Emerging and reemerging infectious diseases

Various emerging and reemerging diseases. Factors contributing to the emergence of infectious diseases. Antibiotic resistance. The global response to control them. Laboratories network in surveillance.

1. Emerging & Re-emerging infectious Diseases Presented By: Dr. Arijit Kundu PG Student Mentored By: Dr. Lipilekha Patnaik Associate Professor 1

2. Introduction Emerging Infectious Diseases: Emerging infectious diseases are “New diseases; new problem (New threats)” An emerging infectious disease is a one that is caused by a newly discovered infectious agent or by a newly identified pathogen, which has emerged and whose incidence in humans has increased during the last 2 decades and is threatening to increase in the near future. 2

3. Re-emerging Infectious Diseases: Re-emerging infectious diseases are “old diseases, new problem. (New threats)”. A re-emerging infectious disease is a one which was previously controlled but once again has risen to be a significant health problem. This term also refers to that disease which was formerly confined to one geographic area, has now spread to other areas. 3

4. Factors contributing to the emergence of infectious diseases: Human demographics and behaviour Technology and industry Economic development and land use International travel and commerce Microbial adaptation and change Breakdown of public health measures Human susceptibility to infection Climate and weather Changing ecosystems Poverty and social inequality War and famine Lack of political will Intent to harm 4

5. Factors contributing to the emergence AGENT : Evolution of pathogenic infectious agents (microbial adaptation & change) Development of resistance to drugs: Wrong prescribing practices Non-adherence by patients Counterfeit drugs Use of anti-infective drugs in animals & plants Resistance of vectors to pesticides 5

6. HOST: Human demographic change (inhabiting new areas) Human behaviour : 1. Unsafe sexual practices (HIV, Gonorrhoea , Syphilis) 2. Changes in agricultural & food production patterns- food- borne infectious agents (E. coli) 3. Increased international travel (Influenza) Human susceptibility to infection (Immunosuppression) Poverty & social inequality 6

7. ENVIRONMENT: Climate & changing ecosystems: Deforestation forces animals into closer human contact- increased possibility for agents to breach species barrier between animals & humans EL Nino- Triggers natural disasters & related outbreaks of infectious diseases (Malaria, Cholera) Global warming- spread of Malaria, Dengue, Leishmaniasis , Filariasis Economic development & Land use (urbanization, deforestation) Technology & industry (food processing & handling) International travel & commerce Deterioration in surveillance systems (lack of political will) 7

8. Breakdown of public health measure (war, unrest, overcrowding): Poor populations- major reservoir & source of continued transmission Poverty- Malnutrition- Severe infectious disease cycle Lack of funding, Poor prioritization of health funds, Misplaced in curative rather than preventive infrastructure, failure to develop adequate health delivery systems Uncontrolled Urbanization & Population Displacement: Growth of densely populated cities- substandard housing, unsafe water, poor sanitation, overcrowding, indoor air pollution (>10% preventable ill health) Problem of refugees & displaced persons Diarrhoeal & Intestinal parasitic diseases, ARI 8

9. Examples: Source: NATURE; Vol 430; www.nature.com/nature 9

10. 1993: Hantavirus pulmonary syndrome (United States) 1994: Plague (India) 1995: Ebola fever (Democratic Republic of Congo) 1996: New variant Creutzfeldt-Jakob disease (United Kingdom) 1997: H5N1 influenza (Hong Kong); 1998: Nipah virus encephalitis (Malaysia, Singapore) 1999: West Nile virus encephalitis (Russia, United States) 2000: Rift Valley fever (Kenya, Saudi Arabia, Yemen); Ebola fever(Uganda) 2001: Anthrax (United States); foot-and-mouth disease(United Kingdom) 2002: Vancomycin-resistant Staphylococcus aureus (United States) 2003: Severe acute respiratory syndrome (SARS) (multiple countries); monkeypox (USA) 2004: H5N1 influenza (Southeast Asia) Examples of Emerging Infectious Diseases 10

11. Examples of Emerging Infectious Diseases Hepatitis C- First identified in 1989 In mid 1990s estimated global prevalence 3% Hepatitis B- Identified several decades earlier Upward trend in all countries Prevalence >90% in high-risk population Zoonoses - 1,415 microbes are infectious for human Of these, 868 (61%) considered zoonotic 70% of newly recognized pathogens are zoonoses Emerging Influenza infections in Humans associated with Chickens, Pigs 11

