EMERGING AND RE-EMERGING 1

INFECTIOUS DISEASES

Mentor:
Dr. Surya B. Parajuli Rakesh kr. Tiwary
Dr. parth Guragain Roll : 24
Department of Community Medicine, MBBS 3rd year
Birat Medical College

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OUTLINE OF PRESENTATION
• Infectious diseases- trends

• Emerging diseases

• Factors contributing to emergence

• Re-emerging diseases

• Antimicrobial resistance

• Public health response

• International Health Regulations

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THE THEME OF THE WORLD HEALTH

DAY ON 7TH APRIL 1997

“Emerging infectious diseases-

Global response, global alert”.

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 CONTRAST
4

• Today The eradication of smallpox and

the world stands on the threshold of effective control of many
a new era in which hundreds of communicable diseases, has led
millions of people will be safe from to a false sense of security and
some of the most terrible diseases complacency in many countries.

• Soon poliomyelitis, neonatal

tetanus, leprosy, guinea worm Emergence of new infections with
disease, river blindness, Chagas' high CFR and potential of their
disease will join smallpox rapid spread has led the WHO to
as diseases of the past issue a wake up call

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 Infectious Diseases: A World in Transition 5

AIDS UP DOWN
Avian Influenza
Ebola
Marburg Guinea worm

?
Cholera
Rift Valley Fever Smallpox
Typhoid Yaws
Tuberculosis
Leptospirosis Poliomyelitis
Malaria Measles
Chikungunya
Dengue Leprosy
JE Neonatal tetanus
Antimicrobial resistance
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A CRISIS FOR TODAY AND A

CHALLENGE FOR THE FUTURE

• 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.

• 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.
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FACTORS RESPONSIBLE FOR EMERGENCE AND

RE-EMERGENCE OF INFECTIOUS DISEASES
(1) unplanned and under planned urbanization;
(2) overcrowding and rapid population growth;
(3) poor sanitation;
(4) Inadequate public health infrastructure;
(5) resistance to antibiotics & Insecticide
(6) increased exposure of humans to disease
vectors and reservoirs of infection in nature;
(7) Rapid and intense international travel
(8) Natural disasters
(9) Weak public health system
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(10) Genetic mutation 6/12/2018
 EMERGING DISEASES
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• Those whose incidence in humans has increased during the last two
decades or which threaten to increase in the near future.
or newly-appearing infectious diseases,
or diseases that are spreading to new geographical areas –
such as cholera in South America and yellow fever in Kenya.

• 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.

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• The most dramatic example of a new disease is HIV-AIDS.

• The existence of the virus was unknown until 1983.

• Presently, estimated 2.3 million cases occur every year

worldwide

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 EXAMPLES OF RECENT 10

EMERGING DISEASES

Source: NATURE; Vol 430; July 2004;

www.nature.com/nature
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 EBOLA VIRUS DISEASE (EHF) 13

• Appeared for the first time in Zaire and Sudan in 1976.

• Member of Filoviridae family
• 5 distinct species –
Zaire EV;
Reston EV;
Sudan EV;
Tai EV;
Bundibugyo EV
• The virus causing the latest outbreak belongs to the Zaire ebolavirus species

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 Year Country Ebolavirus species Cases Deaths Case fatality

2015 Italy Zaire 1 0 0% 14

2014 DRC Zaire 66 49 74%

2014 Spain Zaire 1 0 0%
2014 UK Zaire 1 0 0%
2014 USA Zaire 4 1 25%
2014 Senegal Zaire 1 0 0%
Chronology 2014 Mali Zaire 8 6 75%
2014 Nigeria Zaire 20 8 40%
of previous 2014-2016 Sierra Leone Zaire 14124* 3956* 28%
Ebola virus 2014-2016 Liberia Zaire 10675* 4809* 45%
2014-2016 Guinea Zaire 3811* 2543* 67%
disease Democratic
2012 Republic of Bundibugyo 57 29 51%
outbreaks Congo
2012 Uganda Sudan 7 4 57%
2012 Uganda Sudan 24 17 71%
2011 Uganda Sudan 1 1 100%
Democratic
2008 Republic of Zaire 32 14 44%
Congo
2007 Uganda Bundibugyo 149 37 25%
Democratic
2007 Republic of Zaire 264 187 71%
Congo
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 2004 Sudan Sudan 17 7 41%

