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The Role of Globalization in Emerging Diseases One Health Content Overview • • • • Global Public Health Globalization Emerging / Re-Emerging Diseases The Role of Globalization in Emerging/Reemerging Diseases Globalization in Emerging Diseases 2 Learning Objectives • Define global public health • Explain the role of globalization in emerging and re-emerging diseases • Introduce emerging and re-emerging diseases Globalization in Emerging Diseases 3 Global Public Health • Global public health refers to improving the health of all people on the planet, not just those within one nation • Refers to issues that affect multiple countries Globalization in Emerging Diseases 4 Global Public Health • An area for study, research, and practice • Affected by governmental organizations, intergovernmental organizations, the media, international foundations, nongovernmental organizations, and transnational corporations Globalization in Emerging Diseases 5 Globalization • “The increased interconnectedness and interdependence of peoples and countries.” • Increases importance of Global Public Health • Globalization includes: – Movement of people, products, services, capital, and ideas between borders – Affected by changes in policy at the international and national levels Globalization in Emerging Diseases 6 Globalization History • Dates back 2,000 years to the era of the ancient Silk Road trade route http://en.wikipedia.org/wiki/File:Silk_route.jpg Globalization in Emerging Diseases 7 Global Public Health History • Middle Ages: Plague spread across Europe and Asia • 16th Century: Smallpox and Measles introduced to the New World by European invaders • 16th Century: Europeans took tobacco from America back to Europe • 18th Century: Opium sold to China by Europeans Globalization in Emerging Diseases 8 Globalization Today • Rapidly increasing due to: – Technology – Reduced cost of transactions – Increased mobility of capital – Open economies – International architecture • • • • United Nations World Bank World Health Organization European Union Globalization in Emerging Diseases 9 EMERGING DISEASES Globalization in Emerging Diseases 10 Emerging Diseases • Incidence of emerging diseases in humans has increased recently or threatens to increase in near future • “Zoonotic” diseases – transmitted animals-humans • May be due to – – – – – Spread of a new pathogenic agent Recognition of an agent previously undetected Identification of infectious cause of a disease Mutation or recombination allowing “jump” into humans Changes in human habitation or land use Globalization in Emerging Diseases 11 What Are Emerging Diseases? • Emerging diseases are outbreaks of previously unknown diseases or known diseases whose incidence in humans increased significantly – Examples: Bartonella henselae, Ehrlichiosis, Hendra virus, Lyme disease, and Hepatitis C Globalization in Emerging Diseases 12 What Are Re-Emerging Diseases? • Re-emerging diseases are known diseases that have reappeared after a significant decline in incidence – Examples: Clostridium difficile, Mumps virus, Streptococcus Group A, and Staphylococcus aureus Globalization in Emerging Diseases 13 Why Are There Emerging Diseases? • Changes in Ecology – Land use (dams, agriculture, and deforestation), the design of the built environment, and climate change • Changes in Human Demographics – Population growth and movement from rural areas to cities, war, and immigration • Changes in Human Behavior – Sexual behavior, drug use, outdoor recreation, eating habits, and increased use of child care centers Globalization in Emerging Diseases 14 Why Are There Emerging Diseases? • International Travel and Commerce • Changes in Technology and Industry – Globalization of food supplies, changes in food processing and packaging, organ/tissue transplants, drug therapy resulting in immunosuppression, and the use of antibiotics • Microbial Adaptation and Change • Poor Public Health Measures – Reduction of prevention programs, inadequate sanitation, and inadequate vector control measures Globalization in Emerging