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Andes Hantavirus, Murine Typhus & Salmonella: Pediatric Infectious Disease Update · Pediatrics Now: Cases Updates and Discussions for the Busy Pediatric Practitioner

0:00
Yeah, saliva. Because the thing is that these people are not coughing a lot
0:03
before they get the severe pulmonary syndrome.
0:06
Runny nose is not part of it. And they're usually not having a lot of respiratory symptoms.
0:10
So how do you get sick? You have to get sick by airborne or like,
0:14
you know, aerosolized droplets, which if you're coughing, you could get.
0:17
But otherwise, saliva is a source of the, you know, a source of infection.
0:24
I'm Holly Wehment, and this is Pediatrics Now.
0:28
American passengers exposed to Hantavirus during a cruise outbreak have returned
0:33
to the United States for monitoring at a federal quarantine center in Nebraska.
0:37
And one of the passengers has tested positive.
0:41
Health officials stress the public risk remains low, but the story raises important
0:46
questions for pediatricians and parents alike.
0:48
And we know kids are talking about it. Joining me today here in the podcast studio is Dr.
0:55
Dina Sutter. She's the head of our Pediatric Infectious Disease Division.
1:00
Dr. Sutter, thank you so much for being here on Pediatrics Now. Thanks, Holly.
1:04
It's really unlikely that we're going to have transmission of this expand and
1:09
extend anywhere near what COVID-19 did or even annual influenza epidemics or
1:16
the occasional influenza pandemic.
1:18
So nobody in the infectious disease community expects something like that to happen.
1:23
Most pediatricians are familiar with hantavirus, but this outbreak involves
1:28
the rare Andes strain, which raises different concerns because of its potential
1:32
for person-to-person spread.
1:34
Can you explain what makes this outbreak unusual?
1:38
The thing that's unusual about this outbreak is even though the Andes hantavirus
1:45
has been demonstrated to be
1:47
transmissible from person to person in a few instances in South America,
1:52
the fact that these people are on a ship that are from different locations that
1:56
have to be removed, you know, gotten off the ship or returning to their home
2:01
country, the concern for infection in those cases,
2:04
a little bit of drama because you have people, you know, passing away.
2:07
Away on the ship or passing away shortly getting off the ship.
2:11
So this may not be different than the few published reports and maybe some unrecognized
2:17
reports of the Andes hantavirus spreading within a community from person to
2:23
person as opposed to getting it from the environment, but some of that remains to be seen.
2:27
How does this strain differ from more typical hantavirus infections?
2:32
Hantavirus in general is rare?
2:34
Hantavirus is rare, especially in the Western Hemisphere. So hantavirus was
2:39
probably been around for a really long time.
2:42
The rates are much, much higher in Asia and Europe.
2:45
So the classic hantavirus, which is named Hantan, is named after the Hantan River.
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This is something that was identified in the.
2:55
Korean War in people who returned from there.
2:59
But, you know, if you look back over historical accounts of things that happened
3:02
in various villages or even in prior wars, that type of hantavirus,
3:07
and there are several different species now that have been identified,
3:11
those are called the old world hantaviruses.
3:13
So, you know, we always classify zoonotic and other infectious diseases into
3:17
old world, you know, Asia, Africa, which is not really a hotspot for this,
3:21
surprisingly, and Europe versus, you know, the Americas with the new world.
3:26
So the old world hantoviruses classically can cause, if severe,
3:30
can cause something called hemorrhagic fever renal syndrome,
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and that is much less likely to kill you than the type we're talking about.
3:40
So the case fatality rates are less than 10% for those, but people can have
3:46
severe kidney disease and require dialysis, require more extensive life support in those cases.
3:54
Those patients often will survive, like I said, case fatality rates less than
3:59
10%. And there are a lot more cases of that.
4:02
So there are probably 20,000 plus cases reported in Asia and a few thousand
4:07
cases reported in Europe annually.
4:10
The New World Hantaviruses are much, much less likely reported.
4:13
They're much less likely to be identified.
4:18
But the case fatality rate's much higher. So we really kind of focus on,
4:21
there are several different ones.
4:23
The one we talk about in the U.S., the Sin Nombre virus, which originally was
4:28
called, I can't remember what the original name was, but then it was,
4:31
they called it the Four Corners virus.
4:32
The people at the Four Corners states did not like that, and so they renamed it.
4:36
The Sin Nombre, no name? Yeah, Sin Nombre, no name.
4:39
I don't know if that was kind of like a joke because they had to keep changing the name or what.
4:43
I'd have to read about that. But that was identified first, much more recently
4:48
in 1993, where there were multiple cases identified and fatalities.
4:53
But those were all people who were directly exposed to environmental sources.
4:59
The Andes hantaviruses have been definitely reported to cause,
5:04
like I said, the person-to-person transmission, but most of the time is still
5:08
acquired environmentally.
5:10
And the ones in the new world typically cause hantavirus pulmonary syndrome.
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So instead of primarily renal manifestations, it's typically kind of pulmonary,
5:21
severe pulmonary disease with capillary leak.
