world health organization 1 august 2008 infectious diseases in a globalized world: risks to our...

World Health Organization

1August 2008

Infectious diseases in a globalized world: risks to Infectious diseases in a globalized world: risks to our public health securityour public health security


2August 2008

Cryptosporidiosis

Lyme Borreliosis

Reston virus

Venezuelan Equine Encephalitis

Dengue haemhorrhagic fever

Cholera

E.coli O157

West Nile Fever

Typhoid

Diphtheria

E.coli O157

EchinococcosisLassa feverYellow fever

Ebola haemorrhagic fever

O’nyong-nyong fever

Human Monkeypox

Cholera 0139


Influenza A(H5N1)

Cholera

RVF/VHF

nvCJD

Ross River virusHendra virus

BSE

Multidrug resistant Salmonella

E.coli non-O157

West Nile Virus

Malaria

Nipah Virus

Reston Virus

Legionnaire’s Disease

Buruli ulcer

Emerging and re-emerging infections, 1996 – 2007

Severe Acute Respiratory Syndrome (SARS)

Human Monkepox

Marburghaemorrhagic fever

E.coli O157

Recent outbreaks followed by WHO

Avian influenza (human) Asia/Middle East/AfricaMarburg Haemorrhagic Fever UgandaChikungunya Pacific Islands, ItalyCholera West /Southern AfricaNipah haemorrhagic fever BangladeshLassa Fever Sierra LeoneHigh mortality measles NigeriaMeningococcal meningitis West and Central AfricaYellow Fever Guinea/SudanPoliomyelitis DRC/Bangladesh


3August 2008

Points for discussionPoints for discussion

What do we know about emerging infections?– Resilience/dynamism

– Relationship with animals

– Persons at greatest risk

– Other


4August 2008

Breaches in species barrier: selected emerging Breaches in species barrier: selected emerging infections in humans identified since 1976 infections in humans identified since 1976

Infection Original Yearhost reported(confirmed/hypothesized)

Ebola virus Bats 1976

HIV-1 Primates 1981

E. coli O157:H7 Cattle 1982

Borrelia burgdorferi Rodents 1982

HIV-2 Primate 1986

Hendra virus Bats 1994

BSE/vCJD Cattle 1996

Australian lyssavirus Bats 1996

H5N1 influenza A Chickens 1997

Nipah virus Bats 1999

SARS coronavirus Palm civets 2003 adapted from Woolhouse et al. (2005)


5August 2008

Smallpox: Smallpox: Variola MajorVariola Major

20% - 40% case 20% - 40% case fatalityfatality

100% permanent 100% permanent facial scarringfacial scarring

2.7 million deaths, 2.7 million deaths, 19671967


6August 2008

Smallpox Eradication:Certified 1980


7August 2008

Persons living with HIV infection, 2006: >40 million

3 million deaths during 200320 million deaths since 1981

1984: smallpox vaccination in HIV-infected adult was

AIDS defining event with generalized vaccinia/death


8August 2008

Source: WHO/CDC

0

2

4

6

8

10

12

14

16

7-

Mar

13-

Mar

19-

Mar

25-

Mar

31-

Mar

6-

Apr

12-

Apr

18-

Apr

24-

Apr

30-

Apr

6-

May

12-

May

18-

May

24-

May

30-

May

5-

Jun

11-

Jun

17-

Jun

Non health care workers

Health care workers

Ebola Haemorrhagic Fever by mode of transmission, Kikwit Zaire, 1995


9August 2008

SARS, chain of human-to- human SARS, chain of human-to- human transmission, Singapore 2003 transmission, Singapore 2003


10August 2008

International travellers, 1950 - 2006International travellers, 1950 - 2006

Source: WHO/World Tourism Organization

International airline passengers (millions)

1000

800

600

400

200

01950 1960 1970 1980 1990 2000

1200

1400

Increased to over 2 billion international travellers in 2006


11August 2008

Outbreak of leptospirosis (N = 33) among 312 Outbreak of leptospirosis (N = 33) among 312 participants, Eco Challenge 2000, Malaysiaparticipants, Eco Challenge 2000, Malaysia

Eco Challenge

Eco Challenge

US: 10

Canada: 4

Brazil: 1

Uruguay: 1 Australia: 4

France: 4UK: 9


12August 2008

Doctorfrom

Guangdong

Doctorfrom

Guangdong

CanadaCanada

Hotel MHong Kong

IrelandIreland

USAUSA

New YorkNew York

SingaporeSingapore

Viet NamViet Nam

BangkokBangkok

B

I

K

F G

ED

C

JH

A

Germany1 HCW +

2

Germany1 HCW +

2

Source: WHO/CDC

SARS: international spread from Hong Kong,SARS: international spread from Hong Kong, 21 February – 12 March, 2003 21 February – 12 March, 2003

