EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE

A Summary of a Workshop of the Forum on Emerging Infections

Jonathan R. Davis and Joshua Lederberg, Editors

Board on Global Health

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.



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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE A Summary of a Workshop of the Forum on Emerging Infections Jonathan R. Davis and Joshua Lederberg, Editors Board on Global Health INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C.

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W.Washington, DC 20418 NOTICE: The project that is the subject of this workshop summary was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. Support for this project was provided by the U.S. Department of Health and Human Services' National Institutes of Health, Centers for Disease Control and Prevention, and U.S. Food and Drug Administration; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; Abbott Laboratories; American Society for Microbiology; Bristol-Myers Squibb Company; Burroughs Wellcome Fund; Eli Lilly & Company; Glaxo Wellcome; F. Hoffmann-La Roche, AG; Pfizer, Inc.; SmithKline Beecham Corporation; and Wyeth-Ayerst Laboratories. The views presented are those of the editors and workshop participants and are not necessarily those of the funding organizations. This report is based on the proceedings of a workshop that was sponsored by the Forum on Emerging Infections. It is prepared in the form of a workshop summary by and in the name of the editors, with the assistance of staff and consultants, as an individually authored document. Sections of the workshop summary not specifically attributed to an individual reflect the views of the editors and not those of the Forum on Emerging Infections. The content of those sections is based on the presentations and the discussions that took place during the workshop. International Standard Book Number0-309-07184-4 Additional copies of this report are available for sale from the National Academy Press , 2101 Constitution Avenue, N.W., Box 285, Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at www.nap.edu. The full text is available on line at www.nap.edu . For information about the Institute of Medicine, visit the IOM home page at www.iom.edu. Copyright 2001 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. COVER: The background for the cover of this workshop summary is a photograph of a batik designed and printed specifically for the Malaysian Society of Parasitology and Tropical Medicine. The print contains drawings of various parasites and insects; it is used with the kind permission of the Society.

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections “Knowing is not enough; we must apply. Willing is not enough; we must do.” —Goethe INSTITUTE OF MEDICINE Shaping the Future for Health

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections THE NATIONAL ACADEMIES National Academy of Sciences National Academy of Engineering Institute of Medicine National Research Council The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. William A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. William A. Wulf are chairman and vice chairman, respectively, of the National Research Council

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections FORUM ON EMERGING INFECTIONS JOSHUA LEDERBERG (Chair), Sackler Foundation Scholar, The Rockefeller University, New York, New York VINCENT I. AHONKHAI, Vice President and Director, Anti-Infectives and Biologicals, SmithKline Beecham Corporation, Collegeville, Pennsylvania STEVEN J. BRICKNER, Manager of Medicinal Chemistry, Central Research Division, Pfizer, Inc., Groton, Connecticut GAIL H. CASSELL, Vice President for Infectious Diseases Research, Drug Discovery Research, and Clinical Investigation, Eli Lilly & Company, Indianapolis, Indiana GARY CHRISTOPHERSON, Principal Deputy Assistant Secretary for Health Affairs and Senior Advisor for Force Health Protection, U.S. Department of Defense Reserve Affairs, Washington, D.C. GORDON H. DeFRIESE, Director and Professor of Social Medicine, Epidemiology, Health Policy, and Administration, Sheps Center for Health Services Research, University of North Carolina, Chapel Hill, North Carolina CEDRIC E. DUMONT, Medical Director, Office of Medical Services, U.S. Department of State, Washington, D.C. JESSE GOODMAN, Acting Deputy Director, Center for Biologics Evaluation and Research, U.S. Food and Drug Administration, Washington, D.C. RENU GUPTA, Head of U.S. Research and Development,and Head of Global Cardiovascular, Metabolic, and Endocrine G.I Disorders, Novartis Pharmaceuticals, East Hanover, New Jersey MARGARET A. HAMBURG, Assistant Secretary for Planning and Evaluation, U.S. Department of Health and Human Services, Washington, D.C. CAROLE A. HEILMAN, Director, Division of Microbiology and Infectious Disease, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland JAMES M. HUGHES, Assistant Surgeon General, and Director, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia SAMUEL L. KATZ, Wilburt C. Davison Professor, Department of Pediatrics, Duke University Medical Center; Undersecretary for Health, Veterans Health Administration, U.S. Department of Veterans Affairs, Washington, D.C. MARCELLE LAYTON, Bureau of Communicable Diseases, New York City Department of Health, New York, New York CARLOS LOPEZ, Research Fellow, Research Acquisitions, Eli Lilly Research Laboratories, Indianapolis, Indiana STEPHEN S. MORSE, Professor of Epidemiology, Columbia University School of Public Health, New York, New York MICHAEL T. OSTERHOLM, Chairman and Chief Executive Officer, Infectious Control Advisory Network, Eden Prairie, Minnesota

