When animal diseases strike human
an integrated approach in time and space
Crédit photos A. Epelboin, A. Casanova, P. Formenty, WHO
International Meeting Pierre Formenty – 13 February 2009, Vienna, Austria On Emerging Diseases 2009
Our world is changing ● The way we live ● 2025: 5 Billions urban ● Microbes evolve ● New threats emerge
Emerging or re-emerging infectious diseases outbreaks and countries with conflicts, 1990-2008.
Ebola, Marburg & CCHF
Rift Valley Fever
Plague
Influenza H5N1
SARS CoV
Tularemia
Lassa fever
Yellow fever
Malaria
Monkeypox
Polio virus
Trypanosomiasis
Nipah & Hendra
West Nile
61% of EIDs are Zoonoses affecting Humans Translocation
Encroachment Introduction “Spill over” & “Spill back”
Agricultural Intensification
Wildlife
Domestic Animal
Daszak P. et.al. Science 2000 287:443
Human encroachment Ex situ contact Ecological manipulation
Human
Technology And Industry
Global travel Urbanization Biomedical manipulation
● Frequency of all EID events has significantly increased since 1940, reaching a peak in 1980-1990 ● 61% of EID events are caused by the transmission from animals (zoonoses) ●
74% of these from wildlife.
● Zoonotic EIDs from wildlife reach highest proportion in recent decade
Emerging Zoonotic Diseases: from forecasting to outbreak response.
Emerging Zoonotic Disease outbreak alert and response Animal Outbreak
Animal outbreak
Human Outbreak
40
36
32
28
24
16
8
4
12
TIME
20
Human Amplification
Animal Amplification
0
-4
Climate Vegetation Environment
-8
90 80 70 60 50 40 30 20 10 0
-2 0 -1 6 -1 2
Number of Cases
Human outbreak
Emerging Zoonotic Disease outbreak alert and response Late Detection
Animal outbreak
Delayed Response
40
36
32
Control Opportunity
28
24
16
8
4
12
TIME
20
Human Amplification
Animal Amplification
0
-4
-8
90 First cases 80 In Animals 70 60 Climate 50 Vegetation 40 Environment 30 20 10 0 -2 0 -1 6 -1 2
Number of Cases
Human outbreak
Emerging Zoonotic Disease outbreak alert and response Animal outbreak Human outbreak
90 80
Number of Cases
70
Control Opportunity
60 50 40 30
Animal Amplification
Animal Vaccin°
20 10 0 -20
-15
-10
-5
0
5
10
15
20
25
30
35
TIME
1. Forecasting Readiness
2. Early detection Animal & Human cases
3. Rapid Response
40
Emerging Zoonotic Disease outbreak alert and response
1. Before
2. During
3. After
Emerging Zoonotic Diseases: Risk mapping and Forecasting
Modeling EZD events: Relative risk of an EID
Hot Spots: global distribution of relative risk of an EID event caused by zoonotic pathogens from wildlife, (Jones Nature, 2008).
Modeling EZD events: CCHF risk map
Courtesy David Roger, Oxford University, Department of Zoology, Oxford, UK
Forecasting EZD emergences Ebola surveillance in Central Africa
Collaborators: WCS, CIRMF, IRD, ECOFAC, MoH, National Park Boards, MSF, WHO.
Geographic Distribution of Filovirus and Henipavirus outbreaks and fruit bats of the Pteropodidae Family.
Filovirus outbreaks
Henipavirus outbreaks
Countries at risk for Filovirus (viro or serological evidence)
Countries at risk for Henipavirus (viro or serological evidence)
Home range of Pteropodidae Family fruit bats
Home range of Pteropus genus fruit bats
Climatic and Ecological Conditions for RVF Risk during November 2006
El Niño effect, October 2006
NDVI anomalies, November 2006
HoA climatic and ecological conditions and RVF outbreak sites Sept 2006 to May 2007 Mapping of the RVF human case locations shows that ● 64% of the cases were reported in areas at risk within the RVF potential epizootic area, ● 36% were reported in areas not thought to be at risk of RVF activity
4
0
-4
-8
-12
EZD: risk mapping and forecasting ● Enhance collaboration with MoH, MoA, Vet services, NGOs working in conservation for surveillance of animal outbreaks that precede human cases (CCHF, RVF, Ebola, Yellow Fever, Nipah Hendra, Hantavirus..) ● Generating more accurate risk map to improve forecasting models. WHO, FAO OIE and partners to develop spatial & temporal database of emerging sites
● Developing more specific and less sensitive forecasting models improved with soil type data, elevation data, vector ecology maps, domestic ruminant maps, geolocation of major RVF outbreaks
● Couple models to buy time (6 month) and precision (IOD, SST, NDVI, flood-based risk maps,…)
Emerging Zoonotic Diseases: Surveillance and early warning
WHO Alert and Response Department ● 24 hours / 7days a week. ● 900 events of potential international importance verified, in all countries, in 5 years. ● >400 advice/assistance provided. ● More than 50 international outbreak response coordinated through the Global Outbreak Alert & Response Network (GOARN). ● > 450 issues of the Outbreak Verification List. ● Numerous Outbreak News update on WHO Web site.
