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4. Addressing the Threats: Conclusions and Recommendations
Pages 149-226

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From page 149...
... ENHANCING GLOBAL RESPONSE CAPACITY The emergence of infectious diseases reflects complex social, economic, political, environmental, ecological, and microbiological factors that are globally linked. A number of forces operating in developing countries in particular, including urbanization, deforestation, changes in land use and climate, population growth, poverty, malnutrition, political instability, and even terrorism, have created the conditions for several infectious diseases to become new or recurrent threats.
From page 150...
... Antimicrobial resistance has become a major barrier to treatment of tuberculosis and malaria worldwide, threatens the effectiveness of antiretroviral therapy in persons with AIDS, and has made treatment of common bacterial infections more difficult in the United States and elsewhere. Infectious diseases are appearing abruptly in new locations and claiming hundreds of lives; a case in point is West Nile encephalitis, which spread to most parts of the United States within 3 years following its sudden appearance in the Northeast.
From page 151...
... The interplay among these variables will determine the overall outlook regarding the impact of infectious diseases. In this context, it is clear that the response to emerging infectious diseases at a global level requires an investment in the capacity of developing countries to address these diseases as they arise.
From page 152...
... 52 MICROBIAL THREATS TO HEALTH Improving the global capacity to respond to microbial threats will require sustained efforts over time. Given the imminent nature of many infectious disease threats, however, it is critical that immediate action be taken toward achieving this capacity.
From page 153...
... In yet another collaborative program, FIC and NIAID provide awards to U.S. universities under the International Training and Research Program in Emerging Infectious Diseases, which expands NIH research training efforts in the study of microbial threats.
From page 154...
... Global surveillance, especially for newly recognized infectious diseases, is therefore crucial in responding to and containing microbial threats before isolated outbreaks develop into regional or worldwide epidemics.
From page 155...
... , and the MeKong Delta Surveillance Network, which includes five countries of Asia, as well as the province of Yunan in China. In 1996, DOD was mandated to use its long-standing and well-respected overseas research laboratories in Egypt, Indonesia, Kenya, Peru, and Thailand to establish the Global Emerging Infections Surveillance (GEIS)
From page 156...
... The system was designed to promote communication among the international infectious disease community, and to provide for the exchange of information about outbreaks and other matters of interest regarding emerging infectious diseases (International Society for Infectious Diseases, 2001~. PacNet, an Asian network of health professionals on 20 Pacific Islands, is another such network, established to allow the exchange of information among health professionals regarding epidemics in that region.
From page 158...
... Significant efforts have been made to enhance global surveillance, but the system remains skeletal and is inadequate to monitor disease incidence and prevalence in most parts of the world. The United States should take a leadership role in promoting the implementation of a comprehensive system of surveillance for gioteal infectious diseases that builds on the current global capacity of infectious disease monitoring.
From page 159...
... it, , 1 1 The threat of bioterrorism is intimately related to that of naturally occurring infectious diseases. The response to bioterrorism is much like the response to any microbial threat to health, and the necessary resources for building the public health infrastructure are, in essence, the same as those needed to respond to bioterrorism.
From page 160...
... from a range of disease threats, both naturally occurring and maliciously caused, may be missed. Strong and well-functioning local, state, and federal public health agencies working together represent the backbone of effective response to a major outbreak of infectious disease, including a bioterrorist attack.
From page 161...
... The Health Alert Network is designed to be the nation's rapid online system for health communication and will serve as the electronic platform for the National Electronic Disease Surveillance System (NEDSS) (discussed later)
From page 162...
... It also concludes that all nurses should have at least an introductory grasp of their role in public health, and that all undergraduates should have access to education in public health. Educational strategies in which applied epidemiology programs provide exposure to state and local health departments may help increase awareness of the role of public health in population-based infectious disease control and prevention, and provide for exposure to public health as a potential career choice See the later discussion on educating and training the microbial threats workforce)
From page 163...
