The Interface Between Human and Veterinary Public Health

Emerging Zoonotic Disease SummitGainesville, Florida

August 23, 2005

Lonnie J. KingDirector, Office of Strategy and Innovation, CDC

Dean, CVM, Michigan State University

Historical Epidemiological Transitions

Paleolithic Age Hunters and gatherers Nomadic Small populations Parasitic infections

Historical Epidemiologic Transitions – 1st Transition

10,000 years ago

New social order due to agriculture

Zoonoses through animal domestication

Increases in infectious diseases

Epidemics in non-immune

populations

Deadly Gifts

Human Diseases Animal Origin

Measles Rinderpest of

cattle

TB M. bovis of cattle

Smallpox Cowpox

Influenza Pigs and Ducks

Pertussis Pigs and Dogs

Malaria Birds

Guns, Germs and Steel J. Diamond

Historical Epidemiologic Transitions – 2nd Transition

Coincided with mid-19th century Industrial Revolution

Decreases in infectious disease mortality

Increasing life expectancy Improved nutrition Antibiotics “Diseases of Civilization” – cancer,

diabetes, cardiovascular diseases Environmental problems Chronic diseases

Historical Epidemiologic Transitions – 3rd Transition

Last 25 years

Emerging infectious diseases globally

New diseases and increases in mortality; first since 19th century

Re-emergence

Antimicrobial resistance

75 percent of diseases are zoonotic

Anthropogenic factors of emergence; the microbial “perfect storm”

“The Perfect Storm” Sebastian Junger

an ocean tempest due to a rare combination of factors and circumstances that might occur every century

MICROBIAL THREATS TO HEALTH EMERGENCE, DETECTION, AND RESPONSE  INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES National Academy Press Washington, DC 2003

The “Microbial” Perfect Storm

Due to special combinations and circumstances Relatively common occurrence Doesn’t dissipate, but may perpetuate or

accelerate Convergence model

WHO Map on World –Emerging Diseases

Convergence Model

Convergence Model (Microbial Threats to Health – IOM/NAS, 2003)

Social, Political and Economic Factors

Physical Environmental

Factors

Ecological Factors

Genetic and Biological Factors

Human

Microbe

Factors in Emergence

Microbial adaptation and change Host susceptibility to infection Climate and weather Changing ecosystems Economic development and land use Human demographics and behavior

Technology and industry

Factors in Emergencecontinued

International travel and commerce Breakdown of public health measures Poverty and social inequality War and famine Lack of political will Intent to harm

Multihost Pathogens

60% of all human pathogens are zoonotic 80% of animal pathogens Ecological generalists

New Dynamic

Emerging diseases – 70% zoonotic New zoonoses Food safety Antimicrobial resistance Agents of bio- and agro-terrorism – 80% zoonotic Global trade and movements

Rapidly Increasing Human Population

• 6.1 Billion people in 2000

• ~9.4 to 11.2 Billion in 2050

Source: United Nations, World Population Prospects, The 1998 Revision; and estimates by the Population Reference Bureau.

Rapidly Increasing Urbanization

• 2000- 47% world population

living in urban areas

• 2030- 60% world population

living in urban areas

The Divided World of 2025 – 8.4 Billion People

World 1 Advanced nations

(Advances in medicine and food)

World 2 Middle class

(Livestock Revolution) World 3 People in destitution and poverty

(Sources of traditional pathogens)

El Nino

Leptospirosis Hantavirus Rift Valley fever

Vectors of Disease

Global Warming

Shifting and enlarging the incidence and distribution of disease

Malaria zone 45% of population to 60% Habitat change and disruption via weather

changes

Global Warming Effects on Malaria

Ecosystem

Waterborne Zoonoses

Animals Humans

MicrobialPathogens

WaterborneDisease

Water Environment

Waterborne Zoonoses – Global Threat

4 billion cases of diarrhea per year 2-3 million deaths Poorly reported Zoonotic portion is significant Endemic and epidemic 1.1 billion people with unreliable water supply

Waterborne Zoonoses Pathogens

Cryptosporidium Giardia E. Coli 0157:H7 Salmonella Leptospiria Toxoplasma Campylobacter Entamoeba Ascarsis Viruses and Prions? SARS?

Concentrated Animal Feeding Operations (CAFOs)

Their Impact on Food Safety andHealthy Environments

Foodborne Infections

• Worldwide > 2 million people die from diarrhea caused by

contaminated food and water each year

• U.S. ~ 76 million persons experience foodborne illnesses

(1 in 4 people)

- ~325,000 hospitalizations

- ~5,000 deaths

Most Common Foodborne Pathogens

Campylobacter Salmonella E. coli 0157:H7 Yersinia Listeria Cryptosporidium Cyclospora Norwalk-like viruses

Livestock 2020 –The Next Food Revolution

Global increase and demand for protein and food of animal origin

Shift from poverty of 1-2 billion people to middle class

“Westernization” of Asia and Latin America Concerns with sustainability Increases in emerging zoonoses through the

concentration of people and animals

By 2020, There will be 1 BillionPeople Over the Age of 60

30% of US population are baby boomers Immuno-compromised population

Movement and Interactionsof People and Commerce

Distance and speed of travel increased 1000 fold since 1800

1.4 billion air travelers/year 50 million foreign visitors, to US year through,

102 sites Antibiotic resistance Global trade of food, animals and plants

The Coming Plague

Today’s mingling of people, animals and microbes in new environments has no historical precedent.

