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

2. 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

3. 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

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

5. 1991 – Peru . 23 Jan 1991 Cholera re-emerged after 100 years.
More than cases in 1st year.
In 1992, cases and 2602 deaths.
In 1994, cases and 1321 deaths.

6. 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

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

8. 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

9. 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

10. 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

11. 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)

12. 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

13. 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.

14. 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 cases were reported.
Lapses in vaccination for diphtheria in USSR around 1990 led to outbreaks with more than 5000 cases in 1993.

15. 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.

16. 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 cases and 4000 deaths.
By 1995, more than 1 million cases and more than 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.

17. 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 total infection with 478 deaths

18. Civil Disturbance/ Human displacement
1994 Rwanda – civil disobedience – cases of cholera and 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.

19. 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.

20. 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.

21. 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

22. Examples of recent emerging diseases
Source: NATURE; Vol 430; July 2004;
Dr. KANUPRIYA CHATURVEDI

23. 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

24. 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

25. Swine Flu Influenza A (H1N1)
March – 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

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

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

28. Dr. KANUPRIYA CHATURVEDI

29. 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

30. 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

31. 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.

32. 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

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

34. 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

35. 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

36. 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

37. 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

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

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

40. 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

41. Thank You

42. References
Dikid, T., Jain, S. K., Sharma, A., Kumar, A., & Narain, J. P. (2013). Emerging & re- emerging infections in India : An overview, (July), 19–31.
Morens, D. M., Folkers, G. K., & Fauci, A. S. (2004). The challenge of emerging and re- emerging infectious diseases, 430(July).
Morens, D. M., & Fauci, A. S. (2013). Emerging Infectious Diseases : Threats to Human Health and Global Stability, 9(7), 7–10.
Article, R. (2013). Emerging and re-emerging infections, 7(Suppl 1), 51–56.
Quaglio, G., Demotes-mainard, J., & Loddenkemper, R. (2012). Emerging and re- emerging infectious diseases: a continuous challenge for Europe, 40(6), 1312–
Heymann, D. L. (1992). Emerging and re-emerging infections. Oxford textbook of public health.
Emerging and re-emerging infections . Park textbook for preventive and social medicine.
Delgado, G., Morales, R., Mendez, J. L., & Cravioto, A. (2011). The Re-emergence of Cholera in the Americas, 79–95.