Emerging Infectious Diseases - Winnipeg Regional Health ... ?· 1930's. 1970. 2003. ... tuberculosis…

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  • Emerging Infectious Diseases

    Kevin Kain MD FRCPCDirector, Global Health

    McLaughlin Centre for Molecular MedicineProfessor of Medicine University of Toronto

  • Who are we? Where are we going? What should we do?

    Travel and Emerging Infectious Diseases

  • Wor

    ld P

    opul

    atio

    n in

    bill

    ions

    (

    )

    Day

    s to

    Circ

    umna

    viga

    te (

    )

    th

    e G

    lobe

    Year1850

    0

    400

    350

    300

    250

    200

    150

    100

    50

    2000

    0

    1900 1950

    1

    2

    3

    4

    5

    6

    Speed of Global Travel in Relation toWorld Population Growth

    From: Murphy and Nathanson. Semin. Virol. 5, 87

  • Main migration movements

  • Wars and famines

  • Humans as Vectors of Disease Chen et al Med Clin NA 2008;92:1409

    2007 ~898 million cross international borders by air

    35-fold increase since 1950 (vs 2.6-fold increase in world population)

    > 50 million developing world > 50 million refugees ~500M > 280 million visitors to USA/yr (> 34M are

    foreign born)WTO 2008

  • There is no where in the world from which we are remote and no

    one from whom we are disconnected

    IOM Microbial threats to Health in the USA

  • Global distribution of newly emerging and re-emerging infectious diseases

    Nature 430: 242

  • Leprosy in Toronto Boggild A,. Kain KC. CMAJ 2004

    N = 184 cases at the TDU (66% male) 80% arrived within the last 20 years Indian subC 32% Philippines 27% Vietnam 20% 33% had nerve dysfunction at

    presentation Lag time to Dx: 1.5-4.7 yrs

  • Babesiosis in Canada dos Santos and Kain CMAJ 2000

    59 male editor TO paper to TGH extremely ill fever, toxic, DIC Dx leukemia malaria smear P falciparum 4% TDU Babesia microti (PCR +) Lyme + IgM; Ehrlichia neg (PCR)

  • Babesiosis: Blood Supply Kain et al CMAJ 2001

    53 female GI bleed Hb 70 g/L transfused 5U Oct 98 and Feb 99 re-admitted 7 d. 40C, chills, N&V smear Dx P falciparum at 2.5% TDU Babesia microti 5 donors 40 male smear, PCR+

  • Leishmaniasis MMWR 2004;53:264. Otero AJTMH 2000;62:128

    N = 500,000 troops in Iraq, Afghanistan and Kuwait

    N = >2000 confirmed cases of CL (L. major) N = 2 cases of VL (L. infantum) Delay of 14 months until onset Brazil: 24% of sero+ blood donors = + PCR ~15 cases of TTL pRBCs and plts I.P. = 2-12 months

  • Chagas in North America Kirchhoff NEJM 1993. Herwaldt JID 2000.

    Leiby et al. Transfusion 2002;42:549

    ~5x106 Latin immigrants to USA 50,000-100,000+ infected

    ~20% symptomatic Up to 5% of Latin American immigrants in

    Washington DC are sero+ 0.01-1.1% of blood donors in LA sero+ Risk of infection is 13-23%/unit ~100 USA pts infected by transfusion/yr

  • Clinical Chagas in USA Leiby et al. Circulation 2000;102:2978.

    n = 11430 cardiac surgery pts tested N = 6 sero + by both EIA and RIPA 2 were heart transplants & hearts PCR + For Hispanic pts 2.7% were sero + BUT none had been suspected for Chagas Chagas is under Dx as a cause of cardiac

    disease/CHF

  • T. cruzi in the USA Reisenman C et al. EID March 2010

    Collected triatomines around Tucson, AZ 41.5% (n = 164) were + for T cruzi by PCR 63% of collection sites were + 7 autochthonous cases of Chagas in USA Reservoirs: mice, rats, raccoons, opossums, dogs

    Triatoma rubida

  • Emerging Infectious Diseases

    Where are we? Where are we going? What should we do?

  • Cruise Ships Chen et al. Med Clin NA 2008;92:1409

    11.5 million took cruises in 2005 Passengers and crew risk EID

    Converge from many countries Brief visits multiple countries Many are elderly with underlying disease Widely disperse before IP transmit

    Norovirus 2006 43 outbreaks Legionella >200 cases (spas) Influenza Alaska 1998 >33,000 cases Salmonella, V cholera, diptheriae, rubella

  • Immunosuppression and Travel: BoggildKain JTM 2004 BoggildKain CMAJ 2005

    >25,000 transplants performed in NA/yr >$2.5 billion in 1st year or treatment N= 267 renal, heart, liver transplants 99% were on > 2 immunosuppressives ~2/3s were VFRs

  • A day in the life of Infectious Diseases Tuesday, January 6 2010

    PRO/AH/EDR> Avian influenza, human (01): China PRO/AH/EDR> Avian influenza (02): India (WB) PRO/EDR> Influenza oseltamivir resistance (10): CDC PRO/EDR> Dengue update Rio, Australia(01)

    PRO/EDR> Chikungunya and P. knowlesi - Singapore PRO/AH/EDR> Angiostrongylus meningitis - US: [HI] PRO/EDR> Poliomyelitis - Worldwide, updates PRO/AH> Antibiotic contamination, food supply USA PRO/AH/EDR> Ebola hemorrhagic fever - Congo DR PRO/AH/EDR> Ebola, Zimbabwean soldiers DRC.

