Community Nursing Ch. 15: Emerging Infectious Diseases

Healthcare providers

About 30% of the early SARS cases in China were in these people, with the majority of cases occurring before the cause of SARS was identified and before correct infection control measures were in place.

China

All of the reported cases of A (H7N9) up to mid-2014 had been from

Level 3 travel alert

Although the Ebola virus posed little to no risk to the U.S. general population, on July 31, 2014, the CDC issued one of these (Avoid Nonessential Travel) for Sierra Leone, Guinea, and Liberia and reminded all healthcare providers to (1) take a good travel history to identify patients who had traveled to/from West Africa in the past 3 weeks, (2) know the signs and symptoms of EVD, and (3) follow infection control precautions for suspected and symptomatic cases of EVD to prevent the spread of the Ebola virus

family clusters of H7N9

have been rare, providing evidence that the virus is not easily spread from person to person. Although most cases had contact with live poultry or had visited live-animal markets before the onset of illness, the source of infection remained unclear

Ebola virus

is a member of the Filoviridae family (filovirus), and has five distinct species - Bundibugyo ebolavirus (BDBV) Reston ebolavirus (RESTV) Sudan ebolavirus (SUDV) Taï Forest ebolavirus (TAFV) Zaire ebolavirus (EBOV) (WHO, Ebola virus disease)

suspect TB client

is a person in whom a diagnosis of TB disease is being considered, whether or not anti-TB treatment has been started. People generally should not continue to be suspected of having TB for more than 3 months

Active TB infection

is characterized by a chronic productive cough, low-grade fever, night sweats, and weight loss, along with a positive PPD-tuberculin skin test. People with active TB are contagious.

erythema migrans

is defined as a skin lesion that typically begins as a red macule or papule and expands over a period of days to weeks to form a large round lesion, often with partial central clearing.

Infectious disease prevention

requires global consciousness. Not all countries have the public health infrastructure to combat emerging infectious diseases.

WNV Symptoms

typically develop between 3 and 14 days after the infected mosquito bites someone. Symptoms may vary. Approximately 80% of infected people (about four out of five) do not have any symptoms. Another 20% of those who become infected have symptoms such as fever, headache, body aches, nausea, vomiting, and sometimes swollen lymph glands or a skin rash on the chest, stomach, and back.

T-SPOT TB test (T-Spot) and QuantiFERON-TB Gold In-Tube test (QFT-GIT)

two new interferon gamma (IFN-γ) release assays (IGRAs) were approved by the FDA as aids in diagnosing both latent and active M. tuberculosis infection

TB bacteria

usually attack the lungs, but they can attack any part of the body such as the kidney, spine, and brain. If not treated properly, can be fatal

antigenic drift

Slow and progressive genetic changes that take place in DNA and RNA as organisms replicate in multiple hosts.

Hong Kong flu

The third pandemic, known as "Hong Kong flu" (influenza A [H3N2]), occurred in 1968 to 1969. The first cases were detected in Hong Kong in early 1968. Later that year, the virus spread to the United States, where it claimed approximately 34,000 lives

herd immunity

Type of immunity in which a large proportion of people in a population are not susceptible to a communicable disease and the few people who are susceptible will not likely be exposed and contract the illness.

stage I microbial adaptation

an epidemic occurs. The microbes enter a "virgin" population where hosts have no prior exposure to the organism and have few defenses.

Canada

became the first SARS epicenter in the Western Hemisphere, with two clusters of SARS infection epidemiologically linked to two hospital outbreaks.

Avoid mosquitos

best way to prevent WNV

Ebola transmission

can be spread from person-to-person through direct contact (through broken skin or mucous membranes) with blood, secretions, excretions, or other body fluids of an infected person. has been found in semen up to 61 days. The virus can also be spread by indirect contact through medical equipment and the contaminated environment in contact with these fluids.

Active TB with HIV

can be treated even in people with HIV infection. Because of the relatively high proportion of adults with TB caused by organisms that are resistant to INH, four drugs are necessary in the initial phase to be maximally effective. should consist of a 2-month initial phase of INH, rifampin (RIF), pyrazinamide (PZA), and ethambutol (EMB), followed by a choice of several options for the continuation phase of either 4 or 7 months.

H5N1 virus

can improve its transmissibility among humans by two mechanisms - antigenic shift (reassortment) and antigenic drift

Nonvector WNV transmission

can include blood transfusions, organ transplantation and vertical transmission in utero, has also been reported in laboratory workers and poultry farm workers.