... The public health capacity in the United States must be sufficient to respond quickly to emerging microbial threats and monitor infectious disease trends. Prevention and controt measures in response to microbial threats must be expanded at the local, state, andt national levels andt be executed" by an adleq?
From page 164...
... Gathering and analyzing information quickly and accurately will help improve the nation's ability to identify and track emerging infectious diseases and potential bioterrorism attacks, as well as to investigate outbreaks and monitor disease trends. The long-term vision for NEDSS is that of complementary electronic information systems that automatically gather health data from a variety of sources on a real-time basis; facilitate monitoring of the health of communities; assist in the ongoing analysis of trends and detection of emerging public health problems; and provide information for setting public health policy.
From page 165...
... Astute clinicians are the first line of defense for the identification of most emerging microbial threats. Health care providers are critical in recognizing unusual presentations of illness or clusters of unusual illnesses, and report their observations to local or state health officials.
From page 166...
... and public health officials to enhance reporting of animal infections of relevance to human health; the emergence of West Nile virus has clearly demonstrated this need. Many health care providers do not fully understand their role in infectious disease surveillance, including their role as a source of data (IOM, 20001.
From page 167...
... Innovative strategies to improve communication between health care providers and public health authorities should be developed by working with other public health agencies (e.g., the Food and Drug Administration [FDA1, the Health Resources and Services Administration tHRSA1, USDA, the Department of Veterans Affairs [VAT, state and local health departments) , health
From page 168...
... . FoodNet consists of active surveillance of laboratories, physicians, and the general population for foodborne diseases and related epidemiologic studies designed to help public health officials better understand the epidemiology of foodborne diseases in the United States.
From page 170...
... Automated laboratory reporting of notifiable infectious diseases from private clinical laboratories has been shown to improve dramatically the timeliness and quality of disease reporting for many notifiable infectious diseases, such as foodborne bacterial diseases (Effler et al., 1999; Overhage et al., 1997; Panackal et al., 2002~. CDC has developed the standards and security measures needed for automated reporting of notifiable infectious diseases, having achieved consensus on critical issues.
From page 171...
... , developed by DOD, which provides syndromic surveillance in military treatment facilities using a grouping of International Classification of Disease (ICD) codes.
From page 172...
... The most critical need for these systems is to ensure effective links to local and state public health agencies that would need to respond in the event of an alarm. The central role of public health agencies in the effectiveness of any such system is crucial, since they have both the authority and the expertise for investigations needed to respond should an attack be detected.
From page 173...
... Paviin, GETS, personal communication, January 28, 20021. Data from these systems have also been used in tabletop exercises for a bioterrorism event and have filled a critical need for rapid and continuous assessment of health care utilization for particular problems; this is likely to be the case as well for naturally occurring epidemics, such as influenza pandemics and other crises.
From page 174...
... In summary, syndromic surveillance is likely to be increasingly helpful in the detection and monitoring of epidemics, as well as the evaluation of health care utilization for infectious diseases. At the same time, the potential exists for syndromic surveillance to draw resources away from other systems that have proven to be robust in the detection of microbial threats.
From page 175...
... A specific diagnosis, including results of antimicrobial resistance testing, allows for more appropriate treatment, avoids the inappropriate use of antibiotics, and also informs public health actions. The dramatic rise in the number of unexplained causes of community acquired pneumonia in adults is testament to the current crisis in etiologic diagnosis.
From page 176...
... In Finland, for example, etiologic diagnosis is made in 90 percent of cases of severe respiratory disease in children (Nohynek et al., 1991~. This success rate is attributed to an emphasis on etiologic diagnosis, coupled with a situation in which highly skilled microbiologists work within the relatively compact health care system that characterizes the Scandinavian medical community.
From page 177...
... . Diagnostic immunohistochemistry was key to confirming both the West Nile virus and the anthrax outbreaks.
From page 178...
