IFMSA Policy Proposal [ControlofEmergingInfectiousDiseases]

ProposedbytheTeamofOfficials

AdoptedattheIFMSAGeneralAssemblyAugustMeeting2018inMontreal,Canada

Policy Statement

Introduction EmergingInfectiousDiseases(EIDs)areinfectionswhoseincidenceorgeographicrangeisrapidlyincreasingorthreatenstoincreaseinthenearfuture.Inthepastyears,newEIDshaveemergedatanunprecedentedrate.Theseincidentshaveinmanycaseshighlightedtheinadequaciesofexistingorganizationalstructuresandinternationalframeworkstoprovideaneffectiveresponse. IFMSA position The International Federation ofMedical Students’ Associations (IFMSA) recognizes the need to strengthenpreparednessforcontrolofEmergingInfectiousDiseasesandresponsetopublichealthdisastersasameanstoreducingtheoccurrenceofdiseaseoutbreaksandfurthercatastropheincaseofanoutbreak.EIDshavelong-termnegativeeconomicandsocial impactson the societiesaffectedand thesedamagescanbeavoidedbyincreasedpreparedness.IFMSA also recognizes that Universal Health Coverage andwider health system strengthening ismore costeffective,andwidelybeneficial,thanspendingtocontroloutbreaks.

Call to Action Therefore, IFMSA calls on: IFMSANationalMemberOrganizations(NMOs)andmedicalstudentsto

1. Promoteeducationandadvocacyefforts to increaseknowledgeof infectionpreventionandcontrolamongstbothmedicalstudents,healthcarestudentsandthegeneralpublic.

2. Work with all relevant stakeholders to develop effective global mechanisms to combat emergingdiseases,especiallyintheirowncountry.

3. PromotetheOneHealthapproach,andtherebythecollaborationbetweenveterinarypublichealthand public health stakeholders to allow for thorough understanding of zoonotic diseases (diseasestransmissiblebetweenhumansandanimals)andsuccessfulcontrolofemergingzoonoticdiseases.

WHOMemberStatesto:

1. Strengthencommitmentto,andimplementationof,theInternationalHealthRegulations.

2. RecognisethatUniversalHealthCoverageisessentialtoglobalhealthsecurity,andinvestmentinUHCismuchcheaper,andbeneficial,thanfightinglargeoutbreaksthatweren’tpreventedduetolackofprimarycareandpublichealthcapacity;includingincludinginvestmentinprimarycare,publichealthagenciesandtheirlaboratories.

3. Ensure investment in costeffective research foremerging infectiousdisease treatmentandcontrolandmanufacturecost-effective,accessibleandaffordabletreatmentsandvaccines

4. Educate communities to raise awareness on disease prevention and infection control practicesneeded to stop the spread of current and future EIDs, having in mind the cultural and religiouscircumstancesofthepopulation.

5. Respond in a more transparent way to EIDs, ensuring the necessary information is provided forpopulationsandvisitors.

6. ProvideadequatefinancingforWHOContingencyFundforEmergencies.7. FullyfundtheWorldBankPandemicEmergencyFinancingFacility.8. Providetimely,non-earmarkedfundstoWHOappealsduringmajoroutbreaks9. Promptly and openly share data about outbreakswith aid agencies and non-state actors, avoiding

secrecyandaccountabilityevasion.

TheWorldHealthOrganizationto:1. ContinuetoleadcoordinationofthetheWHOHealthEmergenciesProgrammeforfutureoutbreaks

whilstincludingallrelevantinternational,governmental,non-governmentalandlocalstakeholders.2. ContinuetoempowerandengagewithWHO-WorldBankGlobalPreparednessMonitoringBoard3. Encourage the international community to continue assisting the countries affected by infectious

diseases;thiswillinclude,butnotbeexclusiveto,donatingprotectivegearusedintreatingpatients,handlingmedicinesandcontributingtoresearchanddevelopmentofvaccines.

4. Work closelywith all nations and especially low-income countries to strengthenhealth systems, inordertobebetterpreparedforpublichealththreatssuchasEbola,inthefuture.

