1. The Global Animal Health Initiative: The Way Forward
“Veterinary and Public Health Collaboration”
October 10, 2007
The World Bank
Washington D.C.
Lonnie King, DVM, MS, MPA
Director
National Center for Zoonotic,
Vector-Borne, and Enteric Diseases
Centers for Disease Control and Prevention,
Atlanta, GA

2. 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

3. 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

4. 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”

5. 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

6. 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

7. Convergence Model E I D Genetic and Biological Factors
Physical and Environmental Factors
Animals
E I D
Humans
Wildlife
Social, Political, and Economic Factors
Ecological Factors

8. Convergence of Human and Animal Health: Drivers
Ecological risk and climate
change
Population dynamics
Growing governance gap
Global “foodscapes”
Microbial swarms
Technology and social actions and involvement

9. Emerging and Re-emerging Infectious Diseases
Examples of Emerging/Re-emerging Infectious Diseases
Emerging and Re-emerging Infectious Diseases

11. Multihost Pathogens 60% of all human pathogens are zoonotic
80% of animal pathogens
Ecological generalists

12. CDC’s Most Significant Global Epidemics Over the Last 15 Years
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
2004 – Marburg Virus
2005 – H5N1 Influenza
2006 – E. coli

13. Trends in Global Population70 65 60 55
1950 75 80 85 90 95
2000 05 10 15 1 2 3 4 5 6 7 8
Billions
Total
Global Population:
Source: US Bureau of the Census
Less developed countries
More developed countries

14. Rapidly Increasing Urbanization
2000
47% world population living in urban areas
2030
60% world population living in urban areas

15. Concentrated Animal Feeding Operations (CAFOs)
Their Impact on Food Safety and
Healthy Environments

16. 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

17. Last year, over 21 billion food animals were produced to help feed a population of over 6 billion people resulting in trillions of pounds of products distributed worldwide. Projections toward 2020 indicate that the demand for animal protein will increase by 50%, especially in developing countries.

18. Microbial View

19. Importance of Agricultural Trade
Already 40% of all trade in agriculture, fisheries and forestry occurs between developing and developed countries. More than 20% of all US imports are food products (more than 8 million shipments a year).

20. Human population density
Poultry population density
·   This is a closer look at the population density of both humans and poultry.
·   You will note that India has a very high human population density but when it comes to poultry, it is not as dense as human.
·    That may be one of the reasons why India is not having a serious outbreak of Avian Influenza
Source: FAO, WHO, Rimsa, Mexico City April 2005

21. Mean normalized crop production Human and animal density
Figure Human and livestock densities, and main feed production areas as affected by the distance to Bangkok
Mean normalized crop production 60 50 40 30 20 10
Human and animal density
140
120
100 80 60 40 20
Distance to Bangkok (km) 50
100
150
200
250
300
350
400
450
500
human population (nb/km2/10)
chicken (nb/km2/10)
cassava (tons/km2/2)
maize (tons/km2)
soybean (10 tons/km2)
pigs (nb/km2/10)
Source: Gerber and others 2005.

22. Safe Food begins with healthy animals

23. Ecosystem

24. Waterborne Zoonoses Water Environment Humans Animals Waterborne
Disease
Microbial
Pathogens
Water Environment

25. World’s Most Dangerous Animals

26. West Nile Virus in the Western Hemisphere

27. WNV Neuroinvasive Disease Incidence,
by County, US, 2000
N=19
Human cases remained confined to NYC area and were few in number, but environmental data indicated much wider spread of the virus.
Note that dead birds were noted southward at the time of southern bird migration.
Incidence per million
>=100
Any WNV activity

28. WNV Neuroinvasive Disease Incidence,
by County, US, 2001
N=64
In 2001, few human cases, but cases started occurring in the southeast, coinciding with a new large area of enzootic activity.
Enzootic activity extended westward. It is hard to explain this western spread by bird migration. Random bird dispersal movements may explain the westward spread.
Incidence per million
>=100
Any WNV activity

29. WNV Neuroinvasive Disease Incidence,
by County, US, 2002
N=2946
First large human epidemic. Nearly 3000 cases of neuroinvasive disease.
Largely rural and suburban in nature.
Isolated case in southern California has never been explained.
Incidence per million
>=100
Any WNV activity

30. WNV Neuroinvasive Disease Incidence,
by County, US, 2003
N=2866
Second large human epidemic (also nearly 3000 cases of neuroinvasive disease)
Continued activity and human cases in areas of previous activity.
Spread to West Coast
Incidence per million
>=100
Any WNV activity

31. WNV Neuroinvasive Disease Incidence, by County, US, 2004
Incidence per million
>=100
Any WNV activity

32. WNV Neuroinvasive Disease Incidence,
by County, US, 2005
N=1294
Incidence per million
>=100
Any WNV activity

33. WNV Neuroinvasive Disease Incidence,
by County, US, 2006*
N=1339
Incidence per million
>=100
Any WNV activity
* Reported as of November 7, 2006

