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




August 2008                    World Health Organization   1
         Emerging and re-emerging infections,
                    1996 – 2007


                                            Legionnaire’s Disease
  Cryptosporidiosis                                     Multidrug resistant Salmonella
Human Monkepox                    E.coli O157
                                                    E.coli non-O157                         E.coli O157
                                                           WHO
                              Recent outbreaks followed by Typhoid
                                   BSE
Lyme Borreliosis                                           Malaria
                                                                                 Severe Acute Respiratory
                                   nvCJD
                             West Nile Virus                         Diphtheria Syndrome (SARS)
   E.coli O157                                       West Nile Fever
            Avian influenza (human)
                          Reston virus
                                                             Asia/Middle East/AfricaInfluenza A(H5N1)
            Marburg Haemorrhagic Fever
                              Lassa fever                    Uganda
                                                        Echinococcosis
            Chikungunya         Yellow fever                 Pacific Islands, Italy Nipah Virus
 Venezuelan Cholera                                   Cholera 0139 /Southern AfricaReston Virus
                                                             West
 Equine Encephalitis
            Nipah haemorrhagic fever ulcer
                                   Buruli                       RVF/VHF
                                                             Bangladesh Dengue
                                                          O’nyong-nyong
            Lassa Fever                 Ebola                Sierra Leone haemhorrhagic
                                                          fever
            High mortality measles      haemorrhagic         Nigeria        fever
            Meningococcal meningitis fever
           Dengue                                         Human and Central Africa
                                                             West
           haemhorrhagic                     Marburg      Monkeypox                       Ross River
            Yellow Fever          Cholera                    Guinea/Sudan virus
                                                        Cholera       Hendra
           fever                             haemorrhagic                                 virus
              Poliomyelitis                                        DRC/Bangladesh
                                                fever
August 2008                                                                      World Health Organization   2
                Points for discussion

l   What do we know about emerging infections?
    – Resilience/dynamism
    – Relationship with animals
    – Persons at greatest risk
    – Other




August 2008                                 World Health Organization   3
Breaches in species barrier: selected emerging
  infections in humans identified since 1976
                                       Infection               Original          Year
                                                               host              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
adapted from Woolhouse et al. (2005)   SARS coronavirus        Palm civets       2003

August 2008                                                          World Health Organization   4
              Smallpox: Variola Major


                           20% - 40% case
                           fatality

                           100% permanent
                           facial scarring

                           2.7 million deaths,
                           1967

August 2008                          World Health Organization   5
              Smallpox Eradication:
                 Certified 1980




August 2008                       World Health Organization   6
      Persons living with HIV infection,
             2006: >40 million




                 3 million deaths during 2003
                 20 million deaths since 1981
August 2008                            World Health Organization   7
          Ebola Haemorrhagic Fever by mode of
             transmission, Kikwit Zaire, 1995
    16

    14
                      Non health care workers
    12
                      Health care workers
    10

      8

      6

      4

      2

      0
          7-    13-    19-   25-   31-   6-    12-   18-   24-   30-   6-   12-   18-   24-    30-   5-   11-   17-
          Mar   Mar Mar      Mar   Mar   Apr   Apr   Apr   Apr   Apr May May May May May             Jun Jun    Jun
Source: WHO/CDC

 August 2008                                                                                  World Health Organization   8
       SARS, chain of human-to- human
        transmission, Singapore 2003




August 2008                    World Health Organization   9
   International travellers, 1950 - 2006

           Increased to over 2 billion international travellers in 2006
1400 International airline passengers (millions)

1200

1000
 800
 600
 400

 200

   0
       1950           1960            1970         1980      1990                  2000
                                                             Source: WHO/World Tourism Organization
August 2008                                                   World Health Organization 10
 Outbreak of leptospirosis (N = 33) among 312
  participants, Eco Challenge 2000, Malaysia



        Canada: 4           UK: 9
                          France: 4
     US: 10

                                           Eco
                                         Challenge

              Brazil: 1
          Uruguay: 1                  Australia: 4


August 2008                           World Health Organization 11
SARS: international spread from Hong Kong,
       21 February – 12 March, 2003
                           Doctor
                                                                                 Canada
                            from
                         Guangdong


                                                        F   G
                                              A                                           Ireland
                                                                    K

                                          H
                                                   Hotel M
                                                                        I
                                              J   Hong Kong
                                                                    E
                                                                D
             Hong Kong                                      C                              USA
                                                    B

                             Viet Nam
                                                                                                       Germany
                                                                                                       1 HCW +
                                                                            Singapore                     2


