Emerging and re-emerging infectious disease. ( 16/03/2017) Dr Priyadarsh Moderator – Dr Chetana Maliye Dr Abhay Ambilkar

Infectious Diseases: A World in Transition Guinea worm Smallpox Yaws Poliomyelitis Measles Leprosy Neonatal tetanus DOWN ? AIDS Avian Influenza Ebola Marburg Cholera Rift Valley Fever Typhoid Tuberculosis Leptospirosis Malaria Chikungunya Dengue JE Antimicrobial resistance UP

SARS: The First Emerging Infectious Disease Of The 21st Century No infectious disease has spread so fast and far as SARS did in 2003 SARS: The First Emerging Infectious Disease Of The 21st Century SARS was first recognized at the end of February 2003 in Hanoi, Viet Nam. case, a middle-aged man business man who has traveled extensively in South-East Asia before becoming unwell, was admitted to hospital in Hanoi on 26 February 2003 with a high fever, dry cough, myalgia and mild sore throat. Over the following 4 days he developed symptoms of adult respiratory distress syndrome, requiring ventilator support, and severe thrombocytopenia. Despite intensive therapy he died on 13 March after being transferred to an isolation facility in Hong Kong SAR. On the basis of data from the SARS foci in Hanoi and Hong Kong SAR, the incubation period has been estimated to be 2.7 days, but usually 3.5 days. Attack rates of >56% among health care workers caring for patients with SARS is consistent in both the Hong Kong and Hanoi foci. Dr. KANUPRIYA CHATURVEDI

Emerging infectious disease Newly identified & previously unknown infectious agents that cause public health problems either locally or internationally

1991 – Peru . 23 Jan 1991 Cholera re-emerged after 100 years. More than 300000 cases in 1st year. In 1992, 358174 cases and 2602 deaths. In 1994, 127180 cases and 1321 deaths.

Re-emerging infectious disease Infectious agents that have been known for some time, had fallen to such low levels that they were no longer considered public health problems & are now showing upward trends in incidence or prevalence worldwide

Factors Contributing To Emergence AGENT Evolution of pathogenic infectious agents (microbial adaptation & change) Development of resistance to drugs Resistance of vectors to pesticides

Antimicrobial Drug Resistance Causes: Wrong prescribing practices non-adherence by patients Counterfeit drugs Use of anti-infective drugs in animals & plants Loss of effectiveness: Community-acquired (TB, Pneumococcal) & Hospital-acquired (Enterococcal, Staphylococcal Antiviral (HIV), Antiprotozoal (Malaria), Antifungal Dr. KANUPRIYA CHATURVEDI

Factors Contributing To Emergence HOST Human demographic change (inhabiting new areas) Human behavior (sexual & drug use) Human susceptibility to infection (Immunosuppression) Poverty & social inequality Unsafe sexual practices (HIV, Gonorrhea, Syphilis) Changes in agricultural & food production patterns- food- borne infectious agents (E. coli) Increased international travel (Influenza) Outdoor activity

Factors Contributing To Emergence ENVIRONMENT and CLIMATE Climate & changing ecosystems Economic development & Land use (urbanization, deforestation) Technology & industry (food processing & handling) International travel & commerce Breakdown of public health measure (war, unrest, overcrowding) Deterioration in surveillance systems (lack of political will) 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, Leishmaniosis, Filariasis

Transmission of Infectious Agent from Animals to Humans >2/3rd emerging infections originate from animals- wild & domestic Emerging Influenza infections in Humans associated with Geese, Chickens & Pigs Animal displacement in search of food after deforestation/ climate change (Lassa fever) Humans themselves penetrate/ modify unpopulated regions- come closer to animal reservoirs/ vectors (Yellow fever, Malaria)

Poverty, Neglect & Weakening of Health Infrastructure 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 Growth of densely populated cities- substandard housing, unsafe water, poor sanitation, overcrowding, indoor air pollution (>10% preventable ill health) Problem of refugees & displaced persons Diarrheal & Intestinal parasitic diseases, ARI Lyme disease (B. burgdorferi)- Changes in ecology, increasing deer populations, suburban migration of population Dr. KANUPRIYA CHATURVEDI

Factors influencing emergence and re-emergence Weakened public health infrastructure Failure of safety procedures/regulations. Population increase. Anthropogenic activities or natural variance in climate Civil disturbance/Human displacement Human Behaviour – - Occupation - Mistrust and Misinformation - Anti-infective drug prescription and use - Deliberate use to cause terror and harm.