5. Improve collaborations with relevant stakeholders (notably UN Food and Agricultural Organization(FAO)andWorldOrganisationforAnimalHealth(OIE))inthecontrolofemergingzoonoticdiseases.

Healthcareprovidersto:

1. ContinuetoimproveinfectioncontrolpracticestopreventspreadofEIDS.2. Recognise the vulnerability of healthcareworkers and train theirmedical personnel accordingly in

emergencytreatment,preventionandinfectioncontrolstrategies.3. Commit to provide culturally sensitive and ethically sound care as well as maintain clinical

competencyinthecontextofemergencysituations.4. ComplywiththenationalmechanismstocomplywiththeInternationalHealthregulations.

Position Paper

Background Emerginginfectiousdiseases(EIDs)arebroadlydefinedasinfectionsthathavenewlyappearedinapopulationorhaveexistedbutarerapidlyincreasinginincidenceorgeographicalrange.(1)EIDsencompass:recognisedinfectionsspreadingtonewareasandpopulations;discoverythataknowndiseaseiscausedbyinfection;previously unrecognised infection appearing in areas where habitat is changing; a new infectionresulting from changes in microorganisms; and an old infection re-emerging because it has becomeresistanttotreatment,orduetoabreakdowninpublichealthsystems.(2)Acomprehensiveliteraturereviewidentifiedover 1400 speciesof infectiousorganisms known tobepathogenic tohumans.Outof these, 175pathogenicspeciesareassociatedwithdiseasesconsideredtobe'emerging'.(3).Theseincidentshaveinmanycasesprovedthe inadequaciesofexistingorganizational structuresand international frameworks toprovideaneffectiveresponse.EIDsmaycauselocalisedepidemics,orbecomepandemicsifgiventhecorrectenvironmentalfactors,causingsignificantsufferinganddeathsworldwide.HistoricallysignificantexamplesofEIDsincludetheH1N1influenzain 1918,which is estimated tohave amortality of around50million (4), andHIV/AIDS,withover 1milliondeaths in 2016 alone (5). Outbreaks in recent years which had previously remained localised have sincebecomemajorpublichealthconcerns,notablytheWestAfricanEbolaepidemic,whichhascausedover28,000confirmed cases andover11,000deaths(6).Middle EastRespiratory syndromecoronavirus (MERS-CoV)hasseenanincreaseinincidencesince2012.27countriesworldwidehavereportedcasesofMERS-CoVwiththeRepublic of Korea investigating the largest known outbreak outside the Arabian Peninsula, including 182confirmedcasesand33deaths(7).TheeconomiclossesfromsixmajoroutbreaksofhighlyfatalEIDsbetween1997and2009amountedtoat leastUS$80billion.For instance,thepotential lossesresultingfromasevereinfluenzapandemicthatleadsto71millionhumanfatalitieswouldamount3trillionUSDor4,8%oftheglobalGDP(8) Discussion FactorsdrivingdiseaseemergenceDiseaseemergenceor re-emergence isoften the resultofanetworkofmultifactorial causes.Over thepastthreeandhalfdecadesatleast30newinfectiousagentsaffectinghumanshaveemerged,mostofwhicharezoonoticandtheiroriginshavebeenshowntocorrelatesignificantlywithsocioeconomic,environmental,andecologicalfactors.(9)Thesefactorscontinuetoincrease,puttingpeopleinincreasedcontactwiththediseasecausingpathogens,thereisconcernthatinfectiousdiseasesmaycontinuetopresentaformidablechallenge.Astudyfoundthat75%ofemergingdiseasesarezoonotic,andoverall,zoonoticpathogensaretwiceaslikelytobeassociatedwithemergingdiseasesthannon-zoonoticpathogens(10).Althoughmanyzoonoticdiseasesaredifficulttotrack,thosethatarevectorbornearedirectlyaffectedbyenvironmentalfactors(11).Climatechangeispredictedtohaveaprofoundinfluenceonemergenceofinfectiousdiseaseswithzoonoticvectorsinthecomingdecades,alteringdiseaseincidenceandplacingmillionsmoreatrisk(12).Economicdevelopmentcan increase disease emergence (eg. as dam construction provides new habitats for disease vectors andimproved transport infrastructure accelerates human-to-human transmission across international borders.Weakhealthsystemsandalackofskilledhealthcarepersonnelcanleavecommunitiesvulnerabletochanging

