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Microbiology: A Clinical Approach, Second Edition
Chapter 8 Emerging and Re-Emerging Infectious Disease
Question Bank

Multiple Choice

1. Which of the following is not a potential circumstance that would favor re-emerging
infectious diseases?
A. Loss of health care infrastructure because of political restructuring
B. Deterioration of living standards because of civil war
C. Accidental release from a research lab of a genetically engineered strain of bacteria that is
highly contagious
D. Appearance of an epidemic which damages host immune responses
E. Loss of health care infrastructure and deterioration of living standards because of political
restructuring and civil war

Answer: C
Feedback: Accidental release of a genetically engineered, highly contagious strain of bacteria
would create the potential for an emerging disease, not a re-emerging one. An emerging
infectious disease is one whose incidence has increased in the last 30 years or threatens to
increase in the near future. Emerging diseases may have not previously been seen in humans or
only rarely seen. A re-emerging infectious disease is one that was previously controlled but has
now returned. Loss of health care infrastructure, deterioration of living standards, and an
epidemic of a disease that damages host immune responses would all favor the re-emerging
infectious diseases.
Difficulty: 3

2. A new virus has been identified by DNA sequencing methods in a remote location in the
South Pacific. The World Health Organization is very concerned because infection with
this virus has a death rate of 20% of all infected individuals and no vaccine is available.
This is an example of a(n) _____ disease.
A. Re-emerging infectious
B. Latent
C. Prion
D. Emerging infectious
E. Vector-borne

Answer: D
Feedback: An emerging infectious disease is one whose incidence has increased in the last 30
years while a re-emerging infectious disease is one that has reappeared after a decline in

1
incidence. A latent disease is one in which symptoms reappear long after the initial infection, a
prion disease is caused by abnormally folded, infectious prion proteins, and vector-borne
diseases are transmitted by vectors.
Difficulty: 1

3. Developing nations have seen a dramatic decrease in the number of fatal infectious
diseases in the twentieth century, attributed primarily to the
A. Emergence of multi-drug resistant bacteria
B. Development of herd immunity
C. Development of antibiotics
D. Rising numbers of hospital staff

Answer: C
Feedback: The discovery of penicillin, sulfa drugs, and a host of other antibiotics produced this
decrease. The development of herd immunity and rising numbers of hospital staff did not
produce an marked benefit, while the emergence of multi-drug resistant bacteria can result in an
increase in the number of fatal infections.
Difficulty: 2

4. The potential for a Lyme disease outbreak is closely associated with

A. The number of deer mice residing in a particular region
B. The number of mosquitos breeding in the woods
C. The proximity of piggeries to human populations
D. Crowded housing conditions
E. The number of deer residing in a particular region

Answer: E
Feedback: The vector for Lyme disease is the deer tick. The number of deer residing in a
particular region affects the number of ticks and the potential for outbreaks of Lyme disease. A
greater number of deer results in a greater number of ticks and the potential for increased
transmission of Lyme disease.
Difficulty: 1

5. Which of the following is a mismatched pair?

A. SARS: South America
B. Ebola: Africa
C. HIV: Africa
D. Nipah: Malaysia
E. Avian influenza: China

2
Answer: A
Feedback: SARS emerged in China where a previously unrecognized animal coronavirus
adapted and became transmissible to and among humans. Novel infectious disease can emerge in
any part of the world at any time. Other examples include HIV and Ebola from Africa, avian
influenza from China, Nipah from Malaysia, and Hantavirus from South America.
Difficulty: 1

6. Which of the following describes the process of recombination?

A. Synthesis of a nearly perfect copy of a molecule
B. Portions of chromosomes from different pathogens link
C. Single base in genetic material converts to another
D. Two chromosomes from different pathogens form a pair

Answer: B
Feedback: Recombination is the combining of DNA from two different cells, resulting in a
recombinant DNA molecule.
Difficulty: 1

7. Which of the following describes the process of replication?

A. Synthesis of a nearly perfect copy of a molecule
B. Portions of chromosomes from different pathogens link
C. Single base in genetic material converts to another
D. Two chromosomes from different pathogens form a pair

Answer: A
Feedback: Replication is when a nearly perfect copy of a molecule is synthesized.
Difficulty: B=1

8. Which of the following describes the process of reassortment?

A. Synthesis of a nearly perfect copy of a molecule
B. Portions of chromosomes from different pathogens link
C. Single base in genetic material converts to another
D. Two chromosomes from different pathogens form a pair

