Department of Community, Environmental and Occupational Medicine

Public Health and Preventive Medicine – Fourth Year

EMERGING AND RE-EMERGING DISEASES

ILOS
1. Define Emerging and Re-Emerging Diseases.
2. Identify diseases transmitted by Aedes Aegypti.
3. Identify recent outbreaks of Dengue Fever, Zika Virus, Chickungunya
Virus, and Yellow Fever.
4. Identify food-borne diseases.
5. Describe recent outbreaks of Rabies in MENA Region.
6. Identify recent outbreaks of Influenza A in Europe, MENA Region, and
Egypt.

EMERGING AND RE-EMERGING DISEASES

1. Non-Communicable Diseases
- Nutritional Diseases like Scurvy and Beriberi.
2. Communicable Diseases. Quarantinable diseases

Emerging and re-emerging diseases: Quarantinable Diseases

Definition: Emerging infectious diseases are diseases of infectious origin
whose incidence in humans has increased within the past decades or threatens
to increase in the near future. The reappearance of a previously known infection
after a period of disappearance or decline in incidence is known as re-
emergence.

I. VECTOR-BORNE DISEASES

Diseases Transmitted by Aedes Aegypti:

1. Dengue Fever.
2. Zika Virus.
3. Chickungunya Virus.
4. Yellow Fever.

AEDES MOSQUITO
Aedes Aegypti
Aedes Albopictus: Travel from China to MENA Region by Ships carrying tires
with raining water.
Aedes aegypti and Aedes albopictus female mosquitoes feed both indoors and
outdoors during the daytime. These mosquitoes thrive in areas with standing
water, including pools, water tanks, containers and old tires. Lack of reliable
sanitation and regular garbage collection also contribute to the spread of the
mosquitoes.

Aedes aegypti and Aedes albopictus female mosquitoes can live for 3 to 6
weeks (mean 30 days) and can fly up to 100 meters.

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1. Dengue Fever
Dengue virus belongs to Flavivirus genus of the family Flaviviridae, and its
members include the 4 antigenically related serotypes of dengue virus (DENV
1-4). It is transmitted to humans by the bite of an infected female Aedes
mosquito, usually the Aedes aegypti mosquito.
Dengue infection is characterized by an acute onset of fever associated with
symptoms of malaise, sore throat, rhinitis and cough, headache, muscle ache,
retro-orbital pain, joint pain, abdominal discomfort, and rash. Other clinical
manifestations of dengue are related to the bleeding diathesis from
thrombocytopenia.
Dengue infection is usually a clinical diagnosis but can be confirmed with
laboratory tests based on the time of presentation; frequently used tests include
PCR and IgM or IgG enzyme immunoassays.
It is well documented that serology is negative during the febrile phase and
early infection, becoming positive after the fever settles. In contrast, PCR has a
much higher sensitivity during the febrile phase, becoming negative after fever
settles.
Dengue is usually a self-limiting infection. Recovery from infection with one
serotype provides lifelong immunity against that serotype, but confers only
transient and partial immunity against subsequent infection by other serotypes.
Sequential infections with other serotypes may increase the risk of more serious
systemic diseases, such as dengue hemorrhagic fever or dengue shock
syndrome, which are life-threatening.
Case fatality rate of Dengue Fever: 1%
Case fatality rate of Dengue Hemorrhagic Fever: 5%

New Vaccine for Dengue Fever

The Brazilian regulatory authorities ANVISA approved Dengvaxia®, tetravalent
dengue vaccine, for the prevention of disease caused by all four dengue types
in individuals from 9-45 years of age living in endemic areas. Dengvaxia® was
shown to reduce dengue due to all four serotypes in two-thirds of the
participants and prevent 8 out of 10 hospitalizations due to dengue and up to
93% of severe dengue cases.

- Yemen: Dengue fever is endemic in Yemen, with outbreaks reported in a

number of governorates over the last 10 years.
- Kingdom Saudi Arabia: Confirmed cases of Dengue in the city of Jeddah,
Makkah Region (August, 2017).
- Red Sea Governorate, Egypt (September, 2017): Dengue fever outbreak has
been detected in the Al Qusayr city in the Red Sea governorate in the beginning
of October 2017. Recent reports indicate the shift of dengue virus activity to the
nearby governorates such as Aswan, despite the fact that the only 9 cases
reported in Aswan were originally from the Red Sea area.

2. Zika Virus
Human Zika Virus Disease was discovered in Uganda in 1952.
The virus is transmitted by the mosquito Aedes aegypti, endemic in Africa.
The incubation period is not confirmed yet, but it ranges from 3 to 7 days.
Symptoms of Zika Virus Disease last from 3 to 7 days. The most frequent

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symptoms are fever, headache, rash, arthralgia, and conjunctivitis. The clinical
picture of Zika Virus Disease is quite similar to that of Flu.
Complications include microcephaly and Guillain-Barre syndrome.
Over the last 20 years, Zika Virus Disease has been extended to other
continents like Americas, Asia and Pacific Islands.
In October 2013, an outbreak of Zika Virus Disease was declared in the French
Polynesia with 32,000 cases.
Although the first case of Zika virus transmission in South America was reported
in Chile in February 2013, alarms started with cases of microcephaly in Brazil in
October 2015. The outbreak extended to Columbia and other South American
countries. On February 1, 2016, the WHO declared Zika virus a public health
emergency of international concern.
The current epidemic has more questions than answers:
Why now? Zika virus was discovered in 1952.
Aedes aegypti is endemic in Madeira, Portugal. Is it possible a new epidemic in
the European countries?
Is Zika virus disease a sexually transmitted disease?
Is fumigation safe? Could it be carcinogenic?
What will we do to help families with children with microcephaly?

