Global Health Security Emerging and ReEmerging Infectious Diseases

Global Health Security Emerging and Re-Emerging Infectious Diseases Felice M Apter, Ph. D OLLI Part II 2018

Emerging Infectious Diseases: Multisectoral Everything is Inter-related

Part I Quick Review of Class I

Basic Definitions • Emerging Infectious Disease- disease recognized in a human host for the first time • Re-emerging Infectious Disease- disease that have historically occurred in human hosts, but are now: • New geographical area • New resistance to medical countermeasures (AMR) • Reappear after apparent control or elimination (VPD)

One Health – Public health as part of the “ecosystem” Human Cases Wild Animal Amplification Domestic Animal C A S E S Wildlife Surveillance/ Forecasting Early Detection and Control Opportunities TIME Emerging Threats Program

Early Detection and Mitigation is Crucial Source: WHO, The World Health Report 2007. A Safer Future: global public health security in the 21 st century

Part II Prevent, Detect, Respond

Response and Solutions: At the start of an EID Outbreak: WHO – Is Sick – Index Case WHAT – Is causing the illness – Pathogen + Other Impacting Dimensions: Stochastic Process HOW – Is it spreading WHERE – Did it come from? How – is it spread? epi curve, epi map, R 0, finding cases WHY – Did the Pathogen Emerge

Prevent • Infrastructure – Safe Water • Food Safety • Nutritional Status • Immune Status • Vaccines 3 Dimensions of the Immune System – • Recognizes Self from Other • Attacks Other • Has Memory

- The Challenge - Communicating the Miracle of Vaccines: Myths and Misinformation

Detection • Early Days – Differential Diagnosis based on Symptoms, usually advanced symptoms • TB (consumption), Syphilis, Plague (Yersinia Pestis), Whooping Cough (Pertussis) • Visual Identification of Pathogen and Differential Media • Bacteria (light microscopes), Viruses (electron microscopes) • Immunological Identification • Antibodies • Molecular Diagnostics

Cholera in London Birth of Public Health: John Snow • Coordination Response • Communication Response • Epidemiology – mapping the epidemic and acting on information • Medical Response • A continuum of Basic to Sophisticated Medical Care • Quarantine, Isolation • Drugs • Vaccines – special case of Emerging Disease ***Link to Local, National and International Decision Makers***

Part III Evolution of Global Health Security

Evolution of International Sanitary Regulations Table by Fidler

Frameworks for infectious disease control Frameworks for EID International agreements Regional agreements National policies, strategies, and regulations Local implementation guidelines

IHR revision process (1995 -2005) The Balancing Act “…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’’ • All 196 Member States have Signed On!

International Health Regulations (2005) Goal: Respond to events effectively before they become international public health crises. 2007 -present IHR Component Scope Any Public Health Emergency of International Concern (PHEIC) Communication National IHR Focal Point (NFP) Notification Report to WHO within 24 hours (72 hours to respond to follow up requests) Coordinated Response Assistance in response/recommended measures. Authority WHO can initiate requests for information, including on basis of unofficial sources National Capacity Provide disease inspection and controls at ports of entry, and meet minimum core capacity for detection, assessment, reporting, and response.

Early Detection and Mitigation is Crucial Source: WHO, The World Health Report 2007. A Safer Future: global public health security in the 21 st century

What did States Parties agree to do? (Articles 4, 5, 13, 44 and Annex 1) Communications • Designate a National IHR Focal Point Core Capacities • Meet minimum requirements to detect, assess, report, and respond to public health events Points of Entry • Support disease detection and control at designated ports and borders Notification • Develop a framework for notifying WHO within 24 hours of a potential PHEIC Collaboration and assistance • Provide technical, logistical, or financial support to facilitate implementation Evaluate status • Conduct self-assessments and report to WHO

Annex 1 defines IHR (2005) core capacity • Epidemiological, requirements laboratory, logistical • • Detect unexpected disease or deaths Assess reports within 48 hours Notify WHO Support or implement control measures • • • Intermediate • Detect unexpected disease or deaths Assess and confirm reported events Report to national level Support or implement control measures National Local • • Detect unexpected disease or deaths Assess events immediately Report essential information to appropriate level Implement preliminary control measures • • • support Containment and control measures Coordination with other ministries Information sharing Operational national public health emergency response plan Deployable rapid response teams

Event detected by national surveillance system A case of the following diseases has serious public health impact and is unusual or unexpected, and thus shall be notified: • • Smallpox Poliomyelitis due to wildtype polio virus Influenza with pandemic potential Severe acute respiratory syndrome (SARS) O R Any event of potential international public health concern, including those involving other events or diseases than those listed in the box on the left and the box on the right shall lead to utilization of the algorithm. O R Is the public health impact of the event serious? Ye s N o Ye s Cholera Pneumonic plague Yellow fever Viral hemorrhagic fevers (Ebola, Lassa, Marburg) • Other diseases that are of special national or regional concern, e. g. dengue fever, West Nile fever, Rill Valley Is the event unusual or fever, and meningococcal unexpected? disease. Ye s Is there a significant risk of international spread? N o Is there a risk for international trade restrictions? Ye s • • N o Is the event unusual or unexpected? Ye s An event involving the following diseases shall always lead to utilization of the algorithm, because they have demonstrated the ability to cause serious public health impact and to spread rapidly internationally: N o Ye s N o Not notified at this stage. Reassess when more information becomes available. Event shall be notified to WHO under the International Health Regulations

Slide from HHS/ASPR

PHEIC’s to Date

IHR (2005) – new strategies Goal Respond to events effectively before they become international public health crises. Needs Anticipate emerging threats Mandate timely and transparent reporting Incorporate evidence into decision making Accommodate different national capacities Collect and disseminate sensitive information Protect individuals and economies against unmerited actions

