By Dr Julia Scott, Prof Nick Wilson, Prof Michael Baker.
In a globalised world an infectious disease outbreak anywhere is a potential threat to New Zealand.
Recent such threats have included severe acute respiratory syndrome (SARS), pandemic influenza (2009), Ebola and Zika. In the context of an upcoming University of Otago, Wellington Public Health Summer School symposium on the topic of emerging infectious diseases, this blog discusses how NZ could ensure it is better prepared in this public health domain.
What are the threats?
Emerging infectious diseases (EIDs) are those which have appeared for the first time in a population, increased rapidly in incidence or range or developed antimicrobial resistance (1). EID outbreaks have increased since 1940, due in part to changes in the human-animal-environment interface, and between 1940 and 2004, 60% of EID outbreaks were caused by zoonotic pathogens (2,3,4). EIDs have caused the highest mortality impact human pandemics in history including plague, ‘Spanish’ Influenza in 1918/1919 and HIV (5). Furthermore, antimicrobial resistance (AMR) has been described by World Health Organization (WHO) Director General Margaret Chan as a “slow-motion tsunami” (6).
The world contains multiple pathogens with new pandemic potential. WHO now conducts an extensive annual consultation to identify high priority hazards (7). Their current list includes 9 pathogens (or groups of pathogens) with high potential to cause a public health emergency and where limited preventive and curative measures are available (Table 1) (8).
Table 1: WHO list of priority diseases 2017 in terms of potential to cause a public health emergency
|· Arenaviral haemorrhagic fevers (including Lassa Fever)|
|· Crimean Congo Haemorrhagic Fever|
|· Filoviral diseases (including Ebola and Marburg)|
|· Middle East Respiratory Syndrome Coronavirus|
|· Other highly pathogenic coronaviral diseases (eg, SARS)|
|· Nipah and related henipaviral diseases|
|· Rift Valley Fever|
|· Severe Fever with Thrombocytopenia Syndrome|
It is therefore important and timely to consider how NZ can prepare for the next EID pandemic, taking into account the vastly different ways in which it might present. Could we see another SARS? A zoonotic disease with current stuttering transmission to humans such as nipah virus? Or a common pathogen which has developed complete resistance to antibiotics?
What are the responses?
NZ’s pandemic planning is embedded in the Civil Defence and Emergency Management framework (Figure 1). This arrangement is recommended by WHO (9,10), and is the general pattern for developed countries. Within these documents very little guidance exists for infectious diseases with pandemic potential other than influenza. The National Health Emergency Plan: Infectious Diseases, developed in response to SARS in 2003 (11) is now out-of-date, and the core NZ pandemic planning and response document is the Influenza Pandemic Preparedness Plan 2010 (12). The Ministry of Health’s “Pandemic Planning and Response” webpage links only to documents regarding influenza (13). However, preparedness for pandemic influenza does not guarantee preparedness for another EID, as demonstrated by the emergence of blood-borne (Ebola) and vector-borne (Zika) threats in recent years.
Figure 1: NZ’s current strategic pandemic response framework
The International Health Regulations (IHR) 2005 are a binding agreement between 196 countries aiming to prevent and respond to the international spread of disease (14)(a2). They require States to assess, strengthen and maintain core capacities for surveillance, risk assessment, reporting and response, and notify WHO of all events which may represent a Public Health Emergency of International Concern, including unnamed diseases or events, aiming for an all hazards approach (14). AMR is not specifically listed in the IHR, but is included in the guide to implementation as a risk to be targeted by national initiatives (15). Although the IHR have been widely criticised, according to the Review Committee on the IHR in relation to the Ebola outbreak, it was a lack of implementation rather than the agreement itself that was responsible for failures in this response (16). Unfortunately there has been only a partial international response to the IHR, with only 35% of State Parties (including NZ) having core capacities in place by the end of 2015 (16,17). Full implementation will require support for low-income countries to strengthen their health systems (16).
