MDT Flashcards by Chris Weber

Person or animal that harbors the infectious agent/disease and can transmit it to others but does not demonstrate signs of the disease

Carrier

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Exposure to a source of an infection; a person who has been exposed.

Does not imply infection; it implies possibility of infection

Contact

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Capable of being transmitted from person to person by contact or proximity. Does not need or utilize a vector.

Contagious

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An organism that harbors a parasitic, mutualistic, or commensalism guest

Host

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An organism that lives on or in a host organism and gets its food from or at the expense of its host

Parasite

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Three main classes of human parasites

Protozoa

Helminths

Ectoparasites

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An infectious agent or organism that can produce disease

Pathogen

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Invasion of the body tissues of a host by an infectious agent, regardless if it causes disease or not

Infection

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A pathway into the host that gives an agent access to tissue that will allow it to multiply or act

Portal of entry

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A population of organisms or the specific environment in which an infectious pathogen naturally lives and reproduces; usually a living host of a certain species

Reservoir

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A pathogen that is transmissible from non-human animals (typically vertebrates) to humans

Zoonosis

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An increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area

Epidemic

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Carries the same definition of epidemic but is often used for a more limited geographic area

Outbreak

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The constant presence of an agent or health condition within a given geographic area or population

Endemic

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An epidemic occurring over a widespread area (multiple countries or continents) and usually affecting a substantial proportion of the population

Pandemic

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Any of a group of viruses that are transmitted between hosts by mosquitoes, ticks, and other arthropods

Arbovirus (arthropod-borne virus)

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Resistance developed in response to an antigen (pathogen or vaccine) characterized by the presence of antibody produced by the host

Active Immunity

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When a majority of a given group is resistant/immune to a pathogen. This confers protection to unvaccinated or susceptible individuals/group by reducing the likelihood of infection or spread

Herd Immunity

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Transfer of active humoral immunity of ready-made antibodies produced by another host or synthesized.

Used when there is a high risk of infection and insufficient time for the body to develop its own immune response. Short term.

Passive Immunity

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Describes any illness, impairment, degradation of health, chronic, or age-related disease

Morbidity

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Time interval from a person being infected to the onset of symptoms of an infectious disease

Incubation period

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Time interval from a person being infected to the time of infectiousness of an infectious disease

Latency period

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An infection that is nearly or completely asymptomatic.

A subclinical infected person is an asymptomatic carrier of the infection

Subclinical infection

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A combination of symptoms characteristic of a disease or health condition; sometimes refers to a health condition without a clear cause

Syndrome

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Measure of death in a defined population during a specified time interval, from a defined cause

Mortality rate

Transmission occurs between an infected person and a susceptible person via direct physical contact with blood or body fluids

Direct contact

Transmission occurs when there is no direct human-to-human contact

Indirect contact

Often indicate the onset of a disease before more diagnostically specific signs and symptoms

Prodrome

Leading cause of domestically acquired arboviral disease in the U.S.

West Nile Virus

Organism that transports West Nile Virus

Culex Mosquito

Incubation period of West Nile Virus

2-6 days, can range 2-4

WNV Mosquitoes become infected when they feed on infected _____; then spread the virus to humans

Birds

Considered 'dead-end' hosts for West Nile Virus

Horses and Humans

Should be considered in any febrile patient or acute neurologic illness with recent exposure to mosquitoes during the summer months in endemic areas

West Nile Virus

Acute systemic febrile illness accompanied by: - Headache, weakness, myalgia, or arthralgia - Gastrointestinal symptoms - Transient maculopapular rash

West Nile Virus

West Nile Virus lab diagnosis

IgM in serum or CSF

West Nile Virus Treatment

Pain control for headaches, antiemetic therapy and rehydration for associated nausea & vomiting

Most patients with non-neuroinvasive WNV disease recover completely; however, fatigue, malaise, and weakness can linger for how long?

Weeks to months

Subtypes of Malaria

Falciparum Vivax Ovale Malariae

Malaria is transmitted via:

Female anopheles mosquito

Incubation period of Malaria

7-30 days

Malaria Phase SEXUAL CYCLE in a female Anopheles Mosquito Begins when a female anopheles mosquito takes a blood meal from an infected human Ends when the mosquito salivary glands are filled malaria parasites

Sporogony Phase

Malaria Phase Asexual cycle in the human liver

Exoerythrocytic Phase

Malaria phase Asexual reproduction in RBCs Patient is SYMPTOMATIC at this stage

Erythrocytic Phase

Presentation of Malaria can be broken into what 2 broad categories?

