Fact Sheet No 97 Revised August 1998

EMERGING AND RE-EMERGING INFECTIOUS DISEASES

New microorganisms capable of causing disease in humans continue to be detected (see e amples in !able 1"# $hether an emerging microorganism develops into a public health threat depends on factors related to the microorganism and its environment% or the infected human and his&her environment# Such factors include ease of transmission between animals and people and among people% potential for spread be'ond the immediate outbrea( site% severit' of illness% availabilit' of effective tools to prevent and control the outbrea(% and abilit' to treat the disease# Some of the new agents detected in the past )* 'ears are now genuine public health problems on a local% regional or global scale# What are emerging infectious iseases! Emerging infectious diseases result from newl' identified and previousl' un(nown infections which cause public health problems either locall' or internationall'# A recent e ample of an emerging disease is the new variant of +reut,feldt-.a(ob disease% which was first described in the /nited 0ingdom in 1991# !he agent is considered to be the same as that causing bovine spongiform encephalitis% a disease which emerged in the 1982s and affected thousands of cattle in the /nited 0ingdom and some other 3uropean countries# 3 amples of emerging diseases associated with viruses and bacteria are4 "iruses#
o

Ebola virus4 !he first outbrea(s occurred in 1971 and the discover' of the virus was reported in 1977# 5ndigenous cases have been confirmed in four countries in Africa (+6te d75voire% 8emocratic Republic of +ongo% 9abon and Sudan"# !hrough .une 1997% 1 2*: cases had been reported to $;<% 7*: of which proved fatal# =on(e's infected with an Asian strain of 3bola were imported from the >hilippines into the /nited States of America in 1989 and 1992% and into 5tal' in 199)# !his Asian strain% 3bola-Reston% does not appear to cause illness in

humans# Human immunodeficiency virus (HIV) 4 !he virus which causes A58S was first isolated in 198?# @' the beginning of .une 1998% the number of A58S cases reported to $;< b' national authorities since the beginning of the epidemic was close to 1#9 million# ;owever% it is estimated that% since the start of the epidemic% ?2#1 million people worldwide have become ;5A infected and nearl' 1) million have died from A58S or A58S-related diseases# Hepatitis C4 5dentified in 1989% this virus is now (nown to be the most common cause of post-transfusion hepatitis worldwide% with appro imatel' 92B of cases in .apan% the /nited States and western 3urope# /p to ?B of the world population are estimated to be infected% among which 172 million are chronic carriers at ris( of developing liver cirrhosis and&or liver cancer# Sin nombre (i#e#% an unnamed" virus was isolated from cases of a local outbrea( of a highl' fatal respirator' disease in the southern /nited States in 199?# 5t has subseCuentl' been diagnosed in sporadic cases across the countr' and in +anada and several South American countries# Influenza A(H5 !) virus4 !his influen,a virus is a well (nown pathogen in birds but was isolated from human cases for the first time in 1997# !he emergence of human influen,a A(;*N1" initiall' followed a possible scenario of the e pected ne t influen,a pandemic but% in the event% the virus transmitted poorl' and the spread of the virus appeared to have been contained in 1997#

$acteria#
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"egionella pneumop#ilia$ !he detection of the bacterium in 1977 e plained an outbrea( of severe pneumonia in a convention centre in the /SA in 1971 and it has since been associated with outbrea(s lin(ed to poorl' maintained air conditioning s'stems# Esc#eric#ia coli <1*74;7$ 8etected in 198)% this bacterium is t'picall' transmitted through contaminated food and has caused outbrea(s of haemol'tic uraemic s'ndrome in North America% 3urope and .apan# A widespread outbrea( in .apan in 1991 caused over 1 222 cases among school children% among whom two died# 8uring a single outbrea( in Scotland in 1991% :91 people fell ill% of whom 11 died#

%orrelia burgdorferi$ 8etected in the /SA in 198) and identified as the cause of D'me disease% this bacterium is now (nown to be endemic in North America and 3urope and is transmitted to humans b' tic(s# Vibrio c#olerae <1?9$ First detected in 199) in 5ndia% this bacterium has since been reported in 7 countries in Asia# !he emergence of a new serot'pe permits the organism to continue to spread and cause disease even in populations protected b' antibodies generated in response to previous e posure to other serot'pes of the same organism#

