THE WORLD HEALTH REPORT 2007
A SAFER
FUTURE
GLOBAL PUBLIC HEALTH SECURITY IN THE 21ST CENTURY
WHO Library Cataloguing-in-Publication Data
World Health Organization.
The world health report 2007 : a safer future : global public health security in the 21st century.
1.World health – trends. 2.Disease outbreaks – prevention and control. 3.Legislation, Health. 4.International cooperation.
5.Environmental health. I.Title. II.Title: A safer future: global public health security in the 21st century.
ISBN 978 92 4 156344 4
ISSN 1020-3311
(NLM classification: WA 530.1)
© World Health Organization 2007
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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, Andrée 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, 56, 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, Bibliothèque de l’Académie nationale de Médecine,
Paris (p. 5).
Design: Reda Sadki
Layout: Steve Ewart and Reda Sadki
Figures: Christophe Grangier
Printing Coordination: Raphaël 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
Chapter 1. Evolution of public health security
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
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
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2
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4
5
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8
10
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chapter
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chapter
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2
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chapter
3
4
5
Chapter 3. New health threats in the 21st century
The anthrax letters
SARS: vulnerability revealed
Dumping of toxic chemicals
chapter
Chapter 4. Learning lessons, thinking ahead
chapter
Chapter 5. Towards a safer future
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
Helping countries helps the world
Global partnerships
Strengthening national capacity
Preventing and responding to international public health emergencies
Legal issues and monitoring
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40
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52
54
57
58
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63
64
Conclusions and recommendations
66
Index
69
v
Figures – Chapters
Figure 1.1 Spread of bubonic plague in Europe
Figure 1.2 Examples of international epidemic response missions,
1998–1999
Figure 1.3 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 4.2 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
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8
10
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23
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40
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48
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Boxes – Chapters
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 4.1 WHO meeting concludes that global stockpiles of
H5N1 vaccines are feasible
Box 5.1 IHR (2005) – early implementation efforts
1
7
21
27
39
41
50
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Tables – Chapters
Table 2.1 Examples of major chemical incidents (1974–2006)
Table 5.1 Seven strategic actions to guide IHR (2005) implemention
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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
world health report 2007
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OVERVIEW
overview
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.
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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
288
250
Numbers
x
200
150
108
100
89
81
78
41
50
0
Africa
Western
Pacific
Eastern
Mediterranean
South-East
Asia
WHO regions
Total number of cases = 685
Europe
Americas
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.
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 nuclear 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, Côte 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.
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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 naïve 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
Cases
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Rapid
response
90
80
70
60
50
40
30
20
10
0
Potential cases prevented/
international spread prevented
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4
7
10
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16
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Days
25
28
31
34
37
40
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 case 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).
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CHAPTER SUMMARIES
Evolution of public health security
chapter
1
Chapter 1 begins by tracing some of the first steps, historically, that led to 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.
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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.
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global public health security
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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 Côte
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 Côte 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 Côte 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.
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global public health security
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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 1.5 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.
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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
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.
xxiii
EVOLUTION OF
PUBLIC HEALTH
security
1
Chapter 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 has 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.
well-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
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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.
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 1.1 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
Figure 1.1 Spread of bubonic plague in Europe
1347
1350
Mid-1348
1351
Early 1349
After 1351
Late 1349
Minor outbreak
Copenhagen
Lubeck
London
Warsaw
Brunswick
Rouen
Bruges
Frankfurt
Paris
Prague
Vienna
Bucharest
Milan
Marseille
Toledo
Barcelona
Florence
Ragusa
Thessaloniki
Rome
Athens
economic 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.
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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
Smallpox 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.
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global public health security
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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).
FOSTERING INTERNATIONAL COOPERATION
The three advances described above − in quarantine, sanitation and immunization
− came about separately but gradually came to be seen as requiring 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
Box 1.2 International collaboration on infectious disease control
Timeline of significant events in public health
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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,
1 3
5
4
199 200 200 200
7
200
the Office International d’Hygiène 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 were 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).
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global public health security
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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 1.2 Examples of international epidemic response missions, 1998–1999
Viral meningitis
Romania and
Republic of Moldova
1999
Cluster of infant deaths
Egypt 1999
Acute respiratory
infection
Afghanistan 1999
Viral infection
Libyan Arab Jamahiriya
1998
Relapsing fever
Sudan (southern) 1999
Meningococcal
meningitis
Sudan 1999
Viral haemorrhagic fever/Acute
respiratory infection
Sudan (southern) 1999
Visceral
leishmaniasis
Sudan (southern) 1999
Cholera
Comoros 1999
Rift Valley fever/
Viral haemorrhagic fever
Kenya 1999
Nipah virus
encephalitis
Malaysia 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.
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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 WHA55.16 (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 1.3 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.
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.
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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
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
Escherichia coli O157
Leptospirosis
Multidrug-resistant Salmonella
Lyme borreliosis
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.
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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.
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, policy-makers, military commanders,
public health specialists and the general population – which have dramatic health consequences,
both negative and positive. The following examples
illustrate the public health security repercussions
when human behaviour is influenced by situations
of conflict and displacement or attitudes of complacency, lack of commitment, and mistrust and
misinformation.
world health report 2007
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in the 21st century
Inadequate investment
Inadequate investment in public health, resulting from a false sense of security in
the absence of infectious disease outbreaks, can lead 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, and the training and employment of specialists declined.
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. This is illustrated by the rapid
global emergence and spread of HIV/AIDS in the 1970s. The presence of a new health
threat was not detected by what were invariably weak health systems in many developing countries, and only belatedly became a matter of international concern when it
manifested itself in the first cases in the United States. Figure 2.1 shows developments
over 25 years dating from this event at the beginning of the 1980s.
Surveillance is the cornerstone of public health security. Without appropriately
designed and functioning surveillance systems, unusual but identifiable health events
cannot be detected, monitored for their likely impact, quantified over time or measured
for the effectiveness of interventions put in place to counteract them (see Figure 2.2).
The inability of surveillance systems to recognize new disease trends is not confined
to poorer countries. For instance, the first cases of AIDS were detected and characterized in the United States not by surveillance but by serendipity. Epidemiologists at the
United States Centers for Disease Control and Prevention (CDC) observed an unusual
number of requests to their orphan drug repository for antimicrobials to treat pneumonia
No. of people affected (millions)
Figure 2.1 Twenty-five years of HIV/AIDS
50
45
40
35
30
25
20
15
10
5
0
1980
1 First cases of unusual immune deficiency are found in
gay men in the USA, and a new deadly disease noticed
2 Acquired Immunodeficiency Syndrome (AIDS) is defined
for the first time
3 The Human Immunodeficiency Virus (HIV) is identified as the cause of AIDS
4 In Africa, a heterosexual AIDS epidemic is revealed
5 The first HIV antibody test becomes available
6 Global Network of People living with HIV/AIDS (GNP+)
(International Steering Committee of People Living with HIV/AIDS) founded
7 WHO launches the Global Programme on AIDS
8 The first therapy for AIDS – zidovudine, or AZT –
is approved for use in the USA
1 2 34
5 6
People
living
with HIV
14
11
10
9
12
9 In 1991–1993, HIV prevalence in young pregnant women
in Uganda and in young men in Thailand begins
to decrease, the first major downturns in the epidemic in
developing countries
15 16
10 Highly active antiretroviral treatment (ART) launched
11 Scientists develop the first treatment regimen
to reduce mother-to-child transmission of HIV
12 The United Nations Joint Programme on HIV/AIDS (UNAIDS)
created
13
Children
orphaned
by AIDS in
sub-Saharan
Africa
78
13 Brazil becomes the first developing country to provide
antiretroviral therapy through its public health system
14 The United Nations General Assembly Special Session
on HIV/AIDS. Global Fund to fight AIDS, Tuberculosis
and Malaria launched
15 WHO and UNAIDS launch the “3x5” initiative
with the goal of reaching 3 million people
in the developing world with ART by 2005
16 Global Coalition on Women and AIDS launched
1985
1990
1995
2000
2005
Source: 2006 Report on the global AIDS epidemic. Geneva, Joint United Nations Programme on HIV/AIDS, 2006.
threats to public health security
Viruses, such as dengue, flourish in slums
that result from uncontrolled urbanization.
caused by Pneumocystis carinii, a rare parasitic infection but one that is common in
AIDS cases (2). Yet, what soon became known as AIDS had been occurring for perhaps
many years in Africa and Haiti − poorly detected and poorly characterized. Inadequate
surveillance systems, universal in low and middle income countries, are not capable of
recognizing unusual health events. Similarly, because these systems are poorly funded
and diagnostic facilities are limited, the systems do not allow for the identification and
monitoring of any but a few specific illnesses, for example, tuberculous. Ministries of
health are doubly compromised because, without better surveillance, it is difficult for
them to mount interventions or measure their effectiveness.
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,
whether in Africa, Haiti, or the United States and other industrialized countries. In the
Figure 2.2 Global outbreaks, the challenge: late reporting
and response
Cases
Early
reporting
Rapid
response
90
80
70
60
50
40
30
20
10
0
Potential cases prevented/
international spread prevented
1
4
7
10
13
16
19
Days
22
25
28
31
34
37
40
19
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global public health security
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industrialized world, the 1960s was a period of scientific advances and rapid social
change. The widespread availability of oral contraception contributed to the apparent
liberalization of sexual mores that was furthered by the profound social changes of that
period. Coupled with these developments, attitudes towards and among homosexually
active men became more liberal, particularly in the big cities of the United States, with
a marked migration of gay men to certain key cities. Despite these significant social
and attitudinal changes, no scientific study of sexual behaviour, and its relationship
to the emergence of sexually transmitted diseases, had been carried out in the United
States since the 1950s, and these were long out of date by the time AIDS appeared
as a major public health threat.
As inadequate as behavioural data were in the industrialized world, they were
practically non-existent in the developing world. The understanding of HIV/AIDS in the
context of sexuality in the developing world took years to develop and is still poorly
understood. Only in recent years, a quarter of a century after the description of AIDS,
have population-based surveys of sexual behaviour (demographic and health surveys)
been conducted that allow a better understanding − supported by valid scientific
evidence − of sexual behaviour in countries on multiple continents heavily affected
by HIV/AIDS (3).
Unexpected policy changes
Against a background of armed conflict, families have less
access to health care and are more vulnerable to disease.
Even with reliable operations in place, unexpected policy
changes in public health systems can have lethal and
costly repercussions. Such was the case in August 2003,
when unsubstantiated claims originating in northern
Nigeria that the oral polio vaccine (OPV) was unsafe and
could sterilize young children led to governments ordering 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 poliomyelitis 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. The disease also spread
from northern Nigeria to polio-free countries.
At the beginning of 2003, only seven countries in
the world remained infected: Afghanistan, Egypt, India,
Niger, Nigeria, Pakistan and Somalia. By the end of 2006,
19 polio-free countries in Africa, Asia and the Middle East
had experienced outbreaks traceable genetically to the
Nigerian virus. Mass outbreak response activities across
these countries cost more than US$ 450 million. In July
2004, polio immunization resumed throughout northern
Nigeria, as a result of a tremendous collaborative effort
between state and federal authorities and traditional and
religious leaders, supported by the high-level engagement of organizations such as the African Union and the
Organization of the Islamic Conference − thus showing
that collaboration and partnership that extend beyond
the traditional discipline of health can bring tremendous
change for the good of global public health security.
threats to public health security
21
Public health consequences of conflict
When governments or armed groups engage in armed conflict, a collateral impact is
often the destruction or weakening of health systems, resulting in their diminished
capacity to detect, prevent and respond to infectious disease outbreaks, which in
turn reduces the concerned population’s access to health care. Such was the case in
Angola. One consequence of the 27-year civil war (1975–2002) was the spread of an
outbreak of Marburg haemorrhagic fever in 2004–2005, which affected more than
200 people, 90% of whom died (see Box 2.1). Transmission of Marburg haemorrhagic
fever, an infectious disease related to Ebola, is amplified in situations where poor
health facilities are overcrowded and understaffed, and where lack of investment in
hospitals and clinics results in sub-standard infection control.
Human population movements on a large scale as a result of war, conflict or natural
catastrophes have been tragically common in recent years. The forced migration
or displacement of large numbers of people often oblige them to live in crowded,
unhygienic and impoverished conditions, which, in turn, heighten the
risk of infectious disease epidemics.
This was the cause of 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. The extremely
high crude mortality rate of 20–35
per 10 000 per day can be associated
with an explosive outbreak of combined cholera and shigella dysentery.
Overcrowding exposes displaced
populations to infectious disease outbreaks.
Box 2.1 Marburg haemorrhagic fever and health systems in conflict situations
Angola had witnessed almost three decades of conflict,
which, apart from the immediate human casualties, had
left the country with a severely damaged health infrastructure, a hospital system in dire need of basic equipment and supplies, inadequate communication and transport systems, and a population weakened by economic
hardship. These weaknesses hampered efforts to contain
the outbreak of Marburg haemorrhagic fever in 2005, as
containment of an infectious disease depends on active
surveillance mechanisms, the prompt detection and isolation of new cases in specially designated and equipped
facilities, and the rapid tracing of contacts (4). The Angolan authorities, with the support of the international community, launched a massive effort to reconstruct health
and transport systems and to improve the population’s
nutrition. Despite their best attempts, 70% of the population is still without basic health care (5).
The outbreak of Marburg haemorrhagic fever in
Angola was the largest on record, with the highest fatality rate, but it was not the only outbreak to occur following a conflict situation (6). Another large outbreak
in the eastern region of the Democratic Republic of the
Congo, made inaccessible by the conflict, occurred in
late 1998. As many as 154 cases were reported, with
128 deaths. These were followed by sporadic cases
with small chains of transmission over a two-year
period. The war delayed access and evaluation, so that
supplies were severely limited in all the health facilities
in the region (7 ).
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The speed of transmission and the high attack rate were related to the contamination
with Vibrio cholerae of the only available source of water, Lake Kivu, and the absence
of proper housing and sanitation (8).
The problems associated with people living in high density environments are not
limited to emergency areas such as refugee camps. Rapid urbanization that has become
common in many countries in the 21st century means that cities are now home to over
half the world’s population. Uncontrolled urbanization is characterized by expanding
metropolitan areas, worsening environmental degradation, increasing inequity and the
growth and proliferation of slums and informal settlements. Indeed, a third of global
urban dwellers, or a billion people, live in slums and informal settlements where they
exist in cramped, congested living conditions, without access to safe water, sanitation,
safe food, decent shelter or meaningful employment.
Microbial evolution and antibiotic resistance
Another category of threats to public health security concerns the continuing and
increasing evolution of resistance to anti-infective drugs, which is a major factor in
the emergence and re-emergence of infectious diseases (9). Bacteria can develop
resistance to antibiotics through spontaneous mutation and through the exchange of
genes between strains and species of bacteria.
Bacteria often live in harmony with other inhabitants of the Earth. However, since
penicillin became widely available in 1942, and other antibiotics soon followed, the
killing and growth-inhibitory effects of antibiotics have applied selective pressure
that has reduced the number of susceptible strains, leading to the propagation of
more resistant varieties of bacteria (10). The selection and spread of these varieties
are facilitated paradoxically by either over-prescribing or under-prescribing of drugs,
Contaminated lakes and rivers are often people’s only sources of drinking-water.
threats to public health security
poor compliance with recommended dosages, and unregulated sale by non-health
workers (9). Antibiotics were initially developed for the treatment of infectious diseases
in people, but eventually the same drugs also began to be used for the treatment of
animals and plants. Often the same microbes circulate among their human, animal
and agricultural hosts, providing opportunities for swapping or exchanging resistant
genes and thus assisting the evolution and spread of resistance (10).