Uncomplicated & Severe

Paroxysmal (cyclical) fever Influenza-like symptoms including chills, headache, myalgias, and malaise Jaundice & mild anemia secondary to hemolysis

Uncomplicated Malaria

Malaria with the following symptoms: - Small blood vessels infarction, capillary leakage and organ dysfunction - Altered consciousness - Hepatic failure and renal failure - Acute respiratory distress syndrome - Severe Anemia

Severe Malaria

Hallmark of Malaria

Paroxysmal fevers

Life cycle of malaria

48-72 hours

Both positive and negative Rapid Malaria Testing must always be confirmed by:

Microscopy

Two reliable-supply treatments for Malaria

Atovaquone-proguanil (Malarone) Artemether-lumefantrine (Coartem)

Treatment of uncomplicated Malaria

Chloroquine phosphate 1g (600mg base) PO THEN 0.5g in 6 hours THEN 0.5g daily for 2 days

Treatment of malaria in areas with chloroquine resistance

Malarone (Atovaquone 250mg/Proguanil 100mg) 4 tabs PO QD for 3 days

Treatment for severe Malaria

Artesunate 2.4mg/kg IV at 0, 12, 24, 48 hours Followed by doxycycline 100mg BID x 7 days after parenteral therapy

Treatment of P. ovale

Artesunate 2.4mg/kg IV at 0, 12, 24, 48 hours Followed by Doxycycline 100mg BID x 7 days after parenteral therapy Add Primaquine 52.6mg PO QD x 14 days

Malaria Prevention The most important protective measures are:

Proper clothing and awareness

How many subtypes of dengue are there?

Four | DENV-1, DENV-2, DENV-3, DENV-4

Dengue is transmitted by which mosquito?

Aedes aegypti mosquito

Three phases of Dengue Fever

Febrile Critical Convalescent

Dengue Fever Febrile stage typically lasts __ days and can be biphasic

2-7 days

Headache; retroorbital pain; muscle, joint, and bone pain; macular or maculopapular rash Minor hemorrhagic manifestations

Dengue Fever

Mild Dengue Fever Critical phase of dengue typically lasts ___ hours

24-48 hours

Mild Dengue Fever Most patients clinically improve during the phase and move on to recovery and convalescence stage

Critical Stage

Mild Dengue Fever - ______ Stage Plasma leakage subsides Pt begins to reabsorb extravasated intravenous fluids, pleural, and abdominal effusions Patient continues to improve, hemodynamic status stabilizes and diuresis ensues

Recovery

Dengue Fever Hypotension develops, systolic blood pressure rapidly declines, and irreversible shock and death may ensue despite resuscitation efforts

Dengue Shock Syndrome

Dengue Relatively accurate way to get a general determination a patients’ capillary fragility or hemorrhagic tendency.

Tourniquet Test

Dengue - Tourniquet A positive test is ___ or more petechiae per square inch

Treatment for mild Dengue Fever

Hydration and Acetaminophen Avoid skin injections and NSAIDs due to bleeding risk

Treatment for severe Dengue Fever

ICU-level monitoring and blood products Maintenance of the patient's body fluid volume is CRITICAL

Scientific name of Rocky Mountain Spotted Fever

R. rickettsia

Rocky Mountain Spotted Fever is transmitted by:

American dog tick (east of Rockies & Pacific Coast) Rocky Mountain wood tick (Rocky Mountain region) Brown tick (worldwide)

Incubation period for Rocky Mountain Spotted Fever

2-14 days

Rocky Mountain Spotted Fever is a rapidly progressive disease and without early administration of _______ can be fatal within days

Doxycycline

Fever, HA, GI symptoms, myalgias and rash Rash usually presents 3-5 days after fever onset -small flat pink macules on wrist, forearms, ankles and spreads to trunk

Rocky Mountain Spotted Fever

Rocky Mountain Spotted Fever late disease R. rickettsia infects:

Endothelial cells that line blood vessels, causing vasculitis and bleeding or clotting in the brain or other vital organs

Rocky Mountain Spotted Fever __% people have some type of rash

90%

Rocky Mountain Spotted Fever Sign of severe disease

Petechiae

Treatment of choice for all tickborne rickettsia disease (Rocky Mountain Spotted Fever)

Doxycycline

Perform tick checks at __-hour intervals when training or operating in RMSF endemic areas

12 hour

Never let your personnel go >___ hours without a tick check

>24 hours

Lyme Disease is transmitted via:

Blacklegged ticks

Incubation period for Lyme Disease

3-30 days

Reservoirs for Lyme Disease

Rodents (white foot deer mice, chipmunks, squirrels)

Vectors for Lyme Disease

Blacklegged ticks

Most cases, the tick must be attached for ___ hours or more before B. burgdorferi (Lyme) can be transmitted to the host

36-48 hours

Erythema migrans (red ring like rash) Malaise, headache, fever, myalgia, arthralgia, lymphadenopathy

Lyme Disease

Cardiac manifestation of Lyme Disease

Conduction abnormalities, AV node block Myocarditis pericarditis

Neurologic Manifestations of Lyme Disease

Bell's palsy or other cranial neuropathy Meningitis Encephalitis

Late disseminated stage of Lyme Disease symptoms:

Same as acute disseminated stage with: -Rheumatologic Manifestations

Treatment for EARLY Lyme Disease (Erythema migrans)

Doxycycline 100mg PO BID x 14 days

Treatment for early disseminated Lyme Disease (Bell's Palsy)

Doxycycline 100mg PO BID x 14 days

Treatment for disseminated Lyme disease (Arthritis)

Doxycycline 100mg PO BID x 28 days

Lyme disease prevention medication post-exposure prophylaxis

Doxycycline 200mg PO 1 dose

Leishmaniasis organism type

Obligate intracellular protozoan PARASITE

Scientific name of Leishmaniasis

Leishmania tropica

Leishmaniasis is on every continent except:

AUS & Antarctic

Leishmaniasis is transmitted by:

Female phlebotomine sand flies

Incubation period of Leishmaniasis

2 weeks to several months and cases up to 3 years Some >20 years

Most common manifestation of Leishmaniasis

Cutaneous Leishmaniasis

Begins as a pink colored papule that enlarges to a nodule or plaque-like lesion Lesion ulcerates with indurated border and may have thick white-yellow fibrous material Lesions are often painless

Cutaneous Leishmaniasis

Leishmaniasis lesions healing takes how long?

