[MUSIC] Next we'll talk a little bit about Global Health Security and the Global Health Security Agenda. The Global Health Security Agenda is a relatively new multi-sectoral approach to preparedness. The hallmark of the GHSA is its commitment to this multi-sectoral approach. It recognizes that effective prevention, detection, and response efforts require a broader collaboration and coordination across sectors than the scope of traditional public health initiatives. Global Health Security depends upon collaboration across and within all societal sectors including the ones listed here. There are several technical areas defined in the Global Health Security Agenda supported by the US Centers for Disease Control and Prevention. These technical areas include biosafety and biosecurity, antimicrobial resistance, zoonotic diseases, immunization, surveillance systems, laboratory systems, information systems, including linking and reporting, workforce development, emergency management, medical countermeasures and personnel deployment, and linking public health with law enforcement. The GHSA objectives are binned in three primary areas, prevent, detect, and respond. Prevent includes all of the prevention practices including the emergence and spread of antimicrobial drug-resistant organisms and zoonotic diseases and strengthening the IHR framework for governing food safety in particular. It includes promoting national biosafety and security systems and reducing the number and magnitude of infectious disease outbreaks. The detect bin includes launching, strengthening, and linking global networks for real-time biosurveillance activities, strengthening the global norm of rapid transparent reporting and sample sharing, developing and deploying novel diagnostics and strengthening laboratory systems across the globe, and training and deploying an effective disease surveillance workforce. The final bin respond includes developing an interconnected global network of emergency operation centers, or eocs, and multi-sectoral response to biological incidents, and improving global access to medical and non-medical countermeasures during health emergencies. On this slide, you'll see Annex 2 of The WHO IHR guidelines. This slide represents an algorithm that allows a country to determine if an event should be notified to the WHO under the International Health Regulations. It includes a series of yes or no questions that ultimately make the determination as to whether or not an event should be reported to the WHO. We will use this annex and the four questions in a series of case studies. Improving the assessment and reporting of public health events to the WHO is a critical component of effective IHR implementation. While many countries have reported public health events with the potential for international spread since the IHR entered into force, not all countries have done so and not all have done so frequently or for all appropriate events. The basis for assessment and reporting is to have information to assess, but many countries have not yet reached the minimum requirements that will allow them to detect these types of outbreaks or have not yet built a solid public health framework for notifying others of such events within their own country. Assessment notification is only one side of the coin, while the other side is the ability to quickly and adequately respond to these disease threats in one's own country. This response capacity is another requirement not yet met by many countries on the path towards IHR implementation. As we long past the milestone when countries are supposed to be fully implemented under IHR, many countries have requested extensions to achieve these core requirements for surveillance and response. Many countries have not fully implemented IHR yet. The WHO is working closely with countries to achieve this goal of all countries meeting IHR implementation. The United States is also assisting where possible through training programs of international public health professionals and by providing technical assistance in setting up systems for disease detection. Through the GHSA and supporting the JEE, or the joint external evaluation process, the US is supporting the WHO in getting every country successfully up to IHR implementation. There are strategies for improvement in this space. Much of the information sharing under the IHR happens between the different ministries of health and the WHO. Expanding the capacity for communications between countries in the WHO would support improvement in IHR implementation. Currently, people in affected countries continue to rely on information shared in the media or by responsible public health authorities directly. Expanding public communications with trusted and factual information would facilitate public health response. Better communication will allow countries to quickly share pertinent information about an outbreak with the public and to prioritize communication with the public about ways to prevent and control the spread of disease. The goal of the IHR is to assist with this by allowing all countries, including countries with limited resources, to become aware of what's going on in other parts of the world. Especially neighboring countries to learn what appropriate health prevention and control measures to apply when necessary and to request assistance whenever needed. Now we'll take a look at a few case studies. Our first case study is an outbreak of cholera. An outbreak of cholera erupted in a remote area with 180,000 inhabitants in the center of Country A. The first cases were laboratory confirmed two weeks ago. Within the last 3 days only, 220 new suspect cases of cholera have been reported. Currently 45 severe cases of laboratory-confirmed cholera sensitive to doxycycline are being treated in an isolation unit in the