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'Emerging Infectious Diseases'

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  • Three influenza pandemics have occurred in the 20th century. The “Spanish” flu of 1918-19 killed over 40 million people worldwide. Some virologists refer to this as “Swine” flu. The population of young healthy adults was particularly affected: one of every 100 persons aged 20-39 years died of influenza-related causes. Some historians believe that World War I ended in part because of this pandemic. The “Asian” flu occurred with the transmission into humans of the avian influenza virus type A (H2N2), causing over 1 million deaths in 1957-58 worldwide. The H2N2 virus no longer circulates in humans. The most recent pandemic was the “Hong Kong” flu (H3N2) which occurred in 1968-69 and killed approximately 1 million people worldwide. The 1976 pandemic originated in China and spread round the globe in under a year. Infection was mainly limited to young persons because many older people had antibodies acquired from childhood infection with related strains. Slide 9
  • First case linked to second wave of SARS was 96 yo on an ortho ward – admitted March 22 – onset of illness April 2 Link through patient transfer to rehab hospital 67/74 cases of SARS from april 15 to June 9 resulted directly from exposure in the index hospital
  • Two phases of the outbreak in Taiwan: March 7 to April 18 and after April20. First phase was travel related – first recogized case was a 54 yo businessman who returned from guangdong province by way of hong kong – he became symptomatic Feb 25 About 80% of cases in first wave were travel related. In second wave – 90% cases were hospital acquired Index hospital, spread was related to a laundry worker – seen in the ER from april 12, 14, 15 - interacted with staff, other patients, and vistors – off duty would socialize in the ED – diarrhea, fever, then respitatory symptoms – intubated April 22. -
  • Green dots on this slide represent the locations of WNV infected mosquito pools, the majority of which were culex species. Although no human cases were documented in NJ, positive mosquitoes pools were identified. Northern Queens had the highest concentration of infected mosquitoes.
  • Transcript

    • 1. EMERGING INFECTIOUS DISEASES Mark Loeb, MD, MSc, FRCPC
    • 2. Case Report
      • 11 year old girl in Thailand, lived with aunt
      • Fever, cough, sore throat
      • Admitted to hospital, Temp > 38.5, dyspnea
      • Progressive respiratory distress, hypoxemia, shock
      • Thrombocytopenia, lyphphopenia
      • Sent to provincial hospital next day
    • 3.  
    • 4.  
    • 5. H5N1 Pandemic ?
    • 6. Influenza
      • Single-stranded RNA virus
      • Family Orthomyxoviridae
      • 3 types: A, B, C
      • 8 viral RNA segments
      • Subtypes of type A determined by hemagglutinin and neuraminidase
      Cox RJ. Scandinavian J Immunology 2004; 59:1-15
    • 7.
      • Influenza Virus
      A/Fujian/411/2002 (H3N2) Neuraminidase Hemagglutinin Type of nuclear material Virus type Geographic origin Strain number Year of isolation Virus subtype
    • 8. Cellular Pathogenesis Flint et al . Principles of Virology: Molecular Biology, Pathogenesis, and Control .
    • 9. Natural History of Clinical Influenza Runny Nose Sore Throat Myalgia Headache Cough Anorexia Malaise Symptoms: 0 1 2 3 4 5 6 7 8 Days after Onset 38.5 37.5 36.5 Oral Temperature 0 C Onset of Illness
    • 10. Complications of influenza
      • Febrile convulsions, otitis media, croup, bronchiolitis, Reye’s syndrome
      • Bronchitis, pneumonia, bacterial pneumonia
      • Exacerbations of asthma, COPD
      • MI, CHF, sudden death
      • Myocarditis, encephalitis
    • 11. Transmission
      • Evidence base from human innoculation studies and limited observational studies
      • Most support for respiratory droplet spread (eg coughing, sneezing)
      • Human infectious dose 10-100X lower with inhalation small droplets versus nasal drops
      Moser M et al. Am J Epidemiol 1979;110:1-6 Salgado et al. Lancet Infect Dis 2002; 2:145-55
    • 12. An outbreak of influenza aboard a commercial airliner Moser et al. Am J Epidemiol 1979; 110:1 6.
    • 13. Influenza A Subtypes Nicholson et al, Lancet 2003; 362:1733-1745
    • 14. Antigenic drift versus shift
    • 15. 1918 Pandemic Palese P. Nature Medicine 2004;10: S82-S87
    • 16. Mortality during 1918 Pandemic Palese P. Nature Medicine 2004;10: S82-S87
    • 17. Recent Influenza Pandemics
      • Pandemics/ Distribution Influenza A Estimated
      • large epidemics subtype mortality
      • 1889–1890 Worldwide ? Unreported
      • (first documented
      • pandemic)
      • 1918 "Spanish" flu Worldwide H1N1 40–50 million
      • 1957 "Asian" flu Worldwide H2N2 1 million
      • 1968 Hong Kong H3N2 1 million
      • "Hong Kong" flu
      • 1976 "Swine" flu New Jersey, USA H1N1 Unreported
    • 18.  
