01 Emerging Warmadewa

8/11/2019 01 Emerging Warmadewa

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Emerging and Re-emergingInfectious Diseases

Tuti Parwati Merati

Division of Tropical and Infectious Disease

Department of Internal Medicine

Faculty of Medicine Udayana Univ/SanglahHospital Denpasar - Bali


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DEFINITION

EMERGING INFECTIOUS DIS.:

INCREASING INCIDENCE OR

GEOGRAPHIC DISTRIBUTION RECOGNITION BECAUSE THE DISEASE:

PRESENT IN POPULATION FOR THE FIRSTTIME,

HAS BEEN DETECTED FOR THE FIRST TIME,

OR BECAUSE LINKS BETWEEN ANINFECTIOUS AGENT AND A CHRONIC DIS.

OR A SYNDROME HAVE ONLY RECENTLYBEEN IDENTIFIED


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Definition

New/emerging infections or drugresistant infections whose incidence in

humans has increased within the pasttwo decades or whose incidencethreatens to increase in the near

future Re-emerging infectious diseases :

eg.Tb in developed countries


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Re Emerging Viral Infections

Polio-virus (under control) Chikungunya-virus (still raging mainly in Java)

Avian Influenza virus (hot spots)

Hand Foot Mouth Disease (Kalimantan)

Japanese B Encephalitis Virus (Bali)

Rabies (Bali)

New H1N1 InfluenzaVirus

New Clinical Presentations of VI Dengue Renal Failure

Dengue Retinal Hemorrhage

HIV Reconstitution Syndrome


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TIME TREND (1)

Poor sanitary conditions , water supply,vaccines, AB in the first half of 20th century in USA better

hygiene and water qualityimproved the healthof general population; Medical care and vaccineslowered the rate of ID

After World War II : antibiotics become

available first time HCW can treat majorinfections. New Vaccines available preventand controlled severe infection eg. Polio andmeasles


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TIME TREND(2)

SOME KNOWN DISEASES PERSIST

SOME NEW MICROBES EMERGED

MANY OF ID FIRST RECOGNIZE ONLY IN THE LAST HALF OF

20THCENTURY IN EARLY 1950sPENICILLIN RESISTANCE

IN 1957 AND 1968 NEW STRAINS OF Influenza SPREADRAPIDLY AROUND THE WORLD, ALTHOUGH LESS SEVERETHAN THE 1918 FLU STRAIN RESULTED EXCESS DEATH

IN 1970sLEGIONNAIRES DIS AND LYME Dis. (USA)

IN 1980s HIV APPEARED, AND TB increased in USA

IN 1990s Gonorrhea Resistant and Hanta virus emerged

IN 2000 : SARS, PANDEMIC INFLUENZA (BIRD FLU, SWINE

FLU) AND West Nile VIRUS


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Infectious Disease Mortality in

the United States, 1980-1996

Source: JAMA 1996;275:189-193 and unpublished CDC data

0

10

20

30

40

50

60

70

80

Year

Deat

hsper100,0

00population

C

rudeID

MortalityRate

CDC


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Factors Contributing to Emerging

Infectious Disease (EID)

Two step process :

INTRODUCTION

TRANSMISSION

EXAMPLES :

Hantavirus Rat Mosquito-borne disMosquitos

Ebola Virus direct contact?

HIVevolved from non human primate

human

The cotton ratSigmodon hispidus


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How do infectious disease become

pandemic?

Disease spread very efficiently and quicklyInfluenza

The right strain with the right combinationof biological properties to spread well, andnovel to human pop., come at the right timein the right place

Disease not easily transmitted can becomepandemic byother means

HIV


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Major Factors Contributing to Emerging

Infection Disease (EID) : 1992

1. Human demographics and behavior

2. Technology and Industry

3. Economic development and land use

4. International travel and commerce

5. Microbial adaptation and change6. Breakdown of public health measures

Institute of Medicine Report, 1992


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More Factors Contributing to Emerging

Infections Disease (EID) : 2003

7. Human vulnerability

8. Climate and weather

9. Changing ecosystems10. Poverty and social inequality

11. War and famine

12. Lack of political will

Institute of Medicine Report, 2003


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EID:Human Demographics, Behavior, Vulnerability

More people, more crowding

Changing sexual behavior (HIV, STDs)

Injection drug use (HIV, Hepatitis C) Changing eating habits: out more, more

produce (food borne infections)

