The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by the World Health Organization in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by the World Health Organization to verify the information contained in this publication.
However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall the World Health Organization be liable for damages arising from its use. Information concerning this publication can be obtained from: World Health Report World Health Organization 1211 Geneva 27, Switzerland E-mail: whr@who. int Copies of this publication can be ordered from: bookorders@who. nt This report was produced under the leadership of Director-General, Margaret Chan. David Heymann, Assistant Director-General for Communicable Diseases, was Editor-in-Chief. The main writers were Thomson Prentice and Lina Tucker Reinders of the World Health Report team. Advice and support were gratefully received from all Assistant Directors-General, Regional Directors, numerous WHO technical units, and many others who reviewed and contributed to the text.
Special thanks for their contributions are due to Tomas Allen, Penelope Andrea, Bruce Aylward, Anand Balachandran, Sona Bari, Diarmid Campbell-Lendrum, Amina Chaieb, Claire Lise Chaignat, May Chu, Albert Concha-Eastman, Ottorino Cosivi, Alvaro Cruz, Kevin De Cock,Sophia Desillas, Pat Drury, Pierre Formenty, Keiji Fukuda, Fernando Gonzalez–Martin, Pascal Haefliger, Max Hardiman, Mary Kay Kindhauser, Colin Mathers, Angela Merianos, Francois-Xavier Meslin, Michael Nathan, Maria Neira, Paul Nunn, Kevin O’Reilly, Andree Pinard-Clark, Guenael Rodier, Oliver Rosenbauer, Cathy Roth, Mike Ryan, Jorgen Schlundt, George Schmid, Ian Smith, Claudia Stein and Leo Vita-Finzi. The report was edited by Diana Hopkins, assisted by Barbara Campanini. Figures, tables and other illustrations were provided by Gael Kernen, who also produced the web site version and other electronic media.
Vreni Schoenenberger assisted in historical research. Administrative support to the World Health Report team was provided by Saba Amdeselassie. The index was prepared by June Morrison. Photo credits: Agence France-Presse/Paula Bronstein (pp. viii, 34); International Federation of the Red Cross and Red Crescent Societies (IFRC)/ Christopher Black (p. 25); IFRC/Marko Kokic (p. 22); United Nations Integrated Regional Information Networks (IRIN) (p. 41); Jean-Pierre Revel (p. 30); United States National Library of Medicine (NLM) (p. 47); WHO/Olivier Asselin (pp. viii, 16); WHO/Christopher Black (pp. viii, xiv, xvi, xviii, xx, xxii, 1, 16, 34, 44, 6, 64); WHO/Christopher Black, Chris de Bode, Umit Kartoglu, Marko Kokic and Jean Mohr (cover); WHO/Chris de Bode (p. 19); WHO/Marko Kokic (pp. 20, 21); WHO/Jean Mohr (pp. viii, 1). Illustrations: The Plague Doctor, unknown artist, Wellcome Library, London (p. 2); Death’s Dispensary, George Pinwell, 1866 (p. 4); Edward Jenner Performing the First Vaccination against Smallpox in 1796, Gaston Melingue, 1879, Bibliotheque de l’Academie nationale de Medecine, Paris (p. 5). Design: Reda Sadki Layout: Steve Ewart and Reda Sadki Figures: Christophe Grangier Printing Coordination: Raphael Crettaz Printed in France iii conTenTS Message from the Director-General Overview
Global public health threats in the 21st century Epidemic-prone diseases Foodborne diseases Accidental and deliberate outbreaks Toxic chemical accidents Radionuclear accidents Environmental disasters Global collaboration to meet threats to public health security Chapter summaries Building on historical landmarks Plague and quarantine Cholera and sanitation Smallpox and immunization Fostering international cooperation A new code for international health security International preparedness for chemical emergencies New health regulations in a vastly altered world vi viii x x xi xi xi xi xii xii xiv 1 2 2 4 5 6 8 10 11 17 17 18 20 21 22 24 24 24 25 26 27 29 31 Chapter 1. Evolution of public health security chapter Chapter 2.
Threats to public health security Human causes of public health insecurity Inadequate investment Unexpected policy changes Public health consequences of conflict Microbial evolution and antibiotic resistance Animal husbandry and food processing Human bovine spongiform encephalopathy Nipah virus Weather-related events and infectious diseases Other public health emergencies Sudden chemical and radioactive events Industrial accidents Natural phenomena chapter 1 2 iv chapter chapter chapter 3 4 5 Chapter 3. New health threats in the 21st century The anthrax letters SARS: vulnerability revealed Dumping of toxic chemicals 35 35 37 40 Chapter 4. Learning lessons, thinking ahead
Pandemic influenza: the most feared security threat WHO’s strategic action plan for pandemic influenza Extensively drug-resistant tuberculosis Managing the risks and consequences of the international spread of polio 45 45 52 52 54 Chapter 5. Towards a safer future Helping countries helps the world Global partnerships Strengthening national capacity Preventing and responding to international public health emergencies Legal issues and monitoring 57 58 58 61 63 64 66 69 Conclusions and recommendations Index v Figures – Chapters Figure 1. 1 Spread of bubonic plague in Europe Figure 1. 2 Examples of international epidemic response missions, 1998–1999 Figure 1. International public health security: a global network of national health systems and technical partners, coordinated by WHO, founded on four major areas of work Figure 1. 4 Selected emerging and re-emerging infectious diseases, 1996–2004 Figure 2. 1 Twenty-five years of HIV/AIDS Figure 2. 2 Global outbreaks, the challenge: late reporting and response Figure 2. 3 Evolution of penicillin resistance in Staphylococcus aureus: a continuing story Figure 3. 1 Probable SARS transmission on flight CA112 in March 2003 Figure 3. 2 Direct economic impact of selected infectious disease outbreaks, 1990–2003 Figure 4. 1 WHO influenza surveillance network Figure 4. Cumulative number of confirmed human cases of avian influenza A/(H5N1) reported to WHO since 2003 Figure 4. 3 Poliovirus importations, 2003–2006 Figure 5. 1 Events that may constitute a public health emergency of international concern: the decision instrument Figure 5. 2 Verified events of potential international public health concern, by WHO region, September 2003–September 2006 Box 1. 1 Public health security Box 1. 2 International collaboration on infectious disease control Box 2. 1 Marburg haemorrhagic fever and health systems in conflict situations Box 2. 2 The deliberate use of chemical and biological agents to cause harm Box 3. 1 Economic impact of SARS and influenza pandemics Box 3. 2 The role of the mass media in risk perceptions Box 4. WHO meeting concludes that global stockpiles of H5N1 vaccines are feasible Box 5. 1 IHR (2005) – early implementation efforts 3 8 10 12 18 19 23 38 40 46 48 54 59 63 1 7 21 27 39 41 50 61 28 60 Boxes – Chapters Tables – Chapters Table 2. 1 Examples of major chemical incidents (1974–2006) Table 5. 1 Seven strategic actions to guide IHR (2005) implemention vi global public health security in the 21st century world health report 2007 The world has changed dramatically since 1951, when who issued its first set of legally binding regulations aimed at preventing the international spread of disease. At that time, the disease situation was relatively stable.
Concern focused on only six “quarantinable” diseases: cholera, plague, relapsing fever, smallpox, typhus and yellow fever. New diseases were rare, and miracle drugs had revolutionized the care of many well-known infections. People travelled internationally by ship, and news travelled by telegram. MeSSaGe froM The direcTor-General Since then, profound changes have occurred in the way humanity inhabits the planet. The disease situation is anything but stable. Population growth, incursion into previously uninhabited areas, rapid urbanization, intensive farming practices, environmental degradation, and the misuse of antimicrobials have disrupted the equilibrium of the microbial world.
New diseases are emerging at the historically unprecedented rate of one per year. Airlines now carry more than 2 billion passengers annually, vastly increasing opportunities for the rapid international spread of infectious agents and their vectors. Dependence on chemicals has increased, as has awareness of the potential hazards for health and the environment. Industrialization of food production and processing, and globalization of marketing and distribution mean that a single tainted ingredient can lead to the recall of tons of food items from scores of countries. In a particularly ominous trend, mainstay antimicrobials are failing at a rate that outpaces the development of replacement drugs.
These threats have become a much larger menace in a world characterized by high mobility, economic interdependence and electronic interconnectedness. Traditional defences at national borders cannot protect against the invasion of a disease or vector. Real time news allows panic to spread with equal ease. Shocks to health reverberate as shocks to economies and business continuity in areas well beyond the affected site. Vulnerability is universal. vii The World Health Report 2007 is dedicated to promoting global public health security – the reduced vulnerability of populations to acute threats to health. This year’s World Health Day, celebrated in April, launched WHO’s discussion on global public health security.
Around the world, academics, students, health professionals, politicians and the business community are engaged in dialogue on how to protect the world from threats like pandemic influenza, the health consequences of conflict and natural disasters, and bioterrorism. The World Health Report 2007 addresses these issues, among others, in the context of new tools for collective defence, including, most notably, the revised International Health Regulations (2005). These Regulations are an international legal instrument designed to achieve maximum security against the international spread of diseases. They also aim to reduce the international impact of public health emergencies.
