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5 Incentives for Disease Surveillance, Reporting, and Response “It is essential to provide additional incentives. Different incentives will likely apply at different levels. At the local or district level, training, feedback, and epidemiological or clinical assistance to the reporting clini- cians and local public health are possible incentives. At the country level, financial incentives and resources are needed to encourage reporting as well as to expand the reach of the primary health care and communica- tions infrastructures. Other psychological incentives, such as increased national prestige for recognizing an unusual disease, should also be con- sidered. Encouragement from the international community, to overcome a country’s fear of adverse consequences and help leverage resources, is also necessary.” —Stephen S. Morse “Global Infectious Disease Surveillance and Health Intelligence” Health Affairs, 00 An important lesson from disease outbreaks such as severe acute respi- ratory syndrome (SARS) is that the ability of the global human and animal health system to respond is only as good as the ability and willingness of local and national systems to detect and report outbreaks. Delays in re- porting SARS by China could have resulted in catastrophic consequences worldwide if the pathogen had been more transmissible (Heymann and Rodier, 2004). Data on an outbreak have to be recognized before they can be reported. Current strategies to contain an avian influenza pandemic are contingent on recognizing human-to-human transmission within approximately 3 weeks of the initial case (Ferguson et al., 2005; Longini et al., 2005). One might argue that suppressing information about an outbreak is difficult in today’s world of the Internet, cell phones, and other communication and informa- tion technologies. Countries or regions that are less keen on reporting out- breaks—either because they fear trade or travel sanctions or because they have little capacity to control the outbreak once it has been detected—are likely to spend relatively less on disease surveillance (Laxminarayan et al., 2008). All else being equal, incentives to invest in disease surveillance 

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES are related to incentives for reporting as part of the entire surveillance system. BEHAVIORAL AND CULTURAL DETERMINANTS OF INFORMATION SHARING Socioeconomic and Political Consequences of Reporting Reporting outbreaks of zoonotic and vector-borne diseases may serve the greater good of the global health community, but the publicity associ- ated with such outbreaks can result in huge national and private-sector costs (Zacher, 1999). Promptly reporting the disease outbreak may not be in the government or ruling political parties’ immediate best interests if it will negatively affect trade, tourism, or public confidence in agricultural products (Cash and Narasimhan, 2000). At the national level, government officials may suppress reports of illness among humans as well as animals if they perceive a threat to their careers (Waltner-Toews, 2004; Kaufman, 2008). Government officials may also try to downplay human and animal health system shortfalls and disease outbreaks if those issues lead critics to question an official’s performance and the ability of the government to provide basic services to its citizens (Farmer, 1992). The threat of an epidemic disease may be hidden through the govern- ment’s use of “rhetorical strategies,” such as employing nonspecific terms to describe disease outbreaks to the public. An outbreak of cholera in India was reported instead as gastroenteritis and other nondescript illness catego- ries (Ghosh and Coutinho, 2000). An outbreak of highly pathogenic avian influenza (HPAI) H5N1 in Thailand was first reported as avian cholera (Chuengsatiansup, 2008). Such strategies may be employed as a way to minimize fear and public panic of an epidemic, as well as a means to con- ceal crises that could have economic repercussions including trade impacts. The strategy of regionally isolating the disease has also been employed to deflect attention away from government responsibility for disease epidem- ics. This strategy influences both when and how disease outbreaks are re- ported and perceived. In countries such as Venezuela, it has involved calling attention to the unhygienic behavior of indigenous groups or impoverished sectors of the population, conveying the idea that the rest of the population is relatively safe from disease transmission. This false sense of security is achieved at the cost of impoverished victims of diseases, who are blamed for their own misery (Briggs, 2004). At the Local and Producer Level Decisions by officials to proactively engage in the surveillance of zoo- notic diseases involve social risk to existing or potential social relations

