EMERGING

& RE-EMERGING [parasitic]

INFECTIONS
IN
IMMUNOCOMPETENT &
IMMUNOCOMPROMISED
HOSTS
Rumala Morel
Department of Parasitology
Faculty of Medicine
Peradeniya
Year 3 2005/06 Batch
• Mad cow disease
• H5N1 avian influenza
• Severe Acute Respiratory Syndrome
(SARS)
• Ebola virus
• Hantavirus
• Monkeypox
• Swine flu

New Diseases Emerge

Old Diseases Re-emerge
 Objectives
• Define emerging & re-emerging infections
• List the emerging & re-emerging parasitic
infections which are important globally & in SL
• Briefly describe the factors which predispose to
emergence & re-emergence of infections in
immunocompetent & immunocompromised
hosts
• Recognize the current handicaps when dealing
with the risks of these infections
• Briefly describe the preventive aspects of these
infections
 "emerging," "re-emerging," or
"endemic"
Emerging = diseases
that have not occurred Re-emerging
in humans before = diseases that once were major
health problems globally or in a
or particular country, and then
that occurred only declined dramatically, but are
in small numbers again becoming health
in isolated places. problems for a significant
proportion of the population.
"endemic" • Diseases thought to be
a long term problem. adequately controlled making a
Never significantly “comeback” are “re-emerging”
declining
Eg. pneumonia
 New Diseases Emerge
• Emerging diseases = new infections that arise
from changes in existing organisms
or
• known infections that spread to new geographic
areas or populations
• Incidence of such a disease in people increases
over 20 years or threatens to increase

WHAT ARE EMERGING DISEASE

‘HOT SPOTS’?
Regions where new emerging infectious diseases
are most likely to originate.
Usually tropical – developing countries
ill equipped to cope
 Old Diseases Re-Emerge
(A) EVOLUTION OF THE INFECTIOUS AGENT
• Mutations in bacterial genes that confer
resistance to antibiotics – 20%
• Multidrug-resistant & extremely drug-resistant TB
• Multi drug resistant P.falciparum

(B) REDUCED HUMAN IMMUNITY

• Immunization failure
(breakdowns in public health measures)
a greater proportion of susceptible individuals in
a population and an increased reservoir of the
infectious agent.
• Increased number of immunocompromised
hosts - due to the stress of famine, war,
or disease
 WHY EMERGE?
FACTORS PREDISPOSING TO EMERGENCE

1st step
Introduction of an infection for the first time into the
human population

ZOONOSES
In most cases (60%) that’s an infection that’s already
out there in nature – may be a virus that’s naturally
infecting some other species.

Ecological changes - puts humans in contact with the

virus. Usually due to human activities
 WHY EMERGE?
FACTORS PREDISPOSING TO EMERGENCE

• ENVIRONMENTAL CHANGE
tropical forests are cleared to make way for new
roads, displacing disease-carrying animals and
insects and increased human traffic through
previously isolated areas

• URBANIZATION - person-to-person transmission

• POOR PRIMARY HEALTH CARE
public health services may not be equipped to deal
with some infectious outbreaks
 Globally important Emerging &
Re-emerging Infectious Diseases
EMERGING RE-EMERGING
AIDS tuberculosis
cholera malaria
CJD schistosomiasis
Ebola hemorrhagic
fever
influenza
Legionnaire disease
Lyme disease
 List of NIAID* Emerging and
Re-emerging Diseases

– Group I—Pathogens Newly Recognized in the

Past Two Decades
– Group II—Re-emerging Pathogens
– Group III—Agents with Bioterrorism Potential
• NIAID—Category A
• NIAID—Category B
• NIAID—Category C

* NIAID = National Institute of Allergy & Infectious Diseases - USA

 Emerging and Re-emerging Parasites
NIAID Group 1 - NIAID Group 3 -
Pathogens newly Category B
Food & Waterborne
recognized in past two pathogens
decades  Cryptosporidium
Acanthamoeba parvum
Microsporidia  Cyclospora
cayatanensis
Encephalitozoon cuniculi
 Giardia lamblia
Encephalitozoon hellem  Entamoeba histolytica
Enterocytozoon bieneusi  Toxoplasma gondii
Encephalitozoon cuniculi

coiled polar filament,

thin wall with
endospore,
and
exospore

extruded polar filament.

