Seven BIG reasons to stay briefed on infectious diseases

Patricia Huston, MD, CCFP, MPH

Michel Deilgat, CD, MD, MPA, MEd, CCPE

Family Medicine Forum

November 11, 2017

DISCLOSURES

Dr. Michel Deilgat

COIs: NONENo competing financial interests exist

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DISCLOSURES

Dr. Patricia Huston

In the spirit of transparency here are my biases:

I think CCDR is a great way to stay briefed on IDs

and St. Andrews-by-the-Sea in NB is one of my favourite places on earth:

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Our objective for today:

To inspire, motivate and regale you regarding 7 current ID topics: - Give some facts and identify some federal and other resources/tools

- Pose some reflective questions

In order to advance your CanMED competencies and enjoy an hour together.

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Reason #1: Infectious diseases are evolving

WHY?

1. Globalization

• Over 20% of the

population in Canada

mother tongue

non-English/French

(2016 Census)

• People travel

2. Climate change…

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Resources: TRAVEL.GC.CA

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Resources: CATMAT statements

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#1 Infectious diseases are evolving…

Q: Have you seen

the health effects of

globalization and

climate change?

• What are the implications

for practice?

• Any tips or insights?

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Reason #2: To avoid the risk of totally drug-

resistant infections

Last year at the United Nations Annual Assembly a resolution was passed

identifying

ANTIMICROBIAL RESISTANCE

as a GLOBAL HEALTH SECURITY ISSUE

- All countries committed to

working on this.

- We face a dystopic situation

of running out of treatment

options…

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Reason #2: Risk totally drug resistant

gonorrhea

The situation is NOT pretty:

• Gonorrhea is the second most

common STI in Canada

• Much like the rest of the world,

its incidence has been steadily

rising

• Over the years gonorrhea has

become resistant to

– Tetracyclines

– Sulfonamides

– Trimethoprim combinations,

– Quinolones

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Reason #2: Totally drug resistant infections…

Nasty complications:

• Several-fold increase in HIV

transmission

• Pelvic inflammatory disease

– Acute/chronic lower

abdominal pain

– Ectopic pregnancy

– Spontaneous abortion

– Infertility

Current recommendation:

Combination therapy

• Azithro + either

Ceftriaxone or Cefixime

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Reason #2 Why risk of total resistance?

• We are seeing rising rates of resistance to the last two

effective antibiotics.

• US CDC reported that between 2013 and 2014,

– Resistance to azithromycin rose from 0.6% to 2.5%, while

– Resistance to ceftriaxone rose from 0.4% to 0.8%.*

• CURRENT RATES ARE LOW

– Similar situation in Canada

The trend is concerning

* Kirkcaldy RD et al. N gonorrhoeae antimicrobial susceptibility surveillance. MMWR 2016:65(7):1-19.

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Reason #2: Risk of totally resistant gonorrhea

In a recent online survey

…. only 20% of clinicians indicated they would prescribe a

cephalosporin and azithromycin as first-line therapy for gonococcal

pharyngeal infection.*

• This was a convenience sample

• Suggests not all clinicians are aware of the need for combination therapy.

Q: What are the implications for practice?

TIPS?

* Ha S et al. What are Canadian primary care physicians prescribing for the treatment of gonorrhea?

CCDR 2017;43(2):33-7.

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Resources

STI treatment app

-- from the Public Health Agency of Canada

-- can be downloaded for free for Apple

or Android devices

-- puts all the latest treatment guidance

at your fingertips.

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Reason #3: Lyme disease is expanding its reach

in Canada

• Lyme disease is the most

common vector-borne

illness in North America

• (US) Reported cases of

LD have increased from

approx. 10,000 cases

annually in 1991 to >

25,000 cases in 2014

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Reason #3: Lyme disease is expanding its reach

in Canada

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Reason #3 - Facts about Lyme Disease

1) LD is a treatable multisystem illness

2) LD is predominantly a clinical diagnosis

3) Both underdiagnosis and overdiagnosis:

- Nonspecific symptoms, and

- Shortcomings of available serologic tests

Primary physicians need to be skilled in the clinical recognition of early

localized, early disseminated and late disseminated disease (clinically capable

of differenting from other acute, subacute, and chronic neurologic and

muscoloskeletal conditions)

Also….

