PROMED: Measles and Hepatitis C Human hosts: Measles, smallox, shigella Innate Immunity vs.

Adaptive Immunity INNATE IMMUNITY Physical barrier through skin Antimicrobial peptides in mucosa Phagocytosis (removal of foreign substances) with white blood cells, macrophages, dendritic cells, neutrophils Recruit immune cells (cytokines) Complement system (set of proteins): ID pathogens, activate cells, clear dead cells

ADAPTIVE IMMUNITY Recognizes self and non-self Tailors response to a particular pathogen Immunological memory

B and T cells

Antigen: Part of the pathogen that begins an immune response; any molecule that can bind an antibody Antibody: Bind and neutralize pathogens or prepare them for uptake and destruction by phagocytes Toxoid: Treated bacterial toxins so toxic component is destroyed but antigenicity is maintained B CELLS Make antibodies to pathogens antigens Nave B cells differentiate into plasma cells that secrete antibodies 10% of plasma cells differentiate into memory B cells specific for a pathogen CD4 HELPER T CELLS Not typically phagocytic (do not usually kill) Manage the immune response; help activate Cytotoxic T cells and B cells Th1 Cell mediated (intracellular pathogens) or Th2 humoral/antibody immunity (extracellular pathogens and toxins) Some memory cells CD8 CYTOTOXIC T CELLS Kills cells infected with pathogens (viruses, intracellular bacteria) Nave cells recognize small molecules (peptides) and become armed/activated effector cells Kill infected cells

Small percentage may remain as memory cells

Immunization: Deliberately inducing an adaptive immune response by artificially exposing the host to an antigen Herd Immunity: Vaccine protection to a proportion of the population protects unvaccinated individuals as well (usually around 80%); enough unvaccinated individuals can also swamp out the vaccinated

Goals of Vaccination: 1. To prevent infection 2. To prevent disease (symptoms) 3. To reduce transmission Vaccines to Eradicate Disease: Humans are the only host Transmission occurs when illness is apparent Permanent immunity after recovery Vaccine provides long-lasting protection Types of Vaccines: Killed vaccine K Live, attenuated LA Related non-pathogenic agent RNPA Subunit SU Also peptide-based, recombinant protein, naked DNA, and vectors-based vaccines Characteristics of an Ideal Vaccine: 1. Protective 2. Long-lived 3. Dosage* 4. Immunity (T cell and/or B cell) 5. Delivery* 6. Polyvalent (covers many variants) 7. Cost* 8. Safety* 9. Government* 10. Local resources* 11. Stability* *Roadblocks to vaccine delivery Vaccine Preventable Diseases (and controlled): Variola (smallpox) RNPA Poliomyelitis (polio) K, LA Diphtheria Tetanus Mumps LA Haemophilus influenza type B Varicella (chickenpox) Influenza

Measles** LA Pertussis** SU or whole cell Cholera Hepatitis A & B Japanese encephalitis Meningococcal meningitis Pneumococcal pnemoniae

Rabies Rotavirus Rubella

Typhoid Yellow fever Tuberculosis

Variola (smallpox): Papules and pustules Variolation practiced to prevent smallpox (Ancient Chinese, scratch arm and use pus to inoculate, Lady Mary Montagu 1700s Britain) Edward Jenners innovation: vaccinia virus for smallpox immunization (related non pathogenic virus) WHO eradication campaign 1967-77 Poliomyelitis (polio): Salk Vaccine 1952 injected with killed polio virus Sabin Vaccine 1955 orally take live attenuated virus Polio Eradication Program, 1980 2000 (only 1,000 cases worldwide as of 2001) Endemic in Africa/Middle East Corynebacterium diphtheriae (diphtheria): Gram positive bacteria Bacterial exotoxin is absorbed by the bloodstream, preventing protein synthesis and damaging heart, nerves, and kidneys Risk of suffocation: gray-white membrane formed by clotted blood/killed mucous membrane cells Vaccinate with diphtheria toxoid (DTap vaccine contains toxoids for diphtheria and tetanus and acellular pertussis) Clostridium tetani (tetanus/lockjaw): Gram positive bacteria Vegetative cells secrete a powerful exotoxin (toxin moves to spinal cord, where motor neurons are in constant stimulation) Vaccination with tetanus toxoid Mumps virus: RNA virus Enlarged salivary glands, muscle spasms Live-attenuated vaccine Haemophilus influenzae type B: Gram negative bacteria Normal flora of upper respiratory tract, but can invade bloodstream resulting in meningitis for children under 2 and pneumonia for children 2-5 Vaccine made against the surface protein

