1. health and fitness

HOUSE Calls
Published by the Alachua County Medical Society
Infectious Diseases
Summer 2014
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invisible connection that’s helping us move medicine forward.
ACMS Board of
Directors
Mary C. Grooms, M.D.
President
John D. Colon, M.D.
Vice President
David E. Winchester, M.D.
Treasurer
Matheen A. Khuddus, M.D.
Secretary
Norman S. Levy, M.D., Ph.D.
First Past-President
Christopher R. Cogle, M.D.
Second Past-President
Members-at-Large
Timothy C. Flynn, M.D.
Ronald M. Jones, Jr., M.D.
Patricia P. Moser, M.D.
Charles E. Riggs, Jr., M.D.
Matthew F. Ryan, M.D., Ph.D.
Robert A. Skidmore, M.D.
Ann T. Weber, M.D.
Advisory Members
HOUSE Calls
Summer 2014
From the President's Desk ..............................................................
5
Mary C. Grooms, M.D.
View from the Bay Window ............................................................
6
"ACMS Serving the Physicians and Citizens of Alachua County"
Sally J. Lawrence, Ph.D., ACMS EVP
....................................................
8
2014-15 ACMS Officers .................................................................
10
Highlights of the 2014 FMA Annual Meeting ................................
Charles E. Riggs, Jr., MD
11
"Vaccines: A Historical Perspective" ...........................................
13
Meet the New ACMS President
Arthur A. Mauceri, MD, Private Practice,
North Florida Regional Medical Center, Gainesville, Florida
"What's New in Travel Medicine" .................................................
16
Vini Vijayan, MD, Division of Immunology, Rheumatology and
Infectious Diseases, Department of Pediatrics,
UF College of Medicine
"Public Health Surveillance for Arborviral Diseases in Florida" ... 20
Anna Marie Likos, MD, MPH, State Epidemiologist,
Director for the Division of Disease Control and Health Protection
Florida Department of Health
Carolyn G. Carter, M.D.
Jennifer K. Light, M.D.
In Memoriam: William Fisher Enneking, MD ............................... 22
Jesse A. Lipnick, M.D.
"Control of Hospital Infections" ..................................................... 23
Tri-County Representative
Michael J. Lukowski, M.D.
Michelle Rossi, M.D.
Gerold L. Schiebler, M.D.
Bruce K. Stechmiller, M.D.
We Care Medical Director
Avan J. Armaghani, M.D.
Resident Physician Representative
Joseph T. Sofia
Medical Student Representative
Sally J. Lawrence, Ph.D.
Executive Vice President
House Calls
E. Scott Medley, M.D.
Executive Editor
Sally J. Lawrence, Ph.D.
Managing Editor
4
Robert W. Yancey, Jr., MD, North Florida Regional Medical Center
"Common Tick-borne Illnesses (TBI) in Florida" ........................
27
Maria A. Kima, MD, Infection Prevention and Treatment Center
North Florida Regional Medical Center
"HIV Testing in 2014" .....................................................................
30
Jennifer Janelle, MD, Division of Infectious Diseases and
Global Medicine, UF College of Medicine
"Chikungunya: An In-depth Look at a New Arboviral
Threat in Florida" ......................................................................
34
Amy Vittor, MD, Division of Infectious Diseases and Global Medicine,
UF College of Medicine
ACMS Happenings ..........................................................................
36
A Note From Our Editor .................................................................
40
"Fun in the Gut"
E. Scott Medley, M.D.
HOUSE Calls
From the
President's Desk
Mary C. Grooms, M.D.
“No man is an island unto himself…”
-John Donne (1572-1631)
Growing up in Virginia, I learned many lessons from my
physician father and nurse mother and watched as they
put their advice into practice: Count your blessings…Look
out for others and think of others first … Give back … Be
generous … Take care of family … Be a good friend …
Make a difference …Work hard … Leave every place better
than you found it … Commit to your community. These
guiding principles have always been important to me, and
a series of significant personal and professional losses in
recent years have deepened my understanding of their
importance, particularly the value of community.
When I entered private practice in Gainesville, I joined the
Alachua County Medical Society without much thought.
My new partners believed in supporting membership in
our local medical society and I personally believed that
ACMS membership was an essential part of my commitment to my profession and my community. For many
years, I paid my dues and enjoyed my ACMS Directory and
House Calls subscription and left it at that. It wasn’t until
several years ago—when I started attending ACMS functions—that I began to realize the full potential of our medical society as a vehicle for physician support, professional
enrichment and medical advocacy in our community.
Like many of you, I have a wonderful support system
among my family and friends. But when it comes to understanding the nuances and pressures of daily life in modern
medical practice, I tend to count on encouragement and
advice from my medical colleagues more than anyone else
… because they “get it.”
Whether we are in private practice, affiliated with North
Florida Regional Medical Center, UF Health, the Health
Department or the VAMC, the Alachua County Medical
Society provides the forum through which we can all
gather, support one another, learn from each other, and
SUMMER 2014
work together to enhance the quality of medical care in our
community. Our efforts to know each other as colleagues
and friends allow us to work together to provide better care
to our patients.
We are all busy with various important commitments in our
lives. Sometimes, it is hard to find time for that “one more
thing.” But that one more thing might actually make all the
difference in terms of our feelings of contentment and fulfillment and effectiveness within our profession. We are all
better at what we do when we look out for each other and
work together.
The 2014-2015 year in the life of the ACMS promises to be
an exciting one, with plenty of opportunities for you to
learn and grow in your professional knowledge, to reconnect with your colleagues, and to experience the many
benefits that ACMS membership has to offer. We are
actively working on ways to enhance the ACMS membership experience and to increase the relevance of medical
society membership to our daily lives as physicians. I am
particularly excited about the interesting dinner and CME
programs that we will offer, about increasing the number of
ACMS events that include our families, and I am looking forward to the continued expansion of the COACH (Combating
Obesity for Alachua County’s Health) initiative in the year to
come.
This year, I challenge you to engage in your professional
community by joining or remaining a member of the ACMS.
I look forward to getting to know many of you better this
year, and hope that you will not hesitate to contact me
with your suggestions and concerns. The Alachua County
Medical Society is here to serve you in your endeavor to
provide exceptional care to the citizens of our community.
You are not alone … Let’s work together.
5
View from the
BayWindow
ACMS - Serving the
Physicians and Citizens of
Alachua County
By Sally J. Lawrence, Ph.D.
ACMS Executive Vice President
The Alachua County Medical Society is dedicated to
improving services and benefits for our members while we
continue to grow and evolve.
Your new ACMS President, Dr. Mary Grooms, and the
ACMS Board of Directors have been developing new ways
to reach out to our membership, especially to young
physicians with families. In May 2014, we hosted the first
annual ACMS Family picnic – an event that was wellattended and enjoyed by all. To kick off the 2013-14 year,
the ACMS asked Dr. Ardis Hoven, Immediate Past President
of the AMA, to speak at a “Women in Medicine” luncheon
and at the ACMS September 9th dinner meeting.
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Recently, we started a new event: Practice Management
Network which is a free lunch and learn for ACMS members and their office staff. Plans for this year include continuing the successful COACH walks initiated by Dr. and
Mrs. Levy last year. Plans are in the works for a “Women
in Medicine Network" events and an ACMS tailgate social
before one of the UF home games. We hope the ACMS
events offer a unique opportunity for our members to
socialize, network and learn from each other. Check our
website for updates: www.acms.net. Other membership
benefits:
r
Did you know?
r
6
CME dinners are free (or very low cost) for ACMS
members. They are now offered eight times per year
(up from 3 or 4 CME program per year in 2007). The
required CME program: “Prevention of Medical Errors”
is offered every January.
r
r
r
r
r
You can link your website address to the ACMS website.
Comp Options is a workman’s comp program that
offers dividends (for ACMS members only).
House Calls, our quarterly magazine, is read by leaders
throughout Gainesville including health care professionals.
The annual ACMS Physician Directory is distributed to
1500 health care professionals and leaders in the community. Advertising is discounted for ACMS members.
ACMS started the We Care Physician Referral Network
over 25 years ago. It has been replicated all over the
State of Florida. Over $73 million in health services
have been donated to indigent Alachua County citizens.
The ACMS offices are housed in the Robb House, the
oldest medical museum in Florida.
ACMS advocates for physicians and patients at the
state (FMA) and national (AMA) levels.
Apparently our efforts are working as we welcomed 42
new members in the first eight months of 2014. Please see
the list of new members on the next page.
Thank you for your continued support of the ACMS. We
would love to hear from you: (352) 376-0715 or [email protected].
HOUSE Calls
Continued from page 6
Welcome New ACMS Members (so far in 2014)
Judith Banks, MD
Adrian B. Blotner, MD
Jorge Camacho, MD
Aruthdhati Runi Foster, MD
Lateya Foxx, DO
Joseph Gentile, MD
Ann M. Grooms, MD
Daniel Hall, MD
Ann S. Hatfield, MD
Philip Hess, MD
Timothy A. Hipp, MD
Martin I. Holzman, MD
Mary Hurd, MD
Kevin Johnson, MD
Janeen R. Jordan, MD
Joseph King, III, MD
Mike Krick, DO
Michael MacMillan, MD
Michelle Massias, MD
Guy W. Nicolette, MD
Tenely Noone, MD
Phalyka Oum, MD
Mark Panna, MD
Diego P. Peralta, MD
Scott A. Rivkees, MD
Katheryn Sarantos, MD
Matthew Shannon, MD
Brent T. Stewart, MD
Wade W. Stinson, MD
Eric Svestka, MD
Ashley E. Thomas, MD
Michael B. Tudeen, MD
Sonal S. Tuli, MD
Pediatrics
UF College of Medicine
SIMED Pulmonologist
SIMED Pulmonologist
SIMED Neurology
SIMED, Orthopaedic Surgery
UF Student Health Care Center
Accent Physicians, Otolaryngology
North FL Women's Physicians of Gainesville
UF Health Surgical Specialists
Surgical Group of Gainesville
Community Cancer Center of North Florida
SIMED, Primary Care
UF COM (Resident Physician)
UF Health Surgical Specialists
UF Orthopaedics & Sports Medicine
UF Health Emergency Medicine
SIMED, Spine and Neurosurgery
Alliance Pediatrics
UF Student Health Care Center
SIMED, Primary Care
Gainesville Pediatric Associates, Inc.
UF Health Cardiology - Springhill
UF Health Infectious Diseases Residence
UF Health Pediatric Specialists, Chair
Alliance Pediatrics
UF Health Emergency Medicine
Advanced Pain Medicine of North Florida
VAMC NF/SGVHS
SIMED, Primary Care
SIMED, Neurology
UF COM (Resident Physician)
UF Health Eye Center, Interim Chair
Suzanne Zentko, MD
The Cardiac and Vascular Institute
Advertising in House Calls does not imply approval or endorsement by the Alachua County Medical Society. All advertising
is subject to acceptance by the Board of Directors. Send all advertising and editorial submissions to:
Alachua County Medical Society, 235 SW 2nd Avenue, Gainesville, FL 32601.
(352) 376-0715; Fax: (352) 376-0811; www.acms.net
House Calls is a quarterly publication of the Alachua County Medical Society, Inc., Gainesville, Florida. © Copyright 2014.
No part of House Calls may be reproduced by any means, nor stored in retrieval systems, transmitted or otherwise copied
without written permission from the ACMS. Design and Layout by JOLA, Inc.
SUMMER 2014
7
Meet the New ACMS President
Mary C. Grooms, M.D.
whether or not we as physicians are in a position to deliver
the best care possible to each of our patients, within the constraints of modern medicine. The doctor-patient relationship
is increasingly diluted by outside forces. Bureaucratic, administrative and logistical hassles distract us from the important
work that we are trained to do, and that is a problem.
By: Sally J. Lawrence, Ph.D., ACMS EVP
SL: Where were you born and what brought you to
Gainesville?
MG: I was born and raised on the coast of Virginia. For my
undergraduate studies, I attended Davidson College, where I
met the young man who would eventually become my husband. After I completed my medical degree at the Medical
College of Virginia, we married and moved to Gainesville for
my residency training at the University of Florida, Department
of Pediatrics. When I finished residency, I was offered
my dream job at Pediatric Associates of Gainesville (now
Gainesville Pediatric Associates), and we have been happily
settled in Gainesville ever since.
SL: Why do you believe in supporting organized medicine,
especially through your county medical society?
MG: We need to remember that we are all part of something
bigger than ourselves. When we know and respect each other
and we work together, we are better, smarter, stronger and
more effective than we are alone. I want to be the best physician I can be … Membership in our county medical society is
part of that.
SL: What prompted you to pursue medicine/pediatrics?
SL: Please tell our readers about your family.
MG: As is the case with many physicians, I was drawn to a
career in medicine by a strong desire to serve others and
to have a positive impact on their lives. I attended medical
school with the intention of pursuing a career in Geriatrics
and possibly Hematology-Oncology, but I was drawn to the
positive energy and pace of Pediatrics during my third-year
clerkship. Once I realized the tremendous power of preventive
medicine early on in life, I was hooked.
