2. World Health Organization
26 April 2017
Global capacity and responses to pandemics
WHO's global strategy –
N. Shindo MD, PhD.
Coordinator
Pandemic and Epidemic Diseases Department
Epidemic Clinical Management
ERS International Congress 2015, Amsterdam

3. Asclepius – Greek god of medicine
His daughters are Hygieia ("Hygiene"), Iaso ("Medicine"),
Aceso ("Healing"), Aglea ("Healthy Glow"),
and Panacea ("Universal Remedy").

4. HSE cluster and PED Department
World Health Organization
26 April 2017 DG
FWC
GMG
IHS
HSE
PED
FOS
GCR
HTM
NMH
PEC
Pandemic and Epidemic
Diseases
Food safety and zoonosis
Global Capacity and Respnse

5. How many pathogens able to infect humans?
World Health Organization
26 April 2017
1400 pathogens1 are known to infect human, other are discovered /identified every year
Some of them are responsible of global public health problems e.g. SARS, in 2003, pandemic influenza in 2009
70% from animal origin
HIV (1983)
Discovery curve for human virus species2
Hendra virus
(1994)
Chikungunya virus
(1956)
Monkeypox virus
(1972)
Ebola virus
(1976-7)
1Jones, K, Nature (2008)
2Woolhouse, ME, Proc. R. Soc. B (2008)

6. Pandemic and Epidemic diseases department
Improve shared knowledge and evidence-base for epidemic diseases to inform policies at international and national levels
Perform timely risk assessment and monitoring of infectious epidemic diseases of international concern to define emergency intervention strategies.
Support countries throughout the epidemic cycle: Preparedness, Response and Resilience to epidemics
Optimize treatments and diagnostics to reduce infectious diseases mortality
Implement global mechanisms and processes to deal with the international dimension of epidemic diseases

7. Cross-cutting initiatives and network
PED activities
Diseases
Cholera
Emerging diseases
Hendra virus infection
Influenza (avian, seasonal, pandemic)
Leptospirosis
Meningitis
Nipah virus infection
Plague
Rift Valley fever
SARS and coronavirus infections
Smallpox and human monkeypox
Tularemia
Viral Haemorrhagic fevers (Ebola, Marburg, Lassa, CCHF)
Yellow fever
Cross-cutting initiatives and network
Antimicrobial resistance (AMR)
Battle against Respiratory Viruses (BRaVe) initiative
Communicable Disease Control in Humanitarian Emergencies (DCE)
Emerging and Dangerous Pathogens Laboratory Network (EDPLN)
International Coordinating Group (ICG) for yellow fever, meningitis and cholera
Global Infection Prevention and Control Network (GIPCN)
Global influenza Surveillance and Response System (GISRS)
Global Leptospirosis Environmental Action Network (GLEAN) and Meningitis Environmental Risk Information Technologies (MERIT) project
Pandemic Influenza Preparedness framework (PIP)
Weekly Epidemiological Record (WER)

8. Evidence to reduce disease transmission
e.g. Role of pigs in the transmission/ amplification of some deadly viruses (viral haemorrhagic fever, Influenza)
Impact on preventive measures and cross sectorial work(OIE/FAO)
e.g. Bats in haemorrhagic fever transmission

9. Develop public health research agenda
WHO is streamline research efforts done by academia or industry to answer public health questions
How useful it is to stockpile mask for pandemic preparedness?
What is the actual risk to face an avian influenza pandemic?
How can we foster research on new treatments for viral respiratory diseases to save 700 million children under 5 each year ? (BRAVE initiative)

11. What do we do ? Perform timely risk assessment and monitoring
of infectious epidemic diseases of international concern
to define emergency intervention strategies.

13. Outbreaks on the African continent (2007-2013) A total of 174 epidemics
Number of epidemic by year in Africa
Number of epidemics
( )
Analysis excluded Poliomyelitis, HIV, TB and malaria
A total of 15 diseases cause(d) outbreaks include:
Avian Influenza
Lassa Fever
Plague
Chikungunya
Marburg
Rift Valley Fever Typhoide
Cholera
Meningitis
Ebola
Monkeypox
West Nile Fever
Hepatitis E
Nodding disease
Yellow Fever
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
 WHO All rights reserved
Source: WHO/PED, March 2013

14. Preventive interventions, 2012
Prepositioning of reagents and treatments:
meningitis
Preventive vaccination campaigns (GAVI support)
yellow fever

15. Epidemic responses, 2014 Global stockpile of vaccine and antivirals
Epidemic responses for
MERS CoV (Middle East)
Avian influenza H7N9 (China)
Ebola (West Africa)
Global stockpile of vaccine and antivirals

16. New approaches for old disease: cholera
Close partnership with water sector to reduce cholera transmission
Rational use of oral cholera vaccine during emergencies (e.g. global oral cholera vaccine stockpile)

17. What do we do ?
Optimize treatments and diagnostics to reduce infectious diseases mortality

18. Differential mortality and access to care
Cholera Treatment Unit (2003)
Hospitalized patient during SARS outbreak (2003)

