Emerging infectious disease

Emerging Infectious Dieases
August 31st, 2016
P. Damronglerd MD

Outlines
• Definition
• Zika virus
• Ebola virus
• MERS

Definition
WHO
• An emerging disease is one that has appeared
in a population for the first time,
• Or that may have existed previously but is
rapidly increasing in incidence or geographic
range
= Re-emerging disease

Epidemiology
• Family Flaviviridae
• Genus Flavivirus
• Mosquito-transmitted virus
– Aedes genus, mainly Aedes aegypti in tropical regions
– Usually bite during the day, peaking during early
morning and late afternoon/evening
– Same mosquito that transmits dengue, chikungunya
and yellow fever
• Sexual transmission of Zika virus is also possible
Curr Opin Infect Dis. 2016 Aug 4. DOI: 10.1097/QCO.0000000000000301

TImeline
http://www.who.int/emergencies/zika-virus/zika_timeline1000.jpg

Clinical Features
• 80% = asymptomatic
• Mild symptom and self-
limiting
• Low grade fever & short
term
• Some cases reported
– High fever up to 40oC
– Lymphadenopathy
– Severe abdominal pain
– Thrombocytopenia
– Enantema
– Hematoma

Common Signs and Symptoms

Neurological & Congenital Syndrome
• Guillan-Barré syndrome
• Meningoencephalitis
• Acute myelitis
• Encephalopathy
• Microcephaly

Situation
• As of 3 August 2016, 68 countries and
territories have reported evidence of
mosquito-borne Zika virus transmission since
2007
• 65 of these countries and territories have
reported evidence of mosquito-borne Zika
virus transmission since 2015
http://www.who.int/emergencies/zika-virus/situation-report/4-august-2016/en/

Distribution of Zika Virus, 2013-2016

Countries and Territories Reporting
Mosquito-borne Zika Virus Transmission

Microcephaly and/or CNS Malformation
Cases Potentially Associated Report

Guillain-Barré Syndrome (GBS)
Potentially Associated Report

Laboratory Diagnosis
• Can be detected in blood (plasma, serum),
CSF, urine, saliva, breast milk, semen, vaginal
secretion, amniotic fluid, tissues
• Viral genome: conventional or real-time RT-
PCR
• Serology (anti-ZIKV IgM or IgG): ELISA,
immunofluorescence, plaque-reduction test
(PRNT)

Treatment
• Usually mild and requires no specific
treatment
• Should get plenty of rest, drink enough fluids,
and treat pain and fever with common
medicines
• If symptoms worsen  medical care and
advice
• Currently no vaccine available
http://www.who.int/mediacentre/factsheets/zika/en/

คําแนะนําด้านสุขภาพสําหรับนักกีฬาและเจ้าหน้าทีในการแข่งขัน
กีฬาโอลิมปิก ครังที 31 ณ เมืองริโอ เด จาเนโร สาธารณรัฐบราซิล
ก่อนการเดินทาง
1. ผู้เดินทางหญิงควรคุมกําเนิดป้ องกันการตังครรภ์ ก่อนการเดินทาง 3
เดือน และในระหว่างทีอยู่ในสาธารณรัฐบราซิล จนกระทังเดินทาง
กลับออกมาแล้วอย่างน้อย 3 เดือน
2. หญิงตังครรภ์ควรงดการเดินทางไปสาธารณรัฐบราซิล
http://beid.ddc.moph.go.th/beid_2014/th/diseases/2078

ระหว่างทีอยู่ในสาธารณรัฐบราซิล
1. ป้ องกันตนเองไม่ให้ถูกยุงกัด โดยการใช้สารเคมีฉีด/พ่น/ทาตามเสือผ้าและ
ร่างกาย สวมเสือผ้าปกปิดร่างกายมิดชิดและสวมใส่เสือผ้าทีมีสีอ่อน อาศัย
อยู่ในห้องปรับอากาศ ทีปิดประตู ปิดหน้าต่าง หากไม่มี ควรนอนในมุ้ง
เคลือบสารกําจัดยุง
2. หลีกเลียงการเดินทางเข้าไปในพืนทีทีมีความแออัด มีนําชืนแฉะ เพือลด
ความเสียงต่อการถูกยุงกัด
3. ผู้เดินทางทังชายและหญิง ควรงดการมีเพศสัมพันธ์ หรือมีเพศสัมพันธ์
อย่างปลอดภัยโดยใช้ถุงยางอนามัยและคุมกําเนิดอย่างเคร่งครัด
4. หากมีอาการไข้ หรือรู้สึกไม่สบาย ให้แจ้งผู้จัดการทีม หรือแพทย์ประจําทีม
ทันที

