illness evaluationcdc emergency preparedness 出疹性疾病的评价 cdc应急准备课件

RashIllnessEvaluation DepartmentofHealthandHumanServicesCentersforDiseaseControlandPreventionDecember2002 RashIllnessEvaluation LearningObjectives DescribehowtousetheDiagnosticAlgorithmDiscussCDC sexperiencewiththeuseoftheAlgorithm NeedforaDiagnosticAlgorithm Nonaturallyacquiredsmallpoxcasessince1977 however concernaboutuseofsmallpoxvirusasabioterroristagentRecommencingsmallpoxvaccinationintheUnitedStatesislikelytoheightenconcernsaboutgeneralizedvesicularorpustularrashillnesses NeedforaDiagnosticAlgorithm PublichealthcontrolstrategyrequiresearlyrecognitionofsmallpoxcaseClinicianslackexperiencewithsmallpoxdiagnosisOtherrashillnessesmaybeconfusedwithsmallpox 1 0millioncasesvaricella U S thisyearandmillionsofcasesofotherrashillnessesIf1 1000varicellacasesismisdiagnosed 1000falsealarmsNeedstrategywithhighspecificitytodetectthefirstcaseofsmallpoxNeedstrategytominimizelaboratorytestingforsmallpox riskoffalsepositives NeedforaDiagnosticAlgorithm Assumptions Limitations Firstcaseofsmallpoxmaynotbediagnoseduntilday4 5ofrashFirstcaseofsmallpoxmaynotbediagnosedearlyifitpresentsatypicallyHemorrhagicFlat velvetyHighlymodified SmallpoxDisease IncubationPeriod 7 17daysPre eruptiveStage Prodrome feverandsystemiccomplaints1 4daysbeforerashonset SmallpoxDisease RashstageMaculesPapulesVesiclesPustulesCrusts scabs Scars Smallpox Day2ofRash Smallpox Day4ofRash SmallpoxRashVesiclesPustules Day4and5 Days7 11 ClassicSmallpoxLesions Pustules RashDistribution DifferentialDiagnosis Varicellaisthediseasemostlikelytobeconfusedwithsmallpox DifferentiatingFeatures Varicella NoormildprodromeNohistoryofvaricellaorvaricellavaccinationSuperficiallesions dewdroponarosepetal Lesionsappearincrops DifferentiatingFeatures Varicella LesionsinDIFFERENTstagesofdevelopmentRapidevolutionoflesionsCentripetal central distributionLesionsrarelyonpalmsorsolesPatientrarelytoxicormoribund Varicella VaricellaAdultCase Varicella InfectedLesions DifferentialDiagnosis DisseminatedherpeszosterImpetigoDrugeruptionsContactdermatitisErythemamultiforme DifferentialDiagnosis Enteroviralinfections especiallyHand FootandMouth DisseminatedherpessimplexScabies insectbitesMolluscumcontagiosum inimmunocompromised DifferentialDiagnosis RaredermatologicalconditionsAcneSecondarysyphilisRickettsialdiseasesSmallpoxvaccine relatedrashes Goal RashIllnessAlgorithm SystematicapproachtoevaluationofcasesoffebrilevesicularorpustularrashillnessClassifycasesofvesicular pustularrashillnessintoriskcategories likelihoodofbeingsmallpox accordingtomajorandminorcriteriadevelopedforsmallpoxaccordingtotheclinicalfeaturesofthedisease InvestigationTools Availablethroughstatehealthdepartmentsandatwww cdc gov smallpoxRashalgorithmposterHealthcareproviderslinktoviewandprintposterProtocol writtenguideforuseofposter Filecanbedownloadedandprinted InvestigationTools CaseinvestigationworksheetforinvestigationoffebrilevesicularorpustularrashillnessesQuestionsonprodromalsymptoms clinicalprogressionofillness historyofvaricella vaccinationsforsmallpoxandvaricella exposures labtestingWorksheetcanbedownloadedandprintedfromwww cdc gov smallpox SmallpoxSurveillanceClinicalCaseDefinition Anillnesswithacuteonsetoffever 101oFfollowedbyarashcharacterizedbyfirm deep seatedvesiclesorpustulesinthesamestageofdevelopmentwithoutotherapparentcause Smallpox MajorCriteria Prodrome 1 4daysbeforerashonset Fever 101oF 38 3oC and 1symptom prostration headache backache chills vomiting abdominalpainClassicsmallpoxlesionsFirm round deep seatedpustulesAlllesionsinsamestageofdevelopment ononepartofthebody Smallpox MinorCriteria