12. Emerging Zoonoses : Human-animal interface Marburg virus Hantavirus Pulmonary Syndrome Ebola virus Borrelia burgdorferi (Lyme disease) Deer tick ( Ixodes scapularis ) Mostomys rodent: Lassa fever Avian influenza virus Bats: Nipah virus 12

13. SARS The First Emerging Infectious Disease Of The 21st Century No infectious disease has spread so fast and far as SARS did in 2003 13

14. Lesson learnt from SARS An infectious disease in one country is a threat to all Important role of air travel in international spread Tremendous negative economic impact on trade, travel and tourism, estimated loss of $ 30 to $150 billion High level commitment is crucial for rapid containment WHO can play a critical role in catalyzing international cooperation and support Global partnerships & rapid sharing of data/information enhances preparedness and response 14

15. Swine Flu (H1N1) Swine flu causes respiratory disease – high level of illness, low death rates Causative agent- Influenza A- RNA viruses of the family Orthomyxoviridae RNA virus- highly mutagenic Pigs can get infected by human, avian and swine influenza virus Pandemic outbreak since April 2009 April 15 th 2009 CDC identifies H1N1 (swine flu) April 25 th 2009 WHO declares public health emergency By May 5 th 2009 more than 1000 cases confirmed in 21 countries May 16 th 2009India reports first confirmed case Cases of swine flu have been reported in India, with over 31,156 positive test cases and 1,841 deaths up to March 2015 15

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18. Highly Pathogenic Avian Influenza (H5N1) Since Nov 2003, avian influenza H5N1 in birds affected 60 countries across Asia, Europe, Middle-East & Africa >220 million birds killed by this virus or culled to prevent further spread Majority of human H5N1 infection due to direct contact with birds infected with virus 18

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20. Emerging Food borne & water borne disease Accounts for 20 million cases in the world annually (T.D. Chugh-2008) Incidence is increasing Half of all known food borne pathogens discovered during the past 25 years Most common associated organisms are: Entero hemorrhagic Escherichia coli, Vibrio cholerae , Campylobacter sp. 20

21. Ebola Ebola was first discovered in 1976 near the Ebola River. Since then, outbreaks have appeared sporadically in Africa. Ebola Hemorrhagic Fever Outbreak: 2000-2001: Uganda 2002-2003: Gabon and Democratic Republic of the Congo (DRC) 2004: South Sudan 2007: DRC, Uganda. 2011-2012: Uganda, DRC 2014-2016: West Africa 21

22. Zika Zika virus was first discovered in a monkey in the Zika Forest of Uganda in 1947.  In 1952, the first human cases of Zika were detected and since then, outbreaks of Zika have been reported in tropical Africa, Southeast Asia, and the Pacific Islands. Before 2007, at least 14 human cases of Zika had been documented, although other cases were likely to have occurred and were not reported. The first travel notice for Zika in Brazil was posted in June 2015. On January 22, 2016, CDC activated its Emergency Operations Center (EOC) to respond to outbreaks of Zika occurring in the Americas and increased reports of birth defects and Guillain-Barré syndrome in areas affected by Zika. On February 8, 2016, CDC elevated its EOC activation to a Level 1, the highest level. 22

23. Zika Since 2015, 69 countries and territories reported evidence of vector-borne Zika virus transmission. Brazil is by far the most affected country, reporting the most cases of people infected with the Zika virus. As of September 2016, some 1,949 confirmed cases of Zika-related microcephaly in newborns were reported.  In the U.S., there were over 3,000 Zika virus infections reported up to September 2016.  On 18 th Nov 2016, WHO commits to sustained and robust long-term response to Zika as ‘public health emergency’ is lifted. 23

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25. Malaysian Nipah virus epidemic 1998-1999 An outbreak of Nipah virus in Malaysia and Singapore Nipah virus belongs to family Paramyxoviridae Virus aerosolisation caused infection of pigs Overcrowding results in viral transmission to pig handlers The virus persists in low numbers in the island flying fox ( Pteropus hypomelanus ), a type of fruit bat and Malayan flying fox ( Pteropus vampyrus ) Of the 269 human cases of viral encephalitis associated with Nipah virus infection reported in Malaysia in 1999, 108 were fatal (Ministry of Health Malaysia, 2001). 25

