My topic that I chose was HIV/AIDS. Attached you will find the rubric and a sample. In addition, are some articles, etc that the professor refers to. You will also find the FINAL PROJECT expectations, although this doesn’t pertain to this portion that I am posting, I have attached it for reference for later on.
BIO212 MOD-2 example assignment
Example Student
Disease: COVID-19
·
Why did you choose this disease?
I selected this disease because it has had a major impact on the people of the world during 2020. This danger continues to this day as we deal with the fallout of the pandemic. I have had family and friends who became extremely ill but thankfully, no one died. Understanding how a virus like COVID-19 works and how it can infect the human body is important to my pursuit of a health care career. I hope to achieve a better understanding of what we can do as a society and as individuals to avoid a repeat pandemic such as this.
·
Why do you think is an important disease we should all know more about?
The US has experienced at least 600,000 deaths from COVID-19. The world has had over 3,889,723 confirmed deaths and many more suspected since the pandemic began. (WHO dashboard, 2021) The speed with which the disease spread and our inability to stop this have surprised many scientists and healthcare professionals. We need to be better prepared for the next disease that will inevitably come. Learning from your mistakes with COVID-19 will make us better prepared and save the lives of millions worldwide.
·
What is the microbe that causes this disease and what have you already learned about it? (briefly!)
COVID-19 is a member of the SARS-MERS family of viruses. Related viruses have been found infecting many different species of animals. The infection of COVID-19 is a zoonotic disease. (Hadler, 2020) This means it was mutated in a way that allowed it to infect humans instead of the animals it came from. Scientists think it came from bats and transferred to hogs and other farm animals that have close contact with humans. The research is not complete to clearly identify in which species the virus first appeared.
·
What are two significant questions you hope to answer in researching this disease?
1. I believe my research can highlight the causes of the rapid spread of the disease.
2. My research should also shine a light on how we can be better prepared to fight the next pandemic.
References
Haider N, Rothman-Ostrow P, Osman AY, et al. COVID-19-Zoonosis or Emerging Infectious Disease?. Front Public Health. 2020;8:596944. Published 2020 Nov 26. doi:10.3389/fpubh.2020.596944
World Health Organization, Health Emergency Dashboard, (2021).
https://covid19.who.int/
BIO212 MICROBIOLOGY
FINAL PRESENTATION EXPECTATIONS AND GUIDELINES
You have been asked to prepare an educational presentation to a public health class for high school students.
Your presentation will delve in-depth into one particular epidemic disease caused by a microorganism.
You must select an appropriate disease from the list provided in the course module 2 (also shown here). COVID-19 is NOT one of the allowed selections! Any other ideas that are not listed, must be approved by your instructor BEFORE you submit the module 2 proposal.
First: Select one disease process from the list:
· Malaria
· Cholera
· Plague (Bubonic, plague two forms)
· Tuberculous
· Zika
· Ebola
· Spanish Flu
· Swine Flu
· Asian Flu
· Smallpox
· HIV/AIDS
· SARS
· MERS
· H1N1
· Polio
· Yellow fever
Your presentation should include all of the following aspects of this disease:
· The organism that causes the disease
· A thorough examination of what type of organism this is (virus, bacteria, protozoa, etc.)
· Its life cycle in detail, any other species involved besides humans, life stages, etc.
· How it is spread
· The infection process as it happens inside the human body
· Regions of the world where this is found, where it may be spreading, other environmental concerns that impact the life cycle of the organism. Social and economic issues that impact the spread, war, famine, etc.
· Historic perspective, especially if your disease has been around for a long time. When was it first identified? how often has it resulted in epidemics or pandemics?
· Current statistics about this disease, yearly patients, deaths, changes over time, is it getting worse or better?
· The disease process:
· Follow this from infection through all the symptomology and outcomes
· What is the human immune system response?
· Is the patient a carrier, or infected with recurrent episodes or is the surviving patient immune from further infections?
· What is being done to combat this disease and by who?
· Current medications, vaccines, mosquito nets, draining swamps, etc.
· Latest technologies such as genetic modification of infectious insects.
· National and international efforts to eradicate the disease.
· Future prognosis for this disease: will it continue to exist, spread or disappear?
· What can your audience do to protect themselves?
· What can they do to help the fight against this disease?
Directions for your presentation
This assignment is an opportunity for you to craft a 5 to 8-minute professional presentation of your research on the disease you selected.
· This is an activity that will provide you with skills and techniques that are invaluable as you proceed to future courses and your work in your career.
You have several technology options for executing this presentation (see below), but whatever approach you select, it must be built around a presentation of your disease and include video in some form, either inserted into a PowerPoint or as part of a complete video presentation. Your work must have graphics, diagrams, and illustrations, do not be just a talking head. Think of this as a TED talk.
Presentation Deadlines
· By end of day Thursday (but the earlier the better) of M8, you will need to share a draft of this presentation in our M8 Discussion for peer input (see next page)
· By end of day Sunday of M8, you will need to submit the final version of this presentation (making whatever final edits you see fit).
Content Requirements as outlined above.
Visual Requirements
· Photos and graphics as appropriate illustrations
· Any included graphics should be clear, legible, and labeled correctly with scientific notation.
· All photos and graphics need to have citations included on the slide.
· A video element of you presenting the information, think of a TED talk.
· You must be seen on-screen for at least two minutes (though you may choose to be seen throughout).
Don’t just be a talking head!
Technology Options
Select one of the approaches below showcase your work using both voice-over and on-camera narration. There are four approaches for creating your presentation. Please review the BIO 212 course page Audio/Video Tools, Tips and Instructions for technology specific how-to’s and recording tips.
1. Screen recording with Webcam narration (via Screencast-o-Matic or equivalent tool) which must include all the supporting photos, graphics and visuals
2. A video of you presenting your slides (
this kind of thing
)
3. PowerPoint presentation with webcam video narration (requires latest version of Office 365)
4. PowerPoint presentation with audio narration plus embedded video clips (of you presenting)
· When on-camera: show your upper body, look in the camera, and speak to your audience. Professional attire is highly recommended.
Submission Instructions
Review your presentation and be sure your sound is clear, and you are satisfied with the overall organization.
· Submit your final presentation as a link or a file to the assignment dropbox.
· Include your references as a separate MS Word document.
Your final submission is due in M8 by Sunday, 11:59 PM ET. Per above, you must also post a draft of your presentation to our M8 discussion forum by Thursday, 11:59 PM ET.
Evaluation
Please review the Voice-over PowerPoint Presentation rubric before submitting your work for evaluation details.
This assignment is worth 15 % of your final course grade.
BIO212 M2 Project Work Disease Selection and Examination
Criteria A C F F no
submission
Points 25 25 19 14 0
Selected from the list:
The student selected an appropriate
disease from the list or contacted the
instructor for an appropriate alternative
choice
The work uses the provided
list (or instructor approval) to
select an appropriate topic
The work did not use the
provided list or did not
receive prior approval
The submitted work is not
adequate
No submission
Points 50 50 37 27 0
Content:
The work contains complete, correct
and sufficiently detailed and specific
ideas as
stipulated in the assignment
about the infectious disease selected.
The work contains complete,
correct and sufficiently
detailed and specific ideas as
stipulated in the assignment
about the disease selected.
The work contains some of
the correct ideas as stipulated
but lacks sufficient details.
The work is incomplete in
many areas.
No submission
Points 25 25 19 14 0
Writing Mechanics & Formatting:
Grammar, spelling and syntax are
correct. Length meets requirements for
the assignment.
No errors in grammar,
spelling or syntax throughout
the entire document; meets
length requirements.
A few minor errors in
grammar, spelling and/or
syntax. Does not adhere to
length requirements.
Significant number of errors
in grammar, spelling and/or
syntax throughout. Does not
adhere to length
requirements.
No submission
Point totals 100 75 55 0
BIO212 M2 Project Work Disease Selection and Examination
Criteria A C F F no
submission
Points 25 25 19 14 0
Selected from the list:
The student selected an appropriate
disease from the list or contacted the
instructor for an appropriate alternative
choice
The work uses the provided
list (or instructor approval) to
select an appropriate topic
The work did not use the
provided list or did not
receive prior approval
The submitted work is not
adequate
No submission
Points 50 50 37 27 0
Content:
The work contains complete, correct
and sufficiently detailed and specific
ideas as
stipulated in the assignment
about the infectious disease selected.
The work contains complete,
correct and sufficiently
detailed and specific ideas as
stipulated in the assignment
about the disease selected.
The work contains some of
the correct ideas as stipulated
but lacks sufficient details.
The work is incomplete in
many areas.
No submission
Points 25 25 19 14 0
Writing Mechanics & Formatting:
Grammar, spelling and syntax are
correct. Length meets requirements for
the assignment.
No errors in grammar,
spelling or syntax throughout
the entire document; meets
length requirements.
A few minor errors in
grammar, spelling and/or
syntax. Does not adhere to
length requirements.
Significant number of errors
in grammar, spelling and/or
syntax throughout. Does not
adhere to length
requirements.
No submission
Point totals 100 75 55 0
Key facts about major deadly diseases
Managing epidemics
VERSION 1
Key facts about major deadly diseases
Managing epidemics
© World Health Organization 2018
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Managing epidemics: key facts about major deadly diseases
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Contents
The re-emergence of infectious diseases
– The threat continues
– The 21st century: already a long series of scourges
– Faster and further with a greater impact
– Ready and able to detect the next outbreak
– One Health and emerging and re-emerging pathogens
– Known epidemics: still a severe threat
– Strengthening health systems: essential in epidemics
Burden of epidemics: illustrations
Challenges and risk factors for 21st century epidemics
– New lifestyles spread diseases further
– Revisiting traditional control measures
– Equity and solidarity
– Epidemics of rumours: a new risk to health
Foreword
About this handbook
PART I : EPIDEMICS OF THE 21ST CENTURY
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Key insights into infectious disease epidemics
Response tips and checklists
– Coordinating responders
– Health Information
– Communicating risk
– Health Interventions
Focus 1: Community engagement during epidemics
– Defining a community
– Why engage communities
– Three elements of community engagement
– Ten things to know
– Ensuring effective community engagement
Focus 2: Risk communication – a life-saving action in public health emergencies
– The essence of risk communication
– 21st century aspects change and complicate risk communication
– Making it effective
– Ten things to know and do
– Other factors to remember
Focus 3: Treating patients and protecting the health workforce
– Advances in medicine: antibiotics, antivirals, vaccines and new treatments
– Treating patients with supportive care
– Protecting frontline responders
– Confronting the human resources crisis
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PART II: BE IN THE KNOW. 10 KEY FACTS ABOUT 15 DEADLY DISEASES
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EBOLA VIRUS DISEASE
LASSA FEVER
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)
YELLOW FEVER
ZIKA
CHIKUNGUNYA
AVIAN AND OTHER ZOONOTIC INFLUENZA
SEASONAL INFLUENZA
PANDEMIC INFLUENZA
MIDDLE EAST RESPIRATORY SYNDROME (MERS)
CHOLERA
MONKEYPOX
PLAGUE
LEPTOSPIROSIS
MENINGOCOCCAL MENINGITIS
PART III: TOOL BOXES
Tool box 1: The role of WHO
Tool box 2: The International Coordinating Group (ICG) on vaccine provision
Tool box 3: Tables for laboratory diagnosis and shipment of infectious substances
Tool box 4: Transport of infectious substances
Tool box 5: Vector control during epidemics
Acknowledgements
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Foreword
Can we create a pandemic-free world? There is no such
thing as a guarantee, but with meticulous preparation
and rapid response, we can prevent most outbreaks
from getting out of control, and limit the impact of
those that spread internationally.
First, we must build and sustain resilient capacities at
national, regional and global levels to prevent, detect
and respond to outbreaks, in accordance with the
International Health Regulations.
And second, we must ensure that populations affected
by emergencies have rapid access to essential life-
saving health services, including medicines and
vaccines.
That’s why WHO works all around the world to
strengthen health systems, built on the foundation
of people-centred primary health care that focuses
on health promotion and disease prevention, with a
strong focus on surveillance systems.
Delivering on these priorities will cost money of course,
but only a fraction of what remaining unprepared will
cost. In the end, prevention is not only better than cure;
it’s cheaper.
This year marks the 100th anniversary of Spanish flu, the deadliest
outbreak in recorded history. Up to 50 million people were killed,
more than the death toll from the First World War.
Thankfully, we have not seen a public health emergency on that
scale since then. But we may at any time. Outbreaks are a fact of life,
and the world remains vulnerable. We do not know where or when
the next global pandemic will occur, but we do know that it will take
a terrible toll, both on human life, and on the global economy.
None of us will ever forget the West African Ebola outbreak in 2014.
It taught us a valuable lesson: that global health security is only as
strong as its weakest link. No-one is safe until everyone is safe.
Keeping the world safe is one of WHO’s three top strategic priorities in our new General Programme
of Work. We are setting ourselves a goal that over the next five years, 1 billion more people will be
better protected from epidemics and other health emergencies.
This manual is a valuable tool to help countries make progress towards that goal. It offers expert
guidance to help WHO’s country representatives and others to respond quickly in the earliest stages
of an outbreak.
But it’s not enough just to respond to outbreaks. We must do our best to prevent them by addressing
the root cause of health insecurity: the lack of access of the most vulnerable people to essential
health services.
Ultimately, it’s the absence of universal health coverage that is the greatest threat to health security.
Universal health coverage and health security are two sides of the same coin.
2018 is also a milestone year for WHO.
It’s our 70th birthday – a reminder that the reasons we were created are as relevant now as they were
at our beginning. WHO was founded on the principle that all people should be able to realize their
right to the highest possible level of health. “Health for all” has always been our guiding vision.
Dr Tedros Adhanom Ghebreyesus
Director-General of the World Health Organization
10
About this handbook
Handbook purpose
Epidemics of infectious diseases are occurring more often, and spreading faster and further than
ever, in many different regions of the world. The background factors of this threat are biological,
environmental and lifestyle changes, among others.
A potentially fatal combination of newly-discovered diseases, and the re-emergence of many
long-established ones, demands urgent responses in all countries. Planning and preparation for
epidemic prevention and control are essential.
The purpose of this “Managing epidemics” manual is to provide expert guidance on those
responses.
Although this publication is open to a wide readership, it is primarily intended to help the World
Health Organization (WHO) country representatives (WRs) to respond effectively and rapidly at
the very start of an outbreak.
The manual provides concise and basic up-to-date knowledge with which WRs can advise
Ministries of Health in all countries. Specifically, it examines and explains in detail a total of 15
different infectious diseases and the necessary responses to each and every one of them.
These diseases have been selected because they represent potential international threats for
which immediate responses are critical. Nearly all of them are subject to WHO’s International
Health Regulations (2005) monitoring, and are part of the Global Health Security Agenda.
Perhaps the greatest threat outlined in the manual is an influenza pandemic, which is both
unpredictable and inevitable. In the worst-case scenario, there will be no protective vaccine for six
months or longer after the virus is identified, and even there will be a global shortage of doses.
On this and other threats, the manual focuses on practical and indispensable things to know about
infectious diseases that are most important for national political and operational decision-makers;
it also links readers to more exhaustive WHO guidance. It has been developed in parallel with the
creation of the WHO MOOCs (Massive Open Online Courses) on openWHO (https://openwho.org).
Handbook structure
The manual is structured in three parts.
• Part One “Epidemics of the 21st century”
provides vital insights on the main features of
the 21st century upsurge and the indispensable
elements to manage them.
• Part Two “Be in the know. 10 key facts about
15 deadly diseases” contains key information
about 15 diseases (Ebola Virus Disease, Lassa
Fever, Crimean-Congo haemorrhagic fever,
Yellow Fever, Zika, Chikungunya, Avian and Other
Zoonotic Influenza, Seasonal Influenza, Pandemic
Influenza, Middle East Respiratory Syndrome,
Cholera, Monkeypox, Plague, Leptospirosis and
Meningococcal Meningitis). This section provides
tips on the interventions required to respond to
epidemics of all these diseases.
• Part Three “Tool boxes” gives an overview
and summarized guidance on some other
important topics, including: the role of WHO,
the International Coordinating Group, laboratory
diagnosis and shipment of infectious diseases
substances, and vector control.
The handbook enables the three levels of WHO
– its Headquarters, Regional Offices and Country
Offices to work efficiently together by building the
foundations of a shared conceptual and thinking
framework, which includes common terminology.
This “Managing epidemics” manual will be regularly
updated. The next versions will incorporate
additional infectious diseases.
11
https://openwho.org
PART I Epidemics of the
21st century
13
The re-emergence of
infectious diseases
The threat continues
We are continuously learning about the unpredictable powers of nature.
This is nowhere more true than in the continuous evolution of new infectious
threats to human health that emerge – often without warning – from the
natural environment.
Already in these first two decades of the 21st century, the world has been sharply
reminded time after time of the degree to which people in all countries and on all
continents remain chronically vulnerable to infectious diseases, known and unknown.
In the 1970s, and for years afterwards, this remarkable progress, including the development of
new vaccines, antibiotics and other treatments and technologies, led to a proclamation of a victory
of mankind over microbes. Many experts thought it was “the time to close the book on the problem
of infectious diseases” (Jesse Steinfeld, MD, US Surgeon General, 1969).
Here lay the roots of a dangerous complacency. The microbes didn’t go away. They just went out
of sight. Instead, the focus turned to chronic, noncommunicable diseases, which came to receive
much more attention. But nature was by no means in retreat. In fact, it seemed to return and took
many health institutions and decision makers by surprise.
Since 1970, more than 1,500 new pathogens were discovered, of which 70% proved to be of animal
origin: a connection that deserves renewed scrutiny. Not all of them have had a public health impact
but some of them have become famous. They included the Ebola virus, in 1976, and the human
immunodeficiency virus (HIV), in 1983.
Pause for a moment and reflect that HIV, a relatively new disease in human history, has infected
about 70 million people in just 35 years, and killed an estimated 35 million people in the same
period. Consider also that in the last 40 years, Ebola has surfaced in almost 25 separate and deadly
outbreaks, often after long spells in which it has apparently lain dormant. And now ask the question:
Will history repeat itself?
The answer must be: Yes, it will. A new HIV, a new
Ebola, a new plague, a new influenza pandemic
are not mere probabilities. Whether transmitted
by mosquitoes, other insects, contact with animals
or person-to-person, the only major uncertainty is
when they, or something equally lethal, will arrive.
The obvious follow-up question is: So what are we
doing about it? This purpose of this handbook is
to provide as many answers as possible. In doing
so it examines a range of challenges and real or
potential solutions, ranging from the medical and
technological to the social and political.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 14
The 21st century: already a long series of scourges
In order to try to see the road ahead more clearly, we need frequently to look over our shoulders – all
the more so, because these early years of the 21st century have already been deeply scarred by so many
major epidemics.
Take plague, one of the most ancient scourges. A thing of the past? By no means. A major outbreak in
Madagascar in 2017 led to a total of at least 2,417 confirmed, probable and suspected cases, including
209 deaths. Most cases were of the more fatal pneumonic type which is also transmissible from person to
person, but there were also several hundred cases of bubonic plague. Nine countries and territories with
trade and travel links to Madagascar were put on plague preparedness alert.
The lesson here is that, over time, diseases very rarely disappear. And there always seems to be room for
new ones.
SARS – Severe acute respiratory syndrome – was unheard of before 2003. But it affected more than 8,000
people, killing about one in ten of them, causing fear and panic across the world, and inflicting enormous
economic damage, especially in Asian countries.
In 2009, a novel influenza virus, H1N1, started to spread, creating the first influenza pandemic of the 21st
century. But – and this is a reason for cautious hope – it was not as severe as expected thanks to recent
preparedness efforts. The importance of these efforts is a core issue in this handbook.
In 2012-2013, a new virus surfaced in the Middle East, causing an epidemic of what became MERS –
Middle East respiratory syndrome – that spreads fatally into many countries beyond that region.
The Ebola epidemic in West Africa (Guinea, Liberia, and Sierra Leone) in 2014 was unlike the previous 24
localized outbreaks observed since 1976. Instead of being restricted geographically, this one seriously
affected three African countries and spread to six other countries in three continents, and sparked alarm
worldwide.
In 2015, the Zika virus, transmitted by the Aedes Aegypti mosquito, triggered a wave of microcephaly in
Brazil. This disease causes dreadful damage in the brains of unborn babies. Almost 70 countries, one after
another, then experienced their own Zika epidemic. There are probably many more to come, because
most of the global intertropical zone has a high density of Aedes Aegypti that transports the disease.
And so a clear pattern continues to take shape. Old diseases – Cholera, Plague, Yellow fever among
them – often return, and new ones invariably arrive to join them. About 40 outbreaks of cholera alone are
reported to WHO every year.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 15
Gavi, the Vaccine Alliance, is an
international organisation that was
created in 2000 to improve access to new
and underused vaccines for children living
in the world’s poorest countries.
The International Health
Regulations (2005) or IHR (2005) are
an international law which helps countries
work together to save lives and
livelihoods caused by the international
spread of diseases and other health risks.
The IHR (2005) aim to prevent, protect
against, control and respond to the
international spread of disease while
avoiding unnecessary interference with
international traffic and trade.
The Pandemic Influenza Preparedness
(PIP) Framework brings together Member
States, industry, other stakeholders and WHO
to implement a global approach to pandemic
influenza preparedness and response. Its
key goals include:
– to improve and strengthen the sharing
of influenza viruses with human
pandemic potential; and
– to increase the access of developing
countries to vaccines and other
pandemic related supplies.
The Global Outbreak Alert and
Response Network (GOARN) is a
technical collaboration of existing
institutions and networks who pool
human and technical resources for
the rapid identification, confirmation
and response to outbreaks of
international importance.
2000 2015 2016 2017 201820142013201220112010200920082007200620052004200320022001
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LEGEND
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GAVI
IHR
(2005) PIP
Framework
PIP
Review
IHR
Review
GOARN
LEGEND
Ebola (West Africa)
Cholera (Haiti)
MERS-CoV
H1N1
H7N9
Zika
Yellow fever (Central Africa, Brazil)
H5N1
SARS
Epidemic
Pandemic
Timeline
Major infectious threats in the 21st Century & collaboration mechanisms to fight against them
Cholera (Yemen)
Plague (Madagascar)
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 16
Faster and further with a greater impact
This pattern has another, deeply troubling aspect. The epidemics in the 21st century are spreading faster
and further than ever. Outbreaks that were previously localized can now become global very rapidly – just
as fast, in fact, as an intercontinental aircraft can fly. Thus, an individual flying from one side of the world
can introduce a new disease into the other, within hours, and before even showing symptoms. And in this
way, far from its origins, the microbe finds a new home.
For example, the influenza pandemic of 2009 reached all continents in less than nine weeks. In recent
outbreaks, yellow fever made it all the way from Angola to China, but, fortunately, there were only
imported cases with no sustainable circulation in the mosquito population.
In 2015, it took just one traveler returning home to the Republic of Korea from spending time in the
Middle East to bring MERS back with him. The consequences: a Korean outbreak, 186 cases, 36 deaths,
and outbreak-related losses of approximately US$ 8 billion, all in the space of two months.
Thus, 21st century epidemics can spread more
widely and more quickly, potentially affecting
ever-greater numbers of people. They also
can have a ruinous impact on the economy of
the affected country and spill over into to the
global economy, disrupting travel, trade and
livelihoods.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 17
Ready and able to detect the next outbreak
Given the effects of globalization, the intense mobility of human populations, and the relentless
urbanization, it is likely that the next emerging virus will also spread fast and far. It is impossible to predict
the nature of this virus or its source, or where it will start spreading.
But we can say, with a high degree of certainty, that when it comes, there will be (a) an initial delay in
recognising it; (b) a serious impact on travel and trade; (c) a public reaction that includes anxiety, or even
panic and confusion, and (d) this will be aided and abetted by media coverage.
The concept of global health security, a central issue in this handbook, represents a new determination
by, or on behalf of, human society to protect itself from the health impact and social disruption caused
by outbreaks. It encompasses a spectrum of ways and means that offer worldwide protection against the
threats of infectious diseases, backed by revised and more powerful International Health Regulations
(2005).
But to make the world safer, global health security depends crucially on much greater awareness,
cooperation and collaboration between individual countries, agencies, organizations and communities.
The continuing scientific uncertainty around disease emergence requires even more collaboration and
global awareness than has previously existed, not least to improve early detection.
Recent outbreaks, however, show how difficult this can be, even with good public health surveillance
systems. Early recognition of emergence typically starts with clinicians who can detect unusual clusters of
severe cases, take samples to allow laboratory diagnostics and alert surveillance units.
Often, poorer communities around the world, especially those in remote areas, lack easy access to care.
This has major implications when an infectious threat occurs. The Ebola outbreak in West Africa remained
undiagnosed for more than two months. This time lag allowed the virus to spread unseen, and to reach
capital cities where the outbreaks grew into large epidemics. In such circumstances, it is essential to raise
clinicians’ awareness and provide them with the relevant knowledge and diagnostic tools to enable
them to perform effectively as detectors and first-line responders.
As we have signaled earlier, another indispensable element of increasing health security is
preparedness. This should be flexible enough to adapt to any novel agent, but should be directed
primarily at known pathogens because some of them are likely to behave differently than previously.
The recent plague outbreak in Madagascar, described earlier, is a good example of known diseases
with new patterns.
In addition, the fear generated by the emergence of a previously-unknown infection may be
greatly out of proportion to its real public health impact. Fear often generates inadequate decisions
or inappropriate behaviours, including stigma of certain at-risk populations. The impact on travel and
trade and on economies can be disproportionate, as it has been seen in the Republic of Korea during
the MERS epidemic. To a certain extent, global health security also encompasses economic and human
security. Thus, risk communication is critical to minimise the social, political and subsequently economic
impact of an epidemic, and this is also a major focus of this publication.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 18
One Health and emerging and re-emerging pathogens
Epidemics are sparked either by the re-emergence of pathogens that have been familiar for a long time,
but now threaten new, immunologically vulnerable populations, or are newly-emerging ones. They come
in a daunting array of species of bacteria, viruses, fungi and parasites. Some are borne in contaminated
water or food; others are carried in the air we breathe and by human touch.
As noted earlier, 70% of emerging human pathogens come from animals. This is a burgeoning threat,
because animals are intensively farmed, transported for trade and kept in close contact with other species
and humans in market places.
Early detection often relies on close collaboration between the animal health and wildlife sectors (the
“One Health” approach); otherwise early signals of emergence in animals or the environment are often
missed. This collaborative approach, another pivotal element of global health security, can also contain
outbreaks at an early stage by reducing animal-to-human transmission.
Because these diseases are rare and outbreaks
are generally contained quickly, these
epidemics have not been a priority among the
research community or manufacturers in the
development of medical countermeasures.
Nevertheless, more research is needed to
identify precisely the modes of transmission
and medical countermeasures.
Today’s harsh reality is that there is as yet
no vaccine or treatment for most emerging
diseases. This is not as hopeless as it might
seem at first. WHO has developed a Research
& Development (R&D) Blueprint for action
to prevent epidemics: it is a global strategy
and preparedness plan that allows the rapid
activation of R&D activities during epidemics.
Its aim is to fast-track the availability of effective
tests, vaccines and medicines that can be
used to save lives and avert large scale crisis.
However, public health interventions have to
rely primarily on social-distancing measures
to reduce human transmission, and on
controlling the source of infection (for instance
by culling of infected animals/elimination of
the reservoir). Thus, to prevent the spread of
emerging diseases, it is vitally important to
ensure early detection of a new pathogen and
the start of human-to-human transmission.
Enhanced international information and virus
sharing among laboratories is being actively
encouraged and pursued. This is necessary
to enable research and development of
countermeasures. The results of this sharing
are potentially life-saving interventions
(vaccines, diagnostics and therapeutics). But
they also need to be underpinned by specific
mechanisms to ensure they become widely
available and accessible on an equitable basis.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 19
Known epidemics: still a severe threat
Fortunately, control programmes are already long-established and widely-applied for some known
epidemic diseases, such as cholera, HIV infection, influenza, meningitis, malaria, tuberculosis and yellow
fever.
However, even if medical countermeasures are available, these diseases remain a threat for many of
the world’s populations, either because of their rapidly evolving nature (e.g. influenza) or because
equitable access to effective public health measures is difficult. There are many reasons for limited access
to vaccines: production capacity does not meet the demand (e.g. yellow fever, pandemic influenza),
explosive outbreaks exhaust the available vaccines (e.g. meningitis), or the absence of markets prevents
access to the intervention in case of emergencies (e.g. oral cholera vaccine). In addition, in many
affected countries, the weakness of the existing health care system prevents effective access to medical
interventions (diagnostics and treatment).
Therefore, although it is reassuring that sound knowledge and a range of potential control interventions
are available, expert guidance must be constantly updated to incorporate scientific and technological
progress. Equally important, access to life-saving interventions must be improved in all settings
worldwide.
The current global strategy is to reach elimination or eradication of these diseases through
vaccination or investment in and implementation of other countermeasures.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 20
Strengthening health systems: essential in epidemics
In order to mitigate the impact of epidemics, protect the health workforce and ensure continuity of
health services during and after them, stronger health systems are needed. Epidemics and pandemics
put these systems under great pressure and stress. The sudden influx of large numbers of sick individuals
to health facilities stretches the systems’ capacity and resources, even more so and more noticeably
where resources are already scarce.
When an epidemic emerges and spreads, it inevitably draws most of health responders’ attention and
monopolizes most of the health system’s human and financial resources, as well as medical products and
technologies.
People, efforts, and medical supplies all shift to respond to the emergency. This often leads to the neglect
of basic and regular essential health services. People with health problems unrelated to the epidemic find
it harder to get access to health care services. Some may die as a result, if the disruption overwhelms the
health system. Mortality rates of other diseases for which people could not get treatment may rise.
Furthermore, health care settings, and especially emergency rooms, can become hubs of transmission.
Many people get infected there, if prevention and control measures are not properly implemented. This
is particularly true for unknown and emerging pathogens (for instance, MERS). A delay in the recognition
of the disease will lead to delay in applying the right protection measures. Infected patients will be able
to transmit the disease because health care workers, family members and other patients will not know
how to protect themselves. Because health care settings and emergency rooms are usually crowded,
the lack of appropriate infection prevention and control for example through triage, isolation, and other
precautions can be very significant.
Health systems resilience after epidemics may be challenging for unprepared health systems. Indeed, if
the health system is ill-prepared to cope with epidemics of infectious diseases, health care workers, at
the frontline of the response, may themselves
become infected and die. Tragic as such
cases are, they have wider consequences.
In countries where there are health staff
shortages, the loss of several more health
workers further weakens the health system.
It takes years to train new medical staff and
rebuild the health workforce. In the meantime,
other constraints are burdening the health
system that still has to provide the usual and
regular services.
Long-term substantial investments should
therefore be made to strengthen health
systems so they are able to provide safe,
effective and qualitative health services before,
during and after epidemics. Critical elements
include an appropriate health financing system
and a fit-for-purpose workforce that is trained,
safe and provided with personal protective
equipment. In addition, access to essential
medical products and technologies and a
business continuity plan are essential to ensure
that health systems are strong enough to
withstand the increased needs and to mitigate
the impacts of very disruptive epidemics.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 21
14
8
9
30
36
10
2
4
2
6
4
9
9
13
7
9
9
34
36
9
13
7
9
5
8
6
7
8
7
13
15 17
7
10
7
10
10
6
5
13
26
9
22
16
12
8
5
7
14
6
1
13
4
4
57
4
7
4
7
9
11
1313
7
11
24
1
7
17
3
16
2
3
1
6
6
7
1
22
11
13
1
1
15
5
11
7
115
5
9
7
14
5
30
4
7
16
8
6
6
10
6
4
13
54
7 6
2
6
5 12
5
12
10
8
7
7
1
7
16
11
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15
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5
5
10
9
11
22 3
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7
3
2
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3 3
41
1
2
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1
6
1
5
22
7
8
22
5
2
6
4 11
3
5
1
12
11
4
32
3
Burden of epidemics: illustrations
Epidemic events* globally, 2011 – 2017**: A total of 1,307 epidemic events, in 172 countries
* Analysis excluded Poliomyelitis. The following epidemic and pandemic diseases were analysed: Avian Influenza A(H5N1), A(H7N9), A(H7N6) A(H10N8), A(H3N2), A(H5N6), A(H9N2),
Chikungunya, Cholera, Crimean-Congo haemorrhagic fever, Ebola virus disease, Lassa fever, Marburg virus disease, Meningitis, MERS-CoV, Monkeypox, Nodding syndrome, Nipah virus
infection, Plague, Rift Valley fever, Shigellosis, Typhoid fever, Viral haemorrhagic fever, West Nile fever, Yellow fever, Zika virus disease. If a disease caused more than 1 epidemic event by
year in a country, it was only counted once for the year it occurred in that country. Includes cases imported or locally transmitted.
** WHO/IHM data as of 12 January 2018 (note: 2017 data is not complete)
Source: data reported to WHO and in media
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the
legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for
which there may not yet be full agreement. © WHO 2018. All rights reserved
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 22
Epidemic events* globally, 2011 – 2017**: A total of 1,307 epidemic events
Number of epidemic events* by disease and year
2011 2012 2013 2014 2015 2016 2017**
TOTAL
Yellow fever
Chikungunya
Viral haemorrhagic fever
Ebola virus disease
Marburg virus disease
Crimean-Congo haemorrhagic fever
Rift Valley fever
Cholera
Typhoid fever
Shigellosis
Plague
Lassa fever
West Nile fever
Zika virus disease
Meningitis
MERS-CoV
Influenza A
Monkeypox
Nodding syndrome
Nipah virus infection
* Analysis excluded Poliomyelitis. The following epidemic and pandemic diseases were analysed: Avian Influenza A(H5N1), A(H7N9), A(H7N6) A(H10N8), A(H3N2), A(H5N6), A(H9N2),
Chikungunya, Cholera, Crimean-Congo haemorrhagic fever, Ebola virus disease, Lassa fever, Marburg virus disease, Meningitis, MERS-CoV, Monkeypox, Nodding syndrome, Nipah virus
infection, Plague, Rift Valley fever, Shigellosis, Typhoid fever, Viral haemorrhagic fever, West Nile fever, Yellow fever, Zika virus disease. If a disease caused more than 1 epidemic event by
year in a country, it was only counted once for the year it occurred in that country. Includes cases imported or locally transmitted.
** WHO/IHM data as of 12 January 2018 (note: 2017 data is not complete) Source: data reported to WHO and in media
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 23
17
8
1
3
1
62
20
25
8
2
11
14
5
1
1
12
10
2
1
5
1
51
23
24
7
1
15
20
3
6
1
1
8
3
6
1
47
5
28
6
2
15
5
19
10
7
1
1
2
29
11
1
8
1
37
2
29
10
3
11
7
19
17
9
1
4
27
4
7
1
44
8
4
7
2
11
19
19
12
10
2
1
10
14
6
3
7
4
42
3
2
6
7
18
54
23
7
5
2
4
4
4
1
2
13
5
25
14
1
3
6
10
52
23
8
9
5
57
95
10
22
4
49
14
308
75
113
47
23
91
137
137
57
51
10
2
5
2011
179 183
164
197
182
213
189
220
200
180
160
140
120
100
80
60
40
20
0
2012 2013 2014 2015 2016 2017**
* Analysis excluded Poliomyelitis. The following epidemic and pandemic diseases were analysed: Avian Influenza
A(H5N1), A(H7N9), A(H7N6) A(H10N8), A(H3N2), A(H5N6), A(H9N2), Chikungunya, Cholera, Crimean-Congo
haemorrhagic fever, Ebola virus disease, Lassa fever, Marburg virus disease, Meningitis, MERS-CoV, Monkeypox,
Nodding syndrome, Nipah virus infection, Plague, Rift Valley fever, Shigellosis, Typhoid fever, Viral haemorrhagic
fever, West Nile fever, Yellow fever, Zika virus disease. If a disease caused more than 1 epidemic event by year
in a country, it was only counted once for the year it occurred in that country. Includes cases imported or locally
transmitted.
** WHO/IHM data as of 12 January 2018 (note: 2017 data is not complete)
Number of epidemic events* by year**
Source: data reported to WHO and in media
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 24
The face of epidemics and pandemics has changed in the recent past and continues to do so. Many new
factors contribute to an increase in the transmissibility and severity of infectious diseases.
New lifestyles spread diseases further
New and more intense factors amplify the transmission of diseases, either because they increase contacts
between people, or between animals and people. In an era of rapid global change, many of these factors
are almost inevitable. Among them are the fast and intense mobility of people, with increased transport
and international travel, and greater inter-connectivity between megacities which are major transport
hubs for aircraft, trains, road vehicles and ships.
At the same time, globalization means increased trade among countries as well as greater movement of
people within and between them. For decades, more and more people have been migrating from the
countryside into cities, in search of better jobs and improved living standards. The unprecedented levels
of urbanization and swelling populations of city dwellers inescapably pose greater risks of infectious
disease transmission.
These risks apply at least equally to densely populated areas on the periphery of cities, where rural areas
overlap with them. Here, close and repeated contacts between people and livestock, domestic animals
and wildlife raise the likelihood risk of new epidemics. To make matters worse, these peri-urban areas
tend to be poorer, and local people have less access to health care
facilities. The double jeopardy here is that their infections may
go undetected and untreated, while the options for detection,
prevention and control are reduced. The Ebola outbreak
in 2014 has dramatically demonstrated this.
Regrettably, the early years of the 21st century
have seen many humanitarian emergencies, the
massive displacement of populations fleeing from
civil unrest, political instability, conflicts wars and natural
disasters. Millions of people have been uprooted from
their homes and become either refugees, asylum-seekers or
economic migrants, and find themselves living in conditions,
often overcrowded, that also increase infection risks.
Challenges and risk factors for
21st century epidemics
Potentially hazardous changes are also taking
place in the use of land, agricultural practices
and food production, such as live poultry and
animal markets, and deforestation – which also
leads to increased contact between people
and wildlife. Some of these animals – monkeys,
for example – are likely sources of new
pathogens. Finally, ecological changes, such
as climate change, also contribute to disease
transmission.
Other factors contribute to increase the
virulence and mortality of epidemic diseases.
Chief among them, as we have noted earlier,
are limited access to health care, and poor
health care systems that have inadequate
infection prevention and control practices. The
conflicts and wars referred to above not only
cause civilian casualties and displacements:
they destroy health care facilities exactly when
and where they are most needed.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 25
Revisiting traditional control measures
We have also seen that many traditional containment measures are no longer efficient. They should
therefore be re-examined in the light of people’s expectations of more freedom, including freedom of
movement. Measures such as quarantine, for example, once regarded as a matter of fact, would be
unacceptable to many populations today.
The use of antibiotics to treat infections has been a turning point in the 20th century. Antimicrobial
resistance is now on a rise. This is a major concern because a resistant infection may kill, can spread to
others, and requires finding new ways to treat and limit the spread of the disease. Antimicrobial resistance
occurs naturally, but is facilitated by the inappropriate use of medicines, for example using antibiotics for
viral infections such as cold or flu, or using antibiotics for animal growth in the animal sector. Among
major infectious diseases, the treatment of tuberculosis is the most affected, and there are now strains of
the microorganism that are multi-drug resistant.
Equity and solidarity
Epidemics are complex events: complex in
their origins, their spread, their effects and their
consequences – which can be at one and the same
time medical, social, political and economic.
The global impact of a single pathogen may
vary significantly between settings and there is
no one-size-fits-all intervention strategy.
Equity and solidarity issues are often part of the
picture: access to medical countermeasures
remains difficult, especially for low-income
countries and countries facing humanitarian
emergencies, and this difficulty is worsened
when vaccine or treatment production is
limited. Market mechanisms do not ensure a fair
distribution of resources based on public health
demands. Global mechanisms are needed to
ensure fair access to life-saving interventions
during crises. A number of organizations are
dedicated to this goal (among them are CEPI,
the Coalition for Epidemic Preparedness
Innovations; the International Coordinating
Group; GAVI, the Vaccine Alliance; the Pandemic
Influenza Preparedness Framework) but more
efforts are required.
Epidemics of rumours: a new risk to
health
A new word has entered the public health
vocabulary: “infodemics”. These can be defined
as the rapid spread of information of all kinds,
including rumours, gossip and unreliable
information. They are spread instantly and
internationally through the growing popular use
of mobile phones, social media, the internet
and other communication technologies. A
proliferation of web-based “experts” with diverse
and often contradictory views can generate
confusion, anxiety and even panic in times of
serious infectious outbreaks. False or misleading
information is dangerous. It can cause widespread
public reluctance to adopt well-founded infection
control measures promoted by health authorities
– and thus delay essential interventions.
This is why risk communication, a set of
sophisticated skills, is increasingly employed
by health authorities, agencies, physicians
and professional health personnel. It is more
important now than ever to learn and apply them.
The latest and most accurate information must
be conveyed frequently, and uncertainties related
to an epidemic must be acknowledged in order
to maintain credibility and public trust.
Thus, we are recognizing that the complexity
of 21st century epidemics and their prevention
and control require not just new technologies
techniques, but new skills and new attitudes
all across the public health community. Risk
communication is examined at greater length in
a later section of this handbook.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 26
A whole-of-society approach is needed to
tackle 21st century epidemics so that all
the diverse disease drivers are taken into
consideration: genetics and biological factors,
ecology and the physical environment; human
behaviour and demographics; social, political,
and economic factors, and so on.
This increasing convergence of many factors
that drive and amplify outbreaks requires multi-
disciplinary, multi-sectoral and multi-faceted
approaches.
Moreover, because epidemics are social
problems as much as medical ones, we need
to move beyond the traditional biomedical
approaches to them. Social sciences should
be an integral part of surge capacities adding
anthropologists to the team of first responders.
Such a change enables issues of fear and trust
to be addressed within the social context.
Engaging communities and empowering
them in advance as part of preparedness
ensures that there is a better understanding
of the human ecology. This will link community
and biomedical perspectives for enhancing
effective partnerships, ensuring that pre-
existing relationships are built to respond to
epidemics.
Key insights into infectious
disease epidemics
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 27
Because new infectious disease threats usually start locally, it is important to understand their dynamics in
order to deny them the opportunity to spread further among people and overwhelm health systems. The
dynamics of epidemic and pandemic diseases typically occur in four phases, although not all epidemic
diseases necessarily go through each phase.
The first phase is the introduction or emergence in a community. The second phase is an outbreak
with localized transmission, where sporadic infections with the pathogen occur. In the third phase, the
outbreak amplifies into an epidemic or pandemic – the pathogen is able to transmit from human to
human and causes a sustained outbreak in the community, threatening to spread beyond it. The fourth
phase is reduced transmission when human-to-human transmission of the pathogen decreases, owing
to acquired population immunity or effective interventions to control the disease. These four phases are
illustrated on this page.
The dynamics of epidemics, as described above, define the response and the sequence of interventions
that then become necessary. Here, there are five crucial stages.
