The impact on the Global Health Security of the population movements and the role of points of entry (ports, airports, ground crossings)

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1 The impact on the Global Health Security of the population movements and the role of points of entry (ports, airports, ground crossings) Barbara Mouchtouri, DLSHTM, MSc, PhD EU SHIPSAN ACT Joint Action Manager, Greece

2 Content Population movements Points of entry (ports, airports, ground crossings) and means of transport Recent examples of public health risks due to population movements Health measures to prevent and control public health risks related to population movements at points of entry Actions at Country, European and Global levels

3 Αίτια μετακίνησης πληθυσμού Μετανάστευση (immigration) εσωτερική εξωτερική (internal-external) Νόμιμη παράνομη (legal - illegal) αποδημία επαναπατρισμός (emigration-repatriation) προσφυγικός εποικισμός (refugees) ατομική μαζική (individual - massive) εκούσια αναγκαστική βίαιη (voluntary-involuntary) Μετακίνηση-μεταφορά (transport) Αναψυχή τουρισμός (recreation - tourism) Επαγγελματικά ταξίδια (professional)

4 Μετανάστευση Major Migration Flows: Source: Population Action International

5 Μετανάστευση

6 Refugees/Migrants Emergency Response - Mediterranean

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8 Χρόνος που χρειάζεται για τον γύρο του κόσμου σε σχέση με τον πληθυσμό Days to Circumnavigate ( ) the Globe Year World Population in billions ( ) «Καμιά πόλη δεν απέχει περισσότερο από 24 ώρες από μια άλλη» Economist 2003 «Ετήσια οι αεροπορικές εταιρίες μεταφέρουν περίπου δύο τρισεκατομμύρια άτομα» Κάθε λεπτό πετάνε με αεροπλάνο περίπου άτομα Select Committee on Science and Technology Fifth Report UK Parliament 2000

9 Movements of travellers and goods By air About 3.1 billion passengers made use of the global air transport network for their business and tourism needs in 2013 (ICAO). The number of aircraft departures reached 33 million globally during Approximately 51 million tonnes of freight carried. Route database. Source:

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11 Movements of travellers and goods By sea About 9.2 billion tons of goods were loaded in ports worldwide (UN 2013) From , over 191 million passengers have taken a cruise (CLIA 2010) In July 2009 the global merchant fleet consisted of a total of 53,005 vessels (World ocean review) World busiest ports. Source:

12 8,600 travellers 16 passenger decks 20 restaurants 30 bars 20 recreational water facilities Modern conveyances

13 Τι μπορεί να μεταφερθεί με τα μέσα μετακίνησης Άνθρωποι Αέρας Εμπορεύματα Ζώα Πόσιμο νερό Τρόφιμα Νερά αναψυχής Θαλάσσιο έρμα Διαβιβαστές (έντομα) Φυτά Αποσκευές Φορτία Οχήματα Απόβλητα 1. Humans 2. Air 3. Potable water 4. Food 5. Recreational water (spas, swimming pools) 6. Ballast water 7. Sea water 8. Vectors (insects, rodents etc) 9. Animals 10. Plants 11. Luggage 12. Cargo 13. Vehicles 14. Waste

14 What are travelers carrying with them: Their language and culture Their hygiene standards and lifestyle Their DNA (chronic diseases) Possibly communicable diseases Immunological status Travellers

15 Recent examples of pubic health risks on ships transmitted from country to country Διασπορά Vibrio cholerae με θαλάσσιο έρμα (McCarthy 1994). Μόλυνση οστρακοειδών και νερό λιμένων με Vibrio cholerae κατά την επιδημία χολέρας στην Αϊτή (Hill 2011). Πυρηνικό ατύχημα στη Fukushima: ανίχνευση ραδιενεργού υλικού στα φίλτρα αέρα του πλοίου (Americas Navy 2011) Μεταφορά νυχτερίδων με πλοία και κρούσματα λύσσας σε μέλη πληρώματος εμπορικών πλοίων (Constantine 2003, Rimhanen-Finne 2010) Ελονοσία σε κατοίκους λιμένων στην Ιταλία, Γαλλία, Βέλγιο και Ισραήλ (Anselmo 1996, Delmont 1995, Peleman 2000, Rubin 2005) Προσβολή μεταχειρισμένων ελαστικών με κουνούπια: Aedes albopictus (Derraik JG. 2004)

