Comprehensive Infectious Disease Consultants: Dr. Aaron M. Shelub, MD

Influenza Influenza (flu) is a potentially life threatening illness. It is a contagious disease of the respiratory tract caused by influenza viruses. Each year, influenza causes serious infection and death around the globe, usually in the winter months (seasonal influenza). Due to some pre-existing immunity to the seasonal strains of influenza, most people only suffer a self-limiting illness, lasting from a few days to several weeks. Influenza can lead to complications and for some people - the elderly, people with poor immune systems and people with pre-existing respiratory, cardiac and endocrine disease—influenza can be a significant disease and cause death. It can also cause the death of healthy adults and children. Three different types of influenza viruses infect humans - types A, B and C. Only influenza A and B cause major outbreaks and severe disease. They are included in seasonal influenza vaccines. Influenza C causes a common cold-like illness in children. Only influenza A is known to have been responsible for influenza pandemics. Influenza A and B viruses have two main proteins on the outside of the virus: the haemagglutinin (H); and the neuraminidase (N) proteins. These proteins are referred to as ‘antigens’ because they are the structures to which our immune system responds. New strains of influenza A and B continually emerge because of the tendency of these H and N antigens to change. Of the influenza A viruses, only subtypes H1, H2 and H3 have been transmitted easily between humans. Only the H1 and H3 subtypes are currently circulating causing seasonal influenza in humans. While influenza B is essentially a human disease, influenza A viruses are found in many species. Influenza A occurs as distinct forms or subtypes based principally on their haemagglutinin antigen, of which there are 16 different versions. Water birds are the natural host of influenza A viruses. From time to time influenza A viruses have, however, successfully jumped the species barrier and have become established in other animals, including humans. Valler Fever Valley fever, also known as coccidioidomycosis, is a type of fungal infection caused by Coccidioides immitis. It enters the lungs when you inhale the fungus from soil in which it is present. This fungus is typically found in desert areas of the southwestern United States and parts of Central and South America. Your risk of acquiring valley fever increases if you are traveling to these destinations or if you have been receiving cancer treatment, have HIV or diabetes, have undergone an organ transplant or if you are pregnant. Some people who contract valley fever have no symptoms, while others develop symptoms similar to a cold, the flu or even pneumonia. Symptoms, such as leg swelling, chest pain, coughing, fever, headaches, joint stiffness, loss of appetite and muscle aches, generally begin between five and 21 days after fungal exposure. If the infection spreads beyond the lungs to the bloodstream, skin, bones, lymph nodes or central nervous system, the patient may become very ill. Symptoms can include join swelling, severe lung difficulties, weight loss, change in mental function and sensitivity to light. To diagnose valley fever, a chest X-ray, blood test and sputum culture may be performed. To determine whether the infection has spread, a biopsy, spinal tap or bronchoscopy is sometimes needed. Treatment for the milder form of the condition often revolves around bed rest and over-the-counter medication to relieve discomfort. In those with a compromised immune system, antifungal treatment is usually necessary. The most extreme cases may require surgery to remove the infected portion of the lung. MRSA MRSA (Methicillin-Resistant Staphylococcus Aureus) infection, sometimes referred to as the “superbug,” occurs as a result of a staph infection that has become resistant to the antibiotics typically used to treat such infections. While MRSA most commonly affects people in healthcare-related environments, it can also affect healthy people, spreading through skin contact with an infected person. As with most staph infections, the earliest symptom of MRSA is small red bumps appearing on the skin. If left untreated, these bumps can become painful, eventually requiring surgical drainage to clear the bacteria. To prevent life-threatening complications, seek medical attention for any persistent skin conditions, as they may be a sign of MRSA. To diagnose MRSA, tissue samples and/or nasal secretions are studied in a microbiology lab to determine their resistance to antibiotics. Treatment for MRSA varies; some cases of MRSA may be treated with medications, while others may require surgical drainage of any abscesses on the skin. A personalized treatment plan will be developed based on each patient’s individual condition.

