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Emerging Threats Program Addressing Emerging Pandemic Threats: Lessons from the Past 10 Years Andrew Clements, Ph. D. USAID, Bureau for Global Health 7.

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Presentation on theme: "Emerging Threats Program Addressing Emerging Pandemic Threats: Lessons from the Past 10 Years Andrew Clements, Ph. D. USAID, Bureau for Global Health 7."— Presentation transcript:

1 Emerging Threats Program Addressing Emerging Pandemic Threats: Lessons from the Past 10 Years Andrew Clements, Ph. D. USAID, Bureau for Global Health 7 March 2014 Observations and Lessons from the Past 100 Years

2 Emerging Threats Program Background: Existing vs. New Public Health Threats Existing Public Health Threats HIV/AIDS, TB, malaria, preventable childhood diseases, ARIs, DDs, NTDs, under-nutrition, chronic diseases high (millions of cases annually) geographically dispersed (global, regional) yes scaling up interventions; building capacity insufficient in many countries to go to scale; substantial international/ donor assistance for scale-up Examples Disease burden Affected Areas Diagnostics Interventions Program focus Budget, staffing, training, commodities New Public Health Threats pH1N1, H5N1, and H7N9 influenza; SARS and MERS coronavirus; Nipah virus very low (<1000 cases annually), but case fatality rates 10-70% often geographically contained (country, sub-region) no or limited distribution no gathering evidence for interventions; building capacity insufficient in many countries to gather evidence; very limited international/donor assistance

3 Emerging Threats Program Challenge: Mobilizing Resources for New Threats Relatively low incidence Immediate health threats higher priority than potential future threats Frequent warnings of new threats met with skepticism Difficult to mobilize resources (country level and inter- national/donor level) to: gather evidence develop/distribute diagnostics respond while problem still manageable The sky is falling !

4 Emerging Threats Program Challenges: Understanding New Threats Standard case definitions and reporting procedures usually lacking Health care staff and communities generally not sensitized to signs and symptoms Difficult to determine risk factors with only tens or hundreds of cases spread out over several years Very difficult to design interventions Interventions will most likely be non-biomedical (e.g. policy, behavioral) -Unless current medicines/ vaccines are effective, generally not enough time to develop new medicines/vaccines -Even if current medicines/ vaccines are effective, generally not sufficient quantities for need, especially for a pandemic

5 Emerging Threats Program 2 Map of cholera cases in Soho, London (1858) Dr. John Snow Broad St. pump Intervention = remove pump handle Gathering Evidence for Interventions: A Classic Model

6 Emerging Threats Program Two parallel approaches 1.Study past pandemics (very rare; only 7 since 1900) 2.Study emerging public health threats (rare, but hundreds of events since 1940s) Gathering Evidence on New Public Health Threats Key questions include: Where, how did they start? What impact did they have? Why were these microbes successful? What interventions (if any) worked?

7 Emerging Threats Program Observations on Pandemics Observations: Origin: Asia (4), Africa (1), Americas (1), unknown (1) Source: animals (6), environment (1) Type of microbe: virus (6), bacteria (1) Direct human-to-human transmission (6) Some acute (5), others protracted (2) Potential for very high mortality Low mortality does not equal low economic impact Impact can vary considerably across countries** Only one (SARS) was contained by (non-biomedical) interventions*** Relatively high economic impact Relatively low mortality (<10 million) Relatively high mortality (>10 million) Relatively low economic impact H1N1 flu (1918-1919) HIV/AIDS (~1920-present) H2N2 flu (1957-1958) H3N2 flu (1968-1969) pH1N1 flu (2009-2010) SARS-CoV (2002-2003) 7 th cholera pandemic* (1961-present) Source: WHO; * since 1800. ** e.g. average mortality rate for 1918 flu ranged from 0.2%-20% in part because of income level; *** infection prevention and control in hospitals

8 Emerging Threats Program Many caused by viruses from animals such as bats, rodents, primates*^; livestock may amplify viruses Disease spillover associated with all regions, but some areas are “hot spots” due to favorable conditions such as specific human activities* New diseases can have significant impact** mortality usually low, but economic impact can be significant, e.g. >$200 billion in direct and indirect costs over past decade Most human infections due to animal-to-human transmission; some human-to-human transmission possible, but not efficient Cross-sectoral approaches can improve detection/response In some cases, non-biomedical interventions (changes in farming and livestock marketing; infection prevention and control in hospitals) have reduced amplification/spread among animals and among people * Global Trends in Emerging Infectious Diseases, Jones, et al., 2008, Nature, 451:990-994; ** People, Pathogens and Our Planet – Volume 1: Towards a One Health Approach for Controlling Zoonotic Diseases, World Bank. ^ USAID PREDICT project Diseases emerging from wildlife Diseases emerging from livestock Observations on Other Emerging Public Health Threats

