What’s happening out there? Global Shifts in Disease Musings of Paul Van Caeseele, MD April 25,...
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Transcript of What’s happening out there? Global Shifts in Disease Musings of Paul Van Caeseele, MD April 25,...
What’s happening What’s happening out there?out there?
Global Shifts in DiseaseGlobal Shifts in Disease
Musings of Paul Van Caeseele, MDMusings of Paul Van Caeseele, MDApril 25, 2008April 25, 2008
ObjectivesObjectives
Bird’s eye view of what’s going on Select diseases emerging and
reemerging Introduction to some of the drivers
affecting disease and travel around the world
Learn something that will broaden thoughts of what travel medicine could encompass
Reemergence of Reemergence of Vaccine Preventable Vaccine Preventable Disease & Other Old Disease & Other Old
FriendsFriends In the last few years, we’ve witnessed In the last few years, we’ve witnessed
outbreaks of well-suppressed VPD’soutbreaks of well-suppressed VPD’s Diphtheria (Russia, 1993-96)Diphtheria (Russia, 1993-96) Measles Measles MumpsMumps
Resurgence of dormant diseases or Resurgence of dormant diseases or common diseases with twistscommon diseases with twists
Diphtheria, USSR, 1993-Diphtheria, USSR, 1993-9696
Huge jump in Huge jump in cases due to cases due to collapse of collapse of Soviet Soviet infrastructureinfrastructure
>130,000 >130,000 cases over 4 cases over 4 yearsyears
>4000 deaths >4000 deaths that decadethat decade
Vitek & Wharton, 1998
MeaslesMeasles WhatWhat
Sporadic measles appearing in limited outbreaksSporadic measles appearing in limited outbreaks Most begin with an importationMost begin with an importation
Ontario limited outbreakOntario limited outbreak Most propagated due to inadequate vaccine coverage, i.e Most propagated due to inadequate vaccine coverage, i.e
less than two doses MMR, killed vaccine onlyless than two doses MMR, killed vaccine only More noted in adolescent to adult age groups (atypical to More noted in adolescent to adult age groups (atypical to
historical 5-10 year age group)historical 5-10 year age group) Larger European outbreakLarger European outbreak
>250 cases associated with anthroposophic (naturalistic) >250 cases associated with anthroposophic (naturalistic) schoolsschools
““mobile communities” felt to be the sourcemobile communities” felt to be the source Mostly noted in childhood age groups due to low Mostly noted in childhood age groups due to low
vaccination ratevaccination rate So What?So What?
Measles leading cause of death due to “respiratory Measles leading cause of death due to “respiratory disease” in the third worlddisease” in the third world
AnthroposophyAnthroposophy A spiritual philosophy based on A spiritual philosophy based on
the teachings of Rudolph the teachings of Rudolph Steiner (1861-1925)Steiner (1861-1925)
Believes in the existence of an Believes in the existence of an objectively experienced objectively experienced spiritual world that can be spiritual world that can be accessed with proper inner accessed with proper inner developmentdevelopment Mysticism meets ScienceMysticism meets Science
Very active movement in many Very active movement in many areas, including schools, with areas, including schools, with >900 Steiner/Waldorf schools >900 Steiner/Waldorf schools worldwideworldwide
MumpsMumps WhatWhat
Large outbreak across Large outbreak across Canada (& others) Canada (& others)
>1200 cases in 2007, mostly >1200 cases in 2007, mostly in NS, NB, AB in NS, NB, AB
Mostly 20-29 year olds with Mostly 20-29 year olds with incomplete immunity, highly incomplete immunity, highly social and highly mobile, social and highly mobile, often non-adherentoften non-adherent
Only 8% had two doses of Only 8% had two doses of vaccinevaccine
Also in Ireland, Australia, Also in Ireland, Australia, England, USAEngland, USA
So what?So what? High incidence of orchitis High incidence of orchitis
and hearing lossand hearing loss Appreciable rate of Appreciable rate of
encephalitis and mortalityencephalitis and mortality
FlavivirusesFlaviviruses
Mosquito-borne viruses that includeMosquito-borne viruses that include West Nile VirusWest Nile Virus Yellow Fever VirusYellow Fever Virus Japanese Encephalitis VirusesJapanese Encephalitis Viruses Dengue VirusesDengue Viruses
Increasing due to increasing travel, Increasing due to increasing travel, trade, urbanization, inattention to trade, urbanization, inattention to control programscontrol programs
Dengue feverDengue fever Still a major concernStill a major concern
50-100 million infections per year50-100 million infections per year Mosquito born virus cases “break-bone fever”Mosquito born virus cases “break-bone fever”
Frequently asymptomaticFrequently asymptomatic May be complicated by diatheses, hepatitis, MTCTMay be complicated by diatheses, hepatitis, MTCT Second time around at risk for DHF – Dengue Second time around at risk for DHF – Dengue