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 INCENTIVES FOR DISEASE SURVEILLANCE (Nichter, 2008). Consequently, some producers who discover sick animals may try to sell or dispose of them without reporting infection. Nipah virus outbreak in Malaysia in 1998–1999 is another example of the movement of infected animals without reporting (see Box 5-1). Therefore, local au- thorities need effective disease surveillance to identify local outbreaks and to rapidly contain them to reduce the risks of zoonotic disease spread to human and animal populations. The information needed to accomplish this exists: Local communities are well aware of infection patterns, but there are barriers to reporting processes because of inefficiency and lack of incentives (PPLPI, 2007). The 2006–2007 HPAI H5N1 outbreaks in Indonesia show how these socioeconomic and political factors influence disease surveillance activities in the context of decentralized governance (Padmawati and Nichter, 2008). In central Java, Indonesia, local official support for avian influenza surveil- lance initiatives waned when human cases of the disease did not reach the impending epidemic proportions initially reported in the press. At the time, officials were preoccupied with other pressing needs, such as the occurrence of major earthquakes and the effects of oil price hikes on the costs of basic commodities. HPAI H5N1 was recognized to be an emerging threat to hu- man and animal health, but it was not considered the largest risk facing officials strapped with diminishing funds and growing public demands for assistance. Moreover, as the poultry industry exerted considerable local influence, it was not in the best interests of local politicians to support ag- gressive HPAI H5N1 control measures that would displease this powerful lobby unless public opinion demanded such actions. BOX 5-1 Nipah Virus Outbreak in Malaysia An outbreak of Nipah virus in Bukit Pelandok, Negri Sembilan, lasted from December 1998 to April 1999. Two cases occurred in the state of Selangor, be- tween Perak and Negri Sembilan (CDC, 1999). The transport of infected pigs was accelerated by a “fire sale” that moved grower pigs from Perak to Negri Sembilan, Selangor, Penang, Malacca, and Johore. In response, the Malaysian government banned the movement of pigs within the country, and neighboring countries stopped pig imports from Malaysia. In 1999, the Nipah virus spread to the state of Sarawak, which is on the island of Borneo (Ahmad, 2000). In response, the state government offered a RM 20,000 reward in return for information on people responsible for smuggling Nipah- infected pigs into Sarawak. SOURCES: CDC (1999); Ahmad (2000).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Although aggressive measures, such as banning smallholder poultry keeping, were eventually taken to prevent the spread of HPAI H5N1, other municipalities in Indonesia’s decentralized state weakly complied with dis- ease surveillance initiatives. Those smallholder poultry keepers questioned the severity of the avian influenza threat to their birds. Many did not view the disease as new, but rather as a form of Newcastle disease, a serious threat they had faced for many years (Padmawati and Nichter, 2008). Some continued to consume and sell diseased dead birds. Small to medium-sized contract poultry farmers feared that government officials might cull their birds before definitive laboratory confirmation of the disease, and they were skeptical of compensation schemes or believed compensation was too low. These poultry farmers reported the deaths of chickens to contractors, who in turn sought the services of private veterinarians to determine the causes of bird death, making effective disease surveillance difficult. Smallholder poultry farmers and keepers feared reporting incidents directly to the gov- ernment. This fear was not limited to a concern about losing their own birds, but also to the social risk of angering nearby neighbors, whose birds would be subject to culling within a 2–5 km radius of an outbreak location (Padmawati and Nichter, 2008). Trust and technical skills of government health officers proved to be an important variable in determining whether local stakeholders reported bird death in Central Java and elsewhere in Asia (Kleinman et al., 2008). It was crucial that the local population trust local authorities to provide adequate and timely compensation for culled birds, trust in the efficacy of vaccines to prevent disease and vaccinators who themselves have been associated with spreading disease, and trust that health officials would conduct appropriate scientific tests to ascertain the presence of HPAI H5N1 and not just act on the basis of suspicion. Moreover, local stakeholders had to trust that the provincial and national governments were looking after the public’s best interests and not just particular stakeholders. Widely circulating rumors suggested that the Indonesian government was benefiting from HPAI H5N1 through well-publicized appeals for development aid, and that agribusi- nesses were benefiting from decreased competition in the poultry market because local farmers had the least amount of resources to deal with the losses (Padmawati and Nichter, 2008). The committee concludes that dis- ease surveillance systems need to effectively combine incentives for collec- tive responsibility and self-reporting, and disincentives for not reporting. At the National, Regional, and Global Levels National authorities face conflicting incentives to report disease out- breaks (Malani and Laxminarayan, 2006). Reporting typically brings medi- cal assistance, which is helpful in containing outbreaks, but also brings the

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 INCENTIVES FOR DISEASE SURVEILLANCE threat of trade and travel sanctions that can be devastating to the economies of smaller countries. When the risk of sanctions is high, countries may delay issuing an outbreak report or downplay the human and animal health risk of the outbreak. They may put both human and animal populations at risk, but the incentives to do so are strong. The force of sanctions in discourag- ing reporting can be blunted to some extent by medical assistance, and by external support under the International Health Regulations 2005 (IHR 2005), but the value of medical assistance is often several orders of magni- tude smaller than the cost of sanctions. However, the early declaration of a disease outbreak, even if it brings sanctions, also opens possibilities for formal early intervention in containing the outbreak, and thus reducing the costs of eradication.1 The decision to report depends therefore on a trade-off between the costs of sanctions and the benefits of early outside as- sistance and a reduction in costs of controlling or eradicating the disease. Countries may report outbreaks in order to maintain a reputation for reliability and good global citizenship. An example of this is the prompt reporting of cholera by Peru during the late 1990s even though it resulted in significant economic costs (Panisset, 2000). Another is of the willingness of the United States to report a single case of bovine spongiform encepha- lopathy (BSE). But countries may also be interested in protecting their repu- tations as healthy places. Health and vital statistics are commonly used to judge development and modernity at province, district, or country levels. Reports of emerging illnesses may be taken as a marker of political and infrastructure problems, as well as a symptom of poverty and underdevel- opment. Precisely because disease affects international reputation, tourism, and investment, some governments may prefer not to report outbreaks or to minimally report them (Cash and Narasimhan, 2000). Applying existing least restrictive trade mechanisms (e.g., zoning and compartmentalization sanctions where appropriate) could minimize unnecessary costs of trade sanctions when the countries do effectively demonstrate their ability to de- tect and appropriately control the disease outbreak with routine, evidence- based responses. The same holds true if countries are able to improve the specificity of reporting to reduce false reports. To avoid the problem of outbreak concealment, it is important to incentivize outbreak reporting within countries by designing outbreak control measures and providing adequate compensation schemes. Economic considerations are not the only reasons why countries do not 1 Eradication carries geographically distinct meanings in human and animal medicine. Whereas for human diseases, eradication means purging of the disease from the entire world (e.g., smallpox), in animal health eradication of a specific disease is considered on a nation-by- nation status. To date, no animal disease has been eradicated in the human health sense of the word, but most developed counties can claim to have successfully eradicated various agricul- tural diseases (e.g., foot-and-mouth disease in Uruguay, screwworm in the United States).

