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The Role of Globalization
in Emerging Diseases
One Health
Content Overview
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Global Public Health
Globalization
Emerging / Re-Emerging Diseases
The Role of Globalization in Emerging/Reemerging Diseases
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Learning Objectives
• Define global public health
• Explain the role of globalization in emerging
and re-emerging diseases
• Introduce emerging and re-emerging diseases
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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
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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
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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
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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
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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
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Globalization Today
• Rapidly increasing due to:
– Technology
– Reduced cost of transactions
– Increased mobility of capital
– Open economies
– International architecture
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United Nations
World Bank
World Health Organization
European Union
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EMERGING DISEASES
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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
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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
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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
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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
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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
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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
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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
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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
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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
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A Recent History of Emerging Diseases
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--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
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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
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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
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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
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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
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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
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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.
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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)
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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
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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
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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
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RE-EMERGING DISEASES
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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
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Dengue
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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
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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
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Distribution of Countries or Areas at Risk of
Dengue Transmission Worldwide, 2008
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THE ROLE OF GLOBALIZATION IN
EMERGING DISEASES
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Globalization Factors that Increase Risk
of Spread of Disease
• The movement of:
– People
– Animals / Animal Products
– Food
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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
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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
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Travel Medicine
• Preventing infectious diseases during
international travel
• Ensuring personal safety of international
travelers
• Avoiding environmental risks during travel
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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
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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
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Wilderness travel – vector-borne disease
Walking barefoot/swimming
Contamination of souvenirs
If pets travel, they can get disease that may
spread to people
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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
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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
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SARS Super
Spreading Events
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Hospitals
Hotel
Airplane flight
Housing complex
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Hotel
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Spread from Hotel to Multiple
Countries
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Plane Flight
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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
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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)
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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
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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
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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
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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
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Anthrax
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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.
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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
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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
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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
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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
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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
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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
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Ebola
HIV/AIDS
Monkeypox
SARS
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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
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The Benefits of Globalization
Regarding Disease Outbreaks
• Shared research/medical advances
• Global surveillance and disease response
• Global Health Initiatives
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Shared Research
and Medical Advances
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Global Surveillance & Disease
Response
• Animal Diseases/Zoonotic Diseases
– Global Early Warning and Response System
(GLEWS)
• Human Diseases
– Global Outbreak Alert and Response Network
(GOARN)
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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
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GLEWS Alerts in 2010
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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
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Human Disease Outbreak Response
• Global Outbreak Alert and Response Network
(GOARN)
– Combat international spread of outbreaks among
humans
– WHO, UNICEF, Red Cross, and others
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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)
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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
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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
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Summary
• Summary ideas are still needed here.
• © by Kansas State University
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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
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