Emerging Infections: What is there? What may be coming?

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Emerging InfectionsWhat is there?What may be
coming?

• Infectious Disease Epidemiology Section
• Office of Public Health
• Louisiana Dept of Health Hospitals
• 800-256-2748
• www.infectiousdisease.dhh.louisiana.gov

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Objectives

• 1-Understand the reasons for the changes in the
  impact of infectious diseases

2-Evaluate the merits and short-comings of a
surveillance system and apply the knowledge to
improve surveillance 3-Develop a plan for
surveillance and control for an emerging
infection affecting their health care facility
To achieve these objectives the presentation will
include reviews of some examples and draw lessons
to improve surveillance
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The Concept of Emergence

• Emerging infectious diseases are diseases of
  infectious origin whose incidence in humans has
  increased within the past two decades or
  threatens to increase in the near future

• Menu of Emerging Diseases
• Really NEW infectious disease
• Changing patterns of infectious diseases
• Old infectious diseases NEWLY IDENTIFIED
• Old infectious disease with NEW ENERGY
• Old infectious disease SWINGING BACK FORTH
• Old infectious disease which REFUSE TO GO AWAY

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Understand the Reasons for the Changes in the
Impact of Infectious Diseases
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As the World TurnsIt Changes

1. Aging rising longevity and increasing vulnerable
   elderly population
2. Growing numbers of immuno-comprised people as a
   result of medical progress
3. Growing population
4. Urbanization
5. Increase in disasters ?
6. Bioterrorism events
7. Globalization of human and animal movements and
   food supply.
8. Environmental degradation
9. Cluster detection
10. Institutionalized population increase Hospital,
    long-term care facilities, Schools, day-care
    centers
11. Pandemics
12. Vanishing diseases polio, measles
13. Spreading of hunger in the developing world
14. Increase in refugee populations

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Emerging Diseases
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How Migrations from Rural to Urban Areas in
Africa Triggered a Pandemic
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Once upon a time in Africa

• Two different monkeys, the red-capped mangabey
  (Cercocebus torquatus) and the greater spot-nosed
  monkey Cercopithecus nictitans) were infected
  with the Simian Immunodeficiency Virus (SIV).

The chimpanzees ate the monkeys so they acquired
the monkey viruses. The hybrid virus then spread
through the chimpanzee species to become
SIVcpz. The chimpanzees are not known to
develop any disease symptoms.
Then humans ate the chimps and acquires the
SIVcpz. The virus evolved into the HIV virus In
the 1950s, HIV became a rare infection among
dwellers in African villages
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Then HIV stayed in the villagesPrevalence of
Infection over a 10 Year Period in Zaire

• 1976 659 serum samples collected in Equateur
  Province, Zaire because of Ebola epidemic at
  Yanbuku Mission Hospital
• 1985 samples examined for HIV antibodies 5/659
  Pos 0.8
• 1986 cluster sample of Yambuku population
  selected groups re-surveyed
• Of the 5 positive in 1976 2 alive well, 3 died
  of AIDS-like disease
• Only 1 of the 5 had traveled outside of the
  village
• Population sample 3/388 Pos 0.8
• Femmes Libres 32/283 Pos 11.3
• Pregnant women 3/136 Pos 2.2
• STABLE HIV IN VILLAGE
• present in 1976, No major change in 10 years
• In Kinshasa meanwhile HIV prevalence among
  pregnant women was x10
• Nzilambi N 1988. NEJM 318276

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Finally HIV moved to town and started to travel
worldwide

• 1950 From African forest monkeys ? Humans
• 1950-60 Stable among isolated villages in forest
• 1960-70 Moving to town
• 1970-80 Build up among STD core transmission
  groups
• Few cases among travelers to Africa, all
  missed

• 1981 the first cases recognized
• Few cases of Pneumocystis carinii pneumonia
  clustered among homosexual men in Los Angeles
  (CDC 1981. Pneumocystis pneumonia, Los Angeles.
  MMWR 30 33 409-420)
• Outbreak of Kaposis sarcoma also among
  homosexual men
• Common thread profound immunodeficiency
• ? Acquired Immune Deficiency Syndrome p