The discoverer of penicillin, Alexander Fleming, first warned of the potential
importance of the development of resistance (11). Soon the evidence became alarming.
In 1946, a hospital in the United Kingdom reported that 14% of all Staphylococcus
aureus infections were resistant to penicillin. By 1950, this proportion had increased
to 59%. In the 1990s, penicillin-resistant S. aureus had attained levels greater than
80% both in hospitals and in the community (see Figure 2.3).
It is not only bacteria that develop resistance to drugs: parasites do so too. By
1976, chloroquine-resistant Plasmodium falciparum malaria was highly prevalent in
South-East Asia and 10 years later was found worldwide, as was high-level resistance
to two back-up drugs, sulfadoxine pyrimethamine and mefloquine (9). The development
of parasitic and bacterial resistance to drugs commonly used to treat malaria and
tuberculosis is a grave threat to public health. The same is true for viruses, as shown
by the emerging resistance to anti-HIV drugs (9).
Organisms that are resistant to multiple anti-infective drugs are not unusual (12).
The results of resistance are very serious in terms of increased mortality, with a
doubling of mortality being observed in some resistant infections as well as a need for
an increase in the length of treatment with the more expensive anti-infective drugs or
drug combinations. Complicating the matter, fewer new antibiotics are reaching the
market with no new class of broad-spectrum antibiotic likely to appear soon. New
public-private partnerships, however, are slowly beginning to fill the pipeline of new
drugs for diseases such as tuberculosis and malaria, many of them with initial funding
from the Bill and Melinda Gates Foundation (9).
The spread of resistance worldwide is one reason why efforts to detect and respond
to outbreaks of infectious diseases as quickly as possible are so important, as is the
wider need to rebuild and strengthen health systems, improve water and sanitation systems, minimize the impact of natural and human-influenced changes in the
environment, effectively communicate information about the prevention of infectious
diseases, and use anti-infective drugs appropriately (9). If the use of anti-infective
drugs were better rationalized, the evolutionary pressure on bacteria would be altered
and susceptible strains could again proliferate (12).
Figure 2.3 Evolution of penicillin resistance in
Staphylococcus aureus: a continuing story
1928
1942
1945
1946
1950
1960s–70s
1980s–90s
Penicillin discovered
Penicillin introduced
Fleming warns of possible resistance
14% hospital strains resistant
59% hospital strains resistant
Resistance spreads in communities
Resistance exceeds 80% in communities, 95% in most hospitals
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Animal husbandry and food processing
Human spongiform encephalopathy
In May 1995, the death of a 19-year-old man in the United Kingdom marked the first
human death of what is now known to be variant Creutzfeldt-Jakob disease (vCJD) or
human bovine spongiform encephalopathy (BSE). His illness and death demonstrate
the health consequences of improper animal rendering and feeding practices that had
begun during the 10-year period prior to his death. Briefly, the carcasses of cattle,
including those that had been infected with the BSE-causing agent, were rendered
into livestock feed. Some of the cattle consuming this feed then also became infected
leading to an epidemic of BSE, commonly called “mad cow disease” because of the
animals’ uncharacteristically agitated behaviour. From October 1996 to November
2002, 129 cases of vCJD were reported in the United Kingdom, six in France and one
each in Canada, Ireland, Italy and the United States.
The most likely source of human infection with vCJD is the consumption of meat
contaminated with BSE. The crisis, therefore, led to the recognition of the need for
government intervention along the entire “feed to food” continuum to ensure the safety
of foodstuffs for human consumption. Trade was shown to adapt itself very quickly
to the changing regulatory environment, with immense consequences for the United
Kingdom market.
Only reinforced surveillance in humans and animals can expose how widely the
agent was exported during the late 1980s and mid-1990s from its original European
focus and how far this public health security threat extends. The recent identification in
the United Kingdom of a fourth case of vCJD associated with a blood transfusion that
was later found to be contaminated with vCJD caused additional concern (13). This is
a reminder of the need for adequate investment in ensuring as safe a blood supply as
possible, taking into account risks of disease transmission in each country.
Nipah virus
Nipah virus is an emerging viral pathogen that causes encephalitis − an inflammation of
the brain − which is fatal in up to 75% of the people that it infects. The disease caused
by Nipah virus was first recognized in Peninsular Malaysia in an outbreak which began
in September 1998 and ended in April 1999. During that outbreak, 265 human cases
including 105 deaths were reported (14). When the reports of a severe encephalitis
outbreak began to accumulate, it was initially attributed to Japanese encephalitis, a
disease which is prevalent in Malaysia.
The belief that this outbreak was due to Japanese encephalitis resulted in expensive
and disruptive campaigns directed at mass immunization and mosquito control. These
control efforts were ineffective because it was in fact a new disease caused by a
previously unrecognized virus.
The majority of human cases were associated with direct contact with sick or
dying pigs or fresh pig products. It was eventually recognized that commercially raised
pigs, often housed near fruit orchards, were acting as the intermediate hosts of the
new virus. Transmission among pigs and from pigs to humans is now thought to have
occurred via the aerosol route in the former or following contact with throat or nasal
secretions in the latter. The end of the outbreak coincided with the mass culling of more
than 1 million pigs, which was part of the control strategy. In Singapore, there was a
small related outbreak that infected 11 human cases resulting in one death. A further
89 individuals were subsequently shown by serological tests to have experienced an
asymptomatic or mild infection of the disease. The Singapore outbreak ended following
a ban on the importation of pigs from Malaysia.
threats to public health security
Evidence from additional Nipah virus outbreaks since the events in Malaysia and
Singapore suggests that the virus may have become more pathogenic for humans. In
these cases, it seems that the virus can spread to humans without an intermediate
amplifying host such as the pig, and that human-to-human transmission can occur
with even casual contact. Some evidence points to amplification of transmission
within the health-care setting. In the most recent of these outbreaks, consumption of
contaminated food is considered the most likely route of exposure for several human
infections. Moreover, evidence of Nipah virus infection in fruit bats has now been found
in a broader range of countries than previously assumed.
The emergence and subsequent evolution of Nipah virus illustrate many of the
public health problems caused by emerging pathogens. These include initial diagnostic
confusion leading to delayed detection and inappropriate control measures, and high
mortality in the absence of effective preventive or control measures, which becomes
more difficult when control of an intermediate host, such as the pig, is no longer an
option. Changes in the epidemiological behaviour of the virus underscore the need to
be ready to adapt control measures as a new pathogen evolves.
WEATHER-RELATED EVENTS AND
INFECTIOUS DISEASES
Intensifying climatic conditions, together with a range of environmental, epidemiological
and socioeconomic factors, are bringing about changes in the exposure of populations
to infectious diseases, as illustrated by the following example of Rift Valley fever.
Above-normal rainfall associated with the occurrence of the warm phase of the El
Niño Southern Oscillation phenomenon is increasing the breeding sites of mosquitoes,
with a consequent rise in the number of outbreaks of Rift Valley fever. From December
1997 to March 1998, the largest outbreak ever reported in East Africa occurred in
Above-normal rainfall increases the risk of vector-borne diseases.
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Kenya, Somalia and the United Republic of Tanzania. The total number of human infections in the North Eastern Province of Kenya and southern Somalia alone was estimated
at 89 000, with 478 “unexplained” deaths (15). Complications arising from Rift Valley
fever in humans include retinopathy, blindness, meningo-encephalitis, haemorrhagic
syndrome with jaundice, petechiae and death. The outbreaks in East Africa were linked
to the higher than average rainfall − favouring the hatching of mosquito eggs − and a
complex interaction between non-vaccinated cattle and the mosquitoes, which transmit
the virus from animals to humans principally after feeding on infected animals. Female
mosquitoes are also able to pass the infection to their offspring which spread the virus
to animals on which they then feed, thus perpetuating a vicious circle of infection.
Animal immunization is only partially effective in preventing these outbreaks
because it must be implemented prior to the beginning of an outbreak in animals and,
if carried out during an outbreak, there is a risk of cross-infection from the reuse of
needles and syringes.
After the 1997–1998 outbreaks, a new prevention strategy was developed based
on two components: an accurate forecasting model, based on climatic conditions that
can predict the emergence of Rift Valley fever 2–4 months in advance, and efficient
veterinary public health services capable of implementing emergency mass animal
immunization before the beginning of the animal outbreak.
Forecasting models and early warning systems for Rift Valley fever, based on
satellite images and weather and climate forecasting data, were successfully developed to meet these requirements. In Africa and the Middle-East, collaboration with
affected countries, space agencies (the United States National Aeronautics and Space
Administration (NASA) and the International Reference Ionosphere (IRI) project), the
Food and Agriculture Organization of the United Nations (FAO) and WHO made it possible to draw up a monthly map of the possible emergence zones for Rift Valley fever.
These maps were used to inform the countries and help them with the early detection
of cases. Ultimately, these forecasting alerts should allow authorities to implement
measures to avert an impending epidemic by allowing implementation of mass animal
immunization prior to the start of the animal outbreak and to conduct intensive social
mobilization programmes aimed at changing risky behaviour.
On two occasions, the NASA/WHO monthly mapping of fever emergence was able
to predict an animal outbreak one month before it surfaced. In November 2006, alert
messages were sent to countries in the Horn of Africa. In addition, outbreaks of other
arboviruses (dengue, West Nile fever and yellow fever) were reported in the at-risk
areas for Rift Valley fever. These results show that the Rift Valley fever models may be
useful for the forecasting and early detection of arbovirus outbreaks. Further progress
is necessary in this area to refine models, but the use of predictive climatology for
insect-borne diseases of animals should be encouraged.
While the precise impacts of epidemics are difficult to predict, the necessary public
health response is clear. In such rapidly changing conditions, prevention is of the greatest importance; where prevention has failed, identifying and responding to epidemics
becomes even more important.
OTHER PUBLIC HEALTH EMERGENCIES
The broad scope of the International Health Regulations (2005) allows for the inclusion of radionuclear and chemical events that have the potential to cause harm on
a global scale. Such events, regardless of origin, rely on the same epidemiological
principles of surveillance, early detection and response as biological threats in order
to safeguard health.
threats to public health security
Sudden chemical and radioactive events
For much of the world, life in the 21st century has become greatly dependent on
chemical processing and nuclear power. Public health security in turn relies on the
safety of these facilities and the appropriate use of their products. Major chemical
spills, leaks and dumping, nuclear melt-downs, and the deliberate release of chemical
or biological agents occupy yet another category of threats to public health security.
The possibility of such events invokes the notion of surprise attack or accidents,
innocent victims and malicious or negligent perpetrators, and causes fears that may
be disproportionate to the real risk.
Most countries subscribe to international conventions banning chemical weapons.
Incidents such as the release of sarin gas (the sole purpose of which is to harm the
nervous system) on the Tokyo subway in 1995, however, remind us that although
chemical and biological attacks are rare, there are individuals, groups and governments
who are ready to use this brand of terrorism (see Box 2.2).
Similarly, chemical and nuclear processing plants operate under safety protocols,
such as those outlined by the International Programme on Chemical Safety (21), to
protect their workers, their facilities and the people and environment surrounding them.
Nonetheless, human and mechanical errors occur and accidents happen, sometimes
with devastating effects.
Wide-scale attacks using chemical weapons or major industrial accidents are not
the full picture when it comes to the disease burden from chemical incidents. The
majority of such deaths and illness is attributable to the many medium-sized and smallscale chemical incidents that take place every year around the world. Nevertheless,
Box 2.2 The deliberate use of chemical and biological agents to cause harm
Chemicals
Biological agents
The deliberate large-scale use of chemicals as poison gas
weapons dates back to the First World War, when tear
gas, mustard gas and phosgene were employed against
troops in the trenches of European battlefields to deadly
and disabling effect. Estimates range from about 1.17 to
1.25 million gas casualties on all sides, including between
85 000 and 91 000 fatalities, but exclude those who died
from gas-related injuries years after the end of the war
(16). The use of poison gas, including mustard gas, during
warfare was prohibited by the Geneva Protocol of 1925
and the Chemical Weapons Convention of 1993, which
also banned the development, production and stockpiling
of such weapons.
The largest chemical weapons attack against a civilian population in modern times occurred in 1988, when
Iraqi military forces repeatedly used mustard gas and
other chemical agents against Kurds in northern Iraq. In
the worst attack, on the Kurdish city of Halabja in March
1988, groups of aircraft flying many sorties repeatedly
dropped chemical bombs. About 5000 people were killed
and 65 000 others suffered severe skin and respiratory
diseases and other consequences such birth defects and
cancer (17, 18).
The potential of organisms used as weapons of biological warfare or bioterrorism was graphically illustrated,
albeit unintentionally, by an accident involving anthrax
in the former Soviet Union in 1979. The accident in Sverdlovsk, 1400 km east of Moscow, remains the largest
documented outbreak of human inhalation anthrax. The
number of people who died as a result has been estimated at between 45 and 100, among a total of up to
358 cases. In fatal cases, the interval between onset of
symptoms and death averaged three days.
Attributed at first by government officials to the consumption of contaminated meat, it was later shown to
have been caused by the accidental release of anthrax
spores from a Soviet military microbiology facility.
Epidemiological data revealed that most victims worked
or lived in a narrow zone extending from the military
facility to the southern city limit. Further south, livestock died of anthrax along the zone’s extended axis.
The zone paralleled the northerly wind that prevailed
shortly before the outbreak. Antibiotics and vaccines
were used to treat those affected and to bring the outbreak under control (19, 20).
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Table 2.1 Examples of major chemical incidents (1974–2006)
Chemical(s)
involved
Deaths
Injured
Evacuated
Chemical plant
(explosion)
Cyclohexane
28
104
3000
Seveso, Italy
Chemical plant
(explosion)
Dioxin
193
226 000
1979
Novosibirsk,
Russian Federation
Chemical plant
(explosion)
Uncharacterized
300
1981
Madrid, Spain
Foodstuff
contamination (oil)
Uncharacterized
430
20 000
220 000
1982
Tacoa, Venezuela
(Bolivarian Republic of)
Tank (explosion)
Fuel oil
153
20 000
40 000
1984
San Juanico, Mexico
Tank (explosion)
Liquified
petroleum gas
(LPG)
452
4248
200 000
1984
Bhopal, India
Chemical plant (leak)
Methyl
isocyanate
2800
50 000
200 000
1992
Kwangju,
Democratic People’s
Republic of Korea
Gas store (explosion)
LPG
163
20 000
1993
Bangkok, Thailand
Toy factory (fire)
Plastics
240
1993
Remeios, Colombia
Spillage
Crude oil
430
1996
Haiti
Poisoned medicine
Diethylene glycol
>60
1998
Yaoundé, Cameroon
Transport accident
Petroleum
products
220
130
2000
Kinshasa, Democratic
Republic of the Congo
Munitions depot
(explosion)
Munitions
109
216
2000
Enschede, Netherlands
Factory (explosion)
Fireworks
20
950
2001
Toulouse, France
Factory (explosion)
Ammonium
nitrate
30
>2500
2002
Lagos, Nigeria
Munitions depot
(explosion)
Munitions
1000
2003
Gaoqiao, China
Gas well (release)
Hydrogen
sulphide
240
9000
64 000
2005
Huaian, China
Truck (release)
Chlorine
27
300
10 000
2005
Graniteville, United
States of America
Train tanker (release)
Chlorine
9
250
5400
2006
Abidjan, Côte d’Ivoire
Toxic waste
Hydrogen
sulphide,
mercaptans,
sodium hydroxide
10
>100 000a
Year
Location
Type of incident
1974
Flixborough,
United Kingdom
1976
a The
547
number of consultations, not necessarily the number of people made directly ill.
