Emerging & Re-emerging

infectious Diseases

Mentored By: Presented By:

Dr. Lipilekha Patnaik Dr. Arijit Kundu
Associate Professor PG Student
1
 Introduction
 Emerging Infectious Diseases:

• Emerging infectious diseases are “New diseases; new problem (New

threats)”

• An emerging infectious disease is a one that is caused by a newly

discovered infectious agent
or
• by a newly identified pathogen, which has emerged and whose
incidence in humans has increased during the last 2 decades and is
threatening to increase in the near future.
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 Re-emerging Infectious Diseases:

• Re-emerging infectious diseases are “old diseases, new problem.

(New threats)”.

• A re-emerging infectious disease is a one which was previously

controlled but once again has risen to be a significant health problem.

• This term also refers to that disease which was formerly confined to
one geographic area, has now spread to other areas.

3
Factors contributing to the emergence of infectious
diseases:
1. Human demographics and behaviour 8. Climate and weather
2. Technology and industry 9. Changing ecosystems
3. Economic development and land use 10. Poverty and social inequality
4. International travel and commerce 11. War and famine
5. Microbial adaptation and change 12. Lack of political will
6. Breakdown of public health measures 13. Intent to harm
7. Human susceptibility to infection

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Factors contributing to the emergence

 AGENT:

• Evolution of pathogenic infectious agents (microbial adaptation & change)

• Development of resistance to drugs: Wrong prescribing practices
Non-adherence by patients
Counterfeit drugs
Use of anti-infective drugs in animals & plants
• Resistance of vectors to pesticides

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HOST:
• Human demographic change (inhabiting new areas)

• Human behaviour: 1. Unsafe sexual practices (HIV, Gonorrhoea, Syphilis)

2. Changes in agricultural & food production patterns- food-

borne infectious agents (E. coli)

3. Increased international travel (Influenza)

• Human susceptibility to infection (Immunosuppression)

• Poverty & social inequality

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ENVIRONMENT:
• Climate & changing ecosystems:
Deforestation forces animals into closer human contact- increased possibility for
agents to breach species barrier between animals & humans
EL Nino- Triggers natural disasters & related outbreaks of infectious diseases
(Malaria, Cholera)
Global warming- spread of Malaria, Dengue, Leishmaniasis, Filariasis
• Economic development & Land use (urbanization, deforestation)
• Technology & industry (food processing & handling)
• International travel & commerce
• Deterioration in surveillance systems (lack of political will) 7
• Breakdown of public health measure (war, unrest, overcrowding):

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

• Uncontrolled Urbanization & Population Displacement:

Growth of densely populated cities- substandard housing, unsafe water, poor

sanitation, overcrowding, indoor air pollution (>10% preventable ill health)

Problem of refugees & displaced persons

Diarrhoeal & Intestinal parasitic diseases, ARI 8

 Examples:

9
Source: NATURE; Vol 430; www.nature.com/nature
 Examples of Emerging Infectious Diseases
• 1993: Hantavirus pulmonary syndrome (United States)
• 1994: Plague (India)
• 1995: Ebola fever (Democratic Republic of Congo)
• 1996: New variant Creutzfeldt-Jakob disease (United Kingdom)
• 1997: H5N1 influenza (Hong Kong);
• 1998: Nipah virus encephalitis (Malaysia, Singapore)
• 1999: West Nile virus encephalitis (Russia, United States)
• 2000: Rift Valley fever (Kenya, Saudi Arabia, Yemen); Ebola fever(Uganda)
• 2001: Anthrax (United States); foot-and-mouth disease(United Kingdom)
• 2002: Vancomycin-resistant Staphylococcus aureus (United States)
• 2003: Severe acute respiratory syndrome (SARS) (multiple countries); monkeypox (USA)
• 2004: H5N1 influenza (Southeast Asia) 10
 Examples of Emerging Infectious Diseases
• Hepatitis C- First identified in 1989
In mid 1990s estimated global prevalence 3%
• Hepatitis B- Identified several decades earlier
Upward trend in all countries
Prevalence >90% in high-risk population
• Zoonoses- 1,415 microbes are infectious for human
Of these, 868 (61%) considered zoonotic
70% of newly recognized pathogens are zoonoses
Emerging Influenza infections in Humans associated with Chickens, Pigs
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 Emerging Zoonoses: Human-animal interface