                               Bangkok                                                      New York
Source:
WHO/CDC                                  + 219 health care workers
   August 2008                                                                             World Health Organization 12
Countries in which airport malaria has been
       reported, 1969 – August 2003

                                   Belgium: 1
               United Kingdom: 7
                                          Luxembourg: 2
                                          Germany: 1
 USA: 1               France: 3           Switzerland: 1

                                                Israel: 1


                                                   Australia: 1


 August 2008                                                World Health Organization 13
West Nile Virus in the United States, 2005




                         Genetic sequencing compatible with
                         One-time introduction in late 1990s
 August 2008                        World Health Organization 14
   Increased world trade in agricultural
      products/animals, 1950 - 2006
      World trade in agricultural products has increased 5-fold since 1950

160 export of agricultural products by volume

120

 80

 40

  0
       1950           1960          1970        1980       1990            2000
                                                                      Source: WTO, 2000
 August 2008                                                World Health Organization 15
      Deaths from vCJD by year of death, United
                Kingdom, 1994 - 2006
                      N = 162
40

35

30

25

20

15                                                 28

                                     18                   20
10
                                            15                   17      18
 5                     10     10                                                          14
                                                                                  9
        0          3
 0
     1994     1995     1996   1997   1998   1999   2000   2001   2002   2003    2004    2005

     August 2008                                                  World Health Organization 16
   BSE and vCJD: potential exposure
through international trade, early 1990s

    Cattle, meat and
    bone meal
                                   Food containing beef


                                   Pharmaceuticals
                       Blood
      Human and        and blood
      bovine           products
      tissue used
      in biologicals



August 2008                               World Health Organization 17
vCJD: geographic distribution of human
             infections

          Meat and
          bone meal



                                   Pharmaceuticals
                       Blood
      Human and        and blood
      bovine           products
      tissue used
      in biologicals



August 2008                               World Health Organization 18
     Rift Valley Fever, humans, Yemen,
               September 2000
80    Number of cases


60


40


20


 0

                        September 1-30, 2000

August 2008                                    World Health Organization 19
     Rift Valley Fever, livestock, Yemen
      and Saudi Arabia, October 2000


                                   Area affected




August 2008                    World Health Organization 20
El Nino-associated flooding, East Africa,
                 1998




                     Animal vaccination suspended early 1990s

                     Flooding forced humans and animals to close
                     proximity

                     Increased mosquito breeding sites

August 2008                             World Health Organization 21
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


     August 2008                               World Health Organization 22
               Points for discussion

l   What can be done to prevent the international spread of
    infectious diseases?
l   What measures have been taken by governments in the
    past?
l   Have any of these measures been effective?




August 2008                                      World Health Organization 23
    Concern about public health security
           throughout the 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

August 2008                         World Health Organization 24
              International Health Regulations
                        purpose 1969

                    l    “…ensure the maximum
                        security against the
                        international spread
                              of disease with a
                              minimum
                              interference
                              with world traffic.”



August 2008                           World Health Organization 25
       Content of International Health
       Regulations 1969: requirements

lNotification to WHO: cholera, plague or yellow
fever – reports only accepted from countries
where event is occurring
lHealth Organization at borders: ports, airports
and frontier posts adequately equipped to
prevent vector proliferation
lHealth Measures: describe maximum measures
that a country may require to protect against
cholera, plague and yellow fever (e.g. yellow
fever vaccination card)


June 2007                                World Health Organization   26
    Application of International Health
            Regulations, 1969
                             Disease reporting by
                              countries (cholera,
                             plague, yellow fever)

                             Publication in Weekly
                            Epidemiological Record



                National                              Application of pre-
              containment                            determined measures
                activity                             (maximum allowable)

August 2008                                                    World Health Organization 27
                   Points for discussion

l   Do you think the International Health Regulations are an
    effective means of dealing with the international spread of
    infectious diseases?
l   If yes, why?
l   If no, why?




August 2008                                      World Health Organization 28
    Direct economic impact, selected
infectious disease outbreaks, 1990-2003

        US E. coli 0157
     Food recall/destruction                     Hong Kong - influenza A(H5N1)
            Periodic            UK - BSE              Poultry destruction
                               US$ 39 billion                 1997
                                1990-1998
                                                                              Malaysia- Nipah
                                                                              Pig destruction
                                                           India - Plague          1999
      Peru - Cholera              Tanzania - Cholera       US$ 1.7 billion
      US$ 770 million               US$ 36 million              1995
           1991                         1998

                                                           Asia – SARS
                                                           US$ 30 billion
                                                               2003



 August 2008                                                        World Health Organization 29
    Emerging and re-emerging infections:
               1996 - 2007