Data source: (22). Data from 2000 onwards from the Major Hazard Incident Data Service (MHIDAS), Health and Safety Executive, London,
United Kingdom, except for Goaqiao and Abidjan, which are from WHO.
threats to public health security
it is from some of the larger scale incidents that the world has learned better how to
prevent and respond to chemical and radioactive threats through industrial advances
and diplomatic relations (see Table 2.1). Two major industrial accidents, a natural
phenomenon and a forest fire are described below, all of which point to the necessity
for a global response network for effective surveillance and early warning so as to
mitigate the adverse effects of such occurrences.
Industrial accidents
One of the world’s worst chemical accidents occurred around midnight on 2 December
1984, in the city of Bhopal in central India. A deadly cloud containing the toxic gas
methyl isocyanate spilled from Union Carbide’s large pesticide plant while most of the
population of nearly 900 000 people were asleep (23).
The exact figures for the number of people killed and injured by the gas are disputed.
According to official Indian figures, nearly 3000 people died in the first few hours of
the accident, while hundreds of thousands were harmed, and more than 15 000 people
have since died from cancer and other diseases (23, 24). Some estimates, however,
have put the numbers much higher, suggesting that 10 000 people died initially and over
20 000 subsequently (25). Officially, it is estimated that about 120 000 people continue
to suffer from chronic respiratory, ophthalmic, reproductive, endocrine, gastrointestinal,
musculoskeletal, neurological and psychological disorders associated with the event.
The release of gas also caused hundreds of thousands of people to flee the city and
the polluted local environment.
The emergency and local health services were overwhelmed by the event at
Bhopal. Lack of information about the identity of the gas, its health effects and the
necessary clinical management and mitigation measures contributed to enormous
health consequences. The acute industrial accident triggered a long-term crisis for
the entire population of Bhopal, the Government of India and the industries involved.
The health, economic and environmental consequences of the catastrophe are still
being felt today.
Could a similar incident happen again? The answer is almost certainly yes. Chemical
production and use has increased nearly tenfold worldwide over the last 30 years, and
this is particularly true in developing countries (26). Several governments have learned
from events such as Bhopal − and the accident at Seveso, Italy, where large amounts
of dioxins were released into the environment in 1976 − and have introduced regulations to prevent and prepare for major chemical accidents. Poorer nations, however,
are still struggling with a lack of technical capacity and regulatory infrastructure to
ensure safe chemical management. In some countries with good technical capacity,
the rapid pace of industrialization is outstripping the implementation of effective control
measures. Increasing urbanization in such countries is exposing growing numbers of
people to the risk of chemical incidents as they settle in close proximity to hazardous
installations. This particularly affects the poorer segments of society who have little
choice about where to live.
On 26 April 1986, explosions at reactor No. 4 of the nuclear power plant at Chernobyl
in Ukraine, a republic of the former Soviet Union at that time, led to the release of huge
amounts of radioactive materials into the atmosphere. These materials were deposited
mainly over countries in Europe, but especially over large areas of Belarus, the Russian
Federation and Ukraine. An estimated 350 000 clean-up workers or “liquidators” from
the army, power plant staff, local police and fire services were initially involved in
containing and cleaning up the radioactive debris during 1986–1987. About 240 000
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liquidators received the highest radiation doses while conducting major mitigation
activities within the 30 km zone around the reactor.
Later, the number of registered liquidators rose to 600 000, though only a small
fraction of these were exposed to high levels of radiation. In the first half of 1986,
116 000 people were evacuated from the area surrounding the Chernobyl reactor
to non-contaminated areas. Another 230 000 people were relocated in subsequent
years. At the present time, about 5 million people live in areas of Belarus, the Russian
Federation and Ukraine with levels of radioactive caesium deposition more than 37
kBq/m2 (27 ). Among them, about 270 000 inhabitants continue to live in areas classified by their governments as strictly controlled zones, where radioactive caesium
contamination exceeds 555 kBq/m2.
In 2006, as the world marked the 20th anniversary of the Chernobyl accident, WHO
released a report assessing the health impact of the worst civil nuclear accident in
history (27 ). The report provided clear recommendations for future research directions
and public health measures for national authorities of Belarus, the Russian Federation
and Ukraine, the countries most affected by fall-out from the
reactor explosion. More than 4000 thyroid cancer cases have
been reported in these countries in children and adolescents
for the period 1990–2002. This is significantly more than
would be expected, yet precise estimates of risk are still
unclear. Approximately 40% of these cases were detected
through screening programmes and may otherwise have
gone undetected (27 ). New thyroid cancer cases are likely
to be reported in the coming decades.
The Chernobyl nuclear reactor stands empty after the 1986 explosions.
A child of Chernobyl is examined by medical staff after the accident.
threats to public health security
The same report revealed that the most serious long-term public health impact is
in the area of mental health (27 ). In addition to the lack of reliable information provided
to people affected in the first few years after the accident, there was widespread
mistrust of official information and the false attribution of most health problems to
radiation exposure from Chernobyl. The necessary evacuation and relocation proved
a deeply traumatic experience for many people: their social networks were disrupted
and they had no possibility of returning to their homes. In addition, many had to face
the social stigma associated with being an “exposed person”; this stigma continues
and has led to increases in risk-taking behaviour, depression and other neurological
and psychological disorders.
WHO recommends that both key professionals and the general public should be
provided with accurate information about the health consequences of the Chernobyl
disaster, as part of efforts to revitalize the affected areas. WHO continues its efforts to
support improvements in health care for affected populations through the establishment
of telemedicine and educational programmes, and by supporting research.
Natural phenomena
Chemical poisoning of large numbers of people caused by a natural event rather than
an industrial accident occurred in August 1986, when about 1.6 million tons of CO2
gas were suddenly expelled from Lake Nyos, in the North-West Province of Cameroon.
This event was the result of a natural phenomenon that occurred when CO2 gas on
the bed of the lake was suddenly forced into the atmosphere as a result of a large
landslide into the lake. Because CO2 is heavier than air, the gaseous mass hugged
the ground surface and descended valleys along the north side of the crater at about
50 km per hour. The thick cloud covered a distance of 20 km, suffocating up to 1800
people living in the villages of Nyos, Kam, Cha and Subum (28, 29). Animals were also
killed, including 3500 livestock.
Although a high number of casualties might seem unavoidable following such
a sudden incident, measures can be put in place for prevention and preparedness
to reduce risk and population vulnerability in the future. This can be done by learning lessons from natural disasters and providing sufficient resources and technical
knowledge. Unfortunately, however, this is often not the case. Rare natural events
are eventually forgotten or ignored and communities can face a recurrence without
being prepared.
In the case of Lake Nyos and nearby Lake Monoun, which suffered a similar
eruption in 1984, pipes have been installed to allow some of the CO2 to be siphoned
off. The danger of another expulsion of CO2 remains, however, because there are still
insufficient pipes to remove the gas completely. Moreover, communities have re-settled
around the lakes. Understanding the potential triggers for a catastrophic expulsion of
gas, recognizing the early warning signs, and having in place an alert system could all
contribute to local populations being able to avoid a recurrence of the disaster.
Forest fires produce large amounts of biomass smoke containing a mixture of
particulate matter and toxic and irritant gases such as carbon monoxide, formaldehyde,
acrolein, benzene, nitrogen dioxide and ozone. Wood-smoke particulates can easily be
transported over great distances (30). Such small particles bypass the normal body
defence mechanisms and penetrate deep into the alveoli of the lungs, harming the
respiratory system.
Transboundary air pollution with smoke took place in 1997–1998, when Indonesia
suffered prolonged and uncontrolled forest fires causing a dense haze that spread
as far as the Philippines, Singapore and parts of Malaysia, Thailand and Viet Nam,
31
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global public health security
in the 21st century
encompassing a population of over 200 million people. About 1 million hectares of
forest, plantation and scrub land, chiefly in Sumatra and Kalimantan, burned continuously from July to October 1997. This devastating event was followed by further fires
in early 1998.
There have been other large-scale forest fires in Indonesia both before and since,
many of which have been shown to be caused by plantation companies clearing land
for agricultural use by burning vegetation (31). In 1997, as in some other years, the
spread of the fires had been facilitated by unusually dry conditions caused by El Niño
Southern Oscillation. Moreover, logging activities had also made forests more vulnerable to fire − flammable debris is left behind and the opening up of the forest canopy
allows more sunlight through to dry out the forest floor.
The resulting smoke haze adversely affected the health of populations in Indonesia
and neighbouring countries, causing an increase in the incidence of bronchial asthma,
acute respiratory infection and conjunctivitis. In Indonesia, among the 12 360 000
people exposed to the haze, it was estimated that there were over 1 800 000 cases
of bronchial asthma, bronchitis and acute respiratory infection (32). Health surveillance in Singapore from August to November 1997 showed a 30% increase in hospital
outpatient attendance for haze-related conditions, as well as an increase in accident
and emergency attendances (33). A study in Malaysia found significant increases in
respiratory hospitalizations related to the haze, specifically those for chronic obstructive pulmonary disease and asthma. The most vulnerable group was people over the
age of 65 (34). The long-term effects on health from exposure to the haze are yet to
be determined.
Causes of acute threats to public health security include those outlined for infectious diseases, acute events that occur after war or natural disasters, and chemical
or nuclear events. This chapter has provided examples of many of these causes and
the consequences as seen during the last century.
Chapter 3 describes more recent events in the 21st century and increases our
understanding of why border controls and international agreements are not enough
– there must be strong national surveillance and response mechanisms to detect and
respond to threats where and when they occur, together with global mechanisms to
detect and respond should they become threats to global public health security.
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(http://www.who.int/csr/don/2005_04_06/en, accessed 12 April 2007).
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accessed 12 April 2007).
7. Bausch DG, Borchert M, Grein T, Roth C, Swanepoel R, Libande ML et al. Risk factors for
Marburg hemorrhagic fever in Durba and Watsa, Democratic Republic of the Congo. Emerging
Infectious Diseases, 2003, 9:1531–1537.
8. Goma Epidemiologic Group. Public health impact of Rwandan refugee crisis: what happened
in Goma, Zaire, in July 1994? Lancet, 1995, 345:339–344.
9. Heymann DL. Emerging infections. In: Schaechter M, ed. The desk encyclopedia of microbiology. Amsterdam, Elsevier Academic Press, 2004.
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10. Levy SB. Antibiotic resistance: an ecological imbalance. In: Chadwick DJ, Goode J, eds.
Antibiotic resistance: origins, evolution, selection and spread. Chichester, John Wiley and
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11. Fleming A. Penicillin: Nobel Lecture, 11 December 1945 (http://nobelprize.org/nobel_prizes/
medicine/laureates/1945/fleming-lecture.pdf, accessed 11 May 2007).
12. Levy SB. Antimicrobial resistance: bacteria on the defence [editorial]. British Medical Journal,
1998, 317:612–613.
13. Fourth vCJD case linked with blood transfusion in UK. Minneapolis, MN, Center for Infectious
Disease Research and Policy, 2007 (http://www.cidrap.umn.edu/cidrap/content/other/bse/
news/jan2207vcjd.html, accessed 24 April 2007).
14. FAO/WHO Global Forum on Food Safety Regulators, Marrakech, Morocco, 28-30 January 2002:
Japanese encephalitis/Nipah outbreak in Malaysia. Rome, Food and Agriculture Organization, 2002 (GF/CRD Malaysia-1; http://www.fao.org/DOCREP/MEETING/004/AB455E.HTM,
accessed 18 May 2007).
15. Outbreak of Rift Valley fever, Eastern Africa, 1997-1998. Weekly Epidemiological Record,
1998, 73:105–109.
16. Poison gas and World War I. History Learning (http://www.historylearningsite.co.uk/poison_gas_and_world_war_one.htm, accessed 19 April 2007).
17. Mustard gas. New York, NY, Council on Foreign Relations, 2006 (http://www.cfr.org/
publication/9551/, accessed 19 April 2007).
18. Gosden CM. The 1988 chemical weapons attack on Halabja, Iraq. In: Yonah A, Hoenig M,
eds. Super terrorism: biological, chemical, and nuclear. Ardsley, NY, Transnational Publishers
Inc., 2001.
19. Meselson M, Guillemin J, Hugh-Jones M, Langmuir A, Popova I, Shelokov A et al. The
Sverdlovsk anthrax outbreak of 1979. Science, 1994, 266:1202–1208.
20. Anthrax as a biological weapon, 2002: updated recommendations for management. Journal
of the American Medical Association, 2002, 287:2236–2252.
21. International Programme on Chemical Safety (http://www.who.int/ipcs/en/, accessed on 3
April 2007).
22. Public health and chemical incidents: guidance for national and regional policy makers in
the public health/environmental health roles. Cardiff, International Clearing House for Major
Chemical Incidents, University of Wales Institute, 1999.
23. Facts and figures. Bhopal, Government of Madhya Pradesh, Bhopal Gas Tragedy Relief and
Rehabilitation Department (http://www.mp.nic.in/bgtrrdmp/facts.htm, accessed 24 April
2007).
24. Health effects of the toxic gas leak from the Union Carbide Methyl Isocyanate Plant in Bhopal:
technical report on population-based long-term epidemiological studies (1985–1994). New
Delhi, Indian Council of Medical Research, 2004.
25. Clouds of injustice: Bhopal disaster 20 years on. Oxford, Amnesty International, 2004.
26. Environmental outlook for the chemical industry. Paris, Organisation for Economic Cooperation and Development, 2001.
27. Health effects of the Chernobyl accident and special health care programmes. Geneva, World
Health Organization, 2006 (Fact sheet 303).
28. Baxter PJ, Kapila M, Mfonfu D. Lake Nyos disaster, Cameroon, 1986: the medical effects of
large-scale emission of carbon dioxide? British Medical Journal, 1989, 298:1437–1441.
29. Camp V. Lake Nyos 1986. San Diego, State University Department of Geological Sciences,
(http://www.geology.sdsu.edu/how_volcanoes_work/Nyos.html, accessed 11 March
2007).
30. Brauer M. Health impacts of biomass air pollution. In: Goh K-T et al, eds. Health guidelines
for vegetation fire events. Geneva, World Health Organization, 1999.
31. Byron N, Shepherd G. Indonesia and the 1997-98 El Niño: fire problems and long-term
solutions. Natural Resource Perspectives, 1998, No. 28 (http://www.odi.org.uk/NRP/28.
html, accessed 11 March 2007).
32. Dawud Y. Smoke episodes and assessment of health impacts related to haze from forest
fires: Indonesian experience. In: Goh K-T et al, eds. Health guidelines for vegetation fire
events. Geneva, World Health Organization, 1999.
