New Emerging And Reemerging Infections circa 2006

drtamil@gmail.com 2006
New Emerging &
Re-Emerging
Infections
Dr Azmi Mohd Tamil

Case History of Hantavirus
• 3rd July 2003,
– Petaling District Health Office received a
notification of death of Hantavirus infection
that occurred on 13th June 2003 at HUKM.
– Deceased was a 22-year-old Myanmar male
– He arrived in Malaysia with 9 other Myanmar
males on 7th April 2003

Active Case Detection
• Out of 9 Myanmar workers who arrived together with the
deceased, only 2 workers were symptomatic & referred to
HUKM
– Only 1 was confirmed IgM positive for Hantavirus, currently well
and on follow-up at HUKM
– The other Myanmar worker was reported to be normal
• However, 2 Myanmar workers had absconded from the
workplace, their whereabouts & health status remained
unknown.
• All other co-workers were asymptomatic

What are emerging
infectious diseases?
• Diseases whose incidence in
humans has increased in last 20
years or threatens to increase in
future, usually due to demographic
or environmental factors
Institute of Medicine, 1992

Examples of emerging and
reemerging infectious diseases
• Ebola virus
• HIV
• Hepatitis C
• Sin Nombre Virus
(hantavirus)
• Influenza A(H5N1 and
H7N7)
• SARS coronavirus
• Legionella
pneumophila
• Escherichia coli
O157:H7
• Cyclospora cayetensis
• Borrelia burgdorferi
• Vibrio cholerae O139
Cholera
• Dengue fever
• Diphtheria
• Meningococcal
meningitis
• Monkeypox
• Rift Valley fever
• Yellow fever

Global Burden
• New infections are emerging over the
entire expanse of the globe. Wherever you
find people, you will find the emergence of
infections. The risk of emergence is not
confined to poor countries:as shown by
the E. coli epidemic in Japan, one of the
most affluent economies in the world.
There are global pandemics of HIV and
cholera, and the annual influenza in USA.

Why are they emerging?
• Global travel
• Globalization of food supply and central
processing of food
• Population growth, increased
urbanization, and crowding
• Population movements due to civil wars,
famines, and other man-made or natural
disasters
• Irrigation, deforestation, and reforestation
projects that alter the habitats of disease-
carrying insects and animals

Why are they emerging?
• Human behaviors, such as intravenous
drug use and risky sexual behavior
• Increased use of antimicrobial agents and
pesticides, hastening the development of
resistance
• Increased human contact with tropical rain
forests and other wilderness habitats that
are reservoirs for insects and animals that
harbor unknown infectious agents

O’Neill, 2002
"In failing to look beyond boundaries we fail to take into
account the fact that boundaries are now multiply
porous. Health problems travel across boundaries not
only because diseases travel, but because the mirror
image of a global configuration of social and economic
power is a global configuration of poverty and ill
health"

Current International Efforts at
Infectious Disease Control
• Improve surveillance efforts;
• Develop international standards and
guidelines for disease reporting and
control;
• Strengthen international research;
• Disproportional concern with techno fix
• Encourage national governments to
improve public health systems.
Source: World Health Assembly. Communicable diseases prevention and control:
new,emerging, and re-emerging infectious diseases. WHO Doc. WHA 48.13, May
12, 1995.

International Health
Regulations
• Established under WHO in 1951: ‘Sanitary
and quarantine requirements and other
procedures designed to prevent the
international spread of disease;’
• Lack of compliance almost universal;
• Revisions (1995): Surveillance, response,
increased number of diseases covered.

International Health
Regulations
• Intended to protect industrialized world
commercial investments and armies
• Global infectious disease spread through
mobility, war, etc
• Major effort to protect economies through
control of Infectious Diseases and
subsequent bad publicity.