Infected travelers

can introduce new microbes into new environments, both while traveling to new places and returning home. An increasing number of travelers increases the chances of contamination.

Changes in the environment

cause new interactions between agents and hosts and can potentially lead to new infectious disease threats. For example, cholera outbreaks occurred four times between 1831 and 1854 in England because of the large influx of people into cities and the lack of proper sanitary services. These outbreaks resulted in a total of 10,675 deaths.

Human babesiosis

caused by B. microti, a protozoan blood parasite, has been increasing in prevalence, especially in the Northeast. Babesiosis can be asymptomatic or present with flu-like symptoms (e.g., fever, chills, body aches, weakness, and fatigue) that may not appear for weeks or months after exposure to B. microti. *can be misdiagnosed as lymes disease

PPD-tuberculin skin test

classic example of a delayed (cellular) hypersensitivity reaction, which induces induration.

WHO TB tx recommendation

directly observed therapy (DOT), using the most effective standardized, short-course regimens, and of fixed-dose TB drug combinations as an approach to TB control

Ebola symptoms

early symptoms include sudden onset of fever, muscle pain and weakness, headache, and sore throat. These symptoms are followed by vomiting, diarrhea, rash, compromised liver and kidney function, and, in some cases, internal and external bleeding

As microbes reproduce

genetic changes may result in pathogens that are immunologically distinct from their parental strains

the CDC

has issued a public health alert for healthcare providers to be aware of patients who present with acute respiratory illness and a travel history to countries where the A (H7N9) virus has been confirmed

economic activity and development

In addition to morbidity and mortality, outbreaks of emerging and reemerging infections can disrupt these

deer tick

(I. scapularis in the northeastern and north central United States; I. pacificus in the western United States) is an important vector in human Lyme borreliosis along with the white-tailed deer, the preferred host of the adult deer tick.

epidemiologic triad

(1) a change in the behavior of humans—the host, (2) a change in the behavior of the microbes—the agent, or (3) a change in the environment.

Treating latent M. tuberculosis infection

(LTBI) is a cornerstone of the U.S. strategy for TB elimination. Randomized controlled studies have shown that a new combination regimen of isoniazid (INH) and rifapentine administered weekly for 12 weeks as DOT is as effective for preventing TB as other regimens and is more likely to be completed than the U.S. standard regimen of 9 months of INH daily without DOT

personal protective equipment

(PPE) should be guided by a risk assessment concerning anticipated contact with blood, body fluids, secretions, and nonintact skin for routine patient care. When procedures include a risk of splash to the face and/or body, PPE should include the use of facial protection by either a surgical mask, and eye visor or goggles, or a face shield; and a gown and clean gloves.

Tuberculosis

(TB) is a disease caused by Mycobacterium tuberculosis that is spread from person to person through the air when a person with TB disease of the lungs or throat coughs, sneezes, speaks, or sings. The TB bacteria (droplet nuclei) can stay suspended in the air for several hours, depending on the environment.

CDC updated TB infection control guidelines

(for healthcare settings). A sample recommendation is that the term "tuberculin skin tests" be used rather than PPD. The scope of settings in which the guidelines apply has been broadened to include laboratories and additional outpatient and nontraditional healthcare settings. New terms such as "airborne infection precautions" (airborne precautions) and "airborne infection isolation (AII) room" have been introduced. One of the most critical risks for healthcare-associated transmission of M. tuberculosis in healthcare settings is from clients with unrecognized TB disease who are not promptly handled with appropriate airborne precautions or who are moved out of an AII room too soon

Cases of active TB

By law and regulation, these in the United States must be reported to the local health department.

Global lymes

Cases have been found on all continents except Antarctica.

Isolation precautions

Clients with a history of travel within 10 days to a country with avian influenza activity and who are hospitalized with a serious febrile respiratory illness, or are otherwise being evaluated for avian influenza, should be managed using these

Nonpharmaceutical Strategies to Contain a Community-wide Epidemic

Closing schools Canceling public gatherings Planning for liberal work leave policies Telecommuting strategies Voluntary isolation of cases Voluntary quarantine of household contacts

3

During the past century, how many influenza A pandemics have occurred, and pandemic influenza will inevitably occur in the future.

