Emerging and Reemerging

Diseases
Severe Acute Respiratory Syndrome
(SARS)

Teresita S. de Guzman
Department of Medical Microbiology
College of Public Health
University of the Philippines, Manila
Factors for Emergence
Microbial adaptation
Human susceptibility
Climate and weather
Changing ecosystems
Land use and economic development
Human behavior and demographics
Technology and industry
International travel and industry
Breakdown of public health
Poverty and social inequality
War and famine
Lack of political will
Intent to harm
Some Emerging Diseases
SARS
Avian influenza
Nipah virus
Hendra virus
Hanta virus
E. coli 0157:117
variant
vCJD (prion
disease)
West Nile fever

Rift Valley fever
N. meningitidis
W135
Ebola
Crimean-Congo
HF (hemorrhagic
fever)
Whitewater
Arroyo virus
Lyme disease
Lassa Fever virus
Brief History
SARS was 1
st
described during the
2002-2003 global outbreak of severe
pneumonia associated with human deaths
and person to person disease transmission
A large outbreak occurred in late 2002 in
Guangdong Province, China
Starting late February 2003, similar illness
was reported concurrently in Vietnam,
Hongkong, Canada, Singapore, Thailand, etc.
By the time the outbreak was contained
sometime July of 2003, 8,098 probable
cases, with 774 deaths were identified
in 29 countries ( CDC MMWR, 2003 & URL:
http://www.who.int/csr/sars/country/table2003_09_23/en/ )
Initial clinical & laboratory results focused
on several known agents like Chlamydia,
influenza virus, metapneumovirus, etc.
A virus isolated from the oropharynx of a SARS
patient subsequently identified as belonging to
Coronaviridae family by morphology thru EM
studies, additional culture isolates, immunohisto-
chemistry,immunofluorescence, serologic
assays, RT-PCR, miroarray analysis &
sequencing
1
st
identified in Vietnam on
Feb. 28, 2003 on a patient with
severe pneumonia with no known
cause by Dr. Urbani, a WHO staff
who consequently died of the
disease in Thailand

super spreading event involving a
cluster of cases in Blk E of the Amoy
Gardens Housing State in Hongkong

Rodents & cockroaches as
possible mechanical vectors of
transmission
defective U-traps in bathroom
aerosolization effect of exhaust
fan within small bathrooms
cracked sewer pipe
person to person spread
Outbreak was due to unlucky
convergence of environmental
conditions, i.e.:
The etiologic agent of the syndrome is
now recognized as the

SARS associated coronavirus
(SARS CoV)
Virology of SARS-CoV
Family: Coronaviridae
Genus: Corona virus
virions are spherical; 78 nm mean diameter
(+) RNA virus ; 29,727 nucleotide bases
helical nucleocapsid
enveloped with corona (crown)-like spikes
Antigenic groups:
Grp. 1 & 2 - mammalian CoV
Human CoV
Grp. 3 avian CoV
SARS (4
th
lineage)

Distinct Ultrastructural Features
Of SARS-Associated Coronavirus
Infected Cells
double-membrane vesicles

nucleocapsid inclusions

large granular areas of
cytoplasm
SARS coronavirus is NOT
a mutant nor a recombination of
existing CoV ; it is NEW and
never seen in humans before
Pathogenesis:
infects a variety of mammals & birds
not known number of isolates in humans
neurological symptoms rarely seen
incubation period is 6 - 7 days
95% of patients develop symptoms
within 14 da.
Transmission:
direct mucous membrane (eyes,
nose, & mouth
exposure to virus laden fomites
intense exposure
aerosolizing procedures in
hospitals
role of oral-fecal transmission
is unknown
no reported cases yet of vertical
transmission
Epidemiology:
Risks Factors
health care workers
increase in age (death common
among elderly
male sex
presence of co-morbidics
care and slaughter of wildlife for human
consumption
environmental contamination and
presence of mechanical vectors
Virus is stable in feces and urine
At room temp. , 1-2 days
Stable for up to 4 days in diarrheic
stools
isolated in stools on paper, formica
plastered wall after 36 hrs.; glass slides
after 96 hrs.; plastic surfaces & stainless
steel after 72 hrs.
loses infectivity after exposure to
disinfectant, etc.; rapidly killed by
56
0
C heat
Other Clinical Manifestations
leucopenia; lymphopenia
raised LDH
Specimens to be Collected:
Blood
Respiratory secretions:
nasopharyngeal aspirate (NPA)
nasopharyngeal swab (NPS)
oropharyngeal swab (ORS)
sputum
Stool (in diarrheic cases)
Place in virus transport media (VTM) keep at 4
0
C
BSL-3 facilities & work practices
Collect specimen during onset
of illness 3 days
Maximum shedding of virus at early part
of infection
max. virus excretion from respiratory tract at
about 10 days
virus isolation in stools peaks at 12-14 da.
viral RNA detected in serum; peaks at
6-8 days; undetected by day 12
virus in urine detectable at day 10
Diagnosis:
Negative staining EM (electron
microscopy

RT-PCR (very specific but lacks
sensitivity and standardization)

ELISA

IFAT (immuno-fluorescent Ab test)
Emerging and Reemerging
Diseases
AVIAN INFLUENZA
(BIRD FLU)

Teresita S. de Guzman
Department of Medical Microbiology
College of Public Health
University of the Philippines, Manila
Information on
AVIAN INFLUENZA
Avian influenza A (H5N1) is a
subtype of the Type A influenza
virus
From the family of RNA viruses
Orthomyxoviridae
Wild birds are the natural hosts
1
st
isolated from birds (terns) in
South Africa in1961
The virus circulates among
birds worldwide

Very contagious among and deadly
in birds, particularly
domesticated birds like chickens

The virus does not typically
infect
humans
In 1997, the 1
st
instance of direct
bird-to-human transmission of
H5N1 was documented in an out-
break among poultry in Hong Kong
The virus caused severe
respiratory illness in 18
people that time with 6
deaths
Since then, there have been
other
instances of H5N1 infections in
humans
So far, H5N1 viruses have not
been capable of efficient human-
to-human transmission
Infected birds shed the
virus
in saliva, nasal secretions, and
feces
Avian influenza viruses spread
among susceptible birds upon
contact with contaminated
secretions
Most cases of H5N1 infection in
humans are believed to be from
contact with infected poultry or
contaminated excretions
Current H5N1 Strain
(implicated) In Outbreak
All genes are of bird origin; virus
has not acquired genes from
human influenza virus yet
There are likely different
variations of H5N1 virus
circulating at this time
Genetic sequencing done on
samples from South Korea &
Vietnam showed that the
viruses are slightly different
Genetic sequencing of A (H5N1)
virus samples from human cases in
Vietnam & Thailand showed drug
resistance to antiviral amantadine
& rimantadine (M2 inhibitors)
commonly used vs influenza
Remaining antivirals,
oseltamavir & zanamavir
(neuraminidase inhibitors)
should be effective still vs.
H5N1 strain
Key to containing the outbreak
is
the culling (killing) of sick and
exposed birds
All influenza virus can change.


NO effective vaccine yet vs.
H5N1 avian flu virus
An available vaccine prototype
developed using the 2003 strain of
H5N1 (from Hongkong cases) cannot
be used to expedite vaccine
development; the virus has mutated
significantly
Clinical course (based on the
1997 Hongkong outbreak):
fever
sore throat
cough
severe respiratory distress
secondary to viral pneumonia
(seen in several of the fatal cases)
Previuosly healthy adults & children, & some
w/ chronic medical conditions were affected
THANK YOU !!!