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES report outbreaks. Disease outbreaks call attention to a government’s failure to maintain various infrastructures, and failure to control epidemics may threaten state legitimacy (Farmer, 1992; Ghosh and Coutinho, 2000). As a result, attempts may be made to suppress information about disease out- breaks or classify diseases in ways that minimize collective anxiety. In Cuba, outbreaks of dengue fever in the late 1990s were suppressed and seen as a national embarrassment given the country’s highly praised Aedes aegypti control program implemented in the 1980s following a major dengue fever epidemic (Van Sickle, 1998). In several Caribbean countries, dengue fever has been glossed over as a nonspecific “viral fever” for fear of affecting the tourist industry. This type of obfuscation has made implementing interna- tional health disease surveillance systems, though agreed on in principle, quite challenging (Baker and Fidler, 2006). At the national health authority level, pressures from stakeholders in other economic sectors may play a role in delaying formal reporting, as was the case in East Asia. After the major economic losses resulting from the earlier SARS outbreak, directors of veterinary services in East Asia were un- der pressure from stakeholders to delay the declaration of the HPAI H5N1 outbreak. In addition, HPAI H5N1 was unofficially detected in Indonesia in August 2003, whereas the official declaration took place on January 25, 2004 (Dolberg et al., 2005). This delay in official notification to the World Organization for Animal Health (OIE) likely occurred in most countries, as shown by the proximity of the dates the outbreak was declared in different countries—Vietnam, January 8, 2004; Lao PDR, January 14; Thailand and Cambodia, January 23; and Indonesia, January 25—which is epidemiologi- cally highly unlikely. The delayed notification may be partly attributed to inadequate diagnostic facilities and the lack of skilled staff, and partly to political pressure on human and animal health services to suppress infor- mation because of the economic consequences in lost domestic and export markets for poultry products and tourism (O’Neill, 2004). Reporting of disease outbreaks is not a binary event (confirmation or denial), and countries differ significantly in the speed of reporting out- breaks. A case in point is with reporting of foot-and-mouth disease (FMD) by South America’s main beef-producing countries, including Argentina and Uruguay. A report by the South American Commission for the Fight Against FMD found that of all the countries in the region, Uruguay was the only country that on average quickly reported outbreaks (Comisión Sudamericana para la Lucha Contra la Fiebre Aftosa, 1996). Yet during a 2001 outbreak in Uruguay, uncertainty about the nature of the outbreak and poor communication with Argentine authorities about Argentina’s high cross-border movement fueled the spread of disease and resulted in outbreaks in 4 percent of Uruguay’s total livestock (Rich, 2004). Addition- ally, during an FMD outbreak in Argentina in July 2000, the government

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 INCENTIVES FOR DISEASE SURVEILLANCE failed to acknowledge the severity of the disease spread and did not create an eradication program until April 2001 (Rich, 2004). Consequently, nearly 2.8 million cattle, or 5–6 percent of the cattle population, had been exposed to FMD by the end of the Argentine outbreak in January 2002. The committee gave considerable thought to existing policies and ac- tivities that affect disease reporting at various levels, as well as to those affected by each policy. Table 5-1 summarizes the pros and cons of various types of policies and activities. While it is not exhaustive, it exposes weak- nesses in some policies and activities. By learning from the past, new poli- cies can improve and incentivize disease surveillance and reporting efforts that would ultimately protect human and animal health and minimize the loss of livelihood. Reporting by the Food Production Industry Voluntary reporting by industry could play an important role in de- tecting zoonotic disease outbreaks. In developed countries, food produc- ers sometimes issue safety warnings or withdraw their products from the market to protect themselves from legal action from affected consumers. In addition, producers might take these actions to maintain their reputation as being ethically and socially responsible, or they may do so in an effort to improve their reputation. The efforts of East Asian producers’ organizations in containing HPAI H5N1 in 2004 illustrate how actions tend to work better when the industry is organized rather than when it is disjointed with many small producers. Thailand is a major exporter in poultry products and had a direct interest in controlling the disease. The Thai Broiler Processing Exporters’ Associa- tion, consisting mainly of large-scale members, promoted its interest ag- gressively. It succeeded in convincing the Thai government to institute an immediate culling policy when the outbreak began, particularly targeting small farmyard poultry operations (Chanyapate and Delforge, 2004; Davis, 2005). The same action was expected in intensive farming systems in the country. The poultry producer association of Malaysia was able to coordi- nate production, but the broad-based nature of its membership and its lack of a cohesive structure denied the organization involvement in formulating shared policy positions and influencing the government. Top-down state- sponsored organizations in Vietnam did not represent farmers: When the government—against scientific evidence—advised people not to eat chicken regardless of whether the chickens were sick, these organizations did little to defend their members’ interests (Vu, 2009). Incentives for industry to report outbreaks may be preempted by na- tional or local regulatory authority action, which may or may not be cor- rect about the source of the outbreak. Moreover, concerns about adversely

