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se r yEvolution ofpublic hEalth

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chapter 1 begins by tra ing some o the frst steps, histori ally, that led to the

ntroduct on of t e internat onal healt Regulat ons (1969) – landmarks

e s r g w q r e, a term coined in the 14th century and

employed as a protection against “ oreign” diseases such as plague; improvements insanitation that were e ective in controlling cholera outbreaks in the 19th century; and the advent ovaccination, which led to the eradication o smallpox and the control o many other in ectious diseasesin the 20th century. Understanding the history o international health cooperation – its successes andits ailures – is essential in appreciating its new relevance and potential.

Throughout history, humanity has been challenged by outbreaks o in ectious diseases and otherhealth emergencies that have spread, caused death on unprecedented levels and threatened publichealth security (see Box 1.1). With no better solution, people’s response was to remove the sick romthe healthy population and wait until the epidemic ran its course.

With time, scienti c knowledge evolved, contain-ment measures became more sophisticated and somein ectious disease outbreaks were gradually broughtunder control with improved sanitation and the dis-covery o vaccines. However, microbial organisms arewell-equipped to invade new territories, adapt to newecological niches or hosts, change their virulence ormodes o transmission, and develop resistance todrugs. An organism that can replicate itsel a mil-lion times within a day clearly has an evolutionary

advantage, with chance andsurprise on its side. There ore,no matter how experienced orre ned containment measuresbecame over the years, therewas always the possibility oanother outbreak causing anepidemic anytime, anywhere.The reality is that the battle tokeep up with microbial evolution and adaptation will never be won.

The delicate balance between humans and microbes has been conditionedover generations o contact, exposure to immune systems and human behaviour.Today, it has shi ted so that the equilibrium is driven by changes in human demo-graphics and behaviour, economic development and land use, international traveland commerce, changing climate and ecosystems, poverty, confict, amine andthe deliberate release o in ectious or chemical agents. This has heightened therisk o disease outbreaks.

Box 1.1 Public health securityPublic health security is defned as the activities required,both proactive and reactive, to minimize vulnerability toacute public health events that endanger the collectivehealth o national populations.

Global public health security widens this de nition toinclude acute public health events that endanger the col-lective health o populations living across geographicalregions and international boundaries. As illustrated in thisreport, global health security, or lack o it, may also have

an impact on economic or political stability, trade, tourism,access to goods and services and, i they occur repeatedly,on demographic stability. Global public health securityembraces a wide range o complex and daunting issues,

rom the international stage to the individual household,including the health consequences o human behaviour,weather-related events and in ectious diseases, and natu-ral catastrophes and man-made disasters, all o which arediscussed in this report.

1er

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It is estimated that 2.1 billion airline passengers travelled in 2006 (1). This meansthat diseases now have the potential to spread geographically much aster than at anytime in history. An outbreak or epidemic in one part o the world is only a ew hoursaway rom becoming an imminent threat elsewhere.

In ectious diseases can not only spread aster, they appear to be emerging more

quickly than ever be ore. Since the 1970s, new diseases have been identi ed at theunprecedented rate o one or more per year. There are now at least 40 diseases thatwere unknown a generation ago. In addition, during the last ve years, WHO has veri edmore than 1100 epidemic events.

The lessons o history are a good starting point or this report as they exempli y thehuge challenges to health that occur repeatedly and relentlessly. Some in ectious dis-eases that have persisted or thousands o years still pose threats on a global scale.

Building on historical landmarksSince they rst walked the planet, human beings have struggled – and o ten ailed – toprotect themselves against adversaries that destroy their health, inhibit their abilityto unction and, ultimately, cause their death. It is only in relatively modern timesthat they have made lasting progress in preventing or controlling in ectious diseases,as illustrated by three important historical landmarks in public health. While theseadvances are still o great relevance today, they need to be adapted and rein orced tocon ront the challenges to come.

P e q eThe practice o separating people with disease rom the healthy population is anancient one, with both biblical and Koranic re erences to the isolation o lepers. Bythe 7th century, China had a well-established policy o detaining sailors and oreigntravellers su ering rom plague.

