Dr.T.V.

Rao MD

Dr.T.V.Rao MD 1
 Infectious disease is one of the few genuine adventures left in the
world. The dragons are all dead and the lance grows rusty in the
chimney corner . . . About the only sporting proposition that
remains unimpaired by the relentless domestication of a once free-
living human species is the war against those ferocious little fellow
creatures, which lurk in the dark corners and stalk us in the bodies
of rats, mice and all kinds of domestic animals; which fly and crawl
with the insects, and waylay us in our food and drink and even in
our love.

- (Hans Zinsser,1934 quoted in Murphy 1994)

Dr.T.V.Rao MD 2
 What is a Emerging Infectious
Disease

 The discovery of disease-causing pathogens is an
important activity in the field of medical science, as many
viruses, bacteria protozoa, fungi, helminthes and prions
are identified as a confirmed or potential pathogen. A
Center for Disease Control program begun in 1995
identified over a hundred patients, with life threatening
illnesses which were considered to be of an infectious
cause, but could not be linked to a known pathogen. The
association of pathogens with disease can be a complex
and controversial process, in some cases requiring
decades or even centuries to achieve total control on the
etiological agents.
Dr.T.V.Rao MD 3
 EMERGING INFECTIOUS
DISEASES

Microbes and vectors swim in the
evolutionary stream, and they swim faster
than we do. Bacteria reproduce every 30
minutes. For them, a millennium is
compressed into a fortnight. They are fleet
afoot, and the pace of our research must keep
up with them, or they will overtake us.
Microbes were here on earth 2 billion years
before humans arrived, learning every trick
for survival, and it is likely that they will be
here 2 billion years after we department.
(Krause 1998).
Dr.T.V.Rao MD 4
 Direct economic impact of selected infectious disease
outbreaks, 1990-2003

Heymann DL. Emerging and re-emerging infections. In Oxford Textbook of Public

Dr.T.V.Rao MD 5
Health, 5th ed, 2009, p1267.
 WHO Warns the Trends

 The World Health Organization warned in its 2007
report that infectious diseases are emerging at a rate
that has not been seen before. Since the 1970s, about
40 infectious diseases have been discovered,
including SARS, Ebola, Avian flu, and Swine flu.
With people traveling much more frequently and far
greater distances than in the past, the potential for
emerging infectious diseases to spread rapidly and
cause global epidemics is a major concern.

Dr.T.V.Rao MD 6
 Many are Zoonotic Infections.

 Many emerging diseases


arise when infectious
agents in animals are
passed to humans as
zoonosis. As the human
population expands in
number and into new
geographical regions, the
possibility that humans
will come into close
contact with animal
species that are potential
hosts of an infectious
agent increases.

Dr.T.V.Rao MD 7
 Emerging
Zoonosis


 Emerging zoonotic diseases have potentially serious
human health and economic impacts and their
current upwards trends are likely to continue.
Examples are avian influenza, Bovine Spongiform
Encephalitis (BSE) and the Nipah virus. Some of the
"lingering" zoonosis are re-emerging in some
regions, although they seem to attract less public
awareness. Brucellosis, dog rabies and parasitic
diseases such as cysticercosis/taeniasis and
echinococcosis/hydatidosis for example.

Dr.T.V.Rao MD 8
Climate change Promotes
Emerging Infections

 Climate change is
increasingly becoming
a concern as a factor in
the emergence of
infectious diseases. As
Earth's climate warms
and habitats are altered,
diseases can spread into
new geographic areas.

Dr.T.V.Rao MD 9
 How HIV Emerged

 The example of an emerging
infectious disease that can
be attributed to human
practices is HIV. It is
thought that humans were
first infected with HIV
through close contact with
chimpanzees, perhaps
through bush meat hunting,
in isolated regions of Africa.
It is likely that HIV then
spread from rural regions
into cities and then
internationally through air
travel

Dr.T.V.Rao MD 10
 Emerging infections can be
caused by:

 Previously undetected or unknown infectious agents
Known agents that have spread to new geographic
locations or new populations Previously known
agents whose role in specific diseases has previously
gone unrecognized.
Re-emergence of agents whose incidence of disease
had significantly declined in the past, but whose
incidence of disease has reappeared.
This class of diseases is known as re-emerging
infectious disease

Dr.T.V.Rao MD 11
 Emerging Diseases are New to our
knowledge

Emerging infectious diseases are caused by
new or previously unrecognized
microorganisms (. Although the term became
part of the journalist’s lexicon in the 1990s,
emerging infectious diseases have long been
recognized as an important outcome of host-
pathogen evolution. Because emerging
infections may have severe public health
consequences, they are a focus of both the
popular press and scientific research.
Dr.T.V.Rao MD 12
 Infectious diseases are not
Static but New are Emerging

