Upload
others
View
1
Download
0
Embed Size (px)
Citation preview
Hot Topics in Infectious Diseases:
Enteric Infections in the Arctic
Tobey Audcent MD, FRCPC Department of Pediatrics Children’s Hospital of Eastern Ontario
6th International Meeting on Indigenous Child Health
March 21, 2015
Faculty/Presenter Disclosure
Tobey Audcent has no relevant financial relationships
with the manufacturer(s) of commercial services
discussed in this CME activity
AND
Tobey Audcent does not intend to discuss an
unapproved/investigative use of a commercial
product/device in my presentation
Acknowledgements
Thanks to: with permission
• Dr. David Goldfarb slides and data (ID/Micro,
BC Children’s Hospital)
• Dr. Cedric Yansouni (ID/Micro, McGill
University) for data from Nunavik
• Dr. Sherilee Harper (Guelph University) for
Iqaluit and Rigolet data
Session Objectives:
1. Review the contribution of chronic enteropathy to
childhood development
2. Describe an overview of enteric infections in the Arctic
3. Discuss cryptosporidium as an emerging childhood
enteric infection in the Arctic
Hot Infection Topics
Tuberculosis
Sexually Transmitted Infections
Diarrhoea
Global Burden of Diarrheal
Disease Diarrhea kills 2,195 children every day—more than
AIDS, malaria, and measles combined
Lancet. 2012;379(9832):2151-61
2nd leading cause
of child death
Environmental Enteropathy:
Unifying Mechanism
Nutr Rev. 2008 September; 66(9): 487–505 [15]
PLoS Negl Trop Dis 7(4): e2125. doi:10.1371/journal.pntd.0002125
With permission D Goldfarb from: Guerrant R, Ped Academic Soc Mtg, April 30 2012
Arctic Communities: More
Diarrhea ?
Among American Indian (AI) and Alaskan Native (AN)
children:
diarrhea-associated hospitalization ~2X general U.S.
262.6 vs. 154.7 per 10,000 population
diarrhea-associated outpatient visits also higher than
general U.S.
2,255.4 vs. 1,647.9 per 10,000 population
Singlelton RJ et al; Pediatr Infect Dis J. 2007;26(11):1006-13.
Arctic Communities:
Emerging Data Acute gastrointestinal illness in two Inuit
communities: burden of illness in Rigolet and Iqualuit,
Canada. SL Harper et al. Epidemiol Infect. 2015
Lived experience of acute gastrointestinal illness in
Rigolet, Nunatsiavut: “Just suffer through it”. SL
Harper et al. Social Sci and Med. 2015
Nanolitre real-time PCR detection of bacterial,
parasitic and viral agents from patients with diarrhoea
in Nunavut, Canada. DM Goldfarb et al. Int J
Circumpolar Health. 2013.
AGI in Arctic Communities
Data from Dr. Sheri Harper, University of Guelph
Changes in Diagnostic Methods?
Multiplex PCR
Bacteria
Virus
Parasite
No Pathogen
Conventional Testing
Bacteria
No Pathogen
with permission Goldfarb DM et al; Int J Circumpolar Health. 2013;72:19903.
Molecular Testing old specimens, new tools
with permission Goldfarb et al; Int J Circumpolar Health
2013;72:19903.
Cryptosporidium: New Kid on
the Map
Spring 2013: Crypto retrospectively found to be
leading stool pathogen
July 2013: first observed Crypto outbreak in Arctic
July 2014: new outbreak
With permission, D Goldfarb
Crypto-whaaa? Oocyst forming coccidian protozoa
Fecal-oral transmission, no intermediate maturation cycle
Causes frequent non-bloody watery diarrhea +/- abdo cramps, fatigue, fever, wt. loss, vomiting , anorexia
Self limited in immune competent hosts, incubation 3-14 days, illness usually lasts 6-14 days, continue to shed oocysts for 2 weeks
Extensive waterborne disease outbreaks associated with contaminated drinking and recreational water (oocysts are chlorine tolerant) and in low resource settings and transmission from livestock and animals such as petting zoos (C. Parvum)
Red Book. 29th Ed. 2012.
Sources:
Not the Petting Zoo or the Pool!
Giardia duodenalis and Cryptosporidium Spp . in
the Intestinal Contents of Ringed Seals (Phoca
Hispida) and Bearded Seals (Erignathus Barbatus)
in Nunavik, Quebec, Canada Region. J Parasitology.
Dixon et al.2008;94(5):1161–3.
Molecular characterization of Cryptosporidium sp
isolated from northern Alaskan Caribou (Rangifer
tarandus). J Parasitology. Siefker et al 2002;88:213-
216.
Detection & Treatment Might not be detected on routine O & P of stools
intermittent shedding- need 3 stools on 3 separate days
small size of oocysts (4-6 um)
concentration techniques + modified AF stain
specific DFA gold standard, emerging role for flocked
swabs/molecular testing
No treatment in immune-competent
Crypto in Canada
Thomas MK et al. Foodborne Pathogens and Dis. 2013; 10(7) 639-48
Crypto in the Arctic
SL Harper et al. Epidemiol Infect. 2015
Crypto in kids?
With permission. C. Yansouni
Crypto: QGH vs. the world?
QGH detection
rate
Slide with permission D Goldfarb. Graphic from Shirley DT et al., Curr Opin
Infect Dis 2012, 25:555–563
Practical Implications:
Diagnosis
Gamma – dynacare is doing acid fast staining on all O and P samples
So what? It’s Self-Limiting • Villous blunting
• Can have lasting effects in children, including
• increased diarrheal burden months after infection
• linear growth failure
• cognitive impairment
• Developmental delays has also been found in children with apparently asymptomatic infections
• May remain carrier for months
• No effective treatment (prevention is key)
Guerrant et al (Eds); Tropical Infectious Diseases (2nd Ed)
Practical Implications:
Infection Control
Infection Control (daycare exclusion, handwashing,
animal handling, water ingestion)
Most healthy individuals with acute diarrhea will only need
supportive care
Survey: Health Behaviours
Survey: Health Beliefs
Practical Implications:
Treatment Nitazoxanide is only FDA approved medication (is Health Canada special access)
RCT -Diarrhea was resolved in 80% of adults and children within 7 days of being randomized to receive a 3-day course of nitazoxanide compared with only 41% of those randomized to placebo
Indicated in:
immunocompromised
Chronic disease, particularly with growth failure
Rossignol JF, et al. J Infect Dis 2001; 184:103–106.
Research Questions: 1. What is the incidence and prevalence of (i) intestinal
infections and of (ii) diarrhea in Arctic communities?
2. What are the main infectious causes?
3. Are children being affected by repeated or chronic infections (Growth? Development?)
4. How can enteric infections be prevented in these communities?
Nunavut Gastroenteritis Study
You may have a patient eligible for the…. .
Child under 5 years old?
Has Gastroenteritis?
Pick up the study pack for details
If you have any questions please contact Dr. David Goldfarb
([email protected]) or Dr. Amber Miners ([email protected])
If they are eligible and consent obtained,
collect a swab sample to send to the lab
Take Home Points
1. Diarrhoeal disease is an important, multifactorial, and underappreciated contributor to child health.
2. The burden of disease is higher in Arctic communities, unique prevention challenges.
3. Cryptosporidium is an emerging pathogen, diagnostic challenges, need more data.
4. There is a role for treatment of this pathogen in children with chronic disease.
Questions?
Clyde River, Nunavut. Image courtesy of T Audcent