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Global Health Security

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1 Global Health Security
US efforts towards more rapid and effective response Jeff N. Borchert Health Scientist, Division of Vector-Borne Diseases Global Health Security Demonstration Project Centers for Disease Control and Prevention - Uganda 5th Annual AFENET Conference, Addis Ababa, November 2013

2 Biological threats, whether naturally occurring, intentionally produced or the result of laboratory accident, constitute a growing international threat to humans and the global economy I want to start with the following statement. It reads…….

3 I wanted to tell you about something that happened about a year ago in a village in Uganda very near the border of DRC. Tragically, a young child got sick and died. The mother took the body of the child to a nearby village in DRC for the funeral

4 More than 100 people attended the funeral for this boy.
On the way back the mother also became ill as well as another woman, a friend who cared for the child. The friend also died and the mother was admitted into the hospital.

5 A local team from the Uganda Virus Research Institute invested the cases
They performed a rapid test and culture the mothers blood. The mother then died as well. 3 people dead The tests were positive for plague, pneumonic plague – the most dangerous and contagious form of the disease. Pneumonic plague can be transmitted to others in close contact by coughing.

6 The UVRI Plague Station mobilized and within 12 hours over 130 people, who had been expose were treated with antibiotics to prevent them from developing potential infection. Within 24 hours, the plague team visited every hut in the villages and sprayed them with insecticide, because plague is spread from rats, to fleas to people. There were no further cases

7 So what happened here?? Did the victims get on a bus and travel to Kampala or worse to the airport to Europe or elsewhere? It didn’t even make it into the newspapers. Was this the world’s next big outbreak of disease or international public health emergency. No So what happened? Something worked. Something worked on a very basic level prevented further cases At its heart this is really what Global Health Security is. Disease outbreaks remind us that we are all connected, in some-ways all at risk. An outbreak anywhere can be a risk for people everywhere.

8 Global Health Risks are Increasing
Emergence and Spread of New Pathogens Globalization of Travel, Food and Medicines Rise of Drug Resistance Intentional Engineering of Microbes Recombinant Technologies Anthrax MRSA XDR TB Food Supply Today;s health security threats arise from at least 5 sources: Emergence and spread of new mircrobes, or reemerged microbes Globalization of travel and food supply Rise of drug resistance Accelleration of biological science capabilities Continued concern about terrorist acquisition of biological agents Some repots suggest that new diseases are emerging at about 1/year: better technology to detect, better epi, more awareness Avian Flu HIV

9 Our friends at USAID produce a monthly map on outbreaks that have pandemic potential
These events happen often and it is easy to see how what affects one area of the world can affect others Remember that SARS caused 8,273 cases, 775 deaths and economic damage in the billions of dollars. MERS-CoV has already infected over 270 people and killed more than 100

10 Rapidly detecting and reporting outbreaks
Global Health Security – A world safe and secure from global health threats posed from infectious diseases by: Preventing or mitigating naturally occurring outbreaks and intentional or accidental releases of dangerous pathogens, Rapidly detecting and reporting outbreaks Employing an interconnected global network that can respond effectively to limit spread of infectious disease Mitigating human suffering, loss of life and economic impact So what is Global Health Security? IHR is THE STANDARD by which the world measures preparedness for emerging disease threats and bioterrorist events. Country IDSR plans are the implementation of this

11 3 Pillars of CDC’s Approach to Global Health Security
Detect …threats early Respond …rapidly and effectively There are 3 basic pillars of Global Health Security: 1. Detect threats early Improve surveillance systems and rapid reporting of outbreaks Strengthen laboratory systems Train field epidemiologists Build facilities to investigate outbreaks Embed staff and mentors in Ministries of Health 2 Respond to outbreaks rapidly and effectively: Create interconnected emergency operations centers Build local emergency response expertise Improve border safety and quarantine measures Establish or strengthen the public health workforce Scale-up information management and technology infrastructure to support executive decision-making 3. Prevention entails: Creating safer, more secure labs working with dangerous pathogens Ensure a safer food and drug supply Prevent the emergence and spread of antimicrobial drug resistance and emerging zoonotic disease Immunize against epidemic-prone diseases Promote evidence-based policies and decision-making which reduce the magnitude of infectious disease outbreaks Guide implementation and prevention measures …avoidable catastrophes and epidemics Prevent

12 CDC Global Health Security Demonstration Projects
CDC sought to develop a model approach of rapid GHS capacity upgrades that could be implemented, improved and duplicated Uganda and Vietnam March – September 2013 Engagement with MoH and Stakeholders (AFENET) Mechanism to accelerate country progress toward IHR goals

13 GHS Objectives in Uganda
(April-Sept 2013) Strengthen the disease surveillance system’s capacity for detection, specimen referral and laboratory confirmation of: MDR-TB and XDR-TB Cholera VHF- Ebola Establish a functional public health Emergency Operations Center Enhance information systems to enable real-time monitoring of epidemics and response by integrating data sources from the disease surveillance and EOC The remainder of my talk is about the CDC MoH demonstration project in Uganda. The MoH chose three priority disease to focus on: MDR-TB, Cholera and Ebola as a model for VHFs

