P2 - Zoonotic Diseases - Marzec

Zoonotic Diseases

Natalie Marzec, MD, MPHColorado Department of Public Health and Environment

National Nurse Practitioner SymposiumJuly 11, 2021

Keystone, Colorado

Zoonotic Diseases Natalie Marzec, MD, MPH P2

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Disclosures

• Dr. Marzec has no financial relationships with commercial interests to disclose.

• Any unlabeled/unapproved uses of drugs or products referenced will be disclosed.

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Learning objectives

1. Describe the symptoms of some zoonotic diseases in humans.

2. Describe how to test and treat these zoonotic diseases, including where guidance can be found.

3. Describe public health infrastructure and methods by which diseases are reported.

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Why do we care about zoonotic diseases?

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• Zoonotic diseases (or zoonoses) are caused by pathogens that spread between animals and people

• >60% of known human infectious diseases can be spread from animals

• 75% of new or emerging human infectious diseases come from animals

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https://www.cdc.gov/onehealth/basics/zoonotic-diseases.html(accessed 4/30/2021)

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To keep up to date with One Health:

• Monthly national webinars hosted by the CDC One Health Office

• Free continuing education!

• To register go to: https://www.cdc.gov/onehealth/zohu/

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Public Health 101

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What is public health?

• “Public health promotes and protects the health of people and the communities where they live, learn, work and play.”

• “Public health works to track disease outbreaks, prevent injuries and shed light on why some of us are more likely to suffer from poor health than others.”

• “The many facets of public health include speaking out for laws that promote smoke-free indoor air and seatbelts, spreading the word about ways to stay healthy and giving science-based solutions to problems.”

NNPS 2021 https://www.apha.org/What-is-Public-Health (accessed 5/14/2021)

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10 Great Public Health Achievements, 1900-1999• Vaccination

• Motor-vehicle safety

• Safer workplaces

• Control of infectious diseases

• Decline in deaths from coronary heart disease and stroke

• Safer and healthier foods

• Healthier mothers and babies

• Family planning

• Fluoridation of drinking water

• Recognition of tobacco use as a health hazard

NNPS 2021 MMWR. April 2, 1999. 48(12);241-243.

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10 Great Public Health Achievements, 2001-2010• Vaccine-preventable diseases

• Prevention and control of infectious diseases

• Tobacco control

• Maternal and infant health

• Motor vehicle safety

• Cardiovascular disease prevention

• Occupational safety

• Cancer prevention

• Childhood lead poisoning prevention

• Public health preparedness and response

NNPS 2021 MMWR. May 20, 2011. 60(19);619-623.

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10 Essential Public Health Services

NNPS 2021https://www.apha.org/What-is-Public-Health/10-

Essential-Public-Health-Services (accessed 5/14/2021)

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Overviews of some nationally notifiable zoonoses

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• Animal bites and rabies

• Arboviruses

• Hantavirus

• Plague

• Tularemia

• Brucellosis

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Animal bites and rabies

NNPS 2021https://www.cdc.gov/rabies/index.html

(accessed 4/30/2021)

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NNPS 2021 https://www.cdc.gov/rabies/location/usa/surveillance/wild_animals.html(accessed 4/30/2021)

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NNPS 2021https://www.cdc.gov/rabies/transmission/body.html


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Prevention

Primary• Animal vaccination• Avoid wildlife• Pre-exposure prophylaxis for high risk occupations

Secondary• Post-exposure prophylaxis

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Once symptoms start, rabies is almost universally fatal


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Flavors of potential rabies exposures

• “I woke up and there was a bat in my room.”

• “I was breaking up a dog fight and got bitten by one of the dogs.”

• “I was petting a stray dog in India and it licked a cut on my hand.”

• “I was bitten by a skunk that was attacking my chickens.”

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Managing suspects (animal bites)

• Report dog or cat bites to local animal control

• Call public health for wild animal bites

• Post-exposure prophylaxis guidelines:

https://www.cdc.gov/vaccines/hcp/acip-recs/vacc-specific/rabies.html

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Post-exposure prophylaxis (PEP)

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Human RabiesImmunoGlobulin

Vaccine

*There are no contraindications to PEP


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Common PEP questions

• How soon do I need to get PEP?

