PowerPoint Presentation

Addressing Emerging Pandemic Threats:

Lessons from the Past 10 Years

Andrew Clements, Ph. D.USAID, Bureau for Global Health7 March 2014Observations and Lessons from the Past 100 YearsEmerging Threats ProgramBackground: Existing vs. New Public Health ThreatsExisting 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

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

Programfocus

Budget, staffing, training, commodities

New Public Health Threats

pH1N1, H5N1, and H7N9 influenza; SARS and MERS coronavirus; Nipah virus

very low ($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 projectDiseases emerging from wildlifeDiseases emerging from livestock

Observations on Other Emerging Public Health Threats Emerging Threats Program

spillover from wild animals to peopleNo further transmissionNo further transmissionNo further transmissionsource

amplification spillover from livestock to peopleNo further transmissionspillover from wild animals to livestockNo further transmission

Spillover, Amplification, and Spread human to human transmission

further amplification and spreadEmerging Threats Program

spillover from wild animals to people

source spillover from livestock to people

spillover from wild animals to livestocksource

Minimizing Spillover, Amplification, and Spread

human to human transmissionGood hospital interventions; some community interventionsXGood farm and market interventionsXGood farm and market interventionsLimited interventionsEmerging 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 monthsAt least 17,000 cases after 2 monthsMonths after first human caseSolid lines = efficient human-to-human spreadDotted lines = primarily animal-to-human spreadDashed lines = both animal-to-human and human-to human spreadAlready spreading efficiently from person to person when first detectedMostly animal-to-human transmission with limited human-to-human spreadEmerging Threats Program

H5N1One Example: Reducing Spillover of New ThreatsSources: FAO, OIE, WHO; * = data not complete*

Lesson learned: for some public health threats, the pump handle may be an animal**Interventions:Rapid detectionCulling infected birdsPoultry vaccinationFarm/market biosecurityEmerging 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 decreasedExisting interventions (farm/market biosecurity; infection prevention and control in hospitals) need wider applicationNeed other complementary interventions, e.g. limit spillover of diseases from wildlife to peopleEmerging Threats ProgramMore 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%YearWorld Meat Production by Type, 1961-2005 (FAO)Host animals for influenza virusesEmerging Threats ProgramOpportunities for Disease Spillover from Animals

Live animal marketsExtractive industry/Land use changeCollecting animal wasteBush-meat huntingPets

Wildlife and livestock farmsWhich contribute most to disease spillover?

Which interventions are most effective?Emerging Threats ProgramHuman Activities Disrupting Animal HabitatsFrom the film Contagion, 2011, Warner Bros. PicturesHistory shows again and againhow nature points out the folly of men

From Godzilla by Blue yster Cult (1977)Emerging Threats ProgramHuman Activities Attracting Wildlife

Source: Dr. Steve Luby, Stanford UniversityEmerging Threats Program17

Opportunities for Disease Amplification

Which contribute most to disease amplification?

Which interventions are most effective?Mixing species on farmMixing species in marketFactory farmsRoving flocksEmerging Threats ProgramHunan, 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 AsiaSource: http://wwf.panda.org/what_we_do/where_we_work/amazon/vision_amazon/models/natural_resources_management_amazon/aquarium_trade_amazon_rainforest/

Source: http://www.thestar.com.my/story.aspx/?file=%2f2009%2f8%2f10%2fstarprobe%2f4369565

Source: http://spatial.ly/2013/05/great-world-flight-paths-map/Air travel Which contribute most to disease spread?

Which interventions are most effective?Emerging Threats ProgramCommon menu bar linksFranaisHomeContact UsHelpSearchcanada.gc.caHome > Media Room > News Releases > Speaking Notes Deputy Chief Public Health OfficerFirst North America H5N1 bird flu death confirmed in Canada

8 January 2014 Last updated at 17:35 ETBBC

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.

Emerging Threats ProgramNext Steps for Addressing New Public Health ThreatsStrengthen 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

Emerging Threats ProgramRecent Detection of Avian Influenza Viruses in Asia June 2013-February 2014Sources: OIE, WHO; * Highly-Pathogenic Avian Influenza; ^ Avian Influenza. Hosts for each of the influenzavirus 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-typeH5N1 HPAI*H5N2 HPAIH5N8 HPAIH6N1 AI^H7N2 HPAIH7N9 AIH9N2 AIH10N8 AI

= not detected in people prior to 2013Emerging Threats ProgramDetection 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)Nov 2012-Oct 2013

Nov 2013-Oct 2014

Imported from ChinaEmerging Threats Program23Mapping 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.Emerging Threats ProgramBuilding the Foundation for ActionTimeExisting public health threatsProblem identification, gathering evidenceMostly doneDeveloping/ testing interventionsMostly doneScaling up interventionsIn processYou are hereStrengthening capacityNew public health threatsProblem identification, gathering evidenceIn processDeveloping/ testing interventionsJust beginningScaling up interventionsNot startedStrengthening capacityYou are hereEmerging Threats ProgramThe One Health concept recognizes that the health of humans is connected to the health of animals and the environment.

One Health ApproachSource: CDC http://www.cdc.gov/onehealth/PublicHealthAnimalHealthEnviron-mentalHealthOne HealthBecause 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 sectorsEmerging Threats ProgramLimited 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, budgetsInsufficient 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 coordinationacross society (e.g. government, military, civil society, private sector)across sectors (e.g. public health, animal health, environment)

Existing One Health Capacity LimitedEmerging Threats ProgramUSAID Pandemic Influenza & Other Emerging Threats Activity areas:

Avian Pandemic Other EmergingInfluenzaPreparedness ThreatsCurrent activities

Past activitiesEmerging Threats Program28PIOET Accomplishments (2005-2014): New Threats* Coordinated with CDC and WHO; ^ coordinated with FAO1. Decreased H5N1 threat Faster detection and containmentFewer countries affected

2. Enhanced pandemic preparedness30 countries established national coordinating bodies for preparedness25 countries developed first order pandemic preparedness plansMilitary authorities in 32 countries developed civ:mil preparedness response plans

3. Improved infectious disease detectionDetection of routine infectious diseasesSurveillance and detection of microbes with pandemic potentialImproved understanding of conditions that favor disease emergence/spread

4. Strengthened capacityPre-service training (One Health)In-service training (public health, animal health): lab, surveillance, epi, etc.

Emerging Threats Program5. Rapidly used PIOET platforms and expertise to address new threats:

* Coordinated with CDC and WHO; ^ coordinated with FAOH1N1 influenza pandemic (2009-2010)*detailed technical and logistics experts to WHO to assist in planning distribution of vaccine and ancillary equipmentdeployed >70 million doses of H1N1 pandemic vaccine (including U.S. donation) and injection equipment to >60 countriesupgraded H1N1 surveillance and laboratory capacities in 26 countries in Africa and Latin America

MERS-coronavirus (2012-2014)*

genetic sequence comparison used to target surveillancesurveillance 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 programsSARS-CoV (2002)H5N1 (2005)H1N1 (2009)MERS-CoV (2012)H7N9 (2013)PIOET Accomplishments (2005-2014) continuedEmerging Threats ProgramGlobal Health SecurityWhite 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

Emerging Threats ProgramUSAID Goal Under Global Health SecurityAs 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 enableearly 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.Emerging Threats ProgramFurther 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

Emerging Threats Program