ReEmerging

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Re-Emerging of Communicable Diseases Dr Eva
Lewis-Fuller Director Health Promotion and
Protection Ministry of Health
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Re-Emerging Communicable DiseasesOverview

• RE-EMERGING DISEASES
• Malaria
• Tuberculosis
• Dengue Fever
• Yellow Fever
• Measles
• Cholera
• Bubonic Plague

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Re-emerging Communicable Diseases

• ANTIBIOTIC RESISTANT BACTERIA
• Staphylococcus aureus
• Streptococci pyrogenes
• Pneumonoccus
• Enterococcus faecium
• Yaws

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The Notifyable Diseases

• Classified as Groups I, II, II
• Tracked for early detection through the
  surveillance system

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SELECT NOTIFIABLE COMMUNICABLE DISEASES IN
JAMAICA 1997-2007
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CLASS 1 DISEASES
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CLASS 1 DISEASES
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CLASS 1 DISEASES
Imported Case Suspected Cases
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CLASS 1 DISEASES
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CLASS 1 DISEASES
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CLASS 2 DISEASES
Suspected Cases
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CLASS 3 DISEASES
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OTHER DISEASES OF NATIONAL INTEREST
Suspected Cases
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OTHER DISEASES OF NATIONAL INTEREST
Suspected Cases
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SYNDROMES UNDER SURVEILLANCE
Implemented in 2007
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SYNDROMES UNDER SURVEILLANCE
Implemented in 2007
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Epidemiological Triad of Disease

• Disease does not occur in a vacuum!!!

HOST
VECTOR
ENVIRONMENT
AGENT
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Re-Emerging Communicable Diseases

• These diseases are already well known but have
  undergone a resurgence in their incidence or
  prevalence, or have appeared in areas where they
  were not previously found.

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CAUSES OF RE-EMERGENCE OF COMMUNICABLE DISEASES

• Mans behaviour
• Environmental/ecological changes
• Climate changes, local and global
• Resistance of vectors to control insecticides,
  new habitat
• Changes in the microbes resistance from
  mutations abuse of antibiotics.
• Travel and migration
• Socio-economic situations

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Speed of Global Travel in Relation to World
Population Growth
From Murphy and Nathanson. Semin. Virol. 5, 87,
1994
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Infectious Disease Mortality in the United
States, 1980-1996
80
70
60
50
40
Crude ID Mortality Rate
Deaths per 100,000 population
30
20
10
0
Year
Source JAMA 1996275189-193 and unpublished CDC
data
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CDC Emerging Infections Priority Issues, 1999-2000

• Antimicrobial resistance
• Food and water safety
• Vectors and animal health
• Blood safety
• Infections that cause chronic diseases
• Opportunistic infections
• Maternal and child health
• Health of travelers and refugees
• Vaccines

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Malaria Eradication in Jamaica

• 1961 - Last endemic case of malaria in Jamaica
• 1965 - Jamaica declared malaria free
• 2006 RESURGENCE OF MALARIA INTO JAMAICA

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Malaria

• Resistance to chloroquine was noticed in southern
  Asia in the 1950s. By the 1960s some strains of
  Plasmodium falciparum had developed resistance to
  the 4 main anti-malarial drugs.
• A new drug, mefloquine, was adopted in the 1970s,
  but resistant strains of falciparum emerged by
  the 1980s.
• Strains of falciparum in Thailand have evolved an
  enzyme which expels all hostile chemicals, making
  it resistant to drugs that have not even been
  invented.

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Malaria

• Although malaria is widespread in tropical
  countries, experience in India illustrates how it
  can re-emerge even after effective control.
• In the 1960s malaria was almost eradicated in the
  Indian subcontinent, but because of technical and
  financial problems the eradication programme was
  allowed to lapse.
• Malaria is again a major health hazard in India.
• Another factor in the resurgence of malaria, now
  and in the future, is the possibility of climate
  change, with the likelihood that alterations in
  temperature and rainfall will provide habitats
  for malaria-carrying mosquitoes in new areas.
• Human activity, such as cultivation, may also
  provide new habitats for mosquitoes.