16 Recent examples of pubic health risks on airplanes transmitted from country to country Severe Acute Respiratory Syndrome (Olsen et al 2003) Πυρηνικό ατύχημα στη Fukushima: ανίχνευση ραδιενεργού υλικού σε αεροσκάφος (Americas Navy 2011) Μεταφορά νυχτερίδων σε αεροσκάφος (Constantine 2003, Rimhanen-Finne 2010) Ελονοσία σε κατοίκους αερολιμένων : , 87 suspected cases almost all being P. falciparum close to Paris, Brussels and London airports (Giacomini and Brumpt 1989; Isaäcson 1989; Danis et al., 1996; Giacomini, 1998; Gratz et al., 2000, Tatem 2011)

17 Το κουνούπι Aedes albopictus σε χώρες του Παλαιού Κόσμου το 1930 (κόκκινο χρώμα). Χώρες εντοπισμού ενδιαιτημάτων και αναπαραγωγής του τα τελευταία 30 χρόνια (πορτοκαλί χρώμα). Χώρες εντοπισμού σε λιμάνια και αναχαίτιση της εισαγωγής του (κίτρινο χρώμα) (Tatem et al., 2006)

18 International Health Regulations (2005)

19 IHR 1969 VERSUS IHR 2005 From three diseases to all public health risks From preset measures to tailored response From control of borders to also include containment at source From reactive to proactive

20 Αλγόριθμος για λήψη αποφάσεων (Παράρτημα 2) του ΔΥΚ (2005) για εκτίμηση και δήλωση συμβάντων 4 νοσήματα που πρέπει να δηλώνονται αμέσως (πολιομυελίτιδα, ευλογιά, γρίπη από νέο στέλεχος, SARS) Νοσήματα για τα οποία πάντα χρησιμοποιείται ο αλγόριθμος: χολέρα, πνευμονική πανώλη, κίτρινος πυρετός, αιμορραγικοί πυρετοί (Ebola, Lassa, Marburg), πυρετός του Δυτικού Νείλου κ.α. Ε1: Η επίδραση είναι σοβαρή; Ε2: Ασυνήθιστο και απρόσμενο; Ε3: Κίνδυνος παγκόσμιας εξάπλωσης; Ε4: Κίνδυνος για περιορισμό σε ταξιδιώτες/εμπόριο; Ανεπαρκείς πληροφορίες: Επανεκτίμηση

21 Events detected by national surveillance system or reported by media or any non-governmental organization UNUSUAL DISEASES Smallpox Human influenzae (new subtype) Wild poliovirus Severe acute respiratory syndrome Any event of potential internation al public health concern Is the public health impact of the event serious? Is the event unusual or unexpected? Is there significant risk of international spread? Is there significant risk of travel or trade restriction? KNOWN EPIDEMIC PRONE DISEASES Cholera Pneumonic plague Viral haemorrhagic fevers Yellow fever West Nile fever Other locally or regionally important diseases If yes to any two of these questions National IHR focal point to notify WHO

22 WHO Headquarters International level Regional Surveillance Center* International Surveillance Network* IHR Contact Point, at WHO Regional Office National level Central Surveillance Office IHR National Focal Point NFPs in other countries Intermediate level Intermediate Health Authority Data sources 1 PoE public health intermediate level coordination Local level Local Health Authority Data sources 2 Other points of entry (in-country or abroad ) PoE Health Authority Data are collected and filtered ==> health events under surveillance are communicated upwards Point of entry Customs Veterinary Services Conveyance operators Air Control Tower Harbour Office * Regional/international centers and networks for surveillance exist only in some regions; According to national rules and arrangements; Data sources 1 : health care centers, hospitals, laboratories, point of entry in another country; Data sources 2 : health care centers, hospitals, laboratories, conveyance operators, customs, veterinary services, point of entry in another country

23 Pubic health emergency of international concern public health emergency of international concern means an extraordinary event which is determined, as provided in these Regulations: (i) to constitute a public health risk to other States through the international spread of disease and (ii) to potentially require a coordinated international response IHR Emergency Committee