5:25
You know, people often will have to go on to the ventilator or even ECMO because
5:29
of the severe cardiopulmonary process that occurs.
5:33
And if ECMO isn't available, then that's when the person passes away. Yeah.
5:39
And so a lot of times it progresses so quickly when they reach that phase of
5:43
the illness that adequate medical care can't be sought.
5:47
So they don't, so, you know, the problem with this is that the prodromal phase
5:51
of this may look like a lot of different things, including other tropical diseases,
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you know, other zoonotic things.
5:57
And then we get to the point where they hit the.
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The part where they actually have pulmonary failure or respiratory failure,
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and that's, you may not be able to get to an ICU in time depending on where you are.
6:09
It's usually not going to look like a cough, congestion, runny nose type of thing.
6:12
It's often going to be more like other flu-like illnesses, fever,
6:17
myalgias, abdominal pain, diarrhea.
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Sometimes it actually can mimic acute abdomen with a severe abdominal pain in
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these particular Hantavirus pulmonary syndrome processes.
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And then respiratory distress. And then severe respiratory symptoms.
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You know, they may have cough, but, you know, shortness of breath,
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you know, hypoxemia, and need for, you know, more advanced care.
6:43
And we keep hearing the risk is low, and I'm sure our pediatrician listeners
6:48
are getting asked about this by some of their patients.
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And then you see the video, especially of those Americans getting off the ship,
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and some of those are in the special suits, the guy walking in front of them is in full hazmat.
7:03
Like, if it's so low, from an infectious disease standpoint,
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why is it taken so seriously?
7:11
Some of it just may be because people are terrified.
7:15
You know, these news reports are coming out about, you know,
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not only is it people from different countries and people have to return to different countries,
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but people, you know, dying on a ship, body coming off, and then the spouse
7:28
of the first passenger being going to an airplane.
7:30
So I think being as cautious as possible, even if some of it is for,
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some of it may be for, you know, reassurance of the public, you know, just the optics of it.
7:42
But, you know, you never say never if viruses, you know, which have not been
7:46
well studied, these viruses have been very well studied over years,
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and they don't typically tend to have mutations like our respiratory viruses do. But.
7:55
Because this has just occurred, extensive studying of the particular virus or
8:01
the transmission, you know, has not been done. So I think being more cautious makes sense.
8:06
And what type of virus is it? Because I think a lot of people think it's a respiratory virus.
8:10
Hantavirus is typically caused in, you know, capillary leak syndrome.
8:15
So like, you know, it can look like a lot of other things like we see.
8:19
We don't see typically here, but in Asia can very much mimic dengue fever.
8:23
It can mimic some other febrile illnesses like leptospirosis.
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If it was somebody who showed up here in San Antonio with this kind of fever
8:30
and ill appearing, you know, you would always consider something else that you
8:34
can get from animal exposure, which is murine typhus, which we see a ton of here.
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We'll get from fleas. From fleas, yeah. And that's super common here,
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you know, whereas, you know, I would not expect this to occur.
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It's not really highly endemic here, any of the hantaviruses.
8:49
And it's a good reminder to give your pets the flea medicine that they need. Yes, please do.
8:56
We're starting summer, and I'm dreading how many sick kids I'm going to see
9:00
in the hospital from flea bites.
9:02
How sick can a child get from a flea bite? I mean, they can get sick,
9:06
these kids with murine typhus.
9:08
They don't usually get as sick as the kids with the more classic rickettsial
9:12
infection, which is Rocky Mountain spotted fever. Those children are often in the ICU.
9:16
But they can get very sick. They can be hospitalized. they can't end up in the
9:19
ICU and require several days of inpatient care.
9:22
So yeah, that's what, you know, if people are going to ask this question,
9:27
which I'm sure you're going to ask, like, how do you differentiate between these things?
9:29
It's kind of hard because a lot of these infections are very hard,
9:34
even influenza, although in this case, like I said, you don't present with coughing,
9:38
you know, fever, body aches, abdominal pain, diarrhea, you know,
9:42
abnormalities in your labs, maybe you have some rash. It's like,
9:45
it's a lot of different things it could be. Right. And I mean,
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how many times a day does a pediatrician see a child with a rash? Yeah, yeah.
9:53
And these are not classic rashes. These are just sometimes they may have petechiae
9:56
from thrombocytopenia.
9:58
But again, that looks a lot like things like if they were traveling,
10:02
things like dengue fever, some of the other arboviral infections.
10:06
And then, of course, locally, there's a lot of common viruses that could do
10:11
that type of thing as well. So it's kind of hard to tell things.
10:14
There's nothing pathognomonic or classic about an early presentation that I
10:19
am aware of in terms of, you know, you'd see this type of rash or you'd see
10:22
this type of particular presentation.
10:24
They may have headache, they may have retroorbital, you know,
10:28
eye pain type of thing that is very classic for a lot of these things we just mentioned.
10:33
Dina, how concerning, though, is it the American passenger who has tested positive
10:38
and is not symptomatic, apparently, but could it present.
