Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 235
8
Recommendations, Challenges,
and Looking to the Future
“Sustainability is not just about securing predictable financial resources.
It is also about strengthening health systems while fighting disease, and
using the extraordinary opportunities provided by disease programmes
to deliver other health benefits. It is about training and empowering the
health workforce. It is about drawing on the experience of the private
sector to help us innovate and measure risk and results.”
—Ban Ki-moon
Secretary-General of the United Nations
Remarks at the Forum on Global Health:
The Tie That Binds (June , 00)
Nations bear the responsibility to provide for the security, education,
development, and the health and welfare of their citizens. This includes
responsibility for disease surveillance and response. It is now clear that
contemporary threats from infectious diseases require a system capable
of providing sustainable global coverage, an objective that can only be
achieved through more intensive cooperation among all nations, interna-
tional organizations, and nongovernmental stakeholders.
In studying what will be required for a sustainable global integrated
system for surveillance and response to emerging infectious diseases of
zoonotic origin, the committee found significant weaknesses in the abil-
ity of all nations, but particularly low-income countries, to address their
need for a functional, sustainable, and integrated surveillance and response
system for emerging human and animal diseases. Limited surveillance and
response capacities at the national level represent more than just a national
threat; they are, in fact, a serious global threat, especially in countries in
which the drivers of zoonotic diseases are most concentrated and where
experts predict that zoonotic disease emergence is most likely to occur. The
implication of this is clear: that all countries, in partnership with private
and public stakeholders, should develop, maintain, and globally coordinate
integrated surveillance and response capabilities to prevent, detect, and
respond to the emergence of zoonotic diseases in order to limit loss of life
and livelihoods.
OCR for page 236
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
RECOMMENDATIONS
The National Research Council report, Animal Health at the Cross-
roads, addressed the importance of strengthening collaborations at the na-
tional and international levels. The report specified the need for the United
States to commit new resources and develop shared leadership roles with
other countries and international organizations in order to promote global
systems for preventing, protecting against, detecting, and diagnosing emerg-
ing animal disease threats (NRC, 2005). The committee concurs with that
report and reemphasizes the importance of U.S.-supported collaborations
at the international level for the development and promotion of such a
global system, including a U.S. commitment to provide technical assistance
to other countries and to increase its participation in developing interna-
tional animal health standards for preventing, detecting, and responding to
zoonotic diseases. An effective zoonotic disease surveillance and response
system needs to be integrated across sectors and disciplines so that it identi-
fies and responds to human and animal disease threats at the earliest time
possible, without regard to national boundaries or professional discipline.
The committee therefore offers the following 12 recommendations
for improving zoonotic disease surveillance and response by priority and
category areas (see Table 8-1). The recommendations are grouped as tech-
nical, economic, and political actions needed to achieve the desired sys-
tem. Recommendations assigned as high priority are foundational for a
global, integrated zoonotic disease surveillance and response system. The
remaining recommendations are considered priority and are not listed in
rank order, though they are all considered essential to achieving the goal.
The committee understands that it may be necessary to implement these
recommendations according to different timetables, depending on how the
United States and its partners are able to mobilize the necessary resources.
Ultimately, an effective, sustainable system will require attention to each of
the 12 recommendations.
High-Priority Recommendations
Technical: Strengthen Surveillance and Response Capacity
Establish Surveillance and Response Strategies
Recommendation 1-1: The U.S. Departments of Health and Human
Services (HHS), Agriculture (USDA), Homeland Security (DHS), and
the Interior (DoI) should collaborate with one another and with the
private sector and nongovernmental organizations to achieve an inte-
grated surveillance and response system for emerging zoonotic diseases
in the United States. In addition, these government agencies, including
OCR for page 237
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
TABLE 8-1 Recommendations for Improved Zoonotic Surveillance and
Response by Priority and Category Areas
Technical Economic Political
Governance of Global
Financing and Incentives Efforts to Improve
Strengthen Surveillance for Surveillance and Surveillance and Response
and Response Capacity Response Capabilities
High Establish surveillance Establish sustainable Create a coordinating body
priority and response strategies funding strategies for global zoonotic disease
(Recommendation -) (Recommendation -) surveillance and response
(Recommendation -)
Priority Improve use of Create an audit and Deepen the engagement
information technology rating framework of stakeholders
to support surveillance for surveillance and (Recommendation -)
and response activities response systems
(Recommendation -) (Recommendation -)
Strengthen the Strengthen incentives Revise OIE
laboratory network to for country and governance strategies
support surveillance local reporting (Recommendation -)
and response activities (Recommendation -)
(Recommendation -)
Build human resources Mitigate disease threats
capacity to support from wildlife and trade
surveillance and response (Recommendation -)
efforts
(Recommendation -)
Establish a zoonotic
disease drivers panel
(Recommendation -)
NOTE: OIE = World Organization for Animal Health.
the U.S. Department of State and the U.S. Agency for International De-
velopment (USAID), should collaborate with the World Health Orga-
nization (WHO), the Food and Agriculture Organization of the United
Nations (FAO), and the World Organization for Animal Health (OIE)
to spearhead efforts to achieve a more effective global surveillance and
response system, learning from and informing the experiences of other
nations.
Given finite resources and the complexity of the challenge, an integrated
zoonotic disease surveillance and response system can succeed only if the
OCR for page 238
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
U.S. government demonstrates its commitment to develop and strengthen
the needed capacities at the national level, and to engage others at the global
level. The following strategic approaches are necessary to achieve an effec-
tive, global zoonotic disease surveillance and response system:
First, departments or ministries of health, agriculture, and natural
resources, with external support as needed, should work with researchers
to develop and use science-based criteria to determine and measure the
distribution and magnitude of the drivers of zoonotic disease emergence.
