Emerging and re-emerging

infectious diseases

Lecturer:
Tigran Ugujyan
Epidemiologist,
Master of Public Health
Emerging and re-emerging infectious
diseases
Today the world stands on the threshold of a new era in
which hundreds of millions of people will be safe from some
of the most terrible diseases. Soon poliomyelitis, neonatal
tetanus, guineaworm disease, river blindness, Chagas'
disease will join smallpox as diseases of the past. On the
other hand, the world also stands on the brink of a global
crisis in infectious diseases. No country is safe from them
and no country can afford to ignore their threat any longer.
Emerging and re-emerging infectious
diseases
The optimism of a relatively few years ago that many of
these diseases could easily be brought under control has led
to a tragic complacency among the international
community. This complacency is now costing millions of
lives. Today the infectious diseases are not only a health
issue: they have become a social problem with tremendous
consequences for the well-being of the individual and the
world we live in.
Emerging and re-emerging infectious
diseases
Some infectious diseases once thought to be all but
conquered, have returned with a vengeance. Others have
developed stubborn resistance to antibiotic drugs. New and
previously unknown diseases continue to emerge (Table 1).
Together, these trends amount to a crisis for today and a
challenge for the future.
The factors responsible for emergence and
re-emergence of infectious diseases are:
(1) unplanned and underplanned urbanization;
(2) overcrowding and rapid population growth;
(3) poor sanitation;
(4) Inadequate public health infrastructure;
(5) resistance to antibiotics;
(6) increased exposure of humans to disease vectors and reservoirs of
infection in nature;
(7) rapid and intense international travel;
(8) microbial genetic mutation .
Emerging diseases
During the past 30 years, at least 30 new diseases have
emerged to threaten the health of hundreds of millions of
people. For many of these diseases there is no treatment,
cure or vaccine and the possibility of preventing or
controlling them is limited.
Emerging diseases
Emerging infectious diseases are those whose incidence
in humans has increased during the last two decades or
which threaten to increase in the near future . The term also
refers to newly-appearing infectious diseases, or diseases
that are spreading to new geographical areas - such as
cholera in South America and yellow fever in Kenya.
The diseases in question involve all the major modes of
transmission - they are spread either from person to person,
by insects or animals, or through contaminated water or
food. The most dramatic example of a new disease is AIDS,
caused by the human immunodeficiency virus (HIV). The
existence of the virus was unknown until 1983. Presently,
estimated 2.3 million cases occur every year worldwide.
A new breed of deadly haemorrhagic fevers , of which
Ebola virus disease (previously known as Ebola
haemorrhagic fever) is the most notorious, has struck in
Africa. Ebola appeared for the first time in Zaire and Sudan
in 1976. Since then it has appeared periodically. Ebola virus
is a member of Filoviridae family and comprises of 5 distinct
species - Zaire ebolavirus; Reston ebolavirus; Sudan
ebolavirus; Tai ebolavirus; and Bundibugyo ebolavirus.
The recent epidemic started in December 2013 in Guinea and
spread to South Africa. By 8th April 2015, a total of 25,515
cases have been reported with over 10,000 deaths. Case
fatality rate may be as high as 70 per cent. Ebola has
incubation period of 2-21 days, and is not infective during
this period. Asymptomatic cases are also not infective. The
virus is transmitted through direct contact with the blood,
organs, body secretions or other body fluids of infected
animals like chimpanzees, gorillas, monkeys, fruit bats etc.
Human to human transmission is through blood or body
fluids of an infected symptomatic person or through
exposure to objects (such as needles) that have been
contaminated with infected secretions. It is not transmitted
through air, water or food. The illness is characterized by
sudden onset of fever, intense weakness, muscle pain,
headache, sore throat, vomiting, diarrhoea, rash , impaired
kidney and liver functions and in some cases both internal
and external bleeding. Currently there is no specific
treatment for this disease. However, by intensive supportive
care, the mortality can be reduced and spread of the disease
can be prevented by instituting specific infection control
measures. There is no vaccine against ebola (1).
The United States has seen the emergence of hantavirus
pulmonary syndrome, characterized by respiratory failure
and a case fatality rate of over 50%. Since it was first
recognized in 1993, this type of hantavirus infection has
been detected in more than 20 states in that country, and
has also surfaced in Argentina and Brazil.
This hantavirus is carried by rodents, particularly deer mice. Other
hantaviruses have been recognized for many years in Asia,
where they cause haemorrhagic fever with renal
involvement in humans.
Epidemics of foodborne and waterborne diseases due to
new organisms such as cryptosporidium or new strains of
bacteria such as Escherichia coli have hit industrialized and
developing countries alike. The O157:H7 strain of E.coli
was first reported in 1982 and has since then been
implicated in many serious outbreaks of diarrhoeal illness,
sometimes leading to kidney failure.
