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New and Re-Emerging Infectious Diseases 6 VOJENSKÉ ZDRAVOTNICKÉ LISTY - SUPLEMENTUM Volume LXVIII, 1999, no. 1 NEW AND RE-EMERGING INFECTIOUS DISEASES Václav DOSTAL, Karel HONEGR, Stanislav PLÍŠEK Infectious Diseases Department, University Hospital, Hradec Králové Infectious diseases traverse the usual boundaries quirement, the Specialty of infectious diseases be- established by medical Specialists. All organ sys- comeS the last disciplinary domain of general me- tems may be involved, and all physicians caring for dicine. patients may have to deal with infected patients. lronically, many of the forces that contribute to the Infectious diseases remain leading cause of mor- appearance of new diseases and emergence of old bidity and mortality throughout the world primarily ones are created by human activity - in many in- because known measures of control and therapy stances by what we consider extraordinary achieve- are not applied. In technically advanced countries, ments. We have underestimated the complexity of the pestilences of antiquity no longer occur. Yet, even our environment and the capacity of other species in these areas infectious diseases remain important adapt and evolve. We have overestimated the power contributors to illness and death. of tools, such as antimicrobials, pesticides, and vac- Among clinical specialty areas, that of infectious cines to free us of disease. We have failed to re- diseases is remarkable in being non-Systemic in cognize that events in plants and animals can teach orientation. The specialist in infectious diseases must us and affect our health. We have paid little atten- be prepared to deal with involvement in any organ, tion to the geoclimatic influences on health. We System, or region of the body. A patient comes to have too often ignored the social, economic, and po- See a physician because of a Sore throat, not be- litical contributions to disease. Several general con- cause of infection caused by Streptococcus pyo- cepts can help focus your attention to infectious genes. In assessing illness, he must be capable of diseases. taking into account age, Sex, and genetic constitu- Disease emergence is complex; often several fac- tion; nutritonal, hormonal, and metabolic Status; the tors must change sequentially or simultaneously to consequences of trauma, surgery, and other physical allow a disease to emerge. Infectious diseases are or chemical agents; and the effects of neoplastic, dynamic. New infections will continue to appear, pos- degenerative, and hypersensitive States. In this re- sibly at increasing rates. Volume LXVIII, 1999, no. 1 VOJENSKÉ ZDRAVOTNICKÉ LISTY - SUPLEMENTUM 7 Known infectious diseases will change in distribu- plant recipients who, due to immunosuppression, are tion, Severity and frequency. susceptible to opportunistic infections. Most new infections are not caused by novel pathogens. Some old organisms have apparently adopted Human activities are the most potent factors new tactics. Toxic shock syndrome is the result of leading to the appearance of new infectious di- a previously unknown toxin, produced by the fa- seases and the change in known infectious diseases. miliar pathogen, Staphylococcus aureus. To further Social, economic, climatic, and political forces shape confuse us some old infections are appearing in new disease patterns and influence emergence. clinical guises, such as atypical measles in adoles- Interventions to control infections can paradoxic- cents and young adults who received measles vac- ally increase the burden of disease. cine prior to 1967. Infant botulism, first recognized Understanding disease emergence requires look- as a clinical entity distinct from food-borne botulism ing beyond the organism to the milieu, the ecosys- in 1976, presents the picture of the infant between tem, and society. A global perspective is essential. the ages of one and six months collapsing with a The pathogens identified in most of the newly neuroparalytic illness, fiaccidity, and hypotonia due named diseases, such as Legionnaires’ disease, to Clostridium botulinum growing in the intestinal toxic shock syndrome, Lyme disease, and AIDS tract and liberating a potent toxin. are not novel pathogens that appeared de novo What are the causes for these changing pat- just prior to the recognition of disease. In most terns of infectious diseases? At least three factors instances of new diseases, the pathogens have can be implicated: been present for centuries or longer. The process 1) changes in lifestyle, including sexual behaviour, that leads to the recognition and naming of a travel patterns, dietary trends, leisure activity, and disease often involves social and economic, as well composition of the work force, have impacted as scientific events. Factors that favor recognition