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Infectious diseases in a globalized world:
risks to our public health security
August 2008
World Health Organization
1
Emerging and re-emerging infections,
1996 – 2007
Legionnaire’s Disease
Cryptosporidiosis
Human Monkepox
Lyme Borreliosis
Multidrug resistant Salmonella
E.coli O157
E.coli O157
E.coli non-O157
RecentBSE
outbreaks followed by Typhoid
WHO
Malaria
Severe Acute Respiratory
Diphtheria Syndrome (SARS)
West
Nile
Virus
West
Nile
Fever
E.coli O157
Influenza A(H5N1)
Avian influenza
(human)
Asia/Middle East/Africa
Reston virus
Marburg Haemorrhagic
Uganda
Echinococcosis
Lassa Fever
fever
Chikungunya
Pacific Islands, Italy Nipah Virus
Yellow fever
Venezuelan Cholera
CholeraWest
0139 /Southern AfricaReston Virus
Equine Encephalitis
RVF/VHF
Buruli ulcer
Nipah haemorrhagic fever
Bangladesh
Dengue
O’nyong-nyong
Ebola
Lassa Fever
Sierra Leone haemhorrhagic
fever
haemorrhagic
fever
High mortality measles
Nigeria
Human
Dengue
Meningococcal meningitis fever
West and Central Africa
Monkeypox
Ross River
Marburg
haemhorrhagic
Cholera
Yellow Fever
Guinea/Sudan
Cholera
Hendra virus
virus
haemorrhagic
fever
nvCJD
Poliomyelitis
August 2008
fever
DRC/Bangladesh
World Health Organization
2
Points for discussion

What do we know about emerging infections?
– Resilience/dynamism
– Relationship with animals
– Persons at greatest risk
– Other
August 2008
World Health Organization
3
Breaches in species barrier: selected emerging
infections in humans identified since 1976
Infection
adapted from Woolhouse et al. (2005)
August 2008
Ebola virus
HIV-1
E. coli O157:H7
Borrelia burgdorferi
HIV-2
Hendra virus
BSE/vCJD
Australian lyssavirus
H5N1 influenza A
Nipah virus
SARS coronavirus
Original
host
(confirmed/
hypothesized)
Bats
Primates
Cattle
Rodents
Primate
Bats
Cattle
Bats
Chickens
Bats
Palm civets
Year
reported
1976
1981
1982
1982
1986
1994
1996
1996
1997
1999
2003
World Health Organization
4
Smallpox: Variola Major
20% - 40% case
fatality
100% permanent
facial scarring
2.7 million deaths,
1967
August 2008
World Health Organization
5
Smallpox Eradication:
Certified 1980
August 2008
World Health Organization
6
Persons living with HIV infection,
2006: >40 million
3 million deaths during 2003
20 million deaths since 1981
August 2008
World Health Organization
7
Ebola Haemorrhagic Fever by mode of
transmission, Kikwit Zaire, 1995
16
14
Non health care workers
12
Health care workers
10
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-
17-
Jun Jun
Jun
Source: WHO/CDC
August 2008
World Health Organization
8
SARS, chain of human-to- human
transmission, Singapore 2003
August 2008
World Health Organization
9
International travellers, 1950 - 2006
Increased to over 2 billion international travellers in 2006
1400 International airline passengers (millions)
1200
1000
800
600
400
200
0
1950
1960
1970
1980
1990
2000
Source: WHO/World Tourism Organization
August 2008
World Health Organization 10
Outbreak of leptospirosis (N = 33) among 312
participants, Eco Challenge 2000, Malaysia
Canada: 4
US: 10
UK: 9
France: 4
Eco
Challenge
Brazil: 1
Uruguay: 1
August 2008
Australia: 4
World Health Organization 11
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
Bangkok
Source:
WHO/CDC
August 2008
New York
+ 219 health care workers
World Health Organization 12
Countries in which airport malaria has been
reported, 1969 – August 2003
United Kingdom: 7
USA: 1
France: 3
Belgium: 1
Luxembourg: 2
Germany: 1
Switzerland: 1
Israel: 1
Australia: 1
August 2008
World Health Organization 13
West Nile Virus in the United States, 2005
Genetic sequencing compatible with
One-time introduction in late 1990s
August 2008
World Health Organization 14
Increased world trade in agricultural
products/animals, 1950 - 2006
World trade in agricultural products has increased 5-fold since 1950
160 export of agricultural products by volume
120
80
40
0
1950
1960
1970
1980
1990
2000
Source: WTO, 2000
August 2008
World Health Organization 15
Deaths from vCJD by year of death, United
Kingdom, 1994 - 2006
N = 162
40
35
30
25
20
28
15
18
10
5
0
0
1994
10
10
1996
1997
20
15
17
18
9
14
3
1995
August 2008
1998
1999
2000
2001
2002
2003
2004
2005
World Health Organization 16
BSE and vCJD: potential exposure
through international trade, early 1990s
Cattle, meat and
bone meal
Human and
bovine
tissue used
in biologicals
August 2008
Food containing beef
Blood
and blood
products
Pharmaceuticals
World Health Organization 17
vCJD: geographic distribution of human
infections
Meat and
bone meal
Human and
bovine
tissue used
in biologicals
August 2008
Blood
and blood
products
Pharmaceuticals
World Health Organization 18
Rift Valley Fever, humans, Yemen,
September 2000
80
Number of cases
60
40
20
0
September 1-30, 2000
August 2008
World Health Organization 19
Rift Valley Fever, livestock, Yemen
and Saudi Arabia, October 2000
Area affected
August 2008
World Health Organization 20
El Nino-associated flooding, East Africa,
1998
Animal vaccination suspended early 1990s
Flooding forced humans and animals to close
proximity
Increased mosquito breeding sites
August 2008
World Health Organization 21
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
August 2008
World Health Organization 22
Points for discussion