Hong KongHong Kong

+ 219 health care workers


13August 2008

Countries in which airport malaria has been Countries in which airport malaria has been reported, 1969 – August 2003reported, 1969 – August 2003

USA: 1USA: 1 Switzerland: 1Switzerland: 1

Australia: 1Australia: 1

Belgium: 1Belgium: 1

Germany: 1Germany: 1

United Kingdom: 7United Kingdom: 7

France: 3France: 3

Israel: 1Israel: 1

Luxembourg: 2Luxembourg: 2


14August 2008

West Nile Virus in the United States, 2005West Nile Virus in the United States, 2005

Genetic sequencing compatible with

One-time introduction in late 1990s


15August 2008

Increased world trade in agricultural Increased world trade in agricultural products/animals, 1950 - 2006products/animals, 1950 - 2006

19500

40

80

120

160 export of agricultural products by volume

1960 1970 1980 1990 2000

Source: WTO, 2000

World trade in agricultural products has increased 5-fold since 1950


16August 2008

Deaths from vCJD by year of death, United Kingdom, Deaths from vCJD by year of death, United Kingdom, 1994 - 2006 1994 - 2006

N = 162 N = 162

10 1015

28

2017 18

18

0

5

10

15

20

25

30

35

40

1994 1995 1996 1997 1998 1999 2000 2001 2002 2003

0 39

14

2004 2005


17August 2008

BSE and vCJD: potential exposure BSE and vCJD: potential exposure through international trade, early 1990sthrough international trade, early 1990s

Food containing beefFood containing beef

PharmaceuticalsPharmaceuticalsBlood Blood and bloodand bloodproductsproducts

Cattle, mCattle, meat and eat and bone mealbone meal

Human and Human and bovinebovinetissue used tissue used in biologicalsin biologicals


18August 2008

PharmaceuticalsPharmaceuticalsBlood Blood and bloodand bloodproductsproducts

Meat and Meat and bone mealbone meal

Human and Human and bovinebovinetissue used tissue used in biologicalsin biologicals

vCJD: vCJD: ggeographieographic distribution of human c distribution of human infectionsinfections


19August 2008

Rift Valley Fever, humans, Yemen, Rift Valley Fever, humans, Yemen, September 2000September 2000

0

20

40

60

80

September 1-30, 2000

Number of cases


20August 2008

Rift Valley Fever, livestock, Yemen Rift Valley Fever, livestock, Yemen and Saudi Arabia, October 2000and Saudi Arabia, October 2000

Area affectedArea affected


21August 2008

El Nino-associated flooding, East Africa, 1998El Nino-associated flooding, East Africa, 1998

Animal vaccination suspended early 1990s

Flooding forced humans and animals to close proximity

Increased mosquito breeding sites


22August 2008

Highly pathogenic H5N1 influenza virus in smuggled Thai eagles, Belgium, 2005

Source: Van Borm, et al, Emerging Infectious Diseases Vol. 11, No. 5, May 2005


23August 2008


What can be done to prevent the international spread of infectious diseases?

What measures have been taken by governments in the past?

Have any of these measures been effective?


24August 2008

Concern about public health security throughout Concern about public health security throughout the agesthe ages

1374 Venice Quarantine for Plague

1851 Paris 1st International Sanitary Conference

1947 Geneva WHO Epidemiological Information Service

1951 Geneva International Sanitary Regulations

1969 Geneva International Health Regulations


25August 2008

“…ensure the maximum security against the international spread

of disease with a minimum

interferencewith world traffic.”

International Health Regulations purpose International Health Regulations purpose 19691969

June 2007 World Health Organization 26

Content of International Health Regulations 1969: requirements

NotificationNotification to WHO: cholera, plague or yellow to WHO: cholera, plague or yellow fever – reports only accepted from countries fever – reports only accepted from countries where event is occurringwhere event is occurring

Health Organization at borders:Health Organization at borders: ports, airports ports, airports and frontier posts adequately equipped to and frontier posts adequately equipped to prevent vector proliferation prevent vector proliferation

Health Measures:Health Measures: describe maximum measures describe maximum measures that a country may require to protect against that a country may require to protect against cholera, plague and yellow fever (e.g. yellow cholera, plague and yellow fever (e.g. yellow fever vaccination card)fever vaccination card)


27August 2008

Application of International Health Application of International Health Regulations, 1969Regulations, 1969

National containment

activity

Disease reporting by countries (cholera,

plague, yellow fever)

Publication in Weekly Epidemiological Record

Application of pre-determined measures (maximum allowable)


28August 2008


Do you think the International Health Regulations are an effective means of dealing with the international spread of infectious diseases?