3. Chikungunya Virus
Chikungunya is a viral disease which is transmitted to humans by infected
mosquitoes, including Aedes aegypti and Aedes albopictus.
Symptoms appear between 4 and 7 days after the patient has been bitten by
the infected mosquito and these include: High fever (40°C), Joint pain (lower
back, ankle, knees, wrists or phalanges), Joint swelling, Rash, Headache,
Muscle pain, Nausea, and Fatigue.
Chikungunya is rarely fatal.
Symptoms are generally self-limiting and last for 2–3 days. The virus remains in
the human system for 5-7 days and mosquitoes feeding on an infected person
during this period can also become infected. Chikungunya shares some clinical
signs with dengue and can be misdiagnosed in areas where dengue is
common.
Chikungunya can be detected using serological tests. Recovery from an
infection will confer life-long immunity.
Outbreak in 2007. Migration of infected people introduced the infection in a
coastal village in Italy. This outbreak (197 cases) confirmed that mosquito-borne
outbreaks by Aedes albopictus are plausible in Europe.
Last 30th of September 2018, the Federal Ministry of Health of Sudan informed
WHO of an outbreak of chikungunya that has affected eastern states. Till that
date, a total of 13 430 suspected cases were reported from the country,
primarily from Kassala and Red Sea state. Samples have been tested both by
PCR and by serology. A number of samples have also been tested positive for
dengue fever.

4. Yellow Fever
Increased number of cases in Central Africa over the last 2 years.

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Malaria
Malaria is a life-threatening disease caused by parasites that are transmitted to
people through the bites of infected female Anopheles mosquitoes.
Recently, there is an increase in the number of cases of Malaria in Sudan.

West Nile Virus

West Nile Virus Disease is caused by a virus of the genus Flavivirus family
Flaviviridae, found in both tropical and temperate regions.
The virus infects mainly birds, but also humans, horses, and more rarely, dogs,
cats, bats, and other animal species.
The main route of infection in humans is the bite of an infected mosquito of the
genus Culex.
Usually the disease cures spontaneously, sometimes it leaves sequelae, but
sometimes it is fatal, especially in the elderly or immunocompromised patients
(in 3 to 15 percent of cases).
Tunisia: The Environment Minister announced on [Mon 1 Oct 2018] that the
few cases of West Nile virus infection recorded in the Sousse and Beja regions
have not reached an epidemic dimension, as happened during the previous
episodes of 1996, 1997, 2003, and 2012.
Health Minister said [Thu 4 Oct 2018] that the ministry has recorded a total of
67 cases of suspected West Nile virus in various regions of the country.
He added that for 30 cases, the diagnosis was confirmed biologically. Of these
cases, 12 were cured and returned home, while the others are being kept under
medical supervision.

II. FOOD-BORNE DISEASES

Cholera
Yemen: Important Outbreaks in 2016-2018 (Diarrhea and Dysentery).
This epidemic has affected the entire country.
Yemen's cholera epidemic, currently the largest in the world, has spread rapidly
due to deteriorating hygiene and sanitation conditions and disruptions to the
water supply across the country. Millions of people are cut off from clean water,
and waste collection has ceased in major cities.
It is estimated the more than 1 and half million persons had Cholera in
Yemen over the last 12 months; Case fatality rate is low (0.25%). The WHO
estimates daily 5000 new cases.
The first-ever oral cholera vaccination campaign in Yemen was launched on 6
May and concluded on 15 May 2018, just before the start of Ramadan.

Syria (Aleppo): Recent Outbreaks in 2016 and 2017. Suspected Internally

Displaced Persons “Camp”.

III. ZOONOTIC DISEASES

Rabies
Tunisia and Algeria (Tizi Ouzou).

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In Algeria, since January to October 2018 11 deaths caused by rabies have
been recorded. According to the Ministry of Health, Population and Hospital
Reform (Algeria), the annual average is between 15 and 20 cases of death from
this disease.
Egypt (Al Wadi Al Jadid).

IV. INFLUENZA
Influenza A
Avian Influenza A(H1N5)

A(H7N9) China
In 2013, an influenza virus that had never before been detected began
circulating among poultry in China. It caused several waves of human
infection, and in late 2016, the number of people to become sick from
the H7N9 virus suddenly started to rise. As of late July 2017, nearly
1600 people had tested positive for avian H7N9. Nearly 40 percent of
those infected had died.

A(H5N8) Europe, Egypt

In 2010, strains of H5N8 of were first detected among wild birds in Asia and
later spread to domestic birds across China, South Korea, and Japan. Later,
H5N8 was reported in Russia, with further spread to many countries in Europe,
Asia, and the Middle East. The spread of H5N8 strains has been linked to the
overlapping flyways of migratory wild birds that come from different continents;
this mingling of wild birds poses a major concern worldwide.

Europe
Italy has had 5 outbreaks of highly pathogenic H5N8 avian flu in farms in the
central and northern parts of the country since the start of the month [October
2017]. About 880000 chickens, ducks and turkeys will be culled, officials said on
[Wed 11 Oct 2017]. The biggest outbreak of the H5N8 virus, which led to the
death or killing of millions of birds in an outbreak in western Europe last winter,
was at a large egg producing farm in the province of Ferrara.

Egypt
On November 30, 2016, the identification of H5N8 from 2 common coots was
reported to the World Organization for Animal Health. Notably, this newly
emerged H5N8 was detected in Egypt in the same place, Damietta
Governorate, where H5N1 was first identified in 2006 during the global spread
of H5N1 viruses.

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