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1│ Pandemic and Epidemic Diseases Department│
2│ Pandemic and Epidemic Diseases Department│
Global capacity and responses to pandemics
- WHO's global strategy –
N. Shindo MD, PhD.Coordinator
Pandemic and Epidemic Diseases DepartmentEpidemic Clinical Management
ERS International Congress 2015, Amsterdam
Global capacity and responses to pandemics
- WHO's global strategy –
N. Shindo MD, PhD.Coordinator
Pandemic and Epidemic Diseases DepartmentEpidemic Clinical Management
ERS International Congress 2015, Amsterdam
His daughters are Hygieia ("Hygiene"), Iaso ("Medicine") ,Aceso ("Healing"), Aglea ("Healthy Glow") ,
and Panacea ("Universal Remedy") .
Asclepius – Greek god of medicine
4│ Pandemic and Epidemic Diseases Department│
HSE cluster and PED DepartmentHSE cluster and PED DepartmentDG
FWC GMG IHS HSE
PED
FOS
GCR
HTM NMH PEC
Pandemic and Epidemic Diseases
Global Capacity and Respnse
Food safety and zoonosis
5│ Pandemic and Epidemic Diseases Department│
How many pathogens able to infect humans?
How many pathogens able to infect humans?
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
Chikungunya virus
(1956)
Ebola virus (1976-7)
Monkeypox virus( 1972)
Hendra virus( 1994)
HIV )1983(
1Jones, K, Nature (2008)2Woolhouse, ME, Proc. R. Soc. B (2008)
Discovery curve for human virus species2
Pandemic and Epidemic diseases department
Pandemic and Epidemic diseases department
Perform timely risk assessment and monitoring of infectious epidemic diseases of international concern to define emergency intervention strategies.
Improve shared knowledge and evidence-base for epidemic diseases to inform policies at international and national levels
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│ Pandemic and Epidemic Diseases Department│
PED activities 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│ Pandemic and Epidemic Diseases Department│
Evidence to reduce disease transmissionEvidence 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│ Pandemic and Epidemic Diseases Department│
Develop public health research agenda 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)
10│ Pandemic and Epidemic Diseases Department│
11│ Pandemic and Epidemic Diseases Department│
What do we do ? What do we do ?
Perform timely risk assessment
and monitoring
of infectious epidemic diseases of international concern
to define emergency intervention strategies.
12│ Pandemic and Epidemic Diseases Department│
13│ Pandemic and Epidemic Diseases Department│ Source: WHO/PED, March 2013
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 2013. All rights reserved
Outbreaks on the African continent )2007-2013(A total of 174 epidemics
Outbreaks on the African continent )2007-2013(A total of 174 epidemics
Avian InfluenzaChikungunyaCholeraEbola Hepatitis E Lassa Fever
MarburgMeningitisMonkeypoxNodding diseasePlagueRift Valley Fever
TyphoideWest Nile FeverYellow Fever
Number of epidemics (2007-2013)
Number of epidemic by year in Africa
Analysis excluded Poliomyelitis, HIV, TB and malariaA total of 15 diseases cause)d( outbreaks include :
14│ Pandemic and Epidemic Diseases Department│
Preventive interventions, 2012Preventive interventions, 2012
Prepositioning of reagents and treatments: meningitis
Preventive vaccination campaigns (GAVI support)meningitis yellow fever
15│ Pandemic and Epidemic Diseases Department│
Epidemic responses, 2014Epidemic responses, 2014
Epidemic responses for – MERS CoV (Middle East)– Avian influenza H7N9 (China) – Ebola (West Africa)
Global stockpile of vaccine and antivirals
16│ Pandemic and Epidemic Diseases Department│
New approaches for old disease: cholera
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│ Pandemic and Epidemic Diseases Department│
What do we do ?What do we do ?
Optimize treatments
and diagnostics
to reduce infectious diseases
mortality
18│ Pandemic and Epidemic Diseases Department│
Differential mortality and access to careDifferential mortality and access to care
Hospitalized patient during SARS outbreak )2003(
Cholera Treatment Unit )2003(
19│ Pandemic and Epidemic Diseases Department│
Improvement of clinical management and infection control
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│ Pandemic and Epidemic Diseases Department│
Global Health Security IHR)2005(, a paradigm shift
International legal instrument, 194 countriesAim: help the international community prevent and respond to acute public health risks that have the potential to cross borders and threaten people worldwideIncreased emphasis on early source control rather than bordersApplicability to all hazardsFrom preset measures to adapted response based upon risk assessment, facilitated by communicationIncludes an obligation to build national capacities to detect and respond to potential public health events
21│ Pandemic and Epidemic Diseases Department│
Implementation of the PIP framework Implementation of the PIP framework
Sharing of influenza
VirusesGISRS
Sharing of benefitsVaccines
AntiviralsDiagnostics
Publications
Equal footing
Pandemics of the 21rst centuryPandemics of the 21rst century
23│ Pandemic and Epidemic Diseases Department│
Some recent emerging and re-emerging diseases
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)
Zones infected with Aedes aegypti
New York city16 h
Miami
20 hNelle- Orléans
22 h
Sao Paulo
20 h
26 h
26 h
Brisbane
Sydney
Bangkok
16 h
Delhi
14 h
Les durées moyennes de voyage, incluant le temps de transit, ont été fournies par Carlson Wagons-lits .®
Abidjan
Lagos, Nigeria
