Sustaining Global Surveillance and Response to Emerging Zoonotic Diseases (2009)

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4 Achieving an Effective Zoonotic Disease Surveillance System “Surveillance for emerging diseases contributes to global security. If basic surveillance and laboratory capacities are compromised, will health au- thorities catch the next SARS [severe acute respiratory syndrome], or spot the emergence of a pandemic virus in time to warn the world and mitigate the damage?” —Dr. Margaret Chan Director-General of the World Health Organization Address at the rd Forum on Global Issues (March , 00) Given recent experiences of rapidly spreading global outbreaks across borders and continents, an effective emerging zoonotic disease surveillance system will need to be global in scope and effort. A global, integrated zoonotic disease surveillance system needs to detect disease emergence in human or animal populations anywhere in the world at the earliest time possible. Early detection is essential to trigger a timely disease outbreak investigation. Multidisciplinary teams of professionals that have relevant expertise and field experience would identify populations at risk and causes and risk factors for infection, and then rapidly and widely disseminate this information so that immediate and longer-term disease prevention and control interventions can be implemented. The goal of these interventions would be to control the size and geographic scope of the outbreak and to minimize morbidity, mortality, and economic losses in both human and animal populations. No matter how effective a surveillance and response system is, the increasing prevalence of drivers creates a situation where zoonotic disease pathogens will continue to emerge in human and animal populations, and thus it will be impossible to prevent all disease outbreaks and zoonotic dis- eases from occurring. However, a global zoonotic disease surveillance system provides great benefits by conveying critical data to inform evidence-based responses, therefore minimizing the opportunity for zoonotic disease emer- gence, transmission, and spread in both human and animal populations. This chapter first defines disease surveillance, discusses elements of an effective zoonotic disease surveillance system, and describes how such a system would need to be executed. It then presents an overview of existing  

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES emerging zoonotic disease surveillance systems and capacity-building pro- grams for creating the needed workforce. From this overview, the chapter identifies important existing gaps and challenges in the current state of global surveillance. DEFINING DISEASE SURVEILLANCE The principal purpose of disease surveillance is to “keep one’s finger on the pulse of disease in a population.” Successful disease surveillance detects increases in disease occurrence over expected levels early so that effective and timely disease control interventions can be introduced and appropriately targeted to reduce morbidity, mortality, and economic loss. Though several definitions of disease surveillance have been used by human and animal health agencies and experts (Thacker and Berkelman, 1988; Teutsch and Churchill, 2000; IOM, 2007; WHO, 2007a; OIE, 2008a), the committee chose to adopt more appropriately integrated definitions for this report (see Box 4-1). Disease surveillance strategies were developed to address different sur- BOX 4-1 Definitions of Surveillance Zoonotic disease surveillance: The ongoing systematic and timely collection, analysis, interpretation, and dissemination of information about the occurrence, distribution, and determinants of diseases transmitted between humans and ani- mals. Zoonotic disease surveillance reaches its full potential when it is used to plan, implement, and evaluate responses to reduce infectious disease morbidity and mortality in human and animal populations through a functionally integrated human and animal health system. Surveillance system: The total system of surveillance comprising the compo- nents of collection and reporting of disease outcome data from populations at risk, confirmation of the etiological agent by laboratory scientists, and mechanisms and pathways of data analysis, interpretation, reporting feedback, and communication of information to those who will use the data at local, provincial, national, regional, or international levels for response. Integrated emerging zoonotic disease surveillance system: A system that brings together and links data collection, collation, analysis, presentation/report- ing, and dissemination components to provide linked human and animal clinical, epidemiological, laboratory, and risk behavior information on unusual occurrences of emerging zoonotic diseases in both human and animal populations. The infor- mation brought to both human and animal health officials by human and animal health authorities would be used for early detection and timely response at local, provincial, national, regional, and international levels. 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM veillance goals and objectives, diverse ways information would be used, and varying human and financial resources available to support and oper- ate the system. These disease surveillance strategies and systems employ different methods to collect information, and they include active, passive, sentinel, syndromic, risk-based, informal, and rumor-based disease surveil- lance (Teutsch and Churchill, 2000). ELEMENTS OF AN EFFECTIVE ZOONOTIC DISEASE SURVEILLANCE SYSTEM An effective global, integrated zoonotic disease surveillance system re- quires effective surveillance at national, regional, and international levels, because information from outbreak investigations is used by human and animal health officials at all levels to implement response measures and to evaluate the effectiveness of those responses. A surveillance system is com- prised of cyclical elements that provide critical pieces of information, as seen in Figure 4-1. For disease surveillance to be comprehensive, surveillance will need to be planned and conducted across human and animal populations Systematic monitoring of disease occurrence,* person,** place, and time Implement The Cycle of Detection of intervention; unusual Surveillance Evaluate occurrence effectiveness Outbreak investigation and intensive follow-up; Identify risk factors and targeted points for intervention through research FIGURE 4-1 The cycle of elements comprising an effective infectious disease sur- veillance system. NOTES: *disease by clinical signs or detection and confirmation of pathogen or an- tibody by laboratory diagnoses; **attributes of person would include demographic Figure 4-1.eps variables and risky behaviors. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES (i.e., domesticated livestock, poultry, and companion animals, and aquatic and terrestrial wildlife), and information transfer will need to be facilitated between the human, animal, and environmental health sectors. Disease Surveillance System Framework and Components Designing a disease surveillance system requires decisions on various elements. These include (1) identifying clear objectives; (2) agreeing on a well-defined disease surveillance case definition based on the person (or in the case of animal populations, based on the animal, herd, or flock), place, and time, that can include suspect or probable cases based on clinical and/ or epidemiological data, as well as laboratory-confirmed cases; (3) clarify- ing what information is needed to achieve the objective, and the frequency with which the information is needed; (4) determining the type of dis- ease surveillance system (i.e., active, passive, sentinel, syndromic, etc.); (5) identifying the sources of data and information (clinical, epidemiological, laboratory, and social and anthropological data); (6) determining methods and channels of information dissemination and alerting; and (7) designat- ing clear roles and responsibilities of those who use the information for action (Teutsch and Churchill, 2000). Figure 4-2 shows the further steps Agent, Host, A Reasonable Scenario Question ACTIONS Data Capture The Right Person, Data Operations Place, Research Time Tools Analy tic Epidemiological Methods Interpretation Skills Information Warning & Technologies Staf f & Response Infrastructure Training ENABLERS Roles, Structures, Laws, Policies, and Systems SOPs, C3I FIGURE 4-2 System requirements for comprehensive human and animal health surveillance. Figure 4-2.eps NOTES: SOPs = standard operating procedures, C3I = communications, command, control, and intelligence. SOURCE: IOM (2007). 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM required to design a comprehensive disease surveillance system for human and animal health. A goal of disease surveillance is to be useful at all levels of the human and animal health systems. In order for the disease surveillance system to be useful, information needs to flow back and forth easily among inter- national, national, and local levels; be timely in detection and laboratory confirmation; include risk factors as a component; and be specific and reliably detect and report disease. Furthermore, the surveillance system will need to be robust under adverse conditions; ensure that information on individual patients and food-animal production owners or industries is secure and remains confidential; be flexible to use innovative information technology for data collection, collation, analysis, presentation, and dis- semination; and be compatible for data to be electronically collected and stored across systems. EXECUTING AN EFFECTIVE ZOONOTIC DISEASE SURVEILLANCE SYSTEM Identifying, Gathering, Analyzing, and Disseminating Information The earlier an emerging zoonotic disease can be detected, the timelier the response can be, thereby minimizing transmission and spread and ul- timately reducing morbidity and mortality. Data sources need to correctly distinguish an abnormal disease pattern from a typical or expected one. As data are collected, they need to be transmitted for analysis, and such analyses need to be presented in user-friendly, easy-to-understand formats so that decisionmakers can properly interpret and use the information (Mandl et al., 2004a,b). Given the technology available today, these ele- ments are certainly possible to achieve, yet the current system falls short from the target. Sources of Data Multiple sources of data from traditional and nontraditional sources have potential use in an integrated disease surveillance system (see Box 4-2). Data can be collected in several ways: by interviewing patients, animal owners, community members, or healthcare providers; administering a questionnaire by mail or phone; searching electronic disease records of established surveillance systems; or searching records from human and animal diagnostic laboratories. Biological samples are collected on site, then safely transported to a laboratory performing requisite tests for laboratory confirmation. Some national monitoring and disease surveillance programs use mail and interview questionnaires as well as a collection of biological 