34. The Perfect Microbial Storm: Ravenna, Italy
A Virus from Africa (an alphavirus – Chikungunya)
A mosquito from Asia (Aedes albopictus: tiger mosquito)
A tourist from India (1.25 million human cases in 2006)
A report of 270 people infected with Chikungunya in Ravenna, Italy
Globalization is key to the future of infectious diseases
E.g. global tire trade; 2.1 billion airline passengers/yr; climate change; and, a shift of competent vectors worldwide
- Bloomberg Report 9/25/07

35. Ae. albopictus, the Asian Tiger Mosquito
Initial Discovery Site near Port of Houston, Texas, USA, 1985
Initial discovery site of Ae. albopictus, Houston, Texas. Photo by Chet Moore, CDC.

36. Used Tires Stored at Other Locations
Scrap tires being dumped for “bank stabilization” at undisclosed location. Photo by Don Eliason, CDC.

37. There is no where in the world from which we are remote and no one from whom we are disconnected
PNAS, 2004

39. Climate Change’s Impact on Infectious Diseases
Vector-borne diseases
Water-borne diseases
Agriculture Production
Migration of Animals
Changing ecosystems for wildlife and animals
Built environment
Human-Animal Interface
Ecologies and a new research portfolio
Evidence-based public health impact

42. Nipah Virus

43. Virus Carriers
Fruit bats

44. SARS

45. Horseshoe bat

46. Lessons Learned From SARS
Importance of: integrated surveillance; prompt epidemiologic investigations; and, lab capacity
Disruption of multiple economic sectors
Global implications of local problems
Need for critical linkages and partnerships

47. OIE-CDC Collaborating Center for Emerging and Re-Emerging Zoonoses
First collaboration between CDC and an international animal health organization
Enhance pathogen discovery
Improve diagnostics
Cooperation in better understanding the convergence of human and animal health
Linkage of health system professionals
Jointly contributing to establishing a global applied research portfolio
Improve global preparation in identifying and responding to microbial threats
Enhance surveillance

48. Annual Global Trade in Exotic Animals
4 million birds
640,000 reptiles
40,000 primates
Illegal trade unknown – estimate $4-6 billion
- Wildlife Conservation Society

49. “Double, double toil and trouble; Fire burn, and caldron bubble.”
William Shakespeare

50. Compelling Vision
Accelerating prevention, control, & elimination of ecology-mediated microbial threats
Systems approach with cross-cutting themes
Global organization
Ecosystem Health
Animal Health
Human Health

51. The Convergence of Human and Animal Health
In practice, no aspect of disease control, especially in poor communities, can be tackled effectively without simultaneous attention to people’s livelihoods and the frequent disincentives that they encounter as they are expected to participate in disease control efforts.
- Ministries and departments across government
- Professional groups: medical, veterinary, and
environmental
- NGO and private sector working with communities and
governments
David Nabarro MD
UN System InfluenzaCoordinator

52. Determinants of Success to Address Threats from the convergence/Pandemics
Political leadership and will
Effective alliances with civil society and the public sector
Capabilities and resources to scale-up effective systems for direction, coordination, and management
Support and integrated plans for long-term strategies to reduce risks from animal and human diseases
Collaborations among all stakeholders: sharing information, surveillance findings, samples for detection and identification and effective communication
Full community engagement especially among those affected
Resisting specialization and separation and the incentives that drive this behavior
- Dr. David Nabarro

53. Neglected Zoonotic Diseases
Understanding “One Health: people, livestock and wildlife
Role of livestock as income: 70% of rural poor
Communities at risk: 800 million poor livestock keepers
Dual burden
Pictures from:
Livestock for Life
IFAD.org

54. Neglected Zoonotic Diseases
Another example of health disparities: inverse relationship the lower the income the higher the risk
Need to raise the profile
Significant under-reporting
Human Health and Animal Health Continuum
Risk to human health is often best controlled by animal programs
Image from livestock for life

55. Endemic and Emerging Zoonoses
“The need to fight zoonotic diseases especially in the poorest populations of the world is incontestable – from a moral perspective, a human rights perspective and an economic perspective, as well as a global goods perspective.”
The Control of Neglected Zoonotic Diseases; A Route to Poverty Alleviation

56. “As the HIV disease pandemic surely should have taught us, in the context of infectious diseases, there is nowhere in the world from which we are remote and no one from whom we are disconnected.” 
 IOM, 1992

57. Emerging Retrovirus Zoonoses
2 new retroviruses – Cameroon – Africa
Human T-lymphotropic virus (HTLV) types 3 and 4
Recovered from hunters of nonhuman primates
Role of bushmeat and butchering primates
STLV and HIV with similar origins