Varicella (chickenpox): Varicella-zoster virus (VZV), a Herpesvirus Primary infection is chickenpox Secondary infection is shingles 95% of industrialized countries are infected by age 15 Rubeola virus (measles): Disease with rare, lethal outbreaks (top 10 causes of death by infectious disease) RNA virus Humans only known host, infection provides life-long immunity LA viral vaccine One of the most common causes of vaccine-preventable death in children (highly infectious, surveillance, lack of compliance, vaccine in two doses) Bordetella pertussis (pertussis/whooping cough): Disease with rare, lethal outbreaks Gram negative bacteria Infects respiratory tract Toxin acts as adhesion and toxin, increase in mucous secretion Vaccination with whole cell or subunit vaccines Out of Control Diseases: Tuberculosis (ineffective vaccine) HIV (no vaccine) Hepatitis C (no vaccine) Malaria (no vaccine)

Organisms Linked to Intestinal Disease in Humans: E. coli Vibrio cholera Listeria monocytogenes Salmonella Shigella Campylobacter Clostridium difficile Rotaviruses Noroviruses (most common cause of foodborne illness) Other Infectious Viruses of the GI Tract (do not cause diarrhea): Hepatitis A & E

Poliovirus Other enteroviruses Adenovirus

Normal Flora (Commensal Organisms) of the GI Tract: Aerobic bacteria called coliform (general term referring to E. coli and related bacteria) Anaerobic (low oxygen) bacteria including bacterioides and Clostridium sp.; outnumber E. coli 1000 to 1 Commensal organisms help to aid digestion, secrete vitamins, stimulate development of immune tissues, and prevent colonization of pathogenic microbes Prevention of Intestinal Illness: Chlorination of water and proper sewage treatment Pasteurization of dairy products Irradiation Antimicrobials Wash hands, observe recalls, cook meat Boil it, cook it, peel it, or forget it when traveling Diagnosis of Pathogens: BACTERIAL GI PATHOGENS Normal flora may greatly outnumber pathogenic species Culture on special selective media Biochemical tests: series of reactions that help identify specific pathogens Serotyping (determining antigens) Molecular techniques

VIRAL GI PATHOGENS Diagnoses often made by history and symptoms Test for viral antigens in feces (ELISA)

Pulse Field Gel Electrophoresis (PFGE): Methodology to tracing the source of an epidemic; compares the pattern of DNA bands in isolates to determine the source of contamination Treatment of Bacterial GI Pathogens: Supportive treatment is key: fluid/salt replacement with anti-diarrheals Antibiotic therapies including sulfa/cipro drugs Resistance does occur Treatment of Viral GI Pathogens: Treatment is mostly supportive Gastroenteritis: Inflammation of the GI tract Diarrhea: Frequent, watery stools with intestinal pain, cramps, nausea, and vomiting

Loss of salt/water balance in the blood Dehydration a major danger Transmission is fecal/oral or environment/oral 1.6M deaths annually, mostly in children Leading cause of malnutrition Repercussions for growth and education Access to clean drinking water is a global health priority

Disease Associations: WATER Vibrio cholerae, typhoid fever, Cryptosporidium, Giardia, Entamoeba, helminths (worms) POULTRY Salmonella, Campylobacter, helminths BEEF E. coli O157:H7, helminths, Salmonella DELI MEATS Listeria monocytogenes

