Emerging Infectious Avian Influenza H5N1 Diseases • Endemic in domestic poultry in certain areas • Sporadic human infection from direct contact 2008 with infected poultry and/or wild birds • Person-to-person spread of H5N1 virus from William E. Maher, MD has been very rare, limited and unsustained Ohio State University Medical Center • No evidence of changes to H5N1 to increased transmissibility to or among humans, but infection seen in some mammals Emerging Infectious Avian Influenza H5N1 Diseases - Global View • Update on Avian Influenza A/H5N1 • H5N1 resistant to amantadine and rimantidine, but sensitive to Oseltamivir and • Upsetting the balance Zanamivir • Things that shouldn’t be there • Some Oseltamivir resistant strains reported • Things we weren’t aware of • No available vaccine, work in progress • Unanticipated (but maybe not unexpected) changes 1 Epidemiologic Findings in Malaria Human H5N1 Cases Dominican Republic • Thailand, 2004: limited spread in a family from prolonged and • 1999-2000 outbreak, Hurricanes Mitch and George very close contact. No transmission beyond one person. • 2004, Hurricane Jeanne, Punta Cana • Vietnam, 2004: fatal case presented with fever, diarrhea and seizures, and was initially diagnosed as encephalitis. • Heavy rains and flooding, increased mosquitoes • Vietnam, 2005: Infection via ingestion of raw duck blood. • Malaria-infected migrant workers • Azerbaijan, 2006: teenagers infected by contact with wild dead • 3,000 malaria cases reported in 1999 birds (swans) removing feathers from the birds. • Indonesia, 2006: 8 people in one family were affected, with 7 • 1,500-2,500 malaria cases now reported annually deaths. No further spread outside of the exposed family was documented or suspected. • Europeans in Punta Cana All inclusive resorts, never left the grounds • Vietnam, 2006: high viral concentration and elevated inflammatory cytokine levels in fatal cases. Inflammatory • CDC recommend chloroquine prophylaxis for response appears to be implicated in the pathogenesis travelers to La Altagracia and Duarte provinces. Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO 2003 2004 2005 2006 2007 2008 Total Country death death death death cases deaths cases deaths cases cases cases deaths cases cases s s s s Malaria risk area in Azerbaijan 0 0 0 0 0 0 8 5 0 0 0 0 8 5 Dominican Republic: Cambodia 0 0 0 0 4 4 2 2 1 1 0 0 7 7 China 1 1 0 0 8 5 13 8 5 3 3 3 30 20 Rural, with highest risk Djibouti 0 0 0 0 0 0 1 0 0 0 0 0 1 0 Egypt 0 0 0 0 0 0 18 10 25 9 7 3 50 22 in provinces bordering Indonesia0 0 0 02013554542371613133108 Haiti. In addition, risk in Iraq00000032000032 Lao all areas of La People's 00000000220022 Democratic Altagracia Province, Republic Myanmar0 0 0 000 0 0 1 0 0010 including resort areas. Nigeria0 0 0 000 0 0 1 1 0011 Pakistan 0 0 0 0 0 0 0 0 3 1 0 0 3 1 Thailand 0 0 17 12 5 2 3 3 0 0 0 0 25 17 Turkey 0 0 0 0 0 0 12 4 0 0 0 0 12 4 Viet Nam 3 3 29 20 61 19 0 0 8 5 5 5 106 52 Total 4 4 46 32 98 43 115 79 88 59 31 24 382 241 2 Malaria in Kingston, Jamaica • Fall 2006, confirmed malaria cases, Kingston, Jamaica where Malaria Great Exuma transmission does not normally occur • Ant malarial drugs recommended. • February 29, 2008 CDC removed temporary recommendation for malaria preventive medication (prophylaxis) for travel to Kingston Jamaica. • Kingston continues to experience rare cases of malaria, but the risk to travelers appears to be minimal. Recommendations for Celebrities Who Own Travelers to Great Exuma Islands in the Exumas • Repeated instances of chloroquine-sensitive Plasmodium falciparum malaria occurring in travelers to the island of Great Exuma • Nicolas Cage • Ongoing, low-level risk of malaria for people traveling to the island. • Faith Hill and Tim McGraw • CDC recommends that travelers to Great Exuma, Bahamas take chloroquine malaria preventive medication (prophylaxis) • David Copperfield • There is currently no known risk of malaria on other islands of the Bahamas; therefore, • Johnny Depp prophylaxis is not necessary for those islands 3 Chikungunya Fever in Italy Chikungunya Fever in Italy • In Swahili Chikungunya: illness of the • CHIKV 1st Isolated in Tanzania in 1953 bended walker • African countries, Indian subcontinent, SE Asia. • Fever, arthralgia, myalgia, headache and diffuse maculopapular rash. • Outbreaks: India, Comoros and La Réunion islands in the SW Indian Ocean in early 2005 • Symptoms 4–7 days after bite • During these outbreaks, travelers from • Arthralgia is often severe, persistent industrialized countries became infected with • 12% of patients have chronic arthralgia 3 CHIKV and were still infected on returning home. years after onset of illness • Aedes albopictus—a vector of CHIKV—was introduced a number of years ago and is now • Chikungunya is transmitted by Aedes aegypti widespread in Italy or A. albopictus 85% of the cases were confirmed by either serology or PCR. Lancet. 