The strain has been linked to undercooked hamburger beef and
unpasteurized milk. A completely new strain of cholera, O139, appeared in
south-eastern India in 1992 and has since spread north and west to other
areas of India, into western China, Thailand and other parts of South-East Asia.
The threat of a new global influenza pandemic is increasing. Major shifts in the
make-up of influenza viruses occur every 20 years or so, triggering large
epidemics in many parts of the world, and causing many thousands of
deaths. The next such shift is expected to take place very soon.
Epidemic strains of influenza viruses originate from China. The influenza virus is
carried by ducks, chickens and pigs raised in close proximity to one another on
farms. The exchange of genetic material between these viruses produces new
strains, leading to epidemics of human influenza, each epidemic being due to a
different strain.
Currently avian H5N1 is the strain with pandemic potential, since it might adapt
into a strain that is contagious among humans. Since 1997, 478 cases with 286
deaths have been reported to WHO. The first case was from Hong Kong. Other
countries involved are Cambodia, Indonesia, Thailand and Viet Nam (4).
In late 2002, a new disease called SARS was reported from China with rapid
spread to Hong Kong, Singapore, Viet Nam, Taiwan, and Toronto. During 2003,
8,422 SARS cases were reported from 30 countries with 916 fatalities (5) .
More recently, pandemic due to influenza A (H1N1) 2009 strain is continuing
worldwide involving 214 countries, already taking 18,156 lives. New strains such
as those of cholera and influenza do not follow the usual pattern of being more
common in younger people. They affect all age groups, since older people have
not acquired immunity to them from previous infection.
Table 1 summarizes the
aetiological agents and
infectious diseases in
humans and/or animals
recognized since 1973. The
year may differ from first
appearance and first
identification of cases.
Re-emerging diseases
The term re-emerging diseases refers to the diseases which were
previously easily controlled by chemotherapy and antibiotics, but now
they have developed antimicrobial resistance and are often appearing
in epidemic form .
Re-emerging diseases
The emergence of drug- resistant strains of
microorganisms or parasites is promoted by treatments that
do not result in cure. The increasing use of antimicrobials
worldwide, often in subtherapeutic doses and sometimes in
counterfeit form, indicates that this problem will increase in
the foreseeable future. Changes in lifestyle, behaviour
(including injecting and non-injecting drug use) and cultural
or social values are behind the emergence of some infectious
diseases such as syphilis. Increases in the number of sexual
partners have been the main factor in the spread of HIV
infection and other sexually transmitted diseases.
Re-emerging diseases
Travel, including tourism, also plays a role. The spread of syphilis in
the 18th and 19th centuries was related to the movement of
armies. Today, the introduction of HIV in many parts of the
world is due to greatly increased human mobility. Studies
show that whereas only a few generations ago most people
in their lifetime travelled no further than 40 kilometres from
their birthplace, many today go up to 1,000 times further,
travelling the whole world.
Re-emerging diseases
The practices of modern medicine also contribute. The
spread of viral hepatitis is related in part to techniques such
as kidney dialysis and multiple blood transfusions, as well as
to other forms of transmission. Relaxation in immunization
practices can quickly result in the resurgence of diseases , as,
for example. the recent spread of diphtheria in the Russian
Federation and other former republics of the USSR.
Re-emerging diseases
New animal diseases pose potential foodborne risks to
human health that are sometimes difficult to evaluate or
predict. An example that has caused much public concern in
Europe is bovine spongiform encephalopathy ("mad cow
disease"). Fears have grown that the infectious agent
responsible may be passed through the food chain to cause
a variant of the incurable Creutzfeldt-Jakob disease in
humans, in which the brain is attacked. The British beef
market has been seriously affected and stringent public
health safeguards have been introduced.
Re-emerging diseases
The reasons for outbreaks of new diseases, or sharp
increases in those once believed to be under control, are
complex and still not fully understood. The fact is however,
that national health has become an international challenge.
An outbreak anywhere must now be seen as a threat to
virtually all countries, especially those that serve as major
hubs of international travel.
Re-emerging diseases
Despite the emergence of new
diseases in the last 30 years, there is still a lack of national
and international political will and resources to develop and
support the systems that are necessary to detect them and
stop their spread. Without doubt diseases as yet unknown,
but with the potential to be the AIDS of tomorrow, lurk in
the shadows.
Antimicrobial resistance
Resistance by disease-causing organisms to antimicrobial
drugs and other agents is a major public health problem
worldwide. It is making a growing number of infections
virtually untreatable, both in hospitals and in the general
community. It is having a deadly impact on the control of
diseases such as tuberculosis , malaria, cholera, dysentery
and pneumonia.