  • World migration of chicken wings and legs 5 million tons/year

  • March 4, 2010:

    486 cases and 287 deaths

    CFR = 60%

  • de Jong, M. D. et al. N Engl J Med 2005;353:2667-2672

    Influenza A (H5N1) Viral RNA Load in Throat Swabs from Eight Patients

  • 213 countries >16,455 deaths

  • Dengue/dengue hemorrhagic fever: annual number of cases reported to

    WHO, 1955-2001

    0

    100000

    200000

    300000

    400000

    500000

    600000

    1955-1

    959

    1960-1

    969

    1970-1

    979

    1980-1

    989

    1990-1

    999

    2000-2

    001

    Num

    ber

    of C

    ases

  • Aedes aegypti Distribution in the Americas

    19701930's 2003

  • The Emergence of Dengue Hemorrhagic Fever in the Americas

    Prior to 1981 1981-2003

    DHF: Americas1970: 01990s: >60,000Texas 1980-99: 64Hawaii 2001: 122Florida 2009: 20

  • 1900 cases/85000 inhabitants = 2.2% attack rate!!

  • Mosquitoes and the economy EID Nov 2008; 14:1747

    Mossies take advantage of tough times

    Sharp rise in WNV in California Aerial survey 17% of pools were

    green Culex + Mortgage foreclosures houses

    abandoned

  • >1,500,000 cases

    attack rate 35%

  • Angiostrongyliasis Rat lung worm

    Angiostrongylus cantonensis` eosinophilic meningoencephalitis Spreading in the Pacific Rim including

    Hawaii rats in ships/containers Transmitted to SEA slug also imported Infected by eating slugs or more

    commonly 1-2 mm. larvae on fresh produce

    Rameriz-Avila et al CID 2009;48:322

  • Angiostrongyliasis Rameriz-Avila et al CID 2009;48:322

    Clinical: I.P. 1-4 wks. Presents H/A, paiful migrating parasthesias, peripheral and CSF eosinophilia (occ. Ocular and cranial nerves)

    Epidem: Asia, Australia, South Pacific, Hawaii, Caribbean (rats LA)

    Diagnosis: clinical + serology (Mahidol) CT and MRI usually normalTreatment: albendazole + steroids x 14 d esp. if

    progressive

  • Nigerian outbreak of polio 2003-2008 spread to 20 countries and required >$500M

    Still

  • Vaccine preventable Illness in Travellers ISTM 2009

    Analysis of 37,542 returned travellers in Geosentinel database 2009

    580 Vaccine preventable illness (VPI) Enteric fever = 276 HAV and HBV = 148 Influenza = 70

    55% admitted to hospital 3 deaths

  • Vaccines - USA Nature Medicine Jan 1998

    Disease Max. cases/yr PresentMeasles 894,000 500Diptheria 207,000 1Pertussis 265,000 6400Mumps 152,000 600Rubella 58,000 210

  • Anti-vaccine Movements Measles- Netherlands

    Measles epidemic2,961 cases (97% no vaccine)3 died and 5 enceph (1/300)63 hospitalized (2.1%)439 complications (15%) pneu., OM

    Exported 2 outbreaks in CanadaMMWR April 14, 2000

  • Vaccines do NOT cause autism Offit PA et al CID 2009;48:456

    Rates of autism in vaccinated and unvaccinated children are the same

    20 studies no association MMR with autism

    7 studies no ass. of thimerosal with autism The Right to catch and transmit potentially

    fatal infections. Now Yes No?? Clusters of measles and Hib in unvaccinated

    children

  • January 28, 2007Virulent TB in South Africa May Imperil

    Millions Johannesburg, Jan. 27 More than a year after a

    virulent strain of tuberculosis killed 52 of 53 infected patients in a rural South African hospital, experts here and abroad say the disease has most likely spread to neighboring countries, and some say urgent action is essential to halt its advance.

    XDR TB

    http://topics.nytimes.com/top/news/health/diseasesconditionsandhealthtopics/tuberculosis/index.html?inline=nyt-classifier

  • Extensively-resistant TB USA JAMA Nov 2008;300:2153. EID 2008;14:1715

    1993-2007 XDR TB Resistant INH, RMP, quino, 2nd line IM agent

    3400 R to IHN, RMP 83 XDR 54% unemployed USA born More like to be Hispanic and in jail 400/6000 refugees to USA active TB 24 had MDR TB

  • Antibiotics USA > 50 yrs antibiotics used as growth

    promoters (USA 25 million tons/yr) ~70% of all antibiotics in USA Linked to development of antibiotic

    resistant bacteria in meat and milk transmitted to humans

    ~90% end up in urine and manure Now concerns picked up by fresh

    produce including organic farms

  • Ebola and Primates Bermejo M et al Science 2006;314:1564

    Ebola outbreak killed 5000 gorillas

    Gabon 3 outbreaks chimps N = 110 CFR 59-75% Cooked chimp CFR 0%

  • Bushmeat, animal trade & exotic food

    Serious threat to global wildlife 3.4 M tons/yr

    40,000 primates, 4M birds, 650K reptiles, 350M fish traded/yr

    ~USD $6B/yr