Human Immunodeficiency Virus (HIV) is a sexually transmitted retrovirus that targets vital cells of the immune system. As infection progresses and accelerates, afflicted patients lose their ability to fight off infections from pathogens that are not a problem for healthy immune systems. Once a patient's immune system cell count reaches a critical level (CD4+ count of less than 200 per micro liter), the person is considered to have Acquired Immune Deficiency Syndrome (AIDS). Symptoms of HIV can vary significantly, depending on the severity and phase of the infection, as well as the patient's overall health. In its early stages, patients may not experience any symptoms from this infection, or may notice signs similar to those of the flu, including a fever, headache, sore throat and swollen lymph glands. Further symptoms may not present themselves for as long as eight or nine years, while the virus continues to spread throughout the body with patients often unaware that they are infected. During this time, you may experience minor infections or chronic symptoms of diarrhea, weight loss, fever and cough. During the final stages of infection, which usually occurs 10 years or longer after the initial exposure, this condition usually transitions into AIDS, at which point patients may experience: Night sweats Shaking chills High fevers Chronic diarrhea White spots or lesions in the mouth Weight loss Blurred vision While there is no cure for this infection, there are several effective medications to slow the progression of the disease, strengthen the immune system and help patients maintain their quality of life with minimal side effects. Most patients are treated with Highly Active Antiretroviral Therapy (HAART), which slows the activity of HIV and promotes healthy immune system function. Treatment with HAART usually combines three or more antiretroviral agents that are taken on a regular basis throughout the patient's life. Dr. Shelub will develop a personalized treatment plan for you based on your individual condition and overall health. We strive to remain on the cutting edge of treatment and offer patients the latest and most advanced medications as they become available.

All good hospitals are continuously seeking effective ways to improve the quality of care for their patients. This can be achieved through a combination of obtaining the best results for each patient, preventing any complications that are due to human error and providing comprehensive care and focus to every patient. To be truly successful, all of this needs to be accomplished in a cost-effective way and every step of the process should be documented. Infectious disease specialists team up with other health care professionals to create standards that hospitals can use to prevent and manage infections within the facility. Administrators can enforce policies developed as a result of these evidence-based practices that will work to protect not only patients, but staff members and the community at large. Hospital quality assurance is not meant to be a process that inserts an outside authority that will hinder the decision-making capabilities of either administrators or physicians. Neither is it intended to take the time and attention away from any health care staff member’s primary responsibility of healing and caring for patients in the facility. There are a number of categories that comprise quality assurance in a hospital setting. These include: Earning and maintaining accreditation through a medical governing organization such as the Joint Commission. Performing regular clinical audits, which focus on the collection of data having to do with compliance with quality standards that have been put into place. These reports provide information on performance and fulfillment of these standards as well as assess patient outcomes. Conducting mortality and morbidity reviews, which are structured examinations of cases that resulted in illness or the death of a patient. These reviews are designed to help healthcare professionals gain a greater understanding of problems that occur in order to improve the overall quality of care moving forward. Employing a system that measures patient safety indicators. The Agency for Healthcare Research and Quality, which is part of the Department of Health and Human Services, provides a software program designed to help administrators understand safety issues and areas of vulnerability within their hospitals. When patient data is input into a patient safety indicator, the program can identify preventable mistakes and departures from safe care measures taking place. Requiring Continuing Medical Education (CME) credits be obtained by health care professionals on staff. The most committed of professionals recognize the importance of continually learning about the latest practices and advances in their field of medicine. Following infection protocols. Healthcare-associated infections are the most common complication for hospital patients. In the United States alone, they are the cause of 1.7 million infections and nearly 100,000 deaths annually. Practices should be adopted in every hospital to address the health care staff’s habits including impeccable hand hygiene and other infection safety standards that aid in preventing patient infections. Observing external quality controls designed and implemented to assess performance and determine just how well the patient safety system is working within the hospital. Emphasizing ethics in all work practices. Hospital ethics committees and training programs can provide advice and assistance to all healthcare personnel on legal responsibilities as well as ethical concerns and decision making in the hospital setting. Antimicrobial stewardship is another important factor in hospital quality assurance. This refers to efforts made to coordinate and optimize the use of antimicrobials. These extremely valuable medications have been less effective in some cases lately because of growing antimicrobial resistance. When antimicrobial stewards facilitate programs in healthcare facilities, the use of antimicrobials can be managed most successfully, with patient outcomes improving and adverse events reduced. What Patients Can Do In any healthcare situation, but especially when admitted as a patient to a hospital, people can also help the process along and ensure the likelihood of their own safety. Some of the most important ways patients can protect themselves are: Checking that your admittance wristband contains all correct information. Ask questions about the care you are receiving or the procedure you will be undergoing. Take notes and bring along a friend or relative if you are concerned that you might not understand everything fully. Request complete disclosure about any surgical procedure recommended, including potential risks and complications. Inform all of your healthcare providers about medications you are taking as well as allergies you have. Determine the best course of treatment by getting a second opinion. Maintain your own copy of your health history to ensure accuracy.