                                             Legionnaire’s Disease
  Cryptosporidiosis                                  Multidrug resistant Salmonella
Human Monkepox                    E.coli O157
                                                    E.coli non-O157                        E.coli O157
                                    BSE                               Typhoid
Lyme Borreliosis                                         Malaria
                                                                                   Severe Acute Respiratory
                                   nvCJD
                              West Nile Virus                           Diphtheria Syndrome (SARS)
                                                        West Nile Fever                Influenza A(H5N1)
                           Reston virus
                               Lassa fever                 Echinococcosis
                                 Yellow fever                                             Nipah Virus
 Venezuelan                                              Cholera 0139                    Reston Virus
 Equine Encephalitis               Buruli ulcer                       RVF/VHF
                                                             O’nyong-nyong       Dengue
                                        Ebola                                    haemhorrhagic
                                                             fever
                                        haemorrhagic                             fever
           Dengue                        fever               Human
           haemhorrhagic                        Marburg      Monkeypox                        Ross River
                                   Cholera                 Cholera     Hendra virus
           fever                                haemorrhagic                                  virus
                                                fever
August 2008                                                                     World Health Organization 30
                Global outbreaks, the challenge:
                  late reporting and response
              First                  Late           Delayed
              case                 reporting        response
         90
         80                                               Lost opportunity for control/
         70                                                risk of international spread
CASES




         60
         50
         40
         30
         20
         10
          0
               1      4   7   10    13   16    19    22   25   28   31      34     37    40   DAY

        August 2008                                                      World Health Organization 31
                 Global outbreaks, the solution:
                  early reporting and response
           Early            Rapid
         reporting        response                   Potential cases prevented/
        90                                         international spread prevented
        80
        70
        60
        50
CASES




        40
        30
        20
        10
         0
             1    4   7   10   13   16   19   22    25   28   31     34     37    40   DAY

    August 2008                                                    World Health Organization 32
              Points for discussion


l   What would you do next?




August 2008                       World Health Organization 33
Vision for revision of the International
      Health Regulations, 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



August 2008                           World Health Organization 34
Global Public Health Intelligence Network,
                 Canada




  August 2008                 World Health Organization 35
    Outbreak Verification & Response
       Afghanistan, February 1999


              WHO/local team                   Investigation completed
                preliminary                      Diagnosis confirmed
               investigation

 GPHIN report of
   highly fatal                    WHO
   respiratory                 collaborative
     disease                       team




16 February    19 February     24 February              1 March
August 2008                                          World Health Organization 36
 Information sources, public health risks
         reported to WHO, 2003

 70%
                      Countries ( 23% of reports)
 60%
                      WHO Alert & Response Network ( 77% of reports)
 50%

 40%

 30%

 20%

 10%

  0%




                                                                   PROMED
                                       SEARO




                                                                            Others
                                AMRO




                                                                                     GPHIN
                                               WPRO
        AFRO

               EMRO




                                                            NGOs
                         EURO




                                                      WRs


August 2008                                                        World Health Organization 37
     Operationalizing the IHR in the 21st century:
     partnership for global alert and response to
                 infectious diseases

                    WHO Regional        WHO Collaborating
                  & Country Offices     Centres/Laboratories     Epidemiology and
                                                               Surveillance Networks
Countries/National
 Disease Control
     Centres
                                                                               Military
                                                                             Laboratory
                                                                              Networks
       UN
Sister Agencies



                                                                         GPHIN
             NGOs
                                         Electronic                           FORMAL
                           Media      Discussion sites                        INFORMAL
  August 2008                                                     World Health Organization 38
 Request for GOARN support: terms of
              reference




August 2008                World Health Organization 39
Sample of International epidemic response
    missions in the field, 1998–1999




 August 2008                  World Health Organization 40
Global outbreak alert and response network:
   surveillance network partners in Asia

                                          APEC                         GPHIN
                                                 Pacific Public
                                                 Health
                                      SEAMIC     Surveillance
              Mekong Basin
                                                 Network
              Disease
              Surveillance
                                     SEANET      (PPHSN)                Flu Net
              (MBDS)


                             ASEAN
          EIDIOR

                                                                   + Red Cross,
                                                                     other NGOs
August 2008                                                World Health Organization 41
Reports of respiratory infection, China,
              2002–2003
l   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

l   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

    August 2008                                           World Health Organization 42
Intensified surveillance for respiratory
     infections, Asia, 2002–2003

l   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)

l   4–5 March
     – Hong Kong and Hanoi: 77 medical staff (Hong Kong) plus 7
       (Hanoi) reported with atypical pneumonia, not influenza (WHO
       team/liaison)