First is the anticipation of new and re-emerging diseases to facilitate faster detection and response;
followed by their early detection of emergence in animal and human populations; the third stage is the
containment of the disease at the early stages of transmission; followed by the control and mitigation
of the epidemic during its amplification; and fifth, the elimination of the risk of outbreak or eradication
of the infectious disease. These stages are elaborated in the illustration, and in the section that follows.
Epidemic phases
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 28
Anticipation: In this first stage of response, emergence cannot be predicted, but it can certainly be
anticipated, and the anticipation of risks enables a focus on the most likely threats. Anticipation
encompasses forecasting the most likely diseases to emerge, and the quick identification of the drivers
that will worsen the impact or facilitate the spread. Preparedness plans, based on lessons learned from
past experiences, should contain a variety of scenarios to allow for a reactive response to the unexpected.
Early detection: Emerging and re-emerging diseases include new ones about which there is little
scientific knowledge. These, therefore, often require investigation into their sources at the same time
as the use of coordinated, rapid-containment measures. New diseases require new interventions. And
because they appear irregularly or rarely, there is a need for constant vigilance, proactive risk assessment
and the development of new management tools.
Early detection allows the rapid implementation of containment measures, which are the key to reducing
the risk of amplification and potential international spread. Early detection begins at the health care
setting, so health care workers must be trained to recognize potential epidemic disease, report quickly
an unusual event (such as an unusual cluster of cases or deaths). Their role is also to reduce the risk of
community transmission by isolating severely-ill patients; to prevent household transmission by protecting
health care givers at home; and to reduce the mortality rate. Health care workers must also know how to
protect themselves and employ infection prevention and control measures and how to avoid outbreaks
amplified in health care facilities.
Epidemic phases and response interventions
Anticipation
Early
detection
Control and
mitigation
Elimination or
eradicationContainment
Introduction or
emergence
Localized
transmission
Amplification Reduced
transmission
Response
interventions
Epidemic
phases
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 29
Once a new disease is recognized by the health system, early laboratory confirmation is essential. When
this cannot be done at country level, the affected countries must be confident they can count on the
support of a network of more sophisticated regional or global laboratories. It is critically important for
global health security that there is a system for safely taking samples and shipping specimens to relevant
laboratories in full compliance with biosafety and biosecurity regulations.
Containment: Effective and rapid containment of emerging diseases is just as vital as early detection in
order to avoid a large scale epidemic. Rapid containment should start as soon as the first case is detected
regardless of the etiology, which is most likely to be unknown. It requires skilled professionals to safely
implement the necessary countermeasures. Pre-training of these professionals is essential to guarantee
the safety and efficiency of the operations.
Control and mitigation: Once the infectious disease threat reaches an epidemic or pandemic level, the
goal of the response is to mitigate its impact and reduce its incidence, morbidity and mortality as well as
disruptions to economic, political, and social systems.
Elimination or eradication: Control of a disease may lead to its elimination, which means that is
sufficiently controlled to prevent an epidemic from occurring in a defined geographical area. Elimination
means that the disease is no longer considered as a major public health issue. However, intervention
measures (surveillance and control) should continue to prevent its re-emergence.
Eradication of a disease – much more difficult and rarely achieved – involves the permanent elimination of
its incidence worldwide. There is no longer a need for interventions measures. Three criteria need to be
met in order to eradicate a disease: there must be an available intervention to interrupt its transmission;
there must be available efficient diagnostic tools to detect cases that could lead to transmission; and
humans must be the only reservoir.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 30
Response tips and checklists
A comprehensive outbreak response is
always complex, comprising many elements
that should be harmoniously coordinated.
The following response tips are used to organize ideas
and to make sure no important point is overlooked. In
this handbook, specific tips are listed for each disease
which will help keep focus on essential elements of each
response. They are organized into four main blocks:
• Coordinating responders (C)
• Health Information (HI)
• Communicating risk (C)
• Health Interventions (HI)
The checklists will help you assess what is important
and necessary for the response. The outbreak response
varies depending on the disease. For some diseases
treatment is essential; for other diseases, vaccination is
vital.
C
Coordinating responders
C
Communicating risk
HI
Health Information
HI
Health Interventions
Note: Although Communicating risk (C) is part of Health Interventions (HI); it is seen here as
a separate component in order to underscore the importance of risk communications.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 31
Coordinating responders
An outbreak is by definition an exceptional event which often requires extra human and
financial resources and may also rely on additional partners, agencies and other sectors. Strong
coordination is essential at all times to ensure that all those resources and partners are working
effectively together to control the outbreak. WHO is often expected to lead the international
response to support national health authorities.
Effective coordination requires a dedicated physical space (usually an emergency operation
centre); various tools to ensure optimal organization of meetings and filing of documentation
(such as a list of contacts, and a meetings tracking system); a joint plan of action regularly
updated as the situation evolves, to describe the interventions needed and the distribution
of roles and responsibilities among stakeholders; and finally tools to ensure communication
between the various stakeholders engaged in the response (phone numbers, a dashboard,
maps, and a directory).
Coordinating responders checklist
4 What are the characteristics of the event that describe it as a crisis?
4 Who are the people, groups and organizations who should work for
the response?
4 What should they do? (terms of reference, functions)
4 Where can responders meet? (emergency operation centre)
4 How do they share information? (share point, telephone numbers,
generic email)
For more information about coordinating responders:
• Public Health Emergency Operations Centre Network (EOC-NET)
http://www.who.int/ihr/eoc_net/en/
• WHO Emergency Response Framework (ERF)
http://www.who.int/hac/about/erf/en/
MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 32
http://www.who.int/ihr/eoc_net/en/
http://www.who.int/ihr/eoc_net/en/
http://www.who.int/hac/about/erf/en/
http://www.who.int/hac/about/erf/en/
Health Information
In every event, information is necessary to monitor it, measure the impact of interventions and
to guide decision-making throughout the crisis. There are two particular types of information:
surveillance of the disease, and information on the interventions (process and output indica-
tors), which shows the coverage and impact of the interventions being performed. Surveillance
provides information on the number of cases and deaths by period and place (people, time, and
place). Information on the interventions enables knowing which ones are performed and what is
their coverage and impact.
Health Information checklist
Surveillance
4 Is there a case definition shared by all stakeholders?
4 Which laboratories are involved in the testing /confirmation of cases
and deaths, and where are they situated?
4 Is there an updated epidemiological curve and mapping of cases
and deaths?
4 Which are the risk groups, by gender and age?
Interventions
4 What is the target population?
4 What material and human resources are needed and how much?
4 What are the indicators of success? (e.g. vaccine coverage, house-
holds targeted, number of people treated)
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 33
Communicating risk
During the evolution of any major outbreak, cases and deaths will inevitably increase. An epidemic
is the rapid spread of infectious disease to a large number of people in a given population within
a short period of time. Similarly, there may well be another kind of epidemic – the rapid spread of
information of all kinds, including rumours, gossip and unreliable information. We describe this
phenomenon as an “infodemic”.
Infodemics, like epidemics, can be managed. Field epidemiology is an important part of
outbreak response. It encompasses three main areas: (1) monitoring and identifying health
threats, (2) outbreaks investigation, and (3) actions for mitigation and control. Similarly, successful
management of infodemics will be based on (1) monitoring and identifying them, (2) analysis of
them, and (3) control and mitigation measures1.
Risk communication is an essential intervention in any response to disease outbreaks, and is
equally necessary to manage infodemics. Communicating risk in epidemics involves two-way
communication that is dynamic and evolving as the outbreak develops.
Outbreak risk communication involves three main strands that must work together.
1. Talk. Authorities, experts and response teams must quickly relay information on the nature of
the event and the protective measures that people can take. We can use mass media including
television, radio, newspapers and internet; social media and text-messaging; community radio;
and leaflets and posters. We can use social mobilizers and frontline responders; encourage
community engagement; as well as face-to-face communication via trusted interlocutors
such as community leaders, religious figures and community health workers. We must use
translational communication approaches to develop messages that are appropriate for the
target populations in terms of language, educational level and cultural contexts.
2. Listen. Responders, experts and authorities must quickly assess and understand the fears,
concerns, perceptions and views of those affected; and tailor their interventions and messages
to address such concerns. This requires the use of social science and community engagement
expertise and methods.
3. Manage rumours. Disease outbreaks are often accompanied by the presence of false rumours
and misinformation. Responders need to have ways to listen to such misinformation and
correct examples of it in appropriate ways without delay.
1
This is called “infodemiology”.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 34
Communicating about the risks during outbreaks leads to specific outcomes.
First, early, transparent and understandable communication on the event establishes lines of
dialogue with affected populations and stakeholders, and builds trust in the response. This type
of communication must have facts and information (that cater to the head); and include messages
that acknowledge and respond to people’s concerns and fears (catering to the heart).
Second, frequent but evolving communication will help create a trusted and dynamic relationship
that can deliver advice on protective behaviors that populations and individuals can adopt.
Third, communication must scope the risk in lay language, and also propose practical actions
people can take. It must identify and help enable changes in people’s behaviours or practice (a
temporary change) that can reduce exposure to and protection from the infectious hazard.
Fourth, communication must display accountability by keeping people updated on the situation,
on what is being done, and the impact of those actions in bringing the outbreak under control.
Communicating risk checklist
4 Has the situation been well analyzed in terms of audience, sources and
specificity of the context?
4 Are tools in place in place to monitor an infodemic? Is monitoring
reactive and adaptable enough?
4 Has translational communication taken place (to transform scientific
information into lay language and format)?
4 Are the communication channels (and messengers) adequate, effective
and acceptable to communities? (culturally, cost-effectively)?
4 Is there a plan to communicate regularly with the various audiences?
4 Have all personnel and volunteers in the risk communication response
been trained in risk communication approaches, and consistent
messaging?
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 35
Health Interventions
Each disease requires a different set of health interventions with the objectives of reducing
(a) transmission, (b) severe morbidity and mortality (c) the impact on health systems and also on
the political and other sectors.
Health Interventions checklist
4 What are the key interventions needed to control the outbreak at
this stage of the event?
4 Who should implement them?
4 How is the impact measured on morbidity, mortality, transmission,
and whole of society?
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 36
Six critical functions of the Incident Management System (IMS)
For more information about the
management of events under the ERF:
http://www.who.int/hac/about/erf/en/
The Emergency Response Framework (ERF) is an internal WHO tool that outlines
a set of procedures to better respond to emergencies. Under this framework, for any
emergency that requires a WHO operational response, the Organization activates
the Incident Management System (IMS); recognized best practice for emergency
management. WHO has adapted the IMS to consist of six critical functions. The
four blocks and response tips are integrated into the Incident Management System.
Although, all six functions of the IMS are critical for a successful response, the four
blocks will highlight what is specific for each disease.
Operations
support
& logistics
Finance
&
administration
Health operations
& technical
expertise
HEALTH INFORMATION
HEALTH INTERVENTIONS
COMMUNICATING RISK
Information
& planning
HEALTH INFORMATION
Partner
coordination
COORDINATING RESPONDERS
Leadership/
Incident
management
COORDINATING RESPONDERS
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 37
http://www.who.int/hac/about/erf/en/
FOCUS 1
Community engagement during
epidemics
Defining a community
“Community” is a broad term that can be
applied to a variety of situations. It defines a
distinct group of people who have a sense
of belonging together. A community may be
defined through the sharing of:
• A common geographical location;
• Common values or interests;
• Common identity;
• Etc.
With new technologies, a community may be
totally virtual, for instance a group of people
sharing interests and points of view on social
media.
Why engage communities
People live in unique social-cultural contexts,
with relationship dynamics, and their own
perception of risks, and trusted sources of
advice. These all influence if they accept
health advice or not. Experience has shown
that merely telling people what to do, however
scientific, does not always work. Engaging
them is more effective.
Even more fundamentally, people have a right
to information that could protect their health
and save lives, social fabric and economic well-
being.
Communities, when engaged
are the frontline in detecting
and managing epidemics. They
are most affected and have
the greatest influence in anticipation and
preparedness as new diseases emerge or
old ones re-emerge. They can detect
outbreaks, and help in containment to
prevent epidemic amplification. They
are able to implement mitigation measures
(through change of individual and family
practices change; implementing community
measures and enabling changes at the systems
level) to bring epidemics under control.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 38
Three elements of community
engagement
Disease outbreaks and epidemics are
complex phenomena with three aspects that
are intimately intertwined: medical, social
and political. Community engagement is an
approach to address the social (and to some
degree the political) aspects of epidemics.
Community engagement is essential for the
effective control of infectious diseases, through
acceptance of public health interventions. It is
based on three elements:
1. Establishing a dialogue between
responders and communities to understand
the perceptions and beliefs on both sides,
to identify the specific cultural and social
patterns of transmission that exist at
community level.
2. Building trust through this mutual
understanding to find joint solutions to
reduce transmission.
3. Empowering communities, providing them
with necessary medical and other supplies
to implement the measures required
to stop the disease, and progressively
transferring knowledge for sustained and
safe interventions within the community.
A key community to empower
during outbreaks are health
care workers, and volunteers
who are often the frontline
responders. These frontline
workers are “the face”
or representatives of the
whole outbreak response,
to the community.
Their attitude towards
community members
and their collaboration
in implementing health
advice can have significant
influence on how the advice
is perceived and accepted,
or rejected by community
members.
Key points of health action in epidemics that
require intensive engagement of communities
(affected populations as well as health care
workers and frontline responders themselves)
include:
1. Detecting an outbreak and detection of
newly infected people (case detection,
contact tracing);
2. Minimizing harmful practices (at individual
and community levels) that can increase
susceptibility and exposure; and adopting
protective practices (medical and non-
medical);
3. Seeking and providing health care as
advised (in the household, community and
health facility);
4. Re-integrating of survivors back into the
community and to minimizing stigma;
5. Identifying and managing misinformation
and rumours.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 39
Ten things to know
1. Disease outbreaks affect the social
fabric of communities. A community is a
social network, and infectious diseases
outbreaks are deeply linked to the social
life, the structure of society and people’s
interactions. They spread through personal
and social contacts and links at home
or during professional and recreational
activities.
2. Communities are the main actors in
preventing, identifying, responding and
recovering from the physical, psychological,
social and economic impacts of epidemics.
Communities are not passive subjects of
interventions.
3. Epidemics are by nature rapidly evolving.
The time pressure is particularly challenging
for community engagement. The beginning
of the outbreak is a crucial time to build the
necessary trust with the population who can
break the transmission cycle. Any outbreak
response that builds on existing and trusted
community engagement systems and work
with trusted individuals and interlocutors
are more likely to succeed.
4. Community understanding of diseases and
their spread is complex, context-dependent
and culturally mediated. Thus, a one-size-
fits-all approach is neither desirable nor
effective.
5. Communities are multi-layered, and power
dynamics exist between individuals, groups
and networks. Social scientists can help
analyse these dynamics and work with
specialists in health education, health
promotion and local communities. There
are simple tools that can assess relevant
perceptions and beliefs for any outbreaks
response. Together they can design the
messages and interventions necessary
to raise awareness, and adapt or change
behaviours to meet the demands of a new
infection. Embedding social scientists in
response teams will also help to monitor
how people adapt public health measures
to different social contexts, and whether
these are implemented in a way that
respects social and cultural systems.
6. Community engagement helps to
strengthen and ensure resilience to future
outbreaks: when people have already
learned how to implement their own
solutions, they will be better able to deal
with the next outbreak.
7. The approach and messaging directed
towards each community has to evolve
with the epidemic and incorporate new
messages and communication methods
as it unfolds. These messages must
also proactively detect misinformation
and rumours. Effective community
engagement limits the opportunities for
misunderstandings and the proliferation of
rumours, and it mitigates the spread of fear
and anxiety.
8. Identify people that the community
trusts and build relationships with them.
Involve them in decision-making to
ensure interventions are collaborative,
contextually appropriate and that
communication is community-owned.
9. Two-way communication should be
achieved through the most socially-
acceptable and effective channels.
Messages must be “translated” into local
language, local context and to match
the education levels and preferences
(e.g. visual, written or oral cultures) of the
target population. All communication
with communities should be transparent,
timely, easy-to-understand, acknowledge
uncertainty, address affected populations,
link to self-efficacy, and be disseminated
using multiple platforms, methods and
channels.
10. Disease creates fear which often leads
to practices that further amplify the
epidemic. These can be both individual
and collective. They can relate to the
transmission of the disease, or the stigma,
and extreme stress on the ties that bind
communities.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 40
Ensuring effective community
engagement
To ensure effective community engagement:
3 elements are needed for communities and
for field responders.
For communities:
• Knowledge: communities must know what
the disease is, how it is transmitted, and
how to protect against it (social mobilisation
messages);
• Trust: it is the most important determinant
to ensuring communities heed public
health advice. Communities must be
consulted, engaged, and whenever possible
participate in identifying and implementing
response measures that communities and
responders want above all to treat patients
and stop the epidemic;
• Self-efficacy: communities must be able to
implement control measures (e.g. access
to soap and water, to gloves, to waste
management services, to transportation, to
safe burial teams, etc.).
For field responders:
• Understand: Field responders need to
understand the local perceptions of the
disease and of the response measures;
• Listen: Field responders need to listen to
communities’ fears and beliefs and adapt
their own behaviours accordingly;
• Support: Field responders need to support
communities’ participation, ownership and
resilience.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 41
FOCUS 2
Risk communication – a life-saving
action in public health emergencies
The essence of risk communication
Risk communication is one of the key pillars of
response to outbreaks. It refers to the real-time
exchange of information, advice and opinions
between health experts or officials and people
who face a threat (hazard) to their survival,
health or economic or social well-being. Its
ultimate goal is that everyone at risk is able to
take informed decisions to mitigate the effects
a disease outbreak and take protective and
preventive action.
Effective risk communication not only saves
lives and reduces illness (by informing people
on how to protect their health), it also enables
countries and communities to preserve their
social, economic and political stability in the
face of emergencies.
For these reasons, risk communication is one
of the core capacities that all countries have
agreed to develop in order to prevent the
international spread of disease and other
dangers as required under the International
Health Regulations (2005).
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 42
21st century aspects change and
complicate risk communication
There has been a paradigm shift from
telling people what to do (message-based
communication) to systematically listening
to those affected, mainly due to new
communication and media technologies and
the way practices have evolved in the 21st
century. The three big changes here are:
1. Experts and authorities are less trusted;
2. People now seek health advice mostly on
public on-line sources, and their trusted
social networks;
3. News media now function all day, every
day. In addition, there is an increase of
citizenship journalism and social media,
as well as the rise of opinion versus well-
sourced and referenced stories.
In disease outbreaks and epidemics, life-saving
decisions need to be made rapidly and actions
must follow promptly, with the support of an
informed public. Epidemics are unpredictable
and alarming events that generate great
anxiety in the general public, which can lead
to extreme behaviours. Epidemics and the way
they are managed have a high political profile
and capture the news media’s attention quickly
leading to intense media interest (at national
and international levels).
Furthermore, emergency and outbreak
communications now take place in a variety of
contexts:
• In a shifting complex, crowded environment:
information is incomplete and many
different actors are exchanging public health
information and competing for authority.
• Where communications are diverse: these
include public communication, supporting
national governments in risk communication,
strategic communication, communication
with affected communities and response
personnel, media relations, knowledge
transfer, message development, partner
communication, internal communication and
health promotion functions, etc.
• Where risk communication is an under-
resourced priority with a lack of investment
in skills, resources and expertise at country
level.
• Where there is an increased public demand
for participation in policy-making and for
self-determination.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 43
Making it effective
• Risk communication only works when there
is communication based on trust between
those who know (experts), those in charge
(authorities or response teams) and those
affected (communities). Without trust,
people are unlikely to follow the advice given.
Listening to and understanding peoples’
beliefs, concerns and perceptions is just as
important as providing them with facts and
advice. Explaining honestly what is known
and admitting what is uncertain is essential.
Effective risk communication thus depends
on the credibility of those giving advice; their
expressions of caring and empathy; and their
ability to identify with people at risk.
• Perception is key:
– Experts and affected communities may
not view the same infectious hazard – e.g.
a disease outbreak – the same way. While
experts depend on risk analysis based on
biomedical and epidemiological data,
affected communities use more sub-
conscious pathways to define risk;
– People’s perception of risk can be affected
by their beliefs, culture, education,
political viewpoints, social norms and prior
experience amongst others;
– There are tried and trusted social science
methods and approaches which can be
used in epidemics to gauge perceptions.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 44
Ten things to know and do
1. Build trust
• People must trust those responsible for
managing the outbreak and for issuing
information about it. Public confidence
that a government or agency is acting first
and foremost to safeguard their health will
influence compliance with recommended
control measures, and thus hasten outbreak
containment.
• Accountability is key: communicators
must demonstrate that they and outbreak
managers are accountable for what they say,
promise, and do.
• Evidence shows that to build trust, risk
communication interventions should link
to functioning and accessible services, be
transparent, timely, easy-to-understand,
acknowledge uncertainty, address affected
populations, link to self-efficacy and be
disseminated using multiple platforms,
methods and channels.
• The building blocks of trust include:
– Being perceived as experts with credibility
by providing expert advice that is correct
and accurate and being consistent with other
trusted agencies and entities;
– Being perceived as having a good character
by telling the truth and not omitting important
information, and acting on promises;
– Identifying with the affected population as
sharing the same concerns and fate;
– Exhibiting good will through empathy and
caring in messages and their delivery.
2. Communicate uncertainty proactively
• Communication by authorities to the public
should include explicit information about
uncertainties associated with risks, events
and interventions and indicate what is known
and not known at a given time.
• Announce the event as early as possible, even
when the information is incomplete. This will
establish you as the leader to communicate
risk; it will build trust in you and the response;
it will help enable changes in practice and
behaviors to bring the outbreak under
control; and it will minimize misinformation
and rumours.
• A good template to communicate uncertainty
is as follows:
– State what is known, what is unknown, and
what you/your institution is doing about the
issue;
– Communicate early, be first to announce
the event if possible, communicate often,
communicate regularly;
– Provide information on the risk/danger; but
supplement it with some advice on how
people can protect themselves;
– Speak as a human being, using empathy
appropriately;
– Do not over-reassure.
3. Engage communities
• Identify people that the community trusts
and build relationships with them and
involve them in decision-making to ensure
interventions are collaborative, contextually
appropriate and that communication is
community-owned.
• Community engagement is one important
start for communicating risk and facilitating
changes in behaviours and practices (see
Focus 1, page 38).
4. Message well
• According to the latest evidence, risk should
not be explained in technical terms as this
is not helpful for promoting risk mitigation
behaviours. Consistent messages should
come from different information sources
and emerge early in the outbreak. Messages
should promote specific actions people can
realistically take to protect their health.
5. Establish and use listening and feedback
systems
• Use multiple means (surveys, focus group
discussions, community walk-throughs,
key informants, feedback from front-line
responders, partners’ and stakeholders’
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 45
feedback, social media, etc.) to listen to the
public and affected communities.
• Use these to understand what concerns
people regarding the outbreak or the
measures we are asking them to adopt.
• Use these systems to test messaging
and materials developed to support risk
communication.
6. Use social media as appropriate
• Social media should be used to
engage the public, facilitate peer-to-
peer communication, create situational
awareness, monitor and respond to rumours,
public reactions and concerns during an
emergency, and to facilitate local level
responses.
• Social media and traditional media should be
part of an integrated strategy with other forms
of communication to achieve convergence
of verified, accurate information.
7. Risk communication operations requires
resources
• Risk communication in epidemics is a massive
operational undertaking and requires
people, logistics, material and funds.
• Different types of expertise in many areas
are required: media communications, social
media, spokespersons, social mobilization,
health promotion, community engagement,
behavioral change communication;
stakeholder communication, communication
related to travel and trade, social science
methods, etc.
8. Treat Emergency risk communication as a
strategic role, not an add-on
• Emergency risk communication should be
a designated strategic role in global and
national emergency preparedness and
response leadership teams.
• The International Health Regulations (2005)
require all Member States to build national
capacity to communicate risk in two domains:
– Systems capacities;
– People capacities.
• The Joint External Evaluation (JEE)
process championed by the Global Health
Security Agenda measures national risk
communication capacity in six domains:
– National strategies, policies and plan;
– Coordination;
– Stakeholder communication;
– Public communication (using mass media
approaches);
– Communicating and engaging with
communities;
– Dynamic listening (to misinformation, fears,
concerns) and rumour management.
9. Establish coordination and information
systems
• Develop and build on agency and
organizational networks across geographic,
disciplinary and, where appropriate, national
boundaries.
• Tailor information and communication
systems to the needs of users and involve
local stakeholders to guarantee the flow of
information across sectors.
10. Build capacity for the next emergency
• Preparation and training of personnel for
emergency risk communication should
be organized regularly and focus on
coordination across agencies.
• Emergency risk communication requires a
defined and sustained budget which should
be a part of core budgeting for emergency
preparedness and response.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 46
Other factors to remember
While there is an increasing body of
evidence as to what constitutes effective risk
communication, every outbreak is unique.
Therefore risk communication must be
adapted to:
• The infectious hazard (its severity, lethality,
modes of transmission, how it can be
diagnosed, treated or managed);
• The geography of the outbreak: contained or
widely distributed; national or international
spread; affecting certain vulnerable
communities or the general population;
in a remote forgotten village or major city;
affecting to poor or affecting travel and
trade;
• The levels of trust that exit between the
affected or at-risk populations and their
authorities and experts; or the response
teams;
• People’s underlying beliefs, cultures,
traditions, values and practices;
• Education, levels of awareness, access to
understandable information; and trusted
channels of communication;
• Self-efficacy: do communities have the
ability, resources and environment to follow
health advice?
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 47
FOCUS 3
Treating patients and protecting
the health workforce
Advances in medicine: antibiotics,
antivirals, vaccines and new
treatments
With the remarkable progress in medicine and
related technologies, briefly mentioned at the
beginning of this publication, many infectious
diseases can now be prevented and treated.
This is the result of a public health revolution
that began in the 1940s with the discovery
of antibiotics for bacterial diseases, and
expanded with improvements in their safety,
efficacy and acceptability.
Similarly, the development of vaccines,
particularly for infants and young children, has
given global protection against a number of
childhood killers. For example, WHO estimates
that there is now 86% global coverage of
the combined diphtheria-tetanus-pertussis
vaccine for babies1. In recent decades,
hundreds of millions of children all over the
world have grown up free of the risk of deadly
and disabling diseases. Adults have benefited
likewise, with protection against a wide range
of infections that can explode into epidemics
– cholera, influenza and yellow fever, for
example. For many deadly diseases, there are
vaccines that ideally should be administrated
in routine, large-scale immunization to prevent
the occurrence of the disease. Some vaccines
can also be used during a reactive campaign
when there is an epidemic in which the
immunity of the population is not high enough.
The public health revolution continued towards
the end of the 20th century with the discovery
of antivirals, such as that used against HIV.
Meanwhile, there have also been great
strides forward in the fields of diagnostics and
treatments, such as monoclonal antibodies,
that are also becoming more widely available
but the price of some of them is still very
high and they are not yet available for mass
administration.
Such advances – and the early problems that
followed them – including a degree of public
health complacency, and the emergence
of antibiotic resistance – have completely
changed the way infectious diseases are
confronted today.
1 WHO data, 2016.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 48
Treating patients with supportive
care
But whether the focus is on antibiotics,
antivirals, vaccines or the whole armoury of
other treatments, the vital, universal fact is
that they can only be beneficial when they
are administered by skilled, qualified and
dedicated health personnel, all across the
spectrum of care. When, for example, no
specific treatment is available for a given
disease, adequate clinical management
can still protect and save lives. This has
been shown by a dramatic reduction in
deaths from Ebola in West Africa in 2014
– from 75% to 33% mortality, achieved
through the provision of better supportive
care for patients.
Protecting frontline responders
The role of the health workforce should never
be underestimated nor taken for granted.
In general, much of their day-to-day work is
mundane and routine, providing tried-and-
tested care and treatment for familiar illnesses,
disabilities and injuries.
But when an epidemic strikes, they make
a vital difference at all levels, whether as
community health workers and volunteers,
midwives, nurses, or doctors. With little or no
warning, they are transformed into frontline
responders, thrust into immediate contact with
infected communities and individuals. Family
members, too, take on the role of caring for
their relatives at home, often linking up with
health staff in clinics, hospitals and emergency
centres.
This transformation is double-edged and
dangerous for frontline responders. First, their
immediate priorities are to prevent the spread
of an epidemic, protect those people who
are most at risk, and to care by all possible
means for those who are already infected. The
related dangers are obvious: health workers
are putting themselves at risk. They find
themselves in the most dangerous place at the
most dangerous time.
Yet, because their job is to care for the sick
and injured, health care workers are often
viewed as “immune” to injury or illness. Their
patients come first. However, human-to-
human transmission is a major factor in many
infectious diseases that cause epidemics.
Patients are highly contagious and can spread
the disease at home, at work, in public spaces,
but also in hospitals.
Thus, it is essential to protect them from
infection – both for their own safety and for the
wider protection of the affected community. It
is here that emergency planning, preparation,
training and coordination are so essential, as
is the urgent provision of practical safeguards,
especially the necessary personal protective
equipment and the knowledge of how to use
it properly.
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 49
Confronting the human resources
crisis
These measures may seem obvious, but the
role of frontline responders is frequently
shackled by a major disadvantage: there are
not nearly enough of them. This unpalatable
truth applies to the health workforce in
general. It is a global problem, but it is most
acute in the poorest countries with weakest
health systems, where epidemics are most
likely to erupt.
Protecting the occupational health of health
workers is critical to have an adequate
workforce of trained and healthy health
personnel. This is nowhere more true than at
the heart of an infectious disease epidemic.
Around the world, health care facilities employ
over 59 million workers2. Yet at the same
time, there is a chronic shortage of them in
more than 50 countries. This crisis in human
resources for health has persisted for decades,
despite numerous attempts to tackle it, but
recent actions show notable progress.
It is not just a matter of numbers. While there
has long been an exclusive focus on how many
there are, against how many are needed,
there is growing public health agreement on
according equal importance to accessibility,
acceptability, quality and performance in
addition to availability.
These four factors are inter-related and inter-
dependent. The absence or inadequacy of any
one of them undermines all the others. Without
sufficient availability, accessibility to health
workers cannot be guaranteed. If they are
available and accessible, without acceptability,
the health services may not be used. When the
quality of the health workforce is inadequate,
improvements in health outcomes will not be
satisfactory.
Elaboration of these complex issues at length
goes beyond the scope of this handbook. But
it is important that they are taken into account
in the context of infectious disease prevention,
treatment and control. Indeed, they lead
to recognition that protecting health care
workers has the added benefit to contributing
to quality patient care and health system
strengthening.
If it is accepted that health begins with health
workers, their empowerment is necessary
on a general basis. Their voice, rights and
responsibilities must play a central role in
developing and implementing solid policies
and strategies towards universal health
coverage. This applies to the context of
epidemic disease control as much as it
does to other health issues more widely.
The engagement of communities during
epidemics, including health workforce
community, needs to be at the center of the
epidemic response.
For more information about protecting the
health workforce:
WHO global health workforce alliance
website
http://www.who.int/workforcealliance/en/ 2 WHO data: http://www.who.int/occupational_
health/topics/hcworkers/en/
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 50
http://www.who.int/workforcealliance/en/
http://www.who.int/occupational_health/topics/hcworkers/en/
http://www.who.int/occupational_health/topics/hcworkers/en/
DISEASE SPECIFIC SUPPORTIVEMAJOR MODE OF TRANSMISSION
Clinical management
VACCINATION
SAFE &
DIGNIFIED
BURIALS
ENHANCED INFECTION
PREVENTION & CONTROL
VECTOR
CONTROL
WATER &
SANITATION
Chikungunya
Cholera
Dengue
Ebola virus disease
Hepatitis E
Influenza
Lassa fever
Leptospirosis
Malaria
http://www.who.int/csr/disease/chikungunya/en/
http://www.who.int/cholera/en/
http://www.who.int/denguecontrol/en/
http://www.who.int/ebola/en/
http://www.who.int/mediacentre/factsheets/fs280/en/
http://www.who.int/influenza/en/
http://www.who.int/csr/disease/lassafever/en/
http://www.who.int/topics/leptospirosis/en/
http://www.who.int/malaria/en/
Vector
Fecal oral / water
Vector
Animals / contact
Fecal oral / water
Respiratory
Rodent / contact
Rodent
Vector
Crimean-Congo
haemorrhagic fever
(CCHF)
http://www.who.int/csr/disease/crimean_congoHF/en/
Animals (mainly ticks) /
contact 1
Marburg virus disease
http://www.who.int/csr/disease/marburg/en/
Animals / contact
4
4
4
4
4
4
4
4
4
4 4 4
4
4
4 4
4 4 4 4
4
4
4
4 4 4
4 4 4
4 4
4 4 4
4
4 4
4 4 4
2
3
4 5
1 Ribavirin use currently under review by WHO;
2 Oral vaccines;
3 There is a vaccine (Dengvaxia®) currently under assessment;
4 Intramuscular and intranasal vaccines;
5 Safe and dignified burials for highly pathogenic non-human influenza;
Major modes of transmission and interventions per disease
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 51
http://www.who.int/csr/disease/chikungunya/en/
http://www.who.int/cholera/en/
http://www.who.int/denguecontrol/en/
http://www.who.int/ebola/en/
http://www.who.int/mediacentre/factsheets/fs280/en/
http://www.who.int/influenza/en/
http://www.who.int/csr/disease/lassafever/en/
http://www.who.int/topics/leptospirosis/en/
http://www.who.int/malaria/en/
http://www.who.int/csr/disease/crimean_congoHF/en/
http://www.who.int/csr/disease/marburg/en/
Meningitis
MERS/SARS
Monkeypox
Plague (pneumonic)
Plague (bubonic)
Polio
Rickettsia
Shigellosis
Rift valley fever
Smallpox
Typhoid fever
West Nile fever
Yellow fever
Zika
http://www.who.int/csr/disease/meningococcal/en/
http://www.who.int/topics/coronavirus_infections/en/
http://www.who.int/mediacentre/factsheets/fs161/en/
http://www.who.int/csr/disease/plague/en/
http://www.who.int/csr/disease/plague/en/
http://www.who.int/topics/poliomyelitis/en/
http://www.who.int/csr/disease/riftvalleyfev/en/
http://www.who.int/csr/disease/smallpox/en/
http://www.who.int/immunization/diseases/typhoid/en/
http://www.who.int/mediacentre/factsheets/fs354/en/
http://www.who.int/csr/disease/yellowfev/en/
http://www.who.int/topics/zika/en/
Respiratory
Respiratory
Animals / contact
Respiratory
Rodent
Fecal oral
Vector
Fecal oral / food
Animals / vector
Respiratory
Food
Vector
Vector
Vector
Measles
http://www.who.int/immunization/diseases/measles/en/
Respiratory
DISEASE SPECIFIC SUPPORTIVEMAJOR MODE OF TRANSMISSION VACCINATION
SAFE &
DIGNIFIED
BURIALS
ENHANCED INFECTION
PREVENTION & CONTROL
VECTOR
CONTROL
WATER &
SANITATION
4
4
4
4 4
4
4
4
4
4
4 4
4
4
4 4
4 4
4
44
4
4 4 4
4
4
4 4 4
4
4
4
4 4 4
4
4
4
4 4
4
4
4 4
6
7
8
6 Oral and intramuscular/subcutaneous polio vaccines; 7 Intramuscular and scarification vaccines; 8 Intramuscular/subcutaneous vaccines.
Clinical management
PART IMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 52
http://www.who.int/csr/disease/meningococcal/en/
http://www.who.int/topics/coronavirus_infections/en/
http://www.who.int/mediacentre/factsheets/fs161/en/
http://www.who.int/immunization/diseases/measles/en/
http://www.who.int/csr/disease/plague/en/
http://www.who.int/topics/poliomyelitis/en/
http://www.who.int/csr/disease/riftvalleyfev/en/
http://www.who.int/csr/disease/smallpox/en/
http://www.who.int/immunization/diseases/typhoid/en/
http://www.who.int/mediacentre/factsheets/fs354/en/
http://www.who.int/csr/disease/yellowfev/en/
http://www.who.int/topics/zika/en/
http://www.who.int/immunization/diseases/measles/en/
PART II
10 KEY FACTS ABOUT 15 DEADLY DISEASES
Be in the know
EBOLA VIRUS DISEASE
LASSA FEVER
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)
YELLOW FEVER
ZIKA
CHIKUNGUNYA
AVIAN AND OTHER ZOONOTIC INFLUENZA
SEASONAL INFLUENZA
PANDEMIC INFLUENZA
MIDDLE EAST RESPIRATORY SYNDROME (MERS)
CHOLERA
MONKEYPOX
PLAGUE
LEPTOSPIROSIS
MENINGOCOCCAL MENINGITIS
10 THINGS YOU SHOULD KNOW
Ebola virus disease
1. Ebola virus disease transmits from person to person through close contact
2. Health care workers, mourners and family members are the most at risk to
get infected
3. At-risk persons should be informed about Infection Prevention and Control
(IPC) measures and be provided with appropriate personal protective
equipment
4. Community engagement, active case finding, contact tracing, laboratory
support, and safe and dignified burials are key to control outbreaks
5. Early supportive care improves survival
6. Ebola is difficult to distinguish from other diseases with haemorrhage
presentation
7. The Ebola virus can persist in people recovering from the disease for several
months
8. Ebola survivors may suffer from stigma and sequelae
9. There are ongoing researches for vaccines, diagnostics and treatments
10. Ebola is a viral haemorrhagic fever that occurs mostly in rural and remote
areas of Africa
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 56
Ebola virus disease response tips
Coordinating responders
• Engage with partners involved in the
response (community engagement,
surveillance, laboratory, case management
and IPC)
• Engage with religious and community
leaders
Communicating risk
• Encourage health authorities to:
– Implement active case finding and contact
tracing
– Ensure protection of health care workers
through IPC measures
– Communicate early and frequently
• Key messages are:
– Ebola is transmitted through contact with body
fluids of infected animals and humans
– Dead bodies of patients are contagious
– Apply IPC measures when in contact with sick
or dead patients and animals
– People are not infectious if they do not show
symptoms
– People with symptoms should seek medical
advice as supportive treatment increases
chances of survival
Health Information
• Ensure early laboratory confirmation of
suspected cases
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Community engagement and health
promotion
• Case management and IPC:
– Isolation of cases
– Early supportive treatment
– Protect health care workers
• Surveillance, contact finding and contact
tracing
• Safe and dignified burials
• Vaccination under expanded access (rVSV-
ZEBOV vaccine for Zaire Ebola virus)
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 57
Ebola virus disease transmits from
person to person through close
contact
• Incubation period ranges from 2 to 21
days.
• Humans are not infectious as long as
they do not develop symptoms. During
the course of the disease, they remain
infectious as long as their blood contains
the virus.
• Ebola is first introduced into the human
population through close contact with the
blood, secretions, organs or other body
fluids of infected animals such as fruit
bats, chimpanzees, gorillas, monkeys,
forest antelopes and porcupines found ill
or dead, often in the rainforest.
• Ebola then spreads through human-
to-human transmission via direct
contact (through broken skin or mucous
membranes) with the blood, secretions,
organs or other body fluids of infected
people.
– Infection can also occur if the broken skin
or the mucous membranes of a healthy
person comes into contact with items or
environments contaminated with body
fluids from an infected person. These may
include soiled clothing, bed linen, gloves,
and protective equipment;
– Medical waste, such as used syringes,
should be disposed carefully, as they are
a source of health care workers infection.
• Ebola virus disease has not been reported
to be transmitted by aerosols. It is not
airborne.
Health care workers, mourners
and family members are the most
at risk to get infected
Population at high-risk of being infected
include:
• Health care workers if Infection Prevention
and Control (IPC) measures are not in
place or not well followed while caring for
patients.
• Mourners, as burial ceremonies involve
direct contact with the body or body fluids
of the deceased (washing, touching…)
because levels of Ebola virus remain high
after death.
• Family members or others in close
contact with infected people and caring
for them in contact with body fluids or
contaminated items.
1 2
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 58
At-risk persons should be
informed about IPC measures and
be provided with appropriate
personal protective equipment
• All health care providers working at all
levels of the health system, and family
members caring for the sick, should be
fully informed about the disease and its
mode of transmission and should follow
recommended Infection Prevention and
Control (IPC) measures strictly.
• They should be provided with
appropriate Personal Protective
Equipment (PPE).
• Standard precautions with all patients
should be applied. They include: hand
hygiene; use of gloves before contact
with body fluids, mucous membrane,
non-intact skin and contaminated
items; gown and eye protection
before procedures and patient-care
activities likely to involve contact with
or projection of blood or body fluids;
injection safety practices; safe cleaning,
disinfection and waste management;
isolation of cases and appropriate flow
of patients.
3 Community engagement, active case finding, contact tracing, laboratory support, and safe and dignified burials are key to control
outbreaks
• The aim of Ebola response is to contain
the outbreak at its source. Ebola virus
transmission is stopped by :
1. Community engagement as
communities are essential for
responding to Ebola outbreaks. They
have a role to play in the detection of
new cases. Communities should be
engaged in the response since the
early stage and be provided by the
necessary information so that they
can adapt the public health measures
to their socio-cultural beliefs and
ensure compliance of the community
members.
2. Active case finding, rapid isolation
of patient and early laboratory
confirmation of suspected cases. Active
4 case finding refers to actively searching for new cases (for instance, going from house to house in the community, asking if people are sick or if people
have died). New (suspected) cases
should be rapidly and safely referred
to treatment centres for isolation and
treatment.
3. Laboratory testing in Ebola treatment
units is crucial for classification of
cases, to streamline contact tracing, for
patient triage and management and
to support research and development
(to develop and validate new point-of-
care diagnostics, new therapeutics and
new vaccines).
4. Contact tracing which refers to the
follow-up of persons who may have
come into contact with a person
infected with the Ebola virus (or their
body fluids, exposed environment such
as linens, a dead animal, etc.). Contacts
should be followed-up over a period of
21 days after the last exposure, looking
for symptoms such as fever, and
referred to treatment centres if they
become ill.
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 59
5. Early supportive care (rehydration
and pain relief) should be provided
to patients as early as possible as it
reduces mortality.
6. Safe and dignified burials teams are
necessary to facilitate mourning by
affected families and communities
and to stop transmission of Ebola virus
from deceased patients.
• Other key elements to put in place to
control outbreaks are:
– Surveillance and follow-up of survivors as
the virus may persist in their body fluids
and they may be infectious;
– Psychosocial support to patients and their
families;
– Public health emergency plans and
standard operational procedures at
designated points of entry, in accordance
with the International Health Regulations
(IHR) (2005).
• After 42 days (two 21-day maximum
incubation period for Ebola virus)
with no new cases, the
h u m a n – t o – h u m a n
transmission is
controlled and the
outbreak can be
declared over.
