Download NEW AND EMERGING INFECTIOUS DISEASES

EMERGING PATHOGENS: READY OR
NOT HERE THEY COME!
Presented at AFHSA Training Conference
September 28, 2015
Charleston, SC
Karen K Hoffmann RN, MS, CIC, FSHEA
Adjunct Clinical Instructor
UNC School of Medicine at Chapel Hill
Infection Preventionist Consultant
CMS Survey and Certification Group
Disclosures
Carefusion, speaker (not Current)
 AMA Foundation, consultant (not current)
 CMS, consultant (current)

Disclaimers

The information provided in this lecture is only
intended to be general summary information to
the public. It is not intended to take the place
of statute, regulations or official CMS policy.
Objectives
List risk factors supporting emerging pathogens.
 Describe the most significant emerging pathogens
of the past 2 decades.
 Review the HHS, CMS, CDC responses to recent
Ebola outbreak.

EMERGING INFECTIOUS DISEASES:
DEFINITION

Emerging infectious diseases - defined as infections that
have newly appeared in the population, or have existed but
are rapidly increasing in incidence or geographic range
SUCCESS STORIES
Vaccine Preventable
 Smallpox
 Polio
 Measles
 Rubella
 Varicella
 Invasive Haemophilus
influenzae type b
Other
 Toxic shock (S. aureus)
 Tooth decay
 Tuberculosis
 Rheumatic fever
 Enteric infections from
potable water
 Safer pregnancy/delivery
EMERGING DISEASE THREATS
WORLDWIDE





XDR tuberculosis
Avian influenza
Multi-drug resistant bacteria (MDROs)
Middle eastern respiratory Syndrome (MERS)
Ebola
SOURCES OF EXOTIC DISEASES




Travel
Animal exposure (zoonotic diseases)
 Exposure via travel, leisure pursuits (hunting, camping,
fishing), occupation (farming), pets
Bioterrorist agents
Research
 Exposure via laboratory work or animal care
ZOONOSES AS
EMERGING INFECTIOUS DISEASES
EMERGING INFECTIOUS DISEASES SINCE 1990















1993 (US) - Hantavirus pulmonary syndrome (Sin nombre virus) 
1994 (US) – Human granulocyte ehrlichiosis 
1995 (Worldwide) - Kaposi sarcoma (HHV-8)
1995 (US) – Cyclosporiasis from raspberries
1996 (England) – Variant Creutzfeld-Jakob disease (vCJD) 
1997-present (Asia) – Avian influenza (H5N1) 
1998 (Malaysia) – Nipah virus 
1999 (US) - West Nile encephalitis (West Nile virus) 
2001 (US) - Anthrax attack via letters 
2002 (US) – Vancomycin-resistant S. aureus
2003 (Chinaworldwide) - Severe acute respiratory syndrome (coronavirus)
2003 (US) – Monkeypox 
2009 (Mexico worldwide) – Novel H1N1 influenza (triple reassortment; human,
avian, swine)
2012- Middle East -Middle Eastern Respiratory Syndrome MERS
2014 West Africa- Ebola outbreak
FACTORS LEADING TO EMEGENCE
OF INFECTIOUS DISEASES
FACTORS CONTRIBUTING TO
EMERGENCE OF INFECTIOUS DISEASES
Societal events
 Health care
 Food production
 Human behavior
 Environmental change
 Public health infrastructure
 Microbial adaptation and change

FACTORS CONTRIBUTING TO NEW DISEASES
SOCIETAL EVENTS
 Economic impoverishment
 War or civil conflict
 Population growth and
migration
 Urban decay
 Use of high-density
facilities (e.g., prisons, day
care)
FACTORS CONTRIBUTING TO NEW DISEASES
HEALTH CARE
 New medical devices
 Organ or tissue
transplantation
 Drugs causing
immunosuppression
 Widespread use of
antibiotics
FACTORS CONTRIBUTING TO NEW DISEASES
FOOD PRODUCTION
 Globalization of food
supplies
 Changes in food
processing, packaging,
and preparation
FACTORS CONTRIBUTING TO NEW DISEASES
HUMAN BEHAVIOR
 Travel
 Sexual behavior
 Drug use
 Diet
 Outdoor recreation
 Use of day care facilities
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
2000
World Population in billions
)
Speed of Global Travel in Relation to
World Population Growth
FACTORS CONTRIBUTING TO NEW DISEASES
ENVIRONMENTAL
CHANGES
 Deforestation and/or
reforestation
 Changes in water
ecosystems
 Flood/drought
 Famine
 Global warming
FACTORS CONTRIBUTING TO NEW DISEASES
MICROBIAL ADAPTATION
AND CHANGE
 Changes in virulence and
toxin production
 Development of drug
resistance
 Microbes as cofactors in
chronic diseases
FACTORS CONTRIBUTING TO NEW DISEASES
PUBLIC HEALTH INFRASTRUCTURE
Curtailment or reduction in prevention programs
 Inadequate communicable disease surveillance
 Lack of trained personnel