33. Emmanuel SC. Impact to lung health of haze from forest fires: the Singapore experience.
Respirology, 2000, 5:175-82.
34. Mott JA et al. Cardio-respiratory hospitalizations associated with smoke exposure during
the 1997 Southeast Asian forest fires. International Journal of Hygiene and Environmental
Health, 2005, 208:75-85.
33
NEW
HEALTH THREATS
in the 21st century
chapter
3
35
The previous chapter identified the main causes of infectious diseases and other acute events that threaten collective public health.
Chapter 3 continues with a number of major events that have occurred in the first few
years of the 21st century and which represent new threats to national and global public
health security. The examples discussed are bioterrorism in the form of the anthrax letters in the
United States in 2001, the emergence of Severe Acute Respiratory Syndrome (SARS) in 2003, and
large-scale dumping of toxic chemical waste in Côte d’Ivoire in 2006.
These events demonstrate how much the world is changing in terms of its vulnerability to new
threats to health. Chronologically, the first of these is the arrival of bioterrorism on the international
stage with the anthrax letters attack in the United States in 2001. This was followed in 2003 by the
emergence and rapid international spread of the deadly new disease SARS. The international impact
of this disease contributed to the growing political will to complete the revision and strengthening
of the International Health Regulations (1969), and to enable a much more proactive approach to
preparedness for an expected human influenza
pandemic (see Chapter 4).
In 2006, the illegal dumping of hundreds of tons
of chemical waste in Côte d’Ivoire provoked tens
of thousands of cases of respiratory and other
illnesses, and illustrated a growing phenomenon
− how globalization has exacerbated the dangers
inherent in the movement and disposal of hazardous wastes. The episode, described later in this
chapter, is linked to the extended response system
to chemical incidents that covers such environmental health emergencies (see Chapter 2).
THE ANTHRAX LETTERS
Coming only days after the terrorist events of 11 September 2001
in the United States, the deliberate dissemination of potentially
lethal anthrax spores in letters sent through the United States
Postal Service (1) added the deliberate release of biological or
chemical agents to the realities of life in the 21st century. Anthrax
spores were found in four envelopes. In addition to the human
toll − five people died among 22 cases (2) − the anthrax attack
caused massive disruption of postal services in many countries
around the world and 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 that led to the
updated publication of Public health response to biological and
chemical weapons: WHO guidance (3).
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For years, the United States and other industrialized countries had lived with the
fear − frequently fed by hoax calls and alarms − of just such an attack. Although there
was no evidence that they had been used, it was well known that stocks of biological
weapons, including anthrax, were held by a number of countries. Investigations into the
accidental release of anthrax from a military biological weapons facility in the former
Soviet Union in 1979 showed how lethal it could be (see Chapter 2).
In 1990, during the Gulf War, the United States Government’s concern about
potential anthrax attacks led to the vaccination of more than 100 000 military personnel. In 1995, this concern was again aroused when the United Nations Special
Commission indicated that Iraq had been developing and testing anthrax weapons during the Kuwait War. In 1998, a programme was initiated to vaccinate all United States
military personnel, and government agencies were given directives for responding to
possible deliberate biological or chemical attacks on civilian centres.
Starting in 1997, the United States experienced an increasing number of anthrax
threats and hoaxes that, by the end of 1998, were regular occurrences. Prominent
among these were envelopes containing various powders and materials, which were
sent through the mail to abortion and reproductive health clinics, government offices
and other locations. Until the events of 11 September 2001, none of these materials
had tested positive for pathogenic Bacillus anthracis and there had not been a case of
inhalational anthrax in the United States since 1976.
By 2001, with federal assistance, most American state governments and authorities
of large cities had begun to develop plans to deal with bioterrorism and many had
staged mock attacks to test local emergency response capacity. Effective medical
measures for prevention and treatment of the two forms of the disease – cutaneous
and inhalational anthrax − were established and published in the medical literature
well before the anthrax letter attacks.
Nevertheless the anthrax letters − dated 11 September 2001 and postmarked
seven days later − caused huge public alarm and prompted a massive public health
response. In the end, a total of 22 persons are thought to have been infected: 11 each
with cutaneous and inhalation anthrax. The five patients who died were all infected
with inhalation anthrax (3). Twenty of the 22 patients were exposed to work sites
that were found to be contaminated with anthrax spores; nine had worked in mail
processing facilities through which the anthrax letters had passed. Drugs were made
available on an emergency basis to some 32 000 people who were potentially exposed.
Altogether, about 3.75 million antimicrobial tablets were distributed. People presumed
to be at higher risk were advised to remain on a prolonged course of 60 days and
were also given the option of anthrax vaccination. The CDC sent emergency teams of
epidemiologists and laboratory and logistics staff to support local, state and federal
health investigations and medicine distribution.
The collection and testing of environmental and clinical samples, as well as materials
from suspicious incidents and hoaxes, placed an immense burden on the CDC, public
health laboratories throughout the country and government agencies. The magnitude
of the clinical and environmental testing undertaken would have quickly overwhelmed
the nation’s capacity had a significant investment not already been made in expanding
laboratory training and capacity through a system called the Laboratory Response Network (LRN). The network links state and local public health laboratories with advanced
capacity laboratories, including clinical, military, veterinary and agricultural laboratories,
and those for testing water and food.
new health threats in the 21st century
One legacy of the crisis was the introduction of permanent decontamination, detection and security equipment at mail processing facilities across the country. In order to
reduce potentially contaminated dust and aerosols from the atmosphere in its centres,
the Postal Service introduced some 16 000 high efficiency particulate air filter vacuum
machines and, as a precaution, routinely sterilizes mail going to federal agencies by
electron-beam irradiation. For the two fiscal years 2003 and 2004, US$ 1.7 billion was
budgeted for additional modifications and improvements in the government’s ability
to protect the health of postal workers and to prevent pathogens and other hazardous
substances from being distributed through the mail.
Even though the deliberate release of the anthrax was directed at one country,
it had region-wide effect in the Americas. This was especially so as public health
infrastructures had to divert resources to face an overwhelming demand for laboratory
tests for suspected tainted postal items, personal protective equipment and for the
decontamination of facilities.
Occurring as it did so soon after the September 2001 terrorist attacks, the anthrax
offensive prompted a profound rethinking of threats to national and international security. It showed the potential of bioterrorism to cause not just death and disability, but
social and economic disruption on an enormous scale both in the United States and
internationally.
A simultaneous concern was that smallpox – a debilitating, disfiguring and frequently deadly disease that was eradicated in 19791 – could be used over 20 years
later as one of the most effective biological weapons conceivable. This was of particular concern given that mass smallpox vaccination had been discontinued after
eradication, thus leaving unimmunized populations susceptible. An expert who had
led the smallpox eradication campaign warned in June 1999, “If used as a biological
weapon, smallpox represents a serious threat to civilian populations because of its
case fatality rate of 30% or more among unvaccinated persons and the absence of
specific therapy. Although smallpox has long been feared as the most devastating of
all infectious diseases, its potential for devastation today is far greater than at any
previous time” (4).
WHO has participated in international discussions and bioterrorism desktop exercises, arguing that the surest way to detect a deliberately caused outbreak is to
strengthen the systems used for detecting natural outbreaks, as the epidemiological
and laboratory principles are fundamentally the same. Consideration of the appropriate
response to a biological attack, especially to the smallpox virus, served to test – on
a global scale – the GOARN mechanisms recently introduced by WHO. In addition,
the debate in medical journals, the media, and security and defence circles helped to
persuade political leaders that improved national capacities for disease surveillance
and response are directly relevant to national and international security.
SARS: VULNERABILITY REVEALED
In 2003, SARS – the first severe new disease of the 21st century – confirmed fears,
generated by the bioterrorism threat, that a new or unfamiliar pathogen would have
profound national and international implications for public health and economic security.
SARS defines the features that give a disease international significance as a public
health security threat: it spreads from person to person, requires no vector, displays
1
The global eradication of smallpox was certified by a commission of eminent scientists in
December 1979 based on intensive in-country verification activities. It was subsequently
endorsed by the World Health Assembly in 1980.
37
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global public health security
in the 21st century
no particular geographical affinity, incubates silently for more than a week, mimics
the symptoms of many other diseases, takes its heaviest toll on hospital staff, and
kills around 10% of those infected. These features enable it to spread easily along the
routes of international air travel, placing every city with an international airport at risk
of imported cases (see Figure 3.1).
New, deadly and initially poorly understood, SARS incited a degree of public anxiety that brought travel to affected areas to a virtual standstill and drained billions of
dollars from economies across entire regions. Box 3.1 details the economic costs
of the SARS epidemic and projects the possible economic consequences of a large
influenza pandemic.
SARS demonstrated that the risks and dangers to health arising from new diseases have indeed been increased by the ways in which nations and their populations
interact globally. It showed the magnitude of damage that an emerging disease with
the appropriate features can cause in a world where airlines carried an estimated 2.1
billion passengers in 2006 (7 ), where financial markets and businesses are tightly
intertwined, and where information is instantly accessible (see Figure 3.2).
The emergency response and the level of media attention stimulated by SARS
were on a scale that challenged public and political perceptions of the risks associated
with emerging and epidemic-prone diseases (see Box 3.2). The outbreak raised the
profile of public health to new heights. Neither the public nor government officials at
the highest levels could ignore the adverse effects that a health problem was having
on economies, societies, politics and the international image of countries. Not every
Figure 3.1 Probable SARS transmission on flight CA112 in March 2003
13 Hong Kong
SAR residents
4 employees
of a Taiwanese
engineering
firm
1 Singaporean
2 Chinese
(seat numbers
unknown)
A total of 22 passengers, and the index case, met WHO’s definition of a probable case of SARS.
2 crew
members
Source: Osen SJ et al.
Index case
Mr LSK, 72,
from Beijing,
China
39
new health threats in the 21st century
Box 3.1 Economic impact of SARS and influenza pandemics
seen in the case of SARS, as illustrated below.
If a pandemic were to persist for over a year, as has
been predicted, the long-term consequences in terms of
job loss and bankruptcy would continue to produce hardship for many years. The longer the pandemic remained
active, the greater the damage in terms of losses in productivity, along with hospitalization and other healthcare expenditures.
Of course, the larger the pandemic, in terms of proportion of the population infected, the greater the economic
impact. For infection rates up to 1% of the world’s population, a decrease in global GDP of 5% could be expected,
The 2003 epidemic of SARS could possibly have been a global pandemic responsible for millions of deaths. Instead,
using classic surveillance and epidemiological response
techniques, the epidemic was limited to 8422 cases with
a case-fatality rate of 11% (5). Even so, the estimated cost
of the epidemic to Asian countries was US$ 20 billion in
gross domestic product (GDP) terms for 2003, or a more
dramatic US$ 60 billion of gross expenditure and business
losses (6).
The main drivers of the economic impact of SARS were
tourism and consumer confidence for non-essential spending. The actual number of SARS cases was relatively small,
Estimated economic impact of pandemic influenza
Total GDP loss in billions of US dollars
Pandemic flu: annual economic costs v average % infection rate
10
10
8
8
6
6
World GDP % loss
4
4
2
2
GDP US$ bn
GDP %
Asia GDP % loss
3000
3000
2500
2500
2000
2000
1500
1500
World GDP loss
1000
Scenario: global pandemic flu impact over 1 year
0
0
0.0
0.5
1.0
1.5
2.0
Average % of world population infected at any time
1000
500
500
Global pandemic
0
0
0.0
0.5
1.0
1.5
2.0
Average % of world population infected at any time
Source: Oxford Economic Forecasting Group.
but the fear of transmission caused foreign tourists to
choose alternative holiday locations, and the local population felt safer avoiding restaurants and other public leisure
venues. These sectors of the economy are significant contributors to the GDP of many countries.
Both human and economic consequences were mostly
confined to the second quarter of 2003. Although the duration and economic impact of the outbreak were checked
by strong leadership and coordinated international public
health action, this success invites the question “what could
have happened?”
The total cost of SARS to Asian countries breaks down
to over US$ 2 million per person infected. A true influenza
pandemic would certainly last longer than three months, but
the economic implications of an influenza outbreak lasting
a year or more are not a simple multiplication of what was
with an additional loss of 1% per additional percentage
increase in infection rate (6). Once a critical infection rate
was reached, the cumulative economic disruption would
produce a shut-down of the global economy, similar to
that seen in the United Kingdom’s agricultural economy
following the 2001 outbreak of foot and mouth disease
but, in this case, on a global scale (6).
The potential calamity caused by a global influenza
pandemic justifies naming the control of such a pandemic
a global public good. Current stocks of vaccines and
anti-viral medications are not adequate in any country,
let alone in developing countries. Pandemics, by definition, have no respect for national and regional borders.
The health impact of the pandemic influenza virus will be
shared, as will the economic losses.
world health report 2007
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in the 21st century
country felt threatened by the prospect of deliberate biological attack, but every country
was concerned by the arrival of a disease like SARS.
SARS also highlighted the fact that the danger arising from emerging diseases is
universal. No country is automatically protected – by virtue of its wealth or its high
levels of education, standards of living and health care, or equipment and personnel at border crossings – from either the arrival of a new disease on its territory or
the subsequent disruption this can cause. SARS was, to a large extent, a disease
of prosperous urban centres. Contrary to expectations, it spread most efficiently in
sophisticated city hospitals.
SARS did not become endemic in humans or gradually fade away. Its spread 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. Had SARS been allowed
to establish a foothold in a resource-poor setting, it is doubtful whether the demanding
measures, facilities and technologies needed to interrupt chains of transmission could
have been fully deployed. 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.
DUMPING OF TOXIC CHEMICALS
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 Côte 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
Figure 3.2 Direct economic impact of selected infectious disease outbreaks, 1990–2003a
USA – E. coli 0157
US$ 1.6 billionb
1991–1999
UK – BSE
US$ 39 billion
1990–1998
Asia – SARS
US$ 30 billion
2003
Malaysia – Nipah
US $625 million
1999
Peru – Cholera
US$ 770 million
1991
a
b
Tanzania – Cholera
US$ 36 million
1998
Excludes economic impact of human sickness and death.
Date source: (8 ).
India – Plague
US$ 1.7 billion
1995
new health threats in the 21st century
Toxicological dumping in Côte d’Ivoire –
the clean up begins.
Box 3.2 The role of the mass media in risk perceptions
News travels fast – and it has never travelled faster than
in today’s world of instant information. The mass media
have a powerful influence on people’s perceptions of
risks, whether from a new disease epidemic, deliberate
attacks or natural catastrophes. The Internet, television,
radio, newspapers and magazines are the most influential
sources of everyday information on risks to health.
How should the media evaluate and communicate
information on health risks such as avian influenza
or SARS? Such situations challenge the media to be
responsible when dealing with complicated scientific
issues and conflicting political goals. What information
should be conveyed? How fully should uncertainties and
controversies be explained to the public?
In covering health issues, the media perform two major
functions: they explain and report scientific information
and government policies for the public and, at the same
time, reflect the concerns of the general public. Healthrelated events such as chemical accidents, medical
research discoveries, communicable disease epidemics
and safety defects in new medicines are all likely to make
headlines. Government press releases, scientists and
international scientific journals are often their main
sources of information. Journalists tend to use the
best-organized sources and those press releases that
encapsulate technical information in lay terms. In addition,
international news organizations frequently syndicate
health-risk stories around the world (9 ).
