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The Challenges of Communicable Diseases

The Challenges of Communicable Diseases. Dr Christopher KC Lee Infectious Diseases Unit Department of Medicine Sungai Buloh Hospital Malaysia. Global Leading causes of Death 2002. WHO 2004. Dr Margaret Chan Director-General, WHO 3 rd . April 2007.

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The Challenges of Communicable Diseases

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  1. The Challenges of Communicable Diseases Dr Christopher KC Lee Infectious Diseases Unit Department of Medicine Sungai Buloh Hospital Malaysia

  2. Global Leading causes of Death 2002 WHO 2004

  3. Dr Margaret ChanDirector-General, WHO3rd. April 2007 “The forces of globalization have changed the epidemiology of emerging and epidemic-prone diseases. From 1973 through 2003, when SARS appeared, 39 pathogenic agents capable of causing human disease were newly identified. You will recognize the names of some: Ebola, HIV/AIDS, and the organisms responsible for toxic shock syndrome and legionnaire’s disease. Others include new forms of epidemic cholera and meningitis, Hanta virus, Hendra virus, Nipah virus, H5N1 avian influenza and, of course, SARS. All of this within 30 years.”

  4. Healthcare associated: MRSA MRSE VRE VISA ESBL producing Gm-ve organisms Multidrug resistant Acinetobacter MDR-TB Community: HIV Pandemic / Avian Flu SARS Foodborne diseases Vector borne [malaria, dengue, West Nile] Hepatitis B & C Legionnaire’s disease Pathogens of bioterrorism Emerging Pathogens Center of Disease Control, USA

  5. Methicillin Methicillin-resistant S. aureus (MRSA) [1970s] Vancomycin [1997] [1990s] [ 2002 ] Vancomycin Vancomycin-resistant Vancomycin- resistant S. aureus intermediate- enterococci (VRE) resistant S. aureus (VISA) Evolution of Drug Resistance in S. aureus Penicillin Penicillin-resistant S. aureus [1950s] S. aureus

  6. Bacterial Resistance: An increasing threat to the successful treatment of nosocomial infections • VRSA • Carbapenem resistant Enterobacter/Klebsiella • MDR Pseudomonas/Acinetobacter • ESBL’s resistant to quionolones, aminoglycosides & piperacillin/tazobactam • Options for treatment are diminishing

  7. Antibiotic Resistance: The Global Perspective Klebsiella pneumoniae cefotaxime resistance Germany 1983 Enterococcus faecium vancomycin resistance France 1988 Enterococcus faecium oxazolidinoneresistance USA 2001 Vancomycin intermediate Staphylococcus aureus (VISA) Japan 1996 Neisseria meningitidis penicillin resistance Spain 1988 Salmonella typhimultiresistance India 1990 Staphylococcus aureus vancomycin resistance (VRSA) USA 2002 Shigella dysenteriae multiresistance Burundi 1992 Neisseria gonorrhoeae penicillin resistance The Philippines 1976 Vibrio cholerae multiresistance Ecuador 1993 Streptococcus pneumoniae multiresistance South Africa 1977 Streptococcus pneumoniae penicillin resistance Australia 1967

  8. Vancomycin-Resistant Enterococci Resistance (%) Year Fridkin SK et al. Clin Chest Med. 1999;20:303-316.

  9. Re-emergence of Gram-negative Organisms in Nosocomial Bacteraemia (US data) * % organisms among total isolates *p<0.001 (from 1999 to 2003) Albretch, et al. Arch Intern Med 2006;166:1289–1294

  10. What is driving increasing prevalence of antibiotic resistant pathogens? • The selection of resistant mutants by antibiotic exposure • The transfer of genetic determinants of resistance between bacterial strains • The clonal spread of resistant bacteria among hospitalised patients within and between institutions and community (poor infection control) • Collateral damage

  11. BAD BUGS – FEW NEW DRUGS Introduction of New Antibiotic Classes Lipopeptides e.g Daptomycin Streptogramins Quinolones Chloramphenicol Tetracyclines Cephalosporins Macrolides Glycopeptides Monobactams, fosfomycin Aminoglycosides Carbapenems Penicillins Oxazolidinones e.g linezolid Sulphonamides 1930´s 1940´s 1950´s 1960´s 1970’s 1980´s 1990´s 2000´s

  12. Key Strategies • Prevent infection • Diagnose and treat infection effectively • Use antimicrobials wisely • Prevent transmission Clinicians hold the solution! CDC, USA

  13. 12 Steps in Addressing Nosocomial Infections:

  14. Communicable Diseases Outbreaks: Lessons learnt & Preparing for … • Major Social implications: HIV, SARS • High Mortality: Nipah Encephalitis • Endemic (recurrent): Dengue, Typhoid • Endemic (new manifestations): Leptospirosis • Global Implications: Avian Flu  Pandemic Influenza: Are we prepared?

