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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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57
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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