2INTRODUCTIONRESPONSIBLE FACTORSCLASSIFICATIONDISEASES OF CONCERNPREVENTION
3INTRODUCTION : INFECTIOUS DISEASES Accounted for about 26% of the 57 million deaths worldwide in 2002.Remain among leading causes of death worldwide despite remarkable advances in medical research and treatments.In addition, nearly 30% of all disability adjusted life years (DALYs) could be accounted to infectious diseases.Emergence of new infectious diseases, re-emergence of old infectious diseases and persistence of intractable infectious diseases, all led to persistence and even increase in infectious diseases in many parts of the world .
4DEFINITIONS Emerging Infectious Diseases It includes outbreaks of previously unknown diseases or known diseases whose incidence in humans has significantly increased in the past two decades.Re-emerging Infectious DiseasesThese are the known diseases that have reappeared after a significant decline in incidence.
5“Are infectious diseases emerging more recently than before? “ 5
9Major Factors Contributing to Emerging Infections: 1992 Human demographics and behaviorTechnology and IndustryEconomic development and land useInternational travel and commerceMicrobial adaptation and changeBreakdown of public health measures
10More Factors Contributing to Emerging Infections: 2003 Human vulnerabilityClimate and weatherChanging ecosystemsPoverty and social inequalityWar and famineLack of political willIntent to harm
11Emerging 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 (food-borne infections)More populations with weakened immune system: elderly, HIV/AIDS, cancer patients and survivors, persons taking antibiotics and other drugs.
12Emerging 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)A big city on a sunny day
13Emerging Infections: Economic Development, Land Use, Changing Ecosystems Changing ecology influencing waterborne, vector borne disease transmission (e.g. dams, deforestation)Contamination of watershed areas by cattle (Cryptosporidium)More exposure to wild animals and vectors (Lyme disease, erhlichiosis, babesiosis, …)
14Emerging Infections: International Travel and Commerce Persons infected with an exotic disease anywhere in the world can be into your city within hours (SARS)Foods from other countries imported routinely into your city (Cyclospora,….)Vectors hitch-hiking on imported products (Asian tiger mosquitoes on bamboos….)
15Emerging Infections: Microbial Adaptation and Change Increased antibiotic resistance with increased use of antibiotics in humans and animals (VRE, VRSA, penicillin- and macrolide-resistant Strep pneumoniae, multidrug-resistant Salmonella,….)Increase virulence (Group A Strep)Jumping species from animals to humans (avian influenza, HIV?, SARS?)
16Emerging 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)
17Emerging Infections: Intent to Harm Bioterrorism: Anthrax in US 2001Bio-Crimes: Salmonella , ShigellaPotential agents: Smallpox, Botulism toxin, Plague, Tularemia, ….
18LIST OF EMERGING & RE-EMERGING DISEASES GROUP-1PATHOGENS NEWLY RECOGNIZED IN LAST TWO DECADESACANTHAMOEBIASISBABESIOSISBARTONELLA HENSELEEHERLICHIOSISCORONA VIRUS(SARS)
19CONTD… H.PYLORI HEPATITIS C HEPATITIS E HUMAN HERPES VIRUS8(HHV8) HHV6 LYMEBORRELIOSISPARVO VIRUS B19
27HIV/AIDS Present situation and challenges HIV epidemic in SEAR mainly due to:Unsafe sexInjecting drug usePovertyLow literacyWidespread stigmaWeak health systems.India, Thailand, Myanmar, Indonesia and Nepal – account for the majority of the burden in the Region.
28SARSA patient was admitted in Vietnam on 26th Feb with respiratory illness and died in March 2003.7 health workers who cared for this patient also became ill on 5th March 2003.Since then, the cases have been reported from many countries.International travel facilitated its spread rapidly.It was found that the disease initially emerged in China in November 2002.The etiological agent is a virus -- isolated, but yet to be identified. Perhaps, it is a mutated strain of corona virus or a virus, which has jumped from an animal species to humans.The infection is spread through droplets/aerosols. (It is also possible that SARS is transmitting through other unidentified routes.)
