Old Infections in New Clothes

Old Infections in new clothes

Hiten Thaker Consultant in Infection Hull and east Yorkshire Hospitals NHS Trust 1985, At the Infectious Diseases Society of America's “the millennium where fellows in infectious disease will culture one another is almost here”

Dr. William H. Stewart was the US Surgeon General during 1965–1969 [1]. Despite his significant accomplishments, Dr. Stewart is remembered primarily for his infamous statement: “It is time to close the book on infectious diseases, and declare the war against pestilence won”

US Department of Health & Human Services. Office of the Surgeon General: William H. Stewart (1965–1969). Petersdorf RG. Whither infectious diseases? Memories, manpower, and money. J Infect Dis 1986;153:189-95 . 1985, At the Infectious Diseases Society of America's “the millennium where fellows in infectious disease will culture one another is almost here”

Dr. William H. Stewart was the US Surgeon General during But maybe that was not true ! 1965–1969 [1]. Despite his significant accomplishments, Dr. Stewart is remembered primarily for his infamous statement: “It is time to close the book on infectious diseases, and declare the war against pestilence won”

US Department of Health & Human Services. Office of the Surgeon General: William H. Stewart (1965–1969). Petersdorf RG. Whither infectious diseases? Memories, manpower, and money. J Infect Dis 1986;153:189-95 . In 1947, scientists researching yellow fever placed a rhesus macaque in a cage in the Zika Forest (zika meaning "overgrown" in the Luganda language), near the East African Virus Research Institute in Entebbe, Uganda.

The monkey developed a fever, and researchers isolated from its serum a transmissible agent that was first described as Zika virus in 1952

DISEASE MANIFESTATIONS Acute Rash Syndrome

• About 1 in 5 people infected with Zika virus become ill. • The most common symptoms of Zika are fever, rash, joint pain, or red eyes. • Other symptoms include muscle pain, headache, pain behind the eyes, and vomiting. • The illness is usually mild with symptoms lasting for several days to a week. • Severe disease requiring hospitalization is uncommon.

It is clear that increases in the incidence of the Guillain–Barré syndrome to a level that is 2.0 and 9.8 times as high as baseline, as we have reported here, im- pose a substantial burden on populations and health services in this region.

Boeuf et al. BMC Medicine (2016) 14:112 DOI 10.1186/s12916-016-0660-0

ZIKA IN UK AND TRAVEL Zika cases diagnosed in the UK ZIKV does not occur naturally in the UK. However, as of 23 November 2016, 263 travel- associated cases have been diagnosed since 2015.

Of these, 178 are confirmed cases including: 134 cases with virus detected [PCR positive] 44 cases with antibody evidence indicating recent infection [seroconversion]

85 cases that have antibody evidence highly indicative of recent infection (Zika-specific IgM) [probable cases]. Region of travel Total Caribbean 188 South America 33 Central America 33 North America* 2 Oceania 1 South-Eastern Asia 1

Total 263 *The cases acquired in North America had travelled to the high risk area of Miami-Dade County in Florida

The majority of Zika cases in the UK have travelled to the Caribbean and South and Central America.

More than two-thirds of cases have travelled to the Caribbean. The largest number reported travel to Barbados (43), followed by Jamaica (37), St Lucia (21), Grenada, and Trinidad and Tobago – all countries popular with UK travellers

GOV.UK

Home (https://www.gov.uk/)

Guidance Zika virus: preventing infection by sexual transmission

From: Public Health England (https://www.gov.uk/government/organisations/public-health-england) Part of: Zika virus (ZIKV): clinical and travel guidance (https://www.gov.uk/government/collections/zika-virus-zikv-clinical-and-travel-guidance) First published: 26 January 2016 Last updated: 23 November 2016, see all updates

Guidance on the likelihood of sexual transmission of Zika virus and ways to prevent this.

Contents

Risk of Zika virus sexual transmission Recommendations for prevention Individuals at greatest Zika virus risk All other individuals Last possible Zika virus exposure Further information

Risk of Zika virus sexual transmission

The greatest likelihood of acquiring Zika virus infection is from travelling to a country with high or moderate Zika virus risk (https://www.gov.uk/guidance/zika-virus-country-speciﬁc-risk#atoz). However, sexual transmission of Zika virus is occasionally reported.