MG: The three loves of my life are my wonderful and funny
husband, Greg, and our beautiful and sweet daughters,
Harrison and Sayers. They keep me smiling and laughing on
even the toughest days.
SL: What do you like best about being a physician?
MG: The relationships that I form with patients and
their families are the best parts of my job. It is a
true joy to participate in the care of young people
who are trying to figure out who they want to be
and what they want to contribute to the world
around them. I love getting to be a part of that.
SL: Do you have any hobbies?
MG: Free time is scarce, but when time permits, I enjoy reading, running, cooking with my husband, attending our children's school and sporting events, and travel with my family.
Family time is my greatest joy.
SL: What are your goals for the ACMS in 20142015?
MG: I would like to work on enhancing the relevance of ACMS membership to local physicians.
The medical experience continues to evolve and
the needs of physicians are changing. I am hoping
to explore the different ways in which the ACMS
can add value to our members’ lives.
SL: What do you feel are the challenges facing
medicine?
MG: There are so many challenges facing medicine
today, but I spend the most time worrying about
8
The Grooms Family, L to R: Sayers, Mary, Harrison and Greg
HOUSE Calls
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Alachua County Medical Society
Thanks
Norman S. Levy, M.D., Ph.D.
For his wonderful leadership as ACMS
President, 2013-14
ACMS is pleased to announce Officers for 2014-15
10
President
Mary C. Grooms, M.D.
Vice President
John D. Colon, M.D.
Treasurer
David E. Winchester, M.D.
Secretary
Matheen A. Khuddus,
M.D.
HOUSE Calls
Highlights of the
2014 FMA Annual Meeting
Charles E. Riggs, Jr., M.D.
The 2014 FMA Annual Meeting afforded your ACMS
Delegation and members very positive exposures in
several venues. We were capably represented on Reference
Committees by Dr. Norman Levy and Dr. Michelle Rossi.
Dr. David Winchester wrote and successfully chaperoned a
Resolution (#14-113, directing the FMA to develop programs
to expand residency training in Florida) through an arduous
committee debate. This well-received proposal cleared the
Reference Committee with minor amendment, and was
passed by the full House of Delegates (HOD) on first vote.
Dr. Glen Finney organized and directed the second “Dr.
David Paulus Resident Poster Session,” which has, in its brief
tenure, established itself as a premier exposition of trainee
talent from Florida’s medical schools and teaching hospitals.
Finally, at the first HOD session, I was elected Medical
District H representative to the FMA Board of Governors for
a 3-year term. District H encompasses 10 counties (including
Alachua and Marion) and well over 1,000 FMA members.
Several resolutions of interest to Florida physicians were
passed during the 2nd HOD session. Medical Economics
considered eight items relating to Medicaid and ACA
reimbursements. The best parts of all were incorporated
into three final Resolutions, enthusiastically passed by the
HOD. These directives will, hopefully, result in legislation
addressing this critical and progressively looming issue
which impacts most physician practices. Finance passed
a Resolution specifying that the FMA address the issues
of veterans’ access to care (recollect Past FMA President
Alan Harmon’s call earlier this year for a registry of Florida
physicians willing to provide care to veterans.)
Legislation had new issues relating to: 1) “medical
marijuana;” 2) protection of vulnerable patients; 3)
maintenance of EMRs; 4) perennial reconsiderations of
NICA (opposed repealing); 5) scope of practice (opposing
expansion of DNP practice and affirming need for public
education about training and accurate advertising); and 6)
motorcyclists (favoring helmet laws and sufficient accident
insurance). Statutes regulating marijuana prescribing
and dispensing need to affirm that only physicians can
prescribe, so Schedule II status is sought, if Constitutional
Amendment #2 passes this fall (FMA’s official position is
opposition to this amendment).
Health, Education and Public Policy, the 2nd busiest
SUMMER 2014
Committee after Legislation, heard a variety of topical
Resolutions. Policies protecting Florida’s youths
predominated, with Resolutions asking for 1) banning
of minors’ access to tanning booths; 2) promoting HPV
vaccination of all children; 3) requiring special, verified
exemptions from childhood vaccinations; and 4) training
of high schoolers in CPR. Florida’s citizens were the focus
of Resolutions addressing: 1) health-issue monitoring of
fracking operations; 2) funding for medical student loan
forgiveness for those practicing in underserved or other
areas of need (note there is an unfunded Florida law for
this already); 3) readdressing the pharmacy opioid tracking
laws; and 4) directing the FMA and the State to compile
a meaningful physician workforce database. The latter
Resolution would enhance the mission of an FMA Advisory
Group to examine the impact on medical practice in Florida
of employment of physicians by hospitals and large medical
groups. I serve as the Chair of this Advisory Group and
welcome your comments or suggestions.
The FMA Annual Meeting is a unique opportunity for
physicians to participate in the design and execution of
policies that impact Florida legislation. As the state’s largest
and most representative medical lobby, FMA cultivates close
ties with the elected women and men whose legislative
activities govern how we deliver top-notch medical
care. The success of these efforts depends on you, every
physician practicing in this State. You help by attending the
Annual Meeting; joining the FMA PAC; becoming a valued
member of the MD1000 Club, the elite of FMA’s supporters;
and maintaining a dialogue with your local representatives,
both at home and in Tallahassee every spring. By virtue
of FMA membership, ACMS was allotted 23 delegate
spots at this year’s Annual Meeting. Less than half of that
number took advantage of this opportunity (and look how
visible we were!) I urge every ACMS member to consider
strongly making the commitment, and having the fun and
fellowship, of attending the 2015 FMA Annual Meeting.
We want you to author ACMS-sponsored Resolutions on
the issues you believe need to be addressed, to volunteer
for service to a Reference Committee, to judge the science
at the Dr. Paulus Posters, and to rise as members of our
delegation to voice your opinions at House of Delegates
sessions. You have the talent and experience, and ACMS and
FMA want to see these in action.
11
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Vaccines: A Historical Perspective
Arthur A. Mauceri, MD, FACP, FIDSA
Private Practice, Gainesville, Florida,
North Florida Regional Medical Center
Vaccines are truly the Holy Grail of Medicine: Biologic
agents that can be employed to prevent infectious diseases. The term comes from the Latin for root of cowvacca. A definition of a vaccine: attenuated live or dead
microorganisms given to induce immunity, preventing
diseases.
Toxoids are modified bacteria toxins rendered nontoxic
but that stimulate production of a protective antitoxin.
For the purpose of this discussion, they will be considered together, although toxoids are not strictly speaking
“vaccines.”
The dawning of the use of vaccines dates to 1796 when
Edward Jenner observed that milkmaids who had
contracted cowpox were immune from smallpox. This
astute observation led to the injecting of a suspension
of vesicular fluid from cowpox lesions into susceptible
individuals and inducing active immunity preventing
disease. This was accomplished without any significant
laboratory facilities and is remarkable that it worked at
all. A similar feat was accomplished by Louis Pasteur in
1885 experimenting with a rabies vaccine. Since those
times, global populations have benefited from vaccines
to prevent infectious diseases. Why, may one ask, do
we need to continue exploration for future vaccines,
when there are a plethora of antibiotics available? First,
better to prevent disease than to try to cure it. Second,
microorganisms are far better at producing resistance to
antibiotics than the pharmaceutical industry is at manufacturing new effective antibiotics to combat resistance.
We have multiple vaccines; some very effective and others not so much. There have been some notable failures
in certain vaccine developments. Some infections have
eluded success of effective agents – Malaria, Hepatitis C
and HIV, for example.
Control of tuberculosis with BCG (Bacille CalmetteGuerin) vaccine has had moderate success in prevention
in certain high prevalence areas of the world. It is generally not used in the United States because tuberculosis
is not as big a threat as it once was in the general population due to improvement in sanitation and hygiene,
SUMMER 2014
PPD skin testing, and drug development. Not to say
that there has not been resistance encountered, usually
imported from third world countries and in susceptible
populations of immunosuppressed individuals.
Malaria is a parasite for which no model of effective
immunity exists. A lack of evidence of any immune
response to a specific antigen in the different parasitic
stages of the organism has complicated successful vaccine development.
HIV is a retrovirus which has resisted attempts to develop a preventive vaccine. Research is ongoing since the
infecting organism has been known since the 1980’s.
Vaccine development has not only been a failure, but
has led in some cases to a superinfection with different
strains of the virus.
Hepatitis C does not produce a protective antibody
response, rendering it difficult to being amenable to
vaccine development. Fortunately, recent drug development has been shown to produce a high rate of cure
not previously attainable.
Influenza vaccine has to be re-formulated on a yearly
basis due to a viral antigen shift or drift of types of influenza which occurs spontaneously or by a mechanism
of reassortment of antigens. These are expressed by
determinants on the virion as H and N antigens. The
interaction between fowl hosts is well recognized by
complicating the situation.
Correct use of immunizations of newer vaccines has
been developed by the National Vaccine Advisory
Committee. The Infectious Diseases Society of America
has established guidelines for pediatric and adult standards. These are readily available to patients and health
care workers.
Few medical advances can rival vaccines over the ages.
As more knowledge and experience accumulates,
more doors will open to effective vaccine developContinued on page 14
13
Continued from page 13
ment. A concerted effort by the pharmaceutical industry,
researchers, and government agencies can insure, as in
the most current infectious diseases, that they can be
combated effectively, limited or abolished permanently
as evidenced with smallpox and to a certain extent with
polio. We need to promote intensive research for vaccine
development as well as to encourage the use of current
effective agents to prevent diseases.
Allocation of resources towards development of newer
agents is usually dependent upon significant morbidity
and mortality to large populations and its socioeconomic impact upon global society. One can, therefore, expect
attention to a vaccine initiative for perhaps dengue - for
which no vaccine exists - but not necessarily for Ebola,
with a high mortality rate but limited spread of the disease outside of a local area.
Resistance to use of vaccines in the pediatric population
does a disservice and has the potential to create pockets
of outbreaks of preventable childhood diseases once
controlled and/or eliminated, e.g. measles and poliomyelitis. This resistance is based on unfounded fears of side
effects. These fears are not supported by facts or scientific documentation. Once herd immunity is breached,
these diseases will reappear with a vengeance.
Childhood vaccines no longer contain thimerosal
(Merthiolate) – a mercurial compound - as a preservative.
Although it was never proven to cause alleged problems, it was removed to allay parental concerns. Allergic
responses to vaccine components are rare and only true
anaphylactic responses should preclude administration. A live vaccine should generally not be given to any
immunosupressed individual or to a child too young to
produce effective protection.
In addition to those noted above, other vaccines, have
changed history. Typhus played a large part in wars. It
decimated Napoleon’s army by fifty percent. Typhus vaccine of necessity was a consequence of WWI when more
combatants died from the disease than from war injuries. Subsequently, a killed rickettsia vaccine prevented
deaths of allied personnel in WWII. Coincidentally, control of infectious lice and rodents with improvement in
hygiene during conflicts virtually made acquisition of
typhus a non-issue. Effective vaccines for Hepatitis A&B
are readily available and work well. Booster doses may
be necessary with waning immunity. With universal
Hepatitis B administration, this disease could be totally
eradicated.
Similarly, tetanus infection is almost non-existent in the
civilized world. No recorded case of death from tetanus
has occurred in a person who has received a prior complete course of immunization in the past. Immunity can
be sustained by booster dose every 10 years or sooner,
if need be, with a severe dirty wound.
Uncommon infections such as plague and anthrax are
not easily contracted except when employed as in a
weaponized situation for bioterrorism or warfare. Other
rare infections - e.g. Japanese encephalitis - is limited to
certain areas of the globe, but a current vaccine is available and recommended for travel with stays longer than
30 days.
Pneumococcal vaccine includes two varieties – a 23
type capsular polysaccharide linked to a protein carrier - and a somewhat newer 7-valent conjugate vaccine
originally licensed for children and now approved for
adults, especially immunosupressed and susceptibles,
given together to provide broader protections. I have
not commented on the other usual childhood agents,
since their use is well established.
Smallpox has been eradicated globally. Stores of this
agent are reportedly present only in Siberian Russia and
in the CDC in the United States. Release of any of these
agents into a current population vis-a-vis bioterrorism
would be catastrophic, because a large segment of the
population is unimmunized and those that have been
immunized have had their protection wane.
Neisseria meningitis usually occurs in populations with
a risk exposure seen in military recruits in barracks or
in college freshmen in dormitories in the United States.
The vaccines have become mandatory for matriculation
in U.S. colleges and universities. However, epidemics do
occur during winter and spring of the year in a “belt” of
sub-Saharan Africa from the west areas to the east coast
of the continent. One of the deficits is poor antibody
response in children younger than 2 years of age except
for Type A.
Other vaccines of interest are usually reserved for the
military or world travelers to areas where certain diseases are endemic. These include plague, typhoid, cholera
and yellow fever.
The most recent vaccine available is for Human
Papilloma Virus (HPV). The point to realize is its relationContinued on page 15
14
HOUSE Calls
Continued from page 14
ship to sexual activity in a select
population vulnerable to acquisition early in life. Barrier precautions may not protect transmission.
