PUBLIC HEALTH CONFERENCE

Preparedness, Alert and Response

Lessons Learned in Europe from Last Cross-

Border Health Infectious Threats

INSTITUTO DE SALUD CARLOS III - Campus de Chamartín. Salón

Ernest Lluch

MADRID – SPAIN

15 June 2017

Campus de Majadahonda Campus de Chamartín

The role of Instituto de Salud Carlos III in

the management of health infectious

threatsManuel Cuenca-Estrella

Deputy Director of Institute of Health Carlos III

Spanish National Health System and Public Health

• National Health System and Public Health (PH)services in Spain are under the mandate of theMinistry of Health, Social Services and Equality andalso of regional authorities (AutonomousCommunities)

• The Institute of Health Carlos III (ISCIII) was foundedin 1986 (Ley 14/1986) support the National HealthSystem for diagnosing and controlling of diseases.

The ISCIII

• The Spanish National Centers of ISCIII act as the reference laboratories and services running a variety of activities focused on control of diseases:

– Reference diagnosis, surveillance and advisory activities

– Research programs

– Educational programs

• There is official recognition for some of those reference activities.

National Centers and Schools

• Spanish National Center of Microbiology (CNM)

• Spanish National Center of Epidemiology (CNE)

• Spanish National Center of Environmental Health (CNSA)

• Spanish National Center of Rare and Uncommon Diseases (IIER)

• Spanish National Center of Tropical Diseases (CNMTrop)

• Other units or departments:

– Chronic diseases

– Health cares and nursing

– e-Health and telemedicine

National Centers and Schools

• Agency for Evaluation of HealthcareTechnology

• National School of Health

• National School of Occupational Medicine

• National Library of Health

• Biobanks and repositories

ECDC Core Functions

• Function 1: Reference diagnostics

• Function 2: Reference material resource

• Function 3: Scientific advice

• Function 4: Collaboration and research

• Function 5: Monitoring, alert and response

Personnel of Reference Laboratories 2017

Permanent positions: 50-60%Average age: 57 y.

Coordination and Prioritization

• Services portfolio (550 billable items)

• Public Health Services (non-billable, own funds)

– Surveillance Systems

– Microbiological programs

– Cohort follow-up

– Infectious outbreaks

– Alert services:

• Infectious emerging threats

• Bioterrorism incidents

Early warning and emergency responsecapability and capacity

• Passive surveillance

• Population-based active surveillance programs

• Detection of imported infections

• Detection of resistances

• RELAB: Spanish Network of Laboratories for Biological Alerts:

– Bioterrorist incidents

• Participation in surveillance networks:– Spanish Networks: RENAVE (National Network of Epidemiological Surveillance),

MoMo (Mortality and morbidity reports) and others

• Microbiological confirmation or rule out infectious threats :– Alert services (7 days/24 h)

Alert Services actions

Why does the ISCIII concern the diagnosis ofinfectious threats?

• 1918: The Spanish Influenza, 20-40 M of deathsworldwide, including some famous people (GustavKlimt, Guillaume Apollinaire, Edmundo Rostand)

• 1920: the pandemic ends but great public attentionand social alarm

• Public authorities become aware of relevance ofinfectious threats particularly respiratory diseases

• The white plague: tuberculosis

The ISCIII Ancestors…

• 1921-22: A start is made on the construction ofhospitals for respiratory diseases (Hospital de laFuenfría, de Guadarrama…)

• 1922: Hospital del Rey at Madrid (current campus ofthe ISCIII)

• 1925: Official opening of the Hospital

• 1931 (Second Republic): National Hospital ofInfectious Diseases

The ISCIII Ancestors…1932: Texts of the chaplain of the hospital:

“Estaba el hospital en el extremo norte de Madrid, a sietekilómetros del centro, prácticamente aislado en medio delcampo. Su nombre —"Hospital Nacional de EnfermedadesInfecciosas"— explica el aislamiento. Había sido inaugurado en1925. (Del antiguo régimen le venía lo del "Hospital del Rey").En él se trataban los casos de epidemia y enfermedadescontagiosas; y la terrible tuberculosis, que era entonces laenfermedad que requería más camas y se cobraba másmuertes… Además paludismo, tifus exantemático, fiebretifoidea, poliomielitis…”

Hospital del Rey, 1930, and hospital room

ISCIII, 2017

The ISCIII Ancestors…The three backbones

• 1922: The Kingdom of Spain and the Rockefeller Foundationsigned a MoU for the establishment of the National School ofHealth in line with other schools of medicine in the World.