0
20
40
60
80
100
120
140
160
180
200
Year
Black Men
Black Women
White Men
White Women
*Preliminary data
Trends in Rates of Death from HIV Infection
among Persons 25-44 Years Old,
USA, by Sex and Race, 1982-1997
From national vital statistics,
Centers for Disease Control & Prevention
Deathsper100,000Population
82 84 86 88 90 92 94 9683 85 87 89 91 93 95 97*

Dengue in the Americas, 1980–
1998
Unpublished data: Pan American Health Organization, March 1999
0
100
200
300
400
500
600
700
800
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998*
ReportedCases(Thousands)

Human Rabies Trends:
1980-1989 versus 1990-1998
DVRD / VRZB
0
5
10
15
20
25
Bat
Acquired abroad
Dog/Coyote
Skunk
1
7
2
20
5
2
1980 -1989 1990 -1998

Emerging / Re-emerging diseases
1996 to 2004
Cryptosporidiosis
Lyme
Borreliosis
Reston virus
Venezuelan
Equine
Encephalitis
Dengue
haemhorrhagic
fever
Cholera
E.coli O157
West Nile Fever
Typhoid
Diphtheria
E.coli O157
Echinococcosis
Lassa fever
Yellow fever
Ebola
haemorrhagic
fever
O’nyong-nyong fever
Human
Monkeypox
Cholera 0139
Dengue
haemhorrhagic
fever
Influenza A(H5N1)
Cholera
RVF/VHF
nvCJD
Ross
River
Virus
Equine
morbillivirus
Hendra
Virus
BSE
Multidrug-
resistant
Salmonella
E.coli non-O157
West Nile Virus
Malaria
Nipah Virus
Reston Virus
Legionnaire’s Disease
Buruli ulcer
Influenza A (H7N7)
SARS

Emerging disease threats in Asia
• Outbreaks of known epidemic-prone
diseases continue to occur
– Dengue fever, Japanese encephalitis,
meningococcal disease, typhoid fever, cholera,
leptospirosis, polio
• Newly emerging infectious diseases pose
serious public health threats
– Nipah virus, SARS, avian influenza A (H5N1)
– Other unknown disease threats

Cross-border Spread of Dengue in Mekong
Countries
Jan 1998
Apr 1998 Aug 1998
< 5
5 - 9
10 - 49
50 - 99
> 100

Avian Influenza A (H5N1) in Asia
As of 9 December 2005

Severe Acute Respiratory Syndrome
• WHO has revised the name of this disease to Severe Acute
Respiratory Syndrome (SARS). SARS is an atypical
pneumonia for which the cause has not yet been
determined.
• Fever (>38oC) and respiratory symptoms including cough,
shortness of breath or breathing difficulty;
• an outbreak of respiratory disease that began in southern
China in November and has struck more than 300 people,
killing five.
• HK 123/2, Vietnam 57/1, S’pore 23/0, USA 14/0, Canada 1
death
• the virus belongs to the paramyxoviridae family.

Family 01.048. Paramyxoviridae
• Subfamily 01.048.1. Paramyxovirinae
– Genus 01.048.1.01. Respirovirus
– Genus 01.048.1.03. Rubulavirus
– Genus 01.048.1.02. Morbillivirus
– Genus 01.048.1.04. Henipavirus
– Genus 01.048.1.05. Avulavirus
– Genus 01.048.0.06. "TPMV-like Viruses"
• Subfamily 01.048.2. Pneumovirinae
– Genus 01.048.2.01. Pneumovirus
– Genus 01.048.2.02. Metapneumovirus

The cost of SARS: initial estimates,
Asian Development Bank
76543210 US$ billion
Hong Kong
China, mainland
Taiwan
South Korea
Indonesia
Singapore
Thailand
Malaysia
Philippines
US$ billionUS$ billion
4%
0.5%
1.9%
0.5%
1.4%
2.3%
1.6%
1.5%
0.8%
% of GDP