While Zika is usually an asymptomatic or mild illness for the majority of people, it presents the greatest risk to the developing fetus. It is therefore imperative that women who are pregnant take enhanced measures to avoid exposure to Zika virus (https://www.gov.uk/guidance/zika-virus-travel-advice#pregnant-women- and-their-male-partners-who-are-planning-to-travel), including during sexual contact.

Women who are planning a pregnancy or are of child-bearing age and who may be exposed to Zika virus (either through travel or from their sexual partner), should also take enhanced precautions to prevent pregnancy and exposure to the virus during the speciﬁed risk periods (see below).

Recommendations for prevention GOV.UK

Home (https://www.gov.uk/) Barrier method options recommended for preventing Zika

Guidance virus transmission include male or female condoms for Zika virus: preventing infection by sexual penetrative sex (including sex toys) and male or female condoms or dental dams for oral-genital or oral-anal transmission sexual contact. Sex toys should not be shared. To increase

From: Public Health England (https://www.gov.uk/government/organisations/public-health-england) their effectiveness barrier methods should be used Part of: Zika virus (ZIKV): clinical and travel guidance consistently and correctly, for the entire duration of sexual (https://www.gov.uk/government/collections/zika-virus-zikv-clinical-and-travel-guidance) First published: 26 January 2016 contact. Last updated: 23 November 2016, see all updates Guidance on the likelihood of sexual transmission of Zika virus and ways to prevent this.

Contents

Risk of Zika virus sexual transmission Recommendations for prevention Individuals at greatest Zika virus risk All other individuals Last possible Zika virus exposure Further information

Risk of Zika virus sexual transmission

Recommendations for prevention GOV.UK

Home (https://www.gov.uk/) Barrier method options recommended for preventing

Guidance Zika virus transmission include male or female Zika virus: preventing infection by sexual condoms for penetrative sex (including sex toys) and male or female condoms or dental dams for oral- transmission genital or oral-anal sexual contact. Sex toys should not

From: Public Health England (https://www.gov.uk/government/organisations/public-health-england) be shared. To increase their effectiveness barrier Part of: Zika virus (ZIKV): clinical and travel guidance methods should be used consistently and correctly, for (https://www.gov.uk/government/collections/zika-virus-zikv-clinical-and-travel-guidance) First published: 26 January 2016 the entire duration of sexual contact. Last updated: 23 November 2016, see all updates

Guidance on the likelihood of sexual transmission of Zika virus and ways to prevent this.

Contents

Risk of Zika virus sexual transmission Recommendations for prevention Individuals at greatest Zika virus risk All other individuals The Sun Last possible Zika virus exposure Further information ZIKA WARNING UPDATE Brits visiting Florida warned against having unprotected sex and sharing their sex toys over Zika Risk of Zika virus sexual transmission virus threat The greatest likelihood of acquiring Zika virus infection is from travelling to a country with high or moderate Zika virus risk (https://www.gov.uk/guidance/zika-virus-country-speciﬁc-risk#atoz). However, sexual Warning comes as Public Health England raises threat level of transmission of Zika virus is occasionally reported. Brits catching virus in range of global holiday destinations

Recommendations for prevention History of syphilis

• Syphilis brought through by Christopher Columbus • Pre-Columbian evidence of treponemal disease abounds in cemeteries in both the New and Old World , with diagnoses given for what were perceived to have been isolated individuals with periosteal reaction. Over 240 skeletons exhumed at the site of a medieval friary in Hull. It is claimed that some 60% of the skeletons show leg bone changes compatible with a diagnosis of syphilis. Three skeletons show a variety of bone changes indicative of syphilis. Carbon dating of one of these three skeletons states that it was alive more than 100 years before Columbus's voyage in 1492–3.

