emergingndreemerginginfections-ak-180112051019.pptx

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1. Emerging & Re-emerging Bacterial Infectious Diseases 1 Chijioke A Nsofor PhD, KSM Associate Professor and Group Leader Molecular Epidemiology Research Group Federal University of Technology Owerri

2. Introduction Emerging Bacterial Infectious Diseases: Emerging Bacterial infectious diseases are “New diseases; new problem (New threats)” An emerging bacterial infectious disease is a one that is caused by a newly discovered bacterial 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 Bacterial Infectious Diseases: Re-emerging bacterial 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. Animal Amp li f ic at i on C A S E S TIME Emerging Threats Program Human Cases Wild Animal Domestic Animal Early Detection and Control Opportunities Wildlife Surveillance/ Forecasting One Health – Public health as part of the “ ecosystem ”

5. Factors contributing to the emergence of Bacterial 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 5

6. 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 6

7. HOST: Human demographic change (inhabiting new areas) Human behavior: 1. Unsafe sexual practices (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 7

8. 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 (Cholera ) Economic development & Land use (urbanization, deforestation) Technology & industry (food processing & handling) International travel & commerce Deterioration in surveillance systems (lack of political will) 8

9. 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 9

10. 10 Examples of Bacterial Emerging Infectious Diseases Bacteria Implications for Africa Targets for prevention Rickettsia felis • 2002: Officially described • Before 2010: Only one case reported in Africa • 2010: Prevalence of about 4% of R. felis in blood samples of febrile individuals without malaria in Senegal and Kenya • 2013: Confirmation of role of R. felis in fever in Senegal • 2015: First detection in blood samples of febrile individuals in Gabon, reaching a prevalence of 39.7% in rural area of Fougamou Vector-control measures Tropheryma whipplei • 2001: Officially described • 2010: Prevalence of about 6.4% in blood samples of febrile individuals without malaria in Senegal • 2016: First detection in a febrile patient in Gabon Fenollar  and  Mediannikov 2018 Sanitation facilities

11. 11 Examples of Bacterial Re-emerging Infectious Diseases Yersinia pestis (plague) •Since 2000: Main outbreaks: Recurrent annual human infections and outbreaks in Madagascar, DRC, Uganda, United Republic of Tanzania (2000) • DRC, Uganda, United Republic of Tanzania (2001) • DRC, Malawi, Mozambique, Uganda, United Republic of Tanzania (2002) • Algeria, DRC, Mozambique, Uganda (2003) • DRC (2005) • DRC (2006) • Madagascar (2017): One of worst outbreak in world in past half century, 202 deaths Reduce risk of wildlife-to-human transmission Vibrio cholera (cholera) • Main outbreaks since 2000: • Madagascar, Somalia (2000) • South Africa (2000–2001) • Chad, Nigeria, Tanzania, West Africa (2001) • Burundi, Côte d’Ivoire, DRC, Liberia, Malawi, Niger (2002) •Mozambique (2002–2004): 17 265 cases, 102 deaths • Benin, Côte d’Ivoire, DRC, Liberia, Mali, South Africa, Uganda, Zambia (2003) • Cameroon, Chad, Zambia (2004) • Niger (2004–2005) • West Africa (2005) • Angola and Republic of South Sudan (2006) • West Africa (2008) • Zimbabwe (2008–2009): largest outbreak, 98 585 cases, 4000 deaths • Zimbabwe (2011) • Central Africa, DRC, Sierra Leone, Republic of the Congo (2012) • Republic of South Sudan (2014) • DRC (2015) • United Republic of Tanzania (2015–2018): 33 421 cases, 542 deaths • Kenya, Zambia (2017) • DRC, Mozambique, Somalia (2017–2018) • Algeria (2018): Since mid-August 2018, 41 confirmed cases, two deaths, last reported sporadic cases in 1996 in this country (data provided by Algerian health authorities)   Fenollar  and  Mediannikov 2018 Appropriate water and sanitation facilities Oral cholera vaccination (transient protection about 3–5 years) To be alert during conflicts or natural disasters Bacteria Implications for Africa Targets for prevention

12. 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. 12

13. Examples of Re-Emerging Bacterial 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 . 13

14. 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 14

15. 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 15

16. 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. 16

17. 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) 17

18. 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) 18

19. Control of Emerging and Re-emerging Bacterial 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 19

20. 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 20

21. 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 21

22. Public health measures to prevent infectious diseases Safe water Sewage treatment and disposal Food safety programme Animal control programme Vaccination programme Public health organization 22

23. 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 23

24. 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 24 PREVENTIVE STRATEGY

25. International (Collaborating Centres) like CDC, WHO National Reference Laboratories e.g. NCDC Abuja, State laboratories Intermediate (District/Provincial/Medical College) Private Laboratory State Laboratories National Laboratories District Laboratories Private Laboratories Laboratories network in surveillance 25

26. Private laboratories District laboratories Disease Surveillance unit Disease Surveillance unit Disease Surveillance unit National laboratory State laboratories Disease Surveillance unit ACTION 26

27. Laboratory diagnosis of the emerging / re-emerging bacterial 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 labour intensive. PCR may prove very useful and rapid test . 27

28. 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 28

29. 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. 29

30. 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. 30 Solutions (cont.)

31. 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 31

32. Key tasks - carried out by whom? 32 National Regional Global Synergy

33. What skills are needed? 33 Multiple expertise needed ! Infectious diseases Epidemio- logy Public Health International field experience Information management Laboratory Telecom. & Informatics

34. 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. 34

35. 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. 35

36. 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. 36

37. 37

38. Emerging Infectious Diseases: A Research Approach 38

39. Benefits of Research on Emerging Diseases 39

40. HUMAN ANIMALS ENVIRONMENT VECTORS Zoonosis Population Growth Mega-cities Migration Exploitation Pollution Climate change Vector proliferation Vector resistance Transmission Antibiotics Intensive farming Food production 40

41. 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). 41

42. 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 42

43. 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 . 43

44. 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 44

45. Trends in Malaria in SEA Region, 1976-2002 45

46. P. falciparum Resistance to Antimalarials in WHO SEA Region, 2002 46