Rapid changes in ecology, environmental degradation, population density,
population movements, animal production systems, and close interaction of
humans with livestock, poultry, and wildlife are just a few drivers to study.
From these studies, targeted surveillance would then be designed to focus
on countries and regions within countries where drivers increase the risk
for zoonotic disease emergence.
Second, in countries where disease surveillance in animal populations
is absent or weak, ministries of health, agriculture, and natural resources
should collaborate as broadly as necessary to develop, enhance, and imple-
ment disease surveillance and response systems in human populations that
are at high risk for zoonotic disease infection. For example, surveillance is
needed in the following high-risk human populations:
• Occupational groups that are at high risk for infection with zoo-
notic diseases. Such workers include livestock, dairy, and poultry workers;
live-animal market workers; veterinarians and animal health technicians;
hunters of bushmeat and other wildlife; food preparers (and restaurant
workers handling food prepared from bushmeat and exotic animals);
slaughterhouse workers; and laboratory scientists and technicians working
with animals;
• Healthcare workers who could spread zoonotic diseases to the
general public;
• Household and village members who keep live animals within their
living quarters or come in close contact with animals in village settings;
and
• People engaging in high-risk behaviors known to increase risk of
exposure to zoonotic diseases. Such high-risk behaviors include close con-
tact with wildlife and exotic animals; preparing and consuming bushmeat;
culturally traditional animal husbandry practices and livestock production
systems; failure to use personal protection equipment; failure to follow
recommended hand-washing practices.
Third, to reverse the trend where human outbreaks serve as sentinels
for animal disease, ministries of agriculture and natural resources should
develop and strengthen livestock, poultry, and wildlife zoonotic disease
OCR for page 239
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
surveillance systems, particularly where surveillance in animal populations
is currently limited. In partnership with the private sector, ministries of
agriculture should conduct active and passive disease surveillance in ani-
mal populations that are raised in high-density conditions but lack good
biosecurity measures, that are located in areas of dense human populations
(e.g., Asia, Latin America, and Eastern Europe), and/or that are interspersed
with smallholder livestock farms. Ministries of agriculture and natural re-
sources should also conduct high-priority surveillance in livestock, poultry,
companion animals, and wildlife whenever species are clustered, mixed, and
inhabit areas in close proximity to human populations (e.g., co-habitation
with humans in homes, villages, or are transported to, housed, and sold in
live-animal markets). To detect subclinical or unnoticed infections, minis-
tries of agriculture and natural resources should develop capacity to system-
atically test laboratory specimens from domesticated animals and wildlife
that are at high risk of serving as zoonotic disease reservoirs (e.g., bats,
wild aquatic birds, and nonhuman primates). This will enable responses to
be targeted and can limit pathogen transmission and prevent or minimize
their impact on the health of human and domesticated animal popula-
tions. Ministries of agriculture, natural resources, and health should build
capacity to institute active sentinel surveillance in wildlife—such as bats,
wild aquatic birds, great apes, and rodents—and other important reservoir
species that are in close contact with humans to continuously assess the
“baseline” population with pathogens of concern (e.g., influenza, Ebola,
Nipah, hendra, rabies, Rift Valley fever [RVF], coronaviruses, tularemia,
plague). Targeted wildlife populations should be those most likely to inter-
act with humans, either directly or indirectly through domesticated animals.
The list of pathogens needs to be established by consensus at the global,
regional, and local levels (see Recommendation 3-1 on the recommended
coordinating body) and resources should be commensurate to the identified
need for surveillance.
Fourth, ministries of health, agriculture, and natural resources will
need to develop and formalize a system wherein surveillance information
from these different human and animal populations will be integrated and
synthesized for analysis. These ministries will also need to develop and
formalize effective communication and reporting systems to ensure real-
time reporting of linked surveillance data from human and animal popula-
tions nationally and internationally to those responsible for planning and
instituting prevention, protection, and response interventions. The Danish
Zoonosis Centre could be a model of an effectively integrated national
program for zoonoses (see Box 8-1).
Finally, science-based nongovernmental organizations (NGOs) have a
critical role to play in national and global efforts to develop an integrated
surveillance system. In many cases these organizations have extremely
OCR for page 240
0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
BOX 8-1
Model of an Integrated National Program for Zoonoses
The Danish Zoonosis Centre was established in 1994 in response to the major
fragmentation of the surveillance systems and increasing incidence of zoonotic
diseases at that time. The Centre is part of the National Food Institute of the
Technical University of Denmark, and it has special responsibilities for prevention,
surveillance, and outbreak tracking of zoonotic infections by compiling surveillance
data on food-borne zoonoses and by developing prevention strategies. As such, it
is an integral part of the national contingency plan for outbreaks of food-borne dis-
eases. Funding comes partly from the Danish government and partly from income
generated through the provision of research and advisory service to the private
sector. The Centre has a staff of 13 specialists but relies heavily on industry for
data collection. It is an inter-sectoral center, meaning that representatives of the
Danish Board of Health Food and Veterinary Administration are a part of its Steer-
ing Group, and producer boards and nongovernmental organizations are included
in its coordination groups. The integration of public and private sectors has been
a critical element of the Centre’s success. Its excellent performance continues to
make it a reference center for the World Health Organization and the European
Food Safety Authority, among others, on zoonotic disease-related issues.
