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EMERGING AND
RE-EMERGING
DISEASES
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History
• Human populations have experienced major epidemics of
infectious diseases.

430 BC
Smallpox killed
more than 30,000
in Athens.
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The plague of Justinian(541-542

AD)
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The Black Death-1334 AD

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1520-1521 AD:
Small pox was
responsible for 10-15
million deaths effectively
ending the Aztec
civilization.
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• 1633: Small pox Massachussets

• 1793: Yellow fever in Philadelphia

• 1860s: Modern plague in Hongkong, China and India

• 1918: Great flu Pandemic

• 1984: HIV was identified, as the cause of AIDS

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Infectious diseases-trend
• Receded in western countries 20th century
• Urban sanitization, improved housing, personal hygiene,
antisepsis & vaccination
• Antibiotics further supressed morbidity and mortality
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Emerging Infectious Diseases

• Infectious diseases whose incidence in humans has
increased in the past two decades or threatens to
increase in the near future
• These include
New infections resulting from changes or evolution of
existing organisms
Known infections spreading to new geographic areas or
populations
Previously unrecognized infections appearing in areas
undergoing ecologic transformation

*CDC
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Re emerging Infections

Diseases that once were major health problem globally or in a

particular country and then declined dramatically, but are
again becoming health problems for a significant proportion
of the population.

• World Heath Organization, Regional Office for South-East Asia. New, Emerging and Re-Emerging Infectious Diseases:
Prevention and Control. New Delhi: WHO Regional Office for South-East Asia Language. Oct-19996.14 th HMM-
background documents. Available at:http://www.who.int/iris/handle/10665/127542
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New diseases EMERGE

Old diseases RE-EMERGE

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Factors responsible for emergence and

re-emergence of infectious agents
• Unplanned and under planned urbanization
• Overcrowding and rapid population growth
• Poor sanitization
• Inadequate public health infrastructure
• Resistance to antibiotics
• Increased exposure of humans to disease vectors and
reservoirs of infection in nature
• International travel
• Microbial genetic mutation
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Demographic factors
• Rapid population growth
• Poverty and malnutrition
• Overcrowding, lack of hygiene
• Uncontrolled urbanization with inadequate vector control
• Migration
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Zoonotic factors
• Humans living in close proximity to animals –
 frequent exchange of micro-organisms and
 opportunity for some of the mutant organisms to adapt to human
body and initiate a new cycle of human to human transmission
• Exponential increase in demand for meat production -
 Birds – H5N1
 Animals – H1N1
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Ecological factors
• Global warming – a temperature change of several
degrees may make temperate zone more hospitable to
vectors of tropical areas and vice-versa
o Malaria, dengue, chikungunya – mosquitoes
o West Nile fever moving further from tropics

• Deforestation – altering flora and fauna causing greater

contact to hitherto restricted pathogens
o 1990s- clearing of forest- build an airport-devastating outbreak of
Nipah virus
o Hanta virus infection – conversion of land to rice fields- increased
field mouse population(host) – human infection
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International travel and trade

• Globalization
• Tourists, workers, immigrants and refugees
• Facilitates movement of infections
 SARS documented to be one of the fastest moving micro-
organisms in the history of mankind – carried through international
air travel by infected people to 31 countries
 Spanish influenza travelled around the world in less than 12
months; Hong Kong influenza- only 6 months
 Meningococcal meningitis – after returning from Haj
 COVID-19
• Presence of arthropod vectors in international flights
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Human behaviour
• Increased sexual promiscuity – increase in STIs

• Intra-venous drug users – HIV/AIDS, Hepatitis-B,C

• HIV/AIDS – re-ermergence of a variety of other infections

like Mycobacterium, Cryptococcosis, Toxoplasmosis
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Technological advance

• Modern food practices – increased risk of contamination

• New diagnostic technology – identification of previously

unknown microbes , eg. HHV-6,Helicobacter pylori

• Immuno-compromised patients live longer – prone to get

atypical/ newly emerged infections
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Antimicrobial resistance
• Inappropriate use of antimicrobial

• Prescription of antibiotics in viral infection

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Emerging infections
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Re-emerging infections
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Dikid T. Jain SK. Sharma A. Kumar A and Narain JP. Emerging and Re-emerging infections in India: an
overview. Indian J Med Res. 2013. Vol 1;19-31.
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• Seasonal outbreaks of an acute

unexplained neurological illness have
been reported since 1995 from
Muzaffarpur, Bihar, the largest lychee
fruit cultivation region in the country.