Hemorrhagic Fever (mortality 1-50%)Hemorrhagic Fever (mortality 1-50%) Many tropical beaches at risk nowadaysMany tropical beaches at risk nowadays More frequently diagnosed than malaria in More frequently diagnosed than malaria in
travelers from South America and Asiatravelers from South America and Asia Australian travelers 10X more likely to have Australian travelers 10X more likely to have
Dengue coming from AsiaDengue coming from Asia
Peteresen & Marfin, 2005
Skin infectionsSkin infections
Remain a common problemRemain a common problem 10-23.4% of travelers return with skin 10-23.4% of travelers return with skin
problemproblem 8-18% of these are infections8-18% of these are infections11
Some specific likelihoodsSome specific likelihoods Belize – cutaneous myiasis (Belize – cutaneous myiasis (Dermatobium hominis)Dermatobium hominis) Rickettsial – South Africa & ZimbabweRickettsial – South Africa & Zimbabwe Leishmania - ColumbiaLeishmania - Columbia <18 years more likely to have CLM & dog bites<18 years more likely to have CLM & dog bites >65 more likely to have rickettsial disease or >65 more likely to have rickettsial disease or
cellulitiscellulitis2121
1. Schleucher et al, 2008
2. Lederman et al, 2008
New DangersNew Dangers
Staphylococcus aureusStaphylococcus aureus Reports of returned travelers with Reports of returned travelers with
recurrent skin infectionsrecurrent skin infections MRSA sometimes culturedMRSA sometimes cultured Panton-Valentine Leukocidin (PVL) Panton-Valentine Leukocidin (PVL)
positive strains not uncommonpositive strains not uncommon11
Cytotoxin causing tissue necrosis Cytotoxin causing tissue necrosis and WBC destructionand WBC destruction
Increasingly prevalent in CanadaIncreasingly prevalent in Canada Seen in CA-MRSA, usually native strainsSeen in CA-MRSA, usually native strains
Schleucher et al, 2008
Series #1Series #1
Following a report of imported MRSA in Following a report of imported MRSA in Ireland, Scottish group reportedIreland, Scottish group reported 14 cases of recurrent or moderately severe 14 cases of recurrent or moderately severe
cutaneous cutaneous All associated with travel, non hospital-associatedAll associated with travel, non hospital-associated Some persisted for >3 yearsSome persisted for >3 years
Noted that antibiotics commonly used in Noted that antibiotics commonly used in travel prophylaxis (or empiric treatment) travel prophylaxis (or empiric treatment) were ineffectivewere ineffective Doxycycline and ciprofloxacin resistance noted in Doxycycline and ciprofloxacin resistance noted in
somesomeHelgason et al, 2008
Series #2Series #2
German study also noted thatGerman study also noted that Panton-Valentine Leukocidin-positive Panton-Valentine Leukocidin-positive
MRSA isol.MRSA isol. Mostly imported and associated withMostly imported and associated with
Travel to MediterraneanTravel to Mediterranean Travel to Middle EastTravel to Middle East
Some also no recent travel but did have Some also no recent travel but did have family from the Mediterraneanfamily from the Mediterranean
Maier et al, 2005
MRSA ContinuedMRSA Continued
One Danish Study found evidence of One Danish Study found evidence of importation of strainsimportation of strains11
Usually skin and soft tissue infectionsUsually skin and soft tissue infections Highly associated with arrival from Balkan Highly associated with arrival from Balkan
refugee camps, travel to Mediterranean or refugee camps, travel to Mediterranean or Middle EastMiddle East
Evidence of transmission in familiesEvidence of transmission in families They were able to eradicate effectivelyThey were able to eradicate effectively
Hajj only carry MRSA 1.6% of the timeHajj only carry MRSA 1.6% of the time22
1. Larsen et al, 2008
2. Memish et al, 2006
Invasive MRSA Rates in Europe, Invasive MRSA Rates in Europe, 20042004
Bioquell, 2008
Implications: MRSAImplications: MRSA No longer just a hospital-acquired infectionNo longer just a hospital-acquired infection There may be a future for services targeted at There may be a future for services targeted at
the highest risk travelersthe highest risk travelers Athletes, especially wrestlers, football playersAthletes, especially wrestlers, football players
Early detection and segregationEarly detection and segregation General hygiene and equipment cleaningGeneral hygiene and equipment cleaning
ImmunocompromisedImmunocompromised Tropical travel would predictably be higher risk Tropical travel would predictably be higher risk
(SSTI)(SSTI) Bring empiric topical antibiotics/disinfectants for Bring empiric topical antibiotics/disinfectants for
injuries as a routine? (similar to contact lenses)injuries as a routine? (similar to contact lenses) Often routinely included in “adventure” travel first aid Often routinely included in “adventure” travel first aid
kitskitsBenjamin et al,
2007
Clostridium difficileClostridium difficile: : What now?What now?