Avian influenza virus Bats: Nipah virus Ebola virus Marburg virus

Borrelia burgdorferi Deer tick Mostomys rodent: Lassa fever Hantavirus Pulmonary Syndrome
(Lyme disease) (Ixodes scapularis)

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 SARS
 The First Emerging Infectious Disease Of The 21st Century
 No infectious disease has spread so fast and far as SARS did in 2003
SARS Cases Total: 8,439 cases, 812 deaths,
19 February to 5 July 2003 30 countries in 7-8 months

Europe: Russian Fed. (1)

Canada (243) 10 countries (38)
Mongolia (9)
Korea Rep. (3)
USA (72) China (5326)
Macao (1)
Kuwait (1)
Hong Kong (1755) Taiwan (698)
India (3)
Colombia (1) Viet Nam (63) Malaysia (5)
Indonesia (2)
Singapore (206)
Brazil (3) Philippines (14)

Thailand (9)
South Africa (1)
(
Australia (5)
New Zealand (1)

Source: www.who.int.csr/sars 13
 Lesson learnt from SARS
• An infectious disease in one country is a threat to all
• Important role of air travel in international spread
• Tremendous negative economic impact on trade, travel and tourism, estimated loss
of $ 30 to $150 billion
• High level commitment is crucial for rapid containment
• WHO can play a critical role in catalyzing international cooperation and support
• Global partnerships & rapid sharing of data/information enhances preparedness and
response

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 Swine Flu (H1N1)
• Swine flu causes respiratory disease – high level of illness, low death rates
• Causative agent- Influenza A- RNA viruses of the family Orthomyxoviridae
• RNA virus- highly mutagenic
• Pigs can get infected by human, avian and swine influenza virus
• Pandemic outbreak since April 2009
• April 15th 2009 CDC identifies H1N1 (swine flu)
• April 25th 2009 WHO declares public health emergency
• By May 5th 2009 more than 1000 cases confirmed in 21 countries
• May 16th 2009India reports first confirmed case
• Cases of swine flu have been reported in India, with over 31,156 positive test
cases and 1,841 deaths up to March 2015
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16
17
 Highly Pathogenic Avian Influenza (H5N1)

• Since Nov 2003, avian influenza H5N1 in birds affected 60 countries across Asia,
Europe, Middle-East & Africa

• >220 million birds killed by this virus or culled to prevent further spread

• Majority of human H5N1 infection due to direct contact with birds infected with
virus

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19
 Emerging Food borne
&
water borne disease
• Accounts for 20 million cases in the world annually (T.D. Chugh-2008)

• Incidence is increasing

• Half of all known food borne pathogens discovered during the past 25 years

• Most common associated organisms are: Entero hemorrhagic Escherichia coli, Vibrio

cholerae, Campylobacter sp.

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 Ebola
• Ebola was first discovered in 1976 near the Ebola River. Since then, outbreaks have
appeared sporadically in Africa.

• Ebola Hemorrhagic Fever Outbreak:

• 2000-2001: Uganda

• 2002-2003: Gabon and Democratic Republic of the Congo (DRC)

• 2004: South Sudan

• 2007: DRC, Uganda.

• 2011-2012: Uganda, DRC

• 2014-2016: West Africa 21

 Zika
• Zika virus was first discovered in a monkey in the Zika Forest of Uganda in 1947.
• In 1952, the first human cases of Zika were detected and since then, outbreaks of Zika
have been reported in tropical Africa, Southeast Asia, and the Pacific Islands.
• Before 2007, at least 14 human cases of Zika had been documented, although other
cases were likely to have occurred and were not reported.
• The first travel notice for Zika in Brazil was posted in June 2015.
• On January 22, 2016, CDC activated its Emergency Operations Center (EOC) to
respond to outbreaks of Zika occurring in the Americas and increased reports of birth
defects and Guillain-Barré syndrome in areas affected by Zika. On February 8, 2016,
CDC elevated its EOC activation to a Level 1, the highest level.

