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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
ACHIEVING SUSTAINABLE GLOBAL CAPACITY FOR SURVEILLANCE AND RESPONSE TO EMERGING DISEASES OF ZOONOTIC ORIGIN
WORKSHOP SUMMARY
Alexandra Beatty, Kimberly Scott, and Peggy Tsai, Rapporteurs
Committee on Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin
Board on Global Health
Institute of Medicine
Board on Agriculture and Natural Resources
Division on Earth and Life Studies
INSTITUTE OF MEDICINE AND NATIONAL RESEARCH COUNCIL OF THE NATIONAL ACADEMIES
THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
THE NATIONAL ACADEMIES PRESS
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NOTICE: The project that is the subject of this report 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. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance.
This workshop was supported by the U.S. Agency for International Development Award No. GHN-G-00-07-00001-00. Any opinions, findings, conclusions, or recommendations in this document are those of the authors and do not necessarily reflect the views of the organizations or agencies that provided support for the project. Mention of trade names, commercial products, or organizations does not constitute their endorsement by the sponsoring agency.
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Suggested citation: IOM (Institute of Medicine) and National Research Council (NRC). 2008. Achieving sustainable global capacity for surveillance and response to emerging diseases of zoonotic origin: Workshop summary. Washington, DC: The National Academies Press.
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
THE NATIONAL ACADEMIES
Advisers to the Nation on Science, Engineering, and Medicine
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. Ralph J. Cicerone is president of the National Academy of Sciences.
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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. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council.
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
COMMITTEE ON ACHIEVING SUSTAINABLE GLOBAL CAPACITY FOR SURVEILLANCE AND RESPONSE TO EMERGING DISEASES OF ZOONOTIC ORIGIN
GERALD T. KEUSCH (Co-Chair),
Boston University
MARGUERITE PAPPAIOANOU (Co-Chair),
Association of American Veterinary Medical Colleges, Washington, DC
CORRIE BROWN,
University of Georgia, Atlanta
JOHN S. BROWNSTEIN,
Harvard Medical School, Cambridge, MA
PETER DASZAK,
Consortium for Conservation Medicine, New York
CORNELIS DE HAAN,
The World Bank, Washington, DC
CHRISTL A. DONNELLY,
Imperial College London, United Kingdom
DAVID P. FIDLER,
Indiana University, Bloomington
KENNETH H. HILL,
Harvard University, Cambridge, MA
ANN MARIE KIMBALL,
University of Washington, Seattle
RAMANAN LAXMINARAYAN,
Resources for the Future, Washington, DC
TERRY F. McELWAIN,
Washington State University, Pullman
MARK NICHTER,
University of Arizona, Tucson
MO SALMAN,
Colorado State University, Fort Collins
OYEWALE TOMORI,
Redeemer’s University, Ogun State, Nigeria
KEVIN D. WALKER,
Michigan State University, East Lansing
MARK WOOLHOUSE,
University of Edinburgh, United Kingdom
Study Staff
KIMBERLY SCOTT, Study Director (from May 2008)
ALICIA GABLE, Study Director (February 2008–June 2008)
ALEXANDRA BEATTY, Lead Rapporteur and Senior Program Officer (June 2008–October 2008)
PEGGY TSAI, Program Officer
MILA GONZÁLEZ, Research Assistant (from May 2008)
RACHEL PASSMAN, Research Associate (February 2008–June 2008)
SARAH JANE BROWN, Senior Program Assistant
JULIE WILTSHIRE, Financial Officer
PATRICK KELLEY, Director,
Board on Global Health
ROBIN A. SCHOEN, Director,
Board on Agriculture and Natural Resources
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BOARD ON GLOBAL HEALTH
MARGARET HAMBURG (Chair), Senior Scientist,
Nuclear Threat Initiative, Washington, DC
JO IVEY BOUFFORD,
Institute of Medicine Foreign Secretary, New York Academy of Medicine
CLAIRE V. BROOME,
Emory University, Atlanta, GA
JACQUELYN C. CAMPBELL,
Johns Hopkins University, Baltimore, MD
THOMAS J. COATES,
University of California, Los Angeles
VALENTIN FUSTER,
Mount Sinai Medical Center, New York
SUE GOLDIE,
Harvard University, Boston, MA
RICHARD L. GUERRANT,
University of Virginia, Charlottesville