Twinrix Hepatitis A Hepatitis B Japanese Encephalitis MMR Meningitis Pneumonia Polio Injection Immune Globulin Boostrix PPD Placement Rabies IM Gardasil Zostavax Haemophilus B Diphtheria & Tetanus (dT) Typhoid Varicella Yellow Fever DT Tet Diptox Influenza Twinrix Twinrix is a vaccine that provides protection against both hepatitis A and hepatitis B. It may be used for children at least one year old, adolescents and adults. Hepatitis A Vaccination for hepatitis A is recommended for all children and adults at risk for infection by this highly contagious virus that causes liver inflammation. Hepatitis B Vaccination for hepatitis B is a routine immunization for children and recommended for adults at risk for infection, especially those traveling to contaminated destinations. Japanese Encephalitis Japanese encephalitis is a serious viral infection found mostly in rural areas of Asia and spread by mosquito bites. This vaccine is recommended for travelers who will be spending time anywhere the disease is common. MMR The MMR vaccine is an immunization against measles, mumps and rubella. It is recommended for children in two doses between 12 and 15 months old and 4 to 6 years old as well as for adults born before 1956 if they have received only one dose. Meningitis Meningitis is a serious brain infection that is most common between the ages of 16 and 21. The vaccine is recommended for children 11 to 12 years old, with a booster dose at 16. Pneumonia Pneumonia is a common disease that may be fatal in children, older adults and people with weakened immune systems. The vaccine is recommended for children under the age of 5 as well as for anyone at high risk, including those over 65, people with immunocompromising conditions or asthma sufferers. Polio Injection Immunization from polio, a viral infection that can cause paralysis, typically takes place during childhood, with doses provided at 2 months, 4 months, 6 to 18 months and 4 to 6 years old. Adults traveling to places where polio is active should receive a precautionary booster dose. Immune Globulin Immune globulin is developed from human blood plasma and used for protection after exposure to several contagious diseases. It may also be used to safeguard a fetus in Rh sensitive women or for those with an autoimmune disease. Menactra Menactra is a vaccine that can protect against meningitis. It is given as a two-dose series, three months apart, to children as young as 9 months old. Boostrix Boostrix is a single-dose vaccine used to prevent tetanus, diphtheria and pertussis in people 65 and over. PPD Placement Purified protein derivative (PPD) is a form of skin testing used to diagnose tuberculosis when no symptoms are present. Rabies IM Rabies IM is a vaccine to prevent the development of rabies after exposure has occurred, usually following an animal bite. Gardasil Females between the ages of 11 and 26 may receive Gardasil for protection from human papillomavius (HPV), which causes genital warts and may lead to cancer. Gardasil can also be administered to males to protect against genital warts. Zostavax Shingles is a rash caused by the varicella-zoster virus, which is responsible for chickenpox. Zostavax vaccine is a single-dose injection that can help prevent shingles in adults over the age of 50. Haemophilus B Haemophilus influenzae type b (Hib) is a bacterial disease that can cause meningitis, pneumonia and other serious infections. Vaccination is recommended for children at 2 months, 4 months, 6 months and 12 to 15 months old, as well as for older individuals with immune-compromising conditions. Diphtheria & Tetanus (DT) The dT vaccine protects against diphtheria and tetanus and is recommended for children younger than 7. It is an alternative to the DTaP vaccine with no immunization against pertussis. Typhoid Typhoid vaccination is necessary for visitors to a country where typhoid commonly occurs. Vaccination should take place at least one week prior to travel. Varicella Chickenpox is caused by the varicella-zoster virus and is highly contagious. Vaccination is given between the ages of 12 and 15 months, but older children and adults who have never contracted chickenpox can be vaccinated as well. Yellow Fever Yellow fever is a potentially fatal disease transmitted by mosquito bites and common in parts of Africa and South America. Yellow fever vaccine should be received 10 days prior to travel in high-risk areas. DT Tet Diptox DT Tet Diptox is a tetanus-diphtheria vaccine for adolescents and adults. It can be used as a booster shot every 10 years or after exposure to tetanus.

