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4 Achieving an Effective Zoonotic Disease Surveillance System
Pages 115-164

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From page 115...
... The goal of these interventions would be to control the size and geographic scope of the outbreak and to minimize morbidity, mortality, and economic losses in both human and animal populations. No matter how effective a surveillance and response system is, the increasing prevalence of drivers creates a situation where zoonotic disease pathogens will continue to emerge in human and animal populations, and thus it will be impossible to prevent all disease outbreaks and zoonotic diseases from occurring.
From page 116...
... Integrated emerging zoonotic disease surveillance system: A system that brings together and links data collection, collation, analysis, presentation/report ing, and dissemination components to provide linked human and animal clinical, epidemiological, laboratory, and risk behavior information on unusual occurrences of emerging zoonotic diseases in both human and animal populations. The infor mation brought to both human and animal health officials by human and animal health authorities would be used for early detection and timely response at local, provincial, national, regional, and international levels.
From page 117...
... . ELEMENTS OF AN EFFECTIVE ZOONOTIC DISEASE SURVEILLANCE SYSTEM An effective global, integrated zoonotic disease surveillance system requires effective surveillance at national, regional, and international levels, because information from outbreak investigations is used by human and animal health officials at all levels to implement response measures and to evaluate the effectiveness of those responses.
From page 118...
... . Figure 4-2 shows the further steps Agent, Host, A Reasonable Scenario Question ACTIONS Data Capture The Right Person, Data Operations Place, Research Time Tools Analy tic Epidemiological Methods Interpretation Skills Information Warning & Technologies Staf f & Response Infrastructure Training ENABLERS Roles, Structures, Laws, Policies, and Systems SOPs, C3I FIGURE 4-2 System requirements for comprehensive human and animal health surveillance.
From page 119...
... EXECUTING AN EFFECTIVE ZOONOTIC DISEASE SURVEILLANCE SYSTEM Identifying, Gathering, Analyzing, and Disseminating Information The earlier an emerging zoonotic disease can be detected, the timelier the response can be, thereby minimizing transmission and spread and ultimately reducing morbidity and mortality. Data sources need to correctly distinguish an abnormal disease pattern from a typical or expected one.
From page 120...
... , screening of humans and wild birds for ongoing global influenza
From page 121...
... Informal Data Sources and Use of Rumor-Based Disease Reporting With greater Internet access and use and 24/7 informal reporting networks, information on disease outbreak occurrences is increasingly being shared at the first indication of an event through unofficial channels. Real-time information about infectious disease outbreaks is increasingly found in web-based data streams, ranging from official human and animal health reporting to informal news coverage to individual accounts on chat rooms and blogs (Brownstein et al., 2008)
From page 122...
... . The Program for Monitoring Emerging Diseases (ProMED-mail)
From page 123...
... Laboratory Capability, Capacity, and Networks Specimen collection, analysis, and laboratory confirmation of the etiological cause of emerging zoonotic disease outbreaks are a vital part of any infectious disease surveillance system. Although rapid field tests are available for a select group of infectious agents (such as influenza A)
From page 124...
... Key points for several of these principles are expanded in Box 4-4. Human Capacity Requirements from Multiple Disciplines Executing, managing, and evaluating an effective global, integrated emerging zoonotic disease surveillance system will require human and BOX 4-4 Principles of Good Laboratory Practice and Network Operation Laboratory accreditation: For network laboratories, a quality assurance system will guide the application of good laboratory practice standards.
From page 125...
... . Clinical, Field, and Laboratory Competencies Clinical diagnostic expertise is essential for making a timely "field" diagnosis of an unexpected, emerging zoonotic disease that occurs in human and/or animal populations, whether it is in primary healthcare clinics or on farms.
From page 126...
... H5N1 in humans and poultry, and human monkeypox in the United States are all examples of events where diagnoses were missed early in the outbreaks. Over the years, astute physicians, nurses, veterinarians, animal technicians, and laboratory scientists have been instrumental in the early detection of emerging zoonotic diseases.
From page 127...
... Laboratory professionals, therefore, are important members of the team charged with planning, conducting, and monitoring infectious disease surveillance programs and responding to disease outbreaks. Given the importance of linking epidemiological data to laboratory specimens for proper interpretation of results, it is vital that epidemiologists and laboratory scientists work closely together during disease outbreak investigations, and laboratory confirmation, interpretation, and reporting.
From page 128...
... communication and cooperation. Necessity of Collaborations from Multiple Sectors Close partnership between public and private sectors and across human health, agriculture, and natural resources are required for effectively planning and executing a comprehensive, integrated zoonotic disease surveillance system.
From page 129...