Escherichia coli: Gram negative bacteria Mostly present as a commensal bacteria Used as a marker of coliform contamination of water supplies and as a model organism in research Few serotypes are associated with intestinal disease: o Enterotoxigenic E. coli (has enterotoxin, travelers diarrhea) o Enteroinvasive E. coli (bloody diarrhea) o Enteropathogenic E. coli (no toxin/invasion, hospital infantile diarrhea) E. coli strain O157:H7 leads to hemolytic uremic syndrome (HUS) and kidney failure Vibrio cholerae (cholera): Gram negative bacteria Causes epidemic cholera through the ingestion of contaminated food/water Bacteria produces a toxin that disrupts the salt/water balance in intestinal tract Severe diarrhea, vomiting, shock Untreated patients develop immunity, but die due to extreme dehydration Treatment is supportive through ORHT; antibiotics do not work quickly enough Recent cholera outbreak in Haiti and lawsuit against the UN Listeria monocytogenes (listeria): Gram positive bacteria Causes gastroenteritis, nausea, diarrhea, intestinal infections that can go systemic (CNS) Headache, stiff neck, changes in mental status, seizures Elderly, immunocompromised, and pregnant women are at highest risk (pregnant women should stay away from soft cheese, processed meat, hot dogs, and shredded cabbage)

Cold enhanced bacteria can grow at refrigerator temperature Cantaloupe listeria outbreak 2011 owners charged with misdemeanors

Salmonella sp.: Gram negative bacteria Over 200 species, 1600 serotypes Carried by turtles and other reptiles; improper handling of raw poultry and eggs Causes acute intestinal disease (most common), with diarrhea, abdominal cramps and vomiting; blood infection Ongoing drug-resistant Salmonella Heidelberg outbreak (from chicken) outbreak source mapped via Costco card usage of the affected Most severe reaction is typhoid fever Salmonella typhi (typhoid fever): Causes gastroenteritis, undulating fever, rash Complications including hemorrhage and perforation of the bowel can be fatal (10% mortality if left untreated) 2% become permanent carriers of typhoid fever, like Typhoid Mary excrete bacteria in feces and urine, bacteria found in gall bladder (can be surgically removed) LA and SU vaccines are available and are recommended for those traveling to typhoid-endemic areas (southern hemisphere) Shigella sp.: Gram negative bacteria Unlike salmonella, humans are the only significant reservoir Some strains produce a toxin Can cause dysentery, a severe disease when the microbe penetrates the intestinal wall and invades the surrounding tissue (blood and mucous present in feces) Campylobacter: Gram-negative bacteria Important cause of foodborne illness in the developed world; associated with raw chicken Causes diarrhea, abdominal pain, dysentery Flagella required for virulence Clostridium difficile: Anaerobic, spore-forming bacteria Associated with the depletion of normal flora Toxin causes disease Causes gastroenteritis with abdominal pain, and pseudomembranous colitis when severe

Rotavirus: RNA virus Leading cause of diarrhea in children; subsequent infections are usually mild/asymptomatic because of immune response Seasonal, from October to February Estimated 500,000 deaths annually LA vaccine available from Merck that has reduced hospitalizations by 80% since 2006 PATH (Seattle) Rotavirus Vaccine Program to deliver vaccine to developing countries Norovirus: RNA virus Very infectious: 20M cases annually, with 800 deaths annually Within 24 hours of contracting the virus, an acute self-limiting disease develops including diarrhea, nausea, and vomiting (cruise ship illness)