wide geographic reach, with offices and trained staff based in countries
with the highest risk for new zoonoses. They have often developed the
most effective and closest relationships and collaborations with local com-
munities. NGOs have the capacity to act nimbly to rapidly refocus re-
sources on outbreaks during crises, and they are usually not encumbered by
geopolitical constraints. Science-based NGOs—such as Wildlife Conserva-
tion Society, Wildlife Trust, The Consortium for Conservation Medicine,
and EnviroVet—have launched programs specifically targeted at many of
this committee’s recommendations and should be actively involved in future
efforts to address them. While the focus of this committee is primarily scien-
tific, it recognizes that advocacy groups can also provide an important push
for integrated surveillance by urging relevant policy changes involving food
production, wildlife conservation, poverty alleviation, and global health.
Economic: Financing and Incentives for Surveillance and Response
Establish Sustainable Funding Strategies
Recommendation 2-1: USAID—in partnership with international fi-
nance institutions and other bilateral assistance agencies—should lead
an effort to generate sustainable financial resources to adequately sup-
port the development, implementation, and operation of integrated zoo-
OCR for page 241
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
notic disease surveillance and response systems. An in-depth study of
the nature and scope of a funding mechanism should be commissioned
by these agencies, and the study should specifically consider a tax on
traded meat and meat products as a potential source of revenue.
The committee concluded that an integrated global surveillance and
response system should be designated a national and global public good.
As observed in recent outbreaks, emerging zoonotic pathogens are rapidly
transmitted across borders and from one continent to another. Too often,
responses are either slow but evidence-based or quick but inappropriate
(e.g., non-evidence-based restrictions on travel, transport of goods, culling
of animals). This has resulted in large political, economic, and social im-
pacts on national and global human, animal, and economic health.
Although primary responsibility for creating and maintaining such a
system remains at the national level, the needs of low-income countries
for assistance and the complexities of building an integrated global system
will require both smarter expenditure of existing resources and additional
funding. Without such financial support, the global public good that an
integrated system could produce will not be achieved.
The current global economic crisis underscores the need to develop
sustainable financing strategies to produce this global public good. Coun-
tries with greater resources will need to show leadership by supporting
low-income countries and international organizations to create a global
system. With the continued spread of H1N1 virus to developing countries,
United Nations (UN) Secretary-General Ban Ki-moon stated that the UN
would need more than $1 billion to combat the pandemic for the remain-
der of 2009 alone and made a plea for assistance from developed countries
(Maugh, 2009). The inadequacy of traditional donor support, the limited
duration of commitment, and the competition for resources generated by
other global health problems require the U.S. government, other countries,
and intergovernmental organizations to design and implement strategies
that will provide sustainable resources for zoonotic disease surveillance and
response. National government access to realigned and new funding should
be made conditional on fulfillment of agreed criteria of participation, in-
cluding the willingness to conduct national assessments of surveillance and
response capacity and have such assessments independently reviewed (see
Recommendation 2-2).
While countries need to be encouraged to invest in developing the
capacity to detect, investigate, and report suspected disease outbreaks and
thus prevent sporadic cases from escalating to epidemics (especially of
known diseases), resource-poor countries undoubtedly will need external
support and assistance for this purpose. The challenge of maintaining
global surveillance capacity calls for identifying sustainable funding sources
OCR for page 242
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
rather than depending on development aid budgets, which historically
have fluctuated with donor priorities or changes in leadership. Although a
number of possible suggestions are provided in this report, the committee
did not have the mandate or expertise to conduct a thorough investigation
of the implications of these options. The committee therefore calls for an
in-depth study to further identify innovative funding mechanisms that can
continuously support the need for surveillance and response systems.
Revenue sources should be, in principle, tied to levies on activities that
increase the risk of emergence and movement of zoonotic pathogens. This
has led to the committee’s recommendation for further study on a product
tax for internationally traded meat and meat products, which represent an
important route for the emergence and spread of zoonotic diseases. This
levy would be imposed primarily on wealthier exporting countries (see Ta-
ble 6-4). One of the potential adverse consequences of imposing a levy may
be that it increases product smuggling in an attempt to evade taxes. There
may well be other unintended consequences of this strategy; therefore the
committee concluded that a thorough study of the pros and cons for this,
or other sustainable approaches, is a necessary prerequisite before making
final decisions on the optimal mechanism to fund the required actions.
The committee considered other funding options. These include long-
term commitments from high- and middle-income countries to contribute
directly to a global fund established for this purpose; long-term commit-
ments from governments to fund specific WHO, FAO, and OIE programs;
establishment of endowment funds; increased contribution from founda-
tions and nonconventional donors; and public-private partnerships. These
remain options that could be considered when more intensive and targeted
discussions are initiated.
Initial access to global funding for a recipient country could be made
dependent on its commitment and participation in an assessment of its na-
tional surveillance capabilities (see Recommendation 2-2). Further funding
could be conditional on its subsequent performance to integrate human
and animal health systems and its contribution to pay for the surveillance
and response systems’ operating costs. While the committee did not explore
these options and the institutional arrangements necessary to manage them,
the committee concluded that it would be prudent if the recommended
independent global funding mechanism (e.g., the Global Fund) would not
be administered by a government entity or international governmental
organization.