Weakened public health infrastructure Weakened investment in public health in 2 nd half of twentieth century and deterioration of mosquito control campaigns led to resurgence of Aedes aegypti in urban areas. Dengue , before 1970 only 11 countries of Latin America had outbreak , now its in more than 69 countries. Now dengue is endemic in more than 100 countries. During 2003 , 1.4 million cases and 6600 deaths. Chikungunya outbreak in 2005 with initial 3111 human infection spread across pacific and till March 2006, more than 204000 cases were reported. Lapses in vaccination for diphtheria in USSR around 1990 led to outbreaks with more than 5000 cases in 1993.

Failure of safety Procedures/ Regulations 1980 – USSR , Romania – HIV and Hep B in more than 250 children and health workers. 1976, 1995 – Ebola in democratic republic of Congo where syringes and failed barrier nursing caused the diseases in health workers. Lapses in universal precautions led to nosocomial transmission of SARS in China , Hong Kong, Singapore . The outbreaks then spread through the health workers to the community.

Population Increase During to fast population growth , the sanitation ad basic infrastructure systems had collapsed or are inadequate. Cholera, which was rarely seen in Latin America for more than 100 years , returned back with an outbreak in Peru in 1991. It spread rapidly in Latin America. It caused nearly 400000 cases and 4000 deaths. By 1995, more than 1 million cases and more than 10000 deaths were reported all over south America. Urbanisation has brought its own set of problems. In 1994, India witnessed outbreaks of both bubonic and pneumonic plague in 5 states with around 800 infections and 56 deaths.

Anthropogenic activities or Natural Variance in climate. Deforestation leads to change in habitat of many animals and they start living closely to human population. Lassa fever in west Africa and sine nom virus in North America were spread in a same way. Chagas disease re-emerged due to mis-management of deforested lands & by movement of triatomines nearer to the human settlements. Nisseria meningitides , which is traditionally occurs in sub Saharan Africa spread . After a drought , it spreaded to Uganda and Tanzania. 1998 jpnese encephalitis , spread in png due to a drought , increase breeding sites for culex mostiques in dried river beds. It then transmitted through mosquito from birds, pigs, etc. in the area of Malaysia to India. El Nino – Rift valley fever in Kenya, Somalia, Tanzania. 89000 total infection with 478 deaths

Civil Disturbance/ Human displacement 1994 Rwanda – civil disobedience – 48000 cases of cholera and 23800 death within 1 month of displacement. 2004 – Marburg haemorrhagic fever in Angola which was still going through a civil war, spreading to more than 200 people and killing more than 90 % cases. 1998 – Similar outbreak of Malburg virus in Congo.

Human Behaviour Occupation - Anthrax – wool-sorters disease Ebola with people coming in contact with animals.. ( wood cutters, researchers, zoo workers) H7N7 – investigator, poultry workers. Mistrust and Misinformation -Rumours in 2003 in Nigeria – OPV for infertility. So in 2004 , polio outbreak. Nigeria had 70 % polio cases among world wide that year.

Anti infective drug prescription and use Over prescribing or under prescribing E coli multiple resistant strain are present in each country but more resistant strains in China and Venezuela , where over the counter anti biotics are very easily available. MDR TB, XDR TB in HIV positive people. Use of injudious antibiotics in veterinary cases. Deliberate use for bio-terrorism Anthrax letter following 9/11. Anthrax spores infection through letter to 22 people, 5 of whom died.