The term “quarantine” dates rom the late 14th century and the isolation o peoplearriving rom plague-in ected areas to the port o Ragusa, at the time under the controlo the Venetian Republic. In 1397, the period was set at 40 days (the word quarantinebeing derived rom the Italian or “ orty”). Similar actions were taken by many otherMediterranean ports soon a terwards. Such public health measures became wide-spread and international over the ollowing centuries, with committees o ten beingappointed in cities to coordinate them (2 ). Figure 1.1 shows the rapid spread o bubonicplague across Europe in the mid-14th century.

The continuing devastation regularly wrought by plague and other epidemic diseasesdemonstrated that crude quarantine measures alone were largely ine ective. In the17th century, an attempt to keep plague, which was spreading through continentalEurope, rom reaching England obliged all London-bound ships to wait at the mouth othe River Thames or at least 40 days. The attempt ailed and plague caused devastation

in England in 1665 and 1666. During the 18th century, all major towns and cities alongthe eastern seaboard o the United States passed quarantine laws, which typicallywere en orced only when epidemics seemed imminent.

In recent years, the most serious outbreak o plague occurred in ve states in India in1994, where almost 700 suspected bubonic or pneumonic plague cases and 56 deathswere reported to WHO, as required by the International Health Regulations (1969).The outbreak, which captured international media attention, resulted in catastrophic

F e 14 e y, E pe v p ev w e p e ve , be

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2 g e se r y w r d e re r 2007

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economic consequences or India when a number o countries overstepped the mea-sures set out in IHR (1969) and imposed unnecessary travel and trade restrictions. Theoutbreak 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 tradeand travel and caused a record trade de cit in 1994 (3 ). Since then, there have beenmany smaller, unrelated bubonic plague outbreaks in countries such as Algeria, theDemocratic Republic o the Congo, Malawi and Zambia.

Figure 1.1 Spread of bubonic plague in Europe

1347

Mid-1348

Early 1349

Late 1349

1350

1351

After 1351

Minor outbreak

Paris

Rouen

London

ToledoBarcelona

Marseille

Milan

FlorenceRome

Thessaloniki

Athens

Bucharest

BrugesFrankfurt

Brunswick

Lubeck

Copenhagen

Warsaw

Prague

Vienna

Ragusa

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c e As with virtually all scienti c advances, the physician John Snow’s amous work oncholera − notably during the 1854 epidemic in London − did not emerge rom a vacuumbut was based on years o care ul recording o outbreaks and heated debate as to thecauses. Snow observed o cholera in 1855, “It travels along the great tracks o human

intercourse, never going aster than people travel, and generally much more slowly. Inextending to a resh island or continent, it always appears rst at a seaport. It neverattacks the crews o ships going rom a country ree rom cholera, to one where thedisease is prevailing, till they have entered a port” (4 ).

During the London epidemic, Snow mapped the locations o homes o those whohad died and noted that, in the Broad Street area, cases were clustered around aparticular water pump. There was an underground sewer running close to the well,and people had reported the water rom the well to be oul smelling in the days be orethe outbreak. As soon as Snow persuaded the authorities to remove the pump handle,the number o cases and deaths rom cholera ell rapidly.

While the role o the pump handle removal in the decreased mortality rate has beendebated, Snow’s demonstration that cholera was associated with water was a power ul

rebuttal o “miasma” theories o transmission through poisonous vapours. His work eventually led to improvements in sanitation in the United Kingdom that reduced thethreat o cholera – though not to the same extent as endemic diarrhoeal disease romother 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 hadbeen ree o it or more than a century until, in 1991, a pandemic that had begun 30years earlier and spread throughout many countries in A rica, Asia and Europe struck with devastating human and economic consequences. Thought to have originated

rom sea ood contaminated by the bilge o ships o the coast o Peru, the diseasespread rapidly across the continent and resulted in nearly 400 000 reported cases andover 4000 deaths in 16 countries that year. By 1995, there were more than 1 millioncases and just over 10 000 deaths reported in the WHO Region o the Americas (6 ). Inaddition to human su ering and death, the outbreak provoked panic, disrupted socialand economic structures, threatened development in a ected populations, and led toextreme and unnecessary international reactions (7 ). Some neighbouring countriesimposed trade and travel restrictions on Peru, as did European Union countries, theUnited States and others. Losses rom trade embargoes, damage to tourism, andlost production attributable to cholera-related illnesses and death were estimatedto be as much as US$ 1.5 billion (8 ).

