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 he food chain has undergone considerable and rapid changes over the last 50 years, becoming highly sophisticated and international. Although the safety of food as 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 consider- ble concem, 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 a West Africa, 2006: the dumping of approximately 500 tons of petrochemical waste in at least 15 sites around the city of Abidjan, Cote d'lvoire 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. I 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 ffected by the tainted oil and no cure to reverse the adverse effects of toxic oil syndrome was ever found Radionuclear accidents I 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 drif ted 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
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. overview xi
world health report 2007 global public health security in the 21st century 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 I 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 event requires rapid assessment to determine if it is an international threat. This Overview summarizes some of the above examples, which, together with the les- sons drawn from them, are more widely discussed in the report. The report emphasizes that the international response required today is not only to the known, but also to the unknown-the diseases that may arise from acute environmental or climatic changes and from industrial pollution and accidents that may put millions of people at risk in several countries GLOBAL COLLABORATION TO MEET THREATS TO PUBLIC HEALTH SECURITY These threats require urgent action, and wHO and its partners have much to offer immediately as well as in the longer term. This is an area where real progress to protect whole populations can be made, starting now. It is also where recent history shows that some of the most serious threats to human existence are likely to emerge without warning. It would be extremely naive and complacent to assume that there will not be another disease like aids. another ebola or another sars 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 sup- port 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 respe Potential case intemational spread prev 50 30
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 90 0 Cases 1 Days Figure 2 Global outbreaks, the challenge: late reporting and response 4 7 10 13 16 19 22 25 28 31 34 37 40 80 70 60 50 40 30 20 10 Early reporting Potential cases prevented/ international spread prevented Rapid response xii global public health security world health report 2007 in the 21st century
overview xii 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 ead 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 ensur ing 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 revention 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
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). overview xiii
world health report 2007 xiv global public health security in the 21st century CHAPTER SUMMARIES Evolution of public health security Chapter Chapter 1 begins by tracing some of the first steps, historically, that led to the intro- duction 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 eradica- tion 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 comple 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 RN), this partnership provides an operational to access expertise and skill, and to keep the international community constantly alert 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 yel low 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 environment 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
Chapter summaries Evolution of public health security 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. 1 chapter xiv global public health security world health report 2007 in the 21st century
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 intemational 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 ubtype, 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 chemi cal 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 mea- sures 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 informa- tion 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 his reflects a new reality in a world of instant communications: the concealment of disease outbreaks is no longer a viable option for governments
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. overview xv