Increasing virulence and presence locallyIncreasing virulence and presence locally One third to one half of local cases are One third to one half of local cases are
community acquired – suggests higher carriage community acquired – suggests higher carriage ratesrates
No stats on presence in returned travelers, and No stats on presence in returned travelers, and it is still a low probabilityit is still a low probability
Increasing numbers of reports of Increasing numbers of reports of C. difficileC. difficile in returned travelers with persistent in returned travelers with persistent diarrheadiarrhea Severe cases marked by loperamide and Severe cases marked by loperamide and
(multiple) courses of antibacterial use(multiple) courses of antibacterial use Colectomy reported, deaths uncommonColectomy reported, deaths uncommon
So what?So what? Tweaks to advice on management of diarrhea Tweaks to advice on management of diarrhea
may become necessarymay become necessary
Chikungunya VirusChikungunya Virus Means “that which bends up” (Makonde) Means “that which bends up” (Makonde)
or “walking hunchbacked”or “walking hunchbacked” Mosquito borne virus causing explosive Mosquito borne virus causing explosive
onset disease with fever, severe onset disease with fever, severe arthralgia, hemorrhagic disease (25%)arthralgia, hemorrhagic disease (25%)
““inactive” for 20 yearsinactive” for 20 years Prolonged joint pain isProlonged joint pain is
very commonvery common Usually self-resolvesUsually self-resolves Co-circulates with Dengue,Co-circulates with Dengue,
often under or mis-diagnosedoften under or mis-diagnosed
Chikungunya Chikungunya DistributionDistribution
The distributorThe distributor AedesAedes spp. spp. Works during the Works during the
dayday
Her sales areaHer sales area
Confirmed Sales: Confirmed Sales: RéunionRéunion
2005-2006 epidemic on the Isle of 2005-2006 epidemic on the Isle of RéunionRéunion Population 750,000, cases ~218,000 Population 750,000, cases ~218,000
(29%)(29%)
Eurosurveillance, 2006
The International The International ConcernConcern
No vaccineNo vaccine AedesAedes exists in many other areas of exists in many other areas of
the world and could gain a footholdthe world and could gain a foothold Some mortality possibleSome mortality possible
(more virulent?)(more virulent?)
Chikungunya Market Chikungunya Market CollapseCollapse
Good news: the travel advisory is over Good news: the travel advisory is over as of December 2007as of December 2007 Still a low risk and typically self-resolving Still a low risk and typically self-resolving
diseasedisease Daytime mosquito prevention works Daytime mosquito prevention works
(repellent, light coloured clothing, etc.)(repellent, light coloured clothing, etc.) Bad news: it will be backBad news: it will be back
Still going moderately strong in India, Still going moderately strong in India, Indonesia and Sri Lanka (Italy in late Indonesia and Sri Lanka (Italy in late 2007)2007)
What is a shift?What is a shift?