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TABLE 5-1 Policies That Influence Reporting at Various Levels, Who Is Affected, and Pros and Cons of Each Policy  Policy Actor Pros Cons Quarantine Local and state • Isolates individuals affected by disease • Producers in affected zone cannot move animals or areas human and animal • Minimal loss of life (except that animals within maybe even cannot get feed trucks in, so great loss affected by health agencies plus quarantine zone will probably be killed) in income and animals; can be an animal welfare disease agricultural agencies • Decreases the spread of disease concern • Potential impacts on tourism Pay or State and national • Incentivizes reporting of sick animals • Discourages disease control measures by the reimburse governments • Uniform policy industry for animal partnering with • Addresses social equity for poor • Loss of animal stocks and life culling industry for • Unable to sustain long term agricultural diseases • Could spread more among animals if reimbursement is as high as market value (purposeful spread) • Environmental impacts of carcass disposal • Requires funding that many poorer states do not have Sanction National governments, • Prevents importation of diseased animal • Discourages disease reporting because of regions WTO, international products anticipated sanctions impacted countries • Compartmentalized rather than fully national • Difficult to sanction human cases by disease trade sanctions imposed upon the occurrence of • Loss of income for affected areas, even if no an emerging infectious disease disease present on individual farm Strengthen WHO, FAO, OIE, • Obtains more information about disease • Increases in false positives that have to be informal NAHLN outbreaks for quicker alerts investigated disease • Greater awareness of overall health status, • Attribution/retribution concerns for whistleblowers surveillance locally to globally networks

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Improve Local, state, and • Improves both sensitivity and specificity of • Inefficiencies in disease diagnosis contribute to quality national human diagnostic testing: (1) fewer false positives, larger and longer-lasting outbreaks of testing and animal health resulting in lower costs of outbreak control • Increases in cost due to improvement in technology authorities and due to improved management and control of infrastructure and training, and need for new agricultural agencies, zoonotic diseases; (2) fewer false negatives, reagents veterinary laboratories, which decreases missed outbreaks • Decreases in feasibility discourages local reporting organizations with • Earlier detection reduces cost of outbreak • Increases need for sharing outside of country or international oversight control, which is more timely region decreases control of the information on reporting and • A simpler test possibly reduces costs, provides • Less feedback from national authorities: In laboratory practices more information resource-constrained countries, local reporting standard setting • Cost effectiveness combined with a safer test might decrease vis-à-vis failed feedback from the (WHO, FAO, OIE) • Feasibility of test, leads to better sample quality national level • Safety of laboratory personnel due to new safety requirements Strengthen National governments • Increases the feasibility of response to an • Increases costs associated with strengthening capacity and international outbreak infrastructure and training at country partners proving • More timely response, thus encouraging early • Increases bureaucracy at all levels level to technical assistance or reporting respond to funding • Improved communication across all levels outbreaks • More control in country of the containment of outbreaks, resulting in less dependency on foreign technical support NOTES: FAO = Food and Agricultural Organization of the United Nations, NAHLN = National Animal Health Laboratory Network, OIE = World Organization for Animal Health, WHO = World Health Organization, WTO = World Trade Organization. 

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES affecting a trade or industry group could make public authorities more cautious about reporting an outbreak. Both of these concerns emerged during the 2008 Salmonella outbreak in the United States that resulted in more than 1,300 human cases of salmonellosis. After a preliminary investigation, the U.S. Food and Drug Administration (FDA) and the U.S. Centers for Disease Control and Prevention (CDC) linked the outbreak to raw tomatoes and issued a warning. After 6 weeks, FDA lifted the warn- ing in July 2008 as it discovered that the real cause had been jalapeño and Serrano peppers grown in Mexico. The United Fresh Produce Association estimated that the tomato industry lost more than $100 million while the warning was in effect and called on Congress to compensate the industry for these losses. It also demanded a stricter burden of proof before the FDA could blame a particular food product for any future foodborne outbreak (Venkataraman, 2008). Animal Culling and Voluntary Reporting The culling or intentional slaughter of sick (and potentially infected, although likely healthy) animals is an important part of the human and animal health response to disease outbreaks in animal populations. There are several reasons to compensate private stakeholders for losses incurred as a result of public action, such as paying farmers an indemnity for culling diseased or suspected infected animals for an emerging disease. Justifica- tions to support payment of culling are related to justice, social equity, and incentivizing desirable participation in early disease reporting. The destruc- tion of private property by the state is fair or just when affected citizens are compensated. The poor often depend on food animals for their income and daily nutrition, and ensuring their livelihoods is social equity. Incentivizing local participation in timely disease detection and reporting can encourage farmers or other actors to declare early emergence of a disease, which can then in turn reduce the cost of containment or control. Compensation schemes that were used to contain cattle plague in the mid-19th century continue to be used today in many countries. The level of compensation is a factor that determines the rate of reporting. Compensa- tion levels that are too low induce producers to hide animals from culling, whereas levels too high would encourage the introduction of animals from outside the region. In general, compensation rates have been around 75–90 percent of market value before the disease outbreak for live animals and lower rates for dead animals (World Bank, 2006). It is important, particularly for smallholders, to address not only the rate of compensation, but also the timeliness and reliability of payment. At the farm level, farmers may delay reporting because of fears of economic sanctions or inadequate or delayed compensation. Thus, a delay in payment