24 Έκτακτα Περιστατικά Δημόσιας Υγείας Διεθνούς εμβέλειας Ιούνιος 2007 Απρίλιος 2009 Πανδημία γρίπης Η1Ν1 Αύγουστος 2014 Λοίμωξη από τον ιό Ebola Μάιος 2014 Πολιομυελίτιδα από άγριο πολιοιό Φεβρουάριος 2016 Zika virus disease

25 Γρίπη European Influenza Surveillance Network (EISN):. For the entire official pandemic period of 68 weeks (week 18/2009 to week 35/2010), cases of ILI (27 reporting countries) and cases of ARI were reported by EISN. ECDC SPECIAL REPORT. The 2009 A(H1N1) pandemic in Europe. A review of the experience

26 Πολιομυελίτιδα Ο αριθμός κρουσμάτων πολιομυελίτιδας μειώθηκε >99% κατά τα τελευταία 25 χρόνια, δηλαδή από το 1988 σε 417 κρούσματα το Στο τέλος του 2013, το 60% των κρουσμάτων πολιομυελίτιδας ήταν το αποτέλεσμα μίας διεθνούς εξάπλωσης του άγριου πολιοϊού, και υπάρχουν ενδείξεις ότι οι ενήλικες ταξιδιώτες συνέβαλαν σε αυτή την εξάπλωση. Το 2014, μόνο 3 χώρες παραμένουν ενδημικές για πολιομυελίτιδα: Πακιστάν, Αφγανιστάν και Νιγηρία. 5 May 2014: ΕΠΔΥΔΕ (PHEIC)

27 Ebola Virus Disease Total number of cases and deaths confirmed, probable, and suspected cases of Ebola virus disease, including deaths 6 Αυγούστου 2014: ΠΔΥΔΕ (PHEIC) Guinea: Ebola free on 29 December 2015 Liberia: Ebola free 14 January 2016 (on 15 and 20 January 2 new cases) Sierra Leone: Ebola-free on 7 November 2015 Countries with an initial case (or cases), or with localised transmission United Kingdom: one confirmed case Spain: one case, no deaths United States: four cases including one death Mali: eight cases, six deaths Nigeria: 20 cases and eight deaths Senegal: one confirmed imported case All six countries have been declared Ebola-free Source: European Centre for Disease Prevention and Control. Outbreak of Ebola virus disease in West Africa. Tenth update, 10 April, Stockholm: ECDC;

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29 Fasina FO, Shittu A, Lazarus D, Tomori O, Simonsen L, Viboud C, Chowell G. Transmission dynamics and control of Ebola virus disease outbreak in Nigeria, July to September Euro Surveill. 2014;19(40):pii=20920.

30 Capacity Υποδομές Strengthening στις Πύλες at εισόδου σε μόνιμη βάση Points of Entry (ε) Εκπαιδευμένο προσωπικό και προγράμματα ελέγχου υποδόχων μεταδοτών (α) εκτίμηση και ιατρική περίθαλψη, προσωπικό και εξοπλισμός (γ) Εκπαιδευμέν ο προσωπικό για τον έλεγχο των μεταφορικών μέσων (δ) Διασφάλιση περιβάλλοντος: νερό, τρόφιμα, διαχείριση αποβλήτων, τουαλέτες και προγράμματα ελέγχου (β) εξοπλισμός και προσωπικό για τη μεταφορά άρρωστων ταξιδιωτών

31 Υποδομές στις Πύλες εισόδου για την ανταπόκριση σε έκτακτα περιστατικά α Σχέδιο δράσης σε έκτακτα περιστατικά συντονιστής, σημεία επικοινωνίας στην πύλη εισόδου, άλλες υπηρεσίες β Εκτίμηση και περίθαλψη για μολυσμένους ταξιδιώτες και ζώα: διευθέτηση με ιατρικές και κτηνιατρικές εγκαταστάσεις για απομόνωση, θεραπεία κ.α γ Χώρος για συνεντεύξεις για τον διαχωρισμό μολυσμένων και υπόπτων ταξιδιωτών Εκτίμηση ταξιδιωτών για καραντίνα δ ζ Εξοπλισμό μεταφοράς, μέσα προστασίας και προσωπικό για την μετακίνηση ταξιδιωτών με λοίμωξη στ Εφαρμογή ελέγχων για την αναχώρηση ή την είσοδο επιβατών ε Εφαρμογή προτεινόμενων μέτρων εντομοκτονίας, απολύμανσης αντικειμένων, εμπορευμάτων, ταχυδρομικών δεμάτων, μεταφορικών μέσων κ.α.