More populations with weakened immune

system: elderly, HIV/AIDS, cancer patients

and survivors, persons taking antibiotics and

other drugs


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EID:

Technology and Industry

Mass food production (Campylobacter,E.coli O157:H7, etc)

Use of antibiotics in food animals(antibiotic-resistant bacteria)

More organ transplants and blood

transfusions (Hepatitis C, WNV,) New drugs for humans (prolonging

immuno suppression)


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EID:Economic Development, Land Use, Changing Ecosystems

Changing ecology influencingwaterborne, vectorborne diseasetransmission (e.g. dams, deforestation)

Contamination of watershed areas bycattle (Cryptosporidium)

More exposure to wild animals andvectors (Lyme disease, erhlichiosis,babesiosis, HPS,)


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Monkeypox from Prairie

Dogs


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EID:

International Travel and Commerce Persons infected with an exotic disease

anywhere in the world can be into major

US/Eur/Asia/Aus/Afr city within hours(SARS, VHF,)

Foods from other countries imported routinely

into other countries (Cyclospora,.)

Vectors hitch hiking on imported products

(Asian tiger mosquitoes on lucky

bamboos,.)


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EID:Microbial Adaptation and Change

Increased antibiotic resistance withincreased use of antibiotics in humans

and food animals (VRE, VRSA,penicillin- and macrolide-resistant Streppneumonia, multidrug-resistantSalmonella,.)

Increase virulence (Group A Strep?) Jumping species from animals to

humans (avian influenza, HIV?, SARS?)


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EID:Poverty, Social Inequality, Breakdown of Public

Health Measures

Lack of basic hygienic infrastructure

(safe water, safe foods, etc..)

Inadequate vaccinations (measles,

diphtheria)

Discontinued mosquito control efforts

(dengue, malaria)

Lack of monitoring and reporting

(SARS)


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Preventing Emerging

Infectious DiseasesSurveillance and Response : Detect, investigate,

and monitor (pathogens, disease, the factors

influencing their emergence, respond to

problems as they are identified)

Research

Infrastructure and Training

Prevention and Control

New policies to control the antibiotic resistance


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SITUASI DI INDONESIA

HIV

Dengue virus

Polio-virus (under control)

Chikungunya-virus (still raging mainly in Java - Bali)

SARS

Avian Influenza virus (hot spots)

Hand Foot Mouth Disease (Kalimantan)

Japanese B Encephalitis Virus (Bali)

Rabies virus (Java, Flores, Bali)

Flu A (H1N1)


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44.447.1

23.120.8

27.9

19.2

12.2

49

0

5

10

15

20

25

30

35

40

4550

Waria

Gatsu

Carik

P.Galak

Sanur-1

Sanur-2

Bungalow

Panti Pijat

Gay

SERO-SURVEI TAHUN 2009PADA WARIA,GAY, PS

Source : YKP , 2009


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63

71

6158

64

0

10

20

30

40

50

60

7080

2000 2003 2004 2005 2007

HIV PREVALENCE AMONG IDUs,DENPASAR, BALI

%

Source: Bali Health Department


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1.6

78.8 8.5

12.414.5 15.2

20.522.5

0.25 0.242 2

4 4.1

6.1 7.2

0

5

10

15

20

25

2000 2001 2004 2005 2006 2007 2008 2009 2010

TREND OF HIV PREVALENCE AMONGFEMALE SEX WORKERS (DENPASAR,

BALI)

DIRECT SEX

WORKERS

INDIRECT SW

Source: Bali Health Department

%


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Nelwan, 2009


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Kecendrungan Faktor Risiko KasusAIDS per Periode di Indonesia

Sumber : Laporan Triwulan Pengidap infeksi HIV dan Kasus AIDS September 2008

64.7

43.2

17.6

53.7

72.5

36.6

50.5

17.6

39.5

11.8

1.3

3.47.7

3.4

02.1

53.3

2.61.05 2.2 4.0

5.5

5.90 00

10

20

30

40

50

60

70

80

90

100

87-90 91-95 96-2000 2001- 2005 2006-skrg

Tahun

Persen

Homosex Heterosex IDU Lain-lain Tak diketahui


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CHRONOLOGY INDONESIA POLIO OUTBREAK 2005

INITIAL CASE REPORT & FOLLOW UP

19 months old toddler F experienced fever and convulsions. The family wastoo poor to take him to the doctor but when signs of increasing loss ofstrength appeared both in upper as well as lower extremities since March 13,2005 the child was brought to the local Health Center (Dr. Ana).On the 24th of March a stool sample was taken and send to the laboratorywhere isolation of poliovirus was proven positive a few weeks later.Besides this boy 6 other cases were noted with the same symptoms.The Department of Health was notified on April 22. An Outbreak ResponseImmunization was put into effect 24-28 April posters were up for call of

reporting all flaccid paralysis cases. In the stricken and nearby areasanother 8 cases turned up. Stool samples from these 14 additional casesyieded 8 positive for Polioviruses, as announced by Sukabumi Chief HealthOfficer ( Dr. Buhono T.)

