You are on page 1of 8

A Modern Myth

Emerging Infectious Diseases

In 1899 the Commissioner of the US Patent Office supposedly said: everything already has been invented..." and then he went on to suggest that the Patent Office was unnecessary and could now be closed closed. . Close investigation has debunked this; it is not true. In 1899 there were 3,000 more patent applications than there were in 1898!

A work in continuous progress

Monday, October 22nd, 2012


Fall 2012 1 Fall 2012 2

A More Modern Myth


By the mid-1970s, the discovery of new antibiotics had already sharply declined, but Physicians were confident that all known bacterial diseases were treatable with existing antibiotics. The bulk of microbiology research had already gravitated toward Viruses, against which there was no known therapy. Physicians were openly talking about a PostInfectious Disease Era
Fall 2012

Forty years ago bacterial pathogens were a problem of the past..

In 1969, at the height of antibiotic development, the U. S. Surgeon General publicly declared Victory over infectious disease However, bacterial diseases had persisted, and continue to reemerge across the globe. Vi l diseases Viral di such h as the th flu fl and d AIDS pose an even more challenging threat. Emerging diseases such as Ebola and CJD continue to perplex scientists. Perhaps most frighteningly, antibiotic resistant bacteria lurk in the very places that people go to get well hospitals
.
4

-But this one is true!

Fall 2012

The end of the dream

Definition

July 04, 1976: Bellvue-Strafford Hotel, Philadelphia Pa. The Bicentennial Year at the Bicentennial place. A terrorist incident (perhaps the Weather Underground?) caused many members of the A American i L Legion i t to get t sick i kd during i th their i convention ti there, and some died of pulmonary complications Intense investigation eventually turned up a previously unknown bacterium which we now know as Legionella pneumophilia It was not a deliberate act, after all.
5

There is no simple definition of an emerging infectious disease. In general, it can be a completely new disease or an old disease g in new p places or new p peoples; p ; with occurring new presentations; or is newly resistant to available treatments. There are many recent and historical examples of emerging infectious diseases.

Fall 2012

Fall 2012

http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/FAQs/FAQ3.asp

Patterns of Emergence
1. 2. 3. 4 4. 5. 6.

1. 2.

infection

New Disease: AIDS, Ebola, Legionnaires, Nipah virus Old Disease, New Place: Smallpox, the New World, 16th
Century, Black death (plague), Europe, 14th Century Hepatitis E, Haiti West Nile fever, NY, 1999

Altogether New Disease: Old Disease, New Place: Old Disease Reintroduced: Old Disease Disease, New Population: Increased Virulence: Drug Resistance:

3.

Reintroduced: Dengue fever, Texas : Plague, India: Measles, United States: Malaria, Korea: Adenovirus, US y training g camps p Military New Population: Malaria, US soldiers in Somalia: Marburg virus, lab workers in Germany: Cholera, Peru Increased Virulence: Influenza, 1918 worldwide pandemic H5N1 influenza, Hong Kong E. coli O157:H7, United States Drug Resistance: Campylobacter, Malaria, Strep

4. 5. 6.

Fall 2012

http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/FAQs/FAQ3.asp

Fall 2012

http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/FAQs/FAQ3.asp

Altogether New Diseases

More New Diseases: Ehrlichiosis and Anaplasmosis

Meaning new to humans: These diseases existed in animal populations (somewhere) previously

2008 Case Definition

CSTE Position Statement Number: 09-ID-15

Legionnaires g Disease HIV Marburg and Ebola Hantavirus SARS

1976 early 1980s 1960s and 1970s 1990s 2000s

Ehrlichia chaffeensis infection (formerly Human Monocytic Ehrlichiosis [HME]) Ehrlichia ewingii infection (formerly Ehrlichiosis [unspecified, or other agent]) Anaplasma phagocytophilum infection (formerly Human Granulocytic Ehrlichiosis [HGE]) Ehrlichiosis/Anaplasmosis, human, undetermined
http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm

Fall 2012

Fall 2012

10

Ehrlichiosis and Anaplasmosis Clinical Description

Ehrlichia chaffiensis Lab Diagnosis

Clinical presentation:

Supportive:

A tick-borne illness characterized by acute onset of fever and one or more of the following symptoms or signs: headache, myalgia, malaise, anemia, leukopenia, thrombocytopenia, or elevated hepatic transaminases. Nausea, vomiting, or rash may be present in some cases . Any reported fever and one or more of the following: headache, myalgia, anemia, leukopenia, thrombocytopenia, or any hepatic transaminase elevation.
http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm

Serological evidence of elevated IgG or IgM antibody reactive with E. chaffeensis antigen by IFA, enzyme-linked immunosorbent assay (ELISA), dot-ELISA, or assays in other formats (CDC uses an IFA IgG cutoff of 1:64 and does not use IgM test results independently as diagnostic support criteria.), OR Identification of morulae in the cytoplasm of monocytes or macrophages by microscopic p examination Serological evidence of a fourfold change in immunoglobulin G (IgG)-specific antibody titer to E. chaffeensis antigen by indirect immunofluorescence assay (IFA) between paired serum samples (one taken in first week of illness and a second 2-4 weeks later), OR Detection of E. chaffeensis DNA in a clinical specimen via amplification of a specific target by polymerase chain reaction (PCR) assay, OR Demonstration of ehrlichial antigen in a biopsy or autopsy sample by immunohistochemical methods, OR Isolation of E. chaffeensis from a clinical specimen in cell culture
http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm

Confirmed:

Clinical evidence:

Fall 2012

11

Fall 2012

12

Ehrlichia ewingii infection (formerly Ehrlichiosis [unspecified, or other agent]) Lab Diagnosis

Anaplasma phagocytophilum infection (formerly


Human Granulocytic Ehrlichiosis [HGE])

Lab Diagnosis

Supportive:

Laboratory criteria for diagnosis Confirmed:

Because the organism has never been cultured, antigens are not available. Thus, Ehrlichia ewingii infections may only be diagnosed by molecular detection methods: E. ewingii DNA detected in a clinical specimen via amplification of a specific target by polymerase chain reaction (PCR) assay.
http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm 13

Serological evidence of elevated IgG or IgM antibody reactive with A. phagocytophilum antigen by IFA, enzyme-linked immunosorbent Assay (ELISA), dot-ELISA, or assays in other formats (CDC uses an IFA IgG cutoff of 1:64 and does not use IgM test results independently as diagnostic support criteria.), OR Identification of morulae in the cytoplasm of neutrophils or eosinophils by microscopic examination Serological evidence of a fourfold change in IgG-specific antibody titer to A. phagocytophilum antigen by indirect immunofluorescence assay (IFA) in paired serum samples (one taken in first week of illness and a second 2-4 weeks later), OR Detection of A. phagocytophilum DNA in a clinical specimen via amplification of a specific target by polymerase chain reaction (PCR) assay, OR Demonstration of anaplasmal antigen in a biopsy/autopsy sample by immunohistochemical methods, OR Isolation of A. phagocytophilum from a clinical specimen in cell culture
http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm 14

Confirmed:

Fall 2012

Fall 2012

Ehrlichiosis/Anaplasmosis, human, undetermined Case Classification

Re-emerging Diseases

Exposure

History of having been in potential tick habitat in the 14 days prior to the onset of illness or history of tick bite or history of tick bite. Suspected: A case with laboratory evidence of past or present infection but no clinical information available (e.g. a laboratory report). Probable: A clinically compatible case (meets clinical evidence criteria) that has supportive laboratory results. For ehrlichiosis/anaplasmosis an undetermined case can only be classified as probable. This occurs when a case has compatible clinical criteria with laboratory evidence to support Ehrlichia/Anaplasma infection, but not with sufficient clarity to definitively place it in one of the categories previously described. This may include the identification of morulae in white cells by microscopic examination in the absence of other supportive laboratory results. Confirmed: A clinically compatible case (meets clinical evidence criteria) that is laboratory confirmed.

Case Classification
1. 2.

3.

