The next pandemic: what will it be, when will it come, and why? Mark Collins BA MBA PhD Director,

1. The next pandemic: what will it be, when will it come, and why? • Mark Collins BA MBA PhD • Director, • Commonwealth Foundation

2. Introduction • Patterns of infectious disease emergence over the past 40 years give serious cause for concern • Late 1960s – diseases believed to be under control • New diseases like HIV and SARS emerged • Tuberculosis and malaria grew once again • Resistance to anti-microbials complicates matters • New animal diseases discovered, e.g.BSE • Bird flu becomes a global pandemic and threatens • to bridge across to humans. • Infectious diseases kill more than 20% of people in the world and we don’t know when or from where the next pandemic might come.

3. UN Health Targets • The Millennium Development Goals, adopted in 2000, include some fundamentally important targets for health: • Goal 1: Eradicate extreme poverty & hunger • Goal 4: Reduce child mortality • Goal 5: Improve maternal health • Goal 6 : Combat HIV & AIDS, malaria & • other diseases • At the half way point, the picture is mixed. Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

4. Eradicate extreme poverty • Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf Target: Halve between 1990 and 2015 the proportion (%) of people whose income is less than US$1 per day Achievement: Poverty has fallen from one third of all people to one fifth

5. Improve maternal health • Target: reduce by three quarters the maternal mortality ratio • Histogram shows proportion of deliveries attended by skilled health care personnel, 1990 and 2005 (%) Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

6. Reduce child mortality Target: two thirds reduction in mortality rate of children under five Histogram shows under 5 mortality rate expressed as deaths per 1000 live births in 1990 and 2005 Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

7. Combat HIV, AIDS, malaria & other diseases • HIV prevalence has levelled off in the developing world, perhaps partly because deaths from AIDS continue to increase in sub-Saharan Africa Source: http://www.un.org/millenniumgoals/pdf/mdg2007.pdf

8. Today’s major killers • Disease Worldwide mortality 2002 • % total deaths Total number • Lower respiratory tract 6.8% 4.0 M • HIV and AIDS 4.9% 2.8M • Diarrhoea 3.2% 1.8M • Tuberculosis 2.7% 1.6M • Malaria 2.2% 1.3M • Childhood infections 2.0% 1.1M • Other infections 1.0% 0.6M • TOTALS 22.8% 13.2M • Source WHO 2004 Statistical annexe

9. Impact of disease on nations • Developing countries • Underlying burden of infection greater • Children disproportionately affected • Half of deaths in under 5’s due to infections • Malnutrition exacerbates the problem • Low tech measures can make a big difference • Developed countries • High social costs from infectious disease • In UK 10% of deaths are from infection • 50% of adult consultations die to disease • Prevention of pandemics is costly • But pandemic outbreaks could cripple nations

10. Origins of pandemic infections • Six major sources of potential future pandemics • Novel pathogens – viruses continually evolve • Pathogens acquiring resistance • Zoonoses – diseases acquired from animals • HIV and AIDS, tuberculosis and malaria • Acute respiratory tract infections • Sexually transmitted diseases, including HIV

11. Trends in novel pathogens Bird flu H5N1 SARS HIV vCJD New human pathogen species detected since 1980. Source: Foresight project, UK OSI, 2006

12. Pathogens acquiring resistance • This is a problem that is getting worse: • Resistance arises in bacterial, viral, • fungal and parasitic diseases • Antibiotics, vaccines, fungicides and • insecticides become less effective • Resistance from mutation, acquiring • new genes or natural selection • Enteric pathogens, pneumonia, TB, • gonorrhoea, malaria, HIV and • MRSA all resist • Currently controlled diseases could • re-emerge as a result

13. Zoonoses • Animals are a common • source of human disease • The risk is growing because • of intensive farming • Bushmeat hunting in Africa • presents more chance for • species jump • Viral haemorrhagic fevers • could mutate to chronic • forms and spread

14. Bushmeat - risk of disease • Growth in bushmeat hunting in Africa presents a major risk of new zoonotic diseases – and detection would be slow.

15. HIV and AIDS, TB & malaria • These three diseases are linked as the dominant epidemics in Africa. In some areas 80% of TB cases are in people living with HIV. The cost of malaria to Africa is US$12 billion annually. • Fighting the diseases presents special problems: • Stigma and discrimination against people with HIV and AIDS • Lack of access to care for living with TB • Drug resistance to malaria, and lack of mosquito nets HIV in Africa

16. Respiratory tract infections • Epidemic ARIs are generally zootic in origin • Bird flu is an acute respiratory disease • Today’s biggest new disease threat • Confirmed in 60 countries • Probably worldwide in • nine months • More than 240M poultry • killed • Massive risk of socio- • economic impact in Asia

17. Bird flu: the risk to humans • It could cross to humans as Spanish flu did • Humans have no immunity to this strain • Vaccines cannot be made in advance • World capacity for vaccine production low • Low income countries are most at risk • Rural community risks • contact with poultry • Medical and essential • services overwhelmed

18. Sexually transmitted diseases • Sexually transmitted diseases are on the • increase worldwide • Antimicrobial resistance is on the increase • Many infections remain undiagnosed and even • more are untreated • Pregnant women are a • key target, to reduce • transmission to newborn • children

19. Disease risk from environmental change • Damage to ecological processes can create better conditions for infectious disease. Factors include: • Encroachment into forests that harbour zoonoses • Reduction in natural biodiversity that controls pests • Creation of conditions that favour disease vectors • - climate change • - changes in surface waters • Long distance trade in wild • animals Source: Ecosystems & Human Well-being. Millennium Ecosystem Assessment 2005. WHO

20. Climate change 1 metre sea level rise will inundate 17.5% of Bangladesh • Climate change increases risk of pandemic by: • assisting survival of pathogens, • hosts and vectors; • creating new and favourable habitats, • and through social change. • Disease patterns: • HIV & AIDS and TB unchanged • cholera and diarrhoeal diseases • more common • malaria and other vector borne • diseases spread more widely Source: Baylis M. 2006 Climate change & disease of plants, animals and humans: an overview. OSI, London

21. Health care systems • Human resources limitations in the developing world constrain achievement of the MDGs and heighten the risk of pandemics. Problems include: • Lack of trained personnel • Lack of motivation & poor performance • Migration of health workers, including pharmacists • Impact of HIV and AIDS Source: Wagstaff A. & Claeson, M. 2004. The Millennium Development Goals for Health: Rising to the Challenge. World Bank 186 pp.

22. Medicine access & affordability • Tackling pandemics and the MDGs will require much-improved access to medicines: • Shortages are commonplace in • developing world health centres • Counterfeit drugs are everywhere • Affordability prevents many from • getting access. Source: Wagstaff A. & Claeson, M. 2004. The Millennium Development Goals for Health: Rising to the Challenge. World Bank 186 pp.

23. Pandemics and pharmacists • Pandemic diseases are not yet controlled, and new ones will certainly arise. They kill millions of people and the social and economic costs of control and prevention are huge. • Three principal actions need to be taken: • Increase overseas development • assistance and invest in medical training • and health care systems. • Improve access to and affordability of • genuine drugs; improve drug use to control • resistant strains • 3.Develop and implement new detection, • identification and monitoring systems, from • global satellite surveillance to hand-held • diagnostic kits.

24. Thank you! Commonwealth Foundation Marlborough House Pall Mall London SW1Y 5HY UK Tel: +44 20 7930 3783 Fax: +44 20 7839 8157 Email: geninfo@commonwealth.int Web:www.commonwealthfoundation.com • Questions?