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 INCENTIVES FOR DISEASE SURVEILLANCE of no more than 24 hours is suggested (World Bank, 2006). Important conditions for early payment include pre-outbreak registration of animals per household, and the current availability and operation in a variety of systems (e.g., levies, insurance) of funding for the compensation payments. Assuming that early identification is a global public good, international funding for poor countries will be required and justified. ECONOMIC AND TRADE SANCTIONS SPS and TBT Agreements Several World Trade Organization (WTO) agreements are relevant to health policy, including the Agreements on the Application of Sanitary and Phytosanitary Measures (SPS) and Technical Barriers to Trade (TBT). Both state that health is a legitimate objective for WTO members to take into account when necessary to protect the health of humans, animals, and plants. A major emphasis in WTO rules is to ensure that trade measures are pursued for recognized reasons and avoid discrimination or unnecessary restrictions on trade (WTO and WHO, 2002). Recognizing that techno- logical developments in recent years have created sensitive early warning disease surveillance systems, rapid and reliable verification procedures, preparedness plans including medication stockpiles, and international re- sponse networks, WTO suggests that restrictions should be time-limited and minimally disruptive to international trade and travel (WTO and WHO, 2002). Under the SPS Agreement, measures may be imposed only to the extent necessary to protect life or health (see Box 5-2) and done so on the basis of scientific information to minimize negative trade effects. Under the harmo- nization requirement, members are required to use international guidelines, standards, and recommendations (including those for food safety estab- lished by the Food and Agriculture Organization of the United Nations/ OIE Codex Alimentarius Commission) when available except as otherwise identified in the SPS Agreement. Trade measures that protect animal and plant life or health usually fall within the scope of the SPS Agreement, meaning that the TBT Agreement would not apply. Under the TBT Agreement, WTO members can also ap- ply technical regulations and standards they consider appropriate—for example: for human, animal, or plant life or health; for the protection of the environment; or to meet other consumer interests. Departures from international standards do require justification if requested by another member state (WTO and WHO, 2002). Despite the differences between the SPS and TBT Agreements, their common aim is to prevent unnecessary trade barriers.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES BOX 5-2 Definition of a Sanitary and Phytosanitary Measure at a Glance Measures Taken to Protect: From: Human or animal life Additives, contaminants, toxins, or disease- causing organisms in their food, beverages, feedstuffs Human life Plant- or animal-carried disease (zoonoses) Animal or plant life Pests, disease, or disease-causing organisms A country Damage caused by the entry, establishment, or spread of pests (including invasive species) SOURCE: (WTO and WHO, 2002). Reprinted with permission from WHO. Economic Losses from Trade and Travel Sanctions Outbreaks of zoonotic diseases impose significant effects on human and animal health and lead to economic consequences on affected countries. Disease outbreak reporting often leads unaffected countries to enact travel and trade restrictions on the affected country that far exceed the actual disease threat (Merianos and Peiris, 2005). This can cripple demand for a country’s exports and ripple through its tourism industry, and thus acts as a strong disincentive for outbreak reporting. Thus it is crucial to minimize the spread of diseases across borders, while minimizing trade and travel losses. The 1994 plague outbreak in India provides a seminal example of excessive international sanctions due to panic over disease spread before the creation of WTO or IHR 2005 (see Box 5-3). Numerous other zoonotic disease outbreaks have led to the enactment of trade restrictions on affected countries and impacted meat and poultry im- ports and exports. In the United States, a small outbreak of Newcastle disease among Texas poultry in 2003 prompted a number of countries—including Mexico, Russia, Japan, Cuba, and those in the European Union—to place an embargo on all poultry imports from Texas (Romero, 2003). As mentioned in Chapter 2, major beef importing countries temporarily banned imports of beef and beef products from the United States within a week after announc- ing a BSE outbreak in American cattle in 2003 (USITC, 2008). An earlier U.S. ban on Canadian beef due to a BSE outbreak in May 2003 led to $1 billion in losses for the Canadian beef industry (Grady et al., 2003). In 2007, CDC had imposed trade embargoes on birds and processed bird products from all countries affected by avian influenza (CDC, 2007). Thirty-two countries

