Health Security Challenges in The Republic of MacedoniaLearning Objectives:To give background information about health challenges in the countryTo emphasize the important of Early Warning Rapid Alert System (EWARS) for communicable diseaseTo initiate development of Integrated EWARS in light of International Health regulation (IHR-2005)To stress the significance of improvement of knowledge and experience This lecture was presented during the ANSER Policy Forum which was held on April 6, 2009

Health Security Challenges in The Republic of MacedoniaElisaveta StikovaPresent position1991-Present, Professor, University Ss. Cyril and Methodius, Medical faculty, Skopje, Macedonia (courses taught: Occupational Health, Public Health, Medical Ecology, Hygiene1994 Present, Director and Advisor, National Public Health Institute, Skopje, Macedonia2009 Fulbright Visiting Scholar, Pittsburg University, Graduate School of Public Health New Educational Pathway for Global Public Heath Security

Where is The Republic of Macedonia?Area: 25 713 km2Population: 2.048.000

Typhus in Republic of Macedonia : , 2005

Chart2

329

509

310

545

460

617

664

236

627

501

305

494

285

299

326

351

253

367

255

252

414

630

470

634

795

657

1960

1961

439

348

336

368

359

234

138

124

228

94

60

80

73

81

119

52

236

59

31

42

31

27

33

46

20

28

14

11

5

10

5

9

3

2

1

2

1

0

3

1

0

0

ZABOLENI

DIFTERIJA

zaboleni

192993

1930207

1931255

1932235

1933298

1934187

1936198

193788

1938109

193960

194026

1945224

1946251

1947168

194871

194985

195071

1951398

1952412

1953524

1954465

1955561

1956468

1957653

1958520

1959393

1960192

1961118

1962168

1963107

196479

196582

196665

196736

196836

196933

197016

197115

197211

19732

19740

19750

19761

DIFTERIJA

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Difterija (Diphtheria) i trend vo R.Makedonija vo periodot 1929 - 1976 godina

TETANUS

zaboleni

19297

193016

19319

193220

193318

193424

193614

193722

193830

193927

194035

194516

194630

194739

194835

194942

195034

195142

195260

195343

195441

195548

195648

195737

195862

195942

196046

196133

196226

196328

196437

196534

196661

196755

196847

196927

197024

197130

197216

197313

197414

19758

197610

197710

18788

19796

19804

19816

19829

19833

19846

19852

19863

19873

19884

19894

19900

19911

19921

19933

19941

19951

19962

19971

19981

19994

20000

20010

20021

20030

TETANUS

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Tetanus (Tetanus) i trend vo R. Makedonija vo periodot 1929 - 2003 godina

PERTUSIS

zaboleni

1948258

1949189

1950850

1951873

1952859

19532785

19542298

19552583

19563622

19572806

19583934

19594721

19602832

19611862

19621416

19631207

19641740

1965839

1966159

1967874

1968445

1969258

1970325

1971294

1972363

1973547

1974466

1975346

1976547

1977372

1878541

1979339

1980401

1981232

1982291

1983254

1984175

1985132

1986289

1987169

198842

198959

199068

199184

199246

199338

199453

199527

199620

199732

199813

199910

200021

20015

20024

200316

PERTUSIS

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Golema ka{lica (Pertussis) i trend vo R. Makedonija vo periodot 1948 - 2003 godina

MORBILI

1929287

1930383

1931971

1932149

1933242

1934344

19361058

193758

1938

1939

1940

1945

1946

1947

1948271

19491029

1950355

19511426

1952802

19531942

19542768

19552408

19563622

19572806

19583934

19594721

19602832

19611862

19621416

19631207

196412149

19653811

19667243

196711447

19688500

19698390

19708846

19719090

19728365

19733782

19744390

19754791

19764941

19775047

18783279

1979450

19803993

19813657

19822399

19831282

1984326

19852185

19862946

19872069

19881622

1989575

19901303

1991181

1992180

19932495

1994229

1995217

19961056

199735

199891

199953

200036

200127

200219

200318

MORBILI

PAROTIT

zaboleni

19674243

19686815

19692143

19703610

19718050

19722456

19735168

19745585

19756237

19765846

19775689

18788021

19798436

19805795

19813737

19826156

19835666

19844371

19854638

19865161

19873551

19881016

19891791

19901409

19911851

19922181

19932349

19941653

19951773

19964321

1997358

1998263

1999316

2000441

2001380

2002109

200376

PAROTIT

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Zarazni zau{ki (Parotitis epidemica) i linearen trend vo R. Makedonija vo periodot 1967 - 2003 godina

