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Meeting report: WHO informal consulation: Anticipating emerging infectious disease epidemics, 1-2 December 2015, Geneva, Switzerland

21 декабря 2016 г. Всемирная организация здравоохранения

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MEETING REPORT WHO INFORMAL CONSULTATION

Anticipating Emerging Infectious Disease Epidemics

1-2 December 2015 | Geneva, Switzerland

WHO/OHE/PED/2016.2

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TABLE OF CONTENTS Foreword Executive summary 01 Introduction 02 Opening Session 03 Session 1: Back to the future: Learning from the past 04 Session 2: Future epidemics: moving and blurry targets 05 Session 3: Science and technology: opportunities and challenges 06 Session 4: Making the most of Big Brother 07 Session 5: Curing and not harming: that is the question 08 Session 6: Preventing the spread of infectious diseases in a global village 09 Closing session: Convergence and looking forward 10 Major discussion themes Annex 1: List of Participants Annex 2: Agenda at a glance Annex 3: Speakers by session Annex 4: Ideas Wall and Ideas Box 4 5 10 13 14 21 26 33 38 45 50 54 57 61 63 64

FOREWORD One of the greatest threats to global health is the spread of uncontrolled epidemics due to highly pathogenic infectious diseases, especially those that easily cross borders and have the potential to wreak havoc on societies and their economies. The West Africa Ebola outbreak sounded an alarm to all of the actors involved in securing the health of populations by highlighting the critical need for forethought and pre-emptive action, even when dealing with well-known epidemic-prone diseases. Anticipation and preparedness are key to safeguarding global health security. Today we have at our disposal, more than at any other time in history, technological advances and collaborative partnerships that can transcend the outdated tactic of reactive outbreak control. Epidemics are complex phenomena, the details of which must be better understood to rapidly and effectively detect their emergence, control their spread and mitigate their impact. The increasing convergence of a number of factors that drive and amplify outbreaks requires multi-disciplinary, multi-sectoral and multi-faceted approaches. This consultation of experts was an open forum, conducted as the first in a series of steps the World Health Organization (WHO) is taking to further explore and address the complexity of epidemics. By understanding all the diverse elements involved in infectious disease epidemics – not just the pathogens and their hosts but also and in particular the biologic, socioeconomic, and physical environments in which they interact – we will gain a clearer picture of how and when we can best intervene to limit their spread. The discussions and deliberations in this consultation are aiding WHO as it adapts to the changing world of global health, with a clear vision based on solid evidence and a strong spirit of partnership to ensure countries and their health systems are resilient enough to withstand future epidemic threats.

Dr R Bruce Aylward Executive Director a.i. Outbreaks and Health Emergencies and Special Representative of the Director-General for the Ebola Response

EXECUTIVE SUMMARY Background Having the ability to anticipate epidemic-prone emerging infectious diseases will give us the necessary edge to battle outbreaks which are becoming more frequent. This foresight, if reliable, is central to global health security and provides the tools and strategies to reduce avoidable loss of life, minimize illness and suffering, and reduce harm to national and global economies. With the rapid evolution of technology, know-how, and an increasing appreciation of the interconnectedness of everyone on the planet, on 1 and 2 December 2015, the World Health Organization convened some of the world’s most eminent scientists, experts and practitioners to identify a path forward to better, more accurately and systematically predict epidemics and thereby meaningfully strengthen global and national readiness to address these emerging infectious disease threats. The informal consultation on anticipating epidemics was the first step in an intensified initiative to better predict and be ready to respond to epidemics. It aimed to (1) create a forum for discussion by bringing together multi-disciplinary experts in a forward-thinking exercise on how to better anticipate and prepare for epidemics; (2) engage with a wide range of expertise and experience in order to shape international collaboration to tackle future infectious risks; and (3) identify approaches to improve detection, early analysis and interpretation of factors that drive emergence and amplification of infectious disease epidemics. Summary of discussion The experts agreed that the frame has changed fundamentally for preventing, detecting, responding to and managing global epidemics in the recent years. Some of these key shifts include: rom managing known outbreaks we have to manage uncertainties and unknowns •F •F rom relying on official government reports to anyone potentially alerting on unusual events • A proliferation of information and technology in the hands of many, almost everyone, rather than a few •H ealth-centred approach (mostly MOH, WHO) to multisectoral approach (all UN, whole of society, One Health) • Explosion of initiatives and players that require coordination (e.g. GHSA, PEF, NGOs, defence agencies, etc.) •R ather than be centrist, there is a need to engage and empower local communities in all aspects of preparedness and response •H uman activity and behaviour are the main drivers of emergence and amplification of new pathogens (globalization, food, trade, population expansion, urbanization, tourism, migration etc)

Based on this, many traditional concepts and interventions, such as restrictions at points of entry, quarantine measures, are out-of-date and increasingly difficult to implement. They need to be reviewed as international borders become increasingly porous and movement of people and goods follow ever-increasing and crowded paths. Therefore the overall approach to and strategy for preparedness, readiness and response needs to be overhauled. Deploying resources has to be re-thought. Strategies to build trust among an increasing number of players, in turn enabling coordination, need to be crafted and dynamically reviewed as the context evolves. At-risk populations and the communities to which they belong are no longer homogeneous groups in a specific location. The concept of “community“ is increasingly complex and they must each be identified for their beliefs, values, behaviours along with their role in combating epidemics. They need to be understood by their interests and often virtual and dispersed in large geographic areas. Community engagement should be strengthened, especially understanding the “resistance” of local frontline communities affected by epidemics to desired behaviours to manage the outbreak. The role of social scientists in preparedness and response and in two-way communication, especially reaching out to the most vulnerable (e.g. periurban populations defined by inequality and informality), is crucial early in an epidemic. The fundamental and changing role of the health sector in controlling epidemics requires recognition of the key function of clinicians in the early identification of outbreaks. Engaging the community of health care workers who play a critical function in detecting and responding to outbreaks is essential. However, they are often criticized for not following public health principles of infection control measures and vaccination compliance. Acknowledgement of their potential to amplify epidemics as a result of their role within the health system is essential to ensuring appropriate prevention is in place. The number of players interested and involved in preparedness and response to epidemics has increased significantly leading to a coordination challenge of the many disciplines and many sectors with different but important agendas, perspectives and approaches. Participants at the consultation called for an improved management of the “humanitarian circus” where coordination creates space for everyone to contribute constructively. Some of the elements that are needed include a good definition of roles and responsibilities; a good incident management system that allows inter-operability between players; and a willing leadership as well as followership. New technologies allow for a rapid access to many more types of information and their sources than ever before. Given the multidimensional nature of infectious disease risks, integrating data elements from the micro level (genes) to the macro level (social, political, climate, global mobility patterns) would allow for better information systems to anticipate, assess risks and prepare for epidemics. New approaches such as foresight to identify blind spots, popular epidemiology and local risk mapping are to be considered to ensure the relevant analysis of complex events that could give us an added edge to curtailing their amplification. There are still a number of challenges for the use of data (quality, privacy, data sharing, ownership, ethics) and its interpretation (analysis, risk assessment) and eventually translation into actions (political, social, individual). Public health strategies and interventions are based on the traditional biomedical paradigms for infectious disease but these are becoming obsolete. New and emerging paradigms demand that we re-visit the approach accordingly. Early detection can only happen if front line responders (health care workers, clinicians, farmers) are involved in the preparedness, surveillance and response. Endemic problems and known risks

should be utilized to strengthen multidisciplinary and multisectoral preparedness and readiness especially in low resources settings so that prevention is prioritized, for Rift Valley Fever outbreaks that occur regularly. Disease outbreaks may be inevitable but epidemics are preventable. There are known hot spots for emergence and amplification where targeted efforts for preparedness, surveillance, prevention and response should be focussed using the analogy of smoke detectors and fire fighters being in the same place. There is a need to identify those hot spots analysing biological, ecological and behavioural drivers and concentrating appropriate resources and efforts from different players in specific at-risk settings to ensure more sustainable and robust investments. Multidisciplinary outbreak investigation teams including social and political scientists as well as risk communication experts are needed to fully understand the risks and, barriers to response actions and identify the most effective options for containment within the early phase of the epidemic. Many new technologies (diagnostics, software applications) are now available to improve detection and control of epidemics that need to be better integrated into mainstream public health strategies and systems. Nevertheless, it is people who remain at the centre. Improved education and training is necessary for the epidemic prevention and control workforce of tomorrow to be in line with contemporary and future risks and interventions. Risk communication is perhaps the most essential element of the response to epidemics in the 21st Century. Communication can hamper or facilitate a good response. With ubiquity of the internet and communication technologies, modalities of risk communication have changed fundamentally. Principles of transparency, consistency and trust remain paramount in communicating with affected populations. New elements to consider and to be better understood for the future are the social-emotional patterns of fear and hope in communities and individuals and the social thermometer of risk perception. It is necessary to have multiple channels of communication including local and religious leaders not only during the an epidemic but also during inter-epidemic periods. Health care givers who are usually the most trusted information source for the population have to adapt to new technologies and use them appropriately to remain a solid pillar of the response. Conclusion Three major conclusions emerged from this consultation: (1) j ust response is not enough in dealing with epidemics. Preparedness for outbreaks requires increased readiness and building resilient health system. (2) t echnologically advanced tools are required to anticipate the emergence and, more so, the amplification of infectious disease outbreaks. (3) n ew risks in the context of big cities and intense mobility of a globalized world necessitate newer, better adapted public health interventions. Effectively anticipating epidemics will contribute to reinforcing global health security mechanisms including assessment of infectious disease risks under the IHR 2005. It is expected that the outputs of this consultation will inform and guide preparedness efforts in the future.

01 INTRODUCTION Background and purpose The world stands at a critical juncture in public health. Epidemics of infectious diseases are able to disrupt many spheres of human existence and the impact can be felt across the globe. To better prepare for and respond to those threats, it is imperative that we make fundamental changes to the way we understand them. Significant changes in the world today, mean that it is not enough to just implement traditional measures such as quarantine and isolation for epidemic control. We have to move beyond and find innovative approaches that are relevant for today’s fast-paced, technologically-advanced world and, more importantly, that of the future. Recent major public health crises such as the SARS, H1N1 2009 Pandemic and Ebola in West Africa have unequivocally demonstrated the importance of understanding the many non-biomedical factors that influence the emergence and spread of epidemics. There is no doubt that such epidemic and pandemic diseases will continue to threaten humanity. Following the re-emergence of H5N1 and the spread of SARS, WHO Member States adopted the revised International Health Regulations (IHR 2005). After Ebola in West Africa in 2014, the global community is similarly looking at the necessary mechanisms to better protect humankind from devastating epidemics. We have the benefit of hindsight and an unprecedented opportunity to revamp our collective approach to preventing and controlling epidemics so that we can mitigate their impact. As a forward-thinking exercise, this meeting engaged a broad range of global experts from multi-disciplinary fields along with key stakeholders and partners to define the elements within which epidemics of the future will occur. The ideas and deliberations elucidated some of the drivers of emergence and amplification of infectious disease outbreaks. It is expected that the outputs of this consultation will guide and inform future preparedness; calibrate response, including research and development efforts; and reinforce global health security mechanisms. Objectives The specific objectives of this consultation were: o create a forum for discussion by bringing together multi-disciplinary experts in a forward-thinking •T exercise on how to better anticipate and prepare for epidemics; •T o engage with a wide range of expertise and experience in order to shape international collaboration to tackle future infectious risks; •T o identify approaches to improve detection, early analysis and interpretation of factors that drive emergence and amplification of emerging disease epidemics.

