EMERGING AND RE-EMERGING

INFECTIOUS DISEASE
 OUTLINE
1. Definition
2. Examples of Emerging & Re-emerging
Disease
3. Factors contributed to emerging & Re-
emerging infections
4. Control Measures (solution)
5. Role of Public Health Nurse (PHN)
 INFECTIOUS DISEASE
Infectious disease has played a prominent role
in world history.
•The black death (bubonic Plugue) in the Middle
Aged killed 1/3 Europe’s population
•Measles destroyed the South American Aztec
civilization
•Smallpox destroyed indigenous peoples of
North and South America, facilitating the
conquest of the New World
 EMERGING INFECTIOUS DISEASE
EMERGING = disease that have not occurred in
humans before or that occur only in small
numbers in isolated places
 EMERGING INFECTIOUS DISEASE
• Emerging infectious disease are those whose
incidence has increased over the past 30 years
– some disease that have never been seen before.
– some were previously documented but without a
known etiology.

• More than 30 new disease have been

identified in the past 30 years
 RE-EMERGING INFECTIOUS DISEASE
• RE-EMERGING = disease that once were major
health problems globally or in a particular
country, and then decline dramatically, but
are again becoming health problem for a
significant proportion for the population
• Diseases thought to be adequately controlled
making a ‘comeback’ are ‘re-emerging’
 RE-EMERGING INFECTIOUS DISEASE
• Some disease are re-emerging after being
dormant for more than one hundred years.
- Tuberculosis
- Cholera
 RE-EMERGING INFECTIOUS DISEASE
• Many of these disease were thought to be
controlled through antibiotics.
• in some cases the re-emerging disease is
resistant to antibiotics
 TUBERCULOSIS (TB)
• An estimated 2 billion people worldwide are
infected with tuberculosis
• Mycobacterium tuberculosis is the causative
agent for TB
• Each year eight million people worldwide are
infected with TB
• It is estimated that 2 million death occur
worldwide per year.
 TUBERCULOSIS (TB)
• TB is still the leading killer of young adults
worldwide
• Minority population in the US are affected
disproportionately by TB
– it is 9 X more frequent among foreign-born
individual living in the US than in native-born
people
 TUBERCULOSIS (TB)
• Antibiotic developed in the 1950s slowed the
spread of TB, but by year 2000, the incidence
began to rise
• Possible causes of the increase in TB:
– HIV/AIDS epidemic
– Increase poverty, IV drug abuse, and homelessness
– Increase immigration of infected individual
– Increase elderly population, especially those in long
term care facilities.
– Failure of patient to complete antibiotic treatment.
• In recent years, falling living standards and
decline of infrastructure in some countries has
aided the re-emergence of some infectious
disease
 EMERGING INFECTIOUS DISEASE
• 25-30% of the 60 million deaths worldwide
that occur each year are due to infectious
disease.
• 4 historical patterns of transition have been
identified in emerging diseases.
• All 4 transition mechanism contribute to rapid
spread of emerging and re-emerging diseases.
 EMERGING INFECTIOUS DISEASES
First transition (also referred to crowd
transition)
•Occur when people begin to live in much closer
proximity to one another
•Higher population density
•Proximity between populations allows for easy
transmission of disease.
 EMERGING INFECTIOUS DISEASES
Second transition
•Neighboring civilization made contact with
each other through war or trade
•Contact allowed the exchange of pools of
infectious organism and vectors between
population.
 EMERGING INFECTIOUS DISEASES
Third transition
•Worldwide exploration and colonization led to
the identification of new populations
•Newly identified populations came into contact
with pathogens never seen before within their
cultures.
•Immunologically naïve and susceptible
population.
 EMERGING INFECTIOUS DISEASES
Fourth transition – this is happening today. The
ongoing cause are:
•Globalization
•Global urbanization
•Increase in population density
•Poverty
•Social upheaval
•Travel
•New behaviours
•Long distance trade
•Technology & development
•Land clearance
•Weather & climate
 ENVIRONEMENT & INFECTIOUS
DISEASES
• Humans continue to encroach on uncultivated
environments.
• Creates an increased risk of contact with new
pathogens.
• Examples of disease encountered as a result
of this encroachment are
– Hanta virus
– Dengue fever
FOOD-BORNE INFECTION VECTORS
• As population grow, there is an increased
pressure to produce more meat
• This has led to the emergence and spread of
infections from farm animals to humans
– Salmonella species
– “mad cow” disease
– E.Coli
GLOBALIZATION & TRANSMISSION
• Genetic changes in pathogens can occur
through a process known as re-assortment.