14 Demo - Build Upon Existing Efforts
Ministry of Health (MOH), Uganda Central Public Health Laboratory (CPHL) Uganda Virus Research Institute (UVRI) National TB Reference Laboratory (NTRL) PEPFAR Investments Enhance District Health Information System-2 (DHIS-2); a web-supported, password protected data base Support MOH district surveillance officers to investigate and report credible events via short message service (SMS) alerts through DHIS-2 Utilize Early Infant ‘HIV’ Diagnosis (EID) specimen referral hub system to transport, using motorcycles and postal service, biologic specimens for laboratory testing Augment NTRL’s TB GeneXpert roll-out and testing scheme WHO AFRO and AFRICHOL Support culture-based confirmation of Vibrio cholerae at regional hospitals and AFENET Uganda AFENET: We partnered with AFENET to implement this program with MoH. Capitalized on their

15 Districts and Hubs Coverage for the GHS project

16 Uganda - Laboratory Systems
GHS Uganda pathogens of interest Ebola: Suspect cases isolated, specimens collected and transported to UVRI via hub network and Posta Uganda Cholera: Rapid diagnostic tests pre-positioned at 17 district health facilities with specimen referral to regional referral hospital or CPHL via Posta Uganda for culture MDR TB: Sputum transported to a GeneXpert site via EID transportation hubs; rifampin-resistant TB specimens sent to NTRL via Posta Uganda for culture and drug resistance testing Notification Laboratory results interlinked via EOC through SMS; online reporting and tracking via DHIS-2 GHS improvements capitalized on existing PEPFAR transportation hubs for EID HIV samples. Partnering with govt supported bus system; this network will be the foundation for National Surveillance Program DHIS-2 is an online system accessible to all locations with internet Toll free SMS service We demonstrated that improvements in transport, laboratory diagnostics and sample tracking/reporting decreased the amount of time for accurate diagnosis.

17 Uganda - Emergency Operations Center
Obtained physical space for interim EOC Link with Ministry of Health (MoH) Resource Center (PEPFAR) Permanent facility with National Health Laboratory and Resource Center compound in Port Bell (vision for a NPHI) Organized a visit for senior MoH leaders to CDC Provided emergency management training for operations Supported the EOC manager position

18 Uganda - Information Systems
Improve real-time detection, monitoring and confirmation through improved connectivity, timely data collection and access within the District Health Information System (DHIS2) Develop disease-specific mobile tools for data capture and use during outbreaks (Epi-Info based) Improve lab data quality, timeliness and use through a centralized specimen tracking system and expand availability of results Build an integrated data system using the EOC as the hub Develop dashboards and reports for access by health system stakeholders at all levels on a “need to know” basis All of these improvements will be available to health system stakeholders and multiple levels.

19 Accomplishments SOPs and protocols established
Exercise drill completed Sept 2013 Evaluated specimen transport, SMS communication, DHIS-2 tracking, and EOC management of mock response Used GHS Uganda system components: Crimean-Congo hemorrhagic fever outbreak in Agago District: Referral hub transported suspect VHF specimens within 24 hrs Suspect case of XDR-TB at Mulago Hospital’s isolation ward had sputum collected, tracked and transported to NTRL (extracted M. tuberculosis DNA for sequencing in Atlanta) Besides EOC, key achievements in three areas: 1) communications, 2) specimen transportation and 3) diagnostic capability Visit to CDC EOC by MOH senior staff June 2013 Visit by CDC Director to Uganda including EOC – July 2013 The rapid upgrades of the pilot project (EOC + key achievements above) have rapidly increased UG’s compliance with IHR

20 EOC Activations Pilgrims returning from Hajj
Solar Eclipse in Pakwatch, NW Uganda eMTCT HIV

21 Next Steps - Response Conduct Incident Command Structure training for key staff Train rapid response teams and develop disease-specific district SOPs for outbreak response Train village health teams in disease containment and reporting Re-administer lab assessment tool to identify GHS improvements and maintain continuous quality improvement Expand GHS model beyond 17 pilot districts; add 23 districts/year Perform 2014 exercise drill focused on response capabilities Ultimate goal is to establish surveillance network down to village level Plan to add 23 district per year covering all districts within 5 years MoH considering activation of EOC for eMTCT eMTCT activation will mark the opening of the EOC with high level of engagement from First Lady This high level opening will allow MoH to start marketing the EOC to press and Uganda Uganda GHS project may serve as a model for other countries in it’s entirety or at least some elements are replicable in other countries.

22 Most effective roll out of GHS
Replicable model of GHS capacity upgrades Multi partner engagement International partnerships Different in every country “…we must come together to prevent, and detect and fight every kind of biological danger - whether it’s a pandemic like H1N1, or a terrorist threat or a treatable disease.” President Barack Obama, 2011 Mulitparty engagement – nations to nations, donor to recipients, stakeholders Nuances are different in every country. Must always consider the unique need of host countries Currently USG invests ~$2.7 billion in GHS objectives – about ½ to improve GHS capacity and ½ for research

23 Thank you US DoD Defense Threat Reduction Agency AFENET Uganda
Uganda Ministry of Health Uganda Virus Research Institute CDC Atlanta CDC Fort Collins

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