58. Foresight Analysis EID are the “New normal”
Expect 3-4 new EID annually; 8-34 by 2015
87 new EID since 1980 – 58 viruses - 49 RNA
- mostly zoonotic
Found worldwide but proximity to animal populations or products is the key risk factor
Change in the host-pathogen ecology will be the most important single driver

59. Current and Projected Importance of Factors Influencing Emergence
2007
2017
2027
Human demographics and behavior
Technology and industry
Economic development and land use
International travel and commerce
Microbial adaptation and change
Breakdown of public health measures
Climate change and weather
Changing ecosystems
Poverty and social inequality
War and famine
Lack of political will
Intent to harm

60. Mechanisms By Which Important Factors Will Impact Emergence
Human
vulnerability
Environmental
and zoonotic
exposure
Person-to-
person
transmission
Microbial
evolution
Human demographics and behavior
Economic development and land use
International travel and commerce
Climate change and weather
Poverty and social inequality
Mechanism Influencing Emergence

61. Risk Risk seems to be more complex, if not greater in absolute terms.
Number of catastrophes between 1970 & 2003
Source: Swiss Re, Sigma No. 1, 2004
Risk seems to be more complex, if not greater in absolute terms.
One theme of our global health mapping conference in June ‘05 was that so many forces in health cross borders (e.g., populations, epidemics & dz vectors, environmental hazards, cultural beliefs) that we may want to replace geopolitical borders on our maps with isoclines of health risk & opportunity.
Whether the risks are nano, micro (prions may make hospitals uninsurable - photo, or Dark Winter simulation - graph), meso (photo of mosquito - increase in dz ranges from global warming, macro (urbanization) or global (tsunami), these new risk maps could look like the familiar seismic maps.
GIS could be a major tool.
Urbanization is the most powerful and most visible anthropogenic force on Earth.
Urban population will increase from 1.2B in 1995 to 2.5B in 2025 (with > 400M in cities of 10M or more).
At the beginning of the 20th century, only about 5% of the world population lived in urban areas. Today, that figure is 40% and is projected to grow to 60% in the next 20 years. The largest population growth will occur in Asia, but Africa will have the higher rate of growth. The number of cities with 5M inhabitants will increase from 41 to 59, and the number of cities with 10M people will climb from 19 to 23 (Brennan-Galvin, 2000).
By 2025, 2/3 of the world’s people will live in urban areas, and 80% of these urban residents will live in developing countries.
Global warming cost ~150,000 deaths & ~5.5M DALYs in J.Stephenson Climate Change and Health JAMA 291:291. (See also: Health Effects of Climate Change Haines and Patz JAMA.2004; 291: &
Haines, A. et al. CMAJ 2000;163: )
Graph from Swiss Re report on Risk Landscape of the Future, p. 13
Photo of city -

62. Interdependence: The Shrinking World
1 billion people will soon cross international borders each year or 25/second
Tightly coupled system: unprecedented vulnerability
Threats spread faster, further, and non-linear
Increased threats of global pandemics
Strategic risk analysis: significant risk of developing countries with under funded public and animal health systems
“If the forest is dry enough and dense enough…”

63. If a forest is dense & dry enough…
Worldwide, 25 people/second cross national borders
Increasingly densely connected network
Lessons from monocultures
…roughly 25 people getting off planes every second - but very few airports have anything near the 800 sq ft isolation room in the new Indianapolis airport.
With an increasingly densely connected network, Markov processes - if the forest is dense & dry enough, it doesn’t matter where you strike a match; eventually the entire forest will be ablaze.
With increased travel, mixing of populations and spread of antibiotic resistance, we face a risk of becoming more of a monoculture, with increased vulnerability to epidemics.
Internet globe:
Indianapolis airport isolation room

64. Convergence Challenges
Impact and influence beyond health – goods, services and economies
A shift from problem solving to managing dilemmas
A new global interdependence and connectivity
Factors creating the microbial storm are well entrenched
A great future for complexity: simple but not simplistic
Reconciliation of great change with habitual and traditional thinking and ways of working
Adopting a “One Health – One Medicine” mindset and strategy

65. Convergence Challenges (cont.)
The role of governments, educational institutions, and society
Animal and human health are a continuum of causality and events and need to be viewed as a continuum and integration of strategies
Recognizing the moral and ethical imperative: health disparities
Inclusion of diverse communities, thinking, and tools
The need for new leaders and new ways of leading
Unprecedented events call for unprecedented responses: A call to action – Who? How? When? Where? Why?

66. Consensus of Recommendations
Improve infrastructures
Integrate surveillance strategies and diagnostics
Increase R&D investments
Focus on prevention not just reaction and response – e.g. avian influenza
Build a new infectious disease workforce
Consider a global perspective

67. Consensus of Recommendations
Improve disease reporting with appropriate incentives
Design global strategies and interventions
Create Zoonotic and EID centers
Meet the critical need for leadership and new skills
Address public understanding and appreciation