10:44
Weeks from now, months from now? Yeah. I mean, the incubation period typically
10:48
for this is about two weeks in most cases.
10:51
Now, the reports of the first passenger, the index case, possibly having an
10:56
exposure only a few days before boarding and then becoming ill within a week is a little fast.
11:02
But these patients really need to be monitored for like up to six weeks because,
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you know, cases have been reported six weeks after a presumed exposure,
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at least the environmental exposures.
11:13
I particularly, you know, for that particular passenger, I mean, I hope they do well.
11:19
I hope but there if there's a biocontainment there, you know,
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Nebraska's biocontainment unit is very famous.
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You know, they used it for when people were evacuated out of Africa during the Ebola crisis.
11:31
So it's been it's it's it's world it's world class.
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So if these people have gone to Nebraska, and I think there's one person at
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the CDC in Atlanta, that's good.
11:42
You know, they're going to make good decisions. They're going to,
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you know, maintain them. They're going to watch them. They're going to watch the exposed people.
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My bigger concern is, and not that I think it has pandemic potential,
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because I really don't think so, you know, this will be contained,
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is all the people who maybe were exposed.
11:58
And, you know, and hopefully there's epidemiologists looking at what happened
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and who was exposed to whom, because there were people who got off the ship
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prior to identification of what was going on.
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And I know we have, I think there were six Americans, possibly,
12:13
maybe two Texans who had left the ship prior and then come back.
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And hopefully the state health authorities are appropriately making sure those
12:21
people are, you know, self-quarantining or monitoring themselves.
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But, you know, in the end, how much exposure did these people have to each other?
12:30
You know, what type of exposure might dictate that? And of course,
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you know, I'm not sure who's in charge here. You know, I think the,
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you know, engaging with the local health departments, but local health departments
12:43
hopefully are following those people.
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And then I'm more concerned about the people, the many other passengers who
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were maybe exposed to some of the cases, you know, in terms of being on an airplane
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with some of these people who were either very, very sick or had early symptoms.
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So I think those, you know, hopefully those people are being tracked down.
13:03
You were in the military for more than 20 years and you ran pediatric ICU at
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one point? Oh, I mean, that was when I was deployed to Afghanistan. Yeah.
13:12
That was a unique experience. I was not normally a pediatric ICU doctor.
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But you've seen a lot and you have so much experience. Are you worried about this?
13:23
No, I'm not. I mean, I think it's fascinating and I think it's maybe a good
13:30
test of our public health response.
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But hopefully this could be, if there's a silver lining, could be a wake-up
13:39
call or a reminder that we really need our public health infrastructure and
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we need to cooperate with the rest of the world. It's very important.
13:46
This particular type, as we know, can be transmitted human to human.
13:51
How close of contact are we talking?
13:53
So normally, this is, as many people probably know, hantaviruses are typically
13:59
acquired by inhalation of rodent droppings. That's the vast majority of cases.
14:05
So hantaviruses are, the natural
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reservoirs for hantaviruses are typically rodents of various types.
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Also in things like moles or other kind of like rodent-like things.
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And then also in bats, although bats are not felt to be a very,
14:21
you know, likely source of transmission. Unlike things like,
14:24
you know, rabies and that type of thing.
14:25
And then there are some weird hantaviruses that they found in like reptiles
14:29
and fish, but those are not really sources of transmission.
14:32
So usually, like when we talk about the Sinombre virus, for example,
14:36
which is classically very high rates in like New Mexico, Colorado,
14:40
western United States, I always talk about how, you know, when I lived in Albuquerque,
14:43
there were mouse, there were mice.
14:46
I had never had mice in my life. My whole house had like infestation of mice.
14:49
You're constantly catching them.
14:50
There was mouse poop in the cupboards. You go out to the garage,
14:53
you have to sweep up mouse poop.
14:54
So that's the classic thing. It's like somebody goes into a shed,
14:57
whether it's their own personal property or agricultural workers,
15:01
people who have farms, people who are moving items in storage that they have
15:07
to get out and they have to clean dust and like rodent droppings.
15:11
And it gets swept and aerosolized and they breathe it in and that's how they
15:15
get infected. That's almost all of the cases.
15:17
And it has to be an infected poop. Yes. And these animals don't,
15:22
with the exception of a few species of animals, these animals are not sick.
15:26
So they have the virus in their system and they carry it and they excrete it,
15:30
but they're not like dying or sick.
15:32
There's no way to know. Yeah, there's no way to know. You'd have to have people
15:36
who do site surveys and test animals, and they kind of know where their hot spots.
15:41
And if a person gets it, then they really are doing a lot of investigation.
15:45
You can also get it from rodent bites, although that's uncommon here in the U.S.
15:50
Especially, but rodent bites can transmit and also...
15:54
Pet owners or people who work in like pet stores or pet industry and they have
15:59
animals like captive, mice, rats, whatever, those people are at higher risk,
16:05
especially if they get bitten or they're cleaning up like rodent droppings.
16:08
Really? Even guinea pigs? I don't know about guinea pigs. Hopefully not because I used to have one.