    • 19. Emergence of New Subtypes in Humans
      • Influenza A/Hong Kong/99 ( H9N2 )
      • - 11 human isolates 1998 -1999 Guandong
      • - mild, self-limited illness
      • H1N2
      • - flu-like illness
      • - isolated from patients in UK, middle east
      • -reassortment H1N1 and H3N2
      • - previously identified China 88-89
      • H7N7
      • - 1980, 1996 – purulent conjunctivitis spread from harbour seals in Cape Code, duck in UK
      • -2003 – outbreak poultry farm Netherlands
      • - 82 cases, 1 death
    • 20. Influenza A H5N1
      • 1997 - 18 cases H5N1 Hong Kong (6 deaths)
      • - 1.5 million chickens culled
      • 2001/2002 – re-emerged – no human cases
      • 2003 – 2 cases in family from Hong Kong
      • 2003/2004 - Japan, Viet Nam, South Korea, Cambodia, Indonesia, Laos, Thailand, China
      • - 150 million birds died/culled
      • Dec 2003 to March 2006 – 126 human cases, 64 deaths reported to WHO (Viet Nam, Thailand, Cambodia, Indonesia)
    • 21. Recreating 1918 Influenza Virus
    • 22. Global Spead
    • 23. Influenza Vaccination of School c hildren in Japan Reduction in Excess Pneumonia and Influenza Mortality Among Older Adults Reichert T et al. NEJM 2001;344:889-96.
    • 24. Assumptions of Pandemic Plans
      • The healthcare system will be overwhelmed
      • Best use of resources requires system-wide prioritization
      • There will be limited transfer of resources
      • Usual supply lines will be interupted
      • Delay in availability of pandemic vaccine
      • Anti-influenza drugs in short supply
      • The number of essential services workers will be reduced
      • The pandemic will occur in waves (each 6-8 weeks)
    • 25.  
    • 26. Hamilton
      • 8 week wave, 35% attack rate
      • 3,332 hospital admissions
      • 672 deaths
      • 780 in ICU
    • 27.  
    • 28. Severe Acute Respiratory Syndrome (SARS)
      • Jan-Feb. 2003 - outbreak of atypical pneumonia in Guandong Province, China; 5 deaths; transmission involving HCWs and household contacts (in retrospect, cases identified back to Nov. 2002)
      • Feb. 2003 - Hong Kong cases
      • March 2003 - spread to Canada and other countries
    • 29. SARS-Associated Coronavirus
    • 30. Masked Palm Civet
    • 31. March 25, 2003 March 29, 2003 April 2, 2003 Severe Acute Respiratory Syndrome (SARS)
    • 32. Spread from Hotel “M” March 2003 Hotel M Hong Kong Guangdong Province Hong Kong 95 HCW A A H, J Vietnam 37 HCW B C, D,E Singapore 34 HCW US I, L,M K Ireland F, G Canada 18 HCW
    • 33. Probable and Suspect Cases of SARS in Ontario by Date of Onset Probable Suspect Date of Onset 2-Mr 9-Mar 23-Mar 30-Mar 13-Apr 20-Apr 4-May 11-May 25-May 18-May 6-Apr 16-Mar 23-Feb 1-Jun 8-Jun 15-Jun 22-Jun 30-Jun
    • 34. SARS in Taiwan MMWR 2003; 52:461-464
    • 35.  
    • 36. 1999 WN virus activity in NYC area Mosquitoes Birds Humans
    • 37.  
    • 38. West Nile Outbreaks
      • Israel - 1951-1954, 1957
      • France - 1962
      • South Africa - 1974
      • Romania – 1996
      • Italy 1998
      • Russia - 1999
    • 39. Emerging Clinical Syndromes
      • Emerging clinical syndromes
        • Movement disorders
        • Parkinsonism
        • Flaccid paralysis
        • Rhabdomyolysis
    • 40. West Nile Virus Transmission Cycle
    • 41.  
    • 42. WNV Surveillance Data in Halton 2002
      • Birds
        • > 5000 dead bird sightings
        • >2700 crows
        • 14 Positive Dead Birds (of 38 collected)
      • Mosquitoes
        • 24 positive pools at 6 sites (183 pools collected)
      • Humans (as of February 19, 2003)
        • Confirmed 42
        • Probable 17
        • Suspect 27
    • 43.  
    • 44.  
    • 45.  
    • 46. Challenges of doing Research for Emerging Infectious Diseases
      • Ethics approval
      • Access (patients, hospitals)
      • Competing research groups
      • - redundancy
      • - too many blood tests
      • Trajectory of patients
      • Interface with public health
      • Politics
    • 47. Candidate Factors Affecting Emergence of new infections
      • Human demographics and behavior
      • Human susceptibility to infection
      • Economic development and land use
      • Changing ecosystems
      • International travel
      • Microbial adaption
      • Breakdown of public health system
    • 48. When will new Viral Zoonotic agents arise ?
      • Complex, difficult to predict
      • We understand the effects of mutation and selection e.g genetic relatedness
      • But we don’t understand specific factors that determine selection
    • 49. Prevention
      • Independent scientific and administrative leadership
      • Multi-disciplinary collaboration
      • Primary and reference Laboratory diagnostic systems
      • Federal /regional communication and collaboration
      • Strategic plans
    • 50. Convergence Model