on disease patterns as have of a disease as new are several: clustering of cases 2) immigration and in time or space; increase in prevalence; distinctive 3) the effects of medical progress. signs, symptoms or laboratory findings; short incub- ation; rapid progression; high mortality and so on. History teaches that from time to time it is Changing patterns of Infectious diseases worthwhile looking back at where we have been to better understand where we are and where we Type Of Change Example may be going. During the last 20-30 years, some of New diseases AIDS the most evident, striking, and interesting changes in patterns of disease have occured among those Cryptosporidiosis due to transmissible agents. The increasing human New geographic range Malaria in American population facilitates transmission of disease from for old disease travelers person to person with epidemiologic changes or Chagas’disease in increased virulence, and the expansion of the po- Central America pulation into new ecologic niches brings people in immigrants contact with new potential disease pathogens and New populations at risk Listeriosis in renal the emergence of new disease problems. transplant recipients What types of change have occured in the pat- Giardiasis in day-care terns of infectious diseases? The most dramatic is centers the occasional recognition of so-called new diseases. Some of these are, in fact, old illnesses for which a New tricks for old Toxic shock syndrome cause has been recognized. Diarrhea due to Cam- „bugs“ Pseudomonas pylobacter, unheard of 30 years ago and now con- folliculitis sidered among the most common causes of bac- New faces for old Atypical measles terial enteritis, serves as an example. diseases Infant botulism Some diseases, on the other hand, do seem to New ecologic niches for Sneaker—associated be truly new or at least more common than was old ,,bugs“ Pseudomonas thought. AIDS is the most obvious and previously osteomyelitis lamentable example. ln addition, Some old diseases Hot tub folliculitis are now appearing in new geographic locales. Malaria is being seen increasingly in the United New modes of Rabies following States civilian population, which is no surprise since transmission corneal transplantation millions of Americans each year are traveling to Creutzfeld-Jakob tropical countries. We must also remember new po- disease in recipients of pulations at risk, such as renal and cardiac trans- human growth hormone 3 VOJENSKÉ ZDRAVOTNICKÉ LISTY - SUPLEMENTUM Volume LXVIII, 1999, no. 1 As recently as 20-30 years ago, none of the en- plays a relatively minor role, although for other con- tities Shown On the left-hand Side of the balance ditions, Such as infection with Chlamydia tracho- was part of our medical vocabulary. While acquiring matis, sexual transmission is the major route of many new afflictions, we got rid of one very old one acquisition. - Smallpox. NOW - YEARS AGO IN OUT AIDS AIDS Smallpox Scabies Babesiosis Amebiasis Lassa fever Giardiasis Lyme disease Shigellosis Toxic shock sy Salmonellosis Infant botulism Hepatitis B, G/?l Kawasaki disease Chlamydia infection Rotavirus diarrhea Campylobacteriosis LGV Chlamydia pneumonia Ureaplasma urethritis Syphilis Hepatitis C, D, E, G Cytomegalovirus Gonorrhea Legionnaires’ disease infection Campylobacter enteritis Herpes genitalis Chancroid and others and others Granuloma inguinale Kawasaki disease, which is probably of infectious Changing Lifestyles and New Populations at Risk etiology, produces in children symptoms of fever, skin Cryptosporidium is a protozoan parasite of the and mucous membrane lesions, lymph node en- gastrointestinal tract that only recently has been largement, and sometimes aneurysms of the coro- identified as a cause of human gastrointestinal nary arteries. Recent evidence has implicated retro- disease. It is common in immunologically normal viruses as a possible etiology for this fascinating persons in whom it produces a self-limiting illness, entity. as was described in the day-care-center outbreak. Legionnaires’ disease, first recognized during the The advancing average age of the population and 1976 epidemic in Philadelphia, is now known to be the growing use of nursing homes has generated a cause of sporadic as well as epidemic pneumonia. another new population at risk. Nursing home out- Another new entry to our medical vocabulary is breaks of influenza, tuberculosis, varicella-zoster, amebic meningoencephalitis, a rare but devastating a variety of diarrheal illnesses, and meningitis have infection of the central nervous system. It affects all been reported. people swimming and diving in freshwater lakes Whirlpools, spas, and hot tubs, which were virtu- and is caused by free-living amebas of the genus ally nonexistent a few years ago, are now
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