Infections during Humanitarian Crisis

Steven E. Spencer COL, MC Pediatric Infectious Disease Large Scale Disasters Happen…. Usually Overseas But Sometimes Here Objectives • Participants will recognize the infections with the highest impact on morbidity and mortality during a humanitarian crisis • Discuss antibiotic treatment options for these infections as well as adjunct therapies • Recognize that standard of care may be different during a humanitarian crisis or in a third world country • Identify resources to help caregivers treat patients during humanitarian crisis or in austere environments • We will concentrate on overseas emergency settings • Events in the U.S. generally get overwhelming support (sorry Puerto Rico) • MEDRETE’s are good training for us but don’t really change the lives of the locals long term • Give a man a fish • Trend now is more toward Community Health Engagements • Teach a man to fish A 3 year old boy has what you suspect is measles: • Besides fluids and supportive care what other treatment is indicated a) High dose aspirin for inflammation b) Prophylactic antibiotics to prevent pneumonia c) Vitamin A administration d) Eye drops for measles conjunctivitis A 3 year old boy has what you suspect is measles: • Besides fluids and supportive care what other treatment is indicated a) High dose aspirin for inflammation b) Prophylactic antibiotics to prevent pneumonia c) Vitamin A administration d) Eye drops for measles conjunctivitis A child in a refugee camp has acute onset of watery diarrhea. What intervention is indicated besides oral fluid rehydration? a) Ceftriaxone for Salmonella b) Vitamin A therapy c) Zinc supplementation d) Consult the local Shaman A child in a refugee camp has acute onset of watery diarrhea. What intervention is indicated besides oral fluid rehydration? a) Ceftriaxone for Salmonella b) Vitamin A therapy c) Zinc supplementation d) Consult the local Shaman You diagnose a 7 year old child with acute pneumonia. He is not in respiratory distress and has normal oxygen levels. The most appropriate treatment is?

a) Azithromycin p.o. for 5 days b) Amox/Clavulanic acid p.o. for 10 days c) Chloramphenicol p.o for 10 days d) Amoxicillin p.o. for 5 days You diagnose a 7 year old child with acute pneumonia. He is not in respiratory distress and has normal oxygen levels. The most appropriate treatment is?

a) Azithromycin p.o. for 5 days b) Amox/Clavulanic acid p.o. for 10 days c) Chloramphenicol p.o for 10 days d) Amoxicillin p.o. for 5 days Mortality in Complex Humanitarian Emergencies

Sudan, 1985, Malawai Refugee Camps, Wad Kowli Camp 1990 Mortality < 5 yrs Infectious Mortality in Humanitarian Emergencies

• Measles • Epidemiology

• Malaria • Diagnosis • Diarrhea • Management • Acute Respiratory Infections

Malnutrition present in over 30% of deaths Changing Your Frame of Reference • Standards of Care • Empiricism • Pharmaceuticals • Cultural Medical Practices Differences in “Standards” are Not Differences in Moral or Ethical Standards People in the developing world care about and value many of the same things that we do in the developed world. • children's health and development • the effects of violence on their community • availability of quality health care The “Standard of Care” is Resource Driven

• Average annual per capita health expenditure in a developing country is ~ $ 30-35 • U.S.: Over $8000 WHO

• Resources dictate standard HOW

And honestly in the U.S. we tend to over treat since we have zero tolerance for failure WHAT How Treatment is Administered?

• Oral >> IM >>>>> IV (extraordinary therapy) What is Used to Treat? • Few / no “comfort” meds • Low cost antibiotics • Shorter durations of therapy • Less resistance, less resources, higher tolerance for failure • Remember you can’t refrigerate meds if you have no fridge- so choices may be different Who Delivers Care?

• In long term situations like a refugee camp, most care is given by local population under supervision • Few docs • Mainly nurses or educated volunteers

• Put people to work for you

“Is it ethical for me to change my standards of practice when working in a resource poor environment?”