26. Examples of Re-Emerging Infectious Diseases Diphtheria- Early 1990s epidemic in Eastern Europe(1980- 1% cases; 1994- 90% cases) Cholera- 100% increase worldwide in 1998 (new strain eltor , 0139) Human Plague- India (1994) after 15-30 years absence. Dengue/ DHF- Over past 40 years, 20-fold increase to nearly 0.5 million (between 1990-98) 26

27. Disease Year State Plague 1994 2002 2004 Gujrat H.P. Uttranchal Leptospirosis 1988-2004 1994-2004 1984-1986 1999-2003 2000-2002 Andaman & Nicobar Gujrat Tamil Nadu Kerala Maharastra Anthrax 1999 2000 2001 2003 Karnataka WB Karnataka Orissa 27

28. Dengue/DHF 1996 2003 2004 Delhi Delhi & Kerala Kerala, Sikkim Scrub typhus 2003 2004 H.P Darjeeling, Sikkim JE Yearly U.P, A.P,Haryana Unknown acute viral encephalitis 2001 2002 2003 Siliguri Saharanpur,A.P Karnal, Maharastra 28

29. Antibiotic resistance Emerge in environment due to inappropriate use of antibiotic WHO estimates that 10 million people are dying of infectious diseases related to antibiotic resistance. Proper antibiotic guidelines needed to prevent the drug resistance. 29

30. Multi-resistant pathogens Staphylococcus aureus is the most frequently identified drug-resistant pathogen. Singhal et al (2007)reported ciprofloxacin -resistant meningococci in an outbreak in Delhi. Resistance of Salmonella typhi and S. paratyphi to chloramphenicol, ampicillin and cotrimoxazole is widespread. AMR in Shigella : resistance to azithromycin, ceftriaxone and ciprofloxacin on the increase Methicillin/oxacillin-resistant Staphylococcus aureus (MRSA) 30

31. Vancomycin-resistant enterococci (VRE); Extended-spectrum beta-lactamases (which are resistant to cephalosporins & monobactams) (ESBLs); Penicillin-resistant Streptococcus pneumoniae (PRSP); Multi-drug resistant tuberculosis (MDR-TB); CRKP- Carbapenem Resistant Klebsiella Pneumoniae S. typhimurium - DT104 (resistant to five antibiotics: ampicillin, chloramphenicol, streptomycin, sufonamides and tetracycline) 31

32. Bioterrorism Possible deliberate release of infectious agents by dissident individuals or terrorist groups Biological agents are attractive instruments of terror- easy to produce, mass casualties, difficult to detect, widespread panic & civil disruption Highest potential- B. anthracis, C. botulinum toxin, Y. pestis , Variola virus, Viral haemorrhagic fever viruses Likeliest route- aerosol dissemination 32

33. Control of Emerging and Re-emerging Diseases Controlling the reservoir Interrupting the transmission Protecting the susceptible host Strengthening of the disease surveillance system Encouraging research initiations for treatment regimens and diagnostics Encouraging research for new methods of control measures Establishment of drug resistance 33

34. Role of Doctors in Prevention Increase knowledge and skill ; Educate the public Encourage partnerships with consumers and other disciplines to identify needs, set priorities, develop strategies and evaluate progress Support health care legislation Involve in research Encourage using multidisciplinary efforts. Influence local and National economic and political options Continue to advance nursing concern 34

35. Role of Public Health Authorities National programme for prevention and control of vector borne diseases Legislations for elimination Communities awareness of the disease Minimizing transmission of infection: By Risk communication to the family members Minimizing vector population Minimizing vector – individual contact Reporting to the nearest public health authority 35

36. Public health measures to prevent infectious diseases Safe water Sewage treatment and disposal Food safety programme Animal control programme Vaccination programme Public health organization 36

37. Response of the WHO Developing global and regional strategies Appointing Task Force Generous grant from WHO regular budget Support the World Bank grant GOARN (Global Outbreak Alert & Response Network) Mechanism for combating international disease outbreaks Ensure rapid deployment of technical assistance, contribute to long-term epidemic preparedness & capacity building 37