2003 (Nov-Dec) Congo Zaire 35 29 83% 15

2003 (Jan-Apr) Congo Zaire 143 128 90%

2001-2002 Congo Zaire 59 44 75%
2001-2002 Gabon Zaire 65 53 82%
2000 Uganda Sudan 425 224 53%

South Africa
Chronology 1996
(ex-Gabon)
Zaire 1 1 100%

of previous 1996 (Jul-Dec) Gabon Zaire 60 45 75%

1996 (Jan-Apr) Gabon Zaire 31 21 68%
Ebola virus Democratic
disease 1995 Republic of
Congo
Zaire 315 254 81%

outbreaks 1994 Côte d'Ivoire Taï Forest 1 0 0%

1994 Gabon Zaire 52 31 60%
1979 Sudan Sudan 34 22 65%

Democratic
1977 Republic of Zaire 1 1 100%
Congo

1976 Sudan Sudan 284 151 53%

Democratic
1976 Republic of Zaire 318 280 88%
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Incubation period: 2-21 days

• Route of transmission:
Body fluids (including semen, breast milk) of infected animals
human-to-human transmission via direct contact
Health-care workers have frequently been infected while treating patients
Burial ceremonies that involve direct contact with the body of the
deceased
Source: Cases
Reservoir: Bats
CFR: 40% { upto 70% } {10,000death 25,515 cases till 8thApril 2015}

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• C/F:
• 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
• Laboratory findings include
low white blood cell and platelet counts and elevated liver enzymes.
• Diagnosis
Difficult to clinically distinguish EVD from malaria, typhoid fever and meningitis.
Antibody-capture enzyme-linked immunosorbent assay (ELISA)
antigen-capture detection tests
serum neutralization test
reverse transcriptase polymerase chain reaction (RT-PCR) assay
electron microscopy
virus isolation by cell culture.
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• Treatment: Rehydration & Symptomatic

range of potential treatments including blood products, immune therapies and drug
therapies are currently being evaluated.
The vaccine, called rVSV-ZEBOV, An experimental Ebola vaccine proved highly
protective against the deadly virus in a major trial in Guinea.
• Prevention and control
Reducing the risk of wildlife-to-human transmission. Animal products (blood and
meat) should be thoroughly cooked before consumption.
Reducing the risk of human-to-human transmission from direct or close contact with
people with Ebola symptoms, particularly with their bodily fluids. Gloves and
appropriate personal protective equipment should be worn when taking care of ill
patients at home. Regular hand washing is required after visiting patients in hospital, as
well as after taking care of patients at home.
Reducing the risk of possible sexual transmission, WHO recommends that male
survivors of Ebola virus disease practice safe sex and hygiene for 12 months from onset
of symptoms or until their semen tests negative twice for Ebola virus
Outbreak containment measures, including prompt and safe burial of the dead,
identifying people who may have been in contact with someone infected with Ebola
and monitoring their health for 21 days,
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HANTAVIRUS
PULMONARY SYNDROME
• First recognized in 1993
• surfaced in US (20 states), Argentina and
Brazil.
• Carried by rodents, particularly deer
mice
• Characterized by respiratory failure
• CFR of over 50%

• Other hanta viruses have been

recognized for many years in Asia, where
they cause haemorrhagic fever with
renal involvement in humans.