Nelwan , et al. JKT , 2009


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FIRST KNOWN VICTIM ON LAP

OF MOTHER (F 19 MO)

NOTE RIGHT SIDED FLACCID PARALYSIS

IN UPPER EXTREMITY

Nelwan, etal. Jkt, 2009

POLIO , 2005


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Chikungunya


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Etiologi

Alpha virus.

60 mRNA.

Berselaput sferis.

Berkembang dalam sitoplasma.

Patogen untuk bayi hewan pengerat. Diisolasi pertama kali di Tanzania

(1952).


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Differentiated from DHF

1. No grade III or IV in chikungunya

2. More maculopapular rash in chikungunya

3. More conjunctival injection in chikungunya4. Prominent arthralgia in chikungunya

5. lymphadenopathy in chikungunya


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Chikungunya Conjunctivitis in 31 y Old Woman


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Outbreak of Chikungunya InfectionIndonesia (2006)

Malang Jan 2006 101 cases

Bandung Aug 2006 80 cases

Banyuasin July 2006 501 cases

Depok Oct 2006 90 cases


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Outbreaks of ChikungunyaInfection 2007 ( JanMar)

Kota Semarang 75 kasus

Sukoharjo 175 kasus

Wonogiri 60 kasus

Kediri 500 kasus

Karang Anyar 29 kasus

Klaten 7 kasus

Rembang 8 kasus

Bekasi 98 kasus

Provinsi Banten 130 kasus

Sum Bar 37 kasus

Kal Teng 26 kasus


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SARS


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SARS(Severe Acute Respiratory

Syndrome)


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SARS-Infectious Agent

Coronavirus is likely. Seems to be present in all tested cases.

Paramyxovirus looking less likely.

Other coronavirus strains causecommon colds. However, this new CV isboth novel and lethal.

Lab tests (under development): PCR useful in early stages.

IFA can identify in convalescent.


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15% of cases

85% of cases

Infection Settings

Hospitals

Households


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SARS

50-100-200 patients in hospital allrequiring Intensive Care, barrier

nursing, mechanical ventilation. Most of those patients are hospital

staff.

No available drug treatment. Some die.

This happened in Hong Kong.


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SARS-comments

Effective treatment not available.

Supportive treatment only.

ISOLATION.

STRICT BARRIER NURSING.

Ventilation treatment often necessary.


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SARS-Infection Control

Standard precautions, e.g. handwashing, eye protection.

Contact precautions, e.g. gown andgloves.

Airborne precaution, e.g. isolation

room, negative pressure, use of N95respirator.


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WHO : six phases of AI Infection

before it turns into a pandemic

First, AI infection of poultry with low risk ofinfection to humans;

Second, AI infection with a high risk of thevirus being transmitted to humans;

Third, AI infection of humans ;

Fourth, human-to-human transmission.

Fifth, a significant increase in transmissionfrom human to human;

Sixth, the disease has become a pandemic


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Hand, Foot and Mouth

Disease Flu Singapore Caused by : Coxackie virus A16

Enterovirus 71

Slight fever Sore throat Vesicular lession on buccal mucosa, tongue, hand

and foot

Meningitis, encephalitis, paralysis (EV71)

Since 1997 outbreaks in East Malaysia (borders

with Kalimantan RI), Singapore, Japan, WestMalaysia

Large outbreak in Taiwan 1998 (130.000 cases )

Death reported in all outbreaks


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Viral Encephalitis Japanese Encephalitis

Caused by Togaviruses

2001 : 74 cases in Bali CFR 9,4% sequelae 47,5%

Reported from tourist returning from Bali

Disebarkan oleh nyamuk, babi sebagai amplifier

Vaccine available

Nipah Viral Encephalitis Zoonotic Paramyxovirus infections

Malaysia : 105 death among 265 patients(outbreak)

