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1│ Pandemic and Epidemic Diseases Department│


Global capacity and responses to pandemics

- WHO's global strategy –

N. Shindo MD, PhD.Coordinator

Pandemic and Epidemic Diseases DepartmentEpidemic Clinical Management

ERS International Congress 2015, Amsterdam

Global capacity and responses to pandemics

- WHO's global strategy –

N. Shindo MD, PhD.Coordinator

Pandemic and Epidemic Diseases DepartmentEpidemic Clinical Management

ERS International Congress 2015, Amsterdam

His daughters are Hygieia ("Hygiene"), Iaso ("Medicine") ,Aceso ("Healing"), Aglea ("Healthy Glow") ,

and Panacea ("Universal Remedy") .

Asclepius – Greek god of medicine


HSE cluster and PED DepartmentHSE cluster and PED DepartmentDG

FWC GMG IHS HSE

PED

FOS

GCR

HTM NMH PEC

Pandemic and Epidemic Diseases

Global Capacity and Respnse

Food safety and zoonosis


How many pathogens able to infect humans?

How many pathogens able to infect humans?

1400 pathogens1 are known to infect human, other are discovered /identified every year

Some of them are responsible of global public health problems e.g. SARS, in 2003, pandemic influenza in 2009

70% from animal origin

Chikungunya virus

(1956)

Ebola virus (1976-7)

Monkeypox virus( 1972)

Hendra virus( 1994)

HIV )1983(

1Jones, K, Nature (2008)2Woolhouse, ME, Proc. R. Soc. B (2008)

Discovery curve for human virus species2

Pandemic and Epidemic diseases department

Pandemic 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

http://www.who.int/entity/influenza/resources/pip_framework/en/index.html


PED activities PED activities

Diseases Cholera Emerging diseases Hendra virus infection Influenza (avian, seasonal, pandemic) Leptospirosis Meningitis Nipah virus infection Plague Rift Valley fever SARS and coronavirus infections Smallpox and human monkeypox Tularemia Viral 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)


Evidence to reduce disease transmissionEvidence 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


Develop public health research agenda Develop 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)


What do we do ? What do we do ?

Perform timely risk assessment

and monitoring

of infectious epidemic diseases of international concern

to define emergency intervention strategies.

13│ Pandemic and Epidemic Diseases Department│ Source: 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

Outbreaks on the African continent )2007-2013(A total of 174 epidemics

Avian InfluenzaChikungunyaCholeraEbola Hepatitis E Lassa Fever

MarburgMeningitisMonkeypoxNodding 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 malariaA total of 15 diseases cause)d( outbreaks include :


Preventive interventions, 2012Preventive interventions, 2012

Prepositioning of reagents and treatments: meningitis

Preventive vaccination campaigns (GAVI support)meningitis yellow fever


Epidemic responses, 2014Epidemic responses, 2014

Epidemic responses for – MERS CoV (Middle East)– Avian influenza H7N9 (China) – Ebola (West Africa)

Global stockpile of vaccine and antivirals


New approaches for old disease: cholera

New approaches for old disease: cholera

Close partnership with water sector to reduce cholera transmission

Rational use of oral cholera vaccine during emergencies (e.g. global oral cholera vaccine stockpile)


What do we do ?What do we do ?

Optimize treatments

and diagnostics

to reduce infectious diseases

mortality


Differential mortality and access to careDifferential mortality and access to care

Hospitalized patient during SARS outbreak )2003(

Cholera Treatment Unit )2003(


Improvement of clinical management and infection control

Improvement 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


Global 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


Implementation of the PIP framework Implementation of the PIP framework

Sharing of influenza

VirusesGISRS

Sharing of benefitsVaccines

AntiviralsDiagnostics

Publications

Equal footing

Pandemics of the 21rst centuryPandemics of the 21rst century


Some recent emerging and re-emerging diseases

Some 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)

Zones infected with Aedes aegypti

New York city16 h

Miami

20 hNelle- 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


Modeling EID events: Relative risk of an EIDModeling 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(.