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NIPAH VIRUS

• Genus: Henapi virus

• Transmission in India:
- Occurrence: West Bengal
- Route: Consumption of fruits contaminated
with bats (Pteropus: ‘Flying foxes’) secretions
• Clinical presentation: Encephalitis
• Case fatality rate: 50%
• Vaccine: NONE for humans
• Treatment: Intensive supportive care

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SARS
• Causative agent: Corona virus
• Origin: China, 2002
– Total cases: 8094
– Total deaths: 774
• Route of transmission: Air droplets
• Vaccine: None
• Treatment:
– Antipyretics
– Supplemental Oxygen
– Mechanical ventilation
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MERS-COV
HCoV-EMC/2012, or Human Coronavirus Erasmus Medical Center/2012

• Cause: Betacorona virus (lineage C)

• Origin: Saudi Arabia, 2012
• Incubation period: 2-14 days
• Route of transmission:
– Air droplets
– Camel milk
– Camel meat
• Source: Camels
• Reservoir: Bats
• Case fatality rate: 30%
• Treatment: None
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MARBURG VIRUS
• Outbreak of Marburg virus in Angola.
• This virus, related to Ebola virus, was first detected in 1967 in Marburg, Germany,
when people working with monkeys from Uganda became infected, resulting in
seven deaths.
• Throughout the years in Kenya, South Africa, the Democratic Republic of the
Congo, and most recently, Angola, the virus has re-emerged. Fortunately,
Marburg and Ebola outbreaks tend to appear in localized regions and have not
triggered epidemics throughout the world.
• Unlike influenza, which spreads even when people are relatively
asymptomatic, Ebola and Marburg are generally transmitted from people who
are deathly ill. The people at greatest risk of contracting disease are family
members, physicians, and nurses in hospitals, undertakers, and other people
who come in close contact with infected individuals.
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EPIDEMICS OF FOODBORNE AND

WATERBORNE DISEASES
• New organisms such as cryptosporidium or new strains of bacteria such as
Escherichia coli have hit industrialized and developing countries alike.

• The 0157: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, 0139, 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.

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H7N9 AVIAN INFLUENZA

• Occurrence: First time among humans
• Origin: March 2013, China
• Incubation period: 1-10 day
• Route of transmission: Air droplets
• Case fatality rate: 33%
• Vaccine: NONE
• Treatment: Neuraminidase inhibitors
– Oseltamivir
– Zanamivir

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#################
• SIV strains include influenza C and the subtypes of influenza A known
as H1N1, H1N2, H2N1, H3N1, H3N2, and H2N3
• avian influenza viruses, to infect humans:
H5N1, H7N3, H7N7, H7N9, and H9N2.
• Canine influenza (dog flu) is varieties of influenzavirus A, such as equine
influenza virus H3N8, mutation of H3N2 that adapted from its avian
influenza origins
• Equine influenza (horse flu) is strains of influenza A
equine-1 (H7N7) and equine-2 (H3N8).

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 THREAT OF A NEW GLOBAL 34

INFLUENZA PANDEMIC
• Major shifts In influenza viruses occur every 20 years .
• Next such shift is expected to take place very soon.

Epidemic strains of influenza viruses originate from China and carried

by ducks, chickens and pigs raised in close proximity to one another
on farms.
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 .

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• 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 .

• More recently, pandemic due to influenza A (H1Nl) 2009 strain is

continuing worldwide involving 214 countries, already taking 18, 156
lives.

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 ZIKA VIRUS 41

• family Flaviviridae
• spread by daytime Aedes mosquitoes,
such as A. aegypti and A. albopictus.

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 HISTORY
42

• In 1947, in a small forest in Uganda, near the capital,

Kampala, a filterable transmissible agent was found in
a sentinel rhesus macaque with a high fever.
• The agent was later identified as a virus and named
Zika after the forest in which it was found.
• For the next 60 years, Largely ignored by scientists.
• However, in the summer of 2015, in several cities in
eastern Brazil,
a Zika epidemic was identified concurrently with a
markedly increased number of infant microcephaly
cases in maternity wards.
The virus was confirmed to be spreading among >40
countries in the Americas.
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• A longitudinal study shows that 6 hours after cells are infected with the
Zika virus, the vacuoles and mitochondria in the cells begin to swell.
This swelling becomes so severe, it results in cell death, also known as
paraptosis.
• IFITM3 is a trans-membrane protein in a cell that is able to protect it
from viral infection by blocking virus attachment.
• Cells are most susceptible to Zika infection when levels of IFITM3 are
low. Once the cell has been infected, the virus restructures the
endoplasmic reticulum, forming the large vacuoles, resulting in cell
death

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Zika is usually mild with

symptoms lasting for several
days to a week. People
usually don’t get sick
enough to go to the
hospital, and
they very rarely die of Zika.
For this reason, many
people might not realize
they have been infected.