If yes, why?

If no, why?


29August 2008

Direct economic impact, selected infectious disease outbreaks, 1990-2003

Asia – SARSUS$ 30 billion

2003

UK - BSE US$ 39 billion

1990-1998

Tanzania - CholeraUS$ 36 million

1998

India - PlagueUS$ 1.7 billion

1995

Peru - CholeraUS$ 770 million

1991

Malaysia- Nipah Pig destruction

1999

Hong Kong - influenza A(H5N1) Poultry destruction

1997

US E. coli 0157Food recall/destruction

Periodic


30August 2008

Cryptosporidiosis

Lyme Borreliosis

Reston virus

Venezuelan Equine Encephalitis


Cholera

E.coli O157

West Nile Fever

Typhoid

Diphtheria

E.coli O157

EchinococcosisLassa feverYellow fever

Ebola haemorrhagic fever

O’nyong-nyong fever

Human Monkeypox

Cholera 0139


Influenza A(H5N1)

Cholera

RVF/VHF

nvCJD

Ross River virusHendra virus

BSE

Multidrug resistant Salmonella

E.coli non-O157

West Nile Virus

Malaria

Nipah Virus

Reston Virus

Legionnaire’s Disease

Buruli ulcer

Emerging and re-emerging infections: 1996 - 2007

Severe Acute Respiratory Syndrome (SARS)

Human Monkepox

Marburghaemorrhagic fever


31August 2008

Global outbreaks, the challenge: Global outbreaks, the challenge: latelate reporting and response reporting and response

0

10

20

30

40

50

60

70

80

90

1 4 7 10 13 16 19 22 25 28 31 34 37 40

Delayed response

DAY

CA

SE

S

Lost opportunity for control/risk of international spread

Late reporting

First case


32August 2008

010

2030

4050

6070

8090

1 4 7 10 13 16 19 22 25 28 31 34 37 40

Rapid response

CA

SE

S

Early reporting Potential cases prevented/

international spread prevented

DAY

Global outbreaks, the solution: Global outbreaks, the solution: earlyearly reporting and response reporting and response


33August 2008


What would you do next?


34August 2008

Vision for revision of the International Health Vision for revision of the International Health Regulations, 1996Regulations, 1996

A world on the alert and able to detect and collectively respond to international infectious disease threats within 24 hours using the most up to date means of global communication and collaboration


35August 2008

Global Public Health Intelligence Network, Global Public Health Intelligence Network, CanadaCanada


36August 2008

Outbreak Verification & Response Outbreak Verification & Response Afghanistan, February 1999Afghanistan, February 1999

16 February16 February 19 February19 February 24 February 24 February 1 March 1 March

GPHIN report of highly fatal respiratory

disease

WHO/local teampreliminary investigation

WHO collaborative

team

Investigation completedDiagnosis confirmed


37August 2008

Information sources, public health risks reported Information sources, public health risks reported to WHO, 2003to WHO, 2003

0%

10%

20%

30%

40%

50%

60%

70%

AFR

O

EMR

O

EUR

O

AM

RO

SEA

RO

WPR

O

WR

s

NG

Os

PRO

MED

Oth

ers

GPH

IN

Countries ( 23% of reports)

WHO Alert & Response Network ( 77% of reports)


38August 2008

OperationaliOperationalizing the IHR in the 21zing the IHR in the 21stst century: p century: partnership artnership for global alert and response to infectious diseasesfor global alert and response to infectious diseases

Electronic Discussion sitesMedia

NGOs

MilitaryLaboratoryNetworks

WHO Collaborating Centres/Laboratories Epidemiology and

Surveillance Networks

WHO Regional & Country Offices

Countries/National Disease Control

Centres

UNSister Agencies

FORMALFORMAL

GPHIN

INFORMALINFORMAL


39August 2008

Request for GOARN support: terms of Request for GOARN support: terms of referencereference


40August 2008

Sample of International epidemic response Sample of International epidemic response missions in the field, 1998–1999missions in the field, 1998–1999


41August 2008

Global outbreak alert and response network: Global outbreak alert and response network: surveillance network partners in Asiasurveillance network partners in Asia

