Environmental Influences on Increases in Infectious Diseases

Implications for Prevention

A.J. McMichael National Centre for Epidemiology and Population Health The Australian National University Canberra

Outline
1. Context
Recent upturn in pestilence? [the biblical Fourth Horseman]
Emergence and Resurgence

2. Environmental-Change Influences on IDs

Road-map: many interconnections Future (scenario-based) risks

3. Adaptive/Preventive strategies

1. Context
Microbes Making Merry?

World Health Report (WHO), 2007 4 Key Conclusions re Infectious Diseases

Many new infectious diseases emerging: >1/year since 1970s H5N1 bird flu, SARS; also Ebola, Marburg, Nipah viruses >40 new infectious diseases that were unknown 3 decades ago A flu pandemic could affect >1.5 billion people Recent come-backs by cholera, yellow fever, epidemic meningococcal disease (and dengue and ? malaria) Growing menace of anti-microbial resistance Notably drug-resistant TB (incl XDR TB)

Emerging Infectious Diseases Definition

Infections that have newly appeared in the population, and . Existing infectious diseases that are rapidly increasing in incidence or geographic range
Morse SS (1995) Factors in the emergence of infectious diseases, Emerging Infectious Diseases 1: 715.

Emerging and Re-emerging Infectious Diseases .. past 30 years

(US) Inst of Med, 2003

Number of Emerging Infectious Diseases per Decade

(Jones et al, Nature, 2008)

Vector-borne 80 Non-vectorborne

60

No. of EID Events

40

20

1940

1960

1980

2000

2. Environmental and Social Changes

Major Drivers?
Divine retribution Miasmas Germs/contagion Disturbance of ecological relations

Marcus Terentius Varro (36 BCE): An early Germ Theory?

Plague of Athens 430 BCE

Justinian Plague 541 CE

tiny animals (animalia quaedam minuta) that cannot be followed by the eye are transferred through the air to other persons and cause serious diseases

Girolamo Fracastoro, Italy, 1546, proposed role of contagious particles in disease transmission
De Contagione et Contagiosis. Morbis et eorum Curatione:
infection that passes from one thing to another
by contact, on fomites, by air discrete particles that reproduce

Modern Germ Theory, c. 1880

Robert Koch, physician, Germany
1876: The aetiology of anthrax based on the developmental cycle of B. anthracis
Induced/reproduced infection experimentally Showed/recovered organism in tissues
Kochs photomicrographs of B. anthracis

1882: The aetiology of tuberculosis

Pictures from: Prof Lyn Gilbert, Univ Sydney

Integrated Socio-bio-ecological Model of Emergence of Infectious Disease

Genetic and Biological Factors Physical Environmental Factors Microbe

Emergence Human Society: Social, Animal Political and Economic Factors Ecological Factors

Redrawn from Updated Institute of Medicine report on microbial threats, April 2003 www.infectiousdiseasenews.com/200304/micro.asp

Major factors enhancing infectious disease emergence and spread

Population growth and urban density: numbers, crowds, contacts Peri-urban poverty: privation, under-nutrition, unhygienic conditions Urbanization: changes in sexual relations, mobility, mixing, etc. Globalization: distance and speed of travel and trade Intensified livestock production: BSE/vCJD, Nipah virus, bird flu Live animal markets: longer, faster, supply lines SARS, HIV?, etc. Changes to ecosystems: dams, deforestation, biodiversity loss e.g. various new Sth American rural haemorrhagic viral diseases Global climate change Biomedical exchange of human tissues: transfusion, transplants Antibiotic use/misuse: humans, livestock production, house-plants Increased human susceptibility to infection: under-nutrition, population ageing, HIV, IV drug use, etc.

Spread of Bubonic Plague (Black Death) in Europe, mid-14th Century

With the growth of the trade routes across this terrain [Central Asia], the Plague jumped hosts when black rats originating in India proliferated in the towns and caravan markets along the silk road. the Tartars catapulted corpses over the [Jaffa] town ramparts. (Weiss R, 2001)
Map adapted from: World Health Report, 2007

Jaffa

Global Environmental Changes: health risks

Stratospheric ozone depletion Climate change
Skin damage/cancer Eyes (cataracts, etc.) Immune suppression
Based on original, prepared for Earth System Science Partnership (McMichael, 2006)

Direct impacts

Thermal stress: death, disease events, injury Storms, cyclones, floods, fires Sea-level rise: physical hazards, displacement

Land cover (forest, etc) Land use: soils Fresh water: glaciers river flows chemistry

Human predation

Infectious disease risks

Biodiversity changes, & ecosystem disruption
Changes in ecology/numbers of host species, vectors (mosquitoes, etc.)
e.g. pollination
Immune function: susceptibility

Food production: systems/methods

Food yields: nutrition and health

Avian flu, Nipah virus, BSE, etc.

Oceans:
Anoxic zones Algal blooms Warming Acidity (CO2)

Urbanisation: population size, consumerism, energy use, etc.

Marine food web

Poverty, crowding, hygiene; physical hazards; infectious disease risks

Nipah Virus Disease Outbreak in Malaysian Pig Farmers, 1997-1999: forests, fires, fruit, fatalities
Fruit bats (with their virus: ~40% positive)

Fruit orchards

Forest clearing i.e., Infected El Nio drying multiple influences Pig farming Eaten by pigs (sick) pigs Deforestation El Nio conditions Smoke haze Decline in fruit Rain Forest, 265 humans infected: with seasonal JE-like illness fruiting bat ~40% fatal Forest-fire smoke ? diet ~105 deaths

Virus-contaminated fruit, bat droppings

Avian Influenza: generating new viral strains

Changing patterns of poultry-farming, trade and mobility in Southeast Asia traditional mixed subsistence familyfarming,
versus

intensive monoculture industry

Weiss & McMichael, Nature Medicine, 2004

Is climate change increasing the northern limit of Culicoides vectors of Bluetongue virus in Europe?
Northern limit of BTV: 2004 Northern range, C. imicola group: 2004 Northern limit of BTV: < 1998 Northern range, C. imicola group: < 1998

Purse et al, 2005 Nature Reviews Microbiology

3. How Should We Respond?

Research: epidemiology, entomology, virology links Monitoring Surveillance Vector control Public education Vaccination Rapid case detection/treatment Predictive models: impending increases & outbreaks

Ways Forward
1. Discard militaristic models and language
Understand and anticipate the ecology of the microbial world and its Darwinian imperatives Reduce reliance on Weapons of Mass Destruction (antimicrobials, pesticides)

2. Wiser patterns of contact with wilderness and wild species of animals

Important to lessen poverty-driven risk-taking

3. Rehabilitation of One Health thinking

One Medicine, One Health

Ancient concept that both animal health and the environment influence human health. Veterinary medicine, originally, sought to benefit human health by improving the food supply. Late 19th and early 20th centuries: leaders in medicine (e.g. Drs. Rudolf Virchow and William Osler) recognised basic link between human and animal health. 20th century: collaboration between medicine and veterinary medicine waned. 21st century: emergence of deadly zoonotic diseases (e.g. HIV/AIDS, SARS, and West Nile virus) show urgent need to reestablish collaboration.
Kahn LH et al, Am J Med, March 2008