1. Global Response to Emerging and Re-Emerging Diseases
2012 Pre-Conference: Growing Global: Policy & Research Directions for Building Nursing Capacity October 11, am - 1pm
Continuing the tradition of engaging the Academy’s Expert Panels in the planning process, the Global Health and Emerging and Infectious Diseases Expert Panels are pleased to offer this year’s pre-conference Growing Global: Policy & Research Directions for Building Nursing Capacity. The purpose of this pre-conference is to analyze emerging and re-emerging global health issues including chronic disease, emerging and re-emerging infections. 
The pre-conference objectives include: 
Analyze global responses to emerging and re-emerging infections 
Explore the impact of global chronic diseases 
Examine the social & economic policy issues related to global health 
Identify and establish a policy and research action plan directed to nurse-led solutions to global infectious and chronic disease
Emerging infectious diseases always pose a challenge for the clinical care, and nurses are essential to provide the adequate standards of care, implement the adequate infection prevention precautions, raise alert on new or unusual clinical syndromes or outcomes, and support epidemiological surveillance.
Sylvain Aldighieri, MD
International Health Regulations – Epidemic Alert & Response
PAHO/WHO

2. Objective To analyze global health issues related to EIDs
…with a special focus on the role of nurses in detection. 
NOTE: Pre-Conference participants will work in groups with panelists to develop recommendations for policy, research, education and clinical care for submission to the Academy’s leadership.

3. Plan of the Presentation
Emerging and re-emerging infections: definitions
Examples of EIDs
International Health Regulations IHR(2005)
Role of Nurses in EID detection and response
Conclusions
In this presentation I will discuss the mechanisms of disease emergence, and the importance of the role of human activities and actions in their emergence. Indeed this is the major take home message – that we have to take responsibility for most instances of disease emergence I will do this by posing several questions: - How and where do novel or emergent viruses arise? - What factors precipitate their emergence and spread? - What are our major concerns for the future? - Can we predict where this may happen? 3

4. Epidemics and Pandemics have shaped our history…
World Health Organization
15 April 2017
Epidemics and Pandemics have shaped our history…
1st Millenium
Middle Ages
20th Century
This slide show the spread of bubonic plague across Europe in the middle ages
Estimated to have killed 1/3 of the population of Europe 4

5. …and they continue to threaten us
…and place sudden intense demands on national and international health systems
…on some occasions have brought health and social systems to the point of collapse
…the diseases of most concern are those that may have international significance – either as a possible global epidemic or pandemic, or because they pose a risk for travellers with high case fatality rates or have trade implications. Most of these diseases tend to be emerging diseases.

6. So, in the context of emerging/epidemic disease
at the beginning of the 21st. Century:
We have seen the emergence of new or newly recognized pathogens (e.g. Highly Pathogenic Avian Influenza [H5N1], SARS, Nipah, pandemic influenza [H1N1], novel coronavirus ……)
The resurgence of well characterized outbreak-prone diseases (e.g. dengue, measles, yellow fever, chickungunya - also cholera, TB, meningitis, shigellosis)
Human-made "bio-risk" also increasing: accidental and deliberate release of infectious agents as smallpox, SARS, Ebola, anthrax, tularaemia, etc.
Emergence of new or newly recognised pathogens
These novel pathogens are usually poorly understood in terms of source and transmission and many have the potential to cause large outbreaks. HIV/AIDS is the most recent example of a pathogen that has emerged in the recent past is causing a major epidemic that now threatens the economic future of many nations. Other pathogens, such as influenza and measles, have at some time in the past crossed over from animal species and now regularly cause major outbreaks associated with high mortality and morbidity. While novel pathogens may not always cause major outbreaks, they are often associated with high case fatality rates as they are poorly understood as they emerge, and initial prevention or treatment strategies prove ineffective. Examples of this include Lassa, Ebola, and, most recently, Nipah virus.
Recurrence of well characterised outbreak-prone diseases
Diseases such as cholera, dengue, influenza, measles, meningitis, shigellosis, yellow fever and food-borne diseases present a constant threat to human populations. In general the diseases are well understood and very often effective control measures are available. In many countries these diseases have come under control by the systematic application of control measures such as vaccination or water treatment. However, if public health control measures break down or if the organism adapts (e.g by developing resistance to antibiotics) then there is always potential for renewed outbreaks. This is best demonstrated in countries where conflict has resulted in a breakdown of governmental administrative structures, including the public health sector, and where controllable diseases may cause severe outbreaks in populations displaced due to civil strife, or may spread geographically affecting new populations. Vulnerable populations often experience severe disease (e.g., from epidemic malaria, cholera, or shigellosis) exacerbated by the delayed and ineffective responses from public authorities. Local resources may be rapidly overwhelmed if public health infrastructure is weak, with the consequence of further extension of the outbreak.
Accidental or deliberate release of a biological agent
In practice, these events will exhibit similar features to [1.] or [2.] above, although the mode of introduction may introduce unique features (eg., BSE/vCJD) or necessitate specialised detection systems and preparedness planning (e.g. for deliberate release of pathogens). 6

