Overview of Infectious Disease Risk in Asia

Emerging Infectious diseases E.coli O157 Echinococcosis Lassa fever Yellow fever Ebola haemorrhagic fever O’nyong-nyong fever Human Monkeypox Cholera 0139 Dengue haemhorrhagic fev

Overview of Infectious Disease

Risk in Asia

A Short-term Training on Molecular Epidemiology of Infectious Diseases

January 12, 2017 Tohoku University Graduate School of Medicine

Hitoshi OSHITANI, MD, MPH, PhD

What is emerging infectious

An emerging disease is one that has appeared

in a population for the first time, or that may

have existed previously but is rapidly increasing

in incidence or geographic range

(World Health Organization)

Emerging Infectious diseases

E.coli O157

Echinococcosis Lassa fever

Yellow fever

Ebola haemorrhagic fever

O’nyong-nyong fever Human

Monkeypox

Cholera 0139

Dengue haemhorrhagic fever

Influenza A(H5N1)

Cholera RVF/VHF nvCJD

Ross River Virus

Equine morbillivirus

Hendra Virus

BSE

resistant

Multidrug-Salmonella

E.coli non-O157

West Nile Virus Malaria

Nipah Virus Reston Virus

http://chssp.ucdavis.edu/programs/historyblueprint/maps/medieval-map#blackdeathanch

Emerging diseases are not completely new, but…

Increasing risk of emerging

• Increasing risk of appearance of

emerging diseases

• Increasing risk of global spread of

emerging infectious diseases

Increasing human population

UNEP

Increasing risk of global spread of

emerging infectious diseases

Wikimedia Commons

World airline route map

Emerging Infectious Diseases as a Global Issue

All in 1995

WHO Actions for Emerging Diseases

WHO Western Pacific Regional Office (WPRO),

Manila Philippines

From 1999-2005

In charge of Emerging Disease Program

E Coli )157 (1996) HFMD (1997)

WHO/WPRO

Avian Influenza A(H5N1) in Hong Kong,1999

Nipah Virus in Malaysia, 1998-9

FAO: Manual on the Diagnosis of Nipah Virus Infection in Animals

WHO/WPRO

Major Outbreaks in WPR after 2000

(2009) H5N1 (2003-)

MERS (2015) Avian Influenza

What are differences between outbreaks

in 1990’ and after 2000?

Confirmed Human Cases of H5N1

1997

Hong Kong (18)

Total cases：18 , total deaths：6

Confirmed human cases of H5N1

Bangladesh (8)

Total cases：85 6, total deaths：452

Data source: WHO

Indonesia (199)

Iraq (3)

Laos (2) Myanmar (1)

Nigeria (1)

Pakistan (3) Thailand (25) Turkey (12)

Vietnam (127)

Confirmed cases of Nipah Virus Infection

Singapore (11) Malaysia (265)

Total cases：276 , total deaths：106

Reported probable cases of SARS

Philippines (14) Indonesia (2)

Total cases：8, 096, total deaths：774

Data source: WHO

Human cases of Influenza A(H1N1) in Hong

Kong 1997

New Technologies in 21st Century

New Technologies in 21st Century

Tohoku Medical Megabank

Application of Next Generation Sequencing

Tohma K et al 6 th International Calicivirus Conference, 2016

• New technologies are a powerful tool in

controlling emerging diseases in 21st Century, But,

• They don’t solve all problems

Severe acute respiratory syndrome (SARS) in 2003 ： How the first major emerging disease outbreak in

Public Health Image Library (PHIL), CDC

WHO・SARS Preparedness and Response Team

Philippines (14) Indonesia (2)

Total cases：8, 096, total deaths：774

Data source: WHO

Outbreak of SARS in Guangdong Province

Sporadic

cases

Epidemic in Guangzhou

Initial SARS Cases in Guangdong Province,

Znong NS et al Lancet, 362, 2003

Feb 11, 2003

Dr Keiji Fukuda, CDC, USA

Dr Masato Tashiro,

NIID, Japan

Mr Alan Schnur, WHO, China

Dr Hitoshi Oshitani WHO, Manila

Feb 28, 2003

March 5, 2003

March 10, 2003

Global Alert

‘Knowns’ and ‘Unknowns’ when WHO issued

•  Knowns

1)  Mysterious pneumonia outbreaks

in Guangdong, Hong Kong, Hanoi

•  Unknowns

1)  Cause (virus, bacteria or ???) 2)  Transmission mode???