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 Zika
• Since 2015, 69 countries and territories reported evidence of vector-borne Zika
virus transmission.
• Brazil is by far the most affected country, reporting the most cases of people
infected with the Zika virus. As of September 2016, some 1,949 confirmed cases
of Zika-related microcephaly in newborns were reported.
• In the U.S., there were over 3,000 Zika virus infections reported up to September
2016.
• On 18th Nov 2016, WHO commits to sustained and robust long-term response to
Zika as ‘public health emergency’ is lifted.

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 Malaysian Nipah virus epidemic 1998-1999
• An outbreak of Nipah virus in Malaysia and Singapore

• Nipah virus belongs to family Paramyxoviridae

• Virus aerosolisation caused infection of pigs

• Overcrowding results in viral transmission to pig handlers

• The virus persists in low numbers in the island flying fox (Pteropus hypomelanus), a type
of fruit bat and Malayan flying fox (Pteropus vampyrus)

• Of the 269 human cases of viral encephalitis associated with Nipah virus infection
reported in Malaysia in 1999, 108 were fatal (Ministry of Health Malaysia, 2001).
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 Examples of Re-Emerging Infectious
Diseases
• Diphtheria- Early 1990s epidemic in Eastern Europe(1980- 1% cases; 1994- 90%
cases)

• Cholera- 100% increase worldwide in 1998 (new strain eltor, 0139)

• Human Plague- India (1994) after 15-30 years absence.

• Dengue/ DHF- Over past 40 years, 20-fold increase to nearly 0.5 million (between
1990-98)

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Disease Year State
Plague 1994 Gujrat
2002 H.P.
2004 Uttranchal
Leptospirosis 1988-2004 Andaman & Nicobar
1994-2004 Gujrat
1984-1986 Tamil Nadu
1999-2003 Kerala
2000-2002 Maharastra

Anthrax 1999 Karnataka

2000 WB
2001 Karnataka
2003 Orissa
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Dengue/DHF 1996 Delhi
2003 Delhi & Kerala
2004 Kerala, Sikkim
Scrub typhus 2003 H.P
2004 Darjeeling, Sikkim

JE Yearly U.P, A.P,Haryana

Unknown acute viral 2001 Siliguri

encephalitis 2002 Saharanpur,A.P
2003 Karnal, Maharastra

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Antibiotic resistance
• Emerge in environment due to inappropriate use of antibiotic

• WHO estimates that 10 million people are dying of infectious diseases related to
antibiotic resistance.

• Proper antibiotic guidelines needed to prevent the drug resistance.

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Multi-resistant pathogens
Staphylococcus aureus is the most frequently identified drug-resistant pathogen.

Singhal et al (2007)reported ciprofloxacin-resistant meningococci in an outbreak

in Delhi.

Resistance of Salmonella typhi and S. paratyphi to chloramphenicol, ampicillin

and cotrimoxazole is widespread.

 AMR in Shigella: resistance to azithromycin, ceftriaxone and ciprofloxacin on

the increase

Methicillin/oxacillin-resistant Staphylococcus aureus (MRSA)

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Vancomycin-resistant enterococci (VRE);

Extended-spectrum beta-lactamases (which are resistant to cephalosporins &

monobactams) (ESBLs);

Penicillin-resistant Streptococcus pneumoniae (PRSP);

Multi-drug resistant tuberculosis (MDR-TB);

CRKP- Carbapenem Resistant Klebsiella Pneumoniae

S. typhimurium - DT104 (resistant to five antibiotics: ampicillin, chloramphenicol,

streptomycin, sufonamides and tetracycline)

