Emerging and Re-emerging

Infectious Diseases
Tuti Parwati Merati
Division of Tropical and Infectious Disease
Department of Internal Medicine
Faculty of Medicine Udayana Univ/Sanglah
Hospital Denpasar - Bali

DEFINITION
EMERGING INFECTIOUS DIS.:
INCREASING INCIDENCE OR
GEOGRAPHIC DISTRIBUTION
RECOGNITION BECAUSE THE DISEASE:
PRESENT IN POPULATION FOR THE FIRST
TIME,
HAS BEEN DETECTED FOR THE FIRST TIME,
OR BECAUSE LINKS BETWEEN AN
INFECTIOUS AGENT AND A CHRONIC DIS.
OR A SYNDROME HAVE ONLY RECENTLY
BEEN IDENTIFIED
Definition
New/emerging infections or drug
resistant infections whose incidence in
humans has increased within the past
two decades or whose incidence
threatens to increase in the near
future
Re-emerging infectious diseases :
eg.Tb in developed countries
Re Emerging Viral Infections
Polio-virus (under control)
Chikungunya-virus (still raging mainly in Java)
Avian Influenza virus (hot spots)
Hand Foot Mouth Disease (Kalimantan)
Japanese B Encephalitis Virus (Bali)
Rabies (Bali)
New H1N1 InfluenzaVirus


New Clinical Presentations of VI
Dengue Renal Failure
Dengue Retinal Hemorrhage
HIV Reconstitution Syndrome
TIME TREND (1)
Poor sanitary conditions , water supply,
vaccines, AB
in the first half of 20
th
century in USA better
hygiene and water quality improved the health
of general population; Medical care and vaccines
lowered the rate of ID

After World War II : antibiotics become
available first time HCW can treat major
infections. New Vaccines available prevent
and controlled severe infection eg. Polio and
measles
TIME TREND(2)
SOME KNOWN DISEASES PERSIST
SOME NEW MICROBES EMERGED
MANY OF ID FIRST RECOGNIZE ONLY IN THE LAST HALF OF
20
TH
CENTURY
IN EARLY 1950s PENICILLIN RESISTANCE
IN 1957 AND 1968 NEW STRAINS OF Influenza SPREAD
RAPIDLY AROUND THE WORLD, ALTHOUGH LESS SEVERE
THAN THE 1918 FLU STRAIN RESULTED EXCESS DEATH
IN 1970s LEGIONNAIRES DIS AND LYME Dis. (USA)
IN 1980s HIV APPEARED, AND TB increased in USA
IN 1990s Gonorrhea Resistant and Hanta virus emerged
IN 2000 : SARS, PANDEMIC INFLUENZA (BIRD FLU, SWINE
FLU) AND West Nile VIRUS
Infectious Disease Mortality in
the United States, 1980-1996
Source: JAMA 1996;275:189-193 and unpublished CDC data
0
10
20
30
40
50
60
70
80
Year
D
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0

p
o
p
u
l
a
t
i
o
n

C
r
u
d
e

I
D

M
o
r
t
a
l
i
t
y

R
a
t
e

CDC
Factors Contributing to Emerging
Infectious Disease (EID)
Two step process :
INTRODUCTION
TRANSMISSION

EXAMPLES :
Hantavirus Rat
Mosquito-borne dis Mosquitos
Ebola Virus direct contact?
HIV evolved from non human primate
human
The cotton rat
Sigmodon hispidus
How do infectious disease become
pandemic?
Disease spread very efficiently and quickly
Influenza
The right strain with the right combination
of biological properties to spread well, and
novel to human pop., come at the right time
in the right place
Disease not easily transmitted can become
pandemic by other means
HIV
Major Factors Contributing to Emerging
Infection Disease (EID) : 1992
1. Human demographics and behavior
2. Technology and Industry
3. Economic development and land use
4. International travel and commerce
5. Microbial adaptation and change
6. Breakdown of public health measures

