1. World Health Organization 1 August 2008 Infectious diseases in a globalized world: risks to our public health security

2. World Health Organization 2 August 2008 Cryptosporidiosis Lyme Borreliosis Reston virus Venezuelan Equine Encephalitis Dengue haemhorrhagic fever Cholera E.coli O157 West Nile Fever Typhoid Diphtheria E.coli O157 Echinococcosis Lassa fever Yellow fever Ebola haemorrhagic fever O’nyong-nyong fever Human Monkeypox Cholera 0139 Dengue haemhorrhagic fever Influenza A(H5N1) Cholera RVF/VHF nvCJD Ross River virus Hendra virus BSE Multidrug resistant Salmonella E.coli non-O157 West Nile Virus Malaria Nipah Virus Reston Virus Legionnaire’s Disease Buruli ulcer Emerging and re-emerging infections, 1996 – 2007 Severe Acute Respiratory Syndrome (SARS) Human Monkepox Marburg haemorrhagic fever E.coli O157 Recent outbreaks followed by WHO Avian influenza (human) Asia/Middle East/Africa Marburg Haemorrhagic Fever Uganda Chikungunya Pacific Islands, Italy Cholera West /Southern Africa Nipah haemorrhagic fever Bangladesh Lassa Fever Sierra Leone High mortality measles Nigeria Meningococcal meningitis West and Central Africa Yellow Fever Guinea/Sudan Poliomyelitis DRC/Bangladesh

3. World Health Organization 3 August 2008 Points for discussion l What do we know about emerging infections? – Resilience/dynamism – Relationship with animals – Persons at greatest risk – Other

4. World Health Organization 4 August 2008 Breaches in species barrier: selected emerging infections in humans identified since 1976 Infection Original Year hostreported (confirmed/ hypothesized) Ebola virusBats1976 HIV-1Primates1981 E. coli O157:H7Cattle1982 Borrelia burgdorferiRodents1982 HIV-2Primate1986 Hendra virusBats1994 BSE/vCJDCattle1996 Australian lyssavirusBats1996 H5N1 influenza AChickens1997 Nipah virusBats1999 SARS coronavirusPalm civets2003 adapted from Woolhouse et al. (2005)

5. World Health Organization 5 August 2008 Smallpox: Variola Major 20% - 40% case fatality 100% permanent facial scarring 2.7 million deaths, 1967

6. World Health Organization 6 August 2008 Smallpox Eradication: Certified 1980

7. World Health Organization 7 August 2008 Persons living with HIV infection, 2006: >40 million 3 million deaths during 2003 20 million deaths since 1981 1984: smallpox vaccination in HIV-infected adult was AIDS defining event with generalized vaccinia/death

8. World Health Organization 8 August 2008 Source: WHO/CDC 0 2 4 6 8 10 12 14 16 7- Mar 13- Mar 19- Mar 25- Mar 31- Mar 6- Apr 12- Apr 18- Apr 24- Apr 30- Apr 6- May 12- May 18- May 24- May 30- May 5- Jun 11- Jun 17- Jun Non health care workers Health care workers Ebola Haemorrhagic Fever by mode of transmission, Kikwit Zaire, 1995

9. World Health Organization 9 August 2008 SARS, chain of human-to- human transmission, Singapore 2003

10. World Health Organization 10 August 2008 International travellers, 1950 - 2006 Source: WHO/World Tourism Organization International airline passengers (millions) 1000 800 600 400 200 0 19501960197019801990 2000 1200 1400 Increased to over 2 billion international travellers in 2006

11. World Health Organization 11 August 2008 Outbreak of leptospirosis (N = 33) among 312 participants, Eco Challenge 2000, Malaysia Eco Challenge Eco Challenge US: 10 Canada: 4 Brazil: 1 Uruguay: 1 Australia: 4 France: 4 UK: 9

12. World Health Organization 12 August 2008 Doctor from Guangdong Doctor from Guangdong Canada Hotel M Hong Kong Ireland USA New York Singapore Viet Nam Bangkok B I K F G E D C J H A Germany 1 HCW + 2 Germany 1 HCW + 2 Source: WHO/CDC SARS: international spread from Hong Kong, 21 February – 12 March, 2003 Hong Kong + 219 health care workers

13. World Health Organization 13 August 2008 Countries in which airport malaria has been reported, 1969 – August 2003 USA: 1 Switzerland: 1 Australia: 1 Belgium: 1 Germany: 1 United Kingdom: 7 France: 3 Israel: 1 Luxembourg: 2

14. World Health Organization 14 August 2008 West Nile Virus in the United States, 2005 Genetic sequencing compatible with One-time introduction in late 1990s