Methodology The consultation was designed to include a variety of disciplines and partners relevant to emerging infectious diseases from all over the world. The structure of the meeting entailed moderated panels for each of six sessions followed by extensive discussion with the audience. The panelists’ remarks were restricted to five minutes each with the aim of engendering as much dialogue amongst the participants as possible in order to spark ideas and exchange. The meeting followed Chatham House rules whereby comments are not directly attributed to individuals in order to maintain their confidentiality and therefore allow them to speak candidly. The full proceedings of the meeting were recorded in real-time by a “live scribe” who graphically represented the topics and issues as they were being discussed. These graphic posters along with biographical sketches of each of the participants; abstracts of the panelists; video interviews; and the presentations from each of the sessions are available on the WHO meeting website (http://www.who.int/csr/disease/anticipating_epidemics/ events/informal-consultation/en/). This report summarizes the proceedings. To capture additional ideas and thoughts, participants were encouraged to write these down and post them on an “idea wall” or put them in a box. These comments have been collated and can be found as an annex to this report (Annex 4). This report itself provides a brief summary of the interventions by moderators and panellists and a summary of the discussion with the audience.

02 OPENING SESSION Dr R Bruce Aylward, acting Executive Director of WHO’s recently established WHO Health Emergencies Programme, said the new Programme has been one of several responses by the Organization in the face of the increasing frequency of epidemics in recent years, their increasing severity, and their destabilizing effects on nations, regions, and – in the case of Ebola virus disease – the world. It is clear that health systems have to be better at anticipating outbreaks so that responses can be more rapid and effective. The enormously complex challenge of doing so will be made more difficult by broad trends such as urbanization, deforestation, and climate change. Accordingly, those present at the meeting included not only health experts but experts in the environment and meteorology, the social sciences, information and communication technology, and other fields. It was important to remember that whatever highlevel or technically complex steps are taken in coming years, they will depend for success on what communities do: non-experts have to be able to understand disease threats and often have to be persuaded to change traditional behaviours. “If we don’t get that right,” Dr Aylward said, “it will be very hard to combat epidemics.” Dr Sylvie Briand, Director of the WHO Department of Pandemic and Epidemic Diseases, said upcoming crises likely will be different from those recently faced. Steps can be taken to define possible scenarios, to guide preparedness, and to build in the flexibility necessary for responding to the unexpected. The goal is to have a global system that allows for anticipation, for early detection of emerging disease threats, for rapid containment, and for mitigation. Fig. 1: Drivers for emergence and amplification

Anticipation

Early detection

Containment

Mitigation

EMERGENCE

Localized transmission

OUTBREAK

Ampliﬁcation

EPIDEMIC

CONTROL

DRIVERS FOR EMERGENCE

DRIVERS FOR AMPLIFICATION

03 SESSION 1

Back to the future: Learning from the past This first session focussed on lessons learned from the recent epidemics of Ebola, H1N1 pandemic, SARS and the collective global response to similar emerging disease epidemics. The moderator highlighted that though we know that we must learn from our past experiences, we tend to have a forgetful memory. Anticipating new outbreaks and for epidemic risk assessment and risk management a better understanding of human factors is required in order to understand the impact of changing global trends including intensification of air travel and migration, political upheaval, climate change and deforestation, and new communications tools. We need to modernize and put at the forefront the social sciences for making decisions by focussing on trust, behaviours, and beliefs. The session explored the following key questions: • What are the critical lessons to be learned from major recent epidemics? • What signals and information should we have anticipated that made “routine” events extraordinary? • What are the drivers of emergence and amplification that can turn an outbreak into an epidemic? • What important drivers need to be integrated into the risk assessment? •H ow can we enhance our preparedness and response by “thinking outside the box”? Ebola in West Africa: drivers and lessons learned Seven countries in Africa had Ebola outbreaks in 2014-15. In three countries, there were devastating events; but in the other four the spread was contained. Rapidly detecting the imported cases and establishing accurate laboratory diagnosis of the infection, they introduced classical infection prevention and control (IPC) measures to successfully contain Ebola virus disease (EVD) from spreading widely in their territories. These countries demonstrated that given basic facilities and infrastructures, combined with strong political leadership, effective coordination of an immediate and aggressive response, disease outbreaks can be controlled before they become major public health events. Securing the health of citizens of a nation, including protection from the ravages of disease outbreaks, is the primary responsibility of the government of the nations in which they occur. This first session focussed on lessons learned from the recent epidemics of Ebola, H1N1 pandemic, SARS and the collective global response to similar emerging disease epidemics. The moderator highlighted that though we know that we must learn from our past experiences, we tend to have a forgetful memory. Anticipating new outbreaks and for epidemic risk assessment and risk management a better understanding of human factors is required to understand changing global trends including intensification of air travel and

It is primarily the national governments’ responsibility to ensure their populations are protected from epidemics. This requires not only a strong health system but also government-led coordination with many non-health sectors.

migration, political upheaval, climate change and deforestation, and new communications tools. We need to modernize and put at the forefront the social sciences for making decisions by focussing on trust, behaviours, and beliefs. Ebola in West Africa: drivers and lessons learned Seven countries in Africa had Ebola outbreaks in 2014-15. In three countries, there were devastating events; but in the other four the spread was contained. Rapidly detecting the imported cases and establishing accurate laboratory diagnosis of the infection, they introduced classical infection prevention and control (IPC) measures to successfully contain EVD from spreading widely in their territories. These countries demonstrated that given basic facilities and infrastructures, combined with strong political leadership, effective coordination of an immediate and aggressive response , disease outbreaks can be controlled before they become major public health events. Securing the health of citizens of a nation, including protection from the ravages of disease outbreaks, is the primary responsibility of the government of the nations in which they occur. New perspectives on outbreak response after SARS in Canada SARS was the first major international event of this century which showed that any local crisis can become an international problem and that no country can consider itself isolated from the impacts. In many ways it is an example of what might be expected when the next global outbreak occurs. Secondary effects were felt beyond surveillance, morbidity and mortality in terms of travel and transportation, social services for quarantined persons, huge economic consequences for the city, media frenzies, political

Preparedness requires planning and exercising to be rigorous. But in the midst of uncertainties, the response must allow for nimble and flexible implementation of strategies to meet actual needs.

concerns, and more. The experience raised the spectre of a more easily transmissible agent that will produce even greater, farreaching distress. A mild H1N1 pandemic: critics and anticipation There are medical interventions such as vaccines and antivirals available for influenza but their use raised a number of criticisms and suspicions in many affected countries with parliamentarian investigations after the 2009 H1N1 pandemic crisis. As the world had been preparing for the next pandemic for many years, response plans were deployed including the rapid development of pandemicspecific influenza vaccine and the use of antiviral stockpiles (in those countries where they were available). The overall impact of the pandemic was ultimately considered comparable to that of a moderately severe influenza season. Criticism of over-reaction was voiced and many lessons were learned that led to revision of the WHO global approach to pandemic influenza as well as to national response plans. Multidisciplinary response: strengths and challenges Different partners exist, including non-health sector ones, and they each bring different points of view, perceptions of the risk, and how to address the problem. Emergency response brings actors from many UN agencies, national organizations, civil society (the NGO “community”), and the private, for-profit sector. This is sometimes referred to as “the humanitarian circus”. Lack of a strong and effective ringleader results in a humanitarian response from the health sector that is usually relatively uncoordinated, unsupervised, and totally unregulated. The solution is to empower countries, with technical support of WHO and convening power of the UN system, to develop “whole of society” operational plans; exercise and regularly update them to ensure that local, national, regional and, if feasible, international authorities are able to implement technically sound and fully coordinated assessment and response activities. The role of NGOs and health sector partners Many different institutional actors including NGOs, particularly those that are faith-based, are important providers of health care in poorer parts of the world. The West Africa Ebola experience highlights the speed and adaptability of non-governmental humanitarian actors, it underscores the importance of their role in responding, but it also reflects the need to partner with NGOs to increase their capacity to address non-traditional hazards, including infectious disease outbreaks. NGOs must be considered equal and vital partners in epidemic preparedness, response and recovery as the Africa Ebola outbreak shows including coordination, working alongside UN and local and foreign governmental agencies. Looking ahead we need to consider the opportunities to improve partnerships and enhance our collective response capacity to future outbreaks, building on our comparative advantages. STAGE 2 LOCALISED EMERGENCE

Fig. 2: Stages of epidemic emergence STAGE 3

PANDEMIC EMERGENCE

STAGE 1

PRE-EMERGENCE

All humanitarian actors must be recognized and their complementary strengths enhanced for infectious diseases. Coordination during a response should bring them together for collective action but with countries in the lead. Emergence of pandemic zoonotic disease (ref: Morse SS et al Lancet 2012; 380: 1956-65)

04 SESSION 2

Future epidemics: moving and blurry targets The session moderator highlighted the progressive stages of emergence of epidemics from wildlife and livestock pathogens crossing over to humans, resulting in a zoonotic outbreak and sometimes becoming human-to-human transmissible (e.g. SARS and MERS-CoV). This last stage is too late to contain novel pathogens and so the question remains: can we anticipate microbes in the animal sphere and assess their risk as potential pathogens for humans? H1N1 was not a failure of the signal but a failure in our understanding of the virus. Can we identify common patterns for emergence and control at source? This requires a better understanding of what is circulating in animals but this is a huge list so how to prioritize? How do we assess risk given the diversity of potential microbes? To understand whether zoonotic events precede transmissibility from human to human some knowledge gaps exist, for instance: nfluenza – there has been an attempt to structure risk assessment using IRAT (CDC) and ECDC’s risk assess•I ment tool. Should we do the same for other diseases?