Mekong Basin Disease Surveillance (MBDS)

ASEAN

APEC

SEAMIC

SEANET

EIDIOR

Flu Net

GPHIN

Pacific Public HealthSurveillance

Network (PPHSN)

+ Red Cross, other NGOs


42August 2008

Reports of respiratory infection, China, Reports of respiratory infection, China, 2002–20032002–2003

16 November, 2002 – Guangdong : outbreak of respiratory illness/government

recommending isolation of anyone with symptoms (GPHIN)

– official government report of normal influenza B activity, 7 Dec. 2002

11 February, 2003– Guangdong: outbreak of atypical pneumonia among health workers

(GPHIN)

– official government report of atypical pneumonia outbreak with 305 cases and 5 deaths, influenza virus not isolated, 14 Feb. 2003


43August 2008

26 February– Hanoi: 48-year-old business man with high fever (> 38 ºC),

atypical pneumonia and respiratory failure with history of previous travel to China and Hong Kong (WHO country office)

4–5 March– Hong Kong and Hanoi: 77 medical staff (Hong Kong) plus 7

(Hanoi) reported with atypical pneumonia, not influenza (WHO team/liaison)

Intensified surveillance for respiratory Intensified surveillance for respiratory infections, Asia, 2002–2003infections, Asia, 2002–2003


44August 2008

Global Alert: Severe Acute Respiratory Global Alert: Severe Acute Respiratory Syndrome (SARS)Syndrome (SARS)

12 March: First global alert – Described atypical pneumonia in Viet Nam and Hong Kong

14 March

– 4 persons Ontario, 3 persons in Singapore, with severe atypical pneumonia fitting description of 12 March alert reported to WHO

15 March

– Medical doctor with atypical pneumonia fitting description of 12 March reported by Ministry of Health, Singapore on return flight from New York


45August 2008

Situation on 15 March, 2003Situation on 15 March, 2003

Atypical pneumonia with rapid progression to respiratory failure, none yet recovered

Health workers appeared to be at greatest risk

Unidentified cause, presumed to be an infectious agent

Antibiotics and antivirals did not appear effective

Spreading internationally within Asia and to Europe and North America


46August 2008


What would you do next?


47August 2008

Global Outbreak Containment: Decision 15 Global Outbreak Containment: Decision 15 March, 2003 March, 2003

World Health Organization issues emergency travel advisory

15 March 2003 | GENEVA -- During the past week, WHO has received reports of more than 150 new suspected cases of Severe Acute Respiratory Syndrome (SARS), an atypical pneumonia for which cause has not yet been determined. Reports to date have been received from Canada, China, Hong Kong Special Administrative Region of China, Indonesia, Philippines, Singapore, Thailand, and Viet Nam. Early today, an ill passenger and companions who travelled from New York, United States, and who landed in Frankfurt, Germany were removed from their flight and taken to hospital isolation.

Due to the spread of SARS to several countries in a short period of time, the World Health Organization today has issued emergency guidance for travelers and airlines.

“This syndrome, SARS, is now a worldwide health threat,” said Dr. Gro Harlem Brundtland, Director General of the World Health Organization. “The world needs to work together to find its cause, cure the sick, and stop its spread.”

There is presently no recommendation for people to restrict travel to any destination. However in response to enquiries from governments, airlines, physicians and travelers, WHO is now offering guidance for travelers, airline crew and airlines. The exact nature of the infection is still under investigation and this guidance is based on the early information available to WHO.

TRAVELLERS INCLUDING AIRLINE CREW: All travelers should be aware of main symptoms and signs of SARS which include:

high fever (>38oC)

AND

one or more respiratory symptoms including cough, shortness of breath, difficulty breathing

AND

one or more of the following:

close contact* with a person who has been diagnosed with SARS

recent history of travel to areas reporting cases of SARS.


48August 2008

Global Outbreak Alert and Response Network 115 experts from 26 institutions in 17 countries field teams sent to 5 countries

Strategies that increased power of epidemic Strategies that increased power of epidemic control: global partnershipscontrol: global partnerships


49August 2008

Probable SARS transmission, flight CA112, Probable SARS transmission, flight CA112, March 2006 March 2006


50August 2008

Strategies to control: WHO Strategies to control: WHO travel recommendationstravel recommendationson www.who.int/csr/sars/on www.who.int/csr/sars/

Update 79 - Situation in China China’s Executive Vice Minister of Health, Mr Gao Qiang, and WHO’s Executive Director for Communicable Diseases briefed the press this morning on the situation of SARS control in China. Also in attendance were Dr Qi Ziaoqiu, Director-General of the Department of Disease Control in the Chinese Ministry of Health, and Dr Henk Bekedam, WHO Representative to China.