Zoonotic

E. coli O157:H7 infections can also be caused by this transmission through contact with animals that carry the organism.

2 to 21 days

Ebola incubation period (the average is 8 to 10 days)

pandemic

Epidemic occurring worldwide.

E coli (O157

H7): a Shiga toxin-producing E. coli (STEC), may also be referred to as verocytotoxin-producing E. coli (VTEC) or enterohemorrhagic E. coli (EHEC). It produces symptoms of severe abdominal cramps, bloody and nonbloody diarrhea, and vomiting, which generally resolve within 7 to 10 days.

HIV infection and TB

HIV weakens the immune system, people with prior untreated latent TB infection and HIV infection are at very high risk of developing active TB disease. Therefore, all people with HIV infection should be tested to find out if they have latent TB infection. If they have latent TB infection, they need treatment as soon as possible to prevent them from developing active TB disease.

parasite's dilemma

If the microbe proliferates rapidly, it may kill the host. If it cannot be transmitted quickly to a new host, the microbe dies. However, if the microbe proliferates slowly, within a week the host's immune system will recognize the microbe as foreign, form antibodies, and destroy the microbe

QuantiFERON-Gold (QFT-G)

In 2005, the CDC issued guidelines for using the FDA-approved this test for diagnosing M. tuberculosis infection, including both active TB disease and latent TB infection. The guidelines indicated it may be used in all circumstances in which a PPD test was recommended, including contact investigations, evaluation of recent immigrants, and serial-testing surveillance programs for infection control (e.g., those for healthcare workers).

risk reduction Ebola

In the absence of a human vaccine and lack of effective treatment for EVD, public health measures should focus this, which include the following - Reduction of animal-to-human transmission from contact with infected wildlife and consumption of their raw meat. Animal workers should wear gloves and PPE when handling animals. Hand hygiene should be employed after handling animals. Animal products should be thoroughly cooked before consumption. Reduction of person-to-person transmission from direct/close contact with infected patients and their body fluids. Gloves and PPE should be worn when caring for infected patients in the home, and good hand hygiene should be practiced to prevent contamination and cross-infection

5mm

Induration of _____ or more is considered a positive result in people who have an initial induration of 0 mm.

Novel Avian Influenza A (H7N9) Virus

Influenza A (H7N9) is one of a subgroup of influenza viruses that normally circulate among birds.

Northeast and upper Midwest

Lyme disease does not occur nationwide and is concentrated heavily in the

Seasonal variations

Many infectious diseases have characteristic geographic distributions and these. Probably the most common is the influenza virus that peaks each fall and winter.

MERS-CoV

Middle East respiratory syndrome coronavirus. has been reported in 109 healthcare providers in the Middle East. While the majority (57%) were asymptomatic or with mild symptoms, 32% (n = 35) had moderate symptoms, requiring hospitalization, and another 6% (n = 7) had severe disease, with 4 (4%) being fatal

convergence model

Model illustrating the interaction of 13 factors that contribute to the emergence of infectious diseases.

E coli complications

Most people recover fully from an E. coli infection in 2 or 3 days; however, E. coli O157:H7 can cause fatal hemolytic-uremic syndrome (HUS) and renal failure in the very young and the elderly, and clients may require dialysis.

ecosystem

Natural unit consisting of all living things (plants, animals, bacteria, viruses) interacting with, and dependent on, one another for survival within their nonliving environment.

emerging infectious disease

Newly identified clinically distinct infectious disease, or the reappearance (reemergence) of a known infectious disease after its decline, with an incidence that is increasing in a certain geographic area or among a specific population.

directly observed therapy

Observation of clients to ensure that they ingest each dose of anti-TB medication to maximize the likelihood of completion of therapy.

H5 and H7

Only viruses of these two subtypes are known to cause the highly pathogenic form of type A influenza.

Airborne precautions

Place the client in an airborne isolation room (AIR). Such rooms should have monitored negative air pressure in relation to corridor, with 6 to 12 air changes per hour (ACH), and exhaust air directly outside, or have recirculated air filtered by a high-efficiency particulate air (HEPA) filter. If an AIR is unavailable, a portable HEPA filter should be used to augment the number of ACH. Use a fit-tested respirator, at least as protective as a National Institute of Occupational Safety and Health (NIOSH)-approved disposable N95 filtering face piece respirator, when entering the room (DHHS, 2006).

microbial adaptation

Process by which organisms adjust and change to their environment.

personal steps to reduce spread of infection

Recognize symptoms of the flu and see a healthcare provider immediately - if you have A temperature of greater than 100°F, A cough, A sore throat, An underlying condition that increases risk, Cover your cough or sneeze, Wash hands often and keep hands away from your face, Stay home and do not travel if you are ill, Be prepared for increased illness in your schools and community

Climate change

Scientists have been concerned for some time about this and its effect on zoonotic diseases in human and animal populations.

antigenic shift

Sudden change in the molecular structure of DNA and RNA in microorganisms, resulting in a new strain of the microorganism.

