Global Infectious Disease Surveillance and Detection Assessing the Challenges–Finding Solutions: Workshop Summary (2007) / Chapter Skim
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Summary and Assessment
Summary and Assessment
Pages 1-44
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. Disease surveillance and detection relies heavily on the astute individual: the clinician, veterinarian, plant pathologist, farmer, livestock manager, or agricultural extension agent who notices something unusual, atypical, or suspicious and brings this discovery in a timely way to the attention of an appropriate representative of human public health, veterinary medicine, or agriculture.
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While the workshop did explore a variety of conventional and novel approaches for disease surveillance and detection, the workshop organizers did not attempt to critique standard domestic disease detection approaches nor did the workshop make recommendations about what an "optimal" or "desirable" disease surveillance and detection system would look like. Workshop participants examined current and emerging methods and strategies for the surveillance, detection, and diagnosis of human, animal, and plant diseases in order to assess resource needs and opportunities for improving and coordinating global infectious disease surveillance, detection, and reporting.
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To place these presentations and ensuing discussions in context, we begin by briefly describing the multiple purposes served by public health surveillance, as well as current disease surveillance practices in animals and plants. Surveillance Purposes and Practices Public Health Surveillance In the United States, public health surveillance for infectious disease is conducted through a variety of state and federal programs (GAO, 2004)
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The Real Time Outbreak and Disease Surveillance System (RODS) is used by several states to gather data on the symptoms of emergency room patients (GAO, 2004)
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. Despite the considerable investments that have been made in domestic syndromic surveillance systems, many workshop participants noted, their promise remains largely unproven (Descenclos, 2006; Bravata et al., 2004; Reingold, 2003; RAND Corporation, 2004; Stoto, 2005; Sosin, 2003)
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. Public Health Surveillance: A Local Perspective The traditional model of infectious disease surveillance remains essential to public health practice, particularly at the local level.
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for patterns or clusters of behaviors suggestive of an illness outbreak. The concept of syndromic surveillance is doubly attractive because in addition to its potential to increase the speed and effectiveness of the public health response to natural or deliberate disease outbreaks, it costs far less to implement than traditional, labor-intensive approaches to disease surveillance (Stoto, 2005)
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Syndrome detection is central to this new paradigm, and should be viewed as one of a collection of approaches to global surveillance for infectious diseases, he said. However, he also noted considerable challenges in moving syndromic surveillance from theory to practice.
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He suggested, rather, that syndromic surveillance was most likely to be valuable in detecting potentially large-scale, natural disease outbreaks (e.g., seasonal and pandemic influenza, foodborne disease) for which the useful "detection window" is relatively broad.
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Situational Awareness Several workshop participants described the use of syndromic surveillance data beyond the mere detection of behavioral "signals" of an outbreak. Kelley noted that syndromic data could support efforts to characterize infectious diseases, help target outbreak response, and inform risk communication.
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will require an integrated international approach to disease surveillance. Progress toward this goal has been hampered by a variety of economic and political factors, most notably the threat of trade embargoes against countries that voluntarily report livestock or wildlife disease outbreaks.
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To protect endangered gorillas in central Africa from the Ebola virus, WCS has supported human disease surveillance among the underserved populations that live in close contact with the gorillas by training local people in simple data collection, syndromic surveil
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SARS $50B China, Hong Kong, Singapore, Canada,… $50B+ $40B Foot and Mouth $30B UK $30B $20B Estimated cost Avian flu, Asia Swine flu, U.S., Canada BSE, UK Netherlands $10B Foot and Mouth $10B $10-13B $2.3B Taiwan, $5-8B BSE, Canada BSE, U.S. $1.5B BSE, Nipah,,Malaysia $3.5B Lyme disease Japan Avian flu, EU $350-400M $500M U.S., $2.5B $1.5B 2004 2003 1996 1997 1998 1999 2000 2001 2002 1993 1994 1992 1995 FIGURE SA-1 The economic impact of selected infectious diseases.
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The Wildlife Global Animal Information Network for Surveillance (Wildlife GAINS) aims to establish "a comprehensive worldwide wildlife health surveillance system to enhance preparedness for and awareness of emerging infectious diseases," he reports.
