Guiding Principles of Outbreak Preparedness & Response

1. Guiding Principles ofOutbreak Preparedness& Response Gary L. Simpson, M.D., Ph.D., M.P.H.

2. Infectious Disease Mortality in the United States, 1900 to 1996 1000 80 800 60 40 600 20 0 Mortality Rate per 100,000 400 1970 1980 1990 200 0 1900 1920 1940 1960 1980 Year 1900-'37 1938-'52 1953-'80 1980-'96

3. Infectious Disease Mortality in the United States, 1980-1996 1980 1982 1984 1986 1988 1990 1992 1994 1996 80 70 60 50 40 Crude ID Mortality Rate Deaths per 100,000 population 30 20 10 0 Year CDC Source: JAMA 1996;275:189-193 and unpublished CDC data

4. Emerging Infections in the World and US since 1973 1973 Rotavirus Enteritis/Diarrhea 1976 Cryptosporidium Enteritis/Diarrhea 1977 Ebola virus VHF 1977 Legionella Legionnaire’s dz 1977 Hantaan virus VHF w/ renal flr 1977 Campylobacter Enteritis/Diarrhea 1980 HTLV-1 Lymphoma 1981 Toxin prod. S.aureus Toxic Shock Synd. 1982 E.coli 0157:H7 HUS 1982 HTLV-II Leukemia 1982 Borrelia burgdorferi Lyme disease

5. Emerging Infections in the World and US since 1973 1983 HIV AIDS 1983 Helicobacter pylori Peptic ulcer dz 1988 Hepatitis E Hepatitis 1989 Hepatitis C Hepatitis 1990 Guanarito virus VHF 1991 Encephalitozoon Disseminated dz 1992 Vibrio cholerae O139 Cholera 1992 Bartonella henselae Cat scratch dz

6. Emerging Infections in the World and US since 1973 1993 Sin Nombre virus Hanta Pulm. Synd. 1994 Sabia virus VHF 1994 Hendra virus Respiratory dz 1995 Hepatitis G Hepatitis 1995 H Herpesvirus-8 Kaposi sarcoma 1996 vCJD prion Variant CJD 1997 Avian influenza (H5N1) Influenza 1999 Nipah virus Encephalitis 1999 West Nile virus Encephalitis 2001 BT Bacillus anthracis Anthrax 2003 Monkeypox Pox 2003 SARS-CoV SARS

7. Institute of Medicine 1992 Report on Emerging Infections Defined emerging infections as: “New, reemerging or drug-resistant infections whose incidence in humans has increased within the past two decades or whose incidence threatens to increase in the near future.”

8. Major Factors Contributing to Emerging Infections: 1992 1. Human demographics and behavior 2. Technology and Industry Economic development and land use 4. International travel and commerce 5. Microbial adaptation and change 6. Breakdown of public health measures Institute of Medicine Report, 1992

9. More Factors Contributing to Emerging Infections: 2003 7. Human vulnerability Climate and weather Changing ecosystems Poverty and social inequality War and famine Lack of political will Intent to harm Institute of Medicine Report, 2003

10. Expanding Implications of Emerging Infectious Diseases • Direct threats to global, human public health • Threats to domestic animals and the world’s agricultural capacities • Threats to wildlife and global biodiversity (and indirectly to human health)

11. P. Daszak et al., Science 287, 443 -449 (2000) Published by AAAS

12. Hospitals, Infection Control, & Emerging Infectious Diseases • Hospitals are frequency sentinel sites for detecting index cases of infectious disease outbreaks. • Hospitals may be referral centers for complex cases during an outbreak. • Hospitals are high-risk settings for the transmission of many emerging infectious diseases.

14. SARS Overview • Incubation period: 3-5 days (range 2-10 days) • Etiology: a virus in family Coronaviridae • CBC: normal, leucopenia (by day 3-4), thrombocytopenia (less common) • Signs and symptoms: fever, headache, malaise, coughing, shortness of breath • Transmission: man to man, close contact, secondary attack rate >50% • Total cases globally: over 10,000 • Case fatality: approx. 10% • Over 90% of the early cases occurred in healthcare workers • Most of the patients involve family members and other close contacts of infected people and health care workers.

15. SARS Emergence Horseshoe bats Masked palm civets Humans

18. A Look at Toronto • The capital of Ontario, Canada • Canada’s largest city -- home to more than 2.5 million people • Site of North America’s largest outbreak of SARS During SARS Crisis (February – July 2003) • Toronto: • Fielded 316,000+ hotline calls • Quarantined 23,000 people • Investigated 2,000+ potential cases • Confirmed 358 SARS cases • Suffered 38 deaths Source: Svoboda T, Henry B, Shulman L, et al. Public health measures to control the spread of the severe acute respiratory syndrome during the outbreak in Toronto. NEJM. 2004;350:2352-2361.

22. Amalgam of the Toronto/SARS Experience • Ethics of quarantine • Privacy of personal information and the public need to know • Duty of care • Collateral damage • SARS in a globalized world Singer et al., BMJ, 327:1342-44 (2003)

25. Speed of Global Travel in Relation to World Population Growth From: Murphy and Nathanson. Semin. Virol. 5, 87, 1994

26. The Concept of Discontinuous Change -- based on the assumption that “changes are different this time: they are discontinuous and not part of a pattern; such discontinuity happens… although it is confusing and disturbing, particularly to those in power.” Charles Handy The Age of Unreason

27. Speed of Commercial Travel Speed in MPH Year

28. Ten Key Ethical Values • Individual liberty • Protection of the public from harm • Proportionality • Reciprocity • Transparency • Privacy • Protection of communities from undue stigmatization • Duty to provide care • Equity • Solidarity

29. Conclusions • Infection control practitioners are an integral component of the frontline of public health. • Some change has become discontinuous. • Nobody can make this stuff up. • Exchanging business cards on the first day of an outbreak is the kiss of death. • Establishing guiding principles requires pre-existing, collaborative, productive, trusting relationships.