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SUSTAINING GLOBAL SURVEILLANCE
AND RESPONSE TO EMERGING
ZOONOTIC DISEASES
Gerald T. Keusch, Marguerite Pappaioanou, Mila C. González,
Kimberly A. Scott, and Peggy Tsai, Editors
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
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
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 study 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 docu-
ment 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.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine and National Research Council (U.S.). Committee on Achieving
Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of
Zoonotic Origin.
Sustaining global surveillance and response to emerging zoonotic diseases / editors, Gerald
T. Keusch ... [et al.] ; 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.
p. ; cm.
Includes bibliographical references.
ISBN 978-0-309-13734-8 (pbk.)
1. Zoonoses. 2. Public health surveillance. 3. Global health. I. Keusch, Gerald. II. Title.
[DNLM: 1. Communicable Diseases, Emerging—prevention & control. 2. Zoonoses—
epidemiology. 3. Biosurveillance—methods. 4. Disease Outbreaks—prevention & control.
WA 110 I585s 2009]
RA639.I57 2009
362.196’959--dc22
2009044034
Additional copies of this report are available from the National Academies Press, 500 Fifth
Street, NW, Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the
Washington metropolitan area); Internet, http://www.nap.edu.
For more information about the Institute of Medicine, visit the IOM homepage at: www.
iom.edu.
Copyright 2009 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America
Front cover, from top: Angus cattle on pasture. Photo by Scott Bauer, courtesy of USDA.
Laboratory technician with diagnostic materials at the Washington Animal Disease Diagnos-
tic Laboratory. Photo by Charlie Powell. Designation of H1N1 isolate digitally inserted by
Photoshop. Researcher administers a new medication for bird flu to a young chicken. Photo by
Steve Snowden, courtesy of iStockphoto. Laboratory scientist analyzes data at the Washington
Animal Disease Diagnostic Laboratory. Photo by Henry Moore.
Back cover, from top: Fruit bat surveillance. Photo courtesy of Wildlife Trust. A young male
with a puppy on Independence Day in India. Photo by Jay Graham, courtesy of Photoshare.
Deer runs through a suburban neighborhood. Photo by Lillis Photography, courtesy of
iStockphoto. A girl carries two lambs in rural Bolivia. Photo by Enriqueta Valdez-Curiel,
courtesy of Photoshare.
Suggested citation: IOM (Institute of Medicine) and NRC (National Research Council). 2009.
Sustaining global surveillance and response to emerging zoonotic diseases. Washington, DC:
The National Academies Press.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
— Goethe
Advising the Nation. Improving Health.
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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 Acad-
emy 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.
The National Academy of Engineering was established in 1964, under the charter
of the National Academy of Sciences, as a parallel organization of outstanding en-
gineers. 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 engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Charles M. Vest is presi-
dent 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 Insti-
tute 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. Harvey V.
Fineberg is president of the Institute of Medicine.
The National Research Council was organized by the National Academy of Sci-
ences 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
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Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of
the National Research Council.
www.national-academies.org
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COMMITTEE ON ACHIEVING SUSTAINABLE GLOBAL
CAPACITY FOR SURVEILLANCE AND RESPONSE TO
EMERGING DISEASES OF ZOONOTIC ORIGIN
GERALD T. KEUSCH (Co-Chair), Boston University, MA
MARGUERITE PAPPAIOANOU (Co-Chair), Association of American
Veterinary Medical Colleges, Washington, DC
CORRIE BROWN, University of Georgia, Athens
JOHN S. BROWNSTEIN, Harvard Medical School, Boston, MA
PETER DASZAK, Wildlife Trust, New York
CORNELIS de HAAN, The World Bank (retired), 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 A. SCOTT, Study Director
PEGGY TSAI, Program Officer
MILA C. GONZÁLEZ, Research Associate
SARAH JANE BROWN, Senior Program Assistant
JULIE WILTSHIRE, Financial Officer
PATRICK W. KELLEY, Director, Board on Global Health
ROBIN A. SCHOEN, Director, Board on Agriculture and Natural
Resources
v
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BOARD ON GLOBAL HEALTH1
RICHARD GUERRANT (Chair), University of Virginia School of
Medicine, Charlottesville
JO IVEY BOUFFORD, New York Academy of Medicine, New York
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 School of Medicine, New York
SUE GOLDIE, Harvard University, Boston, MA
PETER J. HOTEZ, George Washington University, Washington, DC
GERALD KEUSCH, Boston University, MA
MICHAEL MERSON, Duke University, Durham, NC
FITZHUGH MULLAN, George Washington University, Washington, DC
PHILLIP RUSSELL, Johns Hopkins University, Baltimore, MD
1 IOM boards do not review or approve individual reports and are not asked to endorse
conclusions and recommendations. The responsibility for the content of the report rests with
the authoring committee and the institution.