Early supportive care improves
survival
• Early supportive care, especially
rehydration with oral or intravenous fluids,
and treatment of specific symptoms,
improves survival.
• Other treatments being used to help
people survive Ebola virus disease
include, where available and IPC
measures strictly implemented, kidney
dialysis, blood transfusions and plasma
replacement therapy.
• It is important that patients and families
trust health workers to accept being care
of in dedicated treatment facilities.
• Care should be patient-centered and
respect patients’ preferences.
• There is, as yet, no commercially treatment
available for Ebola. However, a range of
potential treatments including blood
products, immune therapies and
drug therapies are currently being
evaluated.
5 • An experimental Ebola vaccine was highly protective against the deadly virus in a major trial in Guinea. The vaccine, called rVSV-ZEBOV, was studied in a trial
involving 11841 people during 2015.
Among the 5837 people who received the
vaccine, no Ebola cases were recorded
10 days or more after vaccination. In
comparison, there were 23 cases 10 days
or more after vaccination among those
who did not receive the vaccine.
– The trial was led by WHO, together with
Guinea’s Ministry of Health, Médecins sans
Frontières and the Norwegian Institute of
Public Health, in collaboration with other
international partners. A ring vaccination
protocol was chosen for the trial, where
some of the rings are vaccinated shortly
after a case is detected, and other rings
are vaccinated after a delay of 3 weeks.
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 60
Ebola is difficult to distinguish from
other diseases with haemorrhage
presentation
• First symptoms are common to many
other diseases, they are not specific:
sudden onset of fever, fatigue, muscle
pain, headache and sore throat.
• These first symptoms are usually followed
by: vomiting, diarrhoea, rash, symptoms
of impaired kidney and liver function, and
in some cases, both internal and external
bleeding (e.g. oozing from the gums,
blood in the stools).
• Ebola virus infection can be confirmed
with laboratory diagnostics:
– The diagnostic methods are the following:
o Reverse Transcription Polymerase Chain
Reaction (RT-PCR) assay;
o Antibody-capture Enzyme-Linked
Immunosorbent Assay (ELISA);
o Antigen-capture detection test;
o Serum neutralization test;
o Electron microscopy;
o Virus isolation by cell culture.
– Current WHO recommended tests
include:
o Automated or semi-automated Nucleic
Acid Tests (NAT) for routine diagnostic
management;
o Rapid antigen detection tests for use
in remote settings where NAT are
6 not readily available. These tests are recommended for screening purposes as part of surveillance activities. However reactive tests should be confirmed with
NAT.
– The preferred specimens for diagnosis
include:
o Whole blood collected from live
patients exhibiting symptoms;
o Oral fluid specimen stored in universal
transport medium collected from
deceased patients or when blood
collection is not possible (swab for dead
bodies).
• Recommended case definitions for Ebola
or Marburg virus diseases can be found
on: http://www.who.int/csr/resources/
publications/ebola/case-definition/en/.
During an outbreak, case definitions
are likely to be adapted to new clinical
presentation(s) or different modes of
transmission related to the local event.
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 61
http://www.who.int/csr/resources/publications/ebola/case-definition/en/
http://www.who.int/csr/resources/publications/ebola/case-definition/en/
The Ebola virus can persist in
people recovering from the
disease for several months
• People can survive from Ebola virus
disease.
• Ebola virus is known to persist in immune-
privileged sites in some people who have
recovered from Ebola virus disease. These
sites include the testicles, the inside of
the eye, and the central nervous system.
In women who have been infected while
pregnant, the virus may persist in the
placenta, amniotic fluid and fetus. In
women who have been infected while
breastfeeding, the virus may persist in
breast milk.
• Several cases of sexual transmission
have been reported. All Ebola survivors
and their sexual partners should receive
counselling to ensure safe sexual
practices, be provided with condoms
when discharged from Ebola treatment
unit and enrolled in national semen and
body fluid testing programmes.
• Male Ebola survivors should be offered
semen testing when discharged from
Ebola treatment unit, and then, for those
who test positive, every month thereafter
until their semen tests negative for virus
twice by RT-PCR, with a minimum interval
of two weeks between tests. Relapse-
symptomatic illness in someone who has
recovered from EVD due to increased
replication of the virus in a specific site is
a rare event, but has been documented.
Reasons for this phenomenon are not yet
fully understood.
7 Ebola survivors may suffer from stigma and sequelae • Survivors may suffer from physical sequelae and should be followed-
up. Most common physical sequelae
are: musculoskeletal, ocular, auditory,
abdominal, neurological, and sexual
issues.
• Survivors may suffer from stigma. They
may be rejected from their community
and should be followed-up and assisted,
if needed, regarding employment, living
conditions, family, social support from
their community, etc.
• They should receive education and
counselling regarding the possible
sequelae and psycho-social challenges
they might face.
• Specific follow-up considerations should
be applied for children and pregnant
women.
8
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 62
There are ongoing researches
for vaccines, diagnostics and
treatments
• Research is ongoing to develop and
evaluate vaccines, diagnostics tools and
therapeutics. Currently, no vaccine, or
new therapeutic has been licensed.
• An experimental Ebola vaccine was
highly protective against the deadly virus
in a major trial in Guinea. The vaccine,
called rVSV-ZEBOV, was studied in a trial
involving 11 841 people during 2015.
Results of efficacy trial show to be 100%
effective in those who received it as part
of a ring vaccination trial.
• There are 12 candidate vaccines and
one (rVSV- ZEBOV, efficient against Zaire
Ebola virus) that could be used under
expended access during outbreaks.
• A range of potential treatments including
blood products, immune therapies
and drug therapies are currently being
evaluated.
• Four Nucleic Acid Tests (NAT) and three
Rapid Diagnostic Tests (RDT) were
approved for emergency use during the
Ebola crisis 2014-2016. These tests could
be used during outbreak situation, in
remote settings.
9 Ebola is a viral haemorrhagic fever that occurs mostly in rural and remote areas of Africa
• Ebola virus disease (EVD), formerly known
as Ebola haemorrhagic fever, is a severe
illness in humans. The average case
fatality rate is around 50%. It has varied
from 25% to 90% in past outbreaks.
• Ebola virus disease is a zoonotic disease,
transmittable from wild animals to
humans.
• Reservoir of the disease is fruit bats. The
disease is also found in monkeys, apes,
antelope and porcupines. Ebola virus
disease should be suspected if any of
these animals is found ill or dead in the
rainforest.
10
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 63
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion
whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent
approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reservedSource: WHO/IHM, as of 15 February 2018
Geographic distribution of Ebola virus disease outbreaks (1976-2018)
Country with serological evidence
Country that reported Ebola virus
disease imported cases
Country that reported Ebola virus
disease outbreaks
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 64
More information about
Ebola virus disease:
• Ebola WHO webpage:
http://www.who.int/ebola/en/
• Ebola WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs103/en/
• Ebola and Marburg virus disease epidemics: preparedness, alert,
control and evaluation
http://www.who.int/csr/resources/publications/ebola/manual_EVD/en/
• Case definitions:
http://www.who.int/csr/resources/publications/ebola/case-definition/en/
• Laboratory diagnosis:
http://www.who.int/csr/resources/publications/ebola/laboratory-
guidance/en/
• Clinical management:
http://www.who.int/csr/resources/publications/clinical-management-
patients/en/
• Clinical care for survivors of EVD:
http://www.who.int/csr/resources/publications/ebola/guidance-survivors/en/
• Infection prevention and control guidance for care of patients if health
care settings, with focus on Ebola:
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_
control/en/
• Safe and dignified burials:
http://www.who.int/csr/resources/publications/ebola/safe-burials/en/
• Ebola WHO MOOC:
https://openwho.org/courses/pandemic-epidemic-diseases
EBOLA VIRUS DISEASEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 65
http://www.who.int/ebola/en/
http://www.who.int/mediacentre/factsheets/fs103/en/
http://www.who.int/csr/resources/publications/ebola/manual_EVD/en/
http://www.who.int/csr/resources/publications/ebola/case-definition/en/
http://www.who.int/csr/resources/publications/ebola/laboratory-guidance/en/
http://www.who.int/csr/resources/publications/ebola/laboratory-guidance/en/
http://www.who.int/csr/resources/publications/clinical-management-patients/en/
http://www.who.int/csr/resources/publications/clinical-management-patients/en/
http://www.who.int/csr/resources/publications/ebola/guidance-survivors/en/
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/
http://www.who.int/csr/resources/publications/ebola/safe-burials/en/
https://openwho.org/courses/pandemic-epidemic-diseases
1. The reservoir of Lassa fever is a rat
2. Humans are primarily infected through exposure to rats’ urine or faeces
3. Human-to-human transmission occurs then through direct contact with body
fluids of infected persons
4. Pregnant women and infants may experience severe disease
5. Lassa fever is hard to distinguish from other viral diseases
6. Hygiene and rodent control are the best prevention in communities
7. Strict implementation of infection prevention and control measures in health
care settings is critical to prevent the spread of the disease
8. Early supportive treatment reduces mortality
9. Outbreak control relies on community engagement, active case finding,
contact tracing and safe and dignified burials
10. Lassa fever is a viral haemorrhagic fever that occurs in West Africa
10 THINGS YOU SHOULD KNOW
Lassa fever
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 66
Lassa fever response tips
Coordinating responders
• Engage with partners involved in the response
(surveillance, laboratory, case management,
infection prevention and control (IPC) and
community engagement)
• Engage with religious and community leaders
Communicating risk
• Encourage health authorities to:
– Implement active case finding and contact
tracing
– Ensure protection of health care workers through
IPC measures
– Communicate about how to protect from
becoming infected
– Provide targeted communication to at-risk
groups such as pregnant women
• Key messages to general public:
– Humans are primarily infected through exposure
to rats’ urine or faeces
– Avoid contact with body fluids of sick people
– Seek health advice rapidly if you show symptoms
– Wash your hands regularly
– Implement measures to reduce contact with
rodents
Health Information
• Ensure early laboratory confirmation of
suspected cases
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Community engagement and health
promotion
• Case management and IPC:
– Isolation of cases
– Early supportive treatment
– Protect health care workers
• Surveillance, contact finding and contact
tracing
• Safe and dignified burials
• Rodent control
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 67
The reservoir of Lassa fever is a rat
• The animal reservoir of Lassa virus is a
rodent : the Mastomys rat, commonly
know as the “multimammate rat”.
• Rat are infected at birth and are chronic
asymptomatic carriers of Lassa virus.
• The infected rats do not become ill but
can shed the virus in their urine and
faeces.
• The virus is present in aerosolized excreta,
particularly urine.
Humans are primarily infected
through exposure to rats’ urine or
faeces
• Humans usually become infected with
Lassa virus from exposure to urine or
faeces of infected rats.
• Humans are infected through:
– Direct contact by catching, handling and
preparing Mastomys as a food source
(more frequent);
– Ingestion of food contaminated by
infected rodent excreta;
– Direct contact with objects and surfaces
contaminated by rats’ urine and faeces;
– Inhalation of aerosolized virus (rare).
1 2 • Transmission of Lassa fever virus from rats to humans is common, since these rodents scavenge on human food items and readily colonize areas where humans
live.
• People at high risk of being infected,
through rat-to-human transmission, are:
– Persons living in rural areas where
Mastomys are usually found, especially
in communities with poor sanitation or
crowded living conditions;
– Persons hunting and consuming rodent
products.
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 68
Human-to-human transmission
occurs then through direct contact
with body fluids of infected
persons
• Lassa virus may spread from human
to human through direct contact with
the blood, urine, faeces, or other body
secretions of a person infected with Lassa
fever.
• Humans can also be infected through
direct contact with contaminated
bedding or clothing.
• Human-to-human and laboratory
transmission also occur, particularly in
hospitals lacking adequate infection
prevention and control measures (e.g.
the virus may be spread by contaminated
medical equipment, such as re-used
needles).
• People most at risk of being infected,
through human-to-human transmission,
are:
– Health care workers or anyone caring for
Lassa fever patients in the absence of
proper infection prevention and control
practices;
– People handling dead bodies of infected
patients (e.g. during funerals).
• Sexual transmission of Lassa virus has also
been reported.
• There is no evidence supporting airborne
spread between humans.
3 Pregnant women and infants may experience severe disease• Lassa fever occurs in all age groups and
both sexes.
• The disease is especially severe late in
pregnancy:
– Maternal mortality can be greater than
30% in third trimester and 50% in the last
month;
– Fetal loss is occurring in more than 80%
of cases during the third trimester;
– Pregnant women show increased
level of viraemia (virus levels in
the blood).
• Infection in infants is also
associated with a very high
case fatality rate.
• Infants (up to two years
old) can present a “swollen
baby syndrome” (edema,
abdominal distension and
bleeding, often leading
to death). Older children
experience similar symptoms
as adults.
4
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 69
Lassa fever is hard to distinguish
from other viral diseases
• Symptoms of Lassa fever are very varied
and non-specific, which makes clinical
diagnosis difficult, especially early in the
course of the disease. Lassa fever can
be difficult to distinguish from other viral
haemorrhagic fevers (e.g. Ebola virus
disease) as well as from other diseases
that cause fever such as Malaria, Typhoid
fever, Yellow fever, Influenza, Measles,
Shigellosis, Cholera, Leptospirosis,
Rickettsial infections, Relapsing fever,
Meningitis, Bacterial sepsis, Hepatitis.
• Symptoms of Lassa fever can occur from 2
to 21 days after coming into contact with
the virus. The incubation period is usually
from 7 to 10 days.
• About 80% of infected people do not
show symptoms (they are asymptomatic)
or experience a mild disease.
• The onset of the disease, when it
is symptomatic, is usually gradual.
Symptoms usually start with fever, general
weakness, and malaise.
• After a few days, headache, sore throat,
muscle pain, chest pain, nausea, vomiting,
diarrhoea, cough, and abdominal pain
may follow.
• In mild cases, the patient usually recovers
rapidly.
• In severe cases (20%) facial swelling, fluid in
the lung cavity, bleeding from the mouth,
nose, vagina or gastrointestinal tract and
low blood pressure may develop. Severe
cases require hospitalization.
5 • Shock, seizures, tremor, disorientation, and coma may also be seen in the later stages. Death (1 to 2% of total infected symptomatic people: severe and mild
cases) usually occurs within 14 days of
onset in fatal cases.
• Various degrees of deafness occur in 25%
of severe cases who survive the disease.
In half of these cases, hearing returns
partially after 1–3 months. Transient hair
loss and gait disturbance may occur
during recovery.
• Lassa fever should be considered in febrile
patients returning from West Africa,
especially if they have had exposures in
rural areas or hospitals in countries where
Lassa fever is known to be endemic.
• Patient history is essential for diagnosis.
Suspected case: Illness with gradual onset with one
or more of the following: malaise, fever, headache,
sore throat, cough, nausea, vomiting, diarrhoea,
myalgia, chest pain hearing loss and a history of
contact with rodents or with a case of Lassa fever.
Probable case: A deceased suspected case (where it
has not been able to collect specimen for laboratory
confirmation) that has an epidemiological link with a
laboratory confirmed case.
Confirmed case: A suspected case that is laboratory
confirmed (positive for IgM antibodies, positive for
Lassa virus antigen, positive for Lassa RNA by RT-
PCR or virus isolation).
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 70
• Lassa virus infections can only be
diagnosed definitively in the laboratory
using the following tests:
– Reverse Transcription Polymerase Chain
Reaction (RT-PCR) assay;
– Antibody Enzyme-Linked Immunosorbent
Assay (ELISA);
– Antigen detection tests;
– Virus isolation by cell culture.
• Laboratory specimens may be hazardous
and must be handled with extreme
care. Handling specimens with live virus
requires Biosafety level 4.
• Diagnostic assays have also been made
commercially available, but none have
been evaluated by WHO prequalification
process.
Hygiene and rodent control are the
best prevention in communities
• To prevent infection, people should follow
basic hygiene practices:
– Wash their hands regularly;
– Cook food thoroughly.
• Raising awareness is a first step towards
better rodent management.
• At the community level, to reduce human-
rodent contacts, people are advised to:
– Store food in covered rodent-proof
containers;
– Keep homes clean and clear away any
rubbish in or around the house;
6 – Keep a cat;- Implement measures to reduce rodent populations. This would require strong political commitment and sustained
efforts. Techniques that could be used
include:
o Trapping and poisoning;
o Using non-lethal, non-toxic alternatives
to chemical rodenticides (research
ongoing);
o Reducing reproduction (fertility control);
o Etc.
Infectivity
Days
0 1 2 3 4 5 6 8 97
• Fever
• Extreme fatigue
• General weakness
• Face swelling
• Low blood pressure
• Nose bleeding
• Headache
• Severe sore throat
• Diarrhoea
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 71
Strict implementation of infection
prevention and control measures
in health care settings is critical to
prevent the spread of the disease
• In health care settings, staff should always
apply standard infection prevention
and control precautions when caring for
patients, regardless of their presumed
diagnosis. These include:
– Hand hygiene;
– Respiratory hygiene;
– Use of personal protective equipment
(to block splashes or other contact with
infected materials);
– Safe injection practices;
– Safe and dignified burial practices.
• Health care workers caring for patients
with suspected or confirmed Lassa fever
should apply extra infection control
measures to prevent contact with the
patient’s blood and body fluids and
contaminated surfaces or materials such
as clothing and bedding. When in close
contact (within 1 metre) of patients with
Lassa fever, health care workers should
wear face protection (a face shield or a
medical mask and goggles), a clean, non-
sterile long-sleeved gown, and gloves
(sterile gloves for some procedures).
• Health care workers should remember
that maternity wards are potential sites of
amplification as miscarriage and natural
abortion with massive bleeding may
conclude from women with Lassa fever.
Early supportive treatment
reduces mortality
• Treatment is supportive: it consists in
symptomatic treatment, rehydration,
monitoring fluid and electrolyte balance
and renal function.
• Antiviral drug ribavirin seems to be
effective if given early in course of the
disease.
• There is no post-exposure prophylactic
treatment.
• There is currently no licensed or
commercially available vaccine.
New candidate vaccines are under
development.
• New candidate drugs are in development.
7 8
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 72
Outbreak control relies on
community engagement, active
case finding, contact tracing and
safe and dignified burials
The transmission of the disease can be
stopped through:
1. Community engagement as communities
are essential for controlling Lassa fever
outbreaks. They have a role to play in the
detection of new cases, and reduction
of transmission through safe caring of
the sick at home and safe and dignified
burial. Communities should be engaged
in the response since the early stage
and be provided with the necessary
information and personal protective
equipment so that they can adapt the
public health measures to their socio-
cultural beliefs and ensure compliance
of the community members.
2. Active case finding, rapid isolation
of patients and early laboratory
confirmation of suspected cases. Active
case finding refers to actively searching
for new cases (for instance, going from
house to house in the community, asking
if people are sick or if people have died).
New (suspected) cases should be rapidly
and safely referred to treatment centres
for isolation and treatment.
Lassa fever is a viral haemorrhagic
fever that occurs in West Africa
• Lassa fever is a viral haemorrhagic illness
of 2-21 days duration that occurs in West
Africa.
• Lassa fever has been reported in
Benin, Burkina Faso, Côte d’Ivoire,
Ghana, Guinea, Liberia, Mali, Nigeria,
Sierra Leone, and Togo, but should
be considered endemic in other West
African countries.
• The overall case fatality rate is 1%.
• Observed case fatality rate among
patients hospitalized with severe
presentation of Lassa fever is 15%.
9 103. Contact tracing which refers to the follow-up of persons who may have come into contact with a person infected with the Lassa virus (or their body fluids,
exposed environment such as linens,
etc.). Contacts should be followed-up
over a period of 21 days after the last
exposure, looking for symptoms such as
fever, and referred to treatment centres if
they become ill.
4. Safe and dignified burials. It is necessary
to train people who will have close
contact with dead bodies and provide
them with the necessary personal
protective equipment. People can be
buried in a safe manner while respecting
traditional beliefs.
5. Early supportive care (rehydration
and pain relief) should be provided to
patients as early as possible as it reduces
mortality (see point 8).
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 73
Geographic distribution of Lassa fever in West African affected countries, 1969–2018
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 74
More information about
Lassa fever:
• Lassa fever WHO webpage
http://www.who.int/csr/disease/lassafever/en/
• Lassa fever WHO fact sheet
http://www.who.int/mediacentre/factsheets/fs179/en/
• Lassa fever WHO MOOC
https://openwho.org/courses/pandemic-epidemic-diseases
LASSA FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 75
1. The CCHF virus is transmitted by ticks and the disease is endemic where the tick
vector is present
2. Humans are primarily infected through tick bite and secondary human-to-human
transmission occurs through direct contact with the body fluids of infected persons
3. Infected animals are not sick which makes it difficult to control the disease in animals
and anticipate and prevent infection in humans
4. CCHF is a severe disease with high case fatality ratio
5. Early supportive care improves survival
6. Infection prevention and control measures are critical to control the infection when
caring for patients or during burial ceremonies
7. Raising awareness on risk factors and preventive measures is key to reduce infection
in people
8. Efficient vector control measures are currently lacking
9. CCHF can be misdiagnosed with other viral haemorrhagic fevers and early laboratory
confirmation of suspected cases is critical to mount the response
10. CCHF is one of the priority disease for research and development in public health
emergency contexts (R&D Blueprint)
10 THINGS YOU SHOULD KNOW
Crimean-Congo haemorrhagic
fever (CCHF)
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 76
Crimean-Congo haemorrhagic fever (CCHF) response tips
Coordinating responders
• Engage with partners involved in the response
(community engagement, surveillance,
laboratory, case management, IPC, and vector
control)
• Engage with the animal health and food
production sectors
Communicating risk
• Encourage health authorities to:
– Implement active case finding and contact
tracing
– Ensure protection of health care workers
through IPC measures
– Communicate about how to protect from
becoming infected
• Key messages are:
– CCHF is transmitted by ticks or through contact
with body fluids of infected animals and humans
– Bodies of deceased patients are contagious
– Apply IPC measures when in contact with sick
or dead patients and animals
– People with symptoms should seek medical
advice as early treatment increases chances of
survival
Health Information
• Ensure early laboratory confirmation of
suspected cases
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Community engagement and health
promotion
• Case management and IPC:
– Isolation of cases
– Early supportive and antiviral treatment
– Protect health care workers
• Surveillance, and contact tracing
• Safe and dignified burials
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 77
The CCHF virus is transmitted by
ticks and the disease is endemic
where the tick vector is present
• Ticks of the genus Hyalomma are the
principal vector of the disease, although
a number of tick are capable of becoming
infected with CCHF virus.
• Animals become infected by the bite of
infected ticks and the virus remains in
their bloodstream for about one week
after infection, allowing the tick-animal-
tick cycle to continue when another tick
bites.
• The hosts of the CCHF virus include a wide
range of wild and domestic animals such
as cattle, sheep and goats. Many birds
are resistant to infection, but ostriches
are susceptible and may show a high
prevalence of infection in endemic areas.
• CCHF is a viral haemorrhagic fever that is
endemic where the tick vector is present:
in Africa, the Balkans, the Middle East and
Asian countries south of the 50th parallel
north – the geographical limit of the
principal tick vector.
Humans are primarily infected
through tick bite and secondary
human-to-human transmission
occurs through direct contact
with the body fluids of infected
persons
• CCHF can cause severe outbreaks in
humans.
• Humans are infected either by ticks bite
or through direct contact with blood
or tissues of infected ticks or viraemic
vertebrates including wild animals and
livestock.
• Most at-risk people for the animal-
to-human transmission are people
involved in the livestock industry, such
as agricultural workers, slaughterhouse
workers and veterinarians.
• Secondary human-to-human transmission
occurs through direct contact with the
blood, secretions, organs or other body
fluids of infected persons.
1 2 • There is high human-to-human transmission risk when providing direct patient care or handling bodies of deceased individuals (funerals).
• Hospital-acquired infections can also
occur due to inappropriate infection
prevention and control.
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 78
Infected animals are not sick which
makes it difficult to control the
disease in animals and anticipate
and prevent infection in humans
• Infected animal are not sick and do not
show any symptoms. This allows the virus
to maintain itself in nature in unnoticed
enzootic tick-vertebrate-ticks cycles and
makes difficult to anticipate and prevent
potential infection in humans.
CCHF is a severe disease with
high case fatality ratio
• The mortality rate from CCHF is
approximately 30% (it ranges from 10 to
50%), with death occurring in the second
week of illness. In patients who recover,
improvement generally begins on the
ninth or tenth day after the onset of
illness.
• The length of the incubation period
depends on the mode of acquisition of
the virus. Following infection by a tick bite,
the incubation period is usually one to
three days, with a maximum of nine days.
The incubation period following contact
with infected blood or tissues is usually
five to seven days, with a documented
maximum of thirteen days.
• Onset of symptoms is sudden, with fever,
myalgia (muscle ache), dizziness, neck
pain and stiffness, backache, headache,
sore eyes and photophobia (sensitivity
to light). There may be nausea, vomiting,
diarrhoea, abdominal pain and sore
3 4 throat early on, followed by sharp mood swings and confusion. After two to four days, the agitation may be replaced by sleepiness, depression and lassitude,
and the abdominal pain may localize to
the upper right quadrant, with detectable
hepatomegaly (liver enlargement).
• Other clinical signs include tachycardia
(fast heart rate), lymphadenopathy
(enlarged lymph nodes), and a petechial
rash (a rash caused by bleeding into the
skin) on internal mucosal surfaces, such
as in the mouth and throat, and on the
skin. The petechiae may give way to
larger rashes called ecchymoses, and
other haemorrhagic phenomena. There is
usually evidence of hepatitis, and severely
ill patients may experience rapid kidney
and liver failure or pulmonary failure after
the fifth day of illness.
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 79
Early supportive care improves
survival
• General supportive care with treatment
of symptoms is the main approach to
managing CCHF in people.
• The antiviral drug ribavirin has been
used to treat CCHF infection and may
be beneficial if used early in the course
of the illness. Both oral and intravenous
formulations exist and seem to be
effective. Currently, WHO is reviewing
evidence for ribavirin use for the
treatment of CCHF.
• There is currently no licensed or
commercially available vaccine against
CCHF for humans and the animal hosts.
Infection prevention and control
measures are critical to control
the infection when caring
for patients or during burial
ceremonies
• Infection prevention and control measures
while providing care to patients with
suspected or confirmed Crimean-Congo
haemorrhagic fever are the same as those
for Ebola and Marburg haemorrhagic
fever.
5 6
PRECAUTIONS TO BE TAKEN:
When caring for
patients
Standards precautions regardless
of the diagnosis
• Hand hygiene
• Respiratory hygiene
• Use of personal protective equipment (to block splashes / other contact with infected material)
• Safe injection practices
During burial
ceremonies
• Only trained burial team should handle the bodies of people who may
have died from CCHF
• Burial teams should be trained & equipped to properly, safely and with dignity bury the dead
Health care workers caring for
patients with suspected or
confirmed CCHF virus
• Extra infection control measures to prevent contact with patient’s blood
and body fluids and contaminated surface or material such as clothing or bedding
• Face protection (a face shield or a medical mask and goggles), a clean,
non-sterile long-sleeved gown, and gloves (sterile gloves for some procedures) should be
worn when in close contact (within 1 metre) of patients with CCHF
Caring of patients at home • Gloves and appropriate personal protective equipment should be worn
• Regular hand washing
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 80
Raising awareness on risk factors
and preventive measures is key to
reduce infection in people
• In the absence of a vaccine, the best
way to reduce infection in people is by
raising awareness of the risk factors and
educating people about the measures
they can take to reduce exposure to the
virus. People should be informed about:
• Measures to reduce the risk of tick-to-
human transmission include:
– Wearing protective clothing (long sleeves,
long trousers);
– Wearing light coloured clothing to allow
easy detection of ticks on the clothes;
– Using approved acaricides (chemicals
intended to kill ticks) on clothing;
– Using approved repellent on the skin and
clothing;
– Regularly examining clothing and skin for
ticks; if found, removing them safely;
– Seeking to eliminate or control tick
infestations on animals or in stables and
barns;
– Avoiding areas where ticks are abundant
and seasons when they are most active.
• Measures to reduce the risk of animal-to-
human transmission include:
– Wearing gloves and other protective
clothing while handling animals or their
tissues in endemic areas, notably during
slaughtering, butchering and culling
procedures in slaughterhouses or at
home;
Efficient vector control measures
are currently lacking
• Current vector control measures are not
fully satisfactory:
– Chemicals produce resistant ticks, food
contamination, and environmental
pollution. Furthermore, the tick vectors are
numerous and widespread, so tick control
with acaricides (chemicals intended to
kill ticks) is only a realistic option for well-
managed livestock production facilities;
– Physical measures (heavy grazing, burning
of grasslands) have an important negative
impact on the environment;
– Biological measures (e.g. use of hormones
and growth regulators, use of predators,
bacteria, nematodes and fungi) have not
demonstrated full efficacy.
• An animal vaccine effective against
Hyalomma ticks that prevent the tick-
animal-tick cycle would decrease tick
population, decrease CCHF prevalence
in animals, and therefore decrease human
exposure, being a cost effective CCHF
prevention measure.
7 8
– Quarantining animals before they enter
slaughterhouses or routinely treating
animals with approved acaricides two
weeks prior to slaughter.
• Measures to reduce the risk of human-
to-human transmission in the community
include:
– Avoiding close physical contact with
CCHF-infected people;
– Wearing gloves and protective equipment
when taking care of ill people;
– Washing hands regularly after caring for or
visiting ill people.
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 81
CCHF can be misdiagnosed with
other viral haemorrhagic fevers
and early laboratory confirmation
of suspected cases is critical to
mount the response
• Due to lack of standardized case
definition and knowledge about CCHF,
the disease can be misdiagnosed. This is
why laboratory confirmation is critical to
guide response activities.
9
Proposed case definition:
Suspected case: Illness with sudden
onset of fever with one or more of
the following: headache, myalgia,
nausea, vomiting, diarrhoea,
myalgia, abdominal pain and a
history of tick bite or contact with
wild animals or livestock or contact
with a case of CCHF.
Probable case: A deceased
suspected case (where it has not
been able to collect specimen
for laboratory confirmation) that
has an epidemiological link with a
laboratory confirmed case.
Confirmed case: A suspected
case that is laboratory confirmed
(positive for IgM antibodies, positive
for CCHF virus antigen, positive
for CCHF RNA by RT-PCR or virus
isolation).
• Samples taken from people with
suspected CCHF should be handled by
trained staff working in suitably equipped
laboratories.
• CCHF virus infection can be diagnosed by
several different laboratory tests:
– Enzyme-Linked Immunosorbent Assay
(ELISA);
– Antigen detection;
– Serum neutralization;
– Reverse Transcription Polymerase Chain
Reaction (RT-PCR) assay;
– Virus isolation by cell culture.
• Patients with fatal disease, as well as in
patients in the first few days of illness,
do not usually develop a measurable
antibody response and so diagnosis in
these individuals is achieved by virus or
RNA detection in blood or tissue samples.
• Tests on patient samples present an
extreme biohazard risk and should only
be conducted under maximum biological
containment conditions (BSL4). However,
if samples have been inactivated (e.g. with
virucides, gamma rays, formaldehyde,
heat, etc.), they can be manipulated in a
basic biosafety environment.
Days10d7d
Incubation
3-6 days
Prehaemorrhagic period
1-5 days
Haemorrhagic period
2-5 days
Convalescence
2-5 days
Fever
Virus / Antigen
Neutralizing /
IgG ELISA Antibodies
IgM Antibodies
Death (10-40%)
Polymerase chain reaction: The first 9 days after onset
Myalgia, fever,
nausea, vomiting,
diarrhea
Bleeding from various sites
(hematemesis, melena, etc.)
somnolence
IgM (7 days – 4 months) and IgG (7 days – 5 years)
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 82
CCHF is one of the priority disease
for research and development in
public health emergency contexts
(R&D Blueprint)
• Research and Development roadmaps
and target product profiles are being
developed in consultation with experts
and stakeholders (as part of the R&D
Blueprint).
• Research is ongoing for therapeutics (rib-
avirin, favipiravir, intravenous immuno-
globulin, monoclonal antibodies), for rap-
id diagnostics and for an animal anti-tick
vaccine effective against Hyalomma ticks.
• Given the epidemiology of CCHF, with a
limited number of cases reported yearly,
a human vaccine might not be the most
cost-effective and viable control measure.
10
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 83
50° North latitude: Limit for geographic distribution of genus Hyalomma ticks
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reservedSource: WHO/IHM as of July 2017
Geographic distribution of Crimean-Congo haemorrhagic fever
Hyalomma ticks vector presence
CCHF virological / serological
evidence & vector presence
5–49 CCHF cases reported
per year
50 and more CCHF cases
reported per year
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 84
More information about
Crimean-Congo haemorrhagic fever (CCHF):
• CCHF WHO webpage
http://www.who.int/csr/disease/crimean_congoHF/en/
• CCHF WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs208/en/
• R&D Blueprint:
http://www.who.int/blueprint/en/
• Infection prevention and control guidance for care of patients in health
care settings, with focus on Ebola:
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_
control/en/?ua=1
CRIMEAN-CONGO HAEMORRHAGIC FEVER (CCHF)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 85
http://www.who.int/csr/disease/crimean_congoHF/en/
http://www.who.int/mediacentre/factsheets/fs208/en/
http://www.who.int/blueprint/en/
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/?ua=1
http://www.who.int/csr/resources/publications/ebola/filovirus_infection_control/en/?ua=1
1. Urban Yellow fever (YF), the most threatening form of YF epidemics, is
transmitted through Aedes aegypti mosquito bites
2. Outbreaks of YF in urban areas can be devastating
3. Emergency mass vaccination and vector control are the two main pillars of
YF outbreak response
4. YF vaccine is safe and provides lifelong immunity
5. Vaccine production is limited but there is a global emergency stockpile
6. Routine immunization in children is the key to preventing outbreaks
7. The risk of YF international spread exists but can be prevented by applying
the International Health Regulations (IHR) recommendations
8. YF is hard to distinguish from some other diseases with similar symptoms
9. Early clinical management improves survival
10. African Ministers of Health (MOH) are committed to eliminating YF epidemics
10 THINGS YOU SHOULD KNOW
Yellow fever
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 86
Yellow fever response tips
Coordinating responders
• Contact WHO/ICG for emergency vaccines
• Engage partners and communities for vector
control around cases
• Organize emergency mass vaccination
campaigns including cold chain and waste
management
Communicating risk
• Encourage health authorities to:
– Engage communities for vector control
– Work with partners for social mobilization
for vaccination campaigns
– Ensure vector control in health facilities
• Key messages are:
– YF is transmitted by mosquitoes
– Vaccine is safe and provides lifelong
immunity
– Seek medical care early as this increases
chances of survival
Health Information
• Laboratory diagnosis may be difficult
(serological tests cross-react with Dengue
and other flaviviruses)
• Think of differential diagnosis of febrile
jaundice
• Distribute vaccination cards
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Community engagement
• Emergency mass vaccination
• Vector control
• Control at borders (airports)
• Patient supportive care, with bed nets
(also during the day)
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 87
Urban Yellow fever (YF), the most
threatening form of YF epidemics,
is transmitted through Aedes
aegypti mosquito bites
• The yellow fever virus is transmitted to
humans by infected mosquitoes, most
commonly from the Aedes species
(Aedes aegypti, which can transmit the
disease from human to human in urban
settings) – it is the same mosquito that
spreads Zika, Chikungunya and Dengue
viruses.
• Outbreaks usually occur in areas where
mosquitoes breed.
• The current distribution of Aedes aegypti
is the widest ever recorded and Aedes
mosquitoes are present in all continents.
Urbanization with resulting increased
population densities, further enhanced
by man-made larval habitats, amplifies
mosquito-transmitted diseases.
• Aedes mosquitoes usually bite during the
day, peaking during early morning and
late afternoon/evening.
Outbreaks of YF in urban areas
can be devastating
• YF outbreaks in urban settings can
be very devastating as they have the
potential to amplify rapidly and spread
widely, especially to other countries,
because of:
– Increased human population densities
that lead to rapid amplification of the
disease;
– Increased density of the mosquito vector
of urban YF epidemics that breeds in
man-made containers of water, feeds
predominantly on human blood and bites
multiple individuals in a single blood
meal, and lives in close association with
human dwellings;
– Ease and speed of population movements,
as well as easy access to airports, facilitate
spread of the disease and its exportation
to other countries;
1 2 – Difficulties in assessing target populations, and in mounting reactive interventions in informal urban settings.• There are three types of transmission
cycles. However, with climate and
demographic change in endemic settings,
this classification may be reviewed.
– Sylvatic (or jungle) Yellow fever: In
tropical rainforests, monkeys, which are
the primary reservoir of yellow fever, are
bitten by wild mosquitoes which pass the
virus on to other monkeys. Occasionally,
humans working or travelling in the forest
are bitten by infected mosquitoes and
develop yellow fever. This is the most
common type of outbreak in the Americas;
– Intermediate Yellow fever: In this type of
transmission, semi-domestic mosquitoes
(those that breed both in the wild and
around households) infect both monkeys
and people. Increased contact between
people and infected mosquitoes leads to
increased transmission and many separate
villages in an area can develop outbreaks
at the same time;
– Urban Yellow fever: Large epidemics
occur when infected people introduce
the virus into heavily populated areas with
high mosquito density and where most
people have little or no immunity, due to
lack of vaccination. In these conditions,
infected Aedes Aegypti mosquitoes
transmit the virus from person to person.
This is the most serious outbreak because
it amplifies quickly.
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 88
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 89
Emergency mass vaccination and
vector control are the two main
pillars of YF outbreak response
Vector control:
• Vector control strategies should address
all life stages of the Aedes mosquito
from the egg, to larva and adult.
Community engagement is essential for
these interventions:
– Elimination of breeding sites and
eggs/larvae/pupae in standing water
(e.g. cleaning roof gutters, clean-up
campaigns, etc.);
– Targeted residual spraying of adult
mosquitoes (in areas known to be resting
sites for Aedes mosquitoes) and space
spraying when there is an outbreak;
– Mosquito control programmes targeting
wild mosquitoes in forested areas are
not practical and not recommended
for preventing jungle (or sylvatic) yellow
fever transmission.
3 • Additionally, personal preventive measures such as clothing minimizing skin exposure, use of repellents, as well as windows screens and air conditioning
are recommended to avoid mosquito
bites. The use of insecticide-treated bed
nets is limited by the fact that Aedes
mosquitos bite during daytime.
• Mosquito surveillance is part of vector
control and helps improve timeliness
of decisions to control mosquito
populations and prevention disease.
Both larval and adult vector populations
should be targeted for surveillance.
• Eventually, economic development
will reduce mosquito-borne diseases
by improving standards of living (e.g.
people living in houses with solid floors
and roofs, window screens, and air
conditioning).
Emergency mass vaccination:
• Reactive mass vaccination campaigns, by
increasing immunity in the population,
reduce the possibility of transmission
of the virus. Vaccine coverages greater
than 80%, with a 60-80% security
threshold, are necessary to interrupt
autochthonous transmission (human-
mosquito-human) of YF virus within a
community and ensure that sporadic
unvaccinated cases do not generate
secondary cases.
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 90
Vaccine production is limited
but there is a global emergency
stockpile
• They are four prequalified vaccine
manufacturers and global supply
production is limited. There is a global
emergency stockpile of six million
vaccine doses, which can be accessed
by any country facing an outbreak,
through a request to the International
Coordinating Group (ICG).
• For outbreak response, in case of
shortage of vaccine, it is possible to use
a fraction of the vaccine doses (1/5), in
order to rapidly increase the population
immunity and stop human-to-human
transmission.
– Children under two years of age should
be offered a full dose, as they may have a
weaker immune response to the vaccine
than older people;
– There is no evidence of increased serious
adverse effects when using a fractional
dose.
5YF vaccine is safe and provides lifelong immunity• There is a good vaccine against YF. It
has been used for many decades and is
safe and affordable, providing effective
immunity against yellow fever within
10 days for more than 90% of people
vaccinated and within 30 days for 99%
of people vaccinated. A single dose
provides lifelong protection. A booster
dose of yellow fever vaccine is not
needed.
• Adverse effects of the Yellow fever
vaccine are generally mild and may
include headaches, muscle aches,
and low-grade fevers. Serious adverse
effects are rare.
• In Yellow fever endemic countries,
WHO strongly recommends routine
vaccination for everyone older than
9 months. People over 60 years of
age should be given the vaccine after
a careful risk-benefit assessment.
Some people should not be routinely
vaccinated, including:
– Infants aged less than 9 months;
– Pregnant women (unless during an
outbreak if the risk of disease outweighs
the potential adverse effect of the
vaccine);
– People with severe allergies to egg
protein; and
– People with severe immunodeficiency.
4
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 91
Routine immunization in children is
the key to preventing outbreaks
• Vaccination is the single most important
measure for preventing yellow fever.
The prevention of outbreaks can only be
achieved if the majority of the population is
immunized.
• YF routine immunization in the Expanded
Programme on Immunization (EPI) can
provide sufficient population immunity.
However, it takes about 30 years to build
the population immunity to adequate levels
to stop potentially large scale outbreaks.
Mass preventive vaccination campaigns to
other age groups accelerate the building of
population immunity through what is called
the YF “combined vaccination strategy”.
6
Population protected by routine immunization, preventive mass campaigns and combined vaccination strategy
(A) Routine child immunization
Number of years after the intervention
(C) Combined vaccination strategy: Routine childhood
immunization + one preventive mass vaccination
campaign
(B) Preventive mass vaccination campaign
100
90
80
70
60
50
40
30
20
10
0
1 10
2.3
22.8
45.6
68.4
91.2
20 30
Pr
op
or
tio
n
(%
) o
f p
op
ul
at
io
n
pr
ot
ec
te
d
40
100
90
80
70
60
50
40
30
20
10
0
1 10
80.0
55.1
26.6
0 0
20 30 40 1 10
82.3
77.9
72.2
91.2
68.4
20 30 40
100
90
80
70
60
50
40
30
20
10
0
Vaccine
coverage
security
threshold
(A) Routine childhood immunization (B) Preventative mass vaccination campaign (C) Combined vaccination strategy:
Routine childhood immunization + one
Preventative mass vaccination campaign
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 92
• It is recommended that major sectors
recruiting international workers, with
potential sylvatic exposure (extractive,
mining, construction and forestry
industries), take measures to ensure
their staff and families are vaccinated.
• To prevent international spread, it is
essential that the International Health
Regulations (2005) are applied and
that travelers present yellow fever
vaccination certificates. Under the
IHR (2005), it is also essential to notify
YF cases that have a serious public
health impact and/or are unusual or
unexpected, and/or could lead to
international spread and/or present
a significant risk of travel or trade
restrictions.
• Vector control measures may be
applied in various forms of transport, in
accordance with the IHR (2005).