The IHR (2005) expand the focus of collective defence from just a few “quarantinable” diseases to include any emergency with international repercussions for health, including outbreaks of emerging and epidemic-prone diseases, outbreaks of foodborne disease, natural disasters, and chemical or radionuclear events, whether accidental or caused deliberately. In a significant departure from the past, IHR (2005) move away from a focus on passive barriers at borders, airports and seaports to a strategy of proactive risk management. This strategy aims to detect an event early and stop it at its source – before it has a chance to become an international threat. Given today’s universal vulnerability to these threats, better security calls for global solidarity.
International public health security is both a collective aspiration and a mutual responsibility. As the determinants and consequences of health emergencies have become broader, so has the range of players with a stake in the security agenda. The new watchwords are diplomacy, cooperation, transparency and preparedness. Successful implementation of IHR (2005) serves the interests of politicians and business leaders as well as the health, trade and tourism sectors. I am pleased to present the World Health Report 2007 to our partners and look forward to the discussions, directions and actions that it will inspire. Dr Margaret Chan Director-General World Health Organization viii lobal public health security in the 21st century world health report 2007 overview overview ix at a time when the world faces many new and recurring threats, the ambitious aim of this year’s world health report is to show how collective international public health action can build a safer future for humanity. This is the overall goal of global public health security. For the purposes of this report, global public health security is defined as the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries.
As the events illustrated in this report show, global health security, or the lack of it, may also have an impact on economic or political stability, trade, tourism, access to goods and services and, if they occur repeatedly, on demographic stability. It embraces a wide range of complex and daunting issues, from the international stage to the individual household, including the health consequences of poverty, wars and conflicts, climate change, natural catastrophes and man-made disasters. All of these are areas of continuing WHO work and will be the topics of forthcoming publications. The 2008 World Health Report, for example, will be concerned with individual health security, concentrating on the role of primary health care and humanitarian action in providing access to the essential prerequisites for health.
This report, however, focuses on specific issues that threaten the collective health of people internationally: infectious disease epidemics, pandemics and other acute health events as defined by the revised International Health Regulations, known as IHR (2005), which came into force in June of this year. The purpose of these Regulations is to prevent the spread of disease across international borders. They are a vital legislative instrument of global public health security, providing the necessary global framework to prevent, detect, assess and, if necessary, provide a coordinated response to events that may constitute a public health emergency of international concern.
Meeting the requirements in the revised IHR (2005) is a challenge that requires time, commitment and the willingness to change. The Regulations are broader and more demanding than those they replace, with a much greater emphasis on the responsibility of all countries to have in place effective systems for detection and control of public health risks – and to accomplish this by 2012. A strategic plan has been developed by WHO to guide countries in the implementation of the obligations in the Regulations and to help them overcome the inherent challenges. x global public health security in the 21st century world health report 2007 Global public health threats in the 21st century
Today’s highly mobile, interdependent and interconnected world provides myriad opportunities for the rapid spread of infectious diseases, and radionuclear and toxic threats, which is why updated and expanded Regulations are necessary. Infectious diseases are now spreading geographically much faster than at any time in history. It is estimated that 2. 1 billion airline passengers travelled in 2006; an outbreak or epidemic in any one part of the world is only a few hours away from becoming an imminent threat somewhere else (see Figure 1). Infectious diseases are not only spreading faster, they appear to be emerging more quickly than ever before. Since the 1970s, newly emerging diseases have been identified at the unprecedented rate of one or more per year.
There are now nearly 40 diseases that were unknown a generation ago. In addition, during the last five years, WHO has verified more than 1100 epidemic events worldwide. The categories and examples given below illustrate the variety and breadth of public health threats confronting people today. epidemic-prone diseases Cholera, yellow fever and epidemic meningococcal diseases made a comeback in the last quarter of the 20th century and call for renewed efforts in surveillance, prevention and control. Severe Acute Respiratory Syndrome (SARS) and avian influenza in humans have triggered major international concern, raised new scientific challenges, caused major human suffering and imposed enormous economic damage.
Other emerging viral diseases such as Ebola, Marburg haemorrhagic fever and Nipah virus pose threats to global public health security and also require containment at their source due to their acute nature and resulting illness and mortality. During outbreaks of these diseases, rapid assessment and response, often needing international assistance, has been required to limit local spread. Strengthening of capacity is imperative in the future to assess such new threats. Figure 1 Verified events of potential international public health concern, by WHO region, September 2003–September 2006 350 300 250 288 Numbers 200 150 100 50 0 Africa Western Pacific Eastern Mediterranean South-East Asia Europe Americas 108 89 81 78 41 Total number of cases = 685 WHO regions overview
Gains in many areas of infectious disease control are seriously jeopardized by the spread of antimicrobial resistance, with extensively drug-resistant tuberculosis (XDR-TB) now a cause of great concern. Drug resistance is also evident in diarrhoeal diseases, hospital-acquired infections, malaria, meningitis, respiratory tract infections, and sexually transmitted infections, and is emerging in HIV. xi Foodborne diseases The food chain has undergone considerable and rapid changes over the last 50 years, becoming highly sophisticated and international. Although the safety of food has dramatically improved overall, progress is uneven and foodborne outbreaks from microbial contamination, chemicals and toxins are common in many countries. The trading of contaminated food between countries increases the potential that outbreaks will spread.
In addition, the emergence of new foodborne diseases creates considerable concern, such as the recognition of the new variant of Creutzfeldt-Jakob disease (vCJD) associated with bovine spongiform encephalopathy (BSE). accidental and deliberate outbreaks As activities related to infectious disease surveillance and laboratory research have increased in recent years, so too has the potential for outbreaks associated with the accidental release of infectious agents. Breaches in biosafety measures are often responsible for these accidents. At the same time, opportunities for malicious releases of dangerous pathogens, once unthinkable, have become a reality, as shown by the anthrax letters in the United States of America in 2001. In addition, the recent past has been marked by disturbing new health events that resulted from chemical or uclear accidents and sudden environmental changes, causing major concerns in many parts of the world. Toxic chemical accidents ¦ West Africa, 2006: the dumping of approximately 500 tons of petrochemical waste in at least 15 sites around the city of Abidjan, Cote d’Ivoire, led to the deaths of eight people being attributed to exposure to the waste and to nearly 90 000 more people seeking medical help. Other countries were concerned that they could also have been put at risk as a result of dumping elsewhere or as a result of chemical contamination of transboundary rivers. ¦ Southern Europe, 1981: 203 people died after consuming poisoned cooking oil that was adulterated with industrial rapeseed oil.
A total of 15 000 people were affected by the tainted oil and no cure to reverse the adverse effects of toxic oil syndrome was ever found. Radionuclear accidents ¦ Eastern Europe, 1986: the Chernobyl disaster is regarded as the worst accident in the history of nuclear power. The explosion at the plant resulted in the radioactive contamination of the surrounding geographical area, and a cloud of radioactive fallout drifted over western parts of the former Soviet Union, eastern and western Europe, some Nordic countries and eastern North America. Large areas of Ukraine, the Republic of Belarus and the Russian Federation were badly contaminated, resulting in the evacuation and resettlement of over 336 000 people. xii lobal public health security in the 21st century world health report 2007 Environmental disasters ¦ Europe, 2003: the heatwave in Europe that claimed the lives of 35 000 persons was linked to unprecedented extremes in weather in other parts of the world during the same period. ¦ Central Africa, 1986: more than 1700 people died of carbon dioxide poisoning following a massive release of gas from Lake Nyos, a volcanic crater lake. Such an event requires rapid assessment to determine if it is an international threat. This Overview summarizes some of the above examples, which, together with the lessons drawn from them, are more widely discussed in the report.
The report emphasizes that the international response required today is not only to the known, but also to the unknown – the diseases that may arise from acute environmental or climatic changes and from industrial pollution and accidents that may put millions of people at risk in several countries. Global collaboration to meet threats to public health security These threats require urgent action, and WHO and its partners have much to offer immediately as well as in the longer term. This is an area where real progress to protect whole populations can be made, starting now. It is also where recent history shows that some of the most serious threats to human existence are likely to emerge without warning. It would be extremely naive and complacent to assume that there will not be another disease like AIDS, another Ebola, or another SARS, sooner or later.
A more secure world that is ready and prepared to respond collectively in the face of threats to global health security requires global partnerships that bring together all countries and stakeholders in all relevant sectors, gather the best technical support and mobilize the necessary resources for effective and timely implementation of IHR (2005). This calls for national core capacity in disease detection and international collaboration for public health emergencies of international concern. While many of these partnerships are already in place, there are serious gaps, particularly in the health systems of many countries, which weaken the consistency
Figure 2 Global outbreaks, the challenge: late reporting and response Early reporting 90 80 70 60 50 40 30 20 10 0 1 4 7 10 13 16 19 22 25 Rapid response Potential cases prevented/ international spread prevented Cases 28 31 34 37 40 Days overview of global health collaboration. In order to compensate for these gaps, an effective global system of epidemic alert and response was initiated by WHO in 1996. It was built essentially on a concept of international partnership with many other agencies and technical institutions. Systematic mechanisms for gathering epidemic intelligence and verifying the existence of outbreaks were established and prompted risk assessments, information dissemination and rapid field response.