• Does insurance cover PEP?

• What if I can’t afford the immunoglobulin?

• Where can I go to get PEP?

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Human clinical rabies

• Discomfort at bite site (incubation period is variable –weeks to months)

• Agitation, confusion, cerebral dysfunction within days• Illness lasts 2-10 days

• If you suspect you have a patient with rabies, call your state health department IMMEDIATELY• Testing requires collecting multiple specimens, including a tissue biopsy, and CDC approval

NNPS 2021https://www.cdc.gov/rabies/diagnosis/animals-humans.html


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Infection control measures

• No confirmed person-to-person transmission (except via transplant)

• Transmission through direct contact with tissue or fluids• Environmental transmission does not occur

• Standard precautions are recommended

NNPS 2021https://www.cdc.gov/rabies/specific_groups/hcp/exposure.html


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Arboviruses

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What are they?

• Arthropod-borne viruses

• Transmitted to humans by mosquito, tick, sand fly or midge bites• Also transfusions, transplants, breast feeding, perinatal, laboratory exposure

• Can cause febrile illness and some can cause neuroinvasive disease

NNPS 2021https://wwwn.cdc.gov/nndss/conditions/arboviral-diseases-neuroinvasive-

and-non-neuroinvasive/case-definition/2015/ (accessed 5/13/2021)

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Prevention is key

• Insect repellent

• Long sleeves shirts and long pants

• Mosquito control both indoors and outdoors

• https://www.cdc.gov/westnile/prevention/index.html

NNPS 2021 Accessed 5/13/2021

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Arboviruses in the U.S. and territories• West Nile virus• St. Louis encephalitis virus• Western equine encephalitis virus

• Powassan virus• California serogroup viruses

• California encephalitis• Jamestown Canyon• La Crosse• Snowshoe hare• Keystone

• Territories only:• Dengue• Zika• Chikungunya

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NNPS 2021 Accessed 5/13/2021

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West Nile virus

• Flavivirus• Mosquito-borne (Culex spp)

• Cycles between mosquitoes and birds, humans are a dead end host

• No human vaccine• Supportive treatment

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West Nile virus: symptoms

Febrile illness• 20% of infected

• Headache• Myalgias/Arthralgias• GI symptoms• Rash

Neuroinvasive disease• <1% of infected

• Meningitis• Encephalitis

• 10% mortality rate• Can have permanent neurologic problems

NNPS 2021 https://www.cdc.gov/westnile/symptoms/index.html(accessed 5/13/2021)

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West Nile virus: managing suspect cases

• Not transmissible person-to-person

• Supportive care

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West Nile virus: diagnostics

• Specimens:• Serum• CSF

• PCR (within a week of onset)

• Serology (at least 8 days after onset)• IgM can last for months• Cross reactivity with other flaviviruses (SLE)• Plaque-reduction neutralization can distinguish

NNPS 2021https://www.cdc.gov/westnile/healthcareproviders/healthCareProviders-

Diagnostic.html (accessed 5/13/2021)

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Hantavirus

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Two main categories

New World Hantaviruses

• Hantavirus pulmonary syndrome

• North & South America

Old World Hantaviruses

• Hemorrhagic fever with renal syndrome

• Europe & Asia

NNPS 2021 https://www.cdc.gov/hantavirus/index.html (accessed 5/6/2021)

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Transmission to humans

• Reservoir: rodents

• Each hantavirus has a single primary host

• Most important hantavirus in the U.S. is Sin Nombre virus

NNPS 2021https://www.cdc.gov/hantavirus/technical/hanta/ecology.html


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Sin Nombre virus

• Discovered in 1993• Outbreak of respiratory disease in Four Corners area

• 30-40% mortality rate • More than 90% of cases occur in states west of the Mississippi River

NNPS 2021https://www.cdc.gov/hantavirus/surveillance/reporting-state.html

(accessed 5/6/2021)

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Deer mouse: Sin Nombre virus

NNPS 2021https://www.cdc.gov/hantavirus/rodents/index.html


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Preferred habitat: woodlands, also desert areas


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Cotton rat: Black Creek Canal virus