vi
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BOARD ON AGRICULTURE AND NATURAL RESOURCES
NORMAN R. SCOTT (Chair), Cornell University, Ithaca, NY
PEGGY F. BARLETT, Emory University, Atlanta, GA
ROGER N. BEACHY, Donald Danforth Plant Science Center,
St. Louis, MO
HAROLD L. BERGMAN, University of Wyoming, Laramie
RICHARD A. DIXON, Samuel Roberts Noble Foundation, Ardmore, OK
DANIEL M. DOOLEY, University of California, Oakland
JOAN H. EISEMANN, North Carolina State University, Raleigh
GARY F. HARTNELL, Monsanto Company, St. Louis, MO
GENE HUGOSON, Minnesota Department of Agriculture, St. Paul
KIRK C. KLASING, University of California, Davis
VICTOR L. LECHTENBERG, Purdue University, West Lafayette, IN
PHILIP E. NELSON, Purdue University, West Lafayette, IN
ROBERT PAARLBERG, Wellesley College, Watertown, MA
KEITH PITTS, Marrone Bio Innovations, Davis, CA
CHARLES W. RICE, Kansas State University, Manhattan
HAL SALWASSER, Oregon State University, Corvallis
PEDRO A. SANCHEZ, The Earth Institute, Columbia University,
Palisades, NY
ROGER A. SEDJO, Resources for the Future, Washington, DC
KATHLEEN SEGERSON, University of Connecticut, Storrs
MERCEDES VÁZQUEZ-AÑÓN, Novus International, Inc.,
St. Charles, MO
vii
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Acknowledgments
This report 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 report:
Sir George Alleyne, Pan American Health Organization
Scott Barrett, Paul H. Nitze School of Advanced International Stud-
ies, Johns Hopkins University
Ron Brookmeyer, Johns Hopkins Bloomberg School of Public Health
Donald S. Burke, Graduate School of Public Health, University of
Pittsburgh
Seth Foldy, Division of Public Health, State of Wisconsin
Lawrence O. Gostin, Georgetown University
David Harlan, Global Animal Health and Food Safety, Cargill, Inc.
James M. Hughes, School of Medicine and Rollins School of Public
Health, Emory University
Anni McLeod, Food and Agriculture Organization of the United
Nations
Melinda Moore, RAND Corporation
ix
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x ACKNOWLEDGMENTS
Mark E. White, Division of Global Preparedness and Program Coor-
dination, Centers for Disease Control and Prevention
Tilahun Yilma, International Laboratory of Molecular Biology for
Tropical Disease Agents, University of California, Davis
Although the reviewers listed above have provided constructive com-
ments 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 David Challoner, Vice
President for Health Affairs, Emeritus, University of Florida and James Fox,
Massachusetts Institute of Technology. Appointed by the National Research
Council and Institute of Medicine, they were responsible for making certain
that an independent examination of this report was carried out in accor-
dance with institutional procedures and that all review comments were
carefully considered. Responsibility for the final content of this report rests
entirely with the author committee and the institutions.