Regional and global mechanisms for stockpiling and rapid distribution of vaccines, drugs and specialized investigation and protection equipment were also established for public health events caused by haemorrhagic fevers, influenza, meningitis, smallpox and yellow fever. Today, the public health security of all countries depends on the capacity of each to act effectively and contribute to the security of all. The world is rapidly changing and nothing today moves faster than information. This makes the sharing of essential health information one of the most feasible routes to global public health security. Instant electronic communication means that disease outbreaks can no longer be kept secret, as was often the ase during the implementation of the previous International Health Regulations (1969), known as IHR (1969). Governments were unwilling to report outbreaks because of the potential damage to their economies through disruptions in trade, travel and tourism. In reality, rumours are more damaging than facts. Trust is built through transparency, and trust is necessary for international cooperation in health and development (see Figure 2). The first steps that must be taken towards global public health security, therefore, are to develop core detection and response capacities in all countries, and to maintain new levels of cooperation between countries to reduce the risks to public health security outlined above.
This entails countries strengthening their health systems and ensuring they have the capacity to prevent and control epidemics that can quickly spread across borders and even across continents. Where countries are unable to achieve prevention and control by themselves, it means providing rapid, expert international disease surveillance and response networks to assist them – and making sure these mesh together into an efficient safety net. Above all, it means all countries conforming to and benefiting from IHR (2005). xiii xiv global public health security in the 21st century world health report 2007 chapter summaries evolution of public health security chapter 1 Chapter 1 begins by tracing some of the first steps, historically, that led o the introduction of IHR (1969) – landmarks in public health starting with quarantine, a term coined in the 14th century and employed as a protection against “foreign” diseases such as plague; improvements in sanitation that were effective in controlling cholera outbreaks in the 19th century; and the advent of vaccination which led to the eradication of smallpox and the control of many other infectious diseases in the 20th century. Understanding the history of international health cooperation – its successes and its failures – is essential in appreciating its new relevance and potential. Numerous international conferences on disease control in the late 19th and early 20th centuries led to the foundation of WHO in 1948. In 1951, WHO Member States adopted the International Sanitary Regulations, which were replaced and renamed the International Health Regulations in 1969.
Starting in 1995, the Regulations were revised through an intergovernmental process which took into account new epidemiological understanding and accumulated experience, and which responded to the changing world and the related increased threats to global public health security. It was agreed that a code of conduct was required that could not only prevent and control such threats, but could also provide a public health response to them while avoiding unnecessary interference with international trade and traffic. The revision process was completed in 2005 and the Regulations are now referred to as IHR (2005). Chapter 1 describes how the basis of an effective global system of epidemic alert and response was initiated by WHO in 1996 and how it has been widely expanded since then.
It was built essentially on a concept of international partnership with many other agencies and technical institutions. Called the Global Outbreak Alert and Response Network (GOARN), this partnership provides an operational and coordination framework to access expertise and skill, and to keep the international community constantly alert to the threat of outbreaks and ready to respond. Coordinated by WHO, the network is made up of over 140 technical partners from more than 60 countries. In addition, the unique, large-scale active surveillance network developed by the Global Polio Eradication Initiative is being used to support surveillance of many other vaccine-preventable diseases, such as measles, meningitis, neonatal tetanus and yellow fever.
This network is also regularly supporting outbreak surveillance and response activities for other health emergencies and outbreaks described in the report. In 2002, WHO established the Chemical Incident Alert and Response System to operate along similar lines to GOARN. This was extended in 2006 to cover other environmental health emergencies, including those related to the disruption of environmental health services, such as water supply and sanitation, as well as radiological events and emergencies. overview The revised Regulations define an emergency as an “extraordinary event” that could spread internationally or might require a coordinated international response.
Events that may constitute a public health emergency of international concern are assessed by State Parties using a decision instrument and, if particular criteria are met, WHO must be notified. Mandatory notification is called for in a single case of a disease that could threaten global public health security: human influenza caused by a new virus subtype, poliomyelitis caused by a wild-type poliovirus, SARS and smallpox. The broad definitions of “public health emergency of international concern” and “disease” allow for the inclusion in IHR (2005) of threats beyond infectious diseases, including those caused by the accidental or intentional release of pathogens, or chemical or radionuclear materials.
This extends the scope of the Regulations to protect global public health security in a comprehensive way. The IHR (2005) redirect the focus from an almost exclusive concentration on measures at airports and seaports aimed at blocking the importation of cases, as required in IHR (1969), towards a rapid response at the source of an outbreak. They introduce a set of “core capacity requirements” that all countries must meet in order to detect, assess, notify and report the events covered by IHR (2005) and aim to strengthen collaboration on a global scale by seeking to improve capacity and demonstrate to countries that compliance is in their best interests.
Thus, compliance has three compelling incentives: to reduce the disruptive consequences of an outbreak, to speed its containment, and to maintain good standing in the eyes of the international community. A revolutionary departure from previous international conventions and regulations is the fact that IHR (2005) explicitly acknowledges that non-state sources of information about outbreaks will often pre-empt official notifications. This includes situations where countries may be reluctant to reveal an event in their territories. WHO is now authorized through IHR (2005) to take into account information sources other than official notifications.
WHO will always seek official verification of such information from the country involved before taking any action based on the information received. This reflects a new reality in a world of instant communications: the concealment of disease outbreaks is no longer a viable option for governments. xv xvi global public health security in the 21st century world health report 2007 threats to public health security chapter 2 Chapter 2 explores a range of threats to global public health security, as defined by IHR (2005), which result from human actions or causes, from human interaction with the environment, and from sudden chemical and radioactive events, including industrial accidents and natural phenomena.
It begins by illustrating how inadequate investment in public health, resulting from a false sense of security in the absence of infectious disease outbreaks, has led to reduced vigilance and a relaxing of adherence to effective prevention programmes. For example, following the widespread use of insecticides in large-scale, systematic control programmes, by the late 1960s most of the important vector-borne diseases were no longer considered major public health problems outside of sub-Saharan Africa. Control programmes then lapsed as resources dwindled. The result was that within the next 20 years, many important vector-borne diseases including African trypanosomiasis, dengue and dengue haemorrhagic fever, and malaria emerged in new areas or re-emerged in areas previously affected.
Urbanization and increasing international trade and travel have contributed to rapid spread of dengue viruses and their vectors. Dengue caused an unprecedented pandemic in 1998, with 1. 2 million cases reported to WHO from 56 countries. Since then, dengue epidemics have continued, affecting millions of people from Latin America to South-East Asia. Globally, the average annual number of cases reported to WHO has nearly doubled in each of the last four decades. Inadequate surveillance results from a lack of commitment to build effective health systems capable of monitoring a country’s health status. The rapid global emergence and spread of HIV/AIDS in the 1970s illustrates this.
The presence of this new health threat was not detected by what were invariably weak health systems in many developing countries. It only belatedly became a matter of international concern with the first cases in the United States. In addition to limited disease surveillance capacity and data, early efforts to control the AIDS epidemic were also hampered by a lack of solid data on sexual behaviour in African countries, the United States and other industrialized countries. Behavioural data were practically non-existent in the developing world. The understanding of HIV/AIDS in the context of sexuality, gender relations and migration in the developing world took years to develop and is still poorly understood.
Even with reliable operations in place, other influences on public health programmes can have lethal and costly repercussions. Such was the case in August 2003, when unsubstantiated claims originating in northern Nigeria that the oral poliomyelitis vaccine (OPV) was unsafe and could sterilize young children led to the suspension of polio immunization in two northern states and substantial reductions in polio immunization coverage in a number of others. The result was a large outbreak of polio across northern Nigeria and the reinfection of previously polio-free areas in the south of the country. This outbreak eventually paralysed thousands of children in Nigeria and spread from northern Nigeria to 19 polio-free countries. overview
Chapter 2 also considers the public health consequences of conflicts, such as the outbreak of Marburg haemorrhagic fever against the background of the 1975-2002 civil war in Angola, and the cholera epidemic in the Democratic Republic of the Congo in the aftermath of the crisis in Rwanda in 1994. In July of that year, between 500 000 and 800 000 people crossed the border to seek refuge in the outskirts of the Congolese city of Goma. During the first month after their arrival, close to 50 000 refugees died in a widespread outbreak of combined cholera and shigella dysentery. The speed of transmission and the high rate of infection were related to the contamination with Vibrio cholerae of the only available source of water and the absence of proper housing and sanitation.
The problem of microbial adaptation, the use and misuse of antibiotics and zoonotic diseases, such as human bovine spongiform encephalopathy (BSE) and Nipah virus, is discussed. The history of Nipah virus emergence provides another example of a new human pathogen that originated from an animal source, initially caused zoonotic disease, and subsequently evolved to become a more efficient human pathogen. This trend calls for closer collaboration among sectors responsible for human health, veterinary health and wildlife. Infectious diseases following extreme weather-related events and the acute public health impact of sudden chemical and radioactive events are also discussed.