29AVIAN INFLUENZA REASONS FOR CONCERN ABOUT THE CURRENT OUTBREAKS Most outbreaks caused by the highly pathogenic H5N1 strain.Strain has unique capacity to jump the species barrier & cause severe disease, with high mortality, in humans.Gene swapping between the human & viruses inside the human body can give rise to a comavian pletely new subtype of the influenza virus to which Very few, if any, humans would have natural immunity.
30Sufficient human genes in virus direct man to man transmission Pandemic. influenza pandemic of 1918–1919 when the virus spread around the globe in 4-6 months.existing vaccines, would not be effective against completely new influenza virus.
32Tuberculosis Present situation Every year3 million people newly affected.over lose their lives.Tuberculosis Present situationSEAR with 5million cases, has the highest number of TB cases among all WHO regions.Bangladesh, India, Indonesia, Myanmar and Thailand are among the 22 high-burden countries in the world and together account for 95% of the TB burden in the Region.TB -most common opportunistic infection among HIV-infected.~3 million people co-infected with HIV & TB.
33TB has emerged as MDR-TB & XDR-TB About 50 million people worldwide are infected with drug resistant TB% of MDR-TB in INDIA in 2004 was 2.4 among new casesSTOP TB STRATEGY adopted by WHO in 2006 focusses on prevention & control of MDR-TB & HIV -TB
35Malaria Present situation and challenges PAST TWO DECADESThe proportion of Plasmodium falciparum malaria has increased from 12% to more than 45%.Increasing resistance of Plasmodium falciparum to first- and second line anti- malarial drugs.
36Malaria Present situation and challenges India reports the largest proportion of malaria cases in the Region.Annually there are approximately 100 million cases in SEARPRESENTLYAbout 2.5 million cases and 4000 deaths per year.
37DENGUE Present situation and challenges Dengue has emerged as a serious public health problem over the last few decades.Disease is spreading to new geographical areas, and frequency of outbreaks has increased.During 2007, outbreaks have been reported from a number of countries in Asia including Thailand, Cambodia, Indonesia, Vietnam, Philippines and even in Singapore, which has one of the best dengue control programmes.
39State wise dengue cases and deaths, India, 1998-2001 States1998199920002001CasesDeathsAndhra Pradesh---05NilDelhi33316802180Goa1Gujarat9229Haryana14032Karnataka1153945KeralaMaharashtra199591266Orissa11Punjab4190191RajasthanTamilnadu331358106Uttar Pradesh28Total70718944176220757
40PLAGUEIn SEAR, natural foci of plague- exist in INDIA, INDONESIA , MAYANMAR & NEPALNo case was reported after 1966 in INDIA till it re-emerged in sept 2004 in MAHARASHTRA1997- outbreak of pneumonic plague in SURATcases of pneumonic plague(4 deaths) in hatkoti , distt SHIMLA
42SCRUB TYPHUSDuring world war II, an epidemic of scrub typhus occurred in ASSAM & WEST BENGAL.,it was reported from INDIA, CHINA, JAPAN, INDONESIA & MALAYSIA.In july,2008 ,outbreak occurred in some areas of HP.
43Response To “Threat”Various international & national organizations have come together to combat this threat.WHO, CDC, NIH, Department of Defense & FDA.ALL work in collaboration to develop strategic plans to combat the microbial emergence and re-emergence.
44Prevention of Emerging Infectious Diseases Surveillance and ResponseApplied ResearchInfrastructure and TrainingPrevention and ControlThe plan is organized around four interdependent goals: Surveillance and Response, Applied Research, Infrastructure and Training, and Prevention and Control. Surveillance systems at the state and national levels monitor emerging microbes and detect outbreaks of disease.When surveillance data or other information uncover a change in the occurrence of distribution of a disease, or when a new strain of a microbe becomes a health threat, public health workers investigate, assess the potential public health implications, and mount a rapid response. Through applied research, they provide answers to questions about the disease’s causes, transmission, diagnosis, prevention, and control.A specialized infrastructure supports and equips their work and links them in national and global communications network. Training the next generation of scientific experts is a crucial component of this public health strategy. All of these efforts are ultimately directed toward disease prevention--the institutionalization of public awareness and behavior change, and disease control--the application of the most effective tools and technologies to strengthen personal and community capacities to prevent infectious diseases.
