Outbreaks: Bacteria, Viruses, and Parasites…..Oh My!

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Outbreaks: Bacteria, Viruses, and Parasites…..Oh My!

Beth Landry, MHA, MT(ASCP)

Objectives:

1. Describe patients’ clinical signs and symptoms associated with different outbreaks.

2. Identify organisms that have caused major outbreaks.

3. Recommend preventive measures to reduce spread of disease in the community and in healthcare settings.

4. Describe the major pandemics that have occurred in history.

Outbreak #1

Outbreak #1

• Reported in South Africa

• Patients showed symptoms of gastroenteritis.

Symptoms included fever, flu-like symptoms, headache, stiff neck, confusion, loss of balance, etc.

Pregnant women: miscarriage, stillbirth, premature delivery, or other life-threatening infection of newborn (sepsis, meningitis)

• 85% of patients consumed ready-to-eat processed meat products-polony, Vienna sausages, and other cold meats.

Outbreak #1 – What is polony?

• Polony – finely ground pork and beef sausage.

Derived from bologna

Been in use since the 17th century

Modern product cooked in red or orange skin and served as cold slices

Outbreak #1 Total Cases Reported

January 12, 2018

748 cases

March 4, 2018

200 cases

March 28, 2018

30 cases

July 17, 2018

82 cases

N = 1060 cases with 216 deaths

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Outbreak #1

• Neonates (infants 28 days or younger) were the most affected age group – accounting for 42% of the 1,060 patients.

• Last 5 years: 60-80 cases reported each year

Outbreak #1

Who is our prime suspect?

Outbreak #1

• Gram positive bacilli (short)

• Catalase positive

• Beta hemolytic

• Can be mistaken for Group B Strep on BAP

Outbreak #1


Listeria monocytogenes

Outbreak #1

Outbreak #2

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Outbreak #2

• Reported Cases: 279

• Patients complained of diarrhea, fever, and stomach cramps 12-72 hours after exposure.

• Most patients recovered without treatment.

• Illness lasted approximately 4 – 7 days.

• Diarrhea was so severe that 107 patients needed to be hospitalized.

• One death has been reported.

Outbreak #2

• Epidemiologic investigation discovers that raw turkey products from a variety of sources were contaminated.

• Patients reported eating different types of turkey products purchased from different locations.

• A few patients did not eat turkey, but they fed raw turkey pet food to their pets.

Outbreak #2

• The culprit was identified in raw turkey pet food, raw turkey products, and live turkeys.

• Several recalls were implemented due to the contaminated products.

Outbreak #2

• No single source (supplier, farm, etc) identified.

• However, one bacterial strain was identified as the cause of the outbreak.

Outbreak #2


Outbreak #2

Clues:

Can be isolated from HE (Hektoen Enteric) or XLD (Xylose Lysine Deoxycholate) agar

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Outbreak #2


Salmonella enterica serovar Reading

Outbreak #2

PFGE – Pulsed-field Gel Electrophoresis

Outbreak #2

Whole GenomeSequencing

Outbreak #2

Outbreak #2

• Salmonella causes more illnesses than you suspect.

For every patient confirmed by a lab test, there are approximately 30 more people with Salmonellainfections go unreported.

• Salmonella illness can be very serious for certain patient populations:• Children younger than 5 years of age• Older adults• Patients with weakened immune system due to diabetes,

liver/kidney disease, or cancer

Outbreak #2

• 1.2 million illnesses and 450 deaths due to non-typhoidalSalmonella annually in the U.S.

• Salmonella causes majority of hospitalizations (64%) due to foodborne outbreaks.

• GI infections usually resolve within 5-7 days without treatment.

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Outbreak #2

Sources of infection include:

• Sprouts

• Iceberg lettuce

• Beef

• Pork

• Poultry

• Oysters

• Shepherd dogs, amphibians, and reptiles………oh my!

Outbreak #2

• Antibiotics should only be used when:

1. Patient has a serious illness (severe diarrhea, high

fever, bloodstream infection, or hospitalization)

2. Patient is considered high-risk for serious

complications

Outbreak #2

Antibiotics used for severe Salmonella infections:

- Fluoroquinolones

- 3rd generation Cephalosporins

- Azithromycin

Note: Antibiotic resistance is not uncommon in Salmonella.