Women

TB is one of the top killers of this gender, with 250,000 deaths among HIV-negative women and 160,000 deaths among HIV-positive women in 2012

Camels

The WHO also has reported that MERS-CoV has been found in some of these animals and in some MERS patients who have had contact with them

IOM convergence model

The ability of microbes to adapt and the dynamic interaction between microbes and humans are central to the

Skin lesion (bulls eye rash)

The best clinical marker of Lyme disease is this (i.e., erythema migrans), which occurs in 60% to 80% of people with the disease.

Spanish flu pandemic

The first pandemic occurred in 1918 to 1919. (influenza A [H1N1]), resulted in 20 to 40 million deaths worldwide and more than 500,000 deaths in the United States. The "Spanish flu" was unique because the causative agent was very deadly, and it spread across the globe within 6 months.

Lymes in the tick

The life cycle of the Ixodes tick takes 2 years. Once a tick becomes infected with B. burgdorferi, it remains infected for life and can transmit the organism to new hosts.

Males

The majority of WNV cases occur among this gender

Concentration of droplet nuclei

The probability that a person who is exposed to M. tuberculosis will become infected depends primarily on the concentration of these in the air and the duration of exposure to a person with infectious TB disease. The closer the proximity and the longer the duration of exposure, the higher the risk of becoming infected.

Asian flu pandemic

The second pandemic, known as the "Asian flu" (influenza A [H2N2]), occurred in 1957 to 1958, and it was first identified in China in late February 1957. In less than 6 months, it spread to the United States, where it caused approximately 70,000 deaths. The highest mortality with Asian flu occurred in the elderly.

IGRA

Unlike PPD, these results can be available within 24 hours without the need for a second visit. As laboratory-based assays, they are not subject to the biases and errors associated with PPD placement and reading. However, the cost for this test is substantially greater than that for a PPD skin test.

Contact precautions

Use gloves and gown for all client contact. Use dedicated equipment such as stethoscopes, as well as disposable blood pressure cuffs and disposable thermometers.

Ebola precautions

Use of standard contact and droplet precautions and other infection control measures in healthcare settings to prevent exposure to blood and body fluids and the potentially contaminated environment when caring for patients with suspected or confirmed EBV When caring for a hospitalized patient with confirmed or suspected EVD, specific infection control guidance has been provided by the CDC, including patient placement and PPE to be used by healthcare providers, including donning and removing PPE. When entering the room of a patient with suspected or known EBV, all healthcare providers should wear PPE, including fluid-resistant gown, gloves, mask, and face shield/goggles

Eye protection

Wear goggles or face shields when within 3 feet of the client.

WNV precautions

West Nile virus is not transmitted from person to person. No isolation precautions are indicated other than standard precautions.

Reported

all cases of WNV should be

Ecological changes

are one of the most frequently identified factors in the emergence of infectious diseases. Ecosystems are groups of interacting living things (e.g., plants, animals, bacteria, and viruses) that depend on each other for survival.

Close contacts

are people who share the same air space in a household or other enclosed environment for a prolonged period (days or weeks, not minutes or hours) with a person with pulmonary TB disease.

TB tx individualization

client's management plan should be individualized to incorporate measures that facilitate adherence to the drug regimen. There is no need to hospitalize a person solely because they are infectious. Outpatients should be instructed to remain at home, without visitors, until they are no longer thought to be infectious

Impaired immunity

could be because of environmental stresses, poor nutrition, medication, or the presence of other illnesses

Reassortment

could result in a fully transmissible pandemic virus, which could rapidly spread throughout the world

The CDC guidelines WNV

emphasize avian, animal, mosquito, and human WNV surveillance, along with control and elimination of mosquito breeding sites such as standing water in flowerpots, buckets, and old tires. There are no medications to treat, or vaccines to prevent WNV infection. Recommends using an insect repellent such as DEET (N, N-diethyl-m-toluamide) or picaridin when outdoors, following the directions on the package.