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The Anopheles Mosquito
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• I know this little thing
• A myriad men will save
• O Death, where is thy sting?
• Thy Victory, O Grave.
• - Ronald Ross (1875 1932)

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Imported Malaria in Jamaica
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Haitian refugees
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Malaria Cases 2006- May 2008 Jamaica
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First Line Treatment Plasmodium falciparum

• Chloroquine 25mg/kg body weight divided over
  three days
• PLUS
• Primaquine 0.75mg/kg stat on day 1
• (gametocytocidal effect block transmission)

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Treatment of Malaria

• Prompt treatment - adults
• Day 1 Chloroquine 4 tabs (600mg) Primaquine
  3 tabs (45mg)
• Day 2 Chloroquine 3 tabs (450mg)
• Day 3 Chloroquine 3 tabs (450mg)

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Malaria Control Current Status of Measures

• Early case identification
• Prompt treatment of cases
• Over 500 suspected cases from affected areas need
  treatment
• Vector control 95 complete
• Public education 30,000 flyers distributed,
  meetings with communities etc.

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Dengue Fever

• Dengue fever was originally a disease found in
  Southeast Asia.
• Since the 1950s, it has spread to become the
  world's most common arborvirus (arthropod-borne
  virus) infection.
• In the past 15 years, it has become a problem in
  most urban centres in the tropics and has emerged
  as a major problem in the Americas.
• Transmitted by mosquito bites, it is a severe,
  influenza-like illness that may be manifest as a
  viral haemorrhagic fever, particularly in
  previously exposed individuals.

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DENGUE -

• Over the past 22 years, the incidence of dengue
  in all sub-regions of the Americas has shown a
  rising trend, with ever-growing epidemic peaks
  repeated regularly every 3 to 5 years.

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http//www.paho.org/English/AD/DPC/CD/eid-eer-2007
-09-26.htm
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Dengue in the Americas, 19801998
Reported Cases (Thousands)
Unpublished data Pan American Health
Organization, March 1999
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http//www.paho.org/English/AD/DPC/CD/eid-eer-2007
-09-26.htm
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Dengue Fever in Jamaica 1995 2007
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Confirmed and Suspected Leptospirosis Cases
Reported, Weeks 1 52, 2007
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LEPTOSPIROSIS

• There were 252 confirmed cases of Leptospirosis
  for 2007 - 24 greater than the 204 cases
  reported for the prior year.
• The number of confirmed Leptospirosis cases
  increased in the last quarter of the year as
  expected from prior years and after heavy rains
  of Hurricane Dean and October.

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Tuberculosis

• Although tuberculosis has remained a problem in
  the developing world, it seemed likely that the
  disease would be eradicated from developed
  countries and possibly eventually from the
  developing nations.
• Resurgence of tuberculosis is now well documented
  in both developing and developed countries.
• One factor in this resurgence is the emergence of
  drug-resistant strains of Mycobacterium
  tuberculosis, but another important factor is the
  association between HIV infection and
  tuberculosis.
• This is a particular problem in Africa but occurs
  worldwide.

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Tuberculosis

• Tuberculosis caused 1 billion deaths in 19th and
  20th centuries.
• Declined in developed countries, but it has been
  on the increase since the 1980s. It is the main
  pathogenic cause of death worldwide.
• Many people carry the bacillus but do not develop
  symptoms unless their immune system is
  compromised.
• Tuberculosis has been on the increase since the
  1980s. It is the main cause of death worldwide.
• The resurgence in tuberculosis is associated with
  HIV infection.
• Once they develop symptoms, they can infect other
  people.

