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

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1 Introduction “The confluences of human and animal health, along with wildlife, create new opportunities for pathogens to emerge and reemerge.” —Animal Health at the Crossroads: Preventing Detecting, and Diagnosing Animal Diseases (National Research Council, 00a) Zoonotic1 pathogens have caused the majority of the emerging infec- tious disease events in the past six decades (see Figure 1-1) (Woolhouse and Gowtage-Sequeria, 2005; Jones et al., 2008). These diseases have the potential to cause significant morbidity and mortality in humans and ani- mals, with resulting implications for international trade, travel, economies, and national security. Global interconnectivity has increased opportuni- ties for disease emergence and rapid disease transmission, and the various linkages in the global economy also enable systemic social, political, and economic consequences (World Economic Forum, 2006). Public awareness and concern have grown dramatically as the potential for a global pandemic of influenza was heightened by the emergence of highly pathogenic avian influenza (HPAI) H5N1 infections and with the arrival of pandemic H1N1 in 2009. There is a need and possible momentum for new country-led initiatives and international collaborations aimed at managing this global threat (Murphy, 2008). CHARGE TO THE COMMITTEE Statement of Task The Committee on Achieving Sustainable Global Capacity for Surveil- lance and Response to Emerging Diseases of Zoonotic Origin was convened 1 A zoonotic disease or infection is transmissible between animals and humans. Zoonoses may be bacterial, viral, or parasitic, and may involve unconventional agents (IOM, 2003; WHO, 2008).  

 FIGURE 1-1 Emerging infectious disease events detected from 1940 to 2004. The map is derived for disease events caused by all pathogen types. Circles represent one-degree grid cells, and the area of the circle is proportional to the number of events in the Figure 1-1 color.eps cell. bitmap image SOURCE: Jones et al. (2008). Reprinted with permission from Macmillan Publishers LTD: Nature. broadside 

 INTRODUCTION by the Institute of Medicine (IOM) and the National Research Council (NRC) at the request of the U.S. Agency for International Development to examine the needs and challenges associated with building sustainable global disease surveillance and response for zoonotic diseases. This included a review of the diseases that have emerged in the past several decades and the drivers associated with their emergence and reemergence; a review of the current state of existing global disease surveillance systems for zoonotic disease; and an examination of policy and regulatory options to mitigate or decrease the threat of zoonotic diseases globally. The committee was also asked to recommend ways to strengthen and improve coordination of the human and animal health systems and the mechanisms that govern them to achieve sustainable and timely disease surveillance worldwide that could improve the prevention of and response to these disease threats (see Box 1-1 for the Statement of Task). Limitations on the Scope Security threats can be caused by the intentional introduction of mi- crobes for deliberate disease emergence. While the committee recognizes the dual-purpose nature of zoonotic pathogens and its potential for biosecurity concerns, this report is instead focused on nondeliberate disease emergence and events. In addition, the report predominantly addresses surveillance concerns rather than focusing on response measures. The committee understood the importance of acting on surveillance information to prevent and control emerging zoonotic disease outbreaks. However, given the serious gaps and challenges that currently preclude early detection and reporting and the limitations of the committee’s charge, the committee primarily focused its efforts to address these surveillance gaps and challenges. Significant additional review, discussion, and consideration would be needed at a future time to comprehensively assess how best to implement appropriate evidence-based responses following the detection of an emerging zoonotic disease in human and animal populations. The Committee’s Approach to Its Task Several publications from the IOM and the NRC have examined the topics of infectious diseases and microbial threats to health and security (IOM, 1992, 2003), and the challenges and resources needed to strengthen animal health infrastructure, including the training of veterinarians (NRC, 2004, 2005a,b). This report builds on perspectives outlined in the report Animal Health at the Crossroads: Preventing, Detecting, and Diagnosing Animal Diseases (NRC, 2005a). 

0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES BOX 1-1 Statement of Task The charge to the committee was to provide consensus advice on the chal- lenge of achieving sustainable global capacity for disease surveillance and re- sponse to emerging diseases of zoonotic origin. Specifically, the committee was to address the following issues: 1. eview the emergence and spread over the past several decades of a diverse R range of agents of zoonotic origin. 2. ummarize what is known about the causes underlying this growing phenom- S enon, trends in these factors, and the implications for long-term domestic and international development and security. 3. ssess the evolving nature, extent, and risks of animal and human interac- A tions, focusing specifically on recent infectious disease events of international significance, such as highly pathogenic avian influenza H5Nl. 4. eview the historic human and animal health responses to emergent zoonotic R diseases along with lessons learned that may be applicable to future threats. 5. eview the current state of and gaps in global systems for disease surveillance R of zoonotic infections in human and animal populations. 6. evelop conclusions on the appropriate balance between emergency re- D sponse to threats and establishing sustainable global disease surveillance capacity for early detection, mitigation, and characterization of known, chang- ing, and unknown threats. 7. dentify and prioritize for the international context recommendations to I strengthen and improve coordination of the human and animal health systems to achieve a sustainable and integrated institutional capacity for timely disease surveillance that could improve prevention of and response to zoonotic dis- eases across both realms. 8. xplore options—including policy and regulatory options, such as international E agreements—to mitigate and decrease the threat of emerging zoonotic dis- eases worldwide, and to improve coordination between governments and other relevant international organizations. The Committee on Achieving Sustainable Global Capacity for Surveil- lance and Response to Emerging Diseases of Zoonotic Origin met over 10 months. A 2-day workshop was held in conjunction with the first com- mittee meeting in June 2008 in Washington, DC. At the data-gathering workshop, invited speakers and experts discussed aspects of building capacity for disease surveillance and response to emerging zoonotic dis- eases. Speakers and participants included representatives from international organizations, U.S. government agencies, and researchers and academi- cians from the Americas, Asia, and Africa. A summary of the workshop proceedings, Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of zoonotic Origin: Workshop Summary, 