The risk of YF international
spread exists but can be prevent-
ed by applying the International
Health Regulations (IHR) recom-
mendations
• With the increasing occurrence of urban
YF outbreaks comes an increased risk
of international spread of diseases,
because big cities are transport hubs
with frequent transport connections.
A particularly concerning scenario
would be exportation of the disease to
a country where the vector is present
and population immunity levels are low,
which could lead to local transmission.
• For Yellow fever, exportation of
cases to Asia is especially worrisome
as all favorable conditions for local
transmission (vector such as Aedes
aegypti, non-immune populations)
are present in this continent, as
demonstrated by dengue activity.
7
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 93
YF is hard to distinguish from
some other diseases with similar
symptoms
• Yellow fever is difficult to diagnose
(especially during the early stages)
because its symptoms are not specific
and can be confused with other common
diseases such as Malaria, Viral Hepatitis
(when jaundice), Dengue, Leptospirosis
(when jaundice), other arbovirus diseases,
Ebola virus disease (when haemorrhagic)
as well as with poisoning.
– Once contracted, the Yellow fever virus
incubates in the body for three to six days;
– Most people (about 88% of those infected)
do not experience symptoms;
– Symptoms usually develop in two phases:
o First to occur are common, unspecific
symptoms, including fever, muscle pain
with prominent backache, headache,
loss of appetite, and nausea or vomiting.
In most cases, symptoms disappear
after three to four days.
o A small percentage of patients (about
2-3% of infected people) will then
enter a second, more toxic phase
within 24 hours of recovering from
initial symptoms. High fever returns
and several body systems are affected,
usually the liver and the kidney, hence
the characteristic jaundice – which gives
yellow fever its name – dark urine and
abdominal pain with vomiting. Bleeding
can occur from the mouth, nose, eyes
or stomach. Half of the patients who
enter the toxic phase die within seven
to ten days. The rest recover without
significant organ damage.
8 • Laboratory tests are necessary to confirm yellow fever and access the global stockpile:- In the first phase, blood is collected for RT-
PCR – Reverse Transcription Polymerase
Chain Reaction, to confirm the presence
of the virus (viremia);
– In later stages of the disease, serology
testing to identify antibodies is needed
(ELISA, Enzyme-Linked Immunosorbent
Assay and PRNT, Plaque Reduction
Neutralization Test, for neutralizing
antibodies). The detection of antibodies
indicates that the person has either been
infected or vaccinated, but it cannot
distinguish between the two. The level of
antibodies’ titres and their evolution over
time, on a second sample, can provide
indication of how acute the infection
might be;
– Whenever YF is suspected, there should
also be systematic testing by serology
and PCR for other arboviruses (such as
Dengue, Zika, Chikungunya, West Nile,
Rift Valley Fever) and viral haemorrhagic
fever (VHF, such as Ebola, Lassa, Crimean-
Congo haemorrhagic fever);
– YF tests should be realized in laboratories
with appropriate capacity to test for both
YF and the differential diagnosis.
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 94
African Ministers of Health (MOH)
are committed to eliminating YF
epidemics
• Yellow fever is an acute viral haemorrhagic
disease. The virus is endemic in tropical
areas of Africa and the Americas.
Susceptible non-human primates are
the animal reservoir, they are necessary
to maintain the endemicity.
• Forty of the 47 YF-affected countries
have been identified as priority
nations by the Eliminate Yellow Fever
Epidemics (EYE) Strategy. The updated
Strategy was developed by a coalition
of countries and partners to respond to
the disease’s changing epidemiology,
10 resurgence of mosquitoes, and the increased risk of urban outbreaks and international spread.• African Member States endorsed the
(EYE) Strategy in 2017 and agreed on
ten priority actions to guide countries to
the elimination of YF epidemics by 2026.
9 Early clinical management improves survival• Good and early supportive treatment in hospitals improves survival rates.
• There is currently no specific anti-viral
drug for yellow fever but specific care
to treat dehydration, liver and kidney
failure, and fever improves outcomes.
• Patients need to stay under mosquito
nets during the day to limit the risk
of spread to others through bites of
mosquitoes.
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 95
l
,
Cabo Verde
Guinea-Bissau
Gambia
Senegal
Sierra Leone
Liberia
Guinea –
Côte d’Ivoire
Ghana
Burkina Faso
Togo
Benin
Sao Tome and Principe
Nigeria
Gabon
Congo
Equatorial Guinea
Camer oon –
Angol a
Democratic Republic
of the Congo
South Africa Lesotho
Swaziland
Botswana
Zimbabwe
Namibia
Zambia
Malawi
Mozambique
Madagascar
Comoros
Rwanda
Burundi
United Republic
of Tanzania
Mauritius
Seychelles
Kenya
Uganda
Somalia –
Ethiopia
Djibouti
South Sudan –
Eritrea Sudan
Chad
Niger
Centr al African
Republic
Egypt Libya
Tunisia
Algeria
Mali
Morocco
Mauritania
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018.
Yellow fever (YF) risk classification, by country – Africa, 2016
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 96
Yellow fever (YF) risk classification, by country – LAC* countries, 2016
The boundaries and names shown and the designations used on this map do not imply the expression
of any opinion whatsoever on the part of the World Health Organization concerning the legal status of
any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be
full agreement.
© WHO 2018.
This map illustrates a public-health-intervention oriented YF risk approach at country level. Its purpose is
different from the YF risk area maps for travellers in the context of IHR.
Map 1b a 2016
Argentina
Uruguay
Chile
Peru
Bolivia (Plurinational
State of)
Pa raguay
Ecuador
Colombia
Panama
Venezuela (Bolivarian
Republic of) –
Trinidad and Tobago
Guyana
Suriname
Fr ench Guiana
Brazil
* LAC: Latin American and Caribbean
High-risk
Potential-risk
No evidence available for YF or indicative
arbovirus circulation
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 97
More information about
Yellow fever
• Yellow fever WHO webpage
http://www.who.int/csr/disease/yellowfev/en/
• Yellow fever WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs100/en/
• EYE Strategy
http://apps.who.int/iris/bitstream/10665/255040/1/WER9216 ?ua=1
• Yellow fever WHO MOOC
https://openwho.org/courses/pandemic-epidemic-diseases
• WHO standard case definitions
http://www.who.int/csr/disease/yellowfev/case-definition/en/
YELLOW FEVERMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 98
http://www.who.int/csr/disease/yellowfev/en/
http://www.who.int/mediacentre/factsheets/fs100/en/
http://apps.who.int/iris/bitstream/10665/255040/1/WER9216 ?ua=1
https://openwho.org/courses/pandemic-epidemic-diseases
http://www.who.int/csr/disease/yellowfev/case-definition/en/
1. Zika virus is transmitted by Aedes mosquitoes, which primarily bite during
the day
2. This virus infection is usually asymptomatic, but can lead to severe
complications
3. Infection during pregnancy presents many serious hazards for mother and
child (microcephaly in children)
4. Zika virus is a trigger of Guillain-Barré syndrome
5. The virus is also transmissible through sexual contact, blood transfusion, and
organ transplantation
6. Vector control strategies are important for prevention and control
7. Individuals should protect themselves from mosquito bites
8. Access to laboratory testing is critical for pregnant women
9. There is no vaccine or specific treatment for Zika virus infection
10. Warnings have been issued for pregnant women and their male partners
10 THINGS YOU SHOULD KNOW
Zika
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 100
Zika response tips
Coordinating responders
• Coordination of public health, maternal and child
health, vector control and clinical services
• Social services to support affected children and
families
Communicating risk
• Encourage health authorities to:
– Engage communities for eliminating mosquito
breeding sites
– Communicate with at-risk groups through their
trusted sources of information
• Key messages:
– Zika is transmitted through mosquito bites during
the day
– The babies of pregnant women are at risk for
adverse pregnancy outcomes
– Zika can be sexually transmitted
– Women of reproductive age should seek advice
before getting pregnant during outbreaks and
should seek medical advice if they fall pregnant
Health Information
• Early detection, reporting, and monitoring
of cases
• Laboratory capacity for diagnosis especially
in pregnant women
• Laboratory diagnosis may be difficult
(serological tests cross-react with Dengue
and other flaviviruses)
Health Interventions
• Community engagement and health
promotion
• Early response
• Prevention of infection by Aedes
mosquitoes, particularly pregnant women
• Reduce breeding sites of Aedes
mosquitoes around dwellings
• Clinical supportive care of patients with
Guillain-Barré and severe symptoms
• Support to babies born with microcephaly
• Psychosocial counselling and support
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 101
Zika virus is transmitted by Aedes
mosquitoes, which primarily bite
during the day
• The Zika virus is transmitted to humans
by infected mosquitoes, most commonly
from the Aedes species – it is the same
mosquito that spreads Yellow fever,
Chikungunya and Dengue viruses.
• Outbreaks usually occur in areas where
mosquitoes breed.
• The current distribution of Aedes aegypti
is the widest ever recorded and Aedes
mosquitoes are present in all continents.
Urbanization with resulting increased
population densities, further enhanced
by man-made larval habitats, amplifies
mosquito-transmitted diseases.
• Aedes mosquitoes usually bite during the
day, peaking during early morning and
late afternoon/evening.
• Local transmission of Zika virus by Aedes
mosquitoes has been reported on the
continents of Africa, the Americas, South-
East Asia and the Western Pacific.
• There are 2 types of Aedes mosquitoes
known to be capable of transmitting Zika
virus:
– In most cases, Zika is spread through the
Aedes aegypti mosquito in tropical and
subtropical regions;
– Aedes albopictus mosquitoes can also
transmit Zika virus and can tolerate cooler
temperatures;
– Both species are found biting outdoors
but Aedes aegypti will also feed indoors.
This virus infection is usually
asymptomatic, but can lead to
severe complications
• About 80% of infected people do not
develop symptoms.
• People with symptoms usually present
with mild fever, rash, conjunctivitis
(inflammation of the eyes), muscle and
joint pain, malaise, and headache.
1 2 • Symptoms normally last two to seven days.• The incubation period (the time from exposure to onset of symptoms) of Zika
virus disease is unknown but is most likely
less than one week if it is similar to that of
other mosquito-borne flaviviruses.
• Zika virus infection can lead to severe
neurological complications in a relatively
small proportion of those infected:
– Microcephaly and other congenital
abnormalities;
– Preterm birth and fetal death;
– Guillain-Barré syndrome;
– Investigations are ongoing on the links
between Zika virus and other adverse
outcomes.
• Zika virus can be classified into two main
lineages: the Asian lineage and African
lineage. To date, the Asian lineage Zika
virus strain is responsible for the recent
2015/2016 epidemics. It is not known
whether the African lineage Zika virus
strains would produce neurological
symptoms with similar or worse gravity
than those observed in the 2015/2016
epidemics.
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 102
Infection during pregnancy
presents many serious hazards for
mother and child (microcephaly in
children)
• Zika virus can be transmitted from mother
to child during pregnancy, and can result
in congenital abnormalities:
– Microcephaly is a condition where the
infant’s head is smaller than those of
other babies of the same age and sex
(more than three standard deviations
below average for gestational age).
Infants born with microcephaly are at risk
for severe intellectual disability and may
also develop convulsions and physical
disabilities as they grow older. There is no
specific treatment for microcephaly;
o Diagnosis of microcephaly is often
made at birth. All infants should have
head circumference measured and
recorded within 24 hours of birth.
Early diagnosis of microcephaly can
sometimes be made by fetal ultrasound.
Prenatal diagnosis by ultrasound is
more accurate in the second and third
trimesters.
– Other newborn complications associat-
ed with in-utero Zika infection include
brain calcifications, seizures, irritability,
brainstem dysfunction such as swallowing
Zika virus is a trigger of Guillain-
Barré syndrome
• Guillain-Barré syndrome (GBS) is a rare
condition in which a person’s immune sys-
tem attacks the peripheral nerves.
• People of all ages can be affected, but it
is more common in adults and in males.
• Symptoms typically last a few weeks. If
supported through the critical stages of
disease, most individuals can recover
without long-term complications.
– The first symptoms of Guillain-Barré
syndrome include weakness or tingling,
usually starting in the legs and can spread
to the arms and face;
– Some patients can develop paralysis of
the legs, arms, or muscles in the face. In
20%–30 % of people, the chest muscles
are affected, making it difficult to breathe;
– The ability to speak and swallow may
become affected in severe cases of Guil-
lain-Barré syndrome;
– Severe cases of Guillain-Barré syndrome are
rare, but can result in near-total paralysis.
• Guillain-Barré syndrome is therefore po-
tentially life-threatening. People with Guil-
lain-Barré syndrome should be treated
and closely monitored; severe cases may
require intensive care including ventilato-
ry respiratory support. Treatment includes
supportive care and some immunological
therapies.
• Even in the best of settings, 3%–5% of
Guillain-Barré syndrome patients die from
complications, which include paralysis
of the muscles that control breathing,
infection, sepsis, or cardiac arrest.
3 4problems, limb contractures, develop-mental delay, hearing and sight abnormal-ities, and other brain abnormalities; – Support services for affected infants and
families are an important component of
Zika programmes.
• Other adverse pregnancy outcomes
associated with Zika virus infection
include preterm birth, miscarriage, and
still birth.
• Zika virus has been identified in breast
milk, but transmission by breastfeeding
has not yet been reported. Current
evidence suggests that the benefits of
breastfeeding outweigh the theoretical
risk of Zika virus infection transmission
through breast milk.
• More information is needed on the long
term outcomes of infants infected during
pregnancy, delivery, and in the early post-
partum period.
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 103
The virus is also transmissible
through sexual contact, blood
transfusion, and organ transplan-
tation
• Zika virus can be transmitted through
sexual intercourse. This is of concern
because of the association between Zika
virus infection and adverse pregnancy
outcomes.
• In regions with active Zika virus
transmission, health programmes should
ensure that:
– All people with Zika virus infection and
their sexual partners (particularly pregnant
women) receive information about the
risks of sexual transmission of Zika virus;
– Men and women receive counselling
on safe sexual practices and are offered
condoms;
– Sexually active men and women should
be counselled and offered a full range of
contraceptive methods to make informed
choices about whether and when to
become pregnant, to prevent unintended
pregnancies, and prevent possible
adverse pregnancy outcomes;
– Pregnant women should be advised not
to travel to areas of ongoing Zika virus
outbreaks.
• Other modes of person-to-person Zika
transmission include: blood transfusion,
organ transplantation and laboratory or
other blood-borne exposure.
Vector control strategies are
important for prevention and
control
• Vector control strategies should address
all life stages of the Aedes mosquito from
the egg, to larva and adult. Community
engagement is essential for these inter-
ventions:
– Elimination of breeding sites and eggs/lar-
vae/pupae in standing water (e.g. cleaning
roof gutters, clean-up campaigns, etc.);
– Targeted residual spraying of adult mos-
quitoes (in areas known to be resting sites
for Aedes mosquitoes) and space spray-
ing when there is an outbreak.
• Mosquito surveillance is part of vector
control and helps improve timeliness of
decisions to control mosquito popula-
tions and prevention disease. Both larval
and adult vector populations should be
targeted for surveillance.
• Standard WHO recommendations re-
5 6 garding vector control at airports should be implemented in accordance with the IHR (2005). Countries should consider disinfection of aircraft.
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 104
Access to laboratory testing is
critical for pregnant women
• Because of the association between Zika
virus infection and adverse pregnancy
and infant outcomes, it is important that
women have access to laboratory testing.
The woman (and her partner if she/he
wishes) should be offered non-directive
counselling so that she, in consultation
with her health care provider, can make a
fully informed choice about the next steps
in the management of her pregnancy.
• Laboratories should have the capacity to
test for Zika:
– Laboratory tests are done on blood
or other body fluids (e.g. urine, saliva,
semen):
o Polymerase Chain Reaction (PCR) during
the acute phase of the disease;
o Serological (IgM) testing and Nucleaic
Acid Tests (NAT) testing with Plaque Re-
duction Neutralization Test (PRNT). In-
fection with Zika virus is difficult to con-
firm retrospectively because serological
tests cross react with other flaviviruses,
especially Dengue virus.
7 8Individuals should protect them-selves from mosquito bites• The community, and particularly pregnant women and women of reproductive age,
should be educated about the risk of
transmission and how to minimize this risk
by reducing contact with mosquitoes.
• Personal preventive measures to
avoid mosquito bites include clothing
minimizing skin exposure, use of
repellents, as well as windows screens and
air conditioning. The use of insecticide-
treated bed nets is limited by the fact that
Aedes mosquitos bite during daytime.
• Eventually, economic development will
reduce mosquito-borne diseases by
improving standards of living (e.g. people
living in houses with solid floors and roofs,
window screens, and air conditioning).
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 105
There is no vaccine or specific
treatment for Zika virus infection
• Currently, there are no antiviral drugs
or specific treatment for people with
Zika virus disease. Zika virus disease
in individuals including non-pregnant
women is usually mild and requires
no specific treatment. Individuals with
more severe symptoms should receive
supportive care including rest, fluids,
and management of pain and fever. They
should be offered psychosocial support.
• Research is ongoing for potential
therapies, for vaccines to prevent
Zika virus infection or Congenital Zika
Syndrome, and for diagnostic tests.
Warnings have been issued for
pregnant women and their male
partners
• There are no general restrictions on travel
or trade with countries, areas and/or
territories with Zika virus transmission.
• However, WHO is advising pregnant
women not to travel to the following Zika-
affected areas:
– Areas with new introduction of Zika virus
since 2015 or where the virus has been re-
introduced, with ongoing transmission;
– Areas with evidence of Zika virus circulation
before 2015 or with ongoing transmission
(but not satisfying the category above).
• Health authorities are responsible for
advising travellers on risks and preventive
measures.
9 10
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 106
Countries and territories* with reported Zika virus transmission
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities,
or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
* Note: This includes areas with new introduction or re-introduction with ongoing transmission; areas either with evidence of virus circulation before 2015 or area with ongoing transmission that is no longer in the new or re-introduction phase, but where there is
no evidence of interruption; and areas with interrupted transmission and with potential for future transmission.
Countries and territories* with reported
Zika virus transmission
Source: WHO/IHM; as of 15 January 2018
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 107
More information about Zika
• Zika WHO webpage:
http://www.who.int/csr/disease/zika/en/
• Zika virus WHO fact sheet:
http://www.who.int/mediacentre/factsheets/zika/en/
• Risk communications and community engagement
http://www.who.int/csr/resources/publications/zika/community-
engagement/en/
• Pregnancy management in the context of Zika virus infection:
http://www.who.int/csr/resources/publications/zika/pregnancy-
management/en/
• Care and support of people affected by complications associated
with Zika virus:
http://www.who.int/mental_health/neurology/zika_toolkit/en/
• Prevention of sexual transmission:
http://www.who.int/csr/resources/publications/zika/sexual-
transmission-prevention/en/
• Identification and management of Guillain-Barré syndrome in the
context of Zika virus:
http://www.who.int/csr/resources/publications/zika/guillain-barre-
syndrome/en/
ZIKAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 108
1. Chikungunya is transmitted by Aedes mosquitoes, which primarily bite during
the day
2. Chikungunya outbreaks occur typically in urban settings
3. Chikungunya causes an acute febrile illness
4. Convalescence may be long and patients may present complications and
sequelae
5. Treatment is directed primarily at relieving symptoms
6. Chikungunya is often misdiagnosed with Dengue and other diseases
7. Controlling the mosquito vector is key to outbreak prevention and control
8. Vector surveillance is critical to determine vector control strategies
9. Chikungunya virus infection seems to elicit long-lasting protective immunity
10. Chikungunya is emerging as a global disease
10 THINGS YOU SHOULD KNOW
Chikungunya
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 110
Chikungunya response tips
Coordinating responders
• Coordination of public health, environmental,
clinical services and vector control
Communicating risk
• Encourage health authorities to:
– Communicate to the public about how to protect
from the disease
– Advise on seeking health care for high-risk
groups
– Eliminate mosquito breeding grounds
• Key messages:
– Chikungunya can cause acute and chronic illness
– Chikungunya is transmitted by mosquitoes
Health Information
• Laboratory capacity for diagnosis and
surveillance
• Vector distribution surveillance
• Early detection, reporting, response and
monitoring
Health Interventions
• Community engagement and health
promotion
• Vector control:
– Reduce breeding sites of Aedes
mosquitoes around dwellings
– Prevent mosquito bites during the day
• Supportive care
• Patient care with bed nets (also during
the day)
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 111
Chikungunya is transmitted by
Aedes mosquitoes, which primarily
bite during the day
• The Chikungunya virus is transmitted to
humans by infected mosquitoes, most
commonly from the Aedes species – it is
the same mosquito that spreads Yellow
fever, Zika and Dengue viruses.
• Outbreaks usually occur in areas where
mosquitoes breed.
• The current distribution of Aedes aegypti
is the widest ever recorded and Aedes
mosquitoes are present in all continents.
Urbanization with resulting increased
population densities, further enhanced
by man-made larval habitats, amplifies
mosquito-transmitted diseases.
• Aedes mosquitoes usually bite during the
day, peaking during early morning and
late afternoon/evening.
• There are 2 types of Aedes mosquitoes
known to be capable of transmitting
Chikungunya virus:
– In most cases, Chikungunya is spread
through the Aedes aegypti mosquito in
tropical and subtropical regions;
– Aedes albopictus mosquitoes can also
transmit Chikugunya virus and can tolerate
cooler temperatures;
– Both species are found biting outdoors
but Aedes aegypti will also feed indoors.
• Transmission of the virus can also occur
through blood transfusion and laboratory
or other blood-borne exposure.
Chikungunya outbreaks occur
typically in urban settings
• Human beings serve as the Chikungunya
virus reservoir during epidemic periods.
• Urban Chikungunya virus transmission
follows those observed for Dengue virus.
1 2
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 112
Chikungunya causes an acute
febrile illness
• Chikungunya causes an acute febrile
illness typically accompanied by
arthralgia.
• Other common symptoms and signs
include muscle pain, headache, nausea,
fatigue and rash.
• The joint pain is often debilitating, usually
lasting a few days, but may be prolonged
to weeks. Hence, the virus can cause
acute, subacute or chronic disease.
• The disease shares some clinical signs
with Dengue and can be misdiagnosed in
areas where Dengue is common.
• Children may experience other symptoms
such as minor hemorrhagic manifesta-
tions, arthralgia/arthritis, lymphadenop-
athy, conjunctival injection, swelling of
eyelids and pharyngitis. Rare clinical fea-
tures include neurological manifestations
including seizures, altered level of con-
sciousness, and blindness due to retrob-
ulbula neuritis and acute flaccid paralysis.
• The disease is generally not fatal.
Symptomatic treatment along with rest
usually suffices.
• After the bite of an infected mosquito,
onset of illness occurs usually between
four and eight days but can range from
two to 12 days.
• The acute phase of Chikungunya lasts for
three to 10 days but convalescence can
be prolonged up to one year and more.
• There are asymptomatic patients but it is
unknown how frequently it occurs.
Convalescence may be long
and patients may present
complications and sequelae
• Rare clinical manifestations of
Chikungunya include neurological,
hemorrhagic, and ocular and severe
multiple organs system involvement.
• In older people, the disease can contribute
to earlier death that may be due to the
frequency of concomitant underlying
diseases or decreased immunologic
response.
• Some patients have reported disabling
joint pain or arthritis, which may last for
weeks or months. These patients may
require long-term anti-inflammatory
therapy.
• Patients with Chikungunya should be
assisted from their communities and
enabled to seek occupational and social
rehabilitation.
3 4
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 113
Treatment is directed primarily at
relieving symptoms
• There is no specific antiviral drug
treatment for Chikungunya.
• Treatment is directed primarily at relieving
the symptoms using anti-pyretics (parac-
etamol is the drug of choice), optimal
analgesics and fluids. Applying cold com-
presses have been reported to lessen the
joint symptoms.
• People with Chikungunya should rest and
consume plenty of water.
• Aspirin should be avoided due to its effect
on platelets. Paracetamol or nonsteroidal
anti-inflammatory drugs may be used for
symptom relief.
• All suspected cases should be kept under
mosquito nets during the febrile period.
• Patients and their families should be
provided with psychosocial support.
• There is no Chikungunya vaccine
although some candidate vaccines are
being tested in human beings.
Chikungunya is often
misdiagnosed with Dengue and
other diseases
• Chikungunya patients may present
nonspecific symptoms that could be
confused with many other diseases
such as Dengue, Leptospirosis, Malaria,
Meningitis, and Rheumatic fever.
Laboratory diagnosis is thus critical to
establish the cause of diagnosis and
initiate specific public health response.
• Several methods can be used for
diagnosis:
– Molecular technique: Polymerase Chain
Reaction (PCR);
– Virus isolation: the virus may be isolated
from the blood during the first few days
of infection. Various Reverse Transcription
Polymerase Chain Reaction (RT–PCR)
methods are available but are of variable
sensitivity;
– Serological tests such as Enzyme-Linked
Immunosorbent Assays (ELISA), may
confirm the presence of IgM and IgG anti-
chikungunya antibodies. IgM antibody
levels are highest three to five weeks after
the onset of illness and persist for about
two months.
5 6
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 114
Controlling the mosquito vector
is key to outbreak prevention and
control
• Vector control strategies should address
all life stages of the Aedes mosquito from
the egg, to larva and adult. Community
engagement is essential for these
interventions:
– Elimination of breeding sites and
eggs/larvae/pupae in standing water
(e.g. cleaning roof gutters, clean-up
campaigns, etc.);
– Targeted residual spraying of adult
mosquitoes (in areas known to be resting
sites for Aedes mosquitoes) and space
spraying when there is an outbreak.
• Additionally, personal preventive
measures such as clothing minimizing
skin exposure, use of repellents, as well as
windows screens and air conditioning are
recommended to avoid mosquito bites.
The use of insecticide-treated bed nets is
limited by the fact that Aedes mosquitos
bite during daytime.
• Eventually, economic development will
reduce mosquito-borne diseases by
improving standards of living (e.g. people
living in houses with solid floors and
roofs, window screens, and
air conditioning).
• Standard WHO recom-
mendations regarding
vector control at airports
should be implement-
ed in keeping with the
IHR (2005). Countries
should consider disin-
fection of aircraft.
Vector surveillance is critical
to determine vector control
strategies
• Mosquito surveillance is part of vector
control and helps improve timeliness of
decisions to control mosquito populations
and prevention disease. Both larval and
adult vector populations should be
targeted for surveillance.
• These data will enable the
selection and use of the
most appropriate vector
control tools, and can
be used to monitor their
effectiveness.
7 8
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 115
Chikungunya virus infection
seems to elicit long-lasting
protective immunity
• There are still a lot of unknowns (including
the clinical spectrum of the disease) and
research is ongoing to fill scientific gaps
in our understanding of the disease.
• The reasons for the mysterious behavior
of dramatic outbreaks interspersed by
periods of prolonged absence, virus
survival in nature and factors triggering
outbreaks need to be further studied.
• Research also focuses on diagnostics
tests, treatments and vaccines.
Chikungunya is emerging as a
global disease
• Urbanization, human travel, viral adaption,
lack of effective control measures,
and spread of new vectors likely have
contributed to recent re-emergence of
Chikungunya.
• There is a risk of epidemics in subtropical
and temperate regions of the world where
Aedes albopictus is a potential vector.
• The dramatic spread of the Dengue,
Chikungunya, and Zika viruses in recent
years highlights the urgent need to
identify Aedes control options.
9 10
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 116
Predicted distribution of the Aedes Aegypti mosquito
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 117
Predicted distribution of the Aedes Albopictus mosquito
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 118
More information about Chikungunya:
• Chikungunya WHO webpage:
http://www.who.int/emergencies/diseases/chikungunya/en/
• Chikungunya WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs327/en/
• Prevention and control:
http://www.wpro.who.int/mvp/topics/ntd/Chikungunya_WHO_
SEARO
• WHO standard case definitions:
http://www.who.int/wer/2015/wer9033 ?ua=1
CHIKUNGUNYAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 119
http://www.who.int/emergencies/diseases/chikungunya/en/
http://www.who.int/mediacentre/factsheets/fs327/en/
http://www.wpro.who.int/mvp/topics/ntd/Chikungunya_WHO_SEARO
http://www.wpro.who.int/mvp/topics/ntd/Chikungunya_WHO_SEARO
http://www.who.int/wer/2015/wer9033 ?ua=1
1. Animal influenza viruses have occasionally infected humans (Avian, swine and
other zoonotic influenza viruses)
2. Multisectoral coordination and communication are essential parts of any
outbreak response
3. Protect all individuals with occupational or other risks of exposure
4. Eggs, poultry and poultry products can be safely consumed, provided these
items are properly cooked and properly handled during food preparation
5. To minimize exposure of the public, encourage proper personal hygiene and
instruct the public to seek medical help if illness develops
6. Increase surveillance for human cases of Avian influenza
7. Collecting appropriate samples, and rapid and precise characterization of
virus isolates are essential for early detection and management of patients
8. Health care facilities need to be ready to manage patients with Avian influenza
virus infections
9. The animal health sector is in charge of preventing and controlling outbreaks
of disease in animals, including Avian influenza
10. Influenza A(H5N1) vaccines are not widely available and the decision to use
them depends on the risk of infection
10 THINGS YOU SHOULD KNOW
Avian and other zoonotic influenza
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 120
Avian and other zoonotic influenza response tips
Coordinating responders
• Multisectoral response: collaboration between
animal health sector and public health sector
is key in surveillance, response and prevention
activities
Communicating risk
• Encourage health authorities to:
– Have a way to compensate owners/farmers
for the loss of sick animals to encourage early
reporting
– Have a multisector communications strategy in
place
• Key messages:
– Avian influenza is transmitted primarily from
infected animals to human through direct contact
– There is usually no sustained human-to-human
transmission
– Promote good personal hygiene (i.e.
handwashing)
– Promote proper food safety guidance
– Report sick animals to the authorities
Health Information
• Sharing information from the animal health
sector with human health sector supports
preventive action in the affected areas
• Sharing information on human cases with
the animal health sector is equally important
so that they can target their response
activities
• Ensure sharing of viruses from human cases
with WHO Collaborating Centres
• Report cases to WHO, under the IHR (2005)
Health Interventions
• Investigate cases and enhance surveillance
• Collect appropriate specimens
• Antiviral and supportive treatment for cases
• Monitoring of contacts
• Vaccination of high-risk groups
• Infection prevention and control measures:
– Prevent nosocomial infections
– Personal Protective Equipment
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 121
Animal influenza viruses have
occasionally infected humans
(Avian, swine and other zoonotic
influenza viruses)
• Wild aquatic birds are the reservoir for
influenza A viruses. The emergence of a
new and very different influenza A virus
with the ability infect people and have
sustained human-to-human transmission,
can cause an influenza pandemic.
• Humans can be infected with Avian, swine
and other zoonotic influenza viruses.
• Avian influenza is a disease of domestic
and wild birds with severe consequences
for the poultry sector when outbreaks of
disease occur. Domesticated populations
(poultry: chickens, ducks, turkeys)
can become infected by contact with
wild birds. Avian influenza viruses are
categorized as either low pathogenic
(LP) or highly pathogenic (HP) viruses,
depending on the severity of the disease
they cause in birds and poultry. These
two terms do not refer to the disease in
humans infected with these viruses.
• Avian influenza A viruses are distinct
from human influenza viruses and do not
easily transmit between humans. Human
infections are primarily acquired through
direct contact with infected animals or
contaminated environments, but do not
result in efficient transmission of these
viruses between people.
• Avian and other zoonotic influenza
infections in humans may cause disease
ranging from mild conjunctivitis to severe
pneumonia and even death.
Multisectoral coordination and
communication are essential parts
of any outbreak response
• The first occurrence of a poultry outbreak
of highly pathogenic Avian influenza in a
country often creates widespread concern
and can disrupt social and economic life.
Therefore, effective communication with
all stakeholders is an essential part of any
outbreak response.
• Strong coordination between sectors
(animals and human health) is needed
for surveillance, risk communications and
interventions monitoring.
1 2
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 122
Protect all individuals with
occupational or other risks of
exposure
• Protect people involved in specific, high-
risk tasks such as sampling sick birds,
culling and disposing of infected birds
and cleaning of contaminated premises.
• Provide appropriate personal protective
equipment and training on how to use it
properly.
• All persons involved in these tasks should
be registered and monitored closely by
local health authorities for seven days
following the last day of contact with
poultry or their environments.
• Symptomatic persons should be treated
according to WHO guidelines with
influenza-specific antivirals.
• If sufficient antivirals are available, antiviral
chemoprophylaxis can be considered
(recommendations for regimen of
antiviral prophylaxis can be found in the
WHO guidelines).
• Consideration should be given to the
immunization of persons with high
potential to be exposed to Avian influenza
using the seasonal influenza vaccine.
Eggs, poultry and poultry
products can be safely consumed,
provided these items are properly
cooked and properly handled
during food preparation
• Inform the public about ways to promote
safe food consumption. Promote
thorough cooking of poultry and poultry
products. Separate raw meat from
cooked or ready-to-eat foods. Keep clean
and wash your hands. Handle and store
meat properly.
• Live animal market hygiene and
biosecurity should be assessed and
improved where possible.
• National food safety authorities and
poultry producers should develop and
implement quality assurance schemes in
line with HACCP (Hazard Analysis Critical
Control Point) principles and steps.
• Carefully treat drinking water supplied
from open surface water to minimize any
potential risks. Be aware that properly
treated waste water seems to pose only
a small risk for humans. Be aware that in
some cases, recreational water might be
contaminated. And consider that faeces
from infected animals can be infectious.
3 4
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 123
To minimize exposure of the
public, encourage proper
personal hygiene and instruct
the public to seek medical help if
illness develops
• Minimize exposure of the public to
potentially infected birds and other
sources of contamination and encourage
proper personal hygiene, especially
frequent hand washing, and instruct
people to seek medical help if illness
develops.
• When Avian influenza viruses circulate in
an area, all the people who are exposed
to infected birds are at risk, especially
those who: keep live poultry in their
backyards or homes, or purchase live
poultry or birds at markets; slaughter, de-
feather, or butcher poultry handle and
prepare raw poultry for further cooking
and consumption; transport or sell live
poultry or carcasses; are involved in
culling / depopulating / disposing of
Increase surveillance for human
cases of Avian influenza
• Avian influenza is not easily transmitted
from infected animals to humans and
there has not been sustained human-to-
human transmission.
• However, it is important to ensure
suspected human cases are investigated
in order to give them the best possible
treatment; to identify other potential
human contacts in those cases and
monitor them for occurrence of illness;
and to identify if there is human-to-human
transmission of the virus.
• The most important goal for investigations
of human cases of infections with Avian
influenza viruses is to assess the extent of
potential human-to-human transmission,
especially in clusters of human cases and
contacts of confirmed cases.
• Enhanced surveillance should consider
the health care seeking behaviour of
the population and can include a range
of options such as active and passive
approaches that are health care and/or
community-based.
• Persons with exposure to Avian influenza
should monitor their health for the
duration of the known exposure period
plus an additional seven days. This
will facilitate early detection of illness
and timely commencement of antiviral
treatment and isolation precautions.
They should report any relevant health
problems to a health care facility.
5 6poultry work in the poultry industry, including farmers and veterinarians; have contact with poultry by-products (e.g. viscera, manure, feathers) or water
contaminated with these by-products
(e.g. waste water from a live bird market
or a slaughtering facility); or consume
raw poultry products.
• The general public should minimize
contact with chickens, ducks or other
birds and avoid areas where poultry are
housed, slaughtered or prepared. They
also should:
– Keep children away from birds and their
waste, including feathers and manure.
Children should neither collect eggs
nor assist with slaughtering or food
preparation;
– Report sick or unexpectedly dead poultry
to the authorities immediately;
– Comply with all official measures (e.g.
animal movement restrictions) that are
put in place;
– Do not slaughter and/or consume birds
that are showing signs of disease or that
have unexpectedly died.
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 124
7 8Collecting appropriate samples and rapid and precise characterization of virus isolates are essential for early detection and management
of patients
• Collection of appropriate specimens from
suspected human cases for identification
by a qualified laboratory, together with
rapid and precise characterization of
virus isolates at specialized reference
laboratories, are essential for early
detection of cases, proper management
of patients, and understanding the
epidemiology of the disease.
• In addition, appropriate specimen
collection is important for monitoring the
development of resistance to antivirals,
producing effective vaccines, and
evaluating laboratory methods.
• Ensure that specimen collection materials
are available and collection of specimens
is done safely, correctly and in a timely
manner.
• Promote virus/sample sharing with WHO-
recognized laboratories.
Health care facilities need to be
ready to manage patients with
Avian influenza virus infections
• Implement early infection control
precautions to prevent nosocomial
(originating in a hospital) spread of the
disease.
• Manage cases properly to prevent
severe illness and death. Administer
neuraminidase inhibitors (oseltamivir,
zanamivir) treatment as the primary
choice of antiviral treatment, using the
standard regimen for seasonal influenza
virus infection, as soon as possible (ideally,
within 48 hours following symptom onset)
to maximize therapeutic benefits. Monitor
patients and viruses for indications of
antiviral resistance.
• If there is an insufficient in-country supply
of neuraminidase inhibitors, WHO
can provide it from its strategic global
stockpile.
• Report laboratory-confirmed cases to
WHO, under the International Health
Regulations (2005).
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 125
The animal health sector is
in charge of preventing and
controlling outbreaks of disease
in animals, including Avian
influenza
• Controlling the disease in the animal
source is critical to decrease risk to
humans.
• Reporting new and ongoing outbreaks in
animals is important for focusing human
health prevention action in the affected
areas and raising awareness among
professionals working with potentially
infected animals, as well as with the
public. The sharing of information on
human cases with the animal health
sector is equally important so that they
can target their response activities.
• The Food and Agriculture Organization
(FAO) of the United Nations (UN)
promotes food security and good
nutrition by providing access to
knowledge, policy advice and technical
Influenza A(H5N1) vaccines are
not widely available and the
decision to use them depends on
the risk of infection
• WHO recommends the targeted
administration of seasonal influenza
vaccine to health care workers in all
countries in order to protect their patients
from seasonal influenza infections. In
addition, WHO recommends vaccination
against seasonal influenza infection to
selected groups at increased risk of
exposure to Avian influenza viruses, as
one of several measures for reducing
opportunities for the simultaneous
infection of humans with Avian and
human influenza viruses.
• Vaccines for A(H5N1) virus for human
use have been developed based on
WHO-recommended candidate vaccine
viruses and licensed in several countries.
They are not widely available. Vaccination
with A(H5N1) vaccines for human use
are recommended for first responders
to human or animal A(H5N1) outbreaks,
and for health care workers who evaluate
or manage patients with suspected or
confirmed A(H5N1) virus infection in
designated referral facilities. Be aware
that WHO has no stockpile of A(H5N1)
vaccines.
9 10assistance to Member Countries. FAO publishes information and guidance on Avian influenza, provides direct technical assistance to countries and
works closely with many stakeholders.
• The World Organization for Animal
Health (OIE) sets international standards
for animal health and zoonoses, through
the ‘OIE Code’ and ‘OIE Manual’
and is responsible for collecting and
disseminating official animal disease
information from Member Countries.
It collaborates with National Veterinary
Services as well as with FAO at national,
regional and global levels to provide
technical assistance to countries (e.g.
laboratory support).
• National veterinary services, often
located within the Ministry of Agriculture,
are responsible for implementation of
national Avian influenza measures to
control and prevent the spread of the
disease in poultry.
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 126
Nigeria
Case: 1
Death: 1
Egypt
Cases: 359
Deaths: 120
Turkey
Cases: 12
Deaths: 4
Azerbaijan
Cases: 8
Deaths: 5
Djibouti
Cases: 1
Death: 0
Iraq
Cases: 3
Deaths: 2
Pakistan
Cases: 3
Death: 1
China
Cases: 53
Deaths: 31
Bangladesh
Cases: 8
Death: 1
Myanmar
Case: 1
Death: 0
Thailand
Cases: 25
Deaths: 17
Cambodia
Cases: 56
Deaths: 37
Lao People’s
Democratic Republic
Cases: 2
Deaths: 2
Indonesia
Cases: 200
Deaths: 168
Member State
Cases: cumulative number
Deaths: cumulative number
Areas with confirmed human cases for avian influenza
*All dates refer to onset of illness
Data as of 16 Feb 2018
Source: WHO/GIP
Canada
Case: 1
Death: 1
The designations employed and the presentation of the material in this publication do not imply the expression of any
opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory,
city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on
maps represent approximate border lines for which there may not yet be full agreement.
© World Health Organization 2016. All rights reserved.
Viet Nam
Cases: 127
Deaths: 64
Areas with confirmed human cases for avian influenza A(H5N1) reported to WHO, 2003–2018*
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities,
or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
* All dates refer to onset of illness Source: WHO/IHM, as of 16 February 2018
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 127
More information about Avian and other
zoonotic influenza:
• Avian and other zoonotic influenza WHO webpage:
http://www.who.int/influenza/human_animal_interface/en/
• Avian and other zoonotic influenza WHO fact sheet:
http://www.who.int/mediacentre/factsheets/avian_influenza/en/
• Avian and other zoonotic influenza WHO MOOC:
https://openwho.org/courses/avian-and-other-zoonotic-influenza-
introduction
• WHO Summary Of Key Information Practical To Countries
Experiencing Outbreaks Of A(H5N1) And Other Subtypes Of
Avian Influenza, First Edition July 2016
http://apps.who.int/iris/bitstream/10665/246251/1/WHO-OHE-PED-
GIP-EPI-2016.1-eng ?ua=1
• Case definitions for the four diseases requiring notification to
WHO in all circumstances under the IHR (2005)
http://www.who.int/ihr/survellance_response/case_definitions/en/
• Pandemic Influenza Preparedness Framework for sharing of
influenza virus and access to vaccines and other benefits
http://www.who.int/influenza/resources/pip_framework/en/
AVIAN AND OTHER ZOONOTIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 128
http://www.who.int/influenza/human_animal_interface/en/
http://www.who.int/mediacentre/factsheets/avian_influenza/en/
https://openwho.org/courses/avian-and-other-zoonotic-influenza-introduction
https://openwho.org/courses/avian-and-other-zoonotic-influenza-introduction
http://apps.who.int/iris/bitstream/10665/246251/1/WHO-OHE-PED-GIP-EPI-2016.1-eng ?ua=1
http://apps.who.int/iris/bitstream/10665/246251/1/WHO-OHE-PED-GIP-EPI-2016.1-eng ?ua=1
http://www.who.int/ihr/survellance_response/case_definitions/en/
http://www.who.int/influenza/resources/pip_framework/en/
1. Seasonal influenza is a respiratory disease transmitted through droplets
2. Influenza disease appears in seasonal epidemics and may be very disruptive
3. Influenza A and B viruses can cause epidemics
4. Influenza can be severe and fatal
5. Annual vaccination is the best way to prevent infection
6. Early treatment with antiviral drugs may reduce complications and deaths
7. Seasonal influenza is hard to differentiate clinically from other respiratory
diseases
8. Non-pharmaceutical measures prevent and reduce transmission
9. Monitoring, regular surveillance and sharing of data and viruses are important
10. Border controls do not reduce international spread
10 THINGS YOU SHOULD KNOW
Seasonal influenza
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 130
Seasonal influenza response tips
Coordinating responders
• WHO Global Influenza Surveillance and Response
System (GISRS) monitors influenza activity
globally and provides recommendations in areas
including laboratory diagnostics, vaccines, antiviral
susceptibility and risk assessment
Communicating risk
• Encourage health authorities to:
– Educate on prevention measures
– Communicate about vaccine effectiveness and
safety, especially for high-risk groups
• Promote hand and respiratory hygiene, and cough
etiquette
• Key messages:
– Seasonal influenza is highly contagious
– It spreads through droplets
– Annual vaccination is the best prevention
– High-risk groups such as the elderly, pregnant
women, infants and people with underlying
conditions are most at risk and should seek
medical care
Health Information
• Regular sharing of epidemiological
information and viruses helps to develop
policy to reduce the influenza burden
Health Interventions
• Annual vaccination
• Antiviral drugs
• Non-pharmaceutical interventions:
– Social distancing (e.g. school closure)
– Hygiene: cough etiquette, hand hygiene
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 131
Seasonal influenza is a respiratory
disease transmitted through
droplets
• Seasonal influenza (or “flu”) is an acute
respiratory disease.