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections MARC RUBIN, Vice President of Infectious Diseases Therapeutic Development Group, Glaxo Wellcome, Research Triangle Park, North Carolina DAVID M. SHLAES, Vice President, Infectious Disease Research, Wyeth-Ayerst Research, Pearl River, New York. JANET SHOEMAKER, Director, Public Affairs, American Society for Microbiology, Washington, D.C. JOHN D. SIEGFRIED, Deputy Vice-President, Science and Regulatory Affairs, Pharmaceutical Research and Manufacturers of America, Washington, D.C. P. FREDERICK SPARLING, Chair of Medicine, University of North Carolina at Chapel Hill, and President, Infectious Diseases Society of America, Washington, D.C. C. DOUGLAS WEBB, JR., Senior Medical Director, Infectious Diseases Global Marketing, Bristol-Myers Squibb, Princeton, New Jersey CATHERINE E. WOTEKI, Undersecretary for Food and Safety, U.S. Department of Agriculture, Washington, D.C. Liaisons to the Forum ENRIQUETA C. BOND, President, Burroughs Wellcome Fund, Morrisville, North Carolina NANCY CARTER-FOSTER, Director, Program for Emerging Infections and HIV/AIDS, U.S. Department of State, Washington, D.C. PATRICK W. KELLEY, Colonel, U.S. Army, and Director, Division of Preventive Medicine, Walter Reed Army Institute of Research, Washington, D.C. EDWARD MCSWEEGAN, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland STEPHEN M. OSTROFF, Acting Deputy Director, and Associate Director for Epidemiologic Science, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia GARY ROSELLE, Program Director for Infectious Disease, Veterans Health Administration, U.S. Department of Veterans Affairs, Cincinnati, Ohio JAMES M. SIGG, Contract Liaison Officer, Office of Management and Contracts, Centers for Biologics Evaluation and Research, U.S. Food and Drug Administration, Washington, D.C. FRED TENOVER, Chief, Nosocomial Pathogens Laboratory Branch, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia KAYE WACHSMUTH, Deputy Administrator, Office of Public Health and Science, Food Safety Inspection Service, U.S. Department of Agriculture, Washington, D.C. Study Staff JONATHAN R. DAVIS, Senior Program Officer VIVIAN P. NOLAN, Research Associate

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections NICOLE AMADO, Project Assistant THELMA COX, Project Assistant KATHI HANNA, Consultant MICHAEL HAYES, Copy Editor Division Staff JUDITH R. BALE, Director, Board on Global Health ANDREW M. POPE, Director, Board on Health Sciences Policy SARAH PITLUCK, Research Assistant ALDEN CHANG, Project Assistant ANDREA L. COHEN, Financial Associate CARLOS GABRIEL, Financial Associate

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections REVIEWERS All presenters at the workshop have reviewed and approved their respective sections of this report for accuracy. In addition, this workshop summary has been reviewed in draft form by independent reviewers chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council 's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the Institute of Medicine (IOM) in making the published workshop summary as sound as possible and to ensure that the workshop summary meets institutional standards. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. The Forum and IOM thank the following individuals for their participation in the review process: Kenneth Bart, M.D., M.P.H., Director, Graduate School of Public Health, College of Health and Human Services, San Diego Sate University, San Diego, California Joel Breman, M.D., D.T.P.H., Deputy Director, Division of International Training and Research, Fogarty International Center, National Institutes of Health, Bethesda, Maryland Walter R. Dowdle, Ph.D., Task Force for Child Survival and Development, Decatur, Georgia Nancy B. Mock, Dr.P.H., Director and Tulane University, New Orleans, Louisiana Patricia Quinlisk, M.D., Medical Director, Iowa Department of Health, Des Moines, Iowa Robert E. Shope, M.D., Professor, Department of Pathology, University of Texas Medical Branch, Galveston, Texas Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations nor did they see the final draft of the report before its release. The review of this report was overseen by Adel A. F. Mahmoud, M.D., Ph.D., President, Merck Vaccines, Merck and Co., Inc., Whitehouse Station, New Jersey, who was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the editors.

