Dr Mike Ryan, Director Global Alert and Response

1. Coherence in Response to Globalisation ChallengesThe Global Framework to Address Communicable Diseases – Can we do Better ? Dr Mike Ryan, Director Global Alert and Response

2. Same Ingredients Different Recipe ! • Policy • System • Protection • Access • Security • Research HEALTH

3. 1st Millenium Middle Ages Spread of 1918 Influenza Pandemic in USA Epidemics and Pandemics have shaped our history…

4. They continue to threaten us.. …and place sudden intense demands on national and international health systems ….on some occasions have brought health and social systems to the point of collapse WHO has detected and assessed more than 3,000 events between January 2001 and May 2010

5. Context of emerging/epidemic disease in the 21st. century • Emergence of new or newly recognised pathogens (e.g. Avian flu (H5N1), SARS, Ebola, Marburg, H1N1) • Resurgence of well characterized outbreak-prone diseases (e.g. cholera, dengue, measles, meningitis, shigellosis, yellow fever) • Release (accidental or deliberate) of a biological agent (e.g. BSE /v CJD, smallpox, SARS, anthrax)

6. Drivers of Epidemic Risk PANDEMIC Global spread Global travel and trade • Globalization • Global travel: people, animals, vectors • Global trade: animal and their products EPIDEMIC Amplification • Amplification • Urbanization • Population density • Agricultural Intensification • Technology And Industry • Vector distribution and densities • Transmission in health care centers • Successful A2H, V2H & H2H transmission, Human to human transmission Amplification OUTBREAK Emergence • Emergence • Human encroachment • Exploitation • Translocation • Climate variability • Vector density and distribution • Ecological Pressure Human Ecosystem Environment interface

7. The Environment/Animal/Human Interface Wildlife Domestic Animal Human outbreak Climate Vegetation Environment Number of Cases Human Amplification Animal Amplification spill over spill over TIME

8. Human Development Index Data source UNDP 2009 and UNEP 2006. The human development index (HDI) is calculated using three variables: life expectancy, education level and income. Selected major wilderness areas Human Development Index No data 0,5 0,7 0,8 0,9 1 0,2 Selected terrestrial biodiversity hotspots

9. Countries with a critical shortage of health service providers (doctors/nurse/midwives) Country with critical shortage Country without critical shortage Data source WHO 2009. Global Atlas of Health workforce

10. Countries with crises and emergencies 1990-2010 Country with crises during 1990-2010 Country without conflicts Data source WHO HAC cluster. http://www.who.int/hac/en/index.html

13. Saudi Arabia Cap Verde Yemen 2009

14. 44 megacities in 2020 Moscow London Beijing Chicago Paris Seoul Tokyo Los Angeles Tianjin Istanbul Lahore New York Shanghai Osaka, Kobe Tehran Delhi Wuhan Baghdad Karachi Calcutta Hong Kong Mexico Cairo Dhaka Riyadh Surat Chittagong Ahmadabad Metro Manila Hyderabad Mumbai Chennai Bangkok Bogota Pune Lagos Bangalore Kinshasa Lima Belo Horizonte Jakarta Rio de Janeiro Sao Paulo Buenos Aires 30 millions habitants and more 15>29.9 millions habitants 10 >14.9 millions habitants 7 >9.9 millions habitants

15. Global Aviation Network Hufnagel et al, PNAS, 2004.

16. The reality – we are vulnerable ! • Epidemic diseases and other public health threats will continue to occur because of • Efficient adaptation of the microbial world • Vulnerability and poor adaptation of the human world, • Epidemics and other public health emergencies present a major threat to life, economies and security in an increasing inter-connected and inter-dependant world • These events often • expose existing weaknesses in public health and systems; and the need for rapid response drains resources, staff, and supplies away from other health priorities. • Stress social and political systems, often leading to inappropriate and ineffective adaptive behaviours. • Convergent risks require coherent responses

17. No single institution has all the capacity! CHALLENGE • Ensure that States and the their communities are on the alert and ready to cope with major biological risks and events. • Ensure that the international community can rapidly detect and contain major biological risk/events with potential for international consequences • Get immediate access to the appropriate expertise and interventions and utilise and focus these resources to support countries and communities facing disease threats in time to make a difference WHO and the EU bring partners together to focus and coordinate international resources

18. Epidemic Management has Changed !! Barrier nursing Traditional healers Medical Anthropology Clinical Care Triage IN / OUT COMBI * Posters Psycho Social support Social Mobilization Burial/ funerals Case Management Infection control Radio - TV Health Education Infection Control Discussion Community Media Information Environment Vector control Coordination Life Support Find Cases Diagnosis Surveillance Investigation Logistics Security Communications Track Contacts Field Comms Sampling + Testing Epi/lab Studies Data Analysis Transport Mobile teams Finance Vehicles (* COMBI = communication to change behaviors)

19. The Environment/Animal/Human Interface Animal Vaccin° Wildlife Domestic Animal Rapid Response Human outbreak Early detection Forecasting Readiness Control Opportunity Number of Cases Animal Amplification TIME

20. The Rules have changed ! IHR…..a paradigm shift From control at borders to containment at source From diseases list toall threats From preset measures toadapted response

