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 – 1 st 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 Guns, Germs and Steel  J. Diamond

Historical Epidemiologic Transitions – 2 nd Transition  Coincided with mid-19 th 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 – 3 rd Transition  Last 25 years  Emerging infectious diseases globally  New diseases and increases in mortality; first since 19 th 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 Convergence Model (Microbial Threats to Health – IOM/NAS, 2003) Social, Political and Economic Factors Physical Environmental Factors Ecological Factors Genetic and Biological Factors Human Microbe

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 % world population living in urban areas % world population living in urban areas

The Divided World of 2025 – 8.4 Billion People World 1 Advanced nations (Advances in medicine and food) World 2 Middle class (Livestock Revolution) World 3 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 Microbial Pathogens Waterborne Disease 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 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

Wildlife EID Domestic Animal EID Human EID Translocation Human encroachment Ex situ contact Ecological manipulation Global travel Urbanization Biomedical manipulation Technology and Industry Agricultural Intensification Encroachment Introduction “Spill over” & “Spill back” Emerging Infectious Diseases Dasazak P. et.al. Science :443

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 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

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) H 5 N 1 influenza (Hong Kong) 1998 – Nipah virus (Malaysia) 1999 – West Nile 2000 – Rift Valley Fever 2001 – Anthrax 2002 – Norwalk-like viruses 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 21 st Century – CDC Goal 1:Surveillance and Response Goal 2:Applied Research Goal 3:Prevention and Control Goal 4: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 ever- changing dynamic. Because of this broad perspective, public health teams themselves also need to reflect this reality.