Pneumonia EPICON 2003 Progress Report

Document Sample
Pneumonia EPICON 2003 Progress Report Powered By Docstoc
					Pneumonia EPICON 2003
    Progress Report



   COL Robert DeFraites
       17 SEP 03
                    Contents

•   Pneumonia in US Troops in SWA
•   Pneumonia in the US and in the Military
•   EPICON tasking and deployment
•   Clinical and Pathological findings to date
•   Way Ahead



17 Sep 03                                        2
            PNEUMONIA IN OIF/OEF
               AS OF 11 SEP 03
• Approximately 100 cases of “pneumonia”
  admitted to Combat Support Hospitals in Iraq and
  Kuwait since 1 Mar 03
• Nineteen (19) of these have required intubation
  and assisted ventilation
• Two of the 19 have died.
• Working case definition for “severe pneumonia”:
  Person deployed to CENTCOM AOR, diagnosed
  with bilateral pneumonia requiring intubation and
  ventilator support, since 1 Mar 03.
17 Sep 03                                             3
                      DATE OF ONSET OF
                     SYMTOMS IN SEVERE                                                         Two cases were
                      PNEUMONIA CASES                                                           from the same
                                                                                               military unit (2/8
                     IN SOUTHWEST ASIA,                                                          INF, 4TH ID)
                           CY2003
                                                       Severe Pneumonia from SWA 2003

                     3
cases of pneumonia




                     2

                                      active combat operations



                     1




                     0
                         11 12   13     14 15      16 17         18   19 20 21 22 23 24 25 26 27     28 29 30    31 32
                         Mar              Apr                                                             July
                                                                        May
                                                                        calender week in 2003
                                                                                              June




                     17 Sep 03                                                                                           4
 SEVERE PNEUMONIA PATIENTS, SOUTHWEST ASIA
                   N=19
   •    Sex                             •   Date of illness onset
          – 18 male, one female              – March (2)
    • Age                                    – Apr (2)
          – Range 19-47 years, med 24        – May (1)
    • Service
                                             – June (6) (1 fatal)
          – 17 Army, 1 USMC, 1 USN
                                             – July (4) (1 fatal)
    • Service Component
          – 12 Active, 7 Reserve             – Aug (4)
    • Rank                              •   Deployed location
          – 11 Jr Enl, 7 NCO’s, 1 Off        – Iraq (13)
    • Duty MOS                               – Kuwait (3)
          – Combat arms (8)                  – Qatar, Uzbekistan, Djibouti (1 each)
          – Engineer (3)
          – Signal (2)
          – Transportation (2)
          – Medical (2)
          – Supply (1)
17 Sep 03 – MP (1)                                                          5
   PNEUMONIA HOSPITALIZATIONS (NON-
   FEDERAL) IN THE UNITED STATES, 2000
              Age Group (yrs)                   Rate (per 10,000)

                         <15                                33.3

                       15-44                               10.5
                       45-64                                35.8

                         65+                               221.2

            Source: Hall MJ, Owings MF. 2000 National hospital discharge survey.
            Advance Data from Vital and Health Statistics 2002, 19 June;329:10

17 Sep 03                                                                          6
            COMMUNITY ACQUIRED
            PNEUMONIA IN THE US
• Most often treated successfully in
  ambulatory setting with presumptive broad
  spectrum oral antibiotics
• Etiologic agents includes S. pneumonia, M.
  catarrhalis, L. pneumoniae, and long list of
  common viruses in immunocompetent hosts
• Estimate of 50% + with no identifiable
  etiology

17 Sep 03                                    7
                    PNEUMONIA IN THE MILTARY
  (HOSPITAL DISCHARGE RATE* OF ACTIVE DUTY PERSONNEL
 WITH DIAGNOSIS OF PNEUMONIA AND INFLUENZA [ICD-9 480-487])
            Service   1998   1999    2000    2001    2002    Total

            Army      7.10   8.62   7.70    10.69   11.54   9.14
            Navy      4.45   4.61   4.00    4.48    3.99    4.31
            Air Force 4.22   4.68   6.90    4.85    5.70    5.26
            Marines   5.31   7.18   9.46    10.13   19.02   10.23

            Total     5.41   6.33   6.72    7.45    8.90    6.96


    *PER 10,000 PERSONS                        Rates comparable
                                                to US 15-45 y.o

SOURCE: SIDR, DEFENSE MEDICAL EPIDEMIOLOGY DATABASE, DMSS

17 Sep 03                                                            8
OTHER MILITARY PNEUMONIA
      OBSERVATIONS
• Gulf War experience: in-theater hospital admission rate
  (pneumonia and influenza) 8.6 per 10,000 person-years
  (Source: CDR Megan Ryan, NHRC)
• Military admission rate compares favorably with observed
  ~100 cases in SWA over 6 months (estimated at max
  13/10,000).
• Five to eight % of all Army personnel admitted for
  pneumonia/influenza CY98-02 required mechanical
  ventilation.
• Fatalities: 17 Army deaths attributed to pneumonia/ARDS
  over five years (CY98-02).

