Patologie emergenti e ri-
emergenti, patologie altamente
contagiose e da bioterrorismo
Introduzione
Francesco M. Fusco
INMI “L. Spallanzani”
War and Famine,Bioterrorism threats,
possible importation of HIDs,emerging of new contagious
pathogens,pandemic threats
=Needs for an higher level of knowledge
and preparedness
Emerging Diseases: contributing
factors
• Globalization of travel;
• Human Demographics;
• Close proximity of men to animals;
• General health of a community (e.g. immunosuppressed, unvaccinated);
• Environmental changes (land use, reduction of biodiversity);
• Climate changes;
• Microbial Adaptation and Change;
• Breakdown in Public Health Infrastructure;
• Development of bioterrorist agents;
• Political and social disruption.
World P
opula
tion in b
illions
()
Days t
o C
ircum
navig
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()
the G
lobe
Year1850
0
400
350
300
250
200
150
100
50
2000
0
1900 1950
1
2
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4
5
6
Speed of Global Travel in Relation to
World Population Growth
“No city on the earth is now more than 24 hours away from any other”.Economist 2003
“Annually, the world's airlines carry a staggering total approaching some two billion passengers.
At any one moment, about half a million people world-wide are flying in commercial aircraft “ Select Committee on Science and Technology Fifth Report UK Parliament 2000
Recent events have caused policymaker to focus on public health emergencies
– 2001, September 11
– Anthrax crisis
– SARS outbreak
– Marburg contacts (massively exposed) in Italy
– Possible reemerging of Smallpox
– Human adapted Avian Flu
– Several imported VHFs in European countries
– Chikungunya in Italia
Highly Infectious Diseases: a definition
A HID:
• is transmissible from person-to-person,
• causes life-threatening illness,
• presents a serious hazard in health care
settings and in the community,
• requires specific control measures
Agents/Diseases fulfilling the
definition• Viral haemorrhagic fevers: marburgvirus, ebolavirus, Crimean Congo
haemorrhagic fever virus, Lassa virus, and South American haemorrhagic fever (Junin, Machupo, Sabia, and Guanarito) viruses;
• Multi drug- or Extensively drug- resistant M tuberculosis (MDR and XDR-TB) (known or suspected infection)
• SARS Co-V
• Emerging highly pathogenic strains of influenza virus
• Smallpox and other orthopox infections (eg monkeypox)
• Other emerging highly pathogenic, human-to-human transmitted agents, including agents of deliberate release (pneumonic plague)
Focus on Highly Infectious Diseases (HIDs):
why?
• HIDs requires specific procedures and standardized
technical features for safe management in Health Care
Settings;
• HIDs, according to international guidelines, should be
managed in High Isolation Settings according to
“Precaution Principle”;
Health Care Settings: preferential places
for disease transmission
• presence, in the same limited space, of infectious
patients and many susceptible individuals;
• frequent and close contacts among patients and Health
Care Workers (HCWs), often not protected by Personal
Protective Equipments (PPE) because of delayed
diagnosis, or not adequate perception of risk or
shortage of PPE;
• lack of isolation of infectious patients, because of
delayed diagnosis or not-existing of adequate structures.