Antimicrobial resistance
Antimicrobial resistance is not a new problem, but it has
worsened dramatically in the last decade. During that time,
the pace of development of new antimicrobials has slowed
down while the prevalence of resistance has grown at an
alarming rate. The increase in the number of drug-resistant
bacteria is no longer matched by a parallel expansion in the
arsenal of agents used to treat infections.
Antimicrobial resistance
There is strong evidence that a major cause of the current crisis in
antimicrobial resistance is the uncontrolled and
inappropriate use of antibiotic drugs, in both industrialized
and developing countries. They are used by too many
people to treat the wrong kind of infection, in the wrong
dosage and for the wrong period of time. The implications
are awesome : drugs that cost tens of millions of dollars to
produce, and take perhaps 10 years to reach the market,
have only a limited life span in which they are effective.
Antimicrobial resistance
As resistance spreads, the life span shrinks; as fewer new drugs
appear, the gulf widens between infection and control. So
far, the pattern of excessive or inappropriate use and the
development of resistance has been repeated after the
introduction of each new antimicrobial. The over-use of
expensive drugs designed to cover a range of infections is a
particularly serious problem in industrialized countries.
Antimicrobial resistance
In developing countries, the problem is compounded by the
ready availability of over-the-counter drugs. This allows
patients to treat themselves, either with the wrong medicine,
or in quantities that are too small to be effective. Substandard
and counterfeit drugs which lack adequate
amounts of active ingredients further exacerbate the
resistance problem.
The examples of bacterial resistance are as
follows :
Strains of M. tuberculosis resistant to anti-tuberculosis
drugs are widespread, although attention has recently
focused on the alarming outbreaks of tuberculosis caused by
multidrug-resistant strains in the United States. Drug
resistance is the result of poor prescribing practices, or poor
patient compliance with treatment. It is low in the few
countries with effective tuberculosis programmes. The most
dangerous form of the multidrug-resistant disease occurs
when cases become virtually incurable and doctors face
situations similar to those of the pre-antibiotic era.
The examples of bacterial resistance are as
follows :
Malaria presents a double resistance problem : resistance
of the Plasmodium parasites, which cause the disease, to
antimalarial drugs; and resistance of the Anopheles
mosquitoes, the vectors of the disease, to insecticides. The
arsenal of antimalarial drugs is limited. Most of them act by
killing parasites when they are multiplying in the blood
stream of the human host. Unfortunately, due to inadequate
regimens, poor drug supply, and poor quality and misuse of
drugs, rapid development of drug resistance has occurred in
most areas of the world. Drug resistance is particularly
important in falciparum malaria, the most severe form of the
disease.
The examples of bacterial resistance are as
follows :
Resistance to chloroquine, the most commonly used
drug, has been found in all endemic countries except those
of Central America and the Caribbean. Resistance to
multiple drugs is common in South-East Asia. This serious
obstacle to malaria control efforts is further complicated by
mosquito resistance to insecticides. Many mosquitoes are
reported to be resistant to the three classes of insecticides
available for public health use, and some are becoming
resistant to pyrethroids, widely promoted for bed-net and
curtain impregnation.
The examples of bacterial resistance are as
follows :
Enterococci contribute to some of the most common
infections acquired in hospitals, causing intra-abdominal
abscesses, endocarditis, and infections of the urinary tract
and soft tissues. In some countries, infections resulting from
strains resistant to the main groups of antibiotics, such as the
beta-lactams and the aminoglycosides, can only be treated
with vancomycin, an expensive intravenous drug.
The examples of bacterial resistance are as
follows :
Even resistance to vancomycin has developed in the last 10 years
or so. Staphylococci, which can contribute to skin infections,
endocarditis, osteomyelitis, food poisoning and other
serious disorders, have developed resistance to all
antibiotics except vancomycin. If vancomycin- resistant
strains were to emerge, some of the most prevalent hospitalacquired
infections would become virtually untreatable.
The examples of bacterial resistance are as
follows :
Streptococci have become increasingly resistant to some
antibiotics. They are among the most common diseasecausing
bacteria, responsible for infections of the throat,
middle ear, skin and wounds, and also necrotizing fasciitis
and gangrene. Pneumococci and Haemophilus influenzae
are the most common bacteria causing acute respiratory
infections in children, particularly pneumonia. Both of these
organisms are becoming more and more resistant to drugs .
Strains of pneumococci, once uniformly susceptible to
penicillin, are currently resistant to it in up to 18% of cases
in the United States and, 40% in South Africa.
The examples of bacterial resistance are as
follows :
In addition, they are becoming resistant to many other commonly used
antibiotics, including cotrimoxazole, the drug recommended
by WHO for treatment of pneumonia. The most virulent
type of Haemophilus influenzae is today frequently resistant
to ampicillin, and strains have been identified that are
resistant to other drugs, including cotrimoxazole. In brief,
doctors worldwide are losing some of the most useful and
affordable antibiotics against the two bacteria which are the
major cause of death in children.
