Infectious Diseases in Resource-Limited Settings Outline Introduction

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Infectious Diseases in Resource-Limited Settings Outline Introduction

Rhinehart, Keri, Guest Contact has reference to this Academic Journal, PHwiki organized this Journal Infectious Diseases in Resource-Limited SettingsRamona Bhatia, MD Tuberculosis (TB)EpidemiologyDiagnostics in addition to treatmentPrevention in addition to student health issues MalariaEpidemiologyDiagnostics in addition to treatmentProphylaxis as long as travelling studentsHuman immunodeficiency virus (HIV)EpidemiologyDiagnosis in addition to treatmentNeedlesticks in addition to post-exposure prophylaxis (PEP)OutlineUndergraduate in addition to medical training at Northwestern Clinical experience in IndiaResidency at Baylor College of Medicine, Houston, TXCounty in addition to VA hospital settingsFellowship in Infectious Diseases at NorthwesternHIV outcomesHIV in addition to global healthResearch Associate in addition to Clinical InstructorIntroduction

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8.7 million new cases13% in HIV-infected (HIV+) patientsIndia/China->40%Africa (South Africa>Nigeria)-> 24%Americas-> 3%1.4 million TB-related deaths990,000 in HIV-uninfected (HIV-)430,000 in HIV+One of the top three causes of death as long as adult females in resource-limited settings (RLS)TB: 2011 snapshot WHO Global Tuberculous Control , 2012 2011 Global TB Incidence Rates: “disease of poverty”WHO Global Tuberculous Control , 20122011 Global Burden of HIV/TB Co-InfectionWHO Global Tuberculous Control , 2012

After inhalation, TB may symptomatically infect the lower lobes of the lung (primary TB infection)Or, the bacteria are contained in upper lobes by macrophages in addition to cell-mediated immune responses (latent TB infection, LTBI)Can progress to symptomatic disease later (reactivation or “active” TB)Other patients may completely clear the organismPathogenesis in addition to Types of InfectionLifetime risk of reactivating TB is 10% in those with LTBI5% in the first two years 5% thereafterIn untreated HIV+ patients, the risk is 7-10% per year HIV is the strongest predictor of progression Other immune compromising conditions associated with reactivation:DiabetesTNF- inhibitor useSteroid useReactivation TB www.cdc.gov Latent vs Reactivation TBwww.cdc.gov

WHO Symptoms ScreenAbsence of all of: cough, weight loss, fever, night sweatsCommonly used in HIV+ patientsTuberculin skin test (TST)Look as long as induration (10 mm in med students, 5 mm in HIV+) after 48-72 hoursA positive test indicates prior exposureNot always positive in active TBRecommended in RLSInterferon- Release Assay (IGRA)Looks as long as in-vitro reaction A positive test indicates prior exposureNot always positive in active TBNot recommended in RLSLatent TB Diagnostics WHO Use of Interferon- Release Assays in Tuberculosis Control in Low – in addition to Middle-Income Settings, 2010 Active TB DiagnosticsAcid-fast staining of sputumAnalyze 3 early morning samplesMost common method in RLSMycobacterium tuberculosis cultureMay not be widely available in RLSMolecular techniques (i.e., PCR)Uncommon in RLSPoint of care tests are available (GeneXpert)Chest X-Rays Uncommon in RLS Univ. S. Carolina School of MedicinePreferred regimen has been 9 months of daily isoniazid (INH)Other regimens 4 months of daily rifampin (RIF) 3 months of weekly, directly-observed INH plus rifapentine Latent TB Treatment http://www.cdc.gov/tb/topic/treatment/ltbi.htm

First-line treatment-> RIPEEarly intensive phase: 2 months of RIF, INH, pyrazinamide (PZA), in addition to ethambutol (ETH)Continuation phase: 4 months of RIF in addition to INHMonitor monthly as long as liver toxicityUsually from INH>RIF>PZAIn RLS, use the physical examination (scleral icterus, jaundice, in addition to hepatomegaly)Liver function testing is not widely usedOther side effects: rash, GI disturbance, ocular toxicity, in addition to neuropathyActive TB Treatment WHO Treatment of Tuberculosis Guidelines, 2010 MDR-TB: INH in addition to RIF resistantXDR-TB: MDR-TB isolates that are also resistant to an injectable (i.e., aminoglycoside) in addition to a quinoloneThey have been found in all regionsMDR-TB: 3.7% of new TBHigh prevalence in Eastern Europe Longer treatment (20 months) with more side effectsHigher mortalityMulti-Drug Resistant (MDR-) in addition to Extensively Drug-Resistant (XDR-) TB WHO Global Tuberculous Control , 2012 Global Burden of MDR-TBWHO Global Tuberculous Control , 2012