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. According to Stack, NPDN is currently pursuing a range of passive and active disease surveillance strategies.
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"If they don't know what they are looking for, then that's wasted time." Surveillance Networks In traditional public health surveillance (based on reports from medical practitioners, as described in the previous section) , information travels up or down the public health hierarchy, from the local to the international level and vice versa.
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. Now sponsored by the International Society for Infectious Diseases, PMM is a free, nonprofit, noncommercial, moderated e-mail list that serves in excess of 37,000 subscribers in more than 150 countries, as well as anyone with access to the website.5 As illustrated in Figure SA-2, traditional public health reporting follows a linear "bottom-up" process, beginning with an ill person presenting to a local doctor, where they may receive medical tests.
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World bodies: UN, WHO, FAO, OIE Type Title Here Ministry of Health Ministry of Health Type Title Here Type Title Here Local officials Local officials Local officials Local officials Practitioners Practitioners Practitioners Practitioners Practitioners Practitioners Public Public Public Public Public Public Labs Labs FIGURE SA-2 Traditional public health reporting. SOURCE: Figure courtesy of Dr.
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Harnessing the power of automated Internet searching for disease surveillance, GPHIN scans thousands of websites in eight languages -- including those identified by two "news aggregators," who monitor thousands of news sources in dozens of languages -- for early signs of infectious disease outbreaks in humans, animals, and plants, as well as for chemical incidents and disease threats associated with natural disasters (Mykhalovskiy and Weir, 2006)
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. With GPHIN as a starting point, Brilliant hopes to create a freely available, internationally independent system for the early detection of infectious disease outbreaks.
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It would also satisfy the concerns of Forum member Gerald Keusch, who observed that government-operated sources of surveillance information raise "serious issues of credibility." HealthMap HealthMap,8 a freely available, web-based surveillance network operating since September 2006, provides a global view of infectious disease outbreaks as reported by the WHO,9 PMM, Google News,10 and Eurosurveillance.11 John Brownstein, of the Children's Hospital Informatics Program, Harvard– 8 See http://www.HealthMap.org. 9 See http://www.who.int/csr/don/en/.
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of a long desired and sought-after "system of systems" approach to infectious disease surveillance. GPHIN's current status within Health Canada and its reliance on commercial news aggregation services would likely prohibit the network from supplying data to HealthMap, Mawudeku explained; however, such collaboration could be possible if GPHIN evolves into an open, nongovernmental network as envisioned by Brilliant.
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. The Voxiva Model for Resource-Constrained Environments As several workshop participants observed, a global infectious disease surveillance system capable of early detectionSA-5response must identify outbreaks and where they most often arise: in the world's most impoverished communities.
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Like other electronic surveillance networks, Voxiva is ultimately web-based, Johnson said. The network receives input from a variety of sources, including cellular and fixed-line telephones, personal computers, PDAs, and paperbased communications to "optimize the use of existing infrastructure to create multiple-channel, redundant systems" for data collection, she explained.
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In addition, Voxiva provides basic training in epidemiology and outbreak management to its clients, using freely available, web-based curricula.13 All these functions contribute to Voxiva's overarching purpose, as defined by Johnson, to use informatics to build and support networks of astute clinicians. Considerations for Surveillance Networks In response to these presentations, workshop participants raised a series of general issues regarding the structure, function, and future of public health surveillance networks.
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Brownstein also predicted that basic research in Internet-based surveillance would benefit from the recent "explosion of work" on syndromic surveillance systems; for example, by using previously developed methods to characterize datasets and reveal their hidden biases. Finally, participants observed that surveillance networks, like other advanced technologies that have been integrated into the practice of public health, tend to be driven by innovation rather than designed to solve important problems.