The need to provide sanitation both or drinking-water and hygiene remains ahuge challenge today in developing countries. Currently 1.1 billion people lack access to sa e water and 2.6 billion people lack access to proper sanitation. Asa result, more than 4500 children under ve years o age die every day romeasily preventable diseases such as diarrhoea. Many others, including older

children and adults, especially women, su er rom poor health, diminished productivityand missed opportunities or education.

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s p x zSmallpox is one o the oldest known human diseases. There is evidence o its existenceover 3000 years ago in Egypt: the mummi ed head o Ramses V, who died in 1157BC, shows a pustular eruption that may have been caused by smallpox. It may haveexisted in parts o Asia about the same time and appears to have been introduced

into China about the year 50 AD, to parts o Europe in the ollowing ew centuries, towestern A rica in the 10th century, and to the Americas in the 16th century duringthe Spanish conquests.

During the 18th century, smallpox killed every seventh child born in Russia andevery 10th child born in France and Sweden. Edward Jenner’s experiment in 1796brought hope that the disease could be controlled. Jenner, an English physician, real-ized that many o his patients who had been exposed to cowpox, the much milder butrelated disease, were immune to smallpox. He inoculated an eight-year-old arm boywith cowpox virus and, a ter observing the reaction, reinoculated him with smallpoxvirus. The boy did not develop the deadly disease, demonstrating that inoculation withcowpox could protect against smallpox. Jenner’s procedure was soon widely accepted,resulting in sharp alls in smallpox death rates.

At the beginning o the 20th century, smallpox was still endemic in almost everycountry in the world. In the early 1950s, an estimated 50 million cases occurred glob-ally each year with an estimated 15 million deaths, gures which ell to around 10–15million cases and 3 million deaths by 1967 as access to immunizations increased.

a E , E w Je e , e e f v p x 1796 by b y w wp x v .

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Through the success o the 10-year global eradication campaign that began in 1967,the global eradication o smallpox was certi ed in 1979 (9 ).

Since eradication was certi ed, allegations have been made that some countriesand terrorist groups may be storing smallpox virus, and its potential as a bioterroristthreat is causing major concern in many industrialized countries (10 ). Work is under

way on a new and sa er vaccine against smallpox, which would need to be produced inhuge quantities i immunization against a deliberate release were to be undertaken. Almost 30 years a ter its success ul eradication, smallpox has, there ore, become a

signi cant public health concern in terms o the deliberate release o the virus to causeharm. According to a recent WHO report, “the greatest ear is that in the absence oglobal capacity to contain an outbreak rapidly, smallpox might re-establish endemicity,undoing one o public health’s greatest achievements” (10 ).

FostEring intErnational cooPErationThe three advances described above − in quarantine, sanitation and immunization− came about separately but gradually came to be seen as requiring internationalcoordination in order to strengthen global public health security (see Box 1.1).

By the end o the 19th century, dozens o international con erences on diseasecontrol had been held, ultimately leading to the oundation o WHO in 1948 and thepromulgation o the International Sanitary Regulations in 1951 (see Box 1.2).

The reasons or such international action were clear. One hundred years ago,in ectious diseases such as cholera, plague and yellow ever − and many more such asdiarrhoeal diseases other than cholera, infuenza, malaria, pneumonias and tuberculosis− ravaged most civilizations and threatened public health security. They dominatedentire regions and at times spread in pandemics across the globe. With ew excep-tions, there was little that could be done to halt their progression, until spectacularadvances in medicine and public health during the rst hal o the 20th century yieldednew drugs and vaccines that could prevent or cure in ections. These advances helpedindustrialized countries, which had reliable access to them, to eliminate or markedlydecrease the in ectious disease threats. At the same time, improvements in hygiene andstandards o living in these more prosperous parts o the world altered the conditionsthat had allowed the diseases to fourish.

While it can be argued that the means currently exist to prevent, control or treatmost in ectious diseases, paradoxically, the continuing likelihood o pandemics isstill a huge threat to public health security, principally or two reasons. First, some othese diseases continue to thrive in developing countries where the ability to detectand respond is limited, leading to the potential or them to spread internationally atgreat speed. Second, new diseases emerging in human populations on a sporadicbasis are o ten the result o a breach in the species barrier between humans andanimals, permitting microbes that in ect animals to in ect humans as well, causingunexpected outbreaks that can also spread internationally. There ore, internationalmeasures to prevent the spread o in ectious diseases continue to remain essentialin the 21st century.


