Slide 1 ประชุมวิชาการกลุ่มภารกิจด้านสนับสนุนงานบริการ สุขภาพ ครั้งที่ 3 ปี 2548 การบรรยายเรื่อง ระบบเตือนภัยทาง ห้องปฏิบัติการ ในระดับสากล นายแพทย์สมชาย พีระปกรณ์ นายแพทย์สมชาย พีระปกรณ์ สำนักงานผู้แทนองค์การอนามัยโลก ประจำประเทศไทย สำนักงานผู้แทนองค์การอนามัยโลก ประจำประเทศไทย 2 กันยายน 2548; กันยายน 2548;

Slide 2 Scope: บทเรียนจากการควบคุม ป้องกันโรคระบาดในระดับ สากล ( กรณี SARS, etc.) WHO กับการประสานความ ร่วมมือระหว่างประเทศใน การเฝ้าระวังและสร้างระบบ เตือนภัยโรคที่อันตราย ร้ายแรง

3 V. SARS: lessons from a new disease

4 Exhibit 3: SARS – SERIOUS NEW THREAT * Mortality rates vary by age group 6% (25-44 years), 15% (45-64 years) and >50% (>65 years) Source: WHO; CDC; CNN Severe Acute Respiratory Syndrome Caused by new coronavirus Incubation period of 2-7 days Spread by close person-to-person contact,e.g. respiratory secretions Characterized by fever, cough, shortness of breath and pneumonia Reported cases of asymptomatic carriers Treatment No known treatment to date – currently only supportive care including steroids, antiviral drugs and ventilation devices Isolation and quarantine used to prevent spread Epidemiology High mortality rates of 15%* versus <1% for ordinary influenza Worldwide spread due to globalization, e.g. mass air travel First global health emergency of 21 st century

5 Exhibit 4: DISEASE WITH NO BORDERS Source: WHO 0 confirmed cases cases 101-1,000 cases 1,001-5,000+ cases “In the world today, an infectious disease in one country is a threat to us all.” – Dr. Gro Harlem Brundtland, Director-General, WHO

6 Exhibit 6: DEADLY IMPACT OF SARS WORLDWIDE Tremendous economic cost to economy Severe social impact *Estimates as of June 20, 2003 Source: WHO; World Bank; Wall Street Journal; Asia Development Bank; Merrill Lynch; UK Partnership for Health Over 8,400 cases and 800 deaths in 30 regions* High mortality rates, up to 50% for patients over 60 Disruption of services (e.g schools, hospitals, government services) Public panic (e.g. hoarding, price hikes) $30 $17 $30 $12-28 $20-25 $11 Estimates of global impact US$Billion Estimates of Asian impact US$Billion

7 Exhibit 9: MISSING A SINGLE CASE CAN FIRE UP NEW OUTBREAK Source: Washington Post; Wall Street Journal; CNN April 30 – Toronto taken off WHO travel advisory list May 22 – 60+ new cases, due to one misdiagnosed hospital patient “…Authorities dropped their vigilance in May in a rush to proclaim Toronto safe” – CNN “SARS has demonstrated an ability to come back with a knock-out punch” – Dr. James Hughes, Infectious Disease at CDC Toronto reported first outbreak in early March and place on WHO travel advisory list Risk of additional outbreaks even in well-developed health systems like Toronto

8 Exhibit 10: TAKES ONLY ONE PATIENT TO TRIGGER AN EPIDEMIC SARS “Patient Zero” from China triggered a global epidemic Source: WHO; Washington Post; The Wall Street Journal; Time; U.S. businessman travels to Vietnam Three women from Singapore at hotel Canadian citizen flew to Toronto HK airport worker infected Index case from Guangzhou contracts SARS; checks into Hong Kong Metropole Hotel Index case’s wife, sister, daughter and brother-in-law infected 1 doctor and 5 nurses infected in Kwong Wah Hospital Over 4,000 cases attributable to index case 5 family members are infected Infects 50 doctors and nurses at hospital Kidney patient Over 300 infected in Amoy garden Infects 36 health workers in Hanoi French hospital Infects 198 other Singaporeans Infects 7 factor workers Beijing visitor Infected 17 Air China passengers Infected group of Beijing medical workers Infects mother, father and pastor Other hotel guests and visitors infected Over 27 more infected, including WHO’s Carlo Urbani

