PUBLIC HEALTH CONFERENCE Preparedness, Alert and Response Lessons Learned in Europe from Last CrossBorder Health Infectious Threats INSTITUTO DE SALUD CARLOS III - Campus de Chamartín. Salón Ernest Lluch MADRID – SPAIN 15 June 2017

Campus de Majadahonda

Campus de Chamartín

The role of Instituto de Salud Carlos III in the management of health infectious threats Manuel Cuenca-Estrella Deputy Director of Institute of Health Carlos III

Spanish National Health System and Public Health • National Health System and Public Health (PH) services in Spain are under the mandate of the Ministry of Health, Social Services and Equality and also of regional authorities (Autonomous Communities) • The Institute of Health Carlos III (ISCIII) was founded in 1986 (Ley 14/1986) support the National Health System for diagnosing and controlling of diseases.


• The Spanish National Centers of ISCIII act as the reference laboratories and services running a variety of activities focused on control of diseases: – Reference diagnosis, surveillance and advisory activities – Research programs – Educational programs

• There is official recognition for some of those reference activities.

National Centers and Schools • • • •

Spanish National Center of Microbiology (CNM) Spanish National Center of Epidemiology (CNE) Spanish National Center of Environmental Health (CNSA) Spanish National Center of Rare and Uncommon Diseases (IIER) • Spanish National Center of Tropical Diseases (CNMTrop) • Other units or departments: – Chronic diseases – Health cares and nursing – e-Health and telemedicine

National Centers and Schools • Agency for Evaluation of Healthcare Technology • National School of Health • National School of Occupational Medicine • National Library of Health • Biobanks and repositories

ECDC Core Functions • • • • •

Function 1: Reference diagnostics Function 2: Reference material resource Function 3: Scientific advice Function 4: Collaboration and research Function 5: Monitoring, alert and response

Personnel of Reference Laboratories 2017

Permanent positions: 50-60% Average age: 57 y.

Coordination and Prioritization • Services portfolio (550 billable items) • Public Health Services (non-billable, own funds) – – – – –

Surveillance Systems Microbiological programs Cohort follow-up Infectious outbreaks Alert services: • Infectious emerging threats • Bioterrorism incidents

Early warning and emergency response capability and capacity • • • • •

Passive surveillance Population-based active surveillance programs Detection of imported infections Detection of resistances RELAB: Spanish Network of Laboratories for Biological Alerts: – Bioterrorist incidents

• Participation in surveillance networks: – Spanish Networks: RENAVE (National Network of Epidemiological Surveillance), MoMo (Mortality and morbidity reports) and others

• Microbiological confirmation or rule out infectious threats : – Alert services (7 days/24 h)

Alert Services actions

Why does the ISCIII concern the diagnosis of infectious threats? • 1918: The Spanish Influenza, 20-40 M of deaths worldwide, including some famous people (Gustav Klimt, Guillaume Apollinaire, Edmundo Rostand) • 1920: the pandemic ends but great public attention and social alarm • Public authorities become aware of relevance of infectious threats particularly respiratory diseases • The white plague: tuberculosis

The ISCIII Ancestors… • 1921-22: A start is made on the construction hospitals for respiratory diseases (Hospital de Fuenfría, de Guadarrama…) • 1922: Hospital del Rey at Madrid (current campus the ISCIII) • 1925: Official opening of the Hospital • 1931 (Second Republic): National Hospital Infectious Diseases

of la of


The ISCIII Ancestors… 1932: Texts of the chaplain of the hospital: “Estaba el hospital en el extremo norte de Madrid, a siete kilómetros del centro, prácticamente aislado en medio del campo. Su nombre —"Hospital Nacional de Enfermedades Infecciosas"— explica el aislamiento. Había sido inaugurado en 1925. (Del antiguo régimen le venía lo del "Hospital del Rey"). En él se trataban los casos de epidemia y enfermedades contagiosas; y la terrible tuberculosis, que era entonces la enfermedad que requería más camas y se cobraba más muertes… Además paludismo, tifus exantemático, fiebre tifoidea, poliomielitis…”