Declared PHEICs

*=Emergency Committee Meeting ** * * *

Meetings of IHR Emergency Committee Concerning MERS-Co. V • • • 9 July 2013 (more info needed) 17 July 2013 (serious, but not a PHEIC) 25 September 2013 (no change, Hajj prep) 4 December 2013 (camels, Hajj review, no change) 14 May 2014 (worsening situation, but no PHEIC because no sustained human to human) 17 June 2014 (drop in cases, no PHEIC, prep for Hajj) 1 October 2014 (MERS might be seasonal, no PHEIC) 5 Feb 2015 (need more surveillance, no PEHIC) 17 June 2015 (no sustained transmission, under control, no PHEIC)

2 -year Fully extension No report implement requested 14% ed (no 21% implement 2 -year ation plan) extension 5% obtained (with implement ation plan) 60% States report meeting all core capacity requirement s s OR OR Adopted by States Parties Entered into force 2005 2007 States assess core capacities Request extension 2009 Plan/implement capacity building 2012 Request 2 nd extension 2014

IHR Status as of 2016

Core Challenges • Nations have not built core capacities under the IHR • Need for better metrics; external evaluations • Need for technical and financial resources • Transparency and better decision making at WHO • Stronger and faster response capacity • Sustainability

Biological Weapons Convention

Biological and Toxin Weapons Convention (BWC)

Key provisions of the BWC Prohibition International Assistance and Cooperation

• The Convention has no monitoring or verification agency, no governing council, and no permanent secretariat. • Biological agents are inherently dual-use, know no borders, and are evolutionary, thus cannot be captured in a traditional treaty mechanism. • Benefits of its membership are not always apparent to non-State parties. This “weapons” treaty actually provides entrée to many inter-connected communities which together provide greater security against bio threats, whether natural, accidental or deliberate. • The BWC Implementation Support Unit (ISU) consists of three people who serve as a highly efficient clearing house. • The BWC “community” includes national security, health, law enforcement, preparedness, academia, industry and NGO members.

The BWC: An Integrated Approach BWC Law Enforcement 1540 Emergency Preparedness Professional Associations WHO OIE FAO BWC Intersessional Work Program Industry Scientific Organizations

In the News Lifting the Ban on Making Lethal Organisms https: //www. nytimes. com/2017/12/19/health/lethal-viruses-nih. html

Evolution of Frameworks to meet Common Needs Global Health Security Agenda

Accelerating progress toward a world safe and secure from infectious disease threats Global Health Security Agenda IHR Regional frameworks Specific technical guidance Biosecurity Animal health, food safety, environment BWC, UNSCR 1540 OIE Performance of Veterinary Services Pathway, AMR, etc.

Overlap Between GHSA and IHR GHSA • Prevent AMR • Vaccination Programs • Nosocomial infection control • Regional biosurveillance hubs • Sample sharing • Novel diagnostics • Sharing medical countermeasures and personnel IHR • Surveillance • Laboratory • Preparedness • Response • Zoonotic diseases • Human Resources • Legislation, Policy & Financing • Risk communication • Coordination and NFP Communication • Points of Entry • Food Safety • Chemical Events • Radiological Emergencies

11 action packages define specific GHSA targets PREVENT DETECT RESPOND

Each GHSA Action Package includes milestones and targets for national use • 5 -year targets (as measured by) • Desired national impact • Country commitments • Baseline Assessment and Planning Activities • Monitoring and Evaluation Activities

Funding Sources for JEE and Country Plans

USG Response: Ebola and Zika

2017 Status: Secretary of State Rex Tillerson • In October 2017, Secretary of State Rex Tillerson called the Global Health Security Agenda “one of the most vital initiatives for building global capacity to prevent, detect, and respond to infectious disease threats. ” • Yet the administration hasn’t set aside money to sustain the program after the grant expires next year. And President Trump’s budget proposals have included heavy cuts to global infectious disease programs. • According to the Wall Street Journal, the CDC has picked the 10 countries it will continue to support through the Global Health Security Agenda— • India, Thailand, Vietnam, Kenya, Uganda, Liberia, Nigeria, Senegal, Jordan and Guatemala—on the basis of “strategic or regional importance. ”

Part V Our Modern World

Human

Global Examples of Emerging and Re-Emerging Infectious Diseases Antimicrobial- Enterovirus D 68 Cryptosporidiosis Ebola virus disease r : ; : n t threats West Nile E. coli O 104: H 4 MERS-Co. V Akhmeta virus Rift Valley fever -MRSA - C. difficile - N. gonorrhoeae H 3 N 2 v influenza Cyclosporiasis E. coli. O 15 7: H _7 - _ , l. -_-_-_: . : -: : $5 Qii : - - Human monkey pox Listeriosis Bourbon virus 2009 H 1 N 1 influenza Adenovirus 14 Anthrax bioterrorism -==- - https: //youtu. be/x. OFH 57 Do 2 EM Typhoid fever SFTSV bunyavirus E. coli O 157: H 7 - ---+-- H 10 N 8 influenza H 7 N 9 influenza Hendra virus Enterovirus 71 Human monkeypox Ebola virus disease Hantavirus pulmonary syndrome Human African trypanosomiasis Newly emerging MDR / XDR tuberculosis Zika virus Marburg Plague hemorrhagic fever Re-emerging/resurging • "Deliberately emerging" December 2016 CJj • · J 7 8. 9 Georgetown University Medical Ccntct

Early Detection and Mitigation is Crucial Source: WHO, The World Health Report 2007. A Safer Future: global public health security in the 21 st century

Underpinning All of These Efforts: Systems, Capacities, Communication