•R outes of transmission, host factors, genetic diversity of viruses among human populations. Can we identify common pathways by which they emerge? For influenza: interventions that we know will trigger emergence. Finally, the issue of emergence of epidemics coming from animals requires an integrated approach of One Health (human, animal and environment). The session explored the following key questions: •H ow can we better use our knowledge of the human-animal interface to anticipate and respond to emerging infectious diseases? •W hat could be the impact of the new infectious disease paradigm (microbiota) on the understanding and control of outbreaks? •H ow can we holistically and systematically apply our knowledge on the human-animal interface and the microbiome to mitigate epidemics? • What concrete steps can be implemented to anticipate emergence and prevent amplification? Knowledge on microbiome and research In the past centuries, the classic Pasteurian paradigm, in which the pathogen comes from outside the host, has shaped the strategies and methods for control of infection and epidemics. Cutting-edge research on the human microbiota has revealed that a new paradigm of pathogen-host interaction is required. Gut microbiota have co-evolved symbiotically with the host with functions ranging from absorption of nutrients and contribution to the development of the immune response. The concept of invasion of the host by a pathogen is therefore complicated by the theories of the imbalance within the host’s own bacterial ecology, i.e. the the microbiome, rather than simply invasion of the host by a pathogen from an external source. The development of therapeutic and preventive interventions and diagnostic methods being explored in addressing gut microbiome disorders range from nutrition complements to stimulate immunity to fecal transplantation to treat gut infections.

Fig. 3: E cological determinants of the respiratory microbiome MICROBIAL IMMIGRATION Microaspiration Inhalation of bacteria Direct mucosal dispersion MICROBIAL ELIMINATION Cough Mucociliary clearance Innate and adaptive host defenses REGIONAL GROWTH CONDITIONS Nutrient availability Oxygen tension Temperature pH Concentration of inﬂammatory cells Activation of inﬂammatory cells Local microbial competition Host epithelial cell interactions REGIONAL GROWTH CONDITIONS SEVERE LUNG DISEASE

IMMIGRATION & ELIMINATION HEALTH

It is imperative that we continuously understand and apply the newest scientific tools and knowledge to respond to emerging diseases. New opportunities from the field of the microbiome must be exploited for health. From science to action: microbiome and respiratory diseases Modern, culture-independent techniques have revealed that healthy lungs are not sterile as once believed but harbour diverse communities of micro-organisms. Many questions remain unanswered regarding their role including respiratory dysbiosis in pathogenesis and treatment; whether they can be manipulated for therapeutic effect; and how viruses affect the ecology of respiratory tract. Research is ongoing to address important insights into the pathogenesis of acute lower respiratory tract infections, the role of epidemic viruses in causing or triggering severe respiratory disease, and identification of novel therapeutic or prophylactic interventions. Managing the risks of emergence at the animal level We are all inter-connected. From the animals that populate our human environment on which we rely for food, draught power, savings, security and companionship, to the wildlife inhabiting sky, land and sea. Early warning of disease events is critical. Livestock health is the weakest link in our global health chain, and disease drivers in livestock as well as wildlife have increasing impacts on humans. To respond effectively the following are necessary: (1) evidence to understand problems and opportunities for change; (2) enabling inter-sectoral dialogue and information exchange; (3) raising awareness, promoting health-conscious innovation, improving the way we produce, buy, sell and consume animal products; and (4) enhancing how we jointly investigate and respond to health threats.

Our inter-connectedness with our environment requires close cooperation with joint actions between animal and human health. The two networks must be systematically linked and engaged for preparedness as well as response.

Dickson RP, Huffnagle GB. PLoS Pathog 2015, 11(7): e1004923

Human-animal interface: anticipating risks of emergence Identification of the first cases, i.e. the first clusters, of a disease and to subsequently limit the spread of the disease can only be achieved with improvement of capacities for early detection and notification of sanitary events observed in animals. That means better knowledge of zoonotic pathogens through research programmes and development of laboratory networks etc. But it is also critical to connect with the people who are in close contact with animals as they can serve as sentinels. It is important to combine sophisticated scientific work with studies of predictive epidemiology and multidisciplinary fieldwork to obtain good quality data and to coordinate and organize networks that can disseminate these data.

Fig. 4: Drivers of Zoonotic Disease Emergence (Adapted from USAID/Predict project) Ecological Drivers Land Use Climate Change Natural Resource Extraction Economic Development Migration

In order to enhance anticipation of epidemics, ecological risk assessment methods to identify drivers of emergence and amplification will present a holistic picture and enable improved risk reduction and mitigation measures. Ecosystem surveillance: predicting the next emergence? USAID’s EPT (Emerging Pathogenic Threats) Program has advanced the understanding of ecologic and behavioural drivers underlying zoonotic disease emergence and reshaped our approaches to disease surveillance as well as strategies for preventing the emergence of new threats. Advances in genomics and informatics have further expanded our understanding of the biology of disease emergence and provided indications to how we we can approach the early detection of future threat (ecological, behavioural and biological drivers). Two areas of ongoing work being supported under USAID’s EPT program are “prediction of emergence” and assessing the potential for the “prevention of emergence” looking at evolution and spread.

Behavioral Drivers Bush meat consumption Animal production & marketing Animal-human interfacing Globalization

Biological Drivers Re-assortment Genetic drift Host factors

05 SESSION 3

Science and technology: opportunities and challenges

The session moderator emphasized that new and different solutions were needed to strengthen national and subnational capacities to make sure they are at the optimum. This would be complemented by “planetary security” – global security at its broadest with supra-national institutions, e.g. the UN system, NGOs, partners should work together as equal partners. The weakest link argument is more relevant rather than the old cliché: “diseases respect no borders”. Health and health care industries have to look at the aviation industry, new development banks, insurance and financial sectors and to R&D. The R&D solutions mean innovations and technological solutions. How should we direct the R&D and incentivise manufacturers to make the needed investments and ensure their products come to market? By putting patients and communities back at the centre. The session explored the following questions: ow can new scientific advances and technologies influence the surveillance, detection and control •H of emerging pathogens? •W hat is the impact of increased accessibility, availability and visibility of technologies on risk perception and how should communication strategies be adapted to make them successful? •H ow can we best use new technologies to rapidly detect, communicate and respond to epidemics? • What tools can help to better engage the communities and other actors in outbreak response?

Health security requires application of a dynamic shift to find new solutions to old problems using the best science and technology has to offer. But application of new tools and approaches means opening our traditional health perspectives to views from other disciplines.

What’s new for surveillance and detection? Targeted single isolate detection has been a valuable tool, however, the dramatic increase in emerging and mixed microbial infections, and rising association of food-associated and intestinal microbial community in human and animal health and wellness has led to a need to identify the entire microbial community to understand the dynamics of infections. The ability of next generation sequencing to generate large amounts of DNA sequence data has considerably facilitated metagenomics studies, including of food-associated and intestinal microbes. Specific applications of metagenomics in food safety include, among others, (i) identification, from clinical specimens, of novel and non-culturable agents that cause foodborne disease; (ii) characterization of microbial communities (including pathogens and indicator organisms) in foods and food associated environments (e.g., processing plants); and (iii) characterization of animal and human intestinal microbiomes to allow for identification of microbiota that may protect against infection with foodborne pathogens.

What’s new in diagnostics? Many of the tools first deployed in life sciences research have now been turned into clinical in vitro diagnostic devices with fitfor-purpose features that make them attractive for use in many developing world settings. Ease of access is a key element, i.e. local staff near patient settings without special training and an ability to transmit resultant data in real-time. There are a number of opportunities provided by these advances in technology. Now a new generation of immunoassays is in development that offer multiplexing, quantitation, automation, and electronic reporting and molecular testing systems have been developed for clinical use that automate specimen processing, amplification, detection, and wireless reporting. However, there are some persistent obstacles to their broad impact in public health. Investment for diagnostics development is necessary in the inter-epidemic period along with a global architecture by harnessing partnerships to deploy earliest in an epidemic.

To systematically build preparedness and response capacities investment in innovations and new technologies must be harnessed during inter-epidemic periods. Advances in biology and their applications Nature is still better at producing human threats than we are. For detection and analysis, biosensors from synthetic biology (DNA sequencing and engineering) may enhance our capabilities in differentiating closely related strains. For instance, metagenomic sequencing to analyse patterns that drive diseases. For known emerging infectious diseases, synthetic biology may help by developing support methods for existing technologies such as combinations of biotechnology and nanotechnologies. Analytic and database tools are being put together. Response in the form of treatment or prophylaxis is the area where synthetic biology can greatly enhance our capabilities as well as accelerate vaccine development. But getting the product to the people and making it viable is the basic principle for responsible research in science and technology. Risk perception and community engagement Risk perception is the core to how an individual and community understand, interpret and react to risk and it influences decisions about the acceptability of risk and behaviour before, during and after the risk has passed. Ability to translate information from global

Information technology is ubiquitously owned by everyone which brings with it risk perception challenges. Community engagement and risk communication tools are critical components of any epidemic response.

level into language that is understood by communities is vital so that complex information on risk is understood within societal and cultural influences and is aligned with actual risk to communities, as accurately as possible. The revolution of social media and dire need of better and faster risk communication has driven the use of more technologies including mass SMS, radio, internet (Facebook, social media), but interpersonal communication is still the way we make a difference when psychosocial support is required. Challenges remain as to how to use the networks of Red Cross volunteers (17 million) to pass messages at scale and use them in an alert system. Communicating in the 21st Century Central importance of communities and community ownership highlights the central importance of people taking actions. Five key principles in community engagement are: (1) trust - source of information needs to be trusted by building trust in the health system and through intermediaries; (2) listening is as important as messaging – build on communities’ reference and understand the cultural context (3) professionalism – communication cannot

be improvised so it is imperative to build national capacities; (4) ensuring coherence in complex fields – interagency cluster system; and (5) communities compare information from multiple channels so there is a key role for innovations. Investment for the long-term is needed because we cannot just start at the beginning of the outbreak, rather resources are needed for preparedness.

06 SESSION 4

Making the most of Big Brother The session moderator described the UK’s experience with the Olympic Games in London. As much good information as possible was collected through laboratory and syndromic surveillance in which 30 million people were registered and trends observed. Some of the more challenging questions that were dealt with were: what is the baseline? When does it change? When is it significant change? They are now using social media, the added value of which remains to be seen. The session explored the following questions: ow can real-time information be better used for timely and relevant responses? •H •F orecasting: what can public health learn from other sectors? •H ow can big data approaches be applied to enable epidemic anticipation? •H ow do we capture, collect and optimally analyse data on the drivers and amplifiers of epidemics? •W hat can the health sector learn from other sectors that are further ahead in using newer technologies to anticipate risks? Modelling outbreaks: pros and cons Modelling goes hand in hand with analysis and is not a theoretical exercise. The cycle involves preparedness, real time analysis, and retrospective analysis with on-going monitoring during an event. Modelling can help with “what if” scenarios. It can be a retrospective “what if” (impact of strategies implemented earlier) and it can be a simulation for preparedness, considering a possible set of scenarios. Challenges include access to (timely) data for analysis, who will see the result and if widely available how will they make sense out of it, how to separate the noise from the signals, and how to coordinate a modelling group(s) to get the best value out of them?

A number of newer, more extensive, real-time data sources and analytic methodologies have become available that will allow us to better anticipate outbreaks and their evolution. It is time to apply these at a global scale.

