Global Response to Emerging and Re-Emerging Diseases

1. Global Response to Emerging and Re-EmergingDiseases Sylvain Aldighieri, MD International Health Regulations – Epidemic Alert & Response PAHO/WHO

2. Objective To analyze global health issues related to EIDs …with a special focus on the role of nurses in detection. 

3. Plan of the Presentation Emerging and re-emerging infections: definitions Examples of EIDs International Health Regulations IHR(2005) Role of Nurses in EID detection and response Conclusions

4. 1st Millenium Middle Ages 20th Century Epidemics and Pandemics have shaped our history…

5. …and they continue to threaten us …and place sudden intense demands on national and international health systems …on some occasions have brought health and social systems to the point of collapse …the diseases of most concern are those that may have international significance – either as a possible global epidemic or pandemic, or because they pose a risk for travellers with high case fatality rates or have trade implications. Most of these diseases tend to be emerging diseases.

6. So, in the context of emerging/epidemic disease at the beginning of the 21st. Century: • We have seen the emergence of new or newly recognized pathogens (e.g. Highly Pathogenic Avian Influenza [H5N1], SARS, Nipah, pandemic influenza [H1N1], novel coronavirus ……) • The resurgence of well characterized outbreak-prone diseases (e.g. dengue, measles, yellow fever, chickungunya - also cholera, TB, meningitis, shigellosis) • Human-made "bio-risk" also increasing: accidental and deliberate release of infectious agents as smallpox, SARS, Ebola, anthrax, tularaemia, etc.

7. Emerging diseases: a definition New diseases which have not been recognized previously; Known diseases which are increasing, or threaten to increase, in incidence or in geographic distribution; The terms “re-emerging” or “resurgent diseases” are also used – usually to describe diseases which we had thought had been controlled or conquered through immunization, antibiotic use or environmental changes, but which are now reappearing.

8. Map of geographic origins of EID events, 1940-2004 (Jones et al, Nature 2008)

9. Substantiated public health events of potential international concern by hazard Jan 2001-14 June 2011 (n=2,448; 477 (19%) in AMRO) 85%

10. 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 et al, Nature, 2008).

11. 61% of all Emerging Infectious Diseases are Zoonoses affecting Humans Translocation Human encroachment Ex situ contact Ecological manipulation Encroachment Introduction “Spill over” & “Spill back” Wildlife Domestic Animal Human Global travel Urbanization Biomedical manipulation Agricultural Intensification Technology And Industry • Frequency of all EID events has significantly increased since 1940, reaching a peak in 1980-1990 • 61% of EID events are caused by the transmission from animals (zoonoses) • 74% of these from wildlife • Zoonotic EIDs from wildlife reach highest proportion in recent decade

12. Purpose and scope of the IHR From three diseases to all public health hazards, irrespective of origin or source From control of borders to containment at source From preset measures to adapted response “to prevent, protect against, control and provide a public health response to the international spread of disease in ways that are commensurate with and restricted to public health risks, and which avoid unnecessary interference with international traffic and trade“ (Article 2)

13. Disseminate information States Parties Formal reports WHO Verification Event’s Risk assessment Initial screening Assist Respond Others sources Informal/ Unofficial information` WHO global alert and response systems

14. Early warning function of the public health surveillance system 100% coverage, 100% sensitivity, 100% flexibility Complementary • Event-based surveillance • (unstructured information) • Media reports • Hotlines (community, • professionals, etc.) • NGOs • Diplomatic channels • Military channels • Etc. • Indicator-based surveillance • (discrete variables) • Case based (aggregated, individual) • Laboratory results • Environmental measurements • Drug sales • Absenteeism • Etc. Signal Unusual health event  Risk Assessment Response Triangulation of sources Verification

15. Outbreak Detection and Responsewithout Preparedness First Case Late Detection Delayed Response Cases Opportunity for control Day

16. Outbreak Detection and Responsewith Preparedness Early Detection Rapid Response Potential Cases Prevented Cases Day

17. WHO Portal States Operations PAHO SEARO WPRO EURO EMRO AFRO Information sharing at WHO Event Management System

18. No single institution has all the capacity! Coordinate and support rapid international team deployment to countries for outbreak response To focus and coordinate global resources - local > regional > global

19. SARS Coronavirus (SARS CoV) SARS CoV identified on 27 March 2003 Highly mutable Reservoir unknown 8,098 cases with 774 deaths (CFR% 9.5, age related) 1,707 HCWs affected (21%) 27 countries affected with 92% of casesin mainland China, Hong Kong SAR, and Taiwan, China Age range – 0-97 years; most cases 30-45 years Almost exceeded surge capacity of acute care facilities and public health services

20. SARS…a first (and a wake up) call First epidemic of the 21st century Social, political and economic impact, including psychosocial impact Estimated economic cost of $US30 billion (Stanley Morgan); $US100 billion (Nature); $US48 billion in China alone (Chinese Center for Economic Research) First new pathogen identified in the 21st century and fast discovery (3 weeks after Global Alert) First time EVER that a global surveillance system was implemented in response to an unknown public health emergency

21. Continued ChallengesHuman-Animal Interface Animal Surveillance Human Surveillance Create bridges Joint assessment Exchange data and findings

22. H5N1 Avian InfluenzaDecember 2003 – August 2012 • 608 cases • including 359 deaths • in 15 countries

23. PAHO/WHO Event Management USA via NFP Cases confirmed in NY and OH. ARD (Acute Respiratory Disease) ILI (Influenza-like Illness) PHEIC (Public Health Emergency International Concern)

24. Mexico 2009. Pandemic Epidemic Curves. Source: Mexican Ministry of health – INDRE. Retrospective. Confirmed cases 2010 2009 Deaths

25. Nurses are uniquely positioned to identify events of potential public health significance…… • Any outbreak of disease • Any uncommon illness of potential public health significance • Any infectious or infectious-like syndrome considered unusual by HCWs, based on: • Frequency e.g., a sudden, unexplained, significant increase in the number of patients, especially when it occurs outside the normal season • Circumstances of occurrence e.g., many patients coming from the same location or participating in similar activities • Clinical presentation e.g., a patient’s health rapidly deteriorating out of proportion to the presenting symptoms and diagnosis • Severity e.g., a number of patients failing to respond to treatments

26. “Astute” questions during Patient triage (Credit: Gail Thomson, NMGH, UK) • Thorough travel history • History of fever within 21/7 of travel to an at-risk country, check temperature • Fever and bleeding/bruising after a tick bite from an at-risk area or after killing livestock/abattoir work • Exposure history • Clinical history & vital signs • Airline flight numbers and stop over/transit • documented. • Illness during the journey. • Illness during any stopover/s • Malaria test

27. Nurses and Infection Control • HCWs may be the canaries! • 21 % of the SARS probable cases were HCWs ! • Pneumonic Plague, Peru 2010 They may be the first cluster of cases that triggers an alarm bell that there is something seriously wrong.

28. Nurses and EID detection “In remaining vigilant for the presence of a new disease, the individual nurse functions as a mini-surveillance system.”

29. Hope for the best…and prepare for the worst.Thank you