0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES BOX 4-2 Summary of Data Types and Sources for Human and Animal Health Disease Events Human Health: Human Health: Traditional Sources Nontraditional Sources Emergency department chief complaints Digital detection systems Hospital/clinic medical records Short Message Service technology Text-based notes Syndromic surveillance data Diagnostic laboratory data Records on pharmaceutical purchases Radiological reports Patient self-reports Physician reports Absenteeism data Emergency Medical Services activity Telephone survey results WHO reports Animal Health Diagnostic laboratory data Farm worker observations Hospital/clinic medical records Reportable diseases Abattoir monitoring programs Active surveillance programs Companion animal owner reports Electronic record systems Syndromic surveillance samples for laboratory testing (Traub-Dargatz et al., 2000; USDA, 2000; Wagner et al., 2001). Screening medical and laboratory records (paper files or electronic databases) for specific entries, or biological sample banks for specific patho- gens or lesions, could be part of the active data collection and monitor- ing system for a disease surveillance system. Pathogen phenotypes and genotypes are routinely submitted to global databanks where they are readily accessible for comparison among laboratories examining outbreak samples. The use of such reference databanks facilitates the rapid identi- fication of unsuspected linked outbreaks even if widely spread by global trade. These types of data retrieval methods are routinely performed in many developed countries, such as for testing suspect cases for rabies, bovine spongiform encephalopathy (BSE) screening of fallen livestock and emergency-slaughtered cattle in Europe (Doherr et al., 1999; Doherr and Audigé, 2001) and of “downer cows” in the United States (USDA-APHIS, 2009a), screening of humans and wild birds for ongoing global influenza 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM viruses funded by the U.S. Agency for International Development (USAID), and the genotypic comparison of food and waterborne bacterial isolates by the U.S. Centers for Disease Control and Prevention’s (CDC’s) PulseNet (Swaminathan et al., 2001). Role of Information Technology (IT) in Data Collection and Analysis Evolving IT has led to a number of breakthroughs and new ways to collect and transmit epidemiological, clinical, demographical, and other information in the field. Examples of new technologies include the use of handheld computers, cell phones, remote sensing, and Internet searches (Beck et al., 2000; Lobitz et al., 2000; Google.org, 2008). These technolo- gies are being used to collect and transmit information from even the most remote and resource-challenged countries. Other breakthroughs in IT in- clude data management and decision software and systems, which facilitate the timely analysis, presentation, interpretation, and use of information by decisionmakers. The increasingly electronic information stream in human healthcare has permitted the emergence of semi- and fully-automated surveillance systems for symptoms and for other indicators (such as healthcare or drug utilization), which are commonly lumped under “syndromic surveillance” (International Society for Disease Surveillance, 2009). With comparable political will and investments, electronic systems in animal production and conservation could be developed for several purposes including early detection of wildlife die-offs; unexpected culling of livestock or poultry; aberrations in veterinary drug purchases; electronic tracking of bar codes along trade pathways; and electronic trace-back and trace-forwarding of animal products. Informal Data Sources and Use of Rumor-Based Disease Reporting With greater Internet access and use and 24/7 informal reporting net- works, information on disease outbreak occurrences is increasingly be- ing shared at the first indication of an event through unofficial channels. Real-time information about infectious disease outbreaks is increasingly found in web-based data streams, ranging from official human and animal health reporting to informal news coverage to individual accounts on chat rooms and blogs (Brownstein et al., 2008). Systems that use unstructured informal electronic information have been credited with reducing time to outbreak recognition, preventing governments from suppressing outbreak information, and facilitating the ability of the World Health Organization (WHO) and others to respond to outbreaks and emerging diseases (Madoff and Woodall, 2005). In fact, WHO’s Global Outbreak Alert and Response 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Network (GOARN) relies on web-based data for daily disease surveillance activities (Grein et al., 2000; Heymann and Rodier, 2001). Of major sig- nificance, the revised International Health Regulations 2005 (IHR 2005) authorize WHO to act on informal information to issue recommendations to prevent the spread of diseases (see Chapter 7 on Governance) (Wilson et al., 2008). The Program for Monitoring Emerging Diseases (ProMED-mail) and the Global Public Health Intelligence Network (GPHIN) are two early prototypes of such systems (see Box 4-3). BOX 4-3 Prototypes of Web-Based Data Sources for Surveillance: ProMED-mail and GPHIN Founded in 1994 by the Infectious Disease Society of America, the Program for Monitoring Emerging Diseases (ProMED-mail) pioneered the use of the In- ternet for the detection of outbreaks by e-mailing and posting reports, including many gleaned from its readers, with commentary from a staff of expert modera- tors. ProMED-mail is now one of the largest publicly available emerging disease and outbreak reporting systems, with more than 45,000 subscribers in over 165 countries. An evaluation of the extent to which ProMED-mail reports lead to timely confirmation and human and animal disease prevention and control efforts, nation- ally or internationally, is currently underway in collaboration with the HealthMap system. In collaboration with the World Health Organization (WHO), the Public Health Agency of Canada created the Global Public Health Intelligence Network (GPHIN) in 1997. GPHIN’s software application retrieves articles from news feed aggre- gators based on established search queries in 15-minute intervals on a 24/7 basis to provide an early warning of the possibility of a public health emergency. Although automation is a key component, GPHIN also employs trained analysts who provide essential linguistic, interpretive, and analytical expertise. The data are disseminated to various public health agencies, including WHO, that can perform the necessary public health vetting of the informal report. An early achievement of its potential came in December 1998 when GPHIN was the first to provide prelimi- nary information to the public health community about a new strain of influenza in northern China. During the 2003 severe acute respiratory syndrome outbreak, the GPHIN prototype served as an early-warning system by detecting and informing the appropriate authorities (e.g., WHO and the Public Health Agency of Canada) of an unusual respiratory illness outbreak occurring in Guangdong Province, China as early as November 2002. Comprehensive global access to GPHIN is not available because there is a fee required to join GPHIN. This precludes many resource-challenged countries from participating, including many in areas at higher risk of an emerging zoonotic disease occurrence. SOURCES: Madoff (2004); PHAC (2004); Madoff and Woodall (2005); Cowen et al. (2006); Zeldenrust et al. (2008). 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM A number of online disease surveillance systems are now delivering real- time intelligence on emerging infectious diseases to diverse audiences on user-friendly, open-access websites, similar to ProMED-mail and GPHIN. One of these is HealthMap, a freely accessible, automated real-time system that monitors, organizes, integrates, filters, visualizes, and disseminates online information about emerging diseases (Freifeld et al., 2008). The site pulls data from more than 20,000 sources every hour, many of which come from news aggregators. Similarly, recent efforts using data from Google (Ginsberg et al., 2009) and Yahoo (Polgreen et al., 2008) have shown that search query data can be harnessed as a form of crowd-sourcing where pat- terns of specific searches mimic and may even predict disease outbreaks. Statistical Analysis and Disease Modeling An infectious disease surveillance system needs to have the capacity to detect disease trends and predict outbreaks, allowing human and animal health authorities to respond in a timely and appropriate manner (USAID, 1998). As mentioned in Chapter 2, surveillance data are crucial for model- ing infectious diseases to better understand the dynamics of an epidemic, including transmission patterns, to be able to interpret and critically evalu- ate epidemiological data, and to design treatment and control strategies. Laboratory Capability, Capacity, and Networks Specimen collection, analysis, and laboratory confirmation of the etio- logical cause of emerging zoonotic disease outbreaks are a vital part of any infectious disease surveillance system. Although rapid field tests are available for a select group of infectious agents (such as influenza A), laboratory confirmation is typically required for pathogen characteriza- tion, confirmation of infection, and further preventive actions. Given the multiple problems caused by false-positive reports, laboratory-confirmed cases increasingly provide the bulk of actionable alerts (Rodier et al., 2007). When rapid assays are not available, conventional methods of confirma- tion may result in significant time delays. Because emerging agents are at times previously unknown organisms, the laboratory system needs to have the capacity to know when something is new and different, have logistics in place to move the samples to laboratories with the necessary advanced discovery capacities, and have protocols flexible enough so that labora- tory personnel can cooperate and collaborate to quickly identify the agent causing the outbreak. Disease surveillance systems will therefore need to incorporate both sentinel and reference technical capacity organized into networks at national, regional, or global levels. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Standard for Laboratory Practices and Network Operations Standards for good laboratory practices overlap with standards for good laboratory network operations. Good laboratory practice principles are simply applied to laboratory facilities that meet proper standards for testing, safety, and security; employ a trained and proficiency-tested staff; have standardized operating procedures, validated test protocols, and prop- erly functioning equipment; and use a communication system that relies on common platforms and accurately and reliably reports test results in a timely manner. Communication lines and logistics need to be established before an event occurs. If each disease emergence represents a new problem to solve, the delay will be both unavoidable and unacceptable. Key points for several of these principles are expanded in Box 4-4. Human Capacity Requirements from Multiple Disciplines Executing, managing, and evaluating an effective global, integrated emerging zoonotic disease surveillance system will require human and BOX 4-4 Principles of Good Laboratory Practice and Network Operation Laboratory accreditation: For network laboratories, a quality assurance system will guide the application of good laboratory practice standards. Laboratory accreditation continues to be the “gold standard” by which laboratories and their quality assurance system are assessed. The quality assurance and laboratory assessment processes ensure continuous quality improvement. Validated and standardized assays: Just as a case definition is essential in compar- ing data on disease incidence and prevalence, validated and standardized assays ideally are used in laboratories throughout a network. Validation refers to examina- tion of a laboratory assay to establish whether it is fit for its purpose, and to establish performance characteristics in the laboratory and in populations of naturally infected individuals, whether humans or animals. Standardization (or harmonization) refers to the use of a common procedure for performing an assay in every network laboratory. Reference standards: Reference standards for assessing ongoing assay performance, laboratory performance, and network function are necessary to validate assays and continuously assess laboratories. Identifying, characterizing, and providing reference standards is labor intensive and expensive and will not be available for emerging agents in a time-sensitive fashion. Nevertheless reference standards are a critical component to a surveillance system. Reference standards are also referred to as reference materials. Human resources—training and proficiency testing: Trained technical staff are es- sential to proper performance of a procedure, no matter how much detail is provided 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM animal health personnel from multiple disciplines. This will require profes- sionals who are trained in basic clinical diagnosis of emerging zoonotic dis- eases, field epidemiology, laboratory sciences, social sciences, information technology, and communications at national, regional, and global levels. In addition, personnel are needed who have leadership and management skills; who have a vision and understand the need for a national and global integrated system; who have the interpersonal skills to work with experts from different disciplines; and who understand public–private partnerships (Pappaioanou et al., 2003; Perry et al., 2007). Clinical, Field, and Laboratory Competencies Clinical diagnostic expertise is essential for making a timely “field” di- agnosis of an unexpected, emerging zoonotic disease that occurs in human and/or animal populations, whether it is in primary healthcare clinics or on farms. When a diagnosis is not considered and subsequently missed, serious delays can occur in implementing appropriate, necessary, and immediate in the protocol. Ideally, training programs in a surveillance laboratory network are stan- dardized, and include a “train the trainer” component that facilitates ongoing training of new personnel within individual laboratories by qualified and certified trainers. Once trained, laboratory staff will need to be proficiency tested to ascertain competence to perform an assay. Laboratory facilities: Zoonotic diseases by their very nature are considered trans- missible to humans. The facility will need to provide an environment in which to safely and securely conduct laboratory operations. Levels of biocontainment are commonly referred to as biosafety level (BSL) and are graded from levels 1–4, with the higher number corresponding to the higher degree of containment required to safely work with the agent. Security will also need to be considered in operating a modern laboratory facility. Specific laboratory techniques essential for agent discovery and characteriza- tion (e.g., in vitro or in vivo culture and genetic and molecular analysis) require strict environmental control and specimen flow. Only a limited number of BSL-4 laboratories around the world are designed to work with the most dangerous organisms. Ongoing, expensive operational and technical support is critical to ensure the proper function of BSL-4 facilities. Implementation of new technology: Technology advances often require costly new equipment, maintenance and reagents, and technical capacity. When they provide a significant advance in capability, these technological advances could be employed in reference laboratories and ultimately reengineered for simplicity and reduced cost to disseminate the technology throughout the laboratory surveillance network. Provisions for funding of instrumentation, maintenance and reagent costs, and training and retain- ing personnel are all requirements for quality and sustainability. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES disease control interventions, and in reporting the event to formal health authorities who can offer added resources and assistance. West Nile virus (WNV), severe acute respiratory syndrome (SARS), highly pathogenic avian influenza (HPAI) H5N1 in humans and poultry, and human monkeypox in the United States are all examples of events where diagnoses were missed early in the outbreaks. Over the years, astute physicians, nurses, veterinarians, animal techni- cians, and laboratory scientists have been instrumental in the early detec- tion of emerging zoonotic diseases. Examples include the early detection of anthrax by a keen physician during the U.S. anthrax bioterrorism attack (CDC, 2001) and the suspicion of WNV by a perceptive veterinary patholo- gist at the New York City Bronx zoo and its link between birds and hu- mans (see Appendix B). Clinical training is experiential and best learned by seeing infected individuals or animals with guidance from an experienced clinician. Providing adequate in-person, hands-on training for zoonotic in- fections in either human or animal populations is essential but difficult for rare and sporadic or new diseases. New educational information technology and curricula may be of help in the future, but further development and evaluation is needed. Given the importance of outbreak investigations and other aspects of disease surveillance, competencies in epidemiology, statistics, data col- lection, analysis, dissemination, communication, disease prevention and control, and program management are critical. Knowledgeable and skilled individuals are needed to investigate disease outbreaks in the field, and to identify their causes, sources of infection, and actionable risk factors that place humans and animals at risk of exposure. A skilled and competent workforce is then needed to communicate information learned, and to implement timely and appropriate responses in both the human and animal health sectors, from local to global levels. It is essential to have a trained workforce that has expertise and experience in the areas of infectious dis- eases in humans and different animal species, agriculture and animal hus- bandry practices, natural resources (e.g., wildlife, environment, forestry), and education, both within and across both public and private sectors. Equally important, experts need to be knowledgeable about the valuable kinds of contributions from colleagues in different disciplines and sectors and be able to collaborate and work as a multidisciplinary team. To identify and confirm an infectious disease outbreak’s causative agent in real-time, clinical and epidemiological competencies need to be complemented with expertise and experience in laboratory and pathology diagnostics. Laboratory expertise is needed for correctly obtaining samples and data from the field, analyzing those samples in the laboratory, and interpreting and communicating laboratory-based information to others 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM who have responsibility for determining the best response to the threat. Infectious disease experts within or otherwise connected to the laboratory provide expertise that is often not available elsewhere in a country. Labora- tory professionals, therefore, are important members of the team charged with planning, conducting, and monitoring infectious disease surveillance programs and responding to disease outbreaks. Given the importance of linking epidemiological data to laboratory specimens for proper interpreta- tion of results, it is vital that epidemiologists and laboratory scientists work closely together during disease outbreak investigations, and laboratory confirmation, interpretation, and reporting. The consequences of inaccu- rately interpreting the significance of an event or laboratory result can be disastrous: An incorrect laboratory result or interpretation can cause delays in implementing effective disease control interventions, and result in rapid trade losses, social isolation, international stigmatization, huge costs, and waste of scarce human and medical resources. Social Science Input Many human behaviors increase the risk of emergence, exposure, trans- mission, and spread of emerging infectious diseases. Although risk factor disease surveillance has traditionally been used in human chronic disease and injury efforts (CDC, 2009a), it has increasingly been acknowledged as an important component of infectious disease surveillance (WHO and UNAIDS, 2000). For example, failure to wear personal protective equip- ment has been implicated in SARS virus transmission from infected patients to uninfected hospital staff caring for SARS patients (Seto et al., 2003; Moore et al., 2005). An understanding of the socioeconomic factors that lead to risky behaviors is helpful for developing strategies that can modify or prevent those behaviors from occurring. The public’s perceived risk of disease can change depending on the dis- ease occurrence, the nature of the disease, and the frequency and accuracy of reports in the media. Expertise in the social sciences is therefore needed to monitor and address risk perceptions for accuracy and to carefully read shifts in psychological, cultural, and political responses to disease whenever emerging diseases are reported (Lau et al., 2003; Menon, 2008). Shifts in risk perception are carefully monitored to detect and minimize the dissemi- nation of misinformation, and to promote an accurate understanding of the sources and causes of disease emergence and routes of transmission. This information would then be used for consistent, evidence-based messaging and communications on steps that individuals or whole communities can take to minimize exposure and contribute to prevention and control efforts (Nichter, 2008). 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES The challenge of risk communication is first and foremost ensuring that the messengers are trusted. The next challenge is finding the right bal- ance of evidence-based, credible messages to promote sustained behavior change without needlessly provoking fear or irrational responses, or caus- ing desensitization because warnings are seen as exaggerated or politically motivated. Studies of public response to epidemics of emerging diseases— such as SARS, HPAI H5N1, BSE, and more recently to pandemic H1N1 2009—point to the importance of honesty, transparency, trust in sources of information, credible communicators, and the speed and appropriateness of government response (Kaufman, 2008; Padmawati and Nichter, 2008; Scoones and Forster, 2008; Briggs and Nichter, 2009). Social scientists therefore are also needed to explore and implement ways to engender trust in disease surveillance systems conducted under varying conditions and in different cultures (Gilson, 2003, 2006), and to train health personnel to deal more effectively with political pressures that can negatively impact disease reporting when trade and/or tourism might be threatened (Palmer et al., 2009). When there is a lack of trust along the con- tinuum—from the individual to the local, national, regional, international, and global communities, and between the public and private sectors—an integrated zoonotic disease surveillance and response system cannot func- tion at an optimal level. Finally, social science expertise and capacity is needed to further study the responses of health systems to outbreaks of zoonotic disease at all lev- els, inclusive of factors that positively and negatively affect and influence vertical (within sector) and horizontal (intersectoral) communication and cooperation. Necessity of Collaborations from Multiple Sectors Close partnership between public and private sectors and across human health, agriculture, and natural resources are required for effectively plan- ning and executing a comprehensive, integrated zoonotic disease surveillance system. The human health sector includes private and public physicians, public health professionals, village and community health workers, labora- tories, hospitals, and nongovernmental organizations (NGOs) focused on health education, communication, and training. The agricultural, livestock, and poultry sector includes private- and public-sector veterinarians, village, and community animal health workers and technicians, animal producers, food systems, animal hospitals, and NGOs that provide development and capacity-building programs for small livestock and poultry holders, and programs for wildlife conservation, management, and disease surveillance (Kimball et al., 2008; Palmer et al., 2009). 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM Evaluating the Effectiveness of an Emerging Zoonotic Disease Surveillance System Several attributes are assessed to evaluate the effectiveness of disease surveillance systems. These attributes include timeliness (detection, con- firmation, dissemination), simplicity, flexibility, quality and reliability of data, acceptability, sensitivity (i.e., probability of identifying all cases of disease or outbreaks), high-positive predictive value (i.e., given a report of disease or an outbreak, there is high probability that the outbreak is real), representativeness of the population at risk, stability (i.e., robustness of the system under adverse conditions), and usefulness (WHO, 1977; CDC, 2001; Pappaioanou et al., 2003; Salman et al., 2003; Buehler et al., 2004; Salman, 2008; Wilkins et al., 2008). Important criteria associated with the effectiveness of animal disease monitoring and disease surveillance systems include aims, sampling, coordination and awareness, environmental fac- tors, screening and diagnosis, data collection and transfer, data processing and analysis, and information dissemination (Salman et al., 2003; Salman, 2008). CDC (2001), WHO (1977), the World Organization for Animal Health (OIE), and others have developed guidelines to assess the effectiveness of a disease surveillance system based on those components and attributes deemed essential. Table 4-1 provides a comparison of core capacity require- ments for disease surveillance mentioned in IHR 2005 versus the evaluation of quality mentioned in OIE’s Performance of Veterinary Services tool. REVIEW OF EXISTING DISEASE SURVEILLANCE SYSTEMS FOR ZOONOTIC DISEASES The committee examined several infectious disease surveillance systems already in operation to identify some effective systems, uncover gaps in efforts, and examine important ways that existing systems could improve to achieve the desired global disease surveillance system. In place of an ex- haustive review of all disease surveillance systems that have been developed for human infectious diseases by ministries of health, or those developed for animal diseases of importance by ministries of agriculture, a broad spectrum and mix of existing human and animal infectious disease surveil- lance systems were presented and discussed at a 2-day workshop, Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of zoonotic Origin: Workshop Summary (IOM and NRC, 2008). It is important to learn from these and other disease surveillance and re- sponse programs as efforts are dedicated to building an effective, global emerging zoonotic disease system. 