Well-known old infectious diseases which we once thought to have beaten, but which are resurgent due to shifts in our environment or in our behavior This happens often when, for one reason or the other, th people l stop t practicing ti i vaccination i ti f for a given i disease because the risk of vaccine complications rises over the risk of the disease itself Or it can happen as an unintended consequence when other health or environmental practices change
16

Fall 2012

http://www.cdc.gov/ncphi/disss/nndss/casedef/ehrlichiosis_2008.htm

15

Fall 2012

Re-emerging Disease

Potential Candidates
Any

infectious disease which is endemic in a human population and which is held in check by organized vaccination programmes

Diphtheria Pertussis Herpes Zoster Measles Polio etc

Discontinuation of vaccination for any reason will allow a susceptible population to develop, and the disease will shortly reemerge
17 Fall 2012 18

Fall 2012

Re-Emerging Diseases
due to

Re-Emerging Diseases
due to

Changes in Social or Environmental Practices

Changes in Social or Environmental Practices

Tuberculosis Re-emerged after being effectively beaten


because it was able to persist in the homeless, prison and IV drug using communities, until it got a timely boost from the emergence of HIV

Malaria was brought well under control


throughout the world by the late 1950s, after 10 to 15 years of DDT use. Since DDT was discontinued, malaria has reemerged as the #1 infectious disease killer in the world More recent insecticides have failed to dent the mosquito vector population
20

Prisons throughout the world have historically been incubators for TB. When governments fall and the care (if any) of prisoners deteriorates, TB can re-emerged with a vengeance

After the collapse of the Soviet Union from the Gulags Release of prisoners after fall of the Apartheid government in South Africa.

Fall 2012

19

Fall 2012

Old Diseases in new Places New Host Populations


Many examples in the past 500+ years of history

Old Diseases in new Orifices the New STIs


Certain Safe Sex 1 Anal-Oral practices2 have enabled some of the traditionally Gastrointestinal pathogens to recently make the jump to become real STDs

Plague Smallpox Syphilis Plague again Cholera Measles Polio


Fall 2012

Europe from Asia Old world to the New New world to the Old ? World from India Pacific Islanders Inuit (Eskimo) Peoples

14th Century 16th Century 16th Century 17th Century 18th Century 19th Century 20th Century
21

Giardia Gi di lamblia l bli Amoeba sp. Shigella sp. E. coli Others?


1

- Protozoan P t - Protozoan True Bacteria True Bacteria Hepatitis A, B. and C ?

Safe Sex is a classic oxymoron called Rimming


22

Fall 2012

2 Sometimes

Old bugs with Increased Virulence


Drug Resistance

PPNG
gonorrhoea

Penicillinase positive Neisseria

H1N1 Influenza, 1918 worldwide pandemic H5N1 influenza, 1967 Hong Kong Staph aureus Exotoxin TSST-1 -1980s USA The Flesh Eating Strep 1990s USA E. coli O157:H7, 1990s USA

MDR TB Multiple-Drug resistant Mycobacterium tuberculosis MRSA Methcillin Resistant Staph a aureus re s Emergence of Drug Resistance plasmids which
are spreading through the Enterobacteriaceae and even to non-related bacteria

Fall 2012

23

Fall 2012

24

Patterns of Emergence
1. 2. 3. 4 4. 5. 6. 7.

The Classic: Helicobacter pylori


Altogether New Disease: Old Disease, New Place: Old Disease Reintroduced: Old Disease Disease, New Population: Increased Virulence: Drug Resistance: Old Disease which we are only slowly realizing is infectious in nature
http://www.geis.fhp.osd.mil/GEIS/aboutGEIS/FAQs/FAQ3.asp
25

First seen in the human stomach in 1875 Role in gastric disease first suggested in 1899 Experiments in New Yorks Bellview Hospital in 1947 showed that some ulcers could be cured with antibiotics Barry Marshall and Robin Warren first cultured the organism in 1981-1982 Marshall infected himself with the organism in the late 1980s and proved its pathogenicity Marshall and Warren won the 2005 Nobel Prize for this work.

Fall 2012

Fall 2012

26

Some Diseases which we are just now beginning to recognize as being infectious

Not our Usual Suspects


Cervical Carcinoma Prostate Cancer Head and Neck Cancers Diabetes Mellitis Atherosclerosis Schizophrenia Alzheimers
retrovirus. Disproven ??

HPV XMRV* HPV Mycoplasma sp.