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Largely provoked by the cholera pandemic o the time,threats o plague and the ine ectiveness o quarantinemeasures, many European leaders of the mid-19th centurybegan to recognize that controlling the spread o in ec-tious diseases rom one nation to another required thatthey cooperate. International conventions were organizedand dra t covenants signed, almost all o which related toquarantine regulations ( 8 ).

From 1851 to 1900, 10 International Sanitary Con er-ences were convened, comprising a group o about 12European countries or states, and ocusing exclusively onthe containment o epidemics within their territories. Theinaugural 1851 con erence in Paris lasted six months andestablished the vital principle that health protection wasa proper subject or international consultations.

During the 1880s, a small group o South Americannations signed the frst set o international public healthagreements in the Americas. In addition to cholera andplague, o ten carried among the huge numbers o immi-grants arriving rom Europe, these agreements coveredyellow ever, which was endemic in much o the region. In1892, the frst International Sanitary Convention dealingonly with cholera was signed. Five years later, at the 10thInternational Sanitary Con erence, a similar convention

ocusing on plague was also signed. Important new poli-cies emerged, such as the obligatory telegraphic notifca-tion o frst cases o cholera and plague.

In 1902, 12 countries attended the First InternationalSanitary Convention o the American Republics in Wash-ington, DC, the United States, leading to the creation othe Pan American Sanitary Bureau (now called the PanAmerican Health Organization). Its counterpart in Europe,

the O fce International d’Hygiène Publique (OIHP), wasestablished in 1907 and based in Paris ( 11).

Apart rom its immediate toll on human lives, theFirst World War brought in its wake many epidemicsresulting rom the destruction o public health in ra-structure, rom typhus in Russia that threatened tospread to western Europe, to cholera, smallpox, dysen-tery and typhoid in the Ot toman Empire. These epidem-ics were the basis or the ormation o the League oNations Health Organisation, itsel stemming rom thenewly created League o Nations. In 1920, the HealthOrganisation set up a temporary epidemic commis-sion whose task was to help direct work in a fictedcountries.

In 1951, three years a ter its ounding, WHO adopteda revised version o the International Sanitary Regu-lations rst approved in 1892. They ocused on thecontrol o cholera, plague, smallpox, typhoid everand yellow ever. Their approach was still rootedin misunderstandings o the 19th century − thatcertain measures at border posts could alone pre-vent the spread o in ectious diseases across inter-national borders. They were succeded by IHR (1969),which required Member States to report outbreaks ocertain diseases. Recent events have demonstrated theurgent need or a revised set o regulations withbroader disease coverage, and measures to stop theirspread across borders based on real time epidemio-logical evidence rather than pre-determined measuresconcentrated at borders. The IHR (2005) respond to thisneed and have now come into orce ( 12 ).

Box 1.2 International collaboration on infectious disease control

Timeline of significant events in public health

C h i n a – p

l a g u e q u a r a n t i n e

B u b o n i c p

l a g u e e p i d e

m i c i n E u

r o p e

T h e f i r s t

r e c o r d e d

s m a l l p o x

v a c c i n a t i

o n

F i r s t I n t e

r n a t i o n a l

S a n i t a r y

C o n f e r e n

c e

C h o l e r a e

p i d e m i c

i n L o n d o n

C r e a t i o n

o f W H O

W H O E p i d

e m i o l o g i c a l I

n f o r m a t i o n

S e r v i c e

I n t e r n a t i o

n a l S a n i t a

r y R e g u l a t i

o n s

I n t e r n a t i o

n a l H e a l t h

R e g u l a t i o n s

E r a d i c a t i

o n o f s m

a l l p o x

C h o l e r a e

p i d e m i c s

i n L a t i n

A m e r i c a

S e v e r e A c u t e

R e s p i r a t

o r y S y n d r

o m e ( S A R S )

A v i a n i n f l u

e n z a

I n t e r n a t i o

n a l H e a l t h

R e g u l a t i o n s

( 2 0 0 5 ) e n t

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7 t h C e n t u

r y 1 3 4 7 1 7 9 6 1 8 5 1 1 8 6 6 1 9 4 6 1 9 4 7 1 9 5 1 1 9 6 9 1 9 7 9 1 9 9 1 2 0 0 3 2 0 0 4 2 0 0 7 2 0 0 5

W H A a d o p t s n

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H e a l t h R e

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( 2 0 0 5 )

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a ew e e e e yWays o collectively working together in the ace o emergency events o internationalhealth importance are refected in the new revised International Health Regulations(2005). The Regulations, rst 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 environmentand human behaviour, all o which posed increased threats to global public healthsecurity (these events are described in Chapter 2). An agreed code o conduct wasrequired that could not only prevent and control such threats but could also providea public health response to them while avoiding unnecessary inter erence with inter-national trade and tra c.

