Download ITEM 12: Public health emergencies: From rapid response to

Centre
Health
Shiftingon
theGlobal
paradigm:
from rapid
detection and
response to prevention a
Security
the source
Draft Research Strategy
29th June 2010
February 2015
1
Breaches in species barrier since
1976
Infection
Ebola virus
February 2015
Animal linked
to transmission
Bats
Year infection
first reported
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
2
Potential transmission pathways,
emerging infectious diseases
Emergence
No further
transmission
Continues
transmission
Ceases/
sporadic
February 2015
Continues
transmission
Continues/
endemic
3
Emergence from animals in nature:
Eco Challenge, Malaysia, 2000
February 2015
4
Leptospirosis (N = 33) among 312
participants, Eco Challenge 2000, Malaysia
Canada: 4
US: 10
UK: 9
France: 4
Eco
Challenge
Brazil: 1
Uruguay: 1
February 2015
Australia: 4
5
The current paradigm:
rapid detection, risk assessment, and
emergency response
February 2015
6
SARS: international spread from Hong
Kong, 21 February – 12 March, 2003
Doctor
from
Guangdong
Canada
F
A
H
Hong Kong
J
G
Ireland
K
Hotel M
Hong Kong
B
C
I
D
E
USA
Viet Nam
Germany
1 HCW +
2
Singapore
Source:
WHO/CDC
February 2015
Bangkok
New York
7
Probable cases of SARS by date of onset
worldwide, 1 March – 27 June 2003
8,273 reported cases
775 deaths
February 2015
8
SARS and the economy:
impact on global travel, April 2003
February 2015
9
Passenger movement, Hong Kong
International Airport, March-July 2003
Number of passenger
120 000
WHO travel advisory
2 April
WHO lifted travel advisory
23 May
100 000 102 165
Total
80 000
65 255
60 000
40 000
20 000
3/16
3/20
3/24
3/28
4/1
February 2015
4/5
4/9
4/13
4/17
4/21
4/25
4/29
5/3
5/7
5/11
5/15
5/19
5/23
5/27
5/31
6/4
6/8
6/12
6/16
6/20
6/24
6/28
7/2
14 670
0
10
Economic impact SARS,
Hong Kong

Health (sector) impact small,
but impact on other sectors
large
– Hong Kong retail losses ~
US$334m
Hong K ong Hotels yoy %
c hang e
+ 20.0
+ 10.0
0.0
-10.0
-20.0
-30.0
-40.0
-50.0
-60.0
-70.0
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
R etail s ales HK $Mn
R es taurant R ec eipts HK $Mn
46,000
45,000
44,000
43,000
42,000
41,000
40,000
39,000
38,000
37,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
2002
Q1
2002
Q2
February 2015
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
2002
Q1
2002
Q2
2002
Q3
2002
Q4
2003
Q1
2003
Q2
2003
Q3
2003
Q4
11
The cost of SARS, Asian Development
Bank, 2003
% of GDP
Hong Kong
China, mainland
Taiwan
South Korea
Indonesia
Singapore
Thailand
Malaysia
Philippines
4%
0.5%
1.9%
0.5%
1.4%
2.3%
1.6%
1.5%
0.8%
0
February 2015
1
2
3
As of 30 September, 2003, SARS
had decreased Asia’s combined
GDP by US$18 billion and cost
nearly US$60 billion in lost demand
and revenues
4
5
6
7
US$ billion
12
Influenza A(H1N1) Pandemic as of 13
June 2009
February 2015
13
February 2015
14
Recent infectious disease outbreaks
and their economic impact
February 2015
15
Changing the paradigm:
joint risk assessment, prediction and
prevention
February 2015
16
Changing the paradigm: joint human/animal
surveillance and risk assessment
●
●
share laboratory specimens
between animal and human public
health
●
conduct joint research
●
increase use of animal vaccines
●
February 2015
identify animal infections/assess
their risk to humans
stronger regulation of animal
husbandry
17
Joint risk communication
February 2015
18
Changing the paradigm: risk maps for
emergence of infectious diseases
February 2015
19
Changing the paradigm:
identification/sequencing of animal infections
February 2015
20
Pushing the paradigm even further
upstream:
prevention of emergence at its source
February 2015
21
Nipah virus infection, Malaysia,
1998-1999
Source: Chua KB, Journal of Clinical Virology, April 2003
February 2015
22
Nipah virus outbreaks, humans,
1998 - 2008
Dates
Location
1998-1999
Malaysia;
265
105
40
1999
Singapore
11
1
9
2001
W. Bengal, India
66
45
68
2001
Bangladesh
13
9
69
2003
Bangladesh
12
8
67
2004
Bangladesh
29
22
76
Bangladesh
36
27
75
2005
Bangladesh
12
11
92
2007
W. Bengal, India
5
5
100
2007
Bangladesh
15
8
54
2008
Bangladesh
11
6
54
February 2015
No. cases
No. deaths
CFR(%)
23
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
February 2015
24
Assessing the risk/testing the hypothesis
February 2015
Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University.
25
The risk is plausible through the food chain
February 2015
Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University.
26
Precautionary measures: community
agreement to cover the collection containers
Community agriculture meeting
February 2015
27
Shifting the paradigm from emergency
response to prevention
February 2015
28
Ebola emergence:
current hypotheses
February 2015
29
Ebola Haemorrhagic Fever by mode of
transmission, Yambuku DRC,1976
N
u
m
b
e
r
60
50
Health workers and their contacts
Contact and needle/syringe
Needle/syringe
40
30
Hospital closed
20
10
Cases: 318
0
Source: CDC
September
1
February 2015
6
12
October
18
24
30
6
12
Deaths: 280 (88%)
18
24
30
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
February 2015
31
Ebola Haemorrhagic Fever by mode of
transmission, Kikwit Zaire, 1995
16
14
Non health care workers
12
315 cases
Health care workers
10
250 (80%) deaths
8
6
4
2
0
7Mar
13-
19-
25-
31-
6-
12-
18-
24-
30-
6-
12-
18-
24-
30-
Mar Mar
Mar
Mar
Apr
Apr
Apr
Apr
Apr May May May May May
5-
11-
Jun Jun
17Jun
Source: WHO/CDC
February 2015
32
Ebola outbreaks, West Africa, 2014
February 2015
33
Ebola, new cases as of mid-February,
2015
Source: WHO
February 2015
34
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
February 2015
35
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
February 2015
36
Ebola candidate vaccines, early
2015
Vaccine
Mechanism
Trials
Comment
Ref
Plasmid DNA based.
VRC-EBODNA02300-VP
DNA immunisation
with boosting
adenoviral vector
Phase I Uganda
(completed)
Process takes 6
months to provide
protection in nonhuman 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
February 2015
37
Ebola candidate vaccines, 2015
February 2015
38