• 1924: National School of Medicine begins operating into theHospital del Rey grounds. Infectious diseases educationalprogram

• In addition, 1924, Alfonso XIII Institute is also set, researchand education in microbiology, serology and hygiene also intoHospital del Rey.

• Those organizations replace the Instituto Nacional de laVacuna (1871) and the Instituto Nacional de Bacteriología eHigiene (1894)

1925-1980…Torres Gost J. Medio siglo del Hospital del Rey, 1975

• The tuberculosis control become the main activity ofthe organization

• A female pavilion (Hospital Victoria Eugenia) and apediatric hospital are opened (Hospital Infante DonFelipe)

• Antibiotic Era: Control of tuberculosis is closer andnew activities arise since 1955

1925-1980…Torres Gost J. Medio siglo del Hospital del Rey, 1975

• Vaccination campaigns:

– Smallpox, last Spanish case in 1961

– Poliomyelitis

• Cholera and meningitis outbreaks

• Imported infectious diseases

• Program in many other diseases:

– Escuela Nacional de Medicina del Trabajo, 1948.

– Centro Nacional de Virología y Ecología Sanitarias, 1967. Opening of asecond campus, Majadahonda, Madrid

– Escuela Nacional de Administración Sanitaria, 1970

– Centro Nacional de Salud Ambiental, 1974

1981. First Alerts

• Toxic Oil Syndrome:

– 20,000 cases

– 1,100 deaths

– It is seen as a infection several months

– Atypical pneumonia (Mycoplasma)

– Ingestion of rapeseed oil denatured with 2% aniline

1984

• June 5th, 1981, the US. Centers for Disease Controland Prevention (CDC) publish five cases of pneumoniaby Pneumocystis carinii (currently P. jirovecii)

• 1984: AIDS era (almost 40 M of infected in 2017)

• Our organization is identified as the most adequate tolead the control of AIDS offering services, researchand educational programs

DIRECTORD. Jesús F. Crespo

GOVERNING BOARD

Director SupportUnit

Dª. Rosa Cepeda

General Secretary

D. Pedro Cortegoso

Applied Services, Training &

Investigation

D. Manuel Cuenca

Evaluation and Research

Management

Dª Belén Bornstein

Networks for Cooperative

Research

Dª. Margarita Blázquez

International Programmes

D. Alfonso Beltrán

Cellular Therapy &Regenerative

Medicine

D Manuel Cuenca

National Microbiology Centre

National Epidemiology

Centre

National Centre for Enviromental Health

National Centre for

Tropical Medicine

Unit for Research in Chronic Disease

Telemedicine Research Unit

Nursing and Healthcare Research

Unit

Strategic Action in Health

(AES in Spanish)

RETICS

Scientific-technical Platforms

National Library of Health Sciences

Foundations

International Programmes

European Projects Office

Health Technology Assessment

Agency

Research and Knowledge Transfer

Office

Platform & National Biobank Register

National Cell Line Bank

Spanish Bioethics Commitee

National School of Health

National School of Occupational

Medicine

CIBER

Institute of Health Carlos III1986: Establishment of the Instituto de Salud Carlos III

Campus

Chamartín

Campus Majadahonda

1986-2016. Thirty years. The three backbones again

• The ISCIII takes part in the control of diseases:

– Services in reference centers

– Educational programs in National Schools

– 1994, integration of Funding of Health Research (FIS) intothe ISCIII

Alert Services actions

Contemporary Era in the Public Health Alert Services

• 2001. Anthrax attacks (postal letters). One week laterthan September 11th

• 2003. Severe acute respiratory syndrome (SARS)coronavirus.