Answer: B
Feedback: Re-assortment occurs when whole gene segments are swapped during co-infection
with two pathogens.
Difficulty: 1

3
9. Which of the following describes the process of point mutation?
A. Synthesis of a nearly perfect copy of a molecule
B. Portions of chromosomes from different pathogens link
C. Single base in genetic material converts to another
D. Two chromosomes from different pathogens form a pair

Answer: C
Feedback: Point mutations occur when single nucleotide bases of the DNA sequence change.
This can be due to a substitution of one base for another, or by insertion or deletion of a
nucleotide base in the sequence.
Difficulty: 1

10. SARS is transmitted by all of the following mechanisms except

A. Droplet
B. Fomite
C. Direct contact
D. Mosquitoes
E. Aerosol

Answer: D
Feedback: SARS can be transmitted by direct contact, droplet (including aerosol), and fomite,
all forms of contact transmission. It is deposited on the respiratory mucosal epithelium where it
initiates infection. It is not transmitted by vector.
Difficulty: 1

11. The _____ of the SARS coronavirus is used to bind to receptors on the host cell
membrane.
A. Small membrane protein (M protein)
B. Nucleocapsids protein
C. RNA
D. Spike protein (S protein)

Answer: D
Feedback: The SARS virus enters host cells by attaching spike proteins present on the virion to
receptors on the host plasma membrane. M protein, nucleocapsids protein, and RNA are not
involved.
Difficulty: 1

12. Which of the following is not true of the SARS coronavirus?

4
A. It is a single-stranded viral RNA
B. There is a vaccine available
C. It causes pneumonia
D. It initiates infection on mucosal epithelia of the respiratory tract

Answer: B
Feedback: SARS is a single-stranded RNA virus that first infects mucosal cells in the lungs and
can cause pneumonia. There is no vaccine available for SARS.
Difficulty: 1

13. Which of the following is a target for the virus that causes viral hemorrhagic disease?
A. Monocytes
B. Dendritic cells
C. Endothelial cells
D. Hepatocytes
E. All of the choices

Answer: E
Feedback: Viral Hemorrhagic Fever (VHF) viruses target monocytes, dendritic cells, endothelial
cells, hepatocytes, and adrenal cortical cells. They use endocytosis as the mechanism of
penetration and cause varying degrees of cell destruction.
Difficulty: 1

14. There are no vaccines available for any of the following except
A. SARS
B. HIV
C. Transmissible spongiform encephalitis
D. Diphtheria
E. Marburg virus

Answer: D
Feedback: There is a vaccine for diphtheria. It is part of a vaccine packet called DPT which
contains toxoids of diphtheria and tetanus, and killed whole cells of the pertussis pathogen. There
is currently no vaccine for SARS, HIV, Transmissible spongiform encephalitis, or Marburg
virus.
Difficulty: 1

15. The primary host of the West Nile virus is

A. Birds
B. Mosquitoes

5
C. Humans
D. Horses
E. Monkeys

Answer: A
Feedback: Birds are the primary host of the West Nile virus, and it is spread from bird to bird by
mosquitoes. Humans, and animals such as horses, are incidental hosts and they can be infected
by mosquitoes carrying the virus.
Difficulty: 1

16. All of the following are possible modes of transmission for the West Nile virus except
A. Tainted blood transfusion
B. Inhalation of rodent excrement
C. Mosquito bites
D. Infected organ transplant

Answer: B
Feedback: West Nile fever is a blood-borne disease that could be transmitted by mosquito bite,
tainted blood transfusion, and infected organ transplant. It is not transmitted via the fecal-oral
route and would not be present in rodent feces.
Difficulty: 1

17. All of the following are characteristics of Ebola hemorrhagic fever except
A. Circulatory shock
B. Possibility of transmission from human to human
C. Effective vaccine if received in advance of exposure
D. Disseminated intravascular coagulation (DIC)
E. Petechial hemorrhaging

Answer: C
Feedback: There is currently no approved vaccine for Ebola, although several experimental
drugs have been used in the treatment of infected healthcare workers during the 2014 outbreak.
Characteristics of VHF infection include circulatory shock, DIC, and petechial hemorrhaging.
All VHF viruses are transmissible from human to human, usually through direct contact with
infected blood or bodily fluids.
Difficulty: 1

18. Which of the following groups is susceptible to tuberculosis (TB)?

A. Malnourished individuals
B. AIDS patients

6
C. Immunocompromised individuals living in long-term care facilities
D. Alcoholics
E. All of the choices

Answer: E
Feedback: Individuals with reduced immune defenses are more susceptible to infection with TB.
This includes those who are malnourished, alcoholics, and immunocompromised individuals
such as AIDS patients.
Difficulty: 1

