The next pandemic: what will it be, when will it come, and why?

Mark Collins BA MBA PhDDirector, Commonwealth Foundation

Introduction

Patterns of infectious disease emergence over the past 40 years give serious cause for concern• Late 1960s – diseases believed to be under control• New diseases like HIV and SARS emerged• Tuberculosis and malaria grew once again• Resistance to anti-microbials complicates matters• New animal diseases discovered, e.g.BSE • Bird flu becomes a global pandemic and threatens to bridge across to humans.Infectious diseases kill more than 20% of people in the world and we don’t know when or from where the next pandemic might come.

UN Health Targets

The Millennium Development Goals, adopted in 2000, include some fundamentally important targets for health:

Goal 1: Eradicate extreme poverty & hungerGoal 4: Reduce child mortalityGoal 5: Improve maternal healthGoal 6 : Combat HIV & AIDS, malaria & other diseases

At the half way point, the picture is mixed.

Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

Eradicate extreme poverty

Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

Target: Halve between 1990 and 2015 the proportion (%) of people whose income is less than US$1 per day

Achievement: Poverty has fallen from one third of all people to one fifth

Improve maternal health

Target: reduce by three quarters the maternal mortality ratio

Histogram shows proportion of deliveries attended by skilled health care personnel, 1990 and 2005 (%)

Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

Reduce child mortality

Target: two thirds reduction in mortality rate of children under five

Histogram shows under 5 mortality rate expressed as deaths per 1000 live births in 1990 and 2005

Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

Combat HIV, AIDS, malaria & other diseases

HIV prevalence has levelled off in the developing world, perhaps partly because deaths from AIDS continue to increase in sub-Saharan Africa

Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

Today’s major killers

Disease Worldwide mortality 2002% total deaths Total number

Lower respiratory tract 6.8% 4.0 MHIV and AIDS 4.9% 2.8MDiarrhoea 3.2% 1.8MTuberculosis 2.7% 1.6MMalaria 2.2% 1.3MChildhood infections 2.0% 1.1MOther infections 1.0% 0.6M

TOTALS 22.8% 13.2MSource WHO 2004 Statistical annexe

Impact of disease on nations

Developing countries• Underlying burden of infection greater• Children disproportionately affected• Half of deaths in under 5’s due to infections• Malnutrition exacerbates the problem• Low tech measures can make a big differenceDeveloped countries• High social costs from infectious disease• In UK 10% of deaths are from infection• 50% of adult consultations die to disease• Prevention of pandemics is costly• But pandemic outbreaks could cripple nations

Origins of pandemic infections

Six major sources of potential future pandemics

• Novel pathogens – viruses continually evolve• Pathogens acquiring resistance• Zoonoses – diseases acquired from animals• HIV and AIDS, tuberculosis and malaria• Acute respiratory tract infections• Sexually transmitted diseases, including HIV

Trends in novel pathogens

New human pathogen species detected since 1980.Source: Foresight project, UK OSI, 2006

HIV vCJD

Bird flu H5N1

SARS

Pathogens acquiring resistance

This is a problem that is getting worse:• Resistance arises in bacterial, viral, fungal and parasitic diseases• Antibiotics, vaccines, fungicides and insecticides become less effective• Resistance from mutation, acquiring new genes or natural selection• Enteric pathogens, pneumonia, TB, gonorrhoea, malaria, HIV and MRSA all resist• Currently controlled diseases could re-emerge as a result

Zoonoses

• Animals are a common source of human disease• The risk is growing because of intensive farming• Bushmeat hunting in Africa presents more chance for species jump • Viral haemorrhagic fevers could mutate to chronic forms and spread

Bushmeat - risk of disease

Growth in bushmeat hunting in Africa presents a major risk of new zoonotic diseases – and detection would be slow.

HIV and AIDS, TB & malariaThese three diseases are linked as the dominant epidemics in Africa. In some areas 80% of TB cases are in people living with HIV. The cost of malaria to Africa is US$12 billion annually.

Fighting the diseases presents special problems:• Stigma and discrimination against people with HIV and AIDS• Lack of access to care for living with TB• Drug resistance to malaria, and lack of mosquito nets

HIV in Africa

Respiratory tract infections

• Epidemic ARIs are generally zootic in origin• Bird flu is an acute respiratory disease• Today’s biggest new disease threat• Confirmed in 60 countries• Probably worldwide in nine months• More than 240M poultry killed• Massive risk of socio- economic impact in Asia

Bird flu: the risk to humans

• It could cross to humans as Spanish flu did• Humans have no immunity to this strain• Vaccines cannot be made in advance• World capacity for vaccine production low • Low income countries are most at risk• Rural community risks contact with poultry• Medical and essential services overwhelmed

Sexually transmitted diseases

• Sexually transmitted diseases are on the increase worldwide• Antimicrobial resistance is on the increase• Many infections remain undiagnosed and even more are untreated• Pregnant women are a key target, to reduce transmission to newborn children

Disease risk from environmental change

Damage to ecological processes can create better conditions for infectious disease. Factors include:• Encroachment into forests that harbour zoonoses• Reduction in natural biodiversity that controls pests• Creation of conditions that favour disease vectors

- climate change- changes in surface waters

• Long distance trade in wild animals

Source: Ecosystems & Human Well-being. Millennium Ecosystem Assessment 2005. WHO

Climate change

Climate change increases risk of pandemic by:• assisting survival of pathogens, hosts and vectors;• creating new and favourable habitats, • and through social change.Disease patterns:• HIV & AIDS and TB unchanged• cholera and diarrhoeal diseases more common• malaria and other vector borne diseases spread more widely

1 metre sea level rise will inundate 17.5% of Bangladesh

Source: Baylis M. 2006 Climate change & disease of plants, animals and humans: an overview. OSI, London

Health care systems

Human resources limitations in the developing world constrain achievement of the MDGs and heighten the risk of pandemics. Problems include:• Lack of trained personnel• Lack of motivation & poor performance• Migration of health workers, including pharmacists• Impact of HIV and AIDS

Source: Wagstaff A. & Claeson, M. 2004. The Millennium Development Goals for Health: Rising to the Challenge. World Bank 186 pp.

Medicine access & affordability

Tackling pandemics and the MDGs will require much-improved access to medicines:• Shortages are commonplace in developing world health centres• Counterfeit drugs are everywhere• Affordability prevents many from getting access.

Source: Wagstaff A. & Claeson, M. 2004. The Millennium Development Goals for Health: Rising to the Challenge. World Bank 186 pp.

Pandemics and pharmacists

Pandemic diseases are not yet controlled, and new ones will certainly arise. They kill millions of people and the social and economic costs of control and prevention are huge.

Three principal actions need to be taken:1. Increase overseas development assistance and invest in medical training and health care systems.2. Improve access to and affordability of genuine drugs; improve drug use to control resistant strains3.Develop and implement new detection, identification and monitoring systems, from global satellite surveillance to hand-held diagnostic kits.

Thank you!

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Questions?