Emerging and Re-emerging Infectious Diseases 2003

Emerging and Re-emerging Infectious Diseases 2003 Outline

Emerging and Re-emerging Infectious Diseases 2003 Duc J. Vugia, M.D., M.P.H. Chief, Infectious Diseases Branch Division of Communicable Disease Control California Department of Health Services

WNV

Monkeypox from Prairie Dogs

Are infectious diseases emerging more recently than before?

Infectious Disease Mortality in the United States, 1980-1996 80 70 n 60 latio ate up 50 o 40 rtality R o M 30 e ID er 100,000 p 20 d s p ruC 10 eath D 0 1980 1982 1984 1986 1988 1990 1992 1994 1996 Year Source: JAMA 1996;275:189-193 and unpublished CDC data CDC

Emerging Infections in the World and US since 1973 1973 Rotavirus Enteritis/Diarrhea 1976 Cryptosporidium Enteritis/Diarrhea 1977 Ebola virus VHF 1977 Legionel a Legionnaire’s dz 1977 Hantaan virus VHF w/ renal flr 1977 Campylobacter Enteritis/Diarrhea 1980 HTLV-1 Lymphoma 1981 Toxin prod. S.aureus Toxic Shock Synd. 1982 E.coli 0157:H7 HUS 1982 HTLV-II Leukemia 1982 Borrelia burgdorferi Lyme disease

Emerging Infections in the World and US since 1973 1983 HIV AIDS 1983 Helicobacter pylori Peptic ulcer dz 1988 Hepatitis E Hepatitis 1989 Hepatitis C Hepatitis 1990 Guanarito virus VHF 1991 Encephalitozoon Disseminated dz 1992 Vibrio cholerae O139 Cholera 1992 Bartonel a henselae Cat scratch dz

Emerging Infections in the World and US since 1973 1993 Sin Nombre virus Hanta Pulm. Synd. 1994 Sabia virus VHF 1994 Hendra virus Respiratory dz 1995 Hepatitis G Hepatitis 1995 H Herpesvirus-8 Kaposi sarcoma 1996 vCJD prion Variant CJD 1997 Avian influenza (H5N1) Influenza 1999 Nipah virus Encephalitis 1999 West Nile virus Encephalitis 2001 BT Bacil us anthracis Anthrax 2003 Monkeypox Pox 2003 SARS-CoV SARS

Institute of Medicine 1992 Report on Emerging Infections Defined emerging infections as: “New, reemerging or drug-resistant infections whose incidence in humans has increased within the past two decades or whose incidence threatens to increase in the near future.”

Major Factors Contributing to Emerging Infections: 1992 1. Human demographics and behavior2. Technology and Industry3. Economic development and land use4. International travel and commerce5. Microbial adaptation and change6. Breakdown of public health measures Institute of Medicine Report, 1992

More Factors Contributing to Emerging Infections: 2003 7. Human vulnerability8. Climate and weather9. Changing ecosystems10.Poverty and social inequality11.War and famine12.Lack of political will13.Intent to harm Institute of Medicine Report, 2003

Emerging Infections: Human Demographics, Behavior, Vulnerability • More people, more crowding• Changing sexual mores (HIV, STDs)• Injection drug use (HIV, Hepatitis C)• Changing eating habits: out more, more produce (foodborne infections) • More populations with weakened immune system: elderly, HIV/AIDS, cancer patients and survivors, persons taking antibiotics and other drugs

Emerging Infections:Technology and Industry • Mass food production (Campylobacter, E.coli O157:H7, etc…) • Use of antibiotics in food animals (antibiotic-resistant bacteria) • More organ transplants and blood transfusions (Hepatitis C, WNV,…) • New drugs for humans (prolonging immunosuppression)

Organ Transplantation Year-end Waiting Lists vs. Transplanted 70,000 (kidney, liver, pancreas, heart, lung) 60,000 50,000 40,000 30,000 20,000 10,000 0 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 P atients W aiting Transplantations Source: UNOS CDC

Emerging Infections: Economic Development, Land Use, Changing Ecosystems • Changing ecology influencing waterborne, vectorborne disease transmission (e.g. dams, deforestation) • Contamination of watershed areas by cattle (Cryptosporidium) • More exposure to wild animals and vectors (Lyme disease, erhlichiosis, babesiosis, HPS,…)

Emerging Infections: International Travel and Commerce • Persons infected with an exotic disease anywhere in the world can be into major US city within hours (SARS, VHF,…) • Foods from other countries imported routinely into US (Cyclospora,….) • Vectors hitchhiking on imported products (Asian tiger mosquitoes on lucky bamboos,….)

Speed of Global Travel in Relation to World Population Growth ) 4 0 0 6 ) 3 5 0 5 3 0 0 2 5 0 4 navigate ( lobe 2 0 0 3 ircum 1 5 0 2 1 0 0 ays to C D the G 5 0 1 0 orld Population in bilions ( 0 W 1 8 5 0 1 9 0 0 1 9 5 0 2 0 0 0 Y e a r From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994 CDC

Cyclospora 10 µm Immature oocysts Contaminated raspberries CDC

Emerging Infections: Microbial Adaptation and Change • Increased antibiotic resistance with increased use of antibiotics in humans and food animals (VRE, VRSA, penicillin- and macrolide-resistant Strep pneumonia, multidrug-resistant Salmonella,….) • Increase virulence (Group A Strep?)• Jumping species from animals to humans (avian influenza, HIV?, SARS?)

Emerging Vancomycin-resistant Enterococcal Infections* t esistan R% * in U.S. NNIS Hospitals CDC

Emerging Infections: Poverty, Social Inequality, Breakdown of Public Health Measures • Lack of basic hygienic infrastructure (safe water, safe foods, etc..) • Inadequate vaccinations (measles, diphtheria) • Discontinued mosquito control efforts (dengue, malaria) • Lack of monitoring and reporting (SARS)

Emerging Infections: Intent to Harm • Bioterrorism: Anthrax in US 2001• Bio-Crimes: Salmonella in OR, Shigella in TX. • Potential agents: Smallpox, Botulism toxin, Plague, Tularemia, ….

CDC

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

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

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

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. CDC

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

Preventing Emerging Infectious Diseases: More to Do  Enhance communication: locally, regionally, nationally, globally  Increase global collaboration  Share technical expertise and resources  Provide training and infrastructure support globally  Ensure political support  Ensure judicious use of antibiotics  Vaccines for all

Common Palm Civet

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