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Emerging Infections:
Perfect Storm of Vulnerability
and
Unprecedented Opportunity for Progress
Thomas R. Frieden, MD, MPH
Director
Centers for Disease Control and Prevention
December 11, 2012
“Pathogenic microbes can be
resilient, dangerous foes.
Although it is impossible to
predict their individual
emergence in time and place,
we can be confident that new
microbial diseases will emerge.”
– IOM, 1992
Perfect storm
Something old
Rates per 100,000 population
Despite progress, TB sickens 8.7 million
people a year and kills 1.4 million …
and incidence is declining only slowly
Estimated incidence rate
including HIV-positive TB
Stop TB Partnership targets
Stop TB Partnership targets
Estimated incidence rate
of HIV-positive TB
WHO. Global Tuberculosis Control: WHO Report 2012.
Why is TB incidence falling
only gradually?
• Bad DOTS? Continued spread (rain)
• Implication: Improve diagnosis, treatment,
and infection control
• Reactivation: Waves crashing on beach
• Implication:
• Preventive treatment, with research into new
ways to identify and treat those most likely to
reactivate past infection
• Persistence and recognition that results may
not be immediate
• Need for social change
• Implication: Sustainable long-term change
Infectious diseases continue to spread
from food, water, and health care
• Food- and waterborne disease
• Billions of illnesses and
>4M deaths/year
• Healthcare-associated
infections (lack of basic
hygiene, e.g., hand washing,
sterilization)
• Affects ~1 in 20 patients in U.S.
(hundreds of millions of people/
year)
• Increasingly resistant organisms
Something new
Enormous costs of AIDS
• Detection delayed 80 years
• Detected only after imported
to and established in U.S.
• Epidemic 30 years and counting
• 30M lives lost, another 33M living
with HIV
• $100B in costs to low- and
middle-income countries alone
• HIV deaths in U.S. have
decreased – but HIV has already
killed more Americans than died
in every war since the Civil War
PEPFAR: Creating an
AIDS-free Generation
PEPFAR now
• Gives life-saving treatment to
>4.5M people
• Has prevented >800,000 infants
from becoming infected
• Is supporting scale-up of voluntary
male medical circumcision for nearly
2M by end of year, preventing
hundreds of thousands of infections
in future years
• Has strengthened health systems, increased vaccination
rates and decreased maternal and child mortality
Declining per-patient treatment costs to
PEPFAR with scale-up, 2005‒2011
$1,200
4,500,000
PEPFAR per-patient
annual treatment cost
4,000,000
$1,000
3,500,000
$800
3,000,000
2,500,000
$600
2,000,000
$400
1,500,000
1,000,000
$200
No. of PEPFAR direct
ART patients
500,000
$-
0
2005
2006
2007
2008
2009
2010
2011
Note: Per-patient cost to PEPFAR is estimated as total treatment allocation divided by the lagged count
of PEPFAR directly supported patients
West Nile virus spread nearly
nationwide, 1999—2002
Aedes aegypti range expanded greatly
after control programs ended
Illustration: PAHO/WHO 2002
Zoonoses cause more than 2 billion
illnesses and 2 million deaths per year
Zoonotic pathogens passed from wildlife to humans.
From lowest occurrence (green) to highest (red)
Jones KE, et al. Global trends in emerging infectious diseases. Nature 451, 990-993(21
February 2008)
Outbreaks reported by WHO, 1996—2009
More than half occurred in Africa
Source: Chan EH, et al. Global capacity for emerging infectious disease detection, December 14, 2010,
107:50, pp. 21701-21706; www.pnas.org/cgi/doi/10.1073/pnas.1006219107
Note: Points mark reported origin of outbreak or, if unknown, where highest reported morbidity/mortality rates
were recorded.
Global aviation network
Disease can spread nearly anywhere
within 24 hours
Source: Kilpatrick AM, et al. Drivers, dynamics, and control of emerging vector-borne zoonotic diseases. The
Lancet 380:9857, 1-7 Dec 2012, pp. 1946-55. www.sciencedirect.com/science/article/pii/S0140673612611519
Note: Air traffic to most places in Africa, regions of South America, and parts of central Asia is low. If travel
increases in these regions, additional introductions of vector-borne pathogens are probable.
Something
resistant
Artemisinin drug resistance
is spreading
Percentage of cases positive for
malaria on day 3 after ACT
• Anti-malarial ACT drug
therapies increasingly
ineffective
• No new drug class
expected for >5 years
• Need for better control
of malaria to
• Prevent worsening drug
resistance
• Slow disease spread
WHO. Update on artemisinin resistance, April 2012. Circles represent data before November 2010;
triangles data after November 2010.
Organisms with extensive or
potentially complete resistance
• M. tuberculosis
• P. falciparum
• N. gonorrhoeae
• Carbapenem-
resistant
Enterobacteriaceae
• K. pneumonia
• Others
Something to
turn you blue
Biological innovation – and risk
• Potential intentional or unintentional creation
or release of
• More virulent
• More resistant
• Vaccine-evading
• Higher Ro organisms
• Both high-technology and low-technology
means of creating
• Barriers to entry and costs of bioengineering
are dropping
Unprecedented opportunity
for progress
1. Global commitment
• SARS and other infectious disease costs
• International Health Regulations — window of opportunity
for accountability for progress
• Real progress – success leading to success
2. New technologies
• Lab
• Communication
• Informatics
“A robust public
health system…
is the best
defense against
any microbial
threat.”
