1. The Interface Between Human and Veterinary Public Health Emerging Zoonotic Disease Summit Gainesville, Florida August 23, 2005 Lonnie J. King Director, Office of Strategy and Innovation, CDC Dean, CVM, Michigan State University

2. Historical Epidemiological Transitions Paleolithic Age Hunters and gatherers Nomadic Small populations Parasitic infections

3. Historical Epidemiologic Transitions – 1 st Transition  10,000 years ago  New social order due to agriculture  Zoonoses through animal domestication  Increases in infectious diseases  Epidemics in non-immune populations

4. Deadly Gifts Guns, Germs and Steel  J. Diamond

5. Historical Epidemiologic Transitions – 2 nd Transition  Coincided with mid-19 th century Industrial Revolution  Decreases in infectious disease mortality  Increasing life expectancy  Improved nutrition  Antibiotics  “ Diseases of Civilization ” – cancer, diabetes, cardiovascular diseases  Environmental problems  Chronic diseases

6. Historical Epidemiologic Transitions – 3 rd Transition  Last 25 years  Emerging infectious diseases globally  New diseases and increases in mortality; first since 19 th century  Re-emergence  Antimicrobial resistance  75 percent of diseases are zoonotic  Anthropogenic factors of emergence; the microbial “ perfect storm ”

7. “ The Perfect Storm ”  Sebastian Junger an ocean tempest due to a rare combination of factors and circumstances that might occur every century

8. MICROBIAL THREATS TO HEALTH EMERGENCE, DETECTION, AND RESPONSE INSTITUTE OF MEDICINE OF THE NATIONAL ACADEMIES National Academy Press Washington, DC 2003

9. The “Microbial” Perfect Storm Due to special combinations and circumstances Relatively common occurrence Doesn’t dissipate, but may perpetuate or accelerate Convergence model

10. WHO Map on World – Emerging Diseases

11. Convergence Model Convergence Model (Microbial Threats to Health – IOM/NAS, 2003) Social, Political and Economic Factors Physical Environmental Factors Ecological Factors Genetic and Biological Factors Human Microbe

12. Factors in Emergence Microbial adaptation and change Host susceptibility to infection Climate and weather Changing ecosystems Economic development and land use Human demographics and behavior Technology and industry

13. Factors in Emergence continued International travel and commerce Breakdown of public health measures Poverty and social inequality War and famine Lack of political will Intent to harm

15. Multihost Pathogens 60% of all human pathogens are zoonotic 80% of animal pathogens Ecological generalists

16. New Dynamic Emerging diseases – 70% zoonotic New zoonoses Food safety Antimicrobial resistance Agents of bio- and agro-terrorism – 80% zoonotic Global trade and movements

17. Rapidly Increasing Human Population 6.1 Billion people in 2000 ~9.4 to 11.2 Billion in 2050 Source: United Nations, World Population Prospects, The 1998 Revision; and estimates by the Population Reference Bureau.

18. Rapidly Increasing Urbanization 2000 - 47% world population living in urban areas 2030 - 60% world population living in urban areas

19. The Divided World of 2025 – 8.4 Billion People World 1 Advanced nations (Advances in medicine and food) World 2 Middle class (Livestock Revolution) World 3 People in destitution and poverty (Sources of traditional pathogens)

20. El Nino Leptospirosis Hantavirus Rift Valley fever

21. Vectors of Disease

22. Global Warming Shifting and enlarging the incidence and distribution of disease Malaria zone 45% of population to 60% Habitat change and disruption via weather changes

23. Global Warming Effects on Malaria

24. Ecosystem

25. Waterborne Zoonoses Animals Humans Microbial Pathogens Waterborne Disease Water Environment

26. Waterborne Zoonoses – Global Threat 4 billion cases of diarrhea per year 2-3 million deaths Poorly reported Zoonotic portion is significant Endemic and epidemic 1.1 billion people with unreliable water supply

27. Waterborne Zoonoses Pathogens Cryptosporidium Giardia E. Coli 0157:H7 Salmonella Leptospiria Toxoplasma Campylobacter Entamoeba Ascarsis Viruses and Prions? SARS?

28. Concentrated Animal Feeding Operations (CAFOs) Their Impact on Food Safety and Healthy Environments

29. Foodborne Infections Worldwide > 2 million people die from diarrhea caused by contaminated food and water each year U.S. ~ 76 million persons experience foodborne illnesses (1 in 4 people) - ~325,000 hospitalizations - ~5,000 deaths

30. Most Common Foodborne Pathogens Campylobacter Salmonella E. coli 0157:H7 Yersinia Listeria Cryptosporidium Cyclospora Norwalk-like viruses

31. Livestock 2020 – The Next Food Revolution Global increase and demand for protein and food of animal origin Shift from poverty of 1-2 billion people to middle class “Westernization” of Asia and Latin America Concerns with sustainability Increases in emerging zoonoses through the concentration of people and animals