RUBEOLA

zaboleni

1967689

1968854

1969474

1970255

1971650

1972436

19731664

1974423

19751374

19763490

19772927

18781592

19791594

19801937

1981582

19821726

19834382

1984447

1985599

19861509

19873926

1988739

19891435

19901652

1991443

1992455

1993302

19942020

1995187

1996234

19971123

1998190

1999120

200087

200187

200261

200349

RUBEOLA

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Rubeola (Rubella) i linearen trend vo R. Makedonija vo periodot 1967 - 2003 godina

POLIOMIELT

zaboleni

1929

19301

19312

19323

19332

1934

19361

19373

193845

19394

19401

1945

19464

194719

194810

19495

19503

19515

195210

19538

195420

195516

195657

195740

195821

195943

1960150

196118

19627

19639

19641

19655

196681

196751

196810

196911

197025

197110

19723

1973

19742

19756

1976

197790

18783

1979

1980

19818

19824

1983

1984

1985

19863

19871

POLIOMIELT

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Detska paraliza (Poliomyelitis acuta) vo R. Makedonija vo periodot 1929 - 1987 godina

PEGAV TIFUS

zaboleni

19294

193018

193119

193214

193387

1934257

193633

193780

193890

193911

194074

1945954

1946423

194747

194818

19493

19508

195113

195258

195366

195426

19553

19563

PEGAV TIFUS

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

zaboleni

Zaboleni lica od Pegav tifus (Typhus exantematicus) vo R. Makedonija vo periodot 1929 - 1956 godina

TIFUS ABDOMINALIS

ZABOLENI

1929329

1930509

1931310

1932545

1933460

1934617

1936664

1937236

1938627

1939501

1940305

1945494

1946285

1947299

1948326

1949351

1950253

1951367

1952255

1953252

1954414

1955630

1956470

1957634

1958795

1959657

1960

1961

1962439

1963348

1964336

1965368

1966359

1967234

1968138

1969124

1970228

197194

197260

197380

197473

197581

1976119

197752

1878236

197959

198031

198142

198231

198327

198433

198546

198620

198728

198814

198911

19905

199110

19925

19939

19943

19952

19961

19972

19981

19990

20003

20011

20020

20030

TIFUS ABDOMINALIS

ZABOLENI

PARATIFUS

Zaboleni

193118

193224

193316

193427

1936

193718

193818

193926

194013

19451

19469

194736

194815

194920

195017

195110

195226

195377

1954107

1955102

195692

1957183

1958205

1959257

1960

1961

1962273

1963185

1964178

196597

1966153

196783

196866

1969105

1970152

1971154

1972163

1973241

1974157

197578

1976119

197785

187814

197960

198046

198118

198232

198312

19848

198514

198612

198723

198812

19894

19902

19912

19921

19930

19940

19953

19962

19970

19980

19990

20000

20010

20020

20030

PARATIFUS

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

Zaboleni

Zaboleni lica od Paratifus (Paratyphus) vo R. Makedonija vo periodot 1931-2003 godina

DIZENTERIJA

ZABOLENI

192993

1930207

1931255

1932235

1933298

1934187

1936198

193788

1938109

193960

194026

1945224

1946251

1947168

194871

194985

195071

1951167

1952255

1953403

1954552

1955678

1956723

1957840

19581174

19591198

1960

1961

1962600

1963775

1964754

19658505

19668553

19677176

19685595

19694788

19705088

19716991

19724738

19736085

19744619

19753935

19763165

19776584

18783561

19795021

1980222

1981209

1982243

1983400

1984281

1985344

1986330

1987288

19886309

1989329

1990306

1991254

1992275

1993204

1994289

1995297

1996108

1997212

1998388

1999141

2000110

2001102

200292

200332

DIZENTERIJA

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZABOLENI

Zaboleni lica od Dizenterija (Dysenteria) vo R. Makedonija vo periodot 1929 - 2003 hodina

MALARIJA

ZABOLENI

1937128311

1938113136

1939103549

1940 - 44

194541793

194683795

194746486

19489348

19491375

1950257

1951222

1952249

1953702

19541800

19553258

19562818

19571591

1958775

1959561

1960226

196140

196224

196336

196430

19653

19664

19677

19687

19692

19702

19711

19720

MALARIJA

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

ZABOLENI

Zaboleni lica od malarija (mikroskopski potvrdeni slu~ai) vo R. Makedonija vo periodot 1937 - 1972 godina

