1. S. Machado Emerging Infectious Diseases: A Threat to Global Public Health and Economic Security Duane J Gubler Professor Signature Research Program in Emerging Infectious Diseases Duke-NUS Graduate Medical School, Singapore EcoHealth, Kunming, 16 Oct, 2012

2. Emerging Infectious Diseases: A Threat to Global Public Health and Economic Security Background Snapshot of recent epidemics Reasons for emergence and spread Prospects for the future Challenges to reverse the trends

4. The Global Threat of Infectious Diseases Emerging and re-emerging diseases Adapted from Morens, Folkers, Fauci 2004 Nature 430; 242-9 Emerging diseases Re-emerging diseases Chikungunya Dengue A/H1N1

5. Major Infectious Disease Epidemics since 1980 Dengue/DHF-1970s, SE Asia, global HIV/AIDS-1980s-Africa,global Drug resistant TB-1990s, US, global Cholera-1991-Americas Plague-1994-India, global Foot & Mouth disease-1995,2000- Taiwan & UK West Nile-1990s-Mediterranean, Americas BSE-1990s- UK, Canada, US Swine fever, 1996- Netherlands H5N1 influenza-1997- HK-global Nipah encephalitis-1998-Malaysia,Asia SARS-2002- Asia, global Chikungunya-2004-Africa, Asia H1N1 influenza-2009-Mexico?,global

6. What did these Epidemic Infectious Diseases have in Common ? All were caused by zoonotic pathogens All spread by modern transportation Most had Asian origin Laboratory and clinical diagnoses were problematic Poor communication among countries Major economic impact

7. Major Infectious Disease Epidemics since 1980 Dengue/DHF-1970s, SE Asia, global HIV/AIDS-1980s-Africa,global Drug resistant TB-1990s, US, global Cholera-1991-Americas Plague-1994-India, global Foot & Mouth disease-1995,2000- Taiwan & UK West Nile-1990s-Mediterranean, Americas BSE-1990s- UK, Canada, US Swine fever, 1996- Netherlands H5N1 influenza-1997- HK-global Nipah encephalitis-1998-Malaysia,Asia SARS-2002- Asia, global Chikungunya-2004-Africa, Asia H1N1 influenza-2009-Mexico?,global

8. Plague Pandemics Justinian’s Plague (mid-6 th Century A.D.) Black Death (mid-14 th Century A.D.) Modern Pandemic (1894 – mid-1900s)

10. Surat

11. Potential Spread of Pnuemonic Plague out of India, 1994 India Delhi Calcutta Madras Bombay

12. Pneumonic Plague in India Indian outbreak was a major surprise – no plague confirmed in India since 1966 Clinical and lab diagnosis Media and panic driven epidemic First epidemic to impact global air transportation Caused huge economic loss for India (> $3 billion)

13. Microbial Threats to Health

14. Guangdong Province, China A A Hotel M Hong Kong B J H Hospital 2 Hong Kong A H J B 4 other Hong Kong Hospitals C D E Hospital 3 Hong Kong Hospital 1 HK Hospital 4 Hong Kong 2 family members CDE 34 HCWs HCW B Germany Bangkok Singapor e United States I I L§L§ M§M§ Vietnam K † Ireland K † 37 HCWs HCW 0 HCWs 28 HCWs 156 close contacts of HCWs and patients F G † Canada G † F 4 family members 10 HCWs 37 close contacts 99 HCWs (includes 17 medical students) 4 HCWs* 3 HCWs HCW 2 family members Unknown number close contacts 2 close contacts * Health-care workers; † All guests except G and K stayed on the 9 th floor of the hotel. Guest G stayed on the 14 th floor, and Guest K stayed on the 11 th floor;  § Guests L and M (spouses) were not at Hotel M during the same time as index Guest A but were at the hotel during the same times as Guests G, H, and I, who were ill during this period. Chain of transmission among guests at Hotel M—Hong Kong, 2003 Data as of 3/28/03

15. Global SARS Cases (Probable) WHO 26 September 2003 CountryCasesDeathsCase fatality Canada2514315.3%15.3% China53273496.5%6.5% Hong Kong175529916.9%16.9% Singapore2383315.5%15.5% Taiwan3463712.5% Thailand9222%22% U.S.7500% Vietnam6357.9% Other8156.2% Total80987749.6%

16. Economic Impact of Selected Infectious Diseases Plague, India $5-6 bn

17. Why Have we Seen Such a Dramatic Increase in Epidemic Infectious Diseases? Complacency, Lack of Political Will Policy Changes Changes in Public Health Changing Life Styles/Behavior Microbial Adaptation Technology Intent to Harm Climate Change

18. Why Have we Seen Such a Dramatic Increase in Epidemic Infectious Diseases? Demographic Changes (Pop Growth)  Environmental Change - Uncontrolled Urbanization - Agricultural/Land Use Practices - Deforestation  Animal Husbandry Modern Transportation (Globalization)  Increased Movement of People, Animals, Commodities Lack of Public Health Infrastructure Major Drivers

19. Urban Growth in Asian (1) and American (2) Cities, 1950-2010 1.Mean population of Dhaka, Bangkok, Jakarta, Manila and Saigon. 2.Mean population of Rio de Janeiro, Sao Paulo, San Juan, Caracas and Guayaquil.