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 Summary of differences between cell death pathways
51
Paraptosis Apoptosis Necrosis
Morphology
Cytoplasmic vacuolation Yes No Yes

Chromatin condensation No Yes No

Nuclear fragmentation No Yes No

Apoptotic bodies No Yes No

Mitochondrial Swelling Yes Sometimes Yes

Membrane Blebbing No Yes Yes, late

Programmed cell death Yes Yes No

Caspase activity No Yes Sometimes

Inhibitors
Actinomycin D, cycloheximide Yes Sometimes No
AIP1/Alix Yes No No

Caspase inhibitors (zVAD.fmk,

No Yes No
p53, BAF)

Xiap No Yes No
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Bcl-XL No Yes Usually not
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BIOTERRORISM

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 BIOTERRORISM
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• One of those days in history that we will never forget is September 11, 2001.
• Barely had the dust settled on Ground Zero in New York City and the
Pentagon when an unknown bioterrorist sent anthrax spores through the
mail, resulting in 22 anthrax cases and five deaths.
• Unlike other infectious diseases, anthrax is not communicable, yet it virtually
immobilized Washington D.C. People were afraid to open their mail, and
several mail facilities were closed down. Congressional office buildings
were closed for months.

• Highest potential- B. anthracis, C. botulinum toxin, Francisella tularensis, Y.

pestis, Variola virus, Viral haemorrhagic fever viruses
• Likeliest route- aerosol dissemination

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 BIOTERRORISM AGENTS/DISEASES
• Category A
Anthrax (Bacillus anthracis)
Botulism (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (variola major)
Tularemia (Francisella tularensis)
Viral hemorrhagic fevers, including
Filoviruses (Ebola, Marburg)
Arenaviruses (Lassa, Machupo)
Category C
•Emerging infectious diseases such
as Nipah virus and hantavirus
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Category B
Brucellosis (Brucella species)
Epsilon toxin of Clostridium perfringens
Food safety threats (Salmonella species, Escherichia
coli O157:H7, Shigella)
Glanders (Burkholderia mallei)
Melioidosis (Burkholderia pseudomallei)
Psittacosis (Chlamydia psittaci)
Q fever (Coxiella burnetii)
Ricin toxin from Ricinus communis (castor beans)
Staphylococcal enterotoxin B
Typhus fever (Rickettsia prowazekii)
Viral encephalitis (alphaviruses, such as eastern equine
encephalitis, Venezuelan equine encephalitis, and
western equine encephalitis])
Water safety threats (Vibrio cholerae, Cryptosporidium
parvum)
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RE-EMERGING DISEASES
• Diseases which were previously easily controlled by chemotherapy
and antibiotics, but now they have developed antimicrobial
resistance and are often appearing in epidemic form.

• Those that have reappeared after a significant decline in their

incidence
• Eg: Appearance of plague in an explosive form in 1994 after a period
of quiscence of almost 27 years

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FACTORS INFLUENCING

• Increasing use of antimicrobials worldwide,

often in subtherapeutic doses and sometimes in counterfeit form
• 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
• Travel, including tourism
The spread of syphilis in the 18th and 19th centuries was related to
the movement of armies.

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• Studies show that

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.

