Chapters Transcript Exposed! Management of Common Exposures in Pediatrics Dr. Orscheln reviews the management of common exposures in pediatrics. Well, good morning, everyone, and welcome to Early Bird Rounds. Thank you for joining us today. Today, we have Doctor Rachel Orshland who is specialized in pediatric um infectious disease, and we'll go ahead and turn our attention over to her when she's ready. Mhm. Good morning. Uh, thank you so much for the opportunity to speak at Early Bird Rounds. So the way I designed today's talk, uh, was to cover some of the most common calls we get from pediatricians, or some of them are common, some of them are random, but they're calls we've definitely gotten repeatedly and sometimes clinic visits for common exposures in the community. So with that, I'll get started. Uh, I do not have any financial disclosures, and there will be some off label use of medications for some unusual rare conditions or conditions, uh, for which the drugs have not been FDA approved for the age group, um, will be disgusting. So overall, uh, the objectives of today include to review the management of some of the common exposures, um, that we hear about in pediatrics. This includes things like animals. I got a call yesterday about a guinea pig bite, um, uh, raccoon poop. It is a novel exposure we occasionally hear about, uh, needles in the community, uh, wrong breast milk, and then also pinworm exposure, which causes, I think, the most distress of any other exposure, um, that we hear about. So one of the most common calls we get in pediatric infectious diseases is regarding a bat exposure. So this would be a common scenario. Um, you are called about a mother, uh, by a mother who walked into the nursery of her toddler to find a bat flying around the room. And, you know, I live in University City and had the experience of finding a bat flying around a room in my house, and it is, uh, horrifying. Um, so the bat is captured by the family in this circumstance and then released outdoors, which is what people often do when they capture a bat in their home. So the questions that come up are what rabies post-exposure prophylaxis should be given, how soon should this begin, and who in the family would be recommended for post-exposure prophylaxis for rabies. So I'll just, uh, take a step back and, and talk a little bit more about common carriers of rabies, uh, in our country. So if you look at, um, rabies exposures by animal across the US, you can see the animals that frequently carry rabies include bats all over the United States, um, skunks, especially in the middle of the United States, uh, foxes in some locations. Foxes and skunks in other locations and the mongoose in certain tropical locations. Um, bats, however, make up about 30% of the rabbit, about 5000 rabid animals that are reported in the US each year. And it should be noted that we don't do a ton of surveillance for rabies. Um, we certainly don't do a lot of surveillance for rabies among domesticated animals, so. Um, there's not a lot of rabies reported in dogs and cats, but we don't routinely test them in a systematic way to ascertain the number of animals that are carrying rabies. Um, on average, there are about 1 to 3 human cases of rabies in the US each year, and 70% of the deaths from rabies are from bat rabies. Um, so the most, uh, the other common cause of exposure is exposure to dogs. Dogs overseas. So one, you know, we see a lot of, um, patients prior to travel. And one of the things I talk about with families and kids, especially kids who are old enough to hear advice is, do not touch any animal overseas, uh, because almost any animal exposure in another country will result in the need for post-exposure prophylaxis for rabies, especially things like dogs where, uh, in certain countries, um, rabid dogs are, uh, very frequently found in the community. In terms of in Missouri, if you look at our rate of rabies, and these are animals that are tested, um, because of an exposure or an unusual circumstance, you can see that the most frequently tested positive animals are bats. Almost the majority of cases, uh, of rabies that are found in animals are in bats. Um, uh, this is from. Um, oh, I, I guess this gives us a number by year. Um, I think this is the most recent year that I found, um, skunk would, or, uh, there was one case of, um, cat rabies, one case of skunk rabies, but again, bats by far in a way make up the majority of animals that test positive. So who should receive post-exposure prophylaxis after an exposure, particularly to a bat? And the overarching theme is, it's individuals who cannot reliably exclude contact with that animal. So that would be anybody who is sleeping in the room with the bat. Now, you know, people will often say, Well, we were all in the house and the doors were open, but the CDC is pretty specific about it being in the room. You know, bats are not flying around trying to bite people. They inadvertently get into homes and they're trying to. Find a way out through echolocation. So they're usually not going room to room. So we say if the bat was found in the room where someone was sleeping, or in the room with a young child who couldn't reliably tell you if the bat had landed on them. Now, again, bats aren't trying to land on us, uh, but it should be noted that, you know, bites and scratches from bats would be so small as to be unrecognized, um, potentially. Um, and then also, if someone was, you know, demented or intoxicated. Or otherwise unreliable in reporting the exposure, if they were in a room with a bat, those would be circumstances