16:14
And then the other thing is like you can actually have contamination of food,
16:18
particularly if you had like rodent droppings in your food, which,
16:21
you know, you got to check your food when you live in New Mexico.
16:24
That could be a source of infection as well.
16:27
So the United States version, I guess, that we have here, the Sinombre,
16:31
has never been proven to be spread from human to human.
16:33
There's no evidence that it's been investigated to.
16:36
We only have a handful of cases every year, but there are more cases,
16:40
although not a lot, in Chile and Argentina in particular, which is where this
16:45
little outbreak has thought to be originating from.
16:50
I think they said that the person was birdwatching near a garbage dump,
16:54
is what I read in the, I'm not sure what landfill, I'm not sure what birdwatching
16:58
near a landfill, what the point of that was.
17:00
But that could be a very high risk when there's a lot of rats or mice in a landfill,
17:06
and then you end up, for some reason, earth gets turned up and you breathe it in.
17:10
Now, human transmission of the Andes hantavirus is probably most effective when
17:17
people are very, very, very close.
17:19
So, you know, why sexual contact has been postulated as a source,
17:25
even though I think it's probably saliva.
17:27
Saliva may have very high concentrations of the virus.
17:32
So if a person's not coughing a lot, you know, then it's probably less likely
17:37
to be aerosolized droplets, but they may begin to cough, and that's another
17:41
significant risk as well.
17:43
So I think very sustained close contact has been generally thought to be the
17:49
source. And there was one big outbreak in Argentina in like...
17:52
2018 or something like that. And the index case went to a birthday party while he was febrile.
17:58
Okay. So these are people who are usually acutely ill that they're the most
18:02
likely to, the most infectious then, and went to a birthday party and spent,
18:06
you know, 90 minutes in close quarters of people. And then people got infected from that.
18:10
So it doesn't have to be days and days per se, if they're significantly symptomatic coughing on people.
18:16
But on this cruise ship, we don't know exactly who was near whom.
18:19
We just know that this is a really weird, weird kind of an example of bringing
18:24
a lot of people together and spending a lot of time maybe outdoors,
18:27
but also probably indoors.
18:29
So that's that, you know, all of it's kind of plausible. And is it not out of
18:32
the question that a surface could have something that could be,
18:37
it could be transmissible on a surface?
18:39
Yeah, I mean, it's been, some of the Hantar viruses in particular have been
18:42
studied and they've been found to be, to survive on surfaces for,
18:46
you know, one to two weeks, something like that, I believe.
18:50
But whether that's a source of infection for people is not clear.
18:53
I mean, if you have rodent droppings in dirt and you're sweeping and you're
18:57
breathing that in, that's probably more likely.
18:59
But if you put your hand on a railing or a doorknob and it's got somebody just
19:05
spread hantavirus from their saliva that you didn't know, I don't know that
19:09
anybody's proven it can be spread that way. So.
19:13
Can you give us some advice, what would be some good things to say for our pediatrician
19:18
listeners and viewers about preventing Hantavirus, this strain that we're talking
19:25
about, but also in general?
19:26
Should you wear a mask if you're sweeping up? Oh, yeah.
19:30
So for the Andes, I mean, I think the prevention is like, watch the news.
19:35
And if grandma was on that ship, maybe grandma shouldn't come hang out with you.
19:39
Right. Something like that is obvious, right?
19:41
We're not seeing evidence that people are coming back and transmitting it,
19:45
you know, the people who had left the ship early.
19:47
Like, there's no evidence of that now. This becomes a much bigger deal and becomes
19:51
much more transmissible, which we're not expecting because of that.
19:54
Like I said, there's probably a short period of time where you're very infectious
19:57
and you have to have very close contact.
20:00
In that case, I wouldn't really think about that one too much.
20:02
And I think for the pediatricians out there, you know, people come in and they
20:05
have a febrile illness, their kid's sick.
20:07
I mean, that's not what it's going to be, right, unless something weird happens.
20:11
But advising people about the whole, you know, especially if they're traveling
20:16
to the further west part of the country, you know, camping, staying in like,
20:22
you know, cabins, something.
20:24
Those are the risk situations. And so, like, you know, making sure that people
20:28
are, if there are rodent droppings and it gets cleaned out and they're wearing
20:31
a mask, if they do clean it out, maybe, you know, spray some water on it before you go.
20:37
Brush it off and, you know, aerosolize it. You don't want aerosolization of
20:40
those rodent droppings.
20:42
Open the garage, open the... Open up, wear a mask, you know, yeah.
20:46
Get the stuff out, control the rodents, you know, in any way you can.
20:49
Now, if you're out in nature in some little cabin or some little Airbnb and,
20:54
you know, or camping and there's like, you know, a shed, I mean,
20:57
it's going to be hard to control that.
20:58
But a lot of the classic story is somebody who owns another property that's
21:02
in the woods or owns like, you know,
21:04
a little cabin and they go there and they open it up for the season and the
21:08
rodents have been pooping in there for an extended period of time and there's
21:11
dirt and, you know, that's like the classic exposure.
