Naegleria Fowleri:The Danger in Your Swimming Hole

Nancy Wilson, MPH studentWalden University

PUBH 6165-4, Environmental HealthDr. Raymond Thron

Summer 2014

Learning Objectives

What is Naegleria fowleri?

What is primary amebic meningoencephalitis?

How is a person infected?

How can infection be prevented?

What is Naegleria fowleri?

Thermophilic, free-living ameba Found in warm fresh water

Lakes, ponds, rivers, hot springs Feeds on bacteria

Image credit: Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Kemble, S. K., Lynfield, R., DeVries, A. S., Drehner, D. M., Pomputius III, W. F., Beach, M. J.,...Danila, R. (2012). Fatal Naegleria fowleri infection acquired in Minnesota: Possible expanded range of a deadly thermophilic organism. Clinical Infectious Diseases, 54(6), 805-809. doi:10.1093/cid/cir961

How are people infected?

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Where can N. fowleri be found?

Every continent except Antarctica (Painter, Pfau, Brady, & McFarland, 2013)

In the U.S., more frequently in southern states (Yoder

et al., 2012)

In ponds, lakes, rivers, and hot springs (Painter et al., 2013)

In drinking water

Not regulated (Yoder et al., 2012).

Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162

Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

Reported U.S. Cases, 1962-2013

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Why should we pay attention?

FatalitiesSurvivors

Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C. (2014). Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834

What is PAM?

Primary Amebic Meningoencephalitis

Meningo + encephal + itis

membranes + brain + inflammation

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

The Symptoms of PAM

Headache Fever Nausea/vomiting Stiff neck Altered mental status Seizures

Yousuf, F. A., Siddiqui, R., Subhani, F., & Khan, N. A. (2013). Status of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan. Journal of Water & Health, 11(2), 371-375. doi:10.2166/wh.2013.112

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

How quickly does PAM progress?

Symptoms start 1-7 days after infection (median is 5 days)

Death occurs an average of 10 days after infection, or 1-12 days (median 5.3 days) after initial symptoms

Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Who is at risk?

Children and young adults Males Freshwater swimmers Those who play, swim, or bathe in fresh

water in July or August

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Are people only at risk when swimming?

Short answer: No.

Nasal exposure to infected drinking water Shower or bath Slip-n-slide Nasal irrigation or rinsing

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

How is PAM diagnosed?

Laboratory tests Direct visualization Antigen detection Polymerase chain reaction (PCR) Ameba culture Environmental detection

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

What treatment is available?

Miltefosine, breast cancer drug Successful usage in 2013 (CDC, 2013)

Amphotericin B, confirmed clinical efficacy In combination with fluconazole,

rifampicin, sulfadiazine, dexamethasone, or other drugs (Sood, Chauhan, Chandel, & Jaryal, 2014)

Early treatment is best! Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM).

Retrieved from http://www.cdc.gov/parasites/naegleria/index.html Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C. (2014). Prompt diagnosis and extraordinary survival

from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834

How can infection be prevented?

Avoid activities in freshwater when there is a high water temperature (Yoder et all., 2012)

Avoid getting water up the nose Use nose clips (Yoder et al., 2012)

Avoid head submersion (CDC, 2013)

Avoid stirring up sediment during water-related activities (Yoder et al., 2012)

Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

How can infection be prevented?

Use sterile, distilled, filtered, or previously boiled water for nasal irrigation (Yoder et al., 2012)

Do not allow bathing water to go up in nose (CDC, 2013)

Avoid the use of slip-n-slides (CDC, 2013)

Do not allow children to play unsupervised with hoses or sprinklers (CDC, 2013)

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

What should I do if I suspect Naegleria fowleri infection?

Go to the hospital immediately and report possible exposure

CDC Emergency Operations Center is available for consult on any suspected infection case

Centers for Disease Control and Prevention. (2013). Naegleria fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Points to Remember

Be wary of warm freshwater!

Protect your nose!

It is better to be safe than sorry!

Early is best!

References Centers for Disease Control and Prevention. (2013). Naegleria

fowleri – Primary Amebic Meningoencephalitis (PAM). Retrieved from http://www.cdc.gov/parasites/naegleria/index.html

Kemble, S. K., Lynfield, R., DeVries, A. S., Drehner, D. M., Pomputius III, W. F., Beach, M. J.,...Danila, R. (2012). Fatal Naegleria fowleri infection acquired in Minnesota: Possible expanded range of a deadly thermophilic organism. Clinical Infectious Diseases, 54(6), 805-809. doi:10.1093/cid/cir961

Painter, S. M., Pfau, R. S., Brady, J. A., & McFarland, A. S. (2013). Quantitative assessment of Naegleria fowleri and Escherichia coli concentrations within a Texas reservoir. Journal of Water & Health, 11(2), 346-357. doi:10.2166/wh.2013.162

References Sood, A. A., Chauhan, S. S., Chandel, L. L., & Jaryal, S. C.

(2014). Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report. Indian Journal of Medical Microbiology, 32(2), 193-196. doi:10.4103/0255-0857.129834

Yoder, J. S., Straif-Bourgeois, S., Roy, S. L., Moore, T. A., Visvesvara, G. S., Ratard, R. C.,... Xiao, L. (2012). Primary amebic meningoencephalitis deaths associated with sinus irrigation using contaminated tap water. Clinical Infectious Diseases, 55(9), e79-e85.

Yousuf, F. A., Siddiqui, R., Subhani, F., & Khan, N. A. (2013). Status of free-living amoebae (Acanthamoeba spp., Naegleria fowleri, Balamuthia mandrillaris) in drinking water supplies in Karachi, Pakistan. Journal of Water & Health, 11(2), 371-375. doi:10.2166/wh.2013.112

Thank You!Any Questions?