The examples of bacterial resistance are as
follows :
Neisseria gonorrhoeae, cause of one of the most common
sexually transmitted diseases, has acquired such resistance
to penicillin and tetracyclines in most countries that the use
of these antibiotics to treat it has become unacceptable and
this infection now requires the use of much more expensive
drugs which are often unavailable.
The examples of bacterial resistance are as
follows :
Shigella dysenteriae has been causing outbreaks of
severe diarrhoeal disease in central and southern Africa in
recent years, including those in refugee camps, with the
epidemic strain acquiring increasing resistance to standard
antibiotics. Epidemic dysentery caused by this strain results
in the death of up to 15% of those infected.
The examples of bacterial resistance are as
follows :
Salmonella typhi, the bacterium responsible for typhoid fever, has
developed resistance to antibiotics commonly used in the
past for treatment. Resistant strains have caused outbreaks
of the disease in India and Pakistan. Without effective
antibiotic treatment, typhoid fever kills almost 10% of those
infected. In South- East Asia, 50% or more of the strains of
the bacteria may already be resistant to several antibiotics.
The examples of bacterial resistance are as
follows :
More than half of the antibiotics produced worldwide are
used in animals, largely in subtherapeutic concentrations
which favour the onset of drug resistance. As a result, two
important human pathogens of animal origin, E.coli and
salmonellae, are today highly resistant to antibiotics in both
industrialized and developing countries. For instance, in the
United Kingdom, the increase of multidrug-resistant strains
of Salmonella typhimurium isolated from cattle is paralleled
by increasing resistance among strains of human origin.
The examples of bacterial resistance are as
follows :
In Thailand, salmonellae isolated from food animals are also
highly resistant to the common antibiotics. These bacteria
cause diarrhoeal disease and can lead to life-threatening
complications. Due to the globalization of food supply and
international travel, antimicrobial resistance among animal
bacteria can affect consumers anywhere in the world.
The examples of bacterial resistance are as
follows :
Together, these factors have created perhaps the richest
opportunities ever for the spread of infections, many of
which become global problems that make the first line of
defence - early recognition and adequate and timely
response - essential.
Responding to epidemics
The process of response encompasses a multitude of
activities including : diagnosis of the disease; investigation to
understand the source of transmission; implementation of
control strategies and programmes; research to develop
adequate means to treat the disease and prevent its spread;
and the production and distribution of the necessary drugs
and vaccines.
Responding to epidemics
The strategy for controlling re-emerging diseases is
through available cost-effective interventions such as early
diagnosis and prompt treatment, vector control measures
and the prevention of epidemics, for malaria; and DOTS-directly
observed treatment, short- course - for tuberculosis;
by launching research initiatives for treatment regimens and
improved diagnostics, drugs and vaccines; and above all by
strengthening epidemiological surveillance and drugresistance
surveillance mechanisms and procedures with
appropriate laboratory support for early detection,
confirmation and communication.
Responding to epidemics
The category of diseases - "new diseases - new
problems" - such as Ebola and other viral haemorrhagic
fevers, is probably the most frightening. The need, therefore,
is for expanding research on infectious disease agents, their
evolution, the vectors of disease spread and methods of
controlling them, and vaccines and drug development. Much
of this already applies to HIV/AIDS, one of the most serious
diseases to emerge in recent decades.
18 to 24 November is World Antimicrobial Awareness Week
Antimicrobial resistance (AMR) occurs when bacteria, viruses, fungi and
parasites change over time and no longer respond to medicines, making
infections harder to treat and increasing the risk of disease spread, severe
illness and death. As a result of drug resistance, antibiotics and other
antimicrobial medicines become ineffective and infections become
increasingly difficult or impossible to treat.
A global action plan to tackle the growing problem of resistance to
antibiotics and other antimicrobial medicines was endorsed at the Sixty-
eighth World Health Assembly in May 2015. One of the key objectives of
the plan is to improve awareness and understanding of AMR through
effective communication, education and training.
World Antimicrobial Awareness Week (WAAW) is a global campaign that is
celebrated annually to improve awareness and understanding of AMR and
encourage best practices among the public, One Health stakeholders and
policymakers, who all play a critical role in reducing the further emergence
and spread of AMR.
References
1. WHO (2014) , Fact Sheet on Ebola Viral Disease, No. 103, Sept. 2014.
2. WHO (1996), The World Health Report 1996.
3. WHO (1999), Removing Obstacles to Healthy Development, WHO
Report on Infectious Diseases.
4. WHO (2005), Weekly Epidemiological Record No. 49/50, 14th Oct.,
2005.
5. WHO (2003), World Health Report 2003, Shaping the Future.