November 2011- Avian influenza in Egypt

October 2011- Avian influenza in Indonesia

October 2011- Measles outbreaks in Americas, Europe and Africa

Journal published by IDSP and approved by HEC and CPSP recognised, IDJ is published quarterly and mostly comprises of case reports, editorials and original articles written by local physicians, highlighting our trends and perspective.

Journal is available online for review.

Other important Journals in Infectious Diseases:

Clinical infectious diseases . http://cid.oxfordjournals.org

Journal of Infectious Diseases. http://jid.oxfordjournals.org/content/current

Journal of Antimicrobial Chemotherapy. jac.oxfordjournals.org

Journal of Clinical Microbiology. jcm.asm.org

NEJM ID. http://www.nejm.og/toc/nejm/medical-journal

Lancet ID. www.thelancet.com/journals/laninf/issue/current

AIDS. http://www.medscape.com/viewpublication/744

Case # 1

48 yr old man with poorly controlled diabetes with coronary artery disease comes with two month history of non healing foot ulcer. On examination tendons are exposed and wound has a foul smelling discharge. He doesn’t complain of fever neither has any pain at ulcer site.

In the above case following questions need to be answered

1. What is the diagnosis?
2. What are the risk factors for developing this condition?
3. What is the severity of illness?
4. Is this chronic or acute condition?
5. What are the likely organisms?
6. How would you manage this patient?

Basic requirements before sending specimens for culture

Following measures should be taken before submitting specimens for culture to the clinical laboratory.

1. Collect the specimen before the administration of antimicrobial agents
2. The specimen should be collected carefully to prevent the contamination of the specimen with superficial organisms or normal flora of the body
3. Make sure that the container is not contaminated, and is leak proof.
4. Try to maintain strict aseptic techniques throughout the procedure.
5. Make certain that the specimen is representative of the infectious process (e.g. early morning quality sputum sample) and is adequate in quantity.
6. Label the container appropriately and complete the requisition form.
7. The specimen should be transported immediately to the laboratory.
8. Information regarding the patient, the specimen, collection time and date, clinical history, symptoms and diagnosis, antimicrobial therapy (or use of any other chemotherapeutic agents) and any suspected organisms is essential for the optimal and appropriate processing of the specimen.

Dengue is a viral illness that is transmitted by mosquitoes. It is a zoonotic disease meaning that the virus is actually transmitted from the animal host to the mosquitoes and then to humans. Unfortunately if a mosquito gets infected with dengue virus it will possess and transmit it lifelong without requiring animal host.

What are the common signs and symptoms ?

Dengue fever presents as high grade fever, with nausea, vomiting, abdominal pain, headaches, myalgias or even  diarrhoea or rhinitis. Fever is usually followed by a rash that later becomes itchy. Symptoms usually subside in 4-5 days,  followed by recovery phase in which platelets drop and minor mucosal bleed like nose or gum bleed may ensue. Itching and rhinitis may persist for another week. Relative bradycardia is also seen with dengue.

Is it life threatening ?

Dengue is a self limiting illness, a large number of people infected with dengue recover spontaneously, although a few subset of patients may have dengue with warning signs and if not managed appropriately this group of patients may become critical with multiorgan dysfunction..

How to diagnose dengue ?

Laboratory diagnosis of dengue is based on serology i.e detection of antigen or antibody from human sera. Different labs have different kits that target various antigens and antibody. Different antigens present at different phases of illness e.g Kit meant to detect  NS1 antigen on dengue virus can be used to detect dengue in the first couple of days whereas kit meant to detect dengue antibody ( IgM) can only be used in the second week of illness. Labs at Aga Khan University Hospital can check for both Dengue NS1 antigen and dengue IgM. Patient needs to submit only a couple of cc of blood for dengue testing.

What other lab abnormalities are seen in dengue ?

Liver enzymes especially transaminases may be elevated, coagulation profile (PT/APTT) may be deranged, raised hemglobulin/hematocrit and low platelets, if acalculus cholecystitis occurs than alkaline phosphatase and gamma GT may also be raised. Creatinine and BUN indicate dehydration and kidney involvement.

Does everyone with dengue needs hospitalization ?

No, if people can assure adequate hydration at home there is no need for hospitalization. Even decrease platelets upto 10,000 – 20,000 without any bleed doesn’t need admission to the hospital.

Dengue fever with warning signs, patients with profuse nausea or vomiting who need parenteral fluids, and those who have overt bleeding, need to be managed and observed in a hospital.

What are the warning signs ?