These now fall within the scope of IHR (2005) if they have the potential to cause harm on an international scale, including the deliberate use of biological and chemical agents, and industrial accidents. Among the examples of accidents given here is the Chernobyl nuclear accident in Ukraine in 1986, which dispersed radioactive materials into the atmosphere over a huge area of Europe. Put together, the examples in this chapter reveal the alarming variety of threats to global health security towards the end of the 20th century. xvii xviii global public health security in the 21st century world health report 2007 new health threats in the 21st century chapter 3
Chapter 3 examines three new health threats that have emerged in the 21st century – bioterrorism in the form of the anthrax letters in the United States in 2001, the emergence of SARS in 2003, and the large-scale dumping of toxic chemical waste in Cote d’Ivoire in 2006. Coming only days after the terrorist events of 11 September 2001, the deliberate dissemination of potentially lethal anthrax spores in letters sent through the United States Postal Service added bioterrorism to the realities of life in modern society. In addition to the human toll ? five died out of a total of 22 people affected ? the anthrax attack had huge economic, public health and security consequences.
It prompted renewed international concerns about bioterrorism, provoking countermeasures in many countries and requests for a greater advisory role by WHO led to the updating of the publication Public health response to biological and chemical weapons: WHO guidance. The anthrax letters showed the potential of bioterrorism to cause not just death and disability, but enormous social and economic disruption. A simultaneous worry was that smallpox – eradicated as a human disease in 1979 – could be used over 20 years later to deadly effect in deliberate acts of violence. Mass smallpox vaccination had been discontinued after eradication, thus leaving unimmunized populations susceptible and a new generation of public health practitioners without clinical experience of the disease.
Since then, WHO has taken part in international discussions and bioterrorism desktop exercises arguing that the surest way to detect a deliberately caused outbreak is by strengthening the systems used for detecting and responding to natural outbreaks, as the epidemiological and laboratory principles are fundamentally the same. Expert discussions on the appropriate response to a biological attack, especially with the smallpox virus, served to test – on a global scale – the outbreak alert and response mechanisms already introduced by WHO. In 2003, SARS – the first severe new disease of this century – confirmed fears, generated by the bioterrorism threat, that a new or unfamiliar pathogen might have profound national and international implications for public health and economic security.
SARS defined the features that would give a disease international significance as a global public health security threat: it spread from person to person, required no vector, displayed no particular geographical affinity, incubated silently for more than a week, mimicked the symptoms of many other diseases, took its heaviest toll on hospital staff, and killed around 10% of those infected. These features meant that it spread easily along the routes of international air travel, placing every city with an international airport at risk of imported cases. overview New, deadly and – initially – poorly understood, SARS incited a degree of public anxiety that virtually halted travel to affected areas and drained billions of dollars from economies across entire regions. It challenged public and political perceptions of the risks associated with emerging and epidemic-prone diseases and raised the profile of public health to new heights.
Not every country felt threatened by the prospect of bioterrorism, but every country was concerned by the arrival of a disease like SARS. It showed that the danger arising from emerging diseases is universal. No country, rich or poor, is adequately protected from either the arrival of a new disease on its territory or the subsequent disruption this can cause. The spread of SARS was halted less than four months after it was first recognized as an international threat – an unprecedented achievement for public health on a global scale. If SARS had become permanently established as yet another indigenous epidemic threat, it is not difficult to imagine the consequences for global public health security in a world still struggling to cope with HIV/AIDS.
As well as the international mobility of people, the global movement of products can have serious health consequences. The potentially deadly risks of the international movement and disposal of hazardous wastes as an element of global trade were vividly illustrated in Cote d’Ivoire in August 2006. Over 500 tons of chemical waste were unloaded from a cargo ship and illegally dumped by trucks at different sites in and around Abidjan. As a result, almost 90 000 people sought medical treatment in the following days and weeks. Although less than 100 people were hospitalized and far fewer deaths could be attributed to the event, it was a public health crisis of both national and international dimensions.
One of the main international concerns was that the cargo ship had sailed from northern Europe and had called at a number of ports, including some others in western Africa, on its way to Cote d’Ivoire. It was unclear in the aftermath of the incident whether it had taken on, or discharged, chemical waste at any of those ports of call. xix xx global public health security in the 21st century world health report 2007 learning lessons, thinking ahead chapter 4 Chapter 4 is devoted to potential public health emergencies of international concern, the most feared of which remains pandemic influenza. The response to this threat has already been proactive ? facilitated by early implementation of IHR (2005).
This has been a rare opportunity to prepare for a pandemic, and possibly to prevent the threat becoming a reality by taking full advantage of advance warning and by testing a model for pandemic planning and preparedness. This advantage must be fully exploited to enhance global preparedness within the framework of IHR (2005). Coming on the heels of the SARS outbreak, the prospect of an influenza pandemic sparked immediate alarm around the world. Far more contagious, spread by coughing and sneezing and transmissible within an incubation period too short to allow for contact tracing and isolation, pandemic influenza would have devastating consequences. If a fully transmissible pandemic virus emerged, the spread of the disease could not be prevented. Based on experiences with past pandemics, illness affecting around 25% of the world’s population – more than 1. billion people – could be anticipated. Even if the influenza pandemic virus caused relatively mild disease, the economic and social disruption arising from sudden surges of illness in so many people would be enormous. As the next influenza pandemic is likely to be of avian variety, many interventions have been taken to control the initial outbreaks in poultry, including the destruction of tens of millions of birds. Chapter 4 describes the key actions taken and the remarkable degree of international collaboration that has been achieved to reduce the pandemic risk. Among its many front-line activities, WHO has tracked and verified dozens of daily rumours of human cases.
Field investigation kits have been dispatched to countries and training on field investigations and response intensified. The GOARN mechanism was mobilized to support the deployment of WHO response teams to 10 countries with H5N1 infection in humans and/or poultry, while over 30 assessment teams investigated the potential H5N1 situation in other countries. With the aim of promoting global preparedness, WHO developed a strategic action plan for pandemic influenza that set out five key action areas. ¦ Reducing human exposure to the H5N1 virus. ¦ Strengthening the early warning system. ¦ Intensifying rapid containment operations. ¦ Building capacity to cope with a pandemic. ¦ Coordinating global scientific research and development. overview
By May 2007, when 12 countries had reported 308 human cases including 186 deaths, nearly all countries had established avian and human pandemic preparedness plans. Working together, WHO and some Member States created international stockpiles of oseltamivir, an antiviral drug that potentially could stop transmission in an early focus of human-to-human transmission. The pharmaceutical industry continues to search for a pandemic influenza vaccine. In 2007, outbreaks in poultry continued, as did sporadic cases in humans, but a pandemic virus failed to emerge. Nevertheless, scientists agree that the threat of a pandemic from H5N1 continues and that the question of a pandemic of influenza from this virus or another avian influenza virus is still a matter of when, not if.
Chapter 4 also highlights the problem of XDR-TB in southern Africa, exacerbated by inadequate health systems and the resulting failures in programme management, especially poor supervision of health staff and patients’ treatment regimens, disruptions in drug supplies, and poor clinical management, all of which can prevent patients completing courses of treatment. The current situation is a wake-up call to all countries, and especially those in Africa, to ensure that basic tuberculosis control reaches international standards and to initiate and strengthen management of drug-resistant forms of the disease. The 2003-2005 global spread of poliovirus caused by inadequate control in Nigeria (described in Chapter 2) was another wake-up call. It underscored the risk that polio might re-emerge post-eradication and the importance of the designation of polio as a notifiable disease in IHR (2005).
The alert and reporting mechanisms mandated by IHR (2005) are an essential complement to activities undertaken by the extensive surveillance network already in place around the world that provides for the immediate notification of confirmed polio cases and for standardized clinical and virologic investigation of potential cases. This capacity to remain alert and to respond is fundamental to the ability to eradicate polio because, once the virus is eradicated in nature, the world will need be vigilant in case of accidental or deliberate release of the virus. Finally, Chapter 4 considers natural disasters which, in 2006 alone, affected 134. 6 million people and killed 21 342 others.
Just as these situations endanger individuals, they can also threaten already stressed health systems that people rely on to maintain their personal health security. The indirect effects of natural disasters include the threat of infectious disease epidemics, acute malnutrition, population displacement, acute mental illness and the exacerbation of chronic disease, all of which require strong health systems to deal with them. xxi xxii global public health security in the 21st century world health report 2007 towards a safer future chapter 5 Chapter 5 emphasizes the importance of strengthening health systems in building global public health security.
It argues that many of the public health emergencies described in this report could have been prevented or better controlled if the health systems concerned had been stronger and better prepared. Some countries find it more difficult than others to confront threats to public health security effectively because they lack the necessary resources, because their health infrastructure has collapsed as a consequence of under-investment and shortages of trained health workers, or because the infrastructure has been damaged or destroyed by armed conflict or a previous natural disaster. No single country – however capable, wealthy or technologically advanced – can alone prevent, detect and respond to all public health threats.
Emerging threats may be unseen from a national perspective, may require a global analysis for proper risk assessment, or may necessitate effective coordination at the international level. This is the basis for IHR (2005), but as not all countries will be able to take up the challenge immediately, WHO will have to draw upon its long experience as the leader in global public health, its convening power, and its partnerships with governments, United Nations agencies, civil society, academia, the private sector and the media to maintain its surveillance and global alert and response systems. As described in Chapter 1, WHO surveillance networks and GOARN are effective international partnerships that provide both a service and a safety net.
GOARN is able to deploy response teams to any part of the world within 24 hours to provide direct support to national authorities. WHO’s various surveillance and laboratory networks are able to capture the global picture of public health risks and assist in efficient case analysis. Together, these systems fill acute gaps caused by the lack of national capacity and protect the world when there may be a desire to delay reporting for political or other reasons. The effective maintenance of these systems, however, must be adequately resourced with staff, technology and financial support. The building of national capacity will not diminish the need for WHO’s global networks.