Therefore, prevention is the modality of choice before onset of sexual
activity begins. Recommendation
is for all children to receive the vaccine – boys and girls – starting as
early as ages 9 - 26. This approach
will reduce the incidence of cervical
and oropharyngeal cancer, which
can occur in a relatively younger
patient. The vaccine exists as two
products: Gardasil – Quadrivalent
(HPV 16, 18, 6, 11) and Cervarix –
Bivalent (HPV 16, 18).
As research has become more
complex and mechanisms of disease more sophisticated, advances
depend on the understanding of
new paradigms and developments
in molecular biology and genetics.
The knowledge gained will open
more avenues about the hostimmune response to infectious
diseases. Future increasing developments in biotechnology hopefully will lead to an epiphany of
understanding disease prevention
by vaccines.
With increasing unrest in the world,
it is essential we have ready access
to the latest and most effective
vaccines and to insure adequate
supplies to combat bioterrorism.
Control of dangerous pathogens
with very strict access is of paramount importance. Weaponization
of live organisms and toxins in the
wrong hands can certainly lead to a
catastrophic scenario exposing millions of susceptible populations.
Pathogenic microorganisms versus
vaccines is an ongoing battle. The
war has yet to be won.
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SUMMER 2014
15
What's New in Travel
Medicine
Vini Vijayan, M.D.,
Assistant Professor of Pediatrics,
Division of Immunology, Rheumatology and
Infectious Diseases, Department of Pediatrics,
UF College of Medicine
Introduction
The number of people traveling outside of the United States
(US) for the purpose of business, pleasure, adoption, medical
tourism and adventure travel is increasing. Travel may pose
health risks for the individual and contribute to the global
spread of infectious diseases. The specialty of travel medicine
is aimed at minimizing health risks associated with international travel. This article will describe some basic concepts
of travel medicine for clinicians providing advice to travelers headed for international destinations and will highlight
recently updates in the field.
The Pre-Travel Visit
Risk assessment, stratification and management are fundamental parts of the pre-travel consultation which permit the
clinician to customize education and management based on
the traveler’s health and itinerary. Pregnant women, infants
and children, elderly individuals, patients with chronic medical
conditions, and long-term travelers are at higher risk of acquiring travel-related illnesses and may have contraindications to
certain vaccines or medications. Visiting family, friends and
relatives (VFRs) who are members of immigrant families and
who return to their country of origin are less likely to obtain
pre-travel advice and are therefore at higher likelihood of
acquiring travel-related illness.
A complete review of itinerary and planned activities will help
assess potential exposures during the trip and determine necessary immunoprophylaxis, chemoprophylaxis and counseling. Table 1 describes commonly encountered exposures and
preventive measures that may be advised for a safe trip.
Options for malaria prophylaxis depend on the duration of
the trip, age of the patient and underlying medical conditions.
Chloroquine and mefloquine should be started 2 weeks prior
to departure, and administered weekly during the trip and
for 4 weeks after return. Atovaquone /proguanil and doxycycline are convenient for last minute travelers as they can be
started 1-2 days prior to departure, daily during the trip and
for 7 days after return. In July 2013, the U.S. Food and Drug
Administration (FDA) released a Drug Safety Communication
regarding label changes for mefloquine secondary to neurologic and psychiatric side effects including vertigo, loss of
balance, tinnitus, anxiety, depression and hallucinations. Any
traveler receiving a prescription for mefloquine must also
receive a copy of the FDA medication guide, which can be
found at http://www.accessdata.fda.gov/drugsatfda_docs/
label/2013/076392s008lbl.pdf
Travel Vaccines
Recommendations for a number of routine and travel vaccines have been updated over the past year. Table 2 lists
common vaccines for travel.
Vaccination of Immunocompromised Travelers
In December 2013, the Infectious Disease Society of America
released guidelines regarding vaccination of immunocompromised hosts, which also addresses challenges encountered in immunization of immunocompromised travelers.
Although inactivated vaccines can be prescribed during
immunosuppressive therapy, the post-vaccination antibody
responses are often impaired. Live vaccines are generally
contraindicated and if the risk of disease acquisition in a particular country is high, the potential risks must be carefully
discussed with the patient.
Measles, Mumps and Rubella Vaccine (MMR)
This year, the US is experiencing a record number of measles
cases and as of July 25, 2014, there have been 585 cases of
measles reported in the US. All children >12 months of age
should receive at least 2 doses of MMR prior to departure
regardless of their destination. The minimal interval between
the first and second dose of vaccine is 28 days. Children
between 6-11 months should receive a single dose prior to
departure. Adolescents and adults who have not had measles and have not been vaccinated should get 2 doses separated by 28 days. Encouraging timely delivery of measles
vaccination for persons traveling internationally and sustainContinued on page 17
16
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Continued from page 16
Table 1: The Pretravel Consultation: Hazard Avoidance Advice
Risk encountered
Some Diseases Associated
with Exposure
Insect Exposure
Malaria, Japanese encephalitis,
filariasis, trypanosomiasis,
leishmaniasis, dengue, yellow
fever, Tick bite fever
(Ticks, mosquitos
and sandflies)
Environmental
hazards
Sunburn
Foodborne/Water
borne diseases
Acute diarrheal disease,
hepatitis A, parasitic
infestations , cholera,
gastrointestinal parasites,
typhoid fever,
Water exposure
Schistosomiasis, Leptospirosis
Altitude sickness
Acute mountain sickness,
High-altitude pulmonary
edema (HAPE)
High-altitude cerebral edema
(HACE)
Injury and safety
Motor vehicle crashes, falls,
electrocution, drowning
Animal
Exposures
Rabies, Animal Bites, Bat
exposure, Ebola Virus Disease
Air Travel related
Illness
DVT, motion sickness,
barotrauma, jet lag
Precautions
x Insect repellents with 30%-50% DEET
x Wear loose-fitting clothing, covering as much skin as
possible when traveling to high-risk areas
x Consider permethrin-impregnated bednets
x Minimize outdoor exposure during times of peak vector
activity
x Chemoprophylaxis
x Avoid sun during peak hours, especially at higher altitudes
and lower latitudes
x Wear proper clothing (including broad-brimmed hat)
x Use sunscreen (SPF of at least 30)
x Cook all food thoroughly; avoid foods that cannot be boiled
or peeled
x Drink only bottled, boiled, iodinated or chlorinated water
x Avoid ice in beverages
x Antimotility agents such as loperamide may be used in the
absence of fever/bloody diarrhea
x Self- directed treatment for Traveler’s diarrhea
x Avoid swimming in freshwater
x Ascend gradually
x Try not to ascend directly from low altitude to more than
9000 ft sleeping altitude in 1 day.
x Once above 9,000 ft, move sleeping altitude to no higher
that 1,600 ft per day and plan for extra acclimatization
x Avoid alcohol for the first 48 hours
x Consider prophylactic acetazolamide to speed
acclimatization
x Dexamethasone can be used for prevention and treatment of
HAPE/HACE
x Use seat belts (if available) and other personal protective
measures
x Avoid driving at night
x Obtain medical evacuation insurance
x Avoid large crowds and demonstrations
x Travel in pairs or small groups
x Be familiar with local laws
x Avoid exposure to wild animals
x Avoid dead carcasses
x If bitten, seek medical care
x Staying hydrated, moving around the cabin
x Compression stockings may decrease risk of DVT
x Wait 24-48 hours to fly after scuba diving with
decompression stops
x Avoiding caffeine during air travel- may decrease jet lag
ing high vaccination coverage in the US in accordance with
the Advisory Committee on Immunization Practices (ACIP)
routine immunization schedule are essential to limit measles
importations and the spread of disease.
Yellow Fever Vaccine
In May 2013, the World Health Organization (WHO) Strategic
Advisory Group of Experts concluded that a single dose of
yellow fever vaccine is sufficient to confer sustained immunity
and lifelong protection against yellow fever disease and that
a booster vaccine is not needed. This change will enter into
force legally in June 2016. Previously, booster doses of yellow
fever vaccine every 10 years was recommended for people
residing in or traveling to an area where there is a risk of yellow fever. Despite this recent announcement, the Centers
for Disease Control and Prevention (CDC) still recommends a
Continued on page 18
SUMMER 2014
17
Continued from page 17
TABLE 2: Common Vaccinations for International Travel
Routine Vaccines: These vaccines are the standard child and adult immunizations
recommended by the Advisory Committee on Immunization Practices
Diphtheria, tetanus, pertussis
(DtaP or Tdap)
+DHPRSKLOXVLQIOXHQ]DH type
b (Hib)
Measles, Mumps, rubella
(MMR)
Rotavirus
Varicella
Human papillomavirus (HPV)
Poliomyelitis
Pneumococcal
Hepatitis A
Meningococcal
Hepatitis B
Recommended Vaccines: These vaccines are recommended based on the travel destination
and activities.
Hepatitis A
Typhoid
Hepatitis B
Rabies
Polio
Japanese encephalitis
Required Vaccines: Certain vaccines are required to be documented on the International
Certificate of Vaccination for entry into the country
Yellow fever
booster dose of yellow fever vaccine every 10 years for US
travelers to areas with yellow fever risk. Furthermore, the
International Health Regulations (IHR) have not changed,
and booster doses are still needed if yellow fever vaccination is required for entry into a particular country. Countryspecific requirements for yellow fever can be found at http://
www.cdc.gov/yellowfever/maps/.
Japanese Encephalitis Vaccine
Inactivated Vero cell culture-derived Japanese encephalitis
(JE) vaccine (IXIARO) is the only JE vaccine licensed and available in the US. This vaccine was approved for use in people
aged >17 years. However, in May 2013, the FDA licensed
IXIARO for use in children 2 months-16 years of age. IXIARO
is given as a two-dose series, with the doses spaced 28 days
apart. The last dose should be given at least 1 week before
travel. For persons aged ≥17 years, a booster dose may be
given if a person has received the two-dose primary vaccination series one year or more previously and there is a continued risk for JE virus infection or potential for re-exposure.
JE vaccine is recommended for travelers who plan to spend
1 month or more in endemic areas during the JE virus
Meningitis
transmission season. This
recommendation includes
long-term travelers, recurrent travelers, or expatriates who will be based in
urban areas but are likely
to visit endemic rural or
agricultural areas during a
high-risk period of JE virus
transmission. The vaccine
should also be considered
for short-term (<1 month)
travelers to endemic areas
during the transmission
season, if they plan to
travel outside an urban
area and their activities will
increase the risk of JE virus
exposure or if they are traveling during an outbreak.
Certain activities such as
extensive outdoor activities
(including camping, hiking,
trekking, biking, fishing,
hunting, or farming) are
considered high risk.
Meningococcal Vaccines
On June 14, 2012, the FDA approved a new 1 bivalent
(C; Y) conjugate vaccine (HibMenCY-TT [MenHibrix,
GlaxoSmithKline Biologicals]), which is also approved as
a vaccine for Haemophilus influenzae type b. This is the
first meningococcal vaccine that can be given to infants as
young as six weeks old. Additionally, 2 quadrivalent conjugate vaccines (MenACWY-D [Menactra, Sanofi Pasteur] and
MenACWY-CRM [Menveo, Novartis]) and a quadrivalent (A, C,
W-135, Y) polysaccharide vaccine (MPSV4 [Menomune, Sanofi
Pasteur]) are available.
For travelers to areas with high meningococcal endemicity, such as parts of sub-Saharan Africa, an age-appropriate
meningococcal vaccine that includes serogroups A and W
is indicated. All adults and children aged >2 years traveling
for the Hajj pilgrimage must have received a single dose of
quadrivalent A/C/Y/W-135 vaccine ≤3 years and ≥10 days
before arriving in Saudi Arabia and must show proof of vaccination on a valid International Certificate of Vaccination or
Prophylaxis for entry.
Continued on page 19
18
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Continued from page 18
Influenza Vaccines
Newer options for influenza vaccination were available during
the 2013-14 influenza season. In addition to the traditional
trivalent vaccines, quadrivalent vaccines protecting against
influenza A (H1N1) virus, an influenza A (H3N2) virus and two
influenza B viruses, as well as egg-free and intradermal vaccines were utilized.
Influenza vaccine is routinely recommended yearly for all
people aged ≥6 months. Influenza season varies geographically. The influenza season in the Northern Hemisphere may
begin as early as October and can extend until May. The influenza season in the Southern Hemisphere may begin in April
and last through September. Travelers should be vaccinated
at least two weeks before travel for adequate immunity to
develop.
Current Health Advisories and Travel Alerts for 2014
Globalization remains a key factor in the spread and control
of tropical diseases and clinicians need to be aware of specific infectious diseases involving potential health risks for
travelers. The CDC releases travel notices that are designed
to inform travelers and clinicians about health issues related
to specific destinations and these can be accessed at http://
wwwnc.cdc.gov/travel/notices.
Chikungunya Fever (CHIKF)
In December 2013, the WHO reported local transmission of
the CHIKF on the Caribbean island of St. Martin. CHIKF has traditionally been considered a disease of tropical and subtropical regions but this marked the first outbreak in the Americas.