Global Burden of XDR-TB WHO Global Tuberculous Control , 2012In one study of American students travelling to Kenya, risk of converting the TST was 4.1% There was no association with duration of stay or participation in direct medical careOnly 27% of students reported “ideal” TB prevention measures in addition to monitoringTB in addition to Student Health: risk Gardner A, et al., J Gen Intern Med, 2011VaccineNo. The BCG vaccine is used abroad to prevent childhood TB. It is not available in the U.S.Medical prophylaxisNo medications are available as long as TB prophylaxisBest approach involves limiting exposure in addition to monitoring as long as diseaseTB in addition to Student Health: prevention

Current international guidelines recommend triage in addition to isolation of patients suspected to have active TB, but space in addition to resource limitations may preclude thisEspecially critical to isolate from HIV+ patientsNegative pressure rooms are uncommon Guidelines recommend natural (i.e., opening windows) or mechanical (i.e., fans arranged to blow air out of room) ventilationTB in addition to Student Health: limiting TB exposure http://whqlibdoc.who.int/publications/2009/9789241598323-eng.pdf Personal respiratory protection is the mainoption as long as limiting exposureObtain 1box of N95 masks online Reuse masksUse when seeing a patient with a positive symptoms screen or who is suspected to have active TBShare with the host medical teamThey may not have N95 masks or may only be using them as long as invasive procedures (i.e., intubations)Students should never be seeing patients with known or suspected MDR-/XDR-TBTB in addition to Student Health: limiting TB exposure Kortepeter et al., CID, 2010All student travelers should undergo testing as long as LTBI with TST or IGRA prior to leavingAddressed at student health appointmentRepeat LTBI testing 8-10 weeks after returningSelf-monitor as long as :Fever (can occur 2-8 weeks after exposure)Night sweatsWeight lossCoughOthers: lymphadenopathy, hemoptysis, pleurisy, etc.TB in addition to Student Health: monitoring CDC Yellow Book, 2012

216 million cases in 2010Large burden of disease (81%) in addition to disease-related mortality (91%) in sub-Saharan Africa One child dies every minute from malaria in Africa In the U.S., 8,117 travel-related cases reported over last decade66% acquired from sub-Saharan Africa14% acquired from Asia43 fatalities, mostly from Plasmodium falciparum infection acquired in sub-Saharan AfricaMalaria Epidemiology CDC Yellow Book, 2012 Global Burden of MalariaThis is a general map that does not reflect the within-country variation of malaria endemnicity Transmission depends on survival patterns of the Anopheles vector CDC Yellow Book, 2012Global Burden of MalariaCDC Yellow Book, 2012

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Blood-borne transmission after bite of Anopheles mosquito P. falciparum, ovale, vivax, in addition to malariaeTransmission can occur after needlesticksIn high-burden countries, transmission is stable in addition to most develop immunityPregnant women, children, HIV+ patients, in addition to visitors continue to be at riskIn low-burden countries, transmission is sporadic in addition to immunity may not developMalaria PathogenesisIn RLS, patients with fever are commonly empirically treated as long as malariaThis strategy is associated with overtreatment in addition to development of drug resistanceOther symptoms: conjunctival or palmar pallorEnd organ dysfunction (i.e., low urine output, altered mental status) defines “severe malaria”Ideally, obtain blood smears or rapid tests prior to starting therapyIf a patient is unstable, empiric therapy is warrantedMalaria Diagnosis WHO Guidelines as long as the Treatment of Malaria, 2010Artemisinin-based combination therapy (ACT) is recommended as long as uncomplicated P.falciparum malariaArtemether plus lumefantrine (Coartem)Artesunate plus amodiaquineArtesunate plus mefloquineArtesunate plus sulfadoxine-pyrimethamine Dihydroartemisinin plus piperaquineChoice of preferred ACT is country-specific Severe malaria“ABCs” as long as the critically illHospitalize in addition to start IV or IM artesunateMalaria Treatment WHO Guidelines as long as the Treatment of Malaria, 2010 CDC Yellow Book, 2012

The geographic risk of malaria will be determined at the pre-departure student health appointmentPrevention has four elements:A-awareness of the disease processB-avoid being bitten with effective vector controlC-chemoprophylaxis adherenceD-diagnosis should infection occurPreventing Malaria in Travelers www.who.int/malaria/travellers/en/Malaria Prevention: vector control CDC Yellow Book, 2012http://www.malariaconsortium.org/Insecticide-treated nets (ITNs)Long sleeves in addition to pantsInsect repellantDEET (10-50%)Atovaquone-proguanil (Malarone)Daily dosingStart 1-2 days prior to leaving; continue as long as 1 week after returningOverall well toleratedContraindicated in severe renal failureMefloquineSerious CNS side effects can occurChloroquine, hydroxychloroquine Not used due to high rates of resistanceDoxycyclineSun sensitivityMalaria Prevention: chemoprophylaxis CDC Yellow Book, 2012