32. By 2020, There will be 1 Billion People Over the Age of 60 30% of US population are baby boomers Immuno-compromised population

33. Movement and Interactions of People and Commerce Distance and speed of travel increased 1000 fold since 1800 1.4 billion air travelers/year 50 million foreign visitors, to US year through, 102 sites Antibiotic resistance Global trade of food, animals and plants

36. The Coming Plague Today’s mingling of people, animals and microbes in new environments has no historical precedent. -”We await the coming plague” - Laurie Garrett

37. Remote Sites

38. Pathogen Pollution Human and domestic animal populations Free-living wild animals Example: global decline in amphibian populations due to chytridiomycosis Concern with adverse effects on biodiversity

39. Chytridiomycosis

40. Virus Carriers Fruit bats

41. Flying Foxes

42. Nipah Virus

43. Malaysian Pig Farms

44. Wildlife EID Domestic Animal EID Human EID Translocation Human encroachment Ex situ contact Ecological manipulation Global travel Urbanization Biomedical manipulation Technology and Industry Agricultural Intensification Encroachment Introduction “Spill over” & “Spill back” Emerging Infectious Diseases Dasazak P. et.al. Science 2000 287:443

45. Spill Over and Spill Back

46. What’s Next?

47. Human Monkeypox Cases Marshfield Clinic and MCW Matt Kuehnert

48. Exotic Pets

49. SARS

50. Maintenance Host

51. SARS Airport Screening

52. The Lessons of SARS The need for multinational collaboration Public alarm can lead to huge economic impact - $80 billion Weaknesses in public health infrastructures Consequences of poor reporting –disincentives A true zoonosis: more to come Constant threat due to Emerging Infectious Diseases in less developed countries

59. H5N1 Avian Influenza

60. Pandemic Influenza

61. The Next Influenza Pandemic Not if, but when 1918-1919 Experience: 20 million deaths 150 – 450% increase in patient and hospital visits In 2001 (Asia only), 160 million workdays lost, and for a pandemic, 6 billion workdays lost worldwide

63. Bioterrorism Biodefense Agroterrorism

64. Agents of Bioterrorism

65. CDC’s Most Significant Global Epidemics Over the Last Decade 1993 – Hanta virus 1994 – Plague (India) Ebola virus (Zaire) 1996 – New Variant of CJD (UK) H 5 N 1 influenza (Hong Kong) 1998 – Nipah virus (Malaysia) 1999 – West Nile 2000 – Rift Valley Fever 2001 – Anthrax 2002 – Norwalk-like viruses 2003 - SARS

66. Implications of Emerging Diseases Political Social Economic Psychological Environmental

67. Animal-borne Epidemics Out of Control: Threatening the Nation’s Health – 2003  A report from the Trust for America’s Health

68. Findings from the Report U.S. lacks a national program to prevent and control diseases that impact humans, animals and our food There is no coordinated effort or single agency with a “command and control” responsibility There is a lack of effective communications with the public about these diseases and their impact Disease surveillance systems are not linked

69. Findings from the Report (continued) Funding for bioterrorism has not adequately supported efforts to counter zoonotic disease threats, especially from the animal health perspective and infrastructure There is a fragmentation of jurisdictions, authorities, statutes and research; e.g. 200 different government offices and programs responding to 5 zoonotic diseases Animal and public health are separated by culture and organization

70. Microbial Threats to Health Conclusions & Recommendations 1. Enhancing the global response capability 2. Improving global infectious disease surveillance 3. Rebuilding domestic public health capacity 4. Improving domestic surveillance through better disease reporting (this includes both human health and veterinary health) 5. Exploring innovative systems of surveillance 6. Developing and using diagnostics

71. Microbial Threats to Health Conclusions & Recommendations (continued) 7. Educating and training the microbial threat workforce 8. Developing and producing vaccines 9. Developing and producing antimicrobial drugs 10. Controlling the use of antimicrobials 11. Controlling vectorborne and zoonotic diseases 12. Establishing a comprehensive infectious disease research 13. Creating interdisciplinary infectious disease centers

72. Preventing Emerging Infectious Diseases: A Strategy for the 21 st Century – CDC Goal 1:Surveillance and Response Goal 2:Applied Research Goal 3:Prevention and Control Goal 4:Infrastructure and Training

73. Public Health at the Crossroad New, inclusive vision of public health Shift to focusing on causes of population health Ensuring that population health is a central concern of policymakers Globalization of causes and issues Socioeconomic disparities Emerging threats due to interdependence New team – expanded, integrated and transdisciplinary

74. Population health is a shift from an emphasis on individual health to understanding the multiple determinants of health.

75. Health is an outcome shaped by a wide range of social, economic, natural, built, and political environments that form a complex and ever- changing dynamic. Because of this broad perspective, public health teams themselves also need to reflect this reality.