Toxin: A poisonous substance that is produced by another organism, usually a protein Toxic: Describes any substance that is harmful to an organism (i.e. chemical/environmental hazard) Sources and Functions of Toxins: Plant toxins used for defense (quinine, ricin, THC) Animal toxins/venoms used for defense or predation Bacterial and fungal toxins used for transmission, colonization, immune evasion Types of Bacterial Toxins: Endotoxin (LipoPolySaccharide LPS): Cell wall component of gram negative bacteria that is recognized by innate immunity o LPS is recognized by the TLR4 receptor; TLR4 stimulation activates the innate immune system o Detoxified LPS is used as a vaccine adjuvant Exotoxin: Secreted, soluble proteins that are recognized by adaptive immunity o Act at a distance, but are very potent and have fast-acting effects o Strongly immunogenic in mammals o Can be detoxified: non-toxic immunogenic toxin is called a toxoid Toxoid: Non-toxic immunogenic toxin (used to provide immunity to a host without the negative effects of the toxin) Sepsis: Bacterial infection spreads to blood LPS triggers host innate immune response, but excessive inflammatory response leads to a dangerous drop in blood pressure

Damage is due to the host response to LPS

Bacterial Specificity of Exotoxins: Both gram negative and positive bacteria can produce exotoxins Species-specific production Presence of exotoxin increases virulence of bacterium (no exotoxin is a non-virulent form of the same species) Exotoxin Classification: Pore-forming exotoxins (cytolytic) AB exotoxins (enzymatic) Superantigens (over-activate the immune system) Secondary metabolites (small molecules) Pore-Forming Toxins: Part of RTX family (repeats-in-toxin) Self-assemble on host cell membrane Pore disrupts membrane integrity Influx/efflux of small molecules and ions cause cell death

AB Exotoxins: A subunit is active (enzymatic) B subunit binds the host cell (attachment) Internalization of the AB exotoxin leads to activation and toxic effects

Botulinum Neurotoxin (BoNT) is the most potent toxin by weight and causes flaccid paralysis (neuron cannot stimulate muscle) Also used to treat conditions with muscle spasms

Food-Borne Botulism (FBB): C. botulinum spores in soil germinate after sealing without proper heating/sterilization Toxin produced during bacterial growth in can/jar; toxin causes the disease, not the bacterium Neurological symptoms include dizziness, blurred vision, slurred speech, paralysis, death Treat with anti-toxin and supportive care Wound Botulism: Contamination of a wound with spores that germinate Outbreaks seen in IV drug users Symptoms caused by exotoxin; similar to FBB but with longer incubation time than FBB Infant Botulism: 5-20 week old babies exposed to solid foods with spores, especially honey and corn syrup Colonization of guy before competing normal flora are established Symptoms include constipation, weak suckling, generalized weakness Treat with antibiotics and anti-toxin Tetanus Neurotoxin: A/B toxin produced by environmental bacteria Clostridium tetani Results in violent spastic paralysis (lockjaw) Treatment with tetanus immunoglobulin: passive immunization with antibodies from vaccinated donors Vaccine against tetanus toxoid to prevent disease

Bacillus anthracis (anthrax): Caused by spore-forming bacterium Common in agricultural areas and animals Cutaneous, inhaled, or intestinal infections in humans Two toxins for two diseases: pneumonia (Edema factor, fluid accumulation); lethal form (Lethal factor) AB toxin, but with 3 distinct subunits no one subunit alone is toxic

Drug Development: Target key processes like metabolic pathways, enzymes, and rigid cell walls (bacteria and yeasts) Exploit differences between pathogens and humans Antibacterial Drugs: Target DNA replication and stability with quinolones and metronidazole Interfere with transcription process with rifampicin Prevent protein synthesis/translation with mycins and tetracycline, linezolid Disrupt cytoplasmic membrane with daptomycin (gram positive) and polymyxins (gram negative) Target cell wall with beta-lactams (penicillin) and vancomycin (gram positive, last line of defense)

Bactericidal Drugs: Kill bacteria; penicillin, rifampicin Bacteriostatic Drugs: Inhibit growth, require immune function for recovery; tetracyclines, macrolides, chloramphenicol Therapeutic Index: Activity of a drug against a pathogen vs. the activity of a drug against the human Host Cell Permeability:

Important for intracellular pathogens Penetrate: macrolides and tetracyclines Do not penetrate: penicillin and aminoglycosides How a drug works in vitro (in test tube) may not reflect how it works in vivo (in life) o In vitro: activity against pure bacterial cultures o In vivo: efficacy in curing infection o Drug absorption and metabolism may not be equivalent

Approaches to Drug Discovery: Empirical: no knowledge/target/mode of action; test for activity; most antibiotics found this way Rational: select a target/essential process or enzyme; identify compounds which interfere with the process; develop Almost all antibacterials derived from natural products (penicillin comes from common bread mold) Synthetic products: small molecules like quinolones and linezolid

Drug Resistance: There are two forms of drug resistance, primary (intrinsic) and secondary (acquired) Drugs are usually good for 10 years before resistance makes them ineffective (about the same time as a patent expires) Multidrug Resistant (MDR) resistant to 3+ drug classes (penicillins, macrolides, tetracyclines); Resistant usually to whole class Resistance and Drugs Cause vs. Selection: Drugs do not cause resistance and are not usually mutagenic Drugs select for cells with mutations, resistance plasmids; these cells then outgrow the others under drug pressure Also mutational resistance, plasmid resistance Resistance against HIV, TB, Malaria is mostly mutational Plasmid Resistance: Transposons (assemble a MDR plasmid) Integrons Gene cassettes Genes for resistance Drug Resistance for HIV, Malaria, and TB: TB resistance mostly in foreign born (70%) Drug resistance to malaria began in the 1950s SE Asia and NW South America MRSA (Methicillin-resistant Staphylococcus aureus):

Skin infections, hospital infections, dialysis, surgery, colonization Only treatable with vancomycin

CA-MRSA (community acquired MRSA): Aggressive strain with a peptide toxin From sports teams, prisons, cruise ships No previous hospitalization/medical procedure Results in pimples or boils VISA/VRSA (vancomycin intermediate/resistant Staphylococcus aureus): MDRE (Multidrug-resistant Enterococci): Hospital infections, blood stream, surgical wounds, urinary tracts VRE (vancomycin-resistant Enterococci): Campaign Against Resistance: Prevent infections Diagnose and treat infections effectively Use drugs wisely Prevent transmission Drugs and Money: Few new antibiotic classes developed No financial incentive, especially for drugs needed in poor/developing countries Infectious diseases: usually patient takes the drug for a prolonged period of time

Self vs. Non-Self Recognition: Innate immune system (macrophages, dendritic cells) o First line of defense against invading microorganisms o Non-specific recognition; but no long-lasting immunity against a pathogen Adaptive immune system (B cells, T cells) o Specific recognition o Has immunological memory o Single specificity o Response tailored to specific pathogens Immune Response: Symptoms of an immune response is flu-like full-body aches and pains Inflammation includes redness, swelling, heat, pain, and immobility Tolerance: the lack of an immune response to an antigen

Autoimmune disease: when a response against a self-antigen induces injury systemically or against a particular organ Can arise intrinsically when an individual has an overactive immune response against self antigens Can be triggered by infection of certain pathogens o 3rd most common disease in the US o Higher prevalence in women o Examples of autoimmune diseases: MS, lupus, Crohns disease, Rheumatoid arthritis, Graves disease Molecular Mimicry: Pathogens contain antigens that have similarity to self antigens Once the immune system mounts a response, cross-reactive antibodies can cause damage by attacking self antigens (autoimmune disease) Can occur long after original infection; hard to link disease with infection Example of Strep A and Rheumatic Fever: antibodies against Strep A also act against kidney, joint, and heart antigens leading to inflammation and organ destruction (Rheumatic Fever) Diabetes: 24M worldwide with diabetes Type I: insulin-dependent or juvenile-onset (genetic, environmental, and microbial infection important) o Pancreatic cells targeted by immune system so can no longer make insulin Type II: adult-onset, develops over time (obesity and age) Diabetes linked to viral infections Diabetes and Viruses: Molecular mimicry Altered immune balance for tolerance Expression of superantigens induce non-specific immune response Activate bystanders against self Non-immune destruction Multiple Sclerosis (MS): Chronic inflammatory disease of the central nervous system Neurological disability Women affected twice as much as men; more than 1M people worldwide Susceptibility is inherited, but role of environmental factors to trigger Antibodies made against self-antigens found in the myelin sheath are destroyed when inflammation destroys myelin, leaving areas of scar tissue Relationship between MS and EBV

