Emerging Infectious

Diseases
(II)
BIOM 1005 BIOM1905

Learning Outcomes
To be able to give definition of emerging
infectious disease
To provide named examples of recent
viral emerging infectious diseases and
their aetiological agents
To understand viral detection methods
available including their
advantages/disadvantages and their
application in detecting viral disease
To understand treatment and vaccination
methods available for use in viral disease

Emerging infectious
diseases
Definition of an emerging
infectious disease
emerging infections are those whose

incidence in humans has increased within last 2

decades or threatens to increase in the near
future emergence may be due to spread of a
new agent, or recognition of an infection
present in population but has gone undetected,
or realization that an established disease has
an infectious origin
Emergence may also be used to describe the
reappearance (or re-emergence) of a known
infection after a decline in incidence

Emerging infectious diseases

Bacteria and parasites
TB MDR TB, MRSA, VRE
Multidrug resistant Gram negative
bacteria (such as Klebsiella,
Acinetobacter, NDM-1) Ecoli0157,
Ecoli0104
Zoonotic infections (animal or
mosquito vectors for transmission)
(vancomycin resistant enterococci),

Emerging infectious diseases

Zoonotic infections (animal
or mosquito vectors for
transmission)
Plasmodium spp Malaria (drug resistant
protozoan)
Campylobacter spp (bacterium)
Cyclospora spp (travel-associated
protozoan)
Cryptosporidium spp (protozoan)
Bacillus anthracis (bioterrorism)

Emerging viral infectious

diseases
Avian Influenza (Bird Flu)
Haemorrhagic viruses - Ebola, Lassa, Dengue
Hepatitis
HIV (Human Immunodeficiency Virus)
Prion Diseases (Proteinaceous infectious
particle PrP) vCjD, BSE(bovine spongiform
encephalitis)
SARS (Severe Acute Respiratory Syndrome)
West Nile Virus
Swine Flu Virus

Emerging infectious diseases

Taylor et al (2001) number of human pathogen species (1407)

Influenza Virus
Influenza A and B (Influenza A has
been responsible for pandemics
(Spanish Flu) in past and has
caused outbreaks every 2/3 years
Why?
Neuraminidase and
Haemagglutinin (glycoproteins)

Influenza Virus
Influenza viruses have 3 main antigens
S or soluble antigen (protein in the
ribonucleoprotein core of virus particle) all
Influenza A viruses share common S antigen
Haemagglutinin contained in radiallyprojecting spikes in the virus envelope, it is
strain specific(15 subtypes) involved in virus
attachment/penetration and membrane fusion
Neuraminidase enzyme contained in virus
envelope (9 subtypes) it facilitates release of
virions (cleaving sialic acid residues)
Influenza viruses are characterised into
subtypes according to antigens of
haemagglutinin (H) and neuraminidase (N) on
the viral surface H5N1 subtype

Influenza Virus
Haemagglutinin and Neuraminidase

Influenza Virus
Treatment
Annual Vaccination programme for those at risk
elderly, asthma, heart or respiratory
complaints
Vaccine composition changes because virus
mutates WHO recommends 2006/2007 it
should contain
A/New Caledonia/20/99 (H1N1)-like virus
A/Wisconsin/67/2005 (H3/N2)-like virus
B/Malaysia/2506/2004-like virus

Successful entrepreneur
Started his business 60 years ago with 20 eggs and second
hand
incubator
2008 company profits plunged.

Avian Influenza
Outbreak in UK
Bernard Matthews Turkey farm Holton,
Suffolk (February 2007)
Importation into UK of turkey meat from a
slaughterhouse 30 miles from the source of the
Hungarian outbreak of avian flu
Possibility that meat became crosscontaminated in the slaughterhouse with the
virus UK into sheds housing live birds

Avian Influenza
Antiviral drugs offered to 480 people
310 of whom also received seasonal flu
.
vaccination
(HPA 2007)
No evidence of any of workers
becoming infected with avian influenza

Avian Influenza
There were serious biosecurity shortfalls
Bernard Matthews turkey plant
Government investigation found
holes in turkey sheds where birds, rats
and mice could get in and spread the
H5N1
leaking roofs, and uncovered bins
from which seagulls were seen carrying
off meat waste

Avian Influenza
71 birds died of H5N1 avian influenza
159,000 turkeys were slaughtered as a
precaution
400 redundancies due to 40% drop in
sales

Avian Influenza
Avian influenza is disease of birds
Caused by influenza viruses closely
related to human influenza viruses
Transmission to humans in close contact
with poultry or other birds
Outbreak 175 cases of human disease
(96 people have died)
Possible pandemic if birdhuman
transmission becomes humanhuman
(no herd immunity)
Highly pathogenic H5N1 subtype

Avian Influenza
Transmission
Respiratory aerosol droplets, close
contact
Outbreak originated China Indonesia
Iraq Africa (Nigeria), Turkey
Europe (Italy, Germany, France)

