Emerging Infectious Diseases: The ongoing Pandemics د. وائل أحمد هياجنة Wail A. Hayajneh, MD, FAAP Associate Professor of Pediatric Infectious Diseases JUST, KAUH, & KHCC 26/06/2018 26/06/2018 1 1

Defining Respiratory emerging and re-emerging diseases Objectives Defining Respiratory emerging and re-emerging diseases Why are we worried? Basics of new diseases 2

Global Causes of Children Deaths: 2013

New Millennium Outbreaks 2002-2003 SARS 2012 MERS - CoV 2005 H5N1 2009 PandemicH1N1

Summary of outcomes Disease Cases Deaths SARS 8273 775 H5N1 850 449 ?????? (millions) 284500 MERS - CoV 1733 628

Economic Costs of Major Infectious Diseases Outbreaks

Definition: Emerging Infectious Diseases Newly identified & previously unknown infectious agents that cause public health problems either locally or internationally

Definition: Re-emerging Infectious Diseases 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

Definition New Pathogen A known pathogen invading a new host A known pathogen causing worse disease New antimicrobial resistance patterns

Where is the Origin? (Known Infections) Carnivores Primates Ruminants Birds Rodents Infectious Agents Humans 61 % of 1415 Infections Ann. Rev. Ecol. Evol. Syst. 41 (2010) 231–250.

Where is the Origin? (Emerging Infections) Carnivores Primates Ruminants Birds Rodents Infectious Agents Humans 71 % of emerging infections Ann. Rev. Ecol. Evol. Syst. 41 (2010) 231–250.

Multi-host Species Systems Birds Pigs New Pathogen Human Host 3

Density-dependent transmission Frequency-dependent transmission Do host communities influence the dynamics of pathogens? Density-dependent transmission Directly-transmitted infections Frequency-dependent transmission Sexually transmitted diseases Vector-borne diseases

Recognized in the past 2 decades Emerging Diseases: NIAID List: Group I Recognized in the past 2 decades Acanthamebiasis Australian bat lyssavirus Babesia, atypical Bartonella henselae Ehrlichiosis Encephalitozoon cuniculi Encephalitozoon hellem Enterocytozoon bieneusi Helicobacter pylori Hendra or equine morbilli virus Hepatitis C Hepatitis E Human herpesvirus 8 Human herpesvirus 6 Lyme borreliosis Parvovirus B19

Re-emerging Pathogens Re-emerging Diseases: NIAID List: Group II Re-emerging Pathogens Enterovirus 71 Clostridium difficile Mumps virus Streptococcus, Group A Staphylococcus aureus

Emerging Diseases: NIAID List: Group III Agents with Bioterrorism Potential (Cat A) Bacillus anthracis (anthrax) Clostridium botulinum toxin (botulism) Yersinia pestis (plague) Variola major (smallpox) and other related pox viruses Francisella tularensis (tularemia) Viral hemorrhagic fevers Arenaviruses LCM, Junin virus, Machupo virus, Guanarito virus Lassa Fever Bunyaviruses Hantaviruses Rift Valley Fever Flaviruses Dengue Filoviruses Ebola Marburg

Emerging Diseases: NIAID List: Group III Agents with Bioterrorism Potential (Cat B) Burkholderia pseudomallei Coxiella burnetii (Q fever) Brucella species (brucellosis) Burkholderia mallei (glanders) Chlamydia psittaci (Psittacosis) Ricin toxin (from Ricinus communis) Epsilon toxin of Clostridium perfringens Staphylococcus enterotoxin B Typhus fever (Rickettsia prowazekii)

Emerging Diseases: NIAID List: Group III Agents with Bioterrorism Potential (Cat B) Food- and Waterborne Pathogens Diarrheagenic E.coli Pathogenic Vibrios Shigella species Salmonella Listeria monocytogenes Campylobacter jejuni Yersinia enterocolitica Hepatitis A Cryptosporidium parvum Cyclospora cayatanensis Giardia lamblia Entamoeba histolytica Toxoplasma Microsporidia

Agents with Bioterrorism Potential (Cat C) Emerging Diseases: NIAID List: Group III Agents with Bioterrorism Potential (Cat C) Tickborne hemorrhagic fever viruses (CCHF) Tickborne encephalitis viruses Yellow fever Tuberculosis, including drug-resistant TB Influenza Other Rickettsias Rabies Prions Chikungunya virus SARS Antimicrobial resistance