where we would recommend post-exposure prophylaxis. So, post-exposure prophylaxis for rabies is urgent, but not emergent. So, you know, I, I can understand the sentiment of wanting to rush to the ER, but, you know, it's not an emergency situation. There has never been rabies that's developed within the incubation period of the 1st 10 days after the exposure. And so we generally recommend. And people get their rabies prophylaxis within that 10 days, but paying attention to the fact that it is a 4 dose series, and, you know, having to go to the ER for subsequent doses can be a huge financial burden. So if it's possible to consider when you're giving day 0, rabies vaccine and an immune globulin, when day 3, especially day 7 and 14 will fall, um, can help, uh, families avoid frequent visits to the emergency room. When a person has not previously been vaccinated for rabies, it's always important that they um receive rabies immunoglobulin at the initial visit. I've had a couple of circumstances where people have gone to emergency units and, and the exposure was deemed to be low risk, so they just gave the vaccine, and, and what I'd say to that is if we are thinking about post-exposure prophylaxis for rabies, we should give the most effective, and that includes the vaccine plus the rabies immunoglobulin. If you have a patient that shows up in your office and they have received a vaccine, but without immunoglobulin, you can still give the immune globulin within the 1st 7 days after the rabies vaccine, so we will sometimes see patients where we have to say, oh, OK, well, actually, now we need to give you the immune globulin as well. We cannot get that in our office, um, we used to be able to get it from our hospital pharmacy, but because of dispensing laws, they're not allowed to dispense it to our clinic, so it does usually require a visit to the emergency room to get that immune globulin. Um, when people are exposed to rabies, it typically develops somewhere between 3 and 8, weeks after the exposure. Um, but it can be a really long time period. And it's not something I've had some families say, well, can we just wait for symptoms? Well, you know, once that happens, you're pretty much gonna die. So, uh, we do not recommend waiting to observe for symptoms of rabies. Um, if you have an immunocompromised patient who is, um, seeking post. Exposure prophylaxis, it's generally recommended they receive the 5th dose. Now, you may recall if you've been practicing for a long period of time that we used to always give it in a 5 dose series, um, but we no longer need to do that. Um, but, uh, for immunocompromised individuals, it's recommended that they get an additional dose at day 28, and then you can also consider che testing for serial conversion 7 to 14 days after they complete their series. Um, I have had families that have had subsequent exposures to bats, and you're not off the hook in terms of ever needing post-exposure prophylaxis again. You never need Brady's immune globulin after you've had the initial series, but people who have previously been exposed and then have another exposure need to have a boost, and so that's a two dose series at day 0 and day 3. I used to think there was a window where you didn't need this boost, like maybe within the first year or the 1st 3 years, and I swear there used to be something on the CDC site that said something like that, and I have not been able to find that time frame. So I generally ask people to call us, um, and, you know, uh, if I cannot, I probably would call. The CDC if, um, and if anybody answers, I will ask them if uh people let let's say if it was in the first year after an exposure needed to get that boost, um, but at this time, at least, I would refer patients for consideration of a boosting if they have a subsequent exposure to rabies after they've completed the initial series. Um, what about other exposures? Um, so we, you know, another common scenario we see is, um, uh, dogs and cats. Um, you know, if these are stray animals that can't be observed, we do recommend post-exposure prophylaxis for rabies. Um, you know, again, if you look at the data from Missouri, there are not a high number of dogs and cats that are tested positive for rabies, but we actually don't do surveillance for that. We, among stray animals, and so. We actually don't really know what it is, and it is reported. And so, generally speaking out of an abundance of caution, if the animal is unknown, can't be um, observed, then we do recommend post-exposure prophylaxis. On the other hand, if you have an animal that is known to be vaccinated or can be observed, um, for the signs and symptoms of rabies or is being tested for rabies, you can actually hold off on starting post exposure prophylaxis. The only exception we make for that is if it was a severe bite to the head and neck where theoretically the incubation period for rabies could be shortened, then in those cases, we sometimes do go ahead and start the prophylaxis while we're waiting on any testing, um, and then, you know, we can discontinue it if the testing's negative or if the animal remains healthy. Most people complete the series, I have to say, in that circumstance, but, um, those are some caveats to that. We get a lot of calls about, um, rabies and other animals, um, you know, small animals, rabbits, squirrels, things like that. People, um, guinea pigs, mice, um, and, you know, it's true that all mammals can be infected with rabies, but there have never been any documented cases of rabies transmission to humans from, um, small animals such as, um, uh, rodents