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Preface
In April 2009, as the committee was preparing to respond to reviewer
input and finalize this report, a multi-country outbreak of a new influenza
A(H1N1) virus was being reported. First detected as a cluster of cases of
severe respiratory illness with multiple deaths in Mexico, a unique influenza
A virus was isolated that was originally reported as having genes of swine,
avian, and human origin and therefore it was immediately referred to as
“swine flu.” Influenza A(H1N1) virus has since spread to 74 countries and,
as of June 11, 2009, the World Health Organization declared it the first
pandemic in more than 40 years. Although the virus is now circulating in
humans, the presumed link with swine led to public confusion on how the
virus was being spread, consequently leading to pork industry losses of
approximately $28 million dollars per week and the banned importation
of pigs and pork products by at least 15 countries. The specifics of when
and how this virus emerged, in what populations, how long its circulation
has gone undetected, and the identity of the source of exposure remain the
focus of ongoing investigations. While it is not possible to fully analyze the
progression and impact of events with the benefit of time and hindsight
before completing the work on this report, this outbreak serves to illustrate
many of the issues discussed in this report.
The committee’s consensus report traces the need and existing capacity
for global, sustained, integrated zoonotic disease surveillance and response
capacity; discusses the current gaps, challenges, and inadequacies with ex-
isting systems; and suggests new approaches to more effectively achieve the
requirements of an “ideal” system. Looking forward with the benefit of past
experience, including what we know about the current influenza A(H1N1)
xi
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xvi CONTENTS
The Human–Animal–Environment Interface, 78
Drivers Influencing Emerging and Reemerging Zoonoses, 83
Environmental Factors, 97
Technological Changes Leading to Emerging Disease, 101
Inadequate Governance, 106
Conclusion, 107
References, 107
4 ACHIEVING AN EFFECTIVE ZOONOTIC DISEASE
SURVEILLANCE SYSTEM 115
Defining Disease Surveillance, 116
Elements of an Effective Zoonotic Disease Surveillance System, 117
Executing an Effective Zoonotic Disease Surveillance System, 119
Review of Existing Disease Surveillance Systems for Zoonotic
Diseases, 129
Capacity-Building Programs to Create a Multidisciplinary,
Integrated Workforce, 135
Gaps and Challenges, 138
Conclusion, 157
References, 157
5 INCENTIVES FOR DISEASE SURVEILLANCE, REPORTING,
AND RESPONSE 165
Behavioral and Cultural Determinants of Information Sharing, 166
Economic and Trade Sanctions, 175
Incentives to Improve Disease Surveillance and Reporting, 178
Audit and Rating Framework for Disease Surveillance and Response
Systems, 180
Engaging Multi-Level Stakeholders for Timely Disease
Detection and Reporting, 181
Conclusion, 183
References, 184
6 SUSTAINABLE FINANCING FOR GLOBAL DISEASE
SURVEILLANCE AND RESPONSE 187
Funding Animal Disease Surveillance, 187
Current Funding Efforts, 191
Funding a Global Public Good, 196
Funding Mechanisms, 197
The Institutional Architecture, 202
References, 203
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xvii
CONTENTS
7 GOVERNANCE CHALLENGES FOR ZOONOTIC DISEASE
SURVEILLANCE, REPORTING, AND RESPONSE 205
The Relationship Between Human and Animal Health Capabilities
and Governance, 206
Governance Problems Facing Integrated Surveillance and Response
Systems for Emerging Zoonotic Diseases, 211
Governance Innovations Supporting Integrated Disease Surveillance
and Response in Human and Animal Health, 215
Moving Toward a Global, Integrated Disease Surveillance and
Response System: Future Governance Strategies, 226
Conclusion, 232
References, 233
8 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO
THE FUTURE 235
Recommendations, 236
Challenges to Successfully Integrating and Coordinating International
Disease Surveillance and Response Systems, 257
Looking to the Future, 263
References, 266
APPENDIXES
A Glossary of Terms 269
B Surveillance and Response of Select Zoonotic Disease
Outbreaks 277
C Novel Human Pathogen Species 293
D Public Committee Meeting Agendas 295
E Committee Biosketches 303
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List of Tables, Figures, and Boxes
TABLES
S-1 Recommendations by Priority and Category, 5
2-1 Selected Examples of Recent Zoonotic Outbreaks of International
Significance, 38
2-2 Examples of Human Pathogens with Evolutionary Origins in
Nonhuman Hosts, 52
4-1 Comparison of Disease Detection and Response Evaluation
Standards for Human and Animal Health: International Health