Ebola

first appeared in 1976 during two simultaneous outbreaks in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo.

Texas

first imported case of Ebola infection in the United States occurred in this state, in September 2014 in a man who had traveled from Liberia. Two healthcare providers who had cared for that patient, who died, became ill with the Ebola virus and have since recovered.

1 in 150 people

how many infected with WNV develop severe illness, with severe symptoms that can include high fever, headache, neck stiffness, stupor, disorientation, coma, tremors, convulsions, muscle weakness, vision loss, numbness, and paralysis. These symptoms may last for several weeks, and neurological effects may be permanent.

Travel history

in addition to this, patients should be asked if they have visited farms, markets, barns, or other places where animals are present

WNV should be considered

in any person with a febrile or acute neurologic illness who has had recent exposure to mosquitoes, blood transfusion, or organ transplantation, especially during the summer months in areas where virus activity has been reported. The diagnosis should also be considered in any infant born to a mother infected with WNV during pregnancy or while breast-feeding

Cholera infection

in humans occurred because a series of complex factors existed along Peru's shores. The rapid population growth in the coastal cities exceeded the capability of the public health infrastructure to deal with fecal contamination of water supplies. The cholera outbreak in Peru cost the country US$770 million due to food trade embargoes and adverse effects on tourism.

warmer climates

in these climates, WNV infections can occur year round.

Community sites high risk TB

include neighborhood health centers, jails, homeless shelters, inner-city areas, methadone clinics, syringe/needle-exchange programs, and other community-based social service facilities

Transmission of WNV

involves animals. The most common route of transmission is from the bite of an infected mosquito.

select agent

is a bacterium, virus, or toxin that has the potential to pose a severe threat to public health and safety.

Cholera

is a disease transmitted through the fecal-oral route that is associated with poverty. The disease had been absent from Peru for more than 100 years.

Exposure to Lyme disease

is defined as having spent time (less than or equal to 30 days before onset of the initial skin lesion) in wooded, brushy, or grassy areas (i.e., potential tick habitats) in a county in which Lyme disease is endemic. A history of tick bite is not required.

Multidrug-resistant TB

is defined as resistance to the two most potent "first-line" anti-TB agents.

definitive diagnosis of EVD

lab tests include ELISA, antigen detection tests, PCR assay, and culture isolation of the virus

Active post arrival monitoring

late October 2014, the CDC announced that state and local public health departments would begin this daily for travelers from Sierra Leone, Guinea, and Liberia for 21 days from the date of their departure from West Africa. an additional safeguard to exit screening of all travelers from the affected countries.

Best-practice nursing interventions

must be tied into the role of community and public health nurses in the care and supportive aspects of TB case management. The American Thoracic Society, the CDC, and the Infectious Diseases Society of America support client-centered case management with an emphasis on evidence-based DOT options.

2002 WNV outbreak

nonvector routes of transmission were identified, including blood transfusions, organ transplantation, and vertical transmission in utero.

Surveillance

the critical tool for detecting and monitoring outbreaks of zoonotic diseases in human and animal populations

Three stages of microbial adaptation

occur over varying periods of time and include epidemic, endemic, and hopefully tolerance

Clusters of severe acute respiratory illness

of unknown etiology in the community also should be thoroughly investigated, and if no etiology is identified, this should prompt immediate notification of local public health officials, and testing for MERS-CoV should be conducted if indicated.

Diseases persist

only if the population is dense enough to allow continued transmission of germs and large enough to produce a continual supply of susceptible hosts.

Lymes treatment

people who are treated with antibiotics early in the infection generally recover quickly and completely, as do those in the later stages of the infection. However, clients with persistent and recurring symptoms may require a second 4-week course of antibiotics

Ebola virus disease (EVD)

previously called Ebola hemorrhagic fever, is a severe, often fatal illness with a reported case fatality rate as high as 100%. The virus can be brought into human populations through close contact with blood, secretions, or other body fluids and organs of infected animals such as chimpanzees, gorillas, fruit bats, monkeys, forest antelope, and porcupines.

prevent transmission of acute respiratory infections

respiratory hygiene/cough etiquette measures should be implemented at the first point of contact with a potentially infected person and should be incorporated into standard precautions. This includes covering the nose and mouth when coughing or sneezing, using tissues to contain respiratory secretions and disposing of them in the nearest waste receptacle after use, and hand hygiene (e.g., hand washing with nonantimicrobial soap and water, alcohol-based hand rub, or antiseptic hand wash) after having contact with respiratory secretions and contaminated objects/materials