Use of big data to anticipate epidemics and their evolution Understanding migration and human mobility is critical in infectious diseases providing important insights into risk. Of the almost 6 trillion kilometres travelled 1/6th comes from just the US and a quarter from just three countries: US, UK and China. Hotspots for risk are linked to unequal distribution of movement. In the last 10 years there has been a 60% increase in mobility which is accelerating quicker and faster than our ability to prevent and control infectious diseases; we are getting better at amplifying threats by our global movement. There are better opportunities to get data: internet (GPHIN / ProMed), meteorological (satellite), smartphones with computing power, and social, behavioural, cultural aspects of epidemics. We are working on many kinds of data (open data, from industry, personal health information) but we have to overcome the following challenges: managing a growing volume of data; security/privacy issue; mechanisms to share data; who is going to have access to this data (who is Big Brother?). We need some entity to have a panoramic view – an incident manager – whom we can all trust.

We can learn from other sectors that have analyzed large, dynamic datasets for prediction, such as meteorology and insurance, and adapt their concepts, techniques and strategies for epidemic anticipation.

Fig. 5: SARS, chain of human-to-human transmission, Singapore 2003

Index B

husband

3 patients (TTSH)

7 visitors of TTSH

10 HCWs (TTSH)

C mother died at home undiagnosed Changi General Hospital National University Hospital Healthcare worker Tan Tock Seng Hospital

son HCW (CGH) son visitor HCW (NUH) (NUH)

patient

CGH NUH HCW TTSH

father

playmate HCW (CGH)

4 HCWs (TTSH) (Source: Tan Tock Seng Hospital, Singapore)

Learning from successes in meteorology Evolution of technology since World War II has been a success for weather forecasting which is based on collection and sharing of large amounts of data, thanks to satellites, resulting in real-time sharing to the point where data is gathered every six hours from satellites airplanes and ships, down to a resolution of 15 kilometres. Availability of data is not the only element (only 20% of satellite data is used). The big question is how we translate these data using mathematical models and simulations. What matters most is “initial conditions” after which, using additional new information you correct your initial guess. Weather forecasting has moved from a deterministic to a probabilistic approach. By providing probabilities you share the responsibility whereby interpretation of the probability is left to the user. Key questions remain on how far we can go (i.e. seasonal forecast) and what kind of details we can provide (i.e. 500 or 100 metres)? Learning from the insurance expertise Health surveillance is often a rather reactive process, with no real integration of early signals and wild cards. As a consequence it is difficult to detect radical changes having a strong impact on public health in the medium or long term. To embed this proactive dimension and increase proactivity, foresight is a key approach to use and many such methods exist among which the scenario approach will be explored. In describing possible future scenarios, as well as the elements in favour of one scenario rather than another, health surveillance can help decision makers to influence the context in order to guide towards one or more favourable futures.

A key issue is the use of different kinds of data to make decisions BY whom, FOR whom? Data ownership, privacy, confidentiality, quality etc are considerable challenges that must be address for the use of big data.

07 SESSION 5

Curing and not harming: that is the question The session moderator highlighted the impact on healthcare workers during Ebola and SARS as an example of the critical importance of the health system in handling all kinds of emergencies. But these healthcare workers require the best support possible in terms of training and tools to ensure they serve as a positive influence in managing epidemic emergencies rather than have a negative impact due to poor practices. The session explored the following key questions: •H ow can the health systems of the future minimize the risk of amplifying epidemics and what elements must be in place to mitigate impact of epidemics? •W hat kinds of innovations in medical technologies and patient care will improve epidemic detection and control? •W hat kind of research is needed for the 21st Century to better address the challenge of emerging pathogens? •H ow can we change routine clinical practices including adaptation to cultural beliefs and practices to better prevent and manage infections? Clinical practices and emerging diseases Key lessons learned from the MERS-CoV outbreak in Saudi Arabia include: never underestimate a novel virus; get prepared (planning, training, evaluation and auditing); ensure safe hospitals with security check points; “outbreak quad” (overcrowding, absence of triage, low index of suspicion, non-adherence to IPC measures); sick patients are efficient in getting and efficient in transmitting MERS-CoV; transmission happens because of what we do and not because of what the hospital looks like; administration involvement is critical; line of communication with communities is necessary for mobilizing them; disease does not respect national borders; build a national surge plan.

It is vital to recognize that the health care system can propagate outbreaks just as it can contain them. This requires proper management of the entire system, not only one aspect such as infection prevention or one element such as the health worker.

Systemic view of infections in health care facilities From Ebola we learned that adherence to simple and basic measure such as hand hygiene is more important than building high-tech facilities. At the same time we also learned that high-tech facilities can help contain the infection, providing an argument for building well-equipped health care institutions in the developing world as well. Health care institutions of the future should amalgamate modern strategies to improve human behaviour and at the same time build and design health care facilities to provide a safe environment with the least risk of creation of dangerous pathogens and amplification of the spread of infection. Patient–doctor relationship at the age of the Internet By offering free, unlimited, easily and anonymously accessible health information, the web and social networks incite patients to take more control over their own health. As a result the patientprovider relationship is evolving such that patients often expect to discuss and sometimes challenge their doctors’ recommendations. Health professionals’ role needs to evolve, and in this regard, one size does not fit all. Healthcare providers need to take into consideration the health behaviour profile of their patients in order to build and maintain a trusting relationship.

Health care facilities are defined by the physical infrastructure but the human factors and people who staff them are the most important and must be addressed explicitly to ensure appropriate containment of outbreaks.

Fig. 6: Ebola Haemorrhagic Fever by mode of transmission, Kikwit Zaire, 1995 (Source: WHO/CDC) 16 14 12 10 8 6 4 2 0 713- 19- 25- 316- 12- 18- 24- 30612- 18- 24- 305- 11- 17Jun Mar Mar Mar Mar Mar Apr Apr Apr Apr Apr May May May May May Jun Jun

Non health care workers Health care workers 315 cases 250 (80%) deaths

Impact of strengthening the overall health system When implemented adequately, comprehensive components of health system strengthening should contribute to mitigating the impact of epidemics. The most deadly epidemics occur generally in low-income countries where governments’ investments in health remain low despite their political commitment. Unless this lack of ownership is addressed, health system strengthening sustainability is doomed to failure. Among critical issues for the future are: (i) a thorough multi-stakeholders health system assessment/ review identify gaps; (ii) a “menu à la carte” of low cost and high impact interventions to address gaps; (iii) learning from previous experiences on inter-country cooperation; (iv) enhance socioanthropology component of health system strengthening.

Patients can now take responsibility for their own health-related behavior as a direct result of widespread availability of information. Providers need to capitalize on this dynamic to forge new relationships with their patients.

08 SESSION 6

Preventing the spread of infectious diseases in a global village The session moderator highlighted the issue of defining global drivers and addressing risks in this world where interdependence and interconnectedness clearly show how global security has changed. Outbreaks and diseases are seen as destabilizing factors in the new health security paradigm where security is contrasted with global public good and solidarity. Risks are always defined virtually so the notion of threat becomes very important, i.e. who is defined as vulnerable and has to be supported? Managing risks means also managing the political dimension. Risk definition is a power game: who defines the risk? who holds the narrative? Looking from a WHO perspective, who gets to define a PHEIC – a committee of technical experts or a publicly elected director? The session explored the following questions: ow can we include socio-economic and political determinants into outbreak control? •H • How can we modernize “traditional” control measures (isolation, quarantine, culling etc) in today’s world? • What are the politics and political challenges of responding to escalating outbreaks? hat are the key drivers of epidemics in today’s interconnected global ecosystem and the evolving •W social habitat? ow to better engage with societies of today for preparedness and response to epidemics? •H •W hat public health measures should we revisit and/or adapt, and how do we move from a biomedical approach to a more holistic one?

Table 1: The Evolution of Global Health Security Past (19th to mid-20th Century) Present (20th Century) International Sanitary Regulations List-based. Cholera, plague, yellow fever (smallpox, typhus, relapsing fever). Quarantines, limit restrictions to trade and travel Physical Infrastructure (trade routes) Disjointed response Country-based response International Health Regulations PHEIC (emerging infections including bioterrorism)

Proposed Future (21st Century) International Health Security Framework All public health emergencies, including climate change, emerging infections, antimicrobial resistance, & synthetic biology

Improved Reporting & Building National Prevention & Preparedness at National Level Capacity Post-Industrial Infrastructure - electricity, electronics Revolutionary international law and global governance but still fragmented Multilateral response Knowledge Infrastructure Integrated Shared Information Response Global Response Teams Response Contingency Fund Global Fund for Health Security Predict and Prevent (managing uncertainty) Everybody Global Health Security Preparedness Index UN Under-Secretary for Health Security (multi-sectoral)

Surprise Official government reporting No reporting of capability to meet the regulations French government. 14 International Sanitary Conferences

Expect (managing certainty) Non-state actors (organizations & media) Self-assessments WHA (health centric) & WHO

Evolution of health security concepts Health security at a national level is broad-based protection, response, and recovery efforts to ALL public health threats and it requires capacity in ALL countries centred on government ownership and responsibility. Current reform efforts should consider establishing an essential core in all countries consisting of an emergency operation and data fusion unit with domains derived from the IHR. Fire-fighters and smoke-detectors – one and all, we are in the prevention business. However, ensuring global health security is not just a function of the health sector and requires national level leadership and the in-country support and planning of multiple other sectors. The drivers include changes in genetics and biological factors, ecology and the physical environment; human behaviour and demographics; and social, political, and economic factors. They must all be part of one system.

A whole of society approach to health security must include diverse disease drivers: genetics and biological factors, ecology and the physical environment; human behavior and demographics; and social, political, and economic factors Revisiting traditional containment measures The key to success is aligning incentives of victims, the exposed and a fearful public by building trust and investing in community supports. This means not only food, water, early diagnostics, available treatment and prevention; but also psychosocial support in culturally relevant manner through empowerment. We must recognize the limited times when compulsory measures of isolation and quarantine are necessary and not fear to use them sparingly and in time-limited fashion. The use of public health measures must delicately balance a fearful public without stigmatizing victims while justifiably controlling transmission through restrictive means. Transparent communication prior and during implementation is paramount in building support and trust for such a complex task. Managing epidemics in urban settings The challenges associated with managing epidemics in urban areas are particularly acute in low and middle income countries with public sector resource and capacity constraints, and weak health systems. It is noteworthy that inequalities in living circumstances, incomes and access to services has become a feature of many large cities, which can leave people in certain parts of a city more vulnerable to disease because of trade-offs between health and livelihood. The implications of urban inequalities and urban informality for health risk in urban areas and for seeking strategies for preventative responses that could mitigate risk and build resilience in urban and peri-urban areas require a better understanding of local contexts and perspectives. Local innovations for risk mitigation and control require pragmatism in risk assessment within a “safe” informality.