Epidemiologists
 Laboratory scientists
 Vector and rodent control specialists

ANIMALS ASSOCIATED WITH SARS:
PALM CIVET AND CHINESE HORSESHOE BAT
•
SARS
SARS: CASES AND OUTCOME
Cases: 1 Nov 2003 to 31 July 2004
Deaths
8,096
774 (9.6%)
HCWs
Countries (total)
1,706 (21%)
29
WHO 21 April 2004
LESSONS LEARNED FROM SARS










Initial detection via the astute observer (not via a surveillance system)
New disease can involve multiple countries
Continued threat from zoonotic agents jumping species boundaries
Healthcare workers at high risk with highly communicable diseases
Diagnostic methods key to control
Epidemics can be contained using quarantine and infection control methods
Need to nestle response to a highly communicable disease in hospital
disaster plan
Inadequate supplies of PPE
Inadequate outpatient facilities to handle highly communicable diseases
Need to screen for travel to endemic area at entry to hospital or clinic
EXTREME DRUG RESISTANT
TUBERCULOSIS (XDR-TB)

Risk factors for XDR-TB





Persons who do not take their TB medications regularly
Persons who do not take all their TB medications
Develop active TB disease again, after being treated in the past
Emigrated from areas of the world where XDR-TB common
Contact with a person with XDR-TB
http://www.who.int/tb_beijingmeeting/media/pres
s_pack/presentations/day1_presentation1.pdf
EXTREME DRUG RESISTANT
TUBERCULOSIS (XDR-TB)

Definitions



Concerns





MDR-TB = Resistant to IHN and rifampin
XDR-TB = Resistant to INH and rifampin PLUS resistant to any
fluoroquinolone and at least one of three injectable second-line drugs
(i.e., amikacin, kanamycin, or capreomycin)
Few treatment options
Worse outcomes
Low risk in the US (currently)
High morbidity if HIV+
US frequency = 90 cases, 1993-2012
•
•
Zoonotic virus – bats the most likely reservoir, although species unknown
Spillover event from infected wild animals (e.g., fruit bats, monkey, duiker) to
humans,
followed by human-human transmission
CMS Ebola Response
CDC and CMS Joint Collaboration
 SC 15-10-Hospitals concerning EMTALA
Requirements and Implications Related to the
EVD.
 Emergency Medical Treatment and Labor Act
(EMTALA) and Ebola Virus Disease (EVD) –
Questions and Answers (Q+A)
 'CMS in Response' Preparedness
30
Influenza Disease Burden to U.S. Society
in an Average Year
Deaths
25,000 - 72,000
Hospitalizations
114,000 - 257,500
Physician visits
~ 25 million
Infections and illnesses
50 - 60 million
Thompson WW et al. JAMA. 2003;289:179-86. Couch RB. Ann Intern Med. 2000;133:992-8.
Patriarca PA. JAMA. 1999;282:75-7. ACIP. MMWR. 2004;53(RR06):1-40.
Hampson AW, Mackenzie JS. MJA 2006;185:S39-43
PANDEMIC INFLUENZA
PLANNING CHALLENGES










Pandemic strain unknown unti pandemic
The ability of the virus to rapidly spread worldwide
Simultaneous outbreaks throughout the US, limiting the ability of any
jurisdiction to provide assistance to other areas
People may be asymptomatic while infectious
Long duration (>2 years) and multiple waves
Enormous demands on the healthcare system
 Need for surge capacity: Medications, ventilators, beds, personnel
 Personnel: Exhaustion, concerns about infection
Maintaining social distancing
Providing adequate PPE
Providing adequate antivirals including distribution/allocation
Vaccine development and distribution/allocation
Emergence of Quadruple-Reassortant
H1N1/09
Garten et al., Science, 2009; 325:198
BASIC CONCEPTS IN DISEASE EMERGENCE





Emergence of infectious diseases is complex
Infectious diseases are dynamic
Most new infections are not caused by genuinely new
pathogens
Agents involved in new and reemergent infections cross
taxonomic lines
The concept of the microbe as the cause of disease is
inadequate and incomplete
Wilson ME. Emerging Infectious Diseases 1995;1:39.
BASIC CONCEPTS IN DISEASE EMERGENCE




Human activities are the most potent factors driving
disease emergence
Social, economic, political, climatic, technologic, and
environmental factors shape disease patterns and
influence emergence
Understanding and responding to disease emergence
require a global prospective, conceptually and
geographically
The current global situation favors disease emergence
Toss to Priti here