Lesson Global surveillance in high risk areas
for generating emerging disease, USGov GLOBAL
HEALTH INITIATIVE Lesson In US, keep aware of
new threats
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Emerging DiseasesTravel Dengue
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Dengue

• GOOD OLD DAYS
• 1779-1780 in Asia, Africa, N.America outbreaks
• dengue fever benign, nonfatal disease of
  visitors to tropics
• long intervals (10-40 y) between major epidemics

• MEAN NEW DAYS
• global pandemic started in SEAsia after World War
  II intensified during the last 15 years.
• Before 1970 DHF epidemics in 9 countries
• Since 1970s endemic in 100 countries in Africa,
  the Americas, the Eastern Mediterranean,
  South-East Asia and the Western Pacific
• 1995 endemic in 41 countries
• 2.5 billion (2/5 world) at risk, 50 million cases
  /yr
• 1995 Americas 275,000 cases, 7,715 cases DHF
• attack rates 6.4 per 100 persons exposed

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Geographic Distribution

• Tropical regions, in urban peri-urban
• Transmitted by Aedes aegypti
• Breeding in peridomestic waters (flower pots, tin
  cans, discarded tires, barrels, buckets,
  cisterns)
• Bites during day

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Dengue

• Incubation 2-7 days
• Asymptomatic or
• Breakbone fever
• high fever (40?C), severe pains, headache,
  retro-orbital pain, backache, arthralgias
• transient erythematous rash that blanches under
  pressure

• Starts as classical dengue
• Condition deteriorates sweating, hypotension,
• Disseminated hemorrhagic symptoms (petechiae,
  ecchymoses, spontaneous hemorrhages,
  thrombocytopenia, alteration in clotting factors,
  reduced fibrinogen)
• Case Fatality Rate NoTx50, Tx1 to 5

Lesson Ask about travel history Lesson Order
appropriate lab tests
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Dengue Virus Tree

• Nothing happens for 2,000 years then Dengue virus
  blooms

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Chikungunya
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History

• First isolated from the serum of a febrile human
  in Tanganyika (Tanzania) in 1953
• 1960s - 1980s, virus isolated from countries
• in western Africa (Senegal Nigeria), central,
  southern Africa
• in many areas of Asia
• Since 1953, numerous outbreaks and epidemics in
  both Africa and Southeast Asia, involving
  hundreds of thousands of people
• Recently spread to Caribbean From 2013 to 2014
  increased from few cases to 100,000s
• CHIK probably more common than suspected
• Clinical CHIK mimic dengue fever
• CHIK virus circulates same regions as dengue
• Many CHIK cases probably attributed to dengue

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Chikungunya
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Spread in the Caribbean

• Late in 2013 when chikungunya stowed up on the
  Caribbean Island of St. Martin. A traveler from
  the Far East according to genetic characteristics
  of the virus apparently arrived in Saint Martin
  carrying the virus and was bitten by a local
  mosquito, which then spread it to other people,

• Ae. aegypti is spread the Asian strain of
  chikungunya in Latin America and the Caribbean,
  with tens of thousands of cases confirmed and
  more than 1 million suspected,
• The good news for now is that the chikungunya
  strain that hit the Caribbean and Florida isn't
  carried by the tiger mosquito. That is probably
  why the Caribbean infections haven't penetrated
  North America beyond Florida.

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Emerging Diseases Animals also Travel
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Plague, USA
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Plague in San Francisco

• Summer 1899 ship sailing from Hong Kong to San
  Francisco has 2 cases of plague on board.
• Quarantined on Angel Island
• 11 stowaways found
• Next day 2 missing. Bodies later found in the
  Bay,
• Autopsy plague bacilli
• No immediate outbreak
• Rats probably went ashore
• Mar 1900 autopsy of a deceased Chinese man
  plague

• China town quarantined racial overtones
• Business community against quarantine and public
  notice
• Sewer disinfection w carbolic acid
• Feb 1904, woman in Concord town, California, last
  victim
• Total 121 cases in San Francisco 5 outside,
  with 122 deaths