PETER J. HOTEZ,
George Washington University, Washington, DC
GERALD T. KEUSCH,
Boston University, MA
MICHAEL H. MERSON,
Duke University, Durham, NC
FITZHUGH MULLAN,
George Washington University, Washington, DC
PHILIP K. RUSSEL,
Johns Hopkins University, Baltimore, MD
BOARD ON AGRICULTURE AND NATURAL RESOURCES
W. REG GOMES (Chair),
University of California
(Professor Emeritus),
Oakland
ROGER N. BEACHY,
Donald anforth Plant Science Center, St. Louis, MO
H. H. CHENG,
University of Minnesota (Emeritus), St. Paul
DANIEL M. DOOLEY,
University of California, Oakland
JOAN H. EISEMANN,
North Carolina State University, Raleigh
KIRK C. KLASING,
University of California, Davis
VICTOR L. LECHTENBERG,
Purdue University, West Lafayette, IN
ROBERT PAARLBERG,
Wellesley College, Watertown, MA
BOBBY PHILLS,
Florida A&M University, Tallahassee
KEITH PITTS,
Curragh Oaks Consulting, Fair Oaks, CA
HAL SALWASSER,
Oregon State University, Corvallis
PEDRO A. SANCHEZ,
The Earth Institute at Columbia University, Palisades, NY
NORMAN R. SCOTT,
Cornell University, Ithaca, NY
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
Acknowledgments
This document is a product of the cooperation and contributions of
many people. The committee would like to thank all the speakers
and participants who attended the workshop on June 25–, 2008.
Their presentations helped to set the stage for the fruitful discussions in the
sessions that followed.
This workshop summary has been reviewed in draft form by persons
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 the independent review is to provide
candid and critical comments that will assist the institution in making its
published report as sound as possible and to ensure that the report meets
institutional standards of objectivity, evidence, and responsiveness to the
study charge. The review comments and draft manuscript remain confidential
to protect the integrity of the deliberative process. We wish to thank the
following for their review of this document:
François Elvinger, Department of Large Animal Clinical Sciences, Virginia Tech University
Joel C. Gaydos, Armed Forces Health Surveillance Center
B. Joseph Hinnebusch, Laboratory of Zoonotic Pathogens, The National Institute of Allergy and Infectious Diseases
Lisa Jackson, Group Health Center for Health Studies
Melinda Moore, RAND Corporation
Katey Pelican, Department of Veterinary Population Medicine, University of Minnesota
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Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary
Although the reviewers listed above have provided constructive comments
and suggestions, they did not see the final draft of the report before its
release. The review of this report was overseen by Dr. David Challoner, Vice
President for Health Affairs, Emeritus, University of Florida. Appointed by
the National Research Council, he was responsible for making certain that
an independent examination of this document 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 authors and the institution.
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Preface
The Institute of Medicine (IOM) and National Research Council (NRC) convened a 2-day workshop titled “Workshop on Sustainable Global Capacity for Surveillance and Response to Emerging Zoonoses” in Washington, DC, on June 25 and 26, 2008. The goal of the workshop—as one of several planned data gathering sessions for the committee to meet their overall charge—was more narrowly focused to review the current global capacity to carry out surveillance to detect, report, and monitor emerging infectious diseases in both humans and animals. This included brief discussions that began to examine how these systems might inform the necessary responses to emerging and reemerging infectious diseases of zoonotic origin that would be discussed more in-depth in the committee’s forthcoming consensus report. The workshop did not address, however, the details of any specific global or regional responses to any particular disease outbreak. The workshop did provide an opportunity for participants to examine the effectiveness of communication pathways among multidisciplinary practitioners and researchers, between the human and animal health constituencies, and between these professionals and the public.