  15. Estimated number of people living with HIV globally, 1986–2006 50 Million 40 Number of people living with HIV 30 20 10 0 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 Year

  16. HIV prevalence in adults in Asia, 1990−2005

  17. Adults & children estimated to be living with HIV, 2006 Eastern Europe & Central Asia 1.7 million [1.2 – 2.6 million] Western & Central Europe 740 000 [580 000 – 970 000] North America 1.4 million [880 000 – 2.2 million] East Asia 750 000 [460 000 – 1.2 million] Middle East&North Africa 460 000 [270 000 – 760 000] Caribbean 250 000 [190 000 – 320 000] South & South-East Asia 7.8 million [5.2 – 12.0 million] Sub-Saharan Africa 24.7 million [21.8 – 27.7 million] Latin America 1.7 million [1.3 – 2.5 million] Oceania 81 000 [50 000 – 170 000] Total: 39.5 (34.1 – 47.1) million

  18. Estimated number of adults and children newly infected with HIV, 2006 Eastern Europe & Central Asia 270 000 [170 000– 820 000] Western & Central Europe 22 000 [18 000 – 33 000] North America 43 000 [34 000 – 65 000] East Asia 100 000 [56 000 – 300 000] Middle East & North Africa 68 000 [41 000 – 220 000] Caribbean 27 000 [20 000 – 41 000] South & South-East Asia 860 000 [550 000 – 2.3 million] Sub-Saharan Africa 2.8 million [2.4 – 3.2 million] Latin America 140 000 [100 000 – 410 000] Oceania 7100 [3400 – 54 000] Total: 4.3 (3.6 – 6.6) million

  19. Estimated adult and child deaths from AIDS, 2006 Eastern Europe & Central Asia 84 000 [58 000 – 120 000] Western & Central Europe 12 000 [<15 000] North America 18 000 [11 000 – 26 000] East Asia 43 000 [26 000 – 64 000] Middle East & North Africa 36 000 [20 000 – 60 000] Caribbean 19 000 [14 000 – 25 000] South & South-East Asia 590 000 [390 000 – 850 000] Sub-Saharan Africa 2.1 million [1.8 – 2.4 million] Latin America 65 000 [51 000 – 84 000] Oceania 4000 [2300 – 6600] Total: 2.9 (2.5 – 3.5) million

  20. Over 11 000 new HIV infections a day in 2006 • More than 95% are in low and middle income countries • About 1500 are in children under 15 years of age • About 10 000 are in adults aged 15 years and older • of whom: • almost 50% are among women • about 40% are among young people (15-24)

  21. Cummulative HIV infectionsMalaysia 1993-2006 Year Malaysia 30/6//06

  22. National Strategic Plan 2006 • Endorsed by the Cabinet in April 2006

  23. Main Objectives in NSP • Strengthening Leadership & Advocacy • Training & Building Human Capital • Reducing Vulnerability of Drug users • Reducing Vulnerability of Women & Children • Reducing Vulnerability of other High Risk groups eg. CSW, MSM. • Increasing Access to Treatment, Care & Support In support of the UNGASS (AIDS) declaration

  24. Strengthening Leadership & Advocacy • 3 tiered policy making structure within government • Cabinet Committee on AIDS chaired by the Deputy Prime Minister • National Advisory Committee on AIDS chaired by the Minister of Health • Technical Committee on AIDS chaired by the DG of Health Broad platform of engagement Multisectoral esp. non-health sector

  25. Nipah Encephalitis Malaysian origin • Nipah virus; Zoonotic infection: first isolated in 1999, named after location it was first detected in Malaysia. • Caused disease in animals, & in humans through contact with infected animals. • Outbreak of encephalitis in Malaysia, (initially in Ipoh then Bukit Pelanduk) from Sept 98-April 99. A total of 265 people infected, of whom 105 died, & 93% of cases had a history of occupational exposure to pigs. • An associated outbreak among abattoir workers in S’pore in March 99: 11 cases, with 1 death. These workers had been handling pigs imported from outbreak areas in Malaysia.

  26. Nipah: a public health concern • Although both Nipah and Hendra, a closely related zoonotic virus isolated in Australia (1994), have caused only a few focal outbreaks, their biologic property to infect a wide range of hosts and to produce a disease causing significant mortality in humans has made this emerging viral infection a public heath concern. Both Nipah & Hendra: members of the virus family Paramyxoviridae.

  27. Nipah virus Natural Host Certain species of fruit bats are natural hosts of both Nipah & Hendra viruses. Distributed across an area encompassing northern, eastern & south-eastern areas of Australia, Indonesia, Malaysia, the Philippines & some Pacific Islands. Bats appear to be susceptible to infection with these viruses, but do not themselves become ill. It is not exactly known how the virus is transmitted from bats to animals.