19. Improvement of clinical management and infection control
Guidance for treatment and infection control
Access to medicine (prequalification, essential list of medicine)
Partnership with experts networks: ISARIC, INFACT

20. Global Health Security IHR(2005), a paradigm shift
International legal instrument, 194 countries
Aim: help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwide
Increased emphasis on early source control rather than borders
Applicability to all hazards
From preset measures to adapted response based upon risk assessment, facilitated by communication
Includes an obligation to build national capacities to detect and respond to potential public health events

21. Implementation of the PIP framework
Sharing
of influenza
Viruses
GISRS
Sharing of benefits
Vaccines
Antivirals
Diagnostics
Publications
Equal footing

22. Pandemics of the 21rst century
World Health Organization
26 April 2017
Pandemics of the 21rst century

23. Some recent emerging and re-emerging diseases
Viral haemorrhagic fever : Marburg (1967), Ebola (1976)
HIV –AIDS (1980s- now pandemic disease)
Yellow fever (re-emergence in west Africa 2000)
SARS (2003)
H5N1 (2003), H1N1 pdm (2009), H7N9 (2013)
MERS-Cov (2012)

24. Rapid spread of infectious diseases
Zones infected with Aedes aegypti
New York city
16 h
Miami
20 h
Nelle- Orléans
22 h
Sao Paulo
26 h
Brisbane
Sydney
Bangkok
Delhi
14 h
Les durées moyennes de voyage, incluant le temps de transit, ont été fournies par Carlson Wagons-lits ®.
Abidjan
Lagos, Nigeria
(Source : Carlson Wagons-lits )
YELLOW FEVER INITIATIVE

25. 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 Nature, 2008).

26. Recent influenza pandemics
World Health Organization
26 April 2017
Recent influenza pandemics
A(H1N1)
1918: « Grippe espagnole»
millions de décès
Credit: US National Museum of Health and Medicine
A(H2N2)
1957: « Grippe asiatique»
1-4 millions de décès
A(H3N2)
1968: « Grippe de Hong Kong»
1 million de décès
2009: « Grippe A (H1N1) »
≈ décès
A (H1N1)
Grippe asiatique 1957: Chine en 56, puis Singapour en 02/ 57, HG 04/57, US 06/57, canard sauvage
Grippe de Hong Kong 1968: Fin 07 Vietnam et Singapour, September Inde, Philipines, Australie, Europe, US (en même temps que le retour des soldats de la guerre du VN) en 69 Japon, Afrique, Amérique Latine, cochon hôte intermédiaire, origine aviaire

27. Laboratory-confirmed human avian influenza infections since 1999

28. Avian Influenza A(H7N9) Novel Coronavirus (MERS-CoV)
World experiencing emergence of 2 exceptional new virus infections
Avian influenza A(H7N9)
Novel coronavirus MERS-CoV
Unusual global situation
Unrelated, highly pathogenic
Potential to evolve & spread
No comparable situation since 2003
when SARS & H5N1 (re)emerged
H7N9
EM courtesy of China CDC
nCoV
EM courtesy of U.S. CDC,

29. Sustainable Person-to-Person Transmission Crossing of a Threshold
25 April: PHEIC announcement
4 April: outbreak of ILI in Veracruz
27 April: WHO phase 4
March
April
May
June
July
August
September
October
15-17 April: clusters of severe pneumonia in Mexico
27 April: Canada and Spain report H1N1 cases
23 April: H1N1 confirmed in several patients in MX

30. This is a map showing the availability of PP plans globally in April These are publicly available plans accessed through country websites. Almost all of this preparedness started around 2005 and in about 5 years 141 countries had publicly accessible PP plans. Were they all in pristine condition? No. However many countries had exercised and revised their plans, even had inter-country preparedness activities. For instance Japan, Korea and China from this region were already holding inter-country exercises and planning activities. Similarly Israel, Jordan and Palestine were coming together to work under difficult political circumstances. And G7+Mexico came together to form a GHSAG under which is a PIWG to coordinate and communicate about PP activities.
Looking back at the PP plans at the beginning of the pandemic, we see that while 71% had national pandemic committees, only 21% addressed sub-national planning which showed that there was still room for improvement in implementation. This is an on-going analysis within my group right now and the results should be available shortly.

31. Pandemic Response Tools
PH measures (i.e. school closures, mask, mass gathering)
Non-pharmaceutical
Interventions
Inactivated Influenza Vaccine (IIV)
(1944)
Improved IIV
(1960 purified)
IIV
(1968 fragmented)
(1980 sub-unit)
GISN
(1952)
Cell-based
(2007)
LAIV
(live-attenuated, 1960, Russia)
Adjuvanted
(1997)
Vaccines
(2003, USA)
1918
1957
1968
1997
2003
2009
Spanish flu
pandemic
Asian flu
pandemic
H5N1
Hong Kong
18 Cases (C)
6 Deaths (D)
H5N1
Asia
A (H1N1) 2009
pandemic
Hong Kong flu
pandemic
Amatadane
for influenza (1966)
Rimatadane
(1993)
Neuraminidase inhibitor
Oseltamivir and Zanamivir (1999)
Antivirals
Sulfonamides
(1939)
Penicillin
(1945)
Cephalosporins
(1964)
Aminoglycosides
(1943)
Erythromycin
(1952)
Introduction of other classes of antibiotics
Antibiotics