2007 Dec 1;370(9602):1805-6 Lancet. 2007 Dec 1;370(9602):1805-6 4 Chikungunya Fever in Italy • Outbreak of a tropical disease in a non- tropical area • Index case had recently traveled to an endemic area (India) to visit relatives • Vector infestation traced to imported tires from a tire retreading company that had imported used tires infested with mosquito eggs from Georgia, USA. • Other Diseases: Malaria, Yellow Fever, Dengue, ? MMWR August 10, 2007 / Vol. 56 / No. 31 Dengue in Texas Autochthonous Malaria • Dengue noted in 5 Texas border counties since 1980. • Inadvertent carriage of infective Anopheles mosquitoes by airplane, ship, • Survey in Brownsville, Texas, and baggage, or bilge water may be Matamoros, Tamaulipas, Mexico (n = 600), responsible for these occurrences. in 2004 to assess dengue seroprevalence. • Also, large populations of migrants from • Recent dengue infection was detected in areas highly endemic for malaria may act 2% and 7.3% of residents in Brownsville as human reservoirs for potential and Matamoros, respectively. gametocyte carriers. • Past infection was detected in 40% of • Outbreaks of mosquito borne malaria in Brownsville residents and 78% of areas of New Jersey, New York, and Texas Matamoros residents. 5 Norovirus • Most common cause of infectious gastroenteritis among persons of all ages • Responsible for 50% of all food-borne gastroenteritis outbreaks in the United States • Major problem cruise ships, nursing homes and hospitals • Detected in 35% of persons with sporadic gastroenteritis and in 14% of all children < 3 years old hospitalized for gastroenteritis. • Cause of chronic diarrhea among transplant patients • Diagnostic PCR available at CDC and State Health Dept. • ? Emerging due to lifestyle changes vs. better tests EID Vol 2, No. 1—January-March 1996:37-43 Outbreaks of Acute Gastroenteritis: Settings 2006 Norovirus • Short, self-limited illness Setting Number of Outbreaks • As few as 100 virus particles thought to Cruise ships 37 infectious Long-term care 37 • Stable in the environment and can survive facilities freezing and heating to 60°C (140°F). Restaurants 13 • Transmission to the oral mucosa via hand Hospitals 7 contact with materials, fomites, and environmental surfaces contaminated with feces Colleges 3 or vomitus Parties 3 • May be food borne or waterborne Other 26 • Susceptible to chlorination Total 126 6 Prevention of Norovirus Chagas Disease Transmission Trypanosoma cruzi in The USA • American trypanosomiasis • Endemic to Central and South America • Hand hygiene with alcohol-based hand gels; 9 Romaña’s Sign 9 Megacolon • Disinfect surfaces: 1:10-50 dilution 9 Megaesophagus chlorine bleach 9 Cardiomegaly. • Do not return to work or school for 24 9 Reduvid Bug Vector to 72 hours after symptoms resolve • Rare Transmission 9 IVDA 9 Transfusion Photo courtesy of CDC Prevention of Norovirus Chagas Disease Transmission Range and Vector • During outbreaks 9 Use contact precautions Triatoma sanguisuga 9 Avoid sharing staff members between units or facilities with affected patients 9 cluster symptomatic patients 9 instruct visitors on hand hygiene 9 close affected units to new admissions and transfers Photo courtesy of CDC 7 Chagas Disease • Cases of Chagas disease reported in the United States 93 in infants in Texas 91 in an infant in Tennessee 91 in a 56-year-old woman in California 91 in Louisiana 2006 • Vector in the USA is Triatoma sanguisuga, Photograph courtesy South Florida NRC Chagas Disease Wildlife, Exotic Pets, and Emerging Zoonoses • T. cruzi has been identified in Photos courtesy of CDC 9>18 species of mammals 9raccoons, opossums, armadillos, foxes, skunks, dogs, wood rats, squirrels, and nonhuman primates • Lack of human cases in USA 9Lack of habitat for the bugs in most US homes 9a preference for animal hosts 9delayed defecation of triatomines found in the US compared with those found in Latin America. ►May 22 – Child hospitalized because of festering lesions, fever, sweats, ocular discharge, and new skin lesions. 8 April, 2003 800 rodents from Ghana 200 Native Prairie Dogs 510 Dormice 53 rope squirrels 47 tree squirrels 2 brush-tailed 50 Gambian porcupines giant rats 100 striped mice Illinois Photos courtesy of CDC Distributor Photos courtesy of CDC Wildlife, Exotic Pets Monkeypox and Emerging Zoonoses • In 1958, monkeypox was noted as a viral disease that is found mostly in the rainforest countries of central • Petting zoos linked to Escherichia coli and west Africa. Laboratory studies showed that the O157:H7, salmonellae, and Coxiella burnetii virus could also infect rats, mice, and rabbits. • Salmonellosis from a Komodo dragon exhibit • In 1970, monkeypox was identified as the cause of a rash illness in humans in remote African locations. • Twelve elephant handlers infected with M. tuberculosis, and 1 with active disease • In early June 2003, monkeypox was reported among after 3 elephants died of tuberculosis.