Months to years with noticeable scarring

Cutaneous Leishmaniasis Treatment

Ulcer debrided and cleaned Anti-fungal

Incubation period of MRSA

Highly variable; typically 4-10 days but asymptomatic (years)

The highest risk of being bit by sand flies occurs at what time of day?

Dusk to dawn (typically bite at night and during twilight hours)

Any strain of S. aureus that has developed multiple drug resistance(s) to beta-lactam antibiotics

MRSA

CA-MRSA

Community Acquired

HA-MRSA

Hospital Acquired

Any strain of S. aureus susceptible (able to be killed by) beta-lactam antibiotics

MSSA

Most commonly manifestations of MRSA

Furuncles, carbuncles, and abscesses

Abscess with purulent drainage & fluctuance is a high suspicion for:

MRSA

MRSA treatment

I&D, packing, daily dressing changes - Bactrim - Clindamycin - Doxycycline

An acute or chronic inflammatory process involving bone & structures secondary to infection with pyogenic organisms, including, bacteria fungi, and mycobacteria

Osteomyelitis

Among younger adults osteomyelitis, occurs most commonly in:

Trauma (Penetrating injury) and related surgery

Among older adults, osteomyelitis occurs most commonly as a result of:

Contagious spread of infection from adjacent soft tissues and joints

Patients present with dull pain at the involved joint, with or without movement Tenderness, warmth, erythema, and swelling Fevers

Osteomyelitis

Treatment for Osteomyelitis

Surgical Containment IV Vancomycin & IV Ceftriaxone

Human bites occur in two basic categories

Occlusive wounds (teeth closing over and breaking the skin) Clenched-fist or "fight bites" (skin surface strikes a tooth)

Human Bites Typical human oral and skin flora cause infection

Eikenella Group A Strep Fusobacterium Staphylococci

Antibiotic prophylaxis for Human bites

Amoxicillin-clavulanate 875/125mg PO BID x 5 days

Hand wounds are examined in what positions?

Fingers extended & in the clenched-fist position

Scientific name for Tetanus

Clostridium tentani

Tetanus booster should be within ___ years

10 years

Incubation period for tetanus

3-21 days, usually about 8 days Further the inoculation the site is from CNS the longer the incubation period

An acute, often fatal, exotoxin-mediated disease Widely distributed in soil, and the intestines & feces of farm animals

Tetanus

C. tetani spores can survive autoclaving at _____ degrees Fahrenheit for 10-15 minutes

249.8 F

Tetanus Passive immunization was first used for treatment & prophylaxis of allied forces during:

WWI

Inactivated tetanus toxin was developed in the 1920's and first widely used for allied forces during:

WW2

What conditions allow germination of spores and production of two exotoxins, collectively called 'tetanus toxin'

Anaerobic conditions

Minimum lethal dose in humans for tetanus toxin

2.5 ng per kg

Tetanus Muscle rigidity and spasms occur secondary to the disinhibition of:

Lower motor neurons

Typically the first sign is trismus or lockjaw, followed by nuchal rigidity, dysphagia, and rigidity of abdominal muscles Hyperthermia, diaphoresis, hypertension, episodic tachycardia

Tetanus

Tetanus Death typically occurs secondary to:

Respiratory arrest

Treatment for Tetanus

Clean/deride wounds Supportive therapy and airway protection Antibiotics: - Metronidazole - Pen G - Tetanus Immune Globulin (500 units IM at different sites from the TDAP; part of the dose should be infiltrated around the wound)

When would patients with a completed 3-dose primary tetanus vaccination require a booster of TDAP?

Last documented dose of TDAP was > 5 years ago

Inflammation of the meninges that line the vertebral canal/skull enclosing spinal cord/brain

Meningitis

Inflammation of the brain itself

Encephalitis

Meningitis Risk factors that increase clinical suspicion

Close contact exposure (barracks, dorms) Incomplete vaccinations Immunocompromised >65 y/o & < 5 y/o Alcohol use disorder

Meningitis Typically occurs through what two routes of inoculation?

Hematogenous seeding Direct contagious spread

Febrile, HA, Nuchal rigidity, altered mental status

Meningitis

Labs/Rads for Meningitis

Lumbar puncture CT

Treatment for Meningitis

Ceftriaxone 2g IV OR Pen-G 4 million units IV

Osteomyelitis Antibiotics without activity against _______ should be avoided

E. corrodens

Meningitis Chemoprophylaxis is indicated for close contacts of patients diagnosed with which types of meningitis?