Adopt a standard of practice that is appropriate for the environment. Vigorous resuscitation and extraordinary interventions need to be carefully considered

Medical interventions need to be appropriate and sustainable in that environment A Reality in Humanitarian Emergencies

Population interventions are usually a higher priority than individual patient care Identify and Address Causes Prev Med is key 23 Be aware of different cultural practices and attempt to incorporate these potential obstacles into the therapeutic plan as much as possible Empiricism- the Science of Educated Guessing

• Your environment will dictate your access to diagnostic tests • Patient load will dictate the time you will be allowed to ponder diagnostic possibilities • Pursue evidence based empiricism whenever possible • essential when dealing with diseases of epidemic potential Doxycycline Cipro ORS ORS ORS Zinc Zinc Zinc Pharmaceutical and Other Supplies • Often only what you can carry on your back • “Push packs”- i.e.- prepacked, prepositioned supplies • The Interagency Emergency Health Kit • WHO standard pallets • Red Cross, Unicef usually follow same • Military alternatives The Interagency Emergency Health Kit • Standardized, inexpensive, and appropriate source of essential drugs • Meet the initial primary health care needs of a displaced population without medical facilities, or a population with disrupted medical facilities in the immediate aftermath of a natural disaster or during an emergency. • Driven by past failures in being able to obtain timely and appropriate supplies for disaster settings. • Stored in disaster prone regions of the world and can be rapidly deployed at the outset of an emergency. The Interagency Emergency Health Kit

1,000 1,000 1,000 1,000 1,000 • 10 x 1 Basic unit 1,000 1,000 1,000 1,000 1,000 for 1,000 persons One Health Kit for 10,000 10,000 • 1 Supplementary persons for unit for 10,000 3 months persons

The Interagency Emergency Health Kit

• Contains • Durable supplies • Renewable supplies • Medications • No equipment for resuscitation or major surgery. In situations of war, earthquakes or epidemics, specialized teams will be required. The Interagency Emergency Health Kit

• Assumptions: • Basic Unit will be used by those with limited medical knowledge – treating symptoms rather than diagnoses • Half of the population is 0-14 y/o The Interagency Emergency Health Kit: Basic Unit Anti-infectives (10 / kit) • Artemether – lumefantrine (390 treatments) • Quinine sulfate 300mg (2000 tabs) • Malaria Rapid Diagnostic Tests (800) • Albendazole tab 400mg (200 tabs) • Amoxicillin tab 250 mg (3000 tabs) • Tetracycline eye ointment 1% (50 tubes) • Miconazole, cream 2% (20 tubes)

• ORS sachet 200 packs • Zinc sulfate 20 mg (1000 tabs) The Interagency Emergency Health Kit – Supplementary Unit Anti-infectives (1 / Kit)

• Benzathine benzylpenicillin • Artemetheter • Benzylpenicillin (injectable) • Quinine (injectable) • Procaine benzylpenicillin • Ceftriaxone • Azithromycin (PEP) • Cloxacillin (Cephalexin replacing) • Cefixime (PEP) • Doxycycline • Zidovudine + Lamivudine (PEP) • Metronidazole • Miconazole tablets • Clotrimazole, pessary • Vitamin A, 200 000 IU (4000 Caps) Other Interagency Kits • Nutrition Survey Kits • Nutrition Registration Kits • Outpatient Therapeutic Feeding Kit: 5 sites x 500 persons • Inpatient Therapeutic Feeding Kit: 50 persons • Immunization Kit:10,000 immunizations by 5 teams • Reproductive Health Kit • primary care, hospital care, surgical / OB Army Humanitarian Assistance NSN MES – Echelon III only • 6545-01-453-5658 623A MES, HA ADULT AUG • 6545-01-543-2366 624A MES, HA ASSISTANCE SURG AUG • 6545-01-542-7038 625A MES, HA PEDIATRIC AUG Prepositioned in Japan, Korea, and San Antonio