The number of cases has grown steadily and currently CHIKF
has been considered a serious threat to the US, especially
considering that the vectors for the disease, Aedes aegypti
and A. albopictus, are well-established in the area. The disease
is an acute febrile illness characterized by incapacitating polyarthralgias and resembles dengue. Health-care providers are
encouraged to report suspected chikungunya cases to their
state or local health department to facilitate diagnostic testing and to mitigate the risk for local transmission
Polio
The international spread of wild-type poliovirus constitutes a
public health emergency. Although polio has been eradicated
in the United States, the disease has not been eliminated in
Afghanistan, Nigeria and Pakistan. Polio has been rapidly
spreading to neighboring countries and as of July 25, 2014,
cases have been reported in Equatorial Guinea, Cameroon,
Iraq, Syria, Afghanistan, Kenya, Ethiopia and Somalia.
To prevent ongoing spread, the CDC recommends that
travelers should still receive one dose of polio vaccine prior
to departure, if they have not received a documented dose
SUMMER 2014
of polio vaccine within the previous 12 months. The list of
countries where the polio virus is still circulating is updated
at http://www.polioeradication.org/Infectedcountries/
PolioEmergency.aspx. Additionally, residents or long term
visitors from countries exporting wild poliovirus (Cameroon,
Islamic Republic of Pakistan, Syrian Arab Republic) should
receive a documented polio vaccine booster dose (OPV or
IPV) before leaving the country. The dose should have been
received between 4 weeks and 12 months before departure.
Middle East respiratory syndrome coronavirus
(MERS-CoV)
As of May 2014, more than 635 cases of MERS-CoV have been
reported to WHO. The virus appears to be circulating widely
throughout the Arabian Peninsula and most cases have been
reported by the Kingdom of Saudi Arabia. Based on currently
available information, the overall risk for visitors to acquire
MERS infection appears to be low. Health care providers
should be alert to patients who develop fever and pneumonia
or acute respiratory distress syndrome within 14 days after
traveling from countries in the Arabian Peninsula. Travelers
should wash their hands frequently and avoid contact with
sick persons in order to prevent acquisition of disease.
Ebola Virus Disease
The WHO announced a total of 1093 suspect and confirmed
cases of Ebola virus disease and 660 deaths in the countries
of Guinea, Sierra Leone, and Liberia as of July 20, 2014. Ebola
hemorrhagic fever is a rare and deadly viral illness native to
several African countries. Bats are strongly implicated as both
reservoirs and hosts for the Ebola Virus. Initial infections in
humans result from contact with an infected bat or other wild
animal. Symptoms include fever, headache, joint and muscle
aches, sore throat, and weakness, followed by diarrhea, vomiting, and stomach pain. Skin rash, red eyes, and internal and
external bleeding may be seen in some patients. The risk to
most travelers is low but travelers should avoid contact with
blood and body fluids of severely ill people and avoid contact
with sick wildlife or infected bushmeat.
Conclusions:
Travel-related illnesses arise from a variety of factors, including
exposure to endemic infectious organisms, and participation in certain activities and traveler-specific susceptibilities.
Fortunately, most illnesses can be prevented with a combination of pre-travel planning, immunizations, and safety precautions during travel. Individuals planning international travel
should visit their healthcare provider and/or specialized travel
medicine clinic to help formulate individualized travel-related
medical advice.
19
Public Health Surveillance for Arboviral
Diseases in Florida
Anna Marie Likos, M.D., M.P.H., Director for the Division of Disease
Control and Health Protection, Florida Department of Health
When lay, and sometimes professional, audiences are
asked about the role of public health in the overall health
care system in the United States, many associate public
health with patient services to indigent populations and
children from low-income households. While working with
community partners to assure that all Florida residents
have access to primary care and dental services indeed
is an important role for public health, the Department
protects, promotes and improves the health of people
in Florida in many other ways. The Department lives this
mission through statewide and community public health
efforts. Recently, the Department established a framework
to create a network of Cancer Centers of Excellence in
the state. We have also continued to promote Healthiest
Weight Florida1, a Departmental initiative empowering
private and public community partners to create environments that support healthier food choices and opportunities for active living for Floridians. Of course, a core
function of public health is one that dates back to when
the Department was founded 125 years ago: disease surveillance and outbreak control. The Florida State Board of
Health was created in response to a devastating yellow
fever epidemic in Jacksonville at the time. Today, public
health surveillance for mosquito-borne and other diseases
continues to be an important means of informing policy
and practice to control diseases of community-wide concern.
There are four primary reasons diseases or conditions are
placed under public health surveillance:
1. To detect individual cases of diseases that require
follow-up and intervention to prevent spread (e.g.
meningococcal disease, certain sexually transmitted
diseases).
2. To detect disease outbreaks, allowing investigation
and control.
3. To collect information that defines the risk factors of
exposure and other information enabling the design
and implementation of prevention and control programs and policies.
4. To collect and summarize data needed to support
evaluation of public health prevention and control
programs.
All health care practitioners (physicians, physician assis20
tants, nurse practitioners, etc.) and laboratories are
required by Florida Statutes 381.0031 to report diseases
of public health importance to the Florida Department of
Health. The specific diseases of concern are published in
the Florida Administrative Code 64D-3.0292. A copy of the
reportable disease list is also available on the Department’s
website3. The most recent update to the list on June 4,
2014, included the addition of chikungunya fever, which
is caused by a mosquito-borne alphavirus recently introduced into the Americas.
Chikungunya virus was first isolated in Tanzania in 1952
and since then major epidemics of chikungunya fever
have been detected cyclically every 7-20 years in Africa
and Southeast Asia. The virus generated additional interest
among public health officials in 2004 when a large outbreak in Kenya rapidly spread, through infected travelers,
to countries in the Indian Ocean region and India. In 2007,
it is likely a traveler returning to Italy started the local chikungunya outbreak detected there4. Another wave of chikungunya fever outbreaks started in the Republic of Congo
in 2011. As before, outbreaks were recorded throughout
Africa, Southeast Asia and the Pacific. In addition, virus
transmission was reported on the Caribbean Island of St.
Martin in December of 2013. This was the first documented
evidence of autochthonous chikungunya virus transmission in the Americas. This recent outbreak has spread
throughout the Caribbean, and chikungunya fever cases
have also been reported from Central (El Salvador) and
South (Guyana, Suriname, French Guiana) America.
As of July 10, 2014 more than 350,000 suspected or confirmed cases have been reported in the region. In Florida,
as of the end of July 2014, there are 115 travel-associated
cases and four locally acquired but unrelated cases that
have been documented in Florida. These cases occurred
in Miami-Dade1, Palm Beach2 and St. Lucie Counties1. The
Department posts a weekly arbovirus surveillance report
online at http://www.floridahealth.gov/diseases-and-conditions/mosquito-borne-diseases/surveillance.html.
The principal vectors Aedes aegypti (the house mosquito)
and Aedes albopictus (the Asian tiger mosquito) are common in the subtropics. Both mosquito species are found
Continued on page 21
HOUSE Calls
Continued from page 20
in Florida. Aedes albopictus breeds throughout the state
while Ae. aegypti is more common in urban environments
in the southern part of Florida, including the Florida Keys.
Like dengue, chikungunya virus is transmitted back and
forth between mosquitoes and people with symptomatic
or asymptomatic infections. This is a different transmission cycle than that seen for other arboviruses currently
endemic to Florida (eastern equine encephalitis virus, St.
Louis encephalitis virus and West Nile virus). These endemic viruses are maintained in nature by Culex mosquitoes
and birds. Humans and other mammals such as horses,
serve as incidental hosts and do not develop viremia to
levels infectious to mosquitoes.
Chikungunya fever presents as a non-specific flu-like illness. Patients with an abrupt onset of fever, typically >
102°F, and severe arthralgias that can’t be explained by
other medical disorders should be considered possible
cases among patients likely exposed to the virus. Travelers
who have recently returned from a trip to the Caribbean
or another part of the world where chikungunya fever is
endemic are at particular risk, but the disease should also
be considered as a differential diagnosis among Floridians
with a history of outdoor exposure. The arthralgia is
typically symmetric and bilateral and can be intense and
debilitating, most often affecting joints of the extremities
(ankles, wrists, phalanges). Other symptoms may include
headache, back pain, myalgia, arthritis, a maculopapular
rash (sometimes pruritic), nausea/ vomiting and conjunctivitis. The incubation period is short, typically between 3-7
days (range 1-12 days). Clinical laboratory findings may
include lymphopenia, thrombocytopenia, elevated hepatic
transaminases and elevated creatinine. Symptoms generally resolve after about a week. Migratory, erratic, relapsing painful arthralgia most often experienced in the small
joints of the hands, wrists, ankles and feet, can be seen
among adults and infrequently among children. While the
illness is fairly mild, joint symptoms can persist for weeks,
months, and sometimes even years. Older adults (i.e., >65
years), persons with underlying medical conditions (e.g.,
hypertension, diabetes or cardiovascular disease), and
neonates exposed intrapartum are at higher risk for severe
disease. Mortality has been observed, primarily among
older adults.
Differential diagnoses of chikungunya fever depend on the
patient’s place of residence, travel history and exposures.
For persons travelling to the Caribbean, perhaps the most
important differential diagnosis is dengue. The two diseases present with similar clinical symptoms. However dengue, which has the potential to cause severe disease with
shock and death if not properly managed, is more likely to
cause neutropenia, thrombocytopenia and hemorrhagic
SUMMER 2014
symptoms. Dengue and chikungunya viruses share the
same mosquito vectors and co-infections have been documented. Other differential diagnoses include leptospirosis,
malaria, rickettsia, group A streptococcus, rubella, measles,
parvo- and enterovirus infections as well as post-infectious
rheumatologic conditions.
Laboratory diagnosis is primarily made by identification of
virus or antibodies in serologic specimens (RT-PCR, IgM and
IgG assays). It is important to consider the timing of the
request when determining what laboratory test(s) to order.
Virus can generally be detected by PCR for about a week
post-disease onset. Virus culture can also be performed on
these specimens. IgM antibodies are typically first detectable days 6-7 after disease onset, but can persist for months.
Treatment is symptomatic and includes rest, fluids and
non-steroidal anti-inflammatory drugs (NSAIDs)5. If dengue
infection is included in the patient’s differential diagnosis,
acetaminophen may be preferred over NSAIDs that promote
bleeding such as aspirin. Patients suspected to be infected
with chikungunya, dengue, or other arboviruses causing significant viremia should also be advised to avoid mosquito
bites during the viremic period (typically the first week of
illness). (See Dr. Vittor's article in this issue of House Calls for
a more in-depth look at Chikungunya fever.)
The primary purpose of the public health surveillance effort
for chikungunya fever and other arboviral diseases in Florida
is to detect and prevent local outbreaks of the disease. In
Florida, county health department epidemiologists lead the
disease surveillance efforts in local communities. When the
local public health epidemiologist receives a disease report
with laboratory and clinical information on the patient, the
epidemiologist generally contacts the patient to ask questions about risk factors for exposure, others with similar
symptoms, and his/her travel history. The epidemiologist
often provides education about the disease and shares
information about how to minimize the risk of infecting others. Sometimes the patient may even be asked to submit
additional laboratory specimens.
As soon as local mosquito-borne disease transmission to
humans is suspected, the county health department contacts local mosquito control officials to make sure mosquito
control efforts are promptly put in place. When the investigation is complete, professional partners are notified,
messaging is developed to remind the public to take precautions against mosquito bites, and the case is reported to
the state health department and to CDC.
Diseases are reported based on standardized criteria called
Continued on page 22
21
Continued from page 21
case definitions6. These generally have both specific clinical and laboratory criteria that each case has to meet in
order to be counted. While it is highly likely that reported
cases had the disease in question, case definitions often
exclude cases with unusual disease symptoms, cases
who never had laboratory tests done, and cases who
were misdiagnosed because they were tested too early
or too late. In other words, public health surveillance
does not accurately describe all cases of a disease, but
rather a subset which does not allow for identification
of true incidence. However, since all states count cases
the same way public health surveillance data can reliably
be compared between states and over time for disease
trends.
For endemic arboviruses maintained in nature by mosquitoes and birds in Florida we also perform animal
surveillance. A number of local communities in Florida
maintain sentinel chicken flocks. Chickens bitten by mosquitoes don’t get sick but mount an antibody response
to the viruses. The Department of Health tests these
birds regularly for evidence of infection. The Department
also collects data on horses and other domestic and
wild animals diagnosed with arbovirus illness. Animal
surveillance data, like human surveillance data, are used
to inform mosquito control activities and for public
awareness. Human and animal surveillance in Florida is
compiled and published weekly on the Department’s
webpage http://www.floridahealth.gov/diseases-andconditions/mosquito-borne-diseases/surveillance.html.
The ecological parameters for mosquito-borne disease
transmission are very complex and mosquito-borne
disease outbreaks are almost impossible to predict. For
example, while we can say (based on dengue surveillance data) that we are likely to periodically detect locally
acquired cases of chikungunya fever, and that we also
likely will have outbreaks of the disease, disease surveillance is the only strategy we have to determine when
and where local disease transmission is happening. It
is also important to note that although public health
is coordinating this effort because of the state disease
reporting requirements, as with other public health functions, we depend on close collaborations with health and
community partners in both the private and public sector for successful identification and mitigation of disease.
