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The Interface Between Human and Veterinary Public Health

Dr.Kedar Karki

Historical Epidemiological Transitions

Paleolithic Age  Hunters and gatherers  Nomadic  Small populations  Parasitic infections

Historical Epidemiologic Transitions – 1st Transition
• 10,000 years ago • New social order due to agriculture • Zoonoses through animal domestication • Increases in infectious diseases • Epidemics in non-immune populations

Deadly Gifts
Human Diseases
Measles TB Smallpox I nfluenza Pertussis Malaria

Animal Origin
Rinderpest of cattle M. bovis of cattle Cowpox Pigs and Ducks Pigs and Dogs Birds

Guns, Germs and Steel − J. Diamond

Historical Epidemiologic Transitions – 2nd Transition
• Coincided with mid-19th century Industrial Revolution • Decreases in infectious disease mortality • Increasing life expectancy • Improved nutrition • Antibiotics • “Diseases of Civilization” – cancer, diabetes, cardiovascular diseases • Environmental problems • Chronic diseases

Historical Epidemiologic Transitions – 3rd Transition
• Last 25 years • Emerging infectious diseases globally • New diseases and increases in mortality; first since 19th century • Re-emergence • Antimicrobial resistance • 75 percent of diseases are zoonotic • Anthropogenic factors of emergence; the microbial “perfect storm”

“The Perfect Storm” − Sebastian Junger

an ocean tempest due to a rare combination of factors and circumstances that might occur every century

MICROBIAL

EATS
EMERGENCE,

O HEALTH

CTION,

RESPONSE

The “Microbial” Perfect Storm
  

Due to special combinations and circumstances Relatively common occurrence Doesn’t dissipate, but may perpetuate or accelerate Convergence model

WHO Map on World – Emerging Diseases

Convergence Model
Genetic and Biological Factors

Physical Environmental Factors Microbe

Human Social, Political and Economic Factors Ecological Factors

Convergence Model (Microbial Threats to Health 2003)

Factors in Emergence
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Microbial adaptation and change Host susceptibility to infection Climate and weather Changing ecosystems Economic development and land use Human demographics and behavior Technology and industry

Factors in Emergence
continued
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International travel and commerce Breakdown of public health measures Poverty and social inequality War and famine Lack of political will Intent to harm

Multi host Pathogens
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60% of all human pathogens are zoonotic 80% of animal pathogens Ecological generalists

New Dynamic
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Emerging diseases – 70% zoonotic New zoonoses Food safety Antimicrobial resistance Agents of bio- and agro-terrorism – 80% zoonotic Global trade and movements

Rapidly Increasing Human Population

6.1 Billion people in 2000

~9.4 to 11.2 Billion in 2050

Source: United Nations, World Population Prospects, The 1998 Revision; and estimates by the Population Reference Bureau.

Rapidly Increasing Urbanization

2000
-

47% world population living in urban areas 60% world population living in urban areas

2030
-

The Divided World of 2025 – 8.4 Billion People

World 1 World 2 World 3

Advanced nations (Advances in medicine and food) Middle class (Livestock Revolution) People in destitution and poverty (Sources of traditional pathogens)

El Nino
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Leptospirosis Hantavirus Rift Valley fever

Vectors of Disease

Global Warming

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Shifting and enlarging the incidence and distribution of disease Malaria zone 45% of population to 60% Habitat change and disruption via weather changes

Global Warming Effects on Malaria

Ecosystem

Waterborne Zoonoses
Animals Humans

Waterborne Disease Microbial Pathogens

Water Environment

Waterborne Zoonoses – Global Threat
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4 billion cases of diarrhea per year 2-3 million deaths Poorly reported Zoonotic portion is significant Endemic and epidemic 1.1 billion people with unreliable water supply

Waterborne Zoonoses Pathogens
         

Cryptosporidium Giardia E. Coli 0157:H7 Salmonella Leptospiria Toxoplasma Campylobacter Entamoeba Ascarsis Viruses and Prions? SARS?

Concentrated Animal Feeding Operations (CAFOs)

Their Impact on Food Safety and Healthy Environments

Foodborne Infections

Worldwide

> 2 million people die from diarrhea caused by contaminated food and water each year

U.S.

~ 76 million persons experience foodborne illnesses (1 in 4 people)
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~325,000 hospitalizations ~5,000 deaths

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Most Common Food borne Pathogens
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Campylobacter Salmonella E. coli 0157:H7 Yersinia Listeria Cryptosporidium Cyclospora Norwalk-like viruses

Livestock 2020 – The Next Food Revolution

  

Global increase and demand for protein and food of animal origin Shift from poverty of 1-2 billion people to middle class “Westernization” of Asia and Latin America Concerns with sustainability Increases in emerging zoonoses through the concentration of people and animals

By 2020, There will be 1 Billion People Over the Age of 60
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30% of US population are baby boomers Immuno-compromised population

Movement and Interactions of People and Commerce

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Distance and speed of travel increased 1000 fold since 1800 1.4 billion air travelers/year 50 million foreign visitors, to US year through, 102 sites Antibiotic resistance Global trade of food, animals and plants