Outbreak #2

Outbreak #3

Outbreak #3

• Symptoms: diarrhea and vomiting that may last up to 2 weeks, loss of appetite, weight loss, stomach cramps, bloating, flu-like symptoms

• Onset: within one week of ingesting contaminated food

• Over 500 cases reported. No deaths reported.

• Investigation narrowed down the source to lettuce blend sold in McDonald’s, Trader Joe’s, Walgreens, and Kroger.

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Outbreak #3

• Lettuce supplier (Romaine) was identified as Fresh Express.

• Recalls were initiated. The affected products bear the establishment number “EST. 39985” or “P-39985” inside or next to the USDA mark of inspection.

• Widespread panic….just kidding….where’s my salad????

Outbreak #3


Outbreak #3

• Lettuce was discovered to be contaminated by a parasite.

• Diagnosis: Modified acid-fast stain, fluorescent stain, or PCR

Outbreak #3


Cyclospora cayetanensis

Outbreak #3

Twitter Famous!!

Outbreak #3

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Outbreak #3

• Cyclospora oocysts can be excreted intermittently and in small numbers.

• A single negative stool specimen does not rule out the diagnosis; three or more specimens at 2- or 3-day intervals may be required.

• Concentration procedures should be used to maximize recovery of oocysts. The method most familiar to laboratorians is the formalin-ethyl acetate sedimentation technique (centrifuge for 10 minutes at 500 × g). Other methods can also be used (such as the Sheather’sflotation procedure).

Outbreak #3

Outbreak #3 PANDEMICS IN HISTORY

HIV/AIDS

•Death Toll: 36 million (since 1981)• First identified in Democratic Republic of the Congo in

1976• 31-35 million people living with HIV

-- 21 million in Sub-Saharan Africa•New treatments have been developed that

make HIV a manageable disease•Between 2005 and 2012, annual deaths

reduced from 2.2 million to 1.6 million

HIV/AIDS

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FLU PANDEMIC OF 1968

• Death Toll: 1 million

• Sometimes referred to as the “Hong Kong Flu”

• Caused by Influenza A subtype H3N2

• First reported case: 7/13/68 in Hong Kong

• Only 17 days later – spread to Singapore and Vietnam

• 3 months later – Philippines, India, Australia, Europe and U.S.

• Low mortality rate – 0.5%

• 500,000 deaths were in Hong Kong - 15% of its population

ASIAN FLU PANDEMIC 1956-1958

•Death Toll: 2 million

•Caused by Influenza A subtype H2N2

•Originated in China in 1956 and lasted 2 years

• Spread to Singapore, Hong Kong, and U.S.

• Low mortality rate – 0.5%

• 69,800 deaths in U.S.

FLU PANDEMIC OF 1918

•Death Toll: approx. 50 million

• Infected over a third of the world’s population• 500 million people

•Mortality rate – between 10 - 20%

• This pandemic wreaked havoc for healthy young adults but left children and those with weaker immune system alone.

• 25 million deaths reported in first 25 weeks

FLU PANDEMIC 1889 - 1890

•Death Toll: 1 million

•Also known as the Asiatic Flu or Russian Flu

• Influenza A subtype H2N2 or H3N8

• First observed May 1889 in Bukhara in Central Asia, Athabasca in NW Canada, and Greenland

•Rapid population growth, especially in urban areas, helped spread the virus

BLACK DEATH 1346 - 1353

•Death Toll: 75 - 200 million

•Also known as the Bubonic Plague

• Three forms: bubonic, septicemic, and pneumonic

•Caused by Yersinia pestis

•CAP Laboratory Preparedness Survey (LPX) – anyone subscribe to this survey??


Originated in Asia, then jumped continents via infected fleas living on the rats that lived aboard the merchant ships.

Plague ravaged Europe, Africa, and Asia

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Bubonic plague:

• Symptoms: sudden onset of fever, headache, chills, weakness and one or more swollen, tender and painful lymph nodes (buboes).

• Results from the bite of an infected flea. The bacteria multiply in the lymph node closest to where the bacteria entered the human body. If untreated, the bacteria can spread to other parts of the body.