Sex Transm Infect 2001;77:322-324 doi:10.1136/sti.77.5.322“The syphilis enigma”: the riddle resolved? R S Morton1, S Rashid2 Mozart Died of Mercurial poisoning Beethoven Sensorineural deafness a manifestation of Paganini Mercurial poisoning and Osteonecrosis Neurosyphilis

Schubert In spring 1823, he was admitted to the Vienna General Hospital Schumann noted himself: “In again with a rash and 1831, I was syphilitic and was hair loss, and it is cured by arsenic believed that he suffered from recurrent secondary syphilis Hidden fields

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Learn more about books on Google Play Incidence of syphilis in the Russian Federation, Belarus, Estonia, Kazakhstan, Moldova, and Ukraine: 1980 to 2004. ... from around 5/100000 in 1990 to as much as 170/100 000 in 1996, a rate 34 times higher than those seen in Western ... World Health Organization (WHO) Regional Office for Europe and the European Surveillance of Sexually Transmitted ... Germany England Norway Sweden Austria Spain Ireland Year R a t e p e r 1 0 0 0 0 0 p o p u l a t i o n essti.org). are mainly ... The epidemiology of syphilis has been influencedLoading... by bksenbjcycxFpqEpublicwm8zvFMOGo healtLoading... development s in the HIV epidemic and behavioral public healtchange in MSM. ... proportion of heterosexual cases acquired abroad is similar to that seen in the mid-1990s when incidence was low. TheGoodPublic for: Health and Infectious Diseases edited by Jeffrey Griffiths, James H. Maguire, Kristian Heggenhougen, Stella R. Quah ABOUT THIS BOOK Features: incidence• MyHANGOUTSWeb library of EvenMSEARCHMAPSYOUTUPLAYNEWSGMAILDRIVECALENDGOOGLE+TRANSLATPHOTOSSHOPPINGFINANCEDOCSBOOKSBLOGGECONTACTSY ACCOUNT BE AR R E more from Google congenitalMore •Flowing text Sign in syphilisPages•MyTablet History is displayed / iPad by permission of Elsevier . Copyright. 0 ReviewsWrite review Books on Google Play •Scanned pages related• eReader to the prevalenceTerms of Service Help with devices & formats •ClearSmartphone search Result 1 of 5 in this book for public health england syphilis in 1990s | pagesrelevance | pages- ‹ Previous Next › - View all infectious syphilis within the population. ... In the UK, the emergence of infectious syphilis in the late 1990s was characterized by a series of outbreaks and foci (Simms et al., ... In Western Europe by contrast, syphilis incidence remained relatively stable through the 1990s, but since the end of the decade there ... Outbreaks of infectious syphilis have been seen in major cities in Europe, North America, and Australia, which are mainly focused on ... In the UK, the number of cases associated with Eastern Europe has been small, and the proportion of heterosexual cases acquired ... Although the vast majority of congenital syphilis cases are seen in developing countries, congenital syphilis also occurs in ... In the UK, the emergence of infectious syphilis in the late 1990s was characterized by a series of outbreaks and foci ... EBOOK FROM £38.60 Get this book in

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Whilst numbers of infectious syphilis diagnoses are at their highest since the mid-1950’s the character of the underlying epidemics has changed substantially.

The current syphilis epidemic has a high proportion of primary and secondary cases which indicates that infection is detected and managed at an earlier stage of infection. In turn this has led to the virtual elimination of sequelae and vertical transmission.

Nevertheless, the re- establishment of syphilis as an endemic infection reflects a failure of control strategies.

Over the decade 2003 to 2012 diagnoses of infectious syphilis (primary, secondary and early latent) made at genitourinary medicine (GUM) clinics in England increased by 61% (from 1688 to 2713) in men , of which 2061 were in MSM, Outbreaks • Whilst many of these have been focussed on MSM, several have been seen amongst heterosexuals who typically have been less than 19 years of age. • In common with diagnoses in MSM a high proportion of sexual partners were anonymous which reduces the effectiveness of partner notification (PN). • Finding and treating cases and their partners has been a control priority and has been achieved by rolling out syphilis testing to young people’s clinics,. INFLUENZA

1918 H1N1

• The virus of 1918 was undoubtedly uniquely virulent, although most patients experienced symptoms of typical influenza with a 3- to 5-day fever followed by complete recovery. • Nevertheless, although diagnostic virology was not yet available, bacteriology was flourishing and careful post- mortems actually disclosed bacterial pathogens in the lungs • Bacterial superinfection as in other virus diseases was the cause of death. This information is important in considering the question of "will there ever be another 1918