21:15
So really you should not be getting that stuff out of there.
21:17
You need to get it out of there and you need to not be breathing it in.
21:21
So don't go anywhere fun ever in the mountains or in New Mexico.
21:25
No, go to all those places because they are fun.
21:28
So beautiful. I love them, yeah. But now, yeah, there's so much to worry about.
21:32
Yeah, this is, I have a lot of things to worry about as an infectious disease
21:36
doctor. and a mother. And this is not on my list. Okay.
21:40
That makes me feel better. And is it a good reason to bring up with our kids
21:45
about and or patients about saliva transmission?
21:49
Like I noticed with my daughter, you know, like when we were teenagers,
21:52
it's like, oh, have some of my drink.
21:54
And they pass their drink with their straw and the other kid drinks out of the same straw.
21:58
Like we're sharing because we're so close or they use share utensils.
22:02
Like how chewing each other's gum when your boyfriend gives you gum?
22:05
Is that a thing anymore? That's disgusting. Oh, yeah. No, I remember.
22:07
Right. Super gross. Yeah. It's like, we're close.
22:09
It is so gross. It was like proving that you were going out with somebody.
22:13
That is disgusting. I just thought about that.
22:15
Gross. So, yeah, I mean, in general, it's not for this per se.
22:21
It's like in general, you're less likely to get sick if you don't share drinks,
22:27
wash your hands, you know.
22:29
I mean, the things that we've been taught since we were little kids, right? it.
22:33
If you're worried about your kids sharing drinks and you want to scare them
22:37
and bring this up, I guess you could.
22:38
But I don't think, you know, during COVID, I mean, like, you know,
22:41
you're trying to keep kids away from other kids. You're trying to get things.
22:44
And unfortunately, some of the consequences were that kids didn't get natural
22:47
immunity to certain things because rightfully they were kept,
22:50
you know, home to try to keep people from dying.
22:53
But yeah. Yeah. So you just have to be reasonable, I think. I mean,
22:57
certainly if a kid is sick, you know, they should not be going to school.
23:01
They should not be coming over to hang out. that is like number one, two, and three for me.
23:08
Is there a chance, though, for our clinician listeners, like this,
23:13
could it be a novel form that we just don't know about that we're mutated?
23:18
I mean, I'm hoping they've sequenced it by now and try to see if that's any
23:22
kind of dramatically different sequence, but that's not been reported that I know of.
23:27
So, like, in theory, you would have to have some mutations that made it much
23:32
more likely to be infectious. now are transmissible from human to human.
23:36
Honestly, I think there probably have been lots of cases or some cases in the
23:39
past that haven't been identified, but the thing is that with a case fatality rate of 30%,
23:46
think that we would know, you know, about clusters that have occurred before
23:50
and would think, oh, it's much more transmissible than we know.
23:53
I think this is probably stuff that happens intermittently.
23:58
And the fact that this person probably had a very high viral load after going
24:01
to this whatever, presumably going to this, you know, place where there was
24:05
a lot of rodent droppings, that's how they were able to like infect other people close quarters.
24:10
And it's just a big deal in the news. So I don't think this is going to happen.
24:13
This is not, these viruses are not likely to mutate like influenza or COVID
24:18
or some other respiratory viruses that we see.
24:23
Public health experts often say another pandemic is not a matter of if but when.
24:28
I've even heard it could be in the next five years. Have you heard that?
24:33
What lessons from COVID are helping us respond more effectively to emerging
24:37
infectious disease threats today?
24:41
I think that people in academic centers, I think public health authorities that
24:47
are not handicapped by, you know, are not limited by severe budget cuts.
24:54
You know, like these people are, they have so much more information.
24:57
They have so much more data sharing, if it exists.
25:01
But the science evolved so much, you know, in terms of being able to track and
25:07
sequence and, you know, I mean, things that are way over my head, obviously.
25:11
And, and then, you know, there were lessons learned, good and bad from COVID,
25:16
you know, in terms of what works, what doesn't work.
25:18
And then, of course, you know, vaccine development, which there actually is
25:22
a hantavirus vaccine against the old world version that is used in China with,
25:29
with some success. Yeah.
25:30
So, you know, that could be another thing, like if this were to occur,
25:33
which I do not think is going to happen.
25:34
You know, we have a much more robust capability of responding with,
25:38
like, you know, preventative measures.
25:41
So, yeah, there's a lot. So that vaccine could be effective for this other thing?
25:44
I don't know if it's been tested for the new world viruses. I don't know how
25:48
much cross-reactivity there is.
25:50
It's definitely not approved in any Western countries or in Europe.
25:54
So. Will that be approved? Do you anticipate that? Oh, I have no idea.
25:59
I'm just talking about like, you know, the quick response, like,
26:03
you know, the COVID vaccine, which was developed on a platform,
26:06
that mRNA technology allowed people to make a vaccine very quickly.
26:10
I know this is not going to be the next pandemic, but if there was another one,
26:14
I'm hoping that there would be enough infrastructure left and enough support
26:19
that you could develop preventive measures like that.