9 Emerging Threats Program spillover from wild animals to people No further transmission source amplification spillover from livestock to people No further transmission spillover from wild animals to livestock No further transmission Spillover, Amplification, and Spread human to human transmission further amplification and spread

10 Emerging Threats Program spillover from wild animals to people source spillover from livestock to people spillover from wild animals to livestock source Minimizing Spillover, Amplification, and Spread human to human transmission Good hospital interventions; some community interventions X Good farm and market interventions X Limited interventions

11 Emerging Threats Program Recent Emergence of Select “New” Viruses* * Based on symptom onset data from WHO (H5N1, H7N9, MERS-CoV) through 3/5/14, WHO case counts (H1N1), and Molecular Evolution of the SARS Coronavirus During the Course of the SARS Epidemic in China, Science, 12 March 2004, 303, pp. 1666-1669. ^ November 2003 used for H5N1 since this was the beginning of this virus’ continued spillover into human populations in multiple countries. Cumulative number of reported human cases (confirmed) At least 1,037 cases after 4 months At least 17,000 cases after 2 months Months after first human case Solid lines = efficient human-to-human spread Dotted lines = primarily animal-to-human spread Dashed lines = both animal-to-human and human-to human spread Already spreading efficiently from person to person when first detected Mostly animal-to- human transmission with limited human-to- human spread

12 Emerging Threats Program H5N1 One Example: Reducing Spillover of New Threats Sources: FAO, OIE, WHO; * = data not complete * Lesson learned: for some public health threats, the “pump handle” may be an animal * * Interventions: Rapid detection Culling infected birds Poultry vaccination Farm/market biosecurity

13 Emerging Threats Program What is the Future Forecast for New Threats? Spillover of animal diseases into human populations expected to continue; many diseases benign, some serious Rates of spillover, amplification, and spread will increase over time since drivers (human and animal population size and density, land use change, etc.) will likely continue to increase However, with improved interventions and investments in their proper application, rates of spillover, amplification, and spread could be decreased Existing interventions (farm/market biosecurity; infection prevention and control in hospitals) need wider application Need other complementary interventions, e.g. limit spillover of diseases from wildlife to people

14 Emerging Threats Program More People = More Opportunities for Disease Spillover Rapidly increasing human population ( e.g. timber, minerals, oil/gas) Increasing domestic animal production Increasing crop production Increasing natural resource extraction Increasing animal-human contact and spillover rate Increasing human population + + = + All driven by increasing human population Percent increase +320% +700% +132% +1950% +117% Year World Meat Production by Type, 1961-2005 (FAO) Host animals for influenza viruses

15 Emerging Threats Program Opportunities for Disease Spillover from Animals Live animal markets Extractive industry/ Land use change Collecting animal wasteBush-meat hunting Pets Wildlife and livestock farms Which contribute most to disease spillover? Which interventions are most effective? Which contribute most to disease spillover? Which interventions are most effective?

16 Emerging Threats Program Human Activities Disrupting Animal Habitats From the film Contagion, 2011, Warner Bros. Pictures History shows again and again how nature points out the folly of men From “Godzilla” by Blue Öyster Cult (1977)

17 Emerging Threats Program Human Activities Attracting Wildlife Source: Dr. Steve Luby, Stanford University

18 Emerging Threats Program Opportunities for Disease Amplification Which contribute most to disease amplification? Which interventions are most effective? Which contribute most to disease amplification? Which interventions are most effective? Mixing species on farmMixing species in market“Factory” farms Roving flocks

19 Emerging Threats Program Hunan, Yunnan & Guangxi Opportunities for Disease Spread (via Trade, Travel) Source: FAO commissioned cross-border study reports Pet fish trade out of South America Informal poultry trade in Asia Source: http://wwf.panda.org/what_we_do/where_we_work/amazon/vision_amazon/models/natural_resources_manage ment_amazon/aquarium_trade_amazon_rainforest/ http://wwf.panda.org/what_we_do/where_we_work/amazon/vision_amazon/models/natural_resources_manage ment_amazon/aquarium_trade_amazon_rainforest/ Source: http://www.thestar.com.my/story.aspx/?file=%2f2009%2f8%2f10%2fstarprobe%2f4369565 http://www.thestar.com.my/story.aspx/?file=%2f2009%2f8%2f10%2fstarprobe%2f4369565 Source: http://spatial.ly/2013/05/great-world-flight-paths-map /http://spatial.ly/2013/05/great-world-flight-paths-map / Air travel Which contribute most to disease spread? Which interventions are most effective? Which contribute most to disease spread? Which interventions are most effective?

