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Pierre Formenty – 9 October 2008, Verona, Italy
Avian Influenza at the Human-Animal interface
Tools and methods used to evaluate emergence of other zoonotic diseases
Crédit photosC Black, A. Epelboi
P. Formenty, WHO
Our world is changing
● The way we live
● 2025: 5 Billions urban
● Microbes evolve
● New threats emerge
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44 megacities in 2020
30 millions habitants and more
15>29.9 millions habitants
10 >14.9 millions habitants7 >9.9 millions habitants
Tokyo
Mexico
New York
Sao Paulo
Delhi
Mumbai
Los Angeles
Rio de Janeiro
Buenos Aires
Lagos
Cairo
Istanbul
Moscow
Beijing
Osaka, KobeShanghai
Metro Manila
Jakarta
DhakaCalcuttaKarachi
ParisLondon
Chicago
Bogota
Lima
Seoul
Tianjin
Hong Kong
Chennai
Tehran
Kinshasa
Wuhan
Lahore
Bangalore
HyderabadAhmadabad Surat
BangkokPune
Belo Horizonte
Baghdad
Riyadh Chittagong
Emerging Severe Zoonoses: complexity of implementing disease control strategies
PERIDOMESTICANIMALS
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61% of EIDs are Zoonoses affecting Humans
Daszak P. et.al.Science 2000 287:443
Wildlife
DomesticAnimal Human
Translocation
Human encroachmentEx situ contactEcological manipulation
Global travelUrbanizationBiomedicalmanipulation
Technology And Industry
AgriculturalIntensification
EncroachmentIntroduction“Spill over” &“Spill back”
Frequency of all EID events has significantly increasedsince 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 wildlifereach highest proportion in recent decade
Rift Valley Fever outbreaks forecasting models
Tools and methods used to evaluate emergence of other zoonotic diseases:from forecasting to outbreak response.
Tools and methods used to Tools and methods used to evaluate emergence of other evaluate emergence of other zoonotic diseases:zoonotic diseases:from forecasting to outbreak from forecasting to outbreak response.response.
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0102030405060708090
-20 -16 -12 -8 -4 0 4 8 12 16 20 24 28 32 36 40
Num
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f Cas
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TIME
Emerging Zoonotic Disease outbreak alert and responseEmerging Zoonotic Disease outbreak alert and response
Animal outbreak
Human outbreak
AnimalAmplification
ClimateVegetation
EnvironmentHuman
Amplification
AnimalOutbreak
HumanOutbreak
0102030405060708090
-20 -16 -12 -8 -4 0 4 8 12 16 20 24 28 32 36 40
Num
ber o
f Cas
es
TIME
Emerging Zoonotic Disease outbreak alert and responseEmerging Zoonotic Disease outbreak alert and response
Animal outbreak
Human outbreak
AnimalAmplification
ClimateVegetation
EnvironmentHuman
Amplification
First casesIn Animals
LateDetection
DelayedResponse
Control Opportunity
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0102030405060708090
-20 -15 -10 -5 0 5 10 15 20 25 30 35 40
Num
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f Cas
es
TIME
Emerging Zoonotic Disease outbreak alert and responseEmerging Zoonotic Disease outbreak alert and response
Animal outbreak
Human outbreak
AnimalAmplification
2. Early detectionAnimal & Human cases
3. Rapid Response
Control Opportunity
1. ForecastingReadiness
Animal Vaccin°
Rift Valley Fever outbreaks forecasting models
Risk mapping and Forecasting EID emergence.Risk mapping and Forecasting Risk mapping and Forecasting EID emergence.EID emergence.
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Modeling EID events: Relative risk of an EIDModeling EID 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 EID events: CCHF risk mapModeling EID events: CCHF risk map
Courtesy David Roger, Oxford University, Department of Zoology, Oxford, UK
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Forecasting EID emergences
Ebola surveillance in Central Africa
Collaborators: WCS, CIRMF, IRD, ECOFAC, MoH, National Park Boards, MSF, WHO.