References available upon request.
In Memoriam
William Fisher Enneking, MD
May 9, 1926 - July 17, 2014
Dr. Enneking was born in Madison Wisconsin. He received his
bachelor’s degree (1946) and medical degree (1949) from the
University of Wisconsin. He completed his internship at the
University of Colorado. He started an orthopedic residency at the
University of Chicago which was interrupted by his service in the
Korean War.
After the war he returned to Chicago to complete his residency. In 1960, Dean William Harrell recruited Dr. Enneking to help establish the first medical school for the state of Florida. Dr. Enneking helped
found the Department of Orthopedic Surgery at UF and served as its first chairman. He remained at UF
for his entire career. In 1969, he traveled to England and learned how to perform hip replacement surgery from the surgeon who developed the procedure. Dr. Enneking returned to Gainesville and performed the first hip replacement in Florida. He received the Kappa Delta award three times, an award
given to the leading researcher in US orthopedics.
His wife of 66 years, Margaret Olivia Little died in 2013. They had seven children. He is survived by his
second wife, Edith whom he married in later in 2013.
22
HOUSE Calls
Control of Hospital Infections
Robert W. Yancey, Jr., M.D.
North Florida Regional Medical Center
Modern U.S. hospitals are technological marvels.
Advanced surgical techniques, incredible diagnostic imaging, and ingenious drugs administered by highly trained
and caring personnel are available to virtually all in the
U.S. Life improving and life saving treatments, barely
imaginable 20 years ago, are administered in thousands of
American hospitals every day.
These miracles do not come without some risk. A small but
significant percent of patients experience adverse drug
reactions and surgical complications, most of which are of
no long-term consequence. The other risk of these amazing medical treatments is infection. This article will briefly
inform the reader of the overall risk of infections in hospitals, the most common types of infections, and describe
the extensive and somewhat successful efforts of hospitals
and regulatory agencies to reduce hospital-acquired infections (HAI).
What is the Average Risk of Infection during a
Hospital Admission?
The CDC performed a large sample of US hospitals during
2011 and determined that about 1 of every 25 patients
develops an HAI during hospitalization. There are about
722,000 HAI’s in the US every year, associated (not necessarily causal) with about 70,000 deaths. Another CDC
report estimates that HAIs cost the US $35-40 billion each
year. That figure does not include lost productivity of
patients, families, and their businesses that result.
These statistics are astounding. However, remember
that many of these patients who acquire infections are
extremely ill at the outset and are receiving heroic efforts.
Furthermore, many of these infections are rather easily
treated. Nevertheless, ongoing efforts to reduce the risk of
these infections are present in virtually every US hospital.
What are the Risk Factors for Acquiring an Infection
during Hospitalization?
Risks for HAI increase in those with the following conditions: advanced age, malnutrition, obesity, cigarette use
or second-hand smoking, cancer, immobility, long duraSUMMER 2014
tion of hospital stay, diabetes, end stage kidney disease,
immunosuppressive drugs, antibiotic use, and invasive
lines and drains. All of these conditions result in decreased
resistance to infection. Considering that the majority of
hospitalized patients have multiple risk factors for infection, it is no wonder that infections continue to occur.
What are the most Common Types of HospitalAcquired Infections?
r
Urinary Tract Infections (UTI) – UTI’s are the most
common hospital- acquired infection and usually
fairly easy to treat. Bladder catheters which are often
used for patient hygiene in bedridden or incontinent
patient are the most common cause.
r
Surgical Wound Infections – Even a very small
inoculum of bacteria during surgery or immediately
afterward can cause a wound infection. Certain types
of inherently unsterile surgery such as colon surgery
have a higher incidence of infection. On average there
is a 3% chance of surgical wound infection in low- risk
surgery.
r
Hospital- Acquired Pneumonia – Patients who are
very weak, have had a stroke, are on ventilator support, or who have depressed consciousness and cannot cough well are prone to aspiration of oral contents
and the development of pneumonia.
r
Central Line- Associated Infections – Intravenous
lines that are placed into major central veins such as
the superior vena cava are often necessary to deliver
lifesaving drugs. However, there is a chance the line
may become contaminated introducing bacteria into
the general circulation.
r
Clostridium Difficile Enterocolitis (C diff) – This form
of colitis (colon inflammation/infection) is caused by
an environmental bacterial spore and has become a
major hospital (and community) problem over the last
15 years. Cases can be quite severe in the elderly or
immunosuppressed. C diff is usually related to some
patient antibiotic exposure or possibly even antibiotics
given to feed animals in the U.S.
What are Hospitals doing to Prevent Infections?
It is believed that with intensive efforts hospital infections
can be reduced dramatically. The exact percent reduction
Continued on page 24
23
Continued from page 24
possible is unknown. It is clear that all hospital infections
cannot be prevented, as has been claimed by some. Given
the invasiveness of the procedures performed today and
the severely ill patient populations that exist in hospitals,
100% eradication of all infections is not feasible with our
current understanding and technology. However, new
methods have been introduced in recent years that are
clearly decreasing infection risks in hospitals.
improved outcomes.
r
C diff early identification and treatment programs.
r
Rapid microbiology technology allows early identification of specific infections and allows for accurate treatment and isolation earlier in the course of an infection.
‘Susceptible Patient’
Modern hospitals have multifaceted and active infection
control programs coordinated by certified infection control practitioners. They proactively monitor hospital infections and resistant organisms, and coordinate the wide
variety of infection control programs that are simultaneously occurring in the hospital. In order to understand the
variety of programs hospitals have instituted to control
hospital infections, one should first understand the concept of the ‘Chain of Infection’. See Figure 1 (on the next
page). The chain can begin anywhere and can proceed
clockwise or counterclockwise.
Antibiotic exposure, stress of surgery, or acute medical illnesses such as a stroke or heart attack, and malnutrition
all cause the patient to become susceptible to infection.
r
Reduce hypothermia during and after surgery. Low
body temperature after surgery is associated with
increased infection risk. Intensive programs to keep
the patient warm in the operating room and in recovery have become routine.
‘Hospital Infection’
r
Nutritional Programs. Dietitians assist with all patients
who are at nutritional risk.
An infection in the hospital actually renders the patient
susceptible to other infections due to the prescribed antibiotics and to the stress of the infection. Furthermore, the
infected patient receiving antibiotics is a source or reservoir for resistant bacteria and fungi transmission, while
simultaneously being the victim.
r
Pressure ulcer prevention programs are far more
aggressive than years past. Special beds, frequent
turning of bedridden patients and careful observation
for early signs of wounds are now routine.
r
Antibiotic Stewardship programs to reduce patient
antibiotic exposure.
Clearly, many patients are already infected when they
enter the hospital from home and from other medical facilities such as nursing homes. Hospital programs
to identify and rapidly treat infections will result in less
spread of resistant agents. Examples include:
r
Physical Therapy for weak and bedridden patients.
r
Blood glucose control programs especially for the
hours and days immediately surrounding surgery.
r
Sepsis Protocols which have reduced severe infection
mortality by an average of 30% and also reduce length
of stay in the hospital
Some bacteria can become concentrated in the hospital
environment if reservoirs are not routinely sought and
eradicated. Bacteria such as MRSA, C diff, VRE, and other
r
Programs for prevention, early identification, and
treatment of ventilator- associated pneumonia have
24
Hospital programs to decrease patient susceptibility to
infection:
‘Infection Reservoirs’
Continued on page 25
HOUSE Calls
Continued from page 25
Figure 1 ‘The Cycle of Infection’ Programs designed to break the cycle
are outlined in the square text boxes and in the article.
highly resistant bacteria are of constant concern. The reservoirs of these organisms include patients themselves
who are colonized with these organisms as well as the
hospital environment. Many of these patients come from
a reservoir outside of the hospital such as other medical
facilities or even the home, as these bacteria have become
common in the community.
r
Standard precautions utilized in essentially all hospitals include hand-washing, protective gowns, and
equipment sterilization techniques.
r
Disposable equipment.
r
Isolation protocols for patients with specific infectious
agents.
Hospital Programs to address bacterial reservoirs.
‘Portal of Entry into Patient’
r
Screening of patients for colonization of resistant bacteria.
r
Decolonizing patients of resistant or pathogenic bacteria prior to surgery or during the stay.
r
Decontamination of rooms with high- potency disinfecting agents between patients.
The mere presence of hospital bacteria in a patient’s
environment or on his person does not, in itself, cause an
infection. Usually these bacteria require a portal of entry,
or a means to gain access to the patient’s body tissues or
blood. These portals include surgical wounds, intravenous
lines, aspiration events, bladder catheters, etc.
‘Portal of Exit from Reservoirs and Mode of
Transmission’
Healthcare workers hands, their clothing, and the inanimate objects used to care for patients are the most
common means of disseminating hospital bacteria from
patient and environmental reservoirs.
Programs hospitals use to control transmission include:
SUMMER 2014
Hospital efforts to decrease portals of infection include:
r
Prophylactic antibiotics prior to surgery.
r
Special intravenous line protocols (Bundle practices)
and equipment to minimize the chances of line infection.
r
Early bladder catheter removal programs.
r
Aspiration prevention protocols.
r
Pressure ulcer prevention protocols.
Continued on page 26
25
Continued from page 25
What about Resistant Organisms in Hospitals?
Generally speaking, infections that occur during the first
3-4 days of hospitalization are from the patient’s own
native bacterial flora which were present on admission
and which are not usually as resistant to antibiotics.
However, as the hospital stay extends, antibiotic exposure
and environmental exposure cause the patient to become
increasingly colonized with hospital bacteria that are often
highly resistant to 1st line antibiotics. Infections that occur
with these organisms are more difficult to treat and result
in more expense and complications. Infections with these
multidrug resistant organisms (MDR0) cost $15,000-30,000
more per infection to treat, extend the hospital duration
by nearly a week on average, and result in a higher mortality. Commonly described MDRO include MRSA (methicillin
resistant staphylococcus aureus), VRE (vancomycin resistant enterococcus), and a variety of highly resistant bacteria such as ESBL positive E. coli, Carbapenem Resistant
Enterobacteraciae, etc. The list is quite long.
These organisms are diverse in their ecology but patient
decolonization programs, isolation protocols, screening
cultures, room decontamination systems, and limitations
of environmental antibiotic exposure are used to limit
these organisms.
Trends in Infection Control.
Now is an exciting time in infection control. New technology and increased awareness by hospital administrations
of the importance of infection control have improved
patient safety and outcomes considerably.
For many years much of the emphasis on patient protection from hospital organisms was on provider hand washing. Today it is understood that the patient himself is a
major reservoir and that decolonization of organisms from
the patient's skin and mouth can decrease infections such
as pneumonia and intravenous line infections.
Alcohol hand gel dispensers have become commonplace
over recent years. These gels are very effective in reducing hand bacteria within seconds and have been shown to
reduce hospital infections by ~30-35% in most studies.
Decontamination of patient rooms is enjoying new technologies as well. There are now scanning methods to
document that a room has been adequately cleaned.
Hypochlorite (bleach)- based cleaning solutions have been
used to decrease the incidence of C diff. Systems of aerosolized peroxide and hypochlorite or systems using ultraviolet light have been used to render rooms virtually germ
26
free. A new patient in a new room now has a microbiologically cleaner environment than ever before.
Many hospitals are installing Comprehensive Antibiotic
Stewardship programs. These projects are designed to
reduce the volume of broad -spectrum antibiotic exposure
in the hospital by encouraging doctors to use less aggressive antibiotics when appropriate. Reductions in resistant
organisms and C diff have been routinely enjoyed with
these programs.
Electronic hospitals records have made hospital data mining possible. Using infection control applications and
other monitoring applications has improved efficiency of
infection control practitioners and have allowed earlier
identification of potential hospital problems.
What are Regulatory Agencies doing to prevent
Hospital-Acquired Infections?
The HITECH act of 2008 and the Affordable Care Act
(Obamacare) required hospitals to convert to electronic
medical records providing new tools for monitoring infections. Furthermore, CMS has required the reporting of certain hospital-acquired infections, as well as Lab ID events
(MRSA bacteremias and Cdiff ) to the CDC’s NHSN (National
Healthcare Safety Network) to ensure full reimbursement.
The number of hospitals enrolled in the NHSN program
has increased from 300 to over 5000 as a result of the CMS
reimbursement requirement. These NHSN reports are far
from perfect in that they do not take into account variations in the underlying patient populations, but they do
provide valuable information. Now hospital administrations are highly motivated to reduce infections in order
to look good in these reports. New funding for infection
control efforts have consequently been made available,
making hospitals even safer. The good news is that these
networks now accurately report that the programs outlined above are actually working. National MRSA HAI rates
have decreased more than 30% in 2013. Central line protocols and patient decolonization protocols have reduced
ICU- acquired blood infections by >40%. In Florida, bladder catheter associated UTI’s have been decreased by 16%
in 2013. Colon surgery infections have been reduced by
28%. Hospitals that have followed CDC guidelines for control of C diff have enjoyed a 20% reduction in the rate of
this difficult-to-control infection.