or squirrels. And so, in general, we do not recommend. Exposure prophylaxis, and I think the theory I've heard about this is that these animals, if they, you know, in order to contract rabies, um, it would be often from a larger animal, and they're likely to die in that encounter, and so it's very unlikely that, you know, uh, an animal would be alive, a, a small animal would be alive, infectious with rabies, and able to transmit it to other individuals. So, um, for those exposures, no need to seek post-exposure prophylaxis. So, uh, you know, this is a strange call, but I swear that it has come through. Um, you have a, a small child who, uh, a parent calls regarding a small child who has been playing in a sandbox, and they are witnessed, as many children do, to, um, pick up some small pellets, um, from the sandbox and put them in their mouth, and, you know, the family, uh, becomes concerned and, and they realize that this is raccoon poop. So what should you do in this circumstance? Um, so, you know, there are. You, um, dangers of being an infectious disease doctor, and one of those is that you worry about things that people, other people don't worry about. Um, and one of those is raccoon latrines. So, um, raccoons tend to defecate at a communal site that we call a latrine. And this is often around the base of trees, which is why it comes to mind for me, because my children love to play around trees, and I would always think about raccoon poop in those circumstances. Um, and so they also like to poop on raised horizontal surfaces, decks and panties. sandboxes, particularly, and actually in um garage garages, and one of the um risks of this is transmission of the raccoon roundworm, baileocorous, um, and I'm not even gonna say the last part, um, this is a, a parasite that cause a variety of sy uh syndromes, including ocular larva migraines, visceral larva migraines, and neural larva migraines. Um, the route of spread is by fecal oral route and incubation period is between 1 and 4 weeks. Um, uh, it can cause an eosinophilic meningoencephalitis, I think is the situation we worry about, and there are few cases reported in the US every year. Um, it, uh, you know, presents kind of nonspecifically with nausea, fever, lethargy, um, and then, uh, patients can also have a variety of systemic complaints, uh, hepatosplenomegaly, pneumonitis, but I think the thing that's most. Devastating is an acute eosinophilic meningoencephalitis, and this is almost uniformly fatal or it does have, um, severe neurological sequela associated with this. So when you have a case of a child who has had an exposure to raccoon poop, um, there is a recommendation for actually post-exposure to prophylaxis. So these, this would be cases where you have a high index of suspicion about raccoon poop. Known exposure, um, the, uh, the recommended treatment is that, um, patients receive, um, albendazole, um, orally for 10 to 20 days, um, and there is on the CDC website this, um, sort of disclaimer that the safety of albendazole in children less than 6 years of age is not certain, but that it has been used in other countries, uh, in children as young as 1 year of age and has been. Safe, um, and it's certainly, um, uh, distributed as part of the WHO guidelines for management. Um, and so, um, certainly, um, children can be treated. And in this particular case, where there's a high, uh, risk exposure to something like raccoon feces, it would be recommended to be treated with this, um, anti-parasitic agent. So, um, also, you know, sometimes a question comes up about, um, uh, raccoon latrines and how to manage those, and you do have to be relatively careful. The, uh, the, uh, Missouri Department of Health actually has, um, information on, um, management of raccoon latrines, also a guide to, um, recognizing, uh, the kind of poop that may be around your house. So I thought that was really, um, interesting that you can, you know, sort of look at these pictures and, and determine what type of poop it is that is present, um. Uh, so in terms of if you find a latrine, um, like, let's say in your garage, and I have gotten a call of people having raccoon poop on their deck, let's say, and, and how do you manage that? Um, well, you obviously want to remove the feces as soon as possible, but you want to do this in a careful manner. So you want to dress in a way that you're gonna avoid contaminating your hands and clothes, or wearing gloves, um. Wearing disposable gloves, in particular, um, wearing rubber boots, um, not wearing your tennis shoes outside and then going back in your house, and it is recommended that, um, you wear an N95 respirator if you're going to be working in a confined space, either sweeping or spraying a raccoon poop. So just ways to avoid being infected, um, with this particular pathogen. Uh, maybe a more frequent, uh, uh, uh, raccoon poop is not the most frequent exposure we get a call about, but we do get frequent calls about needle exposure. So, um, I'm sure many of you who practice pediatrics have been called by a parent whose child found a needle. They just always stick themselves with it and draw a small amount of blood. So, um, the question is what do we need to do? How do we need to manage this particular exposure, and what are the risks? So when people um call about these, they're thinking about a variety of different infectious diseases, and there are pathogens that can be transmitted. Certainly, tetanus would be something to consider and other bacterial pathogens. Um, I think people are often most thinking about HIV infection, but hepatitis B and hepatitis C