26:22
Well, any idea when this person who tested positive can go about a normal life?
26:28
They're probably going to be observed.
26:30
Well, all these people who are exposed are probably going to be observed from
26:34
the last presumed exposure, which I guess is being near each other in this person,
26:38
probably for six weeks, I'm assuming.
26:41
Now, whether they're going to keep them in these rooms in Nebraska the whole
26:44
time, they probably won't.
26:46
They'll probably test them serially. And, you know, I guess there's not enough
26:50
known about how, you know, how many negative tests in a row after a couple of
26:55
weeks of exposure, you know, would rule you out.
26:58
So this person who's now in quarantine and isolation, probably,
27:03
you know, once you see their viral load go down, you know, they have very low
27:06
viral loads, then they probably will step down whatever they're doing because
27:10
they're really not going to infect other people.
27:12
There's no, like, biphasic viremia or anything like that that's reported with these hantaviruses.
27:19
And the cases of hantavirus that I've heard of, it just, it seems like it quickly
27:23
can turn fatal. Is that? Yeah, it does.
27:28
So, you know, we talk about that prodromal phase where they might just have,
27:31
like, this sort of vague viral, you know, presentation, which is hard to differentiate.
27:35
And then when they develop cardiopulmonary syndrome, which is classic for the
27:40
new world, they can be very, very sick and, like I said, require ICU care within hours to days.
27:47
It's not like a slow progression where, oh, they have flu and then they're getting
27:52
worse and they have a secondary bacterial infection. This is like a rapid progression.
27:56
So any warning signs you want to mention with hantavirus, rapid progression?
28:02
Is it time to go to the ER? I mean, I think it's time to go to the ER.
28:08
I guess in something like this, where if this became a sustained epidemic of some level, I mean,
28:15
again, I'm not assuming it would be a pandemic, but if there were further person-to-person
28:20
transmission and the patient had traveled to an endemic area or had been around somebody,
28:24
then in this case, I would be sending them to...
28:28
You know, I'd be calling public health authorities and getting them tested and in the hospital.
28:32
So I think any kind of sending somebody to the emergency room or for admission
28:36
is really, you know, those kids are not going to have this.
28:40
And they just need to go when you would normally send them, you know,
28:43
respiratory distress, you know, low oxygen saturations, need for supplemental
28:48
oxygen, low blood pressure, you know, that type of thing.
28:50
So there's not, it's hard for me to say, oh, when should you send this person
28:54
with Hantavirus to the hospital? Because if they have Hantavirus,
28:56
you better be doing something.
28:59
Anything else you want to mention, Dina, to pediatrician listeners and viewers?
29:04
Is there one takeaway from this?
29:06
It's such a huge topic right now, as we know, top of mind for so many people.
29:12
Well, I would just reassure your patients and your families that this is really
29:16
not going to be a pandemic, that there's like, you know, very,
29:20
very low risk unless you had sustained contact with those people.
29:24
And then also remind your families and the patients how important it is that,
29:28
you know, public health authorities are aware of things that are going on,
29:31
that are communicating.
29:32
It's very important for our country and our world that this is,
29:35
that these people have all the information and all the capabilities they have
29:39
because everything can be viewed in the lens of like what happened with COVID,
29:43
lessons learned, and making sure that families are also just aware of things
29:48
that could be a risk, not just travel, which is very low risk,
29:52
you know, to some of these endemic areas, but, you know,
29:54
the rodent exposures at home and making sure they're reducing the risk too.
29:59
And as a mom of four, how many kids do you have? I have three and I have three stepkids. Okay.
30:06
So, so you have a blended family with six kids and as a highly experienced infectious
30:14
disease doctor with all of your knowledge, is there anything you want to say
30:18
or what would you say directly to parents?
30:20
What should we be saying to our children about this.
30:24
I would say exactly that, that this is a weird thing.
30:29
It's a very unusual thing, but it happened because of, you know,
30:34
if you want to not scare them, just say, they were on the ship all in this tight
30:37
little area, and this person happened to get sick, and this is not,
30:40
you know, this is not how it normally goes.
30:43
And then maybe use this as a reminder, you know, that you should wash your hands
30:47
and that you shouldn't share drinks.
30:48
And if your friend is sick, you should not, you know, but that's not what they're
30:52
going to have, you know, that they have some other virus.
30:54
You still want to try to avoid that and use those basic preventive measures.
30:59
But no, this is not going to become a pandemic. And wear a mask if you're sweeping out.
31:05
Yeah, wear a mask if you're sweeping out anything like, Like,
31:08
you know, any kind of environmental exposures like this, if there's a lot of
31:12
rodents, there's rodent poop, yeah, problem.
31:15
Yes. And you mentioned the food. Is that really something we need to look for
31:18
when we're eating out or somewhere? No. I would just say, like...
31:22
If you were in some very remote environment where you didn't know it was,
31:26
you know, I mean, again, this is animals, rodents get into your food,
31:30
and this is not a common way it's transmitted.
