Patologie emergenti e ri-

emergenti, patologie altamente

contagiose e da bioterrorismo

Introduzione

Francesco M. Fusco

INMI “L. Spallanzani”

War and Famine,Bioterrorism threats,

possible importation of HIDs,emerging of new contagious

pathogens,pandemic threats

=Needs for an higher level of knowledge

and preparedness

Emerging Diseases: contributing

factors

• Globalization of travel;

• Human Demographics;

• Close proximity of men to animals;

• General health of a community (e.g. immunosuppressed, unvaccinated);

• Environmental changes (land use, reduction of biodiversity);

• Climate changes;

• Microbial Adaptation and Change;

• Breakdown in Public Health Infrastructure;

• Development of bioterrorist agents;

• Political and social disruption.

World P

opula

tion in b

illions

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Days t

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the G

lobe

Year1850

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350

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250

200

150

100

50

2000

0

1900 1950

1

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Speed of Global Travel in Relation to

World Population Growth

“No city on the earth is now more than 24 hours away from any other”.Economist 2003

“Annually, the world's airlines carry a staggering total approaching some two billion passengers.

At any one moment, about half a million people world-wide are flying in commercial aircraft “ Select Committee on Science and Technology Fifth Report UK Parliament 2000

Recent events have caused policymaker to focus on public health emergencies

– 2001, September 11

– Anthrax crisis

– SARS outbreak

– Marburg contacts (massively exposed) in Italy

– Possible reemerging of Smallpox

– Human adapted Avian Flu

– Several imported VHFs in European countries

– Chikungunya in Italia

Highly Infectious Diseases: a definition

A HID:

• is transmissible from person-to-person,

• causes life-threatening illness,

• presents a serious hazard in health care

settings and in the community,

• requires specific control measures

Agents/Diseases fulfilling the

definition• Viral haemorrhagic fevers: marburgvirus, ebolavirus, Crimean Congo

haemorrhagic fever virus, Lassa virus, and South American haemorrhagic fever (Junin, Machupo, Sabia, and Guanarito) viruses;

• Multi drug- or Extensively drug- resistant M tuberculosis (MDR and XDR-TB) (known or suspected infection)

• SARS Co-V

• Emerging highly pathogenic strains of influenza virus

• Smallpox and other orthopox infections (eg monkeypox)

• Other emerging highly pathogenic, human-to-human transmitted agents, including agents of deliberate release (pneumonic plague)

Focus on Highly Infectious Diseases (HIDs):

why?

• HIDs requires specific procedures and standardized

technical features for safe management in Health Care

Settings;

• HIDs, according to international guidelines, should be

managed in High Isolation Settings according to

“Precaution Principle”;

Health Care Settings: preferential places

for disease transmission

• presence, in the same limited space, of infectious

patients and many susceptible individuals;

• frequent and close contacts among patients and Health

Care Workers (HCWs), often not protected by Personal

Protective Equipments (PPE) because of delayed

diagnosis, or not adequate perception of risk or

shortage of PPE;

• lack of isolation of infectious patients, because of

delayed diagnosis or not-existing of adequate structures.

Modalities of diseases transmission in

Health Care Setting - 1

• Contact:

– Direct: rare but very efficient (scabies, HSV, others)

– Not direct (through hands, instruments, contaminated surfaces): the most frequent (MRSA, HCV, Flu, others)

Modalities of diseases transmission in

Health Care Setting - 2

• Droplets (particles with

diameter larger than 5

μm, produced with cough

and sneeze and not

transported by air more

than 1-2 metres from

source): Bordetella

pertussis, influenza virus,

group A streptococcus,

meningococcus, SARS,

Smallpox, others

Modalities of diseases transmission in

Health Care Setting - 3

• Airborne, through droplet nuclei (particles with diameter smaller than 5 μm, produced with cough and sneeze and transported by air more than 1-2 metres from source):

– Obligate: Tuberculosis

– Preferential: measles, chickenpox

– Opportunistic (in special instances): SARS, Flu

– Rare: smallpox

Modalities of diseases transmission in

Health Care Setting - 4

• Aerosols (dispersion of particles of different dimensions, including those with diameter smaller than 5 μm):

– Are usually produced during “forced” procedures, such as cough and sneezes, but also diagnostic sputum induction, bronchoscopy, endotracheal intubation, and airway suction;

– Increase the risk of airborne transmission (i.e. for SARS)