Most of what we have discussed could Most of what we have discussed could easily fall into predictable cyclical or easily fall into predictable cyclical or sporadic activitysporadic activity
ShiftShift A change or move (outside of the norm)A change or move (outside of the norm) A systematic change as something evolvesA systematic change as something evolves May be of different types, for exampleMay be of different types, for example
ClinicalClinical Demographic/EpidemiologicDemographic/Epidemiologic GeographicGeographic GeneticGenetic
Death rates due to VPD Death rates due to VPD in USin US
Death Rates Compared in Death Rates Compared in USUS
Ausubel et al, 2001
Travel EconomicsTravel Economics
Travel trends affected byTravel trends affected by Strength of local currency vs. costs (oil)Strength of local currency vs. costs (oil) Safety abroad (SARS, war, etc.)Safety abroad (SARS, war, etc.)
Demand for “high-risk” Demand for “high-risk” 11 or adventure travel or adventure travel DemographicsDemographics
More singles (MSM and young adults)More singles (MSM and young adults) More grandparents (some with grandchildren) More grandparents (some with grandchildren)
(denture ventures)(denture ventures) More large familiesMore large families2,32,3
““Conscious” tourismConscious” tourism Ecotourism and geotourismEcotourism and geotourism
1. Valerio et al, 2005
2. World Travel Trends Report, 2006-7
3. Statistics Canada, 1997
Economic Impacts?Economic Impacts? For us in Travel HealthFor us in Travel Health
More retirement age travel (more co-morbidity 24-More retirement age travel (more co-morbidity 24-35%)35%)
15% Thai backpackers >55y15% Thai backpackers >55y11
More immunocompromised also travel – dialysis cruises More immunocompromised also travel – dialysis cruises (2004 - >18,000), transplant patients (2004 - ~1800)(2004 - >18,000), transplant patients (2004 - ~1800) 2 2, etc., etc.
Phase advance (eastward jet lag) longer recovery timePhase advance (eastward jet lag) longer recovery time33
IM Needle length adjustments for body mass (1-1.5”) IM Needle length adjustments for body mass (1-1.5”) 11
More adventure and backcountry travel (more More adventure and backcountry travel (more exposure to harsh environments)exposure to harsh environments)
More pediatric considerations in bothMore pediatric considerations in both In generalIn general
Much more travel, much more “risky” travelMuch more travel, much more “risky” travel1. Reed, 2007
2. CIHI, 2006
3. Brendel et al, 1990
Other Hazards: Habits of Other Hazards: Habits of the Polar Fox, the Polar Fox, AlopexlagopusAlopexlagopus
Verhoeven et al, 2007
Conscious TourismConscious Tourism GeotourismGeotourism
““tourism that sustains or enhances the geographic tourism that sustains or enhances the geographic character of a place”character of a place” (environmental, cultural, (environmental, cultural, heritage and well-being) heritage and well-being) 11
EcotourismEcotourism An ecotourist is one with “ceaseless expectations for An ecotourist is one with “ceaseless expectations for
unique, authentic travel experiences that preserve unique, authentic travel experiences that preserve the ecological and cultural environment”the ecological and cultural environment”11
““Germophobic”Germophobic” One marketing study indicates an increased One marketing study indicates an increased
awareness of germs (80% are concerned, 55% wash awareness of germs (80% are concerned, 55% wash hands more, 27% bring own sheets/towels/sanitizers, hands more, 27% bring own sheets/towels/sanitizers, n=2500)n=2500)22
Movement in the industry to accommodate Movement in the industry to accommodate these travelersthese travelers
1. National Geographic Society, 2002
2. Hotel Industry News, Oct 2007
Medical TourismMedical Tourism Increasing awareness of health-driven tourismIncreasing awareness of health-driven tourism
Medical Tourism (750 K Americans/yr projected)Medical Tourism (750 K Americans/yr projected) Travel across borders to receive health careTravel across borders to receive health care Canada third largest consumer based on indirect reportsCanada third largest consumer based on indirect reports Surgical procedures (Plastic and Dental) seem to Surgical procedures (Plastic and Dental) seem to
predominatepredominate Reproductive TourismReproductive Tourism
Assisted reproduction and IVFAssisted reproduction and IVF 16% in one US Clinic were Canadian patients16% in one US Clinic were Canadian patients22
