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Kopper og andre poxviridae-infeksjoner – veileder for helsepersonell.
Kopper er en svært smittsom og alvorlig sykdom som forårsakes av koppeviruset (variolaviruset). Verdens helseorganisasjon erklærte i 1980 at kopper var utryddet. Andre virus i samme familie, f.eks apekoppeviruset kan gi liknende, men mindre alvorlige infeksjoner.
INNHOLD PÅ DENNE SIDEN
Familien poxviridae omfatter de største virus vi kjenner og det viktigste viruset i denne familien er variolavirus (koppevirus), kukoppevirus og apekoppevirus som tilhører slekten ortopoxvirus, orfvirus som tilhører slekten parapoxvirus og molloscum contagiosum-virus som tilhører slekten molluscipoxvirus.
Om kopper
Kopper var en svært smittsom sykdom som forårsakes av koppeviruset, Variola viruset. Viruset har bare én serotype og mennesket var eneste reservoar. Verdens helseorganisasjon erklærte i mai 1980 at kopper var utryddet. Viruset finnes fortsatt i to offisielle lagre i USA og Russland, under WHO-kontroll. Det er frykt for at virus kan finnes illegalt andre steder og kan benyttes ved bioterrorisme.
Historisk bakgrunn
Koppersykdom ble beskrevet allerede i oldtiden i Asia og Egypt, og man antar at sykdommen kom til Europa på 500-700 tallet med gjentatte epidemier i middelalderen. Sykdommen ble spredt til det amerikanske kontinent og Afrika på 1500-tallet med dødelighet opptil 90% hos den mottagelige urbefolkningen. Europa ble særlig hardt rammet på 1700-tallet, særlig barn. Variolisering (dvs. poding av materiale fra et lett tilfelle av kopper) kom til Europa i begynnelsen av 1700-tallet, men ble erstattet av vaksinasjon med kukoppevirus fra 1796. I 1906 ble det påvist at kopper skyldes et virus. Etter annen verdenskrig var kopper stort sett begrenset til områder i Afrika og Asia. Enkelte tilfeller ble på 1950- og 1960-tallet importert til Europa og ga opphav til små utbrudd. Siste store utbrudd i Europa var i daværende Jugoslavia i 1972. Under dette utbruddet, hvor 172 personer ble syke og hvorav 35 døde, ble over 10 000 personer isolert og nærmere 20 millioner vaksinert. Siste utbrudd i Norden var i Stockholmsområdet i 1963 med 27 tilfeller. Det siste naturlig smittede tilfellet ble registrert i Somalia i 1977. I 1978 ble det diagnostisert to tilfeller av kopper i Storbritannia hvor smitten var overført i et laboratorium som arbeidet med koppeviruset.
Norge
Kopper kom til Norge antagelig på 800-tallet med etterfølgende epidemier i hele middelalderen. På 1700- og 1800-tallet var det flere alvorlige koppeepidemier i Norge, særlig i Bergen. I 1741 døde over 700 barn av kopper bare i Bergen. I 1819 var det et større utbrudd i Kristiania som medførte at tusen mennesker ble vaksinert. Siste innenlandske utbrudd av kopper var i Kristiania 1908-09 med 246 tilfeller. Det folkelige navnet på sykdommen var bolo. Betegnelsen pokker, som egentlig var et navn på syfilis, ble også brukt, men etter hvert skilte man dem ved å omtale kopper som småpokker. Variolisering ble utført første gang i 1755 i Trondheim og Bergen. Den første koppevaksinasjon i Norge ble foretatt i Kristiania i 1803. En forordning fra 1810 gjorde det påbudt med vaksinasjon før barn ble konfirmert. Utover på 1800-tallet måtte man i Norge vise koppvaksinasjonsattest for å få gå på skole, konfirmere seg og for å gifte seg. Vaksinasjonspåbudet ble fornyet i 1954 til å gjelde alle barn før fylte to år. Dette påbudet gjaldt fram til 1976. De siste vaksinasjoner i Norge ble utført i 1980. I de siste årene vaksinasjon var påbudt, døde det i Norge 1-2 barn årlig av alvorlige vaksinasjonskomplikasjoner. Siste tilfelle i Norden var i 1970 hos en norsk student som ble smittet i Afghanistan og døde i København. Oppfølging av hans kontakter medførte den siste store koppesmitteoppsporing i Norge uten at man påviste sekundærtilfeller.
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Om apekopper
Apekopper (monkeypox) gir liknende sykdomsbilde som kopper, men sykdommen er betydelig mindre smittsom og gir langt lavere dødelighet enn kopper. Apekopper er det mest utbredte orthopoxviruset hos mennesker etter at kopper ble utryddet. Sykdommen er mest utbredt i Den demokratiske republikken Kongo, men har også spredt seg til multiple land i sentrale Afrika. I Vest-Afrika har det vært sporadiske tilfeller i flere land, og det var et stort utbrudd i Nigeria i 2017-2018. Det har vært tre tilfeller av importsmitte til UK, i hhv 2018, 2019 og 2021. tillegg ble en helsearbeider i Storbritannia smittet ved pleie av ett av tilfellene før apekoppediagnosen ble stilt. I USA har det også vært flere importtilfeller. I 2003 var det et utbrudd i USA med 47 bekreftede tilfeller etter import av smittede gnagere fra Ghana, som smittet videre til præriehunder holdt som kjæledyr, som igjen smittet videre til mennesker. Noen land i Asia har også hatt enkelte importtilfeller.
Apekoppeviruset ble isolert første gang i 1959 ved et utbrudd av sykdommen hos aper brukt i forskning. De første tilfeller blant mennesker ble identifisert i Demokratiske republikk Kongo i 1970. Viruset smitter ved kontakt med infiserte dyr (gnagere og primater), men kan også smitte mellom mennesker. Det viktigste, kjente reservoaret for viruset i Afrika er gnagere, ekorn og primater. Sykdommen er ikke meldingspliktig til MSIS.
Sykdommen er vanligvis mild, og de fleste smittede vil bli friske uten behandling i løpet av noen uker. Noen vil utvikle hudarr.
Om kukopper
Kukopper er primært en sykdom hos dyr. På tross av navnet, er viruset ikke endemisk hos storfe, og gnagere er sannsynligvis reservoar for viruset. Katter som smittes av gnagere er den vanligste kilde for smitte til mennesker som kan utvikle hudsår. Kukoppevirusinfeksjon forløper som en koppevaksinasjon hos mennesket. Kukopper forekommer sjeldent i Norge, siste humane tilfellet var i 1994. Det rapporteres jevnlig enkelttilfeller i Europa. Vaksinen som har vært mot kopper ble laget av et beslektet kukoppevirus (vacciniavirus). Kukopper smitter ikke fra person til person. Ikke meldingspliktig til MSIS.
Om pseudokukopper (melkerknuter)
Pseudokukopper er en sykdom hos kyr og forårsakes av et poxvirus som er ulikt kukoppevirus og vacciniavirus. Viruset kan smitte fra kyr til mennesker gjennom melking og gir vorteliknende knuter på hendene som tilheles spontant i løpet av 4-8 uker. Melkerknuter smitter ikke fra person til person. Ikke meldingspliktig til MSIS.
Om orfvirussykdom (sauekopper)
Orf (også kalt munnskurv) er en hudsykdom hos sau og geit, men kan smitte til mennesker ved kontakt med disse, ofte i forbindelse med slakting. Munnskurv er utbredt blant småfe. Sykdom hos mennesker kalles vanligvis sauekopper. Inkubasjonstid er 3-6 dager. Pustler utvikles på kontaktpunktene, vanligvis underarm eller hender, sjeldnere i ansiktet. De granulomatøse sårene tilheles spontant etter noen uker. Årlig diagnostiseres 20-30 tilfeller hos mennesker i Norge. Sauekopper smitter ikke fra person til person. Ikke meldingspliktig til MSIS.
Om molluscum contagiosum
Mollusker er en benign epidermal tumor (opptil 10 med mer) som skyldes hypertrofi av epidermis. Mennesker er eneste reservoar for molluscum contagiosum-viruset. Inkubasjonstiden er 2-8 uker. Mollusker er vanligst hos barn, men kan forekomme i alle aldre. Mollusker opptrer til enhver tid hos ca. 10% av barn. Smitten skjer ved direkte kroppskontakt (også seksuell) eller indirekte kontakt gjennom f.eks. håndklær. Hos barn forekommer mollusker spesielt i ansiktet, hos eldre ofte rundt kjønnsorganer og anus. Tilheling skjer vanligvis spontant i løpet av 2-3 måneder. Ved utbredte mollusker kan skraping, frysning eller pensling med salicyloppløsning være aktuelt. Mollusker har ingen betydning for opphold i barnehage/skole eller offentlige badebasseng. Barn med mollusker bør ikke dele håndklær o.l. med andre barn. Ikke meldingspliktig til MSIS.
Smittemåte og smitteførende periode
Kopper: Koppeviruset smitter fra person til person primært ved dråpesmitte via luftveiene(fjerndråpesmitte). Smitte kan også skje ved kontakt med lesjoner eller kontaminert materiale. Sykdommen smittet bare fra syke og det finnes ingen friske smittebærere.
Apekopper:Mennesker kan smittes ved kontakt med infiserte gnagere, primater, mennesker eller forurenset materiale. Viruset kommer inn i kroppen gjennom hud, luftveier eller slimhinner i øyne, nese eller munn. Person til person smitte er uvanlig, men kan forekomme ved:
- kontakt med klær, håndklær eller sengetøy som har vært brukt av en smittet person
- direkte kontakt med apekoppeutslett
- hosting eller nysing fra en person som har apekoppeutslett.
Inkubasjonstid
Inkubasjonstiden for kopper er ca. 2 uker (7 til 17 dager), for apekopper 5-21 dager.
Symptomer og forløp
Kopper: Kopper opptrer som to ulike former; variola major og variola minor. Klinisk er de vanskelig å skille, men letaliteten er betydelig høyere hos uvaksinerte ved variola major (20-40%) enn ved variola minor (<1%). Sykdommen starter med feber, hodepine, ofte brekninger og smerter i rygg og epigastriet. Etter 2-4 dager utslett først i ansiktet og perifert på armer og ben. I løpet av 24 timer sprer utslettet seg til hele kroppen. Etter ytterligere 3 dager blir utslettet omdannet til vesikler som blir purulente med skorpedannelse som tørker inn og etterlater de typiske koppearr. Koppeutslettet kan være vanskelig å skille fra eksantemet ved vannkopper. Ved kopper er alle elementene i utslettet i samme utviklingsstadium, mens man ved vannkopper ser papler, vesikler, pustler og skorper samtidig. Utslettet ved kopper er i tillegg mer perifert lokalisert og går dypere i huden. Dødelighet ved kopper kunne variere mye, normalt mellom 20-60 % (kunne være høyere hos barn). Mellom 65-80 % av de som overlevde fikk alvorlige komplikasjoner, slik som blindhet, deformiteter på ekstremitetene eller skjemmende arr.
Apekopper: Sykdomsbildet ved apekopper likner de ved kopper, men er som regel mildere og kan forveksles med vannkopper. De første symptomene er vanligvis feber, tretthet og hodepine. En del utvikler deretter lymfadenopati (til forskjell fra kopper og varicella), og etter noen dager utvikles det kløende utslett som etter hvert omdannes til purulente vesikler med skorpedannelse som etter hvert tørker inn og faller av. Sykdomsbildet varer normalt 2 til 4 uker. Dødeligheten i afrikanske utbrudd har vært rapportert til 1 til 10 %.
Diagnostikk
Koppediagnosen ble tidligere stilt ved elektromikroskopi og påvisning av virus i pustlene, men ville i dag også kunne påvises ved nukleinsyreamplifiseringstester, f.eks. PCR-teknikk. Koppeviruset er definert som risikogruppe 4 og kan kun analyseres ved høyeste grad av laboratoriesikkerhet. Apekopper kan diagnostiseres ved hjelp av PCR-teknikk ved Folkhälsomyndigheten i Sverige. Prøven anbefales tatt fra hudlesjon. Laboratoriepåvisning skjer etter avtale med Folkehelseinstituttet, se Beredskapsdiagnostikk.
Forebyggende tiltak
Kopper: Den gamle koppevaksinen består av levende vacciniavirus som har betydelige bivirkninger. Alvorligst er utvikling av encefalitt som særlig rammer barn. Vaksinasjon gir sannsynligvis beskyttelse i 5-10 år. Graden av beskyttelse i dag for personer som ble koppevaksinert fram til 1980 er usikker, men risikoen for alvorlige vaksinereaksjoner er mindre hos tidligere vaksinerte. Alle født etter 1976 må regnes som uvaksinerte, og befolkningen er derfor svært mottakelig for alvorlig sykdom dersom kopper kommer tilbake. Folkehelseinstituttet har et forholdsvis stort lager av den gamle koppevaksine med forventet god beskyttende effekt. En vaksine Imvanex® (såkalt tredjegenerasjon koppevaksine) med mindre bivirkninger er også tilgjengelig og Folkehelseinstituttet har normalt et lite lager av vaksinen. Helse- og omsorgsdepartementet tar beslutning om hvem som til enhver tid bør tilbys vaksine som ledd i terrorberedskap.
Apekopper: Reisende til områder med apekopper bør unngå kontakt med gnagere og unngå kontakt med syke og klær, håndklær eller sengetøy som har vært brukt av en smittet person. God håndhygiene er også viktig. Gjennomført koppevaksinasjon kan gi beskyttelse mot apekopper. Koppevaksine kan være aktuelt for helsepersonell som pleier pasienter med apekopper.
Tiltak ved enkelttilfelle
Tiltak i helseinstitusjoner ved kopper eller apekopper
Basale smittevernrutiner. Luftsmitteregime inntil alle skorper er tørket inn og løsnet (3-4 uker). Ikke-vaksinerte helsearbeidere bør ikke være i kontakt med smitteførende pasienter hvis det er immune helsearbeidere tilgjengelig. Ikke-vaksinerte helsearbeidere bør benytte åndedrettsvern.
Ved et mistenkt koppetilfelle, skal pasientene straks isoleres. Dersom luftsmitteisolat ikke er tilgjengelig, kan pasienten observeres i hjemmet. Husstandsmedlemmer, andre nærkontakter og involvert helsepersonell skal vaksineres og være under tilsyn. Vaksinasjon innen fire dager etter første eksponering gir noe beskyttelse mot infeksjon og hindrer vanligvis dødsfall. De siste årene har det kommet flere antivirale medikamenter mot kopper. En av disse antiviraliene (tecovirimat) er godkjent for bruk i Europa av EMA (European medicines agency) mot orthopoxvirus, inkludert apekopper. Det finnes ikke data på behandling av mennesker, men dyrestudier har vist effekt. Det kan også være aktuelt med koppevaksine innen 1-3 dager etter eksponering for apekopper.
Beredskapsplan mot kopper
Det foreligger en nasjonal beredskapsplan mot smittsomme sykdommer fastsatt av Helse- og omsorgsdepartementet i 2019. Responsen på et mistenkt koppetilfelle vil deles i en behandlingssøyle og en smittevernssøyle. Det er lagt opp til sentralisert behandling av høyrisikosmittesykdom ved CBRNE-senteret ved OUS. Et eget uttrykningsteam vil ved behov reise ut til mistenkt koppesyk og ta hånd om den syke innledningsvis.
Meldings- og varslingsplikt
Lege, sykepleier, jordmor eller tannlege som mistenker eller påviser et tilfelle av kopper, umiddelbart varsle kommuneoverlegen, som skal varsle videre til fylkesmannen og Folkehelseinstituttet. Dersom kommuneoverlegen ikke nås, varsles Folkehelseinstituttets døgnåpne Smittevernvakt direkte på tlf. 21076348. Kopper er også varslingspliktig i henhold til det internasjonale helsereglementet (IHR).
Kopper er meldingspliktig til MSIS, gruppe A-sykdom. Kriterier for melding er et klinisk forenlig tilfelle med epidemiologisk tilknytning eller laboratoriepåvisning av orthopox-virus i fravær av nylig vaksinering ved:
- isolering eller nukleinsyreundersøkelse, ev. etterfulgt av sekvensering eller
- elektronmikroskopi.
Kliniske kriterier er feber etterfulgt av utslett karakterisert med faste vesikler i samme utviklingsstadium uten annen åpenbar årsak og med overveiende sentrifugal distribusjon. Atypisk presentasjon kan inkludere hemorragiske lesjoner, flate/fløyelsaktige lesjoner som ikke utvikler seg til vesikler, variola sine eruptione og mildere type. Med epidemiologisk tilknytning menes overføring fra person til person og eksponering i laboratorium.
Varsling til kommuneoverlege, Folkehelseinstituttet og andre instanser ved utbrudd eller ved mistanke om overlagt spredning av smittestoffer, se Varsling av smittsomme sykdommer .
Andre poxviridae som apekopper, sauekopper, kukopper og mollusker er ikke meldingspliktige til MSIS.
Latin: variolus (liten kvise), vacca (ku), molluscus (bløt), orf – fra norrønt hrufa (skorpe)
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