Diseases 15 Where are Diseases Emerging? • Around the world • Typically where there are the most people • Potential hotspots of future disease emergence: – Central America – Tropical Africa – South Asia Globalization in Emerging Diseases 16 What Types of Diseases are Emerging or Re-emerging? • 70% are zoonotic or vector-borne • Drug-resistant infections • Types of pathogens – Viruses – Bacteria – Protozoans – Prions Globalization in Emerging Diseases 17 A Recent History of Emerging Diseases • 29 microbes and infectious diseases recognized since 1973 – 1976 Cryptosporidium parvum – 1977 Ebola virus – 1977 Legionella pneumophila – 1981 Toxin-producing Staphylococcus aureus – 1982 Escherichia coli O157:H7 – 1982 Borrelia burgdorferi Globalization in Emerging Diseases 18 A Recent History of Emerging Diseases • • • • • • • • • • • • • --1983 --1983 --1989 --1992 --1993 --1994 --1994 --1994 --1995 --1999 --1999 --2003 --???? HIV Helicobacter pylori Hepatitis C virus Vibrio cholerae 0139 Sin nombre virus Sabia virus Mad Cow disease Hendra virus Human herpes virus 8 West Nile virus in US Nipah virus SARS virus Next?? Cells Infected with Hepatitis C Virus Globalization in Emerging Diseases 19 Ebola • Initially seen in 1970’s in various locations in Africa—identified as new virus • Related to other viruses causing hemorrhagic fevers—uncontrollable bleeding • Kills >90% of people infected • Subsequent recurrent outbreaks in west and central Africa Globalization in Emerging Diseases 20 Public Health Failures in Ebola Outbreaks • Two largest outbreaks, 1976 and 1995, spread by hospitals—reuse of needles; lack of basic supplies such as gloves and masks • Large number of victims were hospital employees • War and poverty in developing world helped spread disease—probably isolated cases before; now epidemics Globalization in Emerging Diseases 21 Ebola—The Future • Natural host still not known but chimpanzees are suspected • No cure or effective treatment as yet • Vaccine trial (DNA vaccine) is in progress—has shown some potential in chimps Globalization in Emerging Diseases 22 Hendra and Nipah Viruses • Hendra isolated 1994; Australia • Nipah isolated 1999; Malaysia • Disease in animals (pigs, horses, dogs, cats) and humans (spread from infected animals) • Natural host/reservoir – fruit bats • Severe flu-like symptoms with encephalitis and death in some cases Globalization in Emerging Diseases 23 Rift Valley Fever Virus • Losses to livestock, including abortions (sheep especially susceptible) • Primarily affects animals but also humans • Can cause severe disease and death • 1931—Rift Valley of Kenya • Major outbreaks in Africa; has spread to Saudi Arabia and Yemen Globalization in Emerging Diseases 24 Rift Valley Fever Distribution • Blue, countries with endemic disease and substantial outbreaks of Rift Valley Fever (RVF); green, countries known to have some cases, periodic isolation of virus, or serologic evidence of RVF. Globalization in Emerging Diseases 25 Transmission of Rift Valley Fever Virus (RVFV) to Humans • Direct or indirect contact with blood or organs of infected animals • Herders, farmers, slaughterhouse workers, veterinarians at risk • Inoculation through broken skin or inhalation of aerosols • Also via insects (mosquitoes and flies) Globalization in Emerging Diseases 26 Chikungunya • High fever, disabling joint and muscle pain, some hemorrhagic symptoms; low fatality (<0.5%) • First isolated 1952 from humans, Aedes and Culex mosquitos in Tanzania • Zoonotic, cycling through wildlife species via mosquitoes • 2004-06—major human outbreak in India and islands; many European tourists infected Globalization in Emerging Diseases 27 Chikungunya Virus Distribution • 2007—detected in S. Europe in human case and in introduced Aedes species; has new mutation in envelope gene that enhances spread Globalization in Emerging Diseases 28 Crimean-Congo Hemorrhagic Fever • Characterized in Crimea in 1944 and Congo in 1969 • Ticks are reservoir and vector • Wild and domestic animals can be hosts • Human transmission via infected animal blood and tick bites • Symptoms: headache, fever, pain, bleeding; 9-50% fatalities seen Globalization in Emerging Diseases 29 RE-EMERGING DISEASES Globalization in Emerging Diseases 30 Re-Emerging Diseases: Why? • Social and political changes, changes in agricultural or industrial practices, land use, etc., can cause previously quiescent diseases to re-emerge • Sometimes these are much more deadly than before • May have acquired resistance to previously effective drugs • Examples: -- Dengue: transportation, travel, and urbanization --Yellow fever: drug and insecticide resistance Globalization in Emerging Diseases 31 Dengue • • • • • • Viral, insect transmission Rapidly spreading, no vaccine WHO calls “most important arboviral disease” Fever, headache, joint/muscle pain Up to 5% lethality Mosquito vector expanding range Globalization in Emerging Diseases 32 Distribution of Aedes Aegypti Mosquitoes and Dengue Distribution of Aedes aegypti in 1970, at the end of the mosquito eradication program, and in 1997 Confirmed cases of dengue Globalization in Emerging Diseases 33 Distribution of Countries or Areas at Risk of Dengue Transmission Worldwide, 2008 Globalization in Emerging Diseases 34 THE ROLE OF GLOBALIZATION IN EMERGING DISEASES Globalization in Emerging Diseases 35 Globalization Factors that Increase Risk of Spread of Disease • The movement of: – People – Animals / Animal Products – Food Globalization in Emerging Diseases 36 The Movement of People • In 2009, there were 880 million international tourist arrivals for business, leisure, and other purposes – Includes travel by air, road, rail, and sea • If a person contracts a disease in one country, they can quickly travel around the world where they can spread the disease to new populations Globalization in Emerging Diseases 37 The Movement of People • Infected people quickly spread disease around the world • People may contract a disease in one country and travel to other countries before they are symptomatic • May result in super spreading events Globalization in Emerging Diseases 38 Travel Medicine • Preventing infectious diseases during international travel • Ensuring personal safety of international travelers • Avoiding environmental risks during travel Globalization in Emerging Diseases 39 Travel Medicine • Pre-travel – Risk assessment • Traveler: Existing medical conditions, allergies, etc • Risks of travel country: itinerary, season, planned activities, etc – Preventive counseling • Preventing illness – vaccines, sources of illness, vectors, environmental concerns, travel medical kits, etc – Vaccination • Post-travel – Evaluation of ill Globalization in Emerging Diseases 40 Increased Risk of Zoonotic Diseases During Travel • Bites/scratches from direct contact with animals • Visits to farms and agricultural areas • Local food/bushmeat/live animal markets – Slaughter, undercooked meat, raw milk, crosscontamination, raw fish • • • • Wilderness travel – vector-borne disease Walking barefoot/swimming Contamination of souvenirs If pets travel, they can get disease that may spread to people Globalization in Emerging Diseases 41 Severe Acute Respiratory Syndrome (SARS) • November 2002—first reports of new respiratory disease in Guangdong, China • Large outbreaks in Hong Kong, Beijing, Singapore, Taiwan, and Toronto in Spring 2003 • >8000 cases with 774 deaths in 30 countries on 5 continents Globalization in Emerging Diseases 42 Source of SARS? • Agent is a novel coronaviruses • Connection noticed with wild food markets— animal source? • Closely related viruses found in civets, raccoon dogs, and bats • Bat appears to be source; amplified by transmission in civets; following species jump, transmitted between humans Globalization in Emerging Diseases 43 SARS Super Spreading Events • • • • Hospitals Hotel Airplane flight Housing complex Globalization in Emerging Diseases 44 Hotel Globalization in Emerging Diseases 45 Spread from Hotel to Multiple Countries Globalization in Emerging Diseases 46 Plane Flight Globalization in Emerging Diseases 47 Movement of Animals: Travel with Pets • Reasons people travel with pets – Companionship – Reluctance to leave