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 Bioterrorism
• Possible deliberate release of infectious agents by dissident individuals or terrorist groups

• Biological agents are attractive instruments of terror- easy to produce, mass casualties,

difficult to detect, widespread panic & civil disruption

• Highest potential- B. anthracis, C. botulinum toxin, Y. pestis, Variola virus, Viral

haemorrhagic fever viruses

• Likeliest route- aerosol dissemination

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Control of Emerging and Re-emerging Diseases
• Controlling the reservoir

• Interrupting the transmission

• Protecting the susceptible host

• Strengthening of the disease surveillance system

• Encouraging research initiations for treatment regimens and diagnostics

• Encouraging research for new methods of control measures

• Establishment of drug resistance

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 Role of Doctors in Prevention
Increase knowledge and skill ; Educate the public

Encourage partnerships with consumers and other disciplines to identify needs, set
priorities, develop strategies and evaluate progress

Support health care legislation

Involve in research

Encourage using multidisciplinary efforts.

Influence local and National economic and political options

Continue to advance nursing concern

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 Role of Public Health Authorities
National programme for prevention and control of vector borne diseases

Legislations for elimination

Communities awareness of the disease

Minimizing transmission of infection: By

• Risk communication to the family members

• Minimizing vector population

• Minimizing vector – individual contact

Reporting to the nearest public health authority

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Public health measures to prevent infectious
diseases
Safe water

Sewage treatment and disposal

Food safety programme

Animal control programme

Vaccination programme

Public health organization

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 Response of the WHO
• Developing global and regional strategies

• Appointing Task Force

• Generous grant from WHO regular budget

• Support the World Bank grant

• GOARN (Global Outbreak Alert & Response Network)

• Mechanism for combating international disease outbreaks

• Ensure rapid deployment of technical assistance, contribute to long-term epidemic preparedness &
capacity building
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 PREVENTIVE STRATEGY IN INDIA

VECTOR SURVEILLANCE

o Vector borne epidemic prone diseases: JE, Dengue, Plague, Kala Azar, Rickettsial

o Early warning signals

- increase density of vectors
- increase in breeding sites for vectors
o Insecticide susceptibility status

o To assess impact of routine measures under national programme

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LAB SURVEILLANCE

Serological Surveillance

To collect baseline prevalence data

To identify high risk areas
To identify high risk age group
As early warning signal for impending outbreak

Microbial surveillance

Changing genotype
Mutations
Development of Antimicrobial Resistance
Eg. Salmonella, Cholera, Plague, Anthrax
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Laboratories network in surveillance
 International (Collaborating Centres)
like CDC Atlanta

 National Reference Laboratories e.g.

NICD Delhi, NIV Pune, NICED National Laboratories
Kolkata

 State laboratories State Laboratories

 Intermediate
(District/Provincial/Medical College) District Laboratories

 Peripheral (PHC/CHC) Peripheral Laboratories

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 Peripheral Disease
laboratories Surveillance unit

District laboratories Disease

ACTION
Surveillance unit

State Disease
laboratories Surveillance unit

National laboratory Disease

Surveillance unit

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Peripheral Laboratories: Functions
• Collection of specimen
• Preliminary Processing Storage and transport
• Reporting of results
• Undertaking simple tests
• Microscopy for malaria, TB, meningitis, dysentery/Cholera
• Rapid Tests (Typhi Dot for enteric fever, Latex test for HBsAg
• Water Quality Monitoring by rapid H2S Test

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District Laboratories: Functions
• Microscopy for diphtheria, kala azar, Cholera

• Bacterial Cultures for enteropathogens, Enteric fever

• Antimicrobial Susceptibility testing

• Serological tests: Widal test, Latex test for meningitis in CSF, ELISA based test

• Bacteriological examination of water (rapid H2S, coliform count)

• Coordinate with state/ national laboratory and disease surveillance units

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State Laboratories: Functions
• All that is done at district lab+ Specialized microscopy like dark ground,
fluorescent microscopy

• Culture of all common bacteria including mycobacteria and their identification (&
serotype, wherever applicable)

• Antimicrobial susceptibility testing of common bacteria including mycobacteria

• Serology for viral hepatitis markers, dengue, JE, measles, leptospirosis etc.