YELLOW FEVER INITIATIVE
(Source : Carlson Wagons-lits )
Rapid spread of infectious diseases
25│ Pandemic and Epidemic Diseases Department│
Modeling EID events: Relative risk of an EIDModeling 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│ Pandemic and Epidemic Diseases Department│
Recent influenza pandemicsRecent influenza pandemics
A(H2N2)
1957: « Grippe asiatique»
1-4 millions de décès
A(H3N2)
1968: « Grippe de Hong Kong»
1 million de décès
A(H1N1)
1918: « Grippe espagnole»
50-100 millions de décès
Credit: US National Museum of Health and Medicine
2009 » :Grippe A (H1N1)«
≈200 000 décès
A (H1N1)
27│ Pandemic and Epidemic Diseases Department│
Laboratory-confirmed human avian influenza infections since 1999
Laboratory-confirmed human avian influenza infections since 1999
28│ Pandemic and Epidemic Diseases Department│
Avian Influenza A)H7N9( Novel Coronavirus )MERS-CoV(
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
nCoVEM courtesy of U.S. CDC,
H7N9EM courtesy of China CDC
29│ Pandemic and Epidemic Diseases Department│
4 April: outbreak of ILI in Veracruz
15-17 April: clusters of severe pneumonia
in Mexico
27 April: WHO phase 4
May June July August OctoberSeptemberMarch
25 April: PHEIC announcement
23 April: H1N1 confirmed in several
patients in MX
27 April: Canada and Spain report H1N1 cases
April
Sustainable Person-to-Person Transmission Crossing of a Threshold
Sustainable Person-to-Person Transmission Crossing of a Threshold
30│ Pandemic and Epidemic Diseases Department│
31│ Pandemic and Epidemic Diseases Department│
Pandemic Response Tools
1918 1957 1968 1997 2003 2009
Spanish flupandemic
Asian flupandemic
Hong Kong flupandemic
A )H1N1( 2009pandemic
H5N1 Asia
H5N1 Hong Kong
18 Cases )C( 6 Deaths )D(
Sulfonamides(1939 )
Penicillin(1945)
Cephalosporins (1964)
Aminoglycosides (1943)
Erythromycin(1952)
Introduction of other classes of antibiotics
Antibiotics
Amatadanefor influenza )1966(
Rimatadane(1993 )
Neuraminidase inhibitorOseltamivir and Zanamivir )1999(
Antivirals
PH measures )i.e. school closures, mask, mass gathering( Non-pharmaceuticalInterventions
Inactivated Influenza Vaccine )IIV(( 1944)
Improved IIV (1960 purified)
IIV(1968 fragmented)
IIV(1980 sub-unit)
GISN (1952)
Cell-based IIV
(2007)
LAIV (live-attenuated, 1960, Russia) Adjuvanted
IIV(1997)
VaccinesLAIV
(2003 ,USA)
32│ Pandemic and Epidemic Diseases Department│
Epidemic Disease Patterns Varied by Location
Epidemic Disease Patterns Varied by Location
May June
Source: Japanese Ministry of Health, Labour and Welfare
Japan - Kinki area • 390 confirmed cases• No hospitalisation(As of 4 June 2009 )
USA - Utah• 489 confirmed cases • 35 hospitalisations• 2 deaths
( As of 4 June 2009 )Source: Utah department of Health .
May JuneApril
33│ Pandemic and Epidemic Diseases Department│
3. Communication 3. Communication
Technical scientific communication/ risk communication
Naming of the pandemic
Communication on global risks
34│ Pandemic and Epidemic Diseases Department│
Gap between "technical" and "public" communication
Gap between "technical" and "public" communication
It is just a technical definition!
35│ Pandemic and Epidemic Diseases Department│
Global availability of vaccinesGlobal availability of vaccines
0
5
10
15
20
25
30
35
Sept 16-30 Oct 1-15 Oct 16-31 Nov 1-15 Nov 16-27
Pandemic Vaccine Distribution
Nu
mb
er
of
co
un
trie
s
)cu
mu
lati
ve
(
High Income
Middle Income
Low Income
31%
49%20%
World economies1 1 World Bank classification 2009
•Only high income countries had access to the vaccine in fall 2009
36│ Pandemic and Epidemic Diseases Department│
Vaccine deployment to low income countries
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?
EDCARN:Emerging Disease Clinical
Assessment and Response Network
Clinical & Infection Control
Pandemic & Epidemic Diseases
WHO-HQ, Geneva
38 |
Genesis: Virtual network of SARS clinicians
1) Clinical information for case definition, public health purposes
2) 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
39 |
Evolution: IHR(2005), biological threat, pandemic fear, global health security
Avian influenza H5N1
2009 H1N1pdmMERS CoV
Avian influenza H7N9SARS CoVvH3N2, vH1N1
40 |
PED's work on clinical management of EID
1. Provide a platform for information exchange and mutual support throughout outbreak/pandemic of infectious diseases of international concern.
2. Promote clinical data collection and the standardization of clinical research protocols; facilitate greater understanding of the natural history and manifestations.
3. Monitor possible changes in illness manifestations and disease patterns that would have implications for initial case recognition/detection and for public health responses.
4. Provide advice to MoH as well as on-site technical support to frontline clinicians to promote best evidence-based practices.
5. Prepare rapid advice guidelines by quick literature reviews and expert consultations
6. Enhance education and readiness of healthcare workers by clinical workshops and trainings.
41 |
EDCARN: Emerging Disease Clinical Assessment and Response Network
VisionThe 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
MissionIn 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 |
Supply of Neuraminidase Inhibitors Related to Reduced Influenza A )H1N1( Mortality during the 2009–2010 H1N1 Pandemic: An Ecological Study
Paula Miller, Aksharananda Rambachan, Roderick Hubbard, Jiabai Li, Alison Meyer, Peter Stephens, Anthony W. Mounts, Melissa Rolfes, Charles Penn
43 |
Policy case study: Argentina 2009Policy case study: Argentina 2009
44 |