Summary
Infection control is a complex task but has been enjoying
recent success in making hospitals safer from infection.
HOUSE Calls
Common Tick-borne Illnesses (TBI)
in Florida
Marie A. Kima, M.D. Infection Prevention and Treatment Center,
North Florida Regional Medical Center
Case presentation
A 54-year-old male was transferred to our facility in early
March with headaches and fevers. His illness started
5-7 days prior to his transfer. His WBC on admission
was 5000 with a lymphocyte predominance. The AST
was 45g/dl and the ALT 50 g/dl. His lumbar puncture
(LP) showed a pleocytosis with a slightly elevated protein. He was empirically started on IV Vancomycin and
Ceftriaxone. An Infectious Disease consultation was
requested on the second day of admission. His white
blood cell count had decreased to 2000. The patient
complained of severe joint pain and his headache was
worse. The patient lives in the Live Oak area of North
Central Florida where he spends quite a bit of time outdoors. He did not recall any tick bites. He denied any
recent travel. Given the risk factors for TBI and the clinical picture, Vancomycin and Ceftriaxone were stopped
and the patient was empirically started on Doxycycline.
On the 3rd day, his headache seemed to be improving but he developed a non-pruritic maculopapular
rash. The rash was on his palms but did not extend to
the soles of his feet. In subsequent days, the patient
improved clinically and the rash did not worsen. He was
discharged home on day 6. Doxycycline was continued
for an additional 14 days. One week after discharge tests
for serum antibodies to Ehrlichia, Anaplasma and Borrelia
were negative. The serum antibody titer to Rocky
Mountain Spotted Fever (RMSF) was greater than 1: 256.
Discussion
The most common tick-borne illnesses reported in
Florida according to the Florida Department of Health
include: RMSF, Human monocytic Ehrlichiosis (HME
caused by E. chaffeensis), human granulocytic anaplasmosis (HGA caused by Anaplasma phagocytophilum),
and Lyme disease (caused by Borrelia burgdorferi) (1).
Less common tick borne infections reported include Q
fever caused by Coxiella burnetii, spotted fever caused by
to Rickettsia parkeri and Southern Tick Associated Rash
Illness (STARI) whose causative agent is unknown. The
tick-borne illnesses reported in Florida fall into two categories: those that are Florida-Acquired and those that
are Non-Florida Acquired (Non-FL).
RMSF in Florida is a zoonosis transmitted by the
SUMMER 2014
American dog tick Dermacentor variabilis. The causative
agent is Ricketssiae ricketssii, which primarily infects
mammals such as dogs. Humans are accidental hosts.
The incubation period is 2-14 days. The clinical presentation includes fever, and headache, and 60-90%
of patients have a rash and muscle pain. The rash is
characteristically maculopapular, typically affecting the
palms of the hands and the soles of the feet. Untreated
mortality from this infection can be as high as 25%.
When treated it has a 2-5% mortality rate. From 20022012, 182 cases of RMSF were reported in Florida, 77% of
which were Florida acquired. Most of the cases in Florida
were reported in the Northern part of the state and the
Panhandle (North Florida includes Alachua, Bradford,
Levy counties)1. Cases are reported all year around.
Ehrlichiosis (HME) is transmitted to humans by
Ambyloma americanum, also known as the Lone star tick.
This is the most common tick found in the Southeastern
United States. Its preferred host is the white-tailed deer;
however, it also feeds on dogs or humans. The causative
agent of HME is the bacterium Ehrlichia chaffeensis. The
incubation period is 5-10 days. The clinical presentation
includes fever, fatigue, headache and muscle aches. It
can be self-limited; however, in 1% of patients, HME can
be quite severe and require hospitalizations. It is often
referred to as the spotless fever; nonetheless, a rash can
be seen in up to 60% of the cases. In 2002-2012, 107
HME cases were reported in Florida. 73 % of the reported
cases were Florida-acquired. Most cases are reported in
the summer months.
Human Granulocytic Anaplasmosis (HGA) was initially thought to be caused by a species of Ehrlichia. It
is now known that the causative agent of this disease is
Anaplasma phagocytophilium, an intracellular obligate
bacterium. It is transmitted by the Ixodes scapularis
(black legged) tick. Symptoms are indistinguishable
from that of Ehrlichiosis. Most Cases are found in the
northeastern United States. From 2006-2011, 12 cases
were reported in Florida. There has been an increase in
the number of HGA cases reported in Florida since 2011.
From 2002-2012, 49 cases were reported. Less than 45%
Continued on page 28
27
Continued from page 27
of the reported cases were Florida acquired1. Most cases
acquired in Florida are found in the summer months.
Lyme borreliosis - known as Lyme disease - is caused
by the bacterium Borrelia burgdorferi, which is transmitted in the southeastern United States by the Ixodes scapularis tick. The preferred host of this tick is the white-tailed
deer. The most common sign of Lyme disease is a rash.
Sixty percent of patients present with Erythema migrans
(EM), an expanding erythematous rash around the site
of the tick bite. Later, a central clearing develops resembling a Bull’s-eye. Other symptoms such as fatigue, fever,
headache, mildly stiff neck, arthralgia, or myalgia may
occur. Protean manifestations of Lyme disease include
central nervous system (CNS), cardiac and rheumatologic involvement. Patients diagnosed and treated early
respond well to therapy. Patients diagnosed in the later
stages of the disease may develop severe symptoms
and are at a greater risk of developing recurrent infections. There has been an increase in reported cases of
Lyme disease in the US, including in Florida. This increase
is in part attributable to changes in the case definition
from 2008 to 2011; it is noteworthy that the change in
case definition was for surveillance purposes and not for
clinical diagnosis.2 725 cases were reported from 20022012. Prior to 2012, 23% out of the total cases reported
in Florida were Florida-acquired. In 2012, 19 out of 33
or 60% of the cases reported in the state of Florida were
Florida-acquired. An average of 67 cases of Lyme disease
/year are now reported in Florida. Most of the acquired
cases in Florida are found in the central and southern
part of the state. Cases are reported year round, but peak
in the summer months.
white blood cell count or, in the cases of Ehrlichiosis
and Anaplasmosis, there is leukopenia/thrombocytopenia. Sometimes there are abnormal liver function tests
(slightly elevated transaminases). If a lumbar puncture is
done, a pleocytosis can be seen with either lymphocyte
or neutrophil predominance and often an elevated protein. Serology is often negative during the first week of
illness so serum should be evaluated at 2-3 week intervals.
For Lyme disease two-tier testing is required: an initial
Enzyme Immunoassay (EIA) or Immunofluorescence Assay
(IFA); if reactive or equivocal, samples should be tested by
western blot. Lyme bacteria culture or PCR is only recommended in rare circumstances. The western blot should
not be done without the initial tests. Practitioners should
be aware that the CDC cautions against use of unvalidated
assays including urine antigen tests, immunofluorescent
staining for cell wall--deficient forms of Borrelia burgdorferi, and lymphocyte transformation tests. In addition,
some laboratories perform polymerase chain reaction
tests for B. burgdorferi DNA on inappropriate specimens
such as blood and urine or interpret western blots using
criteria that have not been validated.3
Additional considerations: If there is travel history to
the north east or midwest then Babesia serology should
be included. For a patient with recent travel to the Gulf
Coast presenting with the symptoms described above,
tests for Rickessiae parkeri should be included. Q fever
serologies should be requested if there was any exposure to cattle. STARI has no serologic test available, but
it responds readily to Doxycycline. Some patients may
present with more than one Tick-borne illness (Babesiosis,
Lyme, Anaplasmosis are transmitted by the same tick) (1).
In some instances, Immunohistochemistry of a biopsied
Clinical presentations that often indicate a tick-borne
skin lesion might be helpful for the diagnosis of RMSF.
illness (TBI) to the health care provider are the following: 1) patients often present during the months of April Whole blood specimens can be sent for PCR confirmation
through September with a febrile illness. It is noteworthy, of HME, HGA(not always sensitive); a negative does not
exclude the diagnosis. Positive tests should be reported
though, that in Florida TBI are reported all year round;
2) patient complaints often include headache, joint and to the Local Health Department or to the Bureau of
muscle aches; 3) rash is present; 4) although rare, paraly- Epidemiology at (850) 245-4401. Babesiosis is not reportable in Florida.
sis is possible. Certain ticks such as the dog tick release
a toxin that can induce paralysis. Tick vector exposure
should be considered if there was recent travel to the
Empiric treatment with Doxycycline should be considSouth Atlantic, North Central, South Central and New
ered when TBI is suspected since the laboratory results
England states. Also, if there is recent travel history to or will often take at least 10-14 days to return. IV Ceftriaxone
from South America, Africa, Asia and the Middle East in a should be considered for severe Lyme disease when there
patient who spent time in the rural areas.3
is cardiac or CNS involvement. Doxycycline is the drug
of choice; however, it should be avoided in pregnant
women and children less than 8 years old. Amoxicillin
The initial diagnosis is largely based upon clinical
and Cefuroxime may be used if early Lyme disease is
findings, which is then followed by laboratory diagnossuspected. Antibiotic prophylaxis after a tick bite is not
tic testing. Common laboratory data reveal a normal
Continued on page 29
28
HOUSE Calls
Continued from page 28
recommended. Prophylaxis against Lyme disease is recommended in endemic areas when specific criteria are
met.4 In cases of paralysis, especially, removal of the tick
is recommended.
Preventive measures should be discussed with patients
with outdoor activities. The CDC recommends repellents
that contain the following ingredients: 1) N, N-diethyl-3meithylbenzamide (DEET) with proven efficacy against
ticks, mosquitos, chigas, etc. The percentage of DEET
usually correlates with the protective hours of the product, and 2) Picaridin, has been shown to be efficacious
against mosquitos; 20% of Pircaridin is equivalent to
20-35 % of DEET in laboratory testing. It is less caustic
than DEET against fabric (fiber and rayon) and plastic
(4). Data on Picaridin against ticks are variable. The CDC
warns against using combination products such as
IR3535 that combines sunscreen and insect repellents.5
At times of high transmission or in endemic areas, it is
recommended to wear light-colored clothing and to
cover extremities when possible. Apply 0.5% Permethrin
to clothing, camping gear, tents, and shoes (this application may last through several wash cycles; follow instructions on the product) (epa.gov). Adults should check
with their pediatrician as to the strength of DEET that may
be used on children. Shower immediately after spending
time outdoors in an area where ticks are prevalent. Do tick
checks; when a tick is found use tweezers and gently press
down on the skin and slowly and steadily pull upward to
remove the tick whole. Avoid Vaseline, gel etc.
Conclusion. The case reviewed above illustrates a fairly
typical presentation of RMSF. If untreated, the patient
could have progressed and developed a severe vasculitis
(rash) with multi-system organ involvement that could
have resulted in his death. People who spend time out
doors (occupational or recreational) are at an increased
risk of TBI. With increased awareness, Clinicians should be
able to readily recognize, diagnose, treat and report tickborne infections.
Acknowledgements: Thanks to Dr. Peter Kima for critically
reading the manuscript. Thanks to Dr. Josh Barton for
helpful discussions.
References upon request.
The ACMS is proud to announce
Charles E. Riggs, Jr., MD
has been elected to the
Florida Medical Association
(FMA)
Board of Directors in the
FMA District H seat.
Charles E. Riggs, Jr., M.D.
SUMMER 2014
Congratulations,
Dr Riggs!
29
HIV Testing in 2014
Jennifer Janelle, M.D., Clinical Assistant Professor,
Division of Infectious Diseases and Global Medicine,
University of Florida College of Medicine
Significant advances in treatment have substantially
reduced AIDS-related morbidity and mortality, thereby
extending and improving the lives of many people living
with HIV. Despite these treatment advances, many people
living with HIV remain unaware of their infection or have
failed to link to and stay in care. The Centers for Disease
Control and Prevention (CDC) estimate that of the 1.1 million Americans living with HIV, 82% have been diagnosed,
66% linked to care, 37% retained in care, 33% prescribed
antiretroviral therapy but only 25% virally suppressed
(Figure 1).1 Increasing the number of Americans living
with HIV who have suppression of their HIV viral load is
an important goal, both for the improved health of the
infected individual as well as for the health of those in the
community who are at risk of acquiring HIV. Healthcare
providers can impact this epidemic by testing for HIV as
appropriate and by making sure those testing positive are
successfully linked to ongoing care.
Who should undergo HIV testing? In September of
2006, The CDC released Revised Recommendations for
HIV Testing of Adults, Adolescents, and Pregnant Women
in Health-Care Settings. 2 These recommendations include
routine HIV testing for all patients aged 13-64 years,
patients initiating treatment for tuberculosis, all patients
seeking treatment for sexually transmitted infections and
all pregnant women. Annual testing is recommended for
those at increased risk of HIV infection, including injectiondrug users and their sex partners, persons who exchange
sex for money or drugs, sex partners of HIV-infected
persons, and men who have sex with men (MSM) or heterosexual persons who themselves or whose sex partners
have had more than one sex partner since their most
recent HIV test. More recent guidance suggests that at-risk
MSM should be screened every 3-6 months.3
According to these revised HIV testing recommendations,
screening for HIV infection should be voluntary and only
undertaken with the patient’s knowledge and understanding that HIV testing is planned. While signed informed consent should no longer be required according to the CDC,
patients should be informed verbally or in writing that
HIV testing will be performed unless they decline (optout screening). Patients should receive verbal or written
information including an explanation of HIV infection and
the meaning of potential test results. Easily understood
informational material in the languages
commonly encountered in a service area
should be provided. Bilingual staff and
interpreters providing language assistance
to patients with limited English proficiency should be assessed for competence.