Recent influenza pandemicsRecent 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)


Laboratory-confirmed human avian influenza infections since 1999

Laboratory-confirmed human avian influenza infections since 1999


Avian Influenza A)H7N9( Novel Coronavirus )MERS-CoV(

Avian Influenza A)H7N9( Novel Coronavirus )MERS-CoV(

World experiencing emergence of 2 exceptional new virus infections

– Avian influenza A(H7N9)– Novel coronavirus MERS-CoV

Unusual global situation– Unrelated, highly pathogenic– Potential to evolve & spread– No comparable situation since 2003

when SARS & H5N1 (re)emerged

nCoVEM courtesy of U.S. CDC,

H7N9EM courtesy of China CDC


4 April: outbreak of ILI in Veracruz

15-17 April: clusters of severe pneumonia

in Mexico

27 April: WHO phase 4

May June July August OctoberSeptemberMarch

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

Sustainable Person-to-Person Transmission Crossing of a Threshold


Pandemic Response Tools

1918 1957 1968 1997 2003 2009

Spanish flupandemic

Asian flupandemic

Hong Kong flupandemic

A )H1N1( 2009pandemic

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

Amatadanefor influenza )1966(

Rimatadane(1993 )

Neuraminidase inhibitorOseltamivir and Zanamivir )1999(

Antivirals

PH measures )i.e. school closures, mask, mass gathering( Non-pharmaceuticalInterventions

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)

VaccinesLAIV

(2003 ,USA)


Epidemic Disease Patterns Varied by Location

Epidemic 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 JuneApril


3. Communication 3. Communication

Technical scientific communication/ risk communication

Naming of the pandemic

Communication on global risks


Gap between "technical" and "public" communication

Gap between "technical" and "public" communication

It is just a technical definition!


Global availability of vaccinesGlobal availability of vaccines

0

5

10

15

20

25

30

35

Sept 16-30 Oct 1-15 Oct 16-31 Nov 1-15 Nov 16-27

Pandemic Vaccine Distribution

Nu

mb

er

of

co

un

trie

s

)cu

mu

lati

ve

(

High Income

Middle Income

Low Income

31%

49%20%

World economies1 1 World Bank classification 2009

•Only high income countries had access to the vaccine in fall 2009


Vaccine deployment to low income countries

Vaccine 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?

EDCARN:Emerging Disease Clinical

Assessment and Response Network

Clinical & Infection Control

Pandemic & Epidemic Diseases

WHO-HQ, Geneva

38 |

Genesis: Virtual network of SARS clinicians

1) Clinical information for case definition, public health purposes

2) Virtual network of SARS clinician

• New disease

• International spread

• No vaccine, no medicine, IPC?50+ clinicians in 14 countries, telephone conference twice a week

face-to-face meeting, 14 June 2003

39 |

Evolution: IHR(2005), biological threat, pandemic fear, global health security

Avian influenza H5N1

2009 H1N1pdmMERS CoV

Avian influenza H7N9SARS CoVvH3N2, vH1N1

40 |

PED's work on clinical management of EID

1. Provide a platform for information exchange and mutual support throughout outbreak/pandemic of infectious diseases of international concern.

2. Promote clinical data collection and the standardization of clinical research protocols; facilitate greater understanding of the natural history and manifestations.

3. Monitor possible changes in illness manifestations and disease patterns that would have implications for initial case recognition/detection and for public health responses.

4. Provide advice to MoH as well as on-site technical support to frontline clinicians to promote best evidence-based practices.

5. Prepare rapid advice guidelines by quick literature reviews and expert consultations

6. Enhance education and readiness of healthcare workers by clinical workshops and trainings.

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EDCARN: Emerging Disease Clinical Assessment and Response Network

VisionThe 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

MissionIn 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

42 |

Supply 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

43 |

Policy case study: Argentina 2009Policy case study: Argentina 2009

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