3)  Any links between Guangdong,

Hong Kong, Hanoi???

4)  Effective control measures??? 5)  Effective treatment???

6)  Case fatality ratio???

7)  Overall impact???

8)  When outbreaks would end

(months, years, forever)???

, and more………

A major concern when WHO issued Global Alert

•  If these three outbreaks are linked and caused by the same causative agent, it might have already spread

to other counties

Best case scenario

Three unlinked localized outbreaks

Most likely scenario

Linked outbreaks cased by the same causative agent with

some further spread to neighboring areas

Worst case scenario

Outbreaks have already spread to many countries

March 13, 2003

March 14

•  Report from Canada

•  Seven suspect cases (two deaths) in Toronto

•  Two separate extended family (one each had travel history to Hong Kong

March 15

•  New York to Frankfurt

•  A health care worker from Singapore

•  Had close contact with patients in Singapore

•  Visiting New York and boarded a flight from New York

to Frankfurt on March 15

•  Isolated in Frankfurt

•  Two family members and one flight attendant were infected

March 15, 2003

Worst Case Scenario??

Epidemiological link identified

•  Singapore: Reported that the index cases

stayed at M hotel in Hong Kong

•  Toronto and Vancouver: Identified cases also stayed at M hotel in Hong Kong

•  Hospital outbreak in Hong Kong was linked to

M hotel in Hong Kong

•  Hanoi: Initially the link not identified, later found that the index case also stayed at M hotel in

Hong Kong

WHO/WPRO: SARS How a global epidemic was stopped

Index case from Guangdong

F G

E D C J

H A

Extensive epidemiological investigations

and super-spreading events

•  Extensive and comprehensive epidemiological

investigations conducted by national / local health authorities

•  Unprecedented international collaboration and

information exchange

WHO/WPRO: ‘SARS How a global epidemic was stopped’

Flight Associated Transmission

Beijing

Flight Hong Kong – Beijing March 15

The first WHO travel advisory

Transmission of SARS in Singapore

MMWR May 9, 2003 / 52(18);405-411

Index case for SGH cluster

MMWR May 9, 2003 / 52(18);405-411

Transmission of SARS in Singapore

March 29, 2003

Dr Urbani and Global Alert

Dr Urbani and Global Alert

Probable cases of SARS by week of onset

First cases in

Guangdong

Outbreak in Guangdong

M Hotel

removed from the list

Multi-country Outbreaks

How SARS was contained without vaccines and antiviral drugs (even without diagnostic tests in early

stage)?

Active Case Finding

Find all possible cases

Isolation

Isolate all possible cases in appropriate isolation

facilities

Contact Tracing

Actively find all close contacts

Quarantine

Isolate all close contacts

Isolation

Isolate all cases in appropriate isolation facilities as

soon as close contacts develop symptoms

Basic containment strategy for

Ebola Virus Disease Outbreak in West

Participating WHO Liberia Ebola Response Team

•  November 14 – December 5

　 Deputy Technical Coordinator

　 Coordination of County Level

Activities

•  December 6 – December 22

　 Acting Technical Coordinator

Coordination of All Technical Teams　

The Lancet Infectious Diseases 2015 15, 320-326DOI: (10.1016/S1473-3099(14)71075-8)

Copyright © 2015 Elsevier Ltd Terms and Conditions

Analysis of chain of transmission

MMWR May 15, 2015 / 64(18);500-504

Basic containment strategy for

MERS outbreak in South Korea (2015)

Lee SS & Wong NS Int J Infect Dis 2015

Lessons learnt from major outbreaks

in 21st century

•  A risk of emerging diseases is increasing

•  We have many new technologies to fight against these emerging disease threats

•  Conventional and basic approaches such as

epidemiological investigations are still critical

especially in early stage of outbreak

Dr Carlo Urbani on Mekong River