Local contexts (e.g. urbanization) as well as global ones (e.g. migration, travel) must all be addressed to mitigate risks to the most vulnerable with particular attention to economic, social and political drivers and impacts.

Epidemics and tourism Travel and tourism is a growing important economic and societal activity. Many countries are using travel and tourism as a priority tool for economic development. The sector is heavily dependent on an intact environment, whether this is natural, cultural, social or human or animal health environment and thus, can be easily affected by negative events such as epidemics, as it is a trust and belief product. Close cooperation with WHO and other key actors is critical to provide timely information and to promote safe travelling behavior, while ensuring uniformity in information sharing, developing practical response strategies, and providing recommendations for the tourism and travel sector. Political perspectives of global risk Political authorities face three major challenges in responding to epidemic threats: •H ow to apply in the 21st century traditional public health measures in a complex, mobile and selfish society in crisis? • How to talk about risk and uncertainty given the approach adopted by new media sources such as internet? • How to guarantee fair access to resources in case of a crisis in democratic societies? Political choices are described for preparation of societies and health system changes. Key actions are highlighted to fight threats associated with emerging infectious diseases: raising public awareness through information; coordinating multiple sectors and multidisciplinary methods; preventing non-health threats to health; promoting traditional prevention protocols as well as new tools for combating epidemics; manage operational health systems elements; and harmonize global policies for access to vaccines.

Close collaboration across various sectors and partners in developing risk reduction and risk mitigation strategies can be achieved under the guidance of national governments who are empowered to forge partnerships and alliances.

09 CLOSING SESSION

Convergence and looking forward Dr Sylvie Briand presented a summary of each of the sessions of the meeting. She described “bingo” words that we brought up a number of times: trust, training, social science, solidarity. Two concrete outcomes were to: •D evelop new types of information systems to better anticipate risks but these have to rely on new approaches and engaging new partners. •R evisit the concept of preparedness. It has been 10 years that we have been developing IHR core capacities but new approaches are necessary.

Dr Marie Paul Kieny, Assistant Director General for Health Systems Innovation at WHO, presented the recently developed WHO R&D Blueprint which is an attempt to map what should be done to have the world better prepared through R&D. The Blueprint aims to prepare for the inevitable – what is uncertain is what and when. It has two complementary objectives: •R oadmap for priority pathogens – 5 to 10 that are the most threatening in the next years plus unknown pathogens. •E nable roll out of an emergency R&D response It aims to reduce time between declaration of PHEIC and availability of effective medical technologies by encouraging production of diagnostic tools and generating safety data (Phase 1 trials) for vaccines and treatments for most promising experimental products for priority diseases. It also aims to map knowledge and good practices, identify gaps and establish enabling environment for sharing of data so it is a collaborative effort. There are five work streams: (1) Prioritization of pathogens (2) Identification of research priorities (3) Coordination of stakeholders and expertise (4) Alignment of preparedness and impact of intervention (5) Development of innovative funding options For the finale, Dr David Nabarro, Special United Nations Secretary-General’s Special Envoy on Ebola, spoke about having to reassess our thinking and put the lessons learned into practice. The 2030 development agenda (SDGs) required massive change. For instance, climate has now become global citizen issue (COP 21, Paris) and no longer something discussed behind closed doors. This is a period of review of institutional orientation and considerable rethinking at WHO which is in a process of reengineering their work.

Dr Nabarro presented thirteen points for consideration by the participants as outlined below. (1) M ore presidents and prime ministers are thinking of global health now than ever before. More journalists are writing about global health. There is a greater sense that health risks warrant political attention. The paradigm is “keep us safe in ways we can trust”. (2) More actors are involved in public health. We have to look at our narrative and make it much more acceptable and understandable to all kinds of actors. We can no longer say “we are the experts, we’ll tell you what to do” because we are not providers of truth but partners. ocieties are putting more focus on being strong and resilient. (3) S They have a wish to have greater control on their destiny and leadership must be able to work with multiple actors. arly detection involves listening to multiple actors, not just (4) E health people. Everybody has to be engaged to find a potential threat. Risk assessment will not only be based on health professionals – rumors will come from everywhere. umans are becoming increasingly embroiled with nature and (5) H health threats are going to reflect this. Agro-ecology: close cohabitation people-animal has public health implications. ommunications have to be two-way. We cannot just convey (6) C information – we must use empathy, transparency, trustworthiness in the business of earning trust (respect to all). hat is done with data (forecast) – ethical use, sharing and ac(7) W cessibility, inter-operability – is key as is applying information to action. ather than the term “health systems” use “systems for health” (8) R – systems for life, ability, functions that are predictable, accountable, accessible for all at a quality that can be trusted. rust and respect come from creating space so that each has (9) T a place and a role. Coordination so that others can participate, provide a contribution that is respected in safe spaces with defined roles. eal relearning we have to do is multi-disciplinary, multi-di(10) R mensional, and multi-sectorial. The SDGs signify that the goals are universal, people centred, collaborative, respect for all so no one is left behind. hat to do now? This meeting is about paradigm shifts – new (11) W ways of thinking and acting. Allow new thoughts and thought models to emerge, enriched by talking to each other we can apply new ways and be agents of transformation. Be ready to evolve – regenerating and renewal for public health. e are all communities. As a community of health profession(12) W als we can challenge the power structures using the language of “we” and be change agents whilst maintaining humility. ower and politics requires a disciplined and ethical use of P (13) power. We need to become good at power games. We are all humanitarians regardless of our organizational mandate which sometimes create differences between us and those whom we are trying to help.

10 MAJOR DISCUSSION THEMES Recent epidemics have highlighted critical deficiencies in our response mechanisms and control measures. There is little doubt that new paradigms are necessary for developing creative solutions to current problems. Some of the key areas for reforming our approaches were reflected in the plenary discussions: n an emergency response, coordination and collaboration for collective action between the various actors •I is crucial. Clearly defined roles based on an assessment of strengths and weaknesses of the different sectors is necessary to ensure adequate local operational and logistics mechanisms, as well as engagement with local communities. Incident management systems allow for command and control but trusted leadership and mechanisms are keys to success. The fear factor is what makes decision-making irrational. ational governments have to be at the forefront and held accountable to ensure their surveillance sys•N tems are designed to pick up early “signals”. Clinicians have to be linked to the public health infrastructure through appropriate communication channels and networks. The private sector brings impressive resources and a lot of goodwill but mechanisms and accountability for their engagement requires good leadership by national authorities. How can we convince the public to invest sustainably in preparedness even for risks that may not happen? The issue of trusting politicians was raised, with the suggestion of a public debate after each event to teach them to make the better decisions. Ensuring countries have the necessary functional national IHR core capacities by testing them in exercises (exercise the “unthinkable” scenario) requires adequate investments for preparedness during the inter-epidemic periods – this is a continuing challenge for government attention and resources. e need to move beyond the biomedical approach to epidemics because they are social problems as much •W as medical ones. Social sciences need to be an integral part of surge capacities – perhaps reverse the order of the disciplines brought into a response by having anthropologists as first responders – so that we can address issues of fear and trust within the social context. Communities need to be engaged in advance as part of preparedness to ensure that there is an understanding of the human ecology. This will link community and biomedical perspectives for enhancing effective partnerships ensuring pre-existing relationships are built to respond to epidemics. There is a clear need to have anthropologists working in the field and to coordinate information so it rapidly combines what people know from the frontline with emerging medical evidence. e could “get ahead of the curve” by using technologies and working jointly to assess risk and uncertain•W ties to respond to potential threats. Laboratory capacity for detection of a wide range of pathogens in the field level was discussed including ensuring biosafety and biocontainment; PCR and supply chain logistics; identifying existing subnational capacities available through large public health programs such as polio, influenza and tuberculosis; and possibility of target product profiles for outbreak detection. Strategic, targeted and evidence-based tools can help understand the mechanisms of emergence and engineer ways of reducing the risks for humans by prioritizing hotspots based on geographical, biological and ecological data. For instance, tools that knock down viral load and undercut viral evolution opportunities or ones that reduce opportunities for reassortment in virally diverse geographical locations.

•S trengthening of the workforce through education – training of the next generation of public health professionals, doctors and veterinarians so that they think through problems together by working horizontally across ministries (e.g. health and agriculture) will empower the health system to work towards prevention. For instance, the One Health approach supported by WHO, FAO, OIE and USAID ensures a close relationship through coordination mechanism across human and animal sectors at all levels (central to local) that requires sharing of information as well as triggering a joint response. ew technologies won’t solve the issues of communication and community engagement. Dealing with •N uncertainty and adjusting messages throughout an evolving epidemic requires real-time information sharing, data analysis, and feedback. This remains a challenge for the research community, particularly maintaining quality control in the process of translational research. Journalists covering science are considered to be trustworthy sources of information amongst the many sources of information the public is now exposed to daily. The relationship between these journalists and the public health community should be nurtured during the inter-epidemic periods so that effective technologies and interventions can be implemented built on trust. ompiling big data is no longer the limiting factor. It is the shared responsibility of interpretation with •C the end-users who are non-scientist politicians where the issues are to establish ground rules for analysis and privacy and ownership of data. A number of data-related issues were raised: how do we address scale, data gaps and possible innovations, connecting models, data security, privacy and consent, working across sectors, translation at community level for action, “popular” epidemiology to empower local communities to analyse their own data and make local decisions, lack of baseline data, outcomes of foresight scenarios translated into actions, is big data harmful?, ability to geolocalize. Huge opportunities but also challenges exist in using big data. n one hand we need to focus outside the health system, on communities and individuals, for disease •O control measures to work. But addressing the health system deficiencies based on health system research to identify gaps, is also critical, particularly for addressing outbreaks and reducing mortality. These include recognizing the role of health care workers in spreading infection; primary health care; individual responsibility of every citizen; lack of basic facilities in developing countries for sanitation and hygiene; need for political will; cross sectoral challenges for public health systems; and role of family level care givers. For hospitals in particular, challenges include hospital accreditation across large and small hospitals and ensuring surge capacity when they operate at full capacity in normal times. he concept of “health security” is implicitly inequitable because it begs the question “whose security?” •T (e.g. influenza vaccines held by rich countries are not equally distributed to poor ones). Reducing the gap in access to science and technology for developing countries is a key barrier to address but one that requires resources and investment. Global health security should be made a world issue, like climate change, so that it works at all levels. Recognition that health security is broader than just the health sector and requires a holistic, multisectoral approach that will engender global solidarity for health protection.

