pandemics WHOs g lobal strategy N Shindo MD PhD Coordinator Pandemic and Epidemic Diseases Department Epidemic Clinical Management ERS International Congress 2015 Amsterdam H is daughters are ID: 775004
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Slide1
Slide2Global capacity and responses to
pandemics
WHO's
g
lobal strategy –
N. Shindo MD, PhD.
Coordinator
Pandemic and Epidemic Diseases Department
Epidemic Clinical Management
ERS International
Congress 2015, Amsterdam
Slide3H
is daughters are
Hygieia ("Hygiene"), Iaso ("Medicine"), Aceso ("Healing"), Aglea ("Healthy Glow"), and Panacea ("Universal Remedy").
Asclepius – Greek god of medicine
Slide4HSE cluster and PED Department
Pandemic
and
Epidemic Diseases
Global Capacity and Respnse
Food safety and zoonosis
Slide5How many pathogens able to infect humans?
1400
pathogens1 are known to infect human, other are discovered /identified every yearSome of them are responsible of global public health problems e.g. SARS, in 2003, pandemic influenza in 200970% from animal origin
Chikungunya
virus (1956)
Ebola virus (1976-7)
Monkeypox virus (1972)
Hendra virus (1994)
HIV (1983)
1
Jones, K, Nature (2008)
2
Woolhouse, ME,
Proc
. R. Soc. B (2008)
Discovery
curve
for
human
virus species
2
Slide6Pandemic 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
Slide7PED activities
DiseasesCholeraEmerging diseasesHendra virus infection Influenza (avian, seasonal, pandemic)Leptospirosis Meningitis Nipah virus infectionPlagueRift Valley fever SARS and coronavirus infectionsSmallpox and human monkeypox TularemiaViral 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)
Slide8Evidence 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
Slide9Develop 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)
Slide10Slide11What do we do ?
Perform timely risk assessment and monitoring of infectious epidemic diseases of international concern to define emergency intervention strategies.
Slide12Slide13Source: 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
Avian InfluenzaChikungunyaCholeraEbola Hepatitis E Lassa FeverMarburgMeningitisMonkeypoxNodding 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 malaria
A total of 15 diseases cause(d) outbreaks include:
Slide14Preventive interventions, 2012
Prepositioning of reagents and treatments: meningitisPreventive vaccination campaigns (GAVI support)meningitisyellow fever
Slide15Epidemic responses, 2014
Epidemic responses for MERS CoV (Middle East)Avian influenza H7N9 (China) Ebola (West Africa)Global stockpile of vaccine and antivirals
Slide16New approaches for old disease: cholera
Close partnership with water sector to reduce cholera transmissionRational use of oral cholera vaccine during emergencies (e.g. global oral cholera vaccine stockpile)
Slide17What do we do ?
Optimize treatments and diagnostics to reduce infectious diseases mortality
Slide18Differential mortality and access to care
Hospitalized patient during SARS outbreak (2003)
Cholera Treatment Unit (2003)
Slide19Improvement 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
Slide20Global 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
Slide21Implementation of the PIP framework
Sharing of influenza VirusesGISRS
Sharing of benefitsVaccinesAntiviralsDiagnosticsPublications
Equal footing
Slide22Pandemics of the 21rst century
Slide23Some 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)
Slide24Zones infected with
Aedes aegypti
New York city
16 h
Miami
20 h
N
elle
- 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
Slide25Modeling 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).
Slide26Recent 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)
Slide27Laboratory-confirmed human avian influenza infections since 1999
Slide28Avian Influenza A(H7N9) Novel Coronavirus (MERS-CoV)
World experiencing emergence of 2 exceptional new virus infectionsAvian influenza A(H7N9)Novel coronavirus MERS-CoVUnusual global situationUnrelated, highly pathogenicPotential to evolve & spreadNo comparable situation since 2003 when SARS & H5N1 (re)emerged
nCoV
EM courtesy of U.S. CDC,
H7N9
EM courtesy of China CDC
Slide294 April: outbreak of ILI in Veracruz
15-17 April: clusters of severe pneumonia in Mexico
27 April: WHO phase 4
May
June
July
August
October
September
March
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
Slide30Slide31Pandemic Response Tools
1918
1957
1968
1997
2003
2009
Spanish flu
pandemic
Asian flu
pandemic
Hong Kong flu
pandemic
A (H1N1) 2009
pandemic
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
Amatadane
for influenza (1966)
Rimatadane
(1993)
Neuraminidase inhibitor
Oseltamivir and Zanamivir (1999)
Antivirals
PH measures (i.e. school closures, mask, mass gathering)
Non-pharmaceutical
Interventions
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)
Vaccines
LAIV
(2003, USA)
Slide32Epidemic 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
June
April
Slide333. Communication
Technical scientific communication/ risk communication
Naming of the pandemic
Communication on
global
risks
Slide34Gap between "technical" and "public" communication
It is just a technical definition!
Slide35Global availability of vaccines
World economies
1
1
World Bank classification 2009
Only high income countries had access to the vaccine in fall 2009
Slide36Vaccine 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?
Slide37EDCARN:
Emerging Disease Clinical
Assessment and Response Network
Clinical & Infection Control
Pandemic & Epidemic Diseases
WHO-HQ, Geneva
Slide38Genesis: Virtual network of SARS clinicians
Clinical information for case definition, public health purposesVirtual network of SARS clinicianNew diseaseInternational spreadNo vaccine, no medicine, IPC?50+ clinicians in 14 countries, telephone conference twice a weekface-to-face meeting, 14 June 2003
Slide39Evolution: IHR(2005), biological threat, pandemic fear, global health security
Avian influenza H5N1
2009 H1N1pdm
MERS
CoV
Avian influenza H7N9
SARS CoV
vH3N2, vH1N1
Slide40PED's work on clinical management of EID
Provide a
platform for information exchange and mutual support
throughout outbreak/pandemic of infectious diseases of international concern.
Promote clinical data collection
and the standardization of clinical research protocols
;
facilitate greater understanding of the natural history and manifestations.
Monitor possible changes in illness manifestations and disease patterns
that would have implications for initial case recognition/detection and for public health responses.
Provide advice to MoH as well as on-site technical support to frontline clinicians
to promote best evidence-based practices.
Prepare
rapid advice guidelines
by quick literature reviews and expert consultations
Enhance education and readiness of healthcare worker
s by clinical workshops and trainings.
Slide41EDCARN: Emerging Disease Clinical Assessment and Response Network
Vision
The 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
Mission
In 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
Slide42Supply 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
Slide43Policy case
study: Argentina 2009
Slide44