0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES TABLE 4-1 Comparison of Disease Detection and Response Evaluation Standards for Human and Animal Health: International Health Regulations Versus Performance of Veterinary Services Tool Specification of Capacities Related to Disease WHO IHR, OIE PVS Tool, Detection and Response 2005 2008 Requirement for assessments of infrastructure, Yes, mandatory No, assessments are and support for early disease detection, disease within 2 years voluntary, no time surveillance, and response of the date of requirement entry into force (June 2007) Support by state party/country for assessments, Yes No, but best practice planning, and implementation processes made described in qualitative clear and provided ratings Definitions of disease representing an urgent Yes No, but reference to threat provided OIE Terrestrial Code provided for details Explicit criteria and qualitative levels of No Yes advancement described for assessing existing structures and resources to meet core capacity requirements Minimum requirements for disease detection Yes, as core No, but best practice and reporting articulated by level of the health capacities in described in qualitative system Annex 1 rating; reference to OIE Terrestrial Code provided for details Definition/specific listing of essential Yes, but No, reference to information to be provided in reporting is in general Terrestrial Code provided categories only provided for details Minimum requirements for response to Yes No, but general best emergent event, by level of the health system practice described provided in qualitative rating; reference to OIE Terrestrial Code provided for details Development of implementation plans based Yes, and Yes, but not required, on assessment required best practice described in qualitative rating Provides awareness and improves Yes Yes understanding of all sectors regarding fundamental components and critical competencies required to function efficiently Support by international agency for the Yes Yes conduct of assessments and development of implementation plans NOTES: IHR = International Health Regulations; OIE = World Organization for Animal Health; PVS = Performance of Veterinary Services; WHO = World Health Organization. SOURCES: WHO (2007a); OIE (2008b). 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM Infectious Disease Surveillance Systems in Human Populations and Species-Specific Animal Populations At the National Level At the national level, surveillance systems for human and animal in- fectious diseases are under the auspices of different departments or min- istries (hereinafter collectively known as departments). Infectious disease surveillance of humans falls under the departments of health or public health, while surveillance for infectious diseases in food-animals are typi- cally under the auspices of departments of agriculture or livestock. More recently, surveillance of specific infectious livestock diseases has been con- ducted by private food production companies raising large populations of food-animals for international trade and human consumption. Surveillance for diseases in wildlife is most often under the purview of departments of natural resources, wildlife, or fish and game. Based on the spread of HPAI H5N1 in birds, funding has been given to wildlife conservation NGOs and universities to support their efforts in complementing efforts by depart- ments of natural resources to conduct surveillance in wildlife. In a few instances, disease surveillance of zoonotic diseases in companion animals has been conducted as special studies (Glickman et al., 2006). However, despite the close human-animal contact between humans and companion animals, responsibility for zoonotic disease surveillance and reporting in these animals—with exceptions of rabies and psittacosis surveillance in dogs and pet birds, respectively—has not been placed under the purview of any department in any country. At the International Level Infectious disease surveillance efforts in human populations have fo- cused primarily on diseases such as HIV/AIDS, tuberculosis, malaria, chol- era, vaccine preventable diseases, and those causing high morbidity and mortality. Several global disease surveillance systems and their networks have been instituted primarily for detecting either human outbreaks of emerg- ing zoonotic diseases or animal outbreaks of animal diseases. Examples of human disease surveillance systems reviewed in the workshop report include the WHO Global Outbreak and Response Network, and the U.S. Department of Defense’s (DoD’s) disease surveillance efforts with the Global Emerging Infections Surveillance and Response System (GEIS) and Early Warning Outbreak Recognition System in Asia, Africa, and other high-risk areas for emerging zoonotic infectious diseases (IOM and NRC, 2008). With regard to surveillance in animal populations, the OIE World Animal 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Health Information System, and Food and Agriculture Organization of the United Nations (FAO) Emergency Prevention System for Transboundary Animal and Plant Pests and Diseases were also presented and discussed in the workshop summary (IOM and NRC, 2008). Although human surveillance systems have identified a number of zoonotic disease outbreaks in humans, these global systems have yet to be adequate in detecting infections in animal populations early enough to prevent transmission from animal to human populations. Unfortunately, be- cause disease surveillance efforts in livestock, poultry, and wildlife typically have been under-resourced even more than disease surveillance in human populations, it is frequently the detection of disease outbreaks in humans that have led to the detection of disease outbreaks in animal populations rather than the reverse. Integrating Disease Surveillance Efforts Across Human, Animal, and Environmental Health Sectors Surveillance Efforts in the United States CDC has made efforts to integrate its zoonotic disease surveillance ef- forts across human and animal health sectors in the United States. This was most evidently demonstrated in 2007, when CDC established the National Center for Zoonoses, Vector-borne, and Enteric Diseases, which brought expertise in human and animal health together in the same administrative unit. In addition, several animal diagnostic laboratories have joined the Laboratory Response Network for Bioterrorism system of laboratories. The national surveillance system for arboviral diseases, ArboNET, is one example of a national surveillance system that has integrated disease sur- veillance efforts (see Box 4-5). Other efforts include FoodNet and PulseNet for food-borne diseases (CDC, 2008a) and the National Antimicrobial Resistance Monitoring System for detecting changes in antibiotic resistance in food-borne pathogens. Zoonotic agents comprise more than 80 percent of the CDC-listed biothreat agents of concern (CDC, 2003a; IOM and NRC, 2008). An optimally integrated surveillance system could integrate existing biosurveil- lance efforts with ongoing surveillance efforts for zoonotic diseases. Bio- surveillance efforts include the National Biosurveillance Integration Center established by the Department of Homeland Security (DHS, 2009a); the Integrated Consortium of Laboratory Networks (ICLN, 2009) established by the Department of Homeland Security; the Biosurveillance Indications and Warning Analytic Community established by CDC (CDC, 2008b); and the National Biosurveillance Advisory Subcommittee of the CDC and the National Biosurveillance Strategy for Human Health in response to Home- 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM BOX 4-5 ArboNET: Example of an Integrated Zoonotic Disease Surveillance System An example of a currently functioning zoonotic disease surveillance system that is approaching a state of integration across human and animal populations is the national surveillance system for arboviral diseases, or ArboNET, for West Nile virus fever surveillance in the United States. In this system, the results of surveil- lance in mosquito and bird populations are disseminated to human and animal health authorities at state and national levels to provide data to trigger mosquito control and increased public health alerts when the risk of infection increases, cautioning people to use insect repellent, wear long-sleeved clothing, and take other actions to decrease exposures to the virus through the bites of infected mosquitoes. Although ArboNET is an example of positive progress made in efforts to integrate data from several sources, work remains to be done in including addi- tional veterinary diagnostic laboratories into the system and improving timeliness of information and communication across sectors. SOURCE: IOM and NRC (2008). land Security Presidential Directive 21 (DHS, 2009b). It will be important to learn about the challenges, successes, and failures for coordinating these biosurveillance activities, as similar issues may emerge when integrating multiple human and animal epidemiological and laboratory surveillance systems. Global Surveillance Efforts WHO Global Salm-Surv The WHO Global Salm-Surv is a growing in- ternational surveillance system for Salmonella and other major food-borne pathogens. This relatively new initiative is built on a foundation of a global network of institutions and individuals (WHO, 2009a). This program is relevant to the current challenge because diarrhea-causing Salmonella sero- types are zoonotic in origin, and because the mission of this initiative is to “promote integrated, laboratory-based surveillance and foster intersectoral collaboration among human health, veterinary, and food-related disciplines through training courses and activities around the world.” GLEWS WHO, FAO, and OIE have recently joined forces to integrate alert mechanisms for emerging zoonotic diseases in the Global Early Warn- ing System (GLEWS) for major animal diseases. GLEWS builds on the added value of combining and coordinating the alert mechanisms of WHO, FAO, 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES and OIE to communicate with the international community and stakehold- ers on the occurrence of emerging zoonotic diseases; to aid in prediction, prevention, and control efforts; and to deploy joint field missions to assess and control disease outbreaks. Although this system is promising and of- fers a platform bridging across the human and animal health sectors at the global level for disease surveillance, response, and interdisciplinary training, it is relatively new and unproven. Much remains to be done to achieve a global, integrated zoonotic disease surveillance system with respect to clini- cal, epidemiological, laboratory, and risk behavior components. National and Global Surveillance Efforts of HPAI HN One of the best examples of strategic surveillance for influenza viruses in reservoir and other sentinel species is the U.S. Interagency Strategic Plan for the Early Detection of HPAI H5N1. This was implemented in 2006 across national and state agencies of agriculture, natural resources, and hu- man health, and included other institutions essential for conducting HPAI H5N1 surveillance in wild birds (USGS, 2006). This program is funded by the U.S. Department of Agriculture (USDA) and has tested samples from more than 200,000 wild birds and 100,000 environmental samples in multiple flyways in the United States1 (WDIN, 2009). The purpose of this program is to detect types of influenza virus that are of potential high virulence in poultry, with particular emphasis on HPAI H5N1. The data gathered since its launch has provided a much better assessment of the prevalence of influenza A in wild birds in the United States. Fueled by the concern for and specter of the “next 1918 influenza pandemic,” there have been additional global efforts aimed at integrated disease surveillance of HPAI H5N1 in wild birds, poultry, and human populations. The U.S. Department of Health and Human Services (HHS), USAID, DoD, and private-sector partners have funded disease surveillance for HPAI H5N1 viruses in wild birds in Southeast Asia and East Africa (GAINS, 2009). The U.S. National Institutes of Health has funded animal disease surveillance for avian influenza viruses in Southeast Asia and Africa (NIAID, 2008). Targeted disease surveillance for avian influenza in wild birds has resulted from human spillover (e.g., Indonesia), and impressive international laboratory coordination has occurred in regions of the world believed to be at higher risk of avian and human infections, because of the concern that a pandemic influenza virus would emerge from wild birds. Not unlike what has happened with surveillance for HPAI H5N1, in- fectious disease surveillance for human populations in developing countries has typically been funded through vertical programs to monitor specific diseases, such as HIV/AIDS, tuberculosis, malaria, cholera, and vaccine pre- 1 Seth Swafford, USDA/APHIS/Wildlife Services, personal communication, July 1, 2009. 