Annex 1

LIST OF PARTICIPANTS Professor Frank Møller Aarestrup Head of Research Group - National Food Institute, Technical University of Denmark, Kgs. Lyngby, Denmark Dr James Ajioka Senior Lecturer, Department of Pathology, University of Cambridge, Cambridge, UK Dr Hamoud S. Al Garni Director of Health Authority at Point of Entry, Ministry of Health of Saudi Arabia, Riyadh, Saudi Arabia Dr Tammam Aloudat Deputy Medical Director, Médecins Sans Frontières, Geneva, Switzerland Dr Ray Arthur Director, Global Disease Detection Operations Center Division of Global Health Protection, Center Global Health, Atlanta, USA Dr Rana Jawad Asghar Resident Advisor, Field Epidemiology & Laboratory Training Program, National Institute of Health, Islamabad, Pakistan Dr Juliet Bedford Director and Founder, Anthrologica, York, UK Ms Barbara Bentein Head - Principal Advisor Ebola Crisis Cell, UNICEF HQ, New York, USA Dr Ariel Beresniak Chief Executive Officer, Data Mining International SA, Geneva, Switzerland Mr David Bestwick Technical Director, Avanti Communication Group plc, London, UK Dr Peter Black Deputy Regional Manager, FAO Regional Office for Asia and the Pacific, Bangkok, Thailand Professor Mathilde Bourrier Professeure Ordinaire, Départment de Sociologie, Université de Genéve, Geneva, Switzerland Dr Philippe Calain Médecin, Chargé de recherche, Médecins Sans Frontières, Geneva, Switzerland Dr Dennis Carroll Director Pandemic Influenza and other Emerging Threats Unit, United States Agency for International Development, Washington DC, USA Mr Sean Casey Emergency Response Team Leader, International Medical Corps, Los Angeles, USA Dr Marty Cetron Director Division of Global Migration and Quarantine, Centers for Disease Control and Prevention, Atlanta, USA Dr Andrew Clements Senior Scientific Adviser, Global Health Security and Development Unit Bureau for Global Health, United States Agency for International Development, Washington DC, USA Professor Maire Connolly Professor, National University of Ireland Galway, Galway, Ireland Dr Denis Coulombier Head of Unit, Surveillance and Response Support, European Centre for Disease Prevention and Control, Solna, Sweden Mr Thomas Czernichow Head of the Software and Services Department, EpiConcept, Paris, France Dr Inger Damon Director, Division of HighConsequence Pathogens and Pathology, Centers for Disease Control and Prevention, Atlanta, USA Professor Xavier De Lamballerie Director of the Research Unit (EPV), IRD Marseille, Marseille, France Ms Emma Diggle Epidemics and Vaccination Adviser, Save the Children, London, UK Professor Dialo Diop Lecturer in in Virology in Africa, Dakar, Senegal Professor Christl Donnelly Professor of Statistical Epidemiology, Imperial College London, London, UK Dr Henry Dowlen Senior Manager, Health, Government and Public Sector (GPS), Ernst & Young LLP, London, UK Dr Monique Eloit Deputy Director, World Organization for Animal Health, Paris, France Dr Delia Enria Director, Instituto Nacional de Enfermedades Virales Humanas, Pergamino, Argentina Dr Abdul Ghafur Consultant in Infectious Diseases, Apollo Hospital, Chennai, India Dr Dirk Glaesser Director for the Sustainable Development Programme, World Tourism Organization, Madrid, Spain Professor Herman Goossens Head, Department for Microbiology, University Antwerp, Wilrijk, Belgium Professor Stephan Günther Bernhard-Nocht-Institute for Tropical Medicine, Hamburg, Germany Dr Jessica Halverson Manager, HIV/AIDS and TB Section, Surveillance and Epidemiology Division, Centre for Communicable Diseases and Infection Control, Public Health Agency of Canada, Ottawa, Canada

Annex 1: LIST OF PARTICIPANTS Dr Nur A. Hasan Adjunct Faculty, University of Maryland Institute for Advanced Computer Studies, College Park, USA Professor David Heymann Head and Senior Fellow, Centre on Global Health Security - The Royal Institute of International Affairs, Chatham House, London, UK Dr Didier Houssin President, Agence d’Evaluation de la Recherche et de l’Enseignement Supérieur, Paris, France Dr T Jacob John Chairman, Child Health Foundation, Christian Medical College, Vellore, India Senator Fabienne Keller Senator, Sénat, Paris, France Dr Ali S Khan Dean College of Public Health, University of Nebraska Medical Centre, Nebraska Omaha, USA Dr Kamran Khan Research Scientist, Centre for Research on Inner City Health St Michael’s Hospital, Toronto, Canada Dr Nadia Khelef International Affairs Senior Advisor, Institut Pasteur, Paris, France Professor Ilona Kickbusch Director of the Global Health Programme and Adjunct Professor, Interdisciplinary Programmes, Graduate Institute of International and Development Studies, Geneva, Switzerland Dr Ann Marie Kimball Strategic Advisor, Rockefeller Foundation, New York, USA Dr Gary P Kobinger Head of Special Pathogens, Head, Vector Design and Immunotherapy, Special Pathogens Program, National Microbiology Laboratory, Public Health Agency of Canada, Manitoba, Canada

continued

Professor Marion Koopmans Professor of Public Health Virology, ErasmusMC, Rotterdam, the Netherlands Professor Gerard Krause Head of Department Epidemiology, Helmholtz Centre for Infection Research, Braunschweig, Germany Ms Rhonda Kropp Director General, Centre for Immunization and Respiratory Infectious Diseases, Public Health Agency of Canada, Ottawa, Canada Dr Melissa Leach Director, Institute of Development Studies, University of Sussex, Brighton, UK Dr James Le Duc Director, Galveston National Laboratory, The University of Texas Medical Branch, Galveston, USA Professor Vernon Lee Deputy Director, Communicable Diseases Ministry of Health, Singapore and Head, Singapore Armed Forces Biodefence Centre, Singapore Ms Hélène Lepetit Managing Partner, Co-founder, IDM Institut des Mamans, Paris, France Professor Gabriel Leung Dean - Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China Dr Woraya Luang-on Director, Bureau of Emerging Infectious Diseases, Ministry of Public Health, Nonthaburi, Thailand Dr Hayley MacGregor Research Fellow, Institute of Development Studies - University of Sussex, Brighton, UK Ms Debora MacKenzie Health and Global Security Issues Reporter, New Scientist, London, UK

Professor John Mackenzie Research Associate and Professor of Tropical Infectious Disease, Curtin University, Bentley, Perth, Australia Dr Lawrence C. Madoff Editor, ProMED-mail, Brookline, USA Ms Joanne Manrique President and Editor in Chief, Centre for Global Health and Diplomacy, Washington DC, USA Dr Jean-Claude Manuguerra Research Director, Head of laboratory for Urgent Response to Biological Threats. Institut Pasteur, Paris, France Ms Margaux Mathis Consultant, Paris, France Dr Amanda McClelland Senior Officer, Emergency Health, International Federation of Red Cross and Red Crescent Societies (IFRC), Geneva, Switzerland Dr Brian McCloskey Director of Global Health, Public Health England Wellington House, London, UK Dr James Meegan Director, Office of Global Research, National Institute of Allergy and Infectious Diseases, United States Department of Health and Human Services, National Institute of Health, Betsheda, USA Dr Shoji Miyagawa Director, Infectious Diseases Information Surveillance Office, Ministry of Health, Labour and Welfare, Tokyo, Japan Dr Anne-Marie Moulin Research Director Emeritus, Centre National de la Recherche Scientifique, Paris, France Dr David Murdoch Head of Department, Department of Pathology, Christchurch, New Zealand

Annex 1: LIST OF PARTICIPANTS Dr Vickneshwaran Muthu Senior Principal Assistant Director, Ministry of Health of Malaysia, Disease Control Division, Wilayah Persekutuan Putrajaya, Malaysia Dr David Nabarro United Nations Secretary-General’s Special Envoy on Ebola, United Nations Headquarter New York, New York, USA Dr Josh Nesbit Chief Executive Officer, Medic Mobile, San Francisco, USA Dr Carl Newman Deputy Chief Scientist, Cooperative Biological Engagement Program, Cooperative Threat Reduction, Defense Threat Reduction Agency, Fort Belvoir, USA Dr Patrick L Osewe Lead Health Specialist, World Bank, Pretoria, South Africa Dr Heather Papowitz Senior Advisor, Health-Emergencies, UNICEF HQ, New York, USA Dr Malik Peiris Director, Division of Public Health Laboratory Sciences, University of Hong Kong School of Public Health, Hong Kong, China Prof Jorge Pérez Avila Director General, Instituto de Medicina Tropical “Pedro Kouri”, La Habana, Cuba Dr Mark Perkins Chief Scientific Officer, Foundation for Innovative New Diagnostics, Geneva, Switzerland Dr Julio Pinto Animal Health Officer, FAO HQ, Rome, Italy Dr Paolo Ruti Chief, World Weather Research Division, World Meteorological Organisation, Geneva, Switzerland

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Dr Ronald K Saint John Consultant, St John Public Health Consulting International Inc, Manotick, Canada Dr Gérard Salem Directeur du Laboratoire Espace, Santé et Territoires, Université Paris Ouest Nanterre La Defense, Nanterre, France Dr Amadou Alpha Sall Scientific Director, Institut Pasteur de Dakar, Dakar, Senegal Dr Mark Salter Consultant in Global Health, Public Health England Wellington House, London, UK Dr Lars Schaade Vice President, Robert Koch Institute, Berlin, Germany Ms Laura Scheske WHO/WMO Joint Office Dr Jan Slingenbergh Senior Animal Health Officer/Head of EMPRES, FAO HQ, Rome, Italy Dr Franck Smith Campaign Director “No More Epidemics”, Management Sciences for Health, Medford, USA Dr Idrissa Sow Expert on Infectious Disease Epidemics, Mauritanie Professor Oyewale Tomori Professor of Virology, Redeemer’s University, Nigeria Dr Shinya Tsuzuki Medical Officer, Tuberculosis and Infectious Diseases Control Division, Ministry of Health, Labour and Welfare, Tokyo, Japan Dr Fabio Turone Presedent, Science Writers in Italy, World Federation of Science Journalists, Milan, Italy

Mr Richard Vaux Project Manager for the GloPID-R Project, Fondation Mérieux, Lyon, France Dr Niteen Wairagkar Lead, Influenza/RSV Initiative, Bill & Melinda Gates Foundation, Seattle, USA Professor Ronald Waldman Professor, Public Health Department, George Washington University, Washington, USA Dr John Watson Deputy Chief Medical Officer, Department of Health Richmond House, London, UK Dr Cécile Wendling Associate Researcher, Sociology Organization Centre, Paris, France Dr Teresa Zakaria Head of the Health Assistance for Crisis Affected Populations Unit, International Organization for Migration, Geneva, Switzerland