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Tuberculosis

• The problem is compounded by the emergence of
  drug resistant strains, due to patients not
  completing antibiotic courses.
• In 1980 50 per cent of TB bacilli were resistant
  to 1 drug.
• Multi-drug resistant TB (MDR-TB) began to emerge.
  There are now an estimated 1.5m MDR cases
  worldwide.
• Extreme drug resistance (XDR-TB) was reported in
  2006.
• The first completely drug resistant (CDR-TB) case
  was reported in Italy in 2007.

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Yellow Fever

• Yellow fever is transmitted by the Aedes aegypti
  mosquito. The reservoir is capuchin and rhesus
  monkeys.
• Yellow fever was formerly a jungle disease, but
  it is now endemic in Latin American cities.
• Aedes aegypti is actually more common in North
  America, prompting fears that yellow fever could
  become endemic if there was a sufficient
  reservoir of infection.

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AmericasMeasles elimination
Catch-up campaigns
Confirmed cases (thousands)
Routine infant vaccination coverage ()
Follow-up campaigns
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Confirmed Measles Cases Measles/MMR Vaccine
CoverageJamaica 1980-1999
Rubella Mass Campaign (13 - 29 Yr.)
Big Bang
MMR follow-up campaign (1-10 years)
SourceMinistry of Health, Jamaica, May, 1999
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Cholera

• There were no new pandemics for most of the 20th
  century, but the 7th pandemic began in the 1960s
  (the El Tor strain). It spread to Latin America
  in the 1980s. Developed countries have so far
  escaped.
• Cholera was not present in South America until
  1991, when it suddenly became epidemic in
  Peru,for reasons that are not altogether clear.
• Cholera is a water-borne disease and in Peru
  seems to have been transmitted among
  'marginal-urban populations'.
• Eating unwashed fruits and vegetables was
  identified as a means of transmission in other
  areas of the country, and eating a raw marinated
  fish dish (ceviche) has been suggested as another
  source of infection.
• An even more virulent strain (0139) has emerged
  in the Sea of Bengal. This may be the beginnings
  of 8th pandemic. There is no guarantee that
  developed countries will escape.

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Bubonic Plague

• Bubonic plague was introduced into the Chinese
  community in San Francisco at the beginning of
  the 20th century. Since then it has been moving
  underground eastwards in infected ground
  squirrels and prairie dogs. So far few humans
  have been infected.
• A bubonic plague epidemic in India in 1994
  infected 2,500. Fortunately it had low virulence
  and was amenable to tetracycline.

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Diphteria

• In 1990, diphtheria re-emerged as a major health
  problem in the Russian Federation. By 1994, the
  problem had spread to involve all the new
  independent states of the former Soviet Union.
• The reasons for this resurgence include breakdown
  of immunisation and other public health
  programmes and of the healthcare infrastructure
  generally.

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Human Rabies Trends1980-1989 versus 1990-1998
20
7
5
2
2
1
1980 -1989
1990 -1998
DVRD / VRZB
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Blood Safety

• Units donated in the U.S. are routinely tested
  for evidence of seven infectious agents
• HTLV I and II
• HIV 1 and 2
• Treponema pallidum
• Hepatitis B and C viruses

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Conclusion

• The re-emerging old infectious diseases have made
  relatively little impact upon the public
  imagination in DCs because either they affect
  only a small number of people, many of whom are
  already sick or poor (e.g. MRSA or TB), or else
  they are 'out there' in the Third World where
  'life is cheap' and 'these things happen'.
• However, given the rapid development of
  drug-resistant strains, coupled with rapid air
  transportation, it may be only a matter of time
  before one of our ghosts from the past come back
  to haunt us.

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Neglected Diseases

• About 1 billion people are affected by one or
  more neglected tropical diseases (NTDs).
• They are named neglected because these diseases
  persist exclusively in the poorest and the most
  marginalized communities, and have been largely
  elminated and thus forgotten in wealthier places.
  
• The diseases thrive in places with unsafe water,
  poor sanitation, and limited access to basic
  health care.
• Despite the severe pain and life-long
  disabilities they cause, these diseases are often
  less visible and given a low priority alongside
  high mortality diseases.