Summary of the situation of
AI outbreaks in poultry
• Unprecedented outbreaks
– Geographical spread
– Silent reservoir (domestic ducks, wild
migratory birds)
– More outbreaks expected during the
coming cold seasons
– Impact on poultry
• Difficult to contain
– The virus is already entrenched in Asian
countries
– Backyard farms

Human Avian Influenza A/H5N1 Cases
by Onset Date and Country
( 14 December 2005 )
0
5
10
15
20
25
11 12 1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11
Date of onset
No.ofcases
Viet Nam (N=91) Thailand (N=22) Cambodia (N=4) Indonesia (N=14) China (N=5)
2003 2004 2005

Human Avian Influenza A/H5N1 Cases
by Outcome and Age Group
( 14 December 2005 )
0
10
20
30
40
0-9 10-19 20-29 30-39 40-49 50-59 60-69 70-79
Age group
No.ofcases
Dead (N=71) Alive (N=65)
• As of 14 December, total of 138 cases were reported officially to WHO
• 136 cases with available data were included

Risk factors for human infections
• Still not fully understood
• Most cases have occurred in
domestic settings
• High-risk human behaviours
continue
• Unhygienic animal husbandry
practices

Summary of the situation
of human cases
• Continuous and increasing human
cases
• Number of countries with human
cases increasing
– 2004: 2 countries
– 2005: 5 countries
• High case fatality rate (>50%)
• Most cases have been infected
through direct contact with
infected poultry

Current phase of pandemic alert in WHO
global influenza preparedness plan

Global Polio Eradication Initiative: Major Steps
• 1988: Goal to eradicate polio by the year 2000
• 1994: Americas certified polio-free
• 2000: Western Pacific Region certified polio free
• 2002: European Region certified polio-free
• 2004: Interruption of polio transmission by the end of the
year?

We Wanted These To Be The Last Polio Cases*
Western Pacific Region
Mum Chanty
Cambodia 1997
European Region
Melik Minas
Turkey 1998
Americas Region
Luis Fermin Tenorio
Peru 1991
* Due to wild virus

Polio Epidemiology: Then and Now
• 548 cases as of August 10,
2004
• Polio cases confined in 6
endemic countries

Global Cases of Polio (as of 18 August 2004)
TOTAL NUMBER OF CASES : 569
Nigeria 453
India 33
Pakistan 21
Niger 19
Afghanistan 3
Egypt 1
• the remaining 6 polio-endemic countries
➢ Ongoing outbreak in northern Nigeria continue to infect new countries:
- Guinea
- Mali
- Sudan
➢ 12 countries formerly polio-free since Jan 2003 now has cases of polio

Polio - Worldwide situation
• Global Polio Eradication Initiative did not achieve the goal to eradicate
polio by 2000, but still very successful
▪ 3 of the 6 WHO regions are “polio-free“
▪ 6 polio endemic countries
• Worldwide polio eradication seems possible
• Epidemiological situation has an influence on vaccination strategies

Polio - 2006
• As of 2005, Indonesia became the next
country with wild polio infection.
• Now poliomyelitis is just next door to
Malaysia…….
• Will Malaysia be next?

Factors Of Emergence
• HUMAN DEMOGRAPHICS AND
BEHAVIOR
• TECHNOLOGY AND INDUSTRY
• ECONOMIC DEVELOPMENT AND LAND
USE
• INTERNATIONAL TRAVELAND
COMMERCE
• MICROBIALADAPTATION AND CHANGE
• DECLINE OF PUBLIC HEALTH

HUMAN DEMOGRAPHICS AND
BEHAVIOR
• changes in human demographics and
behavior,
• increased numbers of people, and
• urbanization
have an impact on the emergence of disease

TECHNOLOGY AND
INDUSTRY
• ability to lyophilize blood products e.g.
factor VIII - hemophiliacs with HIV
• sophisticated Duramater transplants in
neurosurgery - BSE in Thailand & Japan
• medical technology and our ability to
transport biological and human material
probably also has a role in the
dissemination, transportation and
emergence of new diseases.