7. Emerging diseases: a definition
New diseases which have not been recognized previously;
Known diseases which are increasing, or threaten to increase, in incidence or in geographic distribution;
The terms “re-emerging” or “resurgent diseases” are also used – usually to describe diseases which we had thought had been controlled or conquered through immunization, antibiotic use or environmental changes, but which are now reappearing.

8. Map of geographic origins of EID events, 1940-2004
(Jones et al, Nature 2008)

9. Substantiated public health events of potential international concern
by hazard
Jan June (n=2,448; 477 (19%) in AMRO)
85%

10. Modeling EID events: Relative risk of an EID
Hot Spots: global distribution of relative risk of an EID event caused by zoonotic pathogens from wildlife, (Jones et al, Nature, 2008).

11. 61% of all Emerging Infectious Diseases are Zoonoses affecting Humans
Wildlife
Domestic
Animal
Human
Translocation
Human encroachment
Ex situ contact
Ecological manipulation
Global travel
Urbanization
Biomedical
manipulation
Technology
And Industry
Agricultural
Intensification
Encroachment
Introduction
“Spill over” &
“Spill back”
Frequency of all EID events has significantly increased since 1940, reaching a peak in
61% of EID events are caused by the transmission from animals (zoonoses)
74% of these from wildlife
Zoonotic EIDs from wildlife reach highest proportion in recent decade
More than 75% of EID being of animal origin, we are threaten not only by pathogens spreading across countries and regions but also by diseases crossing borders between human, domestic animal and wildlife. To ensure Global Health Security, WHO need to develop a system to monitor the pathogens in the 3 worlds. 11

12. Purpose and scope of the IHR
“to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade“ (Article 2)
From three diseases to all public health hazards, irrespective of origin or source
From control of borders to containment at source
From preset measures to adapted response

13. WHO global alert and response systems
States Parties
WHO
Others sources
Initial screening
Verification
Informal/
Unofficial information`
Formal reports
Disseminate information
Event’s
Risk assessment
Assist
Respond 13

14. Early warning function of the public health surveillance system 100% coverage, 100% sensitivity, 100% flexibility
Complementary
Event-based surveillance
(unstructured information)
Media reports
Hotlines (community,
professionals, etc.)
NGOs
Diplomatic channels
Military channels
Etc.
Indicator-based surveillance
(discrete variables)
Case based (aggregated, individual)
Laboratory results
Environmental measurements
Drug sales
Absenteeism
Etc.
Signal
Unusual health event 
Risk
Assessment
 Response
With the understanding that surveillance is to ensure the continuum “information for action”, when establishing, or adapting, public health surveillance mechanisms it is imperative to have clear objectives as for the surveillance function that these are going to serve, and a clear understanding of what is operationally feasible in any given setting. 
The efficiency of the early warning function - or ability to detect unusual health events - of any public health surveillance mechanism relies on capturing, in a systematic manner to the extent possible, information coming from any source.  It traditionally depends on two components: indicators-based component, focusing on discrete variables; and event-based component, focusing on unstructured information from a 360 degree spectrum of sources, such as rumours from the community, media reports, etc…Both components are regarded as core capacity for surveillance and response under the current International Health Regulations (IHR).
Although not mutually exclusive, and in a rapidly evolving information and communication technology environment, the event based component as the predominant contributor to the early warning function has become increasingly evident at all levels, from local to global.  Whereas the indicator based component becomes more relevant while verifying signals captured through the event-based component and during the risk assessment and monitoring of an event. 
While the continuum throughout the phases of the risk management process – risk detection, risk assessment, control, and risk communication – requires robust information management tools, to ensure accountability and facilitate learning lessons exercises, by no means an IT platform can substitute the human factors.
Triangulation
of sources
Verification