  28. Transmission: Nipah virus Mode of transmission from animal - animal, & from animal to human is uncertain. Appears to require close contact with tissue or body fluids from infected animals. Nipah Ab have been detected in pigs, other domestic & wild animals. Role of other species in transmitting infection to other animals not yet determined. Nipah not easily transmitted to man. Despite frequent contact between fruit bats & humans; no serological evidence of human infection among bat carers. Pigs: apparent source of infection among human cases in M’sia. Human-to-human transmission of Nipah virus has not been reported.

  29. Clinical features: Nipah encephalitis • Incubation period: between 4 - 18 days. • Many cases mild or inapparent (sub-clinical). • In symptomatic cases, onset usually with "influenza-like" symptoms, with high fever & muscle pains (myalgia). • Disease may progress to encephalitis; with drowsiness, disorientation, convulsions & coma. • 50%percent of clinically apparent cases die.

  30. Learning Points: • Early & accurate surveillance crucial • Early identification of pathogen would have resulted in earlier control of outbreak‘giving a name for my pain” • Multisectoral cooperation important in dealing with large outbreaks‘ ’working together’ • Risk communication esp.with regards to media.‘control the panic’ • Preparedness of hospitals to deal with patient burden:‘’no learning curve’

  31. Severe Acute Respiratory Syndrome (SARS)

  32. WHO Disease Outbreak(11/7/2003) • SARS first recognised on 26/2/03 in Hanoi, Vietnam • Causative agent identified as novel type of coronavirus. Main symptoms /signs include high fever (>38 °C), cough, SOB or breathing difficulties. A proportion of patients with SARS develop severe pneumonia; some of whom needed ventilator support. • As of 11/7/2003, total of 8437 cases with 813 deaths reported from 30 countries.

  33. SARS in Singapore Rapid spread: 200 cases in 6 weeks

  34. Nature Total Admission Health care workers of Hospitals/Clinics and medical students 386 Patients, family members & visitors 1369 Total admission 1755 SARS in Hong KongDeaths: 299 Probables: 1755(22/7/2003) (Up till 22/7/2003)

  35. Infection Control….. our lifesaver

  36. Learning Points: Malaysia’s report card: 5 cases No local transmission • External infective source ‘learning from others’ • Triage at nation’s entry points • Designated hospitals ‘controlling interface’ • Protection of HCWs: most vulnerable possible reservoir surveillance • Isolation facilities: grossly inadequate improvisation • Effective media relations ‘structured access’

  37. Leptospires • Tightly coiled spirochetes • Requires special media to grow • Very slow grower

  38. Epidemiology • Source of infection • From direct or indirect contact of urine of an infected animal • Maintenance hosts (reservoirs) • Infection is endemic • Transferred from animal to animal by direct contact • Chronic infection of the renal tubules of infected animals with intermittent renal excretion • Different species can be reservoirs for different serovars • Accidental / Incidental hosts

  39. Risk factors for Infection • Occupational • Direct contact – livestock farmers, veterinarians • Indirect contact – sewer workers, soldiers, miners, rice field workers • Recreational • Water sports • Activities of daily care • Walking bare foot in damp conditions • Gardening with bare hands • Dogs, rats

  40. Leptospirosis: clinical pyramid

  41. Old Foe – new presentation • 19 yr old Malay male admitted on 17/5/05 in Melaka GH, with 1 week - fever & sore throat. Cough initially with whitish sputum, became blood stained 3 days before admission. Had dyspnoea pleuritic chest pain 1 day prior to admission. • H/O going to Air Terjun Lata Kijang in Perak a week before onset. On admission, Temp 39oC, No jaundice. Required ventilation on the same day of admission for severe pulm hemorrhage. • CXR: diffuse alveolar shadows relatively sparing apices. Hb 10g/dl, TWC 8.5x109/L, Platelet 128x109/l, Creat 113mmol/l, ALT 32U/L, APTT ratio 0.99, INR 1.03. • Treated initially as severe CAP - Clarithromycin & Ceftriaxone. Dengue IgM, SARS antibody test, Mycoplasma & HIV serology -ve. • However his Leptospiral serology was positive, 1:840. • Commenced C. pencillin. Improved & was extubated on 2.06.05

  42. Pulmonary hemorrhage • Several reports of leptospirosis presenting as pulmonary hemorrhage from Taiwan, UK, USA, India, Brazil and tropical areas of Australia • In Peru, 7 patients with histories of only urban exposure to leptospirosis had severe pulmonary manifestations • Clin Infect Dis, 2005. 40(3): p. 343-51. • In Seychelles (Indian Ocean), 19% of the patients had pulmonary hemorrhage • Am J Trop Med Hyg, 1998. 59(6): p. 933-40.

  43. Avian Influenza: Toll 2003-07 • Cumulative cases: • 319 cases • 192 deaths Mortality: 60% 25th. July 2007

  44. Objectives of strategic actions

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