• ?Viral cultures

• Quality Assurance (IQC & EQAS)

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National Laboratories: Functions
• Specialized tests eg for Plague, Anthrax and other possible agents of bioterrorism

• High Containment laboratory (P3/ BSL--3)

• Assist in outbreak investigation

• Confirm new isolates

• All types of Lab based epidemiological markers

• Training/Preparation of Teaching Material and reagents/antisera etc

• Organize external quality assessment schemes

• Collation of national data

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Laboratory diagnosis of the emerging / re-emerging
infections
 Importance of laboratory diagnosis

• The results will alter clinical or infection control management, or as needed for public
health surveillance purposes.
• For infectious diseases, modern serological techniques, more and more based on
recombinant antigens, are being proven to be specific, rapid and less labor intensive.
• PCR may prove very useful and rapid test.
• Conventional methods turned out to be either too insensitive (e.g., during the
asymptomatic stage of HIV infection), too slow (e.g., mycobacterial culture) or too
cumbersome to be used on a large scale (e.g., virus isolation).
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 Recommended laboratory testing in emerging infections
• Molecular testing- PCR- highly sensitive and specific
• Rapid test – for flu- need to confirm with PCR
• Dengue-NS1 antigen (indicated for case < 5 days)
• Antimicrobial resistance-susceptibility testing , gene detection by PCR

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Key Tasks in Dealing with Emerging Diseases
• Surveillance at national, regional, global level
• epidemiological,

• laboratory

• ecological

• anthropological

• Investigation and early control measures

• Implement prevention measures

• behavioural, political, environmental

• Monitoring, evaluation 48
 Solutions
• Strengthen international surveillance networks to issue early warning, detect, control, and
reduce emerging infectious diseases.

• Improve international public health infrastructure e.g. special laboratory that capable of
accurate and rapid diagnosis.

• Improve international capabilities to respond to disease outbreaks with adequate medical

and veterinary resources and expertise.

• Strengthen international research efforts on emerging infectious diseases, giving priority

to antibiotic-resistant strains of diseases.
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 Solutions (cont.)
• Focus attention and resources on training and developing medical and veterinary
capability.

• Encourage national governments to improve their public health care systems, devote
resources to eliminating or controlling causes of emerging infectious diseases and
coordinate public health activities with WHO and other international communities.

• Develop better international standards, guidelines and recommendations.

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 Solutions (cont.)
Factors affecting emerging Solution
infections
Migration Proper health screening, vaccination

Travel Immunization, infection control measure

Urbanization Proper sanitation, adequate housing, good infrastructure

Human behaviour Education, behaviour modification

Antibiotic usage Judicious use of antibiotic

Correct antibiotic for correct pathogen (with right
dosage and route).
Strengthen infection control measures 51
 Solutions (cont.)
 Public health surveillance & response systems
• Rapidly detect unusual, unexpected, unexplained disease patterns
• Track & exchange information in real time
• Response effort that can quickly become global
• Contain transmission swiftly & decisively

 Internet-based information technologies

• Improve disease reporting
• Facilitate emergency communications
• Dissemination of information
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 Solutions (cont.)
Human Genome Project
• Role of human genetics in disease susceptibility, progression & host response
• Microbial genetics

 Methods for disease detection, control & prevention

• Improved diagnostic techniques & new vaccines
• Geographic Imaging Systems

 Monitor environmental changes that influence disease emergence &

transmission
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Key tasks - carried out by whom?

Global
Regional
Synergy

National
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 What skills are needed?

Public
Infectious Health
Telecom. &
diseases
Informatics

International Laboratory
Epidemio- field
Information
logy experience
management

Multiple expertise needed !