Geographic Distribution of Filovirus and Henipavirusoutbreaks and fruit bats of the Pteropodidae Family.
Filovirus outbreaks
Countries at risk for Filovirus (viro or serological evidence)
Henipavirus outbreaks
Home range of Pteropodidae Family fruit bats Home range of Pteropus genus fruit bats
Countries at risk for Henipavirus(viro or serological evidence)
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Forecasting Rift Valley Fever outbreaks
El Niño,SST, IOD
NDVI dataNASA / GSFC
Animal Outbreaks (FAO/OIE)Human Cases WHO/GOARN
Forecast possible RVF outbreaks Early Warning
FAO/WHO Warning message
1. Intensified surveillance2. Human/Vet. collaboration3. General guidelines 4. Reference laboratories5. Shipment guidelines
Conditions for RVF Risk during November 2006
El Niño effect, October 2006
NDVI anomalies, November 2006
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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
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-4
0
-8
-12
Sudan climatic and ecological conditions and RVF outbreak sites May to November 2007
Khartoum
Mapping of the RVF human case locations shows that ● 50% of the cases were reported in areas at risk within the RVF potential epizootic area,● 50% were reported in potential epizootic areas not thought to be at high risk of RVF
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Madagascar climatic and ecological conditions and RVF outbreak sites Sept 2007 to May 2008
RVF Risk Area
RVF Potential Epizootic Area
Outbreak identified as Non-Risk
Outbreak identified as Risk
Egypt, Aug-SeptRVF +/- WN ?
Tunisia, Monastir, Sept.WN ~50 cases, 8 deaths
Morocco, Sept.WN 8 horses
West Nile and RVF Outbreaks, August-Sept 2003
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Yellow fever outbreak August-November 2005
Sudan, Aug-Nov.YF 560 cases 143 deaths+/- Dengue
Need more collaboration with MoA, Vet services, NGOs working in conservation for surveillance of Animal outbreak that precede human cases (Ebola, Yellow Fever, Nipah Hendra)Several RVF Alerts send to countries and Regions but only 2 RVF outbreaks were "predicted" (2003 and 2006)– Some countries take appropriates measures, prepare
outbreak response team and vector control program– detection of others Arboviruses outbreaks (dengue, West Nile,
Yellow Fever)– Need for a more systematic way of sharing forecasting maps
with countries (web site)
Develop models for other diseases (CCHF, Hantavirus)
Is forecasting helping detection ?
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Rift Valley Fever outbreaks forecasting models
Surveillance of EID emergenceSurveillance of EID emergenceSurveillance of EID emergence
● 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.
WHO Alert and Response Department
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Response strategy and Operations
FormalWHO laboratory networks, (sub-)regional networks,
WROs & MoH, UNOs
Finances
Official Sourcese.g. WRO, MoH
InformalGlobal Public Health Intelligence
Network (media), NGOs
Risk Assesment
Verification
EpidemicIntelligence
Coordination Technical & Operational Case management
FuneralsInfection Control
Epidemiological Investigation SurveillanceLaboratory
Social Mobilization Health Education
Medical Anthropology
LogisticSecurity
Communications Medias - Information
GOARN
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EnglishFrenchArabChineseRussianSpanish
and Google may help increase languages
GPHINGPHIN
Sources :- GPHIN 39%- WHO System 33%- Pro-MED 6% - Others (labs, NGO) 22%
Real time gathering information on outbreaks
EIDs Alert and Surveillance PerspectivesPerspectives
● 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 EID vector borne network (bats, rats, primates,
entomology)● Connect the different Lab networks
● Improve forecasting models based on environment and meteorological data
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Emerging Infectious DiseasesResponse and control
Social Mobilization
AnalysisSamplesResultsEpi + Soc
Mobile teams
Triage IN / OUT
Barriernursing
Searchthe source
Database analysis
Follow-upOf contacts
active searchfor cases
MedicalAnthropology
PostersRadio - TV
TransportsVehicles
Epidemiologicalinvestigation Surveillance Laboratory
Logistics Security
Communications
CommunityDiscussion
police
EnvironmentVector control
Health Education
Traditionalhealers
PsychoSocial
supportCase Management
Funerals Infection control
Coordination
Clinicaltrials
Water andSanitation
Burial Team
roads
Lodgingalimentation
COMBI *
(* COMBI = communication to change behaviors)
General strategy for controlling outbreak
Financessalaries
MediaInformation
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● Establish a co-ordination mechanism for response
● Inform the public / health education / social mobilizationRestrict practices that promote transmission and source
infection
● Establish isolation ward / Safe and Humane case managementConduct safe funerals that allow the process of mourning
● Establish an active surveillance system Identification of cases and follow up of their contacts during
the incubation period (prophylaxis if available, isolate if ill). Stop transmission chains and stop source infection.