Political: Governance of Global Efforts to Improve Surveillance and
Response Capabilities
Create a Coordinating Body for Global Zoonotic Disease Surveillance and
Response
OCR for page 243
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
Recommendation 3-1: USAID, in cooperation with the UN and other
stakeholders from human and animal health sectors, should promote
the establishment of a coordinating body to ensure progress toward
development and implementation of harmonized, long-term strategies
for integrated surveillance and response for zoonotic diseases.
As discussed earlier in this report, WHO, OIE, and FAO have im-
proved their coordination efforts on zoonotic diseases, especially through
the creation and operation of the Global Early Warning System (GLEWS)
for major animal diseases including zoonoses. In addition, WHO and OIE
have independently revised their central legal agreements—the International
Health Regulations 2005 (IHR 2005) and the Terrestrial Animal Health
Code, respectively—to facilitate better governance strategies for zoonotic
disease threats. The committee concluded that these positive developments
can and should be supplemented by the establishment of an overarching
global coordinating body. Building on the foundation laid by GLEWS,
the adoption of IHR 2005, changes to the OIE’s Terrestial Animal Health
Code, and better collaboration between OIE and FAO, this coordinating
body could raise the profile of zoonotic disease surveillance and response
efforts and provide the necessary high-level political support to advance
national, regional, and global coordination efforts. The approach devel-
oped in the UN System Influenza Coordinator (UNSIC) strategy is widely
perceived as an effective effort and could serve as a model for the coor-
dinating body needed for an integrated zoonotic disease surveillance and
response. The zoonotic disease coordinating body should work to ensure
that all relevant stakeholders are consulted and involved in coordinating
activities. The mechanism could also draw attention to problems and chal-
lenges faced in implementation of IHR 2005, OIE agreements, OIE/FAO
strategies, and GLEWS. The coordinating body could also facilitate im-
proved and additional funding streams for zoonotic disease control (see
Recommendation 2-1).
Priority Recommendations
Technical: Strengthen Surveillance and Response Capacity
Improve Use of Information Technology to Support Surveillance and Re-
sponse Activities
Recommendation 1-2: With the support of USAID, international or-
ganizations (such as WHO, FAO, OIE, and the World Bank) and
public- and private-sector partners should assist nations in developing,
adapting for local conditions, and implementing information and com-
munication technologies for integrated zoonotic disease surveillance.
OCR for page 244
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
BOX 8-2
Philanthropic Support for Information Technology
Development and Management
The Rockefeller Foundation supports an “eHealth” initiative, along with a port-
folio of grants on surveillance networks. This initiative focuses on a number of
aspects of design and implementation of eHealth including open-source software
development for medical records, laboratory records, and disease reporting. In
2008, a series of Bellagio meetings were held that brought experts together from
many parts of the world to discuss architecture, standards, training needs, and
other activities. The Rockefeller Foundation is supporting the creation of the Cen-
ters of Excellence for Informatics in a number of low-resource settings to facilitate
the implementation of eHealth, including the development and implementation
of standardized tools for disease reporting and public health response. The Bill
& Melinda Gates Foundation recently funded a planning grant for the American
Medical Informatics Association to outline plans for a global informatics scholars
program. Such philanthropic input and support is critical for developing countries
where such expertise will greatly advance efforts at streamlining information sys-
tems for surveillance. While these initiatives are directed towards human disease,
they represent technical models that can be applied to animal disease.
Effective use of such technologies facilitates acquisition, integration,
management, analysis, and visualization of data sources across hu-
man and animal health sectors and empowers information sharing
across local, national, and international levels. To establish, sustain,
and maintain this technologically sophisticated system, both leadership
and investment are critically needed.
Leadership and investment should emerge within each country; how-
ever, low-income countries will need support to engage in broader training
and capacity building. This effort should integrate key nongovernmental
actors, including private philanthropies with interests in infectious disease
surveillance and management (see Box 8-2 for an example); industry part-
ners in food production, information technology, and data management;
and nongovernmental organizations involved in global health. Organiza-
tions should follow the lead of actors such as Google.org., which contribute
both external funding as well as internal efforts to support the development
of open source surveillance technology (see Box 5-5).
Strengthen the Laboratory Network to Support Surveillance and Response
Activities
OCR for page 245
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
Recommendation 1-3: USAID should promote and initially fund the es-
tablishment of an international laboratory working group charged with
designing a global laboratory network plan for zoonotic disease surveil-
lance. The working group’s objective would be to design a laboratory
network that supports more efficient, effective, reliable, and timely
diagnosis, reporting, information sharing, disease response capacity,
and integration of human and animal health components. In addition,
a long-term coordinating body for zoonotic diseases, perhaps modeled
after the United Nations System Influenza Coordinator’s (UNSIC’s) of-
fice (see Recommendation 3-1), should implement the global laboratory
network plan, manage it, and assess its performance in consultation
with the international laboratory working group.
The international working group charged with developing the global
laboratory network plan should include representation from several groups.
These include international organizations (e.g., WHO, FAO, and OIE); na-
tional human and animal health laboratories with experience in laboratory
network development and support (e.g., U.S. Centers for Disease Control
and Prevention [CDC], Department of Defense [DoD] Global Emerging In-
fections Surveillance and Response System, USDA Animal and Plant Health
Inspection Service [USDA-APHIS] National Veterinary Services Labora-
tory, Canadian Science Centre for Human and Animal Health, Australian
Animal Health Laboratory); professional laboratory organizations, such
as the Association of Public Health Laboratories and the American As-
sociation of Veterinary Laboratory Diagnosticians in the United States and
their counterparts in other nations; wildlife health specialists; and private
for-profit and not-for-profit entities with a stake in zoonotic laboratory
network development. Integration of animal and public health laboratory
infrastructure, operations, and personnel should be a driving factor in de-
velopment of the global plan.