The patient should be offered an opportunity to ask questions and to decline
testing. With such notification, consent for
HIV screening should be incorporated into
the patient’s general informed consent for
medical care on the same basis as other
screening and diagnostic tests. The CDC
does not recommend a separate consent
form for HIV testing. If a patient declines
an HIV test, this information should be
documented in the patient’s medical
record.
Figure 1: CDC. Turning the Tide on HIV: Division of HIV/AIDS Prevention Annual
Report 2013
30
Florida statute 381.004 is in line with
Continued on page 31
HOUSE Calls
Continued from page 30
the CDC recommendation that
signed informed consent is no longer
required:
Figure 2
“No person in this state shall order a
test designed to identify the human
immunodeficiency virus, or its antigen
or antibody, without first obtaining the
informed consent of the person upon
whom the test is being performed,
except as specified in paragraph (h).
Informed consent shall be preceded
by an explanation of the right to confidential treatment of information
identifying the subject of the test and
the results of the test to the extent
provided by law. Information shall also
be provided on the fact that a positive HIV test result will be reported to
the county health department with
sufficient information to identify the
test subject and on the availability and
location of sites at which anonymous
testing is performed. As required in paragraph (3)(c), each
county health department shall maintain a list of sites at
which anonymous testing is performed, including the locations, phone numbers, and hours of operation of the sites.
Consent need not be in writing provided there is documentation in the medical record that the test has been
explained and the consent has been obtained.”
While many institutions have transitioned to including
consent for HIV testing in the general consent for care
and allow opt-out testing, some still require a separate
informed consent document signed by the patient. It is
important to be aware of the testing requirements of your
individual institution.
What options exist for HIV testing in 2014?
Patients seeking HIV testing today have a variety of
options, including home HIV testing kits, rapid HIV testing, anonymous testing, as well as conventional HIV blood
testing. It is important to recognize that there are advantages and disadvantages for each of these options so that
patients can be properly counseled. Many of these tests
use older generation HIV antibody tests that diagnose HIV
infection later after exposure (Figure 2).
Currently, there are two home tests approved by the
United States Food and Drug Administration (FDA): the
Home Access® HIV-1 Test System and the Oraquick®
SUMMER 2014
In-Home HIV Test. The Home Access® HIV-1 Test System
is a home collection kit that requires the patient to provide a blood sample and mail it in for testing. Results
are anonymous and available as early as the next business day. Confirmatory testing is automatically done on
the sample in the event of a positive screening test. The
Oraquick® In-Home HIV test is the first and only rapid
over-the-counter HIV test approved in the United States.
This test can detect antibodies to HIV -1 and HIV – 2 with
an oral swab in as little as 20 minutes. A consumer support center provides 24 hour support with information
on HIV/AIDS, instructions on how to properly conduct the
test, and referrals to local organizations for follow-up testing and linkage to care. This test costs approximately $40
per test kit. Positive results require separate confirmatory
testing. Both home tests use older testing methodologies
that find infection later after exposure than the current
laboratory blood-based testing, thus allowing a patient
receiving a negative test to have a false sense of security
regarding their HIV status. However, these tests provide
options for those who would otherwise not seek HIV testing due to concerns regarding privacy.
Rapid HIV tests can make a preliminary diagnosis of
HIV in 30 minutes or less and can be used in traditional
healthcare settings as well as non-clinic settings by outreach teams. Positive results obtained by rapid HIV tests
require confirmatory testing. 10 rapid point-of-care tests
Continued on page 32
31
Continued from page 31
have been approved by the United States FDA. Most of
these rapid tests diagnose only established HIV infection.
However, the new Alere Determine™ HIV-1/2 Combo is the
first rapid point-of-care test that can detect HIV 1/2 antibodies as well as the p24 antigen which allows diagnosis
even during acute HIV infection.
Patients desiring conventional HIV blood testing who do
not want their names linked to the test results can seek
anonymous HIV testing. This process involves linking the
result to a unique identifier rather than to the patient’s
name. The patient must seek the results after testing as
they are otherwise not traceable for follow-up. A list of
local anonymous HIV testing sites is maintained by health
departments.
Conventional blood-based HIV testing is typically done in
healthcare settings. Until recently, the recommended protocol for conventional blood-based HIV testing involved a
screening HIV antibody test confirmed with a Western blot
or immunofluorescence assay (IFA). This algorithm had
several shortcomings including the inability of the Western
blot or IFA to detect early HIV infection, leading to falsenegative or indeterminate results in those with acute HIV
infection, a time when the viral load is markedly elevated
and the risk for transmission is highest. Patients can be
falsely reassured by a negative HIV test at this stage, leading to ongoing risky behaviors and further spread of HIV
in the community. Accurate diagnosis of infection during
Figure 3
the acute phase is critical both for initiation of treatment
of the infected individual and also for prevention efforts
for the community as a whole. An additional problem with
the older testing algorithm was the inability to differentiate HIV-1 and HIV-2 infection. This distinction is important
because laboratory monitoring for these infections is different and some antiretroviral agents effective against HIV-1
are not effective against HIV-2.
On June 27, 2014, the CDC released a new protocol for HIV
testing titled “Laboratory Testing for the Diagnosis of HIV
Infection: Updated Recommendations”.4 The new algorithm
replaces the 3rd generation HIV antibody test with a 4th
generation combined HIV antigen/antibody assay (Figure
3). This 4th generation combined HIV antigen/antibody test
identifies acute HIV infections while maintaining the same
accuracy for detecting established infection. This improvement is critical as it has become recognized that the risk of
HIV transmission from those with acute and early infection is
much higher than that from people with established infection, accounting for 10- 50% of all new HIV transmissions.5-8
Early detection of HIV infection is made possible in the new
algorithm by inclusion of testing for the HIV-1 p24 antigen,
a viral protein present early in infection.
Other benefits of the new algorithm include:
- a shorter processing time as the tests in the current algorithm are able to be done much more quickly.
-the HIV 1/2 differentiation assay can detect HIV-2 infection
which has important treatment and monitoring implications.
-the addition of an HIV nucleic
acid test allows accurate
detection of early HIV infection or can indicate a false
positive from the 4th generation antigen/antibody assay.
-elimination of the Western
blot confirmatory test
decreases the risk of false positive and indeterminate testing results which could occur
with the old testing algorithm
during early HIV infection.
No diagnostic test or algorithm can be completely
accurate in all cases of HIV
infection and if one gets
inconsistent or conflicting test
Continued on page 33
32
HOUSE Calls
Continued from page 32
results, additional testing of follow-up specimens
may be necessary.
Positive results from this algorithm indicate the
need to link the patient to HIV medical care.
Linkage to Care
An important part of counseling patients undergoing HIV testing is a discussion regarding the
implications of a negative result. Patients should
be aware that a negative result does not eliminate the ongoing risk of acquiring HIV infection.
Safer sexual and needle practices should be
encouraged. For those testing positive for HIV
infection, it is critical to provide support, develop
a plan to link to HIV care and encourage ongoing
follow-up of HIV infection.
Figure 4
Patients living with HIV face many physical, emotional and financial challenges. Ensuring access
to quality HIV care is the first issue many providers and their patients face. Those with insurance
may be able to access care without difficulties
and can easily be referred to an HIV specialist.
However, even these patients can face obstacles
in paying copays for labs, doctor’s visits and
medications. Social programs funded by the Ryan
White HIV/AIDS Treatment Extension Act can
assist many of these patients so that they receive
the ongoing care and support needed. In Florida
today, no patient should expect to go without
HIV treatment and medications due to his/her
financial status.
Patients with no insurance and/or no funding
can receive HIV care and medications, as well as
many other services, through Ryan White Care
Act funded programs. These programs provide
medical services, laboratory testing, and access
to antiretroviral therapy and medications to prevent and treat opportunistic infections at no cost
to clients. Other resources include case management services and assistance with housing costs
for those who qualify.
Alachua County is part of a 15 county area
defined as Area 3/13 (Figure 4). Our area receives
Ryan White Part B funding administered by
WellFlorida Council, Inc, a private, non-profit
organization. Access to Ryan White services
in our area is initiated by patients calling Area
SUMMER 2014
3/13 Eligibility Determination Services which is located in Catholic
Charities in Gainesville at (352)378-2868. They should request an eligibility determination for Ryan White services. Eligibility counselors can
guide patients through the enrollment process and link them to case
management and care programs appropriate for their needs. Further
information regarding Ryan White funded services available in our 15
county area is available at http://www.floridahealth.gov/chdalachua/
hiv/313HIV/.
Summary
Despite significant improvements in treatment for people living with
HIV/AIDS, allowing them to live longer and healthier, many remain
unaware of their HIV status or have not successfully linked to care
after diagnosis. More options for HIV testing exist today than ever
before. While rapid and home HIV testing is available and provides
important options for those who cannot or will not seek testing in
traditional healthcare environments, most of these tests fail to detect
infection early after exposure. Recognition of acute HIV is important as the HIV viral load is markedly elevated at this time leading to
increased risk of further HIV transmission with ongoing unsafe sexual
or needle-sharing behaviors. The new CDC recommended laboratory
testing protocol includes screening tests that detect acute HIV infection and can differentiate between HIV-1 and HIV-2 infection, which
has important monitoring and treatment implications. We healthcare
providers continue to have an important role in the control of the HIV
epidemic by promoting and discussing options for HIV testing with
our patients and ensuring linkage to care in the event of a positive
HIV test. Improvements in all stages of HIV care from diagnosis to suppression of the HIV viral load can help individual patients live longer
and healthier and can also reduce the risk of continued HIV transmission in our community.
33
Chikungunya: An In-depth Look at a New
Arboviral Threat in Florida
Amy Y. Vittor, M.D., Ph.D.
Division of Infectious Disease and Global Medicine,
University of Florida College of Medicine
Florida now has yet one more arboviral infection to contend
with: this July, the first cases of locally transmitted chikungunya were reported from Palm Beach, Miami-Dade and St.
Lucie counties. After the dramatic outbreaks occurring in the
Caribbean, starting in December 2013, there have been 137
imported cases in Florida1, placing this mosquito-borne infection on the diagnostic radar.
Chikungunya virus (CHIKV) is a positive-sense single stranded
RNA virus in the genus Alphavirus, family Togaviridae. The
alphaviral genus can be divided into the New World members that primarily cause encephalitis (e.g. eastern equine
encephalitis, Venezuelan equine encephalitis, western equine
encephalitis viruses) and Old World members that give rise
to arthralgias and rash (e.g. Sindbis, Semliki Forest, Mayaro,
Chikungunya, and Ross River viruses). CHIKV was first discovered in Tanzania in the 1950s, where it likely originated,
and derives its name from the Makonde term meaning “that
which bends up”2. It is thought to exist in a sylvatic cycle
between forest-dwelling Aedes species mosquitoes and
non-human primates in Africa, but is capable of human-tohuman transmission utilizing urban Aedes species3. The first
documented urban outbreak occurred in the early 1960s in
Thailand and India, followed by minor outbreaks until 20043.
In 2004, an outbreak on the Kenyan island of Lamu led to
more than 70% of the population becoming infected3. This
was followed by outbreaks in multiple islands in the Indian
Ocean, where large portions of the population (>30%) were
affected4. Upon introduction to Reunion Island, the virus
appears to have undergone a point mutation in the envelope
glycoprotein E1-A226V that led to increased infectivity in
Aedes albopictus, allowing for transmission in locations with
few Ae. aegypti but abundant Ae. albopictus5. The east African
strain also caused a massive epidemic in India, resulting in
millions of cases6. Subsequent local transmission in Italy and
France were reported, as viremic travelers infected local Aedes
mosquitoes7. Now for the first time, the virus has established
itself in the Americas. This outbreak, first detected on the
island of St. Martin, is due to a strain most closely related
to those recently identified in Indonesia, China and the
Philippines8. Since its detection in December, locally acquired
cases have been confirmed in 31 countries and territories in
the Americas, with a total of over 500,000 suspected cases
and nearly 5000 confirmed cases9. This strain does not appear
34
to have the E1-A226V mutation and probably relies more heavily on Ae. aegypti for transmission; nonetheless, laboratory
studies have shown that the more ubiquitous Ae. albopictus is
also highly competent vector for this strain of chikungunya10.