Hospital del Rey, 1930, and hospital room

ISCIII, 2017

The ISCIII Ancestors… The three backbones • 1922: The Kingdom of Spain and the Rockefeller Foundation signed a MoU for the establishment of the National School of Health in line with other schools of medicine in the World. • 1924: National School of Medicine begins operating into the Hospital del Rey grounds. Infectious diseases educational program • In addition, 1924, Alfonso XIII Institute is also set, research and education in microbiology, serology and hygiene also into Hospital del Rey. • Those organizations replace the Instituto Nacional de la Vacuna (1871) and the Instituto Nacional de Bacteriología e Higiene (1894)

1925-1980… Torres Gost J. Medio siglo del Hospital del Rey, 1975

• The tuberculosis control become the main activity of the organization • A female pavilion (Hospital Victoria Eugenia) and a pediatric hospital are opened (Hospital Infante Don Felipe) • Antibiotic Era: Control of tuberculosis is closer and new activities arise since 1955

1925-1980… Torres Gost J. Medio siglo del Hospital del Rey, 1975

• Vaccination campaigns: – Smallpox, last Spanish case in 1961 – Poliomyelitis

• Cholera and meningitis outbreaks • Imported infectious diseases • Program in many other diseases: – Escuela Nacional de Medicina del Trabajo, 1948. – Centro Nacional de Virología y Ecología Sanitarias, 1967. Opening of a second campus, Majadahonda, Madrid – Escuela Nacional de Administración Sanitaria, 1970 – Centro Nacional de Salud Ambiental, 1974

1981. First Alerts • Toxic Oil Syndrome: – – – – –

20,000 cases 1,100 deaths It is seen as a infection several months Atypical pneumonia (Mycoplasma) Ingestion of rapeseed oil denatured with 2% aniline

1984 • June 5th, 1981, the US. Centers for Disease Control and Prevention (CDC) publish five cases of pneumonia by Pneumocystis carinii (currently P. jirovecii) • 1984: AIDS era (almost 40 M of infected in 2017) • Our organization is identified as the most adequate to lead the control of AIDS offering services, research and educational programs

Institute of Health Carlos de III Salud Carlos III 1986: Establishment of the Instituto GOVERNING BOARD

Director Support Unit

DIRECTOR D. Jesús F. Crespo

Dª. Rosa Cepeda

General Secretary

Applied Services, Training & Investigation

Evaluation and Research Management

Networks for Cooperative Research

International Programmes

Cellular Therapy & Regenerative Medicine

D. Pedro Cortegoso

D. Manuel Cuenca

Dª Belén Bornstein

Dª. Margarita Blázquez

D. Alfonso Beltrán

D Manuel Cuenca

National Microbiology Centre

Strategic Action in Health (AES in Spanish)

National Library of Health Sciences

International Programmes

Platform & National Biobank Register

National Epidemiology Centre



European Projects Office

National Cell Line Bank

National Centre for Enviromental Health

Scientific-technical Platforms


Research and Knowledge Transfer Office

Spanish Bioethics Commitee

Health Technology Assessment Agency

National School of Health

National Centre for Tropical Medicine Unit for Research in Chronic Disease Telemedicine Research Unit Nursing and Healthcare Research Unit

National School of Occupational Medicine

Campus Chamartín

Campus Majadahonda

1986-2016. Thirty years. The three backbones again • The ISCIII takes part in the control of diseases: – Services in reference centers – Educational programs in National Schools – 1994, integration of Funding of Health Research (FIS) into the ISCIII

Alert Services actions

Contemporary Era in the Public Health Alert Services • 2001. Anthrax attacks (postal letters). One week later than September 11th • 2003. Severe acute respiratory syndrome (SARS) coronavirus. • 2004. The ISCIII sets its first Alert Unit (microbiologist and epidemiologist): – 24 h/7 days – Coordinated with Health Ministry and Regional Authorities – More than 60 cases of suspected SARS are ruled out