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 Conclusion
• The true prevalence of many diseases is not known. Since we live in a global village,
we cannot afford to be complacent about the tremendous economic, social and
public health burden of these diseases. Effective surveillance is the key to their early
containment.

• There is a need to develop epidemiology improved diagnostic facilities, a strong

public health structure, effective risk communication, epidemic preparedness and
rapid response.

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 References:
• Public Health and Preventive Medicine. MAXY-ROSENMAN-LAST, 15th edition.
• Oxford textbook of Public Health 6th edition.
• Park text Book of Preventive & Social Medicine. 23rd edition
• EMERGING INFECTIOUS DISEASES IN SEAR. WHO1998.
• WHO GLOBAL STRATEGY FOR CONTAINMENT OF ANTIMICROBIAL RESISTANCE.
Executive summary.2001.
• CDC website: https://www.cdc.gov/vhf/ebola/about.html
• Preventing Emerging Infectious Diseases: A Strategy for the 21st Century. Overview of the Updated
CDC Plan
• Review of the emerging infectious disease problem And strengthening of epidemiological surveillance.
Forty fourth meeting of the regional director within WHO representative, New Delhi, 1995.
• Forty-fifth Meeting of the Regional Director with the WHO Representatives, New Delhi 4 to 13
November 1996 SEA/WR45/5. Emerging and re-emerging diseases, including tuberculosis and
malaria.

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 Take Home Massage
• Community health is the pivot of Global health.
Let us join our hands on creating an awareness to
the individual family and community through
effective risk communication.

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59
Emerging Infectious Diseases: A
Research Approach

60
Benefits of Research on Emerging
Diseases

61
 ENVIRONMENT

Climate change Mega-cities

Vector
Pollution Migration
proliferation
Exploitation
Population
Antibiotics HUMAN Growth
Vector
resistance

Food
production
ANIMALS VECTORS

Intensive farming

Transmission
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Entero hemorrhagic Escherichia coli
• Causes no signs of illness

• Low infections dose in humans causes hemorrhagic colitis and hemolytic uremic
syndrome

• Consumption of undercooked beef and contaminated vegetables, fruits and water

for vegetarians.

• Reported in 1.4% of stools from cases of bloody diarrhea in Kolkata (Ministry of

Health and Welfare 2006).

63
Disadvantages of PCR:

• Expensive-need special rooms, expensive reagent

• proper packaging of sample to prevent leaking, risk of contamination
• Immediate transportation as the microorganism eg RNA virus is labile
• Need experience and well trained staff

64
Vibrio cholerae
• Cholera is one of the oldest recorded infectious diseases.

• Pacini in 1854, first described comma shaped bacteria

• Robert Koch in 1883, showed the causative agent V .Cholerae.

• Das and Gupta -2005 reported the diversity of V .Cholerae.

• Narang et al (2008) described the changing patterns of V .Cholerae.

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Campylobacter spp

• Are significant zoonotic poultry pathogens

• Leading cause of gastro enteritis in the world

• Around 2.5 million human infections are reported annually in the

United States.

• In developing countries the presence of the organism was reported in

5-20% in childhood diarrhea

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 Trends in Malaria in SEA Region,
1976-2002

8000000 50.0

45.0
7000000
40.0
6000000
35.0

Pf Percentage
5000000
30.0
Cases

4000000 25.0

20.0
3000000
15.0
2000000
10.0
1000000
5.0

0 0.0

*
76

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90

92

94

96

98

00

02
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19

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20

20
Year
Total Malaria Cases Pf %

67
 P.falciparum Resistance to
Antimalarials in WHO SEA Region, 2002
P. falciparum Resistance to Antimalarials in
WHO SEA Region, 1999

DPR K orea

N epal Bhutan
#

Myanmar

India

T hailand
Banglades h
#

Antimalarials
CQ
CQ +S P
#
CQ +S P +M EF
Sri Lank a
#

Maldives
#
I ndonesia

W E

East Tim or
68