32. Epidemic Disease Patterns Varied by Location
May
June
Japan - Kinki area
390 confirmed cases
No hospitalisation
(As of 4 June 2009)
Source: Japanese Ministry of Health, Labour and Welfare
USA - Utah
489 confirmed cases
35 hospitalisations
2 deaths
(As of 4 June 2009)
Source: Utah department of Health.
April
May
June

33. 3. Communication
Technical scientific communication/ risk communication
Naming of the pandemic
Communication on global risks

34. Gap between "technical" and "public" communication
It is just a technical definition!
But what did that exactly mean? Was it just a technical definition or did it mean more than that? Here the cartoon DG that this declaration was just a technical definition.
In order to understand better what the declaration of Phase 6 means, allow me to take a step back and share with you how the WHO PP GL were developed.
It all started in November 2007 with a working group meeting in Geneva…

35. Global availability of vaccines
Only high income countries had access to the vaccine in fall 2009
Sources:
Media monitoring vaccination annex of 27 November
World Bank list of economies July 2009
World economies1
1 World Bank classification 2009

36. Vaccine deployment to low income countries
WHO has received pledges of approximately 200 million doses of vaccine, 70 million syringes and US$ 48 million for operations.
99 countries requested vaccines
As off May 2010, deployment of vaccine in 39 countries (approx 20M doses)
Extremely complex project: donation agreements, regulatory, supply and timing issues.
What mechanism should be put in place for future pandemics to ensure more equitable access to vaccine and medicines?

37. World Health Organization
26 April 2017
EDCARN:
Emerging Disease Clinical
Assessment and Response Network
Clinical & Infection Control
Pandemic & Epidemic Diseases
WHO-HQ, Geneva

38. Genesis: Virtual network of SARS clinicians
Clinical information for case definition, public health purposes
Virtual network of SARS clinician
New disease
International spread
No vaccine, no medicine, IPC?
50+ clinicians in 14 countries, telephone conference twice a week
face-to-face meeting, 14 June 2003
On a more practical side - how was the response co-ordinated?
One of the main issues with this outbreak response was to identify the causative organism. To enable this to happen, without too many people 'reinventing the wheel' was to co-ordinate the network on aetiology. This network involved 13 laboratories in 9 countries and involved daily teleconferences. A face to face meeting was organised, with video link up, to enable the sharing of information.
The second issue was in the clinical management of these patients. With several hospitals in different countries dealing with SARS patients early on, it was very important to facilitate these groups sharing their knowledge on best clinical practice, infection control practice as well as to try to determine the similarities in what the medical staff were seeing so as to produce an appropriate case definition. This was down through a web site, teleconferencing and a face to face meeting in June.

39. World Health Organization
26 April 2017
Evolution: IHR(2005), biological threat, pandemic fear, global health security
Avian influenza H5N1
MERS CoV
2009 H1N1pdm
Avian influenza H7N9
SARS CoV
vH3N2, vH1N1

40. PED's work on clinical management of EID
Provide a platform for information exchange and mutual support throughout outbreak/pandemic of infectious diseases of international concern.
Promote clinical data collection and the standardization of clinical research protocols; facilitate greater understanding of the natural history and manifestations.
Monitor possible changes in illness manifestations and disease patterns that would have implications for initial case recognition/detection and for public health responses.
Provide advice to MoH as well as on-site technical support to frontline clinicians to promote best evidence-based practices.
Prepare rapid advice guidelines by quick literature reviews and expert consultations
Enhance education and readiness of healthcare workers by clinical workshops and trainings.

41. EDCARN: Emerging Disease Clinical Assessment and Response Network
Vision
The mortality due to emerging pathogens is reduced through improved clinical management, even in absence of vaccine or specific treatment. Enhance/empower the role of clinical care / clinicians  
Mission
In the Global Health Security context,
To strengthen global collaboration between clinicians, researchers, WHO, medical NGO's, national health authorities and other stakeholders in order to improve clinical management of patients during outbreaks of emerging diseases.
Catalyst of new dynamics of PED control – bench to bed and beyond
Basic science>animal models>regulatory mechanism>clinical trials>improved patient care>public health>policy

42. World Health Organization
Supply of Neuraminidase Inhibitors Related to Reduced Influenza A (H1N1) Mortality during the 2009–2010 H1N1 Pandemic: An Ecological Study
26 April 2017
Paula Miller, Aksharananda Rambachan, Roderick Hubbard, Jiabai Li, Alison Meyer, Peter Stephens, Anthony W. Mounts, Melissa Rolfes, Charles Penn

43. World Health Organization
Policy case study: Argentina 2009
World Health Organization
26 April 2017

44. World Health Organization
26 April 2017
High antiviral use in October and November was observed at the same time as lower proportions of hospitalized patients requiring ICU care and invasive mech ventilation