This document is a summary of that workshop and is a companion to the full consensus report (anticipated for summer 2009) of the IOM/NRC Committee on Achieving Sustainable Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin. For the complete study, the committee is charged with exploring how emerging zoonotic disease surveillance, prevention, detection, and response could be strengthened and sustained
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globally over time to reduce or eliminate outbreaks of zoonotic diseases in human populations.
During the latter half of the 20th century, complacency toward infectious diseases as a global threat had set in due to the success of vaccines and antibiotics. The reality, however, was far different. First, although vaccines were developed for a number of important diseases, they were not consistently available in quantities needed by some countries, and it has been difficult to develop vaccines for many major infectious causes of morbidity and mortality. Second, antimicrobial resistance has occurred because antimicrobials were introduced into clinical practice and it now constitutes a real crisis. Third, new or newly discovered or known infectious agents have acquired new virulence attributes and have been emerging and reemerging during the past 30 years. The global spread of HIV/AIDS, multiple-drug–resistant tuberculosis, drug-resistant malaria, diarrheal diseases, and an increasing number of human outbreaks of emerging zoonotic infectious diseases (any disease or infection that is naturally transmissible from vertebrate animals to humans)1 discussed below are examples of the appearance of newly discovered or known agents over the last 30 years.
According to a recent, comprehensive literature review of more than 1,400 species of human pathogens—including viruses, bacteria, rickettsia, fungi, protozoa, and helminths—known to be infectious to human beings, 868 (61 percent) are zoonotic (Cleaveland et al., 2001; Taylor et al., 2001). In the same review, of 175 agents found to be associated with emerging infections, 132 (75 percent) were zoonotic agents (Taylor et al., 2001). The same authors found that zoonotic diseases were twice as likely to be associated with emerging or newly discovered infections as nonzoonotic pathogens. These pathogens are transmitted through direct contact from animals to humans and through air, water, food, and insect vectors.
The increase in infectious disease mortality from HIV/AIDS in persons 25 years of age and older, starting in the 1980s in the United States, was largely unforeseen (Armstrong et al., 1999). Even more catastrophic is the fact that AIDS has reversed the gains in life expectancy that had been achieved in Africa over the past 50 years (UNAIDS, 2004, 2006). Infectious diseases remain among the leading causes of death worldwide for children under 5 years of age (UNICEF, 2007). As we continue into the 21st century, infectious diseases are widely perceived as an unfinished agenda, and the ever-increasing potential of outbreaks or even pandemics caused by
1
The World Health Organization state in their definition of zoonoses: “Animals thus play an essential role in maintaining zoonotic infections in nature. Zoonoses may be bacterial, viral, or parasitic, or may involve unconventional agents. As well as being a public health problem, many of the major zoonotic diseases prevent the efficient production of food of animal origin and create obstacles to international trade in animal products” (WHO, 2008c).
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zoonotic diseases make them an important public health problem in both the developed and the developing world, emphasizing the need to prepare for them.
Since the 1980s, infectious diseases of zoonotic origin have become the focus of public health attention following several large and highly visible zoonotic infectious disease outbreaks around the globe. Some of the outbreaks of emerging zoonotic infections that have affected both human and animal populations and that have commanded attention worldwide include West Nile virus fever, human monkeypox, and Escherichia coli O157:H7 outbreaks in the United States; Hendra virus disease in Australia; Nipah virus encephalitis in Malaysia; Rift Valley fever in Africa; and HIV, Severe Acute Respiratory Syndrome (SARS), avian influenza, and dengue fever outbreaks globally. Of particular concern has been the relatively recent, unprecedented spread of a highly pathogenic avian influenza virus (H5N1)2 throughout Asia, Europe, and into Africa, with transmission from infected poultry to humans having occurred in 15 countries as of June 2008. This has placed the world in Stage 3 of a World Health Organization (WHO) pandemic influenza alert,3 with the threat of an influenza pandemic of tremendous concern around the world. In addition to mortality and morbidity in both human and animal populations, the costs of these outbreaks include severe impacts on national and international economies.