Misure di isolamento 1996

Contatto

Droplet

Aerea

Precauzioni standard

Misure di isolamento 2006

Standard/

Respiratorie universali

Contatto

Aerea

Modalità di trasmissione: la lezione

della SARS

Contatto

Droplet

Aerea

Secrezioni respiratorie

e grandi goccioline nelle

quali il patogeno può sopravvivere

sulle superfici

Goccioline di dimensioni tali da

essere spinte oltre il metro

Si applicano contemporaneamente tutte le misure previste per l’isolamento in ospedale

usando DPI di più alta efficienza

ALTO ISOLAMENTO

in strutture con caratteristiche tecniche appropriate ad isolare i pazienti affetti da

patologie altamente contagiose

Il bioterrorismo: una amara realtà

Bioterrorism alarms

Development of bioterrorist agents:

• easy to develop (Internet, advancements in

biotechnology),

• relatively inexpensive,

• easy to deliver (Postal System, Aerosol

Dissemination)

1346 CRIMEAN PENINSULA - Tartar attack on Caffa; Plague-

bodies catapulted into the city, causing 2nd epidemic in Europe

1500s CENTRAL/ SOUTH AMERICA - Smallpox and measles accompanying Spanish

conquistadors decimate population

1700s CANADA - Smallpox used by British army in Quebec to infect continental

army

1700 TALLIN

Russian troops use smallpox-blankets attacking Swedish troops

1763 USA - British Gen. Amherst orders blankets from smallpox patients to be

given to Delaware Indians

1928 GENEVA PROTOCOL - Prohibits gas and bacteriological warfare

La realtà – Il bioterrorismo nella storia 1

1939-1945 WW II - Fears of revenges prohibit use of bio-

chemical weapons but not development: experimental infections

of Prisoner of War in Germany and Japan

1950 - US accused of germ use in Korean War

1984 WACO-OREGON, US - Cult followers sprinkle Salmonella on salad bars to

prevent election. 750 cases of food poisoning, 45 required hospitalization

1995 TOKIO, JAPAN

Release of Sarin gas in subway by Aum Shinrikyo cult

12 fatalities commuters, thousands injured

1993 – 1995 The cult insufficiently sprayed botulinum toxin and anthrax

2001, US - Anthrax spores in US mail

22 people infected, five fatalities of pulmonary course

La realtà – Il bioterrorismo nella storia 2

CATEGORY A – DEFINITION

Easily disseminated/ transmitted from person to person

High mortality rates

Have potential for major public health impact

Might cause public panic and social disruption

Require special action for public health preparedness

La classificazione per gli agenti di bioterrorismo

CATEGORY A – LIST OF AGENTS

BACTERIA 1. Anthrax (Bacillus anthracis)

2. Plague (Yersinia pestis)

4. Tularemia (Francisella tularensis)

VIRUSES 5. Smallpox (variola major)

6. Viral hemorrhagic fevers

[Filo- and Arenaviruses]

TOXINES 7. Botulism (Clostridium botulinum toxin)

CATEGORY B – DEFINITION

Moderately easy to disseminate

Result in moderate morbidity rates and low mortality

rates

Require specific enhancements diagnostic capacity

and disease surveillance

CATEGORY B– LIST OF AGENTS

BACTERIA 1. Brucellosis (Brucella species)

2. Glanders (Burkholderia mallei)

3. Melioidosis (Burkholderia pseudomallei)

4. Psittacosis (Chlamydia psittaci)

5. Q fever (Coxiella burnetii)

6. Typhus fever (Rickettsia prowazekii)

VIRUSES 7. Viral equine encephalitis (Alphaviruses)

Quindi, di cosa parleremo? - 1

Patologie altamente contagiose:

•Tubercolosi MDR ed XDR;

• SARS;

• Monkeypox e vaiolo;

• Febbri emorragiche;

Altre patologie emergenti e ri-emergenti:

• Chikungunya;

• West Nile Virus.

Focus su:

• Influenza stagionale, aviaria e pandemica (così facciamo

un po’ di chiarezza…).

Quindi, di cosa parleremo? - 2

Patologie da bioterrorismo non precedentemente trattate:

• Antrace;

• Peste;

• Tularemia;

• Botulismo;

Altro:

• La risposta del sistema sanitario a queste patologie;

• Effetti psicologici del bioterrorismo e delle patologiealtamente contagiose;

• Presentazione del modello di risposta presso l’INMI “L.Spallanzani”.