The disease typically presents as an acute febrile illness, accompanied by severe arthralgia. The most commonly involved
joints are those in the wrists, fingers, feet, elbows, ankles, and
knees. The fever starts abruptly and lasts a few days to two
weeks, and is often followed by a maculopapular rash. In addition, headache, myalgia, fatigue and nausea may be seen. After
the acute phase, a fair portion (30-60%) of patients will develop incapacitating fatigue and persistent arthralgia or arthritis11, 12, 13. Older age (>65 years), the presence of severe joint
pain in the acute phase, and underlying osteoarthritis are risk
factors for persistent or relapsing joint symptoms. Particular
hosts (neonates, age > 65 years, hosts with comorbidities
such as hypertension, cardiovascular disease, alcohol disease)
may have an increased risk of developing atypical disease14,
15
. Atypical manifestations include heart failure, myocarditis/
pericarditis, meningoencephalitis, episcleritis, conjunctivitis,
pneumonia, hepatitis, renal failure, pancreatitis, bullous dermatosis, photosensitive hyperpigmentation, and intertriginous
aphthous-like ulcers14, 15.
When obtaining a history, eliciting specific dates and locations
of travel during the two weeks prior to the onset of symptoms
is critical. For example, travel to the Dominican Republic, where
incidence rates have been very high, would raise suspicion
for chikungunya fever. If there is no recent history of travel, it
is helpful to inquire about household contacts who may have
traveled within one month prior to the onset of symptoms.
Physical examination may reveal an elevated temperature,
symmetric distal joint tenderness, tenosynovitis, joint swelling, or a maculopapular rash over the trunk and extremities16.
Other data that are supportive of the diagnosis of chikungunya include lymphopenia (or sometimes lymphocytosis) and
thrombocytopenia, though the latter is not as pronounced as it
can be with dengue. Elevated creatinine and elevated hepatic
enzymes may also be seen16. In those with persistent arthralgia or arthritis, rheumatoid factor and anti-cyclic citrullinated
peptide antibody tend to be negative17. Due to low sensitivity
and specificity, imaging studies are not particularly helpful for
Continued on page 35
HOUSE Calls
Continued from page 34
making the diagnosis. For patients experiencing relapsing
or prolonged joint symptoms, radiography or MRI may show
erosive changes in the joints, and the latter may also reveal
tenosynovitis, tendinitis, joint effusion, synovial thickening,
and marrow edema17.
Specific diagnosis can be made with acute and convalescent serologies (IgM and IgG) and direct viral detection by
means of RT-PCR or viral culture18. Serological testing and
direct viral detection may be requested from the Florida state
health department or the CDC. Acute sera may be sent to the
Department of Health Bureau of Public Health Laboratories
in Tampa or Jacksonville. RT-PCRs should be requested on
samples collected less than or equal to 8 days after symptom
onset. If a patient presents later in the course of disease,
paired acute and convalescent serologies are diagnostic
(laboratory submission forms can be found at http://www.
floridahealth.gov/programs-and-services/public-healthlaboratories/forms-publications/index.html). The Florida
Public Health Laboratories are prioritizing the testing of
specimens from individuals who are suspected to have locally
acquired chikungunya, and samples from uninsured individuals. Insured patients who are not suspected of having locally
acquired disease may have their sera sent to commercial
laboratories for serological testing (Focus Diagnostics through
Quest). If providers wish to have CSF or synovial fluid tested
for chikungunya virus, the Florida Public Health Laboratory
in Jacksonville should be contacted for further information.
Patients tend to have high viral titers early on in the course of
disease, rendering RT-PCR a sensitive and specific test when
performed during the first week of illness. While IgM is also a
reliable diagnostic if the sample is drawn at least 5 days into
the course of illness, it may persist for up to 18 months18. If
seroconversion can be demonstrated with paired acute and
convalescent sera, IgG is also quite reliable. Single IgG positive serum samples must be interpreted with caution since
chikungunya IgG antibodies may cross-react with other alphaviruses. Chikungunya-specific antibodies can be differentiated from nonspecific alphaviral antibodies using the plaque
reduction neutralization test, performed by the CDC.
The Florida State Health Department has defined a clinically
compatible illness as a case with fever or chills, arthralgia or
arthritis involving two or more joints, and the absence of a
more likely clinical explanation. A confirmed case consists of
these same features with the addition of a positive PCR or
plaque reduction neutralization test (PRNT) or IgM antibodies
with confirmatory virus-specific neutralizing antibodies. While
chikungunya is not a notifiable disease, it can be reported to
ArboNET (a national surveillance system for arthropod-borne
diseases; https://wwwn.cdc.gov/arbonet/). Furthermore, the
county health department should be contacted if there is a
suspected case. (See Dr. Likos's article in this issue of House
SUMMER 2014
Calls for more details about public health surveillance for
Chikungunya fever).
If chikungunya is suspected, supportive treatment should be
instituted (analgesics, IV fluids as needed). No specific treatment modalities exist at this time. Small trials have been
conducted to assess the efficacy of ribavirin and chloroquine,
showing possible benefit or no benefit19, 20. A study of sixteen
chikungunya patients with persistent arthritis examined the
role of sulfasalazine and methotrexate, and showed a good
response with these agents21. However, the use of an antitumor necrosis factor drug, etanercept, proved to be deleterious in a mouse model of alphaviral arthritis, resulting in more
tissue damage, inflammatory cell recruitment, and higher viral
titers than in control mice22. In the case of CHIKV-associated
retinitis and acute optic neuritis, steroids may be beneficial23.
All of these studies have had very small numbers of enrolled
patients and varying methodological rigor, limiting the conclusions that can be drawn as to drug efficacy. New developments
in the monoclonal antibody therapy hold promise; however,
these are still in the very early stages of investigation24, 25.
Vaccine development is also underway. Candidates include
formalin-inactivated, DNA, virus-like particle, live-attenuated
chimeric, and subunit vaccines26. While the virus-like particle
and DNA vaccines have a high safety profile, the costs are
anticipated to be high. The live-attenuated vaccines hold much
promise, being effective, safe, and cost-effective26. At this time,
the best methods for prevention include avoidance of mosquito bites. In Florida, Ae. aegypti and Ae. albopictus are both
prevalent, though the former is found only in the southern
and coastal regions. These are day-time biting mosquitoes,
and effective methods for personal protection include wearing long sleeve shirts and pants and applying mosquito repellant containing at least 10% DEET when outdoors. Important
source-control methods include frequently emptying all open
containers and disposing of waste in the peri-domiciliary area.
If larger bodies of stagnant water are present, county mosquito
control services may be able to provide assistance in managing
these potential breeding sites.
Thus, chikungunya virus must now be added to the list of
arboviral infections in Florida, which already includes eastern
equine encephalitis, St. Louis encephalitis, Highland J, West
Nile, and dengue viruses. Local transmission has been limited
thus far, and perhaps will follow the course of locally acquired
dengue, giving rise to only sporadic cases yearly. Nonetheless,
the intensity of human movement between mainland USA and
the Caribbean warrants maintaining a high index of suspicion
for chikungunya disease in patients with acute febrile illness
and severe arthralgia.
References upon request.
35
HAPPENINGS
ACMS
2014 Florida Medical Association
Annual Meeting Hilton Bonnet Creek, Orlando, FL
July 25-27, 2014
Michelle Rossi, MD, ACMS Board Member
Jesse Lipnick, MD, ACMS Board Member
FMA Delegate Group at the FMA House of Delegates session L to R: Mary Grooms, MD, ACMS
President; Carl Dragstedt, MD; Charles Riggs, Jr., MD, ACMS Past President; Sally Lawrence, PhD,
ACMS EVP; Joseph Thornton, MD; and Mark Panna, MD.
36
HOUSE Calls
2014 Florida Medical Association
Annual Meeting Hilton Bonnet Creek, Orlando, FL
July 25-27, 2014
Karen Harris, MD, ACMS
Past President
In the House of Delegates meeting, Mary Grooms, MD, ACMS
President and Charles Riggs, Jr., MD, ACMS Past President.
L to R: David Winchester, MD, ACMS Treasurer; Norman Levy, MD, PhD,
ACMS 1st Past President; and Carl Dragstedt, MD.
SUMMER 2014
37
2014 Florida Medical
Association
Annual Meeting
Hilton Bonnet Creek,
Orlando, FL
July 25-27, 2014
David Winchester, MD, ACMS Treasurer (center) addressing the
Gator Caucus; Looking on: Norman Levy, MD, PhD, ACMS 1st Past
President (left) and Mary Grooms, MD, ACMS President (right).
Alachua General Hospital Historical Marker Ceremony July 10, 2014
Unveiling of the historical marker. L to R: Ms. Melanie Barr, Chair of Alachua County Historic Commission;
Mrs. Florence Van Arnam, Robb House Museum Curator; Gainesville Mayor Ed Braddy; Alachua County
Commissioner Lee Pinkoson, Chair of BOCC; and UF Health Shands Hospital immediate past CEO Tim
Goldfarb.
38
HOUSE Calls
HAPPENINGS
ACMS
Charles E. Riggs, Jr., MD; ACMS Past President and
David E. Winchester, MD, ACMS Treasurer.
Mrs. Florence Van Arnam with the
AGH Historical Marker
Alachua General Hospital
Historical Marker Ceremony
July 10, 2014
Mrs. Florence Van Arnam ACMS Historian
and Robb House Museum Curator, providing a history of AGH.
SUMMER 2014
39
A Note from Our
Editor
Fun In The Gut
By E. Scott Medley, M.D.
Dr. Medley is a retired Family Physician
I thought that this excellent “Infectious Diseases” issue of
House Calls deserved a little levity. And though I know that
intestinal infections are “no laughing matter”, a little frivolity
might be acceptable to our wonderful tolerant readers. So
here goes:
your efforts were supererogations?”
If three organisms and their toxins were living happily in one’s
intestinal tract, their conversations might go something like this:
Camy: “Yeah, and what if I said my existence in this intestine is
phantasmagorical, or that your attitude was supercilious?”
Camilia (“Camy “ ) campylobacter jejuni: “My, my, it sure is dark
and damp inside this intestinal tract!”
Georgie: “Supercilious? Does that have anything to do with the
cilia I saw in this guy’s trachea on my way toward his esophagus?”
“Chloe” Clostridium difficile: “Yeah, but I kind of like it here—I can
wreak havoc with my cytotoxins on this guy’s GI tract”
Camy: “No, dummy, and if you want a really big word, how about
‘SUPERCALAFRAGILISTICEXPIALIDOCIOUS’ --- I learned that
one when our ‘host’ was stuffing his gullet with popcorn while
watching a rerun of ‘Mary Poppins’ “.
“Georgie” Giardia Lamblia: “Actually, I kind of like it in here,
too. Except for causing this guy fever, I can do almost as much
damage as you ladies can.”
Chloe – “Well, we all know how we got here. This dummy went
to a foreign country and drank contaminated water, consuming
large quantities of good ole’ Georgie Giardia here. Then, when
he developed serious diarrhea, he took some old outdated
antibiotics he found in his medicine cabinet, allowing yours truly,
Chloe c. diff to proliferate”
Camy: “Surely this is fun, causing all this cramping and diarrhea
and all, but I must say that I’m feeling a bit sad”.
Georgie: “Why is that Camy? You look lovely all covered in
mucus and stuff.”
Camy: “Yes, but unlike both of you, they describe me as ‘selflimited’. Now that really hurts”.
Chloe: “Don’t be silly, Camy, ‘ self-limited’ is not a commentary
on your initiative or ambition, it just means you may not persist
as long as we do”.
Chloe: “But what I like most of all is when this guy tries to get
rid of us using ‘coffee enemas’-I think the hazelnut vanilla is my
favorite”.
Georgie: “Only one big problem you lovely ladies need to worry
about. Since the Vancomycin didn’t get rid of chloe, and our
dumb host never thought of trying metronidazole for me, guess
what’s coming ‘down the pike’, I mean through the rectum, next?”
Camy and Chloe together: “Oh, Georgie, you know that we are
both big fans of yours, and surely you’re not referring to a stool
transplant, better known as a ‘fecal microbiota transplantation’
where they infuse some fresh donor stool into our nice comfy
colon home via an enema?”
Georgie: “That’s right ladies, and even more scary is the fact
that our host searched the Internet and found a DIY (DO IT
YOURSELF) article on ‘How to safely do a fecal transplant at
home’. [no kidding! ESM] But, either way, get ready for the SH+T
to hit the fans!”
Georgie: “Yeah, and besides, at least you’re a real bacteria, I’m just
a protozoan, and even worse, I’m really just a cyst-a trophozoite.”
And, fortunately for their “host”, thanks to “fecal bacteriotherapy”
(44 refences in Wikipedia), [again no kidding! ESM] these 3
troublesome friends did not “live happily ever after”.
Chloe: “There you go again, using those big words. What if I said
THE END
40
HOUSE Calls
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Mark’s Story
When Mark Saleh experienced the signs of a heart attack, he came to the ER at North Florida Regional for help.
Cardiologist Andrew Smock and ER physician Amit Rawal worked together with registered nurses and paramedics to save Mark.
Now, he’s back to running his café in Live Oak and coaching neighborhood kids in soccer. Mark is going strong.
The full story about the people who were there when Mark needed them most is on our website.
The ER at North Florida Regional. Lifesaving care for life’s emergencies.
www.NFRMC.com/ER