Updates by Carol A. Kemper, MD, FACP
Updates
By Carol A. Kemper, MD, FACP, Section Editor: Updates, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, is Associate Editor for Infectious Disease Alert.
Travel for the Hajj
National Travel Health Network and Centre, September 2012; http://www.nathnac.org/factsheets/Hajj_Umrah.htm
Travel to the Middle East may have gotten less popular recently, but for those planning to travel for the annual pilgrimage to Makkah (Mecca) October 24-29, 2012, The National Travel Health Network has issued updated guidelines, as follows:
- Meningococcal Vaccine: While meningococcal vaccine has previously only been recommended, it is now required for all travelers age 2 years or older. Proof of vaccination against Meningococcal meningitidis ACW1354 is now required to obtain a visa. In addition, in order to reduce the carrier rate, the Saudi Arabian Ministry of Health plans to administer prophylactic antibacterials to all those arriving from the Africa continent.
- Polio: For those traveling from the United States who received polio vaccination more than 10 years earlier, at least one dose of oral polio vaccine should be administered at least 6 weeks prior to departure (Tdap is preferred). In addition, the Saudi Arabian Ministry of Health requires that travelers from countries endemic for polio (India, Pakistan, Afghanistan, Chad, Nigeria, Angola, etc.), regardless of age or polio vaccination status, receive a dose of OPV at least 6 weeks prior to departure, and all such travelers will receive an additional dose on arrival to the country. Further, travelers coming from a country where there has been a case of imported polio within the past 12 months (e.g., China, Yemen, Mali, etc.) must show proof of OPV vaccination within at least 6 weeks in order to obtain a visa — and they also will be required to receive an additional dose on arriving in the country.
- Influenza: Annual influenza vaccination is recommended.
- MMR: Current vaccination is routinely recommended.
- Hepatitis B Vaccine: A common ritual for men participating in Hajj is to have their heads shaved. While licensed barbers are legally required to employ a fresh blade with each new customer, illegal street venders may not follow the law. It is therefore recommended that travelers consider HBV vaccination.
- Malaria: Malaria is not present in Makkah, although it is present in the southwestern areas of Saudi Arabia. Travelers planning to visit this more rural region should consider malaria prophylaxis.
- Specific recommendations for women: They also recommend that women should consider hormonal therapy to avoid having a menstrual cycle.
Banner Year for West Nile Virus in U.S.
ProMEDmail post. September 10 and 13, 2012; http://www.promedmail.org.
This year is proving to be a banner year for West Nile Virus infection in the United States. Thus far, a total of 2,636 WNV cases have been reported in the United States, including 1405 cases of neuroinvasive disease and 118 deaths. More than 70% of cases have been reported from 6 States, including Texas, South Dakota, Mississippi, Oklahoma, Louisiana, and Michigan. Many of these areas have previously not been a focus of WNV infection — and it's not clear why certain areas, such as Dallas should be especially affected this year. As of September 4th, the greatest number of cases have been reported from Texas, with 1013 cases, including 40 deaths. This represents a 50% increase in cases in just 2 weeks. These numbers reflect only those infections that are recognized and reported, and disproportionately represent the severe cases. Most people who become infected have no clinical symptoms.
Two factors may be contributing to this increase. Scientists at the North East Regional Climate Center, Cornell University, who track climate conditions, report this was the warmest spring ever – which may contribute to an increase in mosquito larvae.
In addition, some communities have attempted to cut back on spraying, due to concerns about more general pesticide applications. Spraying for West Nile Virus typically contains a variety of insecticides, including malathion, methoprenes, and synthetic pyrethroids resmethrin and sumithrin. Generalized spraying for WNV in our area with malathion has met with protest. In addition, it has been demonstrated that the great lobster die-off along the Long Island Sound in 1999 (which wiped out more than 90% of the local lobster population) was likely due to the use of methoprenes used in Spraying of New York City that year to combat WNV. Methoprenes have been shown to function as an arthropod juvenile growth hormone agonist, promoting larval insect molting and changes in chitoproteins. Unfortunately, lobsters are also arthropods, and ground water run-off into the ocean containing this insecticide can result in small poorly formed lobsters, often with deformed shells. Similar small lobsters with deformed shells have been reported off the coast of Connecticut this year, probably for similar reasons. The New York House of Representatives just passed a bill in June 2012 banning the use of methoprene as an insecticide.
Alternatives include removing all standing water, empty all containers, bird baths or other pools, and drain ponds and ditches, as well as avoiding mosquito bites, using screens on windows, protective clothing and mosquito deterrents.