1957: Asian Influenza (H2N2)

• After the influenza pandemic of 1918, influenza went back to its usual pattern of regional epidemics of lesser virulence in the 1930s, 1940s, and early 1950s. • The virus from humans was identified in 1933. • The pandemic of 1957 was the first time the rapid global spread of a modern influenza virus was available for laboratory investigation. • It was shown that the virus alone, without bacterial coinfection, was lethal

Swine Flu

• in April 2009, the virus appeared to be a new strain of H1N1 which resulted when a previous triple re-assortment of bird, swine and human flu viruses further combined with a Eurasian pig flu virus, leading to the term "swine flu” • Unlike most strains of influenza, H1N1 does not disproportionately infect adults older than 60 years; this was an unusual and characteristic feature of the H1N1 • Even in the case of previously very healthy people, a small percentage developed pneumonia and ARDS.

In adults:

Difficulty breathing or shortness of breath Pain or pressure in the chest or abdomen Sudden dizziness Confusion Severe or persistent vomiting Low temperature

In children:

Fast breathing or working hard to breathe Bluish skin color Not drinking enough fluids Not waking up or not interacting Being so irritable that the child does not want to be held Flu-like symptoms which improve but then return with fever and worse cough Fever with a rash Being unable to eat Having no tears when crying J.S. Nguyen-Van-Tam, P.J.M. Openshaw, A. Hashim, et al. (2010). "Risk factors for hospitalisation and poor outcome with pandemic A/H1N1 influenza: United Kingdom first wave (May–September 2009)"

Influenza virus People infected Estimated deaths Pandemic Year Case fatality rate type (approximate) worldwide

Spanish flu 1918–1919 A/H1N1 33% (500 million) 50–100 million] 2-3%

Asian flu 1956–1958 A/H2N2 ? 1-4 million <0.2% Hong Kong flu 1968–1969 A/H3N2 ? 1-4 million <0.2%

5–15% mainly A/H3N2, 250,000–500,000 Seasonal flu Every year (340 million – <0.1% A/H1N1, and B per year 1 billion)

Pandemic 18,500 (lab- Swine flu 2009–2010 10-200 million H1N1/09 confirmed; 1976: According to the WHO, there were two outbreaks that occurred simultaneously in Nzara, Sudan, and Zaire (Democratic Republic of Congo)

The first person acquiring Ebola infection was from Yambuku, Zaire on September 1, 1976.

Within the few weeks 17 other cases emerged and the doctors declared it was an unknown disease.

A Beligian nurse who got infected was moved to Kinshasa for treatment, but unfortunately the virus spread to 11 other healthcare workers there.

On October 13, 1976 the virus was finally isolated. By then, the death toll had touched 280 in Zaire and 151 in Sudan 1979: 34 people in in Sudan got infected and 22 were killed..

1994: The outbreak occurred in Gabon, where gold-mining camps were located deep in the rain forest. It infected 52 people, killing 31 of them.

1995: This was again a major outbreak after several years. It affected 315 people from Zaire, killing 250. The fatality rate was highest (81%) after the first outbreak in 1976.

2000-2001: The outbreak occurred for the first time in Uganda The virus infected 425 people, killing 224.

2007-2008: A new strain of Ebola had emerged, infecting 149 people in Bundibugyo.

March 2014-till present: Between 2009 and 2013, there were few cases being reported in Uganda and Zaire. Ebola virus epidemic in West Africa Total cases: 17,145 Total deaths: 6,070 This was a crucial period in the Ebola timeline as rapid diagnostic testing for Senegal Mauritania Ebola was provided by the new CDC Viral Cases: 1 Hemorrhagic Fever laboratory installed Deaths: 0 Mali Cases: 8 Niger at the Uganda Viral Research Institute Gambia (UVRI). Deaths: 6 Burkina Faso The current, on-going Ebola outbreak in Guinea- Guinea West African countries is reported to Bissau Cases: 2,164 Benin Nigerihavea begun in Guinea in December Deaths: 1,327 2013, where a 2-year-old child and his Sierra Leone Togo family members acquired the infection. Cases: 7,312 Côte d’Ivoire Ghana Deaths: 1,583 The WHO declared it as the most severe and deadliest outbreak till now. Liberia

Cases: 7,635 Ebola outbreak 2014 was officially Deaths: 3,145 30 November 2014 notified as a public international health emergency on August 8, 2014.