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections Preface The Forum on Emerging Infections was created in 1996 in response to a request from the Centers for Disease Control and Prevention and the National Institutes of Health. The goal of the Forum is to provide structured opportunities for representatives from academia, industry, professional and interest groups, and government* to examine and discuss scientific and policy issues that are of shared interest and that are specifically related to research and prevention, detection, and management of emerging infectious diseases. In accomplishing this task, the Forum provides the opportunity to foster the exchange of information and ideas, identify areas in need of greater attention, clarify policy issues by enhancing knowledge and identifying points of agreement, and inform decision makers about science and policy issues. The Forum seeks to illuminate issues rather than resolve them directly; hence, it does not provide advice or recommendations on any specific policy initiative pending before any agency or organization. Its strengths are the diversity of its membership and the commitment of individual members expressed throughout the activities of the Forum. A critical part of the work of the Forum is a series of workshops. The first of these, held in February 1997, addressed the theme of public- and private-sector collaboration (IOM, 1997). The second workshop took place in July 1997 and explored aspects of antimicrobial resistance (IOM, 1998). The third workshop (IOM, 2000a) examined the implications of managed care systems and the *Representatives of federal agencies serve in an ex officio capacity. An ex officio member of a group is one who is a member automatically by virtue of holding a particular office or membership in another body.

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections ability to address emerging infectious diseases in the age of managed care. The fourth workshop (IOM, 2000b) examined the core capacities of the public and private health sectors in emerging infectious disease surveillance and response. The fifth workshop, held in October 1999, which this document summarizes, examined the international aspects of emerging infections and the forces that drive these diseases to prominence from the global to the local levels. The topic of zoonotic diseases was the focus of the Forum's sixth workshop, which was held in June 2000. The summary of that workshop is in production. The next workshop sponsored by the Forum will address factors surrounding viral disease eradication. ABOUT THE WORKSHOP In recent years, emerging infections have captured increased attention internationally. This comes at a time when other diseases are gaining in importance. In an effort to increase our knowledge and understanding of the current and probable future public health significance of emerging infections internationally, the Institute of Medicine's Forum on Emerging Infections hosted a 2-day workshop on October 28 and 29, 1999, titled “International Aspects of Emerging Infections. ” The goal of the workshop was to collect new information on this topic from public health practitioners, academicians, and policy makers at the global, regional, national, and local levels from various geographical areas. Their presentations focused on the interplay among emerging infections, economics and trade, public health policies, population and demography, strategic planning and resource allocation, and infrastructure and capacity at their positions of practice. Panel discussions then focused on the interaction of these factors with infectious disease surveillance and response, communication and coordination, and research and training needs with recognition of the lessons and mistakes learned in the process and identification of novel approaches and obstacles at each level. Through the presentations and discussions, we hope to gain new insight into the forces that drive the policies of governments and international organizations; the ways in which diseases are prioritized; and the strengths and weaknesses of past and current local, national, and multinational efforts to effectively bring nations and international organizations closer together to mitigate the impacts of emerging infections. Early-on during the workshop, it was clear that the infrastructure and level of support for surveillance, research, and training on emerging infectious diseases varied widely across geographic regions. For example, in many countries a shrinking number of trained infectious disease specialists was cited. The latter

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections point was accentuated while developing the workshop as some of the foreign scientists invited to make presentations were unavailable owing to exigent schedules and demanding workloads for the qualified few, in addition to difficulty in obtaining government permission to travel and technological obstacles to effective communication. Consequently, although the presentations were rich and wide-ranging, the workshop did not support a comprehensive and balanced treatment of issues across regions. ORGANIZATION OF WORKSHOP SUMMARY This report of the Forum-sponsored workshop is prepared in the form of a workshop summary by and in the name of the editors, with the assistance of staff and consultants, as an individually authored document. Sections of the workshop summary not specifically attributed to an individual reflect the views of the editors and not those of the Forum on Emerging Infections or its sponsors. The contents of the unattributed sections are based on the presentations and discussions that took place during the workshop. The workshop summary is organized as a topic-by-topic description of the presentations and discussions. Its purpose is to present lessons from relevant experience, delineate a range of pivotal issues and their respective problems, and put forth some potential responses as described by the workshop participants. The Summary and Assessment chapter discusses the core messages that emerged from the speakers ' presentations and the ensuing discussions. Chapter 1 is an introduction and overview of the international perspective on confronting emerging infections. Chapter 2, Chapter 3, Chapter 4 and Chapter 5 begin with overviews provided by the editors, followed by the edited presentations made by the invited participants. Appendix A is a glossary and list of acronyms useful to the reader. Appendix B presents the workshop agenda. A list of workshop participants is found in Appendix C. Forum members and staff biographies are presented in Appendix D. Although this workshop summary provides an account of the individual presentations, it also reflects an important aspect of the Forum philosophy. The workshop functions as a dialogue among representatives from different sectors and presents their beliefs on which areas may merit further attention. However, the reader should be aware that the material presented here expresses the views and opinions of those participating in the workshop and not the deliberations of a formally constituted Institute of Medicine study committee. These proceedings summarize only what participants stated in the workshop and are not intended to be an exhaustive exploration of the subject matter. ACKNOWLEDGMENTS The Forum on Emerging Infections and the Institute of Medicine (IOM) wish to express their warmest appreciation to the individuals and organizations