... REVIEW OF EXISTING DISEASE SURVEILLANCE SYSTEMS FOR ZOONOTIC DISEASES The committee examined several infectious disease surveillance systems already in operation to identify some effective systems, uncover gaps in efforts, and examine important ways that existing systems could improve to achieve the desired global disease surveillance system. In place of an exhaustive review of all disease surveillance systems that have been developed for human infectious diseases by ministries of health, or those developed for animal diseases of importance by ministries of agriculture, a broad spectrum and mix of existing human and animal infectious disease surveillance systems were presented and discussed at a 2-day workshop, Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of zoonotic Origin: Workshop Summary (IOM and NRC, 2008)
From page 130...
... 0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES TABLE 4-1 Comparison of Disease Detection and Response Evaluation Standards for Human and Animal Health: International Health Regulations Versus Performance of Veterinary Services Tool Specification of Capacities Related to Disease WHO IHR, OIE PVS Tool, Detection and Response 2005 2008 Requirement for assessments of infrastructure, Yes, mandatory No, assessments are and support for early disease detection, disease within 2 years voluntary, no time surveillance, and response of the date of requirement entry into force (June 2007) Support by state party/country for assessments, Yes No, but best practice planning, and implementation processes made described in qualitative clear and provided ratings Definitions of disease representing an urgent Yes No, but reference to threat provided OIE Terrestrial Code provided for details Explicit criteria and qualitative levels of No Yes advancement described for assessing existing structures and resources to meet core capacity requirements Minimum requirements for disease detection Yes, as core No, but best practice and reporting articulated by level of the health capacities in described in qualitative system Annex 1 rating; reference to OIE Terrestrial Code provided for details Definition/specific listing of essential Yes, but No, reference to information to be provided in reporting is in general Terrestrial Code provided categories only provided for details Minimum requirements for response to Yes No, but general best emergent event, by level of the health system practice described provided in qualitative rating; reference to OIE Terrestrial Code provided for details Development of implementation plans based Yes, and Yes, but not required, on assessment required best practice described in qualitative rating Provides awareness and improves Yes Yes understanding of all sectors regarding fundamental components and critical competencies required to function efficiently Support by international agency for the Yes Yes conduct of assessments and development of implementation plans NOTES: IHR = International Health Regulations; OIE = World Organization for Animal Health; PVS = Performance of Veterinary Services; WHO = World Health Organization.
From page 131...
... At the International Level Infectious disease surveillance efforts in human populations have focused primarily on diseases such as HIV/AIDS, tuberculosis, malaria, cholera, vaccine preventable diseases, and those causing high morbidity and mortality. Several global disease surveillance systems and their networks have been instituted primarily for detecting either human outbreaks of emerging zoonotic diseases or animal outbreaks of animal diseases.
From page 132...
... Unfortunately, because disease surveillance efforts in livestock, poultry, and wildlife typically have been under-resourced even more than disease surveillance in human populations, it is frequently the detection of disease outbreaks in humans that have led to the detection of disease outbreaks in animal populations rather than the reverse. Integrating Disease Surveillance Efforts Across Human, Animal, and Environmental Health Sectors Surveillance Efforts in the United States CDC has made efforts to integrate its zoonotic disease surveillance efforts across human and animal health sectors in the United States.
From page 133...
... . This program is relevant to the current challenge because diarrhea-causing Salmonella serotypes are zoonotic in origin, and because the mission of this initiative is to "promote integrated, laboratory-based surveillance and foster intersectoral collaboration among human health, veterinary, and food-related disciplines through training courses and activities around the world." GLEWS WHO, FAO, and OIE have recently joined forces to integrate alert mechanisms for emerging zoonotic diseases in the Global Early Warning System (GLEWS)
From page 134...
... Much remains to be done to achieve a global, integrated zoonotic disease surveillance system with respect to clinical, epidemiological, laboratory, and risk behavior components. National and Global Surveillance Efforts of HPAI HN One of the best examples of strategic surveillance for influenza viruses in reservoir and other sentinel species is the U.S.
From page 135...
... . Although AFRO was successful in integrating disease surveillance efforts within the human health community, the IDSR is not connected or linked to surveillance for zoonotic diseases in animal populations.
From page 136...
... . In the animal health sector, FAO, OIE, and USDA -- with funding provided by the World Bank, USAID, and other donor agencies -- conduct some capacity-building efforts for disease surveillance and response in animal populations.
From page 137...
... Their program has addressed both communicable and noncommunicable diseases, as well as health system initiatives. To date, they are not yet oriented to integrated human and animal disease surveillance for zoonotic diseases.
From page 138...
... Through that comparison, the committee identified some gaps and challenges that need to be addressed, which are summarized in Table 4-2. Global Coverage of Emerging Zoonotic Disease Surveillance Systems Irrespective of resource availability, the committee was unable to identify a single example of a well-functioning, integrated zoonotic disease surveillance system across human and animal health sectors.
From page 139...
... They lack the fundamental resources to conduct zoonotic disease data collection, collation, analysis, interpretation, and dissemination, and to conduct outbreak investigations and implementation of disease prevention and control efforts that should follow. And whatever national or regional data on zoonotic diseases from human and animal health systems might be collected, they often are not accessible or networked for effective global disease surveillance and response.