15. Outbreak Detection and Response without Preparedness
First
Case
Late
Detection
Delayed
Response
Cases
Opportunity
for control
Day

16. Outbreak Detection and Response with Preparedness
Early
Detection
Rapid
Response
Potential
Cases Prevented
Cases
Day

17. Information sharing at WHO Event Management System
WHO Portal
Information sharing at WHO
States
Operations
Event Management System
PAHO
AFRO
WPRO
EMRO
SEARO
EURO

18. No single institution has all the capacity!
This map shows the deployments of the GOARN response teams worldwide during the period 2000 – 2010.
Let’ s have a look to the light brown dots representing the Ebola outbreak responses in central African countries, the light blue dots representing the SARS response in the asian countries and the dark blue dots representing the H1N1 pandemic response.
In the Americas from April 2009 to December 2009, 80 GOARN experts were deployed to 18 countries in order to support the national authorities to investigate their H1N1 outbreaks and activate the NIPPs regarding laboratory, surveillance, case management, infection control and risk communication components.
No single institution has all the capacity!
Coordinate and support rapid international team deployment to countries for outbreak response
To focus and coordinate global resources - local > regional > global

19. SARS Coronavirus (SARS CoV)
SARS CoV identified on 27 March 2003
Highly mutable
Reservoir unknown
8,098 cases with 774 deaths (CFR% 9.5, age related)
1,707 HCWs affected (21%)
27 countries affected with 92% of cases in mainland China, Hong Kong SAR, and Taiwan, China
Age range – years; most cases years
Almost exceeded surge capacity of acute care facilities and public health services

20. SARS…a first (and a wake up) call
First epidemic of the 21st century
Social, political and economic impact, including psychosocial impact
Estimated economic cost of $US30 billion (Stanley Morgan); $US100 billion (Nature); $US48 billion in China alone (Chinese Center for Economic Research)
First new pathogen identified in the 21st century and fast discovery (3 weeks after Global Alert)
First time EVER that a global surveillance system was implemented in response to an unknown public health emergency
Para poder responder de manera efectiva a la emergencia de un patógeno la la alerta temprana tanto anivel nacional cuanto interncional es essencial. Como podemos ver en el caso del SARS la notificación oficial ocurrió aproximadamente 2 meses despues del inicio del brote. Tenemos que tener en cuenta las dificultades para la identificación etiológica de un nuevo agente.

21. Continued Challenges Human-Animal Interface
Animal Surveillance
Human Surveillance
So, what we can see in fact, is that animal and human surveillance in fact, have two common goals. One, to identify emerging pathogens with morbidity and mortality potential and two, to implement prevention and control measures to limit disease spread.
So, what can we do to combat these challenges. First, it is important for the human surveillance world to appreciate these unique challenges facing those implementing animal surveillance programs and work in a way that promotes collaboration between the two Ministries. Next, it is important to identify and highlight the common benefits to the public health and agriculture in working in a collaborative fashion. Finally, it is important to consider the limited resources available for these types of activities and how these resources can be used to achieve common goals.
Create bridges
Joint assessment
Exchange data and findings 21