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 INCENTIVES FOR DISEASE SURVEILLANCE BOX 5-3 International Sanctions After a Plague Outbreak in India In September 1994, seven cases of a highly fatal disease were reported in a hospital in Surat, India. Though no accurate diagnostic tests were available and a number of infectious agents were suspected, the local government reported that the outbreak was pneumonic plague. The outbreak created mass panic throughout India and drew media attention throughout the world. Within 2 weeks of reporting the outbreak, an estimated 500,000 people fled Surat for other large cities in India, and thousands more fled to other countries around the world. News of the outbreak also led countries to impose massive trade and travel restrictions on India. Bangladesh, Oman, and the United Arab Emirates stopped importing any food from India, and Italy placed an embargo on all Indian products entering Italian ports. Additionally, the United States, Canada, United Kingdom, France, Germany, and Italy issued travel warnings to their citizens. By early Oc- tober 2004, the outbreak was declared over, and the World Health Organization determined that the outbreak was limited with no cases in any major Indian city. Yet the damage to India’s economy was already done, with losses due to trade and tourism restrictions estimated at more than $2 billion. SOURCES: Burns (1994); Cash and Narasimhan (2000); Gubler (2001). throughout Asia, Europe, Africa, and the Middle East were included in this embargo, as well as restricted areas within Denmark, France, Germany, Hungary, Sweden, and the United Kingdom. In 2000, an outbreak of classical swine fever among 35 pig farms in the United Kingdom resulted in import bans of all food animals to the United States, Belgium, the Netherlands, and Spain (Waugh, 2000). Furthermore, after a 2007 FMD outbreak in approximately 60 cattle in the United King- dom, Britain banned all exports of food animals, meat, and milk in hopes of preventing a larger outbreak, such as the one that occurred in 2001 resulting in $16 billion in losses for that country (CBS/AP, 2007). Fear of disease spread has also resulted in travel sanctions. During a 2001 Ebola outbreak in Uganda, the government of Saudi Arabia imposed a travel restriction on all Ugandan Muslims who planned to make a pilgrim- age to Mecca or Medina that year (Borzello, 2001). The SARS epidemic of 2003 also took a huge economic toll through travel sanctions. During the outbreak in Hong Kong, a number of Southeast Asian countries, including Singapore, Malaysia, and Thailand, issued travel warnings, which resulted in an 80 percent reduction in visitors to Hong Kong from these countries as compared to the previous year (Bradsher, 2003). It also resulted in the Chinese government suspending all international adoption of Chinese

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES babies (Eckholm, 2003). The influenza A(H1N1) outbreaks in Mexico and the United States in April 2009 also saw almost immediate travel adviso- ries imposed by the European Union against Mexico and travelers through the United States, although they were later lifted (McNeil and O’Connor, 2009). INCENTIVES TO IMPROVE DISEASE SURVEILLANCE AND REPORTING Disease Outbreak Control Assistance as an Incentive Countries unable to contain outbreaks are far less likely to report them, and providing assistance for outbreak control is perhaps the most important form of external motivation for disease surveillance and prompt reporting (Laxminarayan et al., 2008). In the case of meningitis in sub-Saharan Af- rica, an incentive to report the disease was created when the World Health Organization (WHO) made meningitis vaccine available for countries in the meningitis belt (see Box 5-4). By contrast, the Indonesian government has been unwilling to share HPAI H5N1 samples with WHO due to concerns that these samples would be used to create vaccines for developed countries, but not Indonesians (Sedyaningsih et al., 2008). Because Indonesia’s own ability to control an outbreak was not enhanced in the process of sharing, the government saw no benefit to cooperating on disease surveillance. BOX 5-4 Making Vaccines Available to Incentivize Disease Reporting In the 1990s, a number of countries in the meningitis belt of sub-Saharan Africa were not reporting outbreaks of meningococcal meningitis because they feared their citizens would be barred from the Muslim Hajj. The “meningitis belt” countries include Benin, Burkina Faso, Cameroon, the Central African Republic, Chad, Côte d’Ivoire, the Democratic Republic of the Congo, Ethiopia, Ghana, Mali, Niger, Nigeria, and Togo. Because the $55 meningitis vaccine was not affordable to most citizens of these countries, countries were unable to enforce the Saudi requirement that all Hajj pilgrims be vaccinated against the disease. Following an outbreak of meningococcal disease that resulted in 250,000 cases and 25,000 deaths, the World Health Organization established the Inter- national Consultative Group (ICG) in 1997 to provide meningococcal vaccines to all African countries in the meningitis belt. Countries are now required to provide epidemiological information on their meningitis cases before they can access the vaccine stockpile. By exchanging the tools for outbreak control for information about disease, ICG was able to incentivize reporting by countries.