• The outbreaks begin in mid-May and

peak in June, coincides with lychee
harvesting season.

• Illness was characterized by acute

seizures and changed mental status,
frequently in early morning.
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• Confirmed that recurring outbreak is Muzzafarpur is associated with lychee

consumption and with both hypoglycin A and MCPG toxicity.

• Changes observed in patients in Muzzaffarpur are a result of disrupted fatty acid

metabolism and glucose synthesis is severely impaired, which can lead to acute
hypoglycemia and encephalopathy of the outbreak illness.

• Skipping an evening meal is likely to result in night time hypoglycemia,

particularly in young children who have limited hepatic glycogen reserves.
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Crimean Congo Hemorrhagic Fever

(CCHF)
• The epidemiology of CCHF was unknown in India until
January 2011

• Causes by a tick-borne virus (Nairovirus) of the

Bunyaviridae family.

• Severe viral haemorrhagic fever outbreaks, with a case

fatality rate of 10-40%.

• Transmitted by ticks
• Hyalomma spp. are principal vectors
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Available from: http://www.ncdc.gov.in/writereaddata/linkimages/Newsltr0320156655589079.pdf

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Hemorrhagic phase
Pre-hemorrhagic phase Petechial rash
Sudden onset fever
Chills, headache, dizziness Ecchymoses and large bruises
Dizziness, photophobia, neck pain Hematemesis
Myalgia, arthralgia Melena
Nausea, vomiting Epistaxis
Non-bloody diarrhea
Hematuria
Bradycardia
Low blood pressure Hemoptysis
Bleeding from other sites
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Flavi viruses
• Adapted to their carriers, usually female Aedes
aegypti mosquitoes
• As mosquitoes emerged from forest habitats and
adapted to human blood meals, flaviviruses
followed
• Explains the spread of –
Yellow fever
Dengue
Chikungunya
West Nile fever
Zika
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Zika

• First discovered in rhesus monkey in Uganda’s

Zika forest in 1947
• First human case reported in Nigeria 7 years later
• Grabbed global attention due to its virulent form
• The new virulent strain first emerged on remote
pacific island in 2007
• Borne by female Aedes
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ZIKA-Public Health Emergency of

International Concern
• Feb 1, 2016

• Swept through 26 countries in America, Cape Verde in

Africa and Singapore where 200 infections reported with
in 8 days

• Feb 2016 – it affected China, Bangladesh reported its first

cases in March and US in late July 2016 reported its first
locally acquired case

• Currently 88 countries and territories affected, as per CDC

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Transition in Zika Virus

Relatively Pandemic Strain
benign virus
• More neurotropic
• causing fever, • And better adapted
malaise, skin rash, to grow in humans
conjunctivitis, • One that causes
Mutation in
muscle and joint NS1 gene neurological
pain, headache disorders –
microcephaly and
GBS
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Zika in India
• India contains ‘disease ecology’

Aedes egypti and Aedes albopictus

Crowding
Poverty
Lack of sanitation, hygiene
Travelers and visitors
Warming- lengthened mosquito season
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Ministry of Health and Family Welfare

advised-
1. Enhanced Surveillance
1.1 Community based Surveillance
1.2 International Airports/ Ports
1.3 Rapid Response Teams
1.4 Laboratory Diagnosis

2. Risk Communication
3. Vector Control
4. Travel Advisory
5. Non-Governmental Organizations
6. Co-ordination with International Agencies
7. Research
8. Monitoring
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Dengue
• Widespread through tropics

• Risk factors-
a. Spatial variations of rainfall
b. temperature
c. Relative humidity
d. Degree of urbanization
e. Quality of vector control
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• Before 1970, only 9 countries had experienced severe

dengue epidemics

• Today, endemic in more than 100 countries

• The Americas, South-East Asia, Western Pacific regions

most seriously affected

• In India, the first epidemic of clinical dengue-like illness was

recorded in Madras (now Chennai) in 1780 .