1) Controversial disease between (advocacy groups/patients and main

stream medicine (FM, ID…)

2) Canada – Federal Framework on Lyme Disease Act (Assented to 16th

December 2014 – last reviewed April 25, 2017)

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Natural history of untreated Lyme disease

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Reason #3: LD

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Note on interpretation of Lyme disease

serological assays (NML, 2017)

Enhancing existing

Lyme disease

reporting to include

specific band

information

Interpreting the

results

(Hand-outs)Reply to: michel.deilgat@canada.ca

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Reason #3: LD Tx – IDSA Guidelines

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Reason #3 – LD: Best Treatment is PREVENTION

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Reason #3: LD challenges

MANY ISSUES:

- Making a diagnosis / investigation / treatment

- Lab results from private labs in the US or from « Lyme

literate doctors » and other experts in Lyme treatment

Q: What is needed to increase

confidence/accuracy in diagnosing and treating

LD?

TIPS?

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Reason #3 – LD Resources

Federal LD Framework

• Enhanced surveillance

• Education & Awareness

• Guidelines and Best

Practices (note: IDSA Spring

2018- new guidelines)

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Reason #4: Be part of the plan for the global

elimination of HIV

In 2014, the United Nations AIDs organization released its global

strategy to eliminate HIV. It called upon countries to meet the 90-90-

90 targets by 2020:

• 90% of people living with HIV diagnosed

• 90% of diagnosed people on antiretroviral treatment

• 90% of people on treatment with fully suppressed viral load

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Reason #4

Are we meeting the global targets in Canada?

- Are 90% of people living with HIV diagnosed?

- No. An estimated 21% of people living with HIV are undiagnosed*

Public Health Agency of Canada. Summary: Estimates of HIV incidence, prevalence and proportion

undiagnosed in Canada, 2014 https://www.canada.ca/en/public-health/services/ publications/diseases-

conditions/summary-estimates-hiv- incidence-prevalence-proportion-undiagnosed-canada-2014. html

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Reason #4: HIV can be eliminated

What can we do? ROUTINE SCREENING AND TESTING.

• Normalize it.

• Offer providing information on risk factors, then offer testing to every

adult (and minors at risk).

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Reason #4: HIV can be eliminated

And there is good news : PrEP

- Pre-exposure prophylaxis

- Recently approved by Health

Canada when used in conjunction

with other safe sex/IDU practices

- Now available in generics

- Some provinces have started

to include them on the formulary

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Reason #4: HIV can be eliminated…

Q: Why do you think family physicians often do not

routinely offer HIV screening tests to their patients?

TIPS?

Resources:

CATIE.ca

Also see:

Dec 2017 issue CCDR

Spoiler alert: HIV

in 2016 >10% higher

than 2015.

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Reason #5: Emerging infections can come …

and go!

Good news on Zika virus

1. The Pan American Health Organization (PAHO) has reported a large drop

in the number of Zika cases in the Caribbean…

2. Overall transmission of the virus in the Western hemisphere declined in

2017

3. Decrease in the intensity of Zika virus transmission = concomittant

reduction in # of travel-related Zika cases reported

4. Reporting to PHAC began in March 2016 – As of August 31, 2017 there

has been 529 lab confirmed cases of ZV in Canada

- 103 cases reported in 2017

5. Although the # of cases decline – the testing rates remain relatively high

especially for pregnant women

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Reason #5: Emerging infections can come …

and go!

Zika FACTS • First identified in 1947 Uganda

• Vectors : MOSQUITOES

Aedes aegypti and Ae. albopictus

• Sx: mild fever, skin rash,

conjunctivitis, muscle and joint

pain, malaise or headache,

symptoms normally last for 2-7

days

• Microcephaly in babies and

Guillain-Barré syndrome

• Can be sexually transmitted

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Reason #5 –Zika virus is declining… but

• 99% of reported cases

acquired while travelling

to affected region

• 4 cases sexually

transmitted– no history of travelling to an

affected region within the 2

weeks prior to symptoms

onset

• 2 cases are newborns

who acquired infections in

utero

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Reason #5 – ZIKA Canadian Paediatric

Surveillance Program (CPS) – 2 Special Studies

Severe Microcephaly

(SM) Study

June 1, 2016 to

May 31, 2018

1 x case (meeting the

inclusion criterion for both

studies)

Congenital Zika

Syndrome (CZS)

Study

March 1, 2017 to

February 28, 2019

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Reason #5 – RESOURCES: CATMAT’s Zika virus

recommendations

http://healthycanadians.gc.ca/publications/diseases-conditions-maladies-affections/committee-statement-

treatment-prevention-zika-declaration-comite-traitement-prevention/index-

eng.php?_ga=2.246116484.1655599020.1509985632-330767322.1490794154

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Reason #5: Zika cases are declining BUT …