Pigs eat contaminated food (bat secretion)

Human infections probably by aerosol

More than one million pigs culled to end the

outbreak


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Swine Flu New Flu H1N1

P d i f i fl


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55

Pandemics of influenza

H7H5H9*

1980

1997

Recorded new avian influenzas

1996 2002

1999

2003

1955 1965 1975 1985 1995 2005

H1N1H2N2

1889RussianinfluenzaH2N2

H2N2

1957AsianinfluenzaH2N2

H3N2

1968Hong KonginfluenzaH3N2

H3N8

1900Old Hong KonginfluenzaH3N8

1918SpanishinfluenzaH1N1

1915 1925 1955 1965 1975 1985 1995 20051895 1905 2010 2015

2009PandemicinfluenzaH1N1

Recorded human pandemic influenza(early sub-types inferred)

Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research,National Institute of Infectious Diseases (NIID), Japan. Animated slide: Press space bar

H1N1

Pandemic

H1N1

KASUS KASUS SWINE FLU DI ASEAN Plus Three


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KASUS-KASUS SWINE FLU DI ASEAN Plus Three,19 Juni 2009

Negara Jumlah Kasus

Thailand 518

Singapore 77

Brunei Darussalam 2

Malaysia ?

Filipina >300

Indonesia -

Vietnam 19

Laos 1

Jepang >>?

Korea 79

Hongkong 221

Genetic origins of the pandemic (H1N1)


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Ge et c o g s o t e pa de c ( )2009 virus: viral reassortment

PB2PB1PAHANPNAMP

NS

PB2PB1PAHANPNAMPNS

PB2PB1PAHANPNAMPNS

Classical swine, N. American lineageAvian, N. American lineageHuman seasonal H3N2Eurasian swine lineage

Eurasianswine H1N1

N. American H1N1(swine/avian/human)

Pandemic (H1N1)2009, combiningswine, avian andhuman viralcomponents


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Pencegahan (Filipina DOH) :

Tidur 8 jam sehari

Aktif secara fisik

Hilangkan stres

Minum yang banyak

Makan makanan yang bergizi

De la Paz : Poverty makes Filipinos more vulnerable to flu,

19 Juni 2009


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TRANSMISSION

Transmitted fromhuman to human

Primarily via large-

particle respiratorydroplets (coughing,sneezing)

Close contact Contact with

contaminated

surfaces


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PREVENTION

Avoid close contact

Stay home when you are sick

Cover your mouth and nose

Wash your hands

Avoid touching your eyes, nose ormouth

Practice other good health habits

Thorner AR , 2009


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Proteksi thd Flu A(H1N1)


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Morbidity and Mortality

H1N1 influenza (swine flu) tends tocause high morbidity but low mortality

rates (1%-4%).


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LEGIONNAIRES DISEASE

OUTBREAK DI PHILADELPHIA 1976

PADA ANNUAL MEETING KE 58 DARI

US LEGION LEBIH 200 KASUS DARI PESERTA YG

TINGGAL DI HOTEL YG SAMA

ETIO : LEGIONELLA PNEUMOPHILA

BAKTERI, GRAM NEGATIVE BTK ROD


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GEJALA

SEPERTI FLU : HEADACHE, BODYACHES, FEVER, WEAKNESSES,

COUGH, SPUTUM PNEUMONIA

DX : SPUTUM GRAM, CULTURE, DFA

TREATMENT : SUPPORTIVE,

SYMPTOMATIC

Penyebab belum jelas


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Penyebab belum jelasPengobatan symptomatisPerlu melindungi dg masker N95


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IMMUNOCOMPROMISED

Definition :Immune system that is unable to mount a full

response to pathogens ( viruses, fungi,bacteria), or toxins and tissue damage, i.e. HIV-infected patients

Transplant patients

Autoimmune disorder patients

Cancer patients

Special conditions : preterm infants, elderly,pregnancy-lactation, smokers

Chronic Diseases: DM, Tuberculosis, eating disorders,chronic alcoholism, etc.


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SUMMARY

Infectious diseases seemed to have controlled byantibiotics, vaccines and improved hygiene, 50years ago. But now, health experts recognize theemerged and spread of new infectious dis.

Factors contribute favors these emerging dis.:Modern demographic and environmentalconditions,The ability of microbes to evolve and adapt

amongst the development of many new AB.Poverty and inadequate access to health care


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CONCLUSION


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01 Emerging Warmadewa

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