Systemic Lupus Erythematosus (SLE): Complex autoimmune disease with varied clinical presentations (wide range organ damage) Progressive, can be fatal Etiology and pathogenesis poorly understood Genetic, hormonal, and environmental components Lupus and EBV: autoimmunity likely via molecular mimicry Epitope Spreading: Initial attack of cross-reactive antibodies causes the release of additional self-antigens that can be targeted by other auto-reactive immune cells, leading to more autoimmune reaction Allergen: Normally harmless non-self antigen that is the target of an allergic immune response Anaphylactic Shock: Allergic reaction to a systemically administered allergen; causes circulatory collapse and suffocation Asthma: Chronic condition of respiratory system Airways constrict, inflame, with excessive amounts of mucus Triggered by allergen, environmental, stress, illness Crohns Disease: Chronic episodic inflammation of the digestive tract; inflammatory bowel disease Link to M. paratuberculosis Host-Pathogen Interaction: Disease is an outcome of an interaction between a host and a microorganism The hosts outcome is determined by the amount of damage suffered Host damage can result from the microbe or the hosts immune response Opportunistic microbes pathogenic only in individuals with impaired immune function (AIDS OIs include shingles, MAC, pneumocystic, toxoplasma) Microbes that cause disease with significant immune destruction (H. pylori, shigella sp.) H. pylori has a normal immune response and strong immune response o Normal is asymptomatic o Strong is inflammation of the stomach lining; link to stomach cancer Shigella sp. Strong immune response: Reactive arthritis/Reiters syndrome Autoimmune disease that develops in response to an infection in another part of the body

Parasite:

Eukaryotic organism that lives on or in another host organism in a way that harms or is of no advantage to the host Protozoan parasite: single cell (sexual and asexual reproduction) Metazoan parasite: multicelled (likes sex to reproduce) Parasites have multiple hosts

Parasitic Hosts: Definitive Host: Organism in which a parasite reproduces sexually Intermediate Host: Organism in which a parasite does not reproduce sexually Reservoir: Non-human organism which can harbor parasites Can conduct disease control in any of these hosts

Plasmodium vivax (malaria): Night-biting Anopheles mosquitoes #1 killer of children under 2 years of age Liver infection Blood infection Parasite lives and divides inside a liver cell, which bursts and releases parasites into blood stream Parasites then invade red blood cells, which are able to adhere to the walls of blood vessels Malaria in the US eradicated by 1951 Preventing Transmission: Target the vector, treat the disease Target the vector with insecticides, barriers (bed nets), and source reduction Treat the disease with surveillance, diagnosis, drug therapy, and isolation Trypanosoma brucei rhodesiense/gambiense (African Sleeping Sickness):

Definitive host is Tsetse fly; reservoir is Savannah Antelope Intermediate is human in blood, lymph, spinal fluid Sleeping sickness related to Tsetse fly range in Africa Ulceration at bite site, nodules on neck, chronic disease if untreated Rhodesiense: Acute disease progresses rapidly with organ failure

DNA Viruses Herpes Hepatitis B Oral Hairy Leukoplakia Kaposis Sarcoma CMA Shingles HPV Smallpox (variola major/minor) RNA Viruses Hanta Fever Lassa Fever Lujo Polio Flu SARS Ebola Marburg Rotavirus Norovirus Hepatitis A, C, D, E West Nile Dengue Yellow Fever Mumps Measles Gram Positive Bacteria Strep Staph Diphtheria Tetanus (clostridium tetani) Listeria