31:33
But if you have animals, you know, you have rodents getting into boxes of food
31:37
or, you know, something like that, then, yes, that could be a problem.
31:40
But gastrointestinal acquisition is not a real, is not as common.
31:45
Okay. My own daughter said everyone at school is talking about this,
31:48
and my nephew said the same thing. And understandably, a lot of us carry anxiety from COVID.
31:56
So with that in mind, it's okay to reassure this is not going to be another pandemic.
32:03
I mean, you can never say never, but to the kids, I would say,
32:06
no, it's not going to happen.
32:08
And reassuring, you know, I mean, kids, this is very normal that kids get like
32:11
worked up over something, you know, and the kids have so much access to news now.
32:15
And it's not, you know, always accurate or maybe they're seeing it on TikTok or whatever.
32:19
And then maybe some of these children grew up, you know, they were very young during COVID.
32:23
So maybe the kids who are this age, you know, they have these,
32:26
it's kind of like COVID is looming over their whole childhood, you know.
32:30
So, you know, I think the best thing is if you can, if they're not going to get too anxious,
32:34
explain to them the way these, you know, how rare these infections are,
32:38
how rarely it's transmitted human to human and that this is sort of a kind of
32:42
a fluke and that everybody's working together to try to make sure all the people
32:46
who are at risk are taken care of.
32:49
And are healthy and are not risking, you know, exposing other people.
32:53
But this is not, this is not a normal thing. But, you know, COVID,
32:57
you know, again, coronaviruses have very high risk and high,
33:01
very high epidemic potential.
33:04
There have been lots of different ones. And COVID happened to be one that took
33:07
us, you know, all of us in the infectious disease community a little bit by
33:10
surprise in terms of how, how devastating it was.
33:14
But no, these contraviruses are not, aren't considered to have pandemic potential.
33:20
But with our, as a parent, there's so much to worry about. And then,
33:23
of course, we can't know everything.
33:25
So there is a chance it could become something more serious.
33:29
There's always a chance something could happen. But I'm more worried about things
33:32
like, you know, measles and a lot of other things that have a lot higher risk
33:38
of transmission and, you know, are more likely to happen.
33:43
And as a parent, if you're worried, take those precautions we talked about.
33:47
And then also in the San Antonio, South Texas area, give your on-time flea medicine
33:53
because that's a real risk. The flea medicine thing is really a big deal.
33:56
It's a huge deal, right? I mean, please give your animals flea and tick medicine.
33:59
On time. If you have an animal.
34:01
I had a family recently that, you know, I mean, some of them are like,
34:04
we live in the farm. We live in the farmlands. You know, we have like barn cats.
34:09
Those are a big risk. If your kid is going to be playing with those animals,
34:13
don't let them sleep with animals, you know, cats especially that have not been treated.
34:18
If you get a stray, you know, sometimes the kittens can't be treated yet.
34:22
Those animals should not be sleeping in the bed with the kids until you get
34:26
them on medication that's effective.
34:28
You need to take those animals to the vet and get that done.
34:31
And if we give our dogs the preventive medication, it can help protect the whole backyard.
34:37
I've heard that because the dogs like around the backyard. So it's amazing what
34:41
the prevention medication can do.
34:45
Anything else you want to mention before we wrap up?
34:48
I think that's it. So, and I know you love to travel. Are you going on a cruise
34:53
anytime soon or doing going anywhere fun?
34:55
I do not like cruises because, I mean, I've only been on two and I just did not enjoy them.
34:59
But when I, you know, when I had a nine-month-old with me and the other one
35:02
was like, didn't go anywhere good.
35:04
And were you thinking about like all the infectious disease possibilities?
35:07
I mean, there's a lot. You know, like with classic is norovirus on ships.
35:10
I mean, it does happen. It still happens.
35:15
Infectious risks don't stop me from doing anything really personally.
35:18
I always do things that you're probably not supposed to do.
35:20
All of the eating things you tell people not to do when they travel,
35:25
I have a friend who's in a very remote area in a very limited resource area
35:31
who's sending me messages about
35:33
the diarrhea that's been going on over and over again for three weeks,
35:37
and I was like, I told you to take this with you and do this Oh, I didn't listen to you.
35:41
Okay, I'm not telling you anything Actually, I'm leaving to go to Italy for 10 days and a few days.
35:46
Oh, how nice. I'm not going to get sick, hopefully.
35:50
I'm going to enjoy, you know, traveling and, you know, again,
35:53
not high risk as far as, not high risk as far as like, you know,
35:56
consuming food, that kind of thing.
35:58
But certainly, you know, close travel on trains and airplanes,
36:01
you know, there's got to be careful.
36:04
Will you wear a mask in the airport and on trains? I think I will for this trip.
36:09
I haven't been that good about doing it on domestic flights unless I hear somebody
36:13
coughing, but I don't want to be sick there.
36:16
And when you talk about food, you mean like not buying it out of a van on the
36:20
side of the road? Yeah. I mean, like in Italy, I'd probably buy off a van on the side of the road.