32 Είναι προετοιμασμένες οι πύλες εισόδου; Progress monitoring indicators (8 areas) for annual States Parties report to World Health Assembly Level of implementation of core capacities at PoE Region African Region 29% Region of the Americas 64% South-East Asia Region 65% European Region 64% Eastern Mediterranean Region 53% Western Pacific Region 56% Capacity score for 2012 for PoE SIXTY-SIXTH WORLD HEALTH ASSEMBLY A66/16 Add.1. Agenda item May Implementation of the International. Health Regulations (2005)

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34 EU SHIPSAN ACT Joint Action - The history Situation analysis and needs assessment Addressing passenger ships State of the art: Communicable diseases & outbreaks from 1970 to 2006 EU MS categorised in 4 groups according to their capacity Study: 32 countries and 176 authorities Needs, gaps, legislation Use experience of existing programmes Manual for health and hygiene - outline Development of materials and establishment of training network Manual for health and hygiene Training network and pool of experts Training material Training modules for PHO & seafarers EU SHIPSAN Integrated Program/pilot inspections Web-based Communication Network Joint Action for all types of threats in maritime transport Cargo ships Inland navigation vessels Fishing vessels Passenger ships

35 EU SHIPSAN ACT Joint Action The partnership 32 institutions from 24 countries were designated by their Ministries of Health 1. Austria 2. Belgium 3. Bulgaria 4. Croatia 5. Cyprus 6. Denmark 7. Estonia 8. France 9. Germany 10.Greece 11.Iceland 12.Ireland 13. Italy 14.Lithuania 15.Malta 16.Netherlands 17.Norway 18.Poland 19.Portugal 20.Romania 21.Slovakia 22.Slovenia 23.Spain 24.United Kingdom

36 EU SHIPSAN ACT State of the art European Manual for Hygiene Standards Training to industry and health professionals: Face-to-face training courses (>200 officers and seafarers) e-learning (>400 trainees), webinars (>150 attendants), on-the-job training (110 officers via 140 pilot inspections at 33 ports Ad hoc guidelines for maritime transport: Influenza Ebola virus disease Zika virus disease Scheduling of hygiene inspections of passenger ships at EU level European database for recording ship inspections: 8,500 Ship Sanitation Certificates by EU MS Web-based communication system for ports: 22 public health events