Regulations Versus Performance of Veterinary Services Tool, 130
4-2 Gaps and Challenges in Achieving an Effective, Global, Integrated
Surveillance System for Emerging Zoonotic Diseases, 140
5-1 Policies That Influence Reporting at Various Levels, Who Is
Affected, and Pros and Cons of Each Policy, 172
6-1 Avian and Human Influenza Pledges, Commitments, and
Disbursements as of April 30, 2008, 193
6-2 Estimated Cost of Funding the One World One Health Framework
to 2020, 195
6-3 Disease Prevention and Control Activities at the Human–Animal–
Ecosystems Interface and Their Status Level as a Public Good, 197
xviii
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xix
LIST OF TABLES, FIGURES, AND BOXES
6-4 Value of Meat Export by Country Income Category Group, 200
7-1 A Typology of Governance, 207
7-2 Substantiated Events by Initial Source of Official Information, 220
7-3 Events and Final Designation and Year of Reporting, 220
7-4 OIE Verification Requests and Responses to Them, 221
8-1 Recommendations for Improved Zoonotic Surveillance and
Response by Priority and Category Areas, 237
C-1 List of 87 Novel Human Pathogen Species Discovered
Since 1980, 293
FIGURES
S-1 Zoonotic disease hotspots and selected reference laboratories by
location, 10
1-1 Emerging infectious disease events detected from 1940 to 2004, 18
2-1 Total trade versus total agricultural trade, 29
2-2 International agricultural trade by commodity type, 1961–2006, 31
2-3 Trends in poultry production, 32
2-4 Number of confirmed human cases and deaths of avian influenza A
(H5N1) reported to the World Health Organization by country and
year, 37
2-5 Tourist arrivals in China and Thailand between 2001–2006, 43
2-6 Economic impact of a potential human influenza pandemic by
percentage of GDP, 45
2-7 Household income and expenditure effects of a backyard poultry
ban, 46
2-8 Opportunities to prevent, detect, and respond to the emergence and
transmission of zoonotic diseases, 48
2-9 Patterns of pathogen discovery, 56
2-10 Patterns of reporting of emerging disease “events”: five countries
reporting the highest number of “events” and selected others, 55
3-1 Overview of the driver-pathogen interactions that contribute to the
emergence of infectious zoonotic diseases, 79
3-2 Projected production of animal meat by species, 1961–2025, 81
3-3 World population projections, median variant forecasts, 83
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xx LIST OF TABLES, FIGURES, AND BOXES
3-4 Volume of global air traffic, 1985–2001, and projection of future
trends, 2001–2021, 85
3-5 Distribution of poultry in East and Southeast Asia, 93
3-6 Global swine distribution, 94
4-1 The cycle of elements comprising an effective infectious disease
surveillance system, 117
4-2 System requirements for comprehensive human and animal health
surveillance, 118
4-3 Zoonotic disease hotspots and selected reference laboratories by
location, 152
4-4 Global World Health Organization Vaccine Preventable Disease
Laboratory Network, 155
B-1 National and international response to the SARS outbreak, 282
BOXES
1-1 Statement of Task, 20
1-2 International Institutions and Actors, 23
2-1 Examples of the Underestimated Burden of Zoonotic Diseases, 41
2-2 The Economic Impact of Bovine Spongiform Encephalopathy
Outbreaks in the United Kingdom, the United States, and
Canada, 44
2-3 Selected Examples of the Balance and Imbalance Between Disease
Surveillance and Emergency Response for Past Outbreaks, 50
2-4 Simulation of Human Influenza Transmission in Thailand, 60
2-5 Predicting an Outbreak, 62
3-1 Epidemiological Factors Comparing Natural and Man-made
Ecosystems, 82
3-2 Advantages and Disadvantages of Intensive Agriculture Related to
Zoonotic Diseases, 103
4-1 Definitions of Surveillance, 116
4-2 Summary of Data Types and Sources for Human and Animal Health
Disease Events, 120
4-3 Prototypes of Web-Based Data Sources for Surveillance:
ProMED-mail and GPHIN, 122
4-4 Principles of Good Laboratory Practice and Network
Operation, 124
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xxi
LIST OF TABLES, FIGURES, AND BOXES
4-5 ArboNET: Example of an Integrated Zoonotic Disease Surveillance
System, 133
5-1 Nipah Virus Outbreak in Malaysia, 167
5-2 Definition of a Sanitary and Phytosanitary Measure at a
Glance, 176
5-3 International Sanctions After a Plague Outbreak in India, 177
5-4 Making Vaccines Available to Incentivize Disease Reporting, 178
5-5 Google.org Predict and Prevent Initiative, 182
8-1 Model of an Integrated National Program for Zoonoses, 240
8-2 Philanthropic Support for Information Technology Development
and Management, 244
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Acronyms and Abbreviations
AHI Facility Avian and Human Influenza Facility
APHIS Animal and Plant Health Inspection Service of the U.S.