36:23
But if you're in like a developing country where there's like a lot of,
36:27
you know, I mean, again, you could get some, you maybe get sick in Italy, but...
36:31
If you have food trucks or food vendors, street vendors in a lot of countries,
36:36
you really should not eat things like salads or fresh vegetables.
36:41
You really should just be eating hot, well-cooked things or just even in more reputable areas.
36:46
Now watch me go to Italy and get sick from some kind of food poisoning, so we'll have to see.
36:51
What about in the United States? When you eat out, do you eat salads okay?
36:55
Yeah, I mean, you can get food poisoning, which is different than classic traveler's diarrhea.
37:01
You know, in particular, we've had a lot of salmonella in patients in the hospital.
37:06
It has been a real problem. Recently here? Recently. It's not been good.
37:09
And it's not just our hospital. The hospital's around here.
37:11
Kids? Yeah, my patients, yeah, and my colleagues' patients.
37:15
So that's, you know, either that could happen in the daycare spread,
37:19
which we've seen, having frogs or reptiles, lizards, turtles.
37:25
Those are all, turtles especially are high risk for salmonella. if
37:28
you have pets like those kind of pets it's not a good idea really
37:31
when you have little kids especially and you really
37:34
have to wash your hands every time you touch that animal yes i
37:37
mean like i that's i let my kids do whatever
37:40
and i like do whatever that was one of my hard and fast rules is you're not
37:44
having those in the house you know we had a guinea pig we had a million dogs
37:47
that kind of thing but i'm like absolutely none of those because i know that
37:50
people's houses are completely covered with salmonella when they do that um
37:53
so yeah it's it's not great and historically like they had these like small,
37:59
turtles that they used to sell in pet stores and they still do illegally but
38:02
they became banned I think it was if they have less than I think it's four.
38:09
Inch shell carapace is what they call it they were banned in the US not that
38:14
people still don't sell them because kids would get them as pets and they'd
38:16
put them in their mouth and they'd get salmonellosis,
38:20
like they weren't eating it they were just putting it in their mouth because
38:22
they were like two you know and they were three whatever,
38:25
And then food, you know, the foodborne illness is not uncommon,
38:29
you know, in terms of food sanitation.
38:31
So like if there's a food truck, same thing, or a restaurant that seems like
38:34
it might not have passed inspection, you know, from the health department,
38:38
food that's sitting out too long.
38:41
You know, again, that's probably overdone sometimes. you know
38:44
just be careful with what you eat because eating out especially and
38:47
the a classic source of some of these things is like
38:50
you know like undercooked chicken or cross-contamination in
38:53
the kitchen from chicken and you know making vegetables or
38:56
something that's not cooked so really good practices in the kitchen because
38:59
most chicken has is you know has campylobacter and maybe salmonella you know
39:05
cooking your eggs well all that kind of thing and with with salmonella Is it
39:09
supportive care in the hospital? Some of these kids get antibiotics.
39:14
If you're a young infant, we give you antibiotics.
39:18
Young infants should have a lumbar puncture. If they come in with fever and
39:23
salmonella diarrhea, even if they don't have a proven positive blood culture in most cases,
39:27
those kids and then kids who do have a positive blood culture or who have extra
39:31
intestinal disease, they get an abscess in their belly, they get a salmonella in a bone or a joint.
39:36
Those kids, of course, get antibiotics. Is it an outbreak or just an increase, a slight increase?
39:41
I don't know because I feel like we don't get all the information.
39:45
Some of this, the problem is that some of these high-risk cases are happening
39:49
between different counties.
39:50
And so there's not like one unified message.
39:54
A lot of this is that the pediatric infectious disease doctors in the city have weekly conferences.
40:00
We talk about upticks in things that we've seen. We talk about cases that are
40:05
confusing and we need advice on or interesting or that are good educational cases.
40:10
So this is kind of some of where we get these little...
40:13
These little notifications or these little, you know, warnings,
40:16
I guess, of maybe there's a signal that something's going up.
40:20
So, and then, you know, I just know that I've had many cases of it recently.
40:24
Transmit it. Oh, that's a good point. Diarrhea, you go to a daycare and you're
40:27
like, you know, pooping out salmonella, people aren't washing their hands after
40:31
changing diapers, you don't wash your hands after going to the bathroom, you can transmit it.
40:36
It's not nearly as transmissible as, you know, this is something we always learn
40:39
in medical school as Shigella, which goes, you know, is rampant in daycares.
40:44
You know, like one kid gets chilla like everybody does.
40:46
Or norovirus or some of the other viruses. But it can be transmitted.
40:50
Anything else you want to say? This has all been so informative.
40:53
Talking about a lot of poop.
40:55
We're talking about poop today. Yeah, there's always poop talk. Yeah, no, that's it.
41:00
Dr. Dina Sutter with University Health and UT Health San Antonio,
41:04
head of pediatric infectious disease.
41:06
Thank you for being here today. Back on the show on Pediatrics Now.
41:10
Thanks, Holly. I appreciate it. Becoming a regular.