หลังการเดินทาง
• เก็บปัสสาวะทันทีทีกลับมาถึง เพือรับการดูแลทีเหมาะสม และป้ องกันการ
แพร่กระจายของเชือไวรัสซิกาทีด่านควบคุมโรค สนามบินสุวรรณภูมิ และ
เก็บปัสสาวะซําอีกครัง หลังการเดินทางกลับแล้ว 1 สัปดาห์ (ถ้าได้)
• ผู้เดินทางกลับมาทังชายและหญิง ควรงดการมีเพศสัมพันธ์ หรือมี
เพศสัมพันธ์อย่างปลอดภัยโดยใช้ถุงยางอนามัย และคุมกําเนิดอย่าง
เคร่งครัด ต่อเนืองอย่างน้อย 3 เดือน หากหญิงพบว่าตังครรภ์ หรือชายทีมี
อาการไข้ หรือผืน ให้รีบพบแพทย์ทันที และแจ้งประวัติการเดินทาง
• ผู้เดินทางมาจากประเทศทีมีการระบาดของโรคติดเชือไวรัสซิกา รวมถึงเมือง
ริโอ เด จาเนโร สาธารณรัฐบราซิล ให้งดบริจาคโลหิตเป็นเวลา 4 สัปดาห์
นับตังแต่วันทีเดินทางออกมา

EBOLA VIRUS
http://apps.who.int/iris/bitstream/10665/208883/1/ebolasitrep_10Jun2016_eng.pdf?ua=1

Ebola
• Ebola virus disease (EVD), formerly known as Ebola
haemorrhagic fever
• First appeared in 1976 in 2 simultaneous outbreaks, in
Nzara, Sudan, and in Yambuku, Democratic Republic of
Congo
• Severe fatal illness
• Case fatality rate of up to 90%
http://www.who.int

• Genus Ebolavirus is 1 of 3 members of the Filoviridae
family (filovirus), along with genus Marburgvirus and
genus Cuevavirus. Genus Ebolavirus comprises 5
distinct species:
– Bundibugyo ebolavirus (BDBV)
– Sudan ebolavirus (SUDV)
– Zaire ebolavirus (EBOV)
– Taï Forest ebolavirus (TAFV)
– Reston ebolavirus (RESTV)
Ebola
http://www.who.int

Transmission
• Virus is transmitted to people from wild animals and
spreads in the human population through human-to-
human transmission
• Infection has been documented through the
handling of infected chimpanzees, gorillas, fruit bats,
monkeys, forest antelope and porcupines found ill or
dead or in the rainforest
http://www.who.int

Transmission
• Transmitted by direct contact with the blood, body
fluids and tissues of infected animals or people
• Men who have recovered from the disease can still
transmit the virus through their semen for up to 7
weeks after recovery from illness
http://www.who.int

Signs and Symptoms
• Sudden onset of fever, intense weakness, muscle
pain, headache and sore throat
• Followed by vomiting, diarrhoea, rash, impaired
kidney and liver function
• In some cases, both internal and external bleeding
Incubation period is 2 to 21 days
http://www.who.int

Diagnosis
• Diagnosed definitively in a laboratory through several
types of tests:
– Antibody-capture enzyme-linked immunosorbent assay
(ELISA)
– Antigen detection tests
– Serum neutralization test
– Reverse transcriptase polymerase chain reaction (RT-PCR)
assay
– Electron microscopy
– Virus isolation by cell culture
http://www.who.int

Treatment
• Supportive care-rehydration with oral or
intravenous fluids- and treatment of specific
symptoms, improves survival
• There is as yet no proven treatment available for
EVD
• Potential treatments including blood products,
immune therapies and drug therapies are
currently being evaluated
• No licensed vaccines are available yet, but 2
potential vaccines are undergoing human safety
testing
http://www.who.int/mediacentre/factsheets/fs103/en/

WHO Situation Report, June 10th, 2016
• Ebola in West Africa was lifted on 29 March
2016
• Confirmed cases = 28,616
• Probable and suspected cases have been
reported in Guinea, Liberia and Sierra Leone,
with 11,310 deaths
• Latest cluster = prefectures of N’Zerekore and
Macenta in south-eastern Guinea, Monrovia
in Liberia

WHO Situation Report, June 10th, 2016
• In Guinea, the last case tested negative for
Ebola virus for the second time on 19 April
– Guinea declared an end to Ebola virus
transmission on 1 June
• On 9 June the World Health Organization
(WHO) declared the end of the most recent
outbreak of EVD in Liberia
– This follows 42 days since the last case tested
negative for the second time on 28 April