... The capability for etiologic diagnosis could be significantly improved if inexpensive, rapid, sensitive, and specific tests were available to differentiate not only between viruses and bacteria, but also among different types of viruses and bacteria. The sensitivity of detection methods for cultivation
From page 179...
... CDC and NIH should work with FDA, other government agencies (e.g., DOD, USDA, the national laboratories) , and industry on the development, assessment, and validation of rapid, inexpensive and cost-effective, sensitive, and specific etiologic diagnostic tests for microbial threats of public health importance.
From page 180...
... Payers for health care should cover diagnostic tests for infectious diseases to increase specific diagnoses and thereby inform both public health and medical care, including monitoring of inappropriate use of antimicrobials. As diagnostic tests become more sensitive and increasingly capable of detecting the presence of and differentiating among various types of microorganisms, it is imperative that health care practitioners be able to make clinical sense of the results.
From page 181...
... The real-worId information and skills needed for confronting microbial threats must be better integrated into the training of all health care professionals to ensure a prompt and effective response to any and all infectious disease threats, whether naturally occurring or maliciously introduced. It is vital that on-the-job training opportunities, especially for students and new health professionals, be further developed to ensure that professionals responsible for infectious disease control are well trained in real-life situations, and to expose health professions students to career paths in infectious disease prevention and control.
From page 182...
... The FETPs would be enhanced if all programs were assured of laboratory support in the diagnosis of infectious diseases, as is the case with the Thailand FETP. The Association of Public Health Laboratories' Emerging Infectious Diseases Laboratory Fellowship Program trains qualified bachelor's and
From page 183...
... Increased training in the recognition and diagnosis of animal diseases that can indirectly affect human health is also needed (see Box 4-81. CDC, DOD, and NIH should develop new and expand upon current intramural and extramural programs that train health professionals in applied epidemiology and field-based research and training in the United States and abroad.
From page 184...
... Added to this complex situation is the need for vaccines to protect against microbial agents that could be used in a bioterrorist attack. Despite these challenges, opportunities for major breakthroughs in vaccine development are more promising than ever before as the front across which the basic sciences are advancing broadens.
From page 185...
... An increased commitment to research is necessary to ensure the development of vaccines for the numerous infectious diseases that threaten the worId's human population. Vaccines against acute respiratory infections, diarrhea!
From page 186...
... The reality is that the infrastructure does not exist to produce even a sufficient supply of currently licensed vaccines, let alone to develop new vaccines against emerging microbial threats. Thus in the event of an outbreak whether naturally occurring or an act of bioterrorism the United States will not have the capacity to produce sufficient vaccines to safeguard the population.
From page 187...
... It was not mergers and acquisitions that concentrated responsibility for vaccine innovation in the hands of four multinational firms; rather, the economic forces that drove firms out of the industry were the rising costs of innovation, production, and distribution and the shrinking margins allowed by monopsony, or the concentration of buying power in the hands of a relatively small number of public agencies. In the United States, several large companies ceased vaccine production because the total world market for vaccines was so much smaller than that for pharmaccuticals, government purchases allowed only narrow profit margins, and liability continued to be an issue (Galambos and Sewell, 1995; IOM, 20013~.
From page 188...
... The creation of these funds was a major step forward. So, too, was the development of vaccine production capabilities in the developing world, where 75 percent of the worId's supply of vaccines is now manufactured.
From page 189...
... ~ately funded research base for existing and emerging infectious diseases and the development of an ample supply of routinely recommended vaccines.
From page 190...
... to ensure the development and distribution of vaccines for diseases that affect populations in developing countries disproportionately. NEED FOR NEW ANTIMICROBIAL DRUGS Antibiotics Unfortunately, complacency toward infectious diseases in the 1960s, overconfidence in existing antibiotics, and competition from highly profitable opportunities for pharmaceutical development and sale in other fields of medicine resulted in a lag in the production of new classes of antibiotics.