The basis o an e ective global system o epidemic alert and response was initiatedby WHO in 1996. It was built essentially on a concept o international partnership withmany other agencies and technical institutions. Systematic mechanisms or gatheringepidemic intelligence and veri ying the existence o outbreaks were established andprompted risk assessments, in ormation dissemination and rapid eld response. TheGlobal Outbreak Alert and Response Network (GOARN) was set up as a technical

partnership o existing institutions and networks to pool human and technical resourcesor the rapid identi cation, con rmation and response to outbreaks o international

importance. The network provides an operational and coordination ramework to accessthis expertise and skill, and to keep the international community constantly alert tothe threat o outbreaks and ready to respond.

Coordinated by WHO, the network is made up o over 140 technical partners rommore than 60 countries. These partners’ institutions and networks provide rapid inter-national multidisciplinary technical support or outbreak response. Figure 1.2 showsa sample o international epidemic response missions in the eld in 1998 and 1999.

Figure 1.2 Examples of international epidemic response missions, 1998–1999

Meningococcal

meningitisSudan 1999

Viral meningitisRomania and

Republic of Moldova1999

Cluster of infant deathsEgypt 1999

Acute respiratoryinfection

Afghanistan 1999

Nipah virusencephalitis

Malaysia 1999

Rift Valley fever/ Viral haemorrhagic fever

Kenya 1999

CholeraComoros 1999

Visceralleishmaniasis

Sudan (southern) 1999

Viral haemorrhagic fever/Acuterespiratory infectionSudan (southern) 1999

Relapsing feverSudan (southern) 1999

Viral infectionLibyan Arab Jamahiriya

1998


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Between 2000 and 2005, there were more than 70 GOARN international outbreak responses, involving over 500 experts in the eld. Regional and global mechanisms

or stockpiling and rapid distribution o vaccines, drugs and specialized investigationand protection equipment have been established or haemorrhagic evers, infuenza,meningitis, smallpox and yellow ever. A specialized logistics response unit has been

developed or epidemic response that allows WHO and its partners to be operationalin extreme environments. As part o ongoing e orts to improve operational coordination and in ormation

management, WHO is updating its event management system to support real timeoperational communications and access to critical in ormation on epidemics. TheOrganization continues to strengthen specialized surveillance networks or dangerouspathogens, including dengue, infuenza and plague.

In addition, the unique, large-scale active surveillance network developed by theGlobal Polio Eradication Initiative is being used to support surveillance o many othervaccine-preventable diseases, such as measles, meningitis, neonatal tetanus andyellow ever. This network is also regularly supporting outbreak surveillance andresponse activities or other health emergencies and outbreaks, including avian

infuenza, Ebola, Marburg haemorrhagic ever, SARS and yellow ever.With its local knowledge o communities, health systems and government struc-

tures, the polio network has the technical capacity to plan and monitor immunizationcampaigns, during which the health o cers are o ten the community’s rst point oentry into the health system or a range o diseases and conditions. The polio network is also called upon during outbreaks o meningitis and yellow ever and o ten helps tosustain international and national relie e orts, such as during the responses to theSouth-East Asia tsunami in December 2004 and the Pakistan earthquake in October2005. Once polio eradication has been completed, continued investment in this network to broaden the skills o surveillance o cers, immunization sta and laboratories,will increase capacity nationally and internationally or surveillance and response ovaccine-preventable and other outbreak-prone in ectious diseases.

At the national level, collaboration between donor and recipient countries, whichocuses on ensuring the technical and other resources to meet national core needs in

disease detection and response, is a crucial actor in building the capacity to urtherstrengthen global public health security. E ective implementation requires countriesto invest in, manage and improve the unctioning o a number o public health systemcomponents. These include epidemiological surveillance and in ormation managementsystems, public health laboratory acilities, health and preparedness planning, healthcommunication and intersectoral collaboration.

