Comparison of Neurological Outcome between Tracheal Intubation and Supraglottic
Airway Device Insertion of Out-of-hospital Cardiac Arrest Patients: A
Nationwide, Population-based, Observational Study
Published online: 30 April 2012
Seizan Tanabe, Toshio Ogawa, Manabu Akahane, Soichi Koike, Hiromasa Horiguchi,
Hideo Yasunaga, Tatsuhiro Mizoguchi, Tetsuo Hatanaka, Hiroyuki Yokota, Tomoaki
Journal of Emergency Medicine, The, http://www.jem-journal.com/article/S0736-4679%2812%2900247-8/abstract
Prehospital use of supraglottic airway devices was associated with slightly, but significantly, poorer neurological outcomes compared with tracheal intubation, but neurological outcomes remained poor overall.
Imported Human Rabies in a U.S. Army Soldier — New York, 2011
May 4, 2012 / 61(17);302-305
What is already known on this topic? If not prevented by postexposure prophylaxis, rabies virus infection causes an acute progressive encephalitis that is nearly always fatal. Although considered eliminated from the United States, canine rabies is responsible for the majority of rabies deaths worldwide.
What is added by this report? In August 2011, a recently returned U.S. Army soldier died of rabies after being bitten by a dog in Afghanistan; he did not receive correct postexposure prophylaxis. This is the first rabies death among U.S. service members since 1974.
What are the implications for public health practice? This case demonstrates the need to avoid animal contact while in rabies-enzootic regions and to seek prompt medical evaluation after any animal bite. Early clinical suspicion of rabies and infection control measures can help reduce the need for postexposure prophylaxis among health-care personnel. Prompt suspicion and confirmation of rabies can inform experimental treatment decisions. Canine rabies is and will remain a risk to residents and visitors of many countries around the globe until it is eliminated through vaccination of animals.
On August 19, 2011, a male U.S. Army soldier with progressive right arm and shoulder pain, nausea, vomiting, ataxia, anxiety, and dysphagia was admitted to an emergency department (ED) in New York for suspected rabies. Rabies virus antigens were detected in a nuchal skin biopsy, rabies virus antibodies in serum and cerebrospinal fluid (CSF), and rabies viral RNA in saliva and CSF specimens by state and CDC rabies laboratories. An Afghanistan canine rabies virus variant was identified. The patient underwent an experimental treatment protocol (1) but died on August 31. The patient had described a dog bite while in Afghanistan. However, he had not received effective rabies postexposure prophylaxis (PEP). In total, 29 close contacts and health-care personnel (HCP) received PEP after contact with the patient. This case highlights the continued risks for rabies virus exposure during travel or deployment to rabies-enzootic countries, the need for global canine rabies elimination through vaccination, and the importance of following effective PEP protocols and ensuring global PEP availability.
On August 14, 2011, a previously healthy soldier, aged 24 years, traveled from Grafenwöhr, Germany, to Fort Drum, New York, to begin a new military assignment (Figure). In transit, he experienced neck and shoulder pain and right arm and hand paresthesias. During the days following, he experienced fever, nausea, vomiting, and on August 18, difficulty swallowing. He visited the ED at hospital A on August 15 and 17 and was discharged with diagnoses of neck tendinitis and gastritis, respectively. He twice visited a chiropractor for his pain during August 15–16.
On August 19, the patient experienced ataxia and syncope, was evaluated at Fort Drum’s medical facility, and was transferred to the ED at hospital A. Upon arrival, he was dehydrated and markedly hydrophobic. He was lucid and described having received a dog bite on the right hand during January 2011 while deployed to Afghanistan. Rabies was suspected on the basis of symptoms and this history. The New York State Department of Health (NYSDOH) and CDC were notified. The patient was transferred to hospital B, where a nuchal skin biopsy was performed and samples of serum, saliva, and CSF obtained. On August 20–21, Wadsworth Center (NYSDOH’s public health laboratory) detected rabies virus antigens in hair follicles of nuchal skin biopsy specimens by direct immunofluorescence, and rabies viral RNA in saliva and CSF by reverse transcriptase–polymerase chain reaction. CDC corroborated these findings and detected rabies virus antibodies in serum and CSF. The viral RNA sequence was compatible with a canine rabies virus variant associated with dogs in Afghanistan.