• The practices of modern medicine

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,
Example, the recent spread of diphtheria in the Russian Federation and
other former republics of the USSR.
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WEST NILE VIRUS

• West Nile virus is a re-emerging infection.
• It has existed in Africa and the Middle East for decades.
• In 1999, it landed in Queens, New York, via an unknown route. The infection
then moved across the country, with different hot spots each year.
• However, all the makings for an epidemic were in place:
the right mosquito, the right microbe, and suitable hosts.
• In 2001, the hotspots expanded throughout New York State and to
Connecticut, Maryland, and Florida.
• In 2002, hotspots appeared in the Midwest, and farther west in 2003.
• By 2004, the epidemic had crossed the Rocky Mountains and emerged in
California, Arizona, and Colorado.
• In 2004, 2,470 cases and 88 deaths were reported.
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• West Nile is likely to follow the path of other infectious

encephalopathies such as St. Louis encephalitis and eastern
equine encephalitis, becoming part of the background matrix of
infectious diseases.
• The research enterprise also has moved rapidly to respond to
West Nile virus.
• In particular, scientists have created a chimeric vaccine against
West Nile virus.
• Genes coding for the immunodominant antigens of the West
Nile virus (a flavivirus) were spliced into the genome of an
attenuated yellow fever virus (another flavivirus) vaccine to yield
a chimeric yellow fever/West Nile virus vaccine

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ANTIMICROBIAL RESISTANCE

• Not a new problem, but it has 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.
• 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

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MAJOR CAUSE OF THE CURRENT

CRISIS IN ANTIMICROBIAL RESISTANCE

• 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.

• In developing countries, the problem is compounded by the ready

availability of over-the-counter drugs.

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• 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.

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 Malaria presents a 71

double resistance
• Resistance of the Plasmodium parasites, which cause the disease, to
antimalarial drugs; and
• Resistance of the Anopheles mosquitoes, to insecticides.
• Due to Inadequate regimens, poor drug supply, and poor quality and
misuse of drugs, rapid development of drug resistance has occurred
• Resistance to chloroquine, 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.
• Many mosquitoes are reported to be
resistant to the three classes of insecticides available for public health use,
some are becoming resistant to pyrethroids, widely promoted for bed-net
and curtain impregnation.
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• 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.

Even resistance to vancomycin has developed in the last

10 years or so.

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 TREATMENT OPTIONS FOR VANCOMYCIN- 74

RESISTANT ENTEROCOCCAL INFECTIONS.

• Treatment options include available agents which don't have a specific VRE
approval (chloramphenicol, doxycycline, high-dose ampicillin or
ampicillin/sulbactam), and nitrofurantoin (for lower urinary tract infection).

• Two novel antimicrobial agents (quinupristin/ dalfopristin and linezolid) have

emerged as approved therapeutic options for vancomycin-resistant
Enterococcus faecium on the basis of in vitro susceptibility and clinical
efficacy from multicentre, pharmaceutical company-sponsored clinical
trials.

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QUINUPRISTIN/DALFOPRISTIN
• Quinupristin and dalfopristin are protein synthesis inhibitors in
a synergistic manner.
• While each of the two is only a bacteriostatic agent, the combination
shows bactericidal activity.
• Dalfopristin binds to the 23S portion of the 50S ribosomal subunit, and
changes the conformation of it, enhancing the binding of quinupristin by a
factor of about 100. In addition, it inhibits peptidyl transfer.
• Quinupristin binds to a nearby site on the 50S ribosomal subunit and
prevents elongation of the polypeptide, as well as causing incomplete
chains to be released.

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• 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 hospital acquired infections would become virtually
untreatable.

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• Streptococci have become increasingly resistant to some antibiotics.

They are among the most common disease causing bacteria,
responsible for infections of the throat, middle ear, skin and wounds,
and also necrotizing fasciitis and gangrene.
• Pneumococci and Haemophilus influenza are the most common
bacteria causing acute respiratory infections in children, particularly
pneumonia.
• Are becoming resistant to many commonly used antibiotics,
including cotrimoxazole, the drug recommended by WHO for
treatment of pneumonia.

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• The most virulent type of Haemophilus influenzae is today

frequently resistant to ampicillin,
• 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.

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• 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
• now requires the use of much more expensive drugs which are often
unavailable.

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• 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.
• 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.
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 81

• 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.
In Thailand, salmonellae isolated from food animals are also highly
resistant to the common antibiotics.