• It is highly contagious: it spreads easily
from person to person through droplets
when an infected individual coughs or
sneezes. Sometimes, the transmission
can be airborne, especially when aerosol-
generating procedures are performed.
• It can also be transmitted by touching
contaminated surfaces or hands.
• Therefore, rapid transmission can occur
in crowded areas (e.g. schools or nursing
homes).
• Precautionary measures to limit transmis-
sion include: hand hygiene, respiratory
hygiene and cough etiquette, and drop-
let precautions in hospital settings.
Influenza disease appears in
Seasonal epidemics and may be
very disruptive
• In temperate climates, seasonal
epidemics occur mainly during winter.
The epidemics generally last from eight
to 10 weeks in temperate areas.
• In tropical regions, the pattern of influenza
epidemics is not always as regular. Some
countries have two peaks and some do
not have very regular epidemics.
• Epidemics can be very disruptive.
While the yearly burden is variable
and the average burden is currently
being evaluated, influenza does cause
considerable disease in all countries. In
addition to illness, epidemics can have a
high economic impact because of work
and school absenteeism, productivity
losses and overwhelmed hospital
capacity.
1 2
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 132
Influenza A and B viruses can
cause epidemics
• There are four types of influenza viruses
– types A, B, C and D – but only influenza
A and B cause epidemics. Influenza A can
infect many species (birds, humans, pigs,
horses, etc.). Influenza B and C infect
mainly humans. Influenza type C virus
is less frequent and usually causes mild
infections, thus presents less significant
public health implications.
• The A type of influenza viruses are further
classified in subtypes based on their
surface proteins. There are 18 different
haemagglutinin (H) types and 11 different
neuraminidase (N) types. Different
combinations are possible. Currently,
H3N2, H1N1pdm09 are circulating in
humans as Seasonal influenza A viruses.
Influenza can be severe and fatal
• Influenza can cause severe illness or death
in any person.
• A wide range of complications can be
caused by influenza virus infection of the
upper respiratory tract (nasal passages,
throat) and lower respiratory tract (lungs).
Sinus and ear infections are examples of
moderate complications from flu, while
pneumonia is a serious flu complication,
that people with chronic lung disease are
at higher risk of developing.
• Other possible serious complications
triggered by flu can include inflammation
of the heart (myocarditis), brain
(encephalitis) or muscle (myositis,
rhabdomyolysis) tissues, and multi-organ
failure (for example, respiratory and
kidney failure). Flu virus infection of the
respiratory tract can trigger an extreme
inflammatory response in the body and
can lead to sepsis.
• People at higher risk of developing
complications and severe Seasonal
influenza are:
a. Children younger than five years;
b. People older than 65 years;
c. People with chronic medical conditions
such as HIV/AIDS, asthma, heart and
lung diseases and diabetes.
• Flu also can make chronic medical
problems worse. For example, people
with asthma may experience asthma
attacks while they have the flu, and
people with chronic heart disease may
experience a worsening of this condition
triggered by flu.
3 4• Influenza viruses are in constant mutation. This is called antigenic drift and results in changes to the viruses which make people susceptible to catch flu every year,
as they do not have immunity against the
drifted viruses.
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 133
Annual vaccination is the best way
to prevent infection
• The most effective way to prevent the
disease is getting vaccinated every year.
• Vaccination is especially important for
pregnant women, people at high risk
of exposure, people at higher risk of
serious influenza complications, and for
people who live with, or care for, high-risk
individuals (health care workers).
• Ideally, people should get vaccinated just
before the influenza season begins for
the most effective coverage, although
getting vaccinated at any time during the
influenza season can still help prevent
infections.
• Influenza viruses evolve constantly,
and twice a year, WHO makes
recommendations to update the vaccine
compositions, based on the monitoring
done through the Global Influenza
Early treatment with antiviral
drugs may reduce complications
and deaths
• Antiviral drugs may reduce severe
complications and deaths. Ideally, they
need to be administered early in the
disease (within 48 hours of onset of
symptoms). They are especially important
for high-risk groups.
• They are two types of drugs:
neuraminidase inhibitors and adama-
tanes. Currently, the majority of
circulating influenza viruses are resistant
to the adamantanes, limiting their
effectiveness. Therefore, neuraminidase
inhibitors (oseltamivir and zanamivir,
peramivir and laninamivir) are the
recommended first-line treatment.
• People with Seasonal influenza should
always drink plenty of water, rest and
not go to work, in order to reduce
transmission.
5 6Surveillance and Response System (GISRS). This maximises the effectiveness of the vaccines, as circulating viruses need to be well-matched with the viruses
contained in the vaccines.
• A number of inactivated influenza
vaccines and recombinant influenza
vaccines are available in injectable form.
Live attenuated influenza vaccine is
available as a nasal spray.
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 134
7 Seasonal influenza is hard to differentiate clinically from other respiratory diseases
• People with Seasonal influenza usually
show non-specific symptoms. They
include: sudden onset of fever, cough
(usually dry), headache, muscle and joint
pain, fatigue, and a runny nose.
• The cough can be severe and can last
two or more weeks. Most people recover
within a week without requiring medical
attention.
• Incubation period is usually two days but
may be from one to five days.
• An infected person may be infectious
from one to two days before and until four
to five days after the onset of symptoms
(children may be infectious for longer).
• Laboratory diagnosis is critical to
differentiate Seasonal influenza from
other respiratory diseases:
– The most appropriate specimens for
the diagnosis of influenza are upper
respiratory tract specimens. Samples
should be taken from the deep nostrils
(nasal swab), throat (oropharyngeal swab)
and nasopharynx (nasopharyngeal swab).
Nasopharyngeal aspirate and bronchial
aspirate are also useful;
– The Reverse Transcription Polymerase
Chain Reaction (RT-PCR) is the preferred
technique for diagnosis;
– In addition to RT-PCR, other laboratory
techniques are available for the detection,
identification and characterization of
influenza virus including virus isolation
in cell culture and the identification of
viral antigens (fluorescent antibodies, FA,
test or Enzyme-Linked Immunosorbent
Assay, ELISA). Single serum is not ideal for
diagnosis of an acute infection.
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 135
Non-pharmaceutical measures
prevent and reduce transmission
• The implementation of non-
pharmaceutical measures helps to
prevent and slow transmission and control
epidemics.
• Before an epidemic, to reduce the
potential disruptive effects of Seasonal
influenza, it is critical that:
– There is effective health planning in place
so health education and immunization for
at-risk patients, their close contacts and
health care workers are implemented;
– Increased demand for medical care and
possible absenteeism of health care
workers during the epidemic period are
anticipated.
• During an epidemic, to reduce
transmission:
– Health education should continue;
– Hand hygiene, respiratory hygiene and
cough hygiene (e.g. covering mouth and
nose with a tissue when coughing and
then throwing it out and washing hands)
should be strictly observed by all;
– Personal protective equipment in health
care settings (masks) should be used when
in contact with people with Seasonal
influenza (the sick are wearing the mask);
– Social distancing may help. It includes
isolation of patients, staying at home when
sick, and school closure. School closures
have the greatest benefit when applied
early in the course of the outbreak. The
benefit has to be weighed against the cost
of disruption;
8 – Risk communication and community engagement should be implemented so populations comply with recommended public health measures (especially
needed to implement vaccination
recommendations).
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 136
Border controls do not reduce
international spread
• Border control measures such as entry
and exit screening and quarantining of
travellers crossing international borders
are generally not recommended, as
they have not been shown to reduce the
spread of influenza.
• Screening for detecting people with fever
might be inefficient as:
– Infected people may travel during the
incubation period, during which they will
not show symptoms but will be able to
transmit the disease;
– People may be using anti-pyretics and not
show fever.
• Implementing borders control measures
may also be very expensive and disruptive.
10Monitoring, regular surveillance and sharing of data and viruses are important
• Regular monitoring and surveillance are
important to anticipate severe epidemics
and plan health care services as well as to
be prepared for a pandemic.
• Since 1952, WHO has been coordinating
a network which now has more than 150
laboratories and experts to analyse the
spread of influenza and recommend the
vaccine composition.
• Sharing of viruses and data is also
important to be able to update the
vaccine and antiviral treatments.
9
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 137
More information about Seasonal influenza:
• Influenza WHO webpage:
http://www.who.int/influenza/en/
• Seasonal influenza WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs211/en/
• Seasonal influenza WHO MOOC:
https://openwho.org/courses/seasonal-influenza-introduction
• Patient care:
http://www.who.int/influenza/patient_care/en/
• Global Influenza Surveillance and Response System (GISRS):
http://www.who.int/influenza/gisrs_laboratory/en/
SEASONAL INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 138
http://www.who.int/influenza/en/
http://www.who.int/mediacentre/factsheets/fs211/en/
https://openwho.org/courses/seasonal-influenza-introduction
http://www.who.int/influenza/patient_care/en/
http://www.who.int/influenza/gisrs_laboratory/en/
1. Another influenza pandemic is inevitable but unpredictable
2. Pandemics require global concerted actions
3. A pandemic happens when an influenza virus emerges to which most people
have no immunity
4. Influenza pandemics may be mild or severe and can have a global impact
5. Vaccines will probably not be available in the first months
6. Risk groups and symptoms will be unknown until the pandemic occurs
7. Early treatment with antivirals and other medical support can reduce
complications and deaths
8. Non-pharmaceutical interventions may be the only effective initial measures
in most countries
9. Communicating risk is critical
10. Pandemic response capacity can be built through Seasonal influenza
10 THINGS YOU SHOULD KNOW
Pandemic influenza
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 140
Pandemic influenza response tips
Coordinating responders
• Multisectoral coordination
• Whole-of-society approach
Communicating risk
• Encourage health authorities to:
– Have a plan on the use of antivirals and vaccines
– Have a multisectoral risk communication plan in
place
– Communicate early and frequently about how to
protect from the disease
• Engage communities and individuals to practice
good hygiene
• Key messages:
– Pandemic influenza is caused by a new virus to
which no one has immunity and protection
– You can protect yourself by using proper cough
hygiene, effective hand washing and by distancing
yourself away from others if you fall sick
– Stay at home, drink plenty of fluids
– Seek medical advice if you have severe symptoms
or you already have other medical conditions that
may put you at further risk of severe disease
– Take the new vaccine when it became available if
you are asked to do so
Health Information
• Notify a case of novel influenza to WHO,
under the IHR (2005)
• Share viruses and information with the
WHO GISRS (Global Influenza Surveillance
and Response System)
• Consult WHO surveillance and severity
assessment guidance
Health Interventions
• Vaccines
• Antiviral treatment
• Non-pharmaceutical interventions (at
personal and community level): hygiene,
social distancing etc.
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 141
Another influenza pandemic is
inevitable but unpredictable
• It is not possible to predict when or where
the next Pandemic influenza will occur,
what subtype it will be, and what morbidity
and mortality impact it will have, but it is
certain that there will be one.
• History has shown pandemics occur at 10-
to 50-year intervals, with varying severity
and impact. During the 20th century, there
have been three influenza pandemics (in
1918, 1957 and 1968). Since 2000, there
has been one influenza pandemic, in
2009.
• Influenza viruses are very unstable and
constantly mutating. They undergo small
mutations (antigenic drift) and cause
Seasonal influenza epidemics and out-
of-season outbreaks. But a substantial
change (antigenic shift) can occur at
any time. It will result in a new virus
(different subtype) which may lead to a
pandemic. This antigenic shift can be the
re-assortment of human influenza viruses
with Avian or swine viruses, or significant
point mutations of Avian or swine viruses.
Pandemics require global
concerted actions
• Influenza pandemics are very disruptive
events that can cause severe social,
economic, and political stress.
Preparedness requires a whole-of-society
approach to ensure that when the next
pandemic strikes, the world will be able to
respond rapidly and effectively to reduce
morbidity and mortality. Not only the
health sector but also all other sectors,
individuals, families and communities,
have a role to play in mitigating the
effects of a pandemic.
1 2
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 142
A pandemic happens when an
influenza virus emerges to which
most people have no immunity
• There are three necessary factors for the
emergence of Pandemic influenza:
– A new influenza virus emerges and causes
illness in humans;
– This virus has the ability to cause sustained
human-to-human transmission;
– Human population has little or no
immunity to the virus.
• Because it is a new virus to which
people have not yet been exposed, the
population has no or little immunity and
the virus is able to spread quickly and
cause illness in people.
• A Pandemic influenza virus may arise
when:
– Genes from animal and human influenza
viruses mix together to create a human-
animal influenza re-assortant virus (genetic
re-assortment);
– Genes in an animal influenza virus change
allowing the virus to infect humans and
transmit easily among them (genetic
mutation).
• It is mandatory to notify a human influenza
case caused by a new subtype to WHO,
under the IHR (2005).
3
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 143
Vaccines will probably not be
available in the first months
• Vaccines are one of the most effective
ways to protect people during influenza
epidemics and pandemics.
• However, the availability of a pandemic
vaccine will be delayed by several months
because of the requirements for vaccine
formulation and production lead-time. It
is expected that it takes about 24 weeks
(almost six months) for a vaccine to be
available after the identification of the
pandemic virus.
• It is probable that the worldwide
production capacity will still be insufficient
and restrict global access to the vaccine,
at least during the first phase of the
pandemic. In the best case scenario, it
has been estimated (2015) that annual
production could reach about 6.2 billion
5
doses of vaccines , which is still insufficient
to cover the world population because
two doses of vaccines will probably be
needed to fully protect against the virus.
Furthermore, it is challenging to maintain
this production capacity.
• Vaccination should target the most at risk
of exposure (health care workers, people
living in crowded areas) and those most at
risk of complications.
• Antigen-sparing strategies can be used to
increase vaccine availability.
• Some countries are stockpiling pre-
pandemic vaccines against some Avian
influenza viruses.
Influenza pandemics may be mild
or severe and can have a global
impact
• Influenza pandemics have various levels
of severity and impact.
• It is hard to predict the characteristics,
including level of severity, of the next
pandemic.
• During an influenza pandemic, severity
assessments should be conducted
regularly at local, national and global
levels, to inform public health decisions
(vaccine production and use, antivirals
use, school closures, social distancing
strategies, etc.). Key elements to take into
consideration are: the transmissibility of
the disease, its seriousness (complications,
for which group of people, etc.), the
impact on the health sector (whether it is
overwhelmed or not).
4
Table 3. Characteristics of the past four influenza pandemics (26)
Pandemic year
of emergence
and common
name
Area of
origin
Influenza A virus sub –
type (type of animal
genetic introduction/
recombination event)
Estimated
reproductive
number
Estimated
case
fatality
Estimated
attributable
excess mortality
worldwide
Age groups
most
affected
1918
“Spanish flu”
Unclear H1N1 (unknown) 1.2–3.0 2–3% 20–50 million
Young
adults
1957–1958
“Asian flu”
Southern
China
H2N2 (avian) 1.5 <0.2% 1–4 million
All age
groups
1968–1969
“Hong Kong flu”
Southern
China
H3N2 (avian) 1.3–1.6 <0.2% 1–4 million
All age
groups
2009–2010
“influenza
A(H1N1) 2009”
North
America
H1N1 (swine)
1.1–1.8 0.02% 100 000–400 000
Children
and young
adults
Characteristics of the past four influenza pandemics
Source: Pandemics of the 20th–21st centuries. Stockholm, European Centre for Disease Prevention and Control.
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 144
7 Early treatment with antivirals and other medical support can reduce complications and deaths
• Antiviral drugs may reduce severe
complications and deaths. Ideally, they
need to be administered early in the
disease (within 48 hours of onset of
symptoms). They are especially important
for high-risk groups.
• During an influenza pandemic, antiviral
drugs are an important tool to prevent
the spread of the disease and severe
outcome and complications, as vaccines
will most likely not be available at an early
stage.
• Effectiveness of the drugs on the novel
pandemic virus must be monitored,
as some influenza viruses may be (or
become) resistant to them.
• Pharmaceutical interventions typically
encompass the application of antivirals
treatments and other drug treatment
(e.g. antibiotics to target complications of
influenza).
Risk groups and symptoms will
be unknown until the pandemic
occurs
• Although we start with the assumption that
the risk groups for infection and severe
outcome are the same as in Seasonal
influenza, there might be differences.
• Historical knowledge from the 1918 and
2009 pandemics indicates that healthy,
young adults can be disproportionately
and more severely affected.
• Pandemic influenza might present
differently from Seasonal influenza and
symptoms may be more severe and
complications more frequent.
- People with influenza will usually develop
the following symptoms: sudden onset
of fever, cough (usually dry), headache,
muscle and joint pain, fatigue, sore throat
and a runny nose;
- Complication can include pneumonia,
sepsis, and inflammation of the heart
(myocarditis), brain (encephalitis) or
muscle (myositis);
- The incubation period is usually two days
but may be from one to five days.
6
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 145
Non-pharmaceutical interventions
may be the only effective initial
measures in most countries
• Vaccination is the primary intervention to
prevent infection and severe outcomes
caused by influenza virus. However, at
the beginning of a pandemic, Pandemic
influenza vaccines, matching the new
virus, will most likely not be available.
• In addition to antiviral drugs administration
(which might also be short in supply),
non-pharmaceutical interventions (NPI)
should be put in place, at the early stage
of a pandemic, to slow transmission and
reduce its impact. NPI include (but are not
limited to):
- Social distancing: staying at home when
sick;
- Hygiene such as cough etiquette (covering
coughs and sneezes with a tissue), hand
washing and cleaning of touched surfaces
and objects;
- During severe pandemics, more extreme
measures can be implemented: using
facemasks when sick, schools closures,
decreasing the amount of contacts among
people.
• NPI will help to reduce the number
of people who are exposed and then
infected.
8
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 146
Pandemic response capacity can
be built through Seasonal influenza
• Pandemic influenza would require the
implementation of the same control
measures, on a larger scale: Infection
Prevention and Control and Hygiene;
Health Education; Vaccination; Early
treatment; Social distancing; Risk
communication and Community
engagement.
10Communicating risk is critical• Risk communication is particularly important in a rapidly evolving situation and when there is little known about an
epidemic, which will be the case at the
beginning of an influenza pandemic (novel
virus). Without effective communication,
the many unknowns give enough space
for rumors to develop.
• As the pandemic requires a whole-
of-society approach, individuals and
communities must be engaged, listened
to and see that their concerns are
addressed. People need to be informed
on how to protect themselves and stop
the spread of the disease.
• Strong risk communication must be built
before the emergency occurs.
9
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 147
Highlight: the PIP Framework
• The Pandemic influenza Preparedness Framework or “PIP Framework” is an
innovative public health instrument that seeks to better prepare the world to
respond to Pandemic influenza.
• It brings together Member States, industry, other stakeholders and WHO
to implement a global approach to Pandemic influenza preparedness and
response.
• The PIP Framework has two objectives which are to be pursued on equal
footing:
- To improve the sharing of influenza viruses with the potential to cause
a human pandemic;
- To establish more predictable, efficient, and equitable access to the
benefits that result from the sharing of such viruses, notably vaccines
and antiviral medicines.
• The Framework, developed by Member States, came into effect on 24 May
2011, unanimously adopted by the World Health Assembly.
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 148
More information about Pandemic influenza:
• Influenza WHO webpage:
http://www.who.int/influenza/en/
• Pandemic Influenza WHO MOOC:
https://openwho.org/courses/pandemic-influenza-introduction
• WHO Global Epidemiological Surveillance Standards for Influenza
http://www.who.int/influenza/resources/documents/influenza_
surveillance_manual/en/
• WHO surveillance case definitions for influenza-like illness (ILI) and
severe acute respiratory infections (SARI)
http://www.who.int/influenza/surveillance_monitoring/ili_sari_
surveillance_case_definition/en/
• Pandemic Influenza Risk Management, WHO interim guidance, 2013
http://www.who.int/influenza/preparedness/pandemic/influenza_risk_
management/en/
• WHO Checklist for Pandemic Influenza Risk and Impact Management
http://www.who.int/influenza/preparedness/pandemic/en/
• WHO Pandemic Influenza Severity Assessment (PISA)
http://www.who.int/influenza/surveillance_monitoring/pisa/guidance/en/
• Pandemic Influenza Preparedness Framework:
http://www.who.int/influenza/pip/en/
PANDEMIC INFLUENZAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 149
http://www.who.int/influenza/en/
https://openwho.org/courses/pandemic-influenza-introduction
http://www.who.int/influenza/resources/documents/influenza_surveillance_manual/en/
http://www.who.int/influenza/resources/documents/influenza_surveillance_manual/en/
http://www.who.int/influenza/surveillance_monitoring/ili_sari_surveillance_case_definition/en/
http://www.who.int/influenza/surveillance_monitoring/ili_sari_surveillance_case_definition/en/
http://www.who.int/influenza/preparedness/pandemic/influenza_risk_management/en/
http://www.who.int/influenza/preparedness/pandemic/influenza_risk_management/en/
http://www.who.int/influenza/preparedness/pandemic/en/
http://www.who.int/influenza/surveillance_monitoring/pisa/guidance/en/
http://www.who.int/influenza/pip/en/
1. MERS (Middle East respiratory syndrome) is a respiratory disease caused by a
coronavirus whose reservoir is dromedary camels
2. Humans can be infected through direct or indirect contact with infected dromedary
camels and potentially from camel products
3. The impact ranges from asymptomatic infection to severe pneumonia and death
4. People with weakened immune systems and chronic diseases are at high risk of
severe disease
5. Early supportive clinical management reduces mortality
6. Infection prevention and control measures are critical to prevent the spread of
human-to-human transmission
7. Laboratory diagnostics are available for MERS
8. Thorough case and outbreak investigation and other measures will help to
prevent spread
9. Research is ongoing for treatment in humans and vaccines for camels and humans
10. MERS coronavirus (MERS-CoV) infection is a notifiable disease under the
International Health Regulations (2005)
10 THINGS YOU SHOULD KNOW
Middle East respiratory syndrome
(MERS)
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 150
MERS response tips
Coordinating responders
• Coordination between animal and human health
sectors is essential for:
- Surveillance
- Risk assessment
- Investigation
- Mitigation
Communicating risk
• Encourage health authorities to:
- Identify and target at-risk populations with
information on how to protect themselves and
prevent further transmission
- Have a multi-sectoral risk communication plan
and to activate it
• Key messages:
- Precautions for people at high risk of developing
severe disease include: practicing good personal
hygiene, avoiding contact with camels; not
drinking raw camel milk or camel urine; and not
eating camel meat that has not been thoroughly
cooked
- Enhance infection prevention and control in
health care facilities
- Seek health care early on and follow medical
advice
Health Information
• Report cases to WHO, under the IHR (2005)
• WHO regularly conducts global risk
assessments for MERS-CoV, these can be
found here: http://www.who.int/csr/disease/
coronavirus_infections/archive_updates/en/
• WHO has developed standard case
reporting forms for data analysis and to
guide actions
Health Interventions
• Active case finding and contact tracing
• Supportive case management
• Infection prevention and control
measures to prevent health care workers
infections
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 151
http://www.who.int/csr/disease/coronavirus_infections/archive_updates/en/
http://www.who.int/csr/disease/coronavirus_infections/archive_updates/en/
MERS (Middle East respiratory
syndrome) is a respiratory disease
caused by a coronavirus whose
reservoir is dromedary camels
• Middle East respiratory syndrome (MERS)
is a viral respiratory illness caused by
a coronavirus (Middle East respiratory
syndrome coronavirus, or MERS-CoV)
that was first identified in humans in the
Kingdom of Saudi Arabia in 2012.
• Coronaviruses are a large family of viruses
that can cause diseases in humans,
ranging from the common cold to Severe
Acute Respiratory Syndrome (SARS).
• Dromedary camels (one-humped camels)
are the reservoir host for MERS-CoV.
• Since 2012, MERS has been reported
in 27 countries. Approximately 80% of
human cases have been reported by
the Kingdom of Saudi Arabia. Cases
identified outside the Middle East are
people who were infected in the Middle
East and then travelled elsewhere. On
rare occasions, small outbreaks have
occurred in areas outside the Middle
East.
1 2 Humans can be infected through direct or indirect contact with infected dromedary camels and potentially from camel products
• MERS-CoV is a zoonotic virus: it is
transmitted between animal and people.
• Dromedary camels are the main source of
infection in humans: humans are infected
through direct or indirect contact with
infected dromedary camels.
• At-risk groups of infection, because
they are in contact with dromedary
camels, include: camel farm workers;
slaughterhouse workers; market
workers; veterinarians; anyone handling
dromedary camels or dromedary camels’
products (e.g. cooking). Health care
workers caring for MERS patients without
adequate personal protective equipment
are also at high risk of infection.
• It is recommended that these high-risk
groups practice good personal hygiene,
including frequent hand hygiene. Hands
should be washed with soap and water
and/or alcohol gel after every contact
with an animal. Workers should wear facial
protection where feasible; and protective
clothing, which should be removed after
work (followed by hand hygiene) and
washed daily.
• The consumption of raw or undercooked
animal products, including milk and meat,
carries a potential risk. Animal products
that are processed appropriately through
cooking or pasteurization are safe for
consumption. Properly cooked products
should also be handled with care to
avoid cross contamination with uncooked
foods.
• As a general precaution, anyone visiting
farms, markets, barns, or other places
where dromedary camels and other
animals are present should practice
general hygiene measures, including
regular hand washing before and after
touching animals, and should avoid
contact with sick animals. People should
avoid unprotected direct contact with any
animal that has been confirmed positive
for MERS-CoV infection.
• There is no evidence of sustained human-
to-human transmission: the virus does
not pass easily from person to person
unless there is close and unprotected
contact. There has been limited human-
to-human transmission among family
members. However, human-to-human
transmission has been repeatedly shown
to be amplified in health care settings,
especially when infection prevention and
control measures are inadequate.
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 152
The impact ranges from
asymptomatic infection to severe
pneumonia and death
• The clinical spectrum of MERS-CoV
infection ranges from no symptoms
(asymptomatic) or mild respiratory
symptoms to severe acute respiratory
disease and death.
• MERS symptoms are non-specific
and can include headache, tiredness,
feverishness, mild cough, sore throat, and
runny nose. Some patients may present
3 with gastrointestinal symptoms such as mild diarrhoea. Pneumonia is a common finding, but not always present. • Severe illness can cause respiratory failure
that requires mechanical ventilation and
support in an intensive care unit.
• The average incubation period is
estimated to be approximately five days
but may range from two to 14 days.
• It is not always easy to detect cases early
because symptoms are non-specific and
this may lead to spread of the disease in
health care settings.
People with weakened immune
systems and chronic diseases are
at high risk of severe disease
• The virus causes a more severe disease
in older people, people with weakened
immune systems, and those with chronic
diseases such as renal disease, cancer,
chronic lung disease, blood disease
and diabetes. These people are also at
increased risk of infection.
• People at high risk of developing
severe disease (people with underlying
conditions) should avoid contact with
camels.
4
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 153
Early supportive clinical
management reduces mortality
• Supportive therapies prevent
complications and increase chances
of survival. They include: oxygen,
antimicrobials, specific treatment for
underlying conditions such as diabetes,
kidney failure, etc.
• Treatment is based on a person’s clinical
condition.
• There is no specific treatment or vaccine
available for MERS currently.
5 Infection prevention and control measures are critical to prevent the spread of human-to-human
transmission
• Standard precautions should be routinely
applied to all patients. They include
hand hygiene, respiratory hygiene, use
of Personal Protective Equipment (PPE),
safe waste management, cleaning and
disinfection of equipment and cleaning of
the environment.
• Triage policies should be implemented
to rapidly detect potential MERS-CoV
cases and all cases with acute respiratory
symptoms.
• Triage, waiting areas and patient rooms
should be adequately ventilated.
• Health care workers involved in aerosol-
generating procedures are at greater risk
of infection.
• Droplet precautions should be added to
the standard precautions when providing
care to any patient with symptoms of acute
6 respiratory infection (ARI). They include the use of a mask and eye-protection when
working within 1-2
metres of the patient
and patient isolation
(organization of the
space and processes
to allow separation
of at least 1-2 metres
between patient
with ARI and other
individuals not wearing PPE).
• When performing an aerosol-generating
procedure in patient with ARI, airborne
precautions should be applied. They
include wearing an appropriate PPE,
appropriate ventilation, avoiding
unnecessary individuals in the room.
• Health care workers should be educated
and trained in infection prevention and
control and should refresh these skills
regularly.
• Hospital cleaning staff should also be
informed of and trained to take proper
precautions when cleaning rooms of
MERS patients.
Infection prevention and control when caring for patients with MERS or
suspected MERS
All patients
Patients with ARI
When performing aerosol-generating
procedures in patients with ARI
Standard precautions, triage procedures
Droplet precautions
Airborne precautions
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 154
7 Laboratory diagnostics are available for MERS• Laboratory confirmation of MERS-CoV
infection requires good samples, high
levels of biosafety and good laboratory
capacities.
Testing:
• A case of MERS-CoV infection may be
laboratory confirmed by detection of
viral nucleic acid or by using serology to
demonstrate antibodies.
• The presence of viral nucleic acid can be
confirmed by either:
- A positive real-time Reverse Transcription
Polymerase Chain Reaction (RT-PCR) on at
least two specific genomic targets;
o A case with a positive RT-PCR result for
a single specific target without further
testing but with a history of potential
exposure and consistent clinical signs is
considered a probable case.
- Or a single positive target with sequencing.
• If initial testing is negative in patient who
is strongly suspected to have MERS-
CoV infection, the patient should be
resampled and include lower respiratory
specimens. To confirm clearance of
the virus, respiratory samples should
continue to be collected until there are
two consecutive negative results at least
24 hours apart in clinically recovered
persons.
Samples:
• It is strongly recommended that lower
respiratory specimens such as sputum,
endotracheal aspirate or broncho-
alveolar lavage are collected for MERS-
CoV when possible.
• If not possible, upper respiratory tract
specimens such as nasopharyngeal
aspirate or combined nasopharyngeal
and oropharyngeal swab should be
collected.
Biosafety:
• Molecular testing for MERS-CoV should
be conducted under Biosafety level 2
(BSL-2) conditions. Virus culture requires
BSL-3 biosafety conditions.
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 155
Thorough case and outbreak
investigation and other measures
will help to prevent spread
• Each human case of MERS requires
thorough investigation to understand
the source of infection and the potential
human-to-human spread amongst
contacts.
• Thorough case investigation includes
the investigation of potential human,
animal, and/or environmental sources of
exposure(s) and risk factors for infection.
Patients (confirmed and suspected
cases) and family members should be
interviewed to collect: Essential basic
information; Exposure information and
travel history; and Clinical information.
WHO has generated case report forms
identifying the minimum amount of
information that should be collected for
each case of MERS.
8 • Once a case has been confirmed, to prevent further spread of the disease, active case finding should be implemented in the community and in health care settings:
- All close contacts should be identified and
monitored for the presence of symptoms
for 14 days. A contact is any person who
has cared for or lived with a confirmed
case, or had unprotected contact with
that person’s respiratory secretions, body
fluids and/or excretions when that person
was symptomatic;
- Contacts should be placed under active
surveillance for 14 days after last exposure
to the confirmed or probable case with
monitoring for respiratory symptoms (a
health care worker should visit or call them
on a daily basis);
- Any contacts who develop symptoms
should be isolated in a health care facility
and tested for MERS-CoV infection;
- Health care workers with direct contact
with a MERS patient should be closely
monitored.
• Health Education, including basic
information about MERS, how to prevent
against MERS-CoV infection for different
groups (e.g. contacts of confirmed
patients, health care workers caring for
MERS patients, occupational groups
who work with dromedary camels, and
populations at higher risk of severe
disease) and what to do should an
individual suspect they have MERS-CoV
infection, should be provided by trained
individuals.
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 156
MERS-CoV infection is a notifiable
disease under the International
Health Regulations (2005)
• Probable and confirmed cases must be
reported within 24 hours of classification,
with information about their exposure,
testing and clinical course. MERS case
definitions for reporting to WHO can
be found here: http://www.who.int/csr/
disease/coronavirus_infections/case_
definition/en/
10Research is ongoing for treatment in humans and vaccines for camels and humans
• WHO has developed a MERS-CoV
research agenda to address key
unknowns for this virus focusing on five
major areas of research: i) virus origin
and characteristics, ii) epidemiology and
transmission, iii) clinical management
and infection prevention and control
measures, iv) product development
and implementation, and v) impact of
interventions and operational research.
• WHO’s Research and Development
Blueprint is working to accelerate the
development of medical interventions for
MERS.
- Currently, there are no licensed treatments
for MERS;
- Currently, a dozen vaccine candidates for
both humans and dromedary camels are
in preclinical development.
9
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 157
http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/
http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/
http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/
Data as 12 December 2017
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or
area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2018.
Confirmed global cases of MERS-CoV 2012 – 2017
Thailand
Algeria
Austria
France
Germany
Greece The Islamic
Republic
of Iran
Jordan Republic
of KoreaKuwait
Lebanon
Oman
Malaysia
Netherlands
Qatar
Philippines
United Arab
Emirates
Tunisia
Turkey
United Kingdom of
Great Britain and
Northern Ireland
United States
of America
Saudi
Arabia
Yemen
Egypt
Italy
China
2,119Total number of reported cases:
Number of cases reported
1 - 5
6 - 20
21 - 150
151 - 500
501 - 1000
1000+
2012 2013 20152014
Confirmed global cases or MERS-CoV by month reported
Saudi Arabia Rest of the World
Date reported to WHO
03 05 07 09 11 01 03 05 07 09 11 01 03 05 07 09 11 01 03 05 07 09 11 01 03 05 07 09 11 01 03 05 07 09 11
C
a
se
C
o
u
n
t
240
220
200
180
160
140
120
100
80
60
40
20
0
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on
the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or
concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for
which there may not yet be full agreement.
Coordinate System: GCS WGS 1984
Datum: WGS 1984
Units: Degree
Map Scale (A3):
1 cm = 11,092 km
1:1,109,175,783 Data Source: World Health Organization
© WHO 2017. All rights reserved.
Map date:12/12/2017
Date reported to WHO
20172015201420132012 2016
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 158
More information about MERS:
• MERS-CoV WHO website:
http://www.who.int/emergencies/mers-cov/en/
• MERS WHO MOOC:
https://openwho.org/courses/pandemic-epidemic-diseases
• Latest global risk assessment for MERS-CoV:
http://www.who.int/csr/disease/coronavirus_infections/archive_updates/en/
• Guidance on laboratory testing:
http://www.who.int/csr/disease/coronavirus_infections/mers-laboratory-
testing/en/
• Surveillance guidance including recommendations on criteria for case
investigation and testing:
http://www.who.int/csr/disease/coronavirus_infections/surveillance-
human-infection-mers/en/
• Guidance on the investigation of cases of MERS-CoV infection:
http://www.who.int/csr/disease/coronavirus_infections/mers-
investigation-cases/en/
• WHO case investigation form for MERS-CoV:
http://www.who.int/csr/disease/coronavirus_infections/MERS_case_
investigation_questionnaire ?ua=1
• MERS case definitions for reporting to WHO:
http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/
• Guidance on case management and Infection Prevention and Control:
http://www.who.int/csr/disease/coronavirus_infections/technical-
guidance-infection/en/
• Information about MERS-CoV Research and Development:
http://www.who.int/blueprint/priority-diseases/key-action/mers-cov/en/
MIDDLE EAST RESPIRATORY SYNDROME (MERS)MANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 159
http://www.who.int/emergencies/mers-cov/en/
https://openwho.org/courses/pandemic-epidemic-diseases
http://www.who.int/csr/disease/coronavirus_infections/archive_updates/en/
http://www.who.int/csr/disease/coronavirus_infections/mers-laboratory-testing/en/
http://www.who.int/csr/disease/coronavirus_infections/mers-laboratory-testing/en/
http://www.who.int/csr/disease/coronavirus_infections/surveillance-human-infection-mers/en/
http://www.who.int/csr/disease/coronavirus_infections/surveillance-human-infection-mers/en/
http://www.who.int/csr/disease/coronavirus_infections/mers-investigation-cases/en/
http://www.who.int/csr/disease/coronavirus_infections/mers-investigation-cases/en/
http://www.who.int/csr/disease/coronavirus_infections/MERS_case_investigation_questionnaire ?ua=1
http://www.who.int/csr/disease/coronavirus_infections/MERS_case_investigation_questionnaire ?ua=1
http://www.who.int/csr/disease/coronavirus_infections/case_definition/en/
http://www.who.int/csr/disease/coronavirus_infections/technical-guidance-infection/en/
http://www.who.int/csr/disease/coronavirus_infections/technical-guidance-infection/en/
http://www.who.int/blueprint/priority-diseases/key-action/mers-cov/en/
1. Cholera is closely linked to inadequate access to clean water and sanitation
2. Cholera is transmitted by faecally-contaminated water and food
3. Cholera outbreaks can be explosive
4. Rapid detection of suspected cases and laboratory confirmation are essential
5. People with Cholera experience acute watery diarrhoea with no fever
6. Severe forms of Cholera can kill within hours: early rehydration is the cornerstone
of treatment
7. Oral Cholera Vaccines are safe and should be used with other prevention and
control strategies
8. Populations at risk should be provided with safe water and basic sanitation
9. Mapping the origin of cases is critical to orient control activities
10. WHO can provide countries with Cholera kits
10 THINGS YOU SHOULD KNOW
Cholera
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 160
Cholera response tips
Coordinating responders
• Intersectoral coordination at national and local level is critical to
outbreak response
• Epidemiological data on the origin of cases should drive the
multisectoral response
• Cholera kits are available for preparedness and immediate outbreak
response
• Contact WHO/ICG for emergency Oral Cholera Vaccines
• Technical support is available through the Global Task Force on
Cholera Control (GTFCC)
Communicating risk
• Encourage health authorities to:
- Engage communities to enhance hygiene and food safety practices
- Set up treatment facilities and let the public know how to
access them
- Make sure Oral Rehydration Salts are available
• Key messages:
- Cholera is transmitted through contaminated water or food
- Cholera can rapidly lead to severe dehydration and death if left
untreated: seek treatment quickly
- Wash hands at critical moments
- Mild cases can be treated at home with oral rehydration
- Take the Cholera vaccine if advised, when there is a Cholera outbreak
or its threat, in your area
Health Information
• Investigate the source of the outbreak
• Once Vibrio Cholerae has been confirmed
by culture or PCR, the WHO clinical case
definition is sufficient to identify cases.
Periodic sampling and testing on suspected
cases should be carried out throughout the
epidemic to monitor antimicrobial sensitivity
Health Interventions
• Provide populations with safe water and
sanitation
• Treat early (rehydration):
- Oral rehydration points (ORPs) in the
community facilitate early access to
treatment
- Cholera treatment centres (CTCs) provide
24-hour care for patients with more severe
forms of Cholera
• Infection prevention and control practices
must be implemented in all health
facilities receiving Cholera patients
• Vaccination with Oral Cholera Vaccines in
humanitarian emergencies and to prevent
further spread of epidemics
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 161
Major Cholera Outbreaks in 2017 - 2018
Source: WHO, 2018
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
Mozambique
(0.3%)
Nigeria (1.3%)
Sudan (2.2%)
Angola (2%)
Somalia (1.3%)
Democratic
Republic of the
Congo (2.2%)
Zambia (1.8%)
Uganda (2.1%)
Malawi
(3.3%)
Ethiopia
(1.8%)
Zimbabwe
(5.1%)
South
Sudan
(2.1%)
Yemen
(0.2%)
Kenya (2%)
United Republic
of Tanzania (2%)
6,223
7,209
36,811
713
6,613
62,154
63,829
5,695
5,248
21,439
2,108
1,090,280
904
47,868
137
Map date: 01 May 2018
Not Applicable
Ethiopia and Sudan: Reported as AWD
Number of Cases Case Fatality Rate
(CFR)*
> 100,000
Haiti (1.2%)
818,000
< 1000
1000 to 5000
5000 to 20,000
20,000 to 100,000
0 100 200
km
0 750 1,500
km
< 1%
>1% to 2%
>2% to 3%
>3% to 4%
>4% to 5.1%
Period of Report
*CFR Labelled for
Each Country
Angola: Dec 2017-March 2018
Democratic Republic of the Congo:
Jan 2017 – April 2018
Ethiopia: Jan 2017 – April 2018
Haiti: Oct 2010 – Feb 2018
Kenya: Jan 2017-mid April 2018
Malawi: Nov 2017 – April 2018
Mozambique: Jan 2017 – 8 April 2018
Nigeria: Aug 2017 – April 2018
Somalia: March 2017 – March 2018
South Sudan: Aug 2016 – Dec 2017
Sudan: Aug 2016 – Feb 2018
United Republic of Tanzania:
Jan 2017- mid April 2018
Uganda: Feb 2018 – April 2018
Yemen: April 2017 – April 2018
Zambia: Oct 2017 – April 2018
Zimbabwe: Jan – April 2018
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 162
1 2 Cholera is transmitted by faecally-contaminated water and food• A person can become infected by drinking
water or eating food contaminated by the
bacterium Vibrio Cholerae.
• Bacteria present in the faeces of an
infected person are the main source of
contamination.
• Food may be contaminated by soiled
hands during preparation, or while eating
or by some irrigation practices.
• During funeral ceremonies, transmission
may occur through consumption of
food and beverages contaminated by
someone who touched the corpse of the
deceased and also prepared the food
without adequately washing their hands,
or by funeral attendees touching the
corpse.