1. Abdominal pain or tenderness, 2. mucosal bleed, 3.enlarged liver, 4.lethargy or irritability, 5.increasing hematocrit with rapidly decreasing platelets, 6.persistent vomiting, 7.clinical fluid accumulation. Most of these signs are indicative of capillary leak which if not managed appropriately can have adverse outcomes.

Does decrease in platelets need transfusion ?

Not necessarily usually in viruses like dengue decrease platelet count is a transient phenomenon that rarely causes serious bleeding, even at platetlet count of 10,000 patients rarely bleed and do not require transfusion. Only if patients have some bleeding disorder or having significant bleed then platelets are must.

What is the treatment of dengue ?

Dengue virus is a self limiting illness, till yet antivirals have not demonstrated any benefit. Symptomatic care with painkillers, antipyretics like paracetamol and adequate fluid intake ensures rapid recovery.

How can we prevent Dengue Shock ?

The reason for dengue shock and multiorgan failure in dengue is capillary leak, meaning intravascular volume depletes and fluid accumulates extravascularly causing puffiness and swelling.  As this occurs the volume of blood circulating decreases and body goes in a protective mode that is vasocontriction trying maintain circulation with little volume it has, evident by decrease urine output. In this critical phase the most important therapy is fluid replacement ideally with isotonic fluid. Early and aggressive fluid management can prevent dengue shock.

Is there a vaccine for prevention ?

Efforts are underway for the development of vaccine, but yet we dont have it yet.

What are the factors responsible for dengue fever outbreaks?

The occurrence of DF outbreaks is linked to number of factors such as density of vector (Aedes aegypti), source (an infected febrile person) and presence of susceptible hosts in the community.

What factors increase the density of Aedes aegypti?

Aedes aegypti is commonly found in urban dwellings ,both indoors and outdoors.  Therefore, fast urbanization and dense population facilitates the progress of outbreak

How to prevent dengue fever ?

Protective clothing, mosquito repellents, vapourizers, use of preventive nets, insecticides, preventing water from accumulating around the house where mosquitoes breed, are a few things that can prevent dengue.

Do’s and dont’s in dengue

Information on dengue in urdu

Myth Buster

Written by Senior Vector Control specialists Muhammad Mukhtar, who highlights what is being done and what needs to be done in a evidence based article………………..Read more 

Influenza (or “flu”) is an infection of the respiratory tract (nose, throat, wind pipe and lungs) caused by the Influenza virus. It is important to realize that it is incorrect to call any runny nose or sore throat ‘the flu’ as these symptoms can be caused by a large number of different viruses and are usually mild. Influenza, on the other hand, is a more severe disease which kills hundreds of elderly and young children each year. Compared to the common cold, in influenza, weakness, increased tiredness, muscle aches, headaches and high fevers with sneezing, are more prominent.

What is avian influenza (bird flu)?

Just as humans have influenza, other animals also have their own version of influenza. Avian influenza (or bird flu), is therefore, influenza of birds.

How is bird flu different from human influenza?

Both human and bird flu are caused by the influenza virus. However, the strain (or type) of influenza virus which causes bird flu is different from the one which causes human flu. The bird strain of influenza usually does not infect humans.

Do we have bird flu in Pakistan?

Yes. Bird flu was first reported from Pakistan in 2006 and cases have been reported on and off since then.

How does bird flu spread amongst birds?

The virus spreads through the secretions from the nose of infected birds as well as their feathers and droppings. Surfaces like the cages of infected birds can also spread the virus. Domestic birds can also get the infection from wild birds which may not have any symptoms of the disease.

How would you know a bird has bird flu?

Bird flu can have two types of diseases in domestic birds (such as chickens). The first is a mild illness where the only symptoms are a decrease in egg production and ruffled (tangled) feathers. This is usually missed. The second is a more severe disease and leads to the death of 80 to 90% of chickens usually in 48 hours. It is important to note that the bird can spread the infection even before any symptoms of the disease occur.

How can humans get bird flu?

While this is uncommon, people can get infected with bird flu. Between 2003 and 2004, there have been a little over 300 documented cases of bird flu in humans. People can get bird flu the same way as birds i.e. by contact with nasal secretions, feathers, droppings or cages of infected birds. Therefore, most cases of people getting bird flu have been when they have had close contact with infected birds (such as keeping chickens at home or slaughtering and de-feathering infected chickens)

Can eating chicken meat give you bird flu?

If the meat is well cooked then there is no risk of getting bird flu from eating chicken. There is a slight risk if the meat is raw or incompletely cooked (for example is there is still blood in the meat or if it is visibly raw).

Can eating eggs give you bird flu?