HIV quickly invades the CNS
Valcour, et al. Central nervous system viral invasion and inflammation during acute HIV infection. J Infect Dis 2012; Advance publication June 11, 2012.
Twenty individuals with acute onset HIV infection underwent intensive neurologic evaluation, including comprehensive examination and laboratory study, cerebrospinal fluid examination, MRI and Magnetic resonance spectroscopy. One patient with acute syphilis and a high CSF white blood cell count was excluded. The average time from exposure to detection of infection was estimated to be 14.5 days (range, 4-31 days). The median CD4 count was 384 cells/mm3 (range, 218-740 cells/mm3). Headache was the only clinical complaint (in 11/20 subjects), and none had focal neurologic complaints or physical exam findings.
Lumbar puncture was performed in 18 participants (2 declined) a median of 17 days following estimated exposure. HIV RNA was identified in CSF in 15 subjects, at the earliest date of 8 days following exposure. CSF HIV RNA was negative in a single participant who underwent CSF sampling earlier than this at 4 days following exposure; this person's plasma HIV RNA was 2,231 copies/mL. Two other individuals had negative CSF HIV RNA testing, including one patient at 10 days following exposure (the plasma HIV RNA was 285,651 copies/mL; and another patient at 18 days following exposure (plasma HIV RNA 81,978 copies/mL.
The CSF HIV RNA level appeared to correlate with the plasma HIV level (p < 0.007), and was on average 2.4 log copies/mL lower than in plasma (p < .001). None of the patients had a CSF HIV RNA level higher than that found in plasma level (11 specimens were sampled on the same day). CSF neopterin levels were also elevated and correlated with plasma HIV RNA levels, and intrathecal immune activation was evident in 5 of 18 subjects. No structural abnormalities were identified on MRI. On MRS, there was a trend toward increased choline/creatine levels in the basal ganglia and occipital grey matter in individuals with acute HIV infection compared with those with chronic HIV disease or uninfected controls. The authors observed an association between higher neopterin levels and elevated choline/creatine levels, especially in the posterior cingulate gyrus.
Invasion of the CNS occurs early in the course of HIV infection (as early as 8 days), resulting in disturbances of inflammatory and metabolic markers, especially in the front lobes and cingulate cyrus, although did not result in any significant clinical findings other than headache. CSF HIV RNA levels generally parallel plasma HIV RNA.
This Piggie went to the Fair...
ProMEDmail post September 11, 2012; http://www.promedmail.org.
Of course, I happened to be visiting Minnesota and planned to attend the State Fair the weekend before Labor Day, just as health alerts reported the first cases of "swine flu" in humans associated with the Fair. For those of you not in the know – the Minnesota State Fair is a huge affair, covers several acres with extensive animal barns, and goes on for 12 days, including Labor Day Weekend. More than 1.7 million people attend the Fair yearly – typically 120,000-130,000 per day. And this news did not keep them away.
A total of 4 cases of this new "swine flu" have thus far been confirmed, all of which occurred in children and teens who spent long hours in the swine barn (the kids basically spend the entire day working with their animals and hanging out in the stalls and corridors with friends). The most recent case was identified in a teenage boy who was exhibiting hogs between August 23-26, and became ill 4 days later after going home. All 4 individuals quickly recovered with no sequelae. There has been no evidence of human-to-human transmission with this virus. The Minnesota Department of Health indicates that 2 sick pigs at the fair have also tested positive for H1N2v.
The virus has been identified as a variant H1N2 Influenza A virus (H1N2v). Interestingly, it carriers the matrix gene from the 2009 H1N1 pandemic virus, which suggests that it could potentially be transmissible in humans. Ongoing surveillance by the Department of Agriculture has identified other similar influenza viruses in pigs in Minnesota and other states as early as 2010, some containing the matrix gene, although none had previously caused human disease. Other H1N2 viruses have rarely caused disease in humans, typically in children or teens with close contact with animals.
This H1N2v "swine flu" strain is different from the other new strain of influenza, H3N2v (aren't all these new strains "v" by definition ?), that has resulted in 297 cases in the Midwest, also linked to agricultural fairs. This strain also carries the 2009 H1N1 matrix gene, and while human-to-human transmission with this virus has not been confirmed, the CDC suggests there have been cases where human transmission was suspected.
Travel to the Middle East may have gotten less popular recently, but for those planning to travel for the annual pilgrimage to Makkah (Mecca) October 24-29, 2012, The National Travel Health Network has issued updated guidelines, as follows:Subscribe Now for Access
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