According to a study by the Nuffield Trust, mass
communication can either heighten levels of anxiety or
provide reassurance at times of acute public health events.
Authorities such as governments may use the mass
media, but can seldom keep control of the information
delivered. They have to strike a difficult balance between
saying too much and saying too little: one course of
action may cause an overreaction, the other may seem
complacent (10 ).
Mass communication has both a positive and
negative potential for risk perception. When no
information about health risks is provided through
official channels, the media will find it elsewhere
and their reports may create or heighten a sense of
anxiety. For those in authority, doing or saying nothing
has become a dangerous strategy. For example, early
reports of a disease outbreak are often alarmist, as
was shown in the case of the SARS outbreak in 2003.
This can establish a baseline of accepted “facts” or
beliefs that may be difficult to correct when more –
and especially more accurate – information becomes
available.
“On the other hand, mass communications can be
used to reassure the public. In this respect, the role of
WHO during SARS is instructive,” says the Nuffield Trust
study. “As a trusted international body it was able to use
mass communication to inform and reassure anxious
publics. Indeed, the speed of modern communication
can even be a reassurance in itself: as SARS demonstrated, modern communication technology allowed
the rapid exchange of information which allowed better preventative action, while the exchange of scientific
data through secure web sites, etc. allowed the SARS
genome to be identified remarkably quickly.”
The study says health professionals – and in
particular professional bodies – have a role to play
in reassuring the public over the risks involved, but
such responses need to be agile and perceived as
independent and authoritative.
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and around Abidjan. One month after the dumping, almost 85 000 consultations had
been recorded at different medical facilities in relation to the chemical incident and its
consequences: 69 people had been admitted to hospital and eight deaths had been
attributed to the event.
The composition of the “slop” unloaded from the vessel was initially unknown, but
it caused eye, nose and throat irritation, breathing difficulties, headaches, nausea and
vomiting, and growing anxiety among thousands of people. The most severe cases
presented with respiratory distress, dehydration, and nose and intestinal bleeding.
In addition to the eight deaths attributed to the incident initially, more are suspected
to have occurred due to the worsening of pre-existing medical conditions such as
asthma, respiratory conditions or cardiovascular disease. Even several weeks after
the dumping, the foul odours persisted at certain times of the day, and people with
nose, throat and skin irritation, as well as malaise, nausea and gastrointestinal effects,
were still seeking medical attention at the hospitals, where free care and medication
was provided.
The waste was eventually identified as a mixture of sodium hydroxide, phenols,
mercaptanes, hydrogen sulphide, hydrocarbons and other chemicals used to clean oil
transporters’ tanks, all of which can have severe toxic and caustic effects requiring
symptomatic treatment.
This incident had important public health, social and economic consequences. It
occurred in a climate of social unrest and political instability that was further intensified
by the reactions of the people. Street demonstrations and violent incidents occurred
every day.
Thousands of people arrived at the medical centres with either health complaints
or – especially in the case of pregnant women – fears about the future consequences of
exposure to the chemicals, stretching the provision of normal medical care to the limit.
Pharmaceutical stocks, X-ray plates, laboratory reagents and other supplies were soon
scarce. As the medical personnel were overwhelemed, more staff had to be recruited
in order to deal with the overflow of consultations. The public health system was in
crisis and unable to provide the medical care required by the population.
In addition, there was increasing local and international concern about potential
water and food contamination, as dead fish were reported in the lagoon and vegetables
grown near contaminated sites were being sold in the local markets. Some of the
contaminated areas that happened to be waste disposal sites were closed for security
reasons and, as a consequence, the normal garbage collection system was disrupted
and domestic rubbish began piling up in different areas of the city.
The situation required government intervention at the highest level as well as the
support of national and international organizations. WHO provided technical advice
to country authorities, acquired pharmaceuticals and other resources for the overworked hospitals, supplied computers and case data forms, prepared and circulated
information notes, and established contacts with other organizations of the United
Nations system.
Neighbouring countries were concerned that rivers and the sea would carry contamination and they remained on the alert. One of the main international concerns
was that the ship transporting the waste had sailed from northern Europe and had
called at a number of ports, including some others in western Africa, on its way to
Côte 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.
new health threats in the 21st century
In today’s world, public health security needs to be provided through coordinated
action and cooperation between and within governments, the corporate sector, civil
society, the media and individuals. No single institution or country has all the capabilities
needed to respond to international public health emergencies caused by epidemics,
natural disasters, environmental emergencies, chemical or biological attacks, or new
and emerging infectious diseases. Only by detecting and reporting problems in their
earliest hours can the most appropriate experts and resources be deployed to prevent
or halt the international spread of disease.
Chapter 4 examines recent experience in avian influenza alert and response, the
new threat of XDR-TB and natural disasters caused by extreme weather events.
REFERENCES
1. Diffuse security threats: technologies for mail sanitization exist, but challenges remain.
Washington, DC, United States General Accounting Office, 2002 (GAO–02–365).
2. Jernigan DB, Raghunathan PL, Bell BP, Brechner R, Bresnitz EA, Butler JC et al. Investigation
of bioterrorism-related anthrax, United States, 2001: epidemiologic findings. Online Emerging
Infectious Diseases, 8 October 2002 (http://www.cdc.gov/ncidod/EID/vol8no10/02-0353.
htm, accessed 25 April 2007).
3. Public health response to biological and chemical weapons: WHO guidance. (2nd ed. of Health
aspects of biological and chemical weapons, 1970). Geneva, World Health Organization,
2004 (http://www.who.int/csr/delibepidemics/biochemguide/en/index.html, accessed 15
May 2007).
4. Fenner F, Henderson DA, Arita I, Ježek Z, Ladnyi ID. Smallpox and its eradication. Geneva,
World Health Organization, 1988.
5. Summary table of SARS cases by country, 1 November 2002–7 August 2003. Geneva,
World Health Organization (http://www.who.int/csr/sars/country/2003_08_15/en/index.
html, accessed 11 December 2006).
6. Rossi V, Walker J. Assessing the economic impact and costs of flu pandemics originating in
Asia. Oxford, Oxford Economic Forecasting, 2005.
7. Fact sheet: IATA. Geneva, International Air Transport Association, 2007 (http://www.iata.
org/pressroom/facts_figures/fact_sheets/iata.htm, accessed 10 May 2007).
8. Marsh TL, Shroeder TC, Mintert J. Impacts of meat product recalls on consumer demand in
the USA. Applied Economics, 2004, 36:897–909.
9. The world health report 2002 – reducing risks, promoting healthy life. Geneva, World Health
Organization, 2002.
10. Health, security and the risk society. London, Nuffield Trust Global Health Progamme,
2005.
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LEARNING
LESSONS
thinking ahead
chapter
4
45
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 and
has been a rare opportunity to prepare for a pandemic, and possibly to prevent
the threat becoming a reality.
The IHR (2005) provide the framework for this approach through national core capacity strengthening and a call for collective response to public health emergencies of international concern.
Chapter 4 examines lessons being learned from experiences gained through the early application
of IHR (2005) in the pandemic influenza alert, and their potential application in situations such
as extensively drug-resistant tuberculosis (XDR-TB) in southern Africa and the threat of the
international spread of poliomyelitis.
These latter two situations are examples of the type of public health events that would evoke
use of the decision instrument of IHR (2005) to assess the need to notify WHO of a public health
emergency of international concern (see Chapter 5) and, if deemed necessary, would require a
collective public health response.
PANDEMIC INFLUENZA: THE MOST FEARED SECURITY THREAT
In sharp contrast to the entirely reactive response to the SARS outbreak of 2003, the response to the threat of a new
influenza pandemic has already been emphatically proactive − facilitated by early implementation of IHR (2005). This has
been a rare opportunity to prevent the threat becoming a reality by taking
full advantage of advance warning and by testing a model for pandemic
planning and preparedness.
The threat of pandemic influenza cannot be fully appreciated, however,
without first understanding its relationship to seasonal influenza. Every year,
human influenza rapidly spreads around the world in seasonal epidemics,
typically resulting in an estimated three to five million cases of severe illness
and between 250 000 and 500 000 deaths.
Most deaths currently associated with influenza in industrialized countries
occur among people over 65 years of age. The causative seasonal influenza
viruses are divided into two groups: A and B. Influenza A has two subtypes
of seasonal viruses which are important for humans: A(H3N2) and A(H1N1),
the former of which is currently associated with most deaths.
Seasonal influenza viruses frequently undergo minor genetic changes,
known as “antigenic drift”. These changes require annual reformulation of
influenza vaccines to protect populations in different regions of the world. The
most effective vaccines for seasonal influenza are those that are specifically
produced for the currently circulating virus.
Seasonal influenza outbreaks typically first appear in the East and then
travel westward. Viruses detected early in Asia are therefore analysed and
used to predict the components used in the preparation of the vaccines for
the subsequent influenza season.
For the past 50 years, genetic information on the constantly changing strains of circulating influenza viruses obtained from freely shared and
exchanged viruses from countries, and on the epidemiological trends of influenza infection has been gathered by an extensive surveillance network (the
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Global Influenza Surveillance Network) administered by WHO. The network currently
consists of more than 118 National Influenza Centres in over 89 countries, and four WHO
Collaborating Centres in Australia, Japan, the United Kingdom and the United States
(see Figure 4.1). National Influenza Centres ensure that representative viral insolates
are transferred to the Collaborating Centres for immediate strain identification.
WHO also administers FluNet, an Internet-based geographical information system
with a remote data entry component, which allows real time access to the latest
country-specific data on circulating strains and epidemiological trends. Launched in
1997, FluNet contributes to global influenza surveillance by giving researchers and
others a tool to access information on influenza activity (1).
Apart from guiding the annual composition of recommended seasonal influenza
vaccines, the Global Influenza Surveillance Network and FluNet operate as a global early
warning system on the emergence of influenza variants and new strains. The network
is reliable and sufficiently sensitive to pick up any new influenza virus with pandemic
potential and any outbreak of unusually severe illness and rapid spread. It played a key
role in the early detection, investigation and containment of the 1997 outbreak of H5N1
avian influenza in humans in China, Hong Kong Special Administrative Region.
Human cases and deaths related to H5N1 avian influenza were first reported in Hong
Kong SAR in 1997. By 6 June 2007, the cumulative number of human cases reported
to WHO had risen to 310, including 189 deaths. Although relatively few in number,
they are symbolic of an emerging epidemic disease that presents a major threat to
life, economies and security. While the timing and severity of a pandemic cannot be
predicted, the world has been given the unprecedented advantage of advance warning
that a pandemic may be near. This advantage is being fully exploited to enhance global
preparedness under the framework of IHR (2005).
Although H5N1 was first isolated from humans in 1997, it was intensified surveillance for a recurrence of SARS in 2003 and 2004 that first detected a cluster of young
Figure 4.1 WHO influenza surveillance network
1 Laboratory
>1 Laboratory
National network
learning lessons, thinking ahead
children with H5N1 infection, many of whom had died from severe respiratory disease
at a paediatric hospital in Hanoi, Viet Nam. This outbreak of human cases of avian
influenza was caused by the highly pathogenic H5N1 virus and accompanied by huge
outbreaks in poultry. It was a signal of what might follow.
Coming on the heels of the SARS outbreak, the prospect of an influenza pandemic
sparked immediate alarm around the world and with good reason. Far more contagious, spread by coughing and sneezing and transmitted during an incubation period
too short to allow for contact tracing and isolation, pandemic influenza would extend
the devastating consequences that had been seen with SARS in Asia and Canada to
every corner of the world within a matter of months. Moreover, if a fully transmissible
pandemic virus emerged, the spread of the disease could not be prevented. Even a
measure as drastic as a complete ban on international travel might, at best, delay
arrival of the virus in a country by a few weeks.
Based on experiences with past pandemics, illness affecting around 25% of the
world’s population has been predicted by some experts. This calculates to more than
1.5 billion people – more than the combined populations of China and the United States.
Should this prove accurate, the impact that the first influenza pandemic since the turn
of the century would have on national and international public
health, and on economic and political security, can easily be
foreseen. Even if the virus caused relatively mild symptoms,
the economic and social disruption arising from sudden surges
of illness in so many people – occurring almost simultaneously
throughout the world – would be enormous.
An emergency hospital in the United States during the 1918–1919 influenza pandemic.
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With so much at stake, the expanding outbreaks in poultry and human cases in Viet
Nam, followed within days by cases in Thailand, stimulated a flurry of research activity
involving epidemiologists, clinicians, virologists and veterinarians. Researchers combed
through the histories of past pandemics searching for clues that could shed light on
what might lie in store and how best to prepare. Industry accelerated its efforts to
develop a pandemic vaccine and to augment manufacturing capacity for the principal
antiviral drug, oseltamivir. The WHO Global Influenza Surveillance Network continued to
identify human infections with avian influenza viruses. Although H5N1 human infections
predominated, other human infections with H7 and H9 avian influenza viruses have also
been identified. The notoriously unstable genetic nature of influenza viruses makes it
impossible to predict which, if any, of these avian influenza viruses will be the cause
of the next pandemic and, if so, when that pandemic might occur.
By the end of 2004, it was clear that H5N1 was an especially tenacious virus in
avian populations. Tens of millions of birds in many countries were destroyed as part
of the control strategy. In large parts of Asia, the virus was firmly entrenched. It was
estimated that up to a decade would be required to eliminate it. The threat of a pandemic
would also persist, possibly for just as long (Figure 4.2).
As far as humans were concerned, 72% of those infected with H5N1 had died
by the end of 2004, with infections still confined to Viet Nam and Thailand. The
age profile of cases was disturbing, given that those most frequently infected were
previously healthy children and young adults who had been in contact with sick or
dead chickens. Most severe cases died following the development of primary viral
Figure 4.2 Cumulative number of confirmed human cases of avian influenza A/(H5N1)
reported to WHO since 2003
China
2003–2007
25 cases
16 deaths
Turkey
2006
12 cases
4 deaths
Egypt
2006–2007
34 cases
14 deaths
Iraq
2006
3 cases
2 deaths
Total number of cases includes number of deaths.
WHO reports only laboratory-confirmed cases.
All dates refer to onset of illness.
Data as of 6 June 2007.
Lao
People’s
Democratic
Republic
2007
2 cases
2 deaths
Azerbaijan
2006
8 cases
5 deaths
Viet Nam
2003–2005
93 cases
42 deaths
Nigeria
2007
1 case
1 death
Thailand
2004–2007
25 cases
17 deaths
Djibouti
2006
1 case
Cambodia
2005–2007
7 cases
7 deaths
Indonesia
2005–2007
99 cases
79 deaths
learning lessons, thinking ahead
pneumonia, not from super-infections of bacteria which are among the complications
of seasonal influenza.
In 2005, so-called “relay transmission” of H5N1 began to occur, with the highly
pathogenic virus moving from poultry to wild birds and back again, giving it an ability
to move over long distances. In July 2005, the virus moved beyond its initial home in
South-East Asia and began to spread, reaching the African continent, Central Asia,
Europe and the Eastern Mediterranean Region. With wild birds now involved in the
transmission cycle, the prospects for rapid containment of the virus looked even
bleaker.