Modalities of diseases transmission in
Health Care Setting - 1
• Contact:
– Direct: rare but very efficient (scabies, HSV, others)
– Not direct (through hands, instruments, contaminated surfaces): the most frequent (MRSA, HCV, Flu, others)
Modalities of diseases transmission in
Health Care Setting - 2
• Droplets (particles with
diameter larger than 5
μm, produced with cough
and sneeze and not
transported by air more
than 1-2 metres from
source): Bordetella
pertussis, influenza virus,
group A streptococcus,
meningococcus, SARS,
Smallpox, others
Modalities of diseases transmission in
Health Care Setting - 3
• Airborne, through droplet nuclei (particles with diameter smaller than 5 μm, produced with cough and sneeze and transported by air more than 1-2 metres from source):
– Obligate: Tuberculosis
– Preferential: measles, chickenpox
– Opportunistic (in special instances): SARS, Flu
– Rare: smallpox
Modalities of diseases transmission in
Health Care Setting - 4
• Aerosols (dispersion of particles of different dimensions, including those with diameter smaller than 5 μm):
– Are usually produced during “forced” procedures, such as cough and sneezes, but also diagnostic sputum induction, bronchoscopy, endotracheal intubation, and airway suction;
– Increase the risk of airborne transmission (i.e. for SARS)
Misure di isolamento 1996
Contatto
Droplet
Aerea
Precauzioni standard
Misure di isolamento 2006
Standard/
Respiratorie universali
Contatto
Aerea
Modalità di trasmissione: la lezione
della SARS
Contatto
Droplet
Aerea
Secrezioni respiratorie
e grandi goccioline nelle
quali il patogeno può sopravvivere
sulle superfici
Goccioline di dimensioni tali da
essere spinte oltre il metro
Si applicano contemporaneamente tutte le misure previste per l’isolamento in ospedale
usando DPI di più alta efficienza
ALTO ISOLAMENTO
in strutture con caratteristiche tecniche appropriate ad isolare i pazienti affetti da
patologie altamente contagiose
Il bioterrorismo: una amara realtà
Bioterrorism alarms
Development of bioterrorist agents:
• easy to develop (Internet, advancements in
biotechnology),
• relatively inexpensive,
• easy to deliver (Postal System, Aerosol
Dissemination)
1346 CRIMEAN PENINSULA - Tartar attack on Caffa; Plague-
bodies catapulted into the city, causing 2nd epidemic in Europe
1500s CENTRAL/ SOUTH AMERICA - Smallpox and measles accompanying Spanish
conquistadors decimate population
1700s CANADA - Smallpox used by British army in Quebec to infect continental
army
1700 TALLIN
Russian troops use smallpox-blankets attacking Swedish troops
1763 USA - British Gen. Amherst orders blankets from smallpox patients to be
given to Delaware Indians
1928 GENEVA PROTOCOL - Prohibits gas and bacteriological warfare
La realtà – Il bioterrorismo nella storia 1
1939-1945 WW II - Fears of revenges prohibit use of bio-
chemical weapons but not development: experimental infections
of Prisoner of War in Germany and Japan
1950 - US accused of germ use in Korean War
1984 WACO-OREGON, US - Cult followers sprinkle Salmonella on salad bars to
prevent election. 750 cases of food poisoning, 45 required hospitalization
1995 TOKIO, JAPAN
Release of Sarin gas in subway by Aum Shinrikyo cult
12 fatalities commuters, thousands injured
1993 – 1995 The cult insufficiently sprayed botulinum toxin and anthrax
2001, US - Anthrax spores in US mail
22 people infected, five fatalities of pulmonary course
La realtà – Il bioterrorismo nella storia 2
CATEGORY A – DEFINITION
Easily disseminated/ transmitted from person to person
High mortality rates
Have potential for major public health impact
Might cause public panic and social disruption
Require special action for public health preparedness
La classificazione per gli agenti di bioterrorismo
CATEGORY A – LIST OF AGENTS
BACTERIA 1. Anthrax (Bacillus anthracis)
2. Plague (Yersinia pestis)
4. Tularemia (Francisella tularensis)
VIRUSES 5. Smallpox (variola major)
6. Viral hemorrhagic fevers
[Filo- and Arenaviruses]
TOXINES 7. Botulism (Clostridium botulinum toxin)
CATEGORY B – DEFINITION
Moderately easy to disseminate
Result in moderate morbidity rates and low mortality
rates
Require specific enhancements diagnostic capacity
and disease surveillance
CATEGORY B– LIST OF AGENTS
BACTERIA 1. Brucellosis (Brucella species)
2. Glanders (Burkholderia mallei)
3. Melioidosis (Burkholderia pseudomallei)
4. Psittacosis (Chlamydia psittaci)
5. Q fever (Coxiella burnetii)
6. Typhus fever (Rickettsia prowazekii)
VIRUSES 7. Viral equine encephalitis (Alphaviruses)
Quindi, di cosa parleremo? - 1
Patologie altamente contagiose:
•Tubercolosi MDR ed XDR;
• SARS;
• Monkeypox e vaiolo;
• Febbri emorragiche;
Altre patologie emergenti e ri-emergenti:
• Chikungunya;
• West Nile Virus.
Focus su:
• Influenza stagionale, aviaria e pandemica (così facciamo
un po’ di chiarezza…).
Quindi, di cosa parleremo? - 2
Patologie da bioterrorismo non precedentemente trattate:
• Antrace;
• Peste;
• Tularemia;
• Botulismo;
Altro:
• La risposta del sistema sanitario a queste patologie;
• Effetti psicologici del bioterrorismo e delle patologiealtamente contagiose;
• Presentazione del modello di risposta presso l’INMI “L.Spallanzani”.
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