•The Humanitarian Response Team (HRT) (AS 970P), Pediatric (AS 917C), GYN Team (AS 917L), Geriatric (AS 903K) Navy also has equivalent pack but IEHK’s maintained afloat and ashore in multiple locations Measles - Rubeola virus

• Transmission is by respiratory secretions (contact and aerosol) • Highly contagious infection with a world wide distribution •100% infection of susceptible contacts • Epidemics greatly enhanced by crowding • Devastating effects on malnourished children Measles

“ Measles vaccination should be assigned the highest priority early in emergency situations.... Immunization should begin as soon as the necessary personnel, vaccine, cold-chain equipment and other supplies are available. It should not be delayed until cases of measles have been reported.”

MMWR July 1992 vol. 41:RR-13 Measles- but we are already immunized… • The high priority given to measles immunization holds true even among populations with reasonably high immunization coverage • 50,000 refugees with 80% vaccine coverage in their homeland • 90% vaccine efficacy •10,000 children under 5 yr

2,800 susceptible children •Malnutrition will worsen this number Measles

Your job as a clinician is to

facilitate delivery of measles immunization within your area and to recognize, treat and report clinical cases of measles. Measles Vaccination Strategy Target Population: Emergency Phase

• All children 6 mo- 14 yrs If insufficient vaccine • Priority: 6 months – 5 available: yrs Priorities • Any child immunized 1. Undernourished or sick between 6-9 mo should children 6 mo - 12 yr who are be re-immunized at 9 mo enrolled in a feeding • Older children and adults program (Supplemental or as guided by disease Therapeutic program). surveillance. 2. All children 6-23 months 3. Children 24- 59 months Measles Vaccination Strategy

None of the following are contraindications to immunization: malnutrition fever respiratory infection diarrhea HIV infection tuberculosis Measles The identification of a measles case in a camp should accelerate the immunization process incubation Day 1 Day 2 Day 3 Day 4 Day 5 Day 6 Day 7 Day 8 Day 9 8-12 days

exposure fever ------FEVER------] cough ------> conjunctivitis------] coryza------] RASH------> Koplik spots------] Measles Koplik spots Measles Exanthem Progression Day 1 Day 2 Day 3

Measles: Complications

• Respiratory tract- OM, mastoiditis, croup, bronchiolitis, pneumonia- a leading cause of mortality • Enteritis- diarrhea and dehydration, malabsorption / malnutrition- contributor to mortality • Ocular - keratitis, ulcerating keratomalacia • in Vitamin A deficient • Skin- cancrum oris, pyoderma • CNS- encephalitis (1:1000 during convalesence) • Adenitis- cervical, mesenteric • Myocarditis/pericarditis Vitamin A and Measles: A synergistic effect

Measles Vitamin A deficiency unmasks (even sub-clinical) underlying increases morbidity Vitamin A and mortality of deficiency measles infection

Vitamin A alone administered to the high risk target population can significantly reduce measles associated morbidity and mortality Vitamin A and Measles

• Prophylactic Vitamin A treatments are often carried out at the same time as measles immunization • Vitamin A alone should be administered if measles vaccine will be delayed

Measles – Vit A Prophylaxis < 6 mos 50,000 IU PO once q 6 months 6-11 mos 100,000 IU PO once q 6 months >11 mos-5yrs 200,000 IU PO once q 6 months

Cancrum oris Following Measles

Measles- Case management • Treat complications like pneumonia • Give vitamin A (unless previously treated) < 6 mos 50,000 IU po 6-11 mos 100,000 IU po ≥12 mos 200,000 IU po • Give all cases of measles a second dose on day 2. • Complicated measles cases (pneumonia, diarrhea, stomatitis, malnutrition, croup, otitis, encephalitis, Vit A deficient) receive a third dose in 2 weeks.