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 INCENTIVES FOR DISEASE SURVEILLANCE Incentives to Improve the Quality of Disease Surveillance Information Investments in surveillance depend on the likelihood that the detected outbreak is a novel disease-causing pathogen that will produce a significant epidemic. The more country officials believe a disease will arise and spread, the more significant the investment in disease surveillance will be. However, this investment can be tempered by the likelihood of false positives: the declaration or reporting a disease outbreak when none exists (Malani and Laxminarayan, 2006). Thus, a trade-off exists between a more sensitive sur- veillance system and one that is able to have relatively few false positives. IHR 2005 now calls on national governments to report a wide range of unusual human and animal health events and allows WHO to announce an outbreak, even if it has not first been reported by the government of country of origin (Nicoll et al., 2005). These changes recognize WHO’s enormous power in providing information to the world that would allow other countries to protect their citizens and economies from outbreaks in a single country. Moreover, they also alter incentives for disease surveillance and reporting within countries in two ways. First, by preempting a national report from the country, they alert the international community to the pos- sibility of an event from within a country. The onus is then on the country to show there is no outbreak; failure for which could result in trade and tourism bans. Second, countries may be more forthcoming with informa- tion if they believe that WHO’s report is based on faulty information or false positives. In these instances, the country would benefit from having a strong disease surveillance system that can produce evidence to provide counter information from informal networks. For countries with strong disease surveillance and a reputation for reporting promptly, the credibility of contradictory data from rumor disease surveillance is much weaker. Improving the quality of information from informal disease surveillance systems—such as the Program for Monitoring Emerging Diseases and the WHO Global Outbreak Alert and Response Network—can also be useful to encourage reporting. If countries recognize that information about an outbreak is no longer theirs alone to provide and that other transnational networks are able to perform this function, they are less likely to suppress information and may derive greater benefit from ensuring that the informa- tion reported from these systems is accurate. In instances where the country is able to control an outbreak because it was promptly reported, it may also be in the country’s interests to ensure that informal information networks work well to minimize false positives and false negatives in reporting. The committee was mindful of the global economic crisis at the writing of this report. Nevertheless, pathogens will continue to evolve and emerge. The committee concluded that despite economic adversity and the potential response of still wealthier nations to reduce international aid for health,

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES poverty alleviation, and other important issues, incentives are needed for optimal disease surveillance and reporting. These incentives are important at the national level, enabling countries to take necessary action for con- taining zoonotic disease outbreaks and maintaining their access to markets, and at the local and regional levels to encourage early reporting and prevent disease outbreak concealment. AUDIT AND RATING FRAMEWORK FOR DISEASE SURVEILLANCE AND RESPONSE SYSTEMS Trading partners and neighbors frequently restrict the movement of goods and travel contacts based on unreported outbreaks or on out- breaks that have not been officially reported or confirmed (Malani and Laxminarayan, 2006). These sanctions are not necessarily formal or even under the control of partner governments. For instance, concerns about highly pathogenic avian influenza discouraged tourism to Southeast Asia even before any government imposed legal travel restrictions to that region (Tan, 2006). Preemptive sanctions occur when demand for a country’s products and services responds to both perceived and actual risks to con- sumer health. Post-outbreak sanctions discourage reporting by penalizing source countries. Nonreporting or preemptive sanctions (which displace post-outbreak sanctions) are less likely to disincentivize surveillance and reporting by source countries, but these actions could be based on unreli- able information. Unlike post-outbreak sanctions, nonreporting sanctions encourage investigation and disclosure because trading partners reply rela- tively less on post-reporting sanctions to protect themselves from disease outbreaks (Malani and Laxminarayan, 2006). Moreover, these sanctions complement the various policy levers available to the global community. Of course, not all countries are equally well-informed about the risk of a disease outbreak in any given country. Information about the risk of an unreported outbreak is a global public good in the same way as disease surveillance information. A global emerging disease audit and risk-rating framework would monitor two components: (1) the risk of a novel disease emerging from a given country, and (2) the likelihood that the disease would be undetected (and therefore unreported) by the country’s disease surveil- lance system. Such a framework would also give all countries an incentive to improve their disease surveillance system because a demonstration of prompt disease outbreak reporting would help reduce their rate of risk and alleviate trade and tourism concerns in the event of an unconfirmed outbreak. Any risk identified by the risk-rating framework would alone be insufficient to support a restrictive trade measure for health reasons. However, countries could use this framework to signal their willingness to be transparent about their risk of outbreaks and the likelihood of detection. If countries recognize,

