Introduction to Public Health:

Emerging and Re-emerging Infectious Diseases

Manay Kifle ( Ass.Professor of Public Health)

Department of Public Health
Aksum University

February , 2018
Aksum , Ethiopia
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 Emerging and re-emerging Infectious diseases

Objectives
Describe emerging & re-emerging infections
Identify the globally important emerging & re-emerging
infections
Briefly describe the factors which predispose to emergence
& re-emergence of infections
Identify the Strategies to reduce threats of emerging & re-
emerging infections
Identify the role of public health professional on
controlling emerging and re-emerging diseases

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 Emerging and re-emerging Infectious diseases
Definitions
Emerging Diseases
“An emerging disease is one that has appeared in a
population for the first time, or that may have
existed previously but is rapidly increasing in
incidence or geographic range”( WHO).

An emerging disease is an infectious disease that has

become increasingly common in humans within the
last 20 years or threatens to become more common
in the near future.

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Emerging and re-emerging Infectious diseases
Definitions

Previously undetected or unknown infectious

agents exist or known agents that have spread to
new geographic locations or new populations

Emerging infectious diseases are caused by new or

previously unrecognized microorganisms
• E.g. AIDS, Ebola, H5N1 Avian influenza viruses

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Emerging and re-emerging Infectious diseases
Definitions
Re-emerging or resurging diseases
that once were major health problems globally or in a
particular country, and then declined dramatically or has
been successfully controlled, but are again becoming
health problems for a significant proportion of the
population by the re-emergence of microbes.
– are those that have been around for decades or centuries
(old disease), but have come back in a different form or a
different location and prevalence.
– E.g. Tuberculosis, cholera, and malaria…etc.
• These diseases were previously treatable but have
developed resistance to the drugs
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 Emerging and re-emerging Infectious diseases
Definitions

Some of the emerging/re-emerging diseases are

Deliberately
• these that are intentionally introduced.
– E.g. the most recent and important is Anthrax.

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Classification of Emerging Infectious Diseases

Newly emerging:
• Have not previously been recognised in man
Reemerging/resurging
• Existed in the past but are now rapidly increasing
either in incidence or in geographical or human host
range
Deliberately emerging
• Microbes are those that have been developed by
man, usually for nefarious use
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 Newly emerging infections
Have not previously been recognised in man

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 Newly emerging infections

AIDS model
AIDS have affected > 60 million people worldwide
jumping to humans species, may be a consequence
of the consumption of ‘bush meat’ from non-
human primates
urban poverty, a weakening of family structure all
promoted promiscuous sexual practices, and
increased travel.

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 Newly emerging infections
Dead-end transmission of zoonotic and vector-borne
diseases
• Arenavirus haemorrhagic fevers (inc Lassa fever) and
hantavirus pulmonary syndrome (HPS)
– viruses in these groups have co-evolved with specific
rodent species
– increased human-rodent contact as a result of modern
environmental factors: farming, keeping domestic pets,
hunting and camping, deforestation

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 Newly emerging infections

• Malaysian Nipah virus epidemic 1998-1999

– pigs crammed together in pens located in or near
orchards, attracted fruit bats which are the natural hosts of
the Nipah and Hendra viruses
– virus aerosolisation caused infection of pigs
– Overcrowding results in viral transmission to pig handlers

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 Newly emerging infections
Other newly emerging agents
• Environmentally persistent organisms
– Campylobacter jejuni, Shiga-toxin-producing E. coli infect
agricultural animals
• enter through food, milk, water or direct contact
• Microbial agents and chronic diseases
– Chronic liver damage, hepatocellular carcinoma - Hep B
and C
– Cervical cancer – papillomaviruses
– Burkitt’s lymphoma – Epstein-Barr virus
– Gastric ulcers and gastric cancer –

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 Re-emerging Infections
Existed in the past but are now rapidly
increasing either in incidence or in
geographical or human host range

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 Re-emerging Infections
Geographical spread of infections

• Depend on the rate and degree to which they spread

across geographical areas
– the movement of human hosts/vectors/ reservoirs of
infections
• 1933 – commercial air travel
• 1981 – pandemic spread of acute haemorrhagic
conjunctivitis
– Epidemics of meningococcal meningitis during the Hajj
– Epidemic SARS (a newly emerging disease) from China to
elsewhere worldwide

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 Re-emerging Infections
Infectious agents
• Malaria
– Plasmodium falciparum was thought to be
eradicated because of the effective use of DDT
insecticide
– But mosquito gain resistance
• Tuberculosis
– Isoniazid was initially effective to cure TB
– By 1980s, the era of HIV/AIDS, increased immune
deficiencies of people, increases the risk of latent
M. tuberculosis
• Staphylococcus aureus
– Drug-resistant organism
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 Infectious diseases on the rise
• Global spread of AIDS
• Resurgence of tuberculosis
• Appearance of new enemies (hantavirus, pulmonary
syndrome, hepatitis C and E, Ebola virus, Lyme
disease, cryptosporidiosis and E. coli O157:H7
• Bird flu which attacks the Southeast Asia
• Prion disease of Creutzfeldt-Jakob disease
• Antibiotic resistance Staphylococcus bacteria
• Several major multistate foodborne outbreaks
• A new strain of drug resistance tuberculosis