Rather, increased partnerships, knowledge transfer, advancing technologies, event management and strategic communications will grow as IHR (2005) reaches full implementation. overview xxiii conclusions and recommendations The report concludes with recommendations intended to provide guidance and inspiration towards cooperation and transparency in the effort to secure the highest level of global public health security. ¦ Full implementation of IHR (2005) by all countries. The protection of national and global public health must be transparent in government affairs, be seen as a cross-cutting issue and as a crucial element integrated into economic and social policies and systems. Global cooperation in surveillance and outbreak alert and response between governments, United Nations agencies, private sector industries and organizations, professional associations, academia, media agencies and civil society, building particularly on the eradication of polio to create an effective and comprehensive surveillance and response infrastructure. ¦ Open sharing of knowledge, technologies and materials, including viruses and other laboratory samples, necessary to optimize secure global public health. The struggle for global public health security will be lost if vaccines, treatment regimens, and facilities and diagnostics are available only to the wealthy. ¦ Global responsibility for capacity building within the public health infrastructure of all countries.
National systems must be strengthened to anticipate and predict hazards effectively both at the international and national levels and to allow for effective preparedness strategies. ¦ Cross-sector collaboration within governments. The protection of global public health security is dependent on trust and collaboration between sectors such as health, agriculture, trade and tourism. It is for this reason that the capacity to understand and act in the best interests of the intricate relationship between public health security and these sectors must be fostered. ¦ Increased global and national resources for the training of public health personnel, the advancement of surveillance, the building and enhancing of laboratory capacity, the support of response networks, and the continuation and progression of prevention campaigns.
Although the subject of this report has taken a global approach to public health security, WHO does not neglect the fact that all individuals – women, men and children – are affected by the common threats to health. It is vital not to lose sight of the personal consequences of global health challenges. This was the inspiration that led to the “health for all” commitment to primary health care in 1978. That commitment and the principles supporting it remain untarnished and as essential as ever. On that basis, primary health care and humanitarian action in times of crisis – two means to ensure health security at individual and community levels – will be discussed at length in The World Health Report 2008. evoluTion of public healTh security 1 hapter 1 begins by tracing some of the first steps, historically, that led to the introduction of the international health regulations (1969) – landmarks in public health starting with quarantine, a term coined in the 14th century and employed as a protection against “foreign” diseases such as plague; improvements in sanitation that were effective in controlling cholera outbreaks in the 19th century; and the advent of vaccination, which led to the eradication of smallpox and the control of many other infectious diseases in the 20th century. Understanding the history of international health cooperation – its successes and its failures – is essential in appreciating its new relevance and potential. Throughout history, humanity as been challenged by outbreaks of infectious diseases and other health emergencies that have spread, caused death on unprecedented levels and threatened public health security (see Box 1. 1). With no better solution, people’s response was to remove the sick from the healthy population and wait until the epidemic ran its course. With time, scientific knowledge evolved, containment measures became more sophisticated and some infectious disease outbreaks were gradually brought Public health security is defined as the activities required, under control with improved sanitation and the disboth proactive and reactive, to minimize vulnerability to covery of vaccines. However, microbial organisms are acute public health events that endanger the collective health of national populations. ell-equipped to invade new territories, adapt to new Global public health security widens this definition to ecological niches or hosts, change their virulence or include acute public health events that endanger the colmodes of transmission, and develop resistance to lective health of populations living across geographical drugs. An organism that can replicate itself a milregions and international boundaries. As illustrated in this report, global health security, or lack of it, may also have lion times within a day clearly has an evolutionary an impact on economic or political stability, trade, tourism, advantage, with chance and access to goods and services and, if they occur repeatedly, surprise on its side. Therefore, on demographic stability.
Global public health security no matter how experienced or embraces a wide range of complex and daunting issues, from the international stage to the individual household, refined containment measures including the health consequences of human behaviour, became over the years, there weather-related events and infectious diseases, and natuwas always the possibility of ral catastrophes and man-made disasters, all of which are discussed in this report. another outbreak causing an epidemic anytime, anywhere. The reality is that the battle to keep up with microbial evolution and adaptation will never be won. The delicate balance between humans and microbes has been conditioned over generations of contact, exposure to immune systems and human behaviour.
Today, it has shifted so that the equilibrium is driven by changes in human demographics and behaviour, economic development and land use, international travel and commerce, changing climate and ecosystems, poverty, conflict, famine and the deliberate release of infectious or chemical agents. This has heightened the risk of disease outbreaks. Box 1. 1 Public health security chapter 1 2 global public health security in the 21st century It is estimated that 2. 1 billion airline passengers travelled in 2006 (1). This means that diseases now have the potential to spread geographically much faster than at any time in history. An outbreak or epidemic in one part of the world is only a few hours away from becoming an imminent threat elsewhere.
Infectious diseases can not only spread faster, they appear to be emerging more quickly than ever before. Since the 1970s, new diseases have been identified at the unprecedented rate of one or more per year. There are now at least 40 diseases that were unknown a generation ago. In addition, during the last five years, WHO has verified more than 1100 epidemic events. The lessons of history are a good starting point for this report as they exemplify the huge challenges to health that occur repeatedly and relentlessly. Some infectious diseases that have persisted for thousands of years still pose threats on a global scale. world health report 2007 buildinG on historical landmarks
Since they first walked the planet, human beings have struggled – and often failed – to protect themselves against adversaries that destroy their health, inhibit their ability to function and, ultimately, cause their death. It is only in relatively modern times that they have made lasting progress in preventing or controlling infectious diseases, as illustrated by three important historical landmarks in public health. While these advances are still of great relevance today, they need to be adapted and reinforced to confront the challenges to come. plague and quarantine The practice of separating people with disease from the healthy population is an ancient one, with both biblical and Koranic references to the isolation of lepers.
By the 7th century, China had a well-established policy of detaining sailors and foreign travellers suffering from plague. The term “quarantine” dates from the late 14th century and the isolation of people arriving from plague-infected areas to the port of Ragusa, at the time under the control of the Venetian Republic. In 1397, the period was set at 40 days (the word quarantine being derived from the Italian for “forty”). Similar actions were taken by many other Mediterranean ports soon afterwards. Such public health measures became widespread and international over the following centuries, with committees often being appointed in cities to coordinate them (2). Figure 1. shows the rapid spread of bubonic plague across Europe in the mid-14th century. The continuing devastation regularly wrought by plague and other epidemic diseases demonstrated that crude quarantine measures alone were largely ineffective. In the 17th century, an attempt to keep plague, which was spreading through continental Europe, from reaching England obliged all London-bound ships to wait at the mouth of the River Thames for at least 40 days. The attempt failed and plague caused devastation in England in 1665 and 1666. During the 18th century, all major towns and cities along the eastern seaboard of the United States passed quarantine laws, which typically were enforced only when epidemics seemed imminent.
In recent years, the most serious outbreak of plague occurred in five states in India in 1994, where almost 700 suspected bubonic or pneumonic plague cases and 56 deaths were reported to WHO, as required by the International Health Regulations (1969). The outbreak, which captured international media attention, resulted in catastrophic From the 14th century, european doctors visiting plague victims wore protective clothing, a mask and a beak containing strong-smelling herbs. evolution of public health security 3 Figure 1. 1 Spread of bubonic plague in Europe 1347 Mid-1348 Early 1349 Late 1349 1350 1351 After 1351 Minor outbreak Copenhagen London Rouen Paris Lubeck Brunswick Bruges Frankfurt Prague Vienna Milan Marseille Toledo Barcelona Florence Rome Ragusa Thessaloniki Bucharest Warsaw Athens conomic consequences for India when a number of countries overstepped the measures set out in IHR (1969) and imposed unnecessary travel and trade restrictions. The outbreak was brought under control within two months. During that period, more than 2 million tourism-related trips to the country were estimated to have been cancelled. Overall, the reported outbreak cost India approximately US$ 1. 7 billion in lost trade and travel and caused a record trade deficit in 1994 (3). Since then, there have been many smaller, unrelated bubonic plague outbreaks in countries such as Algeria, the Democratic Republic of the Congo, Malawi and Zambia. 4 global public health security in the 21st century world health report 2007 cholera and sanitation
As with virtually all scientific advances, the physician John Snow’s famous work on cholera ? notably during the 1854 epidemic in London ? did not emerge from a vacuum but was based on years of careful recording of outbreaks and heated debate as to the causes. Snow observed of cholera in 1855, “It travels along the great tracks of human intercourse, never going faster than people travel, and generally much more slowly. In extending to a fresh island or continent, it always appears first at a seaport. It never attacks the crews of ships going from a country free from cholera, to one where the disease is prevailing, till they have entered a port” (4).
During the London epidemic, Snow mapped the locations of homes of those who had died and noted that, in the Broad Street area, cases were clustered around a particular water pump. There was an underground sewer running close to the well, and people had reported the water from the well to be foul smelling in the days before the outbreak. As soon as Snow persuaded the authorities to remove the pump handle, the number of cases and deaths from cholera fell rapidly. While the role of the pump handle removal in the decreased mortality rate has been debated, Snow’s demonstration that cholera was associated with water was a powerful rebuttal of “miasma” theories of transmission through poisonous vapours.