• Beverages prepared with contaminated
water and sold by street vendors are
vehicles of Cholera transmission, as well
as vegetables and fruits “freshened”
with contaminated water and raw or
undercooked seafood.
• The bacterium can persist in water for
long periods and multiply in moist left-
over food.
Cholera is closely linked to
inadequate access to clean water
and sanitation
• The long-term solution for Cholera
control lies in economic development
and universal access to safe drinking
water and adequate sanitation. These
measures prevent both epidemic and
endemic Cholera as well as other faeco-
orally transmitted and water-borne
diseases. They may require substantial
long-term investments.
• Cholera is closely linked to poor
environmental conditions. The absence
or shortage of safe water and of proper
sanitation are the main contributors to the
spread of the disease. Typical at-risk areas
are peri-urban slums, with precarious
basic infrastructure, as well as internally
displaced or refugee camps.
• Actions to reduce the transmission of
Cholera include:
– The implementation of adapted long-
term sustainable WASH (Water Sanitation
and Hygiene) solutions to ensure use of
safe water, basic sanitation
and good hygiene practices
to populations most at risk of
Cholera:
o Interventions at the household
level (water filtration, chemical
or solar disinfection of
water, safe water storage,
the construction of systems
for safe sewage disposal,
including latrines);
o Adoption of basic hygiene
practices;
o Access to safe water and
sanitation in public areas such as health
facilities and schools.
– Rapid access to treatment;
– Implementation of adapted infection
control practices in treatment structures;
– Vaccination.
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 163
Cholera outbreaks can be
explosive
• The incubation period is very short. It
ranges from two hours to five days, usually
two to three days.
• This leads to explosive epidemics as
the numbers of cases can rise extremely
quickly.
• Early detection and treatment of cases
and rapid initiation of control activities
are critical.
• Asymptomatic carriers can transmit the
infection. As long as stools are positive,
infected people can transmit the disease.
Even among asymptomatic carriers, the
pathogens stay in their faeces for up
to 14 days and are shed back into the
environment, possibly infecting other
individuals.
3 Rapid detection of suspected cases and laboratory confirmation are essential
• When an outbreak is suspected, a
multidisciplinary team should be sent to
the field in order to confirm the outbreak
and to take the first measures to control
the spread of the disease. These teams
should carry sampling materials, rapid
diagnostic tests, the means to make clean
water and ORS (Oral Rehydration Salts)
at a minimum. More medical materials
should be carried if a treatment facility is
visited.
• Rapid diagnostic tests (RDTs) should be
used to reinforce suspicion of Cholera.
This allows quick testing without the
need for a laboratory and is frequently
used to increase suspicion during
outbreak investigations. The sensitivity
and specificity of Cholera RDTs are
not sufficient for them to be used as
individual diagnostic tests. Send the RDT
positive stool samples to the laboratory
for confirmation.
• Cholera is confirmed by identifying
V. Cholerae in stool samples from affected
patients using:
– Culture for confirmation and antibiotic
sensitivity testing;
– PCR (Polymerase Chain Reaction) for
confirmation.
• Laboratory confirmation is essential to
confirm that this is a Cholera outbreak.
Once an outbreak is confirmed, a clinical
diagnosis using WHO standard case
definition is sufficient.
4 • Laboratory confirmation should be carried out in each new area (district or region) reporting cases to confirm extension of the outbreak.
• Sporadic sampling and testing on
suspected cases should be performed
throughout an outbreak to monitor the
outbreak, determine antibiotic sensitivity,
and monitor the strain.
• An outbreak is considered over when all
samples from all suspected patients test
negative by RDT, culture or PCR for a
period of two weeks.
• Do not wait for laboratory confirmation
before starting control activities. Access to
clean water and basic sanitation, hygiene
promotion and access to treatment are
important public health interventions
even if the outbreak is not confirmed.
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 164
People with Cholera experience
acute watery diarrhoea with no
fever
• Most people infected with Cholera
(approximately 80%) do not develop
any symptoms although the bacteria are
present in their faeces for up to 14 days
after infection.
• Among people developing symptoms,
approximately 80% present with mild to
moderate watery diarrhoea resulting in no
or only minor signs of dehydration. The
remaining 20% rapidly develop profuse
watery diarrhoea that can lead to severe
dehydration and to death if not treated.
• Other signs and symptoms may include:
– Profuse vomiting;
– Abdominal or muscle cramps;
– Hypoglycemia;
– Hypokalaemia.
• There is a high risk of fetal loss in pregnant
woman with Cholera.
• Fever is not a symptom of Cholera, but
may be a result of co-morbidity in patients
with Cholera.
5 Severe forms of Cholera can kill within hours: early rehydration is the cornerstone of treatment
• The most important treatment is
rehydration, which consists of prompt
replacement of the fluid and salts loss
through severe diarrhoea and vomiting.
Early rehydration can save the lives of
nearly all Cholera patients. With early and
proper treatment, the case fatality rate
should remain below 1%.
• Good assessment of the state of
dehydration is key to appropriate
treatment (see the assessment tool in
the manual “First steps for managing an
outbreak of acute diarrhoea”).
• Patients with no signs or some signs
of dehydration (approximately 80% of
patients), both adults and children, can be
rehydrated quickly and easily by following
standard protocols for treatment with Oral
Rehydration Solution (ORS). ORS should
be given early at home, by volunteers
and family members, to avert delays in
rehydration and death.
• Patients who become severely dehydrated
need to receive fluids intravenously
(Ringer’s Lactate solution).
• Continued breastfeeding of infants and
young children is encouraged.
• Zinc is also an important adjunctive
therapy for children under five years, which
also reduces the duration of diarrhoea
and may prevent future episodes of other
causes on acute watery diarrhoea.
6
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 165
7 Oral Cholera Vaccines are safe and should be used with other prevention and control strategies
• There are three Oral Cholera Vaccines
(OCV):
– Shanchol™ and Euvichol® are essentially
the same vaccine. One dose can be used
to contain epidemics (protection for at
least six months). Two doses are required
for longer protection (both vaccines
provide sustained protection of >65%
for at least three years after two doses).
The two doses can be administered to all
individuals over the age of one year with
a minimum two-week interval between
doses;
– There is a third vaccine, Dukoral®, that is
primarily used for travellers. It also confers
significant short-term protection against
Enterotoxigenic Escherichia coli (ETEC).
The vaccine is administered with a buffer
solution. It can be given to all individuals
over the age of two years with a minimum
of a week between doses.
• Oral Cholera Vaccines are considered
safe for pregnant women.
• OCV can be used for emergencies:
– In humanitarian crises, OCV can be used
to prevent Cholera, even before any
suspected cases are reported;
– For outbreak response, OCV is used to
prevent further spread of Cholera. It
should be used as early as possible to
prevent the greatest number of cases;
– All OCVs currently require cold chain (2-
8°C), but use out of cold chain is currently
under review;
– For emergency use of OCV, there is
a global emergency stockpile of Oral
Cholera Vaccine doses (Shanchol™ or
Euvichol®) managed by the International
Coordinating Group (ICG).
• In endemic settings, Oral Cholera Vaccines
are used as part of a longer-term Cholera
control plan, including reinforcement of
surveillance and laboratory diagnostic
capacity and improving water, sanitation
and hygiene conditions. OCV is used
to provide mid-term protection to the
population while longer term water,
sanitation and hygiene solutions are
being implemented.
– OCV for endemic use is available via the
Global Task Force on Cholera Control.
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 166
Populations at risk should be
provided with safe water and
basic sanitation
• During outbreaks:
– People should be provided with safe
water or means to prepare and store safe
water at home;
– Awareness campaigns should be
organized, and information should be
provided to the community about the
potential risks and symptoms of Cholera,
precautions to take to avoid Cholera, when
and where to report cases, and to seek
immediate treatment when symptoms
appear. The location of appropriate
treatment sites should also be shared.
• Community engagement is critical,
at any time, so that communities
adopt preventive behaviors to avert
contamination:
8 – Health education campaigns should promote the adoption of appropriate hygiene practices such as hand-washing with soap, safe preparation and storage
of food and safe disposal of the faeces of
children;
– Handwashing should be promoted at key
times;
– Funeral practices for individuals who die
from Cholera must be adapted to prevent
infection among attendees;
– Breastfeeding should be promoted;
– Health campaigns should be adapted to
local culture and beliefs.
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 167
WHO can provide countries with
Cholera kits
• WHO can provide necessary materials
for the investigation and confirmation
of Cholera outbreaks, as well as for the
treatment of Cholera patients. Cholera
kits are designed to help prepare for
a potential Cholera outbreak and to
support the first month of the initial
response.
• There are six kits:
– One kit provides the necessary materials
for the investigation of Cholera outbreaks;
– One provides the supplies for laboratory
confirmation of suspected Cholera cases.
10Mapping the origin of cases is critical to orient control activities• Mapping the origin of cases can
help identify priority areas for water
and sanitation activities and hygiene
promotion. The more precise the
mapping, the more effectively
interventions can be targeted.
• Access to treatment for people living in
priority areas should also be ensured.
• Oral rehydration points in key areas and
transport services to Cholera treatment
centres can save lives.
• Active case finding should also be carried
out in these areas.
• In areas with community health
programmes, the community health
workers or volunteers can be trained to
identify and report suspected Cholera,
to safely make and give ORS, and to refer
patients for treatment.
9 Note: triple packaging for sample transport is NOT included;- Three kits are designed for the treatment of Cholera patients within existing
structures at the central, peripheral and
community levels;
– One kit provides the necessary material
to set up a provisional structure for
patient care when no existing structure
is in place.
• There is a tool that quickly estimates
needs of Cholera kits (see link on next
page).
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 168
More information about Cholera:
• Cholera WHO webpage
http://who.int/cholera/en/
• Cholera WHO factsheet
http://who.int/mediacentre/factsheets/fs107/en/
• Ending Cholera: a global roadmap to 2030
http://www.who.int/cholera/publications/global-roadmap/en/
• Cholera kits
http://who.int/cholera/kit/en/
• Cholera outbreak: assessing the outbreak response and improving
preparedness
http://who.int/cholera/publications/OutbreakAssessment/en/
• First steps for managing an outbreak of acute diarrhoea
http://who.int/cholera/publications/firststeps/en/
• Interim guidance document for Cholera surveillance, Global Task Force
on Cholera Control, Surveillance Working Group
http://www.who.int/cholera/task_force/GTFCC-Guidance-cholera-
surveillance ?ua=1
• Interim technical notes on the Use of Cholera Rapid Diagnostic Tests,
Global Task Force on Cholera Control, Surveillance and Laboratory
Working Group
http://www.who.int/cholera/task_force/Interim-guidance-cholera-RDT.
pdf?ua=1
• Oral Cholera Vaccine and technical notes on the use of OCV in
pregnant women and travellers
http://www.who.int/cholera/vaccines/en/
• WHO Oral Cholera Vaccines position paper – 2017
http://apps.who.int/iris/bitstream/10665/258763/1/WER9234 ?ua=1
CHOLERAMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 169
http://who.int/cholera/en/
http://who.int/mediacentre/factsheets/fs107/en/
http://www.who.int/cholera/publications/global-roadmap/en/
http://who.int/cholera/kit/en/
http://who.int/cholera/publications/OutbreakAssessment/en/
http://who.int/cholera/publications/firststeps/en/
http://www.who.int/cholera/task_force/GTFCC-Guidance-cholera-surveillance ?ua=1
http://www.who.int/cholera/task_force/GTFCC-Guidance-cholera-surveillance ?ua=1
http://www.who.int/cholera/task_force/Interim-guidance-cholera-RDT ?ua=1
http://www.who.int/cholera/task_force/Interim-guidance-cholera-RDT ?ua=1
http://www.who.int/cholera/vaccines/en/
http://apps.who.int/iris/bitstream/10665/258763/1/WER9234 ?ua=1
1. Monkeypox virus is in the same family of viruses as Smallpox virus (Orthopoxviruses)
2. Primary infection occurs through direct contact with body fluids or lesions of
infected animals
3. Secondary human-to-human transmission exists
4. Isolation of patients and standard infection prevention and control (IPC) measures
are key to minimizing any possibility of human-to-human transmission
5. Avoid contact with animals that could harbour the virus, especially rodents and
sick or dead animals
6. Active surveillance to ensure rapid identification of new cases is critical for
outbreak containment
7. There is no specific treatment or vaccine recommended for Monkeypox
8. Health education and raising population awareness are the best preventive
measures in at-risk populations
9. Many animal species host the Monkeypox virus, primarily rodent species (rather
than monkeys, after which the disease is named)
10. Monkeypox is a rare disease that occurs sporadically in remote tropical rainforest
areas of Central and West Africa
10 THINGS YOU SHOULD KNOW
Monkeypox
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 170
Monkeypox response tips
Coordinating responders
• Establish an Emergency Operations Centre if
cases are above what is expected
• Ensure the animal and wildlife sector is
involved from the very beginning
• Engage communities
Communicating risk
• Encourage health authorities to:
– Engage communities to prevent exposure
– Ensure training of clinicians for early
detection, sampling and treatment
• Key messages:
– Avoid contact with dead animals (rats,
squirrels and monkeys)
– Human-to-human transmission occurs
through respiratory droplets, contact with
infected persons or contaminated materials
– If you think you might have been exposed
to Monkeypox and have any symptoms, go
to the nearest health facility and avoid self-
medication
– Protect yourself when caring for patients
with a rash
Health Information
• Develop a case definition and a case
investigation form adapted to the context
• Develop a consolidated laboratory/
surveillance database
• Map cases residence
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Community engagement and strong risk
communication
• Contact tracing
• Isolation and supportive care for cases
• Psychosocial support for all suspected
cases and families
• Safe and dignified burials
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 171
1 2 Primary infection occurs through direct contact with body fluids or lesions of infected animals
• Primary infection occurs through direct
contact with the blood, body fluids, or
cutaneous or mucosal lesions of infected
animals.
• Hunters in tropical forests of West and
Central Africa and people who may
be exposed to animals infected with
Monkeypox are at higher risk of infection.
• People living in or near the forested areas
may have indirect or low-level exposure
to infected animals, possibly leading to
subclinical (asymptomatic) infection and
concommitant acquisition of immunity,
although this needs to be further
explored.
Monkeypox virus is in the same
family of viruses as Smallpox virus
(Orthopoxviruses)
• Monkeypox is a rare viral zoonosis
with symptoms similar to those seen in
Smallpox patients, although less severe.
Monkeypox and Smallpox are members
of the Orthopoxvirus family. Smallpox
was eradicated in 1980 and, along with
it, the vaccination programme was
discontinued.
• The incubation period of Monkeypox is
usually from six to 16 days but can range
from five to 21 days.
• Monkeypox infection can be divided into
two periods :
– the invasion period (up to the first five days)
characterized by fever, intense headache,
lymphadenopathy (swelling of the lymph
node), back pain, myalgia (muscle ache)
and an intense asthenia (lack of energy);
– the skin eruption period (within one to
three days after appearance of fever)
where the various stages of the rash
appears, often beginning on the face and
then spreading elsewhere on the body.
The face (in 95% of cases), palms of the
hands and soles of the feet (75%) are
most affected. Evolution of the rash from
maculopapules (lesions with a flat bases)
to vesicles (small fluid-filled blisters),
pustules, followed by crusts occurs in
approximately 10 days. Three weeks
might be necessary before the complete
disappearance of the crusts.
• The number of the lesions varies from a
few to several thousand, affecting oral
mucous membranes (in 70% of cases),
genitalia (30%), and conjunctivae (eyelid)
(20%), as well as the cornea (eyeball).
• Monkeypox is usually a self-limited
disease with the symptoms lasting from
two to three weeks.
• Severe cases occur more commonly
among children and are related to the
extent of virus exposure, patient health
status and severity of complications.
• Case fatality rate in outbreaks has been
between one percent and 10% depending
on the clade of the virus. There are two
distict clades, the Congo Basin which has
a case fatality ratio (CFR) of up to 10% and
the Western Africa clade with a CFR up to
one percent.
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 172
Secondary human-to-human
transmission exists
• It can result from close contact with
infected respiratory tract secretions, skin
lesions of an infected person or objects
recently contaminated by patient fluids
or lesion materials. The virus does not
transmit easily from human to human.
• Persons become infectious to others once
the rash appears.
• As transmission occurs primarily via
droplet respiratory particles and usually
require prolonged face-to-face contact,
household members of active cases and
people caring for the sick are at greater
risk of infection.
• Transmission can also occur by parenteral
means such as inoculation of the virus or
via the placenta (congenital Monkeypox).
• There is no evidence to date that person-
to-person transmission alone can sustain
Monkeypox infections in the human
population.
3 Isolation of patients and standard infection prevention and control (IPC) measures are key to minimizing any possibility of
human-to-human transmission
• Patients should be isolated and treated
symptomatically. Close physical contact
with Monkeypox infected people should
be avoided until the person has fully
recovered.
• Gloves and personnal protective
equipment should be worn when taking
care of ill people.
• Regular hand washing should be carried
out after caring for or visiting sick people.
• Health care workers caring for patients
with suspected or confirmed Monkeypox
virus infection, or handling specimens
from them, should implement standard
infection control precautions.
4
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 173
Avoid contact with animals that
could harbour the virus, especially
rodents and sick or dead animals
• In areas where Monkeypox occurs:
– avoid contact with animals that could
harbour the virus;
– use appropriate infection prevention
and control measures when handling
animals. Gloves and other personal
protective clothing should be worn while
handling animals, their tissues, and during
slaughtering procedures.
• Eating thoroughly cooked animal
products (blood, meat) is safe. However,
preparation using animal products
represents a significant risk.
• Not all animals show signs of illness but
they can still be contagious, making risk
communication difficult, especially in
areas where communities rely on hunting.
Risk communications need to take this
into account.
5 Active surveillance to ensure rapid identification of new cases is critical for outbreak containment
• Laboratory confirmation is important as
Monkeypox is difficult to distinguish from
other pox-like illnesses. The differential
diagnoses to be considered include
other rash illnesses, such as Chickenpox,
Measles, bacterial skin infections, Scabies,
Syphilis, Smallpox and medication-
associated allergies. The development
of severe lymphadenopathy before the
appearance of the rash, in some patients,
is a distinctive feature of Monkeypox
compared to other similar diseases.
• Monkeypox can be confirmed in laboratory
through several tests (Enzyme-Linked
Immunosorbent Assay – ELISA, antigen
detection, Polymerase Chain Reaction
– PCR, or virus isolation in cell culture).
The optimal diagnostic specimens are
from lesions, either vesicular swabs of
lesion exudate or crusts, stored in a dry,
sterile tube (no viral transport media) and
kept cold. Blood and serum do not give
definitive results.
6 • Once a case of Monkeypox is detected, support enhanced surveillance measures to ensure additional Monkeypox cases are detected and that control measures
are implemented.
• At the beginning of an outbreak,
develop a consolidated laboratory and
surveillance database to keep track of the
information collected in case report forms
during outbreak investigation.
• Contact tracing should be conducted for
all suspected and confirmed Monkeypox
cases.
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 174
Symptoms Monkeypox Smallpox Chickenpox
Fever 1-3 days before the rash 2-4 days before the rash At the rash onset
Rash appearance The rash evolves from
maculopapules to vesicles,
pustules, followed by crusts in
approximatively 10 days
Pocks at the same stage Pocks in several stages
Rash distribution Typically starts on face and
spreads to arms and legs, then
hands and feet including palm
and soles
More dense on face and
extremities; present on palms
and soles
More dense on the body; absent
on palms and soles
Other distinctive feature Patients present with
lymphadenopathy (swollen
lymph nodes) before the
appearance of the rash
No lymphadenopathy The rash itches
Rash development Rapid Low Rapid
Death 1-10% Around 30% Rare
Clinical differential diagnosis between Monkeypox, Smallpox and Chickenpox
Note: Smallpox has been eradicated and the information on disease comes from evidence gathered before 1980.
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 175
Health education and raising
population awareness are the best
preventive measures in at-risk
populations
• In the absence of specific treatment or
vaccine, the only way to limit infection in
people is by raising awareness of the risk
factors and educating people about the
measures they can take to avoid exposure
to the virus.
• Health care workers should be trained to
recognize the symptoms of the disease,
ensure samples are collected for testing
and manage patients. Most importantly,
they should be trained on appropriate
isolation and infection prevention and
control procedures.
87 There is no specific treatment or vaccine recommended for Monkeypox
• To date, there are no specific treatments
or vaccines available for Monkeypox
infection.
• Given the genomic conservation among
Orthopoxviruses, it is likely that Smallpox
vaccine is protective against Monkeypox
(estimated at 85% effectiveness) but
the vaccine is no longer available to the
general public, after Smallpox eradication
in 1980.
• Currently, studies are underway to better
understand how effective newer Smallpox
vaccines are at providing cross-protection
against Monkeypox.
• Prior Smallpox vaccination will likely result
in a milder Monkeypox disease course.
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 176
Monkeypox is a rare disease that
occurs sporadically in remote
tropical rainforest areas of Central
and West Africa
• Human Monkeypox is sporadically
reported in Central and West Africa,
particularly areas close to tropical
rainforest where humans have frequent
contact with animals.
• Outbreaks have occured outside Africa
(e.g. in the Midwest of the United States
of America in 2003 due to imported
animals) and outside Central and West
Africa (e.g. in Sudan in 2005).
10Many animal species host the Monkeypox virus, primarily rodent species (rather than monkeys, after which the disease is named)
• The name Monkeypox is misleading as
the disease does not solely come from
monkeys. In Africa, Monkeypox infection
has been found in many animal species:
rope squirrels, tree squirrels, Gambian
rats, rodents, striped mice, dormice and
monkeys.
• Doubts persist on the natural history of
the virus and further studies are needed
to identify the major reservoir of the
Monkeypox virus and how it is maintained
in nature.
9
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 177
Historical distribution of human monkeypox cases
Country reporting monkeypox cases in
2017 and in previous years
Countries reporting human
monkeypox cases
Country reporting monkeypox cases in
previous years
Liberia
Sierra Leone
Côte
d’Ivoire
Nigeria
Cameroon
Gabon
Congo
Central African
Republic
Democratic
Republic of
the Congo
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area
or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 178
More information about Monkeypox:
• Monkeypox WHO factsheet
http://www.who.int/mediacentre/factsheets/fs161/en/
MONKEYPOXMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 179
10 THINGS YOU SHOULD KNOW
Plague
1. Pneumonic Plague can cause widespread epidemics and is difficult to control
2. The most common form of Plague – Bubonic Plague – is not transmittable
from human to human
3. Early diagnosis and treatment are essential for survival
4. Health education, infection prevention and control and vector and rodent
control are critical to prevent and manage epidemics
5. Safe and dignified burials should be conducted to avoid further transmission
6. Initial symptoms of Plague are non-specific and difficult to distinguish from
other acute febrile diseases
7. The potential Plague natural foci are distributed worldwide and are extending
8. Plague is a disease that usually affects disproportionately vulnerable
populations
9. Septicaemic Plague is the third type of Plague, in addition to the Pneumonic
and Bubonic forms, that occurs when the bacteria is circulating in the
bloodstream
10. Plague is a zoonotic disease caused by bacteria usually found in small
mammals (mostly rodents)
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 180
Plague response tips
Coordinating responders
• Engage with partners and communities for
vector control in endemic areas
Communicating risk
• Encourage health authorities to:
– Initiate health education and community
engagement for vector control in endemic
areas
• Key messages:
– Plague is treatable: people who have
symptoms or have exposure to the disease
should receive treatment
– Transmission of Bubonic and Pneumonic
Plague are different
– Human-to-human transmission of Pneumonic
Plague can occur through respiratory
droplets
– Patients with Bubonic Plague are not
contagious
– For Bubonic Plague, take precautions against
flea bites and do not handle animal carcasses
Health Information
• There is a robust and sensitive rapid
diagnostic test for Bubonic Plague
• Find the source of infection for targeted
control measures
• Notify cases to WHO, under the IHR (2005)
Health Interventions
• Treat early with antibiotics
• Ensure safe and dignified burials
• For Pneumonic Plague:
– Closely follow close contacts and provide
them with prophylaxis for seven days
– Give chemoprophylaxis to health care
workers
– Infection prevention and control: Standard
precautions and droplet precautions
(Protective Personal Equipment- PPE)
• For Bubonic Plague:
– Vector and rodent control
– Give chemoprophylaxis for people living in
the same house as patients
– Infection prevention and control (standard
precautions)
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 181
Pneumonic Plague can cause
widespread epidemics and is
difficult to control
• Pneumonic Plague can be transmitted
from person to person via droplets in the
air (coughing, respiratory secretions), so it
has high epidemic potential and is the most
difficult form of Plague to control.
• It is the most virulent form of Plague: the
incubation period can be as short as 24
hours, and untreated Pneumonic Plague is
always fatal.
• Pneumonic Plague occurs when it
reaches the lungs, from the evolution of
an advanced Bubonic Plague, through
bloodstream, or directly from inhalation of
infected respiratory droplets.
• Patients with Pneumonic Plague should
be isolated so they do not infect others via
respiratory droplets and should be cared
for by trained medical staff. Medical staff
should wear Personal Protective Equipment
and potentially receive chemoprophylaxis
to prevent nosocomial transmission.
• Close contacts must be kept under medical
surveillance and must receive a prophylaxis
with antibiotics for seven days.
• Any suspect case should be treated.
• In case of interhuman transmission, the
incubation period is usually one to three
days, followed by sudden onset of fever,
headache, chills, pain, weakness, chest
discomfort, shortness of breath, cough, and
sometimes bloody or mucous secretions.
The most common form of
Plague – Bubonic Plague – is not
transmittable from human to
human
• Bubonic Plague is the most common form
of Plague. It cannot be transmitted from
human to human unless there is contact
with pus from suppurating buboes.
• Around 10% of people with Bubonic
Plague will develop Pneumonic Plague.
• Bubonic Plague results from flea bites
or direct contamination of an open skin
lesion by Plague-infected materials
or body fluids (mostly nosocomial
infections). Infection can occur when
handling dead animals without the
appropriate protective measures. The
infection spreads via the lymphatic
1 2 system to the nearest lymph node where it replicates itself. The lymph node then becomes inflamed, tense and painful, and is called a “bubo”. At advanced stages of
the infection, the inflamed lymph nodes
can turn into suppurating open sores.
• The incubation period is two to six days
followed by sudden onset of illness:
headaches, chills, fever, malaise and
pain in the affected regional lymph
nodes. Bubonic Plague forms buboes,
inflammation and swelling in the neck,
groin, etc.
• Measures to control an epidemic of
Bubonic Plague include: chemopro-
phylaxis for people living in the same
house as patients, and vector and rodent
control.
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 182
Early diagnosis and treatment are
essential for survival
• Plague is treatable.
• Treatment with common antibiotics and
supportive care are very efficient in curing
human Plague but their efficacy depends
on early administration, which presumes
early detection. This is especially important
for the Pneumonic form, which is highly
contagious, can kill in less than 24 hours,
and is invariably fatal in the absence of
treatment. If people are treated in time,
both forms have good recovery rates.
• Recommended antibiotics are:
– For Bubonic Plague: tetracycline,
doxycycline, chloramphenicol;
– For Pneumonic or Septicaemic Plague:
aminoglycosides, fluoroquinolones;
– For post-exposure presumptive treatment:
tetracycline, doxycycline, sulfamethoxazole/
trimethoprim.
• Early treatment requires early diagnosis.
Confirmation of Plague requires laboratory
testing. The best practice is to identify the
3 bacteria Y Pestis in a sample of puss from a bubo, blood or sputum. It can be detected by different techniques:- Microscopy: Staining, Fluorescent
Antibody test;
– Isolation: Colony morphology, Biochemical
reactions, Phage lysis;
– Detection of antigen/antibody: ELISA
(Enzyme-Linked Immunosorbent
Assay), Fluorescent antibody test, PCR
(Polymerase Chain Reaction).
• There is an easy-to-use, robust, reliable
and sensitive rapid diagnostic test for
Bubonic Plague (dipstick test), that
detects antigen and produces reliable
results in 15 minutes, greatly facilitating
containment efforts. It is recommended
that this rapid diagnostic test is used in all
endemic regions.
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 183
5 Safe and dignified burials should be conducted to avoid further transmission
• The bacteria present in the body fluids
of deceased Plague patients can be a
source of infection for people in contact
with them during burials ceremonies.
Safe burials, respecting local cultures and
beliefs, must be implemented.
Health education, infection
prevention and control and vector
and rodent control are critical to
prevent and manage epidemics
• In Plague endemic areas, it is critical
to educate people on the disease, its
symptoms and modes of transmission.
People should be informed when zoonotic
Plague is active in their environment and
be advised to take precautions against
flea bites and not to handle animal
carcasses.
• Avoiding touching dead animals and
wearing insect repellent will help prevent
Bubonic Plague in endemic areas.
• Avoiding close contact (less than two
metres) with suspected Pneumonic
Plague patients who are coughing will
help to prevent Pneumonic Plague.
• Plague, “the Black Death”, can be a very
scary disease as it has caused millions of
deaths in the past, so health education
is particularly essential to prevent panic
during outbreaks.
• Health care workers should specifically
be informed and trained in infection
prevention and control. They should be
provided with the appropriate personal
protective equipment and trained in how
to use it.
• In Plague endemic areas and during
Bubonic Plague outbreaks, flea and
reservoir (usually rodents) controls must
be implemented.
4
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 184
The potential Plague natural foci
are distributed worldwide and are
extending
• Although Plague is most common in
Madagascar, the Democratic Republic of
the Congo and Peru, the potential Plague
natural foci (the bacteria, an animal
reservoir and a vector) are distributed
worldwide.
• We are currently witnessing the
reemergence of the disease in some
places where it had disappeared and its
emergence in other places where it had
never occurred.
• The natural foci are also expanding. This
could be due to:
7Initial symptoms of Plague are non-specific and difficult to distinguish from other acute febrile diseases
• People infected with Plague begin to
develop non-specific symptoms after an
incubation period of one to seven days.
Typical symptoms are the sudden onset
of fever, chills, head and body-aches and
weakness, vomiting and nausea. These
symptoms are difficult to differentiate
from other common endemic pathogens.
• Painful and inflamed lymph nodes
secondarily appear during Bubonic
Plague.
• Symptoms of Pneumonic Plague appear
quickly after infection (sometimes less
than 24 hours). They include severe
respiratory symptoms, such as shortness
of breath and coughing, often with blood-
tainted sputum.
• The clinical picture is not very specific
and misdiagnosis is common, thus the
importance of Rapid Diagnostic Test, for
rapid diagnosis and early treatment.
6 – Environmental modifications (e.g. deforestation);- Ongoing colonization of the black rat (one of the reservoirs);
– Increased national and international
exchanges;
– Uncontrolled urbanization.
• Furthermore, in endemic countries,
entomological and zoological surveillance
activities are expensive and complicated
to maintain. They are very often neglected
in the absence of any human cases and
it is hard to obtain detailed knowledge
about the status or development of
natural foci.
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 185
Septicaemic Plague is the third
type of Plague, in addition to the
Pneumonic and Bubonic forms,
that occurs when the bacteria is
circulating in the bloodstream
• Septicaemic Plague is the third form of
Plague which occurs when the infection
spreads through the bloodstream.
• Septicaemic Plague may result from
flea bites and from direct contact with
infective materials through cracks in the
skin or follow a Bubonic Plague. It could
result in Pneumonic Plague.
9Plague is a disease that usually affects disproportionately vulnerable populations
• Plague is a disease that affects
disproportionately vulnerable populations,
because it thrives in overcrowded
places with poor sanitary conditions and
inadequate health services.
• Outbreaks of Plague are often linked to
civil disturbances and war, and when the
health infrastructure and facilities have
broken down.
• Strengthening health systems thus reduces
the risk of epidemics.
8
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 186
Plague is a zoonotic disease
caused by bacteria usually
found in small mammals (mostly
rodents)
• Plague is a zoonotic disease caused by
the bacteria Yersinia pestis, usually found
in small mammals (mostly rodents). It is
transmitted between animals by their
fleas.
• There is a risk of human Plague wherever
the presence of Plague natural foci
(the bacteria, an animal reservoir and a
vector) and human populations co-exist.
• There are three main forms of Plague
infection, depending on the clinical
presentation of infection: Bubonic,
Septicaemic and Pneumonic. Humans
can become infected by the bite of
infected fleas, by direct contact with
infected materials, or by inhalation of
infectious respiratory particles from
another sick person with Pneumonic
Plague.
• There is a great risk of nosocomial
(hospital) infection, especially for the
Pneumonic form.
• Human Plague is a severe disease, with
a 30-100 % case fatality ratio, depending
on the clinical form.
10 • However, when rapidly diagnosed and promptly treated, Plague may be successfully managed with antibiotics, reducing mortality to less than 15%.
• Plague epidemics have occurred in
Africa, Asia and South America. Since
the 1990s, most human cases have
occurred in Africa. The three most
endemic countries are Madagascar,
the Democratic Republic of Congo and
Peru.
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 187
Global distribution of natural Plague foci, as of March 2016
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World
Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or
boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018.
_̂
Areas* with potential plague natural foci based
on historical data and current information
* First administrative level representation
Source: WHO / IHM, as of March 2016
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 188
More information about
Plague
• WHO Fact sheet
http://www.who.int/mediacentre/factsheets/fs267/en/
• Plague WHO webpage
http://www.who.int/csr/disease/plague/en/
• Plague WHO MOOC
https://openwho.org/courses/knowledge-resources-plague
• Plague manual: epidemiology, distribution, surveillance and control
http://who.int/csr/resources/publications/plague/WHO_CDS_CSR_
EDC_99_2_EN/en/
PLAGUEMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 189
http://www.who.int/mediacentre/factsheets/fs267/en/
http://www.who.int/csr/disease/plague/en/
https://openwho.org/courses/knowledge-resources-plague
http://who.int/csr/resources/publications/plague/WHO_CDS_CSR_EDC_99_2_EN/en/
http://who.int/csr/resources/publications/plague/WHO_CDS_CSR_EDC_99_2_EN/en/
1. Leptospirosis is a disease that usually follows natural disasters in tropical
or subtropical climates
2. Rodents are the main reservoir of the Leptospira, causative bacteria of
Leptospirosis but all kinds of mammals can play a role in human transmission
3. Humans are infected through direct or indirect exposure to infected
animals’ urine
4. Risk of infection is increased in some activities and socioeconomic situations
5. Common antibiotics, if given early, are effective against Leptospirosis
6. Leptospirosis is under-recognized and often mistaken for others diseases
7. Laboratory diagnosis is challenging but critical to confirm leptospirosis
8. Prevention and control measures should target the infection source, the
route of transmission and the disease in humans
9. Climate change and urbanization will increase the frequency and intensity
of outbreaks
10. A multi-sectorial and holistic approach is critical for prevention and control
10 THINGS YOU SHOULD KNOW
Leptospirosis
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 190
Leptospirosis response tips
Coordinating responders
• Engage with animal health sector
Communicating risk
• Encourage health authorities to:
– Engage communities
– Ensure training of clinicians for early detection and
treatment
– Prepare hospitals to receive severe cases
requesting intensive care
• Key messages:
– Humans are infected through direct or indirect
exposure to the urine of infected animals
– Avoid contact with rodents
– Exposure can occur through contaminated water
– Immediately disinfect all skin injuries and avoid
contact with untreated water
– Seek treatment early if showing symptoms
Health Information
• Ensure laboratory confirmation of
suspected cases
Health Interventions
• Early detection of cases
• Provide empirical treatment (antibiotics)
for all probable cases
• Provide population with treated water
• Provide targeted chemoprophylaxis
and protective equipment to very high-
risk populations (rescue, sewage and
sanitation workers)
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 191
Leptospirosis is a disease that
usually follows natural disasters in
tropical or subtropical climates
• Leptospirosis is an infectious disease
caused by bacteria belonging to the
genus Leptospira.
• Leptospirosis occurs worldwide, but is
most prevalent in tropical and subtropical
regions.
• It often has a seasonal distribution,
increasing with heavy rainfall or higher
temperatures.
• Outbreaks classically occur in association
with natural disasters, especially flooding.
Rodents are the main reservoir of
the Leptospira, causative bacteria
of Leptospirosis but all kinds of
mammals can play a role in human
transmission
• Rodents are considered the primary
source of infection to humans.
• Virtually all wild and domestic mammals
can harbour the bacteria that cause
leptospirosis in their kidneys and genital
tracts and act as source of infection to
humans and to other animals.
• Cattle, buffaloes, horses, sheep, goats,
pigs and dogs are also considered
common reservoirs of the bacteria that
cause leptospirosis.
• Natural history of the
disease depends on the
local ecological conditions.
1 2
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 192
Humans are infected through
direct or indirect exposure to
infected animals’ urine
• Leptospirosis is a zoonosis, transmitted
directly or indirectly from animals to
humans.
• Humans become infected through
direct contact with the urine of infected
animals or with a urine-contaminated
environment.
• The bacteria enter the body through cuts
or abrasions on the skin, or through the
mucous membranes of the mouth, nose
and eyes.
• Exposure through water contaminated by
urine from infected animals is the most
common route of infection. Leptospirosis
can occasionally also be transmitted
through the drinking of water or ingestion
of food contaminated with urine of
infected animals and when handling
infected animal tissues.
• Human-to-human transmission occurs
only very rarely.
3 4 Risk of infection is increased in some activities and socioeconomic situations
• The risk of infection depends on exposure.
Some people have more contact with
waters contaminated by rodents or other
domestic animals.
• People can be exposed through their
occupation: Outdoor and agricultural
workers (rice-paddy and sugarcane
workers, for example); Abattoir workers;
Veterinarians; Meat handlers; Pet-shop
workers; Sewer workers.
• People can also be exposed through
recreational activities, through water
sports such as swimming or canoeing.
Survivors from natural disasters (e.g.
flooding) are also at higher risk of
infection.
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 193
Common antibiotics, if given early,
are effective against Leptospirosis
• Leptospirosis can be treated with
antibiotics that should be given as early
in the course of illness as possible,
preferably before the fifth day after the
onset of illness.
• Clinicians should never wait for the
results of laboratory tests before starting
treatment with antibiotics.
• Treatment options include antibiotics such
as amoxycillin, tretracycline, ampicillin
and doxycycline, etc.
• In severe cases, admission to a hospital
is necessary. These severe cases should
be treated with high doses of intravenous
penicillin. Peritoneal or haemodialysis
are indicated in case of renal failure.
Mechanical ventilation is indicated for
lung hemorrhagic manifestation. Severe
forms, which require intensive care, make
case management logistically complex to
organize in an outbreak context.
Leptospirosis is under-recognized
and often mistaken for others
diseases
• Misdiagnosis is common because of
Leptospirosis’ variable symptoms and
non-specific presentations that can mimic
many other infectious diseases.
• The usual presentation is an acute illness
with sudden onset of fever, headache,
myalgia (particularly calf muscle) and
prostration associated with any of the
following symptoms/signs: conjunctival
suffusion, anuria or oliguria, jaundice,
cough, haemoptysis and breathlessness,
haemorrhages (from the intestines, lung
bleeding is notorious in some areas),
meningeal irritation, cardiac arrhythmia
or failure, and skin rash. Other common
symptoms include nausea, vomiting,
abdominal pain, diarrhoea and arthralgia.
• The incubation period of Leptospirosis is
usually five to 14 days, with a range of two
to 30 days. Although the disease is a self-
limiting and often clinically unapparent
illness in the majority of cases (there are
5 6 asymptomatic cases), 5-15% of untreated cases can progress to a more severe and potentially fatal stage.• There are four broad clinical categories of
leptospirosis:
– Mild influenza-like illness;
– Weil’s syndrome (jaundice, renal failure,
hemorrhage, myocarditis);
– Meningitis;
– Pulmonary hemorrhage and respiratory
failure.
• Suspicion of Leptospirosis is further
increased for patients presenting the
above symptoms if there is a history of
occupational or recreational exposure to
infected animals or to an environment
potentially contaminated with animal
urine. It is also important for clinicians to
consider Leptospirosis in the differential
diagnosis of febrile illnesses after
flooding.
• Misdiagnosis or delayed diagnosis have
significant clinical implications because
early treatment of Leptospirosis is crucial
to minimize morbidity and mortality and
timely implement control measures.
Mild forms
Febrile hemorrhagic forms
With severe pneumonia
When icteric fever
Leptospirosis presentations Diseases it could be confused with
Malaria, Dengue, Influenza
Viral haemorrhagic fevers
Plague
Yellow fever or Hepatitis
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 194
2-10 d 4-7 d 1-3 d 0-10+ d
Bacteria enter body through cuts or
mucosal surfaces; bacterial
flagellae aid tissue penetration
Fever & other symptoms
resolve temporarily prior
to onset of Immune
phase
Recurring fever and CNS
involvement (meningitis); primarily
humoral response; antileptospiral
antibodies lead to clearance of the
organism from most tissues except
kidney tubules; leptospires may
continue to shed in the urine for
long periods
Abrupt onset of fever, headache,
muscle pain, nausea; leptospires
isolated from blood, CSF and most
tissues; mostly anicteric, 5-10%
have jaundice
Incubation period Septicaemic phase Interphase Immune phase
Typical course of Leptospirosis
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 195
Laboratory diagnosis is challenging
but critical to confirm leptospirosis
• Laboratory diagnostic is not easy because
of the complexity of the pathogen: there
are 300 species and 25 serogroups,
divided into 250 serovars.
• Laboratory support is needed:
– To confirm the diagnosis and distinguish it
from other diseases;
– To determine the serovar responsible for
infection, which will help guide the control
strategies.
• Current recommendations for laboratory
testing are:
– Serology: Microscopic Agglutination Test
(MAT) is the gold standard serologic test,
due to its high specificity;
– Polymerase Chain Reaction – PCR.
• IgM Enzyme-Linked Immunosorbent
Assay (ELISA) test may be used but it
requires a lag period after infection before
antibodies become detectable. The
results need to be interpreted carefully
due to varying sensitivity and specificity
of the test method.
Prevention and control measures
should target the infection source,
the route of transmission and the
disease in humans
• Control measures at the infection source
(usually local reservoir species of animals)
include: Reducing certain animal reservoir
populations; Separating animal reservoirs
from human habitations (by fences
and screens); Immunizing dogs and
livestock; Removing rubbish and keeping
areas around human habitations clean;
Disposing of excreta from domestic
animals in such a way as to avoid
contamination; Encouraging people
not to leave food around, especially in
recreational areas where rats may be
present; Improving living conditions and
sanitation systems, etc.
• Measures to prevent transmission
through avoiding contact with animal
urine, infected animals or an infected
environment, include: Wearing protective
clothing; Covering skin lesions with
waterproof dressings; Preventing access
to, or giving adequate warning about
water bodies known or suspected to be
contaminated; Washing or showering
after exposure to urine splashes or
contaminated soil or water; Washing and
cleaning wounds; Strictly maintaining
hygienic measures during care or handling
of all animals; Where feasible, disinfecting
contaminated areas (scrubbing floors
in stables, butcheries, abattoirs, etc.);
Consuming clean drinking-water, etc.