Not all countries adequately screen, and ovarian Not all countries adequately screen, and ovarian hyperstimulation can be dangerous (one fatality in Ireland)hyperstimulation can be dangerous (one fatality in Ireland)
Transplantation TourismTransplantation Tourism Foreign travel to receive transplantsForeign travel to receive transplants
1. Patel et al, 2007
2. Leigh, 2005
Companion AnimalsCompanion Animals Because pets are people tooBecause pets are people too Increasing interest in their travel-acquired Increasing interest in their travel-acquired
diseasedisease Increasingly brought on travelIncreasingly brought on travel Small animal travel increasingly importantSmall animal travel increasingly important Imported pathogens/diseases may be poorly Imported pathogens/diseases may be poorly
recognized here and pose a risk for:recognized here and pose a risk for: Autochthonous transmissionAutochthonous transmission Zoonotic transmissionZoonotic transmission
Decreasing vet skill in diagnosingDecreasing vet skill in diagnosing Reflexive antiparasitics Reflexive antiparasitics Increasingly urban practiceIncreasingly urban practice
1. Deplazes, 2006
2. Irwin, 2002
Some Veterinary Some Veterinary ExamplesExamples
Increasingly immunocompromised animalsIncreasingly immunocompromised animals Aged or on immunosuppressive therapyAged or on immunosuppressive therapy
GiardiaGiardia Affects canines as well as humansAffects canines as well as humans Gastrointestinal disease very common in canine Gastrointestinal disease very common in canine
petspets High rates of High rates of Giardia Giardia carriage, even in well-caredcarriage, even in well-cared
Heartworm (Heartworm (Dirofilaria)Dirofilaria) Travel to high-risk areas a well known riskTravel to high-risk areas a well known risk Transmitted by mosquitoes Transmitted by mosquitoes
Canine BabesiosisCanine Babesiosis Cause of refractory anemia, frequently mistaken Cause of refractory anemia, frequently mistaken
for autoimmunefor autoimmune Also Echinococcus, Brucellosis, Lyme, etc.Also Echinococcus, Brucellosis, Lyme, etc.
Way out ThereWay out There
One author suggest that One author suggest that xenotransplantation may be the xenotransplantation may be the wave of the futurewave of the future11
Animal organs in humans in foreign Animal organs in humans in foreign countriescountries
Potential for “xenoses” Potential for “xenoses”
1. Graczyk et al, 2005
Climate Change: What’s Climate Change: What’s HappeningHappening
Is it real? Is it real? Average temperatures worldwide riseAverage temperatures worldwide rise
0.6º C rise in last 100 years0.6º C rise in last 100 years Rising faster (3º C in the next 100 years)Rising faster (3º C in the next 100 years)
Average sea level risingAverage sea level rising Risen Risen >>3 inches since 19613 inches since 1961 Projected to rise another 7.1 to 23.2 Projected to rise another 7.1 to 23.2
inches by 2100inches by 210011
25% of US coastal houses and resorts are 25% of US coastal houses and resorts are anticipated to be submerged by 2060anticipated to be submerged by 206022
1. Intergovernmental Panel on Climate Change report, 2007
2. Heinz Centre for Science, Economics and Environment, 2000
Climate Change & HealthClimate Change & Health
WHO now recognizes climate change as a WHO now recognizes climate change as a danger to human healthdanger to human health Not as a sole determinant, but importantNot as a sole determinant, but important Recognizes these examplesRecognizes these examples
Hurricane Katrina, 2005Hurricane Katrina, 2005 2003 European Heat Wave (22-45 K)2003 European Heat Wave (22-45 K) Cholera in BangladeshCholera in Bangladesh Malaria in East AfricaMalaria in East Africa Droughts in numerous locationsDroughts in numerous locations
Least resourced areas will be least able to copeLeast resourced areas will be least able to cope By 2030, attributable excess risk outcomes will By 2030, attributable excess risk outcomes will
likely doublelikely double
WHO, April 2008
Natural Disasters in Canada, 1900-Natural Disasters in Canada, 1900-20022002
Etkin et al, 2004
Insect Vectors and Warmer Insect Vectors and Warmer WeatherWeather
Increase in malaria?Increase in malaria? AnophelesAnopheles do not breed or develop well below 16º do not breed or develop well below 16º