His work eventually led to improvements in sanitation in the United Kingdom that reduced the threat of cholera – though not to the same extent as endemic diarrhoeal disease from other causes (5). A new sewage system was constructed in London in the 1880s. Cholera continues to be a major health risk all over the world. Latin America had been free of it for more than a century until, in 1991, a pandemic that had begun 30 years earlier and spread throughout many countries in Africa, Asia and Europe struck with devastating human and economic consequences. Thought to have originated from seafood contaminated by the bilge of ships off the coast of Peru, the disease spread rapidly across the continent and resulted in nearly 400 000 reported cases and over 4000 deaths in 16 countries that year.
By 1995, there were more than 1 million cases and just over 10 000 deaths reported in the WHO Region of the Americas (6). In addition to human suffering and death, the outbreak provoked panic, disrupted social and economic structures, threatened development in affected populations, and led to extreme and unnecessary international reactions (7 ). Some neighbouring countries imposed trade and travel restrictions on Peru, as did European Union countries, the United States and others. Losses from trade embargoes, damage to tourism, and lost production attributable to cholera-related illnesses and death were estimated to be as much as US$ 1. 5 billion (8).
The need to provide sanitation both for drinking-water and hygiene remains a huge challenge today in developing countries. Currently 1. 1 billion people lack access to safe water and 2. 6 billion people lack access to proper sanitation. As a result, more than 4500 children under five years of age die every day from easily preventable diseases such as diarrhoea. Many others, including older children and adults, especially women, suffer from poor health, diminished productivity and missed opportunities for education. this sketch, called “death’s dispensary”, was drawn by George pinwell in 1866, around the time John snow was studying the connection between london’s contaminated water supply and outbreaks of cholera. evolution of public health security 5 mallpox and immunization Smallpox is one of the oldest known human diseases. There is evidence of its existence over 3000 years ago in Egypt: the mummified head of Ramses V, who died in 1157 BC, shows a pustular eruption that may have been caused by smallpox. It may have existed in parts of Asia about the same time and appears to have been introduced into China about the year 50 AD, to parts of Europe in the following few centuries, to western Africa in the 10th century, and to the Americas in the 16th century during the Spanish conquests. During the 18th century, smallpox killed every seventh child born in Russia and every 10th child born in France and Sweden.
Edward Jenner’s experiment in 1796 brought hope that the disease could be controlled. Jenner, an English physician, realized that many of his patients who had been exposed to cowpox, the much milder but related disease, were immune to smallpox. He inoculated an eight-year-old farm boy with cowpox virus and, after observing the reaction, reinoculated him with smallpox virus. The boy did not develop the deadly disease, demonstrating that inoculation with cowpox could protect against smallpox. Jenner’s procedure was soon widely accepted, resulting in sharp falls in smallpox death rates. At the beginning of the 20th century, smallpox was still endemic in almost every country in the world.
In the early 1950s, an estimated 50 million cases occurred globally each year with an estimated 15 million deaths, figures which fell to around 10–15 million cases and 3 million deaths by 1967 as access to immunizations increased. an english doctor, edward Jenner, carries out the first vaccination against smallpox in 1796 by inoculating a boy with cowpox virus. 6 global public health security in the 21st century Through the success of the 10-year global eradication campaign that began in 1967, the global eradication of smallpox was certified in 1979 (9). Since eradication was certified, allegations have been made that some countries and terrorist groups may be storing smallpox virus, and its potential as a bioterrorist threat is causing major concern in many industrialized countries (10).
Work is under way on a new and safer vaccine against smallpox, which would need to be produced in huge quantities if immunization against a deliberate release were to be undertaken. Almost 30 years after its successful eradication, smallpox has, therefore, become a significant public health concern in terms of the deliberate release of the virus to cause harm. According to a recent WHO report, “the greatest fear is that in the absence of global capacity to contain an outbreak rapidly, smallpox might re-establish endemicity, undoing one of public health’s greatest achievements” (10). world health report 2007 FosterinG international cooperation The three advances described above ? in quarantine, sanitation and immunization ? came about separately but gradually came to be seen as equiring international coordination in order to strengthen global public health security (see Box 1. 1). By the end of the 19th century, dozens of international conferences on disease control had been held, ultimately leading to the foundation of WHO in 1948 and the promulgation of the International Sanitary Regulations in 1951 (see Box 1. 2). The reasons for such international action were clear. One hundred years ago, infectious diseases such as cholera, plague and yellow fever ? and many more such as diarrhoeal diseases other than cholera, influenza, malaria, pneumonias and tuberculosis ? ravaged most civilizations and threatened public health security. They dominated entire regions and at times spread in pandemics across the globe.
With few exceptions, there was little that could be done to halt their progression, until spectacular advances in medicine and public health during the first half of the 20th century yielded new drugs and vaccines that could prevent or cure infections. These advances helped industrialized countries, which had reliable access to them, to eliminate or markedly decrease the infectious disease threats. At the same time, improvements in hygiene and standards of living in these more prosperous parts of the world altered the conditions that had allowed the diseases to flourish. While it can be argued that the means currently exist to prevent, control or treat most infectious diseases, paradoxically, the continuing likelihood of pandemics is still a huge threat to public health security, principally for two reasons.
First, some of these diseases continue to thrive in developing countries where the ability to detect and respond is limited, leading to the potential for them to spread internationally at great speed. Second, new diseases emerging in human populations on a sporadic basis are often the result of a breach in the species barrier between humans and animals, permitting microbes that infect animals to infect humans as well, causing unexpected outbreaks that can also spread internationally. Therefore, international measures to prevent the spread of infectious diseases continue to remain essential in the 21st century. evolution of public health security 7 Box 1. 2 International collaboration on infectious disease control Timeline of significant events in public health an tine S) n e vice SAR atio erenc a ome ( Ser ns in ric tion tio ns ur al acc onf n ions me ndr in E rma ula latio ulat tion o n A Sy ox v ry C rna 5) Reg Info ry RegRegu lpox in Lati ratory mic allp anita n Lond m al de Inte 00 alth e s ds lS ci gic ita lth al spi epi new s (2 l He forc HO iolo San Hea f sm mic Re za rde iona mi ue lag eco ternat epide n of W idem tionaltional tion o epide Acute fluen dopts lation ationa r into tr cp firs t In oni lera reatio HO Ep terna terna radica holera evere vian in HA a Regu Intern 5) ente W alth E S C Bub C W In In The Firs Cho A 0 (20 He ope 134 7 179 6 6 1 185 186 9 6 7 1 9 194 194 195 196 197 1 3 5 4 199 200 200 200 200 7 C a hin –p lag u ua eq C 7th ent ur y
Largely provoked by the cholera pandemic of the time, threats of plague and the ineffectiveness of quarantine measures, many European leaders of the mid-19th century began to recognize that controlling the spread of infectious diseases from one nation to another required that they cooperate. International conventions were organized and draft covenants signed, almost all of which related to quarantine regulations (8). From 1851 to 1900, 10 International Sanitary Conferences were convened, comprising a group of about 12 European countries or states, and focusing exclusively on the containment of epidemics within their territories. The inaugural 1851 conference in Paris lasted six months and established the vital principle that health protection was a proper subject for international consultations.
During the 1880s, a small group of South American nations signed the first set of international public health agreements in the Americas. In addition to cholera and plague, often carried among the huge numbers of immigrants arriving from Europe, these agreements covered yellow fever, which was endemic in much of the region. In 1892, the first International Sanitary Convention dealing only with cholera was signed. Five years later, at the 10th International Sanitary Conference, a similar convention focusing on plague was also signed. Important new policies emerged, such as the obligatory telegraphic notification of first cases of cholera and plague.
In 1902, 12 countries attended the First International Sanitary Convention of the American Republics in Washington, DC, the United States, leading to the creation of the Pan American Sanitary Bureau (now called the Pan American Health Organization). Its counterpart in Europe, the Office International d’Hygiene Publique (OIHP), was established in 1907 and based in Paris (11). Apart from its immediate toll on human lives, the First World War brought in its wake many epidemics resulting from the destruction of public health infrastructure, from typhus in Russia that threatened to spread to western Europe, to cholera, smallpox, dysentery and typhoid in the Ottoman Empire.
These epidemics were the basis for the formation of the League of Nations Health Organisation, itself stemming from the newly created League of Nations. In 1920, the Health Organisation set up a temporary epidemic commission whose task was to help direct work in afflicted countries. In 1951, three years after its founding, WHO adopted a revised version of the International Sanitary Regulations first approved in 1892. They focused on the control of cholera, plague, smallpox, typhoid fever and yellow fever. Their approach was still rooted in misunderstandings of the 19th century ? that certain measures at border posts could alone prevent the spread of infectious diseases across international borders. They ere succeded by IHR (1969), which required Member States to report outbreaks of certain diseases. Recent events have demonstrated the urgent need for a revised set of regulations with broader disease coverage, and measures to stop their spread across borders based on real time epidemiological evidence rather than pre-determined measures concentrated at borders. The IHR (2005) respond to this need and have now come into force (12). 8 global public health security in the 21st century world health report 2007 a new code for international health security Ways of collectively working together in the face of emergency events of international health importance are reflected in the new revised International Health Regulations (2005).