Vaccination introducedPOLIOMYELITIS IN THE REPUBLIC OF MACEDONIA 1956-1987

Chart1

57

40

21

43

150

18

7

9

1

5

81

50

10

11

25

10

3

0

2

6

0

90

3

0

0

0

8

4

1

0

3

1

BROJ NA ZABOLENI

Sheet1

BROJ NA ZABOLENI

195657

195740

195821

195943

1960150

196118

19627

19639

19641

19655

196681

196750

196810

196911

197025

197110

19723

19730

19742

19756

19760

197790

19783

19790

19800

19810

19828

19834

19841

19850

19863

19871

Sheet1

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

0

&R&"MAC C Times,Bold"&11grafikon br. 5

BROJ NA ZABOLENI

POLIOMYELITIS CASAES IN FYROM IN THE PERIOD 1956 - 1987

Sheet2

&A

Page &P

Sheet3

&A

Page &P

Sheet4

&A

Page &P

Sheet5

&A

Page &P

Sheet6

&A

Page &P

Sheet7

&A

Page &P

Sheet8

&A

Page &P

Sheet9

&A

Page &P

Sheet10

&A

Page &P

Sheet11

&A

Page &P

Sheet12

&A

Page &P

Sheet13

&A

Page &P

Sheet14

&A

Page &P

Sheet15

&A

Page &P

Sheet16

&A

Page &P

Measles in Republic of Macedonia vaccinationrevaccination

Network of Public Health Institutes in Macedonia Today

The Impact of 21st Century: Health Security Challenges in Macedonia

Public health threats are many and diverse, they are multiplying and moving faster than even before going far beyond the national bordersThey present new challenges and require an urgent and collaborative responseStrengthening of public health preparedness, planning and timely response are ultimate goals to minimize human suffering caused by global public health threatsPublic Health Threats New Challenges

Emerging and epidemic prone diseasesEnvironmental changes and natural disastersHuman-made (technological) disastersChemical, biological and radiological terror threatsInternational crises and humanitarian emergencies

Global Public Health Threats in 21th Century

Where Are Public Health Threats Coming From?Speed and volume of travel and tradeOccurrence of new and reemerging pathogensEnvironmental degradationNatural disastersTerrorism

Key Elements of Public Health Preparedness ProgramIdentifying the types or nature of eventsPlanning activities in advance to prevent the occurrence of the events or ensure a coordinate response Building capabilities for effective response to the consequences of the eventsRecovering from the events

Classification of Natural Disaster

1483 events reported between 1990-200642 millions affected; 98119 killed peopleMore than 130 billion euros economic lost

Natural Disasters Around the World, 2007

Background Information: Health Consequences of Floods in Europe

3 millions displaced persons

300 000 deaths

200 000 missed personsBackground Information: Do Not Forget Crises and Humanitarian Emergencies

Background Information: Do not Forget Chronic Diseases-Epidemiological Transition

Background Information: Climate Changes

EWARS Early Warning Rapid Alert System for Communicable Diseases Surveillance, Macedonia-Data Flow-

EWARN global database

Surveillance System in Republic of Macedonia

8 groups of conditions/suspicions are reported,Case definition is based on symptoms or syndromes,Weekly reporting on a regional and central level,Rapid data analysis,Receiving necessary information for undertaking measures and activities,Timely and functional feed-back information.

Basic Principles of Syndromic Surveillance System

10 geographical regions of the country includedRegions of: Tetovo,Kumanovo, Skopje, Ohrid, Bitola, Prilep, Kocani, Strumica, Stip, Veles1014 surveillance unit40% coverage by EWARS1.2 million people

EWARS Data Flow

REPORTING UNITSPrimary Health InstitutionMedical CenterInstitutions for health care of workersInstitutions for health care of studentsPrivate health institutionsSURVEILLANCE UNITSREGIONAL IHPREPUBLIC IHPMINISTRY OF HEALTHHealth Care/Reported Units Data Flow

Skopje Region Example Data Flow

=Data Collecting and Data Processing

LIST OF CLINICAL DEFINITIONS TO BE REPORTEDSuspicion of an upper respiratory tract infection

Suspicion of an lower respiratory tractinfection

2-a Suspicion of acute lower respiratory tract infection in children

LIST OF CLINICAL DEFINITIONS TO BE REPORTEDSuspicion of rash fevers, excluding varicellae

Suspicion of meningitis/meningo- encephalitis

Acute watery diarrhoea

LIST OF CLINICAL DEFINITIONS TO BE REPORTEDAcute bloody diarrhoea

Suspicion of acute infective hepatitis

Suspicion of acute hemorrhagic fever

EWARS Data Sources and outputsAlertsTablesGraphics/chartsMaps Coverage

EWARS Early Warning Alert Rapid System for Communicable Diseases Surveillance

=Is there anything more?