are other infections that can be transmitted uh by needle sticks. So in terms of the basic management, I've. we always want to rapidly clean the area with soap and water, um, that obviously removes um bacteria from the skin. It can inactivate some pathogens, and so that's a um an appropriate first step. And then, uh, as pediatricians, we always want to think about vaccination, are they up to date for tetanus? Have they received all their hepatitis B vaccines? Um, that would be the first step in protecting them. And then we think about um uh whether. Or not, we need to do anything regarding things like HIV. So, um, the risk for HIV just to put it in perspective, from a known positive in a healthcare setting is only 0.3%. So this is, you know, you immediately draw blood from someone they're known to be HIV positive, you stick yourself immediately, um, and that's often a large bore needle because you're drawing blood and the risk of that is about 0.3% without. Post-exposure prophylaxis, um, there are, um, reasons why a risk from a needle sick in the community is much lower risk. For one, there's often not a lot of blood. We're not drawing, people are not drawing blood in the community, it's often diabetes needles maybe that are being, um, discarded in the community, so there's not a lot of blood in the syringe typically, um, and also the virus is, uh, inactivated in environmental conditions, so there's often. Not infectious virus in the syringe, um, that infectivity, if any virus was present on the syringe, is often degraded, uh, under environmental conditions, and most children are not sticking themselves very deeply, um, with a needle. They're sort of grazing the skin, they're having a small poke to their finger, and so there's usually not a deep injury to inoculate any um infectious material that could be present. So, um, there had, uh, there has never been a case of HIV uh that has been transmitted through a needle stick in the community. So I think this is helpful to put this in perspective for people, um, so you would be the first case if you, if your child was infected with HIV, um, so, you know, we usually would not recommend post-exposure prophylaxis in most circumstances. There are a few caveats though. If the source was a known HIV positive individual for whatever reason, uh, then you obviously would want to consider testing and treatment for HIV. If you have an area where people have a high prevalence of injection, drug use, and HIV infection, greater than 15%, uh, that would be a consideration. You know, if there was a large lumen needle, this is not the kind of needle people inject drugs with, but, um, for for whatever reason. if it was a large lumen needle with visible blood in the syringe, that could be a consideration. And if there was a deep penetrating injury or mucosal exposure, then to a known HIV positive person you could consider that. Um, you can always also always call the HIV specialist uh for post-exposure consultation, um, through, um, the a number posted there and um from. Uh, my colleagues who have called this number, they're extremely helpful at determining whether post-exposure prophylaxis would be indicated. Um, and then if you are going to initiate, um, post-exposure prophylaxis, then there is a recommendation for testing individuals for HIV, um, at baseline, 4 to 6 weeks and 3 months afterward. Um, the post-exposure prophylaxis should begin relatively. Urgently within 72 hours um after the exposure and extends for a 28 day course. And you know, these, these medications are not without side effects, and so I do think people need to be um thoughtful before initiating um this course of therapy. Obviously, the infectious disease service would always be interested in consulting and providing guidance on management um if there is a high risk exposure. Um, an infection that is a little bit more transmissible, uh, actually quite a bit more transmissible is hepatitis B. Um, in the healthcare setting, actually, the risk for hepatis B transmission ranges from 23 to 62% from a known hepatitis B E antigen positive source patient. Um, also, hepatitis B is very resilient and can survive in the, uh, environment for about one week under optimal circumstances. Uh, there have been cases, only 2, but there have been cases of community acquired hepatitis B, um, that have been reported in the um medical literature, and hepatitis B has been detected in discarded needles. If we look at the cases of acute hepatitis B by region in the United States, this is from 2020, you can see in Missouri we kind of fall in the lower end range of cases, um, between 0.5 and 0.6, uh, or maybe 0.3 and 0.4 cases per 100,000, so not a super high prevalence, um, uh, in our region, uh, but depending on uh where your patients live, um, there could be higher prevalence of hepatitis B in the community. Um, in terms of, um, post-exposure prophylaxis, um, this is recommendations, um, from the Redbook. Uh, what is generally recommended when you have a patient who is unvaccinated is that you, um, rapidly administer the hepatitis B vaccine. That's a very effective. In preventing um hepatitis B. Fortunately, most children in our region are already vaccinated for hepatitis B, so in a person who has um a positive needle stick, if they're previously vaccinated, there is no um post post exposure prophylaxis that is necessary. Um, if it is necessary to give, um, treatment, uh, or vaccination, it's, um, recommended that we do this as soon as possible. Um, if we do it later than 7 days, it's really unlikely to be beneficial if it's after a needle stick. Um, so