37 Publications 1. Mouchtouri VA, Nichols G. European Union SHIPSAN ACT joint action:preparedness for the response to Ebola virus disease in the maritime transport sector. Euro Surveill Jan 8;20(1). pii: Hadjichristodoulou C, Mouchtouri VA, Guglielmetti P, Lemos CM, Nichols G, Paux T, Schlaich C, Cornejo MD, Martinez CV, Dionisio M, Rehmet S, Jaremin B, Kremastinou J; the SHIPSAN TRAINET partnership. Actions for prevention and control of health threats related to maritime transport in European Union. Travel Med Infect Dis Mar 18. 3: Mouchtouri 3. Mouchtouri VA, Bartlett CL, Diskin A, Hadjichristodoulou C. Water Safety Plan on cruise ships: a promising tool to prevent waterborne diseases. Sci Total Environ Jul 1;429: doi: /j.scitotenv Epub 2012 May Hadjichristodoulou C, Mouchtouri VA, Martinez CV, Nichols G, Riemer T, Rabinina J, Swan C, Pirnat N, Sokolova O, Kostara E, Rachiotis G, Meilicke R, Schlaich C, Bartlett CL, Kremastinou J, Partnership TS. Surveillance and control of communicable diseases related to passenger ships in Europe. Int Marit Health. 2011;62(2): Mouchtouri VA, Bartlett CL, Jaremin B, Nichols G, Paux T, Riemer T, Black N, Varela-Martinez C, Swaan CM, Schlaich C, Rachiotis G, Kremastinou J, Hadjichristodoulou C; SHIPSAN TRAINET project. The decision making process on public health measures related to passenger ships: the example of influenza pandemic Int Marit Health. 2010;62(4): Mouchtouri VA, Nichols G, Rachiotis G, Kremastinou J, Arvanitoyannis IS,Riemer T, Jaremin B, Hadjichristodoulou C; SHIPSAN partnership. State of the art: public health and passenger ships. Int Marit Health. 2010;61(2): Review. 7. Arvanitoyannis IS, Hadjichristodoulou C, Tserkezou P, Mouchtouri V,Kremastinou J, Nichols G. EU legislation on food and potable water safety which could be potentially applied on board ferries and cruise ships: a comparison with US legislation. Crit Rev Food Sci Nutr Jun;50(6): Mouchtouri VA, Westacott S, Nichols G, Riemer T, Skipp M, Bartlett CL,Kremastinou J, Hadjichristodoulou C; SHIPSAN Partnership. Hygiene inspections on passenger ships in Europe - an overview. BMC Public Health Mar 10;10: Rachiotis G, Mouchtouri VA, Schlaich C, Riemer T, Martinez CV, Nichols G,Bartlett CL, Kremastinou J, Hadjichristodoulou C; SHIPSAN partnership**. Occupational health legislation and practices related to seafarers on passenger ships focused on communicable diseases: results from a European cross-sectional study (EU SHIPSAN PROJECT). J Occup Med Toxicol Feb 10;5(1): Mouchtouri V, Black N, Nichols G, Paux T, Riemer T, Rjabinina J, Schlaich C, Menel Lemos C, Kremastinou J, Hadjichristodoulou C; SHIPSAN TRAINET project. Preparedness for the prevention and control of influenza outbreaks on passenger ships in the EU: the SHIPSAN TRAINET project communication. Euro Surveill May 28;14(21).

38 For further information:

39 Information route Scenario: 3 WHO IHR contact point ECDC Web-based form Telephone call EWRS ELDSNet EPIS /fax Hard copies of health documents SSC MoH Coordination of port health authorities Surveillance center NSW IHR NFP EWRS NFP ELDSNet NFP Central level Intermediate level Port level authority Antwerp Intermediate level Port level authority Santander MoH Coordination of port health authorities Surveillance center NSW IHR NFP EWRS NFP ELDSNet NFP Intermediate level Central level MoH Coordination of port health authorities Surveillance center NSW IHR NFP EWRS NFP Central level Intermediate level Port level authority Palma Port level authority Thessalonik i Intermediate level Port level authority Katakolon ELDSNet NFP SIS Next ports of call

40 Department of hygiene and epidemiology - WHO Collaborating Center (CC) on International Health Regulations, Points of Entry Event management Training toolkit Publications Evaluation of training programmes The relevant WHO outputs of the CC is the support provided to the Member States in order to achieve the minimum core capacities required by the International Health Regulations (2005) for the establishment and strengthening of alert and response systems for use in epidemics and other public health emergencies of international concern. The specific tasks of WHO CC are a) to provide support to WHO for the establishment, coordination and maintenance of a roster of experts trainers in the field of ship sanitation and points of entry (specifically ports) and b) to assist WHO - HSE/GCR/SID- PAG Team in training activities related to ship sanitation and event management on ships and at points of entry/ international travel and transport.

41 Συμμετοχή του Πανεπιστημίου Θεσσαλίας στις Οδηγίες του ΠΟΥ WHO Guide to ship sanitation Handbook for inspection of ships and issuance of ship sanitation certificates Technical advice for management of public health events on board ships (draft-unpublished) Coordinated health surveillance between points of entry and national health surveillance systems (draft-unpublished) Learning programme for inspection of ships and issuance of ship sanitation certificates WHO Interim technical advice for case management of pandemic (H1N1) 2009 on ships

42 Conclusions Populations are moving continuously and rapidly as travelers, as immigrants, as refuges Populations moved due to forced migration are vulnerable and need immediate access to health services. Public health emergencies of international concern is more possible to spread through routine travel and trade than migration Countries need to be ready to contain public health risks at the source Points of entry (ports, airports, ground crossings) play a critical role in the prevention and control of cross-border public health threats Points of entry (ports, airports, ground crossings) must have the capacities to detect and respond to cross-border health threats at all times