The disease outbreaks mentioned above and others have underscored the importance of developing an even better understanding of the conditions that give rise to the emergence of these diseases in both human and animal populations, and their routes and mechanisms of transmission between species. As more has been learned about them, including the nationally and globally observed serious health and economic impacts they have had, many have come to understand that multiple disciplines and sectors must work together to carry out effective disease prevention programs, disease
2
Avian influenza is caused by Eurasian strain influenza A viruses, subtype H5N1. Serotyping is based on the hemagglutinin (HA) [with H5 standing for the fifth known type of this protein] and neuraminidase (NA), [with N1 standing for the first of several known types of this protein] on the surface of the influenza A virus.
3
WHO has developed a six-phase pandemic alert system to inform the world of the seriousness of a threat and the need to launch more intense preparedness activities (with 1 = low risk of human cases, 6 = efficient and sustained human-to-human transmission). The designation and progression of phases are made by the Director-General. Each phase coincides with a series of recommended activities to be undertaken by WHO, the international community, governments, and industry. Changes in phases are triggered by several factors, including the epidemiological behavior of the disease and the characteristics of circulating viruses. In Phase 3, a new influenza virus subtype has been causing disease in humans, but there is no or very limited human-to-human transmission or it is not yet spreading efficiently and sustainably among humans (WHO, 2008b).
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surveillance for the early detection of outbreaks, and disease outbreak response and control in both human and animal populations.
Several other IOM reports and workshop summaries have addressed many of the environmental, demographic, social, and other factors leading to the emergence or reemergence of infectious diseases, including Microbial Threats to Health: Emergence, Detection, and Response; The Impact of Globalization on Infectious Disease Emergence and Control: Exploring the Consequences and Opportunities; The Emergence of Zoonotic Diseases: Understanding the Impact on Animal and Human Health; and Global Climate Change and Extreme Weather Events: Understanding the Contributions to Infectious Disease Emergence (IOM, 2003, 2006, 2002, and 2008, respectively).4
During this 2-day workshop in June 2008, epidemiologists, laboratory scientists, researchers, policy makers, human and animal health clinicians, disease prevention and control experts, and others from around the world presented their personal views in 15-minute presentations about a set of topics. Those topics include the human–animal–ecosystem interface and its associated drivers that promote the emergence of infectious diseases; the value and limitations of existing global and regional human and animal health active and passive surveillance networks and systems; reporting standards, data collection, and information sharing; early warning systems for epizootic and zoonotic diseases in animals and humans respectively; and global and regional laboratory and epidemiology capacity. Participants were asked to discuss whether there is a need for sustainable global capacity for surveillance that could inform response to zoonoses; to explore how that capacity might be conceptualized and operationalized on different levels; and to identify stakeholders who would be expected to assume leadership roles to help achieve this capacity. Participants were also asked to consider and explore other critical elements for such an endeavor, including human and animal health infrastructure needs; governance and funding challenges; workforce collaboration and training needs; multidisciplinary data collection and data-sharing challenges; and the complex interactions of economic and trade policies, regulations, and structures with human and animal health needs.
This document is a summary of those presentations and discussions
at the workshop; it is not intended to be a comprehensive examination of
the subject matter. This summary is not a consensus report of the committee,
nor does it include recommendations or endorsements of any formally
convened committee of the IOM or the NRC. The material contained in
this report is directly derived from the remarks and presentations of the
4
These and other reports can be found at the website of the National Academies Press, www.nap.edu.
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the authors, and they do not necessarily represent the views of the convening committee, the IOM, or the NRC.
