Safer countries through global health security.

764 www.thelancet.com Vol 383 March 1, 2014 Countries around the world face a perfect storm of converging threats that might substantially increase the risk from infectious disease epidemics, despite improvements in technologies, communication, and some health systems. New pathogens emerge each year, some of which have high mortality and the potential for effi cient transmission—eg, severe acute respiratory syndrome (SARS), Middle East respiratory syndrome coronavirus, and avian infl uenza A H7N9. Existing pathogens are becoming resistant to available antibiotics and several are now resistant to virtually all available treatment. There is also the potential threat of intentional release of biological agents, which can be developed or synthesised biologically and disseminated at low cost and with little scientifi c expertise. Moreover, the accelerated pace of globalisation amplifi es these risks: a disease is just a plane trip away, and an outbreak anywhere is a threat everywhere. One of the primary responsibilities of any government is to protect the health and safety of its people. There are three key elements of health security: prevention wherever possible, early detection, and timely and eff ective response. Although many countries are now better able to manage infectious disease threats than in the past, these improvements have often been small in scale and limited in scope. The International Health Regulations (IHR), revised by WHO in 2005 to more directly address new and emerging epidemic threats, require all 194 signatory countries to improve capacity in these and other areas as part of their commitment to protecting health. Yet, at least 80% of countries did not report full IHR compliance by the 2012 deadline. There is a perception in some quarters that tackling epidemic threats is less important than addressing major killers, such as HIV, tuberculosis, and malaria, and that international eff orts to stop outbreaks might be more in the interest of high-income than of lowincome and middle-income countries. In fact, epidemic threats are potentially devastating to development through economic dislocation, decreased productivity, avoidable medical costs, loss of revenues from tourism and travel, and negative incentives for investment. The eff ective implementation of measures to ensure global health security builds a fi rm, broad-based public health foundation that promotes country self-suffi ciency and can sustain health progress in any area in which a country decides to focus. Most fundamentally, addressing epidemic threats saves lives. Rapid progress in health security is feasible if there is high-level political motivation, adequate investment, and technical expertise. After the devastating impact of SARS in 2003, China launched an ambitious programme to improve detection of new threats, strengthen response capacity, and report more transparently. The number of infl uenza surveillance laboratories grew to more than 400, the Chinese National Infl uenza Center was designated as the world’s fi fth WHO Collaborating Centre for Reference and Research on Infl uenza, the Chinese Center for Disease Control and Prevention (China CDC) was greatly strengthened with training of fi eld epidemiologists and establishment of an Emergency Operations Centre, and mechanisms for rapid reporting to WHO were put in place. When the infl uenza A H7N9 virus began causing human illness in February, 2013, China was quickly able to identify and sequence the genome, and share the sequence globally within days of the fi rst report, which enabled a rapid start on development of diagnostics and a vaccine. Many countries have improved health security by preventing avoidable epidemics, detecting outbreaks Safer countries through global health security 9 Chetchotisakd P, Chierakul W, Chaowagul W, et al. Trimethoprimsulfamethoxazole versus trimethoprim-sulfamethoxazole plus doxycycline as oral eradicative treatment for melioidosis (MERTH): a multicentre, doubleblind, non-inferiority, randomised controlled trial. Lancet 2013; published online Nov 25. http://dx.doi.org/10.1016/S0140-6736(13)61951-0. 10 Maharjan B, Chantratita N, Vesaratchavest M, et al. Recurrent melioidosis in patients in northeast Thailand is frequently due to reinfection rather than relapse. J Clin Microbiol 2005; 43: 6032–34. 11 Limmathurotsakul D, Wuthiekanun V, Chantratita N, et al. Simultaneous infection with more than one strain of Burkholderia pseudomallei is uncommon in human melioidosis. J Clin Microbiol 2007; 45: 3830–32. 12 Dance DA, Wuthiekanun V, Chaowagul W, White NJ. Interactions in vitro between agents used to treat melioidosis. J Antimicrob Chemother 1989; 24: 311–16. 13 Chaowagul W, Simpson AJ, Suputtamongkol Y, Smith MD, Angus BJ, White NJ. A comparison of chloramphenicol, trimethoprimsulfamethoxazole, and doxycycline with doxycycline alone as maintenance therapy for melioidosis. Clin Infect Dis 1999; 29: 375–80.