Chlamydophila pneumoniae

ALS (Lou Gehrigs Disease) Prions Multiple Sclerosis Epstein-Barr Virus Chronic Fatigue Syndrome Atherosclerosis Cytomegalo Virus OCD (PANDAS)* Streptococcus sp.

Toxoplasma gondii Prions?

* = Xenotropic Murine Leukemia Related Virus, a gammaFall 2012 27

* PANDAS = Pediatric Autoimmune Neuropsychiatric Disorder Associated with Streptococcal Infection

Fall 2012

28

Obesity
may be an infectious disease!
MINIREVIEW:

Even the current epidemic of

Adipocyte, Adipose Tissue, and Infectious Disease 2007, Mahalia S. Desruisseaux,

The National Institute for Allergy and Infectious Disease

Nagajyothi, Nagaj othi Maria E E. Tr Trujillo, jillo Herbert B B. Tano Tanowitz, it and Philipp E. Scherer (Albert Einstein College of Medicine and the Montefiore Medical Center, Bronx, New York) in: INFECTION AND IMMUNITY, Mar. 2007, p. 10661078 Vol. 75, No. 3
Copyright 2007, American Society for Microbiology. All Rights Reserved

Has a lot to say on this subject


See http://www3.niaid.nih.gov/topics/emerging/

Fall 2012

http://iai.highwire.org/cgi/reprint/75/3/1066

29

Fall 2012

30

List of NIAID Emerging and Re-emerging Diseases

List of NIAID Emerging and Re-emerging Diseases

Group IPathogens Newly Recognized in the Past Two Decades Helicobacter pylori Acanthamebiasis Australian bat lyssavirus Hendra or equine morbilli virus Babesia, atypical Hepatitis C Bartonella henselae Hepatitis E Ehrlichiosis Human herpesvirus 8 Encephalitozoon Human herpesvirus 6 cuniculi Encephalitozoon hellem Lyme borreliosis Parvovirus B19 Enterocytozoon
Fall 2012

Group IIRe-emerging Pathogens

Enterovirus 71 Clostridium difficile Mumps virus Streptococcus, Group A Staphylococcus aureus

bieneusi

31

Fall 2012

32

List of NIAID Emerging and Re-emerging Diseases

List of NIAID Emerging and Re-emerging Diseases

Group IIIAgents with Bioterrorism Potential

Group IIIAgents with Bioterrorism Potential

Category A

Category A (continued) Viral hemorrhagic fevers

Bacillus anthracis (anthrax) Clostridium botulinum toxin (botulism) Yersinia pestis (plague) Variola major (smallpox) and other related pox viruses Francisella tularensis (tularemia)
33

Arenaviruses

LCM, Junin virus, Machupo virus, Guanarito virus Lassa Fever Hantaviruses Rift Valley Fever Dengue Ebola Marburg
34

B Bunyaviruses i

Flaviruses

Filoviruses

Fall 2012

Fall 2012

List of NIAID Emerging and Re-emerging Diseases

Group IIIAgents with Bioterrorism Potential

List of NIAID Emerging and Re-emerging Diseases

Category B (part 1 of 3)

Fall 2012

Group IIIAgents with Bioterrorism Potential NIAIDCategory B (part 2 of 3): Food- and waterborne pathogens

Burkholderia pseudomallei Coxiella burnetii (Q fever) Brucella species (brucellosis) Burkholderia mallei (glanders) Chlamydia psittaci (Psittacosis) Ricin toxin (from Ricinus communis) Epsilon toxin of Clostridium perfringens Staphylococcus enterotoxin B Typhus fever (Rickettsia prowazekii)
35

Bacteria

Diarrheagenic E.coli Pathogenic g Vibrios Shigella species Salmonella Listeria monocytogenes Campylobacter jejuni Yersinia enterocolitica

Viruses (Caliciviruses, Hepatitis A) Protozoa


Cryptosporidium parvum Cyclospora cayatanensis Giardia lamblia Entamoeba histolytica Toxoplasma Microsporidia
36

Fungi

Fall 2012

List of NIAID Emerging and Re-emerging Diseases

List of NIAID Emerging and Re-emerging Diseases

Group IIIAgents with Bioterrorism Potential

Group IIIAgents with Bioterrorism Potential

Category B (part 3 of 3)

Additional viral encephalitides


Category C:

West Nile virus LaCrosse California encephalitis VEE EEE WEE Japanese Encephalitis virus Kyasanur Forest virus
37

Emerging infectious disease threats such as Nipah virus and additional hantaviruses.