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Newly identified infectious diseases and pathogens

Year Disease or Pathogen

1993 Hantavirus pulmonary syndrome (Sin Nombre
virus)
1992 Vibrio cholerae O139
1991 Guanarito virus
1989 Hepatitis C
1988 Hepatitis E; human herpesvirus 6
1983 HIV
1982 Escherichia coli O157:H7; Lyme borreliosis;
human T-lymphotropic virus type 2
1980 Human T-lymphotropic virus
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 Newly identified infectious diseases and pathogens

Year Disease or Pathogen

2009 H1N1
2004 Avian influenza (human cases)
2003 SARS
1999 Nipah virus
1997 H5N1 (avian influenza A virus)
1996 New variant Creutzfelt-Jacob disease;
Australian bat lyssavirus
1995 Human herpesvirus 8 (Kaposi’s sarcoma
virus)
1994 Savia virus; Hendra virus

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 Potential factors contributing to the growth and
spread of infectious diseases

Discussion
• What potential factors do you think contributing to
the growth and spread of infectious diseases
– Give example for each factor

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Potential factors contributing to the growth and spread
of infectious diseases
• Multiple factors, including economic development and land use,
human demographics and behavior, and international travel
and commerce, contribute to the emergence and re-emergence
of infectious diseases.
• Main factors involved in their emergence/re-emergence were
identified, such as:
– changes in human behavior,
– industrial and economic development,
– travel and mass movements,
– civil unrest and wars,
– microbial genomic change and adaptation.

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Potential factors contributing to the growth and spread
of infectious diseases
1. Demographic changes and human behaviors
Population dynamics
o the increasing growth and mobility of the world‟s
population, over- crowding in cities with poor
sanitation, massive food preparation and
international distribution.
o As the human population expands in number and into
new geographical regions, the possibility that humans
will come into close contact with animal species that
are potential hosts of an infectious agent increases.

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Potential factors contributing to the emergence and re-emergence
diseases

o Human demographic change by which persons begin

to live in previously uninhabited remote areas of the
world and are exposed to new environmental sources
of infectious agents, insects and animals

o Unsustainable urbanization causes breakdowns of

sanitary and other public health measures in
overcrowded cities (e.g., slums)

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 Potential factors contributing to the emergence and re-
emergence diseases
1. Demographic changes and human behaviors
Population movements: epidemics result from
transmission through rapid person-to-person spread
amongst susceptible populations or through the
carriage of vectors. e.g. SARS
• International Travel
• Not only can people travel much more easily, but so can any
pathogens that live in their bodies.
• World travelers could spread the pathogen around the world
in a short amount of time.

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 Potential factors contributing to the emergence and re-
emergence diseases
2. Human behaviours: HIV, Hepatitis B
– Changing human behaviours, such as increased use
of child-care facilities, sexual and drug use
behaviours, and patterns of outdoor recreation

– non-compliance’ by health care workers, patients,

drug producers, and health care systems is resulting
in drug resistant organisms.
• The change of human sexual behavior also encourages
the spread of AIDs and new hepatitis viruses.
– Changing human susceptibility; e.g. immune
compromization with HIV/AIDS
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Potential factors contributing to the emergence and re-
emergence diseases
3. Economic development and land use:
 Economic development and changes in the use of land,
including deforestation, reforestation, and urbanization
associated with malaria, plague,rabies, yellow fever, rift
valley fever, schistosomiasis

• building of dams, irrigation schemes, hydroelectric

power plants, and roads, which are intended to improve
social well-being, may have negative effects that include
the displacement of people

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Potential factors contributing to the emergence and re-
emergence diseases
• Changes in food processing and handling,
including foods prepared from many different
individual animals and countries, and transported
great distances

• Global Food Supply

• Food also travels around the world.
• If a pathogen is present in a food product, it can spread
quickly.

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 Potential factors contributing to the emergence and re-
emergence diseases worldwide
4. Microbial adaptation (evolution) and change
of the infectious agent
Drug Resistance
• Some diseases are caused by pathogens that can
mutate, or change, over time.
• Sometimes these mutations result in a strain, or type,
of pathogen that no longer responds to medicine
– Multidrug-resistant & extremely drug-resistant TB
– Multi drug resistant P.falciparum

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 Potential factors contributing to the emergence and
re-emergence diseases worldwide

• Resistance of the vectors of vector-borne infectious

diseases to pesticides.

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 Potential factors contributing to the emergence and
re-emergence diseases worldwide

5. Breakdown of infrastructure or public health policy

– Breakdowns in public health measures-making a
“comeback” are “re-emerging” diseases thought to be
controlled
– Diseases associated with the breakdown of public health
include rabies, tuberculosis, whooping cough (pertussis),
and cholera

– Deterioration in surveillance systems for infectious

diseases, including laboratory support, to detect new or
emerging disease problems at an early stage
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 Potential factors contributing to the emergence and re-
emergence diseases worldwide
• Illiteracy limits knowledge and implementation of
prevention strategies
• Lack of political will – corruption, other priorities

Lack of Immunization
• Diseases that were common many years ago can pose a threat
again if people don’t get the proper immunizations.
• The polio virus remains a threat in several Asian and African
countries because many people in those countries have not
received the vaccine.

