Thailand MOPH – US CDC Collaboration

International FETP Training of Trainers

John MacArthur, MD, MPH

Director

Thailand MOPH – US CDC Collaboration

02 July 2018

Emerging Infectious Diseases Why Asia Matters

Driving Forces in Asia

• Population growth, urbanization, environmental changes

• Diverse zoonotic and vector-borne pathogens

• High density, proximity, and mobility of humans and animal reservoirs provide fertile conditions for disease transmission

• Ecologic factors allow rapid pathogen mutation and host adaptation

Asia Population

• Thailand 68m

• Greater Mekong Sub-region 235m • Burma, Cambodia, Laos, Thailand, Vietnam, Yunnan

• ASEAN 625m • ASEAN +3 (+China, Korea, Japan) 2,174m

• WHO:SEARO/WPRO 3,728m

ASIA: 53.3% of world’s population

Global Hotspots for Emerging Diseases Originating in Wildlife

Morse et al., 2012: The Lancet

Nipah Virus

• Isolated and identified in 1999 • Outbreak of encephalitis and

respiratory illness among pig farmers

• 300 human cases with 100 deaths

• Transmission occurs from direct contact with infected bats, pigs, or persons

SARS

• First reported in Asia in 2003 • Outbreak of fever and resp illness

among people with contact with an infected individual

• 8,098 human cases with 774 deaths

• Transmission occurs from airborne contact with infected persons

• Possible origin: bats, palm civets

Influenza A

H5N1 • First reported in humans in 1997

(Hong Kong) • re-emerges in 2003 in HK in patients

with h/o China travel • 846 human cases with 449 deaths

through 2015

• Transmission occurs from direct or close contact with infected poultry; some H2H reported

H1N1 • First reported in mid-April 2009

(USA) • H1N1 picked up as a part of a clinical

study • ~61 million human cases with

>12,000 deaths

• Transmission occurs from person to person (coughing and sneezing)

• Possible origin: reassortment of bird, swine, and human influenza viruses

Keep Calm and … Emerge

H7N9

• First reported in humans in 2013 (China) • Infections found in poultry and

people • >300 human cases with 67 deaths

• Transmission occurs likely from exposure to infected poultry or contaminated environment

• Possible origin: reassortment of H7N1 chicken and duck virus

MERS-CoV

• First identified in 2012 (Saudi Arabia) • Coronavirus family ranging from

common cold to SARS • 1,644 human cases with 590

deaths

• Exact route of transmission still unknown (likely H2H)

• Possible origin: likely bats but transmitted to camels at some point in the past

H5N1 53%

MERS-CoV 36%

Nipah virus 33%

H7N9 22%

SARS 10%

H1N1 0.02%

Case Fatality Rates

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Emerging/Re-emerging Infectious Diseases in Asia • Artemisinin-resistant malaria

• Burkholderia pseudomallei

• Chikungunya

• Dengue

• Japanese encephalitis

• Leptospirosis

• MDR/XDR TB

• multidrug-resistant Acinetobacter baumannii, Salmonella enterica, and Enterobacteriaceae

• Rabies

• Streptococcus suis

• Vibrio cholerae O139

• Zika

18

A health threat anywhere is a health threat everywhere Global Aviation Network

Source: The Lancet 380:9857, 1-7 Dec 2012, pp. 1946-55. www.sciencedirect.com/science/article/pii/S0140673612611519 Note: Air traffic to most places in Africa, regions of South America, and parts of central Asia is low. If travel increases in these regions, additional introductions of vector-borne pathogens are probable

MERS-CoV cases by country of residence and travel history

Global transmission patterns of measles viruses from the

Philippines, 1/1/14 to 3/31/14

Diseases can spread as fast as an airplane

MERS-CoV spread across the Arabian peninsula

//upload.wikimedia.org/wikipedia/commons/9/9c/Carte_des_routes_d'immigration_africaine_vers_l'Europe.svg

648

1378

1026

17

3069

482

322

935

6

1745

430 694

422

13

1559

0

500

1000

1500

2000

2500

3000

3500

Guinea Liberia SierraLeone

Nigeria Total

Cases Confirmed Deaths

Ebola Outbreak as of 28 AUG 2014

Figure 1. Geographical distribution of counties involved in live bird market networks originating from southern China in the (A) January, (B) February, (C) March and (D) April.

Soares Magalhães RJ, Zhou X, Jia B, Guo F, et al. (2012) Live Poultry Trade in Southern China Provinces and HPAIV H5N1 Infection in Humans and Poultry: The Role of Chinese New Year Festivities. PLoS ONE 7(11): e49712. doi:10.1371/journal.pone.0049712 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0049712

ASEAN Economic Community

AEC Single Market and Production base

To create a stable, prosperous and highly

competitive ASEAN economic region

Freer flow of capital

Free flow of goods services, investment,

and skilled labor

characteristic

objective

Global Health Risks are Increasing

Emergence and Spread of New Pathogens

Globalization of Travel, Food and Medicines

Rise of Drug Resistance

Intentional Engineering of Microbes

XDR TB

MRSA

Anthrax

Recombinant

Technologies

HIV

Avian Flu

Food Supply

Global Frameworks IHR, APSED, & GHSA

International Health Regulations (IHR) 2005

• International agreement between WHO and its 196 member states

• Framework for identifying, reporting, and responding to public health emergencies of international concern (PHEIC)