WHO tracked and verified rumours of human cases that reached more than 30
per day. Field investigation kits were dispatched to WHO country offices, and training
on field investigations and response was intensified. The GOARN mechanism was
mobilized to support the deployment of WHO response teams to 10 countries, while
over 30 assessment teams investigated the situation in other countries.
In September 2006, WHO convened a meeting of leading scientists conducting
research on the H5N1 virus to consider whether it or another avian influenza virus would
retain its exceptional lethality if it acquired the ability to spread efficiently from human
to human. It was concluded that, if a pandemic virus emerged following a “reassortment
event” − when genetic material is exchanged between human and avian viruses − it
would almost certainly lose some of its pathogenicity. However, if the pandemic virus
remained entirely avian, yet acquired the ability to transmit from human to human by
mutation, it could very well maintain its present lethality. The death rate during the
1918–1919 influenza pandemic was around 2.5%. At 1 May 2007, the overall death
rate among reported human H5N1 infections was above 58%.
By 11 April 2007, 12 countries in Asia, the Middle East and Africa had reported the
total of human cases and deaths from H5N1 infection given at the beginning of this
section. Of these, 28 cases − including 14 deaths − were reported in the first months
of 2007, most of them in Egypt (20 cases, including four deaths) and Indonesia (six
cases, including five deaths). The outbreaks in poultry continued, as did sporadic cases
in humans, but a pandemic virus failed to emerge. Belief began to grow that the threat
of a pandemic had been exaggerated. WHO was no longer consistently receiving the
information it needed to assess the level of risk and advise the world accordingly.
Nevertheless, the threat of a pandemic persists.
Many lessons have been learned from the global response to the pandemic alert.
First, the response of countries affected by the virus demonstrated a sense of responsibility and accountability to the international community. This was undoubtedly born
of an understanding that, should a country’s mismanagement of an outbreak result in
the emergence of a pandemic virus, every country in the world would suffer.
Second, the inability of affected countries to sustain an emergency response system
over months, if not years, has emerged as an important obstacle to adequate monitoring
and assessment of risk. Two assumptions were made at the start of the outbreaks
in humans and poultry for the purpose of public health planning: that a pandemic
was likely to start quickly and that drastic control measures in poultry would reduce
that risk. While not unfounded, both assumptions proved false. Almost no affected
country was in a position to sustain the response, initially so intensive, to a protracted
emergency. Many other countries introduced appropriate emergency measures at the
outset, but could not sustain them. In many cases, countries with limited resources
were simply exhausted by the continuing demands of tackling such a tenacious virus
in birds and such a treacherous one for humans. Nonetheless, the need for monitoring
and assessment remains. International cooperation in identifying all human cases
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and sharing the viruses that cause them is important in building a complete picture of
the epidemiological situation and maintaining the sensitivity of the warning system.
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.
In May 2006, the World Health Assembly adopted a resolution calling for immediate
voluntary compliance with provisions in IHR (2005) relevant to avian influenza and the
related threat of a pandemic (2). Though the Regulations would not come into legal
force until June 2007, this move to accelerate partial implementation was both a
measure of the level of concern about the pandemic threat and, equally importantly,
an indication of the level of confidence in the difference that the revised Regulations
would make.
Many activities in risk reduction and preparedness have been started since the
early implementation of IHR (2005). It is clear that the most important risk reduction
measure is the control of the panzootic – the equivalent of a pandemic in animals – of
H5N1 in chickens because, as long as the virus is present in chicken populations, the
threat of a pandemic exists. By controlling the pandemic in poultry, the number of
sporadic human infections can also be reduced.
The world remains poorly prepared, however, should control measures in poultry
not be effective in risk reduction. In that case, and if the H5N1 or another avian influenza virus − currently, there are 16 known H subtypes and five N subtypes − should
Box 4.1 WHO meeting concludes that global stockpiles of H5N1 vaccine are feasible
In April 2007, a WHO meeting on Options for Increasing
the Access of Developing Countries to H5N1 and other
Potential Pandemic Vaccines brought together country
representatives and vaccine manufacturers. All agreed
that creating a stockpile of H5N1 vaccine, and separately
developing a mechanism to ensure broader access to pandemic influenza vaccine for developing countries in the
event of a pandemic, may be feasible.
“We have taken another crucial step forward in ensuring that all countries have access to the benefits of
international influenza virus sharing and pandemic vaccine production,” said Dr Margaret Chan, Director-General
of WHO. “All countries will now be better placed to protect
the public health security of their people and the world
at large. Such cooperation is welcome and is consistent
with the International Health Regulations, which soon
come into force.”
Representatives of countries that have experienced
human H5N1 infections, donor countries, and vaccine
manufacturers from industrialized and developing countries agreed that both scientific evidence and international
political commitment supported further efforts to examine
whether and how to establish a stockpile of H5N1 vaccine
and a mechanism for broader access to a vaccine when
the next influenza pandemic occurs.
Participants heard that the Strategic Advisory Group
of Experts on Immunization (SAGE) had concluded that
recent scientific studies on H5 vaccines had shown
them to be safe and immunogenic, and that it was realistic to expect that vaccines offering cross protection
(against immunologically related but different viruses
not contained in the vaccine) could be developed.
The meeting also heard of the willingness of vaccine
manufacturers in developed and developing countries
to work with WHO to pursue the possibility of an H5N1
vaccine stockpile and a mechanism for broader access
to pandemic vaccines. The International Federation
of Pharmaceutical Manufacturers and Associations
(IFPMA), representing research-based pharmaceutical
companies, forecast increased manufacturing capacity
for seasonal influenza vaccines in the next three to five
years, to meet potential growing demand.
As a result of the meeting, WHO will set up expert
groups to focus on the details of how to create, maintain, fund and use an H5N1 vaccine stockpile, and will
continue to consult with appropriate partners and
Member States on the development of mechanisms for
broader access to pandemic vaccine.
Participants agreed that the work on virus sharing,
H5N1 vaccine stockpiles, access to pandemic vaccines
and other means of strengthening pandemic preparedness must all be based on IHR (2005).
learning lessons, thinking ahead
mutate into a pandemic form, and an early focus of human-to-human transmission be
detected before widespread infection occurs, an attempt would be made to contain a
pandemic using an antiviral drug. WHO, the Association of South-East Asian Nations
(ASEAN) and the United States, among others, have created international stockpiles of
oseltamivir, the antiviral drug that potentially could stop transmission in an early focus
of human-to-human transmission. WHO has conducted regional workshops to develop
preparedness for early containment should it be feasible to intervene, understanding
that these measures might not prove effective in stopping or even in slowing the initial
spread of a pandemic.
The strategic action proposed by WHO is linked to the six phases of pandemic alert.
Currently, the world is at phase three: denoting very limited or no human-to-human
transmission. Changes from one phase to another are triggered by several factors,
which include the epidemiological behaviour of the disease and the characteristics of
circulating viruses. A change from phase three to phase four would result in the rapid
containment measures described above.
A shortfall in influenza vaccine production capacity is another reason for the
world’s inadequate preparedness in case of a pandemic. The current maximum annual
production capacity of trivalent seasonal influenza vaccines is 500 million doses, which
currently satisfies demand. A greater production capacity would be needed should a
pandemic vaccine be required. Consequently, WHO has developed the Global Action
Plan for Pandemic Influenza Vaccines to increase the world’s production capacity,
which would then be available if a pandemic vaccine were required against H5N1 or
other avian influenza viruses.
Presently, vaccine manufacturers are producing H5N1 vaccines based on strains
of H5N1 that have been selected by WHO. The Global Influenza Surveillance Network
described earlier permits selection of those H5N1 viruses because of the free-sharing
of these viruses and other avian influenza viruses that infect humans, in addition to
the sharing of seasonal influenza viruses.
The free-sharing of H5N1 influenza viruses permits genetic characterization in order
to determine the strain of each H5N1 virus and its prevalence in humans; development of non-commercial diagnostic tests for use in public health laboratories around
the world in order to assure diagnosis of H5N1 infection; and provision of the most
important viruses to vaccine manufacturers and regulatory agencies for the development of H5N1 vaccines.
Furthermore, the free-sharing of H5N1 viruses is critical in risk assessment and
risk management under IHR (2005) because, without it, effective global preparedness
and global public health security are compromised. Once again, the importance of
collaboration in an interconnected world is clearly demonstrated.
Evidence is being collected to determine whether H5N1 vaccines currently under
development provide widespread immunity against the three different families of H5N1
virus that currently infect humans, all of them mutations from the original H5N1 virus.
This and other scientific evidence are being analysed by WHO to determine, first,
whether H5N1 vaccines could be used as preventive vaccines in the same way as
current seasonal vaccines; second, whether these types of vaccines would have any
value in preventing infection or severe illness should a human pandemic virus develop
from H5N1; and third, whether these vaccines should be used, along with antiviral
drugs, in an attempt to contain an early focus of human-to-human transmission
(see Box 4.1).
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WHO’s strategic action plan for pandemic influenza
In order to assist countries to prepare for an impending pandemic influenza, WHO
developed a strategic action plan for pandemic influenza and works with countries to
assess preparedness and response needs. It clearly sets 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.
By 1 May 2007, nearly all countries had established an avian and human pandemic
preparedness plan based on the major areas under the WHO plan. This is an impressive and encouraging response. Moreover, WHO has undertaken over 50 missions to
support countries experiencing outbreaks of human cases of avian influenza and to
assist in laboratory testing and specimen collection, epidemiological investigations,
surveillance and risk assessment, social mobilization and outbreak communications,
clinical care and infection control, and logistics.
Multi-agency coordination and action within the United Nations system are key
elements in supporting countries. The fact that over 70% of new and emerging diseases
originate in animals requires a deeper level of cooperation between animal and human
health sectors at national and international levels. With the aim of strengthening the
coherence of preparedness against avian influenza and a potential human influenza
pandemic, the United Nations System Influenza Coordination (UNSIC) was established
in 2005. UNSIC’s primary responsibility is to respond to government requests for
coordinated and sustained international support to implement avian and human influenza programmes, with emphasis placed on the synergy of the contributions made
by individual United Nations agencies (3).
EXTENSIVELY DRUG-RESISTANT TUBERCULOSIS
Emergence of XDR-TB is a good example of the need for strong health systems to
improve public health security, because it is essentially a man-made problem. It is
created primarily by inadequate health systems and the resulting failures in programme
management, especially poor supervision of health staff and of patients’ treatment
regimens, disruptions in drug supplies, and poor clinical management, all of which
can prevent patients completing courses of treatment.
From January 2005 to March 2006, 221 cases of multidrug-resistant tuberculosis
(MDR-TB) were identified at the district hospital in Tugela Ferry, KwaZulu-Natal
Province, South Africa. As many as 44 out of 53 patients who were further diagnosed
with XDR-TB were also found to be HIV positive. Half of these patients had never
previously received treatment for tuberculosis. The mortality rate was extremely high
− 52 of the patients died within a median of 16 days of initial sputum collection, of
whom two were health workers and 15 were receiving antiretroviral therapy for HIV
treatment (4).
Widespread infection with HIV provides fertile ground for the transmission of all
forms of tuberculosis. The concentration of HIV-infected people in hospitals and, in
particular, in antiretroviral treatment programmes, without sufficient measures to
control transmission of airborne infections, is enhancing the risk of catching both drugsusceptible and drug-resistant forms of tuberculosis. Health-care workers’ reluctance
to disclose their positive HIV status to their supervisors may also be putting their own
learning lessons, thinking ahead
lives at increased risk. In the presence of HIV, untreated tuberculosis will cause death
in weeks. The resistant form, even if treated with first-line drugs can, in effect, be
considered to be untreated. This was the cause of the extremely high mortality in the
cases in KwaZulu-Natal Province.
Beyond the immediate consequences to the affected individuals, the global public health concern is that XDR-TB is as transmissible as its treatable counterparts.
Although more study is needed, early research supports these suspicions. In any case,
it is of paramount importance that all tuberculosis infections are identified and treated
promptly, and that patients complete medication regimens. As of 1 May 2007, XDR–TB
has been confirmed in 37 countries, including all G8 member countries.
The management of lesser forms of drug resistance is crucial. If so-called secondline drugs used for treating resistant tuberculosis are not properly supervised, the
development of XDR-TB from MDR-TB is only a matter of time. Teams specifically
trained in the management of drug resistance and working in dedicated hospitals or
isolation units within larger hospitals are essential, as are sufficient beds and a regular
supply of high quality second-line drugs.
The neglect of tuberculosis as a major contributor to morbidity and mortality is
probably one cause of this category of threats to public health security. Other causes
include the global and national policy environments, the quality (or lack of quality) of
national tuberculosis control programmes (especially in case management and the
implementation of infection control measures) and the prevalence of HIV infection.
None of these conditions is confined to South Africa. Nevertheless, XDR-TB in
South Africa 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. Preparedness
to respond to XDR-TB includes the provision of laboratories capable of carrying out
drug susceptibility testing, which requires the training of clinical and laboratory staff to
ensure early diagnosis and a secure supply of high quality second-line drugs. Surveys
to determine the geographical spread of MDR-TB and XDR-TB are essential and have
the added advantage of providing governments and the media with information on
where to issue appropriate messages to the public as well as health-care staff to
support correct management, rather than inappropriate enforcement of quarantine
and isolation.
The XDR-TB episode is symptomatic of a wider problem affecting many countries,
namely, that multiple threats to public health security often have to be dealt with
simultaneously. In this case, the tuberculosis crisis is compounded not just by the
weakness of control programmes. There is the additional risk of coinfection with HIV,
among both patients and health workers who may be in close contact in hospitals
and clinics, which are in turn beset by shortages of clinical and laboratory staff and
equipment. These deficits are themselves a problem common to many countries and
reflect the multiple weaknesses of health systems, particularly in developing countries.
In such circumstances, local issues of health security rapidly become national, regional
and international. At the international level, the need to attack multi-drug resistance
with vigour and urgency was recognized in the Global Plan to Stop TB 2006-2015, but
these most recent events have made those working in the field of tuberculosis move
to accelerate their global response to drug resistance, particularly in Africa.
As the XDR-TB epidemic continues, an additional mechanism – IHR (2005) – will
play an increasingly important role through assessment of its importance as a public
health emergency of international concern and a potential collective response.
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MANAGING THE RISKS AND CONSEQUENCES OF
THE INTERNATIONAL SPREAD OF POLIO
Polio is one of the four internationally notifiable diseases specifically listed in IHR
(2005). The 2003-2006 international spread of poliovirus was a wake-up call to a
world expecting to bid farewell to polio. While inadequate control (as described in
Chapter 2) played a catalytic role in that outbreak, the application of IHR (2005) to a
similar situation in the future might greatly facilitate a timely response and substantially
reduce the public health consequences.
For the purpose of polio eradication, an extensive infrastructure has been established to enable weekly surveillance and performance monitoring in every country of
the world, immediate notification of confirmed polio cases, and ongoing standardized
clinical and virologic investigation of potential cases. This infrastructure consists of
human resources, standards, operating procedures and physical assets. Formal surveillance reports are now filed weekly from 180 countries, 66% of which have integrated
routine reporting of other vaccine-preventable and epidemic-prone diseases. Of the
145 institutions housing laboratories that are part of the polio network, over 85%
Figure 4.3 Poliovirus importations, 2003–2006*
Endemic countries
Case/outbreak after importation
* All cases in Niger from 2005 onward are importation related.
learning lessons, thinking ahead
perform analyses for other diseases, such as influenza, measles, meningitis, rubella,
and yellow fever.