pet at home – Save on cost of boarding animal – Taking animal for breeding or medical care Globalization in Emerging Diseases 48 Movement of Animals: Travel with Pets • Risks – Pets may contract diseases, including zoonotic diseases and bring them back home – Exposure to toxins during travel – Physical injuries and stress – Allergies • In pet • In humans traveling near pet (airplanes, trains, etc) Globalization in Emerging Diseases 49 Movement of Animals and Animal Products • Global Animal Trade – Legal • From 2000-2004, there were 37,858,179 live amphibians, birds, mammals, and reptiles legally imported to the U.S. from 163 countries. • Highest demand for animals in U.S., People’s Republic of China, and the European Union – Illegal • Estimated to be $5-20 billion annually • U.S. demand for illegal wildlife estimated to be same as legal demand – $2.8 billion in 2007 Globalization in Emerging Diseases 50 Animal Trade • Primary sources of demand: – Wildlife items for personal use • Souvenirs, exotic pets – Products for commercial use or related to hunting • Hunting trophies – Other sources • Zoos, research, conservation programs, scientific education, food, pets of tourists and immigrants Globalization in Emerging Diseases 51 Animal Trade in the U.S. • Globalization increases demand for illegal animals – Examples • Sea turtle eggs and meat is in demand by immigrants from Central America • Increased demand for traditional Asian medicines Globalization in Emerging Diseases 52 Disease Outbreaks from Animal Trade Anthrax • Anthrax from untreated, imported animal hides for drums – 1974: imported drum from Haiti, cutaneous Anthrax, patient survives – 2006: drum maker imports hides from Côte d'Ivoire; contracts inhalation Anthrax while making drums; patient dies – 2007: drum maker and his child get cutaneous Anthrax form imported hides from Guinea in West Africa; both survive – 2008: drum maker in London contracts inhalation Anthrax from contaminated animal hides from Africa; dies – 2009: gastrointestinal Anthrax contracted while playing in drum circle; multiple drums and environment contaminated; patient survives Globalization in Emerging Diseases 53 Anthrax • • • • • • • • • Bacteria Bacillus anthracis Cutaneous – handling products from infected animals Inhalation – breathing in spores from infected animal products Gastrointestinal – eating undercooked meat from infected animals Weaponized – 22 cases in 2001 Anthrax spores sent through the mail Treat with antibiotics Vaccine is available Anthrax does occur naturally in animals in the U.S. but much more prevalent in Asia, the Middle East, and Africa Importation of cattle and goat hides regulated by the USDA. Hides must be treated to reduce risk of Anthrax. Globalization in Emerging Diseases 54 Disease Outbreaks from Animal Trade Monkeypox • Monkeypox – June 2003—several people in US became infected through contact with pet prairie dogs infected by legally imported African rats Globalization in Emerging Diseases 55 Monkeypox • Found in 1958 among monkeys captured for research • 1970—found in human patients in Africa • Related to smallpox; can kill up to 10% of infected people • Isolated cases during 1980’s; didn’t seem to be major problem—not very contagious Globalization in Emerging Diseases 56 Monkeypox Concerns • Can the virus become more lethal or transmissible???? • Some reports of human-human transmission • Increased host range and geographic spread • HIV infection in Africa makes monkeypox more difficult to control Globalization in Emerging Diseases 57 The Movement of Food • In the United States, 15% of food is imported from more than 150 countries • These numbers have been increasing for past 10 years • When food is contaminated, it can cause widespread outbreaks due to the movement of food Globalization in Emerging Diseases 58 Food and Drug Administration Globalization Act of 2009 • All facilities operating in the U.S. or importing to the U.S. must register with the FDA • Food facilities must have plan to identify and mitigate hazards • FDA inspects all plants on a risk-based schedule • Expanded traceback