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Preferred habitat: overgrown areas with shrubs and tall grasses


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Rice rat: Bayou virus



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Preferred habitat: marshy areas


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White-footed mouse: New York virus



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Preferred habitat: wooded and brushy areas


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Cumulative cases through January 2017

NNPS 2021 https://www.cdc.gov/hantavirus/surveillance/reporting-state.html(accessed 5/6/2021)

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Symptoms

• Prodromal phase: onset 1-6 weeks after rodent exposure• Fatigue, fever, myalgias• Sometimes headaches, dizziness, chills, GI symptoms

• HPS: 4-10 days into illness• Coughing, shortness of breath

• Progression to respiratory failure in 4-12 HOURS• a “… tight band around my chest and a pillow over my face”

(pulmonary edema)

NNPS 2021https://www.cdc.gov/hantavirus/hps/symptoms.html

(accessed 5/6/2021)

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Managing suspects

• Thrombocytopenia consistently seen in prodrome*:• <150K in 98% of cases• <130K in 92% of cases

• Diagnostic test is IgM ELISA• Management should not depend on results

• Do not fluid resuscitate

• Transfer to center with ECMO capability

NNPS 2021*Koster et al. Am J Clin Pathol 2001;116:665-672.

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PlagueYersinia pestis

NNPS 2021Paulus Furst of Nuremberg, Doctor Schnabel von Rom,

1656, British Museum, London

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• Infected fleas

• Direct inoculation of bacteria into wounds

• Respiratory droplets from a pneumonic case (humans and cats!)

NNPS 2021https://phil.cdc.gov/Details.aspx?pid=22259


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Clinical Presentations

• Bubonic

• Septicemic

• Pneumonic• Only presentation that is transmissible human-to-human

Initial presentation depends on exposure

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Symptoms

• Sudden onset of high fever within a week of exposure

• Other presenting symptoms depend on the primary manifestation:

• Buboes (lymphadenitis)• Pneumonia • Sepsis

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Managing suspect cases

• Do not wait for positive testing to start treatment• Obtain specimens for testing as quickly as possible• Alert Health Department immediately

• Isolate and start droplet precautions if suspicious for pneumonic presentation

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Testing

• Alert your lab and infection control program that plague is suspected

• Lymph node aspirate if bubo present

• Blood culture no matter what the presentation

NNPS 2021 https://phil.cdc.gov/Details.aspx?pid=20848

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Treatment

• Do not delay treatment for diagnostics

• IV gentamicin and fluoroquinolones• Transition to PO once stable

• 10-14 days (or until 2 days after fever resolves)• Up to date treatment information can be found here:

https://www.cdc.gov/plague/healthcare/clinicians.html

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TularemiaFrancisella tularensis



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Transmission

• Tick bite: dog tick (Dermacentor variabilis), wood tick (Dermacentor andersoni), lone star tick (Amblyomma americanum)

• Deer flies (Chrysops spp.)• Contact with infected animals

• Eating undercooked meat• Inhaling contaminated dust or aerosols• Drinking contaminated water

NNPS 2021https://www.cdc.gov/tularemia/transmission/index.html


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Symptoms• Fever, and:

• Ulcer at entry site (ulceroglandular)

• Lymphadenopathy (glandular)

• Irritation/inflammation of eye (oculoglandular)

• Sore throat, mouth ulcers, tonsillitis (oropharyngeal)

• Cough, chest pain, dyspnea (pneumonic)

• No localized symptoms (typhoidal)

NNPS 2021https://www.cdc.gov/tularemia/signssymptoms/index.html


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Managing suspects

• Not transmissible person-to-person

• Lab should be notified when testing

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Testing

• Culture: fastidious, slow-growing

• Ulcer swabs• LN aspirate• Pharyngeal swam• Respiratory specimens

• Paired serology: • 1st specimen drawn within

week of onset• 2nd specimen drawn 2-3 weeks

later

• Direct immunofluorescence assay (DFA)

• Immunohistochemical staining (IHC)

• PCR• Single serology (at least 14

days after illness onset)

NNPS 2021https://www.cdc.gov/tularemia/clinicians/index.html


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Treatment

• At least 10-14 days of treatment

• Streptomycin• Doxycycline

• Gentamicin and ciprofloxacin (not FDA-approved for tuli but has been used successfully)

• More details: https://www.cdc.gov/tularemia/clinicians/index.html

NNPS 2021https://www.cdc.gov/tularemia/clinicians/index.html


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BrucellosisBrucella spp.



