grasping public health emergencies: what have we learned from the sars epidemic? frederick m....
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GRASPING PUBLIC HEALTH EMERGENCIES: What have we learned from the SARS epidemic?
Frederick M. Burkle, Jr., MD, Frederick M. Burkle, Jr., MD, MPH , FAAP, FACEPMPH , FAAP, FACEP
Senior Scholar, Scientist and Visiting ProfessorSenior Scholar, Scientist and Visiting ProfessorThe Center for International Emergency, Disaster and The Center for International Emergency, Disaster and
Refugee StudiesRefugee StudiesThe Johns Hopkins University Medical InstitutionsThe Johns Hopkins University Medical Institutions
OR…
“SARS…The best thing since sliced bread…!!”
OBJECTIVES
Using the SARS experience…..Identify how SARS has impacted the expectations of response requirements for ALL accidental and deliberate infectious disease outbreaks
Describe the requirements for surveillance and management in the future
PRE-SARS ENVIRONMENT
Worldwide political interference in public health
National “sovereignty” corrupted public health response
Public health functioned better in the 19th century
PRE-SARS ENVIRONMENT
Repeated failures to cooperate for the common good
Highly competitive/Vertical response
Placed global health initiatives in question
PRE-SARS ENVIRONMENT
World Health Organization (WHO): Mandated reporting only required for yellow fever, cholera and plague
Relied on member states to voluntarily report domestic outbreaks
PRE-SARS ENVIRONMENT
Countries with most diseases and risk of epidemics had little systemic surveillance
Reached a crisis level rapidly
Complex emergencies accounted for over 75% of epidemics in the 1990s
Figure 1 Cholera cases in Monrovia, Parts of G.Bassa, Margibi & Bong Counties
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Figure 4: Trend of Clinical and confimed cases of malaria, Weeks 34 to 40
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PRE-SARS ENVIRONMENT
WHO, once they learned of an outbreak, could only deal with national governments to offer “advice and limited resources”
Political squabbles bogged down polio immunization and eradication efforts (e.g. India, Nigeria)
PRE-SARS ENVIRONMENT
WHO relied on Non-governmental Agencies (NGOs) as eyes and ears during emergencies
Worldwide alert for SARS was the responsibility of one man
INTERSTITIAL-SARS ENVIRONMENT
Dissembling of SARS numbers by Chinese authorities
Political fervor over how or whether international community could assist Taiwan during SARS
INTERSTITIAL-SARS ENVIRONMENT
SARS served as impetus for change…
…best thing that happened to a “ sluggish, unprepared & politically encumbered international Public Health system”
INTERSTITIAL-SARS ENVIRONMENT
World Health Ministers weighed in….directed WHO to ”act on information from all sources!”
WHO developed a “network of networks”…laboratories, experts, and an array of “informants”
ALL pledged to work with WHO
INTERSTITIAL-SARS ENVIRONMENT: NETWORK OF NETWORKS
WHO Tapped into digital information systems
Collaborated with Canada’s Global Public Health Information Network (GPHIN)…searching for hints of disease outbreaks….