19. Which of the following is not an explanation for the re-emergence of TB?
A. Failure of patients with TB to take all of there prescribed antibiotics
B. An increase in the number of elderly living in nursing homes
C. An increase in the rodent population in urban areas
D. An increase in the number of immigrants born in areas where TB occurs
E. The HIV/AIDs epidemic

Answer: C
Feedback: Tuberculosis is mainly spread through droplet transmission and is not transmitted by
rodents. Factors contributing to the re-emergence of TB include inappropriate treatment resulting
in the evolution of antibiotic resistant TB stains, and an increase in susceptible individuals due to
poor socioeconomic conditions in areas where TB occurs, and rising numbers of
immunocompromised individuals such as HIV/AIDS patients and the elderly in nursing homes.
Difficulty: 2

20. Which of the following epidemics was caused by an H1N1 virus?

A. Asian influenza
B. Hong Kong influenza
C. Spanish influenza
D. Swine influenza of 2009
E. Spanish influenza and Swine influenza of 2009

Answer: E
Feedback: H1N1 viruses caused both the Spanish Flu epidemic of 1918 and the Swine Flu
epidemic of 2009. The Asian influenza epidemic of 1957 was caused by H2N2 virus and the
Hong Kong influenza epidemic of 1968 was caused by H3N2 virus.
Difficulty: 1

21. Which of the following is not a characteristic of transmissible spongiform encephalitis

diseases?

7
A. They cause neurodegeneration
B. They are treated with proteases inhibitors
C. They require long incubation periods
D. The earliest documented cases were in the Fore people of New Guinea
E. They are caused by abnormal PrPSCprions

Answer: B
Feedback: There is no treatment for transmissible spongiform encephalitis disease. These
diseases are caused by infectious, abnormal prion proteins, have long incubation periods, and
cause neurodegeneration. The first observed prion disease in humans was kuru, which occurred
in the Fore people of New Guinea.
Difficulty: 1

22. Which is not a characteristic of prions?

A. Resistant to degradation by proteinases
B. Found mainly on outer membranes of nerve cells.
C. Resistant to autoclave treatment.
D. Unable to pass through the intestinal wall
E. Resistant to autoclave treatment and unable to pass through the intestinal wall

Answer: D
Feedback: Prions are able to pass through the intestinal wall. They are also resistant to
degradation by proteinases and autoclave treatment, and are mainly found on the outer
membranes of nerve cells.
Difficulty: 1

23. Which of the following choices regarding Creutzfeldt–Jacob disease (CJD) is a

mismatched pair?
A. Iatrogenic form: blood transfusion
B. Mad cow disease: epidemic in humans
C. Familial form: genetically inherited
D. Prognosis: death within 12 months of first signs
E. Brain morphology: plaques

Answer: B
Feedback: Mad cow disease (BSE) was not a human epidemic as only a few humans ever came
down with the disease. The iatrogenic form of CJD is transmitted through medical treatments
such as blood transfusions and corneal transplants. Familial CJD is genetically linked to
mutations in the genes coding for normal prions. All forms of CJD exhibit plaque deposits in the
brain and death usually occurs within 12 months after the first signs of disease appear.
Difficulty: 1

8
Reference: Figure 1. VHF pathogenesis.
Use the figure below to answer the following questions.

24. In the figure which letter (A to E) indicates virus particles?

Answer: D
Feedback: Virus particles infect macrophages and dendritic cells. Chemokines recruit more
macrophages to the site and these also become infected. Soluble factors are released, acting both
locally and systemically, resulting in lymphocyte apoptosis and increased endothelial porosity
and edema.
Difficulty: 1
Refer to: Figure 1. VHF pathogenesis.

25. In the figure which letter (A to E) indicates a macrophage?

Answer: E
Feedback: Virus particles infect macrophages and dendritic cells. Chemokines recruit more
macrophages to the site and these also become infected. Soluble factors are released, acting both
locally and systemically, resulting in lymphocyte apoptosis and increased endothelial porosity
and edema.
Difficulty: 1

9
Refer to: Figure 1. VHF pathogenesis.

26. In the figure which letter (A to E) indicates recruitment by chemokines?

Answer: C
Feedback: Virus particles infect macrophages and dendritic cells. Chemokines recruit more
macrophages to the site and these also become infected. Soluble factors are released, acting both
locally and systemically, resulting in lymphocyte apoptosis and increased endothelial porosity
and edema.
Difficulty: 1
Refer to: Figure 1. VHF pathogenesis.