Before the patient’s admission to hospital B, staff members were notified, and isolation precautions (including goggles, gowns, gloves, and face masks for all HCP who had contact with the patient) were instituted. Upon admission, the patient exhibited severe aerophobia and hydrophobia, became combative and agitated, and was intubated for airway protection. Dysautonomia and fixed dilated pupils were noted. Computed tomography scan of the brain revealed no abnormalities. Complete heart block required temporary pacemaker placement. Ketamine, fentanyl, and midazolam were administered according to an experimental treatment protocol (1). On hospitalization day 2, an external ventricular drain was placed to monitor intracranial pressure. On day 3, the patient experienced severe neurogenic diabetes insipidus. On day 4, severe brain edema caused erratic intracranial pressure measurements. The patient experienced severe acute respiratory distress syndrome. Extracorporeal membrane oxygenation, anticoagulation, and a hypothermia protocol were started. Chest radiographs indicated worsening confluent parenchymal opacities. These findings, in addition to leukocytosis, prompted intravenous vancomycin and ceftazidime administration beginning on day 6.
On days 10–11, computed tomography revealed two small intracerebral hemorrhages. On day 11, extracorporeal membrane oxygenation and anticoagulation were discontinued, fresh frozen plasma and factor VII were administered, and mechanical ventilation maintained oxygen saturation. On day 12, severe intracerebral hemorrhage was evident, and recovery was deemed unlikely. With the family’s agreement, life support was withdrawn on day 13 (August 31), and the patient died.
Wadsworth Center and CDC tested specimens daily for clinical monitoring (1). Rabies virus–specific immunoglobulin M and immunoglobulin G antibodies were present and increased in serum and CSF throughout hospitalization. Virus neutralizing antibodies (VNA) were first detected in serum at 0.07 IU/mL on August 28 and increased to 0.50 IU/mL on August 31, the day the patient died. No VNA were detected in CSF through August 29, the last day a sample was submitted.
On autopsy, all central nervous system specimens demonstrated edema and mononuclear inflammation. Neurons contained eosinophilic intracytoplasmic inclusions. Immunohistochemical and immunofluorescent staining revealed abundant rabies virus antigens distributed diffusely.
Public Health Investigation
Beginning on August 19, public health officials from multiple jurisdictions were notified about the case. Local health departments and the U.S. Army, with assistance from NYSDOH and CDC, interviewed the patient’s close contacts, including friends, family members, fellow travelers, HCP, hotel staff members, and members of his new and former military units to provide risk assessments and PEP recommendations. Interviewees were counseled regarding rabies virus exposure risks and types of contact that constitute exposures. The patient was considered potentially infectious during the 14 days before illness onset, per CDC recommendations (Charles E. Rupprecht, CDC, personal communication, 2012).
The investigation identified approximately 190 persons who had interacted with the patient during his travel or while in New York. Thirteen persons met exposure criteria (defined as wound or mucous membrane exposure to the patient’s saliva, CSF, neural tissue, or tears) and received PEP consistent with Advisory Committee on Immunization Practices guidelines (2). All exposures occurred before rabies was suspected. Nine HCP contacts without confirmed exposures also received PEP. No seatmates on flights from Germany to New York had exposures requiring PEP. Among 50 assessed members of the patient’s previous Army unit in Germany, seven met exposure criteria and received PEP. The patient had no known contact with additional persons in Germany, except a taxi driver, who did not require PEP.
In January 2011, while in Afghanistan, the patient reported to family members and close friends that he had been bitten by a feral dog and had sought medical treatment, which he described as wound cleansing and injections. However, an Army investigation revealed no documentation of a reported bite wound or treatment. A May 2011 banked serum specimen, tested at CDC in August 2011, did not contain rabies virus–specific antibodies or VNA, further indicating that the patient had not received PEP. No record of submission of the dog for rabies diagnosis was obtained.
This report is the first since 1974 of a U.S. service member dying from rabies after an overseas dog exposure (3). This case highlights the importance of rabies risk awareness for all travelers, including service members, and the need for prompt medical care, including PEP, for potential exposures. Although canine rabies virus transmission is considered eliminated in the continental United States (4), dog exposures remain a concern for all residents and travelers abroad in canine rabies–enzootic areas. During 1996–August 2011, a total of 10 of 45 reported U.S. human rabies cases were associated with canine variant viruses, and all resulted from dog exposures occurring overseas (5). Canine rabies variants acquired as the result of dog bites in Africa and Asia account for >95% of all human rabies deaths worldwide (6). Travel-associated rabies virus exposure rates have not been calculated with accuracy (6).