June 2016 -- WHO declares the end of Ebola virus transmission in the Republic of Guinea and in Liberia. Forty-two days have passed since the last person confirmed to have Ebola virus disease tested negative for the second time. Guinea and Liberia now enter a 90-day period of heightened surveillance to ensure that any new cases are identified quickly before they can spread to other people. Winnipeg lab employee possibly exposed to Ebola virus Ebola nurse banned for hiding Pauline Cafferkey's BBC News-8 Nov 2016 high temperature An employee at the National Centre for Foreign Animal BBC News-25 Nov 2016 Disease in Winnipeg has potentially been exposed to the A senior nurse found to have concealed the true Ebola virus. The employee ... temperature of Ebola survivor Pauline Cafferkey has Canadian lab worker possibly exposed to Ebola from pigs been suspended for two months. Daily Mail-8 Nov 2016 Nurse who risked British Ebola outbreak by hiding Ebola adapted to easily infect people colleague's high ... BBC News-3 Nov 2016 In-Depth-Daily Mail-25 Nov 2016 Ebola dramatically adapted to infect human tissues with Ebola nurse 'dishonestly concealed high ease in the first few months of the 2014-15 outbreak, temperature' research suggests. Two studies ... BBC News-23 Nov 2016 Ebola's West African Rampage Was Likely Bolstered by a A nurse accused of falsifying the temperature of Mutation Ebola-infected colleague Pauline Cafferkey has been Highly Cited-Scientific American-3 Nov 2016 found to be dishonest in her actions. Ebola nurse Donna Wood had unblemished record, Doctors in US, Africa Work to Contain Future Ebola tribunal hears Outbreaks The Guardian-24 Nov 2016 Voice of America-21 Nov 2016 After Ebola: Sierra Leone battles back from the brink Thousands of people died during the Ebola epidemic in West a year on from ... Africa, but as memories fade and concerns about future Mirror.co.uk-25 Nov 2016 outbreaks of that ... The horrific Ebola virus killed thousands in the worst Ebola may have mutated to better infect humans: study outbreak the world has seen when it hit West and The Hindu-20 Nov 2016 Central Africa in 2014 ANTHRAX Anthrax became the first human disease attributed to a specific etiological when Koch showed it to fulfil his "postulates" in 1877. Cutaneous anthrax - Gastrointestinal anthrax- The most common naturally occurring form - 95% of Oropharynegeal anthrax anthrax cases in developed countries. Oral or eosophageal ulcer - regional Exposed areas on the arms and hands followed by face lymphadenopathy, oedema and sepsis and neck Abdominal anthrax Predominantly terminal ileum Pruritic papule ulcer surrounded by vesicles black necrotic or cecum. Nausea, vomiting, malaise progressing central eschar. to bloody diarrhea, acute abdomen and sepsis. After 1 - 2 weeks, eschar dries, loosens, separates, leaving Mortality rate is high. a permanent scar. Regional lymphangitis and lymphadenitis and systemic symptoms. Mortality rate for untreated disease - 20%.

Respiratory anthrax Inhalational anthrax follows deposition of spore-bearing particles Clinical presentation shows a biphasic pattern - non specific symptoms followed by fever, dyspnoea, diaphoresis and shock. Morality rate is 80 - 90%, when untreated. Aggressive, early antimicrobial therapy and improved supportive care improves prognosis.

Early in 2010, a small outbreak of anthrax occurred in the United Kingdom and Germany. All of the patients who came to the hospital were illicit drug users who had used heroin before having symptoms.

Anthrax in these patients did not look like typical cutaneous anthrax.

Many had swelling and infection of the deeper layers of skin but they didn’t have a raised sore with a black center – the tell- tale sign of cutaneous anthrax.

Doctors recognized this anthrax as a new type of anthrax, calling it injection anthrax.