The changing landscape of infectious
diseases over the past 2 decades has
astounded the medical PROFESSIONALS
and the PUBLIC. Emerging pathogens that
cause new diseases (e.g., severe acute
respiratory syndrome–associated coronavirus
[SARS-CoV]), newly recognized microbial
agents of known diseases (e.g., human
metapneumovirus), and rapidly evolving
pathogens (e.g., influenza viruses) all
Dr.T.V.Rao MD 13
contribute to this seismic shift
Respiratory Infections are Major
Threat
 Acute respiratory 
infections are, globally,
the major cause of
mortality in children 5
years of age. The
advent of diagnostic
platforms suited to
surveillance as well to
clinical application will
reduce the morbidity
and mortality of
respiratory
Dr.T.V.Rao MD 14
 

Dr.T.V.Rao MD 15
 Factors Contributing to Emerging
Infections

 Several factors contribute
to the emergence of new
infectious diseases. They
include the increasing
growth and mobility of
the world‟s population,
overcrowding in cities
with poor sanitation,
massive food preparation
and international
distribution,
Dr.T.V.Rao MD 16
 

Dr.T.V.Rao MD 17
 Changes in human behavior, food
habits and environment
 Unsanitary food

preparation,
exposure of humans
to disease vectors and
reservoirs, and
ecological changes
that alter the
composition and size
of insect vectors and
animal reservoirs.
Dr.T.V.Rao MD 18
 Animal origins of Emerging
Infections

 Some emerging infections are caused by microbes
that originate in nonhuman vertebrates. Hantavirus
pulmonary syndrome was first noted in the Four
Corners area of New Mexico in 1993. The disease is
caused by Sin Nombre virus, which is endemic in the
deer mouse (Peromyscus maniculatus).An increase in
the deer mouse population might have been a factor.
In 1992–93, abundant rainfall produced a large crop
of piñon nuts, which are food for both humans and
the deer mouse. As the mouse population rose,
contact with humans increased.
Dr.T.V.Rao MD 19
 Animal origins of Emerging
Infections – Hanta Virus
 The virus is excreted in

mouse droppings, and
contaminated blankets
or dust from floors
provided opportunities
for human infection.
Because humans are
not the natural host for
Sin Nombre virus, the
human disease is rare.

Dr.T.V.Rao MD 20
 Emergence of Lyme disease,

 The emergence of Lyme
disease, t he infection has
probably been present in
North America for
millennia, but it was only
in the 20th century that
conditions in the
northeastern US changed
to favor the propagation
of Lyme disease.

Dr.T.V.Rao MD 21
Dr.T.V.Rao MD 22
 Age old infections can be
Reemerging

Some emerging infectious diseases are
caused not by new pathogens, but by the re-
emergence of microbes that had been
successfully controlled. The mosquito-borne
dengue virus was shown in 1903 to be the
causative agent of dengue fever, a disease
accompanied by fever, rash, and arthralgia.
Fifty years later, a new disease caused by the
virus, dengue hemorrhagic fever, was
identified in Southeast Asia
Dr.T.V.Rao MD 23
 Pan American Health
Organization
 The Pan American Health

Organization led efforts to
eradicate the mosquito vector
of dengue virus, Aedes aegypti,
from most of Central and South
America. As a consequence,
dengue fever and dengue
hemorrhagic fever were largely
eliminated from all but
Southeast Asia. Unfortunately,
the mosquito-eradication
programs ended in the 1970s,
leading to reinfestation of the
Americas.

Dr.T.V.Rao MD 24
 Dengue – A Reemerging Infection
 Dengue virus has been
reintroduced into the

Caribbean, the Pacific,
Australia, and the
Indian subcontinent
and has appeared for
the first time in China,
Venezuela, and Brazil.
Intercontinental
transport of car tires
containing mosquito
eggs has been
implicated in the Dr.T.V.Rao MD 25
spread of the virus.
Millions are affected with
Dengue
Currently there are
an estimated 100
million cases of
dengue fever and
several hundred
thousand cases of
dengue
hemorrhagic fever
each year, and 2.5
billion people are at
Dr.T.V.Rao MD
risk for infection. 26
 Unfulfilled Gaps to
Molecular Methods

 In recent years, there has
been substantial progress
in applying molecular
biologic advances to
respiratory virus
diagnosis nonetheless, a
major gap has been the
lack of a cost-effective,
systematic way to identify
the causes of respiratory
diseases in populations.
Dr.T.V.Rao MD 27
Drug Resistant Pathogens are Emerging

 The problematic as the


threat of emerging
infectious diseases is the
emergence of drug-
resistant pathogens, which
can turn a conquered
microbe into a new threat.
Low-cost, common
antibiotics can no longer
clear infections of
Escherichia coli, Neisseria
gonorrhea, Pneumococcus,
Shigella, and
Staphylococcus aureus.

