Global Response to Emerging and Re-Emerging Diseases
Sylvain Aldighieri, MD
International Health Regulations – Epidemic Alert & Response
PAHO/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
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Emerging and re-emerging infections: definitions
Examples of EIDs
International Health Regulations IHR(2005)
Role of Nurses in EID detection and response
Conclusions
Epidemics and Pandemics have shaped our history…
1st Millenium
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 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 outbreakprone 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 concern
by 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).
61% of all Emerging Infectious Diseases are Zoonoses affecting
Humans
Translocation
Encroachment
Introduction
“Spill over” &
“Spill back”
Agricultural
Intensification
Human
encroachment
Ex situ contact
Ecological
manipulation
Wildlife
Domestic
Animal
Technology
And Industry
Human
Global travel
Urbanization
Biomedical
manipulation
•
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
Purpose and scope of the IHR
“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)
•
•
•
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
WHO global alert and response systems
Formal reports
States Parties
Disseminate
information
Verification
WHO
Event’s
Risk assessment
Initial
screening
Assist
Respond
Others sources
Informal/
Unofficial information`
Early warning function of the public health surveillance system
100% coverage, 100% sensitivity, 100% flexibility
Indicator-based surveillance
(discrete variables)
- Case based (aggregated, individual)
- Laboratory results
- Environmental measurements
- Drug sales
- Absenteeism
- Etc.
Complementary
Event-based surveillance
(unstructured information)
- Media reports
- Hotlines (community,
professionals, etc.)
- NGOs
- Diplomatic channels
- Military channels
- Etc.
Signal
Unusual health event

Risk
Triangulation
Verification
Assessment
of sources

Response
Outbreak Detection and Response
without Preparedness
First
Case
Late
Detection
Delayed
Response
90
80
70
60
Opportunity
for control
50
40
30
20
10
Day
39
37
35
33
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
0
1
Cases
Outbreak Detection and Response
with Preparedness
Early
Detection
Rapid
Response
90
80
70
Potential
Cases Prevented
60
50
40
30
20
10
Day
39
37
35
33
31
29
27
25
23
21
19
17
15
13
11
9
7
5
3
0
1
Cases
Information
sharing at WHO
States
WHO Portal
Operations
Event Management System
EURO
PAHO
EMRO
SEARO
AFRO
WPRO
• 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 Challenges
Human-Animal Interface
Animal
Surveillance
Human
Surveillance
Create bridges
Joint assessment
Exchange data and findings
H5N1 Avian Influenza
December 2003 – August 2012
• 608 cases
• including 359 deaths
• in 15 countries
PAHO Media Surveillance
Concentration of ARD cases detected in hospital in
Oaxaca, Mexico.
PAHO Media Surveillance
ARD outbreak detected in La Gloria,
Veracruz, Mexico.
PAHO/WHO Event Management
USA via NFP notified first confirmed cases of Influenza A H1N1 in California.
PAHO IHR informed Mexico via NFP
about first cases of A H1N1 in California,
USA.
MEXICO via NFP Notification of outbreaks in different states without
laboratory diagnosis and confirmed ILI in Mexicali, Baja California.
PAHO IHR requested more information from Mexico via NFP about
outbreaks in different states.
PAHO IHR requested verification from
Mexico via NFP about ARD situation in
La Gloria, Vera Cruz.
Teleconference between PAHO IHR and Mexico NFP for joint Risk
Assessment.
PAHO EOC activated.
Teleconference between USA,
Mexico, Canada and PAHO about
investigation in USA.
USA via NFP cases confirmed in TX.
CANADA Laboratory confirmation of first Influenza A H1N1 cases in samples from
Mexico.
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 Canada, Mexico and USA on ILI in
students returning from Mexico.
USA via NFP Cases confirmed in KS.
MEXICO via NFP rules out
outbreak in Oaxaca.
DG WHO following Emergency Committee declares PHEIC.
USA via NFP Cases confirmed in NY and
OH.
PAHO IHR requested verification from
Mexico via NFP about ILI in Mexicali,
Baja California.
WHO Declares PHASE 4
CANADA via NFP First cases
confirmed.
WHO Declares
PHASE 5
10
April
11
April
12
April
13
April
14
April
15
April
16
April
ARD (Acute Respiratory Disease) ILI (Influenza-like Illness)
17
April
18
April
19
April
20
April
21
April
22
April
PHEIC (Public Health Emergency International Concern)
23
April
24
April
25
April
26
April
27
April
28
April
29
April
Mexico 2009. Pandemic Epidemic Curves.
Source: Mexican Ministry of health – INDRE. Retrospective.
Confirmed
cases
2009
Deaths
2010
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 atrisk 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