ECONOMIC DEVELOPMENT
AND LAND USE
• altered land use patterns
• deforestation
• Logging in the equatorial rain forest
• Land use changes that prompt exposure to
new vectors and diseases are thought to be
one of the factors related to Ebola, although
the reservoir for Ebola still has not been
identified.

International Travel and
Infectious Diseases

INTERNATIONAL TRAVEL
AND COMMERCE
• means of transportation - 400 million
people per year travel now internationally -
tb & influenza
• Old tires & dengue
• Dengue & air travel
• HIV and tourism industry

WorldPopulationinbillions()
DaystoCircumnavigate()
theGlobe
Year
1850
0
400
350
300
250
200
150
100
50
2000
0
1900 1950
1
2
3
4
5
6
Speed of Global Travel in Relation to
World Population Growth
From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994

Infectious Disease
Information

Antimicrobial Resistance
• Worldwide problem
• Dramatic increase in antimicrobial-
resistant community-acquired and
nosocomial pathogens
• Major risk factors:
Antimicrobial use (misuse)
Infection control practices (noncompliance)

MICROBIALADAPTATION
AND CHANGE
• emergence of resistant organisms
• emergence of Superbugs—Streptococcus
and penicillin, Gonococcus and quinolones,
Staphylococcus and vancomycin,
tuberculosis and isonizid, rifampin, malaria
and chloroquine, mefloquine
• no monitoring program for the emergence
of resistance

0
5
10
15
20
25
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
ICU
Non-ICU
Emerging Vancomycin-resistant
Enterococcal Infections*
%Resistant
* in U.S. NNIS Hospitals

Evolution of Antimicrobial Resistance
S. aureus
Penicillin

[1950s]
Penicillin-resistant
S. aureus
Methicillin

[1980s]
Methicillin-resistant
S. aureus (MRSA)
Vancomycin-resistant
enterococcus (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin
(glycopeptide) -
intermediate
resistant
S. aureus
[ ? ]

DECLINE OF PUBLIC
HEALTH
• the late 1970’s as the International
Monetary Fund and World Bank moved
internationally to shore up economies,
especially in Latin America and Africa, they
forced a reduction in public sector
investment - , immunization levels dropped,
nutrition dropped, etc.
• a serious lack of diagnosis and treatment in
many areas of the world

Prevention of Emerging Infectious
Diseases Will Require Action in Each
of These Areas
Surveillance and Response
Applied Research
Infrastructure and Training
Prevention and Control

Preventing Emerging
Infectious Diseases
Surveillance and Response
Detect, investigate, and monitor emerging
pathogens, the diseases they cause, and the
factors influencing their emergence, and
respond to problems as they are identified.

Applied Research
Integrate laboratory science and
epidemiology to increase the
effectiveness of public health practice.
Preventing Emerging
Infectious Diseases

Infrastructure and Training
Strengthen public health infrastructures to
support surveillance, response, and
research and to implement prevention and
control programs.
Provide the public health work force with
the knowledge and tools it needs.
Preventing Emerging
Infectious Diseases

Prevention and Control
Ensure prompt implementation of
prevention strategies and enhance
communication of public health
information about emerging diseases.
Preventing Emerging
Infectious Diseases

Major issues & challenges
• Emerging diseases continue to occur and pose
serious public health threats
• Many countries do not have basic public health
infrastructure and capacities
• Increasing needs for stronger global collaboration
and partnerships
• Needs for a global framework when responding to
emerging diseases of international concern.

“As we face the new
millennium, we must renew our
commitment to the prevention
and control of infectious
diseases, recognizing that the
competition between humans
and microbes will continue long
past our lifetimes and those of
our children.”
Jeffrey P. Koplan, Director, CDC

NCID Internet Page
http://www.cdc.gov/ncidod

New Emerging And Reemerging Infections circa 2006

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