 INTRODUCTION was published in December 2008 (IOM and NRC, 2008).2 The committee collected more information through four additional committee meetings, two teleconference meetings with invited experts, and multiple conference calls and electronic communications. The committee defined several crucial terms for the purpose of this report, and the definitions are found in Appendix A. The committee consid- ers public health to include both human and animal health. When human health officials, clinicians, researchers, or policymakers are referenced in discussions, the reader should also assume the committee intends to include their equivalents in the animal health realm, although such interactions are not yet routine. The committee refers to integrated systems to convey the importance of connecting and engaging both human and animal sectors in addressing the problem of emerging zoonotic infectious diseases. INTERNATIONAL CONTEXT FOR ZOONOTIC DISEASE SURVEILLANCE AND RESPONSE An important development in the past decade, driven by the emergence of HPAI H5N1 and severe acute respiratory syndrome (SARS), has been a transformation in how governments, international governmental organiza- tions, and nongovernmental actors think about emerging zoonotic disease surveillance and response capacities. Human and animal health threats— and their intersections—have risen in public concern to become subjects of foreign policy and diplomacy. In this rise to political prominence, the committee recognized conceptual innovations in the way stakeholders think about disease surveillance and response capacities, and why they are im- portant. Through foreign policy and diplomacy, governments attempt to achieve four objectives: 1. To protect the nation’s security; 2. To advance the nation’s economic well-being and power; 3. To foster development in countries and regions important to the nation’s security and economic interests; and 4. To protect human dignity through humanitarianism and human rights (Fidler, 2008). Although past governance efforts against human and animal health threats have touched on some of these functions, they have never been systematic or conducted in ways that really mattered in the “high politics” of national or international politics. That may explain why the international regimes for human and animal health developed as devices to reduce the economic 2 Available online through the National Academies Press at www.nap.edu. 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES burden of outbreaks, even though the World Health Organization eventu- ally linked human health to human rights by advocating “Health for All” as a right under the Alma Ata declaration (WHO, 1978). Some key inter- national governmental organizations relevant to the discussion on global surveillance and response of zoonotic diseases are described in Box 1-2. The formal legal obligations that countries have to report emerging human and animal infectious disease events are only one part of the in- ternational institutional frameworks that guide the behavior of actors at the global level; also important are the set of informal norms, rules, and expectations they share. Because the economic, political, military, or even moral power relationships between nations are commonly asymmetric, it is essential to have international governance structures in place to limit the impact of the hierarchy of power among the participating nations, particularly if global public goods3—that is shared objectives for the good of all—are ever to receive support over more narrow national interests. International “institutions,” including the “persistent and connected sets of rules (formal or informal), that prescribe behavioral roles, constrain activity, and shape expectations” (Keohane, 1984; Ostrom, 2005) can play this role by guiding the interactions of actors towards the achievement of shared objectives. These institutions are distinct from the actors involved, which may be states, government agencies, organizations, corporations, foundations, or even individuals. While the institutions and the actors can be stable for long periods of time, some events can so perturb the institutional framework that it becomes necessary to find and negotiate a new set of rules and roles. Emerging zoonotic infectious diseases represent such a redefining event with respect to tourism, travel, and trade of food and animal products across national borders. Moreover, emerging zoonotic infectious diseases are not currently predictable, and so the “global institutions” that will gov- ern the interactions between sovereign states and non-state actors (firms, nongovernmental organizations [NGOs], individuals) will need to have flexibility built in and be able to evolve to allow the involved actors to effectively meet the challenges of governance as they arise. The commit- tee believes that it is important to distinguish between the institutions, in the context described, and the actors that must participate in building and supporting a global surveillance and response system to address emerging zoonotic infectious diseases. For example, as extensively discussed later in 3 The International Task Force on Global Public Goods defines “global public goods” as “issues that are broadly conceived as important to the international community, that for the most part cannot or will not be adequately addressed by individual countries acting alone and that are defined through a broad international consensus or a legitimate process of decision- making” (2006, p. 13). 