• Interventions at the level of the human
host include:
7 8 – Raising awareness in both the general population and at-risk groups. People need to understand the disease and how to avoid risks, but also that timely medication
helps. Doctors and veterinarians should
consider leptospirosis as part of the
differential diagnosis in appropriate cases;
– Antibiotic prophylaxis should be used if
exposure is known to have occurred (e.g.
as a result of a laboratory accident or
other high-risk exposure);
– Immunization in humans is not
recommended. Vaccines do not induce
long-term protection against infection and
do not provide cross-protective immunity
against heterogenous leptospiral serovars
(protective antibodies are produced
only against the serovars present in the
particular vaccine used).
• In epidemic situations, strategic control
measures include:
– Detecting cases early;
– Providing empirical treatment for all
probable cases;
– Providing the population with treated
water;
– Providing targeted chemoprophylaxis
and protective equipment to very high-
risk populations (rescue, sewage and
sanitation workers);
– Rodent control and animal immunization
are useless at this stage.
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 196
Climate change and urbanization
will increase the frequency and
intensity of outbreaks
• Leptospirosis infections are closely linked
to the environment and climate change
will lead to an escalation of the global
burden of leptospirosis:
– Climate change is expected to increase
the occurrence of heavy rainfall and
flooding and the intensity of tropical
cyclones and storms, due to the rise of sea
levels and the rise of sea and land surface
temperatures;
– Natural disasters also increase the risk of
infectious disease by disrupting health
services and infrastructures and damaging
water and sanitation networks.
• Urbanization also increases the incidence
and intensity of leptospirosis. Fast
urbanization usually goes with the
development of urban slums, where
overcrowding, poor sanitation, poor
health care, poverty and abundance of
rats and other animal reservoirs are risk
factors of being infected.
9
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 197
A multi-sectorial and holistic
approach is critical for prevention
and control
• Leptospirosis remains an unknown
disease: transmission dynamics are
poorly understood, symptoms are not
specific, laboratory diagnosis is complex
and laboratory confirmation is often not
available.
• A One Health approach is critical to
prevent and control this environmental
disease that affects both humans and
animal:
– Relationships between animals, humans
and ecosystems needs to be considered
to better understand and manage the
disease;
– Research and control efforts require
a truly integrated, multi-disciplinary
and coordinated approach to improve
prediction, detection, prevention and
response to outbreaks of Leptospirosis.
10
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 198
More information about Leptospirosis:
• Leptospirosis WHO webpage
http://www.who.int/topics/leptospirosis/en/
• Leptospirosis WHO Western Pacific Region Office factsheet:
http://www.wpro.who.int/mediacentre/factsheets/fs_13082012_
leptospirosis/en/
• Leptospirosis WHO MOOC:
https://openwho.org/courses/pandemic-epidemic-diseases
• Global Leptospirosis Environmental Action Network (GLEAN)
website
https://sites.google.com/site/gleanlepto/
• Human Leptospirosis: guidance for diagnosis, surveillance and
control:
http://apps.who.int/iris/bitstream/10665/42667/1/WHO_CDS_CSR_
EPH_2002.23
LEPTOSPIROSISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 199
http://www.who.int/topics/leptospirosis/en/
http://www.wpro.who.int/mediacentre/factsheets/fs_13082012_leptospirosis/en/
http://www.wpro.who.int/mediacentre/factsheets/fs_13082012_leptospirosis/en/
http://www.wpro.who.int/mediacentre/factsheets/fs_13082012_leptospirosis/en/
https://sites.google.com/site/gleanlepto/
http://apps.who.int/iris/bitstream/10665/42667/1/WHO_CDS_CSR_EPH_2002.23
http://apps.who.int/iris/bitstream/10665/42667/1/WHO_CDS_CSR_EPH_2002.23
1. Meningococcal meningitis (MM) is an acute bacterial form of meningitis due to
Neisseria meningitidis (N.m), a serious infection of the meninges (brain membranes)
2. MM occurs worldwide but its highest burden is in the African meningitis belt
3. Several types of N.m can cause epidemics
4. Humans are the only reservoir of MM, transmitted through direct contact and
respiratory droplets
5. MM can have a fatality rate of up to 50% when untreated
6. Specific vaccines are used for prevention and outbreak response
7. Laboratory diagnosis is essential to ascertain whether N.m is the pathogen causing
meningitis
8. Surveillance is critical to detect outbreaks and inform the epidemic response
9. Early antibiotic treatment is the most important factor to save life and reduce
complications
10. Antibiotics reduce transmission risk for close contacts when given promptly
10 THINGS YOU SHOULD KNOW
Meningococcal meningitis
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 200
Meningococcal meningitis response tips
Coordinating responders
• Make sure the epidemic preparedness and
response committee is established before the
epidemic season
• Contact WHO/ICG for emergency vaccines and
antibiotics
Communicating risk
• Ensure populations receive the vaccine to
prevent this disease
• Key messages are:
– Human-to-human transmission occurs through
droplets of respiratory or throat secretions
– Asymptomatic carriers can transmit the disease
– Practice hand hygiene and respiratory hygiene
– Early antibiotic treatment reduces mortality and
complications and therefore sick people should
seek medical treatment early on
Health Information
• Identify the meningococcal serogroup
through laboratory testing
• Monitor thresholds that have been defined
according to specific regional or country
epidemiology
Health Interventions
• Early antibiotic treatment
• Conduct vaccination campaigns promptly
(according to local epidemiology)
• Prophylaxis to close contacts (according
to local epidemiology)
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 201
Meningococcal meningitis (MM)
is an acute bacterial form of
meningitis due to Neisseria
meningitidis (N.m), a serious
infection of the meninges (brain
membranes)
• MM is due to the bacteria Neisseria
meningitidis.
• A variety of other organisms including
bacteria, fungi or viruses, can cause
meningitis.
• MM causes sporadic cases and also
very large outbreaks.
MM occurs worldwide but its
highest burden is in the African
meningitis belt
• The highest burden is observed in
the meningitis belt (26 countries) that
stretches across Africa from Senegal to
Ethiopia.
• The meningitis belt is affected by
seasonal endemicity and cyclical large
scale epidemics, during the dry season
(December to June).
Several types of N.m can cause
epidemics
• Serogroups are named by a letter (A,
B, C, etc.). 6 (out of 12) serogroups
can cause large epidemics (A, B, C, W,
X, Y). Geographic distribution differs
according to serogroup.
• In the meningitis belt, before
2010, serogroup A meningococcus
accounted for an estimated 80–85%
of all cases. Since the introduction of a
new and very efficient meningococcal
A conjugate vaccine through mass
preventive immunization campaigns,
the proportion of N. meningitidis A has
declined dramatically.
• In Europe, the introduction of routine
vaccination for N. meningitidis C led to
the decline of serogroup C outbreaks.
• Independently of the vaccination
strategies, the epidemiology of
serogroups fluctuates over time and
space for reasons that are not fully
understood.
1 2 3
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 202
Humans are the only reservoir of
MM, transmitted through direct
contact and respiratory droplets
• Neisseria meningitidis only infects
humans. There is no animal reservoir.
• The bacteria can be carried in the throat
(asymptomatic carrier). By chance, it
can overwhelm the body’s defenses
allowing the bacteria to spread through
the bloodstream to the brain.
• The bacteria are transmitted from
person-to-person through droplets of
respiratory or throat secretions from
carriers. Smoking, close and prolonged
contact – such as kissing, sneezing or
coughing on someone, or living in
close quarters with an infected person
(a carrier) – facilitate the spread of the
disease.
MM can have a fatality rate of
up to 50% when untreated
• The most common symptoms of the
disease are high fever, headaches, stiff
neck, vomiting, confusion, sensitivity
to light and bulging of the fontanelle
in infants. Sometimes, a haemorrhagic
rash, ranging from a few petechiae to
widespread ecchymoses, occurs as a
result of septicaemia.
• Even when the disease is diagnosed
early and adequate treatment is
started, 8–15% of patients die, often
within 24 to 48 hours after the onset of
symptoms. If untreated, MM is fatal in
50% of cases.
• MM may result in brain damage,
hearing loss or disability in 10% to 20%
of survivors.
4 5• Asymptomatic carriers can transmit the disease. It is believed that 1% to 10% of the population carries N. meningitidis in their throat in endemic situations. In
epidemics, the carriage rate is higher
(10% to 25%).
• Infants and young adults are the most at
risk of getting infected.
• The incubation period is 2 to 10 days,
usually 3 to 4 days.
• Transmission of N. meningitidis is
facilitated during mass gatherings (recent
examples include the Haj pilgrimage,
jamborees, etc.).
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 203
Specific vaccines are used
for prevention and outbreak
response
• Vaccines are serogroup specific and
confer varying degrees of duration of
protection.
• There are 3 types of vaccines available:
– Polysaccharide vaccines are used for
outbreak response mainly in Africa:
o They are either bivalent (serogroups
A and C), trivalent (A, C and W), or
tetravalent (A, C, Y and W);
o They are not effective before 2 years of
age;
o They offer a 3-year protection but do
not induce herd immunity.
– Conjugate vaccines are used in
prevention (into routine immunization
schedules) and outbreak response:
o They confer longer-lasting immunity,
prevent carriage and induce herd
immunity;
o They can be used as soon as one year
of age;
o Available vaccines include:
6 • Monovalent C and Tetravalent (serogroups A, C, Y, W). Both are currently expensive and mostly used in Canada, United States of America and Europe.
• Monovalent A, used for mass preventive
campaigns and routine infant
immunization.
– Protein-based vaccine against N.
meningitidis B. It has been used in
prevention (into the routine immunization
schedule of one country, the UK) and
outbreak response.
• Reactive vaccination in affected and at-
risk populations should be conducted
promptly to prevent the spread of the
disease.
• In Africa, it is essential that a vaccination
campaign is conducted within four weeks
of crossing the epidemic threshold.
• An international stockpile of vaccine has
been constituted, that can be accessed
by any country facing an outbreak,
through a request to the International
Coordinating Group on vaccine provision
for Meningitis.
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 204
Indicative decision tree for meningitis vaccine choice in a reactive vaccination campaign
Source: WHO, Managing meningitis epidemics in Africa, Revised 2015
Alert threshold reached
meningitis cases available
Conduct
investigation
and obtain
specimens
no
Main
pathogen =
Nm A
Main
pathogen =
Nm C or W
Main
pathogen =
Nm X
Main
pathogen =
Spn / Hib
≥ 30% of Nm
positive are
Nm C or W
Case management
no vaccination
yes no
If epidemic threshold is crossed
ACW
containing
vaccine
Men A
conjugate
vaccine
ACW
containing
vaccine
yes
: 2
REMEMBER
If there are NmA cases in
the population already
vaccinated with MenA
conjugate, conduct field
investigation.
* Confirmation includes a positive result from
culture, polymerase chain reaction or rapid
diagnostic test.
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 205
Laboratory diagnosis is essential
to ascertain whether N.m is the
pathogen causing Meningitis
• Confirmation of the disease needs
a laboratory test performed on
Cerebrospinal Fluid (CSF) obtained
through lumbar puncture: tests
include culture (growing the bacteria),
agglutination tests and Polymerase
Chain Reaction (PCR).
• At the field level, to rapidly identify
the N. meningitidis bacteria and
the serogroups, rapid point-of-care
diagnostic tests should be used. Rapid
confirmation of the pathogen is critical
to determine appropriate treatment
and epidemic response.
Surveillance is critical to detect
outbreaks and inform the
epidemic response
• Surveillance systems should be tailored
to detect outbreaks, monitor disease
trends and impact of vaccine.
• Epidemiological and laboratory data
should be linked.
• The definition of a Meningococcal
meningitis outbreak varies from
country to country, based on local
epidemiology and a comprehensive
analysis of surveillance data.
• In the African belt, standard case
definitions are:
– Suspected case (based on clinical
presentation): any person with sudden
onset of fever (>38.5 °C rectal or 38.0
°C axillary) and neck stiffness or another
meningeal sign including bulging
fontanelle in toddlers;
– Probable case (based on non-specific
laboratory test): any suspected case
with macroscopic aspect of CSF turbid,
cloudy or purulent; or with a CSF
leukocyte count >10 cells/mm3; or with
bacteria identified by Gram stain in
CSF;
7 8
o In infants: CSF leucocyte count >100
cells/mm3; or CSF leucocyte count 10–
100 cells/ mm3 AND either an elevated
protein (>100 mg/dl) or decreased
glucose (<40 mg/dl) level.
- Confirmed (based on laboratory test):
any suspected or probable case that
is laboratory confirmed by culturing or
identifying of Neisseria meningitidis in the
CSF or blood.
• In the African belt, incidence thresholds
that will trigger prevention and control
interventions are shown in the table on
the following page.
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 206
Incidence thresholds for detection and control of epidemic Meningococcal meningitis (2014)
Source: WHO, Managing meningitis epidemics in Africa, Revised 2015
— Inform authorities
— Strengthen surveillance
— Investigate
—
laboratory)
— Prepare for eventual
response
inhabitants / week
(Minimum of 2 cases in one
week)
2 suspected cases in one 100,000
week
Or
An increased incidence
compared to previous non-
epidemic years
— Mass vaccination within
four weeks of crossing the
epidemic threshold
— Distribute treatment to
health centres
— Treat according to epidemic
protocol
— Inform the public
inhabitants / week
5 suspected cases in one
week
Or
Doubling of the number of
cases in a three-week period
(e.g. Week 1: 1 case, Week 2: 2
cases, Week 3: 4 cases)
If a neighbouring area to a population targeted for vaccination is
considered to be at risk (e.g. cases early in the dry season, no recent
relevant vaccination campaign, high population density), it should
be included in a vaccination programme.
In special situations such as mass gatherings, refugees, displaced
prompt mass vaccination.
POPULATION
Intervention 30,000 – 100,000 Under 30,000
Alert threshold
Epidemic threshold 100,000
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 207
Early antibiotic treatment is the
most important factor to save life
and reduce complications
• Prompt treatment (within one hour of
diagnosis) is crucial to prevent death and
complications:
- 5 days ceftriaxone (IV) - 7 days in infants
(0-2 months old) - is recommended as a
standard treatment during epidemics in
the African belt.
• Admission to a hospital or health centre
is necessary, although isolation of the
patient is not necessary.
• If there is no improvement of patients’
condition within 48 hours of treatment
of if exhibiting convulsions or comatose,
they should be transferred to higher-level
health facility.
9 Antibiotics reduce transmission risk for close contacts when given promptly
• Outside the African meningitis belt,
chemoprophylaxis is recommended for
close contacts within the household.
• In the meningitis belt, chemoprophylaxis
for close contacts is recommended in
non-epidemic situations.
• Ciprofloxacin antibiotic is the antibiotic of
choice, and ceftriaxone an alternative.
10
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 208
C,W,X,A
SEROGROUP
SEROGROUP
B,C,Y, W
B,C,W
B,C,W
B,C,W, Y A,C
B,C,W, A
B,C, W
B,W, Y
The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the
World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its
frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement.
© WHO 2018. All rights reserved
Source: WHO/IHM, as of 16 February 2018
Invasive Meningococcal Disease – Serogroup distribution, 2018
Most frequent
Less frequent
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 209
More information about
Meningococcal meningitis:
• Meningococcal meningitis WHO webpage:
http://www.who.int/csr/disease/meningococcal/en/
• Meningitis WHO MOOC:
https://openwho.org/courses/pandemic-epidemic-diseases
• Meningococcal meningitis WHO fact sheet:
http://www.who.int/mediacentre/factsheets/fs141/en/
• Managing meningitis epidemics in Africa
http://www.who.int/csr/resources/publications/HSE_GAR_ERI_2010_4/en/
• International Coordinating Group (ICG) on Vaccine Provision
http://www.who.int/csr/disease/icg/en/
MENINGOCOCCAL MENINGITISMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 210
http://www.who.int/csr/disease/meningococcal/en/
https://openwho.org/courses/pandemic-epidemic-diseases
http://www.who.int/mediacentre/factsheets/fs141/en/
http://www.who.int/csr/resources/publications/HSE_GAR_ERI_2010_4/en/
http://www.who.int/csr/disease/icg/en/
PART III Tool boxes
213
TOOL BOX 1
The role of WHO
Example
• WHO is:
- Working with countries to increase and sustain access to prevention,
treatment and care;
- Identifying priorities and setting strategies;
- Leading and coordinating the health response during emergencies.
• Through the International Health Regulations (2005), WHO helps the
countries to strengthen their national core capacities for emergency risk
management to prevent, prepare for, respond to and recover from health
emergencies.
WHO mandate – in light of infectious diseases
WHO is directing and coordinating authority on international health within the United Nations’
system, by its six mains functions:
1. Providing leadership on matters critical to health and engaging in partnerships where joint action is needed;
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 214
2. Shaping the research agenda and stimulating the generation, translation and dissemination of valuable knowledge;
Example
• WHO Research & Development Blueprint is a global strategy and pre-
paredness plan that allows the rapid activation of R&D activities during
epidemics. Its aim is to fast-track the availability of effective tests, vaccines
and medicines that can be used to save lives and avert large scale crisis.
http://www.who.int/blueprint/en/
• The WHO public health research agenda for influenza provides a framework
reflecting public health research priorities for pandemic, zoonotic and
seasonal epidemic influenza to reduce the risk of emergence of pandemic
influenza, limit the spread of pandemic, zoonotic and seasonal epidemic
influenza, minimize the impact of epidemics, optimize the treatment of
patients and promote the development of modern public health tools.
http://www.who.int/influenza/resources/research/en/
• The MERS-CoV research agenda has been developed by WHO to address key
unknowns for this virus focusing on five major areas of research: i) virus origin
and characteristics, ii) epidemiology and transmission, iii) clinical management
and infection prevention and control measures, iv) product development and
implementation, and v) impact of interventions and operational research.
http://www.who.int/emergencies/mers-cov/en/
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 215
http://www.who.int/blueprint/en/
http://www.who.int/influenza/resources/research/en/
http://www.who.int/emergencies/mers-cov/en/
Articulating ethical and evidence-based policy options;
Example
• WHO publishes vaccine position papers, providing global vaccine and
immunization recommendations that have an international public health impact.
WHO position papers follow the recommendations of the WHO Strategic
Advisory Group (SAGE) on immunization. The update of vaccine position paper
depends on the availability of new scientific evidence and public health priorities.
http://www.who.int/immunization/documents/positionpapers_intro/en/
4.
Setting norms and standards and promoting and monitoring
their implementation;
Example
• WHO developed a pocketbook to provide guidance on best management
practices for Viral Haemorrhagic Fevers across health care facilities.
http://www.who.int/csr/resources/publications/clinical-management-patients/en/
• WHO developed a rapid advance guideline on recommendations for the
use of Personal Protective Equipment for use in a filovirus disease outbreak
http://www.who.int/csr/resources/publications/ebola/personal-protective-
equipment/en/
3.TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 216
http://www.who.int/immunization/documents/positionpapers_intro/en/
http://www.who.int/csr/resources/publications/clinical-management-patients/en/
http://www.who.int/csr/resources/publications/ebola/personal-protective-equipment/en/
http://www.who.int/csr/resources/publications/ebola/personal-protective-equipment/en/
Monitoring the health situation and assessing health trends.
Example
• WHO conducts regular global risk assessments regarding infectious diseases
and assesses the risk for any event which could have public health impact.
• WHO publishes a summary of epidemiological situation and risk assessments
of events that are being monitored through the disease outbreak news.
http://who.int/csr/don/en/
• WHO also disseminates epidemiological information on outbreaks and on
communicable diseases of public health importance through the Weekly
Epidemiological Record.
http://www.who.int/wer/en/
6.
Providing technical support, catalysing change, and building
sustainable institutional capacity;
Example
• WHO has developed a web-based platform offering online courses to transfer
knowledge on infectious diseases and improve preparedness and response to
epidemics. Courses include global knowledge on managing epidemics and
public heath interventions, as well as disease-specific knowledge.
WHO Massive Open Online Courses:
https://openwho.org/
5.TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 217
https://openwho.org/
https://openwho.org/
WHO and the International Health Regulations (IHR) creation:
A need for global cooperation in public health
The Cholera epidemics that overran Europe between 1830 and 1847 were catalysts for intensive
infectious disease diplomacy and multilateral cooperation in public health. They showed that
collaboration between countries was needed to control the spread of dangerous diseases across
the world. This led to the first International Sanitary Conference in Paris in 1851. In 1948, the WHO
Constitution entered into force and in 1951, WHO Member States adopted the International
Sanitary Regulations, which were replaced by and renamed the International Health Regulations
in 1969. The 1969 Regulations were subject to minor modifications in 1973 and 1981.
The IHR were primarily intended to monitor and control six serious infectious diseases: Cholera,
Plague, Yellow fever, Smallpox, Relapsing fever and Typhus. Under the IHR (1969), only Cholera,
Plague and Yellow fever remain notifiable, meaning that States are required to notify WHO if and
when these diseases occur on their territory.
Increase in cross-border travel and trade, the development of
information and communication technologies, the resurgence of
some well-known epidemic diseases, such as Cholera and Plague and
the emergence of new infectious agents such as Ebola virus disease,
as well as the limitations of IHR (1969) (narrow scope of three diseases
and dependence on official country notifications), led to their revision.
The World Health Assembly adopted the IHR (2005) on 23 May 2005
and they entered into force on 15 June 2007. The International Health
Regulations (2005) represent a binding international legal agreement
involving 196 countries across the globe. They aim to prevent, protect
against, control and respond to the international spread of disease while
avoiding unnecessary interference with international traffic and trade.
Questions & Answers
1. What are the major changes between
IHR (1969) and IHR (2005)?
• The scope of the IHR (2005) is purposely broader
and more inclusive in respect of the public health
event to which they have application in order to
maximize the probability that all such events that
could have serious international consequences
are identified early and promptly reported by
States Parties to WHO for assessment.
• The IHR (2005) explicitly allow WHO to take into
account information from sources other than
official notifications and consultations, and,
after assessment, to seek verification of specific
events from the concerned States Parties.
2. What are the general obligations of
States under the IHR 2005?
Under the IHR (2005), States parties are required
to:
• Designate a National IHR Focal Point (it may
be a team). Focal points are required to be
available on a 24-hour basis, 7 days a week.
• Assess events occurring in their territory and
to notify WHO of all events that may constitute
a public health emergency of international
concern using the decision instrument.
• Respond to requests for verification of
information regarding events that may
constitute a public health emergency of
international concern, to respond to public
health risks which may spread internationally.
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 218
• Develop, strengthen and maintain the
capacity to detect, report and respond to
public health events; to provide routine
facilities, services, inspections and control
activities at designated international airports,
ports and ground crossings to prevent the
international spread of disease.
• Report to WHO evidence of a public
health risk identified outside their territory
which may cause international disease
spread, manifested by exported/imported
human cases, vectors carrying infection or
contamination, contaminated goods.
• Respond appropriately to WHO-
recommended measures.
• Collaborate with other States Parties and with
WHO on IHR (2005) implementation.
OR
Yes NoNo
No
Yes
Yes
Is the public health impact
of the event serious?
NoYes
Is the event unusual or
unexpected?
Is the event unusual or unexpected?
NoYes
Is there a significant risk of
international spread?
Is there a significant risk of
international spread?
NoYes
1 As per WHO case definitions.
2 The disease list shall be used only for the purposes of these Regulations.
OR
EVENT SHALL BE NOTIFIED TO WHO UNDER THE INTERNATIONAL HEALTH REGULATIONS
Not notified at this stage.
Reassess when more
information becomes
available.
•
Is there a significant risk of inter-
national travel or trade restrictions?
Events detected by national surveillance system
An event involving the following
diseases shall always lead to
utilization of the algorithm,
because they have demonstrated
the ability to cause serious public
health impact and to spread rapidly
internationally:
• Cholera
• Pneumonic plague
• Yellow fever
• Viral haemorrhagic fevers
(Ebola,Lassa,Marburg)
• West Nile fever
• Other diseases that are of special
national or regional concern, e.g.
dengue fever, Rift Valley fever,and
meningococcal disease.
A case of the following
diseases is unusual or
unexpected and may have
serious public health impact,
and thus shall be notified 1, 2:
• Smallpox
• Poliomyelitis due to
wild-type poliovirus
• Human influenza caused
by a new subtype
• Severe acute respiratory
syndrome (SARS).
Any event of potential
international public
health concern,
including those of
unknown causes or
sources and those
involving other events
or diseases than those
listed in the box on the
left and right shall lead
to utilzation of the
algorithm.
OR
Decision instrument for the assessment & notification of events that may
constitute a public health emergeny of international concern
Source: Annex 2, International Health Regulations (2005)
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 219
3. What events should States Parties
notify to WHO?
Under the IHR, States Parties are required to
notify WHO of all events that are assessed as
possibly constituting a Public Health Event
of International Concern (PHEIC), taking into
account the context in which an event occurs.
A decision instrument, provided in Annex 2
of the Regulations, identifies four criteria that
States Parties must follow in their assessment
of events within their territories and their
decision as to whether an event is notifiable
to WHO:
• Is the public health impact of the event
serious?
• Is the event unusual or unexpected?
• Is there a significant risk of international
spread?
• Is there a significant risk of international
restriction(s) to travel and trade?
4. What if States Parties have difficulties
to assess an event?
State Parties have an option of initiating
confidential consultations with WHO and
seeking advice on evaluation, assessment and
appropriate health measures to be taken, in
case they are unable to complete a definitive
assessment.
5. How and when to report these
events?
• These notifications must occur within 24
hours of assessment by the country.
• Notifications must be followed by ongoing
communication of detailed public health
information on the event, including, where
possible, case definition, laboratory results,
source and type of the risk, number of cases
and deaths, conditions affecting the spread
of the disease and the health measures
employed.
6. What States Parties should do if they
identify a public health risk outside
their territory?
States Parties must inform WHO through
the National IHR Focal Point within 24 hours
of receipt of evidence of a public health
risk identified outside their territory that
may cause international disease spread,
as manifested by imported or exported
human cases, vectors which carry infection or
contamination, or by contaminated goods.
7. Can WHO require more information
to States Parties about events
unofficially reported?
States Parties are required under the IHR to
respond to WHO Requests for Verification.
WHO has an express mandate to obtain
verification from States Parties concerning
unofficial reports or communications, received
from various sources, about events arising
within their territories which may constitute
a PHEIC. States Parties must acknowledge
verification requests by WHO within 24 hours
and provide public health information on
the status of the event, followed, in a timely
manner.
8. What are the diseases that should be
mandatorily notified to WHO?
Under the IHR (2005), all cases of four
diseases must be automatically notified to
WHO: Smallpox, Poliomyelitis due to wild-
type poliovirus, SARS and cases of human
Influenza caused by a new subtype.
9. What are the core capacities?
• Under the IHR (2005), each State Party
is required to develop, strengthen and
maintain core public health capacities for
surveillance and response.
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 220
• Public health capacity under the IHR (2005) is
defined as the indispensable, fundamental
actions that are the primary responsibility
of each State Party for achieving the goal
of national health security, i.e. to prevent
the spread of diseases and to detect and
investigate health risks in the community by
efficient multisectoral action (e.g. integrated
disease surveillance systems, laboratory
services and national, regional and global
networks).
• Core capacities at the local (community),
intermediate and national levels, as well as
key sanitary and health services needed at
designated international airports, ports and
ground crossings are described in Annex 1
of the IHR (2005).
10. What are the specific requirements
for Yellow fever?
• A proof of vaccination or prophylaxis
against Yellow fever may be required for
travellers as a condition of entry to a State.
• States Parties must designate at least one
Yellow fever vaccination centre.
11. Why developing the necessary
public health capacities at points of
entry will limit the spread of public
health hazards?
Today’s high traffic at airports, ports and
ground crossings – points of entry, can
play a key role in the international spread
of diseases through persons, conveyances
and goods. This is why countries should
be prepared to detect and respond to any
health event that may be of international
concern and contain risks at source, limiting
unnecessary health-based restrictions on
international traffic and trade and protecting
the health of travellers and populations.
12. What are the guiding principles for
preparedness at points of entry?
• Simplicity;
• Proportionality and practicality: one size
does not fit all;
• Minimal disruption;
• Collaboration: multisectoral approach;
• (Risk) Communication.
For more information:
• International Health Regulations
(2005)
http://www.who.int/ihr/
publications/9789241580496/en/
• More information about IHR
http://www.who.int/ihr/about/en/
• More information about
implementing IHR
http://www.who.int/ihr/procedures/
implementation/en/
• More about public health at points of
entry:
http://www.who.int/ihr/ports_airports/
en/
• Joint External Evaluation Tool and
Process Overview
http://apps.who.int/iris/
bitstream/10665/252755/1/WHO-HSE-
GCR-2016.18-eng ?ua=1
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 221
http://www.who.int/ihr/publications/9789241580496/en/
http://www.who.int/ihr/publications/9789241580496/en/
http://www.who.int/ihr/about/en/
http://www.who.int/ihr/procedures/implementation/en/
http://www.who.int/ihr/procedures/implementation/en/
http://www.who.int/ihr/ports_airports/en/
http://www.who.int/ihr/ports_airports/en/
http://apps.who.int/iris/bitstream/10665/252755/1/WHO-HSE-GCR-2016.18-eng ?ua=1
http://apps.who.int/iris/bitstream/10665/252755/1/WHO-HSE-GCR-2016.18-eng ?ua=1
http://apps.who.int/iris/bitstream/10665/252755/1/WHO-HSE-GCR-2016.18-eng ?ua=1
WHO management of events
under the Emergency Response
Framework (ERF)
The ERF is an internal WHO tool that outlines
a set of procedures to better respond to
emergencies. The ERF provides WHO staff with
essential guidance on how the Organization
manages the assessment, grading and response
to public health events and emergencies with
health consequences, in support of Member
States and affected communities.
Ungraded
Grade 1
Grade 2
A public health event or emergency that is being monitored by WHO but that
does not require a WHO operational response.
A single country emergency requiring a limited response by WHO, but that
still exceeds the usual country-level cooperation that the WHO Country O�ce
(WCO) has with the Member State. Most of the WHO response can be
managed with in-country assets. Organizational and/or external support
required by the WCO is limited. The provision of support to the WCO is
coordinated by an Emergency Coordinator in the Regional O�ce.
A single country or multiple country emergency, requiring a moderate
response by WHO. The level of response required by WHO always exceeds the
capacity of the WCO. Organizational and/or external support required by the
WCO is moderate. The provision of support to the WCO is coordinated by an
Emergency Coordinator in the Regional O�ce. An Emergency O�cer is also
appointed at headquarters to assist with the coordination of
Organization-wide support.
Grade 3 A single country or multiple country emergency, requiring a major/maximal
WHO response. Organizational and/or external support required by the WCO
is major and requires the mobilization of Organization-wide assets. The
provision of support to the WCO is coordinated by an Emergency Coordinator
in the Regional O�ce(s). An Emergency O�cer is also appointed at
headquarters, to assist with the coordination of Organizationwide inputs. On
occasion, the WHE Executive Director and the Regional Director may agree to
have the Emergency Coordinator based in headquarters. For events or
emergencies involving multiple regions, an Incident Management Support
Team at headquarters will coordinate the response across the regions.
Levels for graded emergencies
Source: Emergency Response Framework, second edition, WHO
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 222
WHO internal grading of events
• Once an event is detected or notified to WHO,
it will be verified and analysed. Risk assessment
would be conducted if the event is confirmed. Risk
assessment by WHO team may result in:
- Monitoring, mitigation, preparedness and
readiness if the risk is low or very low;
- Grading the event and activating the Incident
Management System and scaled response if the
risk is high or very high.
• Grading an event is a WHO internal process
which purpose is to define the level of operational
response required by WHO. Grading takes into
consideration 5 criteria: scale, complexity, urgency
of the event, capacity to respond at local and
national levels and reputational risk for WHO.
• They are four levels for graded emergencies shown
here at left.
Linking risk assessment and situation analysis to WHO grading and
operational response
Source: Emergency Response Framework, second edition, WHO
TOOL BOX 1
Discard
Discard
Close event
WHO response required;
Repurposing WCO
WHO response required
and/or high/very high risk Graded Emergency:
G1 – G3
Ungraded /
Pre-grading
Ungraded /
Pre-grading
For acute events and emergencies, grading occurs within 24 hours of risk assessment/situation analysis
Suspected
public health event
Monitoring,
mitigation, prepardness
& readiness
Monitoring,
mitigation, prepardness
& readiness
IMS activation &
scaled response
Risk assessment:
low – very high
Emergency
Verification
Grading
Situation analysis
Detection
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 223
WHO operational response
through the ERF
• Grading will trigger WHO emergency
procedures and activities for the
management of the response. It will
activate the Incident Management System
(IMS). The IMS is recognized best practice
for emergency management. It is simple,
flexible and adaptable to any scenario: it
may be applied in small, simple, or large,
complex incidents. Scaling up or down the
response can be quickly done to suit the
changing needs.
• The IMS is the combination of facilities,
equipment, personnel, procedures and
communications operating within a common
organizational structure. It enables:
- Common terminology and structure that
enhance interoperability;
- Clarification of roles and responsibilities;
- Flow of information and resources;
- Rapid mobilization, deployment and
tracking of resources.
• The IMS implies:
- Determining the overarching objectives
(e.g. stop transmission of an infectious
agent);
- Establishing specific and measurable
objectives for various functional activities;
- Developing strategies and issuing plans,
directions, procedures, and protocols;
- Assigning tasks;
- Establishing an evaluation process.
• WHO has adapted the Incident
Management System to consist of six
critical functions: Leadership, Partner
Coordination, Information and Planning,
Health Operations and Technical Expertise,
Operations Support and Logistics, and
Finance and Administration.
• WHO applies a no regret policy which
affirms that “it is better to err on the side of
over-resourcing the critical functions rather
than risk failure by under-resourcing”. In
terms of financial resources, the WHO
representative and/or the Incident
Manager has increased authority to
approve expenditure. Immediate access to
funds, for the first three months of an acute
emergency, is provided from either the
Contingency Fund for Emergency (CFE)
or the Regional Office’s rapid response
accounts.
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 224
WHO’s Incident Management System organizational structure: critical
functions and sub-functions
Source: Emergency Response Framework, second edition, WHO
WHE Incident Management System (IMS) structure
IMS critical functions
IMS sub-functions
Leadership / Incident management
Partner
coordination
Staff health,
wellbeing &
security
Risk
communication
& community
engagement
External
relations
Liaison ProcurementField support
Human
resources &
surge
Health
logistics
EOC
Management
Health &
intersectoral
coordination
Prevention
& control
measures
Health service
delivery
Training of
health staff
Technical
expertise, science
& research
Planning
Finance,
budget / grants
management
Supply chain
management
Information
• Risk & needs
assessment
• Early warning
& surveillance
• Monitoring &
evaluation
• Information
products
• Strategic &
operational
planning
• Project
management
Communications
Information
& planning
Finance &
administration
Operations
support &
logistics
Health
operations
& technical
expertise
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 225
For more information:
• Emergency Response Framework:
http://www.who.int/hac/about/erf/en/
WHO monitoring of the
response: a criteria for success
• It is critical to evaluate the response to
an event and learn the lessons from past
responses, improving things that could have
gone better and enforcing best practices.
• During grade 2 and 3 emergencies, WHO
performance standards and key performance
indicators are monitored.
- Performance standards should be
monitored with the ERF Monitoring Tool.
The responsibility for completing the ERF
Monitoring Tool is with the Country Office,
with oversight from the Regional Office.
- Key performance indicators (not more 8) are
agreed upon on a case-by-case basis for each
response (e.g. case fatality ratio; vaccination
coverage, etc.).
TOOL BOX 1
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 226
TOOL BOX 2 The International
Coordinating Group
(ICG) on vaccine
provision
What is the ICG?
• The International Coordination Group (ICG) was established in 1997, following major
outbreaks of Meningitis in Africa, as a mechanism to manage and coordinate the provision
of emergency vaccine supplies and antibiotics to countries during major outbreaks.
• The ICG monitors its vaccine security global stock levels for Cholera, Meningitis and Yellow
fever to ensure availability of sufficient supply to respond to disease outbreaks when they
occur.
• The ICG brings partners together to improve cooperation and coordinating of epidemic
preparedness and response.
• The ICG also works on forecasting vaccine stocks, negotiating vaccine prices through
its networks or partners, evaluating interventions and standard protocols for managing
diseases.
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 227
Why is such mechanism needed?
Though outbreaks of Meningitis, Yellow fever and Cholera are unpredictable events, they can
each be controlled by the timely use of vaccine. Vaccine-preventable diseases typically affect
people in vulnerable settings who have limited access to vaccines. But vaccines can take
months to manufacture, and they are not always readily available in the amounts needed during
emergencies. The resulting shortages have raised difficult issues about how limited supplies
should be allocated during periods of high demand. That is why, after public health organizations
found themselves unprepared to respond in a timely manner to a large-scale outbreak of
Meningitis in Nigeria, the ICG mechanism was created in 1997.
What is the ICG mandate?
• The core mandate of the ICG is to make available
and ensure equitable access to vaccines for
Cholera, Meningitis, and Yellow fever during
outbreaks.
• The ICG mechanism seeks to ensure timely and
targeted deployment so that vaccines can be used
as effective outbreak responses where they are
most needed.
• The ICG also manages the global emergency
vaccine stockpiles and, working with manufacturers,
determines their size and composition with
the goal of ensuring that adequate stocks of
emergency supplies are accessible for emergency
response.
What are the guiding principles of
the mechanism?
Three principles guide the mechanism:
• Equity: distribution of vaccine based on public
health priorities;
• Rapid and timely access: delivery of vaccine
within a defined timeframe to control outbreaks;
• Independence: decisions made independent of
any political or economic influences with the sole
goal of improving public health.
TOOL BOX 2
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 228
Who are the ICG’s partners?
The ICG is made up of four member agencies:
• International Federation of the Red Cross
and Red Crescent Societies (IFRC) - Has
strong country presence for community
health promotion, local social and resource
mobilization and provides support to states
during disasters and epidemics.
• Médecins sans Frontières (MSF) - An
independent, field-based NGO that provides
health care to vulnerable populations in
emergency settings.
• United Nations Children’s Fund (UNICEF)
- Conducts wide scale vaccine procurement
and shipment, and provides technical
support on campaign planning and
implementation in country focusing specially
on social mobilization and cold chain.
• World Health Organization (WHO) -
Provides global public health advice and
technical support to countries. During
outbreaks, WHO focuses on vaccine stockpile
management, surveillance, preparedness
and response to disease outbreaks.
Additional expertise and technical advice is
provided on a case-by-case basis from partners
including: Agence de Médecine Preventive,
Epicentre, GAVI the Vaccine Alliance, WHO
Collaborating Centres, the US Centers for
Disease Control (CDC) and the European
Community Humanitarian Office (ECHO).
Vaccine manufacturers, vaccine equipment
providers and financial donor institutions are
also engaged in the ICG operations.
Which vaccine stockpiles are
available through the ICG?
ICGs have been established to provide access
to vaccines for Cholera, Meningitis and Yellow
fever.
TOOL BOX 2
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 229
For more information:
• General information on the ICG:
http://www.who.int/csr/disease/icg/en/
• Application forms and guidelines for
Cholera:
http://www.who.int/csr/disease/icg/
cholera/en/
• Application forms and guidelines for
Meningitis:
http://www.who.int/csr/disease/
meningococcal/icg/en/
• Application forms and guidelines for
Yellow fever:
http://www.who.int/csr/disease/icg/
yellow-fever/en/
Lead time for request reception to vaccine delivery
How a country can access emergency vaccine stockpiles?
• Vaccine security stocks can be accessed by ANY country facing an epidemic ANYWHERE in the
world, as long as the country’s request fulfills ICG’s criteria for release of vaccine stocks.
• As a first step, a country must complete and submit a request to the ICG Secretariat using the
standard application form.
• The ICG Secretariat at WHO then circulates this request to the partners for review and
assessment. Additional requests for information are sent back to the country, if needed.
Following a rapid consultation and evaluation process, the decision to release vaccines and
other supplies is communicated to the requesting country within 48 hours, once all necessary
information has been provided.
• If approved, UNICEF procures vaccines and injection materials and organizes delivery of
vaccines to the country, ideally within 7 days.
• Requests are evaluated taking into account the epidemiological situation, vaccination strategy,
pre-existing stocks in the country and operational aspects of the epidemic response.
TOOL BOX 2TOOL BOX 2
1 day
ICG Sec.
ICG core
members Procurement agency, ICG Secretariat
Request Circulation Decision Delivery
2 working
days
7 days
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 230
http://www.who.int/csr/disease/icg/en/
http://www.who.int/csr/disease/icg/cholera/en/
http://www.who.int/csr/disease/icg/cholera/en/
http://www.who.int/csr/disease/meningococcal/icg/en/
http://www.who.int/csr/disease/meningococcal/icg/en/
http://www.who.int/csr/disease/icg/yellow-fever/en/
http://www.who.int/csr/disease/icg/yellow-fever/en/
TABLE 1: Specimen collection and storage
TOOL BOX 3
Tables for laboratory diagnosis &
shipment of infectious substances
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Diarrhoeal
Syndrome
Cholera • Liquid stool specimen;
• Rectal swab;
• Culture isolates.
• Container for stool specimen;
• Cary-Blair transport medium for
the swab;
• Filter paper if Cary-Blair is not
available, liquid stool sample may
be blotted on filter paper.
• Room temperature up to 4hrs,
refrigerated if longer;
• Sample in Cary-Blair can be stored at
room temperature;
• Sample on dry filter paper can be
stored at room temperature;
• Sample on moistened filter paper can
be stored at room temperature;
• Isolated strains from culture:
• solid non selective culture medium in
test tubes stored at room temperature
for a few days;
• In Stock Culture Agar at room
temperature.
Acute
Haemorrhagic
Fever
Crimean-Congo
haemorrhagic
fever
• Whole blood (2.5ml) collected on
EDTA (alternative serum);
• Frozen tissue specimens;
• Other: formalin-fixed tissue or
paraffin-embedded tissue.
For serology, testing of acute and
convalescent specimens is strongly
recommended.
• EDTA tubes;
• Serum separator tubes;
• Heparin can cause interference
with PCR reagents and tests.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 231
TABLE 1: Specimen collection and storage, (continued)
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Haemorrhagic
Fever
Dengue • Whole blood (serum/plasma –
1ml).
• Serum separator tubes;
• Citrate and heparin plasma can
be tested by RT-PCR;
• EDTA may cause interference of
PCR reagents and testing.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Ebola virus
disease
• Whole blood (1ml) collected on
EDTA (alternative serum);
• Oral fluid collected from deceased
patients;
• Other: formalin-fixed tissue or
paraffin-embedded tissues.
For serology, testing of acute and
convalescent specimens is strongly
recommended.