 What is a Pandemic?
????Panic & Epidemic???

pandemic is a global disease outbreak

• "The world is now at the start of the 2009 influenza

pandemic 30,000 confirmed cases from 74 countries” 11th June 2009

• WHO increases pandemic alert level to phase 6

"community level outbreaks in at least one other country in
a different WHO region in addition to the criteria defined in
Phase 5.
• " Phase 5 is characterized by human-to-human
transmission of the virus into at least 2 countries in 1 WHO
region.
• H1N1 immunization campaign
 Global Warming

• A temperature change of several degrees may

make temperate zones more hospitable to
vectors of tropical diseases

• Malaria, Dengue - mosquitoes

• Schistosomiasis – snails

• At the same time, tropical areas may become

less hospitable to some of the same diseases.
Schistosomiasis
? Spreading from
TROPICAL to
TEMPERATE
regions
Due to spread
of snail vector
With
GLOBAL WARMING
crayfish as a biocontrol agent for the
snail vector of human schistosomiasis,
a disease that has resurfaced
as a growing problem due to
China's rapid land-use change.
Transmission of pathogens with reduced
dependence on host mobility

• water-borne –diarrhoeal agents

• attendant-borne [eg. Escherichia coli]
Emerging hospital-acquired pathogens
• Humans create pathways for transmission
eg. spreading HIV through needle sharing, blood
transfusion, commercial sex trade. It is now pandemic in
spite of its relatively inefficient transmission.
• mosquito-transmitted diseases: water is the limiting step.
So irrigation projects, building of dams, cause an increase
in the mosquito population, and suddenly you see an
increase in the diseases
 MALARIA
• WHO Global Malaria
Programme
aims not only to reduce
the burden of Local Elimination
malaria in endemic the complete interruption
areas, of mosquito-borne malaria
but also to transmission
Limit the in a
geographical extent defined geographical area
of malaria in the
world.
Key interventions to control
malaria include:
•prompt and effective
treatment with
artemisinin-based
combination therapies;
•use of insecticidal nets by
people at risk;
And
• indoor residual spraying
to control the vector
mosquitoes.
Emerging Parasitic Diseases in Sri
Lanka
• Leishmaniasis
• Cryptosporidiosis
• Dirofilariasis
• Toxocariasis
• Cutaneous Larva Migrans
 Sand fly

Cutaneous leishmaniasis is established

Visceral leishmaniasis is
Emerging in Sri Lanka

Promastigotes Amastigotes
Cutaneous leishmaniasis in Sri Lanka
 u
r
r
Since 1981, HIV/AIDS has infected
e
n
60 million & killed half of them.
t
H

2 million die every year &

I
V
S
every 15 seconds a person is infected with HIV
t
a
t
i
s
t
i
c
s
i
n
S
L

HIV IN SL – March 2009

a
s
o
HIV f
E
: 1099
n

AIDS d
M
a
: 293
r
AIDS Deaths
c
h
: 189
2

Children living with HIV

0
0 : 37
9
 Control of HIV/AIDS
“test and treat”
strategy of universal,
voluntary, annual HIV
testing
and immediate treatment
for
those who test positive.