WHO recommended IC practices:Triage pt with TB –depends on regionIsolate TB pts ESP from HIV ptsCough etiquitte as long as TB pts (unknown if a mask on them helps)Natural in addition to mechanical ventilation (fans)In particular, health workers should use particulate respirators: during high-risk aerosol-generating procedures associated with high risk of TB transmission (e.g. bronchoscopy,intubation, sputum induction procedures, aspiration of respiratory secretions, in addition to autopsy or lung surgery with highspeeddevices) when providing care to infectious MDR-TB in addition to XDR-TB patients or people suspected of having infectious MDR-TB in addition to XDR-TB. http://whqlibdoc.who.int/publications/2009/9789241598323-eng.pdfPeople working internationally who will be engaging in high-risk occupational health care activities, such as drawing blood or the other use of sharps during patient care, should consistently follow st in addition to ard precautions to reduce the risk of occupational exposure to HIV in addition to other bloodborne pathogens. St in addition to ard precautions involve the use of protective barriers such as gloves, gowns, aprons, masks, or protective eyewear. Additional in as long as mation about occupational health in addition to safety st in addition to ards as long as bloodborne pathogens can be found at http://www.osha.gov/pls/oshaweb/owadisp.show-documentp-table=STANDARDS&p-id=10051In addition, clinicians working internationally should:Always be mindful of the hazards posed by sharps injuries.Maintain strict safety st in addition to ards while working in environments that may have less stringent st in addition to ards.Use devices with safety features in addition to improved work practices (www.cdc.gov/niosh/docs/2000-108/).Consider bringing their own protective equipment if they are unsure of its availability at their destination.Consider bringing postexposure prophylaxis (PEP) as long as HIV in the event that they are injured with a potentially contaminated sharp.POSTEXPOSURE MANAGEMENTHealth care workers who may have been occupationally exposed to HIV should immediately per as long as m the following steps:Wash the exposed area with soap in addition to water thoroughly. If mucous membrane exposure has occurred, flush the area with copious amounts of water or saline.If possible, assess the HIV status of the source. Rapid HIV testing is preferred. If the source’s rapid HIV antibody test result is positive, assume that it is a true positive.Seek qualified medical evaluation as soon as possible to guide decisions on postexposure treatment in addition to testing.Contact the National Clinicians’ Postexposure Prophylaxis Hotline (PEPline) at 1-888-448-4911 (24 hours a day, 7 days per week) as long as assistance in assessing risk in addition to advice on managing occupational exposures to HIV in addition to other bloodborne pathogens (www.nccc.ucsf.edu/about-nccc/pepline). If the toll-free number is not accessible when calling from another country, the main administrative line as long as the National HIV/AIDS Clinicians’ Consultation Center is 415-206-8700.Consider beginning PEP as long as HIV (see below).Postexposure ProphylaxisA number of medication combinations are available as long as PEP. Since these regimens may change based on new research, refer to MMWR’s Updated US Public Health Service Guidelines as long as the Management of Occupational Exposures to HIV in addition to Recommendations as long as Postexposure Prophylaxis (http://aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspxMenuItem=Guidelines&Search=Off&GuidelineID=10&ClassID=3) in addition to the PEPline as long as more in as long as mation about PEP recommendations. Specific regimens should be determined by clinicians familiar with the medications in addition to the health care worker’s medical history.If the exposed person chooses to initiate PEP, he or she must do so within hours of the exposure. PEP can be stopped if new in as long as mation changes the assessment; however, waiting to start PEP until all in as long as mation is gathered can decrease its efficacy. If indicated, arrange as long as procurement or shipment of additional PEP from a credible source to complete the recommended 4-week course of treatment.Consider other potential infectious disease exposures from the source material, including hepatitis B virus or hepatitis C virus (HCV), in addition to manage as appropriate.Postexposure TestingPeople with occupational exposure to HIV should receive HIV antibody testing by enzyme immunoassay as soon as possible after exposure as a baseline, with follow-up testing at 6 weeks, 3 months, in addition to 6 months. Extended HIV follow-up testing as long as up to 12 months is recommended as long as those who become infected with HCV after exposure to a source coinfected with HIV in addition to HCV. Postexposure counseling in addition to medical evaluation should be provided, whether or not the exposed person receives PEP (http://aidsinfo.nih.gov/contentfiles/Health CareOccupExpoGL-PDA.pdf ).Exposed health care workers should be advised to use precautions (avoid blood or tissue donations, breastfeeding, or pregnancy) to prevent secondary transmission, especially during the first 6–12 weeks after exposure. For exposures as long as which PEP is indicated, exposed people should be counseled regarding possible drug toxicities in addition to interactions, the need as long as monitoring, in addition to the importance of careful adherence to PEP regimens.Cdc yellow book 2012

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