Disease Detective

Welcome Disease Detective! This is the world of public health where sleuthing the source of microbes is what we do. Try to determine the illness, cause, treatment and prevention before time runs out. [[Let's go and meet our first patient!-> Meet Kai]]

Kai is a 25 year old Albertan male who presents to the emergency room with diarrhea, abdominal pain, bloating and exhaustion. He has been sick for a week. To figure out what illness he might have and how he got sick we need to ask him some questions and run some tests. [[Have you travelled in the last month?]] [[Have you had contact with any animals?]] [[What type of water have you been drinking?]] [[Any meat you consumed that was undercooked or raw?]]

Kai indicates that he hasn't left the province in the last month but did go camping with some friends in Jasper National Park. [[Let's ask him more questions-> Meet Kai]] [[I know what disease he has]]

Kai has a 2 year old german shepherd and his girlfriend has a pet snake. He has had no contact with farm animals. [[Let's ask him more questions-> Meet Kai]] [[I know what disease he has]]

Kai indicates that he normally drinks the Edmonton tap water. His parents live on an acreage on well water but not sure if he visited them lately. When he was camping with some friends in Jasper National Park he drank some bottled water and some water directly from a glacial spring. [[Let's ask him more questions-> Meet Kai]] [[I know what disease he has]]

Kai ate some hotdogs that may have been undercooked while camping and some medium rare steaks on the BBQ at his parents. [[Let's ask him more questions-> Meet Kai]] [[I know what disease he has]]

Kai has [[Salmonellosis]] [[Listeriosis]] [[Shiga toxin-producing E. coli (STEC) infection]] [[Giardiasis]] [[Cryptosporidiosis]] [[Typhoid Fever]] [[Norovirus]] [[COVID-19]]

Hmmm could be, especially if he has handled his girlfriend's snake or some raw chicken. [[Do a culture and sensitivity stool sample]] <a href="https://open.alberta.ca/dataset/62b2e30a-df2e-4adb-8db4-2b169e42c5c8/resource/f4c272ea-4c4e-4130-867b-110668de3703/download/health-phdmg-salmonellosis-2021-11.pdf"; target="_blank">More Information about Salmonellosis</a>

Hmmm you could be right. Going camping can be associated with fecal contact, drinking untreated water, and poor meat handling and cooking. [[Do a culture and sensitivity stool sample]] <a href="https://open.alberta.ca/dataset/2b77e542-cfcb-4f93-b825-dca7d140e024/resource/b3c01b4a-8541-47fa-a19a-b7c3835a1cee/download/health-phdmg-escherichia-coli-verotoxigenic-infections-2021-11.pdf"; target="_blank">More Information about E.coli</a>

Hmmm what makes you suspect Giardiasis? [[Beaver Contact]] [[Consumption of Spring Water]] [[Eating Undercooked Hotdogs]] [[Going Camping]] <a href="https://open.alberta.ca/dataset/1efe9423-6c3d-4bfb-b8d8-a442fc4dea32/resource/51871608-dd4c-475c-8475-b8eaa25fc5a9/download/health-phdmg-giardiasis-2021-11.pdf"; target="_blank">Need a Hint</a>

Hmmm contaminated water can be a source of illness as well as person to person transmission. Often we see this condition in farmers as well as it is a common source of scours in cattle and sheep. [[Do an Ova and Parasite Test]] <a href="https://open.alberta.ca/dataset/baf2431b-f03b-4b71-9914-aaa09c8e10f9/resource/be2b20cc-41fb-4a1e-99aa-8efdf5db8215/download/health-phdmg-cryptosporidiosis-2021-11.pdf"; target="_blank">More Information about Cryptosporidiosis</a>

Typhoid Fever with no travel history is very unusual in Alberta. Let's review the symptoms and history again. [[ Meet Kai]] <a href="https://open.alberta.ca/dataset/d846e915-766b-4926-b665-d3febd3d42be/resource/19930030-f8b8-4061-8f45-62e3be15df50/download/health-phdmg-typhoid-fever-2021-10.pdf"; target="_blank">More Information about Typhoid Fever</a>

Hmmm it is weird for Norovirus to last for a week and vomiting is also common with norovirus. We could run a gastroviral panel to see but I think there is a more likely cause here. [[ Meet Kai]] <a href="https://www.cdc.gov/norovirus/about/index.html"; target="_blank">More Information about Norovirus</a>

Hmmm Kai has no respiratory symptoms but some people do have diarrhea or fatigue as their only symptom. [[Order a COVID-19 test]] <a href="https://www.alberta.ca/coronavirus-info-for-albertans.aspx"; target="_blank">More Information about COVID-19</a>

The test is negative. The PCR result the following day is also negative. <img src="https://upload.wikimedia.org/wikipedia/commons/thumb/8/82/COVID-19_rapid_test.jpg/450px-COVID-19_rapid_test.jpg?20201227164847"> [[ Meet Kai]] `Picture by: Lennardywlee, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons`

Despite its common name of "Beaver Fever", contact with Beavers is not a common cause. [[Giardiasis]]

Correct! Drinking surface water is always a risk for aquiring Giardiasis. Just because the water is in the forest or near a glacier does not mean it is safe to drink. [[What could he have done instead?]] [[Let's do an ova and parasite test to be sure->Do an Ova and Parasite Test]]

This is actually more common with [[Listeriosis]] [[Try again->Giardiasis]]

Yes, going camping can be a risk factor as going camping makes it more likely for the patient to engage in one of the other behaviors. [[Beaver Contact]] [[Consumption of Spring Water]] [[Eating Undercooked Hotdogs]]

Hmmm undercooked hotdogs and deli meat can be a risk but this is typically more common in those very young, old, pregnant or otherwise immunocompromised. Listeria requires a blood or CSF test in Alberta so we don't want to run this test unless we have to. [[Review the History and Try Again-> Meet Kai]] <a href="https://open.alberta.ca/dataset/f2f9a60b-a9af-4de1-9211-055aac5af6b6/resource/9dc2d4bc-f397-4e6e-8240-f30a197c49ca/download/health-phdmg-listeriosis-2021-09.pdf"; target="_blank">More Information about Listeriosis</a>

He could have chosen to: Bring bottled water Boil the spring water for 1-3 minutes depending on elevation <a href="https://www.cdc.gov/healthywater/pdf/drinking/Backcountry_Water_Treatment-508.pdf"; target="_blank">Use an effective treatment for the spring water.</a> [[Let's check on the treatment recommended by the doctor.]] [[At this point the lab result for the patient has been sent to the lab and a public health inspector will complete a full interview.]]

Stool sample is negative, let's review the symptoms and exposures again and test for something else. [[Try again-> Meet Kai]]

The test is positive for //Giardia lamblia// cysts and negative for //Cryptosporidium// oocysts. This means he has Giardiasis which is caused by the parasite //Giardia lamblia//. [[What could he have done to prevent this illness?->What could he have done instead?]] <a href="https://open.alberta.ca/dataset/1efe9423-6c3d-4bfb-b8d8-a442fc4dea32/resource/51871608-dd4c-475c-8475-b8eaa25fc5a9/download/health-phdmg-giardiasis-2021-11.pdf"; target="_blank">Learn more about Giardiasis</a>

Should the doctor give him antibiotics? [[Yes, assuming that the patient doesn't have another condition or allergy that contraindicates the antibiotics.]] [[No, antibiotics are not typically recommended unless patient is immunocompromised.]] <a href="https://open.alberta.ca/dataset/1efe9423-6c3d-4bfb-b8d8-a442fc4dea32/resource/51871608-dd4c-475c-8475-b8eaa25fc5a9/download/health-phdmg-giardiasis-2021-11.pdf"; target="_blank">Check the Notifiable Disease Manual</a>

You complete a standardized questionnaire and determine the most likely cause is indeed the consumption of untreated spring water. You provide him advice to prevent this in the future. You also learn that Kai is a chef at a local steakhouse. He indicates he has gone to work a few days while he has been sick as he doesn't have paid sick leave. Luckily none of his camping buddies became ill. There are a few more things we must do before the investigation concludes. Write or type down at least 3 and press [[NEXT]].

This is correct according to the manual. [[Let's go to the public health interview->At this point the lab result for the patient has been sent to the lab and a public health inspector will complete a full interview.]]

This is incorrect according to the manual, but is the recommendation for other enteric illnesses. It is important for physicians to consult the notifiable disease manual or other best practice documents when considering treatment. [[Let's go to the public health interview->At this point the lab result for the patient has been sent to the lab and a public health inspector will complete a full interview.]]

These are the next actions we must or should consider taking [[Consult Medical Officer of Health about an exclusion from work as a chef.]] [[Let Medical Officer of Health (MOH) and local Public Health Inspector (PHI) Team know of the potential exposure of Giardia to patrons of the steakhouse.]] [[Have the local PHI complete an inspection of the restaurant and/or speak to restaurant owner about workplace illness policies]] [[Complete the electronic CD/OM entry to report the disease incident to Alberta Health]] When you have taken all the above actions click [[END]]

The MOH agrees that an exclusion should be provided given the patient already went to work while ill. You fill out the exclusion form and send it to the MOH office for processing. You provide a verbal exclusion to the client and the restaurant owner. (link: "When can the exclusion be lifted assuming the MOH follows the Notifiable Disease Manual?")[Once Kai is over 48 hours symptom free without use of anti-diarrheals for over 48 hours AND has completed his antibiotics for over 48 hours.] [[NEXT]]

The Disease Control Coordinator will monitor for further cases with exposures to the local steakhouse and declare an outbreak if further cases emerge. [[NEXT]]

The local PHI found no other food safety concerns during the inspection and is working with the restaurant owner to update the illness policy. [[NEXT]]

Excellent work. This will help to inform further provincial public health actions for this disease and allow for survaillance. [[NEXT]]

Great work disease detective! You Prevented further people from getting sick. Diagnosed the illness. Provided appropriate treatment. Educated Kai on how to avoid the illness in the future. Thank you for your support of public health! <img src="https://upload.wikimedia.org/wikipedia/commons/e/e6/THIS_IS_PUBLIC_HEALTH.jpg"> Image Attribution: Pete Fecteau, CC0, via Wikimedia Commons