Clinical human rabies infections are nearly always fatal, even when treated using an experimental protocol (1). In this case, after-clinical-onset treatment efforts failed. Prompt PEP administration remains the only consistent method for preventing death after rabies virus exposure (2).
With the exception of transmission through transplantation, human-to-human rabies transmission has not been laboratory-documented but is possible theoretically (7) because rabies virus can be present in saliva, CSF, neural tissue, and tears. Infection control practices can decrease the risk for virus transmission to caregivers of patients with suspected or confirmed rabies. Once rabies is suspected, HCP should wear goggles, gowns, gloves, and face masks, particularly during activities with risk for saliva contact (e.g., intubation and suctioning) (2). Rapid institution of these precautions at hospital B demonstrated these measures’ value for reducing exposures in the health-care setting: none of approximately 150 HCP who had patient contact required PEP. If rabies is confirmed, a standardized risk assessment of patient contacts should be conducted, with strict application of the exposure definitions detailed by ACIP (2). A rabies patient’s autopsy can be conducted safely in facilities equipped to handle postmortem evaluations of infectious disease patients, using standard barrier precautions (i.e., an N95 or higher-grade respirator, full face shield, goggles, heavy gloves, and complete body coverage by protective wear) (8).
The patient’s travel while potentially infectious added a unique public health concern. Local, state, federal, and international parties collaborated to ensure that all persons who potentially had contact with the patient’s infectious secretions during his travel were reached for timely risk assessment. None required PEP.
Travelers should be informed of rabies risks when traveling to rabies-enzootic countries and should be encouraged to keep a safe distance from wild and feral animals. Travelers receiving bites or scratches from such animals should wash the wound thoroughly with soap and water and promptly seek medical attention. Persons who are at increased risk for exposure because of professional or tourist activities in enzootic areas or who might have limited access to medical resources should consult a physician about preexposure vaccination before departure and consider purchasing travel insurance that includes a provision for medical evacuation (6,9). Additional recommendations for travelers are available in the CDC Yellow Book: Health Information for International Travel 2012 (6) and at http://wwwnc.cdc.gov/travel. The case described in this report underscores the need for global partnerships for the prevention, control, and future elimination of canine rabies virus transmission (10).
- Medical College of Wisconsin. Care of rabies. Version 3.1. Milwaukee, WI: Medical College of Wisconsin; 2009. Available at http://www.mcw.edu/filelibrary/groups/pediatrics/infectiousdiseases/milwaukee_rabies_protocol_v3_1.pdf . Accessed April 25, 2012.
- CDC. Human rabies prevention—United States, 2008: recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR 2008;57(No. RR-3).
- Fester JM. Public health aspects of rabies. Aviat Space Enviro Med 1975;46:1194–5.
- Blanton JD, Hanlon CA, Rupprecht CE. Rabies surveillance in the United States during 2006. J Am Vet Med Assoc 2007;231:540–56.
- CDC. Human rabies. Atlanta, GA: US Department of Health and Human Services, CDC; 2012. Available at http://www.cdc.gov/rabies/location/usa/surveillance/human_rabies.html. Accessed April 25, 2012.
- CDC. CDC health information for international travel 2012. New York, NY: Oxford University Press; 2012.
- Fekadu M, Endeshaw T, Alemu W, Bogale Y, Teshager T, Olson JG. Possible human-to-human transmission of rabies in Ethiopia. Ethiop Med J 1996;34:123–7.
- CDC. Human rabies—Kentucky/Indiana, 2009. MMWR 2010;59:393–6.
- Blanton JD, Rupprecht CE. Travel vaccination for rabies. Expert Rev Vaccines 2008;7:613–20.
- Lembo T, Attlan M, Bourhy H, et al. Renewed global partnerships and redesigned roadmaps for rabies prevention and control. Vet Med Int 2011;2011:923149.
Notes from the Field: Identification of Vibrio cholerae Serogroup O1, Serotype Inaba, Biotype El Tor Strain — Haiti, March 2012
May 4, 2012 / 61(17);309-309
On October 20, 2010, an outbreak of cholera was confirmed in Haiti for the first time in more than a century. As of April 10, 2012, a total of 534,647 cases, 287,656 hospitalizations, and 7,091 deaths have been reported in Haiti as a result of the outbreak (1). The Vibrio cholerae strain that caused the Haiti epidemic has been characterized as toxigenic V. cholerae, serogroup O1, serotype Ogawa, biotype El Tor (2).