EWARS Early Warning Alert Rapid System for Communicable Diseases Surveillance (I)EWARS Integrated Early Warning Alert Rapid System for All Hazards and Diseases Surveillance

IHR (2005) Area of Work and Goals

IHR (2005) Area of Work and Goals

A case of any of the following diseases:SmallpoxPoliomyelitis due to wild type poliovirusHuman influenza caused by a new subtypeSevere Acute Respiratory Syndrome

Any event that is a Potential public health emergency of international concert, including those of unknown causes of sources

A case of any of the following diseases:cholerapneumonic plague yellow feverViral hemorrhagic fevers (Ebola, Lassa and Marburg)West Nile feverApply the criteria in the decision algorithmIs the public health impact of the event seriousIs the event unusual of unexpected?Is there a significant risk of international spread?Is there a significant risk of international restrictions on travel or trade?Yes to any two of these criteriaEvent shall be notified to WHO under IHR (2005)

www.pitt.edu/~super1/

Question!How can we improve public health preparedness education worldwide?Answer!Get better lectures

Why dont we share our most exciting PowerPoint lectures for free?

Supercourse is highly valuable tools presenting:network of 64000 scientists from 174 countriesset of 3623 lecture in 26 languages270 Disaster Lectures 50 countries1 Nobel Prize winner75% full professors52 countries

http://www.pitt.edu/~super1/SEE/see.htm

Improve Access to Knowledgeand Experience!

Improve Access to Knowledgeand Experience!

Center for Public Health PreparednessNew challenges need new professional profiles: health preparedness coordinator?emergency management analyst?emergency preparedness health planner?bio terrorism/chemical epidemiologist?CME of medical and public health professionals?Graduated/certified program?BDLS/ADLS?

What is the solution?New educational pathway for global public health securityEstablishment of Regional Public Health Preparedness CenterDo we have experience and good practices?US-CDC Network of Public Health Preparedness CentersResearch, joint projects and cooperative agreements

NEW EDUCATION PATHWAYS FOR GLOBAL PUBLIC HEALTH SECURITY:US-MACEDONIAN COLLABORATION IN HIGHER EDUCATION

*The Impact of 21st Century Health Security: Challenges in the Republic of Macedonia

Public health threats cannot be contained by country boundaries. Their containment depends on a timely response and global preparedness planning. Therefore, every country should develop a core detection and response capacity, but also maintain a level of cooperation with other countries in order to ensure a reduction in the risk and vulnerability of the population In respect to this, every country should strengthen its national public health preparedness capacity. The term "preparedness" covers all aspects, such as: prevention, protection, response and recovery. The term also covers the steps taken to minimise the threat of natural and man-made disasters including deliberate release of chemical, biological and radiological agents. This lecture is developed under the Fulbright Grant for development of US-Macedonian Collaboration in Higher Education in the field of Global Public Health Security. The title of Fulbright Project is New educational Pathway for Global Public health Security(http://www.cies.org/schlr_directories/vsdir08/Publ39.htm)