21. Strategic Actions • Strengthen National Systems & Capacities in disease prevention, Preparedness and response • Build the Global Alert and Response System • Manage specific health threat through Prevention, Risk Reduction and Preparedness • Enhance Global and Regional Operational, technical and Scientific Networks • Drive Knowledge generation, Innovation, Tools and Training for Improved epidemic Interventions • Improve availability and access to tools and interventions • Promote Inter-sectoral Cooperation • Regional & Global Health Leadership, Collaboration and Partnership

22. Risk/Event Management under IHR • WHO and it's Member States have new and explicit obligations to collectively approach the prevention, detection, and timely response to any public health emergency of international concern. • IHR defines a risk management process where Member States work together and through WHO to collectively manage acute public health threats • Increased responsibilities, greater scrutiny • WHO Director General responsible for the Organization's performance under IHR • The key functions of this global system are to • Identify • Assess • Assist • Inform …….Plus, in extra-ordinary circumstances, DG can declare a PHEIC and make global recommendations

23. Key Activities - Identify Informal/Unofficial Information Notifications/Consultations Verification Initial screen Others sources IHR National Focal Points (Member States) WHO

24. Key Activities - Assess Informal/Unofficial Information Notifications/Consultations Verification Initial screen Others sources IHR National Focal Points (Member States) WHO Event Risk Assessment

25. Key Activities – Assist Informal/Unofficial Information Notifications/Consultations Verification Initial screen Assistance / Response Others sources IHR National Focal Points (Member States) WHO Event Risk Assessment

26. Key Activities - Inform Disseminate Public Health Information Informal/Unofficial Information Notifications/Consultations Verification Initial screen Assistance / Response Others sources IHR National Focal Points (Member States) WHO Event Risk Assessment

27. Risk/Event Management Process Disseminate Public Health Information Others sources Informal/Unofficial Information IHR Reports IHR National Focal Points (Member States) Verification WHO Public Health Emergency of International Concern (PHEIC) Assessment Initial screen Event Risk Assessment Assistance / Response

29. Public Health Event Response under the International Health Regulations "Payload and Platform" concept of operations Specialist Programmes CHEMICAL RADIATION FOOD EPIDEMIC Chemical Food Radiation EPIDEMIC Prediction Prevention Risk Reduction Detection Verification Assessment Event and Intervention Management Operational Support & Logistics Information Mgt & Risk Communication Event Management System (HQ/RO/CO) WHO Senior Management

30. EMS current events 2010-06-09

31. Key features of the global EMS (WHO's Event Management System) WHO internal tool for public health event-based information management Secure platform Custom-built for decision support Being rolled-out to 3 levels of WHO IHR (2005) compliant All-hazards approach Risk assessment driven Phase II enhancements being planned

32. Risk communication products • EMS feeds information to the Global Outbreak Alert and Response Network (GOARN) site and the Event Information Site for IHR National Focal Points

33. GOARN is a partnership of over 190 technical institutions and networks coordinating actions and resources to respond to public health events of international concern.

34. GOARN partners have provided experts for over 104operations in 75 countries

35. Epidemic Meningitis Disease: Districts in Alert and EpidemicAfrican Meningitis Belt, 2009 28 million Doses of Meningococcal Vaccines (AC/ACW) Distributed in Africa through the ICG. 2006-2009

36. 61 million people immunized in West Africa through emergency and preventive vaccination campaigns • 12 million more by end 2010 Districts protected through mass vaccination campaigns, 2004-2010

37. Can we do Better ? YES!! • Forecasting/Prediction • Prevention/Preparedness/Readiness • Detection/Verification/Investigation • Risk Assessment & Communication • Response/Control • Evaluation

38. Conclusions - I • Globalization is a fact ! • Benefits • Risks • Our Weaknesses are our strengths ! • Inter-connectedness • Inter-dependance • Risks are Manageable ! • All Hazards • All Sectors • Systems/Tools/Networks/People !

39. Conclusions - II • WHO is most effective when it works through partnership and in a co-ordinated fashion with • member states and other international Organizations • technical partners in the public, academic and private sector • Effective working relationships have been forged when collaboratively dealing with major threats/events • These relationships have been based on mutual need, collective responsibility, solidarity, transparency, personal commitment, and pride in our organizations and systems • This is not reproducible or sustainable without a major investment in national, regional and global public health infrastructure

40. THANK YOU ! outbreak@who.int

41. FOLLOW UPS

42. WHO Relevance • Mandate and International Agreement(IHR) • Decentralized Structure & Capacity • 6 regional and 142 country offices • Our collective Experience in managing public health events • The Networks and Partnerships that we have developed and rely on (e.g. GOARN, regional and sub-regional networks, specialist networks, WHO CCs, GISN…..)

43. WHO Support to Public Health Preparedness and Response at Mass Gatherings 2009 Athletics World Championship Berlin 2010 Winter Olympics Vancouver 2012 European Cup Poland and Ukraine 2012 Summer Olympics London 2010 Commonwealth Games Delhi 2009 Universiade Belgrade 2008 European Cup Switzerland and Austria 2010 Shanghai World Expo 2004 Summer Olympics Athens 2009 South East Asian Games Vientiane 2009 Umra and Hajj 2009 Caribbean Games Trinidad and Tobago 2014 FIFA World Cup Brazil 2008 World Youth Day Sydney 2004 Summer Olympics Rio de Janeiro 2010 FIFA World Cup South Africa Past MG events Up-coming MG events