45Surveillance Global / Regional level laboratory surveillance FLUNET : Surveillance network for monitoring influenza\RABNET : Surveillance network for rabiesPANCET : Pacific Public Health Services Network - to improve surveillance in pacific island.
46Surveillance GPHIN : Global Public Intelligence Network Antimicrobial resistance information bank Global / Regional level epidemiological surveillance.International Health Regulations (IHR) mandatory reporting of certain infectious diseases eg. Cholera, plague, yellow feverWHO Disease / rumor outbreak list - list unconfirmed disease outbreaks worldwide.
48Global & National Surveillance Systems / Networks At National Level - strong surveillance system is required to collect relevant, accurate & timely information of an outbreak.WHO – at Global Level- act as focal point for data exchange. WHO has recommended surveillance standards for 40 specific diseases and 8 syndromes.HIV/AIDS network – through sentinel sitesInfluenza network- Collects information from member laboratories to make decision regarding vaccine composition .Tuberculosis monitoring system- Produces reports on notification, results and the extent of implementation of DOTS .Global salmonella surveillance network .
51Research:Various organizations like CDC, National Institute of Allergy & Infectious Diseases (NIAID), National Institute of Diabetes Digestive and Kidney diseases (NIDDK), has made research contributions in field of HIV/AIDS, Tuberculosis, Malaria, Hepatitis C etc.Advances in genomics, proteomics better understanding of pathogenesis, host immunity & drug resistance and identifying new drug targets & develop new vaccines and diagnostics.
53Infrastructure and Training : Strengthen public health infrastructures to support surveillance, response, and research.To implement prevention and control programs.Provide the public health work force with the knowledge and tools it needs.Infrastructure and Training :Rebuilding the public health infrastructure will require an ongoing and sizable investment in modernization and training to boost local, state, national, and global disease-monitoring power and to augment outbreak-response expertise. These improvements are the only way to guarantee that the United States, and the world, are prepared with trained experts, well-equipped laboratories, and cutting-edge technology to head off emerging microbes in the decades to come. Public health infrastructure and training support public health actions.Nations, states, and communities need strong infrastructure to sustain disease surveillance, research, and prevention and to prepare for the unexpected. They need modern laboratories that are equipped to recognize widespread microbial agents like Helicobacter pylori and E. coli O157:H7. They need people, equipment, and know-how to perform jobs as diverse as disease surveillance, microbe identification, restaurant inspections, water-supply tests, vaccination campaigns, and public health education.They need communications technologies to link scientists in national and global networks. They need training to teach laboratory researchers how to perform diagnostic tests and process hazardous specimens, to instruct workers about new tools and techniques, and to prepare the next generation of scientists to confront emerging disease challenges.
54Prevention and Control Global outbreak Response:It involves- building a team, obtaining access and travelling to affected area, recommending and implementing control measures.
55NATIONAL LEVELDistrict epidemic management committee:-For resource mobilization, monitoring and evaluation of control activities; dissemination of information to public & documentation of outbreak.District rapid response team:- For investigation of outbreak and implementation of control activities at the district level.The Health facility personnel:- For case management, reporting and education of public.Community Leaders: Helping in controlling the epidemic.
56FETP (Field Epidemic Training Programme) PHSWOW Programme (Public Health Schools without walls)- Two year field and academic training programme, established by CDC in collaboration with Rockefeller foundation.TEPHINET : Training programme in epidemiologyEpi – Aid : For rapid deployment of professional staff to aid outbreak verification & control.
57Future Outlook : MAJOR GOAL: -development and production of counter measures.-requires basic research and concept development.Application and research in molecular biology.To develop a second- generation of vaccines (safe and effective) e.g.1.‘naked DNA' vaccine2. recombinant proteinsto fight against HIV/AIDS, malaria and tuberculosisSequencing the genomes develop effective vaccines and drugs.Other developments next-generation anthrax vaccine, Ebola vaccine and monoclonal antibodies against botulism toxin
58Partnerships among clinicians, researchers, government and industry. Improving#surveillance,#disease control# response to an outbreak through improved laboratory facilities# training of personnel# establishing reliable and efficient communication networks# strong public health