• In New Delhi, outbreaks of dengue fever reported in

1967,1970,1982,1996, 2003,2006,2010,2013 & 2015
Gupta N, Srivastava S, Jain A, Chaturvedi UC. Dengue in India. Indian J Med Res. 2012 Sep;136(3):373-90. Review. PubMed
PMID: 23041731; PubMed Central PMCID: PMC3510884.
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Chikungunya
• Is a mosquito borne viral disease
• Causes fever and severe joint pain

• First reported in Tanzania - 1952

• Occurs in Africa, Asia and the Indian subcontinent
• Africa – outbreaks
• 1999-2000 – in Democratic Republic of Congo
• 2007 - Gabon
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*WHO, 2007
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Chikungunya - India
• First major outbreak across India between 1964 and 1973
• 1973 – 2005, no cases reported in India
• 2005-2006, re-emerged as a major outbreak after 32
years
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West Nile Virus (WNV)

• WNV is a mosquito borne arbovirus
belonging to the flavivirus genus
in the family Flaviviridae

• Commonly found in Africa,

Europe,North America and West Asia.

HISTORY

1937: West Nile District, Uganda

First isolated
1950: Egypt
Ecology studied
Additional outbreaks
1951-54, 1957, Israel
1962, 2000: France
1973-74: South Africa
1996: Romania, 1998: Italy
1999: United States
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• WNV in India usually causes a mild, non fatal dengue like

illness in humans.

• Febrile illness in epidemic form and clinically overt

encephalitis cases were observed in Udaipur area of
Rajasthan, Buldhana, Marathwada and Khandesh districts
of Maharashtra.

• Serologically confirmed cases of WNV infections were

reported from Vellore and Kolar districts during 1977,
1978 and 1981.

Banerjee K. Emerging viral infections with special reference to

India. Indian J Med Res 1996; 103 : 177-200
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Disease in Humans
• Incubation: 2 to 14 days
• Many WNV infections
West Nile neuroinvasive disease
asymptomatic
• Occurs rarely
• Two forms of disease
• Progression of West Nile fever
• West Nile fever
• Can be severe and life-threatening
• Most common form
• Three syndromes
• Resembles influenza
• Encephalitis
• Most infections resolve in 2 to 6
• Meningitis
days
• Acute flaccid paralysis
• Persistent fatigue can occur
• Persistent neurological dysfunction may
occur
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Nipah virus encephalitis (NiV)

• Genus Henipavirus
• Severe, rapidly progressive encephalitis in humans
-High mortality rate
-Close contact with infected pigs

HISTORY

• 1998-1999: Malaysia

• 1999: Singapore

• Since 2001 : Bangladesh, India

• Jan-Feb 2001: Siliguri(India)

-66 cases (45 deaths)

• May 2018: Kerala 18 cases (17 deaths)

• May 2019: 1 case
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Ebola
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Reservoir
Human Illness

• Flying foxes (fruit bats) Incubation period: 4 to 20 days

-Carry the virus Fever and headache
Encephalitis
-are not affected Dizziness, drowsiness,
• Virus found in vomiting
Seizures
-Urine Progresses to coma in 24-48
-Partially eaten fruit(Saliva?) hours
Respiratory difficulty
Relapsing neurologic symptoms
Transmission
•Person- to person Complications
(Nosocomial) Septicemia (24%) GI Bleeding (5%)
Renal Impairment (4%)
•Bat to person
(Contaminated fruit, Treatment: Supportive, Ribavarin
unpasteurized date palm juice)
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Ebola

• Sever and often fatal.

• Average case fatality rate is around 50%

• Emerged in 2014 in West Africa

• Previously affected only small groups of people – swept

rapidly through an area to affect tens of thousands and
become extremely difficult to contain
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Combination of factors that led to the worst

outbreak of Ebola the world has ever seen-

• Increased travel
• Closer contact with animals
• Worse health care system
• Slow response
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Influenza
• Spreads due to natural and human factors
• Infamous for its ability to change genetic information
• Large changes in the virus – human system not prepared
to recognize and defend against the new variant - can
cause Pandemics
• Increased chances in humans living in close proximity to
agricultural animals – chicken, ducks, pigs which are
natural hosts of the influenza virus
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H5N1 / Bird flu (avian)

• Pandemic occurred two decades ago (1997)

• Deadly - more than 50% of the infected die due to the

disease

• Not efficient to pass between humans

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H1N1 / Swine flu

• In 2009 – from pigs

• Travelled around the world faster than any other virus in

the history, as a result of human activity particularly air
travel

• Much lesser deadly than H5N1

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SARS
• Emerged in China in 2002
• Spread rapidly to other countries within the region
• Then to Canada via air travel where 800 were infected
and 800 died
• An unprecedented global response halted the spread of
the causative virus
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COVID-19
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Malaria
• Causes by parasites that are transmitted through the bites
of infected female Anopheles mosquitoes.