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections who gave valuable time to provide information and advice to the Forum through participation in the workshop. The Forum is indebted to the IOM staff who contributed during the course of the workshop and the production of this workshop summary. On behalf of the Forum, I gratefully acknowledge the efforts led by Jonathan Davis, study director for the Forum and coeditor of this report, who dedicated much effort and time to developing this workshop 's agenda and for his thoughtful and insightful approach and skill in translating the workshop proceedings and discussion into this workshop summary. I would also like to thank the following IOM staff for their valuable contributions to this activity: Vivian Nolan assisted with the development of the workshop agenda, Thelma Cox assisted with editing various sections of the workshop summary list and provided comprehensive administrative support and Nicole Amado assisted in developing the glossary and acronyms in Appendix A. Other IOM staff also provided invaluable help: Sue Barron, Clyde Behney, Claudia Carl, Michael Edington, Carlos Gabriel, and Andrew Pope. Kathi Hanna, a consultant and technical writer contributed significantly to writing many sections of the workshop summary. The extensive commentary and suggestions made by the copy editor, Michael Hayes, are gratefully acknowledged. Finally, the Forum also thanks sponsors that supported this activity. Financial support for this project was provided by the U.S. Department of Health and Human Services' National Institutes of Health, Centers for Disease Control and Prevention, and the U.S. Food and Drug Administration; U.S. Department of Defense; U.S. Department of State; U.S. Department of Veterans Affairs; Abbott Laboratories; American Society for Microbiology; Bristol-Myers Squibb Company; Burroughs Wellcome Fund; Eli Lilly & Company; Glaxo Wellcome; F. Hoffmann-La Roche AG; Pfizer; SmithKline Beecham Corporation; and Wyeth-Ayerst Laboratories. The views presented in this workshop summary are those of the editors and workshop participants and are not necessarily those of the funding organizations. Joshua Lederberg Chair

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections Contents     SUMMARY AND ASSESSMENT   1      Emerging Infections: The Global Picture,   1      Factors in Emergence of Infectious Diseases,   7      Need for Coordiation and Collaboration,   17      Networks of Global Surveillance,   22      Taking Advangate of Windows of Opportunity,   26  1   INTRODUCTION   29  2   EMERGING INFECTIONS IN LATIN AMERICA   35      Overview,   17      Emerging Infections in Colombia: A National Perspective,   36      A National Strategy for Emerging Infectious Diseases: The Argentine Case of 1999,   39      Diagnosis, Epidemiological Surveillance, and Control Programs for Emerging and Reemerging Infectious Diseases in Mexico,   46      Response of the Pan American Health Organization to Emerging Infectious Diseases in Latin America and the Caribbean,   50  3   EMERGING INFECTIONS IN AFRICA   52      Overview,   52     Integrated Disease Surveillance and Epidemic Preparedness and Response in Africa,    53

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections      Global Emerging Infectious Diseases,   55      Emerging Infections in Africa: The WHO Response,   59  4   EMERGING INFECTIONS IN ASIA AND THE PACIFIC   62      Overview,   62      Emerging Infectious Diseases in Hong Kong and Their Public Health Significance,   63      Emerging Diseases in the Australasian Region,   65      International Smart Partnership in Emerging Diseases: Sense and Sensitivity,68    5   EMERGING INFECTIONS IN EUROPE   72      Overview,   72      Pandemic Strategic Planning,   73      A View from the Ground: Tuberculosis as an Example of a Reemerging Infectious Disease in the Former Soviet Union,   76      European Responses to Emerging Infections and Their Policy Implications,   81     REFERENCES   85     APPENDIXES    A   Glossary and Acronyms,   87  B   Workshop Agenda,   95  C   Workshop Participants,   98  D   Forum Member and Staff Biographies,   107

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EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE: A Summary of a Workshop of the Forum on Emerging Infections EMERGING INFECTIOUS DISEASES FROM THE GLOBAL TO THE LOCAL PERSPECTIVE

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