*Other relevant position:UNDP National expert for chemicals and healthMember of Editorial Board of EuroSurveillancePrevious experience: 2000 - 2002 - Director, National Public Health Institute (Republic Institute for Health Protection), 1998 - 2000 - Deputy-Director, Health Center Skopje, 1994 - 1998 - Director, National Public Health Institute (Republic Institute for Health Protection), 1983 - 1994 - Chief of the Department for planning and organization, Institute for Occupational Health, 1980 - 1982 - Industrial physician, Institute for Occupational Health. Other relevant positions:2007 - Visiting Professor, Erasmus Mundus Europubhealth Master Studies, University of Sheffield, Sheffield, UK, 2007 - Visiting professor, Erasmus Mundus Europubhealth Master Studies, University of Krakow, Poland, 2006 - NATO Partner Country Co-director, Advanced Study Institute, Science for Peace and Security Program, 2004 - Study visit, Braun School of Public Health, Jerusalem, Israel2003 - Study visit, Bordeaux and Bilbao, Preparation of New Curricula in the Field of Environmental and Occupational Health, 2003 - Study visit, Stanford University, USA, Environmental and Occupational Health Services, Risk assessment, 2002 - Professor, Medical Faculty, Courses: Environmental and Occupational health; Occupational Health2002 - Professor, School of Dentistry, Course: Medical Ecology, 2000 - Professor, School for Education, Courses: Preschool Hygiene; School Hygiene,1997 - Associate Professor, Medical faculty, Course: Hygiene and Occupational Health, 1990 - Assistant Professor, Medical faculty, Course: Hygiene, Social Medicine and Occupational Health,1985 - Assistant, Medical Faculty, Topic: Hygiene, Social Medicine and Occupational Health.Specialization:(i)main field Occupational Health(ii)other fieldsRisk Analysis Public HealthAccreditation criteria, quality assurance, ISO/IEC standards(ISO 9000, ISO 45000 and ISO17025),Global Survey - Disease surveillance, Detection and Response page 2 of CVEpidemiology, Medical Statistics, Health Indicators and Data Presentation SystemFood Safety and Control, Codex Alimentarius and HACCP (iii)current research interestChemical, biological and radiological risk assessment; rapid detection of CBR agents, susceptibility of population; biological monitoring; health impact assessment; public health preparedness and response; bioterrorism; pandemic flu; climate change; food safety and control.*pip.rubberfeet.org

**The spread of new and re-emerging communicable and non communicable diseases, natural disasters, environmental change, bioterrorism or chemical spills can all have a major impact on people, their societies and economies around the world. Such threats present new challenges and require an urgent and collaborative response.Health, development and global security are inextricably linked. Investment in health is a cornerstone of economic growth and development. Moreover, the security of all countries is today increasingly dependent on the capacity of each to act effectively, and collectively, to minimize health threats.Life and health are our most precious possessions. We have the knowledge and unprecedented resources to build a healthier and safer world. Now we have to mobilize the political will and to ensure that each country -- rich and poor -- has a robust health system capable of serving all those in need.

*Health systems need to be ready to handle crises affecting public health, thus minimizing damage to people, the community and the economy. Combating these changes will require collaboration and commitment between governments, corporations, foundations and nongovernmental organizations. An absolute concept of national sovereignty has been challenged by these events and by the need to secure collective defence against the emerging public health threats. Emerging and epidemic prone diseases: new, highly contagious diseases, such as SARS and avian influenza, know no borders. In the last few decades, new diseases began emerging at an unprecedented rate of one or more per year. From 1973 to 2000, 39 infectious agents capable of causing human disease were newly identified. The development of microbial resistance is more worrying situation that could change the structure of morbidity and mortality in the world. .Environmental changes and natural disasters: global environmental changes are associated with an increasing number and severity of events, such as tropical storms, floods, droughts, heat-waves, earthquakes that threaten food security or water contamination. In 2006, 134.6 million people were affected and 21 342 were killed by natural disasters, mainly in developing countriesWarmer temperatures influence the migratory patterns of wild birds and hence the potential for more unpredictable spread of viruses, like H5N1, that they carry. Chemical, radioactive and biological terror threats: Anthrax-tainted letters sent through the U.S. postal system in 2001 and the release of sarin on the Tokyo subway in 1995 remind us that although chemical and biological attacks are rare, there are people ready to use this brand of terrorism.For much of the world, 21st century life has become greatly dependant on chemical processing andnuclear power. Public health security in turn relies on the safety of these facilities and the appropriate useof their products. The threat of chemical spills, leaks and dumping, nuclear melt-downs, and chemicalweaponry invokes the notion of surprise attack or accidents, innocent victims and malicious or negligentperpetrators and causes fears that may be disproportionate to the real risk.International crises and humanitarian emergencies: Since the 1990s, the European Region has experienced a number of violent conflicts with vast political, social and human consequences.Fighting in the Balkan countries in 1991-2002 is estimated to have killed more than 125000 people and displaced up to 3 million.Economic stability: public heath dangers have economic as well as health consequences. Containing international threats is good for economic well-being. With fewer than 10,000 cases, SARS cost Asian countries US $ 60 billion of gross expenditure and business losses in the second quarter of 2003 alone.Strenghtening Health Systems. Functioning national health systems are the bedrock of international health security. Their objective is to provide the highest level of protection and care possible across the population. They are also the first line of surveillance for diseases, both infectious and chronic. Most diseases do not cause a public health emergency of international concern. But when a disease emerges which does pose such a threat, the alert and response required to prevent spread depend on an adequately resourced and staffed health system.