• 2004. The ISCIII sets its first Alert Unit (microbiologistand epidemiologist):

– 24 h/7 days

– Coordinated with Health Ministry and Regional Authorities

– More than 60 cases of suspected SARS are ruled out

Contemporary Era in the Public Health Alert Services

• 2009. Swine flu, Influenza A (Mexican outbreak):

– Hundreds of cases (suspected and confirmed)

– The ISCIII confirms cases and coordinate the notification

– New roles of the ISCIII:

• Translation of reference diagnostic techniques

• Funding of research. A specific call of the FIS about swine flu isdone

• Part of several international projects to innovative detection,improve share of information and education

Contemporary Era in the Public Health Alert Services

• 2012. MERS-CoV Middle East Respiratory Syndromeby Coronavirus.

• 2014. African Ebola Virus Outbreak. Spanish Cases

• 2015. Zika virus

• 2016. Spanish endemic case of Crimea-CongoHemorrhagic Fever

Summary• The ISCIII (and ancestors) has been always an organization

focused in the control of infectious threats

• 2010, reorganization of centers and services of ISCIII and aprioritization of activities including Alerts is done

• The number of incidents and alerts has increased significantlyin last years

• The Spanish Alert system has been set:

– CCAES of Spanish Ministry of Health

– Health Systems of Autonomous Communities

– The ISCIII as a support with different roles (the three backbones)

Our Role in Services• Laboratory Reference Services:

– Confirmation or discard of suspected cases of infectiousthreats:• African Ebola Virus: 75 cases studied. 2 imported cases. One secondary case

• Crimea-Congo Virus: First endemic case, first nosocomial case, several othercases rule out

• RELAB: Routine testing of materials finding in presumed bioterrorist incidents(anthrax and ricin). 7-10 incidents a year

– Translation of diagnostic technologies:• Zika virus: Analysis of first 500 suspected cases and then translation of PCR-

based techniques to several hospital. Confirmation of positive cases at theISCIII

Our Role in Services• Epidemiological Reference Services (CCAES and Autonomous

Communities):

– Coordination of notification through the RENAVE

– In charge of other surveillance and notifications systems:• Sistema de Información sobre Vigilancia Epidemiológica (SIVIES)

• Reporte sistemático de datos a ECDC y OMS

• Sistema de Información Microbiológica (SIM)

• Boletín Epidemiológico e informes de vigilancia epidemiológica, alertas y riesgos.

• Brotes de interés en salud pública

• Mortalidad general

• Morbilidad hospitalaria general (CMBD)

– Surveillance of specific cohorts:• AIDS

• Toxic Oil Syndrome

Our Role in Research• Part of several international projects to innovative detection,

improve share of information and education:– EMERGE: Efficient response to highly dangerous and emerging pathogens at EU

level

– ERINHA: European Research Infrastructure for Highly Pathogenic Agents

– EPISOUTH and EPISOUTH PLUS: Network for the Control of Public Health Threatsand other bio-security risks in the Mediterranean Region and Balkans

– MEDIPIET: Further Development and Consolidation of the MediterraneanProgramme for Intervention Epidemiology Training

– IB-BIOALERNET: Iberian Network of Laboratories of Biological Alert

– SHIPSAN ACT: The impact of maritime transport of health threats due to biological,chemical and radiological agents, including communicable disease

– AIRSAN ACT: Coordinated action in the aviation sector to control public healththreats

Our Role in Research

• Calls on Research about specific fields of alerts:– Intramural projects

– Calls for the National Health System (FIS)

• Hemorrhagic fevers

• Alert surveillance

• Respiratory diseases

– Annual average funding: 1.5-2.0 M €

Our Role in Education• Qualification of several clinical laboratories of the National

Health System (stay and translation):

– Hemorrhagic fevers

– Respiratory diseases

– Zika disease

• Educational Programs:

– PEAC: Training Program in Epidemiology and Public Health

– National School of Health: Masters in public Health,Microbiology (50 students yearly)

• Specific activities:

– Train of trainers at the National School of Health in Ebola diseaseoutbreak (1,200 health professionals)

New ISCIII Facilities

(2015-2019)

CNM (8.500 m2)

Campus de Majadahonda Campus de Chamartín