From page 191...
... Antivirals Expanding knowledge in the fields of genomics, cell biology, structural biology, and combinatorial chemistry has resulted in the rapid development of some new antivirals. This is exemplified by the dramatic increase in antiviral drugs targeting HIV and, to a much lesser extent, influenza viruses.
From page 192...
... For example, during the outbreak of West Nile encephalitis in New York, autopsies were performed under the jurisdiction of New York City's Office of the Chief Medical Examiner because of the obvious public health implications (Shieh et al., 2000~. Other notable cases in which autopsies contributed to the discovery or increased understanding of emerging infectious diseases include investigations of hantavirus pulmonary syndrome, Ebola hemorrhagic fever, leptospirosis associated with pulmonary hemorrhage, new variant Creutzfeldt-Jakob disease, and Nipah virus encephalitis.
From page 193...
... 193 o ~ o Cal — U. ~ U
From page 194...
... 194 ._ o pa ~ ˘ o ° C':)
From page 198...
... An effective vaccine to prevent HIV infection has not yet been developed. The remarkable advances in the treatment of HIV have resulted largely from advances in antiviral chemotherapy.
From page 199...
... 199 cat c~ :> ˘ o .
From page 200...
... 200 MICROBIAL THREATS TO HEALTH it: A: ,~.
From page 201...
... Yet new drugs will face problems of bioavailability and the inevitable emergence of resistance. The other difficulty is the high cost of the drugs, making optimal chemotherapy for HIV available only to persons in the upper socioeconomic groups, even in the developed world.
From page 202...
... Two families of antivirals are available for influenza viruses: (1) two derivatives of adamantine amantadine (Symmetrel)
From page 203...
... Although defining the precise public health risk of emergent antibiotic resistance is not simple, the problem is global in scope and very serious. Many generic but essential antibiotics are in short supply (Strausbaugh, 2001)
From page 204...
... Secretary of Homeland Security should protect our national security by ensuring the stockpiling and distribution of antibiotics, antivirals (e.g., for influenza) , and antitoxins for naturally occurring or intentionally introduced microbial threats.
From page 205...
... Many problems associated with antimicrobial resistance have arisen in poor and developing areas of the world, and have subsequently spread globally. In addition to avoiding the inappropriate use of antibiotics to treat viral disease, prudence dictates use of the appropriate antimicrobial when an etiologic diagnosis is made.
From page 206...
... The world is facing an imminent crisis in the control of infectious diseases as the result of a gradual but steady increase in the resistance of a number of microbial agents to available therapeutic drugs. Although defining the precise public health risk of emergent antimicrobial resistance is not
From page 207...
... expanded outreach and better education of health care providers, drug dispensers, and the general public on the inherent dangers associated with the inappropriate use of antimicrobials, and (2) the increased use of diagnostic tests, as well as the development and use of rapid diagnostic tests, to determine the etiology of infection and thereby ensure the more appropriate use of antimicrobials.
From page 208...
... . Various other groups have suggested that because of the increasing risk of antimicrobial resistance, the subtherapeutic use of antibiotics for growth promotion should be banned (some would include use for prophylaxis in the ban as well)
From page 209...
... These changes should be accompanied by substantial outcomes research on the effects on animal health, resistance prevalence in animals and humans, and the economics of food production. VECTOR-BORNE AND ZOONOTIC DISEASE CONTROL The majority of emerging infectious diseases are zoonoses (i.e., diseases transmitted from animals to humans under natural conditions)
From page 213...
... Human Resource Capacity The critical national needs for specialists in vector-borne and zoonotic diseases (e.g., medical entomologists, vector biologists, vector ecologists, mammologists, ornithologists) were illustrated dramatically by the recent emergences of Sin Nombre virus and West Nile virus in the United States.
From page 214...