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Neglected Diseases

• There are 14 diseases currently listed as NTDs.
• Most can be prevented, eliminated and one, guinea
  worm, can be eradicated.
• Children are the most vulnerable.

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Neglected Diseases

• The 14 NTDs are
• Buruli ulcer,
• Chagas disease,
• cholera/epidemic diarrhoeal diseases,
• dengue/dengue haemorrhagic fever,
• dracunculiasis (guinea-worm),
• endemic treponematoses (yaws, pinta, endemic
  syphilis),
• human African trypanosomiasis (sleeping
  sickness),
• leishmaniasis,
• leprosy,
• lymphatic filariasis,
• onchocerciais,
• schistosomiasis,
• soil-transmitted helminthiasis, and
• trachoma.

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Neglected Diseases

• Since neglected tropical diseases do not travel
  easily, they pose little immediate threat to
  wealthier societies.
• Meanwhile, those who are affected have little
  political voice and are too poor to demand
  treatment.
• These diseases therefore do not represent a
  lucrative market for medicines as the
  underfunding for the development of new drugs
  shows Less than 1 of the 1393 new drugs
  registered between 1975-1999 were for tropical
  diseases.

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Neglected Diseases

• For some NTDs, there are simple and affordable
  diagnostic tools which cost as little as four US
  cents per test. For the rest, people in remote
  areas become ill or die before the disease can be
  diagnosed because the currently available
  diagnostic tools require skilled health workers
  and hospitalization.
• Several NTDs are transmitted by insect vectors
  onchocerciasis is carried by the black fly
  leishmaniasis by the sandfly Chagas disease by
  the 'kissing bug' lymphatic filariasis by
  mosquitoes and sleeping sickness by tsetse
  flies.

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Neglected Diseases

• The economic impact of NTDs can be staggering.
  People used to flee fertile river valleys
  infested with the black fly and settle in less
  productive regions. More than 25 million hectares
  of infested land have now been resettled,
  allowing people to plant crops and raise cattle.
  Similarly, the tsetse fly has been eliminated
  through hanging traps (seen in the photograph).
• Drugs for some of the NTDs are safe, inexpensive
  (as low as two US cents per tablet) or even
  donated. They can be delivered by trained
  non-medical staff, like teachers in their
  classrooms, and community health volunteers. For
  other diseases, the medicines are old, toxic,
  expensive and often in short supply. They are
  also difficult to administer and can even be
  lethal if they are administered poorly.

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Neglected Diseases

• With the right medicines and services comes
  success. Over the past 20 years, 116 of 122
  countries endemic for leprosy, have eliminated
  this notoriously old and feared disease as a
  public health problem. Since the introduction of
  multidrug therapy in 1985, 14.5 million people
  have been cured of leprosy.
• Guinea worm is transmitted exclusively by
  drinking contaminated water and it is now only
  found in remote rural villages. It can be
  eradicated with effective and inexpensive
  interventions such as water filtration and vector
  control.Major progress has been made with the
  number of reported cases plummeting from nearly 1
  million in 1989 to 25,000 in 2006.

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Antibiotic Resistant Bacteria (1)

• The discovery of penicillin in 1928 and the
  introduction of other antibiotics such as
  streptomycin, chloramphenicol, tetracycline in
  the 1940s raised hopes that cures could be found
  for all infectious diseases.
• Only one family of antibiotics (quinolones) have
  been developed since the 1960s.
• Strains of Staphylococcus aureus developed
  immunity against penicillin in the 1960s.
  However, methicillin was still effective.
• Methicillin resistant Staphylococcus aureus
  (MRSA) were found by the 1980s. Vancomycin was
  used as a last resort.
• Now vancomycin resistant Staphylococcus aureus
  (VRSA) has been observed in hospitals around the
  world.