21. The global air network

22. Average annual number of global airline passengers by decade, 1950-2010 IATA 2010 Million of Passenger (Mil) Decade

23. Commercial Air Traffic Over a 24 Hour Period

24. Global distribution of dengue virus serotypes, 1970 Gubler, 1998

25. Global distribution of dengue virus serotypes, 1970-2000 1971 1975 1981 DENV – 1; DENV – 2; DENV – 3; DENV – 4 1985 1981 1994 1982 1980 1977 1979

26. Global distribution of dengue virus serotypes, 2012 Adapted from Gubler, 1998

27. Exotic Infectious Diseases That Have Recently Been Introduced to the US West Nile Fever Dengue Fever Yellow Fever Mayaro Fever Chikungunya Epidemic Polyarthritis SARS Influenza Lassa Fever Monkeypox CJD/BSE HIV/AIDS Cholera E. coli O157 E. Coli 0104:H4 Malaria Leishmaniasis Chagas Disease Cyclospora

28. Live Animal Importation into the USA - 2002 47,000 mammals  28 species of rodents 379,000 birds 2 million reptiles & Poisonous snakes 49 million amphibians 223 million fish Data from U.S. Fish & Wildlife Service

29. Exotic Mosquito Species Recently Introduced and Established in the US Aedes (Stegomyia) albopictus Ochlerotatus (Aedes Finlaya) togoi Ochlerotatus (Aedes Finlaya) japonicus Aedes bahamensis Culex biscayensis

30. Global Threat of Epidemic Infectious Diseases Disease and Trade-interwoven History  14 th century, Europe discovers exotic goods from Asia Global Trade Flourishes  18 th, 19, 20 th centuries New Millennium  Integrated global economic system with a transnational flow of knowledge, capital, products, people, animals, and pathogens  Rapid spread of epidemic infectious disease from point of origin

31. Urbanization Agricultural, land use and animal husbandry changes/practices Habitat alteration Species’ Ecological-evolutionary Dynamics Opportunistic habitat expansion/ecological release Vector (domestication) Vector/reservoir species Wildlife/reservoir transport/encroachment Human encroachment Host-Pathogen Dynamics Emergence Processes of ‘Host-Parasite Biology’ Host switching (host novelty) Breaching of pathogen persistence thresholds Transmission amplification and genetic change (pathogen novelty) Disease Emergence ecosystem continuum HUMAN ECOSYSTEM HUMAN ECOSYSTEM NATURAL ECOSYSTEMNATURAL ECOSYSTEM Global climate change Demographic Changes Technology/Globalization Socio-cultural organization REGIONAL ENVIRONMENTAL CHANGE

33. The Global Threat of Epidemic Infectious Diseases Asian countries will lead in economic growth Asian Cities will lead in population growth  Circular rural to urban migration Increased globalization  Increased trade  Increased movement of people, animals and commodities  Increased movement of pathogens Increased probability of epidemic disease Increased threat to global economic security Projected Global Trends

34. Tuesday, Oct 16, 2012 The Armageddon virus: Why experts fear a disease that leaps from animals to humans could devastate mankind in the next five years Warning comes after man died from a Sars-like virus that had previously only been seen in bats Earlier this month a man from Glasgow died from a tick-borne disease that is widespread in domestic and wild animals in Africa and Asia http://www.dailymail.co.uk/science

35. Pathogens of Tomorrow From Whence They Will Come? From Asia From Animals Mostly Viruses 35

36. Global Threat of Epidemic Infectious Diseases Challenge to Reverse the Trend Prevent movement of pathogens and vectors via modern transportation Improve international cooperation and data sharing Improve effective laboratory-based surveillance Rebuild public health infrastructure to prevent & control vector-borne and zoonotic diseases  Trained personnel  Laboratory and epidemiologic capacity  Tools (vaccines, drugs, insecticides, mosquito control, etc)  Understanding disease ecology Political will  Economic support  Regional prevention and control programs