capabilities • Requires country-of-origin labeling and disclosure • FDA may issue mandatory recalls Globalization in Emerging Diseases 59 The Movement of Food • Illegal bushmeat trade from Africa – $50 million annually sold worldwide – Sold to some communities in U.S. – Diseases associated with bushmeat • • • • Ebola HIV/AIDS Monkeypox SARS Globalization in Emerging Diseases 60 The Movement of Food • Legal food imports may also cause disease – 1996: Cyclospora is strawberries from Guatemala – 2000-2002: Salmonella in cantaloupe from Mexico – 2008: Salmonella in peppers from Mexico – 2011: Salmonella in Papayas from Mexico Globalization in Emerging Diseases 61 The Benefits of Globalization Regarding Disease Outbreaks • Shared research/medical advances • Global surveillance and disease response • Global Health Initiatives Globalization in Emerging Diseases 62 Shared Research and Medical Advances Globalization in Emerging Diseases 63 Global Surveillance & Disease Response • Animal Diseases/Zoonotic Diseases – Global Early Warning and Response System (GLEWS) • Human Diseases – Global Outbreak Alert and Response Network (GOARN) Globalization in Emerging Diseases 64 Animal Disease Outbreak Alerts • Global Early Warning and Response System (GLEWS) – For Major animal diseases, including zoonotic diseases – Developed by: • World Health Organization (WHO) • Food and Agricultural Organization of the United Nations (FAO) • World Organization for Animal Health (OIE) – Goals: • Earlier detection • Coordinated response Globalization in Emerging Diseases 65 GLEWS Alerts in 2010 • • • • • • • • • • Rabies in Peru, Trinidad, and Tobago Nipah Virus in Bangledesh H5N1 Influenza in Vietnam, Romania, Bulgaria Highly pathogenic avian influenza in China and Japan Rift Valley Fever in South Africa, Saudi Arabia Foot and Mouth Diseases in Republic of Korea Glanders in Bahrain Venezuelan Equine Encephalomyelitis in Panama African Swine Fever in Armenia and Chad Anthrax in Bangladesh Globalization in Emerging Diseases 66 Human Disease Outbreak Response • Global Outbreak Alert and Response Network (GOARN) – Combat international spread of outbreaks among humans – WHO, UNICEF, Red Cross, and others Globalization in Emerging Diseases 67 GOARN Response to SARS • WHO recognized outbreak in March 2003; declared Global Alert • Goal was to allow all countries time to prepare for possible global epidemic • Created network of 13 labs in ten countries – Identified virus associated with SARS in 2 weeks – Genome sequenced in 2 more – (Took 2 years to identify HIV as cause of AIDS in 80’s) Globalization in Emerging Diseases 68 GOARN Alerts in 2010 • Avian Influenza in Egypt, Indonesia, China, Cambodia, Vietnam • Cholera in Haiti, Pakistan, Central Africa • Polio in Central Asia, the North Caucasus Federal Region of the Russian Federation, Congo, Angola, Tajikistan • Crimean-Congo haemorrhagic fever (CCHF) in Pakistan • Dengue in Pakistan • Yellow Fever in Senegal, Congo, Cameroon, Guinea, Côte d'Ivoire • Plague in Peru • Lead poisoning in Nigeria from mining • Acute Haemorrhagic Fever in Congo • Rift Valley Fever in South Africa • Meningococcal disease in Chad Globalization in Emerging Diseases 69 Global Health Initiatives • Roll Back Malaria – Launched in 1998 – More than 500 partners – Vision: World free from Malaria • Stop TB – Launched in 1998 • Global Alliance for Vaccines and Immunization – Launched in 2000 – Bring vaccines to developing countries • Hepatitis B, Childhood meningitis, Yellow Fever, and respiratory infections Globalization in Emerging Diseases 70 Summary • Summary ideas are still needed here. • © by Kansas State University Globalization in Emerging Diseases 71 References • The WHO Global Health Observatory Map Gallery • The US Centers for Disease Control and Prevention • http://www.ispub.com/journal/the_internet_jour nal_of_biological_anthropology/volume_1_numb er_1_10/article_printable/how_to_deal_with_e merging_and_re_emerging_infectious_diseases_ globally.html • http://www.ispub.com/ostia/index.php?xmlFileP ath=journals/ijba/vol1n1/infections.xml Globalization in Emerging Diseases 72