● Psychosocial support (patients, families, HCW).
● Recommendations on travel and trade
General strategy for controlling outbreak
Outbreak response : evaluate emergenceevaluate emergence
● Need to understand 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 treatmentmeasures 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 disease in animal that precede human infection● Occupation risk● Coordinated human and animal health surveillance● Ecological studies
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Ebola Virus Haemorrhagic Fever outbreakin Bundibugyo, Uganda 2007.
Confirmed caseSuspected case
Description of Jeremiah chain of transmission using FIMS Jungle
Filovirus epidemiology and ecologyEbola incubation period
(DRC, Sudan, Gabon, Uganda and Congo (souche Zaïre et Soudan)
– Ebola maximum incubation period was 19 days
– Ebola incubation period median was 7 days
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Outbreak control : field laboratory
Rift Valley Fever outbreak response, Sudan
RT-PCR pos.
RT-PCR neg.
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.
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Ebola HF outbreak response, Mweka, DRC.
Outbreak control : Laboratory
● 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.
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Outbreak control : Laboratory
● Promote post mortem for acquiring better knowledge in pathogenesis and pathology of emerging diseases
Outbreak control : Social MobilizationSocial Mobilization
● For many EID the only effective control measure is the Prevention
● COMBI = Communication for Behavioral Impact Precise and clear objectives for behavior changeAdministrative 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
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Outbreak control : Ecological studiesImportance of Wildlife Species in Understanding the Epidemiology of Zoonoses
Monkeypox
Avian Influenza
SARS
West Nile
Nipah
EID general conclusion (1)
● EID outbreak detection is better than in the past but could be improve● To intensify collaboration between wildlife, domestic
animals and human health sectors● To improve forecasting models
● EID outbreak response quality need to improve to ensure acceptance by the affected populations (relational behavior with the patients, respect of the local culture and beliefs, respect of funeral customs, etc…).
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EID general conclusion (2)
● The absence of effective therapies or vaccines for EIDs severely limits monitoring activities and containment operations.
● Human new vaccines and new “treatments”●may change the situation ● improve the perception of the medical profession
in areas of the world where modern medicine is often lacking.
● New animal vaccines may prevent human infection or decrease human exposure
EID general conclusion (3)
● Human and animal health authorities, including OIE FAO and WHO, should have a common and coordinated strategy to forecast, detect and control outbreak of emerging diseases
● Need for common SOPs for District Surveillance Officers and Vets to control selected EID (e.g. RVF) from forecasting to outbreak containment with an FAO OIE WHO agreed strategy: One Message, "all on the same page".
● Need for preparedness and occupation health guidelines (e.g. how to protect slaughtering house personnel in different technology settings, farmers, hunters, …)
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EID general conclusion (4)
● 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 (5)
● OIE/FAO reporting system an WHO IHR 2005 support this mechanism and will help the reinforcement the countries capacities in outbreak alert and response
● 3 Worlds = 1 Health Need to intensify collaboration between wildlife, domestic animals and human health sectors at country level and internationally