N. meningitidis H. influenzae type B meningitis

Chemoprophylaxis regimen for meningitis

Ceftriaxone 250mg IM one time (or) Ciprofloxacin 500mg PO one time

Mononucleosis organism type

Virus, one of 9 known human herpesviruses

Mononucleosis scientific name

Epstein-Barr virus

Mononucleosis is transmitted via:

Bodily fluids, primarily saliva

Mononucleosis Has a high risk for __________ which can be fatal

Splenic rupture

Presents consistent with erythematous or exudative pharyngitis or tonsillitis Malaise, Fever, Cervical lymphadenopathy, Splenomegaly Rash

Mononucleosis

Mononucleosis Diagnosis can be made clinically and confirmed with:

Monospot test (positive within 4 weeks after symptoms)

Mononucleosis treatment

Bed rest, Acetaminophen or NSAIDs Saline gargles 3-4 times Treat symptomatically

What drug class do you want to avoid when treated Mononucleosis?

Antivirals

Mononucleosis Fever resolves within ___ days Lymphadenopathy and splenomegaly may persist upwards of ____ weeks

10 days 3-4 weeks

Mono Disposition due to risk of splenomegaly and splenic rupture

Light duty with no physical contact sports for 3-4 weeks

Rabies scientific name

Lyssavirus

How many lyssavirus genus' cause rabies in the mammals?

All 14

Incubation for Rabies

1-3 months, depends on site of inoculation

Lethality of rabies One the rabies virus reaches the CNS it has a __% fatality rate

99.9%

Fatal, acute, progressive encephalomyelitis caused by neurotropic viruses in the family Rhabdoviridae, genus Lyssavirus

Rabies

The only U.S. state that has never had a lab-confirmed case of rabies is:

Hawaii

All mammals are believed to be susceptible to infection, but major rabies reservoirs are:

Terrestrial carnivores and bats

Clinical illness in humans begins following invasion of the peripheral nervous system; and then central nervous system; culminating in acute fatal encephalitis

Rabies

First symptoms of Rabies

Pain and paresthesia at the site of exposure

Anxiety, paresis, paralysis, and other signs of encephalitis; spasms of swallowing muscles can be stimulated by the sight, sound, or perception of water (hydrophobia); and delirium and convulsions can develop, followed rapidly by coma and death

Rabies

Clinical rabies typically manifests as what two major forms?

Encephalitic "Furious" -Fever, hydrophobia, pharyngeal spasms, hyperactivity subsiding to paralysis Paralytic "Dumb" -Ascending paralysis that is similar to Guillain-Barre

Most characteristic feature of Rabies; patient becomes afraid of water due to involuntary pharyngeal muscle spasms when they attempt to drink

Hydrophobia

Rabies Pathognomonic pharyngeal muscle spasms triggered by feeling draft of air Leads to aspiration, coughing, choking, and if severe asphyxiation and respiratory arrest

Aerophobia

Diagnostic confirmation of rabies

Post-mortem brain tissue samples

Rabies Offending animals that appear well will be placed in isolation for ___ days for observation

10-14 days

Diarrhea is defined as ___ or more loose or water stools within a 24 hour period

3 or more

Acute Diarrhea = ___ days Persistent = ___ days Chronic = ___ days

Acute = < 14 days Persistent = 14-30 days Chronic = > 30 days

Presents with blood in loose-watery stools and fever Secondary tissue damage to lining of the colon from certain bacteria, and/or toxins

Inflammatory Diarrhea

Watery stools with no blood & absence of fever

Non-inflammatory Diarrhea

Community outbreaks of infectious Diarrhea are highly suggestive of:

Common food source, or viral etiology

Bacterial Etiologies of infectious Diarrhea

Enterotoxigenic Escherichia coli Campylobacter jejuni Shigella spp. Salmonella spp. Bacterial toxin-releasing

Viral Etiologies of Infectious Diarrhea

Norovirus Rotavirus (primarily children)

Protozoal etiologies of infectious Diarrhea

Giardia Entamoeba histolytica

Viral infectious Diarrhea

Norovirus

Norovirus activity peaks during what season

Winter

Predisposing factors for Viral infectious Diarrhea

Ready-to-eat cold foods (sandwiches and salads) Raw shellfish especially oysters, contaminated ice Close quarters living with high population density

Viral infectious Diarrhea is transmitted via:

Fecal-oral route Aerosols of vomitus Contaminated environmental surfaces/objects

Incubation period for Viral infectious Diarrhea

12-48 hours

Acute onset of nausea, vomiting, and non-bloody diarrhea Abdominal cramps, and sometimes a low-grade fever Illness is generally self-limited, and full recovery can be expected in 1-3 days for most patients

Viral infectious Diarrhea

E. coli AKA Traveler's diarrhea or Montezuma's revenge

Enterotoxigenic E. coli (ETEC)

E. coli Also called Shigatoxigenic Escherichia Coli or STEC

Enterohemorrhagic E. coli (EHEC)

E. coli Inflammatory Diarrhea is transmitted via:

Fecal-oral route

Salmonella Most common clinical presentation of infection

Gastroenteritis

Symptoms typically consist of acute diarrhea, abdominal pain, fever, and vomiting for 4–7 days. Patients typically recover without treatment

Salmonella

Salmonella Inflammatory Diarrhea Treatment for patients with severe diarrhea, high fever, or manifestations of extraintestinal infection