Less than 1/3 of the world is prepared

• All 196 countries of the world committed to International Health Regulations

• By 2014 – only 32% fully prepared to detect and respond to pandemics

ASEAN Countries have a head start

Asia Pacific Strategy for Emerging Diseases Five Objectives

1. Reduce the risk of emerging diseases

2. Strengthen early detection

3. Strengthen rapid response

4. Strengthen effective preparedness

5. Build technical partnerships

Source: WHO

Good but still not there

Global Health Security – “...the activities required, both proactive and reactive, to minimize vulnerability to acute public health events that endanger the collective health of populations living across geographical regions and international boundaries” (World Health Assembly Report,

2007)

• In 2003, SARS cost $30 billion in only 4 months • The anthrax attacks of 2001 infected 22 people,

killed 5, and cost more than $1 billion to clean up • The 2009 H1N1 influenza pandemic killed

284,000 people in its first year alone • AIDS spread silently for decades

Global Health Security Agenda A Move to Accelerate Progress

The Problem

The Process

PREVENT Avoidable Catastrophes

DETECT Threats Early

RESPOND Rapidly & Effectively

Action Packages

AMR

Zoonotic

Biosafety/ Biosecurity

Immunization

Nat’l Lab Sys

Surveillance

Reporting

Workforce Dev

EOC

Public Health Law

Medical Counter- measures

Global Health Security Agenda

Goals Objectives

Prevent avoidable epidemics

Prevent the emergence and spread of antimicrobial drug resistant organisms and emerging zoonotic diseases and strengthen international regulatory frameworks governing food safety

Promote national biosafety and biosecurity systems

Reduce the number and magnitude of infectious disease outbreaks

Global Health Security Agenda

Goals Objectives

Detect threats early

Launch, strengthen and link global networks for real-time biosurveillance

Strengthen the global norm of rapid, transparent reporting and sample sharing in the event of health emergencies of international concern

Develop and deploy novel diagnostics and strengthen laboratory systems

Train and deploy an effective biosurveillance workforce

Global Health Security Agenda

Goals Objectives

Respond rapidly and effectively

Develop an interconnected global network of Emergency Operations Centers and multi-sectoral response to biological incidents

Improve global access to medical and non-medical countermeasures during health emergencies

GHSA Participating Countries

Systems strengthening Global Health Security Agenda

FETP Thailand Highlights

• First FETP established outside North America

• More than 85% of the over 190 FETP graduates hold leadership positions at provincial, national and international levels.

• >1,000 outbreak investigations

• >690 publications

Dr. David Brandling-Bennett and 1st FETP Cohort - 1980

Workforce Development

• Strengthen human capacity for disease surveillance, response, and control

• FETP for veterinarians and wildlife workers • Scientific writing

• Mentors – Increase number and quality

• Develop and update curriculum and new training modules

• Strategic planning

• Regional linkages

Building Upon Success: Global Health Security • 1980 – Begin to build epidemiology capacity

• 2003 – SARS: Intensive collaboration on outbreak investigation

• 2004 – H5N1: Built on previous collaboration to mitigate associated risks

• IMPACT: Thailand immediately identified 3 imported cases of MERS-CoV, isolated the patients, introduced infection control practices, and conducted contact tracing with no secondary cases reported • Contrast to South Korea (186 cases & 36 deaths from a single imported case)

FETP in the 21st Century The Many Flavors of Health Security

Economic Development in Asia 1960-2014

Epidemiologic Transition

There are two major components of the transition:

1. changes in population growth trajectories and composition, especially in the

age distribution from younger to older, and

2. changes in patterns of mortality, including increasing life expectancy and reordering of the relative importance of different causes of death.

Thailand Top Causes of Death 2012

0 10 20 30 40 50 60 70 80

Kidney Disease

Resp CA

Liver CA

Diabetes

AIDS

COPD

RTI

LRI

Stroke

Ischemic Heart Disease

Adult Risk Factors

• Raised Blood Glucose • M: 7.3%

• F: 7.1%

• HTN • M: 24.6%

• F: 20.2%

• Obesity • M: 4.9%

• F: 11.8%

• Tobacco Use • M: 46%

• F: 3%

Making a difference in Asia

• Infectious diseases • Still very important and need attention

• Emerging and re-emerging infectious diseases may affect large numbers in a short amount of time

• May have dramatic impact on economies

• Large portion of ministries’ workforce development

• Non-communicable Diseases • Growing importance

• 8 of 10 top causes of mortality in Thailand

• Will have slower yet significant impact on economy

• Small number of epidemiologists with NCD expertise

You are not here merely to make a living. You are here to enable the world to live more amply, with greater vision, and with a finer sense of hope and achievement. You are here to enrich the world, and you impoverish yourself if you forget the errand.

Woodrow Wilson 28th President of the United States