Department of Agriculture
BSE bovine spongiform encephalopathy
BSL biosafety level
CAFO concentrated animal feeding operation
CDC U.S. Centers for Disease Control and Prevention
CITES Convention on International Trade in Endangered
Species of Wild Fauna and Flora
Codex WHO/FAO Codex Alimentarius Commission
DHS U.S. Department of Homeland Security
DoD U.S. Department of Defense
DoD-GEIS U.S. Department of Defense-Global Emerging Infections
Surveillance and Response System
DoI U.S. Department of the Interior
DoS U.S. Department of State
ENSO El Niño-Southern Oscillation
EU European Union
FAO Food and Agriculture Organization of the United
Nations
xxiii
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xxiv ACRONYMS AND ABBREVIATIONS
FDA U.S. Food and Drug Administration
FELTP Field Epidemiology and Laboratory Training Program
FETP Field Epidemiology Training Program
FMD foot-and-mouth disease
GAINS Global Avian Influenza Network for Surveillance
GATT General Agreement on Tariffs and Trade of the WTO
GDP gross domestic product
GLEWS Global Early Warning System
GOARN Global Outbreak Alert and Response Network
GPAI Global Program for Avian Influenza
GPHIN Global Public Health Intelligence Network
HHS U.S. Department of Health and Human Services
HLSC House of Lords Select Committee
HPAI H5N1 highly pathogenic avian influenza H5N1
IDSR Integrated Disease Surveillance and Response
IFI International Finance Institution
IGO intergovernmental organization
IHR 1969 International Health Regulations 1969
IHR 2005 International Health Regulations 2005
INCLEN International Clinical Epidemiology Network
IOM Institute of Medicine
IPCC Intergovernmental Panel on Climate Change
IT information technology
KEMRI Kenya Medical Research Institute
NAHLN U.S. National Animal Health Laboratory Network
NGO nongovernmental organization
NRC National Research Council
OIE Office International des Epizooties, also World
Organization for Animal Health
PCR polymerase chain reaction
PEPFAR President’s Emergency Plan for AIDS Relief
PHS Public Health Service Act
ProMED Program for Monitoring Emerging Diseases
PVS Performance of Veterinary Services tool
RVF Rift Valley fever
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xxv
ACRONYMS AND ABBREVIATIONS
SARS severe acute respiratory syndrome
SPS Agreement Agreement on the Application of Sanitary and
Phytosanitary Measures
SSAFE Safe Supply of Affordable Food Everywhere
TBT Agreement Agreement on Technical Barriers to Trade
UN United Nations
UNSIC United Nations System Influenza Coordinator
USAID U.S. Agency for International Development
USDA U.S. Department of Agriculture
USFWS U.S. Fish and Wildlife Service
USGS U.S. Geological Survey
vCJD variant Creutzfeldt-Jakob disease
WAHIS World Animal Health Information System
WHO World Health Organization
WHO-AFRO World Health Organization Regional Office for Africa
WNV West Nile virus
WTO World Trade Organization
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