22. H5N1 Avian Influenza December 2003 – August 2012
608 cases
including 359 deaths
in 15 countries

23. PAHO/WHO Event Management
PAHO Media Surveillance
Concentration of ARD cases detected in hospital in Oaxaca, Mexico.
PAHO/WHO Event Management
PAHO Media Surveillance
ARD outbreak detected in La Gloria, Veracruz, Mexico.
USA via NFP notified first confirmed cases of Influenza A H1N1 in California.
PAHO IHR informed Mexico via NFP about first cases of A H1N1 in California, USA.
MEXICO via NFP Notification of outbreaks in different states without laboratory diagnosis and confirmed ILI in Mexicali, Baja California.
PAHO IHR requested more information from Mexico via NFP about outbreaks in different states.
PAHO IHR requested verification from Mexico via NFP about ARD situation in La Gloria, Vera Cruz.
Teleconference between PAHO IHR and Mexico NFP for joint Risk Assessment.
PAHO EOC activated.
Teleconference between USA, Mexico, Canada and PAHO about investigation in USA.
USA via NFP cases confirmed in TX.
CANADA Laboratory confirmation of first Influenza A H1N1 cases in samples from Mexico.
MEXICO via NFP confirmed presence of outbreak of etiology under investigation in La Gloria, Vera Cruz.
PAHO sent Response Team to Mexico GOARN.
PAHO IHR requested verification from Mexico via NFP about ARD in Oaxaca.
Teleconference between Canada, Mexico and USA on ILI in students returning from Mexico.
USA via NFP Cases confirmed in KS.
MEXICO via NFP rules out outbreak in Oaxaca.
DG WHO following Emergency Committee declares PHEIC.
USA via NFP Cases confirmed in NY and OH.
PAHO IHR requested verification from Mexico via NFP about ILI in Mexicali, Baja California.
WHO Declares PHASE 4
CANADA via NFP First cases confirmed.
WHO Declares PHASE 5 10
April
11 April
12 April
13 April
14 April
15 April
16 April
17 April
18 April
19 April
20 April
21 April
22 April
23 April
24 April
25 April
26 April
27 April
28 April
29 April
ARD (Acute Respiratory Disease) ILI (Influenza-like Illness) PHEIC (Public Health Emergency International Concern)

24. Mexico 2009. Pandemic Epidemic Curves.
Source: Mexican Ministry of health – INDRE. Retrospective.
Confirmed
cases
2009
2010
Deaths
Then, in April 2009, the pandemic struck. Here we see two epidemic curves from Mexico, formed with a retrospective understanding. The bars indicate the number of confirmed pandemic influenza cases and the lines indicate the number of confirmed deaths, both by epidemiologic week in 2009 and As you can see, based upon WHO recommendations, the reporting of confirmed cases stopped towards the end of The good news was that based upon the preparedness activities of the past five years, countries were not naïve to the idea of pandemic influenza. The bad news was that the pandemic overwhelmed the Region– both in terms of health care services as well as surveillance. 24

25. Nurses are uniquely positioned to identify events of potential public health significance……
Any outbreak of disease
Any uncommon illness of potential public health significance
Any infectious or infectious-like syndrome considered unusual by HCWs, based on:
Frequency e.g., a sudden, unexplained, significant increase in the number of patients, especially when it occurs outside the normal season
Circumstances of occurrence e.g., many patients coming from the same location or participating in similar activities
Clinical presentation e.g., a patient’s health rapidly deteriorating out of proportion to the presenting symptoms and diagnosis
Severity e.g., a number of patients failing to respond to treatments

26. “Astute” questions during Patient triage (Credit: Gail Thomson, NMGH, UK)
Thorough travel history
History of fever within 21/7 of travel to an at-risk country, check temperature
Fever and bleeding/bruising after a tick bite from an at-risk area or after killing livestock/abattoir work
Exposure history
Clinical history & vital signs
Airline flight numbers and stop over/transit
documented.
Illness during the journey.
Illness during any stopover/s
Malaria test

27. Nurses and Infection Control
HCWs may be the canaries!
21 % of the SARS probable cases were HCWs !
Pneumonic Plague, Peru 2010
They may be the first cluster of cases
that triggers an alarm bell that there is
something seriously wrong.

28. Nurses and EID detection
“In remaining vigilant for the presence of a new disease, the individual nurse functions as a mini-surveillance system.”
Nurses, who are frequently the first contact a patient has with the health care system, may find themselves identifying the presence of infectious diseases, tracking and identifying cases, notifying the proper authorities and implementing disease containment programs. In remaining vigilant for the presence of a new disease, the individual nurse functions as a ‘mini-surveillance system.’ In fact, an astute clinician is a critical component of any national surveillance system. The first lines of detection of a biologic agent released into the population reside with a physician or nurse who diagnoses an individual with signs and symptoms of that biologic agent.
The specific role of the individual nurse will probably be determined by place of employment and the health care needs of the population of patients being seen. However, all nurses should be familiar will the fundamental concepts of epidemiology, early detection, and surveillance, and appreciate the role of the nurse in contributing to the success of this system. Even nurses who do not work in situations directly related to public health should appreciate that they may be contributing to surveillance data collection systems. Each time a nurse enters a patient variable into emergency department records or electronic medical records (EMRs), that data may be used for surveillance purposes. The following section provides an overview of basic concepts of epidemiology, early detection, and surveillance.

29. Hope for the best…and prepare for the worst. Thank you