When travelling to affected countries, Zika is still a risk for

those who do not have antibodies…

Zika persistence (median detection rates) (Source: IDSA)

urine (11 days); serum (2 weeks); and semen (6 weeks)

Bottom line: Important to DISCUSS WITH ALL WOMEN WHO

- ARE PREGNANT (or are planning to get pregnant)

- ARE PLANNING TO TRAVEL to affected countries

(E.G. CARIBBEAN, MEXICO ETC)

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Reason #5: ZIKA cases are declining but…

Q: What are the implications for YOUR practice?

TIPS?

RESOURCE:

WHO ZIKA

MAP

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Reason #6: TB still lurks…

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One quarter of the

world’s population

has latent tuberculosis

infection (LTBI)

Reason #6: TB elimination is in our grasp

Canada has one of the lowest TB rates in the world, but it

is not zero.

INDIGENOUS

- Rates in Nunavut comparable

to highly endemic countries

IMMIGRANTS

- Often have latent TB

HOMELESS with IDU also at risk

- Recent 13-year

outbreak in Montreal

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Reason #6: Elimination of TB

There is good news:

1. A better test (than Mantoux): IGRA

- Interferon gamma release assay – a blood test.

- Results available within 24 hours

- If positive can be Active/Latent TB or post treatment

2. A better treatment under investigation: 3HP

- INH + Rifapentine: 12 doses ONLY - weekly treatment

- Much better adherence.

- Currently only under Special Access Programme

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Reason #4: TB - But really - what does this have

to do with family physicians?

Need a high index of suspicion…

CBC NEWS headline: March 23, 2017

“She was my only girl”: Nunavut

teen’s death sheds light on

failures in fighting TB”

- Young teenager with a cold

- It worsened… she began to get SOB

- Then had headache and weakness

- Got medivac’d - Dx: Pneumonia

- Lost conciousness and died

- Dx: TB MENINGITIS

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Reason #6: The focus of global elimination

is managing LTBI

• One important role family physicians can play is

identifying people with LTBI who:

– Are at high risk of re-activation

• Patients with chronic renal failure on hemodialysis

• Transplant patients on immune suppressants

• Patients with silicosis

– Are at moderate risk of reactivation

• Patients on TNF alpha inhibitors (not uncommon!)

• Glucocorticoids

• Diabetes

– Have started to turn into active TB

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Reason #6: We could eliminate TB…

Q: Is the coordination

between clinical care and

public health optimal

for the management of TB?

TIPS?

Resources:

Canadian TB Standards

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Reason #7: To be better prepared to deal with

another “SARS” or influenza pandemic

• Nationally, we are now better prepared than ever – but

clinicians need to be “plugged in”…

•

• And know how to reach

your

• your LOCAL MEDICAL

OFFICER OF HEALTH

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Reason #7: To be ready for an OUTBREAK

Q: Do you think there

will be another infectious

disease emergency over

your professional lifetime?

Tips?

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Reason #7: To be ready for an OUTBREAK

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Reason #7: OK some good news on preparedness

CCDR - A resource for ID info and outbreak preparedness

for BOTH CLINICIANS and PUBLIC HEALTH

NEW -- LAST 3 YEARS (actually revitalized...)

- NOW ON PUBMED

It has rapidly become THE #1 RESOURCE FOR THE

LATEST ID INFORMATION IN CANADA.

- This is based on a recent readership survey

SIGN UP FOR FREE and receive the monthly Table of Contents with

hyperlinks in your email

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7 BIG reasons to be briefed on infectious diseases

1. Emerging infectious diseases are evolving and are only a

plane ride away

2. If we are not careful, totally antibiotic-resistant diseases

could occur

3. Lyme disease is expanding its reach in Canada

4. HIV could be eliminated: Start screening

5. Zika virus (and microcephaly) is still a risk for pregnant

women who travel.

6. TB is a totally curable disease and still lurks in Canada –

keep a high index of suspicion.

7. You want to be prepared for the next outbreak - know how

to contact your local MOH and subscribe to CCDR!

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Questions?

Feel free to contact us:

Michel.Deilgat@canada.ca

Patricia.Huston@canada.ca

We hope we have inspired, motivated and regaled you…

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THANK YOU for your interest

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