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 INCENTIVES FOR DISEASE SURVEILLANCE apply, and accept existing sanction mechanisms like zoning and compart- mentalization—allowing for continued trade of safe products from countries or zones that have reported a disease—they can minimize the unnecessary cost of more restrictive sanctions. The framework would operate in a manner similar to other mecha- nisms that rate the risk of sovereign debt default or the risk of a national unreported nuclear weapons program. External assistance for improving a country’s disease surveillance infrastructure would be tied to their dem- onstrated improvements on the framework. Ideally, the framework would not require a new institution, but rather could be housed within an existing global institution that has the scientific and technical expertise to assess the country’s risk of disease emergence and nonreporting. Intergovernmental organizations, however, would be excluded to ensure that risk assessments are not affected by political considerations. To implement IHR 2005 by the 2012 deadline and for WHO member states to comply with the requirement for core disease surveillance capaci- ties, greater efforts will be needed by the member states, WHO, and the international community. WHO is also preparing country guidance for developing core capacities for disease surveillance. Although state parties to IHR 2005 are required to assess the ability of their existing national structures and resources to meet the minimum requirements, it is unclear whether these assessments will be made publicly available. On the animal health side, OIE uses the Performance of Veterinary Services (PVS) tool to assess the major components of effective veterinary services in a country (see Table 4-1). However, there is no ratified deadline by which countries must report their competency information if they use the PVS tool to assess their capacities. Questions remain for the commit- tee about whether this recommended tool is available as an open-source tool that can be used freely or if countries are formally assessed by OIE. It should be noted that even though there is no deadline for assessment, OIE is developing guidance to help countries systematically use the tool to assess their country’s veterinary services and infrastructure. Capacity assessment information for both human and animal health is essential. It is useful in devising national and local incentives, establishing a disease surveillance system, and in timely disease reporting by local and national participants to protect human and animal health and livelihoods. ENGAGING MULTI-LEVEL STAKEHOLDERS FOR TIMELY DISEASE DETECTION AND REPORTING As previously discussed, information from all levels is critical for effec- tive disease surveillance, and therefore data collection will need to include information gathered from the grass-roots level (e.g., Roll Back Malaria).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Disease surveillance will be effective if it is informed by the local knowledge base, particularly for places identified as hotspots. Public and private part- ners at the international level are also key stakeholders in both collecting and using data to protect human and animal health. Social networking and mobile technologies offer flexible and dynamic new possibilities for com- munity health options. Science journalism, citizen journalism platforms, mobile video, and “sousveillance” (for example, monitoring that is cap- tured by individuals on cell phones and shared through YouTube) are all examples of emerging tools that may lead to greater access and transmission of health-related information by individuals. Different actors are becoming engaged in disease surveillance because of changes in information and communication technologies. Google.org (the philanthropic arm of Google.com) launched the Predict and Prevent initiative, using information and technology to empower communities to know where to look for disease threats, find them earlier, and know how to respond (see Box 5-5). Select multinationals are also engaged as corporate citizens. The Safe Supply of Affordable Food Everywhere (SSAFE) initiative is a public-private partnership that includes multinationals such as Cargill, Nestle-Purina, McDonald’s, Pfizer Animal Health, and Coca-Cola. One of its stated goals is to help advance science-based global standards for food, animal feed, environmental health, safety and sustainability, and disease prevention and control (Ades, 2008). SSAFE also serves on an OIE advisory BOX 5-5 Google.org Predict and Prevent Initiative Google.org represents a unique model whereby support for information tech- nology to increase collection and reporting surveillance data comes from both internal volunteer efforts and external funding streams. Google.org’s Predict and Prevent Initiative (PPI) is a good example of both these roles. As a philanthropic organization, PPI supports efforts in disease detection, ranging from supporting web-based surveillance and data collection efforts (e.g., HealthMap, the Program for Monitoring Emerging Diseases or ProMED-mail, InSTEDD) to collecting speci- mens for detecting novel zoonotic diseases in the field (Global Viral Forecasting Initiative). Recognizing the potential value of the volunteer efforts of Google soft- ware engineers, PPI has deployed novel surveillance systems such as Google Flu Trends and other efforts devoted to mobile communication for disease report- ing and health resource mapping. These openly available technologies require the internal capacity of engineers that can properly leverage products such as Google Search, Maps, and Android. Although these efforts play an important role in furthering global technological capacity, singular dependence on any particular company’s tools, even if freely available, should be avoided, especially when considering issues of compatibility, scalability, and future availability.

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 INCENTIVES FOR DISEASE SURVEILLANCE committee of the World Animal Health and Welfare Fund (OIE, 2007). In addition, companies such as Cargill have worked closely with health authorities and provided their own field staff and resources to educate and work with communities on HPAI H5N1 in Thailand (Ades, 2008). International businesses2 are increasingly part of the global landscape, as one-third of all global trade takes place directly within international busi- nesses (Moore, 1998). In August 2008, the Kellogg Foundation, ConAgra, Cargill, Kellogg Company, and McDonald’s convened at Michigan State University to address how foundations and businesses can create new models of cooperation (Food and Sustainability Conference, 2008). These corporations will increasingly have a greater role in the global food system and will need to be included in discussions about new approaches to im- prove reporting and sharing of critical information. With the multiplicity of actors, there is a need for improved intersectoral and international coordi- nation, communication, and community of practice to enable environments that facilitate working toward cross-disciplinary collaboration for disease surveillance and response, practice, and research. The committee concludes that participation by partners at various levels in disease surveillance, moni- toring changes in community perception and response to the presence and threat of zoonotic disease, and media coverage of such diseases are essential and should be included for comprehensive disease surveillance systems in human and animal health. CONCLUSION There have been significant improvements in how global health legal frameworks harness new technology to require countries to report disease outbreaks, yet the decision on whether to report and how much effort to expend on disease surveillance remains the province of countries. Even within countries, there may be conflicting economic, cultural, or political incentives to report an outbreak up the chain and those incentives affect whether an outbreak is officially recognized. Yet without prompt reporting of outbreaks, including in resource-poor settings that have the least abil- ity to detect them, the ability of global efforts to prevent the rapid spread of virulent pathogens is limited. Quality disease surveillance information reporting goes beyond just a confirmation or denial: In order to respond effectively, policymakers need a clear assessment of the situation based on reliable scientific information. The committee concludes that a global zoonotic disease surveillance and response strategy that does not address the fundamental incentives and 2 The term is used to include multinational, international, transnational, and global compa- nies doing business in other countries.

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