 INTRODUCTION BOX 1-2 International Institutions and Actors WHO: The World Health Organization (WHO), created by the United Nations (UN) in 1948, is the directing and coordinating authority for health within the UN system. It is responsible for providing leadership on global health matters, shaping the health research agenda, setting norms and standards, articulating evidence- based policy options, providing technical support to countries, and monitoring and assessing health trends. The World Health Assembly is the supreme decisionmak- ing body for WHO and is attended by delegations from all 193 member states. The Secretariat of WHO is staffed by some 8,000 health and other experts and support staff on fixed-term appointments, working at headquarters in Geneva, Switzerland, in the six regional offices, and in countries. WHO is headed by the Director-General, who is appointed by the Health Assembly on the nomination of the Executive Board. WHO collaborates with more than 800 institutions in 90 countries to carry out its programs and activities (www.who.int). FAO: The Food and Agriculture Organization of the United Nations (FAO), created in 1945, has the mission of raising levels of nutrition, improving agricultural pro- ductivity, bettering the lives of rural populations, and contributing to the growth of the world economy. The organization, headquartered in Rome, Italy, is directed by the Director-General, elected by the Conference. FAO employs more than 3,600 staff members (1,600 professional and 2,000 general service staff) and maintains 5 regional offices, 9 subregional offices, 5 liaison offices, and 74 fully fledged country offices—excluding those hosted in regional and subregional offices (www. fao.org/about/mission-gov/en/). OIE: The Office International des Epizooties (OIE, also known as the World Orga- nization for Animal Health) is responsible for improving animal health worldwide. It was created in 1924 by the ratification of an agreement by member states of the League of Nations, and it is recognized as a reference organization by the World Trade Organization. As of June 2009, OIE had a total of 174 member states. The daily operations are managed by the Director-General, elected by the OIE International Committee, from the Paris, France, headquarters. The organization has approximately 40 health experts and support staff. OIE maintains permanent relations with 36 other international and regional organizations and has regional and subregional offices on every continent (www.oie.int). WTO: The World Trade Organization (WTO) is an international organization es- tablished in 1995 with the primary purpose to open trade for the benefit of all. It provides a forum for negotiating agreements aimed at reducing obstacles to international trade and ensuring a level playing field for all, thus contributing to economic growth and development. It also provides a legal and institutional frame- work for the implementation and monitoring of 16 different multilateral agreements (to which all WTO members are parties) and two different plurilateral agreements (to which only some WTO members are parties), as well as for settling disputes arising from their interpretation and application. Decisionmaking is generally by consensus of the entire membership (currently 153 members, of which 117 are developing countries or separate customs territories). The organization is led by the Director-General. The Secretariat is in Geneva, Switzerland, with 700 staff members (www.wto.org). 

 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES this report, the revised International Health Regulations 2005 (IHR 2005) have been ratified by 194 nations and thus represent a legal requirement for compliance under the IHR protocol. However, the underlying institutions that will guide behavior as new challenges arise are less clear and less well understood. Without some debate and agreement on a basic set of rules and expectations, implementation of IHR 2005 may lag, and a truly effective global governance arrangement will remain elusive. ORGANIZATION OF THE REPORT The report presents the committee’s findings, conclusions, and recom- mendations on achieving a sustainable global zoonotic disease surveillance and response system. Chapters 2 and 3 provide background context for exploring the magnitude of the challenges and threats posed by zoonotic diseases to human and animal health, macro- and microeconomies, global trade, and the sociocultural-political impacts and interactions for disease prevention and mitigation. Chapter 4 analyzes the current global capacity for zoonotic disease surveillance and response, while Chapter 5 examines the incentives and protections for improving disease reporting at various levels. Financing challenges for sustaining global disease surveillance are discussed in Chapter 6. Chapter 7 describes the governance mechanisms, processes, and innovations the committee deems critical to strengthening disease surveillance and response capabilities for human and animal health. Finally, Chapter 8 provides recommendations for sustaining global surveil- lance and response to zoonotic diseases and also examines some possible challenges that will need to be overcome in effectively implementing and strengthening efforts to protect human and animal health. REFERENCES Fidler, D. P. 2008. Pathways for Global Health Diplomacy: Perspectives on Health in Foreign Policy (WHO Globalization, Trade and Health Working Paper Series, June). International Task Force on Global Public Goods. 2006. Meeting global challenges: Interna- tional cooperation in the national interest. Final Report. Stockholm, Sweden: Interna- tional Task Force on Global Public Goods. IOM (Institute of Medicine). 1992. Emerging infections: Microbial threats to health in the United States, edited by J. Lederberg, R. E. Shope, and S. C. Oaks, Jr. Washington, DC: National Academy Press. IOM. 2003. Microbial threats to health: Emergence, detection, and response, edited by M. S. Smolinski, M. A. Hamburg, and J. Lederberg. Washington, DC: The National Academies Press. IOM and NRC (Institute of Medicine and National Research Council). 2008. Achieving sus- tainable global capacity for surveillance and response to emerging disease of zoonotic origin: Workshop summary. Washington, DC: The National Academies Press. 

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