20 Emerging Threats Program Common menu bar links Français Home Contact Us Help Search canada.gc.ca HomeHome > Media Room > News Releases > Speaking Notes – Deputy Chief Public Health OfficerMedia RoomNews Releases First North America H5N1 bird flu death confirmed in Canada 8 January 2014 Last updated at 17:35 ET BBC Canadian health officials have confirmed the first known fatal case of the H5N1 avian influenza strain in North America. Canadian Health Minister Rona Ambrose said the deceased person was an Alberta resident who had recently travelled to Beijing. Calling the death an "isolated case", Ms Ambrose said the risk to the general population was low. Ten people have died in Alberta this season from swine flu, or H1N1. H5N1 infects the lower respiratory tract deep in the lung, where it can cause deadly pneumonia. In the latest incident, the infected person first showed symptoms of the flu on an Air Canada flight from Beijing to Vancouver on 27 December, officials said. The passenger continued on to Edmonton and on 1 January was admitted to hospital where they died two days later.

21 Emerging Threats Program Next Steps for Addressing New Public Health Threats Strengthen developing country protocols, platforms, and capacities for cross-sectoral, rapid disease detection/response  these will be used for responding to new threats Understand which public health threats are most likely to spillover from animals to people Investigate (in advance) mechanisms for spillover of animal disease to people Develop interventions and response plans, monitor, and revise as needed

22 Emerging Threats Program Recent Detection of Avian Influenza Viruses in Asia June 2013-February 2014 Sources: OIE, WHO; * Highly-Pathogenic Avian Influenza; ^ Avian Influenza. Hosts for each of the influenza virus sub-types are indicated as follows: humans ( ); poultry ( ); wild birds ( ). Dots shows the approximate location where an influenza virus sub-type was detected in any of the hosts. Virus sub-type H5N1 HPAI* H5N2 HPAI H5N8 HPAI H6N1 AI ^ H7N2 HPAI H7N9 AI H9N2 AI H10N8 AI = not detected in people prior to 2013

23 Emerging Threats Program Detection of Specific Zoonotic Viruses that have Potential to Spread within Human Populations* Sources = OIE, WHO, CDC, Ministry of Agriculture/FAO (Egypt, Indonesia), and IEDCR (Bangladesh) reports between 11/1/12 and 3/14/14. * = All of these viruses are capable of infecting people and human populations likely do not have wide-spread immunity to them; at present, human-to-human transmission appears to be limited. While these reports reflect known infections with these viruses, there may be additional viral circulation in these and other countries that is not detected due to limitations in surveillance and/or detection. = countries (including northeastern Brazil, southeastern China, and most of Indonesia) using USAID funding between FY2012 and FY2014 for surveillance and response to avian influenza and/or other emerging pandemic threats. = H5N1 highly-pathogenic avian influenza (poultry, wild birds, or humans = H7N9 low-pathogenic avian influenza (poultry, wild birds, or humans) = other novel avian influenzas such as H6N1 and H10N8 (humans) = other highly-pathogenic avian influenza H5, H7, or H9 avian influenza (poultry, wild birds) and/or other low-pathogenic H5, H7, or H9 (humans) = H1N1v, H1N2v, and H3N2v swine influenza (humans) = Ebola (humans) = Marburg (humans) = Nipah (humans) = Middle East Respiratory Syndrome-Coronavirus (humans)

24 Emerging Threats Program Mapping Viral Diversity in “Hot Spot” Regions PREDICT Project: Animal and human samples being tested for 20 viral families known to cause human disease including Coronaviruses, Ebola, Influenza, Marburg, Nipah. Over 250 novel viruses have been detected so far.

