Jianshi (Jesse) Huang, Weiyi Xiong, Angus Nicoll
Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China; European Centre for Disease Prevention and
Control, Health Protection Agency, London School of Hygiene and Tropical Medicine, UK
Foresight China II: the Identification and detection of
infectious diseases
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I will discuss
What is the Foresight method?
Why does China need the Foresight Project ?
What is Foresight China IIMethodologyPreliminary resultsConclusion/Implications
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What is the Foresight method?
A scientific approach to the Future
Combining future look at diseases & threats with opportunities for mitigation & control
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Eight Foresight project areas to 2006
Brain Science, Addiction and
Drugs
Detection and Identification of
Infectious Diseases
Intelligent Infrastructure
Systems
Obesity
Cognitive Systems
Flooding andCoastal Defence
Exploiting the Electromagnetic
Spectrum
Cyber Trust and Crime Prevention
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What is the Foresight method?
10 areas of science of relevance to detection, identification and monitoring systems were reviewed and analyzed: Intelligent sensor networks Data mining and fusion Non-invasive scanning and
screening Predictive and real-time
epidemiological modelling ……
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Today’s world is a small village. What happens in China could have significant impact on Europe and vice versa.
It is better to have a capacity to anticipate significant changes in infectious diseases for emergency preparation.
However, “It is very difficult to make predictions, especially about the future”. (American Sage)
Without some moderately accurate predictions or at least early warning, we cannot have a safe global village.
Why does China need Foresight Project ?
04/19/237
Quantitative Predictions The existing methods used to predict
future trends in infectious diseases: (quantitative predictions)Predictions Modelling
Drawbacks: Predictions - short term, max. 5 yearsModelling – by definition all models
are wrong but some are useful
Why does China need Foresight Project ?
04/19/238
The existing quantitative approach is problematic:when we look well beyond five years. When we look groups of infections,
especially emergence of unknown pathogens.
When more than one drivers influence the occurrence of infectious diseases
There is much that we just can’t use the quantitative model to predict, or…
Why does China need Foresight Project ?
04/19/239
Chinese Sage? 大智若愚(世界上有)知道的已知,知道的
未知和不知道的未知。每一年都有一些知道的未知变成知
道的已知。同样,每一年我们都能了解到有更
多的不知道的未知。因此原来不知道的未知变成了知道的未知甚至知道的已知。
当然,有时我们能认识到其实我们不知道一些知道的已知,还自以为是地认为我们知道这些知道的已知。
04/19/2310
…translation from an American Sage“ …There are known knowns, known unknowns and unknown unknowns.
Each year some of the known unknowns become known knowns.
But equally each year we become aware of some more unknown unknowns so that they become known unknowns or even known knowns.
Of course sometimes we realise that we do not know some of the known knowns as well as we thought we knew them…”
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Instead of looking at specific disease Foresight method identified a series of families of factors ‘drivers’ or risks for the study of likely trends in those drivers and hence, families of diseases.
Why does China need Foresight Project ?
04/19/2312
Two applications of information from the Foresight approach:Surveillance prioritization – to
detect if the threat is materialising
Identification of needed countermeasures
Why does China need Foresight Project ?
04/19/2313
Foresight China: A novel and simple approach to anticipating likely future trends in drivers and families of infectious diseases and therefore, needs for surveillance and public health preparedness.
What was Foresight China I
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Foresight China I: 2004-2006Basic Risk Model for Infectious Disease Risks was adapted from UK colleagues, 36 leading Chinese experts were consulted.
Supported by Foresight Funding, Enacted by PUMC, HPA & China CDC
What was Foresight China I
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Some important factors affecting future risks were identified.
Output: Predicting changing risks not actual disease trends so as to plan for surveillance systems improvement and for public health preparedness.
What was Foresight China I?
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Increasing movements of people, animals and animal products
More and greater migrations of people Increasing tourismIncreasing amounts of animal wasteChanging sexual lifestylesChanging public attitudes Increasing genetic uniformity of crops and livestock Rising wealth and levels of education
Important factors affecting future risks
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Better definitions of each driver in the questionnaire would have improved consensus
Need to ask the panel to predict the future of the driver not its potential effect on diseases
Need for an expanded expert panel
Lessons learnt from Foresight China I
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Foresight China II: 2007-2008,A continuation of Foresight China I Improved methodologyExpanded number of experts consulted to 180
Supported by British Embassy BeijingEnacted by PUMC & China CDC
Hence Foresight China II
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Three new features over Foresight China I:
Systematic literature review to identify the scientific evidence for drivers
Extensive analysis of existing infectious disease surveillance systems in 4 countries to identify how they capture data on drivers
Consultations with leading experts in 12 areas to confirm the improvement opportunities and to assess feasibility of the opportunities
Foresight China II: Methodology
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Basic Risk Model for Infectious Disease Risks
DriversClimate change,
Socio-economic drivers, etc.