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 Potential factors contributing to the emergence and re-
emergence diseases worldwide
6. Climate changes
Global warming - climate changes cause changes in
geographical distribution of agents and vectors
– Mosquito-transmitted diseases where water is the
limiting step.
• Mosquitoes will survive in previously mosquito-free
regions introducing diseases such as malaria and
dengue and yellow fever

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Potential factors contributing to the emergence and re-
emergence diseases worldwide

• Irrigation projects, building of dams, cause an

increase in the mosquito population
• Disease (transmitted by mosquitoes) are moving
further from the tropics as the climate warms

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Potential factors contributing to the emergence and re-
emergence diseases worldwide
7. Warfare/terrorism/conflict:
– The British, in the eighteenth century, distributed
smallpox-infected blankets to North American
Indians
– By the 1940s a joint program between the USA, UK
and Canada sought to produce an anthrax bomb
– The Soviet Union by the 1980s advances in genetic
engineering were being harnessed to produce, for
example, strains of plague resistant to antibiotics
– distribution of anthrax through the US postal
service has raised anxiety further.
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 Emerging and re-emerging infectious and Bioterrorism
-Plague
• Athenians have accused the Spartans of infecting
their water springs during the great plague of Athens
(430 BC)

• The Black Death in 14th Europe was claimed to be a

result of Jews poisoning the wells

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Emerging and re-emerging infectious and Bioterrorism
Smallpox
• There is evidence
that Europeans gave
Native Americans
blankets they
believed infected
with smallpox
• To what extent this
was the cause of
smallpox epidemics
is disputed

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 Emerging and re-emerging infectious and
Bioterrorism Anthrax

• 1979 - 64 people died after an accidental release of

anthrax from a secret Soviet plant at Sverdlovsk

• 1992 - President Yeltsin confirmed Soviet and later

the Russian government had engaged in illegal
development of biological agents

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Emerging and re-emerging infectious and
Bioterrorism Anthrax

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List of Emerging and Re-emerging Infectious
Diseases

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List of Emerging and Re-emerging Infectious
Diseases
Group III – Agents with Bioterrorism Potential

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List of Emerging and Re-emerging Infectious Diseases

Group III – Agents with Bioterrorism Potential

Category B

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List of Emerging and Re-emerging Infectious Diseases

Group III – Agents with Bioterrorism Potential

Category C

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 Strategies to reduce threats
Develop political will and funding
Improve global early response capacity
– WHO
– National Disease Control Units (e.g. USCDC, CCDC)
– Training programs
Improve global surveillance
– Improve diagnostic capacity (training, regulations)
– Improve communication systems (web, e-mail etc.) and
sharing of surveillance data
– Rapid data analysis
– Develop innovative surveillance and analysis strategies
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 Strategies to reduce threats
Improve global surveillance (continued)

– Utilize geographical information systems

– Utilize the global atlas of infectious diseases
(WHO)
– Increase and improve laboratory capacity
– Coordinate human and animal surveillance

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 Strategies to reduce threats

Use of vaccines and new drug development

– Increase coverage and acceptability (e.g., oral)
– New strategies for delivery (e.g., nasal spray
administration)
– Develop new vaccines
– Decrease cost
– Decrease dependency on “cold chain”

New drug development

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 Strategies to reduce threats

Decrease inappropriate drug use

– Improve education of clinicians and public
– Decrease antimicrobial use in agriculture and food
production
Improve vector and zoonotic control
– Develop new safe insecticides
– Develop more non-chemical strategies e.g. organic
strategies
Better and more widespread health education
(e.g., west Nile virus; bed nets, mosquito repellent)
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 Strategies to reduce threats
Development of predictive models based on:
–Epidemiologic data
–Climate change surveillance
–Human behavior
Develop new strategies requiring low-cost technology
Greater support for research
Reduce poverty and inequality

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 Essential factors for disease eradication
• Knowledge of its epidemiology and transmission
patterns/mode
• Availability of effective tools for diagnosis, treatment
and prevention
• Knowledge of local cultural and political
characteristics
• Community acceptance and mobilization
• Political will and leadership
• Adequate and sustained funding

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 Role of the public health professional

• Establish surveillance for:

– Unusual diseases
– Drug resistant agents
• Assure laboratory capacity to investigate new
agents (e.g., high-throughput labs)
• Develop plans for handling outbreaks of
unknown agents
• Inform physicians about responsible
antimicrobial use

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 Role of the public health professional

• Educate public about

– Responsible drug compliance
– Emergence of new agents
– Infection sources
• Vector control
• Malaria prophylaxis
• Anticipate future health problems
• Promote health and maximize human functional
ability

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