Formal
Informal
Epidemic Intelligence
WHO laboratory networks, (sub-)regional networks, WROs & MoH, UNOs Official Sources e.g. WRO, MoH
Global Public Health Intelligence Network (media), NGOs
GOARN
Verification Risk Assesment
Response strategy and Operations Social Mobilization Health Education Medical Anthropology
Logistic Security Communications
Coordination Technical & Operational Medias - Information Finances
Epidemiological Investigation Surveillance Laboratory
Case management Funerals Infection Control
GPHIN Real time gathering information on outbreaks
● English ● French ● Arab ● Chinese ● Russian ● Spanish ●and Google may help increase languages
Sources : - GPHIN 39% - WHO System 33% - Pro-MED 6% - Others (labs, NGO) 22%
EZD Alert and Surveillance: perspectives ● Surveillance of zoonotic emerging diseases is improving ● Intensified collaboration with animal disease sector: domestic and wildlife ● GLEWS with FAO and OIE ● Formal collaboration with wildlife disease experts ● Support vector borne network (bats, rodents, birds, primates, ticks, entomology) ● Connect the different Lab networks
Emerging Zoonotic Diseases:
Response and control
EZD: when animal diseases strike human
Rift valley Fever: a young herdsman with high fever, bleeding from the gums, comatose and with severe neurological complications, Gazeera hospital, Intensive care unit, Sudan, 3 November 2007
EZD: when animal diseases strike human
Nipah: Soldiers waving as they have leave the Sepang after 14 days of killin 102.693 pigs. 1999, Malaysia.
General strategy for controlling outbreak Traditional healers
COMBI *
Posters Radio - TV
Social Mobilization Health Education
Discussion
Barrier nursing
Medical Anthropology Psycho Social support
Triage IN / OUT
Case Management Funerals Infection control
Community
Media Information Lodging alimentation roads police
Coordination
Logistics Security Communications
Mobile teams Epi + Soc
Finances salaries
Transports Vehicles
(* COMBI = communication to change behaviors)
Burial Team Water and Sanitation
Environment Vector control
Epidemiological investigation Surveillance Laboratory Database analysis
Clinical trials
Search the source
Follow-up Of contacts active search for cases Analysis Samples Results
Outbreak response: perspectives ● Need to understand better the disease in human: ● epidemiological patterns (CFR, human to human transmission, transmission patterns, behavior risk) ● improve clinical data collection (diagnosis, biochemistry, hematology, autopsy, etc..) to establish the effectiveness of some treatment measures and to progress in our knowledge on pathogenesis and to be ready when new countermeasures come (antiviral and vaccines) ● Social context (community, medical anthropology,…)
● Need to understand animal-to-human transmission ● Occupation risk ● Coordinated human and animal health surveillance ● Ecological studies
Ebola Virus Haemorrhagic Fever outbreak in Bundibugyo, Uganda 2007. Confirmed case Suspected case
Description of Jeremiah chain of transmission using FIMS Jungle
Outbreak control : Laboratory
Rift Valley Fever outbreak response, Sudan ● Laboratory: NAMRU-3 was deployed in Kosti (PCR) for 5 days and in Khartoum (IgM by ELISA) for 7 days. NAMRU-3 confirmed 16/47 human cases in Kosti and Khartoum labs. RT-PCR pos.
RT-PCR neg.
Ebola HF outbreak response, Mweka, DRC.
Outbreak control : Laboratory perspectives ● Diagnostic field laboratory essential (AI, MPX, large outbreaks, concomitant measles/Ebola, VZV/MPX, help link the lab with the field…) ● Field Labs doing Animal and Human tests ● Biochemistry + Hematology field lab for better care of patients ● Non-invasive methods of diagnostic ● Blood bank for future testing development ● WHO CC work is crucial, regional approach, international collaboration. ● Promote post mortem for acquiring better knowledge in pathogenesis and pathology of emerging diseases
Outbreak control : Social Mobilization ● For many EID the only effective control measure is the Prevention ● COMBI = Communication for Behavioral Impact Precise and clear objectives for behavior change Administrative mobilization/public relation / advocacy : intense collaboration with administrative, civil and military local authorities. Interpersonal communication/counselling : Psycho-social aid to the families (food, discussions, condolences, visits, coffins, supplies) Community mobilization; Advertising; Point-of-Service Promotion
● Importance of the social psychology in sanitary interventions ● Essential contributions of the medical anthropology to understand the populations and to adapt the behavior of the medical teams ● Discussion with/Help from traditional medicine
Outbreak control : Ecological studies Importance of Wildlife Species in Understanding the Epidemiology of Zoonoses
West Nile Monkeypox SARS
Nipah Avian Influenza
Emerging Zoonotic Diseases: general conclusion
EZD general conclusion (1) ● EZD outbreak detection is better than in the past but should be improve to intensify collaboration between wildlife, domestic animals and human health sectors
● EZD outbreak response quality need to improve to ensure acceptance by the affected populations
● New animal vaccines will prevent human infection or decrease human exposure ● Human new vaccines and new “treatments” ● May improve the perception of the medical profession in areas of the world where modern medicine is often lacking.
EID general conclusion (2) ● Today's technologies can help to better detect, manage and contain the international spread of Emerging zoonotic diseases ➡NOT Enough
● Key points remain high level governments commitment and international collaboration.
EID general conclusion (3) ● OIE/FAO reporting system and WHO IHR 2005 support this mechanism and will help the reinforcement the countries capacities in outbreak alert and response ● 3 Worlds = 1 Health Æ Need to intensify collaboration between wildlife, domestic animals and human health sectors at country level and internationally
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