INTERSTITIAL-SARS ENVIRONMENT: NETWORK OF NETWORKS
WHO formally unveiled its Global Outbreak Alert & Response Network (GOARN): technical, operational & political at all levels
Stovepiping information to ensure it gets to the right people…
POST-SARS ENVIRONMENT
OUTCOME: ALL countries must now report any disease outbreak of “international concern”
1. WORLD HEALTH ASSEMBLY: “Transparent reporting”
2. INTERNATIONAL HEALTH REGULATIONS: WHO has authority to coordinate response to any infectious disease that is a threat to international public health
POST-SARS ENVIRONMENT
1. WHO can act to verify outbreaks based on any available information (official or non-official sources)
2. Does NOT need to wait for “official government notifications”
3. Reaffirms WHO leadership in deterring severity of outbreaks…accidentalaccidental or deliberatedeliberate
POST-SARS ENVIRONMENT
Challenges:• Must still rely on local expertise
to identify sentinel cases
• Must move fast and decisively to communicate to the public “incredibly well”
POST-SARS ENVIRONMENT
Challenges:• Must ensure that information is
accurate…otherwise negative effect leads to panic or unsuitable response
• Still lack a substantive surveillance system
SURVEILLANCE SURVEILLANCE SYSTEMSSYSTEMS
CONVENTIONAL SURVEILLANCE CONVENTIONAL SURVEILLANCE SYSTEMS SYSTEMS
One-way, medical recording systemsOne-way, medical recording systems
Not real timeNot real time
Background baseline epidemiology Background baseline epidemiology is unknownis unknown
Symptom oriented vs. syndromicSymptom oriented vs. syndromic
Poor compliancePoor compliance
No working relationship between No working relationship between clinical acumen and available clinical acumen and available detectorsdetectors
SensecDNA
LabeledAntisense
cDNA
Hybridization
Patterned Microarray
Cells
Extract RNA andreverse transcribe
1000s of 1000s of teststests
DNA/RNA ARRAY DNA/RNA ARRAY TECHNOLOGIESTECHNOLOGIES
SampleSample
Combination of protein arraysCombination of protein arrays (rapid screening) and DNA microarrays (rapid screening) and DNA microarrays (diagnosis/disease characterization): (diagnosis/disease characterization): rapid detection of emerging ID patternsrapid detection of emerging ID patterns & diagnosis of specific ID s& diagnosis of specific ID s
DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:CRITERIACRITERIA
•Real timeReal time•Presymptomatic/symptomaticPresymptomatic/symptomatic•Multiple body fluidsMultiple body fluids•No false positivesNo false positives•High densityHigh density•Microplate-formatMicroplate-format•High-throughput High-throughput
DNA sequencingDNA sequencing
DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:DNA SEQUENCING PATHOGEN IDENTIFICATION SYSTEM:CRITERIACRITERIA
•Immediately uploadableImmediately uploadable•Two-way reportingTwo-way reporting•Supercomputer assistedSupercomputer assisted•Cost effectiveCost effective•Immediate human interfaceImmediate human interface•Event criteria that generates Event criteria that generates consequence managementconsequence management
Advanced System CriteriaAdvanced System Criteria
Minimal detection-to-confirm & Minimal detection-to-confirm & detection-to-treat timesdetection-to-treat times
Lateral decision-making “human-Lateral decision-making “human-interface” immediately engaged interface” immediately engaged with new or emerging infectious with new or emerging infectious agentsagents
Advanced System CriteriaAdvanced System Criteria
Generation of baseline Generation of baseline epidemiologyepidemiology
Development of “extended time-Development of “extended time-line triage and management” for line triage and management” for training, education, and decisions training, education, and decisions on public health on public health
MANAGEMENTMANAGEMENT
Early Evaluation of Questionable Cases
Anywhere in the world, where early unexplained clinical symptoms occur…
The positive predictive value is improved if used in combination with an epidemiologic networkAll patients screened for exposure, travel, contact with ill humans or animalsOver triage: provisional diagnosis for anyone with fever and respiratory illness
Pacific Public Health Surveillance Network: PPHSN
E-mail/FAX listserverNetwork of practitioners & decision-makersEarly warning for epidemic threatsRaise awareness & preparednessAccess to resources, including technical expertise
A 3 tier network of PH laboratories:L1: National/territorial labsL2: 4 PH Labs L3: Reference Labs
PacNet LabNet
EpiNet
Multidisciplinary National and Regional outbreak response teams
VACCINE DEVELOPMENT
Prepared in fertilized chicken eggs50 year old technology & methodologyTedious & slowMassive #s of eggs required for “surge capacity”“chicken” virus
Cultured cell-based vaccinesOnly the human virus is culturedRapid processEasily escalated to large volumes
CURRENT INFLUENZA VACCINE:
FUTURE INFLUENZA VACCINE:
THREATS
“Benign” viruses turn deadlyInfluenza pandemic developing from current avian (bird) influenzaAgents with long incubation periods (i.e., BSE) have great capacity for damage Increased animal to human spread of disease
THREATS
Conventional surveillance system unable to detect bioagent in food and agriculture
Lack public health infrastructure to respond to: widening urbanization & poverty, population movements & cross-border transmission