Communicable disease control in emergencies: field manual. WHO. 2006 Malaria Malaria • Plasmodium falciparum (the killer!!) • direct cause of death in a substantial number of infected • drug resistance • Chloroquine sensitive P. falciparum is limited mostly to: Haiti, Dominican Republic and Central America • Plasmodium vivax • Plasmodium ovale • Plasmodium malariae • Plasmodium knowlesi • cause morbidity and contribute to multifactorial mortality • most are chloroquine sensitive Malaria

• Diagnosis: Geimsa / Wright blood smears. • THICK SMEAR: screen for and measure parasitemia • THIN SMEAR: identification of species and measure parasitemia • Preparing smears is simple • Reading smears requires experience and resources • Rapid Diagnostic Tests (RDT): now standard in IEHK Field usefulness of RDT

malaria parasites present

NO YES P. falciparum

NO YES FDA approved test Uncomplicated Malaria Severe Malaria Outpatient Inpatient if available altered mental status fever unable to tolerate oral meds chills hypotension headache hypoglycemia myalgias metabolic acidosis diarrhea severe normocytic anemia mild-mod anemia Hct < 15% hemoglobinuria renal failure hyperparasitemia > 2% in low transmission Highest risk- infants and young areas or > 5% in high children stable transmission areas pregnant women malnourished Malaria Sepsis/ Meningitis ???? fever severe anemia chills renal failure headache shock- hypotension, myalgias cardiorespiratory failure diarrhea CNS symptoms-confusion, coma, seizure

How do you distinguish severe malaria from sepsis/meningitis? In an area with endemic P. falciparum malaria, seriously ill febrile patients will receive empiric coverage for both severe malaria and bacterial sepsis/meningitis until specific diagnosis is made.

Diarrheal Disease • Most episodes of diarrhea in the developing world are caused by self limited infections of viruses or bacteria

• Standard of Care is Oral Rehydration Therapy

• Morbidity and mortality are associated with both the causative agent and unnecessary antibiotic treatments • Both can exacerbate dehydration and malabsorption

• The indications for the use of antimicrobials to treat diarrhea in the developing world are LIMITED and include only the following... Cholera Bacillary Dysentery Amoebic Dysentery Giardiasis Cholera

• Disease due to infection with toxin producing Vibrio cholera

• Transmission: fecal-oral, fairly fragile organism, but can survive in water for 7 -10 days

Has epidemic potential Infection produces acute onset disease of variable severity “rice water” stools Cholera Cot

Allows some measure of hygiene and, potentially to measure Cholera: Treatment

• ORS: can achieve a case fatality rate< 1% • Antibiotics not essential; but hasten recovery and limit transmission • Doxycycline- 300 mg PO once • can use even in children • Erythromycin (children ≤20kg)- 12.5 mg/kg/dose QID for 3 days* • Monitor case fatality rates • Improve sanitation

*Azithromycin as alternative Diarrheal Disease: Dysentery Infectious colitis that manifests as diarrhea with visible blood and/or mucous in the stool

Bacillary

Amoebic Bacillary Dysentery

• Outbreaks most commonly caused by Shigella species • Sporadic cases: Campylobacter, Salmonella • Far more common than amoebic dysentery • Distribution: world wide • Transmission: fecal-oral, water, food, fomites • very small inoculum causes disease (10- 100 organisms) Bacillary Dysentery

• Acute onset • Stools change in character as inflammation descends GI tract • watery bloody mucoid with tenesmus • Nausea/vomiting not prominent • Abdominal pain and cramping • Fever (a third to half of patients ) • Dehydration- mild to moderate • stools not voluminous • Seizures (shigellosis) Bacillary Dysentery: Indications to Treat • Children under 5 years of age • especially infants, severely malnourished children and children who have had measles in the past 6 weeks • Malnourished adults and older children • Patients who are severely dehydrated, have had a convulsion, or are seriously ill when first seen • Adults 50 years of age or older Bacillary Dysentery

• Shortens duration of symptoms and excretion of organisms

WHO recommended therapy* Adults Cipro 500mg twice daily 3 days Children Cipro 15 mg/kg twice daily 3 days < 6 months Zinc 10 mg daily 2 weeks 6 months – 3 years Zinc 20 mg daily 2 weeks 2nd line agents: ceftriaxone, azithromycin, pivmecillinam