27. In the figure which letter (A to E) indicates apoptosis?

Answer: B
Feedback: Virus particles infect macrophages and dendritic cells. Chemokines recruit more
macrophages to the site and these also become infected. Soluble factors are released, acting both
locally and systemically, resulting in lymphocyte apoptosis and increased endothelial porosity
and edema.
Difficulty: 1
Refer to: Figure 1. VHF pathogenesis.

28. In the figure which letter (A to E) indicates production of edema?

Answer: A
Feedback: Virus particles infect macrophages and dendritic cells. Chemokines recruit more
macrophages to the site and these also become infected. Soluble factors are released, acting both
locally and systemically, resulting in lymphocyte apoptosis and increased endothelial porosity
and edema.
Difficulty: 1
Refer to: Figure 1. VHF pathogenesis.

Essay

29. Bovine spongiform encephalitis seems to be related to scrapie, a disease in sheep, and to
Creutzfeldt-Jacob disease in humans. Compare and contrast BSE and CJD.

10
Answer: Prion diseases, known as transmissible spongiform encephalopathy (TSE), are a group
of animal and human neurodegenerative diseases which are caused by infectious, abnormally
folded prion proteins that then cause normal prions to fold improperly. These diseases are fatal
and are characterized by long incubation periods and a complex neuropathology including
spongiform effects and plaque deposits in brain tissue.
TSE in sheep is known as scrapie and in cattle as Bovine spongiform encephalitis (BSE).
BSE was first recorded in 1986 and was attributed to cattle feed that had been supplemented with
sheep brains from sheep infected with scrapie. BSE was transmitted to humans by consumption
of contaminated food, causing a new form of human TSE known as variant CJD (vCJD) which
was first recorded in 1996.
Creutzfeldt-Jacob disease (CJD) is a human form of TSE which can occur spontaneously,
can be genetically linked to mutations in the genes coding for normal priors, or can be
transmitted through medical treatments such as blood transfusions and cornea transplants. It is
usually seen in individuals of 55 to 75 years old, has an incubation period of 3 to more than 20
years, and usually causes death within 12 months of the first signs of the disease appearing.
Variant CJD differs from CJD in a number of ways. It occurs in younger individuals, those
between 16 and 39 years old, the disease takes longer to progress and results in larger plaque
deposits in the brain.
Difficulty: 2

30. Name and describe four different transition patterns that emerging diseases have followed
through history. Provide an example for each.

Answer: The four different transition patterns of emerging disease are crowd, war or trade,
exploration and global urbanization. Crowd transition occurs when crowded living conditions
facilitate transmission of both human-derived and zoonotic diseases. An example of this is
measles which was confined to cattle 7000 years ago and then diverged to infect only humans.
War or trade transmission occurs when remote civilizations merge as a result of war or trade,
promoting the exchange of infections and vectors. An example of this is typhus which was first
reported during the Peloponnesian War. Exploration transition occurred when worldwide
exploration and colonization introduced new diseases to areas never before affected by certain
diseases. An example is the introduction of syphilis to Pacific island populations by Captain
Cook and his crew. Global urbanization transition is currently occurring and where expanding,
heavily populated settlements combined with poverty, social upheaval, air travel, technological
development, deforestation, and climate changes are contributing to the emergence and re-
emergence of transmissible diseases. An example of this is SARS which became transmissible to
and among humans in the 1990s, emerging in China and spreading to cause outbreaks in Hong
Kong, Singapore, Vietnam, and Canada.
Difficulty: 2

11
31. Where did the Hantavirus originate and how is it transmitted to humans? Explain the
factors that contributed to the outbreak of Hantavirus in the southwestern region of the
USA in 1993.

Answer: The Hantavirus originated in rodent populations in South America and spread to
rodents in the southwestern region of the United States. The virus is transmitted through rodent
excrement which, when inhaled by humans, causes acute respiratory disease. The 1993 outbreak
of Hantavirus in southwestern USA occurred due to a surge in the deer mouse population that
harbored the virus. The population increase was linked to a surplus of pine nuts, a staple food for
deer mice, in that season and a subsequent increase in human exposure to rodent feces.
Difficulty: 2

32. What are the three molecular processes that contribute to viral diversity? Describe each
process and explain why these mechanisms are of concern.