Given progress towards the goal of global polio eradication and the risk of polio
reintroduction or re-emergence in a post-eradication world, long-term surveillance
for polioviruses takes on a new importance. The designation of polio in IHR (2005) will
further help to prevent, control and interrupt the international spread of the disease in
the event of an outbreak during and after eradication. As IHR (2005) comes into force,
countries will be assessing their capacity to identify, verify and control circulating
wild polioviruses.
The poliovirus has repeatedly shown its ability to travel great distances and enter
polio-free areas by land, sea or air travel (see Figure 4.3). In order to minimize the risk
and consequences of potential future importations, countries are protecting themselves
by maintaining high population immunity and surveillance. The alert and reporting
mechanisms mandated by IHR (2005) are an essential complement to these routine
immunization activities, particularly for a disease that can circulate without causing
symptoms for weeks and has lifelong consequences. This capacity to remain alert and
to respond is fundamental to our ability to eradicate polio. It will become doubly so once
the virus is eradicated in nature and the world has to guard against the accidental or
deliberate release of the virus from facilities where it is being used for research and
diagnostics or for the production and quality-control of vaccines.
Looking ahead, it is clear that acute threats to global health security, such as those
witnessed in the last years of the 20th century and the first years of this century,
will continue to occur, recur or emerge as the world becomes more complex and
interconnected and as the microbial world evolves and adapts its virulence, modes of
transmission and resistance to drugs in line with its changing environment.
A safer world, therefore, needs a global system based on strong national public
health infrastructure and capacity, preparedness and risk reduction for specific health
threats, and an effective international system for coordinated alert and response.
Much progress has been made but this cannot be reproduced or sustained without
major investments in national, regional and global public health infrastructure.
REFERENCES
1. FluNet: global influenza programme. Geneva, World Health Organization, 2003 (http://
gamapserver.who.int/GlobalAtlas/home.asp, accessed 1 May 2007).
2. World Health Assembly agrees to immediate voluntary implementation of influenza-related provisions of International Health Regulations (2005). Geneva, World Health Organization, 2006
(http://www.who.int/mediacentre/news/releases/2006/wha02/en/index.html, accessed 30
April 2007).
3. Enhancing capacity building in global public health. Note by the Secretary-General. New York,
NY, United Nations, September 2006 (61st Session of the General Assembly).
4. Gandi NR, Moll A, Sturm AW, Pawinski R, Govender T, Lalloo U et al. Extensively drug-resistant
tuberculosis as a cause of death in patients co-infected with tuberculosis and HIV in a rural
area of South Africa. Lancet, 2006, 368:1575–1580.
55
TOWARDS
A SAFER
FUTURE
57
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. With rare exceptions, threats
to public health are generally known and manageable.
The world has, after all, accumulated the knowledge and experience of centuries of confronting
such dangers. The evolution of measures such as quarantine, sanitation and immunization, outlined
in Chapter 1, the rapid scientific and technological advances of the late 20th century, and flourishing
international partnerships in health that use the latest communications have
together led to a much better understanding of important public health events
in today’s globalized world.
Chapter 2 gave examples of the tragic and costly consequences of inadequate
health system investment, surveillance and control, as in the case of AIDS,
dengue and other infectious diseases; and Chapter 4 provided a further example
in the case of extensively drug-resistant tuberculosis. Strengthening health
systems is a continuous priority for WHO. As discussed at length in The World
Health Report 2006 – Working together for health, many national health systems today are weak, unresponsive, inequitable and even unsafe. The 2006
report identified 57 countries where shortages are so dire that they are very
unlikely in the near future to be able to provide high coverage of essential
interventions. These shortages are equivalent to a global deficit of 2.4 million
doctors, nurses and midwives.
These 57 countries, most of them in sub-Saharan Africa and South-East
Asia, are struggling to provide even basic health security to their populations.
How, then, can they be expected to become a part of an unbroken line of
defence, employing the most up-to-date technologies, upon which global public
health security depends?
Such a defence is reliant on strong national public health systems that are well-equipped – both with
appropriate technology and talented and dedicated personnel – to detect, investigate, communicate
and contain events that threaten public health security whenever and wherever they occur.
Clearly, the strengthening of weaker health systems is essential not only to assure the best possible
public health of national populations, but also to assure global public health security. These national
and international priorities are welded together by IHR (2005), which call for national core capacity
strengthening and collective global action for public health emergencies of international concern – those
events that endanger global public health.
chapter
5
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HELPING COUNTRIES HELPS THE WORLD
The examples of avian influenza, extensively drug-resistant tuberculosis and poliomyelitis, given in Chapter 4, represent current threats to national and international public
health security – each event should prompt the relevant country to apply the decision
instrument of IHR (2005) (see Figure 5.1).
If an event falls within the requirements of the decision instrument,
and is confirmed to be a public health emergency of international concern,
the country is obliged to report it to WHO. In turn, WHO and its partners
will respond as necessary with support to contain the threat at its source.
This is, of course, how the Regulations best serve the interests of global
public health security in an ideal world. In reality, not all countries have the
resources to fully meet the core capacity requirements of the Regulations
immediately, or even by the 2012 deadline. They are, therefore, poorly
equipped to detect, identify and respond to events, compromising global
public health security.
This limitation poses significant challenges to all countries, WHO
and its partners in global public health security. The following section
explores these challenges and presents strategies to overcome them.
Seven strategic actions are set out in Table 5.1 to assist countries with
the challenges inherent in meeting the new obligations.
Global partnerships
The success of IHR (2005) depends to a large extent upon strong international partnerships. In many areas, such as in the area of infectious
disease and chemical dangers, these partnerships already exist. In others
they need to be built. Partnerships between, for example, ministries of
health and WHO, are well established and will more easily fall in step with the requirements of IHR (2005).
Less traditional partnerships, such as those between health, travel and defence, will
require concerted efforts at the national level to ensure the interests of all parties are
transparent and well represented. The IHR (2005) are intended to minimize impact on
travel and trade, yet there may be times when difficult decisions will have to be made
that will affect these sectors. Strong partnerships, a full understanding of IHR (2005),
and the urgent need to halt the international spread of disease in the best interests of
economies as well as public health will facilitate such decisions.
Part of the challenge when creating and maintaining effective partnerships is in
building trust from various perspectives: trusting individual countries to change mindsets and move from covering up disease outbreaks to adopting transparency from the
initial case or event, and trusting WHO to act on information in the world’s best interests,
while minimizing the impact on the economy of reporting countries.
WHO must, of course, earn this trust through country support during the initial
assessment and ongoing implementation phases of IHR (2005), and through open
dialogue with governments, private sector institutions, funding organizations, partner
United Nations agencies and civil society.
Trust between countries is also critical in establishing the highest level of global
health security possible. All 193 WHO Member States are parties to IHR (2005), but
not all currently have the capacity requirements to implement them fully. Technical
and financial assistance, beyond that provided by WHO, will be necessary. Bilateral
agreements will be built on the understanding that failure in one country is a threat to
all, and global benefits can only come from mutual cooperation.
59
towards a safer future
Figure 5.1 Events that may constitute a public health emergency of international
concern: the decision instrument*
Events detected by national surveillance system
A case of any of the following diseases
is unusual or unexpected and may
have serious public health impact,
and thus shall be notifieda,b:
OR
Smallpox
Poliomyelitis due to wild-type poliovirus
Human influenza caused by a new subtype
Severe acute respiratory syndrome (SARS).
Any event that is a potential
international public health concern,
including those of unknown
causes or sources and those involving
other events or diseases
than those listed in the box on the left
and the box on the right shall lead
to utilization of the algorithm.
An event involving the following
diseases shall always lead
to utilization of the algorithm,
because they have demonstrated
the ability to cause serious public
health impact and to spread
rapidity internationallyb:
OR
Cholera
Pneumonic plague
Yellow fever
Viral haemorrhagic fevers
(Ebola, Lassa and Marburg)
West Nile fever
Other diseases that are
of special national or
regional concern,
e.g. dengue fever,
Rift Valley fever,
and meningococcal disease.
Is the public health impact
of the event serious?
Yes
No
Is the event unusual or unexpected?
Yes
Is the event unusual or unexpected?
Yes
No
No
Is there a significant risk
of international spread?
Yes
Is there a significant risk
of international spread?
No
Yes
No
Is there a significant risk
of international travel or trade restrictions?
Yes
No
Not notified at this stage.
Reassess when more
information becomes available.
EVENT SHALL BE NOTIFIED TO WHO UNDER THE INTERNATIONAL HEALTH REGULATIONS
* Extracted from Annex II of IHR (2005).
a
As per WHO case definitions. b The disease list shall be used only for the purposes of these Regulations.
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Table 5.1 Seven strategic actions to guide IHR (2005) implementationa
Strategic action
Goal
GLOBAL PARTNERSHIP
1
Foster global partnerships
WHO, all countries and all relevant sectors (e.g. health, agriculture, travel,
trade, education, defence) are aware of the new rules and collaborate to
provide the best available technical support and, where needed, mobilize the
necessary resources for effective implementation of IHR (2005).
STRENGTHEN NATIONAL CAPACITY
2
Strengthen national disease
surveillance, prevention,
control and response systems
Each country assesses its national resources in disease surveillance
and response and develops national action plans to implement and meet
IHR (2005) requirements, thus permitting rapid detection and response to
the risk of international disease spread.
3
Strengthen public health
security in travel and transport
The risk of international spread of disease is minimized through effective
permanent public health measures and response capacity at designated
airports, ports and ground crossings in all countries.
PREVENT AND RESPOND TO INTERNATIONAL PUBLIC HEALTH
EMERGENCIES
4
Strengthen WHO global alert
and response systems
Timely and effective coordinated response to international public health
risks and public health emergencies of international concern.
5
Strengthen the management of
specific risks
Systematic international and national management of the risks known to
threaten international health security, such as influenza, meningitis, yellow
fever, SARS, poliomyelitis, food contamination, chemical and radioactive
substances.
LEGAL ISSUES AND MONITORING
a
6
Sustain rights, obligations and
procedures
New legal mechanisms as set out in the Regulations are fully developed and
upheld; all professionals involved in implementing IHR (2005) have a clear
understanding of, and sustain, the new rights, obligations and procedures
laid out in the Regulations.
7
Conduct studies and monitor
progress
Indicators are identified and collected regularly to monitor and evaluate
IHR (2005) implementation at national and international levels. WHO
Secretariat reports on progress to the World Health Assembly. Specific
studies are proposed to facilitate and improve implementation of the
Regulations.
Strategic actions 2–5 are key because they call for significantly strengthened national and global efforts.
towards a safer future
Strengthening national capacity
National, intermediary and local public health systems are charged with providing the
core capacities needed to detect, assess, report and deploy rapid control measures
to public health events of international concern. In line with the Regulations, Member
States must complete an initial assessment of their capacity to meet these requirements by the June 2009 deadline, and, if found insufficient, develop a national plan to
build the necessary capacity within the following three years. Several countries began
capacity building and implementation of the Regulations before they entered into force
(see Box 5.1). For many more countries, financial and human resources constraints will
hamper their ability to meet the deadline. WHO has a critical role to play in assisting
countries to build capacity and estimates that it will have to support 115 countries
to develop national plans of action or strategy papers to meet the Regulations’ core
capacity requirements (1).
Box 5.1 IHR (2005) – early implementation efforts
Global Partnerships
The Andean Health Organization (Organismo Andino de
Salud), an institution of the Andean Integration System,
coordinates and supports the efforts made by its member countries, both individually and jointly, to improve the
health of their people.
During the March 2007 meeting of the Ministries of
Health, it was decided to merge all the existing surveillance
networks in South America and to create a regional network
for surveillance and response in order to harmonize the
instruments and processes in the member states (2).
Several countries have also set up Emergency Operation Centers (EOC) that will enable them to physically as
well as virtually centralize the epidemic intelligence and
the coordination of the response to a real or a potential
emergency. The EOC will have the responsibility to obtain,
organize, analyse, prioritize, monitor and disseminate
information about health emergencies.
A number of countries – Argentina, Brazil, Canada,
Mexico, Peru and the United States – have already set
up EOCs and will support, in collaboration with the WHO
Regional Office for the Americas, other countries in the
region to establish additional centres. In conjunction with
the National IHR Focal Points, EOCs will constitute a powerful infrastructure for alert and response to public health
emergencies.
National capacity building
In anticipation of the coming into force of IHR (2005), the
Kingdom of Morocco has begun activities to strengthen
the competencies of health professionals involved in the
application of the Regulations and is progressively putting in place the necessary tools and means to strengthen
the core capacity requirements for surveillance and
response.
Ongoing workshops and technical training for airport and port health officers were initiated in 2007.
Areas covered include a review of the information
system of airport and port health authorities; the adaptation of existing health documents to the new models
set out in IHR (2005); and comprehensive strengthening
of public health capacities at designated international
points of entry.
In a commitment to cross-sector collaboration and
representation, Morocco has also established an interministerial committee for the implementation of the
Regulations. The first meeting of this group symbolically coincided with the launch of IHR (2005) on 15 June
2007.
Legal issues
Canada’s direct experience with SARS prompted the
government to update its Quarantine Act in 2004. At the
time, the Act contained elements that could be traced
back to 1872, when Canada was a new nation and the
primary mode of travel was by sea. It was, therefore, in
dire need of modernization. A new Quarantine Act was
passed by the Parliament of Canada in May 2005 and
came into force on 12 December 2006, seven months
prior to the implementation of IHR (2005).
The revision of the new Quarantine Act ran in parallel with the development of the revised Regulations,
with their respective adoptions in May and June 2005.
Although the simultaneous development provided the
opportunity for insights, there are some IHR (2005)
obligations, primarily concerning points of entry, which
were not reflected in the new Quarantine Act. The
government is currently reviewing those gaps and will
be proposing amendments to meet the core capacity
requirements of the Regulations.
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National plans will vary from country to country, but will contain components such
as building or strengthening national public health institutes; ensuring that national
surveillance and response systems use internationally recognized quality standards;
strengthening human resources capacity through training programmes in intervention
epidemiology, outbreak investigation, laboratory diagnostics, case management, infection control, social mobilization and risk communication; and using WHO indicators
to carry out regular assessments of core capacities to monitor progress and assess
future needs. In this regard, WHO expects the number of countries participating in
training programmes related to IHR (2005) core capacities to increase from 100 in
2008 to 150 in 2009 (1).
The control of diseases at border crossings – whether land, sea or air – is an
essential element of the Regulations. Many of the requirements for protecting public
health apply to these locations and are new or different from the previous Regulations. They will require close collaboration between WHO and other organizations of
the United Nations system (e.g. the International Civil Aviation Organization (ICAO),
the International Maritime Organization (IMO) and the World Tourism Organization
(UNWTO)) and professional associations (e.g. the International Air Transport Association
(IATA) and the Airports Council International (ACI)). Contingency plans for public health
emergencies and the capacity to implement them must be available at all designated
points of entry in all countries.
Some countries will find it more difficult than others to confront threats to public
health security effectively. This may be because they lack the necessary resources
and technical capacity, 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.