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 82

• 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.

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 COLISTIN, ALSO KNOWN AS POLYMYXIN E 83

• It remains one of the last-resort antibiotics for multidrug-

resistant Pseudomonas aeruginosa, Klebsiella pneumoniae,
and Acinetobacter.
• NDM-1 metallo-β-lactamase MDR Enterobacteriaceae have
also shown susceptibility to colistin.
• Resistance to colistin in human pathogens is rare.
• The first colistin-resistance gene in a plasmid which can be
transferred between bacterial strains was found in 2011 in
China.
• The presence of this plasmid-borne mcr-1gene was confirmed
starting December 2015 in SE-Asia, several European countries
and the United States.
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 84

• This plasmid-borne mcr-1 gene has since been isolated in

China, Europe and the United States.
• India reported the first detailed colistin-resistance study which mapped 13
colistin-resistant cases recorded over 18 months.
• It concluded that pan-drug resistant infections, particularly those in the
blood stream, have a higher mortality.
• Although resistance to polymyxins is generally less than 10%, it is more
frequent in the Mediterranean and South-East Asia (Korea and Singapore),
where colistin resistance rates are continually increasing.
• Colistin-resistant E. coli was identified in the United States in May 2016.
• Use of colistin to treat Acinetobacter baumannii infections has led to the
development of resistant bacterial strains. which have also developed
resistance to antimicrobial compounds LL-37 and lysozyme, produced by
the human immune system.
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 85

• 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

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 86

RESPONDING TO EPIDEMICS
• 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;

• Production and distribution of the necessary drugs and vaccines.

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 87

• 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;
• DOTS - for tuberculosis;
• by launching research initiatives for treatment regimens and improved
diagnostics, drugs and vaccines;
• Above all by strengthening epidemiological surveillance and drug
resistance surveillance mechanisms and procedures with appropriate
laboratory support for early · detection, confirmation and
communication.

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 88

• 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.

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 Sharing Outbreak-related Information 89

• with Public Health Professionals

• with Public

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 KEY TASKS - CARRIED OUT BY WHOM? 90

Global
Regional
Synergy

National
R. K. Tiwary 6/12/2018
 WHAT SKILLS ARE NEEDED? 91

Public
Infectious Health
Telecom. &
diseases
Informatics

International Laboratory
Epidemio- field
Information
logy experience
management

Multiple expertise needed !

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 GLOBAL DISEASE INTELLIGENCE: 92

A WORLD ON THE ALERT

Collection

Verification Distribution

Response
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 93

QQQ. Disease excluded and re-included from International Health

Regulations till date is:
(a) Smallpox [AIPGME 2006]
(b) Guinea worm
(c) Typhoid
(d) HIV/AIDS

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 INTERNATIONAL HEALTH 94

REGULATIONS’ (IHR, 2005)

Ans. (a) Small pox [Ref. World Health Organisation]

• The ‘International Health Regulations’ (IHR, 2005) are an international
law which helps countries working together to save lives and livelihoods
caused by the international spread of diseases and other health risks
• The IHR (1969) were primarily intended to monitor and control six
serious infectious diseases: cholera, plague, yellow fever, smallpox,
relapsing fever and typhus
• Under the IHR (1969), ‘only cholera, plague and yellow fever remain
notifiable’, meaning that States are required to notify WHO if and when
these diseases occur on their territory

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 95

The IHR (2005) broaden the scope of the 1969 Regulations to cover
existing, new and re-emerging diseases, including emergencies caused
by non-infectious disease agents
• Under the IHR (2005), all cases of the following four diseases must also
be automatically notified to WHO:
– Smallpox
– Poliomyelitis due to wild-type poliovirus
– SARS
– Human influenza

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 96

R. K. Tiwary 6/12/2018
REFERENCES 97

• 1. WHO (2014), Fact Sheet on Ebola Viral

Disease, No. 103, Sept. 2014.
• 2. WHO (1996), The World Health Report
1996.
• 3. WHO (1999), Remoulng 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.

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 98

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