OutcomesFuture diseases and levels of infection in: PeoplePlantsAnimalsEcosystems
Risk Analysis
Risk Estimate
SourcesZoonosesNaturalmutationAvailableniches
PathwaysSoilAirborneFood-borneWaterborneVectorsDirect contactWaste disposal
Prioritisation of Surveillance and Control Measures (Preparedness)
Source:Professor Joyce Tait, University of Edinburgh
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Note the simplicity – compare with this model for
Climate Change and Health: Direct and Indirect Effects
Source: A. McMichael et al, The Lancet 2006; 367: 859-869.
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Foresight China II: Preliminary findingsReviewed recent experience of
newly reported emerging human pathogens
0
5
10
15
20
25
30
35
40
1980 1985 1990 1995 2000 2005
Cu
mu
lati
ve n
o.
sp
p
SA
RS
HIV
-1
vCJD
25 (66%) are RNA viruses >80% have animal reservoir/origins; broad range Diversity of transmission routes and drivers of
emergence But only a few emerging diseases are of great public
health importance
04/19/2324 Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.
Number of EID events per decade
04/19/2325 Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.
Global richness map of the geographic origins of EID events from 1940 to 2004
Reflection of local strength of surveillance?
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Global distribution of relative risk of EID event
Reference:Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global trends in emerging infectious diseases,nature,2008,451(21):990-994.
Zoonoses from wildlife Zoonoses from non-wildlife
Drug resistant pathogen Vector-borne pathogen
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The 12 families of drivers in Foresight China II
1.Environment related factors2.Iatrogenic related factors3.Animals and plants related factors
1.Governance and social cohesion2.Demography and population change3.Conflict4.Technology &Innovation and their governance5.Agriculture and land use change6.Economic factors7.Trade and Market related factors8.Transport and Tourism9.Human activity and social pressure10.Environment related factors11.Iatrogenic related factors12.Animals and plants related factors
1.Governance and social cohesion2.Demography and population change3.Conflict4.Technology &Innovation and their governance5.Agriculture and land use change6.Economic factors7.Trade and Market related factors8.Transport and Tourism9.Human activity and social pressure
Fore
sight C
hin
a
I
Fore
sight C
hin
a
II
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Extensive analysis of existing infectious disease surveillance systems in 4 countries
Do the surveillance systems capture data on the drivers? E.g. social factors driving tuberculosis spread
Foresight China II: Findings
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How do infectious diseases relate to the 12 family of drivers
We identified 18 priority infectious diseases according to:
WHO criteriaLeading causes of death/high morbidityEase to spreadingOn the international surveillance listHave a good, feasible preventive measuresCase definitions are clear and ease to detectHave a clear goal for elimination/eradication
Of 37 reportable diseases in China, those are10 leading cause of death of reportable
diseases10 diseases with highest incidence rate10 diseases with highest fatality rate
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18 priority infectious diseases
Tuberculosis (TB)MeaslesTyphoid\paratyphoidMalarianewborn tetanushydrophobia/rabiesgonorrheaSyphilisHIV/AIDSHemorrhagic fever
with Renal Syndrome (HFRS)
encephalitis Bepidemic
cerebrospinal meningitis
Leptospirosisplaguedengue feverViral Hepatitisbacillary and
amoebiasis dysentery
bird flu
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But neither do developed countries!
Percentage of 12 drivers/50 elements data
surveillance system collected by countries
12 family drivers, 50 elements, regarding to the 18 priority surveillanced infectious diseases. One element scores 1, The y-axis is the percents of elements that surveillance system have.
Percentage
%
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Leading experts consultations in 12 areasCharacteristics of the expertsResults
Foresight China II: Findings
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Leading experts consultations in 12 areasCharacteristics of the experts
(available on request)Results
Foresight China II: Findings
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Leading experts consultations in 12 areasCharacteristics of the expertsResults
Foresight China II: Findings
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Experts’ opinions on Four elements of Environment Related Factors in Foresight-China Study. The variables presented below are n (%).
