Jianshi (Jesse) Huang, Weiyi Xiong, Angus Nicoll

Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; European Centre for Disease Prevention and

Control, Health Protection Agency, London School of Hygiene and Tropical Medicine, UK

Foresight China II: the Identification and detection of

infectious diseases

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I will discuss

What is the Foresight method?

Why does China need the Foresight Project ?

What is Foresight China IIMethodologyPreliminary resultsConclusion/Implications

04/19/233

What is the Foresight method?

A scientific approach to the Future

Combining future look at diseases & threats with opportunities for mitigation & control

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Eight Foresight project areas to 2006

Brain Science, Addiction and

Drugs

Detection and Identification of

Infectious Diseases

Intelligent Infrastructure

Systems

Obesity

Cognitive Systems

Flooding andCoastal Defence

Exploiting the Electromagnetic

Spectrum

Cyber Trust and Crime Prevention

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What is the Foresight method?

10 areas of science of relevance to detection, identification and monitoring systems were reviewed and analyzed: Intelligent sensor networks Data mining and fusion Non-invasive scanning and

screening Predictive and real-time

epidemiological modelling ……

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Today’s world is a small village. What happens in China could have significant impact on Europe and vice versa.

It is better to have a capacity to anticipate significant changes in infectious diseases for emergency preparation.

However, “It is very difficult to make predictions, especially about the future”. (American Sage)

Without some moderately accurate predictions or at least early warning, we cannot have a safe global village.

Why does China need Foresight Project ?

04/19/237

Quantitative Predictions The existing methods used to predict

future trends in infectious diseases: (quantitative predictions)Predictions Modelling

Drawbacks: Predictions - short term, max. 5 yearsModelling – by definition all models

are wrong but some are useful

Why does China need Foresight Project ?

04/19/238

The existing quantitative approach is problematic:when we look well beyond five years. When we look groups of infections,

especially emergence of unknown pathogens.

When more than one drivers influence the occurrence of infectious diseases

There is much that we just can’t use the quantitative model to predict, or…

Why does China need Foresight Project ?

04/19/239

Chinese Sage? 大智若愚（世界上有）知道的已知，知道的

未知和不知道的未知。每一年都有一些知道的未知变成知

道的已知。同样，每一年我们都能了解到有更

多的不知道的未知。因此原来不知道的未知变成了知道的未知甚至知道的已知。

当然，有时我们能认识到其实我们不知道一些知道的已知，还自以为是地认为我们知道这些知道的已知。

04/19/2310

…translation from an American Sage“ …There are known knowns, known unknowns and unknown unknowns.

Each year some of the known unknowns become known knowns.

But equally each year we become aware of some more unknown unknowns so that they become known unknowns or even known knowns.

Of course sometimes we realise that we do not know some of the known knowns as well as we thought we knew them…”

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Instead of looking at specific disease Foresight method identified a series of families of factors ‘drivers’ or risks for the study of likely trends in those drivers and hence, families of diseases.

Why does China need Foresight Project ?

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Two applications of information from the Foresight approach:Surveillance prioritization – to

detect if the threat is materialising

Identification of needed countermeasures

Why does China need Foresight Project ?

04/19/2313

Foresight China: A novel and simple approach to anticipating likely future trends in drivers and families of infectious diseases and therefore, needs for surveillance and public health preparedness.

What was Foresight China I

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Foresight China I: 2004-2006Basic Risk Model for Infectious Disease Risks was adapted from UK colleagues, 36 leading Chinese experts were consulted.

Supported by Foresight Funding, Enacted by PUMC, HPA & China CDC

What was Foresight China I

04/19/2315

Some important factors affecting future risks were identified.

Output: Predicting changing risks not actual disease trends so as to plan for surveillance systems improvement and for public health preparedness.

What was Foresight China I?

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Increasing movements of people, animals and animal products

More and greater migrations of people Increasing tourismIncreasing amounts of animal wasteChanging sexual lifestylesChanging public attitudes Increasing genetic uniformity of crops and livestock Rising wealth and levels of education

Important factors affecting future risks

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Better definitions of each driver in the questionnaire would have improved consensus

Need to ask the panel to predict the future of the driver not its potential effect on diseases

Need for an expanded expert panel

Lessons learnt from Foresight China I

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Foresight China II: 2007-2008,A continuation of Foresight China I Improved methodologyExpanded number of experts consulted to 180

Supported by British Embassy BeijingEnacted by PUMC & China CDC

Hence Foresight China II

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Three new features over Foresight China I:

Systematic literature review to identify the scientific evidence for drivers

Extensive analysis of existing infectious disease surveillance systems in 4 countries to identify how they capture data on drivers

Consultations with leading experts in 12 areas to confirm the improvement opportunities and to assess feasibility of the opportunities

Foresight China II: Methodology

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Basic Risk Model for Infectious Disease Risks

DriversClimate change,

Socio-economic drivers, etc.