High-risk populations Community-based outreach

In SL strategies and new social-media
CSWs, Drug users, tools like mobile phones,
Internal migrants the Internet, Twitter, and Facebook
and transport workers
Global fund for
AIDS/TB/Malaria ( GFATM)
 Guidelines for Preventing Opportunistic
Infections Among HIV-Infected Persons --- 2002
Recommendations of the U.S. Public Health Service and the Infectious
Diseases Society of America*

(A) preventing first episodes of disease by

chemoprophylaxis or vaccination (primary
prophylaxis), and preventing disease recurrence
(secondary prophylaxis).
(B) PREVENTING EXPOSURE TO PATHOGENS
• oral-anal contact - to reduce the risk for intestinal
infections e.g., cryptosporidiosis, shigellosis,
campylobacteriosis, amebiasis, giardiasis, and hepatitis
• contact with animals - cryptosporidiosis, toxoplasmosis,
salmonellosis, campylobacteriosis, or Bartonella
infection.
 HIV infected - PREVENTING EXPOSURE TO
PATHOGENS (contd)

• New pet – avoid animals aged <6 months or <1 year for
cats –toxoplasmosis,cryptosporidiosis, Bartonella
infection (avoid cat bite/scratches, flea control),
salmonellosis, and campylobacteriosis
• Poultry and meat are safest when adequate cooking is
confirmed with a thermometer (internal temperature of
180ºF for poultry and 165ºF for red meats). no trace of
pink
• Uncooked meats should not be allowed to come in
contact with other foods; hands, cutting boards,
counters, and knives and other utensils should be
washed thoroughly after contact with uncooked foods
(BIII).
Cryptosporidium parvum: an emerging pathogen

six major outbreaks in the United States

- contamination of drinking water
highly environmentally resistant cyst of
C. parvum survives
 drinking water filtrations
 chlorination

oocysts do not survive cooking

2 types of oocysts
thick-walled - excreted
thin-walled -autoinfection
Cryptosporidium
 TRANSMISSION CLINICAL FEATURES

feco-oral • Watery diarrhea (up to 20

water contaminated by livestock
mammal feces
HIGH RISK GROUPS
infants and younger children
in day-care centers -frequent
diaper-changing
those whose drinking water is
unfiltered and untreated
Farmers / veterinarians
liters/day)
• dehydration, weight loss,
abdominal pain, fever,
nausea and vomiting.
• In immunocompetent –
self limited -1 to 2 wks
• immunocompromised
chronic and severe
diarrhoea
Disseminated - lungs

50% infective dose (ID50) of C. parvum

is only 132 oocysts for healthy persons
 CRYPTOSPORDIOSIS
• Laboratory Diagnosis:
Acid-fast staining
• immunofluorescence microscopy
method of choice - greatest sensitivity and
specificity
• enzyme immunoassays
• Molecular methods - research tool.
 THE U.S. PUBLIC HEALTH SERVICE
AND INFECTIONS DISEASES SOCIETY OF AMERICA
BOTH RECOMMEND THAT HIV-INFECTED INDIVIDUALS
SHOULD NOT BRING INTO THEIR HOMES:
Animals with diarrhea
Stray dogs or cats
Dogs or cats under age 6 months

TREATMENT OF CRYPTOSPORIDIOSIS
Paromomycin.
Cyclospora cayetanensis
Life Cycle
of
Cyclospora
cayetanensis
 Acanthameoba spp.
Isolated from water, soil, air conditioning etc

In healthy -
Acanthamoeba
keratitis
Immunosuppressed -
Granulomatous Amebic Encephalitis (GAE)
Disseminated infection
 Emerging & Re-emerging Infectious
Diseases Surveillance & Control
• Disease surveillance is concentrated not in
developing countries, where emerging diseases
are most likely to arise, but in developed countries
that can afford laboratories

• Global disease surveillance networks

(1) U.S. Defense Department’s GEIS
(2) WHO - Global Outbreak Alert and Response
Network (GOARN)

• Identify, confirm and respond to outbreaks of

international importance.
Emerging Pathogens Institute -prevent or contain
new and re-emerging diseases
 References
• “Global Trends in Emerging Infectious
Diseases,” February 2008 in the journal
Nature.
SGD questions