patternsofdiseasevirulenceorgeographicspread.Infectionpreventionandcontrolmeasuresareinsufficientinmanypoorlyresourcedcountries,withkeyinfrastructuresuchasisolationroomsnotinplace.Inadequatesupportforpublichealthprovision,surveillanceanddiseasemonitoringisakeyinfluenceontheemergenceofinfectiousdisease innewlocationsandcanhaveadevastating impacton localhealthcaresystems.Warandconflict can also drive infectious disease emergence, by damaging health and civic infrastructure aswell asdisplacingpeopleandacceleratingmigration,especiallywaterbornediseases,ordiseasesthataretransmittedby insectvectorsthatbreedinstale/standingwater(13). InappropriateuseofantibioticshasalsocausedanemergenceofvariousstrainsofdrugresistantbacterialikeMRSAaswellasMDR-TBandXDR-TBwhichhavebecomeapublichealthconcern.(14)GlobalnatureofdiseaseemergenceEIDsareaffectingnationsacrosstheworldandoverloadexistinghealthcaresystemsindiversecircumstances.These emerging and reemerging pathogens have demonstrated their ability to overwhelm public healthsystems, causing widespread fear and mistrust of health facilities, even in highly resourced healthcareinstitutions. Changing patterns of human migration, increasing levels of international air travel and novelprocessesintheagriculturalindustrypresentnewrisksandchallengesasnewerpathogensemerge.Thespectreofpandemicinfluenzaisanever-presentthreattoglobalhealthandin2015,theWHOdeclaredthat the world must be on “high alert” for the spread of new strains of influenza (15). These EIDs havedevastatingeffectsontheeconomiesofthecountriesaffected.IntheexampleofEbolainWestAfricain2014,at least 40 countries issues travel restrictions to Guinea, Sierra Leone and Liberia, resulting in a furtherdetrimental impact on trade (16). Societal cohesionwas also disruptedduring instances of violence againsthealthcare workers and security forces. The delayed and ineffective rapid response mechanisms, andsubsequentscaleoftheepidemic,leftgovernmentsunabletocopewiththeemergency,clearlydemonstratingtheneedforeffortstostrengthenhealthsystemsaroundtheworld(17).PreparednessfordiseaseoutbreakcontrolDespitethemanychallengespresentinthecontrolofzoonoticdiseases,successinthispreventionwouldbebothcost-effectiveanddirectlybeneficialtotheburdenonthehumanpopulation.However,certainstrategiessuch as culling are disproportionately dependent on farmers who receive inadequate compensation, asdemonstratedintheoutbreakofH5N1avianinfluenzain2006(18).The‘OneHealth’ approachisthekeytodefeatingemergingandreemergingzoonosesattheinterfacebetweenthehealthofhumans,animalsandtheecosystem. It supports and legitimizes improved cooperation between animal, public and environmentalhealth. It also gives rise to a new call for the strengthening of animal and human health systems,withoutwhich diseases cannot be controlled or defeated (19). Education and advocacy are also imperative, asmechanismsmustbeinplacetodisseminateinformationtothepublicinordertoensurethathealthmessagesarecoherentandquickly transmissible through themedia.Theabsenceof suchprocesses can lead to long-termsocio-economicdamage,suchasthereactiontobovinespongiformencephalopathy(BSE)inEnglandinthe1990scausinglargeeconomiclossesthatextendedwellbeyondthetimeframeoftheoutbreak(20).