Fluoroquinolones

Transmission routes for Campylobacter infectious Diarrhea

Eating contaminated foods (undercooked chicken/raw chicken) Contaminated water or unpasteurized milk

Characterized by diarrhea (frequently bloody), abdominal pain, fever, and occasionally nausea and vomiting. Severe infections can include dehydration, bloodstream infection, and mimic acute appendicitis or ulcerative colitis. Generally self-limiting & lasting < 1 week

Campylobacter

Diarrhea of the _______ tend to be more frequent, smaller volume and are often more painful. Fever, bloody stools, or mucus tends to be more common

Large bowel

Diarrhea of the _______ origin tend to be larger volume and watery and will tend to have more abdominal cramping, bloating and gas

Small bowel

Diarrhea within 6 hours of food consumption is suggestive of toxin possible from:

S. aureus B. cereus

Diarrhea between 8-16 hours after eating suggests

C. perfringens

Diarrhea >16 hours after eating suggests

Viral or other Bacterial etiology

Reptiles have ______ on skin

salmonella

Diarrhea Hiking or outdoor recreation where patient may have drunk stream water would indicate:

Giardia

Diarrhea Being on a ship where others have had recent illness would indicate:

Norovirus

Protozoal Parasitic infectious Diarrhea is caused by:

Giardia

Most common intestinal parasitic disease affecting humans

Giardia

Incubation period for Giardiasis

1-14 days; mean of 7

Giardia life cycle - Infectious form of the parasite - Excreted in stool and can survive in wet environments - After ingestion excystation occurs in the proximal small bowel releasing trophozoites

Cyst Form

Giardia life cycle - Flagellated parasites adhere to proximal small bowel - Trophozoites that pass to large intestine revert to cysts and excreted into the environment

Trophozoite Form

Acute Giardiasis Symptoms typically develop in __ weeks after exposure and resolve within ___ weeks afterwards

1-2 weeks 2-4 weeks

Symptoms - Diarrhea (foul-smelling & greasy) - Abdominal cramps, bloating, flatulence, fatigue, anorexia, and nausea Gradual onset of 2-5 loose stools per day and gradually increasing fatigue. Weight loss may occur over time. Fever and vomiting are uncommon.

Giardiasis

Giardiasis lab diagnostic tests

Antigen detection assays Stool microscopy

Giardiasis Stool microscopy Diagnostic sensitivity increased by examining up to __ stool specimens over several days

Giardiasis treatment

Tinidazole Metronidazole

Giardia Patients need to be excluded from going into water until asymptomatic for ___ hours

48 hours

General treatment guidelines for infectious diarrhea

Rule out more serious pathologies Rehydration BRAT (bananas, rice, applesauce, toast) diet Patient education regarding hygiene

Infectious Diarrhea Symptomatic therapy/conservative treatment for mild-moderate in the absence of fever & bloody stools.

Loperamide Bismuth subsalicylate

Severe fluid loss from infectious diarrhea should be treated with:

1-2 liters of LR

Severe fluid loss from infectious diarrhea What tests should be utilized as a metric for improvement?

Orthostatic hypotension tests

When to consider antibiotics for infectious diarrhea?

Severe disease (Fever, >6 stools/day, signs dehydration) Blood or mucoid stools with no clinical suspicion of E. coli

Infectious diarrhea E.coli 0157:H7: specific strain of E.coli associated with

Undercooked fast-food hamburger meat

Infectious Diarrhea Antibiotic treatment has no clinical benefit in a patient with 0157:H7, and can significantly worsen outcomes by causing:

Hemolytic Uremic Syndrome (HUS)

Most cases of non-inflammatory diarrhea are self-limiting and resolve within:

48-72 hours

Any patient suspected of having infectious diarrhea shall be removed from food handling & food preparation duties until symptom free for:

24 hours

When to consider MEDADVICE or MEDEVAC for a patient with infectious diarrhea

Fever >101.3 Blood in stool Severe Dehydration (with inability to rehydrate) Multiple patients presenting at once with similar symptoms Inability to control symptoms with medication

Influenza scientific name

Orthomyxovirus

Subtypes of influenza

A/B/C/D

Influenza subtypes that cause illness in humans

A & B

Influenza viruses spread from person to person primarily through:

Respiratory droplet transmission

Incubation period for influenza

24-96 hours

Influenza can cause severe illness and death typically at what ages?

>65 or <2

Epidemics of influenza usually occur during which months?

Fall and winter months

Influenza Adults are infectious from 1 day prior to symptom onset to __ days after symptom onset

5-7 days

Flu Infectiousness is highest within __ days of onset and correlated with fever

3 days

Children and immunocompromised/severely ill may shed the flu virus for ___ days after onset of symptoms

>10 days

Two distinct glycoproteins which are necessary for viruses to enter cells and are also how influenza undergoes periodic changes

Hemagglutinin (H1, H2, H3) Neuraminidase (N1 and N2)

Avian influenza glycoproteins

A(H5N1) A(H7N9)

Swine-origin glycoproteins

A(H1N1) A(H1N2) A(H3N2)

Fever/chills (> 100.8 F), myalgias, headache, malaise, occasional nausea, sometimes vomiting Nonproductive cough, sore throat, rhinitis, substernal soreness, nasal congestion Predominantly localized to the respiratory tract; include nasal discharge, pharyngeal inflammation without exudates, and occasionally rales on chest auscultation