Annex 1: LIST OF PARTICIPANTS World Health Organization Dr R. Bruce Aylward Executive Director a.i. Outbreaks and Health Emergencies and Special Representative of the Director-General for the Ebola Response, HQ Dr Marie-Paule Kieny Assistant Director-General, Health Systems and Innovation, HQ/HIS Dr Eric Bertherat Medical Officer, Control of Epidemic Diseases, HQ/ WHE Dr Caroline Sarah Brown Programme Manager, EU/IRP Influenza and other Respiratory Pathogens, DCE/VPR/IRP, Copenhagen Ms Kara Durski Epidemiologist, Ebola Virus Outbreak Response, HQ/ WHE Dr Sarah B. England Senior Adviser, Office of the DirectorGeneral, HQ/ODG Ms Geraldine Hagon Intern, Communication Capacity Building, HQ/CCB

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Dr Dominique Legros Medical Officer, Control of Epidemic Diseases, HQ/WHE Dr Elizabeth Mumford Scientist, Food Safety, Zoonoses and Foodborne Diseases, HQ/FOS Dr William Augusto Perea Caro Coordinator, Control of Epidemic Diseases, HQ/WHE Dr Cathy Ellen Roth Technical Adviser, Health Systems and Innovation, HQ/HIA ADGO Dr Gina Samaan Consultant, Influenza, Hepatitis and PIP Framework, HQ/WHE Ms Carmen Savelli Technical Officer, Risk Assessment and Management, HQ/RAM Dr Anthony Paul Stewart Consultant, Global Preparedness, Surveillance and Response, HQ/PSR Dr Kathleen Louise Strong Technical Officer, Influenza, Hepatitis and PIP Framework, HQ/WHE

Dr Angelika Maria Tritscher Coordinator, Risk Assessment and Management, HQ/ WHE Dr Katelijn A.H. Vandemaele Medical Officer, Influenza, Hepatitis and PIP Framework, HQ/WHE Mr Leender Van Gurp Manager, Business Intelligence Competency Centre, HQ/CMS Dr Wenqing Zhang Scientist, Influenza, Hepatitis and PIP Framework, HQ/WHE Dr Weigong Zhou Medical Officer, Influenza, Hepatitis and PIP Framework, HQ/ WHE Dr Theodor Ziegler Consultant, Influenza, Hepatitis and PIP Framework, HQ/HIP

WHO Secretariat Dr Sylvie Briand Director Pandemic and Epidemic Diseases Department of Outbreaks and Health Emergencies HQ/WHE Ms Nyka Alexander Consultant, Pandemic and Epidemic Diseases, HQ/WHE Ms Mara Frigo Technical Officer, Pandemic and Epidemic Diseases, HQ/WHE Dr Gaya Manori Gamhewage Medical Officer, Pandemic and Epidemic Diseases, HQ/ WHE Ms Erika Garcia Technical Officer, Control of Epidemic Diseases, HQ/WHE Ms Sandra Garnier Technical Officer, Pandemic and Epidemic Diseases, HQ/WHE Dr Asheena Khalakdina Technical Officer, Pandemic and Epidemic Diseases, HQ/WHE Ms Qiu Yi Khut Information Officer, Pandemic and Epidemic Disease, HQ/WHE Ms Kaveri Khasnabis Secretary, Pandemic and Epidemic Diseases , HQ/WHE Ms Anais Legand Technical Officer, Pandemic and Epidemic Diseases, HQ/WHE Mr Oliver Gerd Stucke Technical Officer, Communication Capacity Building, HQ/WHE Ms Ursula Zhao Yu Consultant, HQ/DGO/DGD/DCO

Annex 2

AGENDA AT A GLANCE Tuesday, 01 December 2015 Time 9:00 – 10:00 Session Opening session • • • • Topics Welcome P urpose and methods of the consultation I ntroduction of experts and stakeholders G roup photograph

10:00 – 10:30

Coffee break Session 1 Back to the future: Learning from the past •E bola West Africa: drivers and lessons learned ultidisciplinary response: strengths and challenges •M ew perspectives on outbreak response after SARS in •N Canada • A mild pandemic: critics and anticipation • The role of NGOs and health sector partners iscussion •D

10:30 – 12:00

12:00 – 13:00 13:00 – 14:30

Lunch Session 2 Future epidemics: moving and blurry targets • • • • • • H uman-animal interface: anticipating risks of emergence M anaging the risks of emergence at the animal level K nowledge on microbiome and research F rom science to action: microbiome and respiratory diseases E cosystem surveillance: predicting the next emergence? D iscussion

14:30 – 15:00 15:00 – 16:30

Coffee break • What’s new for surveillance and detection? Session 3 • Advances in biology and their applications Science and technology: opportunities and challenges • What’s new in diagnostics? isk perception and community engagement •R ommunicating in the 21st Century •C iscussion •D Wrap-up

16:30 – 17:00

Annex 2: AGENDA AT A GLANCE Tuesday, 01 December 2015 Time 9:00 – 10:30 Session Session 4 Making the most of Big Brother Topics

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• • • • • • • • • • • • • • • •

M odelling outbreaks: pros and cons Learning from successes in meteorology Use of big data to anticipate epidemics and their evolution Learning from the insurance expertise Discussion C linical practices and emerging diseases S ystemic view of infectious in health care facilities P atient-doctor relationship at the age of the Internet I mpact of strengthening the overall health system D iscussion E volution of health security concepts R evisiting traditional containment measures M anaging epidemics in urban settings E pidemics and tourism P olitical perspectives of global risk D iscussion

10:30 – 11:00

Coffee break Session 5 Curing and not harming – that is the question

11:00 – 12:30

12:30 – 13:30 13:30 – 15:00

Lunch Session 6 Preventing the spread of infectious diseases in a global village

15:00 – 15:30 15:30 – 17:00

Coffee break Final session Convergence and looking forward Close ummary of the meeting deliberations •S • WHO’s R&D Blueprint for epidemic preparedness • The changing landscape for WHO: Global ecosystems, partners and mechanisms

17:00 – 17:30

Annex 3

SPEAKERS BY SESSION SESSION 1: Back to the future: Learning from the past Moderator: Didier Houssin Oyewale Tomori (Nigeria) Ron Waldman (George Washington University) Ron St John (Canada) John Watson (UK PHE) Sean Casey (International Medical Corps) SESSION 2: Future epidemics: Moving and blurry targets Moderator: Malik Peiris Nadia Khelef (Institut Pasteur International Network (RIIP)) David Murdoch (University of Otago, New Zealand) Monique Eliot (World Organisation for Animal Health (OIE)) Julio Pinto (Food and Agriculture Organization of the UN (FAO)) Dennis Carroll (USAID) SESSION 3: Science and Technology: Opportunities and challenges Moderator: Gabriel Leung Nur Hassan (COSMOSID) Jim Ajioka (University of Cambridge) Mark Perkins (FIND) Amanda McClelland (International Federation of the Red Cross (IFRC)) Barbara Bentein (UNICEF) SESSION 4: Making the most of Big Brother Moderator: Brian McCloskey Christl Donnelly (Imperial College, London) Paolo Ruti (World Meteorological Organisation (WMO)) Kamran Khan (University of Toronto) Cécile Wendling (AXA Insurance Company) SESSION 5: Curing and not harming: that is the question Moderator: David Heymann Abdullah M Assiri (Kingdom of Saudi Arabia) Abdul Ghafur (Apollo Hospital, Chennai, India) Hélène Lepetit (Institut des Mamans (IDM)) Idrissa Sow (Mauritania) SESSION 6: Preventing the spread of infectious diseases in a global village Moderator: Ilona Kickbusch Ali S. Khan (University of Nebraska) Inger Damon (US Centers for Disease Control and Prevention (CDC)) Hayley MacGregor (Institute for Development Studies) Dirk Glaesser (UN World Tourism Organization (UNWTO)) Fabienne Keller (France)

Annex 4

IDEAS WALL AND IDEAS BOX The Ideas Wall and Ideas Box collected written, anonymous comments from participants. They are reproduced below, verbatim, with minor edits. Learning from the past - Rapid and easy communication of new findings to those who need local and global overview is essential. - Solution could be web-based data collection system for both syndromic info as well as e.g. genomic info. This could be combined with novel IT tools for genomic analysis and text – mining, machine learning and A.I. Session 1 Remark One is struck by the blatant discrepancy between the delayed reaction to the severe west-African EVD outbreak (both at national and international level) and the strong over-reaction to a mild influenza pandemic in the UK. Similarly the contradiction is conspicuous between large scale endemic infections and parasitic diseases which have been neglected for decades and limited epidemics attracting both public resources and media focus. These issues should be addressed adequately. Instead of emphasizing on enhancement of IHR/capacity building, have we explored the root causes of why countries are not doing these activities, and address the root causes? We need a global advocacy campaign that will engage multiple stakeholders, especially non-health stakeholders, to both expand ownership of the issue and increase political support for epidemic preparedness/ disease surveillance and response. This will ensure greater support and drive up public participation on this issue. We need to be communicating about epidemics between epidemics, not only when outbreaks happen. Communities need to be seen as partners in surveillance and response, not just terrains of response, therefore we need to integrate this into education and public information and communication department as soon as possible. How do we train to be surprised? Factors of resilience are key. Anthropologists are not new to these topics! A lot of work had been done (see DVD, Formenty, Epelboin, Ebola, no laughter) ➔ rediscovery? There are many possible contributors or amplifiers of epidemics. How do we focus our attention to the key drivers, so that we can best utilize our limited resources. Can we model this? In terms of preventions, we should distinguish the primary one aiming at blocking the very emergence of the outbreak from secondary prevention targeting the spread of the epidemic. The tool of the first type is science and technology whereas the second type depends on multidimensional social factors (political will mostly The main note during today’s Sessions is: Coordination is critical in all aspects of preparedness. Coordination, and levers to achieve it, are king. All focus should be on states, NGOs and INGOs rapidly deployable mechanisms to work together. THIS was the big failure, not WHO. Resist the urge of introduce new process and bureaucracy Some failures were humans’ inability to implement sound methodology – such as IDSR Accept that if we get this right, we’ll never know… but if we get it wrong we certainly will. Consider novel approaches to data & analytics as a starting point, not a tool for business as usual New models of governance, operations, planning & communications are available, we don’t need another database… Rapid detection is only relevant if you use the data. In international outbreaks you need to compare data from several places in real-time. We should focus more on data sharing paying for it will be impossible expensive. The frontline needs to be engaged -S tudies in how people bio-psychosocial beings are critical for the everyday practice of medicine. - Vaccine development/drugs development ➔ “people before profits”

-C ommunity approach is not static, is evolving and unique in each community - Adaptation of medical “aid” to the political climate of the host country -P reventive community health training as a long-term programme (not only during the emergency) -M edical “aid” as a paternalistic approach -M edical “aid” messages should focused on medical collaboration or medical cooperation. Research and Development First opportunity ➔ 1) S eparation of Research and Development expenses from prices of drugs/diagnostics technologies, etc.. Does private sector is ready to do it? 2) O ther topics where it is not need only to focus on expensive technology: •H ealth Resilience Research •C ommunity Health delivery research •P reventive medicine We should remember that bio data are big both in complexity and size; a size that cannot be handled locally and often difficult transferred through internet (petabyte). We should ensure access for all to sufficient supercomputer infrastructure. Increasing incentives for sharing data is important, but we also need to address barriers for the frontline diagnostic people and researchers. One aspect is the fear of others stealing and publishing your data. A solution could be if people can do prepublication release for public health but not for research – Would require enforcing by the bio scientific journals. Build a task force. Build an international training centre for infectious diseases. -R esearch centres for diagnostic viral diseases -P repare or train people for handle samples and the mechanism for sending samples -E pidemiological surveillance centres.