25 Emerging Threats Program Building the Foundation for Action Time Existing public health threats Problem identification, gathering evidence Mostly done Developing/ testing interventions Mostly done Scaling up interventions In process You are here Strengthening capacity New public health threats Problem identification, gathering evidence In process Developing/ testing interventions Just beginning Scaling up interventions Not started Strengthening capacity You are here

26 Emerging Threats Program The “One Health” concept recognizes that the health of humans is connected to the health of animals and the environment. “One Health” Approach Source: CDC http://www.cdc.gov/onehealth/http://www.cdc.gov/onehealth/ Public Health Animal Health Environ- mental Health “One Health” Because of the role of animals in the spillover and amplification of Emerging Public Health Threats, prevention, surveillance, detection, response and research efforts along with training need to operate in multiple sectors

27 Emerging Threats Program Limited capacity for dealing with old and new disease threats for both animals and people:  Limitations in disease detection/response capacity, health care services, data for policy, staff, budgets  Insufficient stockpile of biomedical measures (e.g. vaccines, medicines) Limited capacity to predict disease emergence  Some understanding on where, how, and why diseases emerge, but more specificity needed for prevention and containment Lack of effective coordination  across society (e.g. government, military, civil society, private sector)  across sectors (e.g. public health, animal health, environment) Existing One Health Capacity Limited

28 Emerging Threats Program USAID Pandemic Influenza & Other Emerging Threats Activity areas: Avian Pandemic Other Emerging InfluenzaPreparedness Threats Current activities Past activities

29 Emerging Threats Program PIOET Accomplishments (2005-2014): New Threats * Coordinated with CDC and WHO; ^ coordinated with FAO 1. Decreased H5N1 threat –Faster detection and containment –Fewer countries affected 2. Enhanced pandemic preparedness –30 countries established national coordinating bodies for preparedness –25 countries developed “first order” pandemic preparedness plans –Military authorities in 32 countries developed “civ:mil” preparedness response plans 3. Improved infectious disease detection –Detection of routine infectious diseases –Surveillance and detection of microbes with pandemic potential –Improved understanding of conditions that favor disease emergence/spread 4. Strengthened capacity –Pre-service training (One Health) –In-service training (public health, animal health): lab, surveillance, epi, etc.

30 Emerging Threats Program 5. Rapidly used PIOET platforms and expertise to address new threats : * Coordinated with CDC and WHO; ^ coordinated with FAO H1N1 influenza pandemic (2009-2010)* –detailed technical and logistics experts to WHO to assist in planning distribution of vaccine and ancillary equipment –deployed >70 million doses of H1N1 pandemic vaccine (including U.S. donation) and injection equipment to >60 countries –upgraded H1N1 surveillance and laboratory capacities in 26 countries in Africa and Latin America MERS-coronavirus (2012-2014)* –genetic sequence comparison used to target surveillance –surveillance and lab protocols used to identify animal source H7N9 avian influenza (2013-2014)*^ –surveillance and lab protocols used to identify animal source and other potential threats circulating in animals Animal and human infectious disease programs SARS-CoV (2002) H5N1 (2005) H1N1 (2009) MERS-CoV (2012) H7N9 (2013) PIOET Accomplishments (2005-2014) continued

31 Emerging Threats Program Global Health Security White House Global Health Security Vision – “to prevent, detect, and respond to biological threats, regardless of cause” Provides a new and important strategic framework for “re-visioning” our rationale for action and opportunities for broadening our partnerships “To stop disease that spreads across borders, we must strengthen our systems of public health…. And we must come together to prevent, detect, and fight every kind of biological danger – whether it is a pandemic like H1N1, a terrorist threat, or a treatable disease. --President Obama, UNGA, September 22, 2011

32 Emerging Threats Program USAID Goal Under Global Health Security As the “Development” arm of the USG Global Health Security Framework, USAID will launch its Emerging Pandemic Threats Program (ver. 2) in October 2014 to: mitigate the impact of novel high consequence pathogens arising from animals through a suite of “One Health” investments targeted at the animal-human interface that enable early detection of new disease threats*; effective control through enhanced national-level preparedness*; reduction of risk of disease emergence by minimizing practices and behaviors that trigger spillover and spread of new pathogens* * Building on developing-country programs to address infectious diseases in animals and people.

33 Emerging Threats Program Further reading Origins of AIDS, Jacques Pepin, 2011 Global Trends in Emerging Infectious Diseases, Jones et al., 2008, Nature, 451:990-994 The Great Influenza, John Barry, 2004 The Coming Plague, Laurie Garrett, 1994 Guns, Germs, and Steel, Jared Diamond, 1997


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