New influenza virus variants

result from frequent antigenic change (i.e., antigenic drift), which is a consequence of point mutations that occur during viral replication.

smart surveillance

scientists will be able to target their resources and efforts in areas where human-animal interaction is most likely to provide conditions favorable to zoonoses

Initial assessment of close contacts (TB)

should be accomplished within 3 days of reported exposure to a person who has active TB disease. During that initial assessment, a history of previous M. tuberculosis infection or disease and treatment should be taken along with any current symptoms of TB illness and medical conditions that increase the risk of TB infection

Additional precautions

should be observed and PPE worn when performing aerosol-generating procedures, which may be associated with an increased risk of infection transmission, in particular, intubation. These include a particulate respirator (e.g., N95 respirator), eye protection (i.e., goggles or a face shield), gown, and gloves (some procedures may require sterile gloves).

prevent Lyme disease

steps include using insect repellent, identification and removal of deer ticks promptly, applying pesticides, and reducing tick habitat.

Factors of pathogen life cycle

such as temperature, precipitation, and humidity affect the life cycle of many disease pathogens and their vectors, and consequently they can affect disease outbreaks.

Pure bird flu strains

such as the new H7N9 strain and the H5N1 virus, where the latter virus killed 59% of people it infected since 2003, are generally more deadly for humans

stage III microbial adaptation

symbiosis is possible. Further adaptation occurs, resulting in mutual tolerance and sometimes mutual benefit for both the microorganism and the host. This is the preferred outcome.

IOM and National Research Council expert committee

task was to provide consensus advice on the challenge of achieving sustainable global capacity for surveillance and response to emerging diseases of zoonotic origin such as avian influenza, and ways to protect the public from them.

main lessons learned from SARS

the first new infectious disease to emerge in the 21st century, were that (1) astute healthcare providers are likely to be the key to early detection and reporting of initial cases of new CoV infections; (2) containment of disease requires the diligent application of enhanced infection control measures at the national and local levels; and (3) control of an emerging infection necessitates swift action by healthcare providers as well as an adequate public health infrastructure.

As microbes adapt

the illnesses they produce become less acute. Symptoms become milder, and fewer organs are involved as immunity develops.

stage II microbial adaptation

the infection becomes endemic or continuously present in a geographic area or population of people. Routine childhood diseases are an example of such infections.

Isolation precautions/quarantine measures

to prevent the spread of SARS-CoV were established early in the outbreak, which were effective in containing the epidemic.

MERS CoV new cases

was attributed in part due to breaches in infection prevention and control measures in healthcare settings.

Pneumonic plague

was fatal in 95% of its victims and remains resistant to antibiotic treatment today

SARS (CoV) transmission

was found to be mostly transmitted by close contact with respiratory secretions and aerosols, other body fluids, such as saliva, tears, urine, and feces, also demonstrated presence of the virus.

causative agent for SARS

was identified in April 2003 as a variant coronavirus (CoV), with an average incubation period of 4 to 6 days (range, 1 to 14 days) and a maximum of 10 days

WNV

west nile virus has now become endemic in the United States

four types of microbe human interactions

which can lead to emerging/reemerging infectious diseases: (1) genetic and biological; (2) physical/environmental; (3) ecological; and (4) social, political, and economic

droplet precautions

which include wearing a surgical mask when in close contact (i.e., within approximately 3 feet) and upon entering the room of the patient; perform hand hygiene before and after contact with the patient and his or her surroundings, and immediately after removal of a surgical mask

Adaptive mutation

which is expressed initially as small clusters of human cases with some evidence of human-to-human transmission, would probably give the world some time to take defensive action

SARS epidemic

which occurred worldwide between February and July of 2003, began in mainland China in November 2002 but was not reported to the WHO until February 2003, when the Chinese Ministry of Health reported that an outbreak of 305 cases of "atypical pneumonia," including five deaths, had occurred in Guangdong Province.

Influenza A viruses

which originate in birds, are categorized into subtypes on the basis of their surface antigens. These viruses have 16 hemagglutinin (H) surface antigen subtypes and nine neuraminidase (N) surface antigen subtypes.

adventure travelers

who venture into new environments with exotic wildlife, increase their chances of coming into contact with microbes that have never before been recognized as human pathogens