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Infectious Disease Mortality in the United States, Source: JAMA 1996;275: and unpublished CDC data Year Deaths per 100,000 population Crude ID Mortality Rate CDC

Emerging Infections in the World and US since RotavirusEnteritis/Diarrhea 1976CryptosporidiumEnteritis/Diarrhea 1977Ebola virusVHF 1977Legionella Legionnaire’s dz 1977Hantaan virusVHF w/ renal flr 1977CampylobacterEnteritis/Diarrhea 1980HTLV-1Lymphoma 1981Toxin prod. S.aureusToxic Shock Synd. 1982E.coli 0157:H7HUS 1982HTLV-IILeukemia 1982Borrelia burgdorferiLyme disease

Emerging Infections in the World and US since HIVAIDS 1983Helicobacter pyloriPeptic ulcer dz 1988Hepatitis EHepatitis 1989Hepatitis C Hepatitis 1990Guanarito virusVHF 1991Encephalitozoon Disseminated dz 1992Vibrio cholerae O139Cholera 1992Bartonella henselaeCat scratch dz

Emerging Infections in the World and US since Sin Nombre virusHanta Pulm. Synd. 1994Sabia virusVHF 1994Hendra virusRespiratory dz 1995Hepatitis G Hepatitis 1995H Herpesvirus-8Kaposi sarcoma 1996vCJD prionVariant CJD 1997Avian influenza (H5N1)Influenza 1999Nipah virusEncephalitis 1999West Nile virusEncephalitis 2001BT Bacillus anthracisAnthrax 2003MonkeypoxPox 2003SARS-CoVSARS

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: Human demographics and behavior 2. Technology and Industry 3.Economic development and land use 4. International travel and commerce 5. Microbial adaptation and change 6. Breakdown of public health measures Institute of Medicine Report, 1992

More Factors Contributing to Emerging Infections: Human vulnerability 8.Climate and weather 9.Changing ecosystems 10.Poverty and social inequality 11.War and famine 12.Lack of political will 13.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 (kidney, liver, pancreas, heart, lung) Source: UNOS 70,000 60,000 50,000 40,000 30,000 20,000 10,000 0 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 From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994 CDC

Cyclospora Immature oocystsContaminated raspberries 10 µm 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* % Resistant * 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 Response Detect, investigate, and monitor emerging pathogens, the diseases they cause, and the factors influencing their emergence, and respond to problems as they are identified. CDC

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

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. Preventing Emerging Infectious Diseases CDC

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

 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 Preventing Emerging Infectious Diseases: More to Do

Common Palm Civet