Dr.T.V.Rao MD 28
Dynamics of Modern Life
Contributed
  The cost and length of
treatment of many common
diseases are increased, or
infections may be refractory
to treatment. The changing
dynamics of a growing
population children‟s day
care centers, and the overuse
of antibiotics, both in
humans and in the food
chain, have contributed to
the emergence of drug-
resistant microbes.
Dr.T.V.Rao MD 29
 Drug Resistant Malaria a grave
threat to Developing Countries
The emergence of

resistance of
Plasmodium
falciparum to
chloroquine, once a
mainstay in the
prevention of
malaria, has led to a
global resurgence of
this disease
Dr.T.V.Rao MD 30
 Increasing Human Comfort and
Changing Life styles too Contribute
  Humans are always
providing new ways to meet
new pathogens. Air travel,
dam construction, hot tubs,
air conditioning, blood
transfusion,
deforestation, day care
centers, and urbanization
are some of the
technological and social
changes that influence the
spread of microbes.

Dr.T.V.Rao MD 31
 Need for Antibiotic
Stewardship
 While rising rates of

antimicrobial resistance are
driving many institutions to
adopt antimicrobial
stewardship programs,
many are finding the
principle difficult to put into
practice. Some physicians
from across the medical
spectrum ignore
recommendations to reduce
unnecessary use of
antimicrobials.
Dr.T.V.Rao MD 32
 

Dr.T.V.Rao MD 33
 Ever Increasing Population
in Developing Countries
 Most importantly,

growth of the human
population continues,
providing interactions
with other humans and
the environment on an
unprecedented scale,
and ensuring the
propagation of new
diseases.

Dr.T.V.Rao MD 34
 One Health

 One Health is the
collaborative effort of
multiple disciplines –
working locally,
nationally, and globally
– to attain optimal
health for people,
animals, and our
environment.

Dr.T.V.Rao MD 35
 One Health Initiative (OHI)
has four long-term goals

 Goal 1: Develop, implement and sustain a national
strategy for improved public health based on the
principles of One Health
Goal 2: Create national awareness within the veterinary
and medical professions; the broad scientific community;
government institutions; the political leadership; and the
general public of the power of One Health to improve the
health of people, animals and the environment
Goal 3: Illustrate the value of implementing One Health
principles through specific Demonstration Projects
Goal 4: Extend the One Health Initiative to the
international community to achieve tangible
improvements in global health

Dr.T.V.Rao MD 36
 Unfulfilled Gaps to
Molecular Methods

 In recent years, there has
been substantial progress
in applying molecular
biologic advances to
respiratory virus
diagnosis nonetheless, a
major gap has been the
lack of a cost-effective,
systematic way to identify
the causes of respiratory
diseases in populations.
Dr.T.V.Rao MD 37
 We can Track very Fast

Emerging infections
can be tracked by
the hour on the
Internet (ProMED-
mail,
(www.promedmail.org)
and in scientific
journals (e.g.,
Emerging Infectious
Diseases). Dr.T.V.Rao MD 38
 Emerging Infections
Network

 In 1995, the CDC granted
a Cooperative Agreement
Program award to the
Infectious Diseases
Society of America (IDSA)
to develop a provider-
based emerging infections
sentinel network: the
Emerging Infections
Network (IDSA EIN).

Dr.T.V.Rao MD 39
How Emerging Infectious
Diseases Network works
The Emerging
Infections Network
(EIN) is a provider-
based sentinel network
designed to help the
public-health
community detect
trends in emerging
infectious diseases.
Dr.T.V.Rao MD 40
Emerging Infections
Network Works

 IDSA EIN has evolved into
a flexible sentinel network
composed of over 1,100
infectious disease specialists
primarily from North
America, with some global
members. The overarching
goal of the EIN is to
assist CDC and other
public health authorities
with surveillance for
emerging infectious diseases
and related phenomena.
Dr.T.V.Rao MD 41
The Specific goals of the EIN are to:

Detect new or unusual clinical events;
Identify cases during outbreak investigations;
Gather information about clinical aspects of
emerging infectious diseases;
Help connect members to the CDC and other
public health investigators; and
Develop new methods for gathering
epidemiological and clinical information.
Dr.T.V.Rao MD 42
STRATEGIES TO REDUCE THREATS