In addition to a strengthened alert and response capacity component, the Regulations also legally bind WHO to support countries in building their capacity to meet
their obligations under IHR (2005). Work includes facilitating national and international
resource mobilization and advocacy. These activities are especially crucial for the
countries that have the weakest health systems. Health crises of epidemics, natural
disasters and conflict are often unexpected and can quickly overwhelm national health
systems, especially those already in a precarious state.
During public health emergencies, local communities are the first to respond,
followed by district and national governments. Many societies do not have the resources
to be adequately prepared at all times, and countries do not always have the resources
to manage a major emergency or outbreak without external assistance. Qualified,
experienced, and well-prepared international health personnel are often needed to
help. Cooperation between countries is necessary to ensure the safety net provided
for in IHR (2005), as described in Chapter 1. The quality of response, ultimately,
depends upon workforce preparedness based on local capacity backed by timely
international support.
Well-prepared health systems can effectively contribute to preventing health events
from becoming security emergencies. Many newly emerging security scenarios, such
as deliberate releases of chemical, biological or radionuclear substances and potential
terrorist attacks, are intended to jeopardize the health and security of communities,
with health services being the first entry point for possible victims. In the first instance,
such health emergencies might not immediately be recognized as a security event,
towards a safer future
particularly if health systems are inadequately prepared for – or unaware of – such
potential scenarios. It is crucial to promote further collaboration and a continuous
dialogue between health professionals, security officials and policy-makers to increase
mutual understanding of respective systems and operational procedures.
Preventing and responding to international
public health emergencies
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, and may necessitate effective coordination at the international level.
This is the basis for the revised Regulations. As not all countries are able to take
up the challenge immediately, WHO is drawing 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, (e.g. GOARN, ChemiNet, the
polio surveillance network) are effective international partnerships that provide both a
service and a safety net. GOARN, for example, 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 (see Figure 5.2). 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.
Figure 5.2 Verified events of potential international public health concern,
by WHO region, September 2003–September 2006
350
300
288
Numbers
250
200
150
108
100
89
81
78
41
50
0
Africa
Western
Pacific
Eastern
Mediterranean
South-East
Asia
WHO regions
Total number of cases = 685
Europe
Americas
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WHO emergency response teams deploy to
even the most remote regions within 24 hours
Simultaneous with the need to prepare for urgent response is the need to prevent
and contain the diseases and other incidents that could cause a public health crisis
warranting international response. As mentioned previously, medical personnel working
on prevention programmes, such as polio immunization campaigns, are often the first
point of entry into the public health system and can detect the earliest suspicious cases
of disease, food safety outbreak, chemical exposure or other threatening situation. For
the obvious benefit of prevention, particularly of those diseases that either automatically
require notification under IHR (2005) – such as polio due to wild-type poliovirus, or
SARS – or those that always require the use of the decision instrument (e.g. cholera,
pneumonic plague or yellow fever) it is important to maintain and strengthen WHO’s
international disease control programmes.
Legal issues and monitoring
It is not only public health professionals working in clinics and laboratories who must
understand the new requirements under IHR (2005). Policy-makers and national public
health officials must appreciate the new legal requirements agreed to by all parties
and, if necessary, take action to bring national policies in line with them. Canada, for
example, revised its Quarantine Act in parallel with the development of IHR (2005)
(see Box 5.1).
towards a safer future
While the Regulations are not unknown to countries, the shift in conceptual framework – from control at borders to containment at the source; from a list of diseases to
all public health threats; from preset measures to an adapted response – will require
a shift in understanding that will take time to assimilate.
In order to ensure that understanding grows in line with the technical aspects of
implementation, WHO is developing specialized training programmes for legal and
public health professionals and is assisting countries to adapt or develop existing or
new public health legislation to comply with the Regulations.
The only way to ensure understanding of and compliance with the revised IHR (2005)
is to actively monitor the progress of implementation efforts at the national, regional
and global levels. Feedback, particularly during the initial phases, will provide insight
into areas for improvement in training, implementation and adherence strategies. It
should also serve to build donors’ confidence in the capacity of WHO and recipient
countries to execute the core capacities of IHR (2005) with rigour and efficiency.
WHO is charged with making regular assessment reports to the World Health
Assembly that will include quantitative and qualitative measures of progress and difficulties encountered in implementation at all levels, including national public health
systems and legal procedures and processes, as well as proposals for research areas,
recommendations to improve implementation and ongoing resource requirements.
REFERENCES
1. Medium-term strategic plan 2008–2013 and proposed programme budget 2008–2009.
Geneva, World Health Organization, 2007.
2. Resolución XXVIII/428: Resoluciones de la XXVIII Reunión Ordinaria de Ministros de Salud del
Area Andina, Santa Cruz de la Sierra, Bolivia, 29 y 30 Marzo del 2007 [Resolution XXVIII/428:
Resolutions of the XXVIII Ordinary Meeting of Ministers of Health of the Andean Region, Santa
Cruz de la Sierra, Bolivia, 29–30 March 2007]. Lima, Organismo Andino de Salud, 2007.
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CONCLUSIONS &
RECOMMENDATIONS
It cannot be over-emphasized that a truly effective international
preparedness and response coordination mechanism cannot be
managed nationally. Global cooperation, collaboration and investment are necessary to ensure a safer future. This means a multisectoral approach to managing the problem of global disease
that includes governments, industry, public and private financiers,
academia, international organizations and civil society, all of whom
have responsibilities for building global public health security.
In achieving the highest level of global public health security possible, it is important that
each sector recognizes its global responsibility. The IHR (2005) mandate core capacities
for countries and obligations for WHO. They do not oblige other sectors to act in accord.
Nonetheless, the building of global public health security rests on a solid foundation of
transparent and benevolent partnerships. In the spirit of such partnership, WHO urges all
involved to acknowledge their roles and responsibilities for global public health security
through the following recommendations:
1
2
3
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.
towards a safer future
4
5
6
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.
This report has focused primarily on acute threats to health. In order to ensure
a complete spectrum of public health security, however, the discussion would
also include endemic threats to health, such as those related to maternal and
child health, chronic disease, violence and mental health, among others. These
conditions do not meet the notification criteria of IHR (2005), yet they make
up the majority of the global burden of death and disability.
Professionals and policy-makers in the fields of public health, foreign policy
and national security should maintain open dialogue on endemic diseases and
practices that pose personal health threats, including HIV/AIDS, which also have
the potential to threaten national and international health security.
Although the subject of The World Health Report 2007 has taken a global
approach to public health, WHO is not neglecting 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 towards
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.
67
index
index
A
C
AIDS and HIV infection 18
air pollution, forest fires 31–32
air travel x
Andean Health Organization, partnership network 61
Angola, Marburg haemorrhagic fever 21
animal husbandry and feed processing 24–25
anthrax
accidental release 27
economic impact 40
in letters/mail 35–37
vaccination programmes 36
antibiotics, resistance 22–23
antigenic drift 45
antiviral drugs, oseltamivir 51
arboviruses, Rift Valley fever models 26
avian influenza A/(H5N1) 46–50
global stockpiles of A/(H5N1) vaccine 50
human cases since 2003 (map) 48
relay transmission 49
vaccine production and manufacture 50, 51
Azerbaijan, avian influenza A/(H5N1) 48
Cambodia, avian influenza A/(H5N1) 48
Cameroon, Lake Nyos CO2 gas release 31
Canada, Quarantine Act (2005) 61
Chan, Margaret (Director-General, WHO), message 2007
vi–vii
Chemical Incident Alert and Response System 10
ChemiNet 10
chemical and radioactive events 27–29
chemical incidents 1974–2006 28
emergencies 10–11
harmful use of chemicals and biological agents 27
industrial accidents 29–31
toxic chemical dumping 40–43
Chernobyl, nuclear explosion xi, 29–31
China, avian influenza A/(H5N1) 46, 48
cholera 4
Democratic Republic of Congo 21–22
Peru 40
Tanzania 40
communication, non-state information xv
conclusions of Report 66–67
conflicts, consequences 21–22
Côte d’Ivoire, toxic chemical dumping 40–43
CO2 gas release, Lake Nyos, Cameroon 31
Creutzfeldt-Jacob disease (variant CJD) 24
B
bacterial evolution and disease 22–23
Bhopal, India, methyl isocyanate gas explosion 29
biological agents (and bioterrorism) 27, 35–37
bovine spongiform encephalopathy (BSE), human form 24
economic impact 40
bubonic plague 2–3
history of spread in Europe (map) 3
India, economic impact 40
and quarantine 2–3
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D
H
decisions in public health security, instrument IHR (2005)
58–65
Democratic Republic of Congo, cholera outbreak 21–22
dengue 18, 26
Djibouti, avian influenza A/(H5N1) 48
doctors/nurses, shortages in 57 countries 57
drug resistance, and malaria 23
hazardous waste, toxic chemical dumping 40–43
health workers, shortages in 57 countries 57
historical landmarks in public health 2–6
HIV infection and AIDS 18–20
and tuberculosis susceptibility 52–53
Hong Kong SAR, avian influenza A/(H5N1) 46
human causes of public health insecurity 17–25
consequences of conflicts 21–22
late reporting/response to global outbreaks 19
unexpected policy changes 20
human spongiform encephalopathy (BSE) 24
E
early warning systems 26
East Africa, Rift Valley fever 25–26
Egypt, avian influenza A/(H5N1) 48
El Niño Southern Oscillation phenomenon
forest fires 32
and Rift Valley fever 25–26
emergencies in public health 45–55
chemical and radioactive events 10–11
defined xv, 12
infectious diseases 7, 12–13, 45–55
other than infectious diseases 13
surveillance and notification, IHR (2005) 59, 63–64
verified events 2003–2006 63
encephalitis
Nipah virus 24–25
Rift Valley fever 25–26
encephalopathy, human form of BSE 24
environmental disasters xii
epidemic response 8–9
examples (map) 8
extreme environments 9
Escherichia coli 0157, USA, economic impact 39, 40
Europe
food-borne disease xi
heatwave (2003) xii
F
food processing, animal feeds 24–25
food-borne disease xi
forest fires, Indonesia 31–32
future issues in public health security 57–67
G
Global Influenza Surveillance Network 46
global network, national health systems 10
Global Outbreak Alert and Response Network (GOARN) xiv,
8–9, 37
Global Public Health Intelligence Network (GPHIN) 13
I
immunization
avian influenza A/(H5N1) 50–51
smallpox 5–6
India
Bhopal, methyl isocyanate gas explosion 29
bubonic/pneumonic plague 2–3, 40
Indonesia
avian influenza A/(H5N1) 48
forest fires 31–32
industrial accidents, chemical emergencies 10–11
infectious diseases
animal husbandry and feed processing 24–25
bacterial evolution 22–23
concealment xv, 13
control 7
economic impact 1990-2003 (map) 40
emerging and re-emerging (map) 12
global outbreaks 19
notification 12–13
public health emergencies 7, 12–13
urbanization xvi
vector-borne 18–19
weather-related events 25–26
influenza, pandemic 45–52
avian influenza A/(H5N1) 46–50
economic impact 39
FluNet Internet-based geographical system 46
influenza surveillance network (map) 46
mortality in America and Europe (1918-19) 47
strategic action plan 52
types A/B 45
United Nations System Information Coordination
(UNSIC) 52
index
International Health Regulations, IHR (2005) 8, 11–14, 57
aims/purpose ix, 11
as decision instrument 58–65
flowchart 59
international cooperation 13–14
legal issues and monitoring 60, 64–65
national capacity, early implementation 61
non-state information xv
origins 7
resource limitations (core capacity) 58
strategic actions for implementation (table) 60
strengthening national capacity 61–63
surveillance, emergencies and notification 59, 63–64
WHO Member States resource (core capacity)
limitations 58, 61
international health security code (GOARN) 8–9, 37
International Sanitary Conferences (1851–1900) 7
International Sanitary Regulations (1951) xiv, 7
investment, inadequate 18–20
Iraq
avian influenza A/(H5N1) 48
poison gas use against civilians 27
Ivory Coast, toxic chemical dumping 40–43
J
Jenner, Edward, immunization 5–6
L
Latin America
Andean Health Organization 61
cholera outbreak 4
legal issues 60, 64–65
M
mail services security, biological/chemical agents 36–37
malaria, and drug resistance 23
Marburg haemorrhagic fever 21
mass media, and risk perceptions 41
methyl isocyanate gas explosion, India (Bhopal) 29
microbial evolution and antibiotic resistance 22–23
Morocco, national capacity building for IHR (2005) 61
mosquitoes, Rift Valley fever 25–26
N
natural phenomena 31–32
new health threats 35–43
Nigeria
avian influenza A/(H5N1) 48
poliovirus, immunization suspension 20
Nipah virus 24–25
economic impact 40
nuclear power, Chernobyl explosion xi, 29–31
O
oseltamivir 51
P
penicillin resistance 23
Peru
cholera, economic impact 40
cholera outbreak 4
plague, see bubonic plague
poison gases
against civilians 27
CO2 gas release, Cameroon 31
industrial/accidental releases 28–29
terrorist use 27
warfare 27
poliovirus 54–55
designation in IHR (2005) 55
Global Polio Eradication Initiative 9
immunization, suspension xvi, 20
importations 2003–2006 54
management 54–55
surveillance 54
public health
emergencies, potential 45–55
defined 12
infectious diseases 7, 12–13, 45–55
other than infectious diseases 13
surveillance and notification, IHR (2005) 59, 63–64
verified events 2003–2006 63
inadequate investment 18–20
international cooperation 6–14
national health systems and technical partners 10
new health regulations 11–14
security 2–14
defined 1
71
world health report 2007
global public health security
72
in the 21st century
international health security code 8–9, 37
security threats 17–32
chemical and radioactive events 27–29
human causes 17–25
natural phenomena 31–32
new health threats 35–43
weather-related disease 25–26
unexpected policy changes 20
Q
quarantine 2–3
legislation 61, 64
T
Tanzania, cholera 40
Thailand, avian influenza A/(H5N1) 48
tuberculosis 52–53
drug resistance, XDR-TB and MDR-TB 52–53
and HIV infection 52–53
Turkey, avian influenza A/(H5N1) 48
U
Ukraine, Chernobyl nuclear explosion xi, 29–31
V
radioactive events 27, 29–31
recommendations of Report 66–67
Rift Valley fever 25–26
risks, perceptions, mass media 41
vaccines
influenza/avian influenza A/(H5N1) 50, 51
smallpox 5–6
variant Creutzfeldt-Jacob disease (vCJD) 24
vector-borne diseases 18–19
Viet Nam, avian influenza A/(H5N1) 47, 48
S
W
R
sanitation, and cholera 4
sarin gas 27
SARS (severe acute respiratory syndrome) 37–40
economic impact 38–39
international cooperation 13–14
surveillance 39
transmission by aircraft passengers 38
sexual behaviour 19–20
smallpox 5–6, 37
bioterrorism 37
eradication certified 6
immunization 5
Snow, John, water pollution theories 4
South Africa, HIV infection and tuberculosis susceptibility
52–53
Soviet Union (former), accidental release of anthrax 27
Staphylococcus aureus, penicillin resistance 23
Strategic Advisory Group of Experts on Immunization
(SAGE) 50
surveillance 18
early warning systems 26
events detected by national systems 59
pandemic influenza 46
polio 54
SARS 39
warfare
consequences of conflicts 21–22
poison gas 27
water, safe provision 4
weather-related events and disease 25–26
Rift Valley fever 25–26
Y
yellow fever x