To develop the plan the working group should take steps that
include
1. conducting an inventory and assessing the quality of the current
global capacity for laboratory diagnosis and reporting of zoonotic diseases
in human and animal health laboratories;
2. based on this inventory, designing the optimal laboratory network
structure with emphasis on utilizing existing regional laboratories in high-
risk regions as reference labs capable of the work necessary for identify-
ing emerging diseases, and sentinel surveillance laboratories within those
regions;
3. identifying where new laboratory infrastructure is necessary;
4. creating the environment (e.g., common space, common platforms,
OCR for page 258
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
and response. The committee believes its success depends on the following
factors:
• Sufficient national and global surveillance and response
capacities;
• Enhanced compliance and implementation of relevant international
agreements, especially the IHR 2005 and OIE instruments, and global strat-
egies, such as the joint OIE/FAO framework and GLEWS;
• Better utilization of existing financial resources and generation of
new funding for zoonotic disease surveillance and response;
• Effective communication and cooperation across sectors, relevant
disciplines, and institutions;
• Joint resource use and greater equity in resources for implement-
ing surveillance and for human and animal health prevention and control
interventions;
• Improved cross- and interdisciplinary training in medical and vet-
erinary education and allied fields;
• Attention to understanding the nonbiological social, political, and
economic drivers and consequences involved with zoonotic disease and hu-
man and animal health;
• Generation of political will to commit political, economic, and
intellectual capital for zoonotic surveillance and response capabilities;
• Better understanding of zoonotic disease surveillance and response
capabilities as priority national and global public goods; and
• Greater mutual respect and trust between human and animal health
communities, academic institutions, and practitioners.
Uncoordinated Approaches in Designing and Implementing
Zoonotic Disease Surveillance and Response
The committee frequently referred to multiple players involved in
designing, implementing, and evaluating disease surveillance and response
systems at local, national, and international levels. The result of these
multiple players has been many different, often vertical and single-disease
oriented systems that generally have incompatible implementation ap-
proaches. Multiple guidelines have been developed and recommended (e.g.,
by USDA, CDC, WHO, and OIE), and different methods for evaluating
disease surveillance and response systems have been employed. In general,
there is a lack of standard or harmonized laboratory, field epidemiology,
and disease prevention and control protocols. There is also considerable
variation in protocols for disease surveillance in human, food-animal, and
wildlife populations. In addition, aside from rabies, there are no protocols
for zoonotic disease surveillance in companion animals for pathogens such
OCR for page 259
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
as toxoplasmosis or visceral larval migrans (due to Toxocara canis or T.
cati). For disease agents associated with wildlife, laboratory diagnostics that
are reliable, sensitive, and specific to wildlife specimens are lacking.
At the same time, the generally adverse trade and tourism impacts of
disease outbreak reporting can lead to political interference, thereby pre-
cluding the rapid release of important information to the global community
for implementing a rapid and effective response. The committee therefore
believes it is essential to develop and apply a standard method for conduct-
ing and evaluating the effectiveness of zoonotic disease surveillance systems
in different countries, independent of political interference (such as suppres-
sion of information or corruption).
The Complexity of an Integrated Approach
The training mechanisms and health systems necessary to build human
capacity for an integrated zoonotic disease surveillance and response sys-
tem have developed as separate and unequal systems. In the past, greater
resources have been available for training in human health, thus additional
investments to train those in animal health are needed while at the same
time not reducing existing support to train human health professionals. Op-
portunities to jointly train human and animal health professionals together
are particularly valuable. Joint program initiatives, joint workforce educa-
tion and training, and joint performance standards for emerging zoonotic
diseases will need to be given priority to support the widespread changes
essential for implementing a more integrated and effective system. There
will likely be resistance to moving forward, funding may be difficult to find,
and there will be issues at many levels over control. These problems should
be anticipated and will require leadership from both the human and animal
health sectors to overcome them.
For many years, various scholars have argued in favor of increased
collaboration among professionals in the human and veterinary health
communities (Schwabe, 1983; Murphy, 1998; NRC, 2005; Hadorn and
Stark, 2008). The committee is deeply concerned to note that despite these
appeals for action, progress to increase collaboration between the human
and animal health systems has been limited. In response to the fragmented
national and international responses to human and animal health emergen-
cies, there is now considerably greater attention with respect to the need
to increase and strengthen multisectoral and multilateral collaborations for
emerging zoonotic disease surveillance and response. This multidisciplinary
approach is being promoted under the banner of “one health,” defined as
“the collaborative effort of multiple disciplines—working locally, nation-
ally, and globally—to attain optimal health for people, animals and the en-
vironment” (AVMA, 2008, p. 4). The committee supports all such efforts.
OCR for page 260
0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
Zoonotic disease surveillance and response offers an opportunity to
realize the vision of integrated human, animal, and environmental health in
a practical and visible way. Information sharing, laboratory infrastructure,
sample collection, trained workforces, laboratory analysis, and response
teams can and need to be integrated. Community health workers and
paraprofessionals can be trained to collect samples from both humans and
animals, or at a minimum can work side by side to assess and sample hu-
man and animal populations where zoonotic agents are residing, evolving,
and moving. Shared cold chains can deliver samples from humans and
animals to laboratories analyzing all samples using assays that are well-
characterized, validated, and equivalent, if not identical. Information from
laboratories and regulatory agencies can be distributed back to the com-
munity level to all human and animal health workers. When zoonotic dis-
ease outbreaks occur, health teams—that at a minimum include physicians,
veterinarians, public health professionals, and other disease experts when
appropriate, such as medical entomologists and wildlife biologists—can
work together to unravel the problem and set in motion the response com-
ponent from the outset.
