Download Emerging Infections

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
Crude ID Mortality Rate
Deaths per 100,000 population
70
60
50
40
30
20
10
0
Year
Source: JAMA 1996;275:189-193 and unpublished CDC data
CDC
Emerging Infections in the
World and US since 1973
1973
1976
1977
1977
1977
1977
1980
1981
1982
1982
1982
Rotavirus
Cryptosporidium
Ebola virus
Legionella
Hantaan virus
Campylobacter
HTLV-1
Toxin prod. S.aureus
E.coli 0157:H7
HTLV-II
Borrelia burgdorferi
Enteritis/Diarrhea
Enteritis/Diarrhea
VHF
Legionnaire’s dz
VHF w/ renal flr
Enteritis/Diarrhea
Lymphoma
Toxic Shock Synd.
HUS
Leukemia
Lyme disease
Emerging Infections in the
World and US since 1973
1983
1983
1988
1989
1990
1991
1992
1992
HIV
Helicobacter pylori
Hepatitis E
Hepatitis C
Guanarito virus
Encephalitozoon
Vibrio cholerae O139
Bartonella henselae
AIDS
Peptic ulcer dz
Hepatitis
Hepatitis
VHF
Disseminated dz
Cholera
Cat scratch dz
Emerging Infections in the
World and US since 1973
1993
1994
1994
1995
1995
1996
1997
1999
1999
2001
2003
2003
Sin Nombre virus
Sabia virus
Hendra virus
Hepatitis G
H Herpesvirus-8
vCJD prion
Avian influenza (H5N1)
Nipah virus
West Nile virus
BT Bacillus anthracis
Monkeypox
SARS-CoV
Hanta Pulm. Synd.
VHF
Respiratory dz
Hepatitis
Kaposi sarcoma
Variant CJD
Influenza
Encephalitis
Encephalitis
Anthrax
Pox
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.
2.
3.
4.
5.
6.
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
Institute of Medicine Report, 1992
More Factors Contributing to
Emerging Infections: 2003
7. 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
70,000
Year-end Waiting Lists vs.
Transplanted
(kidney, liver, pancreas, heart, lung)
60,000
50,000
40,000
30,000
20,000
10,000
0
1988
1989
1990
1991
1992
1993
Patients Waiting
1994
1995
1996
1997
1998
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,….)
6
5
300
(
Days to Circumnavigate (
the Globe
350
)
400
4
250
200
3
150
2
100
50
1
0
0
1850
1900
Year
1950
World Population in billions
)
Speed of Global Travel in Relation to
World Population Growth
2000
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*
25
% Resistant
20
ICU
Non-ICU
15
10
5
0
1989 1990 1991 1992 1993 1994 1995 1996 1997 1998
* 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
Preventing Emerging
Infectious Diseases
Applied Research
Integrate 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 Control
Ensure 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