C or above 40º C (Dengue limited by winter C or above 40º C (Dengue limited by winter temperatures <10º C)temperatures <10º C)
A 3º C rise in average global temperatures (by A 3º C rise in average global temperatures (by 2100) could lead to 50-80 million more cases of 2100) could lead to 50-80 million more cases of malariamalaria11
Higher altitudes (Asia, Central Africa, Latin Higher altitudes (Asia, Central Africa, Latin America) now seeing more mosquito born disease America) now seeing more mosquito born disease due to presumed influence of warmingdue to presumed influence of warming22
Other Insect vectorsOther Insect vectors Black-legged Ticks moving north in Scandinavia, Black-legged Ticks moving north in Scandinavia,
expected to do the same in North Americaexpected to do the same in North America33
1. Martens et al, 1995
2. Epstein et al, 1998
3. Epstein, 2005
Projected Ranges of Projected Ranges of Ixodes scapularisIxodes scapularis in Canadain Canada
Ogden et al, 2005
Areas vulnerable to malaria in the Areas vulnerable to malaria in the African HighlandsAfrican Highlands
Patz & Lindsay, 1999
Probable Endemic Malaria in US Probable Endemic Malaria in US and Canada, 1882and Canada, 1882
Reiter, 2001
Hot Weather EffectsHot Weather Effects
Heat wavesHeat waves Particularly bad in urban setting (heat island)Particularly bad in urban setting (heat island) Kill or hospitalize thousandsKill or hospitalize thousands
Chicago 1995, Europe 2003Chicago 1995, Europe 2003
Other effectsOther effects Enhances smog, dust, mold and pollen Enhances smog, dust, mold and pollen
persistence (elevated COpersistence (elevated CO22 also exacerbates) also exacerbates)11
Higher rates of asthmaHigher rates of asthma More urban violenceMore urban violence22
Changes in migration of birds, bats and other Changes in migration of birds, bats and other animalsanimals
1. Epstein, 2005
2. Health Canada, Nov 2005
Water: Too much or too Water: Too much or too littlelittle
Too muchToo much Flooding and excess rain linked to (w. other factors)Flooding and excess rain linked to (w. other factors)11
Greater mosquito populations = MalariaGreater mosquito populations = Malaria More standing water = Diarrhea, cholera, schistosomiasisMore standing water = Diarrhea, cholera, schistosomiasis More rodentia = Plague, HantavirusMore rodentia = Plague, Hantavirus
Coastal risesCoastal rises 200 million at risk from coastal storms (13/20 megacities)200 million at risk from coastal storms (13/20 megacities)
Too littleToo little Drought (affects local economies and food prod.)Drought (affects local economies and food prod.) Forest fires (deforestation and smoke)Forest fires (deforestation and smoke) Water crises (violence)Water crises (violence)
>1.7 billion live in water stressed conditions>1.7 billion live in water stressed conditions Projected to rise to 5 billion by 2025Projected to rise to 5 billion by 2025
Patz and Kovnats, 2005
Peter, 2007
Implications for Us?Implications for Us? Changing trends in & geography of diseaseChanging trends in & geography of disease
Shifting malaria & vector borne disease regionsShifting malaria & vector borne disease regions Potential for many regions to be in seasonal crisesPotential for many regions to be in seasonal crises
More early warning systemsMore early warning systems El Niño and other weather pattern monitoring can be El Niño and other weather pattern monitoring can be
predictive for some regions and diseasespredictive for some regions and diseases Malaria (SA), plague, Hantavirus, (cholera), dengueMalaria (SA), plague, Hantavirus, (cholera), dengue Heat waves in Europe, AsiaHeat waves in Europe, Asia
Measures to mitigate warming (Greenhouse Measures to mitigate warming (Greenhouse gases?)gases?) Preserve forests and greeneryPreserve forests and greenery
On a more personal note…On a more personal note… Prairies and North expected to be hit hardPrairies and North expected to be hit hard No Health Plan works for all climatesNo Health Plan works for all climates
El Niño El Niño Affected Affected Weather Weather
Patterns in Patterns in Dec-Feb Dec-Feb and Jun-and Jun-
AugAug
Patz & Kovats, 2002
The Walk Away MessageThe Walk Away Message
The last century was very interestingThe last century was very interesting The next century may be even more The next century may be even more
interestinginteresting We’ll have this talk again in 100 We’ll have this talk again in 100
yearsyears
Thank youv.3