Case Report from MalaysiaJeein Chung, DVM, MPH, DACPVM

Ukraine Regional One Health Workshop

April 2017

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Objectives

• To demonstrate an interactive case study approach to presentation

• To highlight proper usage of citations in presentation

• To illustrate a potential One Health approach to disease surveillance

• Your turn!

2

Clinical History

Malaysia:• 29-year old female

• Complains that for 3 days…• Intermittent fever

• Loss of appetite (anorexia)

• Profuse sweating

• Headache

• Muscle pain

38.5 C

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Asian Pac J Trop Dis. 2014 Apr; 4(2): 150–153.

Diagnostic Tests

•Dengue: • Negative

•Malaria: • Negative

• Presumptive Diagnosis: • Influenza(?)

• Treatment:• Vitamin C• Paracetamol

• Cough Syrup

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1 month later…

• Still not better… patient reports that symptoms are on and off (intermittent)

• Abdominal palpation• Hepatomegaly

• Splenomegaly

• With pain

• Hypotension (90/50 mm Hg)

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Do you have any more questions about patient?• Did she travel anywhere?

• No

• What did she eat?• Nothing unusual

• What is her job?• Veterinary laboratory assistant working with…

• Brucella melitensis

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What would you do next?

• Complete Blood Count (CBC)

• Blood Chemistry

• Diagnostic Tests?

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How would you handle the sample?

• Packaging requirements

• Shipping requirements

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AnemiaNeutropeniaLymphopenia

9Asian Pac J Trop Dis. 2014 Apr; 4(2): 150–153.

Blood Chemistry

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Asian Pac J Trop Dis. 2014 Apr; 4(2): 150–153.

Rose-Bengal plate test

• High antibody

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Asian Pac J Trop Dis. 2014 Apr; 4(2): 150–153.

Other Brucella tests

• Culture

• Serology• Serum agglutination

• Enzyme-linked immuno-assay (ELISA)

• Polymerase Chain Reaction (PCR)

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Treatment

• What do you do in Ukraine?

• For 6 weeks:• Doxycycline 100 mg twice per day• Rifampicin 450 mg once per day

• Tx Options:• Children < 8 years:

• Aminoglycoside + Trimethoprim/sulfamethaxole• Rifampicin + Trimethoprim/sulfamethaxole

• Children > 8 years:• Doxyxclyine + Rifampicin• Gentamicin + Doxycycline

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Brucellosis Standard Operating Procedure (SOP)• Prikaz?

• Case Reporting Form

• Sample Management

• Shipping and Handling

• Processing

• Diagnostic Testing

• Case Definition and Handling

• Data Handling (Epidemiology/Epizootology)

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Brucellosis Case Definition (for animals)

Susp

ect

Cas

e • Abortion

• Retained Placenta

• Orchitis +/-Epididymitis

• Swollen or Inflamed Joints

Pro

bab

le C

ase • Suspect Case

+

• Positive Buffered Brucella Antigen Test (Rose-Bengal Test) C

on

firm

ed C

ase • Suspect Case

+• Positive PCR

or• Positive

Antibody ELISA

Human Brucellosis Case Definition

Clinical description:

• Acute or insidious onset of

• Fever

• Night sweats• Fatigue

• Anorexia, Weight loss

• Headache

• Arthralgia

Laboratory criteria for diagnosis:

• Isolation of Brucella sp. from a clinical specimen, or

• Fourfold or greater rise in Brucella agglutination titer between acute- and convalescent-phase serum specimens

• obtained greater than or equal to 2 weeks apart and studied at the same laboratory, or

• Demonstration of Brucella sp. in a clinical

specimen by immunofluorescence

Human Brucellosis Case Classification

• Probable: a clinically compatible case that is:

• epidemiologically linked to a confirmed case or

• has supportive serology (i.e., Brucella agglutination titer of greater than or equal to 160 in one or more serum specimens obtained after onset of symptoms)

• Confirmed: a clinically compatible illness that is:

• laboratory confirmed

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CPPQMHIRepository

Republican SES/RDL

Rayon/CitySES

NotificationOblast SES

ESU

Notification

MINISTRYOF HEALTH

Info flowSample flowTRV deploy

RDL Surveillance Structure for MOH

DeployedTRVs

Sample Collection and Epidemiological data

Infectious Disease Hospital or Outbreak Location

Oblast SES EDP lab RDL

CPPQMHI=Center for Prophylaxis of Plague and Quarantine of Most Hazardous InfectionsESU: Epidemiological Support UnitSES=Sanitary Epidemiological SurveillanceTRV=Threat Response Vehicle

Institute of Virology

Viral isolate

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CPPQMHIRepository

(MOH)

Rayon Vet

NotificationOblast Vet

ESU

Notification

Info flowSample flowTRV deploy

RDL Surveillance Structure for MAWR

DeployedTRVs

Sample Collection and Epidemiological data

Oblast Vet EDP lab RDL

MSVDMAWR

CVD-EDP

Outbreak location (farm)

CPPQMHI=Center for Prophylaxis of Plague and Quarantine of Most Hazardous InfectionsCVD-EDP= Republic Special Veterinary Laboratory of EDPESU=Epidemiological Support UnitMSVD=Main State Veterinary DeptSES=Sanitary Epidemiological SurveillanceTRV=Threat Response Vehicle

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But where is the connection?

Reporting here?

MOH MAWR

One Health = Working Together…

Human (MOH)

• Human cases

• Human control

• Personal Protective Equipment

• SOPs

• Communication/Coordination

Veterinary (MAWR)

• Animal cases

• Animal control

• PREVENTION (vaccines)

• Reporting

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