*pip.rubberfeet.orgWe live in a world where threats to health arise from the speed and volume of air travel, the way we produce and trade food, the way we use and misuse antibiotics, and the way we manage the environment.All of these activities affect one of the greatest direct threats to health security: outbreaks of emerging and epidemic-prone diseases.Outbreaks are unique public health events because of their ability to cross national borders, undetected and undeterred. Traditional defences at national borders are no protection against a microbe incubating in an unsuspecting traveller or an insect hiding in a cargo hold.All nations are at risk. This universal vulnerability creates a need for collective defences and for shared responsibility in making these defences work.

***In 2007, 414 natural disasters were reported. They killed 16847 persons, affected more than 211 million others andcaused over 74.9 US$ billion in economic damages.Europe, also, witnessed several exceptional events like the two floods in the United Kingdom, which affected more than 370 000 people and caused more than US$ 8 billion in economic damages.Nonetheless, Europe remained a region where natural disasters are relatively rare and their impacts are mainly economic rather than human. Indeed, the 65 disasters reported in Europe in 2007 accounted for 27% of the worlds economic damages from natural disasters, but only 1% of the worlds victims.Hydrological (essentially floods) and meteorological (storms) disasters are the major contributors to this pattern. In recent decades, the number of reported hydrological disasters has increased by 7.4% per year on average. Furthermore, we have witnessed a strengthening of the upward trend in recent years, with an average annual growth rate of 8.4% in the 2000 to 2007 period.________________________________________________________________________________________________*The sources of data for natural and technological disaster is EM-DAT. The EM-DAT international disaster database (http://www.cred.be/emdat) is a database on the occurrence and immediate effects of all disasters in the world, from 1900 to the present. It is maintained by the US office of Foreign Disaster Assistance (OFDA) and the WHO Collaborating Centre for Research on the Epidemiology of Disasters (CRED) and is located at the University of Louvain (Belgium). The database is compiled from various sources, including United Nations agencies, non-governmental organizations, insurance companies, research institutes and press agencies. *Floods are the most common natural disaster in Europe. In the recent years, Europe has witnessed some of the largest flooding events in its history.Indeed, 8 out of the 20 most important floods ever recorded in Europe (in terms of human impacts) occurred during the last decade. Recent flooding events include last summers major floods in United Kingdom and the Elbe and Danube river floods during the summer of 2002. Over the last 20 years, flood in Europe have affected over 7 million people and killed 1931 others.

*Since the 1990s, the European Region has experienced a number of violent conflicts with vast political, social and human consequences.Fighting in the Balkan countries in 1991-2002 is estimated to have killed more than 125000 people and displaced up to 3 million.

*In high-income countries, chronic diseases are some of the leading causes of disability and death inadults aged 65 or older. With the demographic and socio-economic transition in developing countries, causes of deaths will shift from communicable, maternal, perinatal, and nutritional causes in the younger population to chronic diseases in older people, and overall disease patterns will also change from acute infectious diseases to chronic diseases. This is known as the epidemiological transition. These chronic diseases include non-infectious diseases(such as arthritis, hypertension, cardiac insufficiency, renal insufficiency, diabetes, chronic obstructive lung disease, and cancer), mainly in the elderly, and infectious diseases (mainly HIV/AIDS) in all age categories.

*Environmental and climate changes have a growing impact on health, but health policies alone cannot prevent their effects. People are dying- upwards of 60 000 in recent years in climate-related natural disasters, mainly in developing countries.

***The slide shows the tree main categories of diseases and events that shall be notified to WHO under IHR (2005) and the criteria that should be fulfill for notification. *www.pitt.edu/~super1/Supercourse is arepository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 64000 scientists in 174 countries who are sharing for free a library of 3623 lectures in 26 languages. The Supercourse has been produced at the WHO Collaborating Center University of Pittsburgh, with core developers Ronald LaPorte, Ph.D., Faina Linkov, Ph.D., Mita Lovalekar, M.D., Ph.D. and Eugene Shubnikov M.D.. Please contact them at super1@pitt.edu.*http://www.pitt.edu/~super1/SEE/see.htm