9 Source: Washington Post; Wall Street Journal; CNN; PBS; WHO Respiratory viruses and coronaviruses show a seasonal pattern, reemerging in the winter (e.g Spanish flu returned with a 10X higher mortality rate) This fall, every flu patient will need to be initially treated as if they may have SARS! Such a high numbers may lead to lower vigilance and increased risk of missing SARS infections “In just 6 short months, we will see a resurgence of SARS that could far exceed our experience to date.” –Michael Osterholm, Director of Center for Infectious Disease at Univ. of Minnesota “I don’t think SARS is going away.” –Tommy Thompson, U.S. Health and Human Services Secretary Exhibit 11: SECOND SARS OUTBREAK IS POSSIBLE IN WINTER Epidemic curve New cases Time 1918 Spanish flu SARS ? ILLUSTRATIVE

10 The WHO response to SARS 2 Apr.12 Mar. WHO issues first global alert WHO issues second alert and sets out guidelines for SARS WHO issues more stringent advice to travellers and airlines China formally reports outbreak with 305 cases & 5 deaths; WHO Beijing alerts GOARN First recom- mendation to postpone travel to certain areas 16 1st known case occurs in Guangdong, China 27 WHO lab network identifies causative agent Guidelines for infection control issued 1629 Recommen- dation for lab. testing issued 27 May WHA adopts a SARS resolution 5 Jul. WHO says the outbreak is contained 1511 Feb Nov. GPHIN picks up rumour of “flu outbreak” in China 24

11 SARS: 7 lessons learnt l Need to report, promptly and openly l Awareness raised by timely global alerts l Travel recommendations appear to be effective l International collaboration of world’s scientists, clinicians and public health experts is necessary l Weak health systems allow infections to amplify and spread l Existing interventions help containing an outbreak l Risk communication

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 12

13 FLU PANDEMIC, 1918: How the virus spread via ships and trains World population: 1.8 billion Virus spread via troop ships and trains Spread around the globe in 4 months No vaccine available Estimated death toll: 20 to 40 million

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 14

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 15

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 16

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 17

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 18

World Health Organization, Western Pacific Regional Office Communicable Disease Surveillance and Response 19 >10 times higher mortality in October 1918

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WHO COMMUNICABLE DISEASES SARS, June Surveillance network epidemiology and laboratory partners in Asia Mekong Basin Disease Surveillance (MBDS) Pacific Public Health Surveillance Network (PPHSN) ASEAN APEC SEAMIC SEANET EIDIOR FluNet

WHO COMMUNICABLE DISEASES SARS, June Surveillance network electronic partner in Canada: GPHIN

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WHO COMMUNICABLE DISEASES SARS, June Partnership for global alert and response to infectious diseases: network of networks Electronic Discussion sites Media NGOs Military Laboratory Networks WHO Collaborating Centres/Laboratories Epidemiology and Surveillance Networks WHO Regional & Country Offices Countries/National Disease Control Centres UN Sister Agencies FORMAL GPHIN INFORMAL

Slide 27 Surveillance Treatment Diagnosis Lab Access Quality

Slide 28 FluNet: Global surveillance of human influenza, participating labs laboratory > 1 laboratory national net

Slide 29 WHO Influenza Network (FLUNET) Initiated in 1947 WHO Geneva Collaborating Centres for Influenza ATLANTA LONDON MELBOURNE TOKYO Reports Vaccine Formulation Consultations Virus Isolates National Influenza Centres 114 Centres in 84 Countries Diagnosis

Slide 30 Role of lab in surveillance and response Early Detection and confirmation of aetiology of outbreaks Monitoring trends and spread of infections Detection of new agents Detection of Agents of Biological Warfare / Bioterrorism Elimination and eradication

Slide 31 Expected functions of laboratories Specimen collection Specimen processing Specimen transport Specimen testing Recording results Reporting results Establishment of baselines (Serology) Analysis of trends in isolation and identification Drug resistance Monitoring These functions are performed at various levels

Slide 32 Levels at which laboratories can be involved Peripheral (PHC/CHC) Intermediate (District/Provincial/Med College) Regional laboratories (Intracountry) National Reference Laboratories Regional Reference Lab (Intercountry) International (Collaborating Centres)

Slide 33 “Surveillance” … …... the systematic ongoing collection, collation and analysis of data for public health purposes and the timely dissemination of public health information for assessment and public health response as necessary. (IHR2005)

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Slide 35 สรุป กรณี SARS ความร่วมมือ ระหว่างวิชาชีพ และระหว่าง ประเทศนำความสำเร็จมาให้ คนต้องมีระบบสาธารณสุขที่ เข้มแข็งทุกหนแห่ง จึงจะ รับมือภัยคุกคามจากเชื้อโรค ได้ IHR 2005 เป็นพันธะสัญญา ของทุกฝ่ายเพื่อสร้างระบบ เตือนและต้านภัยร่วมกันของ ประชาคมโลก

Slide 36 ขอบคุ ณ Thanks