Internal Medicine & Patient Care

The global medical community is witnessing incredible trends in globalization, increase in population, which provides grounds for emergence and reemergence of viral epidemics throughout the world.  These epidemic can potentially overwhelm the healthcare delivery systems for provision of a comprehensive medical care delivery.  In the past two decades, we have witnessed some of the deadly viral epidemics of the 21st century such as the Ebola virus epidemic in West Africa, the 2009 flu pandemic, dengue fever and Zika outbreak especially in Brazil.  From such outbreaks occurring unpredictably around the world, global health experts acknowledge viruses now have evolved to rapidly cross international borders.     

In 2014, an outbreak of Ebola occurred in West Africa, primarily in Liberia, Sierra Leon and Guinea.  The virus took the lives of more than 11,000 people in three countries.  Recovery from Ebola is dependent on early disease onset, adequate supportive care, and the patient’s immune system.  The virus causes internal hemorrhage and has a remarkable capability to rapidly spread through contact with a miniscule amount of bodily fluid.  In Congo, the epidemic was often transmitted to humans by contact with an infected animal.  Ebola continues to be a threat - the virus has killed 26 people in a recent epidemic in the Democratic Republic of Congo. 

Influenza outbreaks take place during the winter months.  The virus has genetically evolved to continuously modify itself by what is known to be antigenic shift and drift.  In the case of antigenic shift, the virus evades immune system.  Annual fatality of influenza is well established and elderly are more prone to this virus.  Clinical characterization of influenza is well documented in practice of respiratory medicine which are associated with morbidities and mortalities.  The first flu pandemic was recognized in 1918 known as the Spanish flu which killed an estimated 50–100 million people worldwide, and has been referred to as “the mother of all pandemics.”  There have been two major deadly outbreaks namely the 2005 avian influenza - Bird Flu H5N1, and the H1N1 (Swine flu) pandemic of 2009.  Both H5N1 and H1N1 subtypes are highly contagious.  The highly pathogenic avian H5N1 was initially discovered in South Africa in 1961.  Migratory shore birds were determined to be affected by the virus which is often deadly.  In 1997, serious illness occurred in Hong Kong – the H5N1 was responsible for 18 documented cases of severe respiratory illness with 6 cases of fatalities. The affected individuals were investigated to be in close contact with contaminated poultry.  The Spanish flu along with H5N1 and H1N1 have been attributed to produce specific type of cytokine response which is termed cytokine storm with significant mortality.  The H1N1 pandemic occurred on June 2009.  One of the most important lessons of H1N1’s pandemic was its impact on the healthcare system.  There are general consensus worldwide that it had caused the signs of stress in the developing and resource-limited countries.  It overwhelmed the healthcare system especially the intensive care units (ICUs). 

Another medical concern is dengue virus which is an acute febrile illness.  It is transmitted by mosquitos of the genus Aedes.  This virus was discovered in 1943 by two Japanese scientists in Nakasaki.  It is an old virus that has reemerged during the latter half of the 2oth century.  The infection primarily is caused by four serotypes; DEN-1, DEN-2, DEN3, and DEN-4.  All serotypes can be found worldwide.  It is a major health issue throughout the tropics and subtropics with more than 100 countries at risk of endemic.  The incidence of dengue has increased dramatically in the recent years.   There are more than 50 million cases occurring annually.  Nearly 40% of the world’s population is at risk of dengue virus transmission.  Some individuals who have developed infection with one dengue serotype, they may develop bleeding and endothelial leak upon infection with another dengue serotype which is termed dengue hemorrhagic fever as well as dengue shock syndrome.  In the viremic phase, dengue virus becomes a blood-borne infection, which can also be transmitted from mother to fetus in utero or to infants at the delivery – perinatal transmission.  According to the CDC, dengue has become the leading cause of acute febrile illness in US travelers retuning from the Caribbean, South America, and Asia.  One of the largest outbreaks occurred in 2018 in Thailand with 126 fatalities.  Thailand also recorded its worst dengue epidemic in 1987 with 174,000 infected cases and with a fatality of 1,007.  The lack of selective antiviral agents and an effective vaccine results in approximately 500,000 affected individuals, mainly children, being hospitalized each year throughout the world let alone dengue produces significant economic losses for both households and whole nations.     

Another virus that has crossed international boundaries is Zika virus.  This virus was first described in a febrile rhesus monley in the Zika forest of Entebbe, Uganda.  Shortly thereafter, it was reported in a field worker.  Zika is known to widely cross international boundaries outside Africa. Zika epidemics have also been described in Micronesia and French Polynesia.  The transmission to human takes place through the bite of an infected Aedes aegypti mosquito.  In 2015, the outbreak of this virus was reported in Brazil, the illness for which, was characterized by skin rash and absent or low grade (short-term) fever.  Based upon clinical presentation, it was challenging to diagnose Zika from dengue or Chikungunya virus.  Brazil has also experienced epidemics of Chikungunya virus.  Because of the mild nature of the disease, more than 80% if Zika virus infection cases likely go unnoticed.  Zika maculopapular rash is the predominant presenting symptom which is likely immune-mediated involving the face, trunk, and extremities, including palms and soles.  In few affected individuals, Zika virus can cause neurological complications such as Guillain-Barre syndrome.  Of greatest clinical concern over the complications of Zika virus infection is over congenital malformations which is primarily due to transplacental transmission of the virus causing microcephaly complications.  Zika epidemic of Brazil highlighted an unequal burden on healthcare delivery system.

Most recently, Venezuela is facing a resurgence in dengue, Zika, Chagas disease and malaria due to its ongoing political and humanitarian crises which have already further compromised it’s already existing broken down health system and is seriously threatening its public health infrastructure.  The World Health Organization has alarmed the global community that diseases transmitted by insects in Venezuela can lead to a significant loss of life. The incidence of dengue increased by more than four times from 1990 to 2016.  Furthermore, the frequency of Zika outbreaks with epidemic potential appear to be increasing as experts found 2,057 cases of Zika virus per 100,000 people.  The high prevalence of such diseases is further compounded by the lack of public health standards, shortage of food, medicine, and vaccine in Venezuela.    

Although tremendous progress has been made in the past years to improve epidemiological surveillance and rapid detection of viruses that cross international borders, yet capacity-building for rapid detection and optimal care delivery are just examples of few obstacles and challenges that global health faces especially in resource-limited countries.  The emergence and reemergence of deadly viral outbreaks are major international public health concern.  As reemergence of deadly outbreak can take place again, viruses without borders highlighted in this keynote address will continue to get the attention of healthcare professionals, international media, infectious diseases epidemiologists, NGOs, and national/international public health sectors.  It must be emphasized while hand washing which presents the basic principle of prevention and control, such preventive measure may not be adequate for the spread of deadly viruses in the communities.  A “One Health” perspective can help to address these complex issues of preparedness and response.  A comprehensive framework such as One Health approach encompasses a systemic perspective which is fundamental to understand, address, and tackle the consequences of viral epidemics.  To meet the global challenges in the context of deadly viral infections, interdisciplinary collaborations facilitate synergism with respect to an optimal healthcare delivery system.