Telemedicine makes use of technology and electronic communications to exchange medical information remotely for the use in patient care. The technologies utilized may be standard telephones, high-speed Internet access on computers, satellites, fiber optics and other devices and software. It allows for a broad array of health-related services that includes patient portals and other forms of e-health, video conferencing, nursing call centers, vital sign monitoring from another site, transmitting diagnostic images and continuing medical education courses. Telemedicine is used to expand and broaden healthcare options in a number of different ways. Some of the most commonly employed applications of telemedicine are: Specialist referrals. An internist or another general practitioner may use telemedicine to consult with a specialist on a case. This might be conducted as a remote exam in which the physician visit takes place over a live video feed or by electronically providing the specialist with images and medical information on the patient for review at a later point. Many doctors have begun to use telemedicine in this respect to gain access to the knowledge and experience of top experts in all of the various specialties and subspecialties of medicine. Patient appointments. In areas where healthcare is not easily accessible or a patient is not readily mobile, telemedicine can provide an essential basic service. Video feeds, images and audio links can all be used to give a healthcare provider the necessary information to make a diagnosis and formulate an appropriate treatment plan. Patient monitoring. Medical equipment provided to patients requiring home health care can be programmed to not only collect but transmit data to a facility. This enables healthcare professionals to interpret and analyze the status of the patient’s health and assess any changes that have taken place. It may be used for fetal monitoring in pregnant patients and to check glucose levels, vital signs, heart rate and other gauges of health. Continuing medical education. Physicians can keep abreast of the latest advances in their field of specialty by taking online courses and participating in video seminars designed to enhance their medical expertise. Patient health knowledge. Any individual can increase his or her awareness of any medical topic by visiting a reputable health-related website on the Internet. There are also very good forums people can visit online to become involved in ongoing discussions on specific health subjects and find out about support groups. The benefits to patients from telemedicine are myriad. Patients can remain at home to receive the care and support of local relatives and friends. They will save money by not having to travel to see a top specialist for their particular condition. In addition, care can be provided instantly in urgent cases. An earlier diagnosis may be made when the patient does not have to wait for an appointment. Finally, patients can use telemedicine to arm themselves with knowledge that will bolster their treatment and improve their health. The Growing Field Of Telemedicine As the population ages, thanks in large part to the number of baby boomers, there is a greater need for more medical care at a lower cost to the healthcare system. Processes such as telemedicine can provide expert patient care, often for much less of an expense. For example, using medical monitoring devices in a home care situation is more cost effective than having home health care workers come to the location every day. And monitoring can be performed whenever necessary, not just when a health worker is on duty. Telemedicine can also be used to reduce the number of hospital visits and admissions in many cases. Patients will easily be able to find out if a symptom such as a chronic sore throat is just a sign of a cold or allergies or if it is indicative of something more serious that requires testing simply through a convenient, video-based appointment. There are a number of telemedicine terms with which patients should become familiar as eventually, most people will likely be receiving some medical care in this manner. The hub site, or distant site, is the location where the physician is providing the healthcare service. The originating site, or spoke site, is the place where the patient is while receiving the service. A “store and forward” is a method of transferring data for telemedicine use from one site to another. A recording device stores the image or information, then some form of telecommunication is utilized to forward the data on to the appropriate site.