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM ventable diseases. The simultaneous existence of so many independent, ver- tically operated initiatives duplicates costs, slows the reporting of emerging disease events and data analysis and interpretation, and adversely impacts the use of disease surveillance data to guide and evaluate disease prevention and control efforts. The WHO Regional Office for Africa (AFRO) imple- mented the Integrated Disease Surveillance and Response (IDSR) program in the 1990s to strengthen disease surveillance by using simplified tools for data collection and analysis, providing channels for reporting and feedback, and strengthening district-level capacity to generate and transform disease surveillance data to inform human and animal health action (Nsubuga et al., 2002; CDC, 2009b). Although AFRO was successful in integrating disease surveillance efforts within the human health community, the IDSR is not connected or linked to surveillance for zoonotic diseases in animal populations. The task of integrating disease surveillance for multiple infec- tious diseases within ministries of health in developing countries has been difficult, but the barriers to successful linkage and integration of human and animal health surveillance systems have proven to be far greater. CAPACITY-BUILDING PROGRAMS TO CREATE A MULTIDISCIPLINARY, INTEGRATED WORKFORCE United States In the United States, more than 3,000 physicians, PhDs, veterinarians, nurses, dentists, and other professions have graduated from the CDC Epi- demic Intelligence Service program since its inception in 1951. The 250+ veterinarians who are graduates of this program have played critical roles in serving public health by working in positions across all CDC centers and at state health departments. In addition to fulfilling their public health responsibilities in infectious diseases, environmental and global health, they have played an important role in bridging human and agricultural health concerns. A growing number of U.S. colleges of veterinary medicine and schools of public health offer joint doctoral degrees in veterinary medi- cine and master’s degrees in public health, an important step in achieving integration across human and animal health sectors (Hueston, 2008). For instance, the Center for Food Security and Public Health at Iowa State University posts a variety of web-based educational materials on zoonotic diseases (The Center for Food Security and Public Health, 2009a). European Union In the European Union (EU), the European Programme for Interven- tion Epidemiology Training provides experiential field training in inter- vention epidemiology at the national centers for surveillance and control 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES of communicable diseases (EPIET, 2009). The program is aimed at EU physicians, public health nurses, microbiologists, veterinarians, and other health professionals with experience in public health that have an interest in population-based disease prevention and control. The program is hosted at the European Centre for Disease Prevention and Control in Stockholm, Sweden. Global Programs Since the 1970s, a number of international programs have been launched to strengthen field epidemiological, laboratory, and program management capacity (Pappaioanou et al., 2003). WHO has sponsored large global human capacity-building efforts to implement immunization programs (WHO, 1980), diarrheal disease control (CDC, 1983), integrated management of the sick child (Victora et al., 2006), and tuberculosis control (WHO, 2009b), among many other programs. CDC, WHO, Rotary Inter- national, and others have collaborated to support major capacity-building efforts for polio elimination (CDC, 2009c). USAID has funded significant training programs for the IDSR hosted at AFRO (USAID, 2009). In the animal health sector, FAO, OIE, and USDA—with funding pro- vided by the World Bank, USAID, and other donor agencies—conduct some capacity-building efforts for disease surveillance and response in ani- mal populations. These initiatives have trained hundreds of animal health experts around the world in diagnostic methods and disease prevention and control for diseases of importance, including zoonoses associated with animal trade (Kerwick et al., 2008). The USDA Animal and Plant Health Inspection Service is oriented to U.S. domestic concerns, but offers clini- cal and laboratory diagnostic training in foreign animal diseases that can be imported into the United States (USDA-APHIS, 2009b). To address the current risk of HPAI H5N1, the USDA Agricultural Research Service and USDA Foreign Agricultural Service, with funding from the Institute for International Cooperation in Animal Biologics, has provided training on avian influenza diagnostics and disease control to poultry experts around the world (The Center for Food Security and Public Health, 2009b). The USDA and Global Livestock Collaborative Research and Support Pro- gram, supported by USAID, has funded the University of California–Davis Avian Flu School Program’s 8 training modules and 15 training sessions by Colorado State University on all aspects of avian influenza diagnosis, transmission, surveillance, and disease prevention and control of relevance to poultry, wildlife, and human populations for international use (Salman, 2008; UC Davis School of Veterinary Medicine, 2009). In general, these independent initiatives are funded by public and pri- vate sectors, and they address goals and objectives aimed at confronting 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM human and animal health challenges from single diseases with little to no overlap across human and animal populations. They represent a patchwork of systems that lack the necessary integration to create a global system robust enough to cover emerging zoonotic diseases for both humans and animals. INCLEN In 1980, The Rockefeller Foundation created and funded the Interna- tional Clinical Epidemiology Network (INCLEN), a unique global network of clinical epidemiologists, biostatisticians, health social scientists, health economists, and other health professionals. INCLEN is affiliated with 82 key academic healthcare institutions. Through collaborative, interdisciplin- ary, evidence-based research, they study high-priority health problems and promote equitable healthcare and efficient use of resources. Their program has addressed both communicable and noncommunicable diseases, as well as health system initiatives. To date, they are not yet oriented to integrated human and animal disease surveillance for zoonotic diseases. FETPs and FELTPs With funding from HHS, WHO, USAID, and other partners, CDC has collaborated with more than 40 countries to establish Field Epidemiology Training Programs (FETPs) (Thacker et al., 2001). These programs are modeled on CDC’s Epidemic Intelligence Service program but are tailored to the needs of host countries. To date, more than 1,000 trainees have graduated from these 40 programs, and more than 500 trainers have been trained.2 Laboratory training components have more recently been added to the FETP model, resulting in the Field Epidemiology and Laboratory Training Programs (FELTPs) (CDC, 2009d). These programs have recently begun to accept veterinarians and laboratory scientists along with physicians in their classes. In 1994, the FELTP in Kenya was established and supported by the Ellison Medical Foundation through the CDC Foundation. It uses both human and animal health expertise to conduct surveillance for emerg- ing zoonotic infectious diseases in special at-risk populations in Nairobi. Its graduates are required to be placed in national or local positions focused on disease surveillance, prevention, and control. A major constraint of FELTPs is that in each country program, a maximum of 15 people are accepted per country program each year. Although there have been other attempts to 2 Dionisio Jose Herrera Guibert, the Training Programs in Epidemiology and Public Health Interventions NETwork, personal communication, May 26, 2009. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES train many more health professionals annually through shorter programs, the FELTP model has proven most successful in establishing and building sustained national core capacity for field epidemiology and laboratory experience with regard to infectious and other disease concerns in both developed and developing countries. The 40 FETPs and FELTPs function independently under national control (CDC, 2009d), but have formed an organization—the Training Programs in Epidemiology and Public Health Interventions NETwork—to enhance communication, coordination, col- laboration, and networking. Integrated multidisciplinary disease surveillance and training efforts are beginning to see success in Africa. The African Field Epidemiology Network is supported by USAID and CDC, and it includes FETP and FELTP pro- grams in Kenya, Ghana, Uganda, and South Africa, and associate programs in Nigeria, south Sudan, Tanzania, Burkina Faso, Mali, Niger, and Togo. Several of these programs are taking steps to further integrate human and animal health surveillance systems in these key African countries (AFENET, 2009). GAPS AND CHALLENGES Existing surveillance and response programs were compared to compo- nents and attributes previously described in this chapter as essential for an effective global zoonotic disease surveillance and response system. Through that comparison, the committee identified some gaps and challenges that need to be addressed, which are summarized in Table 4-2. Global Coverage of Emerging Zoonotic Disease Surveillance Systems Irrespective of resource availability, the committee was unable to iden- tify a single example of a well-functioning, integrated zoonotic disease surveillance system across human and animal health sectors. The committee was alarmed by the large gaps in existing disease surveillance networks, in- cluding coverage across species and across geographic space. Of particular concern is that in 90 percent of human infectious disease cases the causative pathogens have not actually been identified, even in developed countries (Farrar, 2008). The current capacity for disease surveillance is strongest in developed countries, particularly when it is linked to response. The United States and Europe are greatly overrepresented in their reports of emerging disease outbreaks, which is directly related to disease surveillance and laboratory capacity (see Figure 2-10). Countries with weak disease surveillance capac- ity may not capture emerging disease outbreaks, and the level of outbreaks may be grossly underreported. For HIV/AIDS, a disease where substantial 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM global resources have been made available, recent survey results on public health-related infrastructure and capacities revealed that only 21 of 30 country respondents had substantial activities in place for surveillance, meaning that the 9 low- or lower middle-income countries surveyed had insufficient capacity to respond to a known disease (Binder et al., 2008). Developing countries have often focused their scarce resources on HIV/ AIDS, tuberculosis, malaria, and other diseases that cause high morbidity and mortality in human populations. They lack the fundamental resources to conduct zoonotic disease data collection, collation, analysis, interpreta- tion, and dissemination, and to conduct outbreak investigations and imple- mentation of disease prevention and control efforts that should follow. And whatever national or regional data on zoonotic diseases from human and animal health systems might be collected, they often are not accessible or networked for effective global disease surveillance and response. The com- mittee highlighted challenges for a few resource-constrained regions: sub- Saharan Africa, South Asia, and Southeast Asia. Although other regions of the world were not addressed in the same fashion, the lessons learned for Africa and Asia would also apply to other regions of the world. In Africa Despite significant advances in disease prevention and control in other parts of the world, communicable and zoonotic diseases still constitute major health problems in Africa (WHO, 2009c). HIV/AIDS is a pandemic of zoonotic origin, though it is now a chronic endemic disease transmitted from human to human. Together with the associated resurgence of tuber- culosis in the region, HIV has gained considerable attention and resources commensurate with the threat to human health and development that it represents. Its relevance to zoonotic disease surveillance now is its origins in animals and the impact it has on the use of national and international resources for disease surveillance and response in poor countries. The resur- gence of malaria and yellow fever in Africa in the past 15 years is a stark testimony to the serious breakdown of disease surveillance and control efforts (Roberts, 2007). More recently, the emergence and spread of HPAI H5N1 has seriously compromised the poultry industry in Nigeria and a few other West African countries (Xinshen and Liangzhi, 2006). Most public attention has been on the 421 human infections and 262 human deaths in 15 countries recorded through the end of June 2, 2009, with only 1 case and 1 death reported from Africa (both occurring in Nigeria in 2007) (WHO, 2009d). In many African countries, disease surveillance systems in human and different animal populations function vertically, as they represent specific global initiatives set up to monitor specific diseases. In human health, 

0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES TABLE 4-2 Gaps and Challenges in Achieving an Effective, Global, Integrated Surveillance System for Emerging Zoonotic Diseases Essential Components of an Effective Zoonotic Disease Surveillance System Identified Gaps and Challenges Global coverage • Many countries do not have surveillance for zoonotic infectious diseases in human or animal populations • At the global level, collaboration among WHO, OIE, and FAO is nascent but improving Multisectoral collaboration for planning, • In most countries, there are nonexistent implementation, and evaluation or weak channels of communications, or platforms between sectors and multiple disciplines • There is a divide/gap in information sharing between the public and private sectors Information gathering, dissemination • Surveillance is nonexistent or severely • Disease surveillance in humans limited in human populations at greatest • Disease surveillance in livestock and risk of emerging threats, making early poultry detection nearly impossible • Disease surveillance in wildlife • Surveillance in livestock and poultry is • Disease surveillance in companion animals weak in developing countries; CAFOs may • Risk behavior surveillance surveil their stock assiduously, but relevant • Surveillance of risk communication, information is not shared with animal or messaging, public perceptions human health public-sector authorities • Disease surveillance in wildlife is nonexistent, inconsistent, or weak in all countries • Integrated disease surveillance in companion animals is mostly nonexistent in all countries • Surveillance of risk behaviors putting people at risk of exposure to zoonotic disease agents is mostly nonexistent • Surveillance of risk communication, messages, public perceptions of danger, threat, cause, and interventions is nonexistent or weak 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM TABLE 4-2 Continued Essential Components of an Effective Zoonotic Disease Surveillance System Identified Gaps and Challenges Information Technology • An automated, real-time, and integrated • Field-based data collection technology process of data collection, analysis, and with emphasis on the availability of interpretation across the multiple sectors mobile phones concerned is absent • Open source, user friendly, bi-directional • Standard protocols are absent to information communication tools harmonize epidemiological and laboratory • Signal detection algorithms and software aspects of detection, confirmation, packages outbreak investigation, and design and • Improved web-based visualization of implementation of disease control efforts outbreaks and hotspots resulting from modeling efforts Laboratory Capacity • Human, domestic animal, and wildlife • Laboratory infrastructure with sector laboratories are currently not appropriate biocontainment in resource- integrated, or operating seamlessly constrained regions • Assessment of current global capabilities • Protocols and procedures for sample is inadequate and limits ability to develop collection and diagnosis an integrated laboratory network system • Adequately trained laboratorians and field nationally, regionally, or globally staff for sample acquisition in resource- • Resource constraints limit the ability to constrained areas further develop the network when plan is in place Response Capacity • Due to the committee’s limited charge and major gaps and challenges in early detection, a full analysis of response was not addressed by this report. However, the lack of collaboration and communication across sectors was identified as a major gap in planning, implementing, and evaluating an effective response following detection of an emerging zoonotic disease Human Capacity • Limited numbers of field-oriented, multidisciplinary training programs and graduates • Expertise lacking in clinic-pathological diagnosis, field epidemiology, laboratory science, social science and communications • Leadership programs are essential but not widely available NOTES: CAFO = concentrated animal feeding operation; FAO = Food and Agriculture Or- ganization of the United Nations; OIE = World Organization for Animal Health; WHO = World Health Organization. