EMERGING AND REEMERGING INFECTIOUS DISEASES Learning Objective To

EMERGING AND RE-EMERGING INFECTIOUS DISEASES

Learning Objective • To able to define and give example of emerging and reemerging infectious disease (ERID). • Able to discuss what is the factors contributed to ERID • List current pathogens classified as ERID • Explain what steps is used to lower the threat of ERID • Have understanding of Influenza and dengue as ERID cases

IMPACT OF INFECTIOUS DISEASES • 14 th century • 1831 • 1854 -56 • 1899 -1902 - Europe - plague kills 20 -45% of the world’s population - Cairo - 13% of population succumbs to cholera - Crimean war – deaths due to dysentery were 10 times higher than deaths due to casualties - Boer War – deaths due to dysentery were 5 times higher than deaths due to casualties

Direct economic impact of selected infectious disease outbreaks, 1990 -2003 Heymann DL. Emerging and re-emerging infections. In Oxford Textbook of Public Health, 5 th ed, 2009, p 1267.

Forum on Microbial Threats. The impact of globalization on infectious disease emergence and control. Institute of Medicine of the National Academies, Washington DC, 2006, p. 5.

Definition • Emerging infectious disease (EID): – Infectious disease whose incidence has increased in the past 20 years and threatens to increase in the near future – Include • Newly recognized agents (SARS, acinetobacter) • Mutation of zoonotic agents that cause human disease (e. g. , H 5 N 1, H 1 N 1) • Resurgence of endemic diseases (malaria, tuberculosis)

• Re-emerging infectious disease: – re-emergence of microbes that had been successfully controlled. – E. g: • • • Dengue Enterovirus 71 Clostridium difficile Mumps virus Streptococcus, Group A Staphylococcus aureus

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (1) 1. Human demographic change – Human move to new area and are exposed to new environmental sources of infectious agents, insects and animals 2. Unsustainable urbanization – causes breakdowns of sanitary and other public health measures in overcrowded cities (e. g. , slums)

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (2) 3. Economic development and changes in the use of land – including deforestation, reforestation, and urbanization 4. Global warming – changes in geographical distribution of agents and vectors 5. Changing human behaviours – increased use of child-care facilities, sexual and drug use behaviours, and patterns of outdoor recreation 6. Social inequality

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (3) 7. International travel and commerce – that quickly transport people and goods vast distances 8. Changes in food processing and handling – including foods prepared from many different individual animals and countries, and transported great distances

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (4) 9. Evolution of pathogenic infectious agents – by which they may infect new hosts, produce toxins, or adapt by responding to changes in the host immunity. (e. g. influenza, HIV) 10. Development of resistance by infectious agents – such as Mycobacterium tuberculosis and Neisseria gonorrhoeae to chemoprophylactic or chemotherapeutic medicines.

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (5) 11. Resistance of the vectors of vector-borne infectious diseases to pesticides. 12. Immunosuppression of persons due to medical treatments – result in infectious diseases caused by agents not usually pathogenic in healthy hosts. (e. g. leukemia patients)

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (6) 13. Deterioration in surveillance systems for infectious diseases, – including laboratory support, to detect new or emerging disease problems at an early stage (e. g. Indonesian resistance to “scientific colonialism”) 14. Illiteracy limits knowledge and implementation of prevention strategies 15. Lack of political will – corruption, other priorities

FACTORS CONTRIBUTING TO EMERGENCE OR RE-EMERGENCE OF INFECTIOUS DISEASES (7) 16. Biowarfare/bioterrorism: – potential source of new or emerging disease threats (e. g. anthrax and letters) 17. War, civil unrest – creates refugees, food and housing shortages, increased density of living, etc. 18. Famine causing reduced immune capacity, etc. 19. Manufacturing strategies; – e. g. , pooling of plasma, etc.

NEWLY IDENTIFIED INFECTIOUS DISEASES AND PATHOGENS (1) Year Disease or Pathogen 1993 Hantavirus pulmonary syndrome (Sin Nombre virus) Vibrio cholerae O 139 Guanarito virus Hepatitis C Hepatitis E; human herpesvirus 6 HIV Escherichia coli O 157: H 7; Lyme borreliosis; human T-lymphotropic virus type 2 Human T-lymphotropic virus 1992 1991 1989 1988 1983 1982 1980 Source: Workshop presentation by David Heymann, World Health Organization, 1999

NEWLY IDENTIFIED INFECTIOUS DISEASES AND PATHOGENS (2) Year Disease or Pathogen 2009 2004 2003 1999 1997 1996 H 1 N 1 Avian influenza (human cases) SARS Nipah virus H 5 N 1 (avian influenza A virus) New variant Creutzfelt-Jacob disease; Australian bat lyssavirus Human herpesvirus 8 (Kaposi’s sarcoma virus) Savia virus; Hendra virus 1995 1994 Source: Workshop presentation by David Heymann, World Health Organization, 1999

STRATEGIES TO REDUCE THREATS (1) 1. DEVELOP POLITICAL WILL AND FUNDING 2. IMPROVE GLOBAL EARLY RESPONSE CAPACITY – WHO – National Disease Control Units (e. g. USCDC, CCDC) – Training programs

STRATEGIES TO REDUCE THREATS (2) 3. IMPROVE GLOBAL SURVEILLANCE – Improve diagnostic capacity (training, regulations) – Improve communication systems (web, e-mail etc. ) and sharing of surveillance data – Rapid data analysis – Develop innovative surveillance and analysis strategies

STRATEGIES TO REDUCE THREATS (3) 3. IMPROVE GLOBAL SURVEILLANCE (continued) – Utilize geographical information systems – Utilize global positioning systems – Utilize the Global Atlas of Infectious Diseases (WHO) – Increase and improve laboratory capacity – Coordinate human and animal surveillance

STRATEGIES TO REDUCE THREATS (4) 4. USE OF VACCINES – Increase coverage and acceptability (e. g. , oral) – New strategies for delivery (e. g. , nasal spray administration) – Develop new vaccines – Decrease cost – Decrease dependency on “cold chain” 5. NEW DRUG DEVELOPMENT

STRATEGIES TO REDUCE THREATS (5) 6. DECREASE INAPPROPRIATE DRUG USE – Improve education of clinicians and public – Decrease antimicrobial use in agriculture and food production 7. IMPROVE VECTOR AND ZOONOTIC CONTROL – Develop new safe insecticides – Develop more non-chemical strategies e. g. organic strategies 8. BETTER AND MORE WIDESPREAD HEALTH EDUCATION (e. g. , west Nile virus; bed nets, mosquito repellent)

STRATEGIES TO REDUCE THREATS (5) 9. Develop new strategies requiring low-cost technology 10. Social and political mobilization of communities 11. Greater support for research 12. Reduce poverty and inequality

EPIDEMIOLOGY AND BIOLOGY OF INFLUENZA

Clinical Outcomes of Influenza Infection • Asymptomatic • Symptomatic § Respiratory syndrome - mild to severe § Gastrointestinal symptoms § Involvement of major organs - brain, heart, etc. § Death

Virology of Influenza Subtypes: A - Causes outbreak B - Causes outbreaks C - Does not cause outbreaks

Immunogenic Components of the Influenza Virus • Surface glycoproteins, 15 hemagglutinin (H 1 -H 15), nine neurominidases (N 1 -N 9) • H 1 -H 3 and N 1 N 2 established in humans • Influenza characterized by combination of H and N glycoproteins § 1917 pandemic - H 1 N 1 § 2004 avian influenza - H 5 N 1 § 2009 H 1 N 1 • Antigenic mix determines severity of disease • Human response specific to hemagglutinin and neurominidase glycoproteins

Figure 1. Natural hosts of influenza viruses Nicholson et al. Influenza. Lancet 362: 1734, 2003

The H 1 N 1 Epidemic

Factors Influencing the Response to Influenza • Age • Pre-existing immunity (some crossover) • Smoking • Concurrent other health conditions • Immunosuppression • Pregnancy

Kaplan K. How the new virus came to be. LA Times, 14 Sept, 2009; latimes. com/health

EPIDEMIOLOGY AND BIOLOGY OF H 5 N 1 INFLUENZA

Characteristics of H 5 N 1 Avian Influenza 1. Highly infectious and pathogenic for domestic poultry 2. Wild fowl, ducks asymptomatic reservoir 3. Now endemic in poultry in Southeast Asia 4. Proportion of humans with subclinical infection unknown 5. Case fatality in humans is >50%

12 14 16 18 20 22 24 26 28 30 1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 2 December, 2003 January 2004 Feb Europe, Africa Resurgence in Thailand, Vietnam, Cambodia and Indonesia Thailand Cambodia China & Laos Japan Vietnam South Korea Spread of H 5 N 1 Avian Influenza 2005 -6 2006 -7

Intervention Strategies (H 5 N 1) • Culling (killing of infected flocks) • Innovative surveillance strategies - Identification and analysis of human to human clusters - Characterization of strains * Necessity for vaccine development (Science 304: 968 -9, 5/2004) • Vaccination of bird handlers (vaccine being developed) • Vaccination of commercial bird flocks

Barriers to H 5 N 1 Control • Reservoir in wild birds and ducks • Economic impact of culling of poultry stocks • Popularity of “wet markets” promotes transmission within poultry and to other species (e. g. , pigs) • Resistance to antivirals and vaccines • Mistrust of rich nations

Don’t get the flu vaccine!

RECOMMENDATIONS TO PREVENT FLU

STRATEGIES TO PREVENT FLU (1) • COVER MOUTH AND NOSE WHEN SNEEZING • WASH HANDS FREQUENTLY WITH SOAP AND WATER OR ALCOHOL • AVOID TOUCHING EYES, NOSE AND MOUTH • AVOID CONTACT WITH SICK PEOPLE • AVOID CROWDED CONGESTED ENVIRONMENTS