Answer: The three molecular processes that contribute to viral diversity are mutation,
recombination, and re-assortment. Mutation is a change in the nucleotide sequence which occurs
when errors during nucleic acid replication result in substitution, addition, or deletion of
nucleotides. Recombination is a rare event in which foreign genetic material gets incorporated
into the viral genome. Re-assortment is where gene segments from two co-infecting viruses are
redistributed to form new strains. These mechanisms are of concern because they can give rise to
new biological properties of the virus such as new virulence characteristics or new host range
specificities.
Difficulty: 3

33. Describe two hurdles to the interspecies transfer of viruses and how these may be
overcome. Which viruses are most effective at accomplishing this? Provide examples.

Answer: The two hurdles to interspecies transfer are first, that the virus must adapt to replicate
successfully in the new host species, and second, that the virus must acquire the capacity to be
transmitted among individuals of the new host species. The hurdles are overcome by alterations
to the genetic makeup of the virus and this occurs through the molecular mechanisms of point
mutation, recombination, and re-assortment. RNA viruses are the most effective at overcoming
these hurdles as they are the best adapted to enable these molecular mechanisms generate viral
diversity. Examples of such viruses include the influenza virus, SARS coronavirus, and viral
hemorrhagic fever viruses.
Difficulty: 3

34. Identify and explain four different factors that have contributed to the re-emergence of
tuberculosis.

12
Answer: Factors contributing to the re-emergence of TB include an increase in the number of
immunocompromised individuals, an aging population, poor socioeconomic conditions, and the
development of drug resistance. An increasing number of immunocompromised individuals,
such as the increased number of AIDS patients, has resulted in a greater number of individuals
susceptible to TB. An aging population with an increased number of residents in nursing homes
has also increased the number of cases. This is due to reactivation of latent TB infections in the
elderly that become active cases, exposing other immunocompromised individuals to infection in
an environment with a high concentration of susceptible individuals. Poor socioeconomic
conditions also contribute. The risk of infection is increased in areas with high levels of poverty
and crowded housing, where immune competence is often compromised by poor nutrition, drug
abuse, and alcoholism. Migration of individuals from geographic areas with a high prevalence of
TB can also contribute to increasing numbers of active cases. The development of drug
resistance is a major factor in the re-emergence of TB. This is facilitated by inappropriate
treatment as if patients do not follow the prescription regimen it not only increases the period of
infectivity but also increases the chance that drug resistance will evolve. Both multi-drug
resistant TB (MDR-TB) and extensively drug resistant TB (XDR-TB) are now seen in many
countries across the world.
Difficulty: 3

35. Could there be a connection between global warming and the dissemination of deadly
strains of avian influenza? Explain your answer.

Answer: Global warming will have an impact on the migratory patterns of birds and as such
could affect the migration of birds harboring the avian influenza virus (H5N1), spreading this
virus to new geographical regions, individuals and species. H5N1 is one of the most potentially
devastating emerging infections as it has an extremely high rate of mutation, can acquire genes
from other viruses, and has a very high mortality rate. It is already capable of infecting humans
although it has yet to become transmissible among humans. Of particular concern is the potential
for co-infection of pigs with both avian and human influenza, which could result in gene re-
assortment, and produce a virus that would be extremely virulent and transmissible in humans.
Difficulty: 3

36. Explain which measures led to the development of resistance to amantadine and
rimantadine in the H5N1 influenza virus and why this resistance is a problem. Are there
any alternative drugs to combat H5N1 and, if so, could sufficient protection be provided
if there was an influenza pandemic?

Answer: The antiviral drugs amantadine and rimantadine are no longer effective against H5N1
as these drugs were administered in high doses to infected birds in an attempt to control
influenza in birds in Asia. This did little to control the virus in birds, but instead fostered the
development of resistance to these drugs. This is a problem as the amantadine and rimantadine

13
are among the few antiviral drugs available to combat influenza infections. An alternative drug is
Tamiflu, which has some effect on H5N1. However, there is a worldwide shortage of this drug
and there would be an insufficient supply in the event of a pandemic, resulting in a high
mortality rate.
Difficulty: 3

37. Explain the term “incubator” as it applies to an influenza pandemic involving pigs.

Answer: Pandemics usually arise when gene re-assortment between two different influenza
strains occurs, giving rise to a new influenza variant to which the population is not immune.
Gene re-assortment requires a cell to be infected with both viral types simultaneously, such as
with both the avian and human influenza strains. As pigs can be infected with both these viruses,
they therefore provide a potential host in which incubation of both viruses could occur, providing
an opportunity for gene re-assortment inside pig cells and the evolution of a new influenza
variant capable of causing a pandemic.
Difficulty: 2

14
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