 IMPROVE GLOBAL RESPONSE CAPACITY
 WHO
 National Disease Control Units (e.g. USCDC, CCDC)
 IMPROVE GLOBAL SURVEILLANCE
 Improve diagnostic capacity (training, regulations)
 Improve communication systems (web, e-mail etc.)
 Rapid data analysis
 Develop innovative surveillance and analysis strategies
 Utilize geographical information systems
 Utilize global positioning systems
 Utilize the Global Atlas of Infectious Diseases (WHO)
Dr.T.V.Rao MD 43
 STRATEGIES TO REDUCE
THREATS

 USE OF VACCINES
 Increase coverage and
acceptability (e.g., oral)
 New strategies for
delivery (e.g., nasal
spray administration)
 Develop new vaccines
 Decrease cost
 Decrease dependency on
“cold chain”
 NEW DRUG
DEVELOPMENT
Dr.T.V.Rao MD 44
 STRATEGIES TO REDUCE
THREATS

DECREASE INAPPROPRIATE DRUG USE
 Improve education of clinicians and public
 Decrease antimicrobial use in agriculture and food
production
IMPROVE VECTOR AND ZOONOTIC CONTROL
 Develop new safe insecticides
 Develop more non-chemical strategies e.g. organic
strategies
BETTER AND MORE WIDESPREAD HEALTH
EDUCATION (e.g., west Nile virus; bed nets,
mosquito repellent)
Dr.T.V.Rao MD 45
 ROLE OF THE PUBLIC HEALTH
PROFESSIONAL
 Establish surveillance for: 
 Unusual diseases
 Drug resistant agents
 Assure laboratory
capacity to investigate
new agents (e.g., high-
throughput labs)
 Develop plans for
handling outbreaks of
unknown agents
 Inform physicians
about responsible
antimicrobial use
Dr.T.V.Rao MD 46
 ROLE OF THE PUBLIC HEALTH
PROFESSIONAL
Educate public about 
 Responsible drug compliance
 Emergence of new agents
 Infection sources
 Vector control
 Malaria prophylaxis
Be aware of potential adverse effects of
intervention strategies
Anticipate future health problems
Promote health and maximize human functional
ability
Dr.T.V.Rao MD 47
 Our Vision should look for
Our Survival

 Human population growth,
technological advances, and
changing social behaviors lead
to the selection of new
microbial pathogens.
Antimicrobial drugs, vaccines,
diagnostics, and treatments for
emerging infectious diseases
must be developed. The
selective forces that drive the
emergence of new infectious
diseases, and the implications
for our survival, are just
beginning to be understood.
Dr.T.V.Rao MD 48
 Role of Microbiology
Crucial link
 The importance of

Microbiology laboratories
rests with prompt
identification and reporting
can cure with simple
remedies, as most of the
emerging infections respond
to several drugs and choice
lies with optimal selection
based on Antibiograms, as
resistance is not a menace
with emerging, newer and
uncommon isolates
Dr.T.V.Rao MD 49
 Up gradation of Diagnostic
Microbiology Laboratories a Must

The modern
generation of
Microbiologists
should be familiar
with Identification
of the Microbes with
newer generation of
Technological
advances.
Dr.T.V.Rao MD 50
 Share your Observations on
www

 Today sharing the
knowledge on
Microbes through
World Wide Web
(WWW) helps for
faster dissemination
of Knowledge and
many lives in the
Developing world
can be saved

Dr.T.V.Rao MD 51
 Research on Emerging
Infectious Disease Agents

 The development of
vaccines and antimicrobial
drugs and the remarkable
eradication of smallpox had
created hope that infectious
diseases could be controlled
or even eliminated.
However, the current
realization that infectious
diseases continue to emerge
and re-emerge (including
the possibility of
bioterrorism), underscores
the challenges ahead in
infectious disease research.

Dr.T.V.Rao MD 52
 Caution ….
Donot discard Unfamiliar bacteria in the
routine Diagnostic work
 Many important

pathogens both
unfamiliar, emerging
and reemerging are
discarded without
much consideration
and review.
 Be wise to consult a
colleague and some
one who is more
familiar
Dr.T.V.Rao MD 53
 Need for global help to
Developing countries
 Commitment to technology

transfer and global
collaboration is essential if
we are to have the agility
required to keep pace with
emerging infectious
diseases. Pathogen
surveillance and discovery
can promote global
interaction via
collaborations on matters
that know no national or
political boundaries but
simply reflect our common
Dr.T.V.Rao MD 54
goals.
Update your Knowledge from
CDC


Dr.T.V.Rao MD 55
Follow me for More Articles of
Interest on Infectious Diseases


Dr.T.V.Rao MD 56
 
Created by Dr.T.V.Rao MD for „e‟
learning resources for Medical and
Public Health Personal in the
Developing World
 Email
 doctortvrao@gmail.com

Dr.T.V.Rao MD 57