In order to ensure the maximum possible global public health securit y, countries – incollaboration with WHO and other relevant international organizations – must develop,maintain and strengthen appropriate public health and administrative capacities ingeneral, not only at international ports, airports and land crossings. This requiresclose collaboration not only between WHO o ces and Member States, but also amongMember States themselves. Such multilateral cooperation will better prepare the world

or uture public health emergencies.

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i e p ep e e e e e e eIt has long been recognized that many countries have limited capacities to detect andrespond to chemical incidents, and that such events occurring in one country couldhave an impact on others. Equally recognized has been the need to strengthen bothnational and global public health preparedness and response. World Health Assembly

resolution WHA55.16 (13 ) urges Member States to strengthen systems or surveillance,emergency preparedness and response or the release o chemical and biologicalagents and radionuclear materials in order to mitigate the potentially serious globalpublic health consequences o such releases (see Chapter 2).

In 2002, WHO established the Chemical Incident Alert and Response System tooperate along similar lines to the alert and response system or communicable diseases.In 2006, this system was extended to cover other environmental health emergencies,including those related to the disruption o environmental health services, such aswater supply and sanitation, as well as radiological events.

An integral part o the system is ChemiNet, which pools human and technicalresources or detecting, veri ying and responding to environmental health events o(potential) international public health concern. ChemiNet draws on human and technical

resources rom institutions, agencies and academia in Member States as well as rominternational organizations, as illustrated in Figure 1.3.

ChemiNet is designed to mitigate chemical incidents and outbreaks o illnesso chemical etiology that are o international public health concern by early detec-tion, assessment and veri cation o outbreaks; provision o rapid, appropriate and

e ective assistance in responseto outbreaks; and contributionto long-term preparedness andcapacity building – the sameprotocol utilized in response toany public health emergency.In accordance with IHR (2005),ChemiNet provides a source ointelligence by in orming WHO ochemical incidents or outbreakso illness o potential internationalpublic health importance.

Prevention o and preparednessor uncontrolled chemical releases

are part o a continuum o activitiesin ChemiNet that also encompassevent detection, response andrecovery. Since large-scale chemi-cal incidents, such as that in Bho-pal, India (see Chapter 2), shockedthe world, much has been learnedabout measures or preventionand preparedness concerningsuch occurrences. Even in tech-nically advanced, well-resourcedcountries, however, the risks oa large-scale chemical release

Figure 1.3 International public health security: a globalnetwork of national health systems and technicalpartners, coordinated by WHO, founded on fourmajor areas of work

Nationalcapacity

strengthening

Global alertand response

Containmentof specific

threats

Traveland

transport

WHO

Partners

NationalIHR Focal

Point

NationalIHR Focal

PointNationalIHR Focal

Point

NationalIHR Focal

Point

NationalIHR Focal

Point

NationalIHR Focal

Point

Partners

Partners

Country national network

Partners’ network


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remain, particularly with the more recent threat o deliberate chemical release. Nocountry can a ord to be complacent.

Preventive measures include good land-use planning and en orcement so thatchemical installations are not built close to places o high population density, theen orcement o high sa ety standards in chemical industries, and the monitoring o

ood, water and air quality to detect chemical contamination.Preparedness measures include ensuring that there is a well-designed andrehearsed chemical emergency plan in place that involves all stakeholders, that localhealth-care acilities are in ormed about chemical risks in their catchment area, andthat they are provided with the necessary decontamination and medical equipment.National capacity or detection o outbreaks caused by chemical releases includes theavailability o a 24-hour poisons centre. Some countries, such as the United States,have ully integrated poison centres into their public health surveillance systems.

Since chemicals released into the environment can spread beyond the immediatevicinity o the event and, in some cases, have the potential to cross national borders,there is also a need or coordination o international preparedness and response.Some international agreements already exist, such as the United Nations Economic

Commission or Europe (UNECE) Convention on the Transboundary E ects o Industrial Accidents (14 ).