Fall 2012

Fall 2012

38

Serratia marscesens

Another possible Category of emerging infectious diseases:


- Well-known organisms that were once thought to be completely harmless to humans for example.
Fall 2012 39

Between Sept. 20 and Sept. 27 of 1950, a Navy mine-laying vessel cruised the San Francisco coast, spraying an aerosol cocktail of Serratia and Bacillus microbes all believed to be safe over the city from giant hoses on deck deck, according to declassified Army reports. Based on results from monitoring equipment at 43 locations around the city, the Army determined that San Francisco had received enough of a dose for nearly all of the citys 800,000 residents to inhale at least 5,000 of the particles.

Serratia is a Gram-negative rod, a member of the Enterobacteriaceae family. It grows aerobically on common lab media, and it is easy to detect because it forms brightly pigmented colonies on plain Nutrient Agar

Fall 2012

40

SERRATIA MARCESCENS, CONTAMINATED SOLUTION - USA (02): (ALABAMA) **************************************************************** A ProMED-mail post <http://www.promedmail.org> ProMED-mail is a program of the International Society for Infectious Diseases http://www.isid.org Date: Thu 7 Apr 2011 Source: Fox 6 News, WBRC [edited] <http://www myfoxal com/story/14404429/bacteria outbreak initated on> <http://www.myfoxal.com/story/14404429/bacteria-outbreak-initated-on> Bacteria that affected 19 Alabama hospital patients and possibly led to the death of 9, initiated on a faucet [tap] at the Homewood-based Meds IV pharmacy, according to the Alabama Department of Public Health. Samples of the bacteria, Serratia marcescens , were identified on a sink faucet in the pharmacy. Water from that tap was used along with soap to clean out a container used to create an amino-acid compound used to create TPN [total parenteral nutrition],

Finding Serratia bacterium on a faucet is not uncommon, according to State Health Officer Dr Don Williams. What's troubling, he said, is that the filter used to sterilize the product failed and this is where the real problem lies. Williams said in a press conference Thursday [7 Apr 2011] it was his department's 1st experience dealing with an outbreak of this kind and is working with the FDA to determine if washing containers with unsterile water is within federal guidelines. Williams confirmed that there is no risk to any other patients going forward and the problem is absolutely limited to the TPN obtained by Meds IV. He said the Centers for Disease Control and Prevention [CDC] polled other states to see if anyone else was seeing similar problems with the bacteria and TPN. The CDC fo nd the problem was found as limited to Alabama, Alabama and only onl to the patients who ho received TPN from Meds IV. "There is nothing to suggest that any of the infections were associated with any pharmacy other than Meds IV," Williams said. "Based on everything that we know, it is clearly linked to the compounding of TPN in that pharmacy.

Fall 2012

41

Fall 2012

42

Emerging Infectious Diseases is published


monthly by the Centers for Disease Control and Prevention (CDC),
1600 Clifton Road, Mailstop D61, Atlanta, GA 30333, USA. Telephone 404-639-1960, fax 404-639-1954, e-mail eideditor@cdc.gov.

Some Important Web Sites

US Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS)

http://www.geis.fhp.osd.mil/aboutGEIS.asp

National Institute of Allergy and Infectious Disease

http://www3.niaid.nih.gov/topics/emerging/

CDC National Center for Infectious Disease

http://www.cdc.gov/ncidod/diseases/eid/
43 Fall 2012 44

Fall 2012

Books on the Subject

Ewald, Paul, Plague Time: the New Germ Theory of Disease, 2002, Anchor Books, New
York. ISBN 0-385-72184-6

END

York. ISBN 1-4000-5275-0

Levy, Elinor and Fischetti, Mark , The New Kill Di Killer Diseases 2004, 2004 Three Th Rivers Ri P Press, N New

Zuk, Marlene, Riddled with Life 2007, Houghton Mifflin Harcourt, Orlando, Fl. ISBN 978-0-15-603468-5

Fall 2012

45

Fall 2012

46