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CDC Brucellosis Reference Guide

https://www.cdc.gov/brucellosis/pdf/brucellosi-reference-guide.pdf

Or:

https://www.cdc.gov/brucellosis/clinicians/index.html

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Important Brucella species & hosts

More frequently cause human brucellosis:

• B. abortus: cattle• B. melitensis: sheep, goats,

camels• B. suis: pigs

Less frequently cause human brucellosis:

• B. canis: dogs• B. ceti and pinnipediae:

marine mammals

NNPS 2021https://www.cdc.gov/brucellosis/clinicians/brucella-species.html


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Brucellosis in host species

• Causes abortions or weak young particularly with first pregnancy

• Dairy cattle must be vaccinated (B. abortus) to move across states

• Can be spread vertically

• Can be spread sexually

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• Exposure to infected animal birthing/abortion tissues or fluid • B. abortus, B. melitensis in endemic countries • B. canis in U.S.

• Consumption of unpasteurized dairy products from infected animals

• B. melitensis, B. abortus in endemic countries• B. abortus RB51 in the U.S.

• Field dressing infected feral swine (B. suis)

NNPS 2021https://www.cdc.gov/brucellosis/clinicians/brucella-species.html


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Symptoms

Initially

• Fever• Sweats• Malaise• Anorexia• Headache• Fatigue• Muscle/joint/back pain

Later on

• Recurrent fever• Arthritis• Endocarditis• Neurologic symptoms• Testicular/scrotal swelling• Chronic fatigue• Depression• Hepatic/splenic swelling

NNPS 2021 https://www.cdc.gov/brucellosis/symptoms/index.html (accessed 5/12/2021)

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Managing suspects

• Person-to-person spread is rare:• Potential vertical transmission via breastfeeding• Rare sexual transmission• Rare tissue transplantation or blood transfusion

transmission

• B. abortus, melitensis, suis are bioterrorism agents• Be wary of suspects without animal exposure

NNPS 2021https://www.cdc.gov/brucellosis/transmission/index.html


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Testing

• Culture is best

• Serology available for abortus, melitensis or suis• No human serologic test for B. canis or B. abortus RB51

• Paired sera:1. Within a week of symptom onset2. 2-4 weeks later

NNPS 2021https://www.cdc.gov/brucellosis/clinicians/serology.html


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Treatment

• Combination therapy reduces the risk of relapse*:• Doxycycline + rifampin x 6 weeks• Children < 8 years old: TMP-SMX x 4-6 weeks +/- rifampin

• B. abortus RB51 resistant to rifampin

NNPS 2021 CDC Brucellosis Reference Guide (Feb 2017)

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Public Health Reporting

NNPS 2021 https://wwwn.cdc.gov/nndss/ (accessed 5/12/2021)

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At the national level

• Centers for Disease Control & Prevention (CDC) coordinate with the Council of State and Territorial Epidemiologists (CSTE) to determine which conditions (infectious and noninfectious) are nationally notifiable

• National Notifiable Disease Surveillance System (NNDSS)

• States and territories transmit de-identified data to CDC for national surveillance

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At the state/territory level

• Each state/territory government determines what conditions are reportable in their jurisdiction

• In Colorado: • Board of Health established by state statute• State health department proposes any changes to the notifiable conditions list

but BoH approves them to move them into law

• Public health agencies collect reports and investigate cases or delegate investigations to partners as appropriate

• A subset of these data are shared with CDC

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Privacy

• Public health authorities are not covered by HIPAA• HIPAA provides for reporting to public health• Release of information is not needed to share patient information

• Patient information is protected by health department to similar standards as HIPAA covered entities like providers and health plans

https://www.hhs.gov/hipaa/for-professionals/privacy/guidance/disclosures-public-health-activities/index.html

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[email protected]

Thank you!


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P2 - Zoonotic Diseases - Marzec

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