We greatly appreciate the support of the U.S. Agency for International Development for the activities of the Committee on Achieving Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin. This committee has organized and convened this workshop in collaboration with the IOM and the NRC staff. The committee co-chairs wish to express their deep appreciation to the workshop presenters and participants (see Appendixes B and C), the committee members for their time and engagement in this study, and the following IOM staff: Patrick Kelley and Robin Schoen, board directors for Global Health and Agriculture and Natural Resources; Kimberly Scott, study director; Peggy Tsai, program officer; Mila González, research assistant; Sarah Jane Brown, senior program assistant; and Julie Wiltshire, financial associate, for their able assistance in the organization of this meeting. We also recognize the contributions of Allison Brantley, Sarah Bronko, Reine Homawoo, and Karen Imhof of the IOM and the
NRC for their logistic support during the meeting. Finally, special thanks go to our lead author Alexandra Beatty, as well as Kimberly Scott and Peggy Tsai for their revisions to the draft workshop summary and response to the comments of the external reviewers.
Gerald T. Keusch, M.D.
Committee Co-Chair
Marguerite Pappaioanou, D.V.M., Ph.D.
Committee Co-Chair
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Contents
ACRONYMS AND ABBREVIATIONS
xix
SUMMARY
1
1
INTRODUCTION
15
Charge to the Committee,
16
Organization of the Workshop Summary,
17
2
THE CONVERGENCE OF FORCES RESPONSIBLE FOR ZOONOSES
19
How Zoonoses Develop,
21
Human Factors,
23
Environmental Factors,
25
Animal Factors,
26
Challenges,
26
3
CURRENT SURVEILLANCE SYSTEMS FOR DETECTING ZOONOSES IN ANIMALS
33
The Global Early Warning System,
33
Standards of the World Organization for Animal Health,
35
Wildlife Disease Surveillance and Investigation,
36
Ebola Surveillance in Nonhuman Primates,
41
Global Surveillance of Bats,
43
Surveillance of Bushmeat and Exotic Animals,
46
Surveillance of Infectious Diseases in Companion Animals,
47
Discussion,
49
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4
DISEASES IN HUMANS: EARLY WARNING SYSTEMS
53
Global Public Health Intelligence Network,
54
Global Outbreak Alert and Response Network,
55
Program for Monitoring Emerging Diseases (ProMED-Mail),
57
Department of Defense Global Emerging Infections Surveillance and Response,
59
ArboNET,
62
Emerging Infections Network,
65
Discussion,
66
5
LABORATORY AND EPIDEMIOLOGICAL CAPACITY
69
Veterinary and Agricultural Laboratory Capacity in Resource-Constrained Countries,
69
The Reference Laboratory Perspective—The Global H5N1 Crisis,
71
The Application of NAHLN Principles to International Animal Health Efforts,
73
Laboratories in Tanzania,
74
Building Epidemiological Capacity to Address Emerging Infections in Africa,
75
Laboratory and Field Training in Southeast Asia,
77
Discussion,
78
6
CONCLUDING PARTICIPANT DISCUSSIONS ON FACILITIATING COMMUNICATION AND DEVELOPING A GLOBALLY SUSTAINABLE SURVEILLANCE SYSTEM
81
REFERENCES
87
APPENDIXES
A
Committee Biographies
91
B
Workshop Agenda
101
C
List of Workshop Participants
107
D
Speaker Biographies
111
E
Overview of Disease Surveillance Systems Presented in the Workshop by Order of Presentation
123
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List of Tables, Figures, and Boxes
TABLES
2-1
Select Significant Outbreaks of Emerging Diseases (1993–2007),
22
2-2
U.S. Government Agencies Concerned with Zoonotic Disease Control,
29
3-1
Biothreat Agents in Dogs and Cats,
48
4-1
Disease Events Verified by the World Health Organization, January 2001 to April 2008,
55
E-1
Overview of Disease Surveillance Systems Presented in the Workshop by Order of Presentation,
124
FIGURES
2-1
Infectious diseases and pathogens newly identified from 1973–2004,