While no anthrax was found in the heroin itself, the evidence gathered by epidemiologists strongly suggested that was anthrax was in the heroin.

General Register office for Scotland: Drug related deaths in Scotland in 2008. Edinburgh. 2009 EXANTHEMA IN A CHILD

Vaccination rates fell year-on-year in England between 1995-96 and 2003-04. A particularly significant decline was observed between 2000 and 2004, which can arguably be attributed to deterioration in public confidence about the safety of MMR. Health Protection Agency (2010). HPA National Measles Guidelines: Local and Regional Services.

Andrew Wakefield published a paper in The Lancet suggesting a link between the MMR vaccine and the development of autistic spectrum disorders in children

Lancet 2004 363:750, Source: Economic and Social Research Council survey (2003):Towards a better map: science, the public and the media 8 Source: OECD Health Data 2008 10

Confirmed Measles

2002 319 (316) Upto 2015 2003 437 (393) 2004 188 (178) 2005 78 (78) Year Measles 2006 740 (736) 2030 2007 990 (977) 2012 2008 1370 (1331) (1912) 2009 1144 (985) 1843 2013 2010 380 (372) (1413) 2011 1087 (1068) 2014 121 (103) 2012 2030 (1912) 2013* 1843 (1413) 2015* 91 (91) PHE (March 2016). ‘Laboratory confirmed cases of measles, mumps and rubella, England: January to March 2016’, HPR 10(18): immunisation. 2. Measles clusters in London and East of England, HPR 10(10): news, 11 March 2016 Is Measles changing once again

• In England, 167 new measles infections were confirmed in the second quarter of 2016 compared to 67 in the first quarter (first half of the year to 234). • Four times higher than the same period in 2015 (54 cases) and more than twice as high as 2014 (87 cases) • 47% of the measles diagnoses in England were in adults (aged ≥19 years), the majority of whom were born abroad and unimmunised . • 39% hospitalised in the first half of 2016 cf 2015 (26%) and 2014 (22%), reflecting the larger proportion of adults affected. • Only nine (5%) of the cases reported this quarter were in children under the age of one.

PHE (March 2016). ‘Laboratory confirmed cases of measles, mumps and rubella, England: January to March 2016’, HPR 10(18): immunisation. 2. Measles clusters in London and East of England, HPR 10(10): news, 11 March 2016

ANTIBIOTIC RESISTANCE

Multiply resistant Klebsiella from blood cultures Carbapenem resistant Klebsiella from blood cultures E coli resistant to 3rd gen cephalosporins from blood cultures - ESBLs

Joint Statement on Antimicrobial Resistance

The UK Faculty of Public Health (FPH), the Royal College of Physicians (RCP), the Royal Pharmaceutical Society (RPS), the Royal College of Nursing (RCN) and the Royal College of General Practitioners (RCGP)

Summary of recommendations

Local level National level International level

1. Healthcare and public 6. Antimicrobial 9. Concerted action is health professionals need stewardship data should needed to reinvigorate the to take personal be monitored and development of new responsibility for enabling incorporated into outcome antibiotics changes in culture around measures antibiotics prescribing

2. Healthcare and public 7. Licensing of new 10. Preventive health professionals have antimicrobials should programmes to reduce the a professional duty to help include minimum dosage burden of infection also educate patients and the information reduce the burden of public in minimising the antimicrobial resistance use of unnecessary and need to be supported antibiotics

3. Antimicrobial 8. Labelling of foods that stewardship should be a use antibiotics as growth recognised quality marker promoters should be for local health systems mandated to give the

public informed choice 4. Commissioners in about this issue England should ensure optimal antimicrobial prescribing

5. Equivalent bodies in devolved nations should also take on this leadership role

3 Conclusion

• Waves of infections • What we know we are loosing control – Loss of control or mutational change with different disease manifestation • What we don’t know…...... we don’t know. • Continue to be a part of the global village – Future variations and mutations “It is time to close the

book on infectious diseases, and declare the war against pestilence won” (1967)

“If we don’t act now, any one of us could go into hospital in 20 years for minor surgery and die because of an ordinary infection that can’t be treated by antibiotics. And routine operations like hip replacements or organ transplants could be deadly because of the risk of infection”. (2016) The End