The Interface Between Human and Veterinary Public Health

The Interface Between Human and Veterinary Public Health Emerging Zoonotic Disease Summit Gainesville, Florida August 23, 2005 Lonnie J. King Director, Office of Strategy and Innovation, CDC Dean, CVM, Michigan State University Historical Epidemiological Transitions  Paleolithic Age     Hunters and gatherers Nomadic Small populations Parasitic infections Historical Epidemiologic Transitions – 1st Transition  10,000 years ago  New social order due to agriculture  Zoonoses through animal domestication  Increases in infectious diseases  Epidemics in non-immune populations Deadly Gifts Human Diseases Measles TB Smallpox Influenza Pertussis Malaria Animal Origin Rinderpest of cattle M. bovis of cattle Cowpox Pigs and Ducks Pigs and Dogs Birds Guns, Germs and Steel  J. Diamond Historical Epidemiologic Transitions – 2nd Transition  Coincided with mid-19th century Industrial Revolution  Decreases in infectious disease mortality  Increasing life expectancy  Improved nutrition  Antibiotics  “Diseases of Civilization” – cancer, diabetes, cardiovascular diseases  Environmental problems  Chronic diseases Historical Epidemiologic Transitions – 3rd Transition  Last 25 years  Emerging infectious diseases globally  New diseases and increases in mortality; first since 19th century  Re-emergence  Antimicrobial resistance  75 percent of diseases are zoonotic  Anthropogenic factors of emergence; the microbial “perfect storm” “The Perfect Storm”  Sebastian Junger  an ocean tempest due to a rare combination of factors and circumstances that might occur every century MICROBIAL THREATS TO HEALTH EMERGENCE, DETECTION, AND RESPONSE INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES National Academy Press Washington, DC 2003 The “Microbial” Perfect Storm     Due to special combinations and circumstances Relatively common occurrence Doesn’t dissipate, but may perpetuate or accelerate Convergence model WHO Map on World – Emerging Diseases Convergence Model Genetic and Biological Factors Physical Environmental Factors Microbe Human Social, Political and Economic Factors Ecological Factors Convergence Model (Microbial Threats to Health – IOM/NAS, 2003) Factors in Emergence       Microbial adaptation and change Host susceptibility to infection Climate and weather Changing ecosystems Economic development and land use Human demographics and behavior Technology and industry Factors in Emergence continued       International travel and commerce Breakdown of public health measures Poverty and social inequality War and famine Lack of political will Intent to harm Multihost Pathogens    60% of all human pathogens are zoonotic 80% of animal pathogens Ecological generalists New Dynamic       Emerging diseases – 70% zoonotic New zoonoses Food safety Antimicrobial resistance Agents of bio- and agro-terrorism – 80% zoonotic Global trade and movements Rapidly Increasing Human Population • 6.1 Billion people in 2000 ~9.4 to 11.2 Billion in 2050 • Source: United Nations, World Population Prospects, The 1998 Revision; and estimates by the Population Reference Bureau. Rapidly Increasing Urbanization • 2000 - 47% world population living in urban areas 60% world population living in urban areas • 2030 - The Divided World of 2025 – 8.4 Billion People  World 1 World 2 World 3   Advanced nations (Advances in medicine and food) Middle class (Livestock Revolution) People in destitution and poverty (Sources of traditional pathogens) El Nino    Leptospirosis Hantavirus Rift Valley fever Vectors of Disease Global Warming    Shifting and enlarging the incidence and distribution of disease Malaria zone 45% of population to 60% Habitat change and disruption via weather changes Global Warming Effects on Malaria Ecosystem Waterborne Zoonoses Animals Humans Waterborne Disease Microbial Pathogens Water Environment Waterborne Zoonoses – Global Threat       4 billion cases of diarrhea per year 2-3 million deaths Poorly reported Zoonotic portion is significant Endemic and epidemic 1.1 billion people with unreliable water supply Waterborne Zoonoses Pathogens           Cryptosporidium Giardia E. Coli 0157:H7 Salmonella Leptospiria Toxoplasma Campylobacter Entamoeba Ascarsis Viruses and Prions? SARS? Concentrated Animal Feeding Operations (CAFOs) Their Impact on Food Safety and Healthy Environments Foodborne Infections • Worldwide  > 2 million people die from diarrhea caused by contaminated food and water each year • U.S.  ~ 76 million persons experience foodborne illnesses (1 in 4 people) - ~325,000 hospitalizations ~5,000 deaths - Most Common Foodborne Pathogens         Campylobacter Salmonella E. coli 0157:H7 Yersinia Listeria Cryptosporidium Cyclospora Norwalk-like viruses Livestock 2020 – The Next Food Revolution      Global increase and demand for protein and food of animal origin Shift from poverty of 1-2 billion people to middle class “Westernization” of Asia and Latin America Concerns with sustainability Increases in emerging zoonoses through the concentration of people and animals By 2020, There will be 1 Billion People Over the Age of 60   30% of US population are baby boomers Immuno-compromised population Movement and Interactions of People and Commerce      Distance and speed of travel increased 1000 fold since 1800 1.4 billion air travelers/year 50 million foreign visitors, to US year through, 102 sites Antibiotic resistance Global trade of food, animals and plants The Coming Plague Today’s mingling of people, animals and microbes in new environments has no historical precedent. -”We await the coming plague” - Laurie Garrett Remote Sites Pathogen Pollution     Human and domestic animal populations Free-living wild animals Example: global decline in amphibian populations due to chytridiomycosis Concern with adverse effects on biodiversity Chytridiomycosis Virus Carriers Fruit bats Flying Foxes Nipah Virus Malaysian Pig Farms Emerging Infectious Diseases Encroachment Introduction “Spill over” & “Spill back” Translocation Wildlife EID Human encroachment Ex situ contact Ecological manipulation Agricultural Intensification Domestic Animal EID Human EID Global travel Urbanization Biomedical manipulation Dasazak P. et.al. Science 2000 287:443 Technology and Industry Spill Over and Spill Back What’s Next? Human Monkeypox Cases Marshfield Clinic and MCW Matt Kuehnert Exotic Pets SARS Maintenance Host SARS Airport Screening The Lessons of SARS       The need for multinational collaboration Public alarm can lead to huge economic impact $80 billion Weaknesses in public health infrastructures Consequences of poor reporting –disincentives A true zoonosis: more to come Constant threat due to Emerging Infectious Diseases in less developed countries H5N1 Avian Influenza Pandemic Influenza The Next Influenza Pandemic     Not if, but when 1918-1919 Experience: 20 million deaths 150 – 450% increase in patient and hospital visits In 2001 (Asia only), 160 million workdays lost, and for a pandemic, 6 billion workdays lost worldwide Bioterrorism Biodefense Agroterrorism Agents of Bioterrorism Bacteria, Rickettisia, Category Toxins Anthrax; Botulism; Plague; Tularemia Brucellosis; Epsilon toxin of C. perfringens; Glanders; Staphylococcus, enterotoxin B; Q Fever Multidrug-resistant tuberculosis Total (% Zoonotic) 6 (83%) Viruses Smallpox Viral Hemorrhagic Fevers A 5 (80%) B C Hantaviruses; Nipah 4 (80%) virus; Tickborne encephalitis viruses; Yellow Fever CDC’s Most Significant Global Epidemics Over the Last Decade      1993 – Hanta virus 1994 – Plague (India) Ebola virus (Zaire) 1996 – New Variant of CJD (UK) H5N1 influenza (Hong Kong)       1998 – Nipah virus (Malaysia) 1999 – West Nile 2000 – Rift Valley Fever 2001 – Anthrax 2002 – Norwalk-like viruses 2003 - SARS Implications of Emerging Diseases      Political Social Economic Psychological Environmental Animal-borne Epidemics Out of Control: Threatening the Nation’s Health – 2003  A report from the Trust for America’s Health Findings from the Report     U.S. lacks a national program to prevent and control diseases that impact humans, animals and our food There is no coordinated effort or single agency with a “command and control” responsibility There is a lack of effective communications with the public about these diseases and their impact Disease surveillance systems are not linked Findings from the Report (continued)    Funding for bioterrorism has not adequately supported efforts to counter zoonotic disease threats, especially from the animal health perspective and infrastructure There is a fragmentation of jurisdictions, authorities, statutes and research; e.g. 200 different government offices and programs responding to 5 zoonotic diseases Animal and public health are separated by culture and organization Microbial Threats to Health Conclusions & Recommendations 1. Enhancing the global response capability 2. Improving global infectious disease surveillance 3. Rebuilding domestic public health capacity 4. Improving domestic surveillance through better disease reporting (this includes both human health and veterinary health) 5. Exploring innovative systems of surveillance 6. Developing and using diagnostics Microbial Threats to Health Conclusions & Recommendations (continued) 7. Educating and training the microbial threat workforce 8. Developing and producing vaccines 9. Developing and producing antimicrobial drugs 10. Controlling the use of antimicrobials 11. Controlling vectorborne and zoonotic diseases 12. Establishing a comprehensive infectious disease research 13. Creating interdisciplinary infectious disease centers Preventing Emerging Infectious Diseases: A Strategy for the 21st Century – CDC Goal 1: Goal 2: Goal 3: Goal 4: Surveillance and Response Applied Research Prevention and Control Infrastructure and Training Public Health at the Crossroad        New, inclusive vision of public health Shift to focusing on causes of population health Ensuring that population health is a central concern of policymakers Globalization of causes and issues Socioeconomic disparities Emerging threats due to interdependence New team – expanded, integrated and transdisciplinary  Population health is a shift from an emphasis on individual health to understanding the multiple determinants of health.  Health is an outcome shaped by a wide range of social, economic, natural, built, and political environments that form a complex and everchanging dynamic. Because of this broad perspective, public health teams themselves also need to reflect this reality.