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES examples include poliomyelitis, meningitis, cholera, and other vaccine- preventable diseases (WHO-AFRO, 2001). In animal health, examples include rinderpest and foot-and-mouth disease (FMD) in cattle, classical swine fever and African Swine Fever in pigs, and Newcastle disease in poultry—diseases causing loss of production, which threatens local food availability and impedes international trade. These vertical programs have often succeeded in the development and use of disease-specific data collec- tion tools, reporting formats, and surveillance guidelines for diseases of major interest to external donors, but these facilities have been minimally used for the surveillance or control of a country’s endemic diseases (WHO- AFRO, 2001). Many specific interventions for vertical disease surveillance and response have not been sustained because of lack of appropriately trained local staff to maintain and sustain the programs when the threat level diminishes and donor support lags. The many vertical programs have resulted in a landscape consisting of islands of high-quality disease surveillance and laboratory structures brought in and supported by the vertical programs, surrounded by sub- standard national disease surveillance efforts and laboratory facilities, with dismal working conditions and poorly trained, valued, and paid laboratory scientists. Given this history, it is no surprise that integration of disease surveillance and response is almost nonexistent, there being little to no in- terest in building local capacity for an integrated approach. Recent trends of importing technologies in lieu of hiring competent laboratory scientists locally have been appealing in the shorter term because fewer resources are required to support personnel costs. Nonetheless, this approach fails to deliver a sustainable system and in the end usually requires recruiting and retaining well-trained, competent, local laboratory science expertise. The major obstacles to an effective disease surveillance and control sys- tem in Africa are insufficient funding, inadequate staffing, inappropriately trained personnel, and a failure to appreciate the cost effectiveness of a reliable disease surveillance system in healthcare delivery (Nigerian Federal Ministry of Health, 2007). Countries often do not have clear guidelines, procedures, and tools for disease detection, analysis, and interpretation of disease surveillance data, and/or the means for timely and complete report- ing (WHO-AFRO, 2001). Another major challenge to effective zoonotic disease surveillance in Africa is poor support given to human and animal health laboratories, which are inadequately staffed and often lack basic equipment and reagents. Moreover, few countries have functioning systems for timely transmission of epidemiological information and transport of laboratory specimens to better equipped reference laboratories (WHO- AFRO, 2001). These weaknesses affect disease detection, analysis, and interpretation of data, as well as timeliness and completeness of disease reporting. 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM Even if zoonotic disease surveillance were sufficient to result in early detection and reporting, most African countries are currently ill-prepared to respond to emerging zoonotic disease outbreaks in humans and animals. Currently, a direct consequence of not having valid and timely surveillance information is that efforts to investigate and target disease prevention and response efforts are typically not guided by surveillance-based information, but rather are based on other political priorities, or just as problematic, a lack of understanding. This can further weaken the perceived role of disease surveillance in the prevention and control of communicable diseases. Thus priority diseases are sometimes not properly monitored, there is often a lack of response, and decisions on disease control can often be made under public and political pressure rather than on the basis of evidence. In Asia The Asian region has repeatedly been the source of new zoonotic dis- ease agents. Although Asia was the source for the first alerts of HPAI H5N1 infections in humans (Hong Kong in 1997) and of Nipah virus encephalitis in pigs and swine workers (Malaysia and Singapore in 1997–1998), SARS served as the “wake-up call” for the Asian region. Even though SARS responded to simple containment strategies and even though human-to- human transmission has not been detected since 2003, the SARS outbreak highlighted the need to first strengthen surveillance for emerging zoonotic infectious diseases in both human and animal populations, and then to integrate disease surveillance across these multiple sectors. Because Asia spreads across multiple WHO regions—the Regional Office for Southeast Asia and the Regional Office for the Western Pacific—communication across these regions has been a source of friction within the regional and international network, and has therefore made the sustained early detec- tion of unusual events even more challenging. Fortunately, the joint Asia- Pacific Strategy on Emerging Diseases has moved this critical collaboration forward (WHO, 2006). At a national level, the Chinese Center for Disease Control and Pre- vention initiated a web-based disease surveillance system after the SARS outbreak that involves a network of 1,500 centers in China at district, provincial, and central levels. This network is largely involved in human disease surveillance, but a great deal of attention is on the threat of zoo- noses. Meanwhile, countries profoundly affected by HPAI H5N1 (e.g., Indonesia, Vietnam, China) have been working to bring the agricultural and human sectors of disease surveillance together. Notable is the “One Health” initiative, which Google among many others is promoting in the Mekong region. The Thailand FETP has trained veterinarians in their epi- demiological investigation program, and there are initiatives to make this linkage stronger. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Avian influenza has spurred discussions and information sharing across sectors in many countries, with Thailand being especially engaged. How- ever, early detection will require veterinarians and agricultural workers to closely integrate and communicate with human health authorities. As recently as 2007, a committee member observed that ministry of health workers in one Mekong country still learned of avian influenza outbreaks primarily through the media. In addition, officials from several international health agencies have noted that one Mekong country lacked poultry vet- erinarians with competent clinical skills to diagnose and differentiate avian influenza from other avian diseases affecting poultry. There was a serious call for assistance to strengthen local and national capacity in the clinical, basic animal husbandry, field epidemiology, and laboratory competencies. Indonesia, the country most highly impacted by HPAI H5N1, has also experienced many obstacles in carrying out an integrative approach to disease surveillance and response. Politics, economic concerns, trust, and failure to ensure that the benefits of sharing specimens are equitably applied to the populations at risk and the international community have seriously impaired global collaboration on virus sharing (Padmawati and Nichter, 2008). Multisectoral Collaboration for Planning, Implementation, and Evaluation Coordination Across Human and Animal Populations and Multiple Governmental Sectors In addition to geographic coverage gaps, other gaps include the limited coverage of disease surveillance in human populations and in different species of animal hosts, including food-animals, companion animals, and particularly wildlife. Another challenge is the lack of collaboration across the human and animal sectors charged with overseeing health. Surveillance in Humans As previously mentioned, there are large-scale surveillance programs for major infectious diseases in humans that cause high morbidity and mortality (e.g., HIV/AIDS, tuberculosis, malaria, vac- cine preventable diseases). However, with regard to surveillance for emerg- ing zoonotic diseases in human populations, occupational surveillance is nonexistent or is sporadic and weak to detect new infections in people having greatest contact with animals. Surveillance in Livestock and Poultry Populations Disease surveillance systems for livestock, poultry, and captured or farmed wildlife animal spe- cies often monitor the production parameters (such as milk production, egg production, and weight gain), use diagnostic tests to detect specific diseases, 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM and have response plans in place to reduce the spread of diseases when they occur. Several countries, including the United States, have successfully reduced and even eradicated livestock and poultry diseases through effective surveillance and response. Also, brucellosis has been eradicated from coun- tries such as New Zealand, Iceland, and Denmark through field epidemio- logical diagnosis and confirmatory testing, followed by culling of infected herds. In the United States, eradicating bovine brucellosis from domestic cattle is nearing the final stage, with only 1–3 infected herds reported for 2008–2009. In commercially raised turkeys in Minnesota, occurrences of low pathogenic avian influenza in domestically raised turkeys was dramati- cally reduced when surveillance data were used to change and evaluate the impact of housing conditions and disease occurrence (Halvorson, 2002). Despite increased investments in surveillance for HPAI H5N1 and other influenza viruses relevant to U.S. poultry producers, very few influenza viruses that are detected in poultry, swine, and other animals have been characterized. These viruses have potential to genetically reassort and infect across species. If the goal of influenza surveillance is to monitor influenza virus types with potential importance to humans, it can be argued that surveillance should first strategically target animal species most likely to transmit viruses to other animal populations, and then analyze a subset of those viruses for features that may contribute to cross-species transmission and virulence in humans. For resource-constrained regions, it might be most cost beneficial to continuously monitor influenza virus populations where there are a mix of animal species: for instance, when both swine and poultry are in close proximity to each other. Genetic characterization tools are now available to produce a much broader and more robust influenza database, and the NIH-funded Centers of Excellence for Influenza Research and Surveillance tracks and shares influenza data (NIAID, 2008). Surveillance in Wildlife Even though wildlife populations are known res- ervoirs for high-impact zoonoses, surveillance for zoonotic pathogens in wildlife populations around the world is fragmented and incomplete at best, and nonexistent at worst. This is due to a variety of factors, including the expense and feasibility involved in reaching and capturing hard-to-reach populations, often leading to small sample sizes. In addition, even if a wild animal is reached, size limitations of birds, bats, and small rodents provide only small volumes of tissues or body fluids for testing. A few developed countries routinely conduct wildlife disease surveil- lance for certain zoonotic diseases, such as rabies in bats, foxes, and rac- coons in the United States (Blanton et al., 2008). Surveillance for WNV has been ongoing since 2003. With more than 2,000 human cases of WNV reported annually in the United States, it has become the most prevalent vector-borne human pathogen reported in the country (Petersen and Hayes, 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES 2004). Accordingly, state and county departments of health routinely con- duct disease surveillance in dead birds and mosquitoes early in the transmis- sion season so that they can follow the spread of emergence and institute preventive interventions (i.e., mosquito control, and health education advis- ing the population to avoid exposure to mosquitoes). The United States has devoted greater investments in wildlife surveillance since the early 1990s, when it was found that tuberculosis-infected wildlife play an important role in bovine tuberculosis emergence in cattle and that cross-infection of U.S. cattle and bison resulted in brucellosis-infected cattle herds. Even though the human monkeypox virus was introduced into the United States via the wildlife trade, mandatory testing of the 500 million wild animals imported into the United States annually remains confined to a handful of agriculturally significant diseases such as Newcastle disease, FMD, brucellosis, psittacosis, and more recently avian influenza. The re- maining potential threats are handled through ad hoc research studies to detect and explore relationships among emerging zoonotic disease agents in wildlife, domesticated animals, and humans. SARS is a good example of such ad hoc efforts in wildlife: There