38. VECTOR SURVEILLANCE Vector borne epidemic prone diseases: JE, Dengue, Plague, Kala Azar, Rickettsial Early warning signals - increase density of vectors - increase in breeding sites for vectors Insecticide susceptibility status To assess impact of routine measures under national programme PREVENTIVE STRATEGY IN INDIA 38

39. LAB SURVEILLANCE Serological Surveillance To collect baseline prevalence data To identify high risk areas To identify high risk age group As early warning signal for impending outbreak Microbial surveillance Changing genotype Mutations Development of Antimicrobial Resistance Eg . Salmonella, Cholera, Plague, Anthrax 39

40. International (Collaborating Centres) like CDC Atlanta National Reference Laboratories e.g. NICD Delhi, NIV Pune, NICED Kolkata State laboratories Intermediate (District/Provincial/Medical College) Peripheral (PHC/CHC) State Laboratories National Laboratories District Laboratories Peripheral Laboratories Laboratories network in surveillance 40

41. Peripheral laboratories District laboratories Disease Surveillance unit Disease Surveillance unit Disease Surveillance unit National laboratory State laboratories Disease Surveillance unit ACTION 41

42. Peripheral Laboratories: Functions Collection of specimen Preliminary Processing Storage and transport Reporting of results Undertaking simple tests Microscopy for malaria, TB, meningitis, dysentery/Cholera Rapid Tests ( Typhi Dot for enteric fever, Latex test for HBsAg Water Quality Monitoring by rapid H2S Test 42

43. District Laboratories: Functions Microscopy for diphtheria, kala azar, Cholera Bacterial Cultures for enteropathogens , Enteric fever Antimicrobial Susceptibility testing Serological tests: Widal test, Latex test for meningitis in CSF, ELISA based test Bacteriological examination of water (rapid H2S, coliform count) Coordinate with state/ national laboratory and disease surveillance units 43

44. State Laboratories: Functions All that is done at district lab+ Specialized microscopy like dark ground, fluorescent microscopy Culture of all common bacteria including mycobacteria and their identification (& serotype, wherever applicable) Antimicrobial susceptibility testing of common bacteria including mycobacteria Serology for viral hepatitis markers, dengue, JE, measles, leptospirosis etc. ?Viral cultures Quality Assurance (IQC & EQAS) 44

45. National Laboratories: Functions Specialized tests eg for Plague, Anthrax and other possible agents of bioterrorism High Containment laboratory (P3/ BSL--3) Assist in outbreak investigation Confirm new isolates All types of Lab based epidemiological markers Training/Preparation of Teaching Material and reagents/antisera etc Organize external quality assessment schemes Collation of national data 45

46. Laboratory diagnosis of the emerging / re-emerging infections Importance of laboratory diagnosis The results will alter clinical or infection control management, or as needed for public health surveillance purposes. For infectious diseases, modern serological techniques, more and more based on recombinant antigens, are being proven to be specific, rapid and less labor intensive. PCR may prove very useful and rapid test. Conventional methods turned out to be either too insensitive (e.g., during the asymptomatic stage of HIV infection), too slow (e.g., mycobacterial culture) or too cumbersome to be used on a large scale (e.g., virus isolation). 46

47. Recommended laboratory testing in emerging infections Molecular testing- PCR- highly sensitive and specific Rapid test – for flu- need to confirm with PCR Dengue-NS1 antigen (indicated for case < 5 days) Antimicrobial resistance-susceptibility testing , gene detection by PCR 47

48. Key Tasks in Dealing with Emerging Diseases Surveillance at national, regional, global level epidemiological, laboratory ecological anthropological Investigation and early control measures Implement prevention measures behavioural, political, environmental Monitoring, evaluation 48

49. Solutions Strengthen international surveillance networks to issue early warning, detect, control, and reduce emerging infectious diseases. Improve international public health infrastructure e.g. special laboratory that capable of accurate and rapid diagnosis. Improve international capabilities to respond to disease outbreaks with adequate medical and veterinary resources and expertise. Strengthen international research efforts on emerging infectious diseases, giving priority to antibiotic-resistant strains of diseases. 49

50. Focus attention and resources on training and developing medical and veterinary capability. Encourage national governments to improve their public health care systems, devote resources to eliminating or controlling causes of emerging infectious diseases and coordinate public health activities with WHO and other international communities. Develop better international standards, guidelines and recommendations. Solutions (cont.) 50