The First Case
60-year-old Saudi man who was
admitted to a private hospital in
Jeddah on June 13, 2012
• Fever, cough, expectoration,
and shortness of breath
• Died 11 days later from
progressive respiratory failure
• Human Coronavirus
Erasmus Medical Center
(HCoV-EMC)
Infect Drug Resist. 2014 Nov 3;7:281-7

The Second Case and Afterward
• Qatar, a 49-year-old man, was
diagnosed in September 2012
with the novel coronavirus
• He was transported to the
United Kingdom for intensive
care
• The isolated viruses from the
Saudi and the Qatari cases
were 99.5% identical
• Majority of cases (>80%) have
been reported from Saudi
Arabia
• Since then 1333 cases have
been reported from 26
countriesInfect Drug Resist. 2014 Nov 3;7:281-7

MERS 2012
http://www.who.int/csr/disease/coronavirus_infections/mers-2012-2015-global-situation-2015-06-26.png?ua=1

Phylogeny
• Enveloped RNA virus
• Subfamily Coronavirinae
• Novel virus is a representative
of a new, yet-to-be-established
species in lineage C of the
genus Betacoronavirus
J Virol. 2013 Jul; 87: 7790–7792

Symptom
• Range of presentation
– Asymptomatic
– Mild respiratory symptoms
– Severe acute respiratory disease
– Death (36%)
• Typical presentation:
– Fever, cough and shortness of breath
– Pneumonia is a common finding, but not always present
• Gastrointestinal symptoms, including diarrhoea, have also been
reported
• The virus appears to cause more severe disease in older people,
people with weakened immune systems, and those with chronic
diseases such as cancer, chronic lung disease and diabetes.
http://www.who.int/mediacentre/factsheets/mers-cov/en/

Transmission
• Sporadic (community-onset)
• Intra-familial transmission
• Health-care-related transmission

MERS 2013

Study
populations
Number
of cases
Median age
(range)
Male :
female
ratio
Asymptomati
c (%)
Severe case
(%)
Fatality rate
(%)
Saudi
Arabia, May
2013
23 56 (24–94) 2.8:1 0 100 65
Saudi
Arabia Sept
2012 - June
2013
47 NA 3.3:1 0 100 60
9 countries,
Mar 2012 -
Sept 2013
133 NA 1.5:1 13.5 86.5 45
9 countries,
Sept 2012 -
Oct2013
161 50 (14-94) 1.8:1 11.1 63.4 -
Saudi
Arabia, April
- June 2014
402 46 (0.75-94) 1.4:1 28.6 44.5 28.3
Saudi
Arabia, May
2013 - Feb
2014
113 41 (0.25-89) 1.3:1 28.9 NA 30

MERS 2014

Korea
St. Mary Hospital (37)
Asian Medical Center (1)
Yoel Lin Hospital (1)
Samsung Hospital (59

Treatment and Prevention
• No vaccine or specific treatment is currently available
• Treatment is supportive and based on the patient’s clinical
condition
– Cysteine protease inhibitor K11777  targeting cathepsin-
mediated cell entry1
– Oral ribavirin (dose based on calculated creatinine clearance, for
8-10 days) and subcutaneous pegylated interferon alfa-2a (180
μg per week for 2 weeks)2
• 14 (70%) of 20 patients in the treatment group had survived
after 14 days, compared with seven (29%) of 24 in the
comparator group (p=0·004)
1 Antiviral Res. 2015 Feb 7;116C:76-84
2 Lancet Infect Dis. 2015 Jan 15;211:13

WHO update and clarification on recent MERS
cases reported by the Kingdom of Saudi Arabia
• Between 19-22 June 2016, WHO published 3
reports on the Disease Outbreak News (DON)
describing 25 cases of Middle East Respiratory
Syndrome (MERS)
• 24 of the cases contacted with a probable, single
index case who was diagnosed with MERS in a
hospital in Riyadh City, Riyadh Region
• The 22 June 2016 DON reported that the index
case had died
http://www.who.int/emergencies/mers-cov/saudi-arabia-update/en/

WHO update and clarification on recent MERS
cases reported by the Kingdom of Saudi Arabia
• As of 22 June 2016 twenty-four (24) contacts
have tested positive for MERS including twenty
(20) healthcare contacts and three (3) household
contacts
• In addition, one case has been diagnosed in a
household contact of a hospital patient who was
diagnosed with the disease after exposure to the
probable index case
• Twenty (20) of the twenty-four (24) have not
exhibited any MERS symptoms

Cumulative Cases
• Globally since September 2012 WHO has been
notified of over 1,700 laboratory-confirmed
cases of infection with MERS, in 27 countries,
including more than 600 related deaths

Emerging infectious disease

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