Political Will and Elevating Integrated Surveillance and
Response to Emerging Zoonotic Diseases as a Priority
Among the many challenges for establishing an integrated surveillance
and response system is the lack of political will to address emerging zoo-
notic health threats. Furthermore, health is often assigned as a low priority
by political leadership; there is an accompanying lack of commitment to
finance the system; ownership of the disease surveillance system is unclear;
and there are often conflicting partner priorities. The sequential emergence
of infectious diseases of zoonotic origin in the past few decades—such as
HIV/AIDS, Escherichia coli O157:H7, severe acute respiratory syndrome
(SARS), HPAI H5N1, and most recently influenza A(H1N1) 2009, which
contains genes from human, pig, and bird influenza viruses—have captured
the public’s attention and raised the level of engagement of political lead-
ers. With attention and engagement has come funding; however, it has been
disease specific and primarily oriented to address consequences affecting hu-
man health. It has also failed to build the broader surveillance and response
system that is necessary and described in this report.
In many developing countries where the human health system is inad-
equate, it is not surprising that the priority placed on the interface of human
and animal health is low. These realities for both human and animal health
are amply demonstrated by the lack of funding, inadequate staffing, poor
quality or inappropriate training for existing personnel, and the failure to
appreciate the cost effectiveness of a reliable disease surveillance system in
OCR for page 261
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
healthcare delivery. Given the low priority and limited expertise, decision-
makers often do not understand how to interpret and use available informa-
tion on emerging zoonotic diseases. Even if they know what they should do,
they typically lack the authority and resources needed to rapidly respond
(Pappaioanou et al., 2003). Furthermore, the fear of sanctions and eco-
nomic losses as immediate consequences of reporting trumps any instinct to
act quickly. As these countries are also confronted with HIV/AIDS, malaria,
and tuberculosis, for which considerable international assistance has been
generated, it is no wonder that national policymakers are unable to allocate
scarce resources to newly emerging zoonotic diseases. Any support that has
been directed towards zoonotic disease control has come mainly through
external and vertical targeted programs. The lack of funds for veterinary
and environmental agencies is a particularly serious impediment to effective
action (GAO, 2001; NRC, 2005). In Kenya, for example, the Ministry of
Health could deploy five times more staff to address the recent outbreak of
RVF than could the Veterinary Service that is actually charged with control-
ling the main source of human RVF infection.2
Disease surveillance systems function vertically in many African coun-
tries, because they were set up to support global initiatives for monitor-
ing and controlling specific diseases. These include poliomyelitis, bacterial
meningitis, measles, cholera, yellow fever, and other vaccine-preventable
diseases. The ad hoc system of establishing specific disease surveillance
systems has in many ways prevented the establishment of a reliable and
comprehensive national disease surveillance system. The vertical programs
may have succeeded in the use of disease-specific data collection tools,
reporting formats, and disease surveillance guidelines for donor-targeted
disease. However, the facilities are minimally used for disease surveillance
or control of other emerging zoonotic infectious diseases. Where there are
facilities, often the same person or team performs all disease surveillance
activities, limiting their ability to attend to other problems.
At this time, there is sufficient global concern to mobilize international
leadership because of the potential for influenza A(H1N1) 2009 to return
later in 2009 with considerably greater virulence, perhaps through reassort-
ments with avian influenza A(H5N1) viruses. This is an opportune time for
international organizations—such as WHO, FAO, and OIE—and national
governments and local authorities to take ownership of the surveillance and
response system. These various actors need to make the commitment and
take the first steps towards creating the local to global systems: If there is
no local “ownership” of the disease surveillance system, especially at the
health district level where most epidemics originate, it is hard to generate
and sustain political will at the higher levels to take action. On top of this,
2 Ester Schelling, International Livestock Research Centre, personal communication, 2008.
OCR for page 262
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
inflexible regulatory constraints are commonly imposed by donor agencies
for their own administrative and reporting requirements. This hampers the
maximum use of facilities and especially human and financial resources for
integrating disease surveillance systems.
Implementing the International Health Regulations
The adoption of IHR 2005 by the World Health Assembly represents
a giant leap forward because it provides a comprehensive framework for
human disease surveillance (Fidler, 2005). The committee recognizes that
IHR 2005 took 10 years to develop, and its slow implementation in many
countries restricts the ability to reach the full promise of IHR 2005. The
committee reemphasizes that full implementation of IHR 2005 is the bed-
rock for building a new integrated and sustainable human and animal
surveillance and response system for emerging zoonotic diseases.
With increasing disease risks related to globalization of trade, in 2007–
2008, the OIE refined an evaluation tool originally developed in collabora-
tion with the Inter-American Institute for Cooperation on Agriculture to
produce the Performance of Veterinary Services tool. This was developed
to assist the country’s veterinary services by assessing their existing level of
performance, identifying gaps and weaknesses in their capacity to comply
with OIE international standards, and developing new strategies and ap-
proaches for the public and private sectors to collaborate in addressing the
identified gaps and challenges (OIE, 2008). In general, by strengthening
veterinary services and infrastructure with enhanced capacity to imple-
ment strategic and sensitive surveillance methods, this will allow local and
national integrated health systems to better detect the emergence of new
zoonoses. However, if IHR 2005 is not fully implemented, there is little
chance that OIE efforts can be successful. For this reason, the committee
recognizes the critical importance of full implementation of IHR 2005 and
registers its concerns about the pace of progress.