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, but the diversity of genotypes and mechanisms associated with this phenotype, and the difficulty of predicting expression from simple gene detection, have hampered the universal adoption of this approach. Real-time quantitative PCR, which permits sample processing in minutes, powers environmental detection systems for infectious diseases and biological warfare agents, as well as innovative point-of-care diagnostic tests (Ivnitski et al., 2003; Peruski and Peruski, 2003; Raja et al., 2005)
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Nevertheless, Perkins concluded, "Our belief at FIND is that if you make the right technology, people will use it." On the Battlefield Much like public health workers in developing countries, soldiers at risk of contracting infectious diseases, either from the natural environment or from
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are of greater concern than false positives." The military currently relies on a combination of PCR tests, immunoassays, and traditional microbiology to diagnose infectious diseases in the field, while pursuing a strategy to develop comprehensive diagnostic tools. Animal Diseases Recognizing the advantages of DNA-based diagnostic tools, Alex Ardans and colleagues have developed PCR-based assays to screen for pathogens associated with exotic Newcastle disease (END)
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FIGURE SA-7 Star Trek medical tricorder.16 SOURCE: Printed with permission from CBS Paramount. 16The medical tricorder was a palm-sized, handheld, device used by doctors in the Star Trek universe of the 23rd and 24th centuries to help diagnose diseases and collect bodily information about a patient.
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you have to do serology." More importantly, he observed, because diagnosis requires the integration of various test results with other information, such as epidemiological data, the GreeneChip "is never really going to replace a seasoned, thoughtful clinician." Lipkin also noted that, despite the obvious advantages of multiplexed detection (and in anticipation of less expensive versions of microarrays) , the widespread adoption of microarrays for disease detection would require a revision in regulatory standards based on the more sensitive single-agent model.
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Host-based, presymptomatic diagnosis could be accomplished by monitoring a person's blood serum chemistry for changes suggestive of compromised health status, Johnston explained; he is currently involved in developing a device to perform such analyses. He noted that the noninvasive sampling of breath and saliva is attractive in theory, but that neither of these sources offered the diversity or concentration of metabolic components found in blood.
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. Nevertheless, participants urged that the vast experience of commercial producers of medical diagnostics be brought to bear on public efforts to develop applications for infectious diseases.
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. Shifting the Public Health Paradigm Certain powerful concepts and conditions that influence the practice of public health inhibit the coordination of infectious disease surveillance, detection, and diagnosis, according to Hueston.
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Now, he said, "if they monitor and get positive reports, they are culpable and have self-incriminated, so they stopped monitoring." Coordinating the spectrum of public health activities associated with disease surveillance and detection is an inherently political task, and therefore strongly influenced by societal and organizational culture, Hueston asserted. "To be effective in politics over the long term and to build coordination and collaboration requires people skills," he observed, and yet increasingly in educational fields relevant to public health, considerations of interpersonal and executive skills are largely ignored under the misguided assumption that science and technology can replace them.
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If we want to foster a further schism between the public and the scientific community, the best thing we can do for that is to withhold information." Hueston responded that he agreed with Johnston's position in principle, but insisted that under some circumstances, the unintended consequences of publicizing information outweighs the potential benefits, such as sharing of animal disease surveillance data in wildlife that precipitates unwarranted trade restrictions on commercially produced products. He concluded that the release of surveillance information should be evaluated on a case-by-case basis.
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Their suggestions include the following: • Identify the essential components of a global infectious disease surveillance system in order to prioritize funding. • Support operational research to evaluate and optimize informatic systems for processing epidemiological data, particularly when used in syndromic surveillance.
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• Reconsider the role of syndromic surveillance in disease control, given the lack of evidence for its effectiveness in early detection of biological attacks and its promise for tracking large-scale, natural disease outbreaks such as H5N1 avian influenza. Integration of Information Workshop participants also stressed the importance of integrating information on infectious diseases from diverse sources and methods to obtain a comprehensive view of disease risk and severity.
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• Support parallel efforts by OIE, NATO, USDA, and the European Union to develop global surveillance capacity for animal and plant diseases. From Alarm to Action In the spirit of beginning with the end in mind, workshop participants also considered the fate of information derived from infectious disease surveillance and detection systems.
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2004. Emerging infectious diseases: Review of state and federal disease surveillance efforts.
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2006. Animal disease surveillance.
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2004. Implementing syndromic surveillance: A practical guide informed by early experience.
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2003. Syndromic surveillance: The case for skillful investment.
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