Institute of Medicine Report, 1992
More Factors Contributing to Emerging
Infections Disease (EID) : 2003
7. Human vulnerability
8. Climate and weather
9. Changing ecosystems
10. Poverty and social inequality
11. War and famine
12. Lack of political will
Institute of Medicine Report, 2003
EID:
Human Demographics, Behavior, Vulnerability
More people, more crowding
Changing sexual behavior (HIV, STDs)
Injection drug use (HIV, Hepatitis C)
Changing eating habits: out more, more
produce (food borne infections)
More populations with weakened immune
system: elderly, HIV/AIDS, cancer patients
and survivors, persons taking antibiotics and
other drugs
EID:
Technology and Industry
Mass food production (Campylobacter,
E.coli O157:H7, etc)
Use of antibiotics in food animals
(antibiotic-resistant bacteria)
More organ transplants and blood
transfusions (Hepatitis C, WNV,)
New drugs for humans (prolonging
immuno suppression)
EID:
Economic Development, Land Use, Changing Ecosystems
Changing ecology influencing
waterborne, vectorborne disease
transmission (e.g. dams, deforestation)
Contamination of watershed areas by
cattle (Cryptosporidium)
More exposure to wild animals and
vectors (Lyme disease, erhlichiosis,
babesiosis, HPS,)
Monkeypox from Prairie
Dogs
EID:
International Travel and Commerce
Persons infected with an exotic disease
anywhere in the world can be into major
US/Eur/Asia/Aus/Afr city within hours
(SARS, VHF,)
Foods from other countries imported routinely
into other countries (Cyclospora,.)
Vectors hitch hiking on imported products
(Asian tiger mosquitoes on lucky
bamboos,.)
EID:
Microbial Adaptation and Change
Increased antibiotic resistance with
increased use of antibiotics in humans
and food animals (VRE, VRSA,
penicillin- and macrolide-resistant Strep
pneumonia, multidrug-resistant
Salmonella,.)
Increase virulence (Group A Strep?)
Jumping species from animals to
humans (avian influenza, HIV?, SARS?)
EID:
Poverty, Social Inequality, Breakdown of Public
Health Measures
Lack of basic hygienic infrastructure
(safe water, safe foods, etc..)
Inadequate vaccinations (measles,
diphtheria)
Discontinued mosquito control efforts
(dengue, malaria)
Lack of monitoring and reporting
(SARS)
Preventing Emerging
Infectious Diseases
Surveillance and Response : Detect, investigate,
and monitor (pathogens, disease, the factors
influencing their emergence, respond to
problems as they are identified)
Research
Infrastructure and Training
Prevention and Control
New policies to control the antibiotic resistance


SITUASI DI INDONESIA
HIV
Dengue virus
Polio-virus (under control)
Chikungunya-virus (still raging mainly in Java - Bali)
SARS
Avian Influenza virus (hot spots)
Hand Foot Mouth Disease (Kalimantan)
Japanese B Encephalitis Virus (Bali)
Rabies virus (Java, Flores, Bali)
Flu A (H1N1)


44.4
47.1
23.1
20.8
27.9
19.2
12.2
4
9
0
5
10
15
20
25
30
35
40
45
50
Waria
Gatsu
Carik
P.Galak
Sanur-1
Sanur-2
Bungalow
Panti Pijat
Gay
SERO-SURVEI TAHUN 2009
PADA WARIA, GAY, PS
Source : YKP , 2009
63
71
61
58
64
0
10
20
30
40
50
60
70
80
2000 2003 2004 2005 2007
HIV PREVALENCE AMONG IDUs,
DENPASAR, BALI
%
Source: Bali Health Department
1.6
7
8.8
8.5
12.4
14.5
15.2
20.5
22.5
0.25 0.24
2 2
4 4.1
6.1
7.2
0
5
10
15
20
25
2000 2001 2004 2005 2006 2007 2008 2009 2010
TREND OF HIV PREVALENCE AMONG
FEMALE SEX WORKERS (DENPASAR,
BALI)
DIRECT SEX
WORKERS
INDIRECT SW
Source: Bali Health Department
%
Nelwan, 2009
Kecendrungan Faktor Risiko Kasus
AIDS per Periode di Indonesia
Sumber : Laporan Triwulan Pengidap infeksi HIV dan Kasus AIDS September 2008
64.7
43.2
17.6
53.7
72.5
36.6
50.5
17.6
39.5
11.8
1.3
3.4
7.7
3.4
0
2.1
53.3
2.6 1.05
2.2
4.0
5.5
5.9
0
0
0
10
20
30
40
50
60
70
80
90
100
87-90 91-95 96-2000 2001- 2005 2006-skrg
Tahun
P
e
r
s
e
n
Homosex Heterosex IDU Lain-lain Tak diketahui
CHRONOLOGY INDONESIA POLIO OUTBREAK 2005
INITIAL CASE REPORT & FOLLOW UP

19 months old toddler F experienced fever and convulsions. The family was
too poor to take him to the doctor but when signs of increasing loss of
strength appeared both in upper as well as lower extremities since March 13,
2005 the child was brought to the local Health Center (Dr. Ana).
On the 24
th
of March a stool sample was taken and send to the laboratory
where isolation of poliovirus was proven positive a few weeks later.
Besides this boy 6 other cases were noted with the same symptoms.
The Department of Health was notified on April 22. An Outbreak Response
Immunization was put into effect 24-28 April posters were up for call of
reporting all flaccid paralysis cases. In the stricken and nearby areas
another 8 cases turned up. Stool samples from these 14 additional cases
yieded 8 positive for Polioviruses, as announced by Sukabumi Chief Health
Officer ( Dr. Buhono T.)