again, uh, the, the primary management of hepatitis B is to ensure that your patients are up to date for vaccination. You want to complete the whole series, not just a single dose, um, and then, uh, generally speaking, the risk would be low for transmission of hepatitis B. Hepatitis C, um, in it's kind of the midpoint between HIV and um hepatitis B. The risk of acquiring it from a known positive in healthcare setting is between 3 and 10%. Um, hepatitis C is also degraded slowly over time under environmental conditions. Um, and if you look at the prevalence among people who are injection drug users, such as in a needle exchange program, between 10 and 15% of those needles that are returned through those programs are positive for hepatitis C. There have been 3 cases of hepatitis C infection through a community exposure that had been reported in the community, so, um, it's possible, uh, it's an infection that's possibly transmitted, um, unfortunately, we don't have a lot of post-exposure prophylaxis for hepatitis C. If you look at how frequent, um, we have patients who are infected, um, with hepatitis C in the United States. Again, Missouri falls somewhere in the mid range of um uh population rates of hepatitis C um and in terms of exposure, there is not uh um specific post-exposure prophylaxis for hepatitis C. Um, you know, there is good treatment for hepatitis C, uh, now that can even be given to children, so if there's a very high. Fiveristic exposure, those children should be tested at baseline in 6 months, um, uh, by hepatitis C RNA and then um if there is a positive test, those patients should be uh sorry, be referred to hepatology where they can be followed, um, and then, uh, treatment can be considered, uh, in some cases. But in terms of management of needle sticks, again, uh, the primary thing that message we want to give to families is that those wounds need to be cleaned, um, as pediatricians, we want to make sure our patients are up to date for hepatitis B and tetanus and provide those vaccinations if the patient is not up to date, and then assess the risk of exposure. Or you know, is it from a known positive individual? Is it in the community where there's a high, very high risk of injection drug use, and HIV infection, and then, um, you know, contact the CDC of uh post-exposure um uh helpline can provide advice about a particular case and if testing is indicated. For a high risk exposure then, uh, or sorry, treatment, then we do consider testing um for HIV it'd be baseline about 1 month and 3 months, and for hepatitis C baseline in 6 months uh and then for hepatitis B, if we're a patient's unvaccinated, then we want to test for um immune response um after the series is completed. Another common, uh, exposure we see in pediatrics, this can even happen in, this happens in daycares, this can even happen in the hospital, is, um, an infant is inadvertently given the wrong breast milk. And the question is, is there any risk to the infant, uh, associated with this exposure to another mother's breast milk? So overall, um, there are some pathogens that can be transmitted via breast milk. Um, HIV is often the leading concern for families, but the risk of HIV is very low, um, by the a single exposure to breast milk, and there's a number of reasons for this. um, uh, transmission to an, uh, uh, from an HIV positive mother on anti-retro anti. Retroviral therapy is less than 1%. So, um, many of you may be aware that we do have circumstances where we now, um, work with mothers who are HIV positive to be able to breastfeed their infants. Um, historically, women who are HIV positive did not and were counseled against breastfeeding, and that's one reason, you know, many, uh, HIV positive women do not breastfeed their infants. Um, women who are breastfeeding their infants who, who are HIV. Be positives are those who are very well suppressed on antiretroviral therapy, so the risk to their infants, uh, is very low for transmission, um, and, um, there have been no cases of HIV transmission that have been documented from a single exposure to breast milk. Again, this is a one-time event, um, it's, uh, the mothers often do not have HIV or or well controlled, and so very low risk. Um, hepatitis B and hepatitis C, um, transmission would be very unlikely unless the, um, breast milk was grossly contaminated with blood, and infants are routinely, uh, vaccinated against hepatitis B. Hepatitis C is not a contraindication to breastfeeding, so again, we think the risk of transmission to infants is very low because we allow mothers with hepatitis C to breastfeed their babies. There are other pathogens such as CMV um if we're talking about a very low birth weight infant, a premature infant, this can cause a serious risk. Um, approximately 50% of women are sero positive for CMV, and that virus can be transmitted through breast milk, um, but for most infants, you know, this is not a high risk exposure, um, if CMV is present, if they're in daycare. Many of their classmates and being transmitted in saliva and urine, um, you know, in a neonatal intensive care unit, uh, if it's a very uh low birth weight infant, there can be a risk of severe disease, um, but in most cases in children in, um, in, in, uh, a childcare setting, um, we wouldn't consider screening or any other intervention for CMV. There are bacterial pathogens. Group B strep has been transmitted through breast milk. Staph aureus can be transmitted through breast milk, but again, um, these are, you know, for a breastfeeding baby, uh, just because it's from another mother, not any substantially higher