Cumulative Number of Reported Probable Cases Of SARSFrom: 1 Nov 20021 To: 2 June 2003, 18:00 GMT+2 Revised: 3 June 2003, 9.00 GMT +2Country Cumulative number of case(s)2 Number of new cases Brazil 2 0 0 2 10/Apr/2003 24/Apr/2003 Canada 198 10 30 116 1/Jun/2003 1/Jun/2003 China 5328 2 334 3495 1/Jun/2003 2/Jun/2003

SARS Travel Recommendations Summary TableThis table, updated daily, indicates those areas with recent local transmission of SARS for which WHO has issued recommendations pertaining to international travel.


51August 2008

Probable cases of SARS by date of onset Probable cases of SARS by date of onset worldwide, 1 March – 27 June 2003worldwide, 1 March – 27 June 2003


52August 2008

SARS Epidemic curve, China, SARS Epidemic curve, China, 2002 - 20032002 - 2003


53August 2008

Passenger movement, Hong Kong International Passenger movement, Hong Kong International Airport, March-July 2003Airport, March-July 2003

WHO lifted travel advisory WHO travel advisory

0

20 000

40 000

60 000

80 000

100 000

120 000

3/16

3/20

3/24

3/28 4/1

4/5

4/9

4/13

4/17

4/21

4/25

4/29 5/3

5/7

5/11

5/15

5/19

5/23

5/27

5/31 6/4

6/8

6/12

6/16

6/20

6/24

6/28 7/2

Num

ber o

f pas

seng

er

Total

23 May2 April

14 670

102 165

65 255


54August 2008

The cost of SARS: initial estimates for six month The cost of SARS: initial estimates for six month outbreaks, Asian Development Bank, 2003outbreaks, Asian Development Bank, 2003

76543210 US$ billion

Hong Kong

China, mainland

Taiwan

South Korea

Indonesia

Singapore

Thailand

Malaysia

PhilippinesUS$ billionUS$ billion

4%

0.5%

1.9%

0.5%

1.4%

2.3%

1.6%

1.5%

0.8%

% of GDP

As of 30 September, 2003, SARS had decreased Asia’s combined GDP by US$18 billion and cost nearly US$60 billion in lost demand and revenues


55August 2008


How would you ensure that the new way of working during the SARS outbreak remains a permanent way of responding to infectious diseases with international spread?


56August 2008

New norms for reporting and responding to New norms for reporting and responding to infectious diseases established, 2003infectious diseases established, 2003

Reporting of infectious diseases from other sources accepted by WHO Member States

All infectious diseases with potential for international spread to be reported

Revised International Health Regulations to serve as a formal framework for pro-active international surveillance and response to all public health emergencies of international concern

Severe acute respiratory syndrome (SARS)


57August 2008

International Health Regulations 2005

From three diseases to all public health threats

From passive to pro-active using real time surveillance/evidence

From control at borders to detection and containment at source


58August 2008

Requirements, International Health Requirements, International Health Regulations (2005)Regulations (2005)

• Strengthened national core capacity for surveillance and control including at border posts

• Mandatory reporting of possible public health emergency of international importance, and of four specific diseases: SARS, smallpox, avian influenza and polio

• Collective, pro-active global collaboration for prevention, alert and response to international public health emergencies

• Monitoring of implementation by the World Health Assembly


59August 2008

Decision making and response and the revised Decision making and response and the revised International Health RegulationsInternational Health Regulations


of public health risk

Public health risk reporting by countries


of public health risk

NO YES

Public health risk reporting from WHO Alert & Response Network

Collaborative risk-based public health measures identified and managed

pro-actively by WHO

Decision-tree analysis to determine if of urgent international public health importance


60August 2008


Do the revised International Health Regulations meet the vision for their revision?

If not, tell what more could be done

What are some major infectious disease threat today that would fall under the Revised Regulations?


61August 2008

Defining Health SecurityDefining Health Security

Individual Health Security:

Access of persons to health care and to medicines/vaccines and other health goods; removal of obstacles to good health

Public Health Security:

Activities required to minimize vulnerability to public health events that endanger the health of populations

Global Public Health Security:

Collective activities required to protect the public health of populations living across geographical regions and international boundaries

world health organization 1 august 2008 infectious diseases in a globalized world: risks to our...

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