Nelwan , et al. JKT , 2009
FIRST KNOWN VICTIM ON LAP
OF MOTHER (F 19 MO)
NOTE RIGHT SIDED FLACCID PARALYSIS
IN UPPER EXTREMITY
Nelwan, et
al. Jkt, 2009
POLIO , 2005
Chikungunya
Etiologi
Alpha virus.
60 mRNA.
Berselaput sferis.
Berkembang dalam sitoplasma.
Patogen untuk bayi hewan pengerat.
Diisolasi pertama kali di Tanzania
(1952).
Diagnosis
1. Isolation of virus from blood
2. Conventional serology :
HI ( Charles & Casals)
CF (Futton & Dumbell)
3. Modern technique : ELISA
4. Super modern tech : PCR
5. Latest development : RT PCR
(2002)
Differentiated from DHF
1.

No grade III or IV in chikungunya
2. More maculopapular rash in chikungunya
3. More conjunctival injection in chikungunya
4. Prominent arthralgia in chikungunya
5. lymphadenopathy in chikungunya
Chikungunya Conjunctivitis in 31 y Old Woman
Outbreak of Chikungunya Infection
Indonesia (2006)
Malang Jan 2006 101 cases
Bandung Aug 2006 80 cases
Banyuasin July 2006 501 cases
Depok Oct 2006 90 cases
Outbreaks of Chikungunya
Infection 2007 ( Jan Mar)
Kota Semarang 75 kasus
Sukoharjo 175 kasus
Wonogiri 60 kasus
Kediri 500 kasus
Karang Anyar 29 kasus
Klaten 7 kasus
Rembang 8 kasus
Bekasi 98 kasus
Provinsi Banten 130 kasus
Sum Bar 37 kasus
Kal Teng 26 kasus
SARS
(Severe Acute Respiratory
Syndrome)
SARS-Infectious Agent
Coronavirus is likely.
Seems to be present in all tested cases.
Paramyxovirus looking less likely.
Other coronavirus strains cause
common colds. However, this new CV is
both novel and lethal.
Lab tests (under development):
PCR useful in early stages.
IFA can identify in convalescent.
15% of cases
85% of cases
Infection Settings
Hospitals
Households
SARS
50-100-200 patients in hospital all
requiring Intensive Care, barrier
nursing, mechanical ventilation.
Most of those patients are hospital
staff.
No available drug treatment.
Some die.
This happened in Hong Kong.
SARS-comments
Effective treatment not available.
Supportive treatment only.
ISOLATION.
STRICT BARRIER NURSING.
Ventilation treatment often necessary.
SARS-Infection Control
Standard precautions, e.g. hand
washing, eye protection.
Contact precautions, e.g. gown and
gloves.
Airborne precaution, e.g. isolation
room, negative pressure, use of N95
respirator.

AVIAN INFLUENZA
PADA MANUSIA

WHO : six phases of AI Infection
before it turns into a pandemic

First, AI infection of poultry with low risk of
infection to humans;
Second, AI infection with a high risk of the
virus being transmitted to humans;
Third, AI infection of humans ;
Fourth, human-to-human transmission.
Fifth, a significant increase in transmission
from human to human;
Sixth, the disease has become a pandemic
Hand, Foot and Mouth
Disease Flu Singapore
Caused by : Coxackie virus A16
Enterovirus 71
Slight fever Sore throat
Vesicular lession on buccal mucosa, tongue, hand
and foot
Meningitis, encephalitis, paralysis (EV71)
Since 1997 outbreaks in East Malaysia (borders
with Kalimantan RI), Singapore, Japan, West
Malaysia
Large outbreak in Taiwan 1998 (130.000 cases )
Death reported in all outbreaks
Viral Encephalitis
Japanese Encephalitis
Caused by Togaviruses
2001 : 74 cases in Bali CFR 9,4% sequelae 47,5%
Reported from tourist returning from Bali
Disebarkan oleh nyamuk, babi sebagai amplifier
Vaccine available
Nipah Viral Encephalitis
Zoonotic Paramyxovirus infections
Malaysia : 105 death among 265 patients
(outbreak)
Pigs eat contaminated food (bat secretion)
Human infections probably by aerosol
More than one million pigs culled to end the
outbreak