Surveillance and response, the key elements in controlling EIDs depend on rapid clinical diagnosis anddetection followedbycontainment inpopulationsand in theenvironment.RecentpracticalexperiencewithBSE and SARS demonstrates that rapid detection and identification leading to the rapid introduction ofpreventive measures can prove highly effective in combating outbreaks of novel diseases (21). Thissurveillance needs to be global, especially considering the unprecedented rates of international travel andtradethatcanallownewinfectiousdiseasestospreadaroundtheworldovertimescalesofdaysorweeks.Awealth of new technologies are becoming increasingly available for the rapid molecular identification ofpathogens but also for themore accuratemonitoring of infectious disease activity.Web-based surveillancetoolsandepidemicintelligencemethods,usedbyallmajorpublichealthinstitutions,areintendedtofacilitateriskassessmentandtimelyoutbreakdetection.Preparing for emerging disease threats involves not only complying to international regulations, but alsostrengthening laboratory capacity and communicating appropriately with the public. In some recent cases,thesepreparatory taskshavebeen inadequatelyundertakendue to chronicunderinvestment inhealth caresystems.Theinternationallegalframeworkfordiseaseoutbreakcontrol-theInternationalHealthRegulations(IHR) - require that countriesdeclarePublicHealth Emergenciesof International Concern (PHEIC) promptly,andmandatearesponsefromWorldHealthOrganization(WHO).Theyalsorequirethatcountriesstrengthensurveillance capacity to monitor epidemics, and that countries make every effort not to introduce travelrestrictionswhichwould further damage international trade (22). However, in the context of fragile socio-political situations such as those inWestAfrica during the 2014 Ebola outbreak, a PHEICwas not reportedpromptly(atalocal,nationalorinternationallevel),whichleadtothecallforasemi-autonomousinternationalbodyasheardat theWorldHealthAssembly2015. Failureof theglobal community to respond rapidlyandeffectively to the Ebola outbreak demonstrates that there remain major implementation challenges, evenbeyond fundingandpoliticalwill. It is time to considerwhetherornotaspectsof the foundation forglobalhealthsecurityembodiedintheIHR(2005)aretoovague,missing,orneedtobestrengthenedinorderforIHRtostayrelevantanduseful(23).TheWHOHealthEmergenciesProgrammewascreated in2016,aimedto fill thegaps identified inthe2015Ebola response. The programmes responds to health emergencies caused by infectious diseases, war andconflict,naturaldisastersandother incidents. Inmanyrecents incidents,thenewprogrammehasproventobeeffective,deliveringfastresponsestorecentoutbreaks.Despitethesepositivesigns,thefactremainsthattheprogrammeisstrugglingtofundraisemoneyneededforitscorefunctions.Duringthe2018WorldHealthAssembly,theWHOandWorldBanklaunchedtheirjointGlobalPreparednessMonitoringBoard(GPMB)(co-chairedbyElhadjAsSy,SecretaryGeneraloftheIFRC(24),andGroHarlemBrundtland,formerWHODirector-General). The Board will “monitor preparedness activities on a global scale” holding all actors (from bothprivateandpublicsectors)accountableforbuildingessentialpublichealthcapacities,generatingsustainablefinancingandensuringthatnecessaryresearchanddevelopmentisconducted"(25).ThestarkinabilitytoraisemoneyfortheearlystagesoftheoutbreakwerealsohighlightedandsubsequentlytheWorldBankformedthePandemicEmergencyFinancingFacility,aninnovativeformofbondthatwouldallowfortherapidmobilisationoffundstotacklediseaseoutbreakswiththepotentialtobecomepandemic,iftheBankdeemsitnecessary.Itishopedthatthisworldfirststrategywillpreventthestagnationoffundraisingandpreventanotheroutbreakofthatsize,especiallywhenusedinconjunctionwiththeaforementionedGPMB(26).

ConclusionsInfectiousdiseaseswill continue toemergeand re-emerge, leading tounpredictableepidemics anddifficultchallengestopublichealthaswellas tomicrobiologyandalliedsciences.EIDsareacomplexproblem,rightfrom the patterns of their emergence to the public health challenges they create. There are no overnightsolutions that can be chanced upon. However, acknowledgment of problems and using all the resourcesavailabletoreducetheassociatedrisksisthebestwaytomoveforward.

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http://www.who.int/news-room/detail/24-05-2018-who-and-world-bank-group-join-forces-to-strengthen-global-health-security

26. PandemicEmergencyFinancingFacilityhttp://www.worldbank.org/en/topic/pandemics/brief/pandemic-emergency-financing-facilityhttp://www.who.int/news-room/detail/18-05-2018-statement-on-the-1st-meeting-of-the-ihr-emergency-committee-regarding-the-ebola-outbreak-in-2018