Global Response to Emerging and Re-Emerging Diseases

Sylvain Aldighieri, MDInternational Health Regulations – Epidemic Alert & ResponsePAHO/WHO

Objective

To analyze global health issues related to EIDs

…with a special focus on the role of nurses in detection.

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

1st Millenium

Epidemics and Pandemics have shaped our history…

Middle Ages

20th Century

…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.

So, in the context of emerging/epidemic diseaseat 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.

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.

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

Substantiated public health events of potential international concernby hazard

Jan 2001-14 June 2011 (n=2,448; 477 (19%) in AMRO)

85%

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).

Wildlife

DomesticAnimal Human

Translocation

Human encroachmentEx situ contact

Ecological manipulation

Global travelUrbanizationBiomedical

manipulation

Technology And Industry

AgriculturalIntensification

EncroachmentIntroduction“Spill over” &“Spill back”

• 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

61% of all Emerging Infectious Diseases are Zoonoses affecting Humans

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)

States Parties

WHO

Others sources

Event’sRisk assessment

AssistRespond

Disseminate information

Initial screening

Verification

Informal/Unofficial information`

Formal reports

WHO global alert and response systems

Early warning function of the public health surveillance system 100% coverage, 100% sensitivity, 100% flexibility

SignalUnusual health event

Risk

Assessment

Response

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.

Verification Triangulationof sources

0

10

20

30

40

50

60

70

80

90

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Outbreak Detection and Responsewithout Preparedness

Delayed Response

Day

Cases Opportunity for control

Late Detection

First Case

0

10

20

30

40

50

60

70

80

90

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Outbreak Detection and Responsewith Preparedness

Rapid Response

Day

Cases

Early Detection

Potential Cases Prevented

Information sharing at WHO

PAHOPAHO

AFROAFROWPROWPRO

EMROEMROSEAROSEARO

EUROEURO

OperationsStatesWHO Portal

Event Management SystemEvent Management System

• 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

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 cases in

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

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

Continued ChallengesHuman-Animal Interface

Animal Surveillance

Human Surveillance

Create bridgesJoint assessment

Exchange data and findings

H5N1 Avian InfluenzaDecember 2003 – August 2012

• 608 cases• including 359 deaths• in 15 countries

10April

11 April

12 April

13 April

14 April

15 April

16 April

17 April

18 April

19 April

20 April

21 April

22 April

23 April

24 April

25 April

26 April

27 April

28 April

29 April

PAHO Media SurveillanceConcentration of ARD cases detected in hospital in Oaxaca, Mexico.

USA via NFP notified first confirmed cases of Influenza A H1N1 in California.

MEXICO via NFP Notification of outbreaks in different states without laboratory diagnosis and confirmed ILI in Mexicali, Baja California.

USA via NFP Cases confirmed in KS.

WHO Declares PHASE 4

DG WHO following Emergency Committee declares PHEIC.

CANADA via NFP First cases confirmed.

USA via NFP Cases confirmed in NY and OH.

PAHO Media SurveillanceARD outbreak detected in La Gloria, Veracruz, Mexico.

WHO Declares PHASE 5

PAHO IHR requested verification from Mexico via NFP about ARD situation in La Gloria, Vera Cruz.

MEXICO via NFP confirmed presence of outbreak of etiology under investigation in La Gloria, Vera Cruz.

PAHO sent Response Team to Mexico GOARN.

PAHO IHR requested verification from Mexico via NFP about ARD in Oaxaca.

Teleconference between USA, Mexico, Canada and PAHO about investigation in USA.

MEXICO via NFP rules out outbreak in Oaxaca.

PAHO IHR requested verification from Mexico via NFP about ILI in Mexicali, Baja California.

ARD (Acute Respiratory Disease) ILI (Influenza-like Illness) PHEIC (Public Health Emergency International Concern)

PAHO/WHO Event Management

PAHO EOC activated.

PAHO IHR informed Mexico via NFP about first cases of A H1N1 in California, USA.

Teleconference between PAHO IHR and Mexico NFP for joint Risk Assessment.

PAHO IHR requested more information from Mexico via NFP about outbreaks in different states.

USA via NFP cases confirmed in TX.

CANADA Laboratory confirmation of first Influenza A H1N1 cases in samples from Mexico.

Teleconference between Canada, Mexico and USA on ILI in students returning from Mexico.

Mexico 2009. Pandemic Epidemic Curves.

Confirmed cases

Deaths

20102009

Source: Mexican Ministry of health – INDRE. Retrospective.

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

“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

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.

Nurses and EID detection

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

Hope for the best…and prepare for the worst.

Thank you