17 Sep 03                                                    9
      EPIdemiologic CONsultation
• TSG formally tasked USACHPPM 17 July. COL
  Bruno Petruccelli MC, is EPICON leader
• Two teams deployed:
     – EPICON LRMC: 1 Infectious disease physician, 1
       epidemiologist deployed 20 July 03
     – EPICON Iraq: 1 Epidemiologist, 1 Infectious Disease
       physician, 2 laboratory officers, 2 NCOs’ deployed to
       Iraq 6 August 03
• Augmentation: Physician epidemiologist from
  National Center for Environmental Health, CDC
  arrived at CHPPM 12 August.
17 Sep 03                                                      10
            EPICON AUGMENTATION
• Centers for Disease Control
    – Telephonic consultation beginning 1 July 03
    – Dr. Steve Redd joined EPICON Team 12 August
• Armed Forces Epidemiologic Board
    – Weekly teleconferences
• AFIP:
    – Office of Armed Forces Medical Examiner
      coordinating post-mortem exam on fatal cases.
    – Added formal consultation with Mayo Clinic
      (Pulmonary pathology)

17 Sep 03                                             11
TYPICAL CLINICAL
 PRESENTATION
                CLINICAL FEATURES
• All febrile (Temp 100.4 to 105o F.)
• No neutropenia (at least 9 with WBC >12K).
• Ten (10) with eosinophilia; peripheral, in lung tissue or BAL*, or both
• Eight (8) with pleural effusions
• Infectious agents implicated in 4 cases (Streptococcus pneumoniae in
  2, Coxiella burnettii and Acetinobacter baumanii 1 each).
• 15 of 19 smoked cigars of cigarettes, including all eosinophilic cases;
  9 of 10 eosinophilic cases were recent onset smokers
• All cases treated with broad spectrum antibiotics



    17 Sep 03                               *broncho-alveolar lavage   13
      CLINICAL PERTINENT NEGATIVES

• So far, testing incomplete, but negative for:
     –      Hantavirus
     –      SARS coronavirus
     –      Legionella
     –      Mycoplasma
     –      Adenovirus
     –      Influenza
     –      TB
     –      Coccidiomyces immitis (by culture)
17 Sep 03                                         14
            SAMPLE CASE HISTORY

• 29 y/o male in the Army National Guard from
  New Mexico. 88M (truck driver). Currently based
  at Camp Cedar Iraq.
• He presents with 4 days of fever and fatigue.
• This developed into a non productive cough and
  SOB
• Admitted, started on antibiotics (levofloxacin).
• Respiratory distress worsens and patient is
  intubated.

17 Sep 03                                        15
            ADMISSION X-RAY




17 Sep 03                     16
             OTHER FINDINGS

• Peripheral Eosinophilia 26.7%. absolute number
  2,600 eosinophils per ul3
• Dips tobacco, but his brand was not available in
  Iraq and started smoking 2 weeks ago.
• Dust was “very bad”.
• No ill contacts.
• PMH positive PPD before deployment but did not
  take INH. Negative for Asthma.
• Taking doxycycline for malaria prophylaxis.
17 Sep 03                                        17
    CLINICAL COURSE

• Extubated the day
  after arriving to
  Landstuhl.
• He was doing well
  and sent on to Fort
  Bliss for further care.

                            Hospital Day 3
17 Sep 03                                    18
            EOSINOPHILIC PNEUMONIA

• Eosinophilic Pneumonia is usually diagnosis of exclusion
   – Acute febrile illness of short duration (<1 week)
   – Hypoxemic respiratory failure
   – Diffuse pulmonary opacities on X ray
   – BAL eosinophilia >25%
   – Lung biopsy showing eosinophilic infiltrates
   – Absence of other known causes of eosinophilia