Recently, two V. cholerae isolates collected on March 12 and 13, 2012, in Anse Rouge, Artibonite Department, were characterized at the National Public Health Laboratory in Haiti as non-Ogawa serotypes. The isolates subsequently were confirmed by CDC to belong to the Inaba serotype. By molecular analyses (pulsed-field gel electrophoresis, multilocus variable number of tandem repeat analysis, and virulence gene sequencing [ctxB and tcpA]), these two isolates are indistinguishable from the currently circulating V. cholerae serotype Ogawa strain in Haiti. The molecular analyses conducted to date suggest that they arose from serotype switching, which is a commonly observed phenomenon in cholera epidemics, often driven by population immunity to the circulating serotype. Further characterization efforts are ongoing. Finding these two isolates does not change current clinical management guidelines (3).
Ogawa and Inaba serotypes do not appear to differ in the severity or duration of illness they cause; most persons infected with V. cholerae of either serotype will not develop clinically apparent disease. Type-specific immunity is induced by infection; however, cross-protective immunity between the two serotypes is incomplete (4). Previous studies have indicated that the Ogawa serotype offers less protective immunity than Inaba from reinfection with the heterologous serotype (5). Thus, if the Inaba strain becomes established in Haiti, persons who previously were infected with the Ogawa serotype of V. cholerae might be relatively more susceptible to reinfection with the Inaba serotype than with the Ogawa serotype because there tends to be stronger serotype-specific protective immunity. Immunologically naïve persons are equally susceptible to both serotypes. Because the Inaba strain is also biotype El Tor, its ability to survive outside of a host is likely the same as that of the Ogawa strain.
The two World Health Organization prequalified vaccines provide protection against the Ogawa and Inaba serotypes. In addition, the cholera rapid diagnostic tests detect all O1 serogroup infections, including Ogawa and Inaba serotypes.
This serotype conversion illustrates the increasing diversity of V. cholerae in Haiti (2) and emphasizes the importance of continued public health surveillance by the National Public Health Laboratory and CDC, which are partnering to establish a laboratory-enhanced sentinel surveillance system for a range of infectious diseases, including cholera and other diarrheal diseases. The system will provide data to determine the burden of diarrheal disease attributable to cholera and to help direct prevention efforts and programs to reduce morbidity and mortality from cholera in Haiti.
- Ministry of Public Health and Population, Haiti. Rapports journaliers du MSPP sur l’évolution du choléra en Haiti. Port-au-Prince, Haiti: Ministry of Public Health and Population, Haiti; 2012. Available at http://www.mspp.gouv.ht/site/index.php. Accessed April 25, 2012.
- Talkington D, Bopp C, Tarr C, et al. Characterization of toxigenic Vibrio cholerae from Haiti, 2010–2011. Emerg Infect Dis 2011;17:2122–9.
- CDC. Defeating cholera: clinical presentation and management for Haiti cholera outbreak. Available at http://www.cdc.gov/haiticholera/clinicalmanagement. Accessed April 27, 2012.
- Longini I, Yunus M, Zaman K, Siddique AK, Sack RB, Nizam A. Epidemic and endemic cholera trends over a 33-year period in Bangladesh. J Infect Dis 2002;186:246–51.
- Ali M, Emch M, Park JK, Yunus M, Clemens J. Natural cholera infection-derived immunity in an endemic setting. J Infect Dis 2011;204:912–8.
Upcoming COCA Webinar: Improving Disaster Planning in Nursing Homes and Home Health Agencies
Date: Today May 8, 2012
Time: 2:00 – 3:00 PM (Eastern Daylight Time)
Call Number: 1-888-790-6180
Join the webinar at: http://emergency.cdc.gov/coca/calls/2012/callinfo_050812.asp
CDC’s Office of Public Health Preparedness and Response funds Preparedness and Emergency Response Research Centers (PERRCs) to examine the organization, function, capacity, and performance of components in the public health system in preparing for and responding to all potential threats and hazards. The Emory University PERRC conducted a study examining disaster preparedness in nursing homes and home health agencies. Although nursing homes and home health agencies care for over 2 million patients, they typically have not been included in disaster planning efforts. Please join us for this COCA call where subject matter experts will share findings from their study and discuss strategies to incorporate nursing homes and home health agencies into community-wide disaster planning.
Archived COCA Conference Calls are available at: http://emergency.cdc.gov/coca/callinfo.asp
Free CE credit/contact hours (CME, CNE, ACPE, CEU, CECH, and AAVSB/RACE) are available for most COCA calls.