• Failure to respond in 2 days  change therapy • drug resistance is more likely than misdiagnosis of amoebic dysentery

* Not FDA approved regimens Amoebic Dysentery

• Due to Entamoeba histolytica • Consider treating a patient who has failed two courses of therapy for Shigella or • if exam of the stool demonstrates amoebic trophozoites on micro or an antigen test is positive

• Metronidazole or tinidazole Diarrheal Disease Giardia • Acute or chronic infection due to a protozoan parasite • Transmission: fecal-oral, water (particularly surface water), person- person / fomite • Non-bloody diarrhea • can be profuse and foul smelling (malabsorption) Diarrheal Disease Giardia: Treatment

• Consider treating chronic malabsorptive, non- bloody diarrhea without fever or • if stool exam demonstrates cysts or trophozoites • Metronidazole, tinidazole, furizolidone, paromomycin Indications for Parenteral Therapy

• Patients who present with severe dehydration • Patients with severe and protracted vomiting • Patients with excessively high stool output • Patients with evidence of severe glucose malabsorption

• Patients with severe diarrhea should also be offered oral rehydration therapy Composition of WHO ORS

• Sodium Chloride 2.6 g/75mEq (from 3.5g) • Trisodium Citrate 2.9g/10mmol Dihydrate • Potassium Chloride 1.5 g/20mEq • Glucose 13.5g/75mEq (from 20g) • Water 1 liter

• TOTAL OSMOLARITY = 245 mOsm/L Practical Considerations

• Need a clean, potable water source • Standard ORS available as packets through the military supply system Drug Therapy for Diarrhea

• Antibiotics should only be used for dysentery or suspected cholera • Anti-parasitic drugs should only be used for amoebiasis and giardiasis • Anti-diarrheal and anti-emetic drugs should not be utilized Zinc Therapy for Diarrhea

• Decreases length/severity of diarrhea as well as overall mortality • Helps prevent recurrences in the following 2-3 months • <6 months = 10 mg daily for 10-14 days • >6 months = 20 mg daily for 10-14 days Respiratory Infections in Austere Conditions

• Crowding increases direct transmission

• Personal hygiene compromised

• no hand washing, bathing, clean clothes 79 Acute Respiratory Infections • 20% of deaths in children < 5 are due to respiratory infections  90% due to pneumonia • The majority of ARI in the developing world are self resolving viral URI’s • Antibiotics should not be used without indication • contribute to drug resistance • contribute to enteral dysfunction • Antibiotics are appropriate for Pneumonia Complicated URTI Acute Respiratory Infections • Assess for danger signs: • cyanosis, retractions, lethargy, seizure, inability to take/tolerate po, malnutrition • If danger signs: • (very severe) Ampicillin + IM gent x 5 days or Ceftriaxone x 5d; Then amoxicillin + IM gent x 5 d • (severe) benzylpenicillin x 3 days  amox x 2d • Amox 45 mg/kg/dose for 5 days if unable to use IV/IM • No danger signs: “non-severe pneumonia” Amoxicillin 25 mg/kg/dose BID x 5 days

•Trial of albuterol for wheeze and retractions

Integrated Management of Childhood Illness. World Health Organization, 2008. Acute Respiratory Infections Complicated URTI Treatment Plan

Acute Otitis Media with Fever Amox x 5 days

Chronic draining otitis Quinolone otic x 2 weeks + dry wick

Acute Sinusitis Amox x 5-10 days if mild-mod with Fever Ceftriaxone  amoxicillin x 10 days for severe sx

Mastoiditis Ceftriaxone x 10 days

WHO Model Formulary: World Health Organization. Integrated management of Childhood Illness: IMCI Chart Book. World Health Organization Skin and Soft Tissue

