UBC Tropical Medicine Rounds Dengue measles recent events

UBC Tropical Medicine Rounds Dengue, measles, recent events and time for discussion of cases Hajek March 8, 2019

First lets start with a case…. • 24 F with itchy rash after a trip to Ethiopia • Feb 12 – 28 • North-Western Ethiopia • Volunteer work at a hospital • Episodes of diarrhea, improving • Feb 28 - fever, headaches, muscle aches • March 3 – itchy rash over torso and back….

Fever in returned traveler • Exact dates – • Walk them through their travel – • Feb 12 – landed in Addis, what next… what did you do… • Particular exposures • • • Fresh water Unboiled milk or very strange foods Bitten by animals Sex Did anyone else get sick

Back to the case…. • 24 F with itchy rash after a trip to Ethiopia • Feb 12 – 28 • North-Western Ethiopia • Volunteer work at a hospital • • • Swam in waterfall No sex No raw milk No animals No one else sick • Feb 28 - fever, headaches, muscle aches • March 3 – Itchy rash over torso and back… • March 4 - Rash worse. . . • What else to you want to know?

Fever in returned traveler • What to order? • • Routine labs Blood cultures Malaria Serology 1. 2. 3. 4. 5. Dengue Zika BCCDC will do Ig. M and automatic pan-flavivirus PCR! HIV Syphilis Other – rickettsia, leptospirosis, schistososomiasis, brucellosis

Fever and a rash arbovirus

Dengue • 4 billion people at risk • 400 million infections per year • 100 million symptomatic cases • 0. 5 million severe cases • 25, 000 deaths

Dengue •

Dengue • Why are there mosquito nets over these patients in hospital in Islamabad?

Dengue • 1997 – • Dengue Fever vs. Dengue Hemorrhagic Syndrome • 2009 • Uncomplicated Dengue vs, Severe Dengue 1. Shock or respiratory distress due to severe plasma leakage 2. Severe bleeding 3. Severe organ involvement – Liver, CNS, cardiac

Dengue • Clinical • 3 phases: • Febrile phase • Critical phase - transient period of vascular permeability as the fever breaks • Recover phase

Dengue • Warning signs • Occur around day 3 -7, either recover or progress… • • • Abdominal pain Vomiting Lethargy or restless, “unwell” Mucosal bleeding Falling platelets and rising hematocrit

Dengue Diagnosis

Dengvaxia • Recombinant live attenuated YF vaccine – with DEN • 2015 - 3 clinical trials showed ~60% efficacy • 2016 -2017 - Philippines vaccinated 800, 000 children • 2017 - re-analysis of the trial using serology of previous infection • Overall prevented severe Dengue • If 1 million children in high prevalence country vaccinated, over 5 years, vaccination would prevent approximately: • 11, 000 hospitalizations • 2500 severe cases

Should we use a vaccine that helps most people, but hurts a few? • If 1 million children in high prevalence country were vaccinated, over 5 years, vaccination would prevent: • 11, 000 hospitalizations • 12, 000 avoided among seropositive persons; • 1000 excess among seronegative persons • 2500 severe cases • 3000 avoided among seropositive persons; • 500 excess among seronegative persons

Dengue vaccine controversy

• Measles outbreak 203 deaths in 2 months (Feb 2019) 25 deaths n 2 months (Feb 2018) Measles vaccination rates fell: 88% in 2014 55% in 2018 Measles cases rose: 18 000 cases in 2018 2, 400 cases in 2017.

Global rise in measles cases • Before 1963 - 2. 63 million deaths per year of measles • • • 2006 – 500, 000 deaths 2015 – 134, 000 2016 – 90, 000 2017 – 110, 000 2018 – 136, 000 deaths • Ukraine • 35, 120 cases in 2018 • 4, 782 in 2017 • Philippines • 15, 599 cases in 2018 • 2, 407 in 2017 • Brazil • 10, 262 cases in 2018 • Zero in 2017

Measles Incidence Rate per Million (12 M period) Top 10** Country India Cases Rate 64972 49. 07 Ukraine 53218 1197. 56 Pakistan 33224 171. 96 Philippines 20755 200. 88 Yemen 12617 457. 40 Madagascar 12052 484. 12 Brazil 10262 49. 42 Nigeria 6836 36. 75 Venezuela (Bolivarian Republic of) 5643 178. 76 DR Congo 5494 69. 78 Notes: Based on data received 2019 -02 and covering the period between 2018 -01 and 2018 -12 - Incidence: Number of cases / population* * 100, 000 - * World population prospects, 2017 revision - ** Countries with the highest number of cases for the period - *** Countries with the highest incidence rates (excluding those already listed in the table above)

• Measles virus can only be maintained by unbroken chains of transmission. • There are latent or chronic infections that can spread the virus • There are no animal reservoirs • Eradication is possible https: //luckylosing. com/2012/08/18/australian-vaccination-network-crashes-and-burns-on-seminar-tour/measles-deaths-and-cases-usa/

WHO • 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. Air pollution and climate change Noncommunicable diseases Global influenza pandemic Fragile and vulnerable settings Antimicrobial resistance Ebola and other high-threat pathogens Weak primary health care Vaccine hesitancy Dengue HIV

Measles • • • Incubation – 1 -3 weeks Infectious – 4 days before onset of rash Prodrome - cough, coryza, conjunctivititis Rash ( face body; non-blanching ) Complications • • Pneumonia Blindness (vit A) Encephalitis Death (1/4 to 1/1000) • Measles can give you immunity naturally, it can also give you brain damage naturally …. Lancet 2017; 390: 2490– 502