district hospital. In total, four deaths attributed to this outbreak have been recorded. All the cases have been from this rural area with poor sanitation services. The cases have been attributed to recent rain setting in with human waste and other materials being washed into existing water sources, leading to widespread contamination and environmental pollution. In response, chlorinated water supply and improved sanitation facilities are being established by public health workers in the affected municipality. Cholera is a recurring problem in the affected area, especially during the rainy season, resulting sometimes into case fatality rates on 2%. So under the IHR 2005, the presence of any two of the four criteria provided in the decision instrument of Annex 2 means that the event needs to be notified. Let's use this decision instrument to answer the following questions. Is the public health impact of this event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? Is there a significant risk of international travel or trade restrictions? So the first question, is the public health impact of this event serious, we would answer yes. Cholera is one of the epidemic-prone diseases appearing in the upper right box that will always lead to utilization of the decision instrument to see if any two of the four assessment criteria are fulfilled. Is the event unusual or unexpected? Here we would answer no. The occurrence of a serious diseases such as cholera does not necessarily constitute an unusual public health event or an actual risk to international spread. Is there significant risk of international spread? As we just stated, no, there's not here. And is there a significant risk of international travel or trade restrictions? No, the epidemiologic context and risk of international spread posed by a disease event are important determinants of a potential public health emergency of international concern. Consequently, the public health assessment of this event must be coupled with circumstances, such as place, for example, proximity to an international border and airport. Time and size of the outbreak as well as clinical and epidemiologic characteristics of the pathogen. Though an event might be assessed as not being notifiable, there could nevertheless be good reasons for consulting the WHO. These reasons might include limited local capacity to respond, specific vulnerability of the population, etc. So is this a reportable event? Technically, the answer is no because this only meets one of the four criteria. We only answered yes to the question, is the public health impact of this event serious. However, the country can still consult the WHO if they need additional resources or assistance in responding to the emergency. Case scenario two, cholera outbreak in a different setting, 12 tourists become ill with acute gastrointestinal symptoms just prior to departing Country B. They'd all been staying at the same popular tourist hotel where they attended several organized group tours and excursions. Cholera was identified in the stools of six of these patients. Health authorities in Country B suspect a contaminated seafood salad as the source of infection. All symptomatic tourists consumed a seafood salad during one of the boat trips. During the previous years, sporadic cases of cholera have occurred in Country B, but there have not been any epidemics. Country C just reported to WHO two likely imported cholera cases in persons who have just returned from Country B. So let's take a look at those four questions again. Is the public health impact of this event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? And is there a significant risk of international travel or trade restrictions? So again, we know that cholera is one of the diseases that will always lead to utilization of the decision instrument. However, events involving cholera or any other disease that require to be assessed do not necessarily have serious character in the context of given geography, the population at risk, and the season. So is the public health impact of this event serious? No. Is the event unusual or unexpected? Yes, the potential or actual export of even a few cases or their contacts presenter risk of international disease spread, which is both serious. So answering yes to question two, and a possible risk of international spread, answering yes to question three. Is there significant risk to international travel or trade restrictions? Yes, in previous years, news of disease outbreak in an area of intense international traffic have often, possibly unjustified, led to restrictions of international travel and trade by other countries. Today such restrictions must comply with the IHR, but there still is risk in this circumstance to those restrictions being applied. So in this situation, we would absolutely report as we answered yes to three of the four questions. Case scenario three is a toxic chemical spill. Following an industrial accident in City D, 100 tons of benzene have spilt into a major river. This is the first time this type of accident has occurred in the area. The river is a main source of drinking water for both City D and also three major cities in a neighboring country downstream of the river. Benzene is a known human carcinogen. Authorities in City D have shut off drinking water supplies to the residents in response, and alternative water sources are being mobilized. However, decontamination efforts have been limited due to a lack of equipment and a lack of expertise. So we'll review those four questions again. Is the public health impact of this event serious? Is the event unusual or unexpected? Is there a significant risk of international spread? And is there a significant risk of international travel or trade restrictions? Is the public health impact of this event