Antimicro%ia& resistance# Another emerging public health issue is the rapidl' growing number of bacteria becoming resistant to an increasing range of antibiotics# 5n man' regions% the low cost% first choice antibiotics have lost their power to clear infections of Esc#eric#ia coli% eisseria gonorr#oea%&neumococcus' S#igella% Stap#ylococcus aureus increasing the cost and length of treatment of man' common diseases including epidemic diarrhoeal diseases% gonorrhoea% pneumonia and otitis# Further problems stem from the use of antimicrobial substances in food animal production# What are re-emerging infectious iseases! Re-emerging infectious diseases are due to the reappearance of% and an increase in% the number of infections from a disease which is (nown% but which had formerl' caused so few infections that it had no longer been considered a public health problem# C#olera$ +holera has been re-introduced into countries and continents where it had previousl' disappeared% and where it can spread because water and sanitation s'stems have deteriorated and food safet' measures are not adeCuate# 5n 1991% the 7th cholera pandemic reached the Americas where cholera had not been registered for a centur'# 5n that 'ear% over ?92 222 cases were notified in over 12 South American countries% which altogether accounted for )&? of the number of cases notified in the world# 5n 1997% cholera outbrea(s chiefl' affected 3astern Africa and% while the overall numbers have declined since 1991% there were still over 1:7 222 cases reported globall' in 1997# 5n 1998% the epidemic spread over eastern and southern Africa and new outbrea(s occurred in South America# (engue fever$ 8engue fever has spread in man' parts of South-3ast Asia since the 19*2s and re-emerged in the Americas in the 1992s following deterioration in active mosCuito control and spread of the

vector into urban areas# 5nfection with dengue virus has often resulted in dengue haemorrhagic fever (8;F" in Asia% but rarel' in the Americas until a severe outbrea( in +uba in 1981# 8engue haemorrhagic fever has since spread and during the epidemics in +entral and South America in 199*-1997% 8;F was reported in ): countries# (ip#t#eria$ 8iphtheria re-emerged in the Russian Federation and some other republics of the former Soviet /nion in 199: and culminated in 199* with over *2%222 cases reported# !he reemergence was lin(ed to a dramatic decline in the immuni,ation programmes following the disruption of health services during the unsettled times immediatel' after the brea(-up of the Soviet /nion# Since then immuni,ation services have been re-established% reversing the upward trend4 in 1991% 1? 187 cases were reported in the Russian Federation# )eningococcal meningitis4 =eningococcal meningitis occurs worldwide but devastating% large-scale epidemics have mainl' been in the dr' Sub-Saharan regions of Africa% designated the EAfrican meningitis beltE# Since the mid 1992s% epidemics in this area have been on an unprecedented scale and epidemic meningitis has also emerged in countries south of the Emeningitis beltE# A new strain of eisseria meningitidis (serogroup A clone 555#1"% which was first seen in the 1982s in Nepal and +hina% has spread west and has now been diagnosed in maFor meningitis outbrea(s in Africa# *ift Valley fever (*V+)4 RAF is a ,oonotic disease t'picall' affecting sheep and cattle in Africa# =osCuitoes are the principal means b' which RAF virus is transmitted among animals and to humans# >ersons in contact with sic( animals occasionall' become infected# !he disease in humans is t'pified b' fever and m'algia but% in some cases% progresses to retinitis% encephalitis or haemorrhage# Following abnormall' heav' rainfall in 0en'a and Somalia in late 1997 and earl' 1998% RAF occurred over vast areas% producing disease in livestoc( and causing haemorrhagic fever and death among the human population# !he e tent of the outbrea( and the severit' of the disease was probabl' due to man' factors% including climatic conditions% malnutrition and% possibl'% route of infection# ,ello- fever (,+)$ GF is an e ample of a disease for which an effective vaccine e ists but% because it is not widel' used in man' areas at ris(% epidemics continue to occur# !he threat of GF is present in ?? countries in Africa and eight in South America# Since the mid-1982s there has been a stead' increase in the number of cases or countries