OutcomesFuture diseases and levels of infection in: PeoplePlantsAnimalsEcosystems

Risk Analysis

Risk Estimate

SourcesZoonosesNaturalmutationAvailableniches

PathwaysSoilAirborneFood-borneWaterborneVectorsDirect contactWaste disposal

Prioritisation of Surveillance and Control Measures (Preparedness)

Source:Professor Joyce Tait, University of Edinburgh

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Note the simplicity – compare with this model for

Climate Change and Health: Direct and Indirect Effects

Source: A. McMichael et al, The Lancet 2006; 367: 859-869.

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Systematic literature review

Foresight China II: Findings

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Foresight China II: Preliminary findingsReviewed recent experience of

newly reported emerging human pathogens

0

5

10

15

20

25

30

35

40

1980 1985 1990 1995 2000 2005

Cu

mu

lati

ve n

o.

sp

p

SA

RS

HIV

-1

vCJD

25 (66%) are RNA viruses >80% have animal reservoir/origins; broad range Diversity of transmission routes and drivers of

emergence But only a few emerging diseases are of great public

health importance

04/19/2324 Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.

Number of EID events per decade

04/19/2325 Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.

Global richness map of the geographic origins of EID events from 1940 to 2004

Reflection of local strength of surveillance?

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Global distribution of relative risk of EID event

Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.

Zoonoses from wildlife Zoonoses from non-wildlife

Drug resistant pathogen Vector-borne pathogen

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The 12 families of drivers in Foresight China II

1.Environment related factors2.Iatrogenic related factors3.Animals and plants related factors

1.Governance and social cohesion2.Demography and population change3.Conflict4.Technology &Innovation and their governance5.Agriculture and land use change6.Economic factors7.Trade and Market related factors8.Transport and Tourism9.Human activity and social pressure10.Environment related factors11.Iatrogenic related factors12.Animals and plants related factors

1.Governance and social cohesion2.Demography and population change3.Conflict4.Technology &Innovation and their governance5.Agriculture and land use change6.Economic factors7.Trade and Market related factors8.Transport and Tourism9.Human activity and social pressure

Fore

sight C

hin

a

I

Fore

sight C

hin

a

II

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The inventory of 12 families drivers and their 50 elements

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The inventory of 12 families drivers and their 50 elements

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Extensive analysis of existing infectious disease surveillance systems in 4 countries

Do the surveillance systems capture data on the drivers? E.g. social factors driving tuberculosis spread

Foresight China II: Findings

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How do infectious diseases relate to the 12 family of drivers

We identified 18 priority infectious diseases according to:

WHO criteriaLeading causes of death/high morbidityEase to spreadingOn the international surveillance listHave a good, feasible preventive measuresCase definitions are clear and ease to detectHave a clear goal for elimination/eradication

Of 37 reportable diseases in China, those are10 leading cause of death of reportable

diseases10 diseases with highest incidence rate10 diseases with highest fatality rate

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18 priority infectious diseases

Tuberculosis (TB)MeaslesTyphoid\paratyphoidMalarianewborn tetanushydrophobia/rabiesgonorrheaSyphilisHIV/AIDSHemorrhagic fever

with Renal Syndrome (HFRS)

encephalitis Bepidemic

cerebrospinal meningitis

Leptospirosisplaguedengue feverViral Hepatitisbacillary and

amoebiasis dysentery

bird flu

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Do China surveillance systems collect data on the drivers? Not a lot!

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But neither do developed countries!

Percentage of 12 drivers/50 elements data

surveillance system collected by countries

12 family drivers, 50 elements, regarding to the 18 priority surveillanced infectious diseases. One element scores 1, The y-axis is the percents of elements that surveillance system have.

Percentage

%

04/19/2335

Leading experts consultations in 12 areasCharacteristics of the expertsResults

Foresight China II: Findings

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Leading experts consultations in 12 areasCharacteristics of the experts

(available on request)Results

Foresight China II: Findings

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Leading experts consultations in 12 areasCharacteristics of the expertsResults

Foresight China II: Findings

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Experts’ opinions on Four elements of Environment Related Factors in Foresight-China Study. The variables presented below are n (%).