What can be done to prevent the international spread of
infectious diseases?

What measures have been taken by governments in the
past?

Have any of these measures been effective?
August 2008
World Health Organization 23
Concern about public health security
throughout the ages
1374
Venice
Quarantine for Plague
1851
Paris
1st International
Sanitary Conference
1947
Geneva
WHO Epidemiological
Information Service
1951
Geneva
International Sanitary
Regulations
1969
Geneva
International Health
Regulations
August 2008
World Health Organization 24
International Health Regulations
purpose 1969

August 2008
“…ensure the maximum
security against the
international spread
of disease with a
minimum
interference
with world traffic.”
World Health Organization 25
Content of International Health
Regulations 1969: requirements

Notification to WHO: cholera, plague or yellow
fever – reports only accepted from countries
where event is occurring

Health Organization at borders: ports, airports
and frontier posts adequately equipped to
prevent vector proliferation
Health
Measures: describe maximum measures
that a country may require to protect against
cholera, plague and yellow fever (e.g. yellow
fever vaccination card)
June 2007
World Health Organization
26
Application of International Health
Regulations, 1969
Disease reporting by
countries (cholera,
plague, yellow fever)
Publication in Weekly
Epidemiological Record
National
containment
activity
August 2008
Application of predetermined measures
(maximum allowable)
World Health Organization 27
Points for discussion

Do you think the International Health Regulations are an
effective means of dealing with the international spread of
infectious diseases?

If yes, why?

If no, why?
August 2008
World Health Organization 28
Direct economic impact, selected
infectious disease outbreaks, 1990-2003
US E. coli 0157
Food recall/destruction
Periodic
Peru - Cholera
US$ 770 million
1991
UK - BSE
US$ 39 billion
1990-1998
Hong Kong - influenza A(H5N1)
Poultry destruction
1997
Tanzania - Cholera
US$ 36 million
1998
India - Plague
US$ 1.7 billion
1995
Malaysia- Nipah
Pig destruction
1999
Asia – SARS
US$ 30 billion
2003
August 2008
World Health Organization 29
Emerging and re-emerging infections:
1996 - 2007
Legionnaire’s Disease
Cryptosporidiosis
Human Monkepox
Lyme Borreliosis
Multidrug resistant Salmonella
E.coli O157
E.coli non-O157
BSE
Malaria
Dengue
haemhorrhagic
fever
August 2008
West Nile Virus
Reston virus
Lassa fever
Yellow fever
Echinococcosis
Nipah Virus
Reston Virus
Cholera 0139
Buruli ulcer
Ebola
haemorrhagic
fever
Cholera
Typhoid
Severe Acute Respiratory
Diphtheria Syndrome (SARS)
West Nile Fever
Influenza A(H5N1)
nvCJD
Venezuelan
Equine Encephalitis
E.coli O157
RVF/VHF
O’nyong-nyong
fever
Dengue
haemhorrhagic
fever
Human
Monkeypox
Marburg
Cholera
Hendra virus
haemorrhagic
fever
Ross River
virus
World Health Organization 30
Global outbreaks, the challenge:
late reporting and response
CASES
First
case
Late
reporting
Delayed
response
90
80
70
60
50
40
30
20
10
0
Lost opportunity for control/
risk of international spread
1
August 2008
4
7
10
13
16
19
22
25
28
31
34
37
40
DAY
World Health Organization 31
Global outbreaks, the solution:
early reporting and response
CASES
Early
reporting
Rapid
response
Potential cases prevented/
international spread prevented
90
80
70
60
50
40
30
20
10
0
1
August 2008
4
7
10
13
16
19
22
25
28
31
34
37
40
DAY
World Health Organization 32
Points for discussion