has been significant research interest in the wildlife origins of SARS in China, yet to date there are no coordinated integrated disease surveillance programs for SARS or other pathogens in wildlife. The lack of human SARS cases since 2003 is one factor for wan- ing interest and loss of commitment to conduct ongoing SARS coronavirus surveillance in wildlife reservoirs. Investigators have monitored the virologic evolution of the HPAI H5N1 virus in southern China markets (Smith et al., 2006), although it appears that a nationally led disease surveillance effort was not created. Australia, with a long history of leadership in zoonotic disease surveillance and con- trol programs, has set up the Australian Biosecurity Cooperative Research Center for Emerging Infectious Disease, which conducts preborder disease surveillance of wildlife and food-animals in countries across Southeast Asia that trade with Australia. Despite these several positive examples, the com- mittee concludes that the use of ongoing, sustained disease surveillance to detect potential new zoonoses in wildlife remains limited, even in wealthy, developed countries. Detecting Subclinical Infections in Livestock, Poultry, and Wildlife Animal and environmental reservoirs are capable of transmitting zoonotic patho- gens to others with limited or no impact on individual animal or population health. Disease surveillance is challenging in animal reservoirs because the reservoirs either do not display clinical signs of infection, or if they do, the infection is mild. However, existing knowledge about these reservoir spe- cies allows strategic surveillance programs to be designed to continuously assess the agent population for its prevalence in the reservoir and to assess 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM changes that can lead to pathogen emergence in humans or other animal species. Where these characteristic features are known, it is possible to pre- dict emerging events in advance of significant mortality and morbidity. Many pathogens affecting livestock and poultry cause no clinical ill- ness in individual animals but result in human cases and outbreaks. Cattle infected with brucellosis may not show clinical signs, and the most likely cases are identified by conducting active surveillance through routine speci- men collection from herds, then testing with serological assays and bacterial culture. Asymptomatic infections in food animals can cause significant human food-borne illness and mortality. The H5N1 virus circulates in ducks, an important food source for humans, but the ducks do not show clinical signs of disease. Cattle infected with Escherichia coli O157:H7 and Salmonella enterica often do not show clinical signs of illness (Dewell et al., 2005), but the bacteria cause illness in humans (Mead et al., 1999; CDC, 2006). Infec- tion can be detected through culture or antigen detection assays including molecular techniques in several organs including lymph nodes, digestive tracts, and even mucosal membrane (Dargatz et al., 2005). In the United States and other selected countries, testing and monitoring of E. coli O157: H7 and S. enterica in both live and slaughtered animals are conducted as part of a surveillance system for meat safety. Molecular pheno- and geno- typing (e.g., PulseNet in the United States) during the past few years has led to the condemnation of infected meat products (CDC, 2008c). However, despite ongoing surveillance efforts, human foodborne outbreaks of E. coli O157:H7 persist and underscore the imperfection of existing surveillance methods for these types of infections. The pandemic influenza A(H1N1) 2009 virus has molecular signatures of swine, avian, and human influenza viruses. Influenza is a mild respiratory disease in pigs and difficult to differentiate from other diseases. Because classical swine fever is a common illness in pigs, strategic sampling of swine and characterization of triple reassortment influenza viruses would be needed to provide a much better base to predict and prevent disease emergence. This could also guide continuous diagnostic assessment modi- fications in animal and human health laboratories. Communicating and Collaborating Across Sectors, Professions, and Health Systems The negative impact of emerging zoonotic disease outbreaks these past few decades has brought increased attention to the need for disease surveillance that links and provides information across human and animal health sectors for early detection and response. Despite considerable un- derstanding of the need for such an integrated approach, one of the biggest 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES challenges has been effectively communicating across these sectors before, during, and after disease outbreaks. Failed communication among sectors can lead to delays in detecting and confirming emerging zoonotic disease outbreaks. Examples include the failure of human health authorities in 1999 to follow up on a veterinary pathologist’s alert that disease outbreaks in birds and humans could be related and caused by the same agent, WNV (GAO, 2001); the failure of the animal health sector to alert human health authorities of sick rodents imported from Africa and housed with prairie dogs, ultimately leading to a human outbreak of monkeypox (CDC, 2003b,c); the failure by animal health officials in Southeast Asia in 2003 to alert WHO about HPAI H5N1 outbreaks in poultry in the region, and leading to delays in confirmation of human HPAI H5N1 cases in Vietnam (WHO, 2004); and the failure of human health authorities in Africa, at least twice, to take action to prevent human exposure to Ebola during 2001–2003 when they were alerted to wild animal outbreaks weeks before human cases occurred (Rouquet et al., 2005). Other factors can influence the success of cross-sectoral communi- cation. These include protocols for appropriate communication, techno- logical capacity and resources, level of active outreach and persistence by individuals, and political will. It furthermore depends on the extent that professionals in different disciplines understand and respect the expertise of their counterparts in other professions. The busy schedules of profes- sionals and their dispersed office locations also limit opportunities for ca- sual contacts. Therefore intentional meetings are necessary for developing integrated disease surveillance and response strategies, reviewing disease surveillance findings, and reaching joint decisions on prevention and con- trol strategies. Risk communications by human and animal health authorities and the media can affect how the public understands the disease and affect its actions during an outbreak. Yet relatively few surveillance programs have brought social science professionals on board with their efforts to effectively communicate with the public about ongoing disease risks and behaviors. Lessons learned to date suggest that easy channels of communication between departments of human and animal health and the public and private sectors are mostly nonexistent. Some efforts to improve commu- nication across medical and veterinary health sectors were launched when HPAI H5N1 began spreading, but those were weak at best. Given the disap- pointing experiences previously noted—followed by similar communication difficulties encountered with SARS and Nipah virus outbreaks in Hong Kong and Malaysia—several countries have organized special multisectoral coordinating committees and task forces to oversee HPAI H5N1 disease surveillance and response and to formulate appropriate disease control 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM policies (Tanzania, Kenya, Asia). These initiatives will need to be assessed for their success and to determine how best to overcome communication barriers between human, animal, and environmental health officials that seem to exist independently of the resources available to a country. Employing Strategic Approaches for Effective Surveillance and Response Emerging zoonotic diseases can emerge at any time in any part of the world, therefore it is difficult to predict which pathogens may emerge, which human and or animal populations it may impact, or how these pathogens may spread. From a growing number of experiences, the world has learned that it is critically important to detect and report emerging zoonotic disease outbreaks that occur in a single country or region. Early detection and reporting at the local level give the international commu- nity an opportunity to assist national authorities and implement effective response measures. Because local outbreaks in today’s world can quickly spread beyond national borders and have significant global health and economic impacts, it is crucial to invest in disease surveillance capacity for countries that cannot afford it. No matter the wealth or capacity of any country, resources are often not available and are at best limited at all levels for detecting and respond- ing to zoonotic diseases. National expertise and current levels of disease surveillance system development vary by country and region. Resource- challenged countries are often those geographically located in areas that place them at an increased risk of pathogen emergence and cross-species transmission, due to factors such as climate change, ecosystem degradation, biodiversity, and population density. Thus, strategic approaches tailored to different settings and different resources are needed for surveillance in dif- ferent animal species—including terrestrial and aquatic wildlife, livestock, and poultry—to detect disease early, improve animal health, and minimize the likelihood of human exposure. Securing and Providing Information Technology New disease surveillance data sources hold tremendous potential to initiate epidemiological follow-up studies and provide complementary epi- demic intelligence context to conventional sources, yet are subject to a num- ber of potential hazards that need to be studied in depth, including false reports (mis- or disinformation) and reporting bias. An open and accessible IT system assists users in overcoming existing geographical, organizational, and societal barriers to information, a process that can lead to greater em- powerment, involvement, and democratization. Because regions with the least advanced communication infrastructure also tend to bear the greatest 

0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES infectious disease burden and risk, system development needs to be aimed at closing the gaps in these critical areas. Global coverage requires attention to creating and capturing locally feasible channels of communication and making sure that system outputs are more accessible to users in vulnerable regions. Low-bandwidth options, including mobile phone alerts, could be considered for helping to transmit information. Much work needs to be done to integrate the processes of data col- lection, analysis, and interpretation across the multiple sectors concerned. Standard protocols are lacking and necessary to harmonize epidemiological and laboratory aspects of detection, confirmation, outbreak investigation, and design and implementation of disease control efforts. The commit- tee could not identify any system that had incorporated routine disease surveillance for human risk behaviors into disease surveillance capacity, a capacity needed for an optimally effective disease surveillance and response system. The principal concern with any web-based, early alert system is the reliability and verification of information in a similarly rapid and transpar- ent manner. A second high-priority concern is determining how best to use the voluminous amount of information, especially when there is conflicting information. In addition, users need to determine how to filter informa- tion to accurately separate actual events from “noise,” how to support the diverse set of data reported and who can provide the service, whether it is possible to integrate various data sources into a user-friendly format, and what the cost is for accomplishing all the above. Timeliness and the reliability in confirmation of the diagnosis of the etiologic agent of human or animal outbreaks are two characteristics that can be in direct opposi- tion to one another. For example, the automated media scanning program GPHIN provides a great volume of alerts to WHO’s GOARN, which expends significant efforts in confirming these alerts. Given the frequent absence of laboratory confirmation at the time of informal outbreak alerts, an increased rate of false-positive reports is expected. Thus validating the information quickly is essential to minimize false-positive alerts. Moreover, because regions with the least advanced communication infrastructure also tend to carry the greatest infectious disease burden and risk, system devel- opment would need to be aimed at closing the gaps in these critical areas. Another challenge is keeping identifiable data about patients and ani- mal owners secure and confidential. Identifiers can be important for disease tracing, but if divulged can result in unintended harms (e.g., sanctions or stigma). Such outcomes have serious adverse impacts because the willing- ness to report is based in large part on trust that punitive actions will be avoided. When disease tracing is not essential, data that identify individuals do not need to be collected. When disease trace-backs and trace-forwards are indicated for disease control purposes, however, information on indi- 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM vidual people and animals (including the population source) needs to be available. For a disease surveillance system to function effectively, identify- ing information needs to be kept confidential to engender trust but be avail- able if necessary for an appropriate response to the health risk. Laboratory Capability and Capacity Previous National Research Council and Institute of Medicine reports provide a summary of laboratories operated by developed countries, univer- sities, and donor agencies (NRC, 2005; IOM and NRC, 2008). Although the committee was aware of specific laboratories in resource-constrained countries that have outstanding capabilities for zoonotic disease diagno- sis (e.g., the CDC–Kenya Medical Research Institute [KEMRI] Emerging Infections Laboratory in Nairobi, the Uganda Virus Research Institute in Entebbe, the Dhaka-based International Center for Diarrheal Disease Research in Bangladesh), it was beyond the committee’s scope and task to thoroughly identify existing laboratory capacity and capability for zoo- notic diseases on a global basis. Such a database is sorely needed but not available. The committee was able to request information from WHO, FAO, OIE, and DoD-GEIS about their laboratory locations and capacity. That infor- mation provided the basis for the committee’s analysis of existing labora- tory locations compared to where they are most needed. Figure 4-3 shows DoD-GEIS laboratories and WHO, FAO, and OIE reference laboratories and collaborating centers superimposed on a map depicting the predicted global hotspots for disease emergence, as previously seen in Figure 1-1. There are many additional private and government laboratories with dis- ease diagnostic capabilities that are not designated on this map. It is ap- parent that there is at a minimum a striking geographic mismatch between intergovernmental organization-designated reference laboratory locations and capacity and hotspot regions suspected to be ideal for pathogen adap- tation, selection, and emergence. It is important to recognize that these reference laboratories typically do not have broad capabilities in disease diagnosis, that they are often research laboratories with agent-specific expertise, or that their mandates are not directed specifically at zoonotic disease surveillance. Thus there is no resource that provides current data on existing zoonotic disease diag- nostic laboratory capability and capacity worldwide. In addition, among reference laboratories, there are no common operational protocols as one might expect in a laboratory network, whereas research laboratories often do not seek or maintain accredited laboratory status and are oriented to the particular research program of the institution in which they reside. There is a critical global shortage of qualified laboratories for zoonotic 