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Plague in San Francisco

• 1906 Earthquake in SFO
• May 1907 onset of epidemic
• Sep 1907 epidemic peak
• Total 160 human cases, 77 died,
• all white persons, many of them of a good
  condition in life ... and dwelling in houses that
  would commonly be called 'sanitary'

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Plague in California

• San Francisco is thought to be the origin of the
  third plague pandemic (an epidemic that spans
  worldwide) in 1898
• Wild rodents squirrels (ground squirrels),
  chipmunks, woodrats, mice and marmots
• Other wild animals--rabbits, carnivores
  (including coyotes, bobcats, badger, bear, gray
  fox, and skunk) wild pigs-- can also acquire
  plague but usually with no signs of illness.
• Domestic animals can acquire plague and pose a
  direct threat to humans.
• Dogs rarely ill
• Cats highly susceptible, severe illness. Cat w
  plague pneumonia can infect humans by coughing /
  sneezing.
• Pets transport rodent fleas from field into homes
  and campsites

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The Third Plague Pandemic

• 1894 Start in China, Spread throughout the world
  via modern transportation
• 1894 Alexandre J. E. Yersin discovers Yersinia
  pestis
• Manchurian pneumonic plague epidemic of
  19101911, 50,000 deaths
• 1898 Bombay during next 50 years, killed gt13
  million Indians died
• March 1900 SanFrancisco
• 1900 New York City and Washington state
• 1924-26 New Orleans,
• Rodents throughout the western United States were
  infected from SFO
• focus, leading to more infected rodents in
  western USA
• After general rat control hygiene instituted in
  port cities, urban plague vanished
• But spread into rural areas, where virtually all
  cases in USA have been acquired since 1925

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Plague in the USA

• 1970-95 341 cases 13 cases per year
• 80 SW New Mexico, Arizona, Colorado, 9
  California
• flea bite 78 contact with infected animal 20,
  droplets 2
• 5/7 infected by inhalation exposed to cats

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West Nile Fever
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West Nile Virus

• First isolated in 1937 in Uganda (West Nile
  Province) from blood of a febrile woman.
• Transmitted by mosquitoes, reservoir in birds
• Originally a Fever

• Moved to Europe in the 1950s
• Became neurotropic
• Israel 1951,1954,1957(Nursing homes), France
  1962, South Africa 1974, Romania 1996 (393
  cases), Italy 1998, Russia1999, Israel 2000,
  France 2000

• Imported from Mid/East in 1999 in NY
• In Louisiana in 2001
• Moved throughout the US, reached West Coast in
  2004

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West Nile Scope of Human Disease

• Incubation period usually 5 to 15 days
• Asymptomatic
• WEST NILE FEVER (1/10-1/20)
• Febrile, influenza-like illness with abrupt onset
• Moderate to high fever
• Headache, sore throat, backache, myalgia,
  arthralgia, fatigue
• Rash, lymphadenopathy

WNME 1
WNFever 10-20
Asymptomatic 89

• ACUTE ASEPTIC MENINGITIS OR ENCEPHALITIS
  (1/150-1/300)
• CNS involvement and death in minority of cases
• Severe muscle weakness (50 in NY)
• Complete Flaccid Paralysis (10 in NY)
• Axonal and demyelinating syndromes
• GBS-like
• Most fatal cases gt50 years old.

lt65 ME 1/300 65 ME 1/50
Lesson Think beyond the original label
(diagnosis) Lesson Know local situation
(geographical distribution, season)
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Leprosyin Louisiana
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Leprosy Cases and Ten Year Average Incidence
Rates, Louisiana 1930-2008
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Leprosy Incidence Rates, Louisiana 1930-2008 By
10 Year Periods
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Average Annual Incidence Rate Of Leprosy By Sex
And Age Group 1930-1959, 60-89, 90-08
1930-59
1960-89
1990-2008
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Geographical Distribution of Leprosy By Sex And
Age Group 1930-1959, 60-89, 90-08
1930-59
1960-89
1990-2008
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The Armadillo Connection

• 1975 leprosy-like infection found among the
  nine-banded armadillo Dasypus novemcinctus