Fostering Trust
An effective disease surveillance system is one in which diseases are
detected early and reported in a timely fashion. That is fully dependent on
achieving a level of trust between (1) the local population and (2) local,
national, and international human and/or animal health authorities. Too
often, those locally reporting disease in animal populations are confronted
with what appears to be arbitrary loss of their food animals without com-
pensation. Countries reporting zoonotic diseases internationally may face
unilaterally imposed trade restrictions, often accompanied by the imposi-
tion of travel advisories and a subsequent drop in tourism. In order for
OCR for page 263
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
timely, transparent, and credible information to transfer up the line, and for
information and support to come back down to the community, prior trust
needs to be established between the community, scientists, and the politi-
cal system at the local, national, and global levels. Building trust will also
involve understanding how individuals assess risk and behave in response,
and whether various stakeholders believe their concerns can be fairly ad-
dressed in the surveillance and response system.
LOOKING TO THE FUTURE
Since the Institute of Medicine released its 1992 report Emerging In-
fections: Microbial Threats to Health in the United States, there has been
a growing awareness of the frequency with which new and reemerging
infectious diseases are appearing. As the number and frequency of emerg-
ing threats increases, the committee realizes that the old veterinary maxim,
“When you hear hoofbeats on the covered bridge, don’t think about the
zebra,” needs re-working in today’s environment to “When you hear hoof-
beats on the covered bridge, at least think about the possibility of a zebra.”
Most newly emerging infections are zoonotic in origin, for which a limited
but broad-based set of microbiological, ecological, and behavioral drivers
have been identified. The United States and other well-resourced nations
have increased their research efforts and held conferences, leading to an
increased number of scientific publications, reports, and to some extent
improved disease surveillance and global response on a disease by disease
basis. However, more effort is needed, as demonstrated by the first pan-
demic of the 21st century caused by influenza A(H1N1) 2009, the recent
emergence and rapid spread of SARS (albeit to a limited number of coun-
tries), and the discovery of West Nile virus in the United States (which has
become endemic across the country within a few years). With the exception
of pandemic (H1N1) 2009, these examples show how delayed information
reporting can result in the further spread of disease. Although subsequent
catch-up efforts in the latter two examples finally enabled human and ani-
mal health experts to effectively connect and collaborate with each other,
those connections had to first be forged during the outbreak, enabling the
disease to spread and making it more difficult to contain. Together with
HPAI H5N1 as an emerging threat to both humans and animals, these
events have captured public attention as never before, highlighting the
ongoing risk these pathogens represent and the deficiencies in our disease
surveillance and response mechanisms. They further demonstrate to the
public the need for continued investment in disease surveillance, as another
veterinary adage best describes how it is cheaper to invest in some good
stall doors than to try to collect all the horses after they leave the barn.
Perhaps the most serious concerns identified in this report are the
OCR for page 264
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
continued separation of human and animal health expertise and infrastruc-
ture, the vertically organized responses to the recent threats of SARS and
HPAI H5N1 infection, and the lack of coordinated governance and funding
sufficient to effect change. The committee believes the longstanding cultural
and organizational tendencies toward stovepiping are no longer acceptable:
Disease surveillance needs to be integrated, developed, and implemented
across sectors and disciplines. It would be useful to have a system that
requires reporting and action; however, other incentives will surely be nec-
essary to ensure full participation.
Locations where the drivers of emerging zoonotic infectious diseases
are most active currently coincide with the developing regions of the world,
precisely where the resources for disease surveillance and response are the
most limiting. This is a global concern because the impact of zoonotic dis-
ease emergence is global, not just local. Because of this interconnectedness,
this requires commitment among all nations to share in the cost of develop-
ing effective disease surveillance and to sustain and continually improve the
technical capabilities of this system. This also requires countries to ensure
that responses intended to prevent spread and limit the impact on human
and animal health, including the financial and economic consequences of a
local or global outbreak, are evidence-based and prompt. The recommenda-
tions in this report are broad in their reach and involve technical, financial,
and organizational inputs, and they include significant changes in the way
global governance of zoonotic disease surveillance and response should
be handled. They are based on the full implementation of IHR 2005, and
will necessitate significant changes in the way animal disease surveillance,
reporting, and response is conducted. None of this will be simple to ac-
complish, but efforts need to begin now.
Future Research Needs and Considerations
The disease surveillance and response system is never static. As a com-
ponent of continuous quality improvement and because it is a dynamic sys-
tem, additional research and other considerations will be needed to evaluate
the impact of integrated disease surveillance. Zoonotic disease surveillance
and response would benefit from research in the following areas:
• Developing global standards and evaluation criteria for integrated
zoonotic disease surveillance systems;
• Adapting evolving methodologies from other basic science disci-
plines that could be incorporated into integrated surveillance systems;
• Identifying future pathogens (microbiome-type projects) to guide
the development of diagnostics, vaccines, and drugs;
OCR for page 265
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
• Determining efficacy of and resistance to antibiotics and
antivirals;
• Evaluating the effectiveness of laws and regulations on compliance
with reporting requirements;
• Evaluating the effectiveness of integrated zoonotic disease preven-
tion programs;
• Identifying and evaluating social and economic incentives to com-
ply with and disincentives to ignore reporting requirements;
• Identifying incentives for communicating, cooperating, and build-
ing trust across sectors and disciplines;
• Evaluating the timeliness and level of response that results from
early warning systems and the separation of accurate reports from false-
positive ones;
• Developing community-based participatory research in the epide-
miology of zoonotic diseases;
• Developing social incentives at the local level to promote early
disease reporting, avoid outbreak concealment, and engage in effective
responses;
• Evaluating how communities understand zoonoses epidemiology,
prevention, and treatment in order to foster local participation in disease
reporting and surveillance activities; and
• Tracking media representations of zoonotic diseases and assessing
how information is produced, circulated, and responded to by the commu-
nity and policymakers.