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Experts’ opinions on Four elements of Environment Related Factors in Foresight-China Study. The variables presented below are n (%).

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Experts opinion on driver 1: Governance and social cohesion

Experts opi ni on re: dri ver 1: governance and soci al cohesi on

Yes % , 86%（ ）Yes % , 80%（ ）

0%

20%

40%

60%

80%

100%

Dri vers of I nf ect i ous Di seases ? Need survei l l ance?

Experts opi non re: The change trend of thefactor?

Strong %（ ）70%

No change%（ ）

17%

Weak %（ ）13%

04/19/2341

Experts opinion on the 12 families of drivers

Expert overal l opi ni on re: 12 dri vers

86%80% 78%

0%10%20%30%40%50%60%70%80%90%

100%

Dri vers of I nfecti ousDi seases ?

Need survei l l ance? Feasi bi l i ty of survei l l ance?

The change trend of the factor?

Strong,70%

No Change,17%

Weak, 13%

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Feasibility of surveillance for 50 Elements?

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Feasibility of surveillance(experts opinion)

Of 50 elements, 47 are identified as major influencing elements

Of the 47 major influencing elements, for 46 of them the experts considered it would be important to monitor them

But of the 46 elements, only 32 are considered to be feasible for monitoring surveillance

04/19/2344

Feasibility of surveillance(experts opinion)

Of the 46 elements:16 elements were considered

likely to result in trends that would be beneficial to the control of certain infectious diseases, e.g. education & economic development - food poisoning, tuberculosis

04/19/2345

Experts opinions on Trends in Drivers

Of 46 elements:30 elements were

considered to be associated with worsening occurrence and spreading of infectious diseases

04/19/2346

Experts opinions on Trends in Drivers

Of these 30 elements:o 7 elements were considered likely to

improve in the future e.g. poverty, hospital infection control and associated diseases would lessen.

o 18 elements are likely to deteriorate e.g. immigration, bioterrorism

o 5 elements were considered likely to stay unchanged e.g. unemployment, environmental pollution

04/19/2347

Feasibility of surveillance One Family of Drivers 1.

Governance and social cohesion

Readily Doable 1.Bio-security governance 2.International/national/regional

interactions affecting governance 3.lack of interaction between policy and

regulatory agencies 4.Marginalization of some groups specifyCan be done with some effort E.g. Illegal practicesDifficult to do or measure ? Consider later E.g. Social cohesion, political leadership

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Conclusions/Implications

We identified improvement opportunities for identification and detection of infectious disease using the Foresight framework in China

We are able to predicting changing risks not actual disease trends of infectious diseases. Thirty two (32) elements are identified as doable for sureillance systems improvement.

Now astudy is needed to test Foresight findings in test location.

04/19/2349

References Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global

trends in emerging infectious diseases,nature,2008,451(21):990-994.

Louise Swift, Paul R. Hunter, Alexander C. Lees, ect. Wildlife Trade and the Emergence of Infectious Diseases. Ecohealth ,2007,4:25-30.

Mary E. Wilson. Travel and the Emergence of Infectious Diseases. Emerging infectious disease journal.1995,1(2):39-46.

McNeill WH. Plagues and peoples. Garden City, N.Y.:Anchor Press/Doubleday, 1976.

Stephen S. Morse. Factors in the Emergence of Infectious Diseases. Emerging infectious disease journal.1995,1(1):7-15.

Anthony Zwi, Pilar Ramos-Jimenez. Conflict, crisis and infectious disease.TDR Nnews.2002,68.

Strategic social ,economic and behavioral research. special programme for research &training in tropical disease(TDR). 2005,12.

Gaetan Gavazzi, Francois Herrmann, Karl-Heinz Krause. Aging and Infectious Diseases in the Developing World. Aging and infectious disease. 2004,39:83-91.

Elizabeth M. Prescott. The Politics of Disease: Governance and Emerging Infections. Global Health Goverance, 2007,1(1):1-8.

The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Workshop Summary .http://www.nap.edu/catalog/11588.html.

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Acknowledgements

UK-China Partners in SciencesDr David Concar - British Embassy Beijing

Ms. Duying - British Embassy Beijing

142 experts consulted64 field interviewers

04/19/2351

THANKSQ & A

How to work with HPA and European

countries?