1. 1 February 2015 Centre on Global Health Security Draft Research Strategy 29 th June 2010 Shifting the paradigm: from rapid detection and response to prevention at the source

2. 2 February 2015 Breaches in species barrier since 1976 Infection Animal linked Year infection to transmission first reported Ebola virus Bats 1976 HIV-1 Primates 1981 E. coli O157:H7 Cattle `1982 Borrelia burgdorferi Rodents 1982 HIV-2 Primate 1986 Hendra virus Bats 1994 BSE/vCJD Cattle 1996 Australian lyssavirus Bats 1996 H5N1 influenza A Chickens 1997 Nipah virus Bats 1999 SARS coronavirus Palm civets 2003 Influenza (H1N1) Swine 2009 MERS coronavirus Camel 2012

3. 3 February 2015 Potential transmission pathways, emerging infectious diseases Emergence No further transmission Continues transmission Continues transmission Ceases/ sporadic Continues/ endemic

4. 4 February 2015 Emergence from animals in nature: Eco Challenge, Malaysia, 2000

5. 5 February 2015 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

6. 6 February 2015 The current paradigm: rapid detection, risk assessment, and emergency response

7. 7 February 2015 Source: WHO/CDC SARS: international spread from Hong Kong, 21 February – 12 March, 2003 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 Hong Kong

8. 8 February 2015 Probable cases of SARS by date of onset worldwide, 1 March – 27 June 2003 8,273 reported cases 775 deaths

9. 9 February 2015 SARS and the economy: impact on global travel, April 2003

10. 10 February 2015 Passenger movement, Hong Kong International Airport, March-July 2003 WHO lifted travel advisory WHO travel advisory

11. 11 February 2015 Economic impact SARS, Hong Kong l Health (sector) impact small, but impact on other sectors large – Hong Kong retail losses ~ US$334m

12. 12 February 2015 The cost of SARS, 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

13. 13 February 2015 Influenza A(H1N1) Pandemic as of 13 June 2009

14. 14 February 2015

15. 15 February 2015 Recent infectious disease outbreaks and their economic impact

16. 16 February 2015 Changing the paradigm: joint risk assessment, prediction and prevention

17. February 2015 17 Changing the paradigm: joint human/animal surveillance and risk assessment ● identify animal infections/assess their risk to humans ● share laboratory specimens between animal and human public health ● conduct joint research ● increase use of animal vaccines ● stronger regulation of animal husbandry

18. 18 February 2015 Joint risk communication

19. 19 February 2015 Changing the paradigm: risk maps for emergence of infectious diseases

20. 20 February 2015 Changing the paradigm: identification/sequencing of animal infections How feasible is prediction in preventing infections at the animal/human interface?

21. 21 February 2015 Pushing the paradigm even further upstream: prevention of emergence at its source

22. 22 February 2015 Nipah virus infection, Malaysia, 1998-1999 Source: Chua KB, Journal of Clinical Virology, April 2003

23. 23 February 2015 Nipah virus outbreaks, humans, 1998 - 2008 DatesLocationNo. casesNo. deathsCFR(%) 1998-1999 1999 Malaysia; Singapore 265 11 105 1 40 9 2001W. Bengal, India6645 68 2001Bangladesh13969 2003Bangladesh128 67 2004Bangladesh 29 36 22 27 76 75 2005Bangladesh 12 11 92 2007W. Bengal, India 5 5 100 2007 2008 Bangladesh 15 11 8 6 54

24. 24 February 2015 Changing Nipah virus epidemiology: Bangladesh and India Human-to-human transmission first suspected 2001, hospitalized patients, India Human to human transmission suspected again in 2003, 2005, and 2007, Bangladesh – cases could not be linked to domestic animal exposure, including pigs – index cases not identified: one potential exposure to bat guano in palm wine

25. 25 February 2015 Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University. Assessing the risk/testing the hypothesis

26. 26 February 2015 Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University. The risk is plausible through the food chain

27. 27 February 2015 Precautionary measures: community agreement to cover the collection containers Community agriculture meeting

28. 28 February 2015 Shifting the paradigm from emergency response to prevention

29. 29 February 2015 Ebola emergence: current hypotheses

30. 30 February 2015 Ebola Haemorrhagic Fever by mode of transmission, Yambuku DRC,1976 Source: CDC Cases: 318 Deaths: 280 (88%)

31. 31 February 2015 Mission Hosptial, Tandala Zaire (DRC), 1977 1 clinical case/died 1 contact (sister) fit possible case definition/survived 1 historical probable clinical case/recovered,1972

32. 32 February 2015 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 315 cases 250 (80%) deaths

33. 33 February 2015 Ebola outbreaks, West Africa, 2014

34. 34 February 2015 Ebola, new cases as of mid-February, 2015 Source: WHO

35. 35 February 2015 Ebola outbreaks can be stopped Patient identification, isolation and protection of health workers/infection control Surveillance/contact tracing and fever surveillance with rapid diagnosis and isolation Community understanding with safe patient and body transport systems, safe burial and household/environmental decontamination

36. 36 February 2015 Vaccines against Ebola: possible uses Short-duration immunity: – Front line health workers – Front line community workers: transporters of patients and bodies, decontamination workers – Ring vaccination: prevent third generation cases Long-duration immunity – Primary prevention: health workers in Ebola Belt

37. 37 February 2015 VaccineMechanismTrialsCommentRef Plasmid DNA based. VRC-EBODNA023- 00-VP DNA immunisation with boosting adenoviral vector Phase I Uganda (completed) Process takes 6 months to provide protection in non- human primates Sullivan et al Nature 2000 Accelerated vaccine of above ChAd-EBO Adenoviral vector delivers DNA encoding Ebola GP Phase I (started in UK, U.S) Recruiting in Mali, pending in Gambia Process takes 28 days (NH primates and mice). Potential for outbreaks Sullivan et al Nature 2003 VSV-EBO (Canadian) Vesicular stomatitis virus delivers Ag Phase I Currently recruiting Up to thirty minutes post infection (protection against Ebola -50%, Marburg 100%) 33% protection after 48 hrs Feldmannet al Plos Pathog 2007 Ebola candidate vaccines, early 2015

38. 38 February 2015 Ebola candidate vaccines, 2015 Keep the research protocols and vaccines ready and on the shelf