20
2-2
Infectious disease mortality rate in the United States, 1900–1996,
21
2-3
World meat consumption projections from 1983–2017,
23
2-4
Human–animal–ecosystem domain interface,
27
2-5
Five stages through which pathogens of animals evolve to cause diseases confined to humans,
28
3-1
Complexity of disease investigation in wildlife populations,
37
3-2
All-cause mortality for white males in the United States, 1988–1992,
39
3-3
Wildlife mortality events, 1990–2008,
40
3-4
Proposed structure for a wildlife disease reporting system,
41
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3-5
Emerging infectious disease hotspots,
45
3-6
Ideal data integration from multiple animal species,
49
4-1
Structure of the Global Outbreak Alert and Response Network,
56
4-2
Pathogens reported by global location via ProMED,
58
4-3
ProMED-mail disease report summary, 2007–2008,
59
4-4
Overview of Department of Defense Global Emerging Infections Surveillance and Response System (DoD-GEIS),
60
4-5
Incidence of West Nile Virus Human Neuroinvasive Disease in the United States, 2007,
64
BOXES
1-1
Statement of Task,
17
3-1
Zoonotic Viruses That Originated in Bats Since 1994, with Year of Outbreak or Discovery,
44
4-1
Examples of Arboviruses Tracked in ArboNET,
63
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Acronyms and Abbreviations
AIDS Acquired Immunodeficiency Syndrome
AI-watch Avian Influenza-watch
ALERTA Alerta Surveillance System in Peru
ArboNET National surveillance system for arboviral diseases in the United States
BSE Bovine spongiform encephalopathy
BSE-vCJD Bovine Spongiform Encephalopathy and variant Creutzfeldt-Jakob disease
BSL biosafety level
CDC Centers for Disease Control and Prevention
CSREES Cooperative State Research, Education, and Extension Service
DNA Deoxyribonucleic acid
DoD U.S. Department of Defense
DoD-GEIS U.S. Department of Defense-Global Emerging Infections Surveillance and Response System
ECE embryonated chicken eggs
EIN Emerging Infections Network
ESSENCE Electronic Surveillance System for Early Notification of Community-based Epidemics
EWORS Early Warning Outbreak Recognition System
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FAO Food and Agriculture Organization of the United Nations
FELTP Field Epidemiology and Laboratory Training Program
FMD Foot-and-mouth disease
GAINS Global Avian Influenza Network for Surveillance
GLEWS Global Early Warning System
GOARN Global Outbreak Alert and Response Network
GPHIN Global Public Health Intelligence Network
H5N1 influenza A virus subtype H5N1
HAZMAT hazardous materials
HIV Human Immunodeficiency Virus
HPAI highly pathogenic avian influenza
IEIP International Emerging Infections Program
IOM/NRC Institute of Medicine/National Research Council
KEMRI Kenya Medical Research Institute
NAHLN National Animal Health Laboratory Network
NCASP National Companion Animal Surveillance Program
NWHC National Wildlife Health Center
OIE Office International des Epizooties (World Organization for Animal Health)
PAHO Pan American Health Organization
ProMED Program for Monitoring Emerging Diseases
ProMED-ESP Program for Monitoring Emerging Diseases-Spanish
ProMED-FRA Program for Monitoring Emerging Diseases-French
ProMED-Port Program for Monitoring Emerging Diseases-Portuguese
ProMED-RUS Program for Monitoring Emerging Diseases-Russian
RFV Rift Valley fever
SARS Severe Acute Respiratory Syndrome
UNICEF United Nations Children’s Fund
USAID U.S. Agency for International Development
USDA U.S. Department of Agriculture
USGS U.S. Geological Survey
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WCS Wildlife Conservation Society
WDIN Wildlife Disease Information Node
WHO World Health Organization
WISDOM Wildlife Information System for Disease Observation and Monitoring
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