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GRASPING PUBLIC HEALTH EMERGENCIES: What have we learned from the SARS epidemic? Frederick M. Burkle, Jr., MD, MPH, FAAP, FACEP Senior Scholar, Scientist.

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Presentation on theme: "GRASPING PUBLIC HEALTH EMERGENCIES: What have we learned from the SARS epidemic? Frederick M. Burkle, Jr., MD, MPH, FAAP, FACEP Senior Scholar, Scientist."— Presentation transcript:

1 GRASPING PUBLIC HEALTH EMERGENCIES: What have we learned from the SARS epidemic? Frederick M. Burkle, Jr., MD, MPH, FAAP, FACEP Senior Scholar, Scientist and Visiting Professor The Center for International Emergency, Disaster and Refugee Studies The Johns Hopkins University Medical Institutions

2 OR… SARS…The best thing since sliced bread…!!

3 OBJECTIVES Using the SARS experience….. Identify how SARS has impacted the expectations of response requirements for ALL accidental and deliberate infectious disease outbreaks Describe the requirements for surveillance and management in the future

4 PRE-SARS ENVIRONMENT Worldwide political interference in public health National sovereignty corrupted public health response Public health functioned better in the 19 th century

5 PRE-SARS ENVIRONMENT Repeated failures to cooperate for the common good Highly competitive/Vertical response Placed global health initiatives in question

6 PRE-SARS ENVIRONMENT World Health Organization (WHO): Mandated reporting only required for yellow fever, cholera and plague Relied on member states to voluntarily report domestic outbreaks

7 PRE-SARS ENVIRONMENT Countries with most diseases and risk of epidemics had little systemic surveillance Reached a crisis level rapidly Complex emergencies accounted for over 75% of epidemics in the 1990s



10 PRE-SARS ENVIRONMENT WHO, once they learned of an outbreak, could only deal with national governments to offer advice and limited resources Political squabbles bogged down polio immunization and eradication efforts (e.g. India, Nigeria)

11 PRE-SARS ENVIRONMENT WHO relied on Non-governmental Agencies (NGOs) as eyes and ears during emergencies Worldwide alert for SARS was the responsibility of one man

12 INTERSTITIAL-SARS ENVIRONMENT Dissembling of SARS numbers by Chinese authorities Political fervor over how or whether international community could assist Taiwan during SARS

13 INTERSTITIAL-SARS ENVIRONMENT SARS served as impetus for change… …best thing that happened to a sluggish, unprepared & politically encumbered international Public Health system

14 INTERSTITIAL-SARS ENVIRONMENT World Health Ministers weighed in….directed WHO to act on information from all sources! WHO developed a network of networks…laboratories, experts, and an array of informants ALL pledged to work with WHO

15 INTERSTITIAL-SARS ENVIRONMENT: NETWORK OF NETWORKS WHO Tapped into digital information systems Collaborated with Canadas Global Public Health Information Network (GPHIN)…searching for hints of disease outbreaks….

16 INTERSTITIAL-SARS ENVIRONMENT: NETWORK OF NETWORKS WHO formally unveiled its Global Outbreak Alert & Response Network (GOARN): technical, operational & political at all levels Stovepiping information to ensure it gets to the right people…

17 POST-SARS ENVIRONMENT OUTCOME: ALL countries must now report any disease outbreak of international concern 1.WORLD HEALTH ASSEMBLY: Transparent reporting 2.INTERNATIONAL HEALTH REGULATIONS: WHO has authority to coordinate response to any infectious disease that is a threat to international public health

18 POST-SARS ENVIRONMENT 1.WHO can act to verify outbreaks based on any available information (official or non-official sources) 2.Does NOT need to wait for official government notifications accidentaldeliberate 3.Reaffirms WHO leadership in deterring severity of outbreaks …accidental or deliberate

19 POST-SARS ENVIRONMENT Challenges: Must still rely on local expertise to identify sentinel cases Must move fast and decisively to communicate to the public incredibly well

20 POST-SARS ENVIRONMENT Challenges: Must ensure that information is accurate…otherwise negative effect leads to panic or unsuitable response Still lack a substantive surveillance system


22 CONVENTIONAL SURVEILLANCE SYSTEMS CONVENTIONAL SURVEILLANCE SYSTEMS One-way, medical recording systems Not real time Background baseline epidemiology is unknown Symptom oriented vs. syndromic Poor compliance No working relationship between clinical acumen and available detectors

23 Sense cDNA Labeled Antisense cDNA Hybridization Patterned Microarray Cells Extract RNA and reverse transcribe 1000s of tests DNA/RNA ARRAY TECHNOLOGIES Sample Combination of protein arrays (rapid screening) and DNA microarrays (rapid screening) and DNA microarrays (diagnosis/disease characterization): rapid detection of emerging ID patterns & diagnosis of specific ID s & diagnosis of specific ID s

24 DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM: DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:CRITERIA Real timeReal time Presymptomatic/symptomaticPresymptomatic/symptomatic Multiple body fluidsMultiple body fluids No false positivesNo false positives High densityHigh density Microplate-formatMicroplate-format High-throughputHigh-throughput DNA sequencing

25 DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM: DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:CRITERIA Immediately uploadableImmediately uploadable Two-way reportingTwo-way reporting Supercomputer assistedSupercomputer assisted Cost effectiveCost effective Immediate human interfaceImmediate human interface Event criteria that generates consequence managementEvent criteria that generates consequence management

26 Advanced System Criteria Advanced System Criteria Minimal detection-to-confirm & detection-to-treat times Lateral decision-making human- interface immediately engaged with new or emerging infectious agents

27 Advanced System Criteria Advanced System Criteria Generation of baseline epidemiology Development of extended time-line triage and management for training, education, and decisions on public health


29 Early Evaluation of Questionable Cases Anywhere in the world, where early unexplained clinical symptoms occur… The positive predictive value is improved if used in combination with an epidemiologic network All patients screened for exposure, travel, contact with ill humans or animals Over triage: provisional diagnosis for anyone with fever and respiratory illness

30 Pacific Public Health Surveillance Network: PPHSN E-mail/FAX listserver Network of practitioners & decision-makers Early warning for epidemic threats Raise awareness & preparedness Access to resources, including technical expertise A 3 tier network of PH laboratories: L1: National/territorial labs L2: 4 PH Labs L3: Reference Labs PacNet LabNet EpiNet Multidisciplinary National and Regional outbreak response teams

31 VACCINE DEVELOPMENT Prepared in fertilized chicken eggs 50 year old technology & methodology Tedious & slow Massive #s of eggs required for surge capacity chicken virus Cultured cell-based vaccines Only the human virus is cultured Rapid process Easily escalated to large volumes CURRENT INFLUENZA VACCINE: FUTURE INFLUENZA VACCINE:

32 THREATS Benign viruses turn deadly Influenza pandemic developing from current avian (bird) influenza Agents with long incubation periods (i.e., BSE) have great capacity for damage Increased animal to human spread of disease

33 THREATS Conventional surveillance system unable to detect bioagent in food and agriculture Lack public health infrastructure to respond to: widening urbanization & poverty, population movements & cross- border transmission

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