To evaluate its progress and impact, it is essential to periodically con-
duct an in-depth review of how the zoonotic disease surveillance and re-
sponse system is implemented and functions. Such an evaluation needs to be
conducted by an independent, multisectoral, scientific body encompassing
human, animal, and environmental expertise to monitor and evaluate the
progress of this report’s recommendations. As part of that evaluation, an
interim report card should be issued by 2012, which coincides with the
target date for full-implementation of IHR 2005, and a full report should
be issued by 2016 to allow time for responding to the interim evaluation.
Closing Thoughts
The 12 recommendations in this report represent the committee’s con-
sensus view on how to systematically address the multiple requirements
needed for an effective and sustainable system. In its deliberations, the
committee attempted to ensure that its recommendations are pragmatic,
focused, informed, and supported by the review of evidence, even when
OCR for page 266
GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
they may challenge convention in some areas. This report reflects the broad
disciplinary experience necessary to accomplish the goals it addresses,
informed by the broad disciplinary expertise of the committee members.
In many ways, the committee is a microcosm of the expertise needed to
achieve the sustainable integrated disease surveillance and response called
for by the report, and also demonstrates that reaching consensus is no
simple task yet is possible. It is essential to begin the process now toward
achieving this system. U.S. agencies, in particular USAID, can and should
take a lead role—working together with international, intergovernmental,
and multinational partners from the public and private domains—in mov-
ing from discussion to action.
Global sustainability of zoonotic disease surveillance is predicated on
a system that assures international exchange and collaboration to contain
the spread of zoonotic diseases through the creation of an atmosphere of
transparency, trust, and accountability. The system needs to assist devel-
oping countries through relevant capacity building, enabling countries to
appropriately contribute in improving global disease surveillance and using
information to promptly implement the necessary evidence-based responses.
For countries to assume responsibility for zoonotic disease surveillance, the
system needs to survive within available national resources and be sustain-
able. It also needs to be adaptable and flexible enough to meet the needs of
each country’s changing national demands and priorities and be acceptable
to its stakeholders.
Reaching the goal of a sustainable and better integrated global human
and animal surveillance and response system for zoonotic emerging diseases
depends on a number of preconditions: sufficient political and social will
to accomplish it; allocation of necessary financial and technical resources
in a sustainable and continuous way; and ensuring that human and animal
health officials have the authority and resources to regulate the drivers
associated with zoonotic disease emergence, to report emerging events as
they occur, and to determine the proper interventions based on the specific
nature of the agent and the circumstances of the emergence itself. This is
certainly a tall order, but given that political will and financial resources
have been individually marshaled for one emerging zoonotic disease after
the other, the committee believes that it is possible to create a reliable and
sustainable zoonotic disease surveillance system that is flexible, has assured
funding, is efficiently implemented, and is acceptable to all stakeholders.
REFERENCES
AVMA (American Veterinary Medical Association). 2008. One health: A new professional
imperative—One Health Initiative Task Force final report. Washington, DC: AVMA.
OCR for page 267
RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE
Fidler, D. P. 2005. From international sanitary conventions to global health security: The new
International Health Regulations. Chinese J of International Law 4(2):325–392.
GAO (U.S. Government Accountability Office). 2001. Challenges in improving infectious
disease surveillance systems. GAO-01-722. Washington, DC: GAO.
Hadorn, D. C., and K. D. Stark. 2008. Evaluation and optimization of surveillance systems
for rare and emerging infectious diseases. Vet Res 39(6):57.
IPCC (Intergovernmental Panel on Climate Change). 2009. Organization. http://www.ipcc.
ch/organization/organization.htm (accessed July 20, 2009).
Maugh, T. H., II. 2009. WHO will urge most countries to stop H1N1 testing. The Los Angeles
Times, July 8.
Murphy, F. A. 1998. Emerging zoonoses. Emerg Infect Dis 4(3):429–435.
NRC (National Research Council). 2005. Critical needs for research in veterinary science.
Washington, DC: The National Academies Press.
OIE (World Organization for Animal Health). 2008. OIE tool for the evaluation of perfor-
mance of veterinary services, 3rd ed. Paris, France: OIE.
Pappaioanou, M., M. Malison, K. Wilkins, B. Otto, R. A. Goodman, R. E. Churchill,
M. White, and S. B. Thacker. 2003. Strengthening capacity in developing countries
for evidence-based public health: The data for decision-making project. Soc Sci Med
57(10):1925–1937.
Schwabe, C. W. 1996. Ancient and modern veterinary beliefs, practices and practitioners
among Nile Valley peoples. In Ethnoveterinary research and development, edited by
C. M. McCorkle, E. Mathias, T. W. Schillhorn van Veen. London, UK: Intermediate
Technology Publications.
OCR for page 268