Avian Influenza
Control Measures
Surveillance of birds
(migratory/wild/poultry)
Bird importation quarantine measures
France - vaccination of poultry flocks

Treatment
Tamiflu vaccine antiviral (poultry
workers)
Problem with vaccine is until pandemic
starts do not know which strain
therefore cannot predict which vaccine
composition will be most useful

SARS Virus
SARS (Severe Acute Respiratory
Syndrome)
Originally this was a disease of unknown aetiology
described in patients (Asia, North America, Europe)
March 2003 WHO issued a global health alert for
authorities to be aware of a new atypical pneumonia
called SARS which had been reported in SE Asia
Origin of disease thought to be in Guangdong
Province in China
Between March and July 2003 >8,400 probable
cases of SARS were reported in 32 countries
Most of patients 25-70yrs old (few cases in children)
close family members and hospital workers caring
SARS patients

SARS Virus
64 yr old medical doctor from
GuangDong Province China staying at
Metropole Hotel Hong Kong develops
disease contact tracing by public
health officials found he was index case
which resulted in 94 cases of disease
occurring
Spread by close contact
Disease spread rapidly by
ease/frequency of international travel

SARS Virus
Cause of SARS now known to be a SARS
coronavirus (SARS CoV) a new member of the
coronavirus family
This virus family includes viruses which cause
the common cold
At present no vaccine or specific treatment
Public Health systems continue to be vigilant
and prepare for possible re-emergence of SARS
(use of quarantine measures)
Since the outbreak in 2003 diagnostic methods
have been developed for testing of virus using
PCR and serology

SARS Virus
Current Public Health Approach to
Prevention and Control of SARS
Surveillance: case detection, verification and
reporting
Case management: isolation, infection control,
treatment and follow up
Management of contacts
Information education and travel advice
Lab diagnosis
Contingency planning
International collaborations WHO , CDC, HPA
Research and development

West Nile Virus (WNV)

RNA virus (Flaviviridae)
Originally WNV found tropical/subtropical areas
arbovirus (arthropod borne)
First isolated in 1937 in West Nile district of
Uganda
Host = birds, vector= mosquitoes
Causes meningoencephalitis
Late 1990s 62 people infected (7 die) of WNV in
New York, USA
Since then WNV spread as far south as Florida
and as far north as Canada ?UK

West Nile Virus (WNV)

WNV Lifecycle - Transmission

West Nile Virus (WNV)

Cause
Migrating wild birds
Climate change
Urbanisation

Control
Surveillance (testing sick/dead birds)
No vaccine as yet although some are
under development
Education regarding WNV transmission
Elimination/reduction of suitable
habitats for mosquitoes
Use of larvicides vector control

Swine Flu
H1N1 'swine flu' pandemic virus
emerged in Mexico (April 2009)
H1N1 spread around the world causing
mild/asymptomatic disease in the
majority of cases but severe illness and
death in a small proportion of cases,
particularly in more vulnerable groups

In August 2010 WHO officially declared

the H1N1(2009) pandemic over

Swine Flu
Epidemiology
First reported case in UK April 2009
Two waves of pandemic activity
First pandemic wave peaked July2009 - most
affected areas were the West Midlands, London
and central Scotland
Second pandemic wave peaked October 2009
(return to school)

Swine Flu
Source HPA Epidemiological Report of Pandemic H1N1 (2010)

Swine Flu in UK
Epidemiology
474 deaths in UK (359 England)
Most affected were <65years
Especially at risk from 6months to <65yrs those with
underlying chronic respiratory, neurological or heart
condition were 10xs more at risk of being hospitalised
Death was most likely in those with chronic
neurological, chronic liver and immunosuppression
conditions

Virus Detection Methods

Electron microscopy
Tissue Culture methods
Immunofluorescence
Complement fixation
ELISA
Molecular methods PCR

Virus Detection Methods

Figure to show: Viral Shedding and Antibody Response in response
to Avian Influenza infection

Electron Microscopy
Electron Microscope
Expensive to run/maintain
EM
Requires highly skilled
staff
Labour intensive
Fewer clinical
laboratories now use EM
confirming presence of virus in
patient samples

for

Tissue culture methods Gold

Standard for viral detection
Viruses are obligate intracellular parasites
requiring metabolically active cells to support
their replication
All tissue cell cultures are available
commercially consisting of either
single layers of cells (monolayers) of
metabolically active cells which adhere to either
side of glass tube or
surface of a cover slip contained in a flatbottomed shell vial

Tissue culture methods

Viral tissue culture media
Earls or Hanks medium (balanced salt solution)
Eagles medium (minimum essential medium)
Foetal calf serum

Tissue culture methods

Viruses which may be isolated include
Adenoviruses
Cytomegalovirus (CMV)
Echoviruses
Enteroviruses,
Herpes Simplex Virus (HSV)
Influenza A & B
Respiratory Syncytial Virus (RSV)
Varicella zoster virus (VZV)