-”We await the coming plague”

- Laurie Garrett

Remote Sites

Pathogen Pollution

Human and domestic animal populations Free-living wild animals Example: global decline in amphibian

populations due to chytridiomycosis Concern with adverse effects on biodiversity

Chytridiomycosis

Virus Carriers

Fruit bats

Flying Foxes

Nipah Virus

Malaysian Pig Farms

Wildlife EID

DomesticAnimal EID

Human EID

Translocation

Human encroachmentEx situ contactEcological manipulation

Global travelUrbanizationBiomedicalmanipulation

Technology andIndustry

AgriculturalIntensification

EncroachmentIntroduction“Spill over” &“Spill back”

Emerging InfectiousDiseases

Dasazak P. et.al.Science 2000 287:443

Spill Over and Spill Back

What’s Next?

Human Monkeypox Cases

Marshfield Clinic and MCW

Matt Kuehnert

Exotic Pets

SARS

Maintenance Host

SARS Airport Screening

                                     

                                                                

The Lessons of SARS

The need for multinational collaboration Public alarm can lead to huge economic impact -

$80 billion Weaknesses in public health infrastructures Consequences of poor reporting –disincentives A true zoonosis: more to come Constant threat due to Emerging Infectious

Diseases in less developed countries

H5N1 Avian Influenza

Pandemic Influenza

The Next InfluenzaPandemic Not if, but when 1918-1919 Experience:

20 million deaths 150 – 450% increase in patient and hospital

visits In 2001 (Asia only), 160

million workdays lost, and for a pandemic, 6 billion workdays lost worldwide

Bioterrorism Biodefense

Agroterrorism

Agents of Bioterrorism

Category

Bacteria, Rickettisia, Toxins

Viruses

Total (%

Zoonotic) A

Anthrax; Botulism; Plague; Tularemia

Smallpox Viral Hemorrhagic Fevers

6 (83%)

B

Brucellosis; Epsilon toxin of C. perfringens; Glanders; Staphylococcus, enterotoxin B; Q Fever

5 (80%)

C

Multidrug-resistant tuberculosis

Hantaviruses; Nipah virus; Tickborne encephalitis viruses; Yellow Fever

4 (80%)

CDC’s Most Significant Global Epidemics Over the Last Decade

1993 – Hanta virus 1994 – Plague (India) Ebola virus (Zaire) 1996 – New Variant of CJD

(UK) H5N1 influenza (Hong

Kong)

1998 – Nipah virus (Malaysia)

1999 – West Nile 2000 – Rift Valley Fever 2001 – Anthrax 2002 – Norwalk-like

viruses 2003 - SARS

Implications of Emerging Diseases

Political Social Economic Psychological Environmental

Animal-borne EpidemicsOut of Control: Threateningthe Nation’s Health – 2003

A report from the Trust

for America’s Health

Findings from the Report U.S. lacks a national program to prevent and control

diseases that impact humans, animals and our food There is no coordinated effort or single agency with a

“command and control” responsibility There is a lack of effective communications with the public

about these diseases and their impact Disease surveillance systems are not linked

Findings from the Report(continued)

Funding for bioterrorism has not adequately supported efforts to counter zoonotic disease threats, especially from the animal health perspective and infrastructure

There is a fragmentation of jurisdictions, authorities, statutes and research; e.g. 200 different government offices and programs responding to 5 zoonotic diseases

Animal and public health are separated by culture and organization

Microbial Threats to HealthConclusions & Recommendations

1. Enhancing the global response capability

2. Improving global infectious disease surveillance

3. Rebuilding domestic public health capacity

4. Improving domestic surveillance through better disease reporting (this includes both human health and veterinary health)

5. Exploring innovative systems of surveillance

6. Developing and using diagnostics

Microbial Threats to HealthConclusions & Recommendations (continued)

7. Educating and training the microbial threat workforce 8. Developing and producing vaccines 9. Developing and producing antimicrobial drugs10. Controlling the use of antimicrobials11. Controlling vectorborne and zoonotic diseases12. Establishing a comprehensive infectious disease

research 13. Creating interdisciplinary infectious disease

centers

Preventing Emerging Infectious Diseases: A Strategy for the 21st Century – CDC

Goal 1: Surveillance and Response

Goal 2: Applied Research

Goal 3: Prevention and Control

Goal 4: Infrastructure and Training

Public Health at the Crossroad

New, inclusive vision of public health Shift to focusing on causes of population health Ensuring that population health is a central concern of

policymakers Globalization of causes and issues Socioeconomic disparities Emerging threats due to interdependence New team – expanded, integrated and transdisciplinary

Population health is a shift from an emphasis on individual health to understanding the multiple determinants of health.

Health is an outcome shaped by a wide range of social, economic, natural, built, and political environments that form a complex and ever-changing dynamic. Because of this broad perspective, public health teams themselves also need to reflect this reality.