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Staphlyococcus aureus
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Antibiotic Resistant Bacteria (2)

• Streptococcus A which caused scarlet fever more
  or less vanished by the 1960s, but it re-emerged
  in a much more deadly form in the late 1980s.
• Streptoccous pyrogenes (dubbed the flesh eating
  bug) causes life threatening necrotizing
  fasciitis unless stopped by amputation.
• Various strains of Pneumonoccus have resistance
  to whole classes of antibiotics.
• Hospitals are a major breeding ground for
  antibiotic resistant bacteria.

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Antimicrobial Resistance

• Worldwide problem
• Dramatic increase in antimicrobial-resistant
  community-acquired and nosocomial pathogens
• Major risk factors
• Antimicrobial use (misuse)
• Infection control practices (noncompliance)

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Evolution of Antimicrobial Resistance
Penicillin ? 1950s
Methicillin ? 1980s
Penicillin-resistant S. aureus
Methicillin-resistant S. aureus (MRSA)
S. aureus
Vancomycin
1997
1990s
Vancomycin-resistant enterococcus (VRE)
Vancomycin (glycopeptide) - intermediate resistant
S. aureus
Vancomycin- Resistant S. aureus
?
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Staphylococcus Aureus

• Staphylococcus aureus is very common, but also
  very deadly if it gets into the blood stream.
• It was formerly a major cause of death following
  surgery.
• Penicillin proved to be very effective.
• When penicillin began to fail in 1950s,
  methicillin proved effective.
• Methicillin resistant strains were identified in
  1961 but did not become common until the 1990s
  (MRSA).
• Vancomycin was an effective drug of last resort,
  but VRSA was reported in the late 1990s.
• About 2 billion people worldwide carry Staph A.
  and about 50 million carry MRSA.

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Emerging Vancomycin-resistant Enterococcal
Infections
Resistant
in U.S. NNIS Hospitals
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Streptococcus pyrogenes
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Streptococcus Pyrogenes

• Streptoccus pyrogenes was cause of scarlet fever,
  rheumatic fever, and puerperal fever but more or
  less vanished by 1960.
• Displaced by Strep B.
• Reappeared in 1989. Causes necrotizing fasciitis
  the flesh eating bug. Can only be stopped by
  amputation.
• Still susceptible to penicillin, but resistant to
  macrolides (e.g. Erythromycin).

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Streptococcus pneumoniae
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Other Resistant Bacteria

• Penicillin resistant Pneumococcus was discovered
  in Spain in 1980s. Became resistant to
  cephalosporin antibiotics in US in 1990s. Still
  responds to vancomycin.
• Enterococcus faecium developed a Vancomycin
  resistant form (VREF) in 1989. It is now
  resistant to all antibiotics.
• Severe diarrhoea in patients on antibiotics
  caused by Clostridium difficile. At least two
  fatal epidemics in the community. Developing
  resistance to quinolones.
• Broad-spectrum antibiotics may also kill
  commensals (i.e. beneficial bacteria) which help
  keep the pathogenic bacteria in check (e.g.
  Candida albicans).

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Clostridium difficile
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Prevention Partners
Business Industry
Local Health Departments
Political Leaders
Hospitals
Healthcare Providers
Professional Organizations
Ministry of Health
CDC
Public Health, Medical, Veterinary Schools
Government Agencies
International Health Organizations
Consumers
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International Health Regulations 2005

• Four major changes in the revision
• Public Health Emergency of International concern
• Epidemic alert and response
• National IHR Focal Point
• Dictates the core requirements for
• surveillance and response
• ports of entry

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The Role of the National Epidemic Alert and
Response System
WHO International
Authorities/ Decision Makers
National Laboratory System
Veterinarian Surveillance System
Notification/ Risk Communication
Media, General Public
Public Health Measures
Food Surveillance
Response
Verification Assessment Investigation
Detection (Early Warning)
Health Care Services
Health Care Services
National Health Emergency Response System
National Surveillance System
Unofficial (Rumors) Sources
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