• According to latest WHO estimates, there are 212 million

cases of malaria in 2015 and 429,000 deaths.

• Between 2010 and 2015, malaria incidence among

populations at risk fell by 21% globally; during the same
period, malaria populations at risk decrease by 29%.
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• In recent years, parasite

resistance to artemisinin has
been detected in 5
countries of Greater
Mekong subregion:
Cambodia, Lao’s people’s
Democratic Republic,
Myanmar, Thailand and
Vietnam.

World Health Organization.Malaira-Fact sheet.Dec 2016 Available from

.http://www.who.int/mediacentre/factsheets/fs094/en/
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Diphtheria and Pertussis

• Inadequate vaccination of the population

• When the proportion of immune individuals in a population

drops below a particular threshold, introduction of the
pathogen into the population leads to an outbreak of the
disease
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Combating emerging diseases

•The goal of the new initiative is safeguarding people’s

health and developmental gains in the face of the threat
of emerging infectious diseases.

•The objectives are to detect, identify, and monitor

emerging infectious diseases, understand factors
influencing their emergence and spread; and develop
effective interventions for prevention and control of these
infections.

World Health Organization.Combating Emerging Infectious Diseases in the South-East Asia Region.[Internet] 1st ed. New Delhi;
2005. Available from:http://www.searo.who.int/entity/emerging_diseases/documents/b0005.pdf
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1. Epidemic preparedness and rapid

response
• To mount an effective public health response, the
surveillance forms an important cornerstone for control of
emerging and re-emerging infections.

• Surveillance in its simplest form is collection of information

for action.

• A diseases/event under surveillance is first picked up by

the health care system which reports it to the public health
authority for interpretation and initiating action.
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Conceptual framework of public health surveillance and action

Support Activity
Acute
(Epidemic-Type)
Feedback
Response

Analysis

Reporting Public Health Public Health Action

Surveillance
Confirmation
(Epidemiologic
& laboratory)

Detection Planned
Registration Data-Information-Messages (Management-Type)
Response
McNabb S, Chungong S, Ryan M, Wuhib T, Nsubuga P, Alemu W et al. Conceptual framework of public health surveillance
and action and its application in health sector reform. BMC Public Health. 2002;2(1).
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Integrated Disease Surveillance

Programme (IDSP)
• Launched by Government of India in November 2004 with
the World Bank assistance.

Objective: To detect early warning signals, so that timely

and effective public health actions can be initiated in
response to health challenges in the country at the district,
state and national level.

• IDSP receives disease outbreak reports from the

States/UTs on a weekly basis.
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2. Use Of Vaccines
• Increase coverage and acceptability
• New strategies for delivery Develop new vaccines
• Decrease cost

3.New Drug Development

4.Decrease Inappropriate Drug Use

• Improve education of clinicians and public
• Decrease antimicrobial use in agriculture and food
production
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5.Improve Vector And Zoonotic Control

• Develop new safe insecticides
• Develop more non-chemical strategies e.g. organic strategies

6. Better And More Widespread Health Education

7. Development Of Predictive Models Based On:

•Epidemiologic data
•Climate change surveillance

8. Establish Priorities
•The risk of disease
•The magnitude of disease burden
•Morbidity/disability
•Mortality
• Economic cost
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GOARN is a network composed of public health institutions,

laboratories, NGOs, and other organizations that work to observe and
respond to threatening epidemics.

The GOARN contributes towards global health security by:

OBJECTIVES
•Combating the international spread of outbreaks
•Ensuring that appropriate technical assistance reaches affected states
rapidly
•Contributing to long-term epidemic preparedness and capacity
building.
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Conclusion
• Newer microbes will continue to appear and infectious
diseases will continue to emerge.

• Populations have to be protected by staying one step

ahead of the microbes by creating and sustaining a strong
and vigilant public health system.

• Challenges can be met effectively through a national

commitment, strengthened public health infrastructure,
skilled and competent human resources, intersectoral
collaboration and intercountry cooperation.
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THANK-YOU