The World Health Organization: Does it have a Role in Critical Illness?

The World Health Organization: Does it have a Role in Critical Illness? Rob Fowler, MDCM, MS(Epi), FRCP Department of Medicine & Critical Care Medicine Sunnybrook Hospital, University of Toronto rob.fowler@sunnybrook.ca

What is Critical Illness?

What is the World Health Organization?

Health Spending as a Percent of the GDP Fowler RA, Adhikari N, et al Crit Care 2008

Life Expectancy and per capita Health Spending

Health Care Spending and ICU beds per 100,000 Population

Number of ICU Beds by Country Adhikari N, et al Lancet 2010

Mortality by Region: Pandemic (H1N1) Duggal A et al 2015 (thesis dissertation) Institute of Health Policy, Management and Evaluation, University of Toronto

Why would the WHO be interested in Critical Care?

SARS 2003

SARS Critical Illness Outcomes Mortality, at day 28 34% Ventilation, at day 28 16% Poor Outcome at day 28 50%

H1N1 2009

Air Travel from Mexico March 1 April 30, 2009 N Engl J Med 361;2: 2009.

The Challenge

Clinical Outcomes Canada Mexico

H1N1 Clinical Outcomes - 2014 90-day Mortality 13.9% Canada 50.5% Mexico OR death 6.75 [95% confidence interval 2.46-18.51] Dominguez G et al 2015 (submitted)

When will the next outbreak or pandemic occur?

published on April 24, 2013, at NEJM.org

Mortality ~ 30%

Ebola

Aug 26 2015 (+ 36 cases in Nigeria, Senegal, Mali, USA, Spain, UK = 28,041)

Kenema, Sierra Leone, July-August 2014

Case Fatality by Age http://www.nejm.org/doi/pdf/10.1056/nejmoa1411100

WHO: Challenges Faced

The Goldilocks Curse of Epidemics There is no response that is Just Right

The Goldilocks Curse of Epidemics There is no response that is Just Right It is easy to over-react

The Goldilocks Curse of Epidemics There is no response that is Just Right

The Goldilocks Curse of Epidemics There is no response that is Just Right It is easy to under-react

Politics & Responsibilities

Budget* (and Personnel)

WHO: Opportunities

WHO: Opportunities There is no one else who can do (a portion of) this work Inherent focus is on developing world Neutrality Intimately connected at global (UN), regional (AFRO, EMRO, PAHO, WPRO, EURO, SEARO), country (MOH) and district levels Ability to convening partners who would not work together (MSF, medical branches of military, etc.) Ability to produce guidance that is generally viewed as the authoritative Its agenda influences other bodies

WHO integrated, clinically compatible guidelines & tools for limited-resource countries Second-level learning programme: District clinicians at small hospitals in limited-resource countries Larger than child pocket book- adults have more diverse problems - Sex, drugs - Mental health - More chronic problems etc First-level learning programme: Health centres/outpatients Usually nurse or clinical officer led teams IMCI IMAI IMAI-IMCI-IMPAC IMAI-STB IMAI-IMCI STB-PIH-IMAI IMPAC CHWs, community/family caregivers, peer support Home-based care, treatment support; palliative care tools

Uganda- December 2013 - printed Feb 2014 Ebola/Marburg, CCHF WHO- interim emergency guidelines - Generic draft for West African adaptation - 30 March 2014 - printed April 2014 Ebola/Marburg, CCHF, Lassa fever Sierra Leone adaptation- printed December 2014 Focused on Ebola; includes Marburg, CCHF, Lassa fever WHO- second generic version- based on Sierra Leone version, removes SL specifics; some updates.

CCM 2013:41(2)

Goderich, SIERRA LEONE Italian Emergency NGO

Courtesy of Prof Antonio Pesenti & Dr. Gino Strada

rob.fowler@sunnybrook.ca fowlerr@who.int

Emerging Disease Clinical Assessment and Response Network Clinical & Infection Control Pandemic & Epidemic Diseases WHO-HQ, Geneva

WHO Emerging Disease Clinical Assessment and Response Network (EDCARN) Vision The mortality due to emerging pathogens is reduced through improved clinical management, even in absence of vaccine or specific treatment. Enhance/empower the role of clinical care / clinicians Mission In the Global Health Security context, To strengthen global collaboration between clinicians, researchers, WHO, medical NGO's, national health authorities and other stakeholders in order to improve clinical management of patients during outbreaks of emerging diseases.

EDCARN Partner mapping Network (InFact) Network (ISARIC) Network (SCC) WHO ERC WHO Secretariat Disease / initiatives Specific Advisory Panel Network (WFICCS) Ministry of Health WHO CC Clinical trials WHO CC Preclinical research WHO CC Training of EID Clinical management and clinical research WHO CC Systematic reviews Working Groups Institutions, clinicians, researchers

Research

Timeline of Start-up Activities for an Observational Study of SARI If we Wait until Outbreaks Start to Initiate Outbreak Research we will Fail to Improve Care

Research Challenges Example Research Timelines for Ebola Late Fall 2013: March 21 2014: April 2014: August 2014: October 2014: Likely Outbreak Onset Outbreak Recognition Date for Case Series Generation Country Research Ethics Approval Approval to Submit Case Series

WHO Research Potential Ways Forward If we wait for an outbreak or epidemic to start planning, initiating research, we will almost always fail to improve care during the outbreak and for the future We must have somewhat generalizable, flexible observational studies, with paper and electronic case report forms, ready and ethics approved BEFORE These CRFs should be tiered and be the platform upon which biological sampling and interventions are tested Tier 0: 1-page minimal CRF with descriptors and outcomes Tier 1: Traditional observational study with characteristics, severity of illness, course of care, treatments, available labs, outcomes Tier 2: Biological sampling studies Tier 3: Intervention Evaluation, open or randomized There must be funds / a virtual fund-in-waiting to get this work done

WHO-ISARIC Research Collaboration Potential Ways Forward

rob.fowler@sunnybrook.ca fowlerr@who.int

Ebola Virus Disease