 FIGURE 4-3 Zoonotic disease hotspots and selected reference laboratories by location. NOTE: The white dots signify the location of identified World Health Organization, Food and Agriculture Organization of the United Nations, World Organization for Animal Health, and U.S. Department of Defense reference laboratories and collaborating centers, many of which have a single disease or other focus mandate. Green dots are laboratories that have a broader function in zoonotic and emerging diseases. Locations shaded in red and orange represent hotspot regions. The map does not include univer- sity-based research and other laboratories working in the area of emerging disease detection and characterization. Numerous other private-sector and national laboratories may be able to provide laboratory support capability (e.g., those of the Institute Pasteur and Meriux Alliance), but were not included on this map. New S-1 and 4-3 Color SOURCE: Hotspot location data derived from Jones et al., 2008. Reference laboratory data received from committee’s communica- tion with Stephane de La Rocque, Tracy DuVernoy, Cassel Nutter, Alejandro Thiermann, and Chris Thorns (2008). 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM disease surveillance in animals. Investments in laboratory facility renovation and new construction in developed countries can be justified, particularly for animal disease testing laboratories. Furthermore, there is a shortage of trained professionals in diagnostic medicine. These infrastructure and personnel shortages can be met in developed countries if the political will and commitment are made to meet these challenges. In contrast, the laboratory infrastructure status in areas of the globe struggling to develop is distressing. When viewed broadly, all parts of the infrastructure neces- sary to meet the challenge of surveillance for zoonotic diseases (facilities, trained personnel, equipment, reagents, operational support, informatics) are substandard. For every example of success attributable to laboratory investments made in preparation for pandemic influenza, FMD, or another high-profile targeted disease, many more laboratories have only a single refrigerator available to store reagents requiring cold storage, and it may even operate sporadically. The future of those few laboratories that have been improved with donor funding is questionable at best without further sustained national or international commitment. Donor agencies and international partners have funded significant labo- ratory upgrades and new facilities in resource-constrained countries for dis- ease surveillance and research projects on specific infectious agents such as HIV/AIDS and influenza (including but not limited to HPAI H5N1). Some of these are modern research laboratories with trained personnel and the latest equipment that meet all biosafety and biocontainment requirements, and these laboratories are a resource for agent-specific zoonotic disease testing. However, they were neither built for nor do they have a mandate or operating funds to support general zoonotic disease testing. Given the expense of establishing and sustaining laboratory infrastructure in develop- ing nations, duplicating these facilities for broad disease surveillance testing is unlikely. Thus an investigation is warranted to determine the extent that these laboratories can be shared by nations and include capacity for both human and animal laboratory disease surveillance in a single facility— unless the joint use of the laboratory is biologically risky. The committee applauds the recent efforts by WHO and 13 African countries to strengthen African medical laboratories by developing an ac- creditation program (Kaiser Family Foundation, 2009). The committee encourages similar efforts with animal health laboratories to build capacity for zoonotic diseases and additional investments in strengthening labora- tory capacity. Gaps in the Global Laboratory Network Only a limited number of diagnostic laboratory networks exist that em- brace and meet the outlined guiding principles. Examples include the U.S. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES National Animal Health Laboratory Network and its Canadian equivalent, the U.S. Laboratory Response Network for Bioterrorism, and the European Centre for Disease Control and Prevention’s Food- and Water-Borne Dis- ease Surveillance Network. These networks were established to focus on a specific group of agents (e.g., those thought to be the greatest threat from terrorist activities or food- and water-borne agents), some or all of which may be zoonotic, and each operates on the guiding principles of laboratory and network operation. One of the gains of the vertically organized polio eradication initiative in Africa is the establishment of a reliable acute flaccid paralysis disease surveillance system, backed by a regionwide polio laboratory network in Africa. The 16-member polio laboratory network has been technically upgraded, is accessible to the 46 countries in the WHO African region, and have provided timely and accurate results to national (polio) disease control programs. The success of the polio laboratory network has led to the establishment of other disease-specific laboratory networks, with their associated disease surveillance systems. Currently in the African region, there are five laboratory networks that cover polio, integrated measles, yellow fever, rubella, HIV, pediatric bacte- rial meningitis, rotavirus, and human papillomavirus. These networks are functioning despite minimal collaboration among them, either as individual laboratories or networks at large. Figure 4-4 shows the location of WHO laboratories in these networks. Initial efforts to integrate activities of the polio, measles, yellow fever, and rubella laboratories in their respective networks have resulted in some sharing of equipment and facilities, as well as human and financial resources. The similarities in standardized sample collection and testing strategy has led to a higher level of integration of the measles, rubella, and yellow fever laboratories; in training of laboratory staff; use of equipment and reagents; and quality assessment and assurance. Measles labs are routinely required to test samples for rubella when the measles IgM is negative. For resource-constrained countries, the integration of a disease surveillance system, including laboratory services, is required to reduce avoidable duplication of efforts and waste of scarce resources, in- cluding trained, skilled, competent laboratory personnel. In addition, joint planning of activities at the laboratory level and joint conduct of internal and external accreditation exercises has taken place. These are certainly positive developments that need to be fully supported. Laboratory networks in the African region that focus on animal dis- eases are in their infancy. FAO recently completed an effort to catalog the existing influenza testing laboratory infrastructure for avian samples in sub- Saharan Africa, and it is organizing these animal disease testing laboratories into four African regional networks: Eastern, West/Central, North, and Southern African regions (FAO, 2006). The goal is for each of these regions 

FIGURE 4-4 Global World Health Organization Vaccine Preventable Disease Laboratory Network.  SOURCE: WHO (2007b). 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES to have one regional reference laboratory, and for the networks to operate on the principles of good laboratory and network practices. Although there are some examples of laboratory infrastructure and disease surveillance sys- tems in developing regions, the overall disease surveillance infrastructure is fragmented at best, and a foundation of laboratory capability and capacity is nearly nonexistent in nearly every country. Worse still, there is virtually no effort to integrate the human and animal laboratory disease surveillance systems for emerging zoonotic diseases. Laboratories need to work together as an effective network to cover testing of specimens from different spe- cies and for a broad spectrum of emerging zoonotic disease agents of high priority to human and animal populations. Field-Oriented Multidisciplinary Capacity-Building Programs and Retaining National Expertise in Resource-Challenged Countries There is a critical shortage of trained field epidemiology and parapro- fessional personnel in both human and animal disease surveillance. Over the past 40 years, training for thousands of health personnel in the hu- man health sector has occurred primarily for vertically funded infectious disease control or disease elimination programs. Yet many such training efforts have not led to a sustained cadre of professionals from different sectors and disciplines, with the expertise and experience needed to imple- ment and manage an effective global, integrated emerging zoonotic disease surveillance system. More promising results have been observed with the more mature FETP programs—in places such as Thailand, Mexico, and the Philippines—where FETP graduates have moved into higher level positions in ministries of health. In the animal health sector, vertical training programs have also oc- curred with similar results, but on a smaller scale to those seen in the human health sector. Moreover, funding for training animal health profes- sionals has been insufficient to provide the needed number of trained lead- ers and experts in this area. Disease recording systems, if they exist, are not coordinated between human and veterinary medical professionals, so the capacity to integrate and synthesize findings and approaches is limited. Joint human and animal health field epidemiology training programs are absent and needed to improve multisectoral field training, coordination, and communication, and to produce a workforce capable of carrying out zoonotic disease surveillance, outbreak investigation, and response. Exist- ing educational and field-based training programs need further improve- ments to provide cross-disciplinary training, and new programs are needed in areas where field training programs have not yet been established. The CDC KEMRI FELTP program is a model that could be used for field epi- demiology and laboratory training programs. 

 EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM Finally, in both sectors, trained medical and veterinary health officials from developing countries frequently seek and obtain employment in inter- national agencies, other countries and or regions that offer higher salaries and benefits, places where resources are available for experts to apply their training in the conduct of their work, and where there is greater potential for professional advancement. Taken together, these factors have resulted in many countries having neither human nor animal health personnel available in sufficient numbers. The few that are available are not adequately trained to recognize zoonotic diseases clinically, to conduct a quality outbreak investigation, to design and implement an effective zoonotic disease sur- veillance system (including risk factor and risk perception surveillance), to provide timely and accurate laboratory confirmation of the etiologic agent causing the outbreak, or to work and communicate effectively as part of a multi-sectoral team. Countries have the responsibility to train, employ, and retain profes- sionals in their areas of expertise. These training programs therefore need to be implemented through collaborations among relevant ministries, local universities, and extension programs. Individuals could be preferentially targeted to train in geographic areas at higher risk for zoonotic disease emergence so they can properly detect disease. CONCLUSION An effective global, integrated zoonotic disease surveillance and re- sponse system currently does not exist. National and international commit- ment to the purpose and goal of such a system are essential. True leadership and collaboration by leaders and professionals in both public and private sectors, and across countries and regions of the world in all relevant health, agricultural, natural resource, education, and other sectors, with financial support and commitment will be critical to building an effective system that meets the purpose and goals of this system. As the system is built, continual assessment and evaluation of surveillance in human, animal, and linked sur- veillance systems will be needed regarding their comprehensiveness, quality, multisectoral collaborative aspects, and other aspects of the systems. WHO and OIE have begun this assessment and evaluation process, but further effort and support from the international community at large is critically needed to support their efforts. REFERENCES AFENET (African Field Epidemiology Network). 2009. AFENET: Background. http://www. afenet.net/english/background.php (accessed June 15, 2009). 

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