Other frameworks have been developed to assist countries implement the IHR, notably the Asia Pacific Strategy for Emerging Diseases (APSED), and the Global Health Security Agenda (GHSA). APSED is a strategic framework for countries of the Western Pacific and South East Asian regions to strengthen their capacity to manage and respond to EID threats (18). APSED recommends collaboration mechanisms between human and animal health sectors, and that national pandemic preparedness and response plans should be integrated into a public health emergency plan for all EIDs (19). Its third version is currently in draft, and has been expanded to explicitly include AMR within a new focus area; prevention through health care (20).
The GHSA was launched in 2014 by the United States Centers for Disease Control and Prevention (CDC), in collaboration with 43 other countries, WHO, the Food and Agricultural Organization (FAO) of the United Nations, the World Organization for Animal Health (OIE) and civil society (21, 22). It aims to promote global health security and accelerate progress towards full IHR implementation (22). Eleven “Action Packages” (Table 2) encompass the three key elements of health security: prevention, detection, and response (23), each with five-year targets, actions and indicators. These action packages are intended to facilitate specific commitments and leadership from countries involved. An assessment tool for essential national structures and functions has also been developed and piloted (22).
Table 2: Global Health Security Agenda (GHSA) Action Packages
|GHSA Action Packages|
|Prevent||1. Antimicrobial resistance|
|2. Zoonotic disease|
|3. Biosafety and biosecurity|
|Detect||5. Laboratory system|
|6. Real-time surveillance|
|8. Workforce development|
|Respond||9. Emergency Operations Centres|
|10. Linking public health with law and multi-sectoral rapid response|
|11. Medical countermeasures and personnel deployment|
The IHR specifies a number of diseases which constitute a Public Health Emergency of International Concern, but neither APSED or GHSA provide guidance on development of preparedness for particular diseases or categories. A number of frameworks have been created to prioritise or classify diseases to inform such development, for example through expert consensus on diseases of importance using a number of pre-set criteria (24,25). The National Expert Panel on New and Emerging Infections of the United Kingdom (UK) developed a two-algorithm risk assessment process for EIDs, considering the likelihood a pathogen will infect the population and its potential impact on human health (26). This tool has been used to assess the threat of a range of infections in the UK and communicate information to government departments and other agencies (26).
What more can and should NZ do to prepare?
A NZ-based workshop and series of interviews with public health professionals (undertaken by one of us [JS] in 2015 (27)), assessed the utility of ranking pandemic ‘scenarios’ to inform planning. These were thought a useful way to consider threats for training and testing capacity. Other key components of EID preparedness identified during these discussions were retention of institutional knowledge, exercising responses, national public health leadership, and consideration of potential impact on vulnerable populations. Surveillance outside notifiable diseases and laboratory capacity for highly pathogenic organisms were identified as major gaps in current NZ preparedness. Recommendations from NZ health sector debriefs on the response to Ebola also emphasised the need for further development of intelligence, communication and decision support tools and a framework providing for infectious disease management across a range of disease types and transmission methods (28).
Given this background (in particular the IHR Core Components Questionnaire, the APSED Framework, and the GHSA Action Packages), we recommend NZ health authorities consider the following priorities:
- Developing or adopting a framework to cover prevention, detection and response to a broad range of EIDs, especially those with greatest potential to spread in our region. Scenarios or disease prioritisation could be used to facilitate this process. Doing this would be in line with IHR core capacity development and NZ’s own Ebola debrief recommendations, and could be undertaken as part of the next review of the National Health Emergency Plan: Infectious Diseases.
- Joining the GHSA to further assess and develop NZ’s own capacity and contribute to global health security. As part of this process, NZ could further assist low- and middle-income countries in the Pacific Region to develop their capacities in this area.
- Completing and implementing an AMR action plan (currently in development) (29).
- Strengthening collaboration between human and animal health sectors at all levels.
- Developing laboratory capacity for highly pathogenic organisms.
- Developing real time surveillance beyond notifiable diseases and influenza.