الانفلــــونزا الموسمية: حقائـــق وأوهــــام 26/06/2018 KAUH-2015 20

INFLUENZA VIRUS 26/06/2018 KAUH-2015

INFLUENZA: Types Influenza A Influenza B Influenza C HA √ √ √ NA √ √ X DRIFT √ √ X SHIFT √ X X Human √ √ √ Animals √ X X Epidemics √ √ X Pandemics √ X X 26/06/2018 KAUH-2015

INFLUENZA VIRUSES H1----H16 N1----N9 H5N1 H5N2 H5N3 H5N4 H5N5 H5N6 26/06/2018 KAUH-2015

HUMAN VIRUSES H1 H2 H3 N1 N2 H1N1 H2N1 H3N1 H1N2 H2N2 H3N2 26/06/2018 KAUH-2015

EPIDEMICS HISTORY Year Strain Deaths 1889 H2N2 1900 H3N2 1918 H1N1 Comments 1889 H2N2 1900 H3N2 1918 H1N1 40 millions Spanish Flu 1957 H2N2 70,000 Asian Flu 1968 H3N3 34,000 Hong Kong Flu 1977 H2N2 1997 H5N1 Hong Kong Epidemic 2003 H7N7 2004 26/06/2018 H5N1 KAUH-2015

الانفلونزا الاسبانية 1918 26/06/2018 KAUH-2015

كيف تكون الفيروس فيروس 3 فيروس 2 فيروس 1 26/06/2018 KAUH-2015

Minor changes during genomic Replication Major changes (Reassortment) GENETICS DYNAMICS SHIFT Minor changes during genomic Replication DRIFT Major changes (Reassortment) 26/06/2018 KAUH-2015

PANDEMIC PHASES Virus only in animals The virus has caused infection in human PHASE 3 Few Human-to-Human transmission PHASE 4 Community-level outbreaks PHASE 5 Spread in 2 countries of the same WHO region PHASE 6 PANDEMIC: 2 WHO Regions 26/06/2018 KAUH-2015

PANDEMIC PHASES 27-4-09 29-4-09 10-8-10 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses: Northern Hemisphere 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses: Southern Hemisphere 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses: EMRO 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses: Jordan 26/06/2018 KAUH-2015

Global Circulation of Influenza Viruses: Jordan 26/06/2018 KAUH-2015

الفحوصات اللازمة PCR Full blood count (CBC) Serum electrolytes Hepatic function (AST,ALT) Renal function (urea,creatinine) Glucose Urine analysis Chest x ray CPK, LDH Blood Culture 26/06/2018 KAUH-2015

Mild Case with risk factors Evaluation of suspected case In Isolation Room at ER Mild Case without risk factors Mild Case with risk factors Severe Case Discharge home No PCR No Oseltamivir Infection Control Education at Home Return to ER if worsens Discharge home No PCR Give Oseltamivir Infection Control Education at Home Return to ER if worsens Admission PCR Oseltamivir Infection Control precautions 26/06/2018 KAUH-2015

ANTIVIRALS 26/06/2018 KAUH-2015

ANTIVIRAL USE 75 mg twice per day for 5 days No Prophylaxis < 15 kg Agent Weight or Age Treatment Prophylaxis Oseltamivir Adults   75 mg twice per day for 5 days No Prophylaxis Children ≥ 12 months < 15 kg 30 mg twice per day for 5 days 15-23 kg 45 mg twice per day for 5 days 24-40 kg 60 mg twice per day for 5 days >40 kg Children < 12 months < 3 months 12 mg twice per day for 5 days 3-5 months 20 mg twice per day for 5 days 6-11 months 25 mg twice per day for 5 days Zanamivir 10 mg (two inhalations) twice per day Children ≥ 7 years Children 5-6 years Not recommended Children < 5 years 26/06/2018 KAUH-2015

IIV-(Inactivated Influenza Vaccine) Flu Vaccines IIV-(Inactivated Influenza Vaccine) - IIV3(egg-based and cell culture-based trivalent inactivated influenza vaccine (IIV3), and - IIV4(egg-based quadrivalent inactivated influenza vaccine (IIV4). RIV4 LAIV4 26/06/2018 KAUH-2015

REDUCING RISK FOR COMUNITY Frequent handwashing Covering coughs Reduction of unnecessary social contacts Avoidance crowded settings whenever possible . 26/06/2018 KAUH-2015

MERS - CoV 26/06/2018 KAUH-2015 44