 An example of this is Avian influenza.
• Modern air travel disperses pathogens
worldwide very rapidly
• Increasing numbers of immunocompromised
hosts presents an increasing number of
susceptible targets.
HURDLES TO INTERSPECIES TRANSFER
• A pathogen must overcome two major
hurdles to replicate successfully in an human
host
– Must adapt in such a way that it can infect and
replicate in human cell
– This can be complex problem for pathogen.
– Must be able to configure itself so that it can be
easily transmitted from one human to another.
 HURDLES TO INTERSPECIES TRANSFER
• Some diseases have overcome the first hurdle
but not the second one.
– Hanta virus
– Nipah virus
– Avian Influenza (H5N1)
 HURDLES TO INTERSPECIES TRANSFER
• Hurdles To Interspecies Transfer can be overcome through:
– Extensive genetic mutation
– Genetic re-arrangement
– Genetic re-assortment
 INFLUENZA
• Influenza is caused by an RNA virus
– Contains eight separate segment of RNA
– High mutation rates continuously change viral
characteristics
– The body immune system only recognized viruses
that have previously infected the body.
 INFLUENZA
• Several influenza pandemics have occurred
throughout history. Best documented within
the last century.
• Pandemic history
 INFLUENZA: Virulence Factors
• The severity of infection depends on the viral
virulence and host’s overall health
• Virulence factor genes constantly mutating
• H and N mutating affecting immune
recognition
• These mutations influence virulence and
mean there is always the potential for
increased virulence in future strains.
 SARS
• SARS become readily transmissible in the 1990s
• First documented case was identified in mainland
China
• It is transmitted by droplet aerosol and fomites
deposited on the respiratory mucosal epithelium.
• Pneumonia like disease
• 2002-2003 outbreak infected 8400++ with 916
confirmed death.
 SARS: Pathogenesis
• SARS is an infection of the lower respiratory system.
• Symptoms include fever, malaise and T cell
lymphopenia
• 20-30% of patients infected with SARS require
intensive care and approximately 10% will die.
• The pathogenesis of SARS is due to a high viral load
in the lower respiratory tract.
• Therapy includes antiviral drugs but they are only
effective if given during the first few days of the
infection.
 WEST NILE VIRUS
• West Nile Virus is caused by an Arbovirus
(arthropod borne, RNA viruses)
• The virus is carried in the saliva of mosquitoes
is transmitted through bites.
• Birds are the primary host (Crow & Cardinals)
• Infection is spread from bird to bird by
mosquitoes.
VIRAL HEMORRHAGIC FEVER (VHF)
• VHF is emerging infectious disease include the
condition caused by the Ebola, Marburg, and
yellow fever viruses.
• Fatality rates average 5-20% for all of these
viral infections.
– The Ebola death rate is between 50-90%
– Outbreaks of VHF are often is small remote areas.
– There is currently no successful therapy for VHF
infection.
 VIRAL HEMORRHAGIC FEVER (VHF)
• These viruses are transmitted in diverse ways
including both arthropod and rodent vectors.
– All of the hemorrhagic viruses can be transmitted
directly from human to human
– Symptom include fever, bleeding, and circulatory
shock.
 PRION AND PRION DISEASE
• These infectious disease are not caused by
microorganism.
• They are caused by infectious proteinc called
prions
• Disease are called transmissible spongiform
encephalopathies (TSE)
 PRION
• Prions are proteins normally found on nerve
cells and are known as PrPᶜ (prion protein
cellular)
• Infectious prions are folded improperly and
are known as PrPˢᶜ (prion protein scrapie)
– They are routinely found in scrapie ( a
neurological disease of sheep)
 PRION
• Abnormal folded PrPˢᶜ prions:
– Aggregate into fibrous structures in the brain,
referred to as a plaque.
– Distrupt the cell membrane, causing cell death.
– Convert normal prions into abnormal prions.
 PRION
• Prions are practically indestructible
– They can withstand cooking
– They can withstand autoclaving
– They are resistant to strong alkali treatment
– They are resistant to disinfectants
– They can survive in soil for years.
Inactivation requires autoclaving in an alkali solution
(bleach containing 2% chlorine) for one hour
 TRANSMISSIBLE SPONGIFORM
ENCEPHALOPATHIES (TSE)
• Infective prions can be ingested with prion-
containing material
• These prions can move through the intestinal
wall rapidly and enter lymph nodes where they
incubate.
– They are picked up by peripheral nerves and moved
to the spinal cord and brain
– Infectious prions can be transmitted between species
– Incubation time is significantly longer when they cross
between species.
 TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES (TSE)