15. World Health Organization 15 August 2008 Increased world trade in agricultural products/animals, 1950 - 2006 1950 0 40 80 120 160 export of agricultural products by volume 19601970198019902000 Source: WTO, 2000 World trade in agricultural products has increased 5-fold since 1950

16. World Health Organization 16 August 2008 Deaths from vCJD by year of death, United Kingdom, 1994 - 2006 N = 162 10 15 28 20 17 18 0 5 10 15 20 25 30 35 40 1994199519961997199819992000200120022003 0 3 9 14 2004 2005

17. World Health Organization 17 August 2008 BSE and vCJD: potential exposure through international trade, early 1990s Food containing beef Pharmaceuticals Blood and blood products Cattle, meat and bone meal Human and bovine tissue used in biologicals

18. World Health Organization 18 August 2008 Pharmaceuticals Blood and blood products Meat and bone meal Human and bovine tissue used in biologicals vCJD: geographic distribution of human infections

19. World Health Organization 19 August 2008 Rift Valley Fever, humans, Yemen, September 2000 0 20 40 60 80 September 1-30, 2000 Number of cases

20. World Health Organization 20 August 2008 Rift Valley Fever, livestock, Yemen and Saudi Arabia, October 2000 Area affected

21. World Health Organization 21 August 2008 El Nino-associated flooding, East Africa, 1998 Animal vaccination suspended early 1990s Flooding forced humans and animals to close proximity Increased mosquito breeding sites

22. World Health Organization 22 August 2008 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

23. World Health Organization 23 August 2008 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?

24. World Health Organization 24 August 2008 Concern about public health security throughout the ages 1374Venice Quarantine for Plague 1851Paris1st International Sanitary Conference 1947GenevaWHO Epidemiological Information Service 1951GenevaInternational Sanitary Regulations 1969GenevaInternational Health Regulations

25. World Health Organization 25 August 2008 l “…ensure the maximum security against the international spread of disease with a minimum interference with world traffic.” International Health Regulations purpose 1969

26. June 2007 World Health Organization 26 Content of International Health Regulations 1969: requirements l Notification to WHO: cholera, plague or yellow fever – reports only accepted from countries where event is occurring l Health Organization at borders: ports, airports and frontier posts adequately equipped to prevent vector proliferation l Health Measures: describe maximum measures that a country may require to protect against cholera, plague and yellow fever (e.g. yellow fever vaccination card)

27. World Health Organization 27 August 2008 Application of International Health Regulations, 1969 National containment activity Disease reporting by countries (cholera, plague, yellow fever) Publication in Weekly Epidemiological Record Application of pre- determined measures (maximum allowable)

28. World Health Organization 28 August 2008 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?

29. World Health Organization 29 August 2008 Direct economic impact, selected infectious disease outbreaks, 1990-2003 Asia – SARS US$ 30 billion 2003 UK - BSE US$ 39 billion 1990-1998 Tanzania - Cholera US$ 36 million 1998 India - Plague US$ 1.7 billion 1995 Peru - Cholera US$ 770 million 1991 Malaysia- Nipah Pig destruction 1999 Hong Kong - influenza A(H5N1) Poultry destruction 1997 US E. coli 0157 Food recall/destruction Periodic

30. World Health Organization 30 August 2008 Cryptosporidiosis Lyme Borreliosis Reston virus Venezuelan Equine Encephalitis Dengue haemhorrhagic fever Cholera E.coli O157 West Nile Fever Typhoid Diphtheria E.coli O157 Echinococcosis Lassa fever Yellow fever Ebola haemorrhagic fever O’nyong-nyong fever Human Monkeypox Cholera 0139 Dengue haemhorrhagic fever Influenza A(H5N1) Cholera RVF/VHF nvCJD Ross River virus Hendra virus BSE Multidrug resistant Salmonella E.coli non-O157 West Nile Virus Malaria Nipah Virus Reston Virus Legionnaire’s Disease Buruli ulcer Emerging and re-emerging infections: 1996 - 2007 Severe Acute Respiratory Syndrome (SARS) Human Monkepox Marburg haemorrhagic fever

31. World Health Organization 31 August 2008 Global outbreaks, the challenge: late reporting and response 0 10 20 30 40 50 60 70 80 90 147 1013161922252831343740 Delayed response DAY CASES Lost opportunity for control/ risk of international spread Late reporting First case

32. World Health Organization 32 August 2008 0 10 20 30 40 50 60 70 80 90 1471013161922252831343740 Rapid response CASES Early reporting Potential cases prevented/ international spread prevented DAY Global outbreaks, the solution: early reporting and response