The International Health Regulations (2005) and World Health Assembly resolutionWHA55.16 (13 ) provide a ramework or preparedness. Within this ramework, WHOcan conduct activities to respond immediately to events that threaten global publichealth security and can work collectively and proactively to prepare or such events.Chapter 4 shows how the ramework can be applied to the current threats o avianinfuenza, XDR-TB and natural disasters.

new e e v y e e w As outlined earlier, concern about the international spread o in ectious disease out-breaks and other events that threaten global public health security is not a modernphenomenon. In the past, attempts have o ten been made to stop these events romspreading by en orcing border controls. In the globalized world o the 21st century,although there is still collective interest in preventing the international spread o dis-eases, it is understood that borders alone cannot accomplish this. In recent decades,diseases have spread aster than ever be ore, aided by high-speed travel and the tradein goods and services between countries and continents, o ten during the incubationperiod be ore the signs and symptoms o disease are visible. The rapid spread odisease can only be prevented i there is immediate alert and response to diseaseoutbreaks and other incidents that could spark epidemics or spread globally and i thereare national systems in place or detection and response should such events occuracross international borders. GOARN and ChemiNet are examples o such systems.

The aim o the collaboration set out in IHR (1969) was to achieve maximum pro-tection against the international spread o disease with minimal disruption to tradeand travel. Based mainly on attempts to stop the spread o disease through controlmeasures at international borders, IHR (1969) o ered a legal ramework or the noti-

cation o and response to six diseases – cholera, plague, relapsing ever, smallpox,typhus and yellow ever – but su ered rom very patchy compliance among WHOMember States.

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From 1996 to 2005, Member States examined and revised IHR (1969) in order tomeet the new challenges that had arisen in the control o emerging and re-emergingin ectious diseases, including the rapid global transit o diseases and the exchange oanimals and goods that may inadvertently carry in ectious agents. Several emergingand re-emerging diseases identi ed in this period are shown in Figure 1.4. Another

challenge was the management o near instantaneous modes o communication, suchas mobile telephones and the Internet, which have the potential to cause panic inpopulations. The resulting revised Regulations – IHR (2005) (12 ) – came into orce inJune 2007. They provide a legal ramework or reporting signi cant public health risksand events that are identi ed within national boundaries and or the recommendationo context-speci c measures to stop their international spread, rather than establishingpre-determined measures aimed at stopping diseases at international borders as inthe case o IHR (1969).

The IHR (2005) de ne an emergency as an “extraordinary event” that could spreadinternationally or might require a coordinated international response. Events that mayconstitute a public health emergency o international concern are assessed by StateParties using a decision instrument and, i particular criteria are met, WHO must

be noti ed (see chapter 5). Mandatory noti cation is called or in a single case oa disease that could threaten global public health security: smallpox, poliomyelitiscaused by a wild-type poliovirus, human infuenza caused by a new virus subtype,and SARS. In parallel, a second limited list includes diseases o documented – but

Figure 1.4 Selected emerging and re-emerging infectious diseases: 1996–2004

Cryptosporidiosis

Leptospirosis

Lyme borreliosis

Escherichia coli O157

Multidrug-resistantSalmonella

Plague

Ebola and Crimean–Congo haemorrhagic feverInfluenza H5N1

Hantavirus

Lassa fever

Monkeypox

Nipah Hendra

New variantCreutzfeld–Jakob diseaseRift Valley fever

SARS coronavirusVenezuelan equineencephalomyelitis Yellow fever

West Nile fever


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not inevitable – international impact. An event involving a disease on this second list,which includes cholera, pneumonic plague, yellow ever, viral haemorrhagic evers(Ebola, Lassa and Marburg), West Nile ever and other diseases that are o nationalor regional concern, should always result in the use o the decision instrument o theRegulations that permits evaluation o the risk o international spread. Thus, the two

sa eguards create a baseline o security by obliging countries to respond in designatedways to well-known threats.The broad de nitions o “public health emergency o international concern” and

“disease” allow or the inclusion in IHR (2005) o threats beyond in ectious diseases,including those caused by the accidental or intentional release o pathogens or chemi-cal or radionuclear materials. The basic epidemiological, laboratory and investigativeprinciples, and the veri cation and noti cation procedures, are undamentally thesame or all events. Moreover, such events are routinely included in the daily globalsurveillance activities undertaken by WHO through many di erent networks o collabo-rating laboratories and surveillance networks. Many o these events are automaticallypicked up by the Global Public Health Intelligence Network (GPHIN) (15 ), an electronicintelligence-gathering tool, thus providing a sa ety net or detection o events not

otherwise reported. The inclusion o public health emergencies other than in ectiousdiseases extends the scope o the Regulations to protect global public health securityin a comprehensive way.