What would you do next?
August 2008
World Health Organization 33
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
August 2008
World Health Organization 34
Global Public Health Intelligence Network,
Canada
August 2008
World Health Organization 35
Outbreak Verification & Response
Afghanistan, February 1999
WHO/local team
preliminary
investigation
Investigation completed
Diagnosis confirmed
GPHIN report of
highly fatal
respiratory
disease
WHO
collaborative
team
16 February
24 February
August 2008
19 February
1 March
World Health Organization 36
Information sources, public health risks
reported to WHO, 2003
70%
Countries ( 23% of reports)
60%
WHO Alert & Response Network ( 77% of reports)
50%
40%
30%
20%
August 2008
GPHIN
Others
PROMED
NGOs
WRs
WPRO
AMRO
EURO
EMRO
AFRO
0%
SEARO
10%
World Health Organization 37
Operationalizing the IHR in the 21st century:
partnership for global alert and response to
infectious diseases
WHO Regional
& Country Offices
WHO Collaborating
Centres/Laboratories
Countries/National
Disease Control
Centres
Epidemiology and
Surveillance Networks
Military
Laboratory
Networks
UN
Sister Agencies
GPHIN
NGOs
Media
August 2008
Electronic
Discussion sites
FORMAL
INFORMAL
World Health Organization 38
Request for GOARN support: terms of
reference
August 2008
World Health Organization 39
Sample of International epidemic response
missions in the field, 1998–1999
August 2008
World Health Organization 40
Global outbreak alert and response network:
surveillance network partners in Asia
APEC
SEAMIC
Mekong Basin
Disease
Surveillance
(MBDS)
EIDIOR
SEANET
GPHIN
Pacific Public
Health
Surveillance
Network
(PPHSN)
Flu Net
ASEAN
+ Red Cross,
other NGOs
August 2008
World Health Organization 41
Reports of respiratory infection, China,
2002–2003

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

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
August 2008
World Health Organization 42
Intensified surveillance for respiratory
infections, Asia, 2002–2003

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)

4–5 March
– Hong Kong and Hanoi: 77 medical staff (Hong Kong) plus 7
(Hanoi) reported with atypical pneumonia, not influenza (WHO
team/liaison)
August 2008
World Health Organization 43
Global Alert: Severe Acute Respiratory
Syndrome (SARS)

12 March: First global alert
– Described atypical pneumonia in Viet Nam and Hong Kong

14 March
– 4 persons Ontario, 3 persons in Singapore, with severe atypical
pneumonia fitting description of 12 March alert reported to WHO

15 March
– Medical doctor with atypical pneumonia fitting description of 12
March reported by Ministry of Health, Singapore on return flight
from New York
August 2008
World Health Organization 44
Situation on 15 March, 2003

Atypical pneumonia with rapid progression to respiratory
failure, none yet recovered

Health workers appeared to be at greatest risk

Unidentified cause, presumed to be an infectious agent

Antibiotics and antivirals did not appear effective

Spreading internationally within Asia and to Europe and North
America
August 2008
World Health Organization 45
Points for discussion

What would you do next?
August 2008
World Health Organization 46
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.
August 2008
World Health Organization 47
Strategies that increased power of epidemic
control: global partnerships
Global Outbreak Alert and Response Network
 115 experts from 26 institutions in 17 countries
 field teams sent to 5 countries
August 2008
World Health Organization 48
Probable SARS transmission, flight
CA112, March 2006
August 2008
World Health Organization 49
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 20021 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.
August 2008
World Health Organization 50
Probable cases of SARS by date of onset
worldwide, 1 March – 27 June 2003
August 2008
World Health Organization 51
SARS Epidemic curve, China,
2002 - 2003
August 2008
World Health Organization 52
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
August 2008
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
World Health Organization 53
The cost of SARS: initial estimates for six month
outbreaks, 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
August 2008
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
World Health Organization 54
Points for discussion

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?
August 2008
World Health Organization 55
New norms for reporting and responding
to infectious diseases established, 2003

Severe acute respiratory syndrome (SARS)
Reporting of infectious diseases from other sources accepted by WHO
Member States

All infectious diseases with potential for international spread to be
reported

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
August 2008
World Health Organization 56
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
August 2008
World Health Organization 57
Requirements, International Health
Regulations (2005)
•
•
•
•
August 2008
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
World Health Organization 58
Decision making and response and the
revised International Health Regulations
Public health risk reporting from
WHO Alert & Response Network
Public health risk
reporting by countries
Decision-tree analysis to determine if of urgent
international public health importance
YES
NO
National
containment
of public
health risk
August 2008
National
containment
of public
health risk
Collaborative risk-based
public health measures
identified and managed
pro-actively by WHO
World Health Organization 59
Points for discussion

Do the revised International Health Regulations meet the
vision for their revision?

If not, tell what more could be done

What are some major infectious disease threat today that
would fall under the Revised Regulations?
August 2008
World Health Organization 60
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
August 2008
World Health Organization 61