• Bubonic plague:

BLACK DEATH 1346 - 1353 BLACK DEATH 1346 - 1353

Septicemic plague:

• Symptoms: fever, chills, extreme weakness, abdominal pain, sepsis, shock, and possibly bleeding into the skin and other organs.

• Skin and other tissues may turn black and die, especially on fingers, toes, and the nose.

• Septicemic plague can occur as the first symptom of plague, or may develop from untreated bubonic plague. This form results from bites of infected fleas or from handling an infected animal.

• Least common form



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Pneumonic plague:

• Symptoms: fever, headache, weakness, rapidly developing pneumonia with shortness of breath, chest pain, cough, and sometimes bloody or watery mucous.

• May develop from inhaling infectious droplets or from untreated bubonic or septicemic plague after the bacteria spread to the lungs.

• The pneumonia may cause respiratory failure and shock.

• Most serious form of the disease

• Only form of plague that can be spread from person to person (by infectious droplets).





• First detected in the U.S. in 1900

•Arrived by rat-infested steamships from Asia

• Epidemic in U.S. occurred 1924-1925

• 80% of U.S. cases have been bubonic form.


U.S. Plague Cases and Deaths 2000 - 2017

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U.S. Reported Cases of Human Plague. 1970 - 2017


The Comeback Kids……..Syphilus

Symptoms: ulcers/sores appear on palms and soles of feet, as well as whole-body rash

Caused by Treponema pallidum

2000 – 2001: U.S. rate of infection was 2.1 cases per 100,000 population

2017: Increased to 9.5 cases per 100,000 population

The Comeback Kids……..Measles

Symptoms: cough, conjunctivitis, rhinitis, high fever, head-to-toe rash

2010: 63 cases in the U.S.

As of 2/9/19: 79 cases in the U.S.

Increased number of anti-vaxxers

The Comeback Kids……..Measles The Comeback Kids……..Mumps

Symptoms: puffy cheeks, swollen jaw, fever, headache, tender parotid glands, muscle aches, fatigue, loss of appetite

2012: 229 cases in the U.S.

2016: 6,366 cases in the U.S.


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The Comeback Kids……..Whooping cough

Symptoms: runny nose, low-grade fever, cough, and apnea appear within 5-10 days of exposure

Within 1-2 weeks, rapid cough develops followed by “whooping” sound, vomiting, and exhaustion

Caused by Bordetella pertussis

50% of babies <=1 year old are hospitalized


The Comeback Kids……..Gonnorhea

STD – manifests as cervicitis, urethritis, proctitis, and conjunctivitis

Can spread and lead to more serious complications

Caused by Neisseria gonorrhoeae

”Super gonorrhea” – resistant to

Azithromycin and Ceftriaxone

The Comeback Kids……..Chlamydia

STD – sometimes it is GC’s partner in crime

More common than GC

2000: 251.4 cases per 100,000 population

2017: 528.8 cases per 100,000 population

Treated with Azithromycin or Doxycycline

PREVENTIVE MEASURES -COMMUNITY

1. Handwashing (of course).

2. Use antibiotics sensibly.

3. Stay at home if you are sick.

4. Be smart about food prep.

5. Disinfect “hot zones” in your house.

PREVENTIVE MEASURES -COMMUNITY

6. Practice safer sex.

7. Don’t share personal items.

8. Travel wisely.

(Stepping on soapbox….)

9. VACCINATE.

(Stepping off….)

PREVENTIVE MEASURES –HEALTHCARESETTING

1. Handwashing (of course).

2. Use antibiotics sensibly.

3. STAFF - Stay at home if you are sick.

4. Be smart about food prep.

5. Decontaminate patient rooms, hospital equipment, etc.

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PREVENTIVE MEASURES –HEALTHCARESETTING

6. Use screening tools for symptoms and travel history.

7. Create a quarantine room for patient with suspicious symptoms.

8. Collaborate with other departments when developing processes (registration, ED, lab, infection control, IT, bed board, etc.)

9. VACCINATION PROTOCOLS FOR PATIENTS AND STAFF.

(Yes, I got back up there….)

When will it stop…….

•Ebola

•Zika

•Measles

QUESTIONS…….

Documents

Outbreaks: Bacteria, Viruses, and Parasites…..Oh My!