Swine Flu New Flu H1N1

55
Pandemics of influenza
H7

H5

H9
*
1980
1997
Recorded new avian influenzas
1996 2002
1999
2003
1955 1965 1975 1985 1995 2005
H1N1
H2N2
1889
Russian
influenza
H2N2
H2N2
1957
Asian
influenza
H2N2
H3N2
1968
Hong Kong
influenza
H3N2
H3N8
1900
Old Hong Kong
influenza
H3N8
1918
Spanish
influenza
H1N1
1915 1925 1955 1965 1975 1985 1995 2005 1895 1905 2010 2015
2009
Pandemic
influenza
H1N1
Recorded human pandemic influenza
(early sub-types inferred)
Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research,
National Institute of Infectious Diseases (NIID), Japan.
Animated slide: Press space bar
H1N1
Pandemic
H1N1
KASUS-KASUS SWINE FLU DI ASEAN Plus Three,
19 Juni 2009
Negara Jumlah Kasus
Thailand 518
Singapore 77
Brunei Darussalam 2
Malaysia ?
Filipina >300
Indonesia -
Vietnam 19
Laos 1
Jepang >>?
Korea 79
Hongkong 221
57
Genetic origins of the pandemic (H1N1)
2009 virus: viral reassortment
PB2
PB1
PA
HA
NP
NA
MP
NS
PB2
PB1
PA
HA
NP
NA
MP
NS
PB2
PB1
PA
HA
NP
NA
MP
NS
Classical swine, N. American lineage
Avian, N. American lineage
Human seasonal H3N2
Eurasian swine lineage
Eurasian
swine H1N1
N. American H1N1
(swine/avian/human)
Pandemic (H1N1)
2009, combining
swine, avian and
human viral
components
Pencegahan (Filipina DOH) :
Tidur 8 jam sehari
Aktif secara fisik
Hilangkan stres
Minum yang banyak
Makan makanan yang bergizi


De la Paz : Poverty makes Filipinos more vulnerable to flu,
19 Juni 2009


TRANSMISSION
Transmitted from
human to human
Primarily via large-
particle respiratory
droplets (coughing,
sneezing)
Close contact
Contact with
contaminated
surfaces
PREVENTION
Avoid close contact
Stay home when you are sick
Cover your mouth and nose
Wash your hands
Avoid touching your eyes, nose or
mouth
Practice other good health habits
Thorner AR , 2009
Proteksi thd Flu A(H1N1)
Morbidity and Mortality

H1N1 influenza (swine flu) tends to
cause high morbidity but low mortality
rates (1%-4%).
LEGIONNAIRES DISEASE
OUTBREAK DI PHILADELPHIA 1976
PADA ANNUAL MEETING KE 58 DARI
US LEGION
LEBIH 200 KASUS DARI PESERTA YG
TINGGAL DI HOTEL YG SAMA
ETIO : LEGIONELLA PNEUMOPHILA
BAKTERI, GRAM NEGATIVE BTK ROD
GEJALA
SEPERTI FLU : HEADACHE, BODY
ACHES, FEVER, WEAKNESSES,
COUGH, SPUTUM
PNEUMONIA
DX : SPUTUM GRAM, CULTURE, DFA
TREATMENT :
SUPPORTIVE,
SYMPTOMATIC
Penyebab belum jelas
Pengobatan symptomatis
Perlu melindungi dg masker N95
IMMUNOCOMPROMISED
Definition :
Immune system that is unable to mount a full
response to pathogens ( viruses, fungi,
bacteria), or toxins and tissue damage, i.e.
HIV-infected patients
Transplant patients
Autoimmune disorder patients
Cancer patients
Special conditions : preterm infants, elderly,
pregnancy-lactation, smokers
Chronic Diseases: DM, Tuberculosis, eating disorders,
chronic alcoholism, etc.
SUMMARY
Infectious diseases seemed to have controlled by
antibiotics, vaccines and improved hygiene, 50
years ago. But now, health experts recognize the
emerged and spread of new infectious dis.
Factors contribute favors these emerging dis.:
Modern demographic and environmental
conditions,
The ability of microbes to evolve and adapt
amongst the development of many new AB.
Poverty and inadequate access to health care
CONCLUSION