1February 2015

Centre on Global Health Security

Draft Research Strategy29th June 2010

Shifting the paradigm: from rapid detection and response to prevention

at the source

2

February 2015

Breaches in species barrier since Breaches in species barrier since 19761976

Infection Animal linked Year infection to transmission first reportedEbola virus Bats 1976 HIV-1 Primates 1981

E. coli O157:H7 Cattle `1982 Borrelia burgdorferi Rodents 1982

HIV-2 Primate 1986 Hendra virus Bats 1994

BSE/vCJD Cattle 1996 Australian lyssavirus Bats 1996

H5N1 influenza A Chickens 1997

Nipah virus Bats 1999 SARS coronavirus Palm civets 2003

Influenza (H1N1) Swine 2009

MERS coronavirus Camel 2012

3

February 2015

Potential transmission pathways, emerging Potential transmission pathways, emerging infectious diseasesinfectious diseases

Emergence

No further transmission

Continuestransmission

Continuestransmission

Ceases/sporadic

Continues/endemic

4

February 2015

Emergence from animals in nature:Emergence from animals in nature:Eco Challenge, Malaysia, 2000Eco Challenge, Malaysia, 2000

5

February 2015

Leptospirosis (N = 33) among 312 participants, Leptospirosis (N = 33) among 312 participants, Eco Challenge 2000, MalaysiaEco Challenge 2000, Malaysia

Eco Challenge

Eco Challenge

US: 10Canada: 4

Brazil: 1

Uruguay: 1 Australia: 4

France: 4UK: 9

6

February 2015

The current paradigm: The current paradigm: rapid detection, risk assessment, and emergency rapid detection, risk assessment, and emergency

responseresponse

7

February 2015

Source: WHO/CDC

SARS: international spread from Hong Kong, SARS: international spread from Hong Kong, 21 February – 12 March, 2003 21 February – 12 March, 2003

Doctorfrom

Guangdong

Doctorfrom

Guangdong

CanadaCanada

Hotel MHong Kong

IrelandIreland

USAUSA

New YorkNew York

SingaporeSingapore

Viet NamViet Nam

BangkokBangkok

B

I

K

F G

ED

C

JH

A

Germany1 HCW +

2

Germany1 HCW +

2

Hong KongHong Kong

8

February 2015

Probable cases of SARS by date of onset Probable cases of SARS by date of onset worldwide, 1 March – 27 June 2003worldwide, 1 March – 27 June 2003

8,273 reported cases775 deaths

9

February 2015

SARS and the economy:SARS and the economy:impact on global travel, April 2003impact on global travel, April 2003

10

February 2015

Passenger movement, Hong Kong International Passenger movement, Hong Kong International Airport, March-July 2003Airport, March-July 2003

WHO lifted travel advisory WHO travel advisory

0

20 000

40 000

60 000

80 000

100 000

120 000

3/16

3/20

3/24

3/28 4/1

4/5

4/9

4/13

4/17

4/21

4/25

4/29 5/3

5/7

5/11

5/15

5/19

5/23

5/27

5/31 6/4

6/8

6/12

6/16

6/20

6/24

6/28 7/2

Num

ber o

f pas

seng

er

Total

23 May2 April

14 670

102 165

65 255

11

February 2015

Economic impact SARS, Hong Economic impact SARS, Hong KongKong

Health (sector) impact small, but impact on other sectors large

– Hong Kong retail losses ~ US$334m

R es taurant R ec eipts HK $Mn

0

2,0004,000

6,000

8,000

10,00012,000

14,000

16,000

2002Q1

2002Q2

2002Q3

2002Q4

2003Q1

2003Q2

2003Q3

2003Q4

R etail s ales HK $Mn

37,00038,00039,00040,00041,00042,00043,00044,00045,00046,000

2002Q1

2002Q2

2002Q3

2002Q4

2003Q1

2003Q2

2003Q3

2003Q4

Hong K ong Hotels yoy % c hang e

-70.0-60.0-50.0-40.0-30.0-20.0-10.00.0

+10.0+20.0

2002Q1

2002Q2

2002Q3

2002Q4

2003Q1

2003Q2

2003Q3

2003Q4

12February 2015

The cost of SARS, Asian Development The cost of SARS, Asian Development Bank, 2003Bank, 2003

76543210 US$ billion

Hong Kong

China, mainland

Taiwan

South Korea

Indonesia

Singapore

Thailand

Malaysia

PhilippinesUS$ billionUS$ billion

4%

0.5%

1.9%

0.5%

1.4%

2.3%

1.6%

1.5%

0.8%

% of GDP

As of 30 September, 2003, SARS had decreased Asia’s combined GDP by US$18 billion and cost nearly US$60 billion in lost demand and revenues

13February 2015

Influenza A(H1N1) Pandemic as of 13 June Influenza A(H1N1) Pandemic as of 13 June 20092009

14February 2015

15

February 2015

Recent infectious disease outbreaks and Recent infectious disease outbreaks and their economic impacttheir economic impact

16February 2015

Changing the paradigm: Changing the paradigm: joint risk assessment, prediction and preventionjoint risk assessment, prediction and prevention

February 2015 17

Changing the paradigm: joint human/animal surveillance and risk assessment

● identify animal infections/assess their risk to humans

● share laboratory specimens between animal and human public health

● conduct joint research

● increase use of animal vaccines

● stronger regulation of animal husbandry

18February 2015

Joint risk communicationJoint risk communication

19February 2015

Changing the paradigm: risk maps for Changing the paradigm: risk maps for emergence of infectious diseasesemergence of infectious diseases

20February 2015

Changing the paradigm: identification/sequencing Changing the paradigm: identification/sequencing of animal infectionsof animal infections

How feasible is prediction in preventing infections at th

e

animal/human interface?