Influenza

Influenza typically resolves within __ days

1-7 days

Treatment goal for influenza

Alleviate and control symptoms while preventing spread to others

Antiviral medication for Influenza that can shorten the duration of fever and other symptoms and reduce the risk of complications

Oseltamivir 75mg PO BID

- Transmitted through consumption of contaminated water or food and certain sex practices. - Infections are typically mild, with most making a full recovery & gaining lifelong immunity. - Most people in areas of the world with poor sanitation have been infected with this virus. - Safe and effective vaccines are available

Hepatitis A Virus (HAV)

-Transmitted through exposure to infective blood, semen, body fluids, contaminated blood products, and IV drug use. - Poses risk to healthcare workers (needle stick injuries). - Safe and effective vaccines are available

Hepatitis B Virus (HBV)

Transmitted through exposure to infective blood, contaminated blood & blood products, and IV drug use. Sexual transmission is possible but less common. There is no vaccine

Hepatitis C Virus (HCV)

Infections occur only with Hepatitis B infection Dual infection, results in a more serious disease and worse outcome Hepatitis B vaccines provide protection

Hepatitis D Virus (HDV)

Transmitted through consumption of contaminated water or food. Common cause of hepatitis outbreaks in developing nations. Vaccines exist but are not widely available.

Hepatitis E Virus (HEV)

No vaccination for Hepatitis C but can be cured with:

Antiviral Treatment

Hepatitis Can both remain dormant in the liver and cause chronic hepatitis & hepatocellular carcinoma

Hep B & Hep C

Fatigue, fever, muscle/joint pains, runny nose, pharyngitis, nausea, vomiting, anorexia - Low grade fever - Hepatomegaly with liver tenderness - Jaundice and scleral icterus - Right upper quadrant abdominal pain

Hepatitis

Hepatitis Within __ weeks, jaundice & RUQ pain develops

1-3 weeks

Lab diagnostic test for Hepatitis

Hepatitis panel serologic testing

Lab findings for Hepatitis

WBC = Normal or low UA = Proteinuria and Dark urine (bilirubinuria) LFT = Increased levels of AST and ALT * Viral: ALT>AST * Alcoholic: AST>ALT CMP Elevated bilirubin and alkaline phosphates

TB scientific name

Mycobacterium tuberculosis

Subtypes of TB

Multi-drug resistant TB (MDR-TB) Extensively drug-resistant TB (XDR-TB)

TB is transmitted via:

Contagious patient coughs, spreading bacilli through the air

Leading infectious cause of death worldwide

Characterized by local granulomatous inflammation in periphery of the lung (GHON focus) may be accompanied by ipsilateral lymph node involvement (GHON complex)

Vaccines against TB

Bacille Calmette-Guerin (BCG) Interferon-Gamma Release Assays (IGRAs) - QuantiFERON – TB Gold In-Tube test (QFT–GIT) - SPOT TB test (T–Spot)

TB vaccination may cause a false positive reaction to a TB skin test.

BCG

Positive result on the following labs: (a) Tuberculin skin test (TST) (b) Purified protein derivative (PPD) (c) Positive QuantiFERON Gold blood test (d) Positive IGRA-TB blood test Patient is infected with M. tuberculosis but does not have active TB disease

Latent TB

Labs and Rads for Latent TB

(1) Positive TST/PPD or blood test (2) Normal CXR (3) Negative acid-fast sputum test

TB Document History on which form?

NAVMED 6224/7, Initial TB Exposure Risk Assessment

Latent TB infection Baseline LFTs are indicated in patients who have:

Elevated risk for liver disorder (heavy/regular ETOH use)

LTBI regimens

Isoniazid & rifapentine (3HP) PO once a week x 12 weeks. Rifampin PO QD x 16 weeks Isoniazid PO QD for 6-9 months, plus Pyridoxine PO QD for 6-9 months to mitigate peripheral neuropathies

The provider must rule-out active TB before started the treatment for LTBI via:

Labs and Chest X-ray

LTBI Who should you consult for preferred treatment regimen and the likelihood of drug-resistant strains in the region?

Local NEPMU/MTF

LTBI Monthly follow up is required and will be documented on which form?

NAVMED 6224/9

Where do you document successful completion of LTBI?

Medical Record

Active TB is denoted from which three terms?

Post-primary TB Reactivation TB Active TB

Prolonged & productive cough with or without hemoptysis, chest discomfort & pain, low-grade fever, decreased appetite & anorexia, unexplained weight loss, night sweats

Active TB infection (pulmonary)

TB Most common in adults (60%–80%). Can occur years to decades after primary infection after immunological impairment.

Post-primary Re-activation TB

Lab test Measures immune response to TB antigens Does not differentiate LTBI & ATB

IGRA-TB

TB Screening and provisional testing, not confirmatory Does not differentiate between active LTBI and ATB

Tuberculin Skin Test (TST)

Gold standard for confirmatory TB diagnosis Can differentiate between LTBI and ATB

Sputum Test - Acid-Fast Bascillus (AFB) with NAAT

What might you find on a CXR for a patient with Post-primary Re-Activation TB:

Fibrosis/scarring, cavitations Enlargement of hilar and mediastinal lymph nodes

Patients with suspected/known active TB immediately get _______ to minimize aerosolization of respiratory secretions and spread

Surgical masks

Active TB Medical department must wear:

Particulate respirators (N95)

TB Medical event report must be submitted within:

24 hours

Suspected or confirmed case of active TB, the SMDR notifies _______ as soon as possible

Cognizant NEPMU

TB Follow routine testing and screening guidelines from which instruction?

