world health report 2007 xvi global public health security in the 21st century Threats to public health security chapter 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 trypanosomia- sis, dengue and dengue haemorrhagic fever, and malaria emerged in new areas or re-emerged in areas previously affected. Urbanization and increasing intemational 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 ystems 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 healt threat was not detected by what were invariably weak health systems in many develop ing 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 AldS 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 ven 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 vac- cine(OPV)was unsafe and could sterilize young children led to the suspension immunization in two northern states and substantial reductions in polio immun coverage in a number of others. The result was a large outbreak of polio across 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
Threats to public health security 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. 2 chapter xvi global public health security world health report 2007 in the 21st century
overview X 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 e 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 ternary 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
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. overview xvii
world health report 2007 viii global public health security in the 21st century New health threats in the 21st century chapter bioterrism in the form of the antha leers in the nted states in 2001. the emer- gence of SARS in 2003, and the large-scale dumping of toxic chemical waste in Cote 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 years later to deadly effect in deliberate acts of violence. Mass smallpox vaccination had been discontinued after eradication, thus leaving unimmunized populations eptible and a new generation of public health practitioners without clinical exper of the disease Since then, WHO has taken part in international discussions and bioterrorism desk op 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 Is 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 intermational airport at risk of imported cases
New health threats in the 21st century 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. 3 chapter xviii global public health security world health report 2007 in the 21st century
overview xix 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 intemational threat-an unprecedented achievement for public health on a global scale. If SARS had become permanently established as yet another indigenous epidemic threat, it is not difficult to imagine the consequences for global public health security in a world still struggling to cope with HIV/AIDS As well as the international mobility of people the global movement of products can have serious health consequences. The potentially deadly risks of the international movement and disposal of hazardous wastes as an element of global trade were vividly illustrated in Cote d'lvoire in august 2006. Over 500 tons of chemical waste were unloaded from a cargo ship and illegally dumped by trucks at different sites in and around abidjan. As a result, almost 90 000 people sought medical treatment in the following days and weeks. Although less than 100 people were hospitalized and far fewer deaths could be attributed to the event, it was a public health crisis of both national and international dimensions One of the main international concerns was that the cargo ship had sailed from northern Europe and had called at a number of ports, including some others in western Africa, on its way to Cote d' lvoire. 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, 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. overview xix
world health report 2007 x global public health security in the 21st century Learning lessons, thinking ahead Chapter 4 is devoted to potential public health emergencies of international concern, chapterthe most feared of which remains pandemic influenza. The response to this threat has 4 aready 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 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 worlds population- more than 1.5 billion people- could be anticipated. Even if the influenza pandemic virus caused relatively mild disease, the economic and social dis- ruption 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 gree 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 nd training on field investigat 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. a Reducing human exposure to the H5N1 vir a Strengthening the early warning system a Intensifying rapid containment operations a Coordinating global scientific research and development
Learning lessons, thinking ahead 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. 4 chapter xx global public health security world health report 2007 in the 21st century