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

Examples of recent emerging diseases Source: NATURE; Vol 430; July 2004; www.nature.com/nature Dr. KANUPRIYA CHATURVEDI

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

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 Dr. KANUPRIYA CHATURVEDI

Swine Flu Influenza A (H1N1) March 18 2009 – ILI outbreak reported in Mexico April 15th CDC identifies H1N1 (swine flu) April 25th WHO declares public health emergency April 27th Pandemic alert raised to phase 4 April 29th Pandemic alert raised to phase 5 By May 5th more than 1000 cases confirmed in 21 countries Screening at airports for flu like symptoms (especially passengers coming from affected area) Schools closed in many states in USA May 16th India reports first confirmed case Stockpiling of antiviral drugs and preparations to make a new effective vaccine Dr. KANUPRIYA CHATURVEDI

Pandemic H1N1. Worldwide- Cases - 162,380 Deaths -1154 India- Cases - 558 Death - 1 26 Dr. KANUPRIYA CHATURVEDI

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) In India, plague reemerged in August 1994, when it was detected in the Beed district of Maharashtra. This was followed by pneumonic plague in Surat in Gujarat state, resulting in over 50 deaths and inducing a mass exodus of people. Eventually plague was reported from 12 Indian states. Dr. KANUPRIYA CHATURVEDI

Dr. KANUPRIYA CHATURVEDI

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, F. tularensis, Y. pestis, Variola virus, Viral haemorrhagic fever viruses Likeliest route- aerosol dissemination Dr. KANUPRIYA CHATURVEDI

National surveillance: current situation Independent vertical control programmes Surveillance gaps for important diseases Limited capacity in field epidemiology, laboratory diagnostic testing, rapid field investigations Inappropriate case definitions Delays in reporting, poor analysis of data and information at all levels No feedback to periphery Insufficient preparedness to control epidemics No evaluation Dr. KANUPRIYA CHATURVEDI

IHR and PHEIC 1969 – Member states of WHO agreed to new set of regulations – The International Health Regulations. For better regulations during trade and travel with minimum interference for public health security. Reporting 4 diseases – Cholera, plague, yellow fever, smallpox. Pre-established control measures at inter national borders. 2005 – IHR provided a more up-to-date legal framework of reporting any Public Health Emergency of International Concern. Using real time evidence to recommend measures to stop the international spread of diseases. Decision tree instrument is used to classify diseases under PHEIC or not. If the disease falls under PHEIC, its notification is needed even for single case.

GOARN- Global Outbreak Alert & Response Network Coordinated by WHO Mechanism for combating international disease outbreaks Ensure rapid deployment of technical assistance, contribute to long-term epidemic preparedness & capacity building Multidisciplinary network of technical and operational resources from over 200 global, regional and national public health institutions, specialist public health networks in epidemiology, infection control and biomedical sciences, networks of laboratories, many United Nations organizations and international nongovernmental organizations. GOARN harnesses international resources at the request of affected WHO Member States to augment their response to ongoing or potential public health emergencies. Since its inception GOARN has responded to over 120 deployments in 85 countries deploying more than 2300 experts in the field to assist Member States characterise and control disease outbreaks and respond to natural disasters and humanitarian emergencies The Global Outbreak Alert and Response Network (GOARN) is a technical collaboration of existing institutions and networks who pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. The Network provides an operational framework to link this expertise and skill to keep the international community constantly alert to the threat of outbreaks and ready to respond. The Global Outbreak Alert and Response Network contributes towards global health security by: combating the international spread of outbreaks ensuring that appropriate technical assistance reaches affected states rapidly contributing to long-term epidemic preparedness and capacity building. Dr. KANUPRIYA CHATURVEDI

Sharing Outbreak-related Information with Public Health Professionals with Public Dr. KANUPRIYA CHATURVEDI

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 Dr. KANUPRIYA CHATURVEDI

Solutions Internet-based information technologies Improve disease reporting Facilitate emergency communications & Dissemination of information 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 Solutions Dr. KANUPRIYA CHATURVEDI

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

Strategy 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 Dr. KANUPRIYA CHATURVEDI

Key tasks - carried out by whom? Global Regional Synergy National Dr. KANUPRIYA CHATURVEDI

Global Disease Intelligence: A world on the alert Collection Verification Distribution Response Dr. KANUPRIYA CHATURVEDI

The Best Defense (Multi-factorial) Coordinated, well-prepared, well-equipped PH systems Partnerships- clinicians, laboratories & PH agencies Improved methods for detection & surveillance Effective preventive & therapeutic technologies Strengthened response capacity Political commitment & adequate resources to address underlying socio-economic factors International collaboration & communication Dr. KANUPRIYA CHATURVEDI

Thank You

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