21February 2015

Pushing the paradigm even further upstream:Pushing the paradigm even further upstream:prevention of emergence at its sourceprevention of emergence at its source

22February 2015

Nipah virus infection, Malaysia, Nipah virus infection, Malaysia, 1998-19991998-1999

Source: Chua KB, Journal of Clinical Virology, April 2003

23February 2015

Nipah virus outbreaks, humans,Nipah virus outbreaks, humans, 1998 - 2008 1998 - 2008

Dates Location No. cases No. deaths CFR(%)

1998-1999

1999

Malaysia;

Singapore

265

11

105

1

40

9

2001 W. Bengal, India 66 45 68

2001 Bangladesh 13 9 69

2003 Bangladesh 12 8 67

2004 Bangladesh

Bangladesh

29

36

22

27

76

75

2005 Bangladesh 12 11 92

2007 W. Bengal, India 5 5

100

2007

2008

Bangladesh

Bangladesh

15

11

8

6

54

54

24February 2015

Changing Nipah virus Changing Nipah virus epidemiology: Bangladesh and epidemiology: Bangladesh and

IndiaIndia Human-to-human transmission first

suspected 2001, hospitalized patients, India

Human to human transmission suspected again in 2003, 2005, and 2007, Bangladesh – cases could not be linked to domestic animal

exposure, including pigs

– index cases not identified: one potential exposure to bat guano in palm wine

25February 2015Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University.

Assessing the risk/testing the hypothesisAssessing the risk/testing the hypothesis

26February 2015Courtesy: Dr Shovon Shazzad, Dr Salah Uddin Khan, and Dr Steve Luby, ICCDR,B and Stanford University.

The risk is plausible through the food chainThe risk is plausible through the food chain

27February 2015

Precautionary measures: community agreement to Precautionary measures: community agreement to cover the collection containerscover the collection containers

Community agriculture meeting

28February 2015

Shifting the paradigm from emergency response to prevention

29February 2015

Ebola emergence: current hypotheses

30February 2015

Ebola Haemorrhagic Fever by mode of transmission, Yambuku DRC,1976

0

10

20

30

40

50

60

6 12 18 24 30 6 12 18 24

Health workers and their contacts

Contact and needle/syringe

Needle/syringe

September October

N

u

m

b

e

r

1

Hospital closed

Source: CDC

Cases: 318

Deaths: 280 (88%)

31February 2015

Mission Hosptial, Tandala Zaire (DRC), 1977Mission Hosptial, Tandala Zaire (DRC), 1977

1 clinical case/died

1 contact (sister) fit possible case definition/survived

1 historical probable clinical case/recovered,1972

32February 2015

Source: WHO/CDC

0

2

4

6

8

10

12

14

16

7-

Mar

13-

Mar

19-

Mar

25-

Mar

31-

Mar

6-

Apr

12-

Apr

18-

Apr

24-

Apr

30-

Apr

6-

May

12-

May

18-

May

24-

May

30-

May

5-

Jun

11-

Jun

17-

Jun

Non health care workers

Health care workers

Ebola Haemorrhagic Fever by mode of transmission, Kikwit Zaire, 1995

315 cases

250 (80%) deaths

33February 2015

Ebola outbreaks, West Africa, 2014Ebola outbreaks, West Africa, 2014

34February 2015

Ebola, new cases as of mid-February, 2015Ebola, new cases as of mid-February, 2015

Source: WHO

35February 2015

Ebola outbreaks can be stoppedEbola outbreaks can be stopped

• Patient identification, isolation and protection of health workers/infection control

• Surveillance/contact tracing and fever surveillance with rapid diagnosis and isolation

• Community understanding with safe patient and body transport systems, safe burial and household/environmental decontamination

36February 2015

Vaccines against Ebola: possible usesVaccines against Ebola: possible uses

• Short-duration immunity:– Front line health workers

– Front line community workers: transporters of patients and bodies, decontamination workers

– Ring vaccination: prevent third generation cases

• Long-duration immunity– Primary prevention: health workers in Ebola Belt

37February 2015

Vaccine Mechanism Trials Comment Ref

Plasmid DNA based. VRC-EBODNA023-00-VP

DNA immunisation with boosting adenoviral vector

Phase I Uganda (completed)

Process takes 6 months to provide protection in non-human primates

Sullivan et al Nature 2000

Accelerated vaccine of above ChAd-EBO

Adenoviral vector delivers DNA encoding Ebola GP

Phase I (started in UK, U.S)Recruiting in Mali, pending in Gambia

Process takes 28 days (NH primates and mice). Potential for outbreaks

Sullivan et al Nature 2003

VSV-EBO (Canadian)

Vesicular stomatitis virus delivers Ag

Phase I Currently recruiting

Up to thirty minutes post infection (protection against Ebola -50%, Marburg 100%) 33% protection after 48 hrs

Feldmannet al Plos Pathog 2007

Ebola candidate vaccines, early 2015Ebola candidate vaccines, early 2015

38February 2015

Ebola candidate vaccines, 2015Ebola candidate vaccines, 2015

Keep the re

search

protocols

and

vaccines r

eady and on the sh

elf