• EDTA tubes;
• Heparin can cause interference
with PCR reagents and tests;
• Dacron/polyester swab with
flocked tip stored in universal
transport medium.
• < 24 hours: room temperature ;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Lassa fever • Whole blood (2.5ml) collected on
EDTA (alternative serum);
• Frozen tissue specimens;
• Other: formalin-fixed tissue or
paraffin-embedded tissues
For serology, testing of acute and
convalescent specimens is strongly
recommended.
• EDTA tubes;
• Serum separator tubes;
• Heparin can cause interference
with PCR reagents and tests.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 232
TABLE 1: Specimen collection and storage, (continued)
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Haemorrhagic
Fever
Marburg virus
disease
• Whole blood (2.5ml) collected on
EDTA (alternative serum);
• Oral fluid collected from deceased
patients;
• Other: formalin-fixed tissue or
paraffin-embedded tissues.
For serology, testing of acute and
convalescent specimens is strongly
recommended.
• EDTA tubes;
• Serum separator tubes;
• Heparin can cause interference
with PCR reagents and tests.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Rift Valley fever • Whole blood (2.5ml) collected on
EDTA (alternative serum);
• Frozen tissue specimens;
• Other: formalin-fixed tissue or
paraffin-embedded tissues.
For serology, testing of acute and
convalescent specimens is strongly
recommended.
• EDTA tubes;
• Serum separator tubes;
• Heparin can cause interference
with PCR reagents and tests.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Yellow fever • Whole blood (serum – 1ml);
• Other: urine (10ml) has been
recommended but is not a
validated specimen type.
• EDTA tubes;
• Serum separator tubes;
• Sterile urine collection tube.
• < 24 hours: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Acute Jaundice
Syndrome
Leptospirosis • Whole blood (250 uL);
• Serum (250 uL);
• Cerebrospinal fluid (CSF – 250 uL);
• Urine (10ml);
• Isolate and media inoculated with
clinical specimens (blood, tissue
and urine).
• Blood specimens should be
collected in EDTA or Sodium
Citrate tubes;
• Blood specimens collected in
heparin are not acceptable.
• Cultures should be stored at room
temperature;
• Clinical specimens to be kept frozen
at -20°C;
• Serum to be stored at 4°C.
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 233
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Neurological
Syndrome
Meningococcal
meningitis
• Blood (Adult: 5-10ml / Child:
1-3ml);
• Cerebrospinal fluid (CSF – 3ml);
• Aspirate or biopsy of any normally
sterile site (e.g. cardiac fluid) and/
or purpuric skin lesion.
• CSF:
– 1 dry tube and 1 Cryotube (for
PCR);
– If dry tube cannot be processed
in <2 hours, inoculate into trans-
isolate (T-I) medium;
• Blood: Collected blood should
be diluted in blood culture
broth in order to obtain blood
cultures. Specimens should be
immediately inoculated (within
one minute) into a blood culture
bottle.
• CSF in dry tube: room temperature;
• CSF in Cryotube: stored at refrigerator
temperature and transported in cold
chain;
• CSF isolates: stored frozen at -20°C to
allow further testing;
• Trans-isolate (TI) media vials should
never be frozen. Before inoculation TI
vials should be kept in the refrigerator.
Once inoculated, TI vials should be
kept at room temperature. Inoculated
TI vials must be ventilated if not
transported the same day;
• Inoculated blood culture media
should be protected from temperature
extremes (<18°C or >37°C) with a
transport carrier and thermal insulator
(such as extruded polystyrene foam);
• Inoculated blood culture bottles
should not be placed in the
refrigerator.
Acute
Respiratory
Syndrome
Anthrax • Whole blood;
• Skin lesion exudates;
• Pleural fluid;
• Cerebrospinal fluid (CSF);
• Rectal swab;
• Ascites fluid;
• Tissues from biopsy or autopsy.
• Blood specimens should be
collected in EDTA or Sodium
Citrate tubes (not heparin);
• Tissues for Immunohistochemistry
(IHC) should be formalin-fixed.
• Most samples can be sent 2-8°C;
• Fresh tissue should be sent frozen
and fixed tissue can be sent at room
temperature.
TABLE 1: Specimen collection and storage, (continued)
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 234
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Respiratory
Syndrome
Influenza • Virus isolates;
• Respiratory clinical specimens
(i.e. nasopharyngeal swabs,
nasal swabs, throat swabs, nasal
aspirates, nasal washes, lower
respiratory tract specimens,
broncho lavage);
• Nucleic acid.
(1ml)
For suspected avian influenza
samples: collect lower respiratory
tract specimens in addition to upper
respiratory tract specimens
• Dacron or polyester flocked
swabs with universal transport
medium
• Dacron orSpecimens received cold
should be stored refrigerated (2°–8°C)
for up to 72hrs before processing.
• Dacron orStore any residual specimens
at ≤ -70°C.
• Dacron orAlthough optimal
performance is met when testing fresh
specimens within 72hrs of collection,
performance has been demonstrated
with frozen specimens:
– If testing of a fresh specimen is not
possible within 72 hours storage at
2–8°C, the specimen may be frozen
at ≤ -70°C and tested at a later time;
– Specimens received frozen should
be stored at ≤ -70°C until processing;
– Store any residual specimens at ≤
-70°C;
– Ship extracted RNA and frozen
specimen on dry ice.
Plague • Bubonic plague: bubo aspirate
plus, swabs in bacterial transport
media (e.g. Cary-Blair);
• Pneumonic plague: sputum plus
swabs in bacterial transport media
(e.g. Cary-Blair);
• Blood for serology.
Specimens should be collected
during the acute phase of illness
and ideally before commencement
of antibiotic treatment
• Fresh or frozen: swab, biopsy,
touch prep slides, formalin-fixed,
paraffin block;
• Swabs should be made of nylon,
polyester, or Dacron material.
• Storage at 2-8°C
TABLE 1: Specimen collection and storage, (continued)
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 235
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Respiratory
Syndrome
MERS • Lower respiratory tract:
– Sputum;
– Aspirate;
– Lavage;
• Upper respiratory tract:
• Naso-pharyngeal and Oro-
pharyngeal swabs;
• Naso-pharyngeal
• wash / naso-pharyngeal aspirate;
• Serum.
(1ml)
Collection of both upper and
lower respiratory tract specimens is
recommended
• Dacron, polyester swabs with
universal transport medium;
• Blood: EDTA.
• < 24 hrs: room temperature;
• > 24hrs-72hrs: 0-4°C;
• Long term storage: -20°C or -70°C
(preferable).
Acute
Dermatological
Syndrome
Cutaneous
anthrax
• Skin lesion exudates;
• Tissues from biopsy or autopsy;
• Other:
– Whole blood;
– Pleural fluid;
– Cerebrospinal fluid (CSF);
– Rectal swab;
– Ascites fluid.
• Blood specimens should be
collected in EDTA or Sodium
Citrate tubes (not heparin);
• Tissues for immunohistochemistry
(IHC) should be formalin-fixed.
• Most samples can be sent 2-8°C;
• Fresh tissue should be shipped frozen;
• Fixed tissue should be shipped at
room temperature.
Monkeypox • Lesion fluid and/or material:
– Vesicle/pustule skin or fluid;
– Scab, crust;
• Optional but not preferred: blood.
(0.5ml for fluids)
• Swabs without individual holders
may be stored in a sterile
container;
• Dry swabs are preferred but a
minimal amount of viral transport
media may be added.
• Storage at 4°C, shipments within 72hrs
TABLE 1: Specimen collection and storage, (continued)
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 236
Information to be recorded:
Patient information, EPID number, date of sample collection, laboratory ID number, and clinical/epi information
SYNDROME DISEASE PREFERRED SPECIMEN TYPES &
SPECIMEN VOLUMES (minimum)*
SPECIMEN COLLECTION
MATERIALS
STORAGE OF SPECIMENS
Acute
Dermatological
Syndrome
Smallpox • Cutaneous lesion scabs;
• Pustule fluid.
(0.5ml for fluids)
• Swabs without individual holders
may be stored in a sterile
container;
• Dry swabs are preferred but a
minimal amount of viral transport
media may be added.
• Storage at 4°C, shipments within 72hrs
Acute Fever
and Rash
Chikungunya • Whole blood, serum (4-5ml venous
blood);
• Other: urine has been
recommended but is not a
validated specimen type;
• CSF in meningoencephalitis cases:
– Synovial fluid in arthritis with
effusion;
– Autopsy material – serum or
available tissues.
• EDTA tubes;
• Serum separator tubes;
• Sterile urine collection tube.
• Storage at 0 to 4⁰C
Zika • Whole blood, serum, plasma (4-
5ml venous blood);
• Urine;
• Cerebrospinal fluid (CSF – 0.25ml);
• Other: semen.
• EDTA tubes;
• Serum separator tubes;
• Sterile urine collection tube.
• Storage at 4⁰C;
• >48hrs, serum should be separated.
TABLE 1: Specimen collection and storage, (continued)
* For detection, specimens should be collected during the acute phase of illness. Test results are highly dependent on timing of specimen collection in relation to
disease onset; therefore, multiple specimens are required to confirm/exclude diagnosis.
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 237
TABLE 2: Laboratory diagnosis and shipment of infectious substances
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Diarrhoeal
Syndrome
Cholera • RDT for field use (needs
additional confirmation);
• PCR, MLVA, sequencing;
• Culture;
• Antibiotic susceptibility
testing.
• PCR: 24-48hrs;
• Culture and
susceptibility
testing: up to 8
weeks.
• Amoebic Dysentery
• Cryptosporidiosis
• Giardiasis
• Shigellosis
• E.coli
(enterotoxigenic and
enterohaemorrhagic)
• Viral gastroenteritis
(Norwalk-like and
rotavirus)
• Salmonellosis
• Campylobacter
• UN3373 – Biological
Substance
• Packing Instruction 650
Acute
Haemorrhagic
Fever
Syndrome
Crimean-Congo
haemorrhagic
fever
• Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Antigen detection;
• Serum neutralization;
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 72hrs.
• Hantaviruses
• South American
arenaviruses
• Tick-borne flaviviruses
• Chikungunya
• West Nile
• Sindbis
• Invasive Meningococcal
Disease
• UN2814 – Infectious
Substance affecting humans
• Packing Instruction 620
Dengue • Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Antigen detection: IgM,
IgG, RDTs;
• Serology; IgM, RDTs;
• Virus isolation.
• PCR: 24hr;s
• ELISA: 72hrs.
• Cultures:
– UN2814 – Infectious
Substance affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 238
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Haemorrhagic
Fever
Syndrome
Ebola virus
disease
• Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Antigen detection (RDT);
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 72hrs.
• Hantaviruses
• South American
arenaviruses
• Tick-borne flaviviruses
• Chikungunya
• West Nile
• Sindbis
• Invasive Meningococcal
Disease
• UN2814 – Infectious
Substance affecting humans
• Packing Instruction 620
Lassa fever • Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 72hrs.
• UN2814 – Infectious
Substance affecting humans
• Packing Instruction 620
Marburg virus
disease
• Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 72hrs.
• UN2814 – Infectious
Substance affecting humans
• Packing Instruction 620
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
TABLE 2: Laboratory diagnosis and shipment of infectious substances, (continued)
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 239
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Haemorrhagic
Fever
Syndrome
Rift Valley fever • Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Virus isolation by cell
culture.
• PCR:24hrs;
• ELISA: 72hrs.
• Hantaviruses
• South American
arenaviruses
• Tick-borne flaviviruses
• Chikungunya
• West Nile
• Sindbis
• Invasive Meningococcal
Disease
• Cultures:
– UN2814 – Infectious
Substance affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
Yellow fever • Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Neutralization assays;
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 10 days;
• PRNT: up to 2
weeks.
• Cultures:
– UN2814 – Infectious
Substance affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
Acute Jaundice
Syndrome
Leptospirosis • Serology: MAT-micro
agglutination;
• Molecular: Polymerase
Chain Reaction (PCR);
• Microscopy.
• 2 weeks;
• Primary isolation
from clinical
specimens takes up
to 6 months.
• Hepatitis A-E
• CMV
• EBV
• Other flaviviruses
• UN3373 – Biological
Substance
• Packing Instruction 650
Yellow fever • Reverse transcriptase
polymerase chain reaction
(RT-PCR) assay;
• Enzyme-linked
immunosorbent assay
(ELISA);
• Neutralization assays;
• Virus isolation by cell
culture.
• PCR: 24hrs;
• ELISA: 10 days;
• PRNT: up to 2
weeks.
• Cultures:
– UN2814 – Infectious
Substance affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
TABLE 2: Laboratory diagnosis and shipment of infectious substances, (continued)
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 240
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Neurological
Syndrome
Meningococcal
meningitis
• Culture;
• PCR.
• PCR: 48hrs;
• Culture: 4-5days.
• H.influenzae
• Strep. Pneumoniae
• Enteroviral meningitis
• Malaria
• Poliomyelitis
• Rabies and other
lyssaviruses
• African trypanosomiasis
• Meningoencephalitis
• Tick-borne encephalitis
viruses
• Japanese encephalitis
• UN3373 – Biological
Substance
• Packing Instruction 650
Acute
Respiratory
Syndrome
Anthrax • Culture;
• PCR;
• Immunohistochemistry
(IHC);
• Toxin detection.
• PCR: 24hrs;
• Culture, toxin
detection: 2 weeks.
• Diphtheria
• Hantavirus Pulmonary
Syndrome
• Mycoplasma
• Legionellosis
• Respiratory syncytial
virus
• Pertussis
• Other respiratory
viruses
• Cultures:
– UN2814- Infectious Substance
affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
Influenza • PCR;
• Virus isolation;
• HAI (Hemagglutination
Inhibition Test).
• PCR: 24hrs;
• HAI: 72hrs;
• Culture: 1-2 weeks.
• Cultures of avian influenza
and suspected avian/
pandemic influenza:
– UN2814 – Infectious Substance
affecting humans
– Packing Instruction 620
• Diagnostic clinical specimen:
– UN3373 – Biological
Substance
– Packing Instruction 650
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
TABLE 2: Laboratory diagnosis and shipment of infectious substances, (continued)
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 241
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Respiratory
Syndrome
Plague • Rapid dipstick test;
• PCR;
• ELISA IgM;
• culture;
• DFA.
• PCR: 24hrs;
• Culture: 1 week.
• Diphtheria
• Hantavirus Pulmonary
Syndrome
• Mycoplasma
• Legionellosis
• Respiratory syncytial
virus
• Pertussis
• Other respiratory
viruses
• Cultures:
– UN2814 – Infectious Substance
affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
MERS • Molecular: PCR positive on
at least two gene targets:
Screening assay (e.g. up
E or N gene NAAT) and
Confirmatory assay (e.g.
ORF 1a, ORF 1b or N gene
NAAT);
• Serology:
immunofluorescence
assays, serum neutralization
assays, protein microarray
technology, recombinant
nucleocapsid (N) and
spike (S) protein-based
indirect enzyme-linked
immunosorbent (ELISA),
and a neutralization
test based on retroviral
pseudoparticles.
• PCR: 24hrs;
• IFA: 24hrs;
• ELISA and
microneutralization:
1-3 days.
• UN3373 – Biological
Substance
• Packing Instruction 650
TABLE 2: Laboratory diagnosis and shipment of infectious substances, (continued)
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 242
SYNDROME DISEASE TYPE OF TEST FOR CONFIRMATION*
AVERAGE
TEST RESULTS
TURNAROUND TIME
DIFFERENTIAL
DIAGNOSIS
SHIPMENT CLASSIFICATION
BASED ON INTERNATIONAL
SHIPMENTS**
Acute
Dermatological
Syndrome
Cutaneous
anthrax
• Culture;
• PCR;
• Immunohistochemistry
(IHC);
• Toxin detection.
• 2 weeks
• Chickenpox
• Herpes
• Enterovirus
• Measles
• Medication-associated
allergies
• Bacterial skin infections
• Cultures:
– UN2814- Infectious Substance
affecting humans
– Packing Instruction 620
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
Monkeypox • PCR • 24hrs • UN2814- Infectious
Substance affecting humans
• Packing Instruction 620
Smallpox • PCR • 24hrs • UN2814- Infectious
Substance affecting humans
• Packing Instruction 620
Acute Fever
and Rash
Chikungunya • PCR;
• Serology;
• Viral culture.
• PCR: 24hrs;
• ELISA: 2-5 days;
• Virus isolation ≤ 8
days.
• Leptospirosis,
• Alphavirus infections
• Dengue
• Malaria
• Meningitis
• Post-infectious arthritis
(incl. rheumatic fever)
• Invasive Meningococcal
Disease
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
Zika • PCR;
• Serology;
• Neutralization tests.
• PCR: 24hrs;
• ELISA: 2-5 days.
• Diagnostic clinical specimens:
– UN3373 – Biological
Substance
– Packing Instruction 650
* Consideration must be given to the design and performance of the diagnostic products to ensure that testing is safe and effective
** Safety measures remain the same for national shipments
TOOL BOX 3
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 243
TOOL BOX 4 Transport of
infectious substances
Infectious substances: definition
For the purposes of transport, infectious
substances are defined as substances which
are known or are reasonably expected to
contain pathogens. Pathogens are defined as
microorganisms (including bacteria, viruses,
rickettsiae, parasites, fungi) and other agents
such as prions, which can cause disease in
humans or animals.
This tool box highlights some important features of the Guidance on
regulations for the Transport of Infectious Substance 2017-2018 1,
World Health Organization, 2017.
1 The full guidance can be found on: http://www.who.int/ihr/publications/WHO-WHE-CPI-2017.8/en/
Laboratory diagnosis
Patient
Specimen
collection
National
laboratory
International
laboratory
The definition is applied to all specimens
except those explicitly exempted:
• Cultures;
• Patient specimens;
• Biological products;
• Genetically modified microorganisms
(GMMOs) and organisms (GMOs);
• Medical or clinical wastes.
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 244
http://www.who.int/ihr/publications/WHO-WHE-CPI-2017.8/en/
Classification
Infectious substances are classified in Division
6.2 of the Dangerous Goods Regulations and
assigned to proper shipping names according
to their hazard classification and their
composition (UN 2814, UN 2900, UN 3291 or
UN 3373).
Infectious substances are divided into the
following categories:
• Category A – An infectious substance which
is transported in a form that, when exposure
to it occurs, is capable of causing permanent
disability, life-threatening or fatal disease in
otherwise healthy humans or animals.
• Category B – An infectious substance which
does not meet the criteria for inclusion in
Category A.
• Exemptions.
General preparation of
shipments for transport
Because of the differences in the hazards posed
by Category A infectious substances (UN
2814 and UN 2900) and Category B infectious
substances (UN 3373), there are variations in
the packaging, labelling and documentation
requirements for the two categories.
Note 1: Hand carriage of Category A and
Category B infectious substances and transport
of these materials in diplomatic pouches are
strictly prohibited by international air carriers.
Note 2: Inner packaging containing infectious
substances shall not be consolidated with
inner packaging containing unrelated types of
goods.
Shippers of infectious substances shall ensure
that packages are prepared in such a manner
that they arrive at their destination in good
condition and present no hazard to persons or
animals during transport.
Basic triple packaging system
This system of packaging shall be used for
all infectious substances. It consists of three
layers as follows:
• Primary receptacle. A primary watertight,
leak-proof receptacle containing the
specimen. The receptacle is packaged with
enough absorbent material to absorb all
fluid in case of breakage or leakage.
• Secondary packaging. A second durable,
watertight, leak-proof packaging to enclose
and protect the primary receptacle(s).
Several cushioned primary receptacles may
be placed in one secondary packaging,
but sufficient additional absorbent material
shall be used to absorb all fluid in case of
breakage or leakage.
• Outer packaging. Secondary packagings
are placed in outer shipping packagings
with suitable cushioning material. Outer
packagings protect their contents from
outside influences, such as physical damage,
while in transit. The smallest overall external
dimension shall be 10 x 10 cm.
Each completed package is normally
required to be correctly marked, labelled
and accompanied with appropriate shipping
documents (as applicable).
There are specific packaging, labelling and
documentation requirements for infectious
substances in Category A and with lesser
constrains for substances in Category B.
Overpacks
• For both categories it is possible to use
overpacks.
• “Overpack” is the term used when several
packages are combined to form one unit
and sent to the same destination by a single
shipper. When refrigerants are used to protect
contents, the overpacks may comprise
insulated vessels or flasks. Whenever an
overpack is used, the required marks and
labels shown on the outer packaging must
be repeated on the outermost layer of
the overpack. This requirement applies to
infectious substances in Categories A and B.
Overpacks are also required to be marked
with the word “overpack”.
• It is very important not to reproduce UN
specifications mark on the overpack.
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Reusing packaging materials
Shipping packages can be reused. If the
shipper plans on reusing a package, it must
be appropriately disinfected. Before reusing a
package, the shipper must make sure all marks
and labels reflect the substances actually being
shipped. If the shipper plans on shipping an
empty package, all non-applicable marks and
labels must be removed or covered. Before
an empty package is returned to the shipper,
or sent elsewhere, it must be appropriately
disinfected or sterilized to nullify any hazard.
Any label or mark indicating that it had
contained an infectious substance shall be
removed or covered.
Refrigerants
• Refrigerants may be used to stabilize
infectious substances in Categories A and B
during transit.
• Packed infectious substances requiring
cooling meet the appropriate requirements
as described in the guidance on regulations
for the Transport of Infectious Substances
2017-2018.
Trainings
• The Dangerous Goods Regulations require
all personnel involved in transport to
undergo appropriate training.
• For the transport of Category A infectious
substances, personnel must undergo training
in accordance with the modal requirements.
This can involve attendance at approved
courses and passing examinations.
• For the transport of Category B infectious
substances, there is a requirement that clear
instructions on the use of the packaging
are supplied to the user; this is regarded as
sufficient “training” for the shipping of these
substances. However, if such specimens are
consigned with other dangerous goods (e.g.
flammable liquids, radioactive materials,
liquefied gases, etc.), then personnel must
be trained in the proper procedures for their
transport.
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PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 246
Transport
• It is the responsibility of the shipper to
ensure the correct classification, packaging,
labelling, and documentation of all infectious
substances destined for transport.
• The efficient transport and transfer of
infectious substances requires good
coordination between the sender, the carrier
and the receiver to ensure that the material is
transported safely and arrives on time and in
good condition. Such coordination depends
upon well-established communications and
a good working relationship between the
three parties.
Main actors in the infectious substance
transport chain are:
• The shipper;
• The carrier;
• The receiver.
Descriptions of their respective responsibilities
and duties can be found in the guidance on
regulations for the Transport of Infectious
Substances 2017-2018. For more information on the
transport of infectious substances:
• Guidance on regulations for the transport of infectious
substances 2017–2018, World Health Organization,
2017:
http://www.who.int/ihr/publications/WHO-WHE-
CPI-2017.8/en/
TOOL BOX 4
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 247
TOOL BOX 5
Vector control
Prevention of Vector-Borne Diseases and control measures against
vectors during epidemic situations
Some epidemic diseases are transmitted by arthropods vectors, such as ticks and insects. To
prevent the transmission of these infectious diseases called Vector-Borne Diseases (VBDs),
actions can be taken to protect human beings from the vectors and/or to eliminate or reduce
vectors population. These actions include community engagement, personal protection and
vector control operations.
Recommendations and deployment of the available tools are modulated according to the level
of the transmission of the disease, which can range from sporadic to endemic levels and finally
to epidemic level. Coordination of the deployment of the different tools at different levels is
aided by having a preparedness plan and trained staff.
Countries are recommended to have national preparedness plans for the prevention and
control of VBDs, as well as a training program for staff engaged in vector control activities.
Regional coordination is also necessary as most of the VBDs cross borders.
PART III: TOOL BOXESMANAGING EPIDEMICS | KEY FACTS ABOUT MAJOR DEADLY DISEASES 248
Below is a list of epidemic-prone VBDs that are included in the handbook. These are transmitted
by different vectors but share the common transmission mode, via the bite (in other VBDs such
as Chagas disease and Typhus, other transmission modes are found):
These different vectors have different ecologies,
behaviors, biting times and transmission cycles. The
bionomics of the vectors affects the type of actions
taken to prevent and control these diseases. In all
situations, there are four key actions:
a. Personal protection tools: Table 1 summarizes
the biting behavior of the different vectors and the
type of personal protection available.
b. Vector control operations implemented by
public and/or private agencies and deployed at
the community level. Table 2 summarizes vector
control tools available for each vector type.
c. Community engagement, essential for outbreak
response.
d. Communication of the different actions, as an
essential component for success. Public Health
recommendations must take into account social
and cultural factors.
• The Crimean-Congo haemorrhagic fever virus (CCHFV) is transmitted
by ticks of the family Ixodidae, mainly by Hyalomma genus. In the
Mediterranean and Middle Asia regions, the most prominent vector is
Hyalomma marginatum.
• The Yellow fever (YFV), Zika (ZIKV) and Chikungunya (CHIKV) viruses are
transmitted by mosquitoes, through different cycles from sylvatic (wild), rural,
peri-urban and urban, with different vector species according to the cycle.
Zoonoses can occur in sylvatic transmission involving various vector species,
whereas epidemics are found to occur in rural and urban environments, with
the main vector being Aedes aegypti, and an emerging secondary vector
being Aedes albopictus.
• The Plague is a bacterial disease transmitted by fleas into wild cycles in
which rodents’ fleas are playing a major role. For epidemics in domiciliary
environments, the rodent’s fleas, such as the most known Xenopsylla cheopis,
are the major vectors. However, the association between the disease caused
by Yersinia pestis and the fleas species is not very specific, thus many fleas
species can act as plague vectors.
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TABLE 1: Personal protection tools according to the type of vectors
Type of vector (VBDs)
Vectors bionomics
Personal Protection tools
Natural environment
Biting time
Need animal cycle
Bednet
Repulsive
Window screen
Insecticide Sprays
Electric devices
Elimination of domestic
breeding sites
Forest, wild
Day
Yes
–
++
+
+
–
–
Ticks
(CCHFV)
Aedes mosquitoes
(YFV, CHIKV, ZIKAV)
Fleas
(PLAGUE)
Domestic, rural & urban
Day
No
+
+++
+++
+++
++
+++
Domestic, wild
All day
Yes / No
–
++
–
++
–
+++
The vector control activities are deployed at the community level to eliminate the vectors and larvae as much as
possible, in order to prevent or control the transmission of VBDs. The operationalization of vector control varies
according to the type of vector and transmission intensity.
• Vector control strategies should address all life stages of the Aedes mosquito from the egg, to larva and adult.
• Among the control measures, insecticide applications are the most frequently used, either on the animal bearing
the vectors, such as the ticks and the fleas, or in the breeding places to kill vectors’ larvae, and finally, as adulticide-
spraying to eliminate adult female mosquitoes.
• Other vector control activities include:
– Environmental measures through sanitation, habitat management and livestock management;
– Mechanical measures with trapping of vectors;
– Biological tools using natural enemies and biological larvicides for mosquitoes;
– Other chemicals such as the use of mimics of natural hormones to stop the insect development;
– A new generation of vector control products is also arriving with genetically modified organisms (e.g. bacteria
Wolbachia).
TOOL BOX 5
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TABLE 2: Vector control tools according to the type of vectors
Type of vector (VBDs)
Endemic situation
Epidemic situation
Insecticide against larvae
Insecticide against adults
Animal sprayed
Physical elimination of all breeding
sites (public and domestic)
Mechanical trapping
Environmental measures
Insecticide against larvae
Insecticide against adults
Animal sprayed
Physical elimination of all breeding
sites (public and domestic)
Mechanical trapping
Environmental measures
+
+
Yes
+
+
+
+++
+++
Yes
+
+
+
Ticks
(CCHFV)
Aedes mosquitoes
(YFV, CHIKV, ZIKAV)
Fleas
(PLAGUE)
+++
+
No
+++
+
++
+++
+++
No
+++
+++
+++
+++
+++
Yes
+++
++
+++
+++
+++
Yes
+++
+++
+++
• Vector control tools can be used alone or in combination, through an Integrated Vector Management (IVM)
approach (WHO, 2012) 1. The deployment, efficiency and results of the vector control activities require Monitoring
and Evaluation (M&E), but the methods to perform this M&E, both at the level of the vector population, and in terms
of disease transmission, are often lacking.
• Mosquito surveillance is part of vector control and helps improve timeliness of decisions to control mosquito
populations and prevention disease. Both larval and adult vector populations should be targeted for surveillance.
Epidemiological and entomological surveillance/indicators should be collected and analyzed in close
collaboration. This surveillance will include:
– Mosquitoes densities and geographical distribution;
– Contacts with human hosts;
– Effectiveness of control tools (e.g. susceptibility of resistance to insecticides).
1 WHO, Handbook for integrated vector
Management, 2012 http://apps.who.int/iris/
bitstream/10665/44768/1/9789241502801_eng
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http://apps.who.int/iris/bitstream/10665/44768/1/9789241502801_eng
Disease-specific approaches based
on the vectors’ ecology and
control options
The Crimean-Congo haemorrhagic fever
virus (CCHFV) is transmitted by Hyalomma
marginatum ticks.
• These ticks blood feed at all stages from the
6-legged larval stage to the adult stage to
complete their development and mature
their eggs. In addition to being transmission
vectors, ticks fulfil the role of reservoir of
CCHFV.
• The larval stages usually feed on small animals,
and the adult stages feed on larger animals
such as deer, sheep and cattle. The ticks do
not have feeding preference for the host and
humans are considered as accidental hosts.
The CCHFV circulates into animal populations
without causing diseases (except in ostriches)
and humans are considered as dead-end
hosts.
• In the regions with transmission risks, where
animals are infected by the CCHFV, the main
objective is to inform the public and the local
communities how to promote practices that
decrease transmission of the disease.
– Such practices would include preventing
contacts with the blood of virus-infected
animals (e.g. slaughtering activities),
preventing tick bites, and preventing the
transmission during care at home or during
funerals.
Key behavioral interventions
Animal settings
Home settings
Health care
settings
• Reduce ticks in the environment and decrease tick infestations on animals or in
stables/barns. The tick vectors are numerous and widespread and tick control
with acaricides (chemicals intended to kill ticks) is only a realistic option for
well-managed livestock production facilities.
• Implement quarantine for animals before they enter slaughterhouses or
routine treatment of ruminants with pesticides 2 weeks prior to slaughter. This
activity will decrease the risk for animal to be viraemic during its slaughtering.
• Wear personal protective equipment (masks, gloves and gowns) when
slaughtering and butchering animals in slaughterhouses or at home. This will
prevent skin contact with infected animal tissue or blood.
• Wear protective clothing (long leaves, long pants, etc.) and light colored
clothing (to allow easy detection of ticks on the clothes).
• Avoid of areas where tick vectors are abundant, when they are active (spring
to fall).
• Regular examination of clothing and skin for ticks.
• Use of repellents on the skin (e.g. DEET) and clothing (e.g. permethrin).
• Remove ticks safely from the skin.
• Seek early treatment for fever after a history of tick bites or contacts with
CCHF patients.
• Avoid any direct unprotected contact with blood or body fluids when
managing patients.
• Wash hands with soap and clean water regularly.
• Organise safe and dignified funerals.
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• Current vector control measures are not fully satisfactory:
– Chemical methods produce resistant ticks, food contamination, and environmental pollution.
Furthermore, chemical tick control is only realistic for well-managed and sufficiently resourced
livestock production facilities that are rare in most affected countries;
– Physical methods (e.g. heavy grazing, burning of grasslands) have an important environment
negative impact;
– Biological methods (e.g. use of hormones and growth regulators, use of predators, bacteria,
nematodes, and fungi) have not demonstrated full efficacy.
• Vaccination is considered a promising alternative to control tick infestations. An animal vaccine
effective against Hyalomma ticks that prevent the tick-animal-tick cycle would decrease tick
population, decrease CCHF prevalence in animals, and therefore decrease human exposure,
being a cost effective CCHF prevention measure.
• The virus cannot be amplified into humans and thus directly transmitted into a human cycle.
It needs amplifying hosts (domestic and wild animals) to provide blood meals to support tick
populations.
The Yellow fever (YFV), Zika (ZIKV) and Chikungunya (CHIKV) viruses are transmitted at an
epidemic level by mosquitoes belonging to the species Aedes aegypti and Aedes albopictus.
The Aedes mosquitoes also transmit the Dengue virus (DENV).
• Although these viruses can be transmitted by other mosquito vectors species in sylvatic
environments and potentially cause zoonoses, only the Aedes species are responsible for
epidemics as they have adapted to urban settings and can lay eggs in any kind of recipient
containing water in and around houses and other human dwellings in urban and scattered
rural areas.
• The development of the larvae can be very short, less than a week, and thus the increase of
the mosquito population can be exponential if the conditions are favorable (temperatures and
water) in the absence of any vector or larvae control.
• It is thus strongly recommended to maintain regular control of these mosquito populations
through the physical elimination of all breeding sites, in private and public spaces, and
through the use of larvicides in breeding places that cannot be eliminated. The biological
larvicide with Bacillus thuringiensis var. israelensis toxins are recommended because of the
lack of resistance and no environmental drawback.
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• During an epidemic situation, all tools to protect humans from mosquito bites (Table 1), as well
as all available tools to eliminate adult mosquitoes are recommended, with reinforcement of
the elimination of breeding sites, use of larvicide and use of adulticide 2.
– The efficacy of the products needs to be monitored in advance with tests on resistance and,
if necessary, an integrated resistance management plan must be developed.
– The spraying of adulticides must be done on a daily basis until the mosquito populations are cut
down under the necessary Breteau Index (BI) (that is the number of positive containers in 100
houses) which should be less than 1 3.
– Community engagement is also a very important component for controlling Ae. aegypti and
Ae. albopictus populations. Through participative actions, such as recommendations for personal
protection in the working places and schools, elimination of breeding sites, installation of window
screens, and overall surveillance of the environment to make it less favorable for mosquitoes, are
some of the major actions that can be taken by communities.
• Vector control against Ae. aegypti and Ae. albopictus, the main vectors of urban arboviruses
have not been reported as efficient as it is required due to many factors (including unplanned
urbanization and lack of resources). However, these tools are the only ones available in many
situations and will result in controlling the transmission if well applied.
Plague circulates into mammals, especially
rodents, in almost all regions of the world.
• The humans are affected by Plague epidemics
according to two main transmission modes.
At the beginning of an epidemic, rodents are
affected by the disease with fleas as vectors,
then the fleas leave the dying rodents and
move on to humans. At this stage, the Plague is
called bubonic because bubonic abscesses are
the main clinical symptoms. With the spread of
the bacterial into the lungs, humans can directly
transmit the Plague bacteria to other human
beings, and the Plague is called pneumonic.
• The fleas are host-specific and animal fleas bit
human rather by accident.
• Sanitation and rat control are the best
practices to prevent human Plague. When
Plague cases are reported, control measures
must first target fleas and secondarily
rodents, because the use of raticide may result
in the adverse effect, with fleas leaving the
dead rats and moving onto humans.
• Depending on environmental context, large
deployment of insecticide baited traps for
rats can be recommended.
• Environmental measures to repel rat population
as well as strong disinsectisation of places
where rats are installed can also be applied.
• The community engagement is also very
important for coordinated rat control activities,
management of wastes and domestic
environment.
2 WHO, Pesticide and their application for the control of vectors and pests of public health importance, 2006.
http://apps.who.int/iris/bitstream/10665/69223/1/WHO_CDS_NTD_WHOPES_GCDPP_2006.1_eng
3 Bowman LR,Runge-Ranzinger S and McCall PJ. Assessing the Relationship between Vector Indices and Dengue
Transmission: A Systematic Review of the Evidence. PLoS Negl Trop Dis. 2014 May; 8(5): e2848. doi: 10.1371/
journal. pntd.0002848
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Acknowledgements
The Managing epidemics handbook is a WHO collective endeavour
with the involvement of the WHO Health Emergencies Programme
(WHE) departments and, in particular, many Infectious Hazard
Management (IHM) experts at HQ, Regional and Country levels. It
has also been developed in collaboration with other departments
within the WHO:
The Special Programme for Research and Training in Tropical
Diseases (TDR), Health Emergency Information & Risk Assessment
(HIM), Emergency Operations (EMO), Country Health Emergency
Preparedness & IHR (CPI), Information Evidence and Research
(IER), Polio Eradication (POL), and Control of Neglected Tropical
Diseases (NTD) departments.
256
Authors & contributors
WHO acknowledges the contributions given
by the following individuals who have provided
inputs and/or contributed to the drafting,
review and/or production of the handbook:
Aysheshim Ademe, Hernando Agudelo, Kate
Alberti, Sylvain Aldighieri, Yahaya Ali Ahmed,
Sophie Allain Ioos, Yokouide Allarangar, Inacio
Alvarenga, Javier Aramburu, Richelot Ayangma
Mouko, Jean-Christophe Aze, Freddy Banza
Mutoka, Cecile Barbou des Courieres, Mady Ba,
Maurizio Barbeschi, Philippe Barboza, Jennifer
Barragan, Ahmadou Barry, Rodrigue Barry,
Bienvenu Baruani Ngoy, Marie Roseline Darnycka
Belizaire, Luisa Belloni, Simeon Bennett, Justus
Benzler, Isabelle Bergeri, Eric Bertherat, Terry
Besselaar, Aphaluck Bhatiasevi, Viviane Bianco,
Bonkoungou Boukaré, Anna Bowman, Rick
Brennan, Sylvie Briand, Caroline Brown, Gisèle
Bwende Kasungi, Jorge Castilla, Andersen
Chimusoro, Stella Chungong, Laurence Cibrelus,
Ian Clarke, Peter Clement, Rudi Coninx, Alejandro
Costa, Ana Paula Coutinho Rehse, Fernando Da
Silveira, Arsene Daizo, Farah Dakhlallah, Lucia
Dell Amura, Ghyllain Demba Lubambo, Janet
Diaz, Heidi Divecha, Devika Dixit, Mamoudou
Harouna Djingarey, Sabelo Dlamini, Emmanuel
Douba, Patrick Drury, Kara Durski, Amgad
Abdalla Elkholy, Nedret Emiroglu, Rocío Escobar,
Anthony Eshofonie, Socé Fall, Ana Fernandes,
Katya Fernandez, Johanna Fihman, Julia Fitzner,
Pierre Formenty, Florence Fouque, Mara Frigo,
Florence Fuchs, Caroline Fuhrer, Christian Fuster,
Gaya Gamhewage, Erika Garcia, Sandra Garnier,
Semere Gebregiorgis, Yohannes Ghebrat,
Carolina Gomes, Philip Gould, Peter Graaff,
Michael Griffin, Mary-Anne Groepe, Aspen
Hammond, Alexandra Hill, Siddhivinayak Hirve,
Daniel Hougendobler, Khelifi Houria, Stéphane
Hugonnet, Poonam Huria, Anne Huvos, Benido
Impouma, Christian Itama Mayikuli, Yurie Izawa,
Alpha Jallow, Sandrine Joucla, Hilary Kagume
Njenge, Arnaud Kahn, Lingawako Kalinde
Mangachi, Ebba Kalondo, Masaya Kato, Erin
Kenney, Joyce Kerubo Onsongo, Asheena
Khalakdina, Moakofhi Kentse, James Kojo Teprey,
Davi Kokou Mawulé, Innocent Komackech,
Alexandra Kontic, Thomas d’Aquin Koyazegbe,
Eve Lackritz, Andersson Latt, Sharmila Lareef-Jah,
Anaïs Legand, Dominique Legros, Ellen Leroy,
Ailan Li, Francois Libama, Maja Lievre, Clement
Lingani, Jennifer Linkins, Daniel Lucey, André
Lukusa, Nuha Mahmoud, Kevin Makadzange,
Mamunur Malik, Awandha Mamahit, Koria
Mankampa, Stephen Maphosa, Rima Marrouch,
Christian Massidi, Humphreys Masuku, Margaux
Mathis, Petrus Mhata, Ruhana Mirindi Bisimwa,
Ann Moen, Vital Mondonge Makuma, Oliver
Morgan, Sylvie Mortier, Amadou Mouctar Diallo,
Mireille Flore Mouele, Ahamada Msa Mliva, Kelias
Msymbaoza, Martin Muita, Marjorie Mupandare,
Robert Musoke, Abrahams Mwanamwenge,
Dhamari Naidoo, Michel N’da Konan Yao, Miriam
Nanyunga, Jérôme Ndaruhutse, Charlotte Faty
Ndiaye, Jean-Bosco Ndihokubwayo, Landry
Ndriko Mayigane, Bla François Nguessan, Tim
Nguyen, Dorit Nitzan, Lionel Nizigama, Ian Norton,
Deo Nshimirimana, Alex Ntale Gasasira, Innocent
Nzeyimana, Roderico Ofrin, Sally-Ann Ohene,
Ifeanyi Okudo, Babatunde Olowokure, David
Olson, Catherine Oswald, Heather Papowitz,
Cyr Passi-Louamba, Scott Pendergast, William
Augusto Perea Caro, Anne Perrocheau, Arturo
Pesigan, Lorenzo Pezzoli, Marcia Poole, Jukka
Tapani Pukkila, Arthur Rakotonjanabelo Lamina,
Otim Patrick Cossy Ramadan, Bardan Jung Rana,
João Rangel De Almeida, Peter Rehse, Bertrand
Renaud, Tatiana Resnikoff, Amelie Rioux, Guenael
Rodier, Jose Rovira Vilaplana, Olivier Ronveaux,
André Rusanganwa, Florence Rusciano, Michael
Ryan, Massambou Sacko, Grace Saguti, Niang
Saidou Doro, Mohamed Sainda, Peter Salama,
Rosine Sama Kanembe, Gina Samaan, Magdi
Samaan, Ravi Santhana Gopala Krishnan, Nikki
Shindo, Véronique Sicilia, Raphael Slattery,
Catherine Smallwood, Vincent Sodjinou, Peter
Songolo, Mary Stephen, Oliver Gerd Stucke,
Ute Ströher, Aka Tano Bian, Israel Tareke, Joanna
Tempowski, Michel Thieren, Desta Tiruneh, Ciro
Ugarte Casafranca, Heini Utunen, Maria Van
Kerkhove, Katelijn Vandemaele, Reinhilde Van
De Weerdt, Raman Velayudhan, Sirenda Vong,
Christèle Wantz, Sergio Yactayo, Sanyang Yaya,
Daniel Yota, Zebulon Yoti, Wenqing Zhang, Ursula
Zhao, Weigong Zhou.
The development of the handbook was led by
Sylvie Briand, Director of the Department of
Infectious Hazard Management, and Margaux
Mathis in collaboration with the experts mentioned
above.
Edited by: Thomson Prentice
Design & layout by: Vivian Lee
Illustrations by: Sam Bradd (Drawing Change)
257
Key facts about major deadly diseases
Managing epidemics
World Health Organization
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CH-1211 Geneva 27
Switzerland
ISBN 978-92-4-156553-0
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