Microbial Threats – What’s Next?

RADM Ali S. Khan, MD MPH

Deputy Director National Center for Zoonotic, Vectorborne,and Enteric Diseases (NCZVED)

Assistant Surgeon General, US Public Health Service

EBOLA-RESTONPHILIPPINES 2008

ARENAVIRUS OUTBREAK ZAMBIA-SOUTH AFRICA 2008

Death Rates for Typhoid Fever in the U.S.

Ra

te p

er

100

.00

0

Po

pu

lati

on

Year

0

8

16

24

32

1900 1910 1920 1930 1940 1950 1960

Examples of Emerging and Re-emerging Infectious Diseases

Factors in Emergence

• Genetic and biological factors– Microbial adaptation and change– Human susceptibility to Infection

• Physical environmental factors– Climate and weather– Economic development and land use

• Ecological factors– Changing ecosystems– Human demographics and behavior

• Social, political, and economic factors– International Travel and commerce– Poverty and Social inequity– War and Famine– Lack of political will– Intent to harm

Woesian Tree of Life

3.5 Billion 90% of all life 30 generation in a day Transposons & plasmids

The Age of Microbes

The Zoonotic ‘Pool’*

• Assume 50,000 vertebrates, each with 20 endemic viruses. There are likely 1 million vertebrate viruses

• Only 2,000 or so identified, so 99.8% of vertebrate viruses remain to be discovered

*Morse, 1993

Speed of Global Travel in Relation toWorld Population Growth

Wor

ld P

opula

tion in

bill

ions

(

)

Day

s to

Circ

umna

v iga

te (

)

th

e G

lobe

Year1850

0

400

350

300

250

200

150

100

50

2000

0

1900 1950

1

2

3

4

5

6

Incubation periods

• Plague - 2-6 days• Yellow fever - 3-6 days• Cholera - 1-3 days • Influenza - 1-4 days • Ebola - 2-21 days • Polio - 7-14 days • Pertussis - 7-14 days • Measles - 9-12 days • Smallpox - 7-17 days • Chicken pox - 14-16 days • Mumps - 14-18 days • Rubella (German measles) - 14-21 days

SARS Clusters Linked to Hotel M

Hotel MHong Kong

B

B

Singapore

34 HCW

United States

1 HCW

I, L,M

I,L,M

Vietnam

37 HCW

KIreland

0 HCWK

Guangdong Province,

China A

A

H,J

A

H,J

Hong Kong SAR

95 HCW

>100 close contacts

F,G

Canada

18 HCWF,G

C,D,E

C,D,E

West Nile Virus in the Western Hemisphere

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence,by County, US, 2000

N=19

WNV Neuroinvasive Disease Incidence,by County, US, 2001

N=64

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence,by County, US, 2002

N=2946

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence, by County, US, 2003

N=2866

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence, by County, US, 2004

N=1142

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence,by County, US, 2005

N=1294

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence,by County, US, 2006

N=1339

* Reported as of November 7, 2006

Incidence per million.01-9.99

10-99.99

>=100

Any WNV activity

WNV Neuroinvasive Disease Incidence,by County, US, 2007*

N=1213N=1213

You said it was ONLY a virus!

Nature. February 2008; vol 451(21)

Global Distribution of Relative Risk of an EID

Event

zoonotic pathogens from wildlife zoonotic pathogens from non-wildlife

drug-resistant pathogens vectorborne pathogens

Physical and Environmental

Factors

Physical and Environmental

Factors

Ecological Factors

Ecological Factors

Humans

Wildlife

Animals

E I DE I D

Social, Political, and Economic

Factors

Social, Political, and Economic

Factors

Genetic and Biological Factors

Genetic and Biological Factors

Convergence Model

WHO Issues Global Alert 12 March

WHO Issues first travel advisory 15 March

Adapted from the SARS WHO Epidemic Curves [http://www.who.int/csr/sars/epicurve/epiindex/en/index1.html]

African ShipmentArrives April 9

Purchased by Illinois ShopApril 21

6

Identification of the Etiologic Agent of SARS

Spec

Isolation studies – unknown (3-18), adenovirus

PCR for respiratory viruses- Rhino+ (3-15)+, HMPV+ (3-19)

Consensus PCR – herpes+, paramyxovirus+

Antigen detection, PCR for bacterial pathogens

Histopathologic studies

EM – paramyxovirus-like structures

Conference call consultation (3-19)

Isolation material to UCSF for multiple array studies (3-22)

EM+

A-C+

PCR+

Seq

Anti-v

New

CoV

Thu

3-13

Fri

3-14

Sat

3-15

Sun

3-16

Mon

3-17

Tue

3-18

Wed

3-19

Thu

3-20

Fri

3-21

Sat

3-22

Sun

3-23

ArboNet: Capturing Human and Animal Data

BioPHusion: Information Fusion

“The compelling message is that sustained global disease surveillance

is a basic public health necessity because ongoing interactions among humans,

animals, and the environment will inevitably lead to disease emergence or re-

emergence and the impact of disease reverberates throughout national and

global social, economic, and trade systems.”

Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin. Workshop Report

Lessons Learned from Recent Outbreaks:

Support a Global Strategy

Focus on Prevention & Preparedness as Foundation of Response

Build New Collaboration between Human and Animal Health• Integration of surveillance, diagnostic, and information systems• Incorporate pathogen discovery and risk-based focus• Adopt a “One Health” mindset and strategy

Infectious Disease Ecology Centers & Distributed Networks• Establish R&D prototypes at various interfaces• Design scalable strategies for successful prototypes• Shift “up-stream” for earlier detection and intervention• Meet local/national needs• Multi-disciplinary partners and public-private partnerships• Proactive communications• Identify political barriers & be transparent

Nipah Virus

What’s Next?

The Perfect Microbial Storm: Chikungunya

A report of 270 people infected with Chikungunya in Ravenna, Italy

A Virus from Africa (an alphavirus – Chikungunya) A mosquito from Asia (Aedes albopictus: tiger

mosquito) A tourist from India (1.25 million human cases in

2006)

What’s Next?

Thank You !

RADM Ali S. Khanask0@cdc.gov 404.639.7377

www.cdc.gov/nczved/blogThe views and conclusions of this report are those of the authors and do not

necessarily represent the views of the CDC.

Acknowledgements

• Dr. Lyle Petersen

• Dr. Jim Leduc

• Dr. Thomas Ksiazek

• Dr. Peter Daszak

• Dr. Kate Glynn

• Dr. Robert Swanepoel

• Sarah Nystrom