risk, and so no specific intervention is recommended in that case. So in terms of management of an inadvertent breast milk exposure, it obviously it's important to inform both the donor and the parents about this exposure. Uh, questions for the donor might include how is the breast milk expressed, how is it handled, um, are they on any medications that we wanna let the family know? Um, do. They have any recent infectious disease concerns that may be relevant? Um, do they have, um, currently cracked or bleeding nipples that could be um a risk for transmission and are they willing to share the results of their HIV and hepatitis B status in order to reassure the family of the child who received the breast milk? Um, you know, when we're informing the, uh, recipient parents, it's nice if we have all this information, we can discuss how the milk was handled. Again, this is breast milk that was expressed for a woman's own child and so often, um, obviously it's handled with care, um, we can provide families with. The information that the risk of any transmission of infectious diseases is very low, they should alert their primary care provider, which is you, I guess if we're talking uh about this kind of circumstance, um, so that if there is any new syndrome in the child, then they're aware of this potential exposure. OK. Uh, pinworm exposure, um, so this, I, I would say of all the things I deal with in infectious diseases, the most distress I've seen in my clinic is regarding pinworms. Um, so you were called about by a family, uh, who's received notice that several children in the child's daycare, um, have been diagnosed with pinworms, and the child has been periodically itching their body. So it wouldn't be an infectious disease talk without a pinworm life cycle, at least one life cycle slide. So the way that um people are infected with pinworms is by ingesting the eggs, usually inadvertently. Um, these eggs um travel into the small intestine where the where the larvae hatch, um, uh, they become uh adults, um. In the lumen of the secu, uh, the females, um, after reproduction takes place, um, migrate to the perianal region, uh, where they emerge at night to lay their eggs in the perianal folds. Um, after, uh, laying their eggs, those worms die. And so actually, um, uh, if people have, uh, good hygiene, and, and we'll talk a little bit about the hygiene measures that are necessary, um, the, the infection is. Really self-limited, so unless you auto inoculate again with eggs or from yourself or from another individual, this infection will cease. So um in terms of the clinical presentation, most or many people with pinworms are asymptomatic, but children can have um perianal pruritis, you know, they, uh, the sort of uh matrix in which the, the females lay the eggs and the eggs can provide or cause irritation. Um, there can be sleep disturbances related to this, bedwetting, um, there can be infection in the vulva vaginal area that can cause some irritation, and, and I would say this often causes intense psychological distress for families, um. In terms of the highest risk individuals are those often in daycare, um, in the or in young school age children, um, they're, uh, between the ages of 4 and 11 years of age, um, you know, it's kids who might scratch their bottom or have their fingers and hands in their mouth after touching environmental surfaces, kids who bite their nails, um, kids with unsupervised hygiene in the bathroom, which these are the kids. They're becoming independent with toileting, and so are not being overseen by adults. Um, and then kids who might not wash their hands frequently. Um, you know, there's a high burden of, um, pinworms in the United States, you know, maybe 20 to 30% of children at some time, uh, may be infected with pinworms. Um, and so how do we make this particular diagnosis? Um, there are a couple different ways. One is just. Clinically, you know, uh, with the clinical after an exposure and, and the clinical syndrome, um, although we often will have families come in repeatedly with negative testing, and they have become fairly obsessed about the diagnosis, and so I think you do have to take the clinical diagnosis with a grain of salt. You can perform a scotch tape test where you put some tape um on in the peri uh around the anus and. And then you can, under the microscope, um, observe uh these um eggs that have been deposited. Um, there, there's a kit that you can get that, um, it allows you to perform this testing, um, and if you don't, um, observe the eggs on one, specimen collection, um, increasing to 3 samples increases the sensitivity of detection from 50% to 90%. Um, 1 note is that sending stool for parasites is a relatively insensitive way. So sometimes people. We'll send repeated stool parasite exams, and you may not be able to detect the infection by that mechanism, frequently not helpful. Um, also, blood tests are not helpful because these are not, um, worms that migrate through your tissue, which is what is required to generate eosinophilia or an elevated IgE level, so those types of tests are not, um, helpful. You can have the parents perform a. Visual inspection of the perianal region at night with a flashlight, um, after the child has, um, been in bed. And sometimes you can see the worms emerging, uh, which is horrifying. Uh, um, and also, uh, there's a swoop test, which is this paddle, um, that has a sticky material that you can use to swab the peri, um, anal area to be able to detect the, uh, the worm, or sorry, the AIDS. In terms of treatment, treatment is available over the counter, so you can get Reese's pinworm medication, um, it's available for kids over 1 year of age. We generally recommend that you treat both the patient and the family and repeat in 2 weeks in case there's um uh residual worm infection, um, or auto inoculation. Um, other medications such as mebendazole and albendazole can be used, but usually are not necessary. Often when the infection is recurrent, it's because that a person has been reinoculated. So it's really important to focus on hygiene, um, measures when you're thinking about preventing pinworms. So a couple of these include, um, obviously, emphasizing hand hygiene. That's critically important before eating around toileting. Um, avoiding biting nails or keeping the nails short, because that's a way where kids can, you know, um, you know, have their fingers in their mouth a lot, and then if they're in an environment such as a preschool or school where there's pinworms, eggs in the environment, um, then that's a way that they can be. Become inoculated, um, wearing tight fitting underwear overnight. So the, the eggs can, um, contaminate the clothing and, and the worms shed thousands and thousands of eggs, and these can become aerosolized. Um, so in terms of how to manage the environment, making sure the individuals wearing tight fitting, or just get regular cotton panties, but, you know, not boxer shorts, that they're wearing underwear, that, um, they're changing it daily, that, um, when you're taking off the pajama. And, and, um, underwear of a child with um pinworms that you're not shaking that bedding, shaking those clothes, that you're kind of just handling them normally. Um, we do recommend that children shower in the morning because that can wash off the eggs that have been deposited overnight. Um, we want, in a household setting, obviously there's a possibility of um spreading this infection to other individuals, and so we wanna make sure that people aren't sharing things that come in close close contact with a body such as towels or clothing. Um, if there's, um, carpeting in the room, we recommend vacuuming that carpeting, um, or wet mopping the floor, and then again, it is important to treat the whole household at the same time so that you can, um, eradicate the infection from any individual who may then pass it to other individuals in the household. So That's the last I'll say about pinworms before we, um, move on to, I think maybe our last exposure, which is a primate bite. And when I was preparing to make this talk, I was, I went into our fellow's office and I was talking about that I was gonna talk about a variety of exposures, including monkey bites, and they had all had a call about a monkey bite. So, you know, maybe you haven't had a call from one of your patients yet, but it's coming because we do, um, hear about monkey bites. So, uh, you know, the scenario we hear is that, uh, A child, this is, um, at least the details I remember about a child who was bitten recently or not recently, um, but, uh, in the past by a monkey. So, uh, this would be, um, a child who's in the park and a person is there with a monkey. I think in one particular case, um, it was the, they had a dog and a monkey, and the dog was the monkey's dog, and the child touched the dog and the monkey bit the child because it was their dog. Um, and then let the person, because of, I'm sure a risk of liability, left the park without leaving any contact information or any information about the monkey. And you think, well, maybe this is rare. But, um, about, it's estimated about 15,000 pet monkeys, uh, live in the United States. Um, and in terms of the type of, uh, monkeys that are present, you know, there's a variety of different types. The most common would be marmosets, um, but lemurs, uh, uh, squirrel monkeys. So, um, you know, I mean, who did it, want a monkey at one point and. But most of us grew up and we did not get a monkey. Um, if you, uh, there's actually a study or a, a site that looks at, there's a public website that tracks primate sales in the US. Um, and, um, there was a study that looked at this and found that there were 5, 51 primate sales in one year between June 2019 and June 2020. Um, and, you know, many of the primates that are sold are males, and males are going to be more aggressive. I think the reason for this, uh, this sort of, um, skew in male-female is because, you know, people who own, uh, and sell primates don't want the females out there, and so it's mostly males that are sold, um, and, you know, the public perception of. Um, primates is that they're cute, cuddly, friendly, um, tame, um, but if you ask scientists and veterinarians about, um, primates, uh, they are noted to be aggressive, difficult to care for properly, um, there's a disease transmission risk, obviously, that's why we're talking about them today, and there is probably some negative impact on conservation efforts with, um, a primate ownership. You may think, uh, we're in the middle of the United States. We're not, um, uh, a high risk area, but if you look at the top five states for primate ownership, uh, Missouri is in the top 5, in terms of sales of primates, uh, in the United States, um, and so. Um, you know, if you, uh, look at the types of animals, and that becomes important for the type of infections we worry about, um, uh, you know, you can see that, you know, there's a, a broad range, and we're often worried about, um, macaques in particular for one type of infection. And, and again, you can see, um, that, um, in terms of the price points, you know, for the average price, um, you know, they, they all fall about the same range, and the cats are in that list of, uh, affordable pets, affordable pet primates, if you're willing to shell out 4000 to $5000 for a pet. You know, why do people want to do this? Um, you know, it is, um, noted that people are influenced by what they see in the media. So there's both movies, you know, even for dogs and cats and things, you know, when there's a movie. That has a particular animal, there's often a rush to adopt those types of animals, um, or types of dog breeds. That's true for pri primates as well, when there are movies that have characters that are primates, there's often a surge in a desire for primate ownership. Now, on social media, there are a variety of creators that have, um, primates as pets, and they make it look, you know, very fun. Um, it's also a status symbol, you know, these are expensive animals, so they can serve as a stat. Symbol for people, um, as a sign of wealth, and so, um, that may be another reason that people um want to own these pets. They're, you know, always is the lack of appreciation how difficult it is to care for these animals. Um, so in terms of infectious disease exposure, there are just a ton of infections that people can be exposed to when they have a pregnant bite, similar to what you can get from human bites. And so, um, there are viral infections depending on how the animal was handled, where the animal. Came from um bacterial infections, stool transmitted infections, even TB um and so um we really do have to handle um a an exposure a bite from a primate, um, with careful consideration. So like many bites, the most important step initially is going to be to wash the area, uh, it's recommended that you wash the area immediately and for greater than 20 minutes with soap and water, concentrated detergent, providone iodine, or chlorhexidine. Um, for the, um, patient who has been bitten, uh, you want to provide tetanus vaccination status, and you do have to consider rabies vaccine. Now, this is typically not, um, uh, a concern for a domesticated, uh, monkey that's, um, been in ownership in the United States for a period of time, but if a bite occurred in an endemic area, then you have to consider, um, rabies post-exposure prophylaxis. So, you know, a person who's traveling and sees a monkey and gets bitten, that would be an indication for post-exposure prophylaxis. Um, in terms of antibiotic prophylaxis, it's recommended like other, um, bites for moderate to severe wounds with crush injury, puncture wounds, uh, bites of the hands and feet, facial wounds, genital wounds, or any bite wound in an immunocompromised or asplenic. Patient and we typically will use amoxicillin lab like we do for human bites or dog bites, um, and people who have an allergy, then it's clindamycin plus trimethroprine sulfa and it can be a shorter duration, so, um, again, this is an acute prophylaxis, not an infection treatment, but for 3 days' duration. But the reason, uh, that the question comes to us is not so much the bite, but, uh, the risk of a particular infectious disease that can be transmitted, particularly from Rhesus macaques. And you may say, well, how many, uh, you know, you showed slides, there aren't that many, I mean, uh, but I think the problem that we run into in infectious diseases when we're getting these calls, is the family doesn't have. Information, they know it was a monkey, but they don't know what type of monkey, so we have to assume that could potentially been uh a macaque that caused the bite. Um, the, the problem with these types of bites is that, um, rhesus macaques or, uh, monkeys that are housed with those can be infected with B virus, herpes B virus, which is a deadly rare and deadly viral and. Infection that can be spread by bites and scratches of macaques, um, the symptoms can begin between 2 days and 5 weeks after an exposure. We'll start with a really non-specific flu-like illness, um, patients can have a blister like other herpes viruses that develop at the site of inoculation, and then the disease progresses if a person is not treated properly to encephalitis and death. And so, um, because this becomes a fatal disease after it's developed, there is a recommendation for post-exposure prophylaxis after monkey bites for B virus infection, particularly if the monkey was a rhesus macaque or if you do not know what the monkey was. And that prophylaxis is with Valley cyclovir, uh, the pediatric dosing is 20 mg per kg. Now, again, this is not an FDA approved usage of the. Medication, but it's generally accepted, and the adult dosing at least is posted on the CDC website, um, but the pediatric dosing, uh, I, um, have, uh, extrapolated from consultation with our pharmacist, um, you know, you really want to begin this, um, treatment, um, in a, an acute time frame after, um, the exposure, um, again, they're not really controlled trials. of giving this medication, but it is a recommendation, um, you know, the risk of valley cyclovir is relatively low, there can be um some neuropathy that can happen with vallecyclovir if people are dehydrated, there can be some crystallization in the kidneys, um, impact on blood counts, but generally people tolerate this very well, and so it is recommended that um patients be treated for 14 days after the exposure to the monkey bite, so. So that is my last slide for today. I really appreciate your attention today. Feel free to reach out if there are any other questions that come up. Created by Presenters Rachel C. Orscheln, MD Professor of Pediatrics, Infectious DiseasesVice Chair, Community Health and Strategic Planning View full profile