BUMEDINST 6224.8C

TB Prevention Ensured TST/PPD is conducted during which timeframes?

Pre-deployment and Post-deployment

Anthrax scientific name

Bacillus anthracis

Predisposing factors for Anthrax

Working with any unvaccinated animal that is a common reservoir More common in ranchers, leather workers, veterinarians, wildlife researchers

Incubation period for Anthrax

Cutaneous anthrax 1-7 days; 17 days in rare cases

Zoonotic disease primarily affecting ruminant herbivores such as cattle, sheep, goats, antelope, and deer that become infected by ingesting contaminated vegetation, water, or soil

Anthrax

Four main clinical presentations of Anthrax

Cutaneous Ingestion Injection Inhalation

Most common form of anthrax in humans (95-99%)

Cutaneous

Hallmark of cutaneous anthrax

Eschar with extensive surrounding edema

Small, painless, pruritic papules emerge anywhere from 1 – 12 days after exposure Papules enlarge rapidly to vesicles or bulla (blisters) Vesicle or bulla start to erode and leave painless black necrotic ulcer

Cutaneous Anthrax

Treatment for Anthrax

Refer to an infectious disease specialist Antibiotics - Ciprofloxacin - Levofloxacin - Doxycycline

If untreated, cutaneous anthrax may result in:

Sepsis Meningitis

Scientific name for Chlamydia

Chlamydia trachomatis

Most frequently reported bacterial STI in the U.S

Chlamydia

Chlamydia transferred from mother to child can cause:

Infant blindness "trachoma"

Known as a ‘silent’ infection because most infected people are asymptomatic & lack abnormal physical examination findings.

Chlamydia

Male presentation for chlamydia

Urethritis - CLEAR WATERY discharge - Dysuria is most common complaint - Scant discharge on underwear usually presents in the morning

Urethritis - Dysuria - Pyuria - Increased urinary frequency Cervicitis - Increased vaginal discharge - Intermenstrual vaginal bleeding - Dyspareunia

Female presentation for chlamydia

___% of chlamydia and gonorrhoeae co-infections

>50%

Gold standard for laboratory diagnosis for Chlamydia

Nucleic Acid Amplification Testing (NAAT) | -UA or discharge swab

Preferred treatment for Chlamydia

Doxycycline 100mg PO BID for 7 days

Antibiotic of choice for chlamydia if concerned for coinfection with gonorrhea

Ceftriaxone

Untreated chlamydia can cause:

- Pelvic Inflammatory Disease - Pre-term delivery in women who are pregnant - Reactive Arthritis

Gonorrhea scientific name

Neisseria gonorrhoeae

Incubation period for Gonorrhea

1-14 days, can be as short as 2-4

Male presentation for gonorrhea

Dysuria | -White/yellow/green urethral discharge

Female presentation for gonorrhea

- Dysuria, increased vaginal discharge, or vaginal bleeding - Lower abdominal discomfort - Dyspareunia

Diagnostic lab tests for Gonorrhea

GC/NAAT Culture (important due to antibiotic resistant strains)

__% of gonorrhea infections are resistant to at least one antibiotic

50%

Emergence of fluoroquinolone-resistant N. gonorrhoeae left _________ as the sole remaining class available for treatment of gonorrhea in the U.S.

Cephalosporins

Treatment for Gonorrhea

Ceftriaxone 500mg IM single dose AND Doxycycline 100mg PO BID x 7 days

STI screening includes:

Gonorrhea Chlamydia HIV RPR for syphilis HPV vaccination counseling

Scientific name for syphilis

Treponema pallidum

Incubation period for Syphilis

10-90 days; average is 21 days

Stages of Syphilis

Primary Syphilis Secondary Syphilis Latent Stage Tertiary Syphilis

Begins as a painless papule that proceeds to ulcerate. Ends as a to 1-2cm painless ulcer with raised margins. This is called a chancre. Lymphadenopathy is typically in the inguinal lymph nodes. Chancre lasts 3 to 6 weeks and heals.

Primary Syphilis

Skin rashes and/or mucous membrane lesions (sores in the mouth, vagina, or anus) Syphilitic rash is characterized by diffuse non-pruritic maculopapular eruption on the trunk and extremities that includes the palms and soles. Additional symptoms may include fever, swollen lymph glands, sore throat, patchy hair loss, headaches, weight loss, muscle aches, and fatigue.

Secondary Syphilis

Stage is a period of no visible signs or symptoms of syphilis. Without treatment, the patient will continue to be infected but will not realize it.