Knowledge of such factors as a pathogen’s spread and persistence into a variety of different ecosystems, its number of amplifying hosts and its number of possible competent vectors, would help predict its potential for emergence. System for health -S hould we not give responsibility for PH/GHS to Ministries of Education/Education System - Teachers were key in Ebola control - They are key in empowering children and communities ➔ health literacy - They can do surveillance -H igher education for health workers needs substantial rethinking ➔ PH – GHS has to be central How to increase the level of knowledge of statistical modelling at the local countries where the epidemic or the emergency disease will stand. These countries will need human resources and technology and technician to observe and diagnostic during epidemic great events. How we can prevent that those disease cross from country to countries. The work with the communities, the need to find and train leaders in the communities and help with the social work. In order to have their personnel well prepared ahead of the emergency. Important to help the local government to have those people ready and with the necessary knowledge to set whenever emergency. The role of education. Important to have people well trained to stand and to do diagnostic. Cuba is willing to continue work with WHO and help with medical personnel (doctors and nurses and also train people with/from those countries in order to be prepared to face an emergency disease. Elements to have in place vaccination: -M ulti sectorial (make “adaption” move easy) socialized medicine - Vaccination programs • Active community participation •U niversality • Trust

Annex 4: IDEAS WALL AND IDEAS BOX •E mphasis in vaccine education from an early age •C ommunity groups follow-up on vaccine schedules -I mprove health provision and design at the community level -H igh levels of epidemiological awareness and vigilance -O rganizational features in developing countries health system -F ragmented health system vs integrated health system How can we, concretely, find + harness the opportunities in “big data” and “open data” without getting lost in, or, overwhelmed by it? “Little data” is proliferating, e.g. mobile support applications for citizens, communication tools for clinics. What does WHO (or central monitors) want to “ask” these networks? What specific signals should be monitored (both freedom + structured data sets)? Clear guidelines, formats for data submissions, and global/national/regional points of contact would allow community health system designs and owners to share data more effectively and efficiently. When discussing data and big data we are assuring that information and facts drive political decisions. We know this is not the case, climate change is an example of this political decisions are made on an emotive as well as ration bases, therefore we need other means of getting messages across soul as a public campaign. How relevant are “countries” alone? “Sovereignty” is nearly most false? The accountability paradigm has to change? Make communities “in large sense” accountable? -P CR is good, but not all that is needed during an outbreak. - You need a number of assays (for antigen, for antibis – IgG, IgM, etc.) to control on outbreaks. For example: 1) P CR doesn’t work if no pathogen is present. So if the patient comes into the clinic after his viraemic period, PCR will not work and … detection is important. This is often the case with viral encephalitis that develops after viraemic – perhaps because the developing antibodies cause the illness. 2) S urveillance of where an illness has been requires serology. 3) D etermining possible amplifying or maintain …. After requires serology. 4) N ot all labs have the expensive equipment and training to do PCR

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5) This treatments develop, beside diagnosis (i.e. lateral flow) would be needed (cheap+fast) 6) To evaluate if a vaccine works, antibiol. and T-Cell assays are vital 7) To evaluate if a therapy works, immunological measurements are important to establish if the treatment stopped an infection. -P ast epidemics showed that multiple Rx assays were vitally important. Should include military as a contributor in a number of ways: 1) Surveillance: •M ilitary research laboratories worldwide •M oving acceptable groups of soldiers into epidemic areas 2) D ial with response: • Treatment • Logistics -M osquito movement and invasion of new countries is important - Also we are losing methods for mosquito control – this is important. Also not training many medical entomologist. Basic research has a major role in establishing pathogens’ potential for emergence. Example would be establishing a pathogen ability to infect and be transmitted by different mosquito species - To anticipate emerging diseases, it is important to have good knowledge of the pathogen’s ability to spread and exist in different environments. -I t’s vital for research to give us knowledge of the pathogen’s amplifying hosts (many of few) and its transmission methods (i.e. does it infect many or few mosquito species?) - The more hosts and vectors, the more spreadable to new areas. The model proposed by FIND runs the risk of setting the stage for a very costly system, commercially driven. Alternatives: look at routine labs and see how they handle EID. FY: we run 100 targets for clinical virology AND emerging diseases preparedness with a small number of people Issue with availability of tests “for research only”: this is regulatory and protection of markets. There are models for doing that, used across Europe (see ENND network, i.e.). Model is: back-up tests until there is sufficient expertise to transfer to routing testing.

Annex 4: IDEAS WALL AND IDEAS BOX ID outbreaks and epi analysis & modelling: the current model, where …institution has access to mandatory reporting data provided by a wide group of volunteers, and produces high profile publications, is setting a bad example. The data sharing platforms should apply to lab and epi data and be somehow accessible to data relevant providers and other stakeholders. An important challenge is decision making in the absence of evidence, coupled with the willingness to help collect essential info and share that while an outbreak evolves. We do need a data/info/sharing & analysis platform, that could be WHO coordinated but customized to the situation. No one knows how ED work, we need an open mind. Nearly every speaker says public information is crucial. Most people get information from journalists. Yet the relationship between health actors and journalists is poor. Perhaps the two groups shared discuss how to improve it include journalists. Public health people should seek to be, not trusted, but accountable. This is hard for many, as they feel they are the “good guys”. Attacks prompt defensiveness, rarely effective response. Learn to engage and respond. They don’t care how much you know until they know how much you care. Let us speak with one voice – tell countries to own the control of the diseases in their domains. Donors stand back and only assist, not take over Nation’s duty. Nations wake up, do your duty; depend on self. 1) B uild on existing capacities 2) Avoid vertical capacity building (H5N1, Ebola… ) 3) U se what we have: i.e. IHR course, 4 way linking protect animal/human – need funds! 4) D ata management – big gap countries & WHO 5) WHO report: burden of outbreaks Try to build a transdisciplinary model team that can initiate the process of capacity building at a global scale (or the more global it could be). Many attacks on public health people & measures are led by a class of delusional people called “denialists”. Learn about this psychology, and prepare to deal with it promptly and publicly.

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How can we use the systems designed to follow/answer/ contribute to social media and other communications to fight other rumours basting important domains such as vaccination (so needed to prevent epidemics!)? How do we better use digital epidemiology and participatory epidemiology to help anticipate epidemics? Peer-review. What is its role in signifying the quality of evidence? We all know of wrong papers which got through peer review! Big brother How does the health community develop informative & standardized variables to use “big data” for epidemic anticipation. 1) C apacity/lab ability/cure are abstract terms without concrete measures 2) F ailure of H1N1/Ebola due to stubbornly sticking to the playbook. Need better way to integrate new science in real-time during a response. Data collection and management is still a big challenge on the field. Needs: •S end IT •U se system that can be adapted to local field constraint Standardized need communications messages before (focus on preparedness & prevention) and during outbreaks (focus on prevention & response using latest data). Don’t wait until after outbreaks start to begin developing messages. Engaging public before outbreaks build trust early which is not easily done in the middle of an outbreak. Being a medical professional does not equate to being a bureaucrat. While exploring new sophisticated technologies, don’t forget but implement the basics: -I HR core capabilities -S trong coordinating entity -E ducation and training - Transparent information sharing • The best way to prevent a global spread is to stamp out an outbreak very early • Then should be a triggers for international support below PHEIG declaration •I n classical humanitarian aid funds and mechanisms for immediate response are in place ➔ should be implemented for epidemic as well.

Annex 4: IDEAS WALL AND IDEAS BOX Can we learn how little we have managed to do to protect the health of civilians in conflict settings as Syria. We should think about creating cluster like systems for epidemics. -G lobal change -H ost environment change -D isease ecological change -N ew pathogen emergence And so we’re doomed! Nature still better than humans for biological threats is one said. So what type of lessons are we to learn from mothernature: her gifts or her threats? An old French saying goes: “you only get command over nature by obeying to it”. It seems the 3rd millennium science called “biomimicry” (biomimétisme) didn’t forget this proverb. Since there’s only one planet earth and one global village let’s get together to put an end to double standard. -C rucial questions of weakness of States in Africa -L inks between science, democracy & development -M ore and more specialized academic training vs pluridisciplinarity. R&D can’t be isolated from its socio-economic environment. Funded mainly by public money it requires a paradigm shift to fulfil its mission: -M ind set: secular and not religious -O bjectives: nor for profit rather than profit - Approach: civilian and not military -O utcome: majority well-being rather than minority luxury There is neither a developed world nor an underdeveloped one; there is only one ill developed world Inequality is a disease medics can’t cure but politicians can and should The major change during the 20th century is urbanization. More than 50% of the population are living in urban places. - A new challenge - The next places of emergence and diffusion of … old & new diseases.

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The monitoring parameter of preparedness and core capacity is the success of control of endemic diseases that is dress rehearsal for response to emerging diseases Focus or creating decentralized, community-based, health systems that care for people every day – we will get data (as a by-product) and responsive/resilient health systems as a result. We need health systems that “know” people, that people trust and that can delines many types of thing to people. Should always think about “WHO IS NOT IN THE ROOM” How does the global community maintain focus on the current health emergency and the accumulating number of other emerging threats (with no new money or staff)? How to get big pharma to invest: POSITIVE PSICHOLOGY such as done by ACCESS TO MEDICINES FOUNDATION Ranking on R&D for development The future? World Health Security Organization (WHSO) The agriculture/ farm industry is frequently manned by migrant workers, who may not all be regular migrants. In many countries preparedness plans, this group, although vulnerable, is not adequately included. This needs to change.. We need NEW TOOLS for qualitative risk assessment in the face of little or poor data for decision making and response to “new” pathogens. -M obile data collection is key -G eocode everything! -D ata quality is a bigger challenge than the analytics No integration/collaboration at field level between human/animal health. Solution: train them together and put them in same EOC, go to OI as a group Behavioural drivers of outbreaks: epidemics necessarily include cultural understandings (epistemology) of health, illness, and mechanisms of disease spread.

ANTICIPATING EMERGING INFECTIOUS DISEASE EPIDEMICS World Health Organization 20 Avenue Appia 1211 Geneva 27 - Switzerland FOR MORE INFORMATION www.who.int/csr/disease/anticipating_epidemics/en

Основные сведения

Организация Всемирная организация здравоохранения (ВОЗ / WHO)

Тип документа Technical Documents

Дата принятия 21 декабря 2016 г.

Источник Всемирная организация здравоохранения