The virus is present both inside and in the shell of eggs. However, if the egg is well cooked, there is no risk of getting bird flu from an infected egg. A well cooked egg is one which is not runny (liquid). In other words, full boiled eggs and omelets are absolutely safe while half boiled eggs or half-fried eggs are not. Similarly, food with raw or partially cooked eggs (egg pudding or fresh mayonnaise) is not safe.

Can one person give bird flu to another person?

As the strain of influenza virus causing bird flu is specific to birds, it is not able to spread from one person to another. There have been occasions when person to person spread of bird flu has occurred, but this is extremely rare.

What are the symptoms of bird flu in humans?

Bird flu in humans causes a severe illness. Patients have high fevers, difficulty breathing and a cough. Some will also complain of a sore throat, headaches and diarrhea. It is important to remember, that compared to the common cold, the symptoms are much more severe.

How is bird flu detected in humans?

A laboratory test is needed to confirm avian influenza in humans. This test is currently only available at a few hospitals in the country.

Why do we worry about bird flu in humans?

When the bird strain of influenza infects people, it causes a very severe illness in which less than a third of those infected will live. If treated early more people survive, however, half of the patient still die.
An additional fear is that the strain of bird flu will ‘combine’ with the strain of human influenza allowing human to human spread to occur more easily. If this occurs then a world-wide epidemic (pandemic) of influenza is predicted. Similar pandemics of flu in the past have led to millions of deaths worldwide.

How is avian influenza in humans treated?

Drugs are available to kill the virus (antivirals). However, not all of these are effective and treatment must be started early in the course of the disease.

How can you protect yourself from bird flu?

Avoid all activities which will expose you to the virus. This would include direct contact with infected poultry or with surfaces and objects contaminated by their droppings. Remember the exposure risk is highest during slaughter, defeathering, butchering. Also chicken shops often have feathers and dust from chicken droppings floating in the air which can spread the infection. Similarly, avoid keeping chickens or ducks at home. If you have chickens or ducks at home, keep them cornered and do not allow them to roam freely. Do not let children play with the birds. Keep away from any dead or ill appearing birds.

What can you do at home while handling chicken meat?

Regardless of the threat of bird flu, chicken meat is very often contaminated with different bacteria which can cause a variety of disease. Chicken meat should therefore always be handled with care. Simple precautions include:

• Keeping the cutting board of raw meat separate from other cutting boards. DO NOT cut vegetables or cooked meat on the same surface as raw meat and NEVER at the same time as raw chicken.
• Wash your hands with warm water and soap as soon as you have handled chicken. DO NOT touch anything else until you have washed your hands. There is no need to wear gloves while handling chicken meat.
• DO NOT use the same knife to cut anything else until you have washed the dirty knife.
• Do not mix cooked and uncooked meat together
• Cook the chicken thoroughly. Most cooking done at home, including those for salan (curry) is hot enough to kill any viruses or bacteria. Beware of chicken which may not be cooked thoroughly such as if care has not been done while barbequing or while deep frying a large piece of chicken. Make sure there is no blood or pink parts while eating.
• Juices from raw poultry or poultry products should never be allowed during food preparation to touch or mix with items eaten raw.

Does freezing chicken meat also make it safe?

No. Freezing does not kill the bird flu virus. Therefore the same precautions must be taken when handling frozen and fresh chicken meat.

Is processed chicken safe?

Processed chicken products such as “chicken cubes” and various chicken flavorings are safe. The manufacturing process will inactivate any virus in the meat.

What precautions can be taken to reduce the risk for infection from wild birds?

As a general rule, you should always observe wildlife, including wild birds, from a distance. Avoid touching any wildlife. If there is contact with wildlife do not rub eyes, eat, drink, or smoke before washing hands with soap and water. Do not pick up diseased or dead wildlife.

What precautions can people working with poultry take to reduce the risk for infection?

Poultry farmers and those who butcher poultry should take protective measure like wearing masks, gloves, gowns, and boots. It is very important to wash the body and clothing after contact with poultry.

Will the flu vaccine protect you against bird flu?

The yearly influenza vaccine is designed against the human flu and not bird flu. It will therefore protect you against human influenza during the flu season but not against bird flu. Similarly, the yearly flu shot will not protect you against the common cold.

Is there a vaccine for bird flu?

A vaccine has been developed for bird flu, though, this is currently not marketed in Pakistan. However, as most people are low risk for acquiring bird flu, getting the vaccine is not recommended at this time.

Are keeping pet birds at home safe?

As long as the birds are kept away from wild bird they should be safe. If you have caged birds, keep the top of the cage covered to prevent any contact with wild birds.