• Prions produce transmissible spongiform

encephalitis (TSE)
– It is a neurodegenerative disease
– It can affect cattle and humans
– There is no test for it in live organisms
– There is no treatment
– There is no cure
TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES (TSE)

• Symptoms include:
– Lack of coordination
– Staggering
– Slurred speech
– Dramatic mood swings
– Paralysis
– Death within one year of symptom onset.
TRANSMISSIBLE SPONGIFORM ENCEPHALOPATHIES (TSE)

• “Mad Cow” disease was first seen in Britain in

1984
– By the year 2000, there were 180,000 confirmed
cases in cattle Britain
– The infection in cattle has been attributed to
sheep brain supplement included in cattle feed.
– First human case documented in Britain was in
1996
– Estimates of the number of new cases in the next
few decades vary far from a few to 150,000
• The Mad Cow Disease in cow, Scrapie in Sheep,
The Creutzfeldt-Jacob Disease in human beings
belong to a class of disease called Transmissible
Spongiform Encephalopathy (TSE)

• Initially thought to be due to “slow viruses” due

to long icubation period between time of
infection and appearance of disease, these are
now known to be caused by agents called prions.
 Middle east respiratory syndrome
coronavirus (Mers-CoV)
• First reported in June 2012, Saudi Arabia
• Coronaviridae Family, Genus Betacoronavirus
(same as SARS-CoV)
• Positive sense, single stranded RNA virus
• Till 15 Sept 2015 – 1651 laboratory confirmed
cases with 590 death
• In Malaysia – 1 cases (source of infection in
Saudi Arabia)
 RE-EMERGING INFECTIOUS DISEASE
• Diphtheria- early 1990s epidemic in Eastern
Europe (1980-1% cases: 1994-90% cases)
• Cholera-100% increase worldwide in 1998
• Human plague-India (1994) after 15-30 years
absence
• Dengue/DHF – over past 40 years, 20-fold
increase to nearly 0.5 million (between 1990-
1998)
 RE-EMERGING INFECTIOUS DISEASE
• Measles outbreak in Disneyland 2015
• Polio outbreak in Pakistan 2015
• Multidrug resistance Tuberculosis
• Drug resistance malaria
• Rabies in Malaysia 2015
• Leptospirosis- widespread zoonotic disease.
• In Kelantan the cases increase 3 times after flood
2015, 1928 cases compared 1030 cases same
period in 2014
 LEPTOSPIROSIS
• Re-emerging infection in Malaysia
• Genus: Leptospira, Family: Leptospiraceae
• 24 serogroup, > 200 serovars and stains
• Major reservoir hosts – rodents esp. rats and
domestic mammal eg cat & dog
• Infected animals may excrete leptospires –
intermittently or regularly every month/years/
or lifetime
 LEPTOSPIROSIS
• Mode of transmission
• Infection are acquired from:
– Direct contact with reservoir
– Indirect contact with an environment
contaminated with reservoir urine
– Ingestion of contaminated water/food may also
cause infection
* There is NO documentation of human to human
transmission.
 FACTOR CONTRIBUTING TO
EMERGING & RE-EMERGING DISEASE
 EPIDEMIOLOGICAL TRIAD