serious? Yes, notifiable events can extend beyond communicable diseases and may arise from biological and chemical agents or radionuclide materials. Is the event unusual or unexpected? Yes, the seriousness of an event can be determined by its acute and delayed public health consequences. The assessment of the IHR notification obligation has to therefore consider whether an event carries a potential for future impact on public health and requires immediate action to reduce the potential consequences. For this example, assistance from WHO and other international partners might be requested, depending on existing national chemical emergency response plans and capacities. Is there significant risk of international spread? Yes, given the location of the river and three major cities in a neighboring country downstream, we know that there's potential for international spread. Is there significant risk of international travel or trade restrictions? Yes and no. The potential exportation of a public health hazard across international borders is a major concern. However, we don't necessarily know that the contamination of this river will explicitly cause risk of international trade or travel restrictions. So in this situation, this would be a reportable event as we've answered yes to at least three of the questions. Our last case scenario is the outbreak of unknown etiology. During the last 4 days, 23 cases of a febrile encephalitis associated with respiratory illness were reported to the Ministry of Health in Country L. These had a 35% case fatality rate. The index case and eight additional cases occurred among abattoir workers of the same slaughterhouse. Three cases are household members of one of those workers, and the other cases occurred among traders and customers exposed to cows and pigs at a cattle market held a week and a half ago. Meanwhile, two of the patients died, and two healthcare workers caring for these fatal cases have also fallen ill. Concurrent with the human cases, illness and death occurred among swine from the same regions one to two weeks before illness in humans. The disease in swine, which so far is of unknown etiology, is not well-defined but appears to include rapid and labored breathing, an explosive non-productive cough, and neurologic changes, including lethargy and aggressive behavior. All human cases have occurred in the two rural areas of two distinct provinces and are primarily adult men who have histories of close contact with the swine. Illness has been characterized by initial fever and headache, followed by mild blurred vision, generalized seizures, and disorientation that can progress to a coma within 24 to 48 hours as well as the development of respiratory failure in some of the patients. Most cases become ill 6 to 10 days after their last known exposure to swine. Initially Japanese Encephalitis, or JE, was considered to be the probable etiologic agent for this outbreak since specimens from one early patient tested positive for infection with JE virus. However, the predominance of cases in humans who had close contact with the swine suggest that the possibility of another causative agent, which the laboratory diagnosis, despite numerous testing, has not been able to be determined. An epidemiologic outbreak investigation team started a study to identify the source of human infection and to define specific risk factors associated with illness and humans and to determine the risk for human-to-human transmission. So let's go back to our four questions. Is the public health impact of this event serious? Is the event unusual or unexpected? Is there significant risk of international spread? And is there significant risk of international travel or trade restrictions? Is the public health impact of this event serious? Yes, events with no or very few human cases yet identified may still represent a serious and notifiable public health event, especially if associated with deaths in animals. Cases among healthcare workers should always prompt further investigation and indicate a potential high public health impact event. Is the event unusual or unexpected? Yes, events caused by unknown or unusual agent, source, or route of transmission may represent a public health emergency of international concern. Early consultation with the WHO during an evolving outbreak of unknown origin is advised given the potential for seriousness and the lack of available information at this point. Is there significant risk of international spread? No, at this time, the outbreak seems to be contained to the environment surrounding the swine. And is there a significant risk of international travel or trade restrictions? Yes, the association of an event with food products potentiates the possibility of the imposition of trade restrictions. So we would answer yes to this last question. Given that we have answered yes to three of the four questions, this is absolutely a reportable event, and the WHO should be notified immediately. So we can see from those case studies that the threshold for notifying the WHO is actually quite low, and this is to encourage ongoing and collaborative communications between member states and the WHO. As outbreaks and other public health emergencies continue to increase in frequency and severity, preparedness is key. Communication is absolutely critical to effective emergency preparedness and response. And the global health security agenda and IHR programming can support public health responses to public health emergencies of international concern or even potential PHEICs. However, the initial and most important work must be done at the local level. If you're interested in learning more about the WHO International Health Regulations or the Global Health Security Agenda, this slide includes a bit more further reading and a few more resources. [MUSIC]