• Normally MSSA or GAS • Very little MRSA • Very little resistance • If water exposure add gram negative coverage • If rapidly progressing cellulitis add doxycycline for Vibrio species Resources • WHO website • Full of great resources • AKO teleconsultation e-mails (no longer maintained) • See list at end of slides. Most don’t work but some still do • PATH/HELP system • ADVISOR system • Military Medical Humanitarian Assistance Course (MMHAC) • Joint Humanitarian Operations Course (JHOC) at Defense Medical Readiness Training Institute • Textbooks at Borden Institute –free!! Teleconsultation Groups Specialties organized into email groups – send teleconsult to appropriate email

• [email protected] (Burn-trauma) • [email protected] (Cardiology) • [email protected] (Dermatology) • [email protected] (Ophthalmology and Optometry) • [email protected] (Infectious Diseases) • [email protected] (Infection Control) • [email protected] (Internal Medicine) • [email protected] (Laboratory Services) • [email protected] (Nephrology) • [email protected] (Neurology) • [email protected] (Orthopedics and Podiatry) • [email protected] (Pediatrics Intensive Care) • [email protected] (Preventive Medicine) • [email protected] (Rheumatology) • [email protected] (Sleep Medicine) • [email protected] (Traumatic Brain Injury) • [email protected] (Toxicology) • [email protected] (Urology)

No longer updated!! Immunizations

• https://health.mil/Military-Health- Topics/Health- Readiness/Immunization-Healthcare FIRST CLICK

87 Commercial: 1 (833)-ADVSRLN (238-7756) or DSN 429-9089 You have reached the Advanced Virtual Support for Operational Force (ADVISOR) system, please listen to the following menu options: “Press 1 to connect directly with a critical care provider for emergency critical care support.” “Press 2 to connect with a specialty provider to include Ortho, general surgery, pediatrics, toxicology, and infectious disease.” “Press 3 to connect directly with an emergency department provider for emergent support.” *After an option is pressed, “Please hold, you are now being transferred”

Option #3 Option #1 Transfers call to Option #2 Transfers call to (210) 916-STS3 (7873) or DSN 429-7873 “You are now being connected to the (210) 916- To connect with a specialty provider, please listen to the following menu on-call Emergency VCCC (8222) options: Press 1 to connect to the general/trauma surgeon on call Department” Press 2 to connect to the orthopedic surgeon on call Press 3 to connect to Transfers Call to the pediatrician on call programed On-call ED Press 4 to connect to the toxicologist on call Press 5 to connect to the infectious disease doctor on call Press 6 if the Calls directly to consultant you need is not listed the VC3 line Press 0 to hear these options again Calls directly to the on-call ED

Option #1 Option #2 Option #3 Option #4 Option #5 st Calls 1st on-call Calls 1st on-call Calls 1 on-call Calls 1st on-call Calls 1st on- General surgery Ortho surgeon Pediatrician Toxicologist call ID Option #7 Physician “You are now being connected to the BAMC Virtual Medical Center for additional care coordination., please hold“ *If no answer, redirect call to the on-call ED Calls 2nd on-call Calls 2nd on-call Calls 2nd on-call Calls 2nd on-call Calls 2nd on-call General surgery Ortho surgeon Pediatrician Toxicologist ID Physician

We are unable to access the (provider type) on call. Your call is being directed to the on-call emergency room physician. When the call is answered, please state that you are a deployed medical caregiver accessing the ADVISOR Virtual Health Support Line and that you need to speak to a (Provider Type) . MAMC ED DSN – 782- 1396 • Routine consultations are best managed via the e- mail teleconsultation system, or the Pacific Asynchronous Telehealth (PATH) consultation portal • Service provides consultation within 24 hours (median response time is approximately 4 hours).

• Urgent (phone calls answered immediately 24/7)

• Emergent consultation (phone calls answered immediately 24/7) • Critical care consultation for patients with critical illness or injury or consultation that is needed immediately due to a narrow communications window, or consultation by low- bandwidth connection is best managed by calling the VC3 number. Borden Institute Questions? • COL Spencer has no financial interests to disclose with regard to this subject or the contents of the presentation