HOST
Demographic characteristics
Biological characteristic
Sosioeconomic characteristic

Physical environment
Biological agents
Biological environment
Physical agents
Social environment
Chemical agents
ENVIRONMENT AGENT
 FACTOR CONTRIBUTING TO
EMERGENCE
AGENT
•Evolution of pathogenic infectious agents
(microbial adaptation & change)
•Development of new strains & more virulence
•Development of resistance to drugs
•Resistance of vector to pesticides
 FACTOR CONTRIBUTING TO
EMERGENCE
AGENT
•Antimicrobial drug resistance causes:
– Wrong prescribing practices
– Non-adherence by patient (non-compliance)
– Use of anti-infective drugs in animal & plants
– Loss of effectiveness (community acquired &
hospital acquired)
 FACTOR CONTRIBUTING TO
EMERGENCE
HOST
•Human demographic change (inhibiting new
areas)
•Human behaviour (sexual & drug use)
•Human susceptibility to infection
(immunosuppression)
•Poverty & social inequality
 FACTOR CONTRIBUTING TO
EMERGENCE
HOST
•Human behaviour
– Unsafe sexual practices (HIV, Gonorrhea, Syphilis)
– Change in agricultural & food production pattern-
food-borne infectious agents (E-coli)
– Increased international travel (H1N1)
– Outdoor activity
 FACTOR CONTRIBUTING TO
EMERGENCE
HOST
•Poverty, neglect & Weakening of Health
Infrastructure
– Poor populations – major reservoir & source of
continued transmission
– Poverty- malnutrition – severe infectious disease cycle
– Lack of funding, poor prioritization of health funds,
misplaced in curative rather than preventive
infrastructure, failure to develop adequate health
delivery systems.
 FACTOR CONTRIBUTING TO
EMERGENCE
ENVIRONMENT
•Climate & changing ecosystems
•Economic development & Land use (urbanization,
deforestation)
•International travel & commerce
•Breakdown of public health measure (war, unrest,
overcrowding)
•Deterioration in surveillance systems (lack of
political will).
 FACTOR CONTRIBUTING TO
EMERGENCE
ENVIRONMENT
•Climate & Environmental Changes
– Deforestation forces animals into closer human
contact, increased possibility for agents to breach
species barrier between animals & humans
– El-Nino – triggers natural disaster & related outbreaks
of infectious disease (malaria, Cholera)
– Global warming – spread of Malaria, dengue filariasis
– Flood increased risk of Food water borne disease &
Leptospirosis.
 FACTOR CONTRIBUTING TO
EMERGENCE
ENVIRONMENT
•Transmission of infection agent from animals to
humans
– > 2/3rd emerging infections originate from animals
wild & domestic
– Emerging influeza infections in Humans associated
with Avian eg. Geese, chicken & pigs
– Animal displacement in search of food after
deforestation/ climate change – Lassa fever
 CONTROL MEASURE (SOLUTION)
• Public health surveillance & response systems
5. Rapidly detect unusual, unexpected,
unexplained disease patterns
6. Track & exchange information in real time
7. Response effect that can quickly become global
8. Contain transmission swiftly & decisively
 CONTROL MEASURE (SOLUTION)
• Public health surveillance & response systems
– Improved methods for disease detection, control &
prevention - Diagnostic technique & new vaccine
– Geographic imaging systems – monitor environmental
changes that influence disease emergence &
transmission
– Internet-based information technologies
• Improve disease reporting
• Facilitates emergency communications &
• Dissemination of information
 CONTROL MEASURE (SOLUTION)
• The best defense (Multi-factorial)
– Coordinated, well-prepared, well equipped Public
systems
– Partnerships- clinicians, laboratorians & Public
health agencies
– Improved methods for detection & surveillance
 ROLE OF PHN
1. Preparedness plan
– Universal precaution- prevent infection especially
new disease
– Adequate & proper use of PPE
– Early detection-triage/ screening activities
2. Increase immunization coverage/ vaccine
3. Knowledge on emerging & Re-emerging
4. Health education
THANK YOU FOR YOUR ATTENTION