reporting cases (up to * ?22 per 'ear worldwide"% 'et the true number of cases occurring could be man' times higher% as outbrea(s in general occur in remote areas and miss the attention of health services# GF is t'picall' a disease of the tropical forest areas where the virus survives in mon(e's# ;umans bring it bac( to their villages and if a suitable mosCuito vector is present% the disease will spread Cuic(l' and (ill a large proportion of the population% which has no immunit'# What causes emergence or re-emergence of infectious iseases! Several factors contribute to the emergence and re-emergence of infectious diseases% but most can be lin(ed with the increasing number of people living and moving in the world4 rapid and intense international travelH overcrowding in cities with poor sanitationH substantiall' increased international trade in food% mass distribution of food and unh'gienic food preparation practicesH increased e posure of humans to disease vectors and reservoirs in natureH and alteration of the environment and climatic changes which have a direct impact on the composition and si,e of the population of insect vectors and animal reservoirs# <ther factors include a deteriorating public health infrastructure which is unable to cope with the needs of the population# !ravel has alwa's been a vehicle to spread disease across the world# According to data from the $orld !ourism <rgani,ation% over **2 million travellers were counted at national borders in 199* and over 117 million of them had crossed continents to arrive at the destination# Duc(il'% the vast maForit' of infections brought along with travellers are common worldwide and the disease is more a nuisance to the traveller than to societ'# !he traveller can avoid man' health ris(s with vaccines% protective measures against malaria and good personal h'giene (for more details% see International .ravel and Healt#% issued b' $;< each 'ear and accessible from $;<=s website - http4&&www#who#ch&emc&"# W'O(s Res)onse Since 199)% alarm over emerging and re-emerging diseases has resulted in a number of national and international initiatives to restore and improve surveillance and control of communicable diseases# 5n 199*% a resolution of the $orld ;ealth Assembl' ($;A" urged all =ember States to strengthen surveillance for infectious diseases in order to promptl' detect re-emerging diseases and identif' new infectious diseases# !his resolution led to $;<7s establishment of the 8ivision of 3merging and other +ommunicable 8iseases Surveillance and +ontrol (3=+"% whose mission is to strengthen national and

international capacit' in the surveillance and control of communicable diseases% including those that represent new% emerging and reemerging public health problems#

Ta%&e *# E+am)&es of )athogens recogni,e since *-./

0ear 197? Micro%e Rotavirus Disease =aFor cause of infantile diarrhoea globall' Acute and chronic diarrhoea 3bola haemorrhagic fever Degionnaires disease ;aemorrhagic fever with renal s'ndrome 3nteric diseases distributed globall' !-cell l'mphoma-leu(emia

1971 1977 1977 1977 1977 1982

Cryptosporidium parvum 3bola virus "egionella pneumop#ilia ;antaan virus Campylobacter /e/uni ;uman !-l'mphotropic virus 1 (;!DA-1" !o in producing strains ofStap#ylococcus aureus Esc#eric#ia coli <1*74;7

1981

!o ic shoc( s'ndrome

198)

;aemorrhagic colitisH haemol'tic uraemic s'ndrome ;air' cell leu(emia D'me disease A58S >eptic ulcer disease 3ntericall' transmitted non-A% non-@ hepatitis Aene,uelan haemorrhagic fever +onFunctivitis% disseminated disease

198) 198) 198? 198? 1988

;!DA-55 %orrelia burgdorferi ;5A Helicobacter pylori ;epatitis 3

1992 1991

9uanarito virus Encep#alitozzon #ellem

199)

Vibrio c#olerae <1?9

New strain associated with epidemic cholera +at-scratch diseaseH bacillar' angiomatosis @ra,ilian haemorrhagic fever >arenterall' transmitted non-A% non @ hepatitis Associated with 0aposi sarcoma in A58S patients New Aariant +reut,feldt-.a(ob disease 5nfluen,a

199)

%artonella #enselae

199: 199*

Sabia virus ;epatitis 9 virus

199*

;uman herpesvirus-8

1991 1997

!S3 causing agent Avian 5nfluen,a I!'pe A (;*N1"J

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