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The Northern March of the Armadillo
Lesson Keep list of resources (physicians, labs)
for referrals Lesson When in doubt, call Public
Health
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Ebola Epidemiologic Parameters
Basic R0 R0 CI SI Doubling Time Doubling Time CI
Guinea 1.71 1.44-2.01 15.3 15.7 12.9-20.3
Sierra Leone 1.83 1.72-1.94 24.0 23.6 20.2-28.2
Liberia 2.02 1.79-2.26 30.0 30.2 23.6-42.3
Disease Transmission R0
Measles Airborne 1218
Pertussis Airborne droplet 1217
Smallpox Airborne droplet 57
Polio Fecal-oral route 57
Rubella Airborne droplet 57
Mumps Airborne droplet 47
HIV/AIDS Sexual contact 25
SARS Airborne droplet 25
Influenza (1918) Airborne droplet 23
Ebola (2014) Bodily fluids 1.5-2.5 
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EpidemicCurve
Day Influenza Measles Ebola   Day Influenza Measles Ebola
1 1 1 1   28 512 196 4
2         29      
3         30      
4 2       31 1,024    
5         32      
6         33      
7 4       34 2,048    
8         35      
9         36      
10 8       37 4,096    
11         38      
12         39      
13 16       40 8,192    
14   14 2   41      
15         42   2,744 8
16 32       43 16,384    
17         44      
18         45      
19 64       46 32,768    
20         47      
21         48      
22 128       49 65,536    
23         50      
24         51      
25 256       52 131,072    
26         53      
27         54      
  55 262,144    
          56   38,416 16
          57      
          58 524,288    
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Ebola Spread
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Ebola Spread
Lesson There is time for prevention BUT to take
advantage of the time, START EARLY Lesson When
in doubt, call Public Health
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Economics of Food Supply
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Mad Cow Disease
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Mad Cow Disease or Bovine Spongiform
Encephalopathy (BSE)

• 1985 first cases of BSE in GB
• Massive (1 million inf, 170,000 cases since
  1990) common-source epidemic
• 3 cardinal features
• 1-Nervousness,
• 2-Heightened reactivity to external stimuli,
• 3-difficult movement, hind limbs
• Wastes away and dies within 6 months
• Spongiform change in brain BSE diagnosis
• Experimental transmission to mice cattle by
  brain homogenates from cattle with clinical BSE

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Origin of the GB Epizootic
MBM

• GB cattle got nutritional protein supplement (MBM
  for Meat and Bone Meal) Viscera and trimmings
  of sheep and cattle
• Steam treatment then hydrocarbon solvent
  extraction
• Protein rich fraction, 1 fat ? cattle
• Fat rich fraction ? sold as tallow
• 1970 tallow price ?, not profitable to extract
  fat, entire supplement with 14 fat ?cattle
• High fat content of new supplmt protected
  infectious agents from steam inactivation
• Supplement became infectious
• 1989 ban on certain bovine offal in human food.
• MBM banned in Jul 1998

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CJD Surveillance in GB
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CJD Surveillance in GB
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New Variant CJD

• Young age 16-52
• Long duration 14 months (classic CJD 4-5mo)
• CLINICAL
• Early symptoms psychiatric,
• Neurologic signs later 6-7 mo
• Characteristic EEG of sporadic CJD not in nvCJD
• Florid plaques, extensive cerebellar lesions
  with multiple PrP deposits
• MRI detection of 14-3-3 protein
• Diagnosis from tonsil biopsies or brain biopsy or
  postmortem examination

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Creutzfeldt Jakob disease (CJD)

• worldwide, low rate 0.3 to 1 per million /year,
  ave 0.5
• incubation 2-30 years
• 40 to 69 years old
• sporadic cases familial clusters
• FAMILY CLUSTERS
• 1980 73 families with gt1case, 286 cases
• no vertical transmission from mother to newborn
• no transmission to close contacts
• probably arise from mutation of the PrP protein
• most GSS familial linked with mutation of
  specific codon (117, 198)
• NO link between sporadic CJD animal disease
• Scrapie areas have NO higher incidence of CJD
• Case control studies ? NO clues