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Experts’ opinions on Four elements of Environment Related Factors in Foresight-China Study. The variables presented below are n (%).
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Experts opinion on driver 1: Governance and social cohesion
Experts opi ni on re: dri ver 1: governance and soci al cohesi on
Yes % , 86%( )Yes % , 80%( )
0%
20%
40%
60%
80%
100%
Dri vers of I nf ect i ous Di seases ? Need survei l l ance?
Experts opi non re: The change trend of thefactor?
Strong %( )70%
No change%( )
17%
Weak %( )13%
04/19/2341
Experts opinion on the 12 families of drivers
Expert overal l opi ni on re: 12 dri vers
86%80% 78%
0%10%20%30%40%50%60%70%80%90%
100%
Dri vers of I nfecti ousDi seases ?
Need survei l l ance? Feasi bi l i ty of survei l l ance?
The change trend of the factor?
Strong,70%
No Change,17%
Weak, 13%
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Feasibility of surveillance(experts opinion)
Of 50 elements, 47 are identified as major influencing elements
Of the 47 major influencing elements, for 46 of them the experts considered it would be important to monitor them
But of the 46 elements, only 32 are considered to be feasible for monitoring surveillance
04/19/2344
Feasibility of surveillance(experts opinion)
Of the 46 elements:16 elements were considered
likely to result in trends that would be beneficial to the control of certain infectious diseases, e.g. education & economic development - food poisoning, tuberculosis
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Experts opinions on Trends in Drivers
Of 46 elements:30 elements were
considered to be associated with worsening occurrence and spreading of infectious diseases
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Experts opinions on Trends in Drivers
Of these 30 elements:o 7 elements were considered likely to
improve in the future e.g. poverty, hospital infection control and associated diseases would lessen.
o 18 elements are likely to deteriorate e.g. immigration, bioterrorism
o 5 elements were considered likely to stay unchanged e.g. unemployment, environmental pollution
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Feasibility of surveillance One Family of Drivers 1.
Governance and social cohesion
Readily Doable 1.Bio-security governance 2.International/national/regional
interactions affecting governance 3.lack of interaction between policy and
regulatory agencies 4.Marginalization of some groups specifyCan be done with some effort E.g. Illegal practicesDifficult to do or measure ? Consider later E.g. Social cohesion, political leadership
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Conclusions/Implications
We identified improvement opportunities for identification and detection of infectious disease using the Foresight framework in China
We are able to predicting changing risks not actual disease trends of infectious diseases. Thirty two (32) elements are identified as doable for sureillance systems improvement.
Now astudy is needed to test Foresight findings in test location.
04/19/2349
References Kate E. Jones, Nikkita G. Patel, Marc A. Levy,ect. Global
trends in emerging infectious diseases,nature,2008,451(21):990-994.
Louise Swift, Paul R. Hunter, Alexander C. Lees, ect. Wildlife Trade and the Emergence of Infectious Diseases. Ecohealth ,2007,4:25-30.
Mary E. Wilson. Travel and the Emergence of Infectious Diseases. Emerging infectious disease journal.1995,1(2):39-46.
McNeill WH. Plagues and peoples. Garden City, N.Y.:Anchor Press/Doubleday, 1976.
Stephen S. Morse. Factors in the Emergence of Infectious Diseases. Emerging infectious disease journal.1995,1(1):7-15.
Anthony Zwi, Pilar Ramos-Jimenez. Conflict, crisis and infectious disease.TDR Nnews.2002,68.
Strategic social ,economic and behavioral research. special programme for research &training in tropical disease(TDR). 2005,12.
Gaetan Gavazzi, Francois Herrmann, Karl-Heinz Krause. Aging and Infectious Diseases in the Developing World. Aging and infectious disease. 2004,39:83-91.
Elizabeth M. Prescott. The Politics of Disease: Governance and Emerging Infections. Global Health Goverance, 2007,1(1):1-8.
The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities, Workshop Summary .http://www.nap.edu/catalog/11588.html.
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Acknowledgements
UK-China Partners in SciencesDr David Concar - British Embassy Beijing
Ms. Duying - British Embassy Beijing
142 experts consulted64 field interviewers