Centrifugal distal distributionFirstlesions oralmucosa face orforearmsPatienttoxicormoribundSlowevolution eachstage1 2days Lesionsonpalmsandsoles EvaluatingPatientsforSmallpox ImmediateActionforPatientwithGeneralizedVesicularorPustularRashIllness AirborneandcontactprecautionsinstitutedInfectioncontrolteamalertedAssessillnessforsmallpoxrisk HighRisk All3MajorCriteria Prodrome 1 4daysbeforerashonset ClassicsmallpoxlesionsAlllesionsinsamestageofdevelopment ononepartofthebody Response HighRiskCase Infectiousdiseases andpossiblydermatology consulttoconfirmhighriskstatusAlerthealthdepartmentDigitalphotosAlertCDCrash illnessresponseteamspecimencollectionmanagementadvicelaboratorytestingatCDC ModerateRisk ProdromeAND1othermajorcriteriaORProdromeAND 4MINORsmallpoxcriteria Response ModerateRiskCase Infectiousdiseases andpossiblydermatology consultLaboratorytestingforvaricellaandotherdiseasesSkinbiopsyDigitalphotosRe evaluaterisklevelatleastdaily LowRisk NofebrileprodromeORFebrileprodromeAND 4MINORsmallpoxcriteria Response LowRiskCase Patientmanagementandlaboratorytestingasclinicallyindicated SmallpoxPre eventSurveillance Goal torecognizethefirstcaseofsmallpoxearlywithout GeneratinglargenumberoffalsealarmsthroughconductinglabtestingforsmallpoxcasesthatdonotfitthecasedefinitionDisruptingthehealthcareandpublichealthsystemsIncreasingpublicanxiety CDCRashIllnessResponseTeamExperiencewithUseofAlgorithm 23callstoCDCJanuary1 November30 200214statesandNewYorkCity17adultsand6childrenSmallpoxriskclassification Highrisk 0 NoindicationsforvariolavirustestingModeraterisk 4Lowrisk 19 CDCRashResponseTeamExperiencewithUseofAlgorithm 50 ofthecasesincluding2deathshavebeenvaricella12diagnosesconfirmedbylaband orpathology 11clinicallydiagnosedOtherdiagnoses drugreactionerythemamultiformedisseminatedherpeszosterdisseminatedHSV2contactdermatitisotherdermatologicaldisorders ExperiencewithImplementationofRashAlgorithm RuleinVaricellaZosterVirus VZV Algorithmhaslimitedvariolatestingbystandardapproachtoevaluation DifferentialDiagnosis LessonsfromthePast GeneralizedRashesfollowingSmallpoxVaccination GeneralizedVaccinia Uncommon rate 240permillionprimaryvaccineesfrom10statesurveyOccurs6to9daysfollowingvaccinationLesionsusuallysmallandsuperficial maturemorerapidlythansmallpoxlesionsandmorelikelytobeconfusedwithmodifiedsmallpoxRashdistributionisindiscriminate followsnosetpattern Historyofrecentvacciniavaccination GeneralizedRashesfollowingSmallpoxVaccination EczemaVaccinatum Rarebutlife threateningcomplicationofsmallpoxvaccinationMayoccurinvaccineeorinaclosecontact5 19daysfollowingvaccination40permillionprimaryvaccinees 10statesurvey GeneralizedRashesfollowingSmallpoxVaccination EczemaVaccinatum 10 20casesincontactspermillionprimaryvaccinees Neff JAMA 2002 Distributionisnotcentrifugal lesionsusuallycommenceinabnormalareasofskinandthenspreadHistoryofvaccinationorcontactwithavaccinee LaboratoryandPathologySupportforRashIllnessEvaluation Assessavailabilityoflaboratoryand orpathologytestinglocally hospitalandprivatelabs especiallyTzancksmearandskinbiopsyContactStatehealthdepartmentforothertesting VZVrapidtests pathologyDFAPCRTzancksmear alphaherpesvirusinfection ElectronmicroscopyPoxvirusHerpesvirusOthervirusesHSV1andHSV2TzancksmearPCRandculture LaboratoryandPathologySupportforRashIllnessEvaluation VacciniaPCR ifvaccinated Othertestsasclinicallyindicated Syphilis enterovirus rickettsia staph strep molluscumcontagiosum scabies LaboratoryandPathologySupportforRashIllnessEvaluation RashIllnessEvaluationTechnicalSupport Statehealthdepartments24houremergencyphonenumberLaboratoryandpathologytesting VZV otherInfectiousdisease d