    August 2008                                   World Health Organization 43
    Global Alert: Severe Acute Respiratory
              Syndrome (SARS)
l   12 March: First global alert
     – Described atypical pneumonia in Viet Nam and Hong Kong

l   14 March
     – 4 persons Ontario, 3 persons in Singapore, with severe atypical
       pneumonia fitting description of 12 March alert reported to WHO

l   15 March
     – Medical doctor with atypical pneumonia fitting description of 12
       March reported by Ministry of Health, Singapore on return flight
       from New York

    August 2008                                         World Health Organization 44
          Situation on 15 March, 2003

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

l     Health workers appeared to be at greatest risk

l     Unidentified cause, presumed to be an infectious agent

l     Antibiotics and antivirals did not appear effective

l     Spreading internationally within Asia and to Europe and North
      America

    August 2008                                        World Health Organization 45
              Points for discussion

l   What would you do next?




August 2008                       World Health Organization 46
Global Outbreak Containment: Decision 15
              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.

   August 2008                                                                                                  World Health Organization 47
Strategies that increased power of epidemic
        control: global partnerships




Global Outbreak Alert and Response Network
 115 experts from 26 institutions in 17 countries
 field teams sent to 5 countries
   August 2008                                       World Health Organization 48
    Probable SARS transmission, flight
           CA112, March 2006




August 2008                   World Health Organization 49
Strategies to control: WHO   Update 79 - Situation in China

 travel recommendations
                             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

 on www.who.int/csr/sars/
                             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 SARS
                                         From: 1 Nov 20021 To: 2 June 2003, 18:00 GMT+2
                                         Revised: 3 June 2003, 9.00 GMT +2
                                         Country 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 Table
                                                   This table, updated daily,
                                                   indicates those areas with
                                                   recent local transmission of
                                                   SARS for which WHO has
                                                   issued recommendations
                                                   pertaining to international travel.


 August 2008                                    World Health Organization 50
Probable cases of SARS by date of onset
   worldwide, 1 March – 27 June 2003




August 2008                  World Health Organization 51
              SARS Epidemic curve, China,
                     2002 - 2003




August 2008                         World Health Organization 52
                        Passenger movement, Hong Kong
                      International Airport, March-July 2003
                                   WHO travel advisory           WHO lifted travel advisory
                      120 000
                                          2 April                    23 May


                      100 000 102 165
Number of passenger




                                                         Total
                      80 000
                                                                                                  65 255
                      60 000


                      40 000


                      20 000


                          0                                       14 670



                                            5/23
                              3/28




                                            4/21
                              3/16
                              3/20
                              3/24




                                            4/13
                                            4/17

                                            4/25
                                            4/29




                                            5/15
                                            5/19

                                            5/27
                                            5/31



                                            6/12
                                            6/16
                                            6/20
                                            6/24
                                            6/28
                                            5/11
                                             4/9




                                             6/4
                               4/1
                                             4/5




                                             5/3
                                             5/7




                                             6/8




                                             7/2
                 August 2008                                                     World Health Organization 53
The cost of SARS: initial estimates for six month
   outbreaks, Asian Development Bank, 2003
                                                             % of GDP
          Hong Kong                                             4%
      China, mainland                                       0.5%
                Taiwan                                   1.9%
         South Korea                        0.5%
             Indonesia               1.4%
            Singapore                2.3%
               Thailand             1.6%               As of 30 September, 2003, SARS
                                                       had decreased Asia’s combined

              Malaysia           1.5%                  GDP by US$18 billion and cost
                                                       nearly US$60 billion in lost demand

           Philippines        0.8%
                                                       and revenues


                          0   1    2    3      4   5        6        7      US$ billion

August 2008                                                      World Health Organization 54
              Points for discussion

   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?




August 2008                                World Health Organization 55
New norms for reporting and responding
to infectious diseases established, 2003




             Severe acute respiratory syndrome (SARS)
   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
August 2008                                                 World Health Organization 56
      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
August 2008                                     World Health Organization 57
   Requirements, International Health
          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
August 2008                                World Health Organization 58
 Decision making and response and the
revised International Health Regulations
       Public health risk reporting from                    Public health risk
       WHO Alert & Response Network                       reporting by countries



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

      NO                                                               YES

         National                       National       Collaborative risk-based
       containment                    containment      public health measures
         of public                      of public      identified and managed
        health risk                    health risk      pro-actively by WHO

August 2008                                                         World Health Organization 59
               Points for discussion


   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?




August 2008                                    World Health Organization 60
               Defining 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

 August 2008                                       World Health Organization 61

				
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