GRASPING PUBLIC HEALTH EMERGENCIES: What have we learned from the SARS epidemic

1
GRASPING PUBLIC HEALTH EMERGENCIES What have we
learned from the SARS epidemic?
Frederick M. Burkle, Jr., MD, MPH , FAAP,
FACEPSenior Scholar, Scientist and Visiting
ProfessorThe Center for International Emergency,
Disaster and Refugee StudiesThe Johns Hopkins
University Medical Institutions

2
OR

• SARSThe best thing
• since sliced bread!!

3
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

4
PRE-SARS ENVIRONMENT

• Worldwide political interference in public health
• National sovereignty corrupted public health
  response
• Public health functioned better in the 19th
  century

5
PRE-SARS ENVIRONMENT

• Repeated failures to cooperate for the common
  good
• Highly competitive/Vertical response
• Placed global health initiatives in question

6
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

7
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

8
(No Transcript)
9
(No Transcript)
10
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)

11
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

12
INTERSTITIAL-SARS ENVIRONMENT

• Dissembling of SARS numbers by Chinese
  authorities
• Political fervor over how or whether
  international community could assist Taiwan
  during SARS

13
INTERSTITIAL-SARS ENVIRONMENT

• SARS served as impetus for change
• best thing that happened to a sluggish,
  unprepared politically encumbered international
  Public Health system

14
INTERSTITIAL-SARS ENVIRONMENT

• World Health Ministers weighed in.directed WHO
  to act on information from all sources!
• WHO developed a network of networkslaboratories
  , experts, and an array of informants
• ALL pledged to work with WHO

15
INTERSTITIAL-SARS ENVIRONMENT NETWORK OF
NETWORKS

• WHO Tapped into digital information systems
• Collaborated with Canadas Global Public Health
  Information Network (GPHIN)searching for hints
  of disease outbreaks.

16
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

17
POST-SARS ENVIRONMENT

• OUTCOME ALL countries must now report any
  disease outbreak of international concern
• WORLD HEALTH ASSEMBLY Transparent reporting
• INTERNATIONAL HEALTH REGULATIONS WHO has
  authority to coordinate response to any
  infectious disease that is a threat to
  international public health

18
POST-SARS ENVIRONMENT

• WHO can act to verify outbreaks based on any
  available information (official or non-official
  sources)
• Does NOT need to wait for official government
  notifications
• Reaffirms WHO leadership in deterring severity of
  outbreaksaccidental or deliberate

19
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

20
POST-SARS ENVIRONMENT

• Challenges
• Must ensure that information is
  accurateotherwise negative effect leads to panic
  or unsuitable response
• Still lack a substantive surveillance system

21
SURVEILLANCE SYSTEMS
22
CONVENTIONAL SURVEILLANCE
SYSTEMS

• One-way, medical recording systems
• Not real time
• Background baseline epidemiology is unknown
• Symptom oriented vs. syndromic
• Poor compliance
• No working relationship between clinical acumen
  and available detectors

23
DNA/RNA ARRAY TECHNOLOGIES
Combination of protein arrays (rapid screening)
and DNA microarrays (diagnosis/disease
characterization) rapid detection of emerging
ID patterns diagnosis of specific ID s
1000s of tests
Sample
24
DNA SEQUENCING PATHOGEN
IDENTIFICATION SYSTEM CRITERIA

• Real time
• Presymptomatic/symptomatic
• Multiple body fluids
• No false positives
• High density
• Microplate-format
• High-throughput
• DNA sequencing

25
DNA SEQUENCING PATHOGEN
IDENTIFICATION SYSTEM CRITERIA

• Immediately uploadable
• Two-way reporting
• Supercomputer assisted
• Cost effective
• Immediate human interface
• Event criteria that generates consequence
  management

26
Advanced System Criteria

• Minimal detection-to-confirm detection-to-treat
  times
• Lateral decision-making human-interface
  immediately engaged with new or emerging
  infectious agents

27
Advanced System Criteria

• Generation of baseline epidemiology
• Development of extended time-line triage and
  management for training, education, and
  decisions on public health

28
MANAGEMENT
29
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 network
• All patients screened for exposure, travel,
  contact with ill humans or animals
• Over triage provisional diagnosis for anyone
  with fever and respiratory illness

30
Pacific Public Health Surveillance
Network PPHSN
LabNet
PacNet

• E-mail/FAX listserver
• Network of practitioners decision-makers
• Early warning for epidemic threats
• Raise awareness preparedness
• Access to resources, including technical expertise

• A 3 tier network of PH laboratories
• L1 National/territorial labs
• L2 4 PH Labs
• L3 Reference Labs

EpiNet
Multidisciplinary National and Regional outbreak
response teams
31
VACCINE DEVELOPMENT
CURRENT INFLUENZA VACCINE
FUTURE INFLUENZA VACCINE

• Prepared in fertilized chicken eggs
• 50 year old technology methodology
• Tedious slow
• Massive s of eggs required for surge capacity
• chicken virus

• Cultured cell-based vaccines
• Only the human virus is cultured
• Rapid process
• Easily escalated to large volumes

32
THREATS

• Benign viruses turn deadly
• Influenza pandemic developing from current avian
  (bird) influenza
• Agents with long incubation periods (i.e., BSE)
  have great capacity for damage
• Increased animal to human spread of disease

33
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