Diagnosis, Treatment and Response of Rocky Mountain Spotted Fever (RMSF) for Non Medical Professionals. Objectives

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1 Diagnosis, Treatment and Response of Rocky Mountain Spotted Fever (RMSF) for Non Medical Professionals Joanna Regan, MD, MPH, FAAP Medical Epidemiologist Rickettsial Zoonoses Branch Integrated Pest Management February 13 15, 2012 National Center for Emerging and Zoonotic Infectious Diseases Division of Vector Borne Diseases Objectives Briefly describe the biology of the disease as it relates to the work you do Describe follow up and response when RMSF cases are identified Prepare you for common questions you are likely to be asked about RMSF Biology of RMSF Timeline First there is a tick bite Many people don t remember it! Not all ticks are carrying the bacteria The first symptoms of disease are 2 14 days after the tick bite Most people with RMSF in AZ go to the doctor in the first 2 days of symptoms 1

2 Biology of RMSF Timeline Treatment is most likely to prevent death if started before day 5 of symptoms Many people who are not treated will start to look very sick on day 5 (confused, lethargic, etc.) The average time of death for fatal cases is day 8 Most people with RMSF begin to have detectable antibodies (the test turns positive) between day 7 14 This means the test doesn t help save lives! Most symptoms will resolve in weeks to months When would you use the timeline? To figure out where the patient was exposed To figure out who else was exposed To understand urgency and convey that to others RMSF Symptoms Classic RMSF Tick bite + Fever + Rash Only occurs in 20% of cases Fever 80% have it on day 1, may come and go Headache Approximately 60%, often severe Stomach problems common Pain, nausea, vomiting, diarrhea, loss of appetite Cold symptoms Coughing/nasal congestion reported in about ¼ to 1/3 of patients 2

3 RMSF Symptoms Rash 65% cases, may be late or absent Delayed or absent rash means higher risk of misdiagnosis Palms and soles 30% of the time Pink blotches and bumps, rarely itches Purple rash is a bad sign, day 5 May cover entire body, come and go What do you need to know about symptoms? The symptoms are different for different people People (including yourself) should get treated even if the symptoms are not classic Biology of RMSF Treatment Doxycycline!!!!! There is no resistance Doctors often think they can treat with strong broad spectrum antibiotics, but they don t work Only need a low dose for 5 14 days Can be taken orally Not commonly used due to concerns of dental staining in children and developing babies Relatively safe when used at the dose and duration needed for this disease If you don t feel sick at all, you don t need it yet 3

4 What do you need to know about treatment? It is always a treatable disease if caught early Make sure your community knows treatment is easy and well tolerated Biology of RMSF Testing Serology (paired serum samples) Most common test and best test for most cases Takes a lot of time First test is drawn in first week (usually negative) Second test drawn 2 4 weeks later shows rise in antibodies Never base a decision on the first test. It s a baseline PCR Fast and accurate detection of bacterial DNA Hard to detect until it is an overwhelming infection Not helpful in preventing death but useful in fatal cases What do you need to know about testing? It isn t accurate in the treatable stage of the disease Encourage people to go in for the second test, even though they feel better You need to know the second test results to know where real RMSF cases are happening Positive test results should be reported to the state, and can guide you to save others at risk 4

5 INVESTIGATION AND INTERVENTION Investigation is important!! Cases often occur in clusters, so investigations save lives! Lab results take time and don t give the entire picture Symptoms and travel history help you confirm a case and build a timeline The patient s environment put them at risk, and will continue to put people at risk until changes are made Investigation Key points for intervention People who are currently ill can be identified and sent for treatment Contacts can be notified Animals can be treated or removed Yard and house may be treated Risk factors like debris can be identified Anticipatory guidance and education can be given 5

6 Investigation Clinical symptom investigation form Environmental check list investigation form COMMON QUESTIONS Why can t they tell me if I have RMSF? Testing is important but takes time Treatment should be based on symptoms It may take weeks to get a positive result The faster test only works in fatal or near fatal cases 6

7 I was bitten by a tick, do I need medicine? Not unless you start to feel sick Watch for signs for 2 14 days, if any develop, go to a doctor immediately If you were bitten by a tick, that means things in your environment need to change (treat dogs, yard, etc.) Can my family members catch RMSF from me? It isn t spread person to person If you got RMSF, you were bitten by a tick If you were bitten at home, other people in your home are at risk Can my pets get RMSF? Yes! Dogs can get sick and die Other animals are not likely to be harmed 7

8 It is unknown Can I get RMSF more than once? If a severe case is confirmed with PCR it isn t likely, but people who have been treated once should not assume they are safe I keep my house clean, am I at risk? Ticks don t care how clean or dirty you are Ticks are attracted to carbon dioxide you breathe out Some items like old couches can make it easier for ticks to live, but ticks can be found in clean homes Well groomed dogs can get ticks if they aren t treated with a good tick collar or other approved treatment Removing couches and other items and doing frequent tick checks can help, but an untreated dog in the area will keep you at risk I ve never had a tick bite. Could I have RMSF? Many people who get RMSF don t remember seeing ticks or being bitten If your doctor says you have RMSF, take the medicine 8

9 There have not been cases in my neighborhood, am I at risk? Unfortunately yes Dogs love to travel Lack of animal control and leash laws may be putting you at risk If you think you may have the illness, trust your instincts and go to the doctor If you see untreated dogs, debris or ticks, take action! Use tweezers How do you remove a tick? Cover your hands with gloves if possible Grab tick close to the skin Pull straight up slowly If part of the head is left in the skin, don t worry Wash area and everyone s hands with soap and water Watch for signs and symptoms for 2 14 days I was treated for RMSF last week and I still have a headache, what should I do? Sometimes the headache and fatigue can linger If you are getting better rather than worse, you don t need more medicine Make sure your doctor is aware of your symptoms 9

10 Conclusions RMSF is a preventable disease Keep ticks away from people by treating yards, homes, dogs RMSF is a serious and potentially fatal disease RMSF is a treatable disease Treat by day 5 to prevent severe illness and death No one should stay home if they think they have it Investigate, report, educate and intervene Find cases and prevent clusters of new ones Encourage treatment Eliminate environmental risks You can save lives! Closing Statement Myriad Pro, Bold, 28pt For more information please contact Centers for Disease Control and Prevention 1600 Clifton Road NE, Atlanta, GA Telephone, CDC INFO ( )/TTY: E mail: Web: The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. National Center for Emerging and Zoonotic Infectious Diseases Rickettsial Zoonoses Branch 10

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