... and other approaches for control of vector-borne and zoonotic diseases. The emergence of West Nile virus resulted in an intensive effort by CDC to train individuals in mosquito identification' processing, and control, and the emergence of Sin Nombre virus led to similar efforts by CDC to train individuals in rodent identification' surveillance, and control.
From page 215...
... The continued presence of long-term, sustainable laboratories in selected disease-endemic countries is critical. Such laboratories are invaluable for research, training, and surveillance for tropical and emerging infectious diseases.
From page 216...
... Novel Strategies to Prolong Pesticidle Usage Pesticide usage in integrated pest management programs, which incorporate established agricultural practices for mitigating the evolution of resistance (e.g., rotation of pesticides used, inclusion of refugia with no pesticide applications) , would extend the useful life of existing pesticides.
From page 217...
... For example, viruses could be used to transduce effector molecules in order to enhance vector knockdown or manipulate vector phenotypes. Novel Strategies to Interrupt Pathogen Transmission Strategies for vector-borne disease control remain focused on approaches that involve immunizing humans, using pesticides to reduce vector populations, or repellents to reduce contact with vectors.
From page 218...
... Genetic approaches in which vector populations are manipulated to become incompetent vectors are being investigated for their potential to interrupt pathogen transmission. Such approaches could minimize potential environmental issues associated with pesticide usage and prevent an ecological vacuum that other vectors could occupy.
From page 219...
... CDC, DOD, and NIH should work with state and local public health agencies and academia to expand efforts to exploit geographic information systems (GIS) and robust models for predicting and preventing the emergence of vector-borne and zoonotic diseases.
From page 220...
... As previously noted, bioterrorism represents but the extreme end of a continuum of serious infectious disease threats, including the emergence of new infectious diseases, the resurgence of old ones, the appearance of new antimicrobial-resistant forms of old diseases, recognition of the infectious etiology of chronic diseases, and the creation of bioengineered organisms that produce disease in unforeseen ways. For such an integrated agenda to be effective, it must address both long- and short-term needs, involve both basic science and applied public health research, be multidisciplinary in nature, and utilize modern and robust molecular and quantitative tools.
From page 221...
... This agenda should be designed to investigate the role of genetic, biological, social, economic, political, ecological, and physical environmental factors in the emergence of infectious diseases in the United States and worI`lwi~le. This agenala should also income the development and assessment of public health measures to address microbial threats.
From page 222...
... Furthermore, the absence of an interdisciplinary collaborative approach results in failure to adequately train the workforce needed to address the emerging microbial threats facing the world today. While federally proposed Research Centers of Excellence in Biodefense and Emerging Infections may provide some of the infrastructure needed to address specific emerging disease threats (e.g., basic research, vaccine and antimicrobial drug development)
From page 223...
... Unfortunately, today there are too few scientists who can bring to bear all the various tools and approaches that may be of use in the detection, diagnosis, investigation, prevention, and control of emerging infectious diseases. These problems are not unique to infectious diseases.
From page 224...
... These centers should be based within academic institutions and link (both physically and virtuallyJ the relevant disciplines necessary to support such an approach. They would collaborate with the larger network of public agencies addressing emerging infectious diseases (e.g., local and state health agencies, CD C, DOD, the U.S.
From page 225...
... Emerging infectious diseases and persistent infections create an urgent need for such centers. In addition to helping to meet national and even international needs in addressing emerging infectious diseases, the proposed centers would play a critical role in improving our national capacity to deal with nosocomial infections, drug resistance, socioeconomic issues in the emergence and transmission of infection, and the infectious etiologies of cancer and chronic inflammatory and degenerative diseases.
From page 226...
... deals with the reportable diseases of animals, only certain influenza virus types that are highly pathogenic for poultry are of concern those viruses that are found to be rather nonpathogenic in poultry, but for which a potential threat to humans exists, are ignored. Given the remarkable mutability of influenza viruses, it might be expected that there would be strong links between WHO and its human influenza tracking system and OIE and its still-primitive animal influenza tracking system.


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