Tissue culture methods

Advantages
Isolate viruses from patient samples
Observation of specific cytopathic effects of viruses
on tissue culture cells using ordinary inverted
microscope e.g. haemadsorption effects seen with
influenza viruses (where added erythrocytes adhere
to surface of infected cells)
Perform further confirmatory tests on these viral
cultures such as immunofluorescence to confirm
identity of virus

Disadvantages
Require training and skilled staff to produce tissue
culture media free from bacterial and fungal
contamination
Require skilled virologist to examine the tissue
culture cells and ascertain presence of particular
virus
Some viruses may be slow growing (few weeks to
grow)_

Use of Immunofluorescence (IF)

Virus antigen present in patient sample may be
stained on a microscope slide using monoclonal
viral antibody (tagged with a fluorescent dyefluorescein) which recognises viral antigen
available commercially
Direct IF or Indirect IF may be used
IF demonstrates good specificity and sensitivity
and is reasonably cheap
however
Require skilled staff to interpret microscope
slides, fluorescence microscope

Immunofluorescence methods
Viruses which may be diagnosed by
immunofluorescence includes following
Adenoviruses
Cytomegalovirus (CMV)
Enteroviruses,
Herpes Simplex Virus (HSV)
Influenza A & B
Respiratory Syncytial Virus (RSV)

Immunofluorescence methods

Herpes Simplex Virus

Serology
Detection of viral antibody in patient sera
Commercial kits available Hepatitis, HIV
testing amongst others
Advantages automated analysers available
(such as VIDAS) can process large numbers of
patient samples quickly
Disadvantages cost of analysers/reagents

ELISA

(Enzyme Linked Immunosorbent

Assay)
Detection of viral antigen or antibody from
patient sample - commercial kits
An antibody is tagged with an enzyme which
reacts when suitable substrate is added later
visible colour change detected by use of
spectrophotometer
Advantages reliable and good for processing
large numbers of samples
Disadvantages may be expensive

Molecular methods-PCR
(polymerase chain reaction)
Piece of viral DNA/RNA is amplified so
that it may be detected
Advantage very rapid results
Disadvantage expensive and requires
clean environment

Treatment and Control

Vaccination e.g. MMR
(measles, mumps, rubella)
influenza vaccine
Antiviral Agents antibiotics
which work against
bacteria/fungi are no use
against viruses (acyclovir
good antiviral agent)
Misuse of antibiotics to treat

Dengue fever outbreak in

Europe
October 2012
Health Protection Agency (HPA) is aware of 18 confirmed cases and 191 probable cases of
dengue fever in Madeira, Portugal since early October 2012,
By 4 November 2012 there have been 517 laboratory confirmed cases of dengue fever reported
in Madeira since the outbreak began (A further 631 probable cases have been reported)
This is the first time that dengue fever has been reported in Madeira
Dengue is a mosquito-borne (Aedes mosquito) viral infection (Dengue fever virus) all travellers
should avoid mosquito bites when visiting area
Causes a range of clinical symptoms from a mild flu-like illness to a more serious illness including
rash and bone pain break bone fever and can sometimes lead to severe complications/death
The health authorities in Madeira are investigating and implementing control and prevention
measures, alongside a public awareness campaign
Dengue fever cannot be passed from person to person as infection occurs after being bitten by
the Aedes mosquito carrying the virus
Laboratory confirmation of dengue fever restricted to reference laboratories which have
Containment Level 4 laboratories e.g. Porton Down

Dengue fever
Mosquito Aedes aegypti identified as resident in Portugal since
2005 (also found in other European countries) (Aedes
albopictus)
Previously dengue infections found tropical and subtropical
regions Thailand/India/S.America (affecting 50-100million a
year)
DEN1 strain in Madeira (flavivirus)
Also in Croatia, Greece and France
In Greece 1927-1928 dengue outbreak (thousands affected)
No Tx (vaccine development trials)
Control - eradicate vector mosquito
Oxitec
http://www.youtube.com/watch?v=-2pO_d4HAmc

Aedes aegypti feeding

http://www.youtube.com/watch?v=dSm-N-C7BA0&feature=related

Aedes aegypti is also a vector of chikungunya virus (Kenya

and the Comoros Islands)
Aedes aegypti also a highly effective vector of Yellow
Fever virus

Yellow Fever occurs in South America and also West, Central

and East Africa, where large severe epidemics have been
recorded with tens of thousands of deaths (Yellow Fever
vaccine available)

Self Directed Reading

Emerging Infectious Diseases
Which microbe was responsible for outbreak in
Europe which caused HUS and was blamed initially on
Spanish cucumbers/tomatoes?
NDM-1 has recently emerged in UK associated with
medical tourism
Which microbes are involved? Why is it a problem?
Dengue fever outbreak in Portugal how is dengue
virus detected in laboratory?
Ebola virus outbreak 2014
Effects of climate change on vector-borne diseases
http://
www.hpa.org.uk/webc/HPAwebFile/HPAweb_C/131713
5969235

Summary
Emerging viral diseases and
causative agents
Viral detection methods
Treatment and control of
emerging diseases