International travel is an exciting prospect, especially if you are visiting a place you have never been before. However, there are health issues that may be present in some foreign destinations that we do not commonly face in the United States. For that reason, it is essential to seek pre-travel health advice from a physician who is an infectious disease specialist in order to ensure that you take all necessary medical preparations before your trip. SHELUB CDC HEALTH CARE PROFESSIONAL TRAVEL LECTURE Detailed Itinerary The more information you can provide your doctor with about the specifics of your destinations, the better your chances are of remaining healthy during the trip. Specifics About Your Travel Should Include: all of the cities or villages you will be visiting in a particular country any planned excursions taking place within the trip the length of the visit the type of accommodations or lodging means of travel activities in which you expect to participate time of year, since certain diseases are more prevalent during rainy season or hot weather Armed with knowledge, your physician can tailor a prophylactic medical plan designed to protect you from known health-related concerns in your region of travel. Advance Planning Some foreign destinations require more precautions than others. It is ideal to have an initial consultation with your doctor four to six weeks before your travel is scheduled to occur. This will provide enough time to receive any necessary immunizations or medications as well as documentation of these if necessary to the travel. Your doctor can also offer instructions for the prevention and treatment of illnesses common to travelers to the location you are visiting, such as diarrhea and conditions spread by insect bites. By checking your medical history, your doctor can determine whether you are up-to-date on all routine vaccinations, such as polio and measles/mumps/rubella, which should be current before traveling to a country in which these diseases may be communicable. Depending upon the destination you are visiting, other immunizations might be recommended as well. For certain countries where malaria is present, pre-treatment with anti-malarial medications can be very helpful in preventing infection. Traveler’s Diarrhea The most frequently occurring malady among visitors to other nations is traveler’s diarrhea. Caused by exposure to bacteria, viruses or parasites, this illness is especially common for visitors to less developed countries. Loose stools are often accompanied by fever, nausea, cramps and/or vomiting. Many patients with traveler’s diarrhea are forced to spend several days in during the trip because they are too sick to participate in normal activities. Your doctor can give you specific information for avoiding traveler’s diarrhea based on the destination you will be visiting. In general, though, safety precautions include eating only fruits and vegetables you can peel yourself, opting for dry food items and consuming only cooked foods that are served thoroughly cooked and very hot. Stay away from tap water, juices, ice cubes, salads, unpasteurized dairy products and any reheated food. You cannot be vaccinated against traveler’s diarrhea and prophylactic prescription drugs are rarely necessary. Hydration is important if you do acquire this illness and your doctor can recommend which over-the-counter medications are most effective so you can bring them with you as a precaution. Insect-Carried Illnesses There are numerous diseases that can be transmitted by an insect bite during a foreign trip. They are often serious illnesses, including malaria, dengue fever, yellow fever and tick-borne encephalitis. Insect repellent is typically the most effective method of prevention for the majority of these conditions. Use a repellent containing Diethyltoluamide (deet) in a 30 percent concentration for adults and a 10 percent concentration for children to receive the maximum protection safely. Apply it directly to exposed skin, but wash it off as soon as your risk of exposure to insects has decreased. In addition, clothing and bed-netting treated with permethrin can help you avoid getting bitten by an insect. After The Trip Prior to the journey, your physician will provide you with information on symptoms of many travel-related illnesses to help make you aware of whether to seek medical assistance during or after the trip. If you return home and you are not feeling well, it is essential to schedule an appointment with your doctor. Some of the diseases prevalent in foreign countries have longer incubation periods with no signs showing up until days, weeks or even months after the travel has ended.