The Regulations, first issued in 1969, and discussed later in this chapter, were revised according to understanding and experience accumulated in the 1990s in response to changes in the human world, the microbial world, the natural environment and human behaviour, all of which posed increased threats to global public health security (these events are described in Chapter 2). An agreed code of conduct was required that could not only prevent and control such threats but could also provide a public health response to them while avoiding unnecessary interference with international trade and traffic. The basis of an effective global system of epidemic alert and response was initiated by WHO in 1996. It was built essentially on a concept of international partnership with many other agencies and technical institutions. Systematic mechanisms for gathering epidemic intelligence and verifying the existence of outbreaks were established and prompted risk assessments, information dissemination and rapid field response.
The Global Outbreak Alert and Response Network (GOARN) was set up as a technical partnership of existing institutions and networks to pool human and technical resources for the rapid identification, confirmation and response to outbreaks of international importance. The network provides an operational and coordination framework to access this expertise and skill, and to keep the international community constantly alert to the threat of outbreaks and ready to respond. Coordinated by WHO, the network is made up of over 140 technical partners from more than 60 countries. These partners’ institutions and networks provide rapid international multidisciplinary technical support for outbreak response. Figure 1. 2 shows a sample of international epidemic response missions in the field in 1998 and 1999. Figure 1. Examples of international epidemic response missions, 1998–1999 Viral meningitis Romania and Republic of Moldova 1999 Viral infection Libyan Arab Jamahiriya 1998 Cluster of infant deaths Egypt 1999 Acute respiratory infection Afghanistan 1999 Relapsing fever Sudan (southern) 1999 Nipah virus encephalitis Malaysia 1999 Viral haemorrhagic fever/Acute respiratory infection Sudan (southern) 1999 Meningococcal meningitis Sudan 1999 Visceral leishmaniasis Sudan (southern) 1999 Cholera Comoros 1999 Rift Valley fever/ Viral haemorrhagic fever Kenya 1999 evolution of public health security Between 2000 and 2005, there were more than 70 GOARN international outbreak responses, involving over 500 experts in the field.
Regional and global mechanisms for stockpiling and rapid distribution of vaccines, drugs and specialized investigation and protection equipment have been established for haemorrhagic fevers, influenza, meningitis, smallpox and yellow fever. A specialized logistics response unit has been developed for epidemic response that allows WHO and its partners to be operational in extreme environments. As part of ongoing efforts to improve operational coordination and information management, WHO is updating its event management system to support real time operational communications and access to critical information on epidemics. The Organization continues to strengthen specialized surveillance networks for dangerous pathogens, including dengue, influenza and plague.
In addition, the unique, large-scale active surveillance network developed by the Global Polio Eradication Initiative is being used to support surveillance of many other vaccine-preventable diseases, such as measles, meningitis, neonatal tetanus and yellow fever. This network is also regularly supporting outbreak surveillance and response activities for other health emergencies and outbreaks, including avian influenza, Ebola, Marburg haemorrhagic fever, SARS and yellow fever. With its local knowledge of communities, health systems and government structures, the polio network has the technical capacity to plan and monitor immunization campaigns, during which the health officers are often the community’s first point of entry into the health system for a range of diseases and conditions.
The polio network is also called upon during outbreaks of meningitis and yellow fever and often helps to sustain international and national relief efforts, such as during the responses to the South-East Asia tsunami in December 2004 and the Pakistan earthquake in October 2005. Once polio eradication has been completed, continued investment in this network to broaden the skills of surveillance officers, immunization staff and laboratories, will increase capacity nationally and internationally for surveillance and response of vaccine-preventable and other outbreak-prone infectious diseases. At the national level, collaboration between donor and recipient countries, which focuses on ensuring the technical and other resources to meet national core needs in disease detection and response, is a crucial factor in building the capacity to further strengthen global public health security.
Effective implementation requires countries to invest in, manage and improve the functioning of a number of public health system components. These include epidemiological surveillance and information management systems, public health laboratory facilities, health and preparedness planning, health communication and intersectoral collaboration. In order to ensure the maximum possible global public health security, countries – in collaboration with WHO and other relevant international organizations – must develop, maintain and strengthen appropriate public health and administrative capacities in general, not only at international ports, airports and land crossings.
This requires close collaboration not only between WHO offices and Member States, but also among Member States themselves. Such multilateral cooperation will better prepare the world for future public health emergencies. 9 10 global public health security in the 21st century world health report 2007 international preparedness for chemical emergencies It has long been recognized that many countries have limited capacities to detect and respond to chemical incidents, and that such events occurring in one country could have an impact on others. Equally recognized has been the need to strengthen both national and global public health preparedness and response. World Health Assembly resolution WHA55. 6 (13) urges Member States to strengthen systems for surveillance, emergency preparedness and response for the release of chemical and biological agents and radionuclear materials in order to mitigate the potentially serious global public health consequences of such releases (see Chapter 2). In 2002, WHO established the Chemical Incident Alert and Response System to operate along similar lines to the alert and response system for communicable diseases. In 2006, this system was extended to cover other environmental health emergencies, including those related to the disruption of environmental health services, such as water supply and sanitation, as well as radiological events.
An integral part of the system is ChemiNet, which pools human and technical resources for detecting, verifying and responding to environmental health events of (potential) international public health concern. ChemiNet draws on human and technical resources from institutions, agencies and academia in Member States as well as from international organizations, as illustrated in Figure 1. 3. ChemiNet is designed to mitigate chemical incidents and outbreaks of illness of chemical etiology that are of international public health concern by early detection, assessment and verification of outbreaks; provision of rapid, appropriate and effective assistance in response to outbreaks; and contribution Figure 1. International public health security: a global to long-term preparedness and network of national health systems and technical capacity building – the same protocol utilized in response to partners, coordinated by WHO, founded on four any public health emergency. major areas of work In accordance with IHR (2005), Partners’ network ChemiNet provides a source of intelligence by informing WHO of National chemical incidents or outbreaks IHR Focal Partners Point of illness of potential international public health importance. Country national network National Global alert Prevention of and preparedness capacity and response National for uncontrolled chemical releases strengthening IHR Focal are part of a continuum of activities Point National WHO in ChemiNet that also encompass IHR Focal Point event detection, response and Containment Travel of specific and recovery.
Since large-scale chemithreats transport cal incidents, such as that in BhoNational pal, India (see Chapter 2), shocked IHR Focal Partners Point the world, much has been learned about measures for prevention and preparedness concerning National such occurrences. Even in techPartners IHR Focal National nically advanced, well-resourced Point IHR Focal countries, however, the risks of Point a large-scale chemical release evolution of public health security remain, particularly with the more recent threat of deliberate chemical release. No country can afford to be complacent. Preventive measures include good land-use planning and enforcement so that chemical installations are not built close to places of high population density, the enforcement of high safety standards in chemical industries, and the monitoring of food, water and air quality to detect chemical contamination.
Preparedness measures include ensuring that there is a well-designed and rehearsed chemical emergency plan in place that involves all stakeholders, that local health-care facilities are informed about chemical risks in their catchment area, and that they are provided with the necessary decontamination and medical equipment. National capacity for detection of outbreaks caused by chemical releases includes the availability of a 24-hour poisons centre. Some countries, such as the United States, have fully integrated poison centres into their public health surveillance systems. Since chemicals released into the environment can spread beyond the immediate vicinity of the event and, in some cases, have the potential to cross national borders, there is also a need for coordination of international preparedness and response.
Some international agreements already exist, such as the United Nations Economic Commission for Europe (UNECE) Convention on the Transboundary Effects of Industrial Accidents (14). The International Health Regulations (2005) and World Health Assembly resolution WHA55. 16 (13) provide a framework for preparedness. Within this framework, WHO can conduct activities to respond immediately to events that threaten global public health security and can work collectively and proactively to prepare for such events. Chapter 4 shows how the framework can be applied to the current threats of avian influenza, XDR-TB and natural disasters. 11 new health regulations in a vastly altered world
As outlined earlier, concern about the international spread of infectious disease outbreaks and other events that threaten global public health security is not a modern phenomenon. In the past, attempts have often been made to stop these events from spreading by enforcing border controls. In the globalized world of the 21st century, although there is still collective interest in preventing the international spread of diseases, it is understood that borders alone cannot accomplish this. In recent decades, diseases have spread faster than ever before, aided by high-speed travel and the trade in goods and services between countries and continents, often during the incubation period before the signs and symptoms of disease are visible.
The rapid spread of disease can only be prevented if there is immediate alert and response to disease outbreaks and other incidents that could spark epidemics or spread globally and if there are national systems in place for detection and response should such events occur across international borders. GOARN and ChemiNet are examples of such systems. The aim of the collaboration set out in IHR (1969) was to achieve maximum protection against the international spread of disease with minimal disruption to trade and travel. Based mainly on attempts to stop the spread of disease through control measures at international borders, IHR (1969) offered a legal framework for the notification of and response to six diseases – cholera, plague, relapsing fever, smallpox, typhus and yellow fever – but suffered from very patchy compliance among WHO Member States. 12 global public health security in the 21st century
From 1996 to 2005, Member States examined and revised IHR (1969) in order to meet the new challenges that had arisen in the control of emerging and re-emerging infectious diseases, including the rapid global transit of diseases and the exchange of animals and goods that may inadvertently carry infectious agents. Several emerging and re-emerging diseases identified in this period are shown in Figure 1. 4. Another challenge was the management of near instantaneous modes of communication, such as mobile telephones and the Internet, which have the potential to cause panic in populations. The resulting revised Regulations – IHR (2005) (12) – came into force in June 2007.