Latent Stage

Rare and develops in a subset of untreated syphilis infections that appear 10–30 years after infection and can be fatal. Cardiovascular syphilis Neurosyphilis - General paresis - Tabes dorsalis Gummatous syphilis

Tertiary syphilis

Diagnostic tests for Syphilis

Serologic test (the standard) Nontreponemal tests (RPR) Treponemal test (FTA-ABS) (confirmatory test)

Nonspecific Syphilis test, not definitive Can be falsely positive (Lupus, mononucleosis, pregnancy) Need to be confirmed with treponemal test

RPR

Standard treatment for all stages of syphilis

Penicillin G

Treatment for Primary Syphilis

Penicillin G 2.4 million units IM once PCN allergy: Doxycycline 100mg PO BID x 14 days

Treatment for secondary syphilis

Penicillin G 2.4 million units IM once weekly for 3 weeks Doxycycline 100mg PO BID x 4 weeks

An acute febrile reaction frequently accompanied by headache, myalgia, fever, that can occur within 24 hours after initiation of therapy for syphilis. Reaction occurs most frequently among persons who have early syphilis, presumably because bacterial burdens are higher during these stages.

Jarisch-Herxheimer reaction

Trichomoniasis organism type

Anaerobic, flagellated protozoan PARASITE

Trichomoniasis scientific name

Trichomoniasis vaginalis

Incubation period for Trichomoniasis

5-28 days

T. vaginalis principally infects ______ epithelium in the urogenital tract

Squamous epithelium

Purulent, malodorous discharge, burning, pruritis, dysuria, dyspareunia Physical exam: erythematous vulva, green-yellow malodorous discharge

Trichomonas

Trichomonas lab diagnostic tests

Wet mount prep NAAT

Treatment for trichomonas

Metronidazole 2g PO single dose or 500mg BID x 7 days *No alcohol consumption during treatment and 24 hours after completion*

Trichomonas Abstain from sex until they have been treated and asymptomatic for __ days

7 days

HSV scientific name

Human alphaherpesvirus 1 & 2

Incubation period of HSV

2-12 days; average is 4 days

Severe. painful genital ulcers Dysuria Fever Local inguinal lymphadenopathy

Primary infection HSV

Unilateral small vesicular lesions on erythematous base or ulcerative lesions “dew drops on a rose petal” May have mild tingling or shooting pains in buttocks and legs prior to recurrent episode

Recurrent HSV infection

Acute treatment for Primary HSV infection

Acyclovir 400 mg orally TID for 7–10 days Acyclovir 200 mg orally five times a day for 7–10 days Valacyclovir 1 g orally BID for 7–10 days Famciclovir 250 mg orally TID for 7–10 days

Reactivation of HSV can be triggered by:

Stress, menstruation, anxiety

Scientific name of HPV

Human papilloma virus

Most common strains of HPV causing anogenital warts

Types 6 & 11

HPV strains that are high-risk subtypes for developing a malignancy

16 & 18

Most common STD in the world

HPV

Incubation period for HPV

2 weeks to 1 year

Anogenital lesions may be found on the penis, vulva, vagina, cervix, perineum, and the anal region. -Usually appear as raised, skin-colored, fleshy papules that range in size from 1-5 mm. -They can be broad and flat, pedicled, or occasionally have a cauliflower-like appearance

HPV

HPV Treatment

Topical therapies Cryotherapy Surgical excision

HPV treatment should be pursued if:

Lesions that persist for more than two years if the lesions are symptomatic, or for cosmetic purposes.

HPV topical therapies

Imiquimod cream Podophyllotoxin Solution

HPV treatment Inexpensive, minimally painful, and safe during pregnancy Weekly treatment for 6-10 weeks.

Cryotherapy

HPV therapy that has a clearance rate near 100%

Surgical excision

HPV Infection is preventable with:

Vaccination (Gardasil)

Who should get vaccinated against HPV?

All females and males 11-26 years of age

9 of every 10 cases of cervical cancer are caused by:

HPV

HPV can cause what types of cancer?

Female: Cervix, Vagina, Vulva Male: Penis

Scientific name for HIV

Human immunodeficiency virus

Subtypes of HIV

HIV-1 & HIV-2

Incubation period for HIV

2-4 weeks

Untreated survival timeframe for HIV

9 to 11 years

Sex workers have a __x higher infection rate of HIV than the general population

12x

The acute phase of HIV infection is called:

Acute Retroviral Syndrome (ARS)

Fever, maculopapular rash, arthralgia, myalgia, malaise, lymphadenopathy, oral ulcers, pharyngitis, and weight loss. The presence of fever and rash have the best positive predictive value

Acute Retroviral Syndrome (acute phase of HIV)

HIV laboratory testing

Screening test: OraQuick ADVANCE Rapid HIV-1/2 Antibody test Confirmatory test: 4th Gen HIV immunoassay

HIV PrEP

Pre-exposure prophylaxis

HIV PrEP Guidelines

DHA IPM 18-020: Guidance for HIV (PrEP) for Persons at High Risk

Initiation of PrEP requires:

Negative 4th gen HIV test within 7 days if infection is not suspected Negative 4th gen HIV test & Nucleic Acid Test within 7 days if infection is suspected

HIV PEP

Post-exposure Prophylaxis

Medication type that has improved life expectancy for HIV patients

ART

HIV in Military Service Members instruction

DoDI 6485.01

DoDI member with HIV Clinical evaluations required by military infectious disease physicians at least every ____ months after diagnosis

6-12 months