- Conducting regular exercises to test plans for EIDs other than pandemic influenza. Such exercises can provide a realistic method for testing and refining key elements such as Emergency Operations Centres and multi-sectoral rapid responses.
These issues will be discussed further at a one day Public Health Summer School symposium in Wellington on 7 February, which you may wish to attend – Responding to Emerging Infectious Diseases.
The Sciblogs Horizon Scan
This post is part of the Sciblogs Horizon Scan summer series, featuring posts from New Zealand researchers exploring what the future holds across a range of fields.
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- World Health Organization. Emergency Preparedness, Response: List of Priority Diseases 2017 (revised). 2017 30/1/2017]; Available from: http://www.who.int/csr/research-and-development/list_of_pathogens/en/.
- World Health Organization, Consultation on the Health Emergency Risk Management Framework and Improving Public Health Preparedness: Meeting Report. 2013, World Health Organization: Geneva.
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- Ministry of Health New Zealand, National Health Emergency Plan: Infectious Diseases. 2004, Ministry of Health: Wellington.
- Ministry of Health New Zealand, New Zealand Influenza Pandemic Plan: A framework for action. 2010: Wellington.
- Ministry of Health New Zealand. Pandemic Planning and Response. 7/7/2015]; Available from: http://www.health.govt.nz/our-work/emergency-management/pandemic-planning-and-response.
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- World Health Organization. International Health Regulations (2005) Areas of Work for Implementation. 2007; Available from: http://www.who.int/csr/ihr/IHR_Areas_of_work.pdf.
- World Health Organization. Implementation of the International Health Regulations (2005): Report of the Review Committee on the Role of the International Health Regulations (2005) in the Ebola Outbreak and Response. 2016 24/1/2017]; Available from: http://apps.who.int/gb/ebwha/pdf_files/WHA69/A69_21-en.pdf?ua=1.
- World Health Organization, International Health Regulations (2005) Summary of State Parties 2013 report on IHR Core Capacity Implementation: Regional Profiles. 2014: Geneva.
- World Health Organization, Asia Pacific strategy for emerging diseases progress report 2014: securing regional health. 2014.
- World Health Organization, Asia Pacific strategy for emerging diseases 2010. 2011.
- World Health Organization. DRAFT Asia Pacific Strategy for Emerging Diseases and Public Health Emergencies: Advancing Implementation of the International Health Regulations beyond 2016. 2016; Available from: http://www.wpro.who.int/about/regional_committee/67/documents/wpr_rc67_9_apsed.pdf.
- Frieden, T.R., et al., Safer countries through global health security. Lancet, 2014. 383(9919): p. 764-766.
- Centers for Disease Control and Prevention. Global Health Security Agenda. 2014 10/10/2015]; Available from: http://www.cdc.gov/globalhealth/security/.
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- Ng, V. and J.M. Sargeant, A quantitative and novel approach to the prioritization of zoonotic diseases in North America: a public perspective. PLoS One, 2012. 7(11): p. e48519.
- Balabanova, Y., et al., Communicable diseases prioritized for surveillance and epidemiological research: results of a standardized prioritization procedure in Germany, 2011. PLoS One, 2011. 6(10): p. e25691.
- Morgan, D., et al., Assessing the risk from emerging infections. Epidemiol Infect, 2009. 137(11): p. 1521-30.
- Scott, J., Developing New Zealand’s Pandemic Preparedness, [MPH Dissertation]. 2015, University of Otago, Wellington.
- Ministry of Health New Zealand. Response to Suspected Ebola Virus Disease Cases in New Zealand: Key themes from sector and Ministry debriefs. 2015; Available from: http://www.health.govt.nz/our-work/diseases-and-conditions/ebola-updates/ebola-information-health-professionals.
- Ministry of Health New Zealand. Antimicrobial Resistance Strategic Action Plan Development Group. 2016 26/1/2017]; Available from: http://www.health.govt.nz/our-work/diseases-and-conditions/antimicrobial-resistance/antimicrobial-resistance-strategic-action-plan-development-group.