– IOM, 2003
Global
commitment
Economic impact of recent zoonotic
has increased public commitment
12 August 2008.SARS and the New Economics of Biosecurity, 2003
Many countries can contribute
Influenza investments in Thailand
$35
$30
Millions
$25
$20
$15
$10
Thai investment
$5
CDC investment
$0
2004
2005
2006
2007
2008
2009
2010
2011
Progress:
success to
success
Post 9/11 – progress in preparedness
Before 1999-2001
After 2001
CDC doesn’t fund all states for
public health preparedness
CDC funds all states
No national stockpile
Few states have plans to handle
stockpiled assets
Strategic National Stockpile in
place
All states have plans
CDC performs all tests to detect
and confirm presence of
biological threat agents
No secure system to share
information about emerging
health threats
CDC coordinates state and local
response efforts from outdated
emergency operations center
150+ labs can perform tests
Secure, web-based system in
place (Epi-X)
CDC operates emergency
operations center 24/7/365 to
monitor health threats and
coordinate emergency response
Time from outbreak start to
outbreak discovery is shrinking
Source: Chan EH, et al. Global capacity for emerging infectious disease detection, December 14,
2010, 107:50, pp. 21701-21706; www.pnas.org/cgi/doi/10.1073/pnas.1006219107
H1N1 public health response saved lives
• Tracking
• 38M emergency department visits tracked: >100,000/day
• ~650,000 virus specimens tested at participating WHO
collaborating laboratories in U.S., with >4,000 H1N1
isolates sequenced
• Communication: Up to 8M page views a day on cdc.gov
• Vaccination and treatment
• ~330,000 vaccine shipments to ~67,000 sites
• Vaccination prevented >1M cases
• Vaccination and treatment prevented ~17,000
hospitalizations and ~850 deaths
Despite Haiti earthquake and cholera,
HIV testing/treatment increased steadily
APR 10
90,000
80,000
Earthquake
50,000
70,000
40,000
60,000
38,500
30,000
20,000
FY12 (Oct-Jun)
61,000
60,000
40,000
100,000
APR 11
Cholera peak
50,000
40,000
30,000
20,500
20,000
10,000
# cholera cases per month
# of HIV tests completed per month
# of patients on ART (current/cumulative)
70,000
10,000
0
0
April
2009
2009
Cholera cases
Jan
2010
2010
Jan
2011
2011
Total HIV tests completed
Jan
2012
2012
June
2012
Current # patients on ART
Progress in Ebola outbreak detection
and response, Uganda
• Uganda Virus Research Institute upgraded
biosecurity and biosafety
• Improved testing/monitoring for Ebola outbreak
Year
Response timeline
No. of cases
2000
38 days from 1st known case to preliminary
investigation
425
2007
2.5 months from 1st known case to preliminary
investigation
131
2011
1 day between case confirmation and response
1 confirmed case
2012
2 days between lab confirmation & response (but 38
days between index death & response – need for
quicker response even in absence of lab
confirmation)
24 cases, 16 deaths
Increasing response capacity in Global
Disease Detection Regional Centers
1000
400
Respond to outbreaks
800
911
Train public health leaders
376
300
376
600
200
400
100
200
147
0
2006
80
2007
2008
2009
2010
2011
Detect pathogens not previously
known to be in the area
66
60
0
2006
34
220
2007
2008
2009
2010
Build laboratory
diagnostic capacity
200
180
2011
202
160
140
120
40
100
80
60
20
40
3
0
2006
20
2007
2008
Numbers are cumulative
2009
2010
2011
11
0
2006
2007
2008
2009
2010
2011
Global Disease Detection
Regional Centers
Field Epidemiology Training Programs
• 2-year, full-time postgraduate
program
• Modeled after CDC’s Epidemic
Intelligence Service
• Since 1980, 41 FETPs trained
>2,600 epidemiologists
• Residents assigned to positions that
provide epidemiologic service to MOH
• >80% stay in-country after graduating
• Effective, low-cost, practical – but
has trained only small proportion of
numbers needed
Current CDC-supported FETPs
Strengthening global lab capacity
• Concrete aspect of
strengthening health
systems at national,
referral, and clinical
levels
• Sustainable,
accredited labs
• Coordinated epidemiology and lab development
• Point of care tests expanding, potentially low cost
• Multi-pathogen assays for rapid detection and
response, as well as surveillance
Vaccination saves >3 million lives
worldwide each year
Categories
Vaccines
Lives saved/globally/year
Existing,
widely used
vaccines
• Measles
• Pertussis
• Polio
Lives saved, compared to pre-vaccine era
• Measles: 2.5M
• Pertussis: 687,000
• Polio (paralytic cases prevented): 350,000
Vaccines
being
scaled up
• Human
papillomavirus
(HPV)
• Pneumococcus
• Rotavirus
Potential additional lives saved:
• HPV: 275,000 women
• Pneumococcus: 1.6M
• Rotavirus: 450,000
Potential
new
vaccines
• HIV
• Malaria
• TB
Potential lives saved:
• HIV: 1.7M
• Malaria: 780,000
• TB: 1.4M
Sources: All sources from WHO
HPV and rotavirus source: GAVI Alliance, 2012
The world is closer than ever to polio
eradication
Data as of 20 Nov 2011 and 2012; source: www.polioeradication.org
A Safer U.S. and
a Safer World
A safer U.S. and a safer world
Detect threats early
• Surveillance systems
• Lab systems to characterize
pathogens
• Trained disease detectives
• Facilities to investigate outbreaks
Respond effectively
• Interconnected emergency
operations centers and response
capacity
• Improved border safety, quarantine
measures, and rapid response
Prevent avoidable catastrophes
• Safer food and drug supply
• Reduced pace of drug resistance
• Safer, more secure labs working
with dangerous pathogens
Centers for Disease Control and Prevention
1600 Clifton Road NE, Atlanta, GA 30333
Phone: 1-800-CDC-INFO (232-4636)/TTY: 1-888-232-6348
E-mail: [email protected]
Web: www.cdc.gov