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FOOD ALSO TRAVEL FAR
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NEWER FOOD OUTBREAKS
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FOODBORNE Newer Outbreaks

• Diffuse and widespread outbreaks, involving many
  counties, states, countries, identified more
  frequently
• Different scenario result of low-level
  contamination of a widely distributed commercial
  food product
• Increase in cases inapparent
• Outbreak detection fortuitous ? cases in one
  location
• Pathogen unusual
• Paboratory-based subtyping of strains
• Investigation require coordinated efforts to
  clarify extent and source
• No obvious terminal food-handling error is found
• Contamination event in industrial chain of food
  production
• Investigating, controlling, and preventing such
  outbreaks can have industrywide implications

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New foodborne pathogens come to the front...

• Salmonella (nontyphoid) increased since WW II
• V. vulnificus
• fulminant infections of liver failing
• after eating raw oysters or exposure to seawater
• in sea
• natural summertime commensal organism in
  shellfish
• E. coli O157H7
• identified in 1982 in outbreak of bloody diarrhea
  traced to hamburgers from a fast-food chain
• reservoir in healthy cattle
• Cyclospora
• taxonomic designation in 1992
• outbreaks due to Guatemalan raspberries in 1996

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New outlook on old pathogens...

• Listeria monocytogenes
• was known as cause of meningitis and other
  invasive infections in immunocompromised hosts
• recent investigations identified food as the most
  common source
• Campylobacter jejuni
• was known as rare opportunistic BSI
• vet diagnostic methods used on human specimens ?
  common cause of diarrheal illness
• poultry most common source of sporadic cases
• raw milk most common source of outbreaks
• Yersinia enterocolitica
• rare in USA
• common cause of diarrhea and pseudoappendicitis
  in northern Europe
• most frequently associated with undercooked pork.
  

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Food borne Zoonosis become more important

• new zoonoses do not often cause
• illness in the infected host animal.
• chicken with lifelong ovarian infection with
  S.enteritidis,
• calf carrying E. coli O157H7,
• oyster carrying Norwalk virus or V. vulnificus
• appear healthy
• public health concerns must now include the
  safety of what food animals themselves eat and
  drink.

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Global Aspects

• Y. enterocolitica spread globally among pigs in
  the 1970s
• Salmonella enteritidis appeared simultaneously
  around the world in the 1980s
• Salmonella typhimurium Definitive Type (DT) 104
  is now appearing in North America, Europe, and
  perhaps elsewhere

Lesson Public health concerns must now include
events happening around the world, Lesson Ask
about food consumption
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These Changes Impact Epidemiologic Methods

• 1-Bioterrorism Detection of early cases and
  assessment of extent
• 2-Disasters Surveillance methods for assessing
  impact on public health and challenges in
  implementing these new methods
• 3-Environmental concerns Correlating
  environmental exposures and health effects

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These Changes Impact Epidemiologic Methods

• 4-Pandemics Detection of early cases, evaluation
  of preventive measures
• 5-Detection of opportunistic pathogens Modern
  medicine and technology have sustained lives of a
  large vulnerable population allowing
  opportunistic pathogens to become a major cause
  of new diseases.
• 6-Increase of institutionalized populations
  (health care facilities, long-term care
  institutions and refugee camps) Increased risks
  of disease transmission call for more rapid
  detection and intervention.

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These Changes Impact Epidemiologic Methods

• 7-Reporting to Health Department Detection of
  early cases, clusters or outbreaks
• 8-Electronic laboratory reporting
• 9-Syndromic surveillance

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Surveillance To Do List

• 1-Maintain awareness Keep current on new
  developments in Public Health News media, CDC
  website, State Health Department health alerts,
  newsletter,
• 2-Carefully document risk factors Travel, food,
  hobby, outdoors activity, immuno-suppression,
  institution
• 3-Make as much as possible a definite diagnosis
• 4-Assess severity of infection
• 5-Call specialists, public health when in doubt
• 6-Facilitate reporting Voluntary, laboratory,
  syndromic surveillance
• 7-Investigate anything unusual

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• not by some answering service that takes a
  message

Calls to CDC are referred to the State
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Questions