They provide a legal framework for reporting significant public health risks and events that are identified within national boundaries and for the recommendation of context-specific measures to stop their international spread, rather than establishing pre-determined measures aimed at stopping diseases at international borders as in the case of IHR (1969). The IHR (2005) define an emergency as an “extraordinary event” that could spread internationally or might require a coordinated international response. Events that may constitute a public health emergency of international concern are assessed by State Parties using a decision instrument and, if particular criteria are met, WHO must be notified (see chapter 5).
Mandatory notification is called for in a single case of a disease that could threaten global public health security: smallpox, poliomyelitis caused by a wild-type poliovirus, human influenza caused by a new virus subtype, and SARS. In parallel, a second limited list includes diseases of documented – but world health report 2007 Figure 1. 4 Selected emerging and re-emerging infectious diseases: 1996–2004 Ebola and Crimean– Congo haemorrhagic fever Influenza H5N1 Hantavirus Lassa fever Monkeypox Nipah Hendra New variant Creutzfeld–Jakob disease Rift Valley fever SARS coronavirus Venezuelan equine encephalomyelitis Yellow fever West Nile fever Cryptosporidiosis Leptospirosis Lyme borreliosis Escherichia coli O157 Multidrug-resistant Salmonella Plague evolution of public health security not inevitable – international impact.
An event involving a disease on this second list, which includes cholera, pneumonic plague, yellow fever, viral haemorrhagic fevers (Ebola, Lassa and Marburg), West Nile fever and other diseases that are of national or regional concern, should always result in the use of the decision instrument of the Regulations that permits evaluation of the risk of international spread. Thus, the two safeguards create a baseline of security by obliging countries to respond in designated ways to well-known threats. The broad definitions of “public health emergency of international concern” and “disease” allow for the inclusion in IHR (2005) of threats beyond infectious diseases, including those caused by the accidental or intentional release of pathogens or chemical or radionuclear materials.
The basic epidemiological, laboratory and investigative principles, and the verification and notification procedures, are fundamentally the same for all events. Moreover, such events are routinely included in the daily global surveillance activities undertaken by WHO through many different networks of collaborating laboratories and surveillance networks. Many of these events are automatically picked up by the Global Public Health Intelligence Network (GPHIN) (15), an electronic intelligence-gathering tool, thus providing a safety net for detection of events not otherwise reported. The inclusion of public health emergencies other than infectious diseases extends the scope of the Regulations to protect global public health security in a comprehensive way.
The IHR (2005) redirect the focus from an almost exclusive concentration on measures at seaports and airports aimed at blocking the importation of cases towards a rapid response at the source of an outbreak. They introduce a set of “core capacity requirements” that all countries must meet in order to detect, assess, notify and report the events covered by the Regulations. Rather than take to task violators, the new Regulations aim to strengthen collaboration on a global scale by seeking to improve capacity and demonstrate to countries that compliance is in their best interests. Thus, compliance has three compelling incentives: to reduce the disruptive consequences of an outbreak, to speed its containment and to maintain good standing in the eyes of the international community.
Collaboration between Member States, especially between developed and developing countries, to ensure the availability of technical and other resources is a crucial factor not only in implementing the Regulations, but also in building and strengthening public health capacity and the networks and systems that strengthen global public health security. A revolutionary departure from previous international conventions and regulations is the fact that IHR (2005) explicitly acknowledge that non-state sources of information about outbreaks will often pre-empt official notifications. This includes situations where countries may be reluctant to reveal an event in their territories. WHO is now authorized through IHR (2005) to take into account information sources other than official notifications. WHO will always seek verification of such information from the country involved before taking any action on it.
This reflects yet another of the realities stemming from the SARS outbreak: in an electronically transparent world where outbreaks are particularly newsworthy events, their concealment is no longer a viable option for governments. Also, at a time when information is shared at the click of a button, reputable sources of information are critical in maintaining public awareness and support of prevention and control measures. The sudden emergence in 2003 of SARS was a vivid example of how an infectious disease can pose a serious threat to global public health security, the livelihood of populations, the functioning of health systems and the stability and growth of economies. 13 14 global public health security in the 21st century
The major lessons learned from SARS and other diseases, discussed in Chapter 3, have been not only the need to collectively build up surveillance and information systems that enable timely reporting and response, but also the need to improve infection control capacity. Unfortunately, these capabilities are often lacking and so vulnerability to acute public health events will not simply go away. They need to be confronted urgently. The question is: how can this best be done? Part of the answer relates to the background factors or causes that lead or contribute to epidemics and other acute health emergencies. These may be natural, environmental, industrial, human, accidental or deliberate.
Some of the most important of these causes, and examples of their recent impact in different parts of the world, are discussed in the next chapter. world health report 2007 reFerences 1. Fact sheet: IATA. Geneva, International Air Transport Association, 2007 (http://www. iata. org/pressroom/facts_figures/fact_sheets/iata. htm, accessed 10 May 2007). 2. Porter R. The greatest benefit to mankind: a medical history of humanity, from antiquity to the present. London, Harper Collins, 1997. 3. International notes update: human plague, India, 1994. Morbidity and Mortality Weekly Report, 1994, 43:761–762 (http://www. cdc. gov/mmwr/preview/mmwrhtml/00032992. htm, accessed 11 April 2007). 4. Davey Smith G.
Behind the Broad Street pump: aetiology, epidemiology and prevention of cholera in mid-19th century Britain [commentary]. International Journal of Epidemiology, 2003, 31:920–932. 5. Cairncross S. Water supply and sanitation: some misconceptions [editorial]. Tropical Medicine and International Health, 2003, 8:193–195. 6. Cholera in the Americas. Epidemiological Bulletin of the Pan American Health Organization, 1995, 16(2) (http://www. paho. org/english/sha/epibul_95-98/be952choleraam. htm, accessed 11 April 2007). 7. Global epidemics and impact of cholera. Geneva, World Health Organization (http://www. who. int/topics/cholera/impact/en/index. html, accessed 11 April 2007). 8.
Knobler S, Mahmoud A, Lemon S, Pray L, eds. The impact of globalization on infectious disease emergence and control: exploring the consequences and opportunities. Workshop summary – Forum on Microbial Threats. Washington, DC, The National Academies Press, 2006. 9. Fenner F, Henderson DA, Arita I, Jezek Z, Ladnyi ID. Smallpox and its eradication. Geneva, World Health Organization, 1988. 10. Global smallpox vaccine reserve: report by the Secretariat. Geneva, World Health Organization, 2005 (report to the WHO Executive Board, document EB115/36; http://www. who. int/ gb/ebwha/pdf_files/EB115/B115_36-en. pdf, accessed 11 May 2007). 11. Howard-Jones N.
The scientific background of the International Sanitary Conferences 1851–1938. Geneva, World Health Organization, 1975. 12. International Health Regulations (2005). Geneva, World Health Organization, 2006 (http:// www. who. int/csr/ihr/en/, accessed 18 April 2007). 13. Global public health response to natural occurrence, accidental release or deliberate use of biological and chemical agents or radionuclear material that affect health. Geneva, World Health Organization, 2002 (World Health Assembly resolution WHA55. 16; http://www. who. int/gb/ebwha/pdf_files/WHA55/ewha5516. pdf, accessed 13 May 2007). 14. Convention on the transboundary effects of industrial accidents.
Geneva, United Nations Economic Commission for Europe, 1992 (http://www. unece. org/env/teia/welcome. htm, accessed 14 May 2007). 15. Information: Global Public Health Intelligence Network (GPHIN). Ottawa, Public Health Agency of Canada, 2004 (http://www. phac-aspc. gc. ca/media/nr-rp/2004/2004_gphin-rmispbk_e. html, accessed 3 May 2007). ThreaTs To public healTh securiTy chapter 2 17 chapter 2 explores a range of threats to global public health security, as defined by the international health regulations (2005), which result from human actions or causes, from human interaction with the environment, and from sudden chemical and radioactive events, including industrial accidents and natural phenomena.
It begins by illustrating how inadequate investment in public health, resulting from a false sense of security in the absence of infectious disease outbreaks, has led to reduced vigilance and a relaxing of adherence to effective prevention programmes. The new regulations are no longer limited to the scope of their original six diseases – cholera, plague, relapsing fever, smallpox, typhus and yellow fever. Rather, they address “illness or medical conditions, irrespective of origin or source that present or could present significant harm to humans” (1). Such threats to public health security, be they epidemics of infectious diseases, natural disasters, chemical emergencies or certain other acute health events, can be traced to one or more causes.
The causes may be natural, environmental, industrial, accidental or deliberate but – more often than not – they are related to human behaviour. This chapter explores the threats to global public health security, as defined by IHR (2005), which can result from human action or inaction and natural events. The importance of the more fundamental causes of health security embedded in the social and political environments that foster inequities within and between groups of people will be discussed in subsequent publications. human causes oF public health insecurity Human behaviour that determines public health security includes decisions and actions taken by individuals at all levels – for example, political leaders,