33. World Health Organization 33 August 2008 Points for discussion l What would you do next?

34. World Health Organization 34 August 2008 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

35. World Health Organization 35 August 2008 Global Public Health Intelligence Network, Canada

36. World Health Organization 36 August 2008 Outbreak Verification & Response Afghanistan, February 1999 16 February 19 February 24 February 1 March GPHIN report of highly fatal respiratory disease WHO/local team preliminary investigation WHO collaborative team Investigation completed Diagnosis confirmed

37. World Health Organization 37 August 2008 Information sources, public health risks reported to WHO, 2003 0% 10% 20% 30% 40% 50% 60% 70% AFRO EMRO EURO AMRO SEARO WPRO WRs NGOs PROMED Others GPHIN Countries ( 23% of reports) WHO Alert & Response Network ( 77% of reports)

38. World Health Organization 38 August 2008 Operationalizing the IHR in the 21 st century: partnership for global alert and response to infectious diseases Electronic Discussion sites Media NGOs Military Laboratory Networks WHO Collaborating Centres/Laboratories Epidemiology and Surveillance Networks WHO Regional & Country Offices Countries/National Disease Control Centres UN Sister Agencies FORMAL GPHIN INFORMAL

39. World Health Organization 39 August 2008 Request for GOARN support: terms of reference

40. World Health Organization 40 August 2008 Sample of International epidemic response missions in the field, 1998–1999

41. World Health Organization 41 August 2008 Global outbreak alert and response network: surveillance network partners in Asia Global outbreak alert and response network: surveillance network partners in Asia Mekong Basin Disease Surveillance (MBDS) ASEAN APEC SEAMIC SEANET EIDIOR Flu Net GPHIN Pacific Public Health Surveillance Network (PPHSN) + Red Cross, other NGOs

42. World Health Organization 42 August 2008 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

43. World Health Organization 43 August 2008 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) Intensified surveillance for respiratory infections, Asia, 2002–2003

44. World Health Organization 44 August 2008 Global Alert: Severe Acute Respiratory Syndrome (SARS) 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

45. World Health Organization 45 August 2008 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

46. World Health Organization 46 August 2008 Points for discussion l What would you do next?

47. World Health Organization 47 August 2008 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.

48. World Health Organization 48 August 2008 Global Outbreak Alert and Response Network  115 experts from 26 institutions in 17 countries  field teams sent to 5 countries Strategies that increased power of epidemic control: global partnerships

49. World Health Organization 49 August 2008 Probable SARS transmission, flight CA112, March 2006

50. World Health Organization 50 August 2008 Strategies to control: WHO travel recommendations on www.who.int/csr/sars/ Update 79 - Situation in China 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 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 2002 1 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.

51. World Health Organization 51 August 2008 Probable cases of SARS by date of onset worldwide, 1 March – 27 June 2003

52. World Health Organization 52 August 2008 SARS Epidemic curve, China, 2002 - 2003

53. World Health Organization 53 August 2008 Passenger movement, Hong Kong International Airport, March-July 2003 WHO lifted travel advisory WHO travel advisory

54. World Health Organization 54 August 2008 The cost of SARS: initial estimates for six month outbreaks, Asian Development Bank, 2003 76543210US$ billion Hong Kong China, mainland Taiwan South Korea Indonesia Singapore Thailand Malaysia Philippines US$ billion 4% 0.5% 1.9% 0.5% 1.4% 2.3% 1.6% 1.5% 0.8% % of GDP As of 30 September, 2003, SARS had decreased Asia’s combined GDP by US$18 billion and cost nearly US$60 billion in lost demand and revenues

55. World Health Organization 55 August 2008 Points for discussion l 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?

56. World Health Organization 56 August 2008 New norms for reporting and responding to infectious diseases established, 2003 l Reporting of infectious diseases from other sources accepted by WHO Member States l All infectious diseases with potential for international spread to be reported l 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 Severe acute respiratory syndrome (SARS)

57. World Health Organization 57 August 2008 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

58. World Health Organization 58 August 2008 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

59. World Health Organization 59 August 2008 Decision making and response and the revised International Health Regulations National containment of public health risk Public health risk reporting by countries National containment of public health risk NO YES Public health risk reporting from WHO Alert & Response Network Collaborative risk-based public health measures identified and managed pro-actively by WHO Decision-tree analysis to determine if of urgent international public health importance

60. World Health Organization 60 August 2008 Points for discussion l Do the revised International Health Regulations meet the vision for their revision? l If not, tell what more could be done l What are some major infectious disease threat today that would fall under the Revised Regulations?

61. World Health Organization 61 August 2008 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