From page 140...
... 0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES TABLE 4-2 Gaps and Challenges in Achieving an Effective, Global, Integrated Surveillance System for Emerging Zoonotic Diseases Essential Components of an Effective Zoonotic Disease Surveillance System Identified Gaps and Challenges Global coverage • Many countries do not have surveillance for zoonotic infectious diseases in human or animal populations • At the global level, collaboration among WHO, OIE, and FAO is nascent but improving Multisectoral collaboration for planning, • In most countries, there are nonexistent implementation, and evaluation or weak channels of communications, or platforms between sectors and multiple disciplines • There is a divide/gap in information sharing between the public and private sectors Information gathering, dissemination • Surveillance is nonexistent or severely • Disease surveillance in humans limited in human populations at greatest • Disease surveillance in livestock and risk of emerging threats, making early poultry detection nearly impossible • Disease surveillance in wildlife • Surveillance in livestock and poultry is • Disease surveillance in companion animals weak in developing countries; CAFOs may • Risk behavior surveillance surveil their stock assiduously, but relevant • Surveillance of risk communication, information is not shared with animal or messaging, public perceptions human health public-sector authorities • Disease surveillance in wildlife is nonexistent, inconsistent, or weak in all countries • Integrated disease surveillance in companion animals is mostly nonexistent in all countries • Surveillance of risk behaviors putting people at risk of exposure to zoonotic disease agents is mostly nonexistent • Surveillance of risk communication, messages, public perceptions of danger, threat, cause, and interventions is nonexistent or weak
From page 141...
...  EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM TABLE 4-2 Continued Essential Components of an Effective Zoonotic Disease Surveillance System Identified Gaps and Challenges Information Technology • An automated, real-time, and integrated • Field-based data collection technology process of data collection, analysis, and with emphasis on the availability of interpretation across the multiple sectors mobile phones concerned is absent • Open source, user friendly, bi-directional • Standard protocols are absent to information communication tools harmonize epidemiological and laboratory • Signal detection algorithms and software aspects of detection, confirmation, packages outbreak investigation, and design and • Improved web-based visualization of implementation of disease control efforts outbreaks and hotspots resulting from modeling efforts Laboratory Capacity • Human, domestic animal, and wildlife • Laboratory infrastructure with sector laboratories are currently not appropriate biocontainment in resource- integrated, or operating seamlessly constrained regions • Assessment of current global capabilities • Protocols and procedures for sample is inadequate and limits ability to develop collection and diagnosis an integrated laboratory network system • Adequately trained laboratorians and field nationally, regionally, or globally staff for sample acquisition in resource- • Resource constraints limit the ability to constrained areas further develop the network when plan is in place Response Capacity • Due to the committee's limited charge and major gaps and challenges in early detection, a full analysis of response was not addressed by this report. However, the lack of collaboration and communication across sectors was identified as a major gap in planning, implementing, and evaluating an effective response following detection of an emerging zoonotic disease Human Capacity • Limited numbers of field-oriented, multidisciplinary training programs and graduates • Expertise lacking in clinic-pathological diagnosis, field epidemiology, laboratory science, social science and communications • Leadership programs are essential but not widely available NOTES: CAFO = concentrated animal feeding operation; FAO = Food and Agriculture Organization of the United Nations; OIE = World Organization for Animal Health; WHO = World Health Organization.
From page 142...
... . Another major challenge to effective zoonotic disease surveillance in Africa is poor support given to human and animal health laboratories, which are inadequately staffed and often lack basic equipment and reagents.
From page 143...
... Even though SARS responded to simple containment strategies and even though human-tohuman transmission has not been detected since 2003, the SARS outbreak highlighted the need to first strengthen surveillance for emerging zoonotic infectious diseases in both human and animal populations, and then to integrate disease surveillance across these multiple sectors. Because Asia spreads across multiple WHO regions -- the Regional Office for Southeast Asia and the Regional Office for the Western Pacific -- communication across these regions has been a source of friction within the regional and international network, and has therefore made the sustained early detection of unusual events even more challenging.
From page 144...
... . However, with regard to surveillance for emerging zoonotic diseases in human populations, occupational surveillance is nonexistent or is sporadic and weak to detect new infections in people having greatest contact with animals.
From page 145...
... A few developed countries routinely conduct wildlife disease surveillance for certain zoonotic diseases, such as rabies in bats, foxes, and raccoons in the United States (Blanton et al., 2008)
From page 146...
... The remaining potential threats are handled through ad hoc research studies to detect and explore relationships among emerging zoonotic disease agents in wildlife, domesticated animals, and humans. SARS is a good example of such ad hoc efforts in wildlife: There has been significant research interest in the wildlife origins of SARS in China, yet to date there are no coