELISA
- Treatment
- - Acute infection doxycycline for 21
days - - Chronic infection
- doxycycline and hydroxychloroquine
for 18 months
8Emerging Issues with Q fever
- What is the risk?
- - How to prevent?
- Diagnostics
- How to stratify those needing more aggressive
treatment? - How to identify those with chronic infection?
- - Endocarditis
- Chronic sequelae
- - Chronic fatigue syndrome
9Multidrug Resistant Gram Negative Bacteria
- Acinetobacter baumanii, ESBL producing
Klebsiella, - E. coli, Pseudomonas
- Issue is infection control
- - In theatre MTF
- - During transfer
- - CONUS military and
civilian - - Occupational transmission
- - Nosocomial transmission to
more vulnerable patients -
- Running out of effective antibiotics
- - Colistin (respiratory, CNS
penetration)
10Wortmann G. ICHE. 2008. 29(6)553-5
11Tuberculosis
- Afghanistan has 12th highest per capita rate of
TB in world - - 3 new cases are MDR TB, 36 prior Rx
cases (2007) - - Category 1 regimen is 2 (HR)ZE/6(HE)
(WHO) - - National Reference Lab
- US medical facilities in theatre send AFB culture
to LRMC - - Significant turnaround time, AFB
culture capacity not intrinsic - - Opportunity to partner with CDC for
rapid resistance testing (72 hr ) - none of current rapid tests
are FDA approved assays - How are potentially exposed MDR TB contacts
followed, LTBI managed? - Late reactivating disease may have downstream
impact US -
12Undifferentiated Febrile Illness
- Limited diagnostic capability in theater
- - Examples of endemic diseases with
possible chronic sequelae - Brucellosis
- Typhoid Fever/ non typhoidal
Salmonellosis - - Emerging or possible Viral Infections-
how could they be detected? - Sand Fly Fever
- Dengue
- Chikingunya
- Novel Influenza
- Control of new diseases in and out of theatre as
troops deploy -