1. Emerging and Re-emerging Infectious Diseases

2. INTRODUCTION
RESPONSIBLE FACTORS
CLASSIFICATION
DISEASES OF CONCERN
PREVENTION

3. INTRODUCTION : 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 .

4. DEFINITIONS 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 Diseases
These are the known diseases that have reappeared after a significant decline in incidence.

5. “Are infectious diseases emerging more recently than before? “5

6. 6

9. Major Factors Contributing to Emerging Infections: 1992
Human demographics and behavior
Technology and Industry
Economic development and land use
International travel and commerce
Microbial adaptation and change
Breakdown of public health measures

10. More Factors Contributing to Emerging Infections: 2003
Human vulnerability
Climate and weather
Changing ecosystems
Poverty and social inequality
War and famine
Lack of political will
Intent to harm

11. 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 (food-borne infections)
More populations with weakened immune system: elderly, HIV/AIDS, cancer patients and survivors, persons taking antibiotics and other drugs.

12. 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)
A big city on a sunny day

13. Emerging 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, …)

14. Emerging 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….)

15. Emerging 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?)

16. 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)

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

18. LIST OF EMERGING & RE-EMERGING DISEASES
GROUP-1
PATHOGENS NEWLY RECOGNIZED IN LAST TWO DECADES
ACANTHAMOEBIASIS
BABESIOSIS
BARTONELLA HENSELE
EHERLICHIOSIS
CORONA VIRUS(SARS)

19. CONTD… H.PYLORI HEPATITIS C HEPATITIS E HUMAN HERPES VIRUS8(HHV8) HHV6
LYME
BORRELIOSIS
PARVO VIRUS B19

20. REMERGING PATHOGENS GROUP-2 ENTEROVIRUS71 CLOSTRIDIUM DEFFICILE
COCCIDIOIDES IMMITIS
MUMPS VIRUS
PRION
STREPTOCOCCUS GROUP A
STAPHYLOCOCCUS AUREUS

21. AGENTS WITH BIOTERRORISM POTENTIAL CATEGORY A B.anthracis C.botulinum
GROUP-3
AGENTS WITH BIOTERRORISM POTENTIAL
CATEGORY A
B.anthracis
C.botulinum
Y.pestis
V.major
F.tulariensis
Hanta virus

22. CATEGORY B
B.mallei
B.pseudomallei
C.brunetti
Brucella
Ricin toxin
Epsilon toxin(c.perfringens)
EnterotoxinB(staphylococcus)
Viral encephalitides(Japanese encephalitis virus,kyasanur forest virus)

23. FOOD &WATER BORNE DISEASES
CONTD…
FOOD &WATER BORNE DISEASES
BACTERIA(E.coli,Vibrio,shigella)
VIRUS(Hepatitis A,Calcivirus)
PROTOZOANS(Giardia,Entamoeba,Cryptosporidium)

24. CATEGORY C TICK BORN HAEMORRHAGIC FEVERS TICK BORN ENCEPHALITIC FEVER
YELLOW FEVER
MDR TB & XDR TB
RABIES
SARS ASSOCIATED CORONAVIRUS
ANTIMICROBIAL RESISTANCE

25. IMPORTANT RE-EMERGING DISEASES
TUBERCULOSIS
DENGUE FEVER
MALARIA
MENINGOCOCCAL MENINGITIS
BUBONIC PLAGUE
HANTA VIRUS PULMONARY SYNDROME

27. HIV/AIDS Present situation and challenges
HIV epidemic in SEAR mainly due to:
Unsafe sex
Injecting drug use
Poverty
Low literacy
Widespread stigma
Weak health systems.
India, Thailand, Myanmar, Indonesia and Nepal – account for the majority of the burden in the Region.

28. SARS
A 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.)

29. AVIAN 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.

30. Sufficient 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.

31. 31

32. Tuberculosis Present situation
Every year
3 million people newly affected.
over lose their lives.
Tuberculosis Present situation
SEAR 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.

33. TB 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 cases
STOP TB STRATEGY adopted by WHO in 2006 focusses on prevention & control of MDR-TB & HIV -TB

35. Malaria Present situation and challenges
PAST TWO DECADES
The 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.

36. Malaria Present situation and challenges
India reports the largest proportion of malaria cases in the Region.
Annually there are approximately 100 million cases in SEAR
PRESENTLY
About 2.5 million cases and 4000 deaths per year.

37. DENGUE 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.

39. State wise dengue cases and deaths, India, 1998-2001
States
1998
1999
2000
2001
Cases
Deaths
Andhra Pradesh
--- 05
Nil
Delhi
333
168 02
180
Goa 1
Gujarat 92 29
Haryana 14 03 2
Karnataka
115 39 45
Kerala
Maharashtra
199 59 12 66
Orissa 11
Punjab
419 01 91
Rajasthan
Tamilnadu 33
135 81 06
Uttar Pradesh 28
Total
707 18
944 17
622 07 57

40. PLAGUE
In SEAR, natural foci of plague- exist in INDIA, INDONESIA , MAYANMAR & NEPAL
No case was reported after 1966 in INDIA till it re-emerged in sept 2004 in MAHARASHTRA
1997- outbreak of pneumonic plague in SURAT
cases of pneumonic plague(4 deaths) in hatkoti , distt SHIMLA

42. SCRUB TYPHUS
During 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.

43. Response 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.

44. Prevention of Emerging Infectious Diseases
Surveillance and Response
Applied Research
Infrastructure and Training
Prevention and Control
The 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.

45. Surveillance Global / Regional level laboratory surveillance
FLUNET : Surveillance network for monitoring influenza\
RABNET : Surveillance network for rabies
PANCET : Pacific Public Health Services Network - to improve surveillance in pacific island.

46. Surveillance 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 fever
WHO Disease / rumor outbreak list - list unconfirmed disease outbreaks worldwide.

48. Global & 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 sites
Influenza 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 .

51. Research:
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.

52. EMERGING DISEASES RESEARCH

53. Infrastructure 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.

54. Prevention and Control
Global outbreak Response:
It involves- building a team, obtaining access and travelling to affected area, recommending and implementing control measures.

55. NATIONAL LEVEL
District 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.

56. FETP (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 epidemiology
Epi – Aid : For rapid deployment of professional staff to aid outbreak verification & control.

57. Future 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' vaccine
2. recombinant proteins
to fight against HIV/AIDS, malaria and tuberculosis
Sequencing the genomes  develop effective vaccines and drugs.
Other developments  next-generation anthrax vaccine, Ebola vaccine and monoclonal antibodies against botulism toxin

58. Partnerships 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

59. GUIDED BY:- DR. ANUPAM PARASHAR

60. PRESENTED BY: Nandini sood(0537) Neha chauhan(0538) Nitin Sood(0539)
Nishant sharma(0540)
Nripen Gaur(0541)
Priyanka Sood(0542)

61. THANKS