The IHR (2005) redirect the ocus rom an almost exclusive concentration on mea-sures at seaports and airports aimed at blocking the importation o cases towards arapid response at the source o an outbreak. They introduce a set o “core capacityrequirements” that all countries must meet in order to detect, assess, noti y and reportthe events covered by the Regulations. Rather than take to task violators, the newRegulations aim to strengthen collaboration on a global scale by seeking to improvecapacity and demonstrate to countries that compliance is in their best interests. Thus,compliance has three compelling incentives: to reduce the disruptive consequences oan outbreak, to speed its containment and to maintain good standing in the eyes o the

international community. Collaboration between Member States, especially betweendeveloped and developing countries, to ensure the availability o technical and otherresources is a crucial actor not only in implementing the Regulations, but also inbuilding and strengthening public health capacity and the networks and systems thatstrengthen global public health security.

A revolutionary departure rom previous international conventions and regulationsis the act that IHR (2005) explicitly acknowledge that non-state sources o in ormationabout outbreaks will o ten pre-empt o cial noti cations. This includes situationswhere countries may be reluctant to reveal an event in their territories. WHO is nowauthorized through IHR (2005) to take into account in ormation sources other thano cial noti cations. WHO will always seek veri cation o such in ormation rom thecountry involved be ore taking any action on it. This refects yet another o the reali-ties stemming rom the SARS outbreak: in an electronically transparent world whereoutbreaks are particularly newsworthy events, their concealment is no longer a viableoption or governments. Also, at a time when in ormation is shared at the click o abutton, reputable sources o in ormation are critical in maintaining public awarenessand support o prevention and control measures.

The sudden emergence in 2003 o SARS was a vivid example o how an in ec-tious disease can pose a serious threat to global public health security, the livelihoodo populations, the unctioning o health systems and the stability and growth oeconomies.

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The major lessons learned rom SARS and other diseases, discussed in Chapter3, have been not only the need to collectively build up surveillance and in ormationsystems that enable timely reporting and response, but also the need to improvein ection control capacity. Un ortunately, these capabilities are o ten lacking and sovulnerability to acute public health events will not simply go away. They need to be

con ronted urgently. The question is: how can this best be done?Part o the answer relates to the background actors or causes that lead or contributeto epidemics and other acute health emergencies. These may be natural, environ-mental, industrial, human, accidental or deliberate. Some o the most important othese causes, and examples o their recent impact in di erent parts o the world, arediscussed in the next chapter.

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org/pressroom/ acts_ gures/ act_sheets/iata.htm, accessed 10 May 2007).

2. Porter R. The greatest beneft to mankind: a medical history o humanity, rom 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/000329 92.htm, accessed 11 April 2007).

4. Davey Smith G. Behind the Broad Street pump: aetiology, epidemiology and prevention ocholera in mid-19th century Britain [commentary].International Journal o 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 o the Pan American Health Organiza- tion, 1995, 16(2) (http://www.paho.org/english/sha/epibul_95-98/be952choleraam.htm,accessed 11 April 2007).

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8. Knobler S, Mahmoud A, Lemon S, Pray L, eds.The impact o globalization on in ectious 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 Organiza-tion, 2005 (report to the WHO Executive Board, document EB115/36; http://www.who.int/ gb/ebwha/pd _ les/EB115/B115_36-en.pd , accessed 11 May 2007).

11. Howard-Jones N. The scientifc background o the International Sanitary Con erences 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 o biological and chemical agents or radionuclear material that a ect health . Geneva, WorldHealth Organization, 2002 (World Health Assembly resolution WHA55.16; http://www.who.int/gb/ebwha/pd _ les/WHA55/ewha5516.pd , accessed 13 May 2007).

14. Convention on the transboundary e ects o industrial accidents. Geneva, United NationsEconomic Commission or Europe, 1992 (ht tp://www.unece.org/env/teia/welcome.htm,accessed 14 May 2007).

15. Information: Global Public Health Intelligence Network (GPHIN).Ottawa, Public Health Agencyo Canada, 2004 (http://www.phac-aspc.gc.ca/media/nr-rp/2004/2004_gphin-rmispbk_e.html, accessed 3 May 2007).


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