The Coming Plague
Today’s mingling of people, animals and microbes in new environments has no historical precedent. -”We await the coming plague”

- Laurie Garrett

Remote Sites

Pathogen Pollution
  

Human and domestic animal populations Free-living wild animals Example: global decline in amphibian populations due to chytridiomycosis Concern with adverse effects on biodiversity

Chytridiomycosis

Virus Carriers

Fruit bats

Flying Foxes

Nipah Virus

Malaysian Pig Farms

Emerging Infectious Diseases
Encroachmen t Introduction “Spill over” & “Spill back”

Translocation

Wildlife EID

Human encroachment Ex situ contact Ecological manipulation

Agricultural Intensification

Domestic Animal EID

Human EID

Global travel Urbanization Biomedical manipulation

Dasazak P. et.al. Science 2000 287:443

Technology and Industry

Spill Over and Spill Back

What’s Next?

Human Monkey pox Cases

Marshfield Clinic and MCW
Matt Kuehnert

Exotic Pets

SARS

Maintenance Host

SARS Airport Screening

The Lessons of SARS

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   

The need for multinational collaboration Public alarm can lead to huge economic impact $80 billion Weaknesses in public health infrastructures Consequences of poor reporting –disincentives A true zoonosis: more to come Constant threat due to Emerging Infectious Diseases in less developed countries

H5N1 Avian Influenza

Pandemic Influenza

The Next Influenza Pandemic
 

Not if, but when 1918-1919 Experience: 20 million deaths 150 – 450% increase in patient and hospital visits In 2001 (Asia only), 160 million workdays lost, and for a pandemic, 6 billion workdays lost worldwide

Bioterrorism Biodefense Agroterrorism

Agents of Bioterrorism
Bacteria, Rickettisia, Category Toxins A B Anthrax; Botulism; Plague; Tularemia Brucellosis; Epsilon toxin of C. perfringens; Glanders; Staphylococcus, enterotoxin B; Q Fever Multidrug-resistant tuberculosis Total (% Zoonotic) 6 (83%) 5 (80%)

Viruses Smallpox Viral Hemorrhagic Fevers

C

Hantaviruses; Nipah 4 (80%) virus; Tickborne encephalitis viruses; Yellow Fever

Most Significant Global Epidemics Over the Last Decade
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1993 – Hanta virus 1994 – Plague (India) Ebola virus (Zaire) 1996 – New Variant of CJD (UK) H5N1 influenza (Hong Kong)

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1998 – Nipah virus (Malaysia) 1999 – West Nile 2000 – Rift Valley Fever 2001 – Anthrax 2002 – Norwalk-like viruses 2003 - SARS

Implications of Emerging Diseases
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Political Social Economic Psychological Environmental

Animal-borne Epidemics Out of Control: Threatening the Nation’s Health – 2003
− A report from the Trust

for America’s Health

Findings from the Report
 

lack of national program to prevent and control diseases that impact humans, animals and our food There is no coordinated effort or single agency with a “command and control” responsibility There is a lack of effective communications with the public about these diseases and their impact Disease surveillance systems are not linked

Findings from the Report
(continued)

Funding for bioterrorism has not adequately supported efforts to counter zoonotic disease threats, especially from the animal health perspective and infrastructure There is a fragmentation of jurisdictions, authorities, statutes and research; e.g. 200 different government offices and programs responding to 5 zoonotic diseases Animal and public health are separated by culture and organization

Microbial Threats to Health Conclusions & Recommendations
1. Enhancing the global response capability 2. Improving global infectious disease surveillance 3. Rebuilding domestic public health capacity 4. Improving domestic surveillance through better disease reporting (this includes both human health and veterinary health) 5. Exploring innovative systems of surveillance 6. Developing and using diagnostics

Microbial Threats to Health Conclusions & Recommendations

(continued)

7. Educating and training the microbial threat workforce 8. Developing and producing vaccines 9. Developing and producing antimicrobial drugs 10. Controlling the use of antimicrobials 11. Controlling vectorborne and zoonotic diseases 12. Establishing a comprehensive infectious disease research 13. Creating interdisciplinary infectious disease centers

Preventing Emerging Infectious Diseases: A Strategy for the 21st Century.
Goal Goal Goal Goal 1: 2: 3: 4: Surveillance and Response Applied Research Prevention and Control Infrastructure and Training

Public Health at the Crossroad
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New, inclusive vision of public health Shift to focusing on causes of population health Ensuring that population health is a central concern of policymakers Globalization of causes and issues Socioeconomic disparities Emerging threats due to interdependence New team – expanded, integrated and transdisciplinary

Public Health at the Crossroad

Population health is a shift from an emphasis on individual health to understanding the multiple determinants of health.

Public Health at the Crossroad

Health is an outcome shaped by a wide range of social, economic, natural, built, and political environments that form a complex and everchanging dynamic. Because of this broad perspective, public health teams themselves also need to reflect this reality.