17 Sep 03                                              19
AGENTS IMPLICATED TO CAUSE EOSINOPHILIC PNEUMONIA
    • Nitrofurantoin
    • Phenytoin
    • L-tryptophan
    • Ampicillin                                         None
                                                      implicated
    • Minocycline
                                                        so far in
    • Acetaminophen                                    any of 19
    • Inhaled heroin                                     cases.
    • Crack cocaine
    • Inhalation injury following building collapse
    • HIV infection
    • Helminith infections (Toxocara, flilaria, Strongyloides,
      Acaris)
    • Fungal Infections (Trichosporon, Trichoderma, Aspergillus)
    • Coxsackie Virus
17 Sep 03                                                           20
                              3
                                                                    Severe Pneumonia from OIF 2003                                    203 ENG BN
                                                                                                                                      Missouri
                                    all 3 factors                                                                                              HHC 1/293 INF
                                    severe and smoker                                                    86 CSH
                                    severe and eosinophiles
                                    severe only                                                                                                   720 TRANS Co
cases of pneumonia per week




                                                                                                         ENG Bn
                              2              822 MP                                                      1st CBT Corps
                                             Illinois
                                                                            945 ENG                        2/3 AR
                                  1st
                                    Radio                                   Colorado
                                  Bn, HI                                                      HHC 1/35 AR
                                          active combat operations

                              1
                                                                                       HHB 101 FA
                                                     C 2/8 INF
                                                     4th ID



                              0
                                  11    12    13     14   15   16    17     18    19     20    21   22    23   24    25    26    27   28    29    30   31   32
                                             March                  April                     May                   June                   July

                                                                                 calendar week, 2003
                                                                                       calender week in 2003               HHB 3/29 FA
                                                                                                                                HHC 22 SIG Bn

                                    17 Sep 03                                                                                     425 TRANS Co 21
        Broncho-Alveolar Lavage (BAL) fluid from patient GT6205*
        13Aug03 showing sheets of eosinophils.




        *47 y.o. male evacuated from Djibouti in respiratory failure
        11Aug.
17 Sep 03                                                              22
                                                                             Eosinophil counts from all OIF soldiers with blood drawn at LRMC Mar-Jul 2003

                                                        800
number of soldiers with a particular eosinophil count




                                                        700
                                                                                                                  JS1259
                                                        600             RG4948
                                                                                                                                                                                    MN5856
                                                                                                                       JK6114
                                                        500

                                                                                            SD5854                                  JN4168
                                                        400
                                                                                                                           NC9279
                                                                                                                FM1586
                                                        300


                                                        200                  Individual severe pneumonia patient's highest eosinophil count indicated by position of initials and last 4
                                                                             SSN
                                                        100


                                                         0
                                                              0.1 0.3 0.5 0.7 0.9 1.1 1.3 1.5 1.7 1.9 2.1 2.3 2.5 2.7 2.9 3.1 3.3 3.5 3.7 3.9 4.1 4.3 4.5 4.7 4.9 5.1 5.3 5.5 5.7 5.9 6.1 6.3 6.5
                                                                                                     absolute number of eosinophiles /microliter




                        17 Sep 03                                                                                                                                                            23
                          CASE REPORTS

    2 soldiers who presented with Adult Respiratory
    Distress Syndrome, peripheral eosinophilia and
    10% eosinophilia on BAL.

     – Both cases occurred within days of returning from the
       National Training Center at Fort Irwin, CA in 1997.
     – Both cases were smokers.

     Giacoppe GN, Degler DA, Rapidly evolving Adult Respiratory Distress Syndrome
        with eosinophilia of unknown cause in previously healthy active duty soldiers at an
        Army Training Center: Report of two cases. Mil Med. 1999 Dec; 164(12): 911-6.


17 Sep 03                                                                                24
EOSINOPHILIC PNEUMONITIS FROM CIGARETTE
       SMOKING IN THE LITERATURE

• Two cases of eosinophilic pneumonitis
  (from Japan)
     – Both smoked for less one month
     – Both were less than 30 years of age.

      Shiota Y, Kawai T, Matsumoto H, Hiyama J, Tokuda Y, Marukawa M, Ono
        T, Mashiba H.Acute eosinophilic pneumonia following cigarette smoking.
        Intern Med. 2000 Oct; 39(10):830-3.

17 Sep 03                                                                   25
                     OTHER ACTIONS

• Prevention message published in theater,
  emphasizing:
     –      Hydration
     –      Smoking cessation
     –      Dust protection and indoor dust abatement
     –      Appropriate care seeking when symptomatic
     –      Other non-vaccine interventions for respiratory
            disease
• Communication with families and other
  stakeholders (Congress/public)
17 Sep 03                                                     26
                WAY AHEAD


• Pursue confirmation of pertinent negative
  laboratory findings
• Pursue additional association of eosinophilic
  pneumonia with desert or deployment
  environment
• Pursue association of eosinophilic pneumonia
  with cigarette smoking and other exposures
  (Case-control study)


17 Sep 03                                         27