Contemporary Era in the Public Health Alert Services • 2009. Swine flu, Influenza A (Mexican outbreak): – Hundreds of cases (suspected and confirmed) – The ISCIII confirms cases and coordinate the notification – New roles of the ISCIII: • Translation of reference diagnostic techniques • Funding of research. A specific call of the FIS about swine flu is done • Part of several international projects to innovative detection, improve share of information and education

Contemporary Era in the Public Health Alert Services • 2012. MERS-CoV Middle East Respiratory Syndrome by Coronavirus. • 2014. African Ebola Virus Outbreak. Spanish Cases • 2015. Zika virus • 2016. Spanish endemic case of Crimea-Congo Hemorrhagic Fever

Summary • The ISCIII (and ancestors) has been always an organization focused in the control of infectious threats • 2010, reorganization of centers and services of ISCIII and a prioritization of activities including Alerts is done • The number of incidents and alerts has increased significantly in last years • The Spanish Alert system has been set: – CCAES of Spanish Ministry of Health – Health Systems of Autonomous Communities – The ISCIII as a support with different roles (the three backbones)

Our Role in Services • Laboratory Reference Services: – Confirmation or discard of suspected cases of infectious threats: • African Ebola Virus: 75 cases studied. 2 imported cases. One secondary case • Crimea-Congo Virus: First endemic case, first nosocomial case, several other cases rule out • RELAB: Routine testing of materials finding in presumed bioterrorist incidents (anthrax and ricin). 7-10 incidents a year

– Translation of diagnostic technologies: • Zika virus: Analysis of first 500 suspected cases and then translation of PCRbased techniques to several hospital. Confirmation of positive cases at the ISCIII

Our Role in Services • Epidemiological Reference Services (CCAES and Autonomous Communities): – Coordination of notification through the RENAVE – In charge of other surveillance and notifications systems: • • • • • • •

Sistema de Información sobre Vigilancia Epidemiológica (SIVIES) Reporte sistemático de datos a ECDC y OMS Sistema de Información Microbiológica (SIM) Boletín Epidemiológico e informes de vigilancia epidemiológica, alertas y riesgos. Brotes de interés en salud pública Mortalidad general Morbilidad hospitalaria general (CMBD)

– Surveillance of specific cohorts: • AIDS • Toxic Oil Syndrome

Our Role in Research • Part of several international projects to innovative detection, improve share of information and education: – EMERGE: Efficient response to highly dangerous and emerging pathogens at EU level – ERINHA: European Research Infrastructure for Highly Pathogenic Agents – EPISOUTH and EPISOUTH PLUS: Network for the Control of Public Health Threats and other bio-security risks in the Mediterranean Region and Balkans – MEDIPIET: Further Development and Consolidation of the Mediterranean Programme for Intervention Epidemiology Training – IB-BIOALERNET: Iberian Network of Laboratories of Biological Alert – SHIPSAN ACT: The impact of maritime transport of health threats due to biological, chemical and radiological agents, including communicable disease – AIRSAN ACT: Coordinated action in the aviation sector to control public health threats

Our Role in Research • Calls on Research about specific fields of alerts: – Intramural projects – Calls for the National Health System (FIS) • Hemorrhagic fevers • Alert surveillance • Respiratory diseases

– Annual average funding: 1.5-2.0 M €

Our Role in Education • Qualification of several clinical laboratories of the National Health System (stay and translation): – Hemorrhagic fevers – Respiratory diseases – Zika disease • Educational Programs: – PEAC: Training Program in Epidemiology and Public Health – National School of Health: Masters in public Health, Microbiology (50 students yearly) • Specific activities: – Train of trainers at the National School of Health in Ebola disease outbreak (1,200 health professionals)

New ISCIII Facilities (2015-2019) CNM (8.500 m2)

Campus de Majadahonda

Campus de Chamartín



PUBLIC HEALTH CONFERENCE Preparedness, Alert and Response Lessons Learned in Europe from Last CrossBorder Health Infectious Threats INSTITUTO DE SALUD...

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