51. Factors affecting emerging infections Solution Migration Proper health screening, vaccination Travel Immunization, infection control measure Urbanization Proper sanitation, adequate housing, good infrastructure Human behaviour Education, behaviour modification Antibiotic usage Judicious use of antibiotic Correct antibiotic for correct pathogen (with right dosage and route). Strengthen infection control measures Solutions (cont.) 51

52. Solutions (cont.) Public health surveillance & response systems Rapidly detect unusual, unexpected, unexplained disease patterns Track & exchange information in real time Response effort that can quickly become global Contain transmission swiftly & decisively Internet-based information technologies Improve disease reporting Facilitate emergency communications Dissemination of information 52

53. Solutions (cont.) Human Genome Project Role of human genetics in disease susceptibility, progression & host response Microbial genetics Methods for disease detection, control & prevention Improved diagnostic techniques & new vaccines Geographic Imaging Systems Monitor environmental changes that influence disease emergence & transmission 53

54. Key tasks - carried out by whom? National Regional Global Synergy 54

55. What skills are needed? Multiple expertise needed ! Infectious diseases Epidemio- logy Public Health International field experience Information management Laboratory Telecom. & Informatics 55

56. Conclusion The true prevalence of many diseases is not known. Since we live in a global village, we cannot afford to be complacent about the tremendous economic, social and public health burden of these diseases. Effective surveillance is the key to their early containment. There is a need to develop epidemiology improved diagnostic facilities, a strong public health structure, effective risk communication, epidemic preparedness and rapid response. 56

57. References: Public Health and Preventive Medicine. MAXY-ROSENMAN-LAST, 15 th edition. Oxford textbook of Public Health 6th edition. Park text Book of Preventive & Social Medicine. 23rd edition EMERGING INFECTIOUS DISEASES IN SEAR. WHO1998. WHO GLOBAL STRATEGY FOR CONTAINMENT OF ANTIMICROBIAL RESISTANCE. Executive summary.2001. CDC website: https://www.cdc.gov/vhf/ebola/about.html Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. Overview of the Updated CDC Plan Review of the emerging infectious disease problem And strengthening of epidemiological surveillance. Forty fourth meeting of the regional director within WHO representative, New Delhi, 1995. Forty-fifth Meeting of the Regional Director with the WHO Representatives, New Delhi 4 to 13 November 1996 SEA/WR45/5. Emerging and re-emerging diseases, including tuberculosis and malaria. 57

58. Take Home Massage Community health is the pivot of Global health. Let us join our hands on creating an awareness to the individual family and community through effective risk communication. 58

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60. Emerging Infectious Diseases: A Research Approach 60

61. Benefits of Research on Emerging Diseases 61

62. HUMAN ANIMALS ENVIRONMENT VECTORS Zoonosis Population Growth Mega-cities Migration Exploitation Pollution Climate change Vector proliferation Vector resistance Transmission Antibiotics Intensive farming Food production 62

63. Entero hemorrhagic Escherichia coli Causes no signs of illness Low infections dose in humans causes hemorrhagic colitis and hemolytic uremic syndrome Consumption of undercooked beef and contaminated vegetables, fruits and water for vegetarians. Reported in 1.4% of stools from cases of bloody diarrhea in Kolkata (Ministry of Health and Welfare 2006). 63

64. Disadvantages of PCR: Expensive-need special rooms, expensive reagent proper packaging of sample to prevent leaking, risk of contamination Immediate transportation as the microorganism eg RNA virus is labile Need experience and well trained staff 64

65. Vibrio cholerae Cholera is one of the oldest recorded infectious diseases. Pacini in 1854, first described comma shaped bacteria Robert Koch in 1883, showed the causative agent V .Cholerae. Das and Gupta -2005 reported the diversity of V .Cholerae. Narang et al (2008) described the changing patterns of V .Cholerae . 65

66. Campylobacter spp Are significant zoonotic poultry pathogens Leading cause of gastro enteritis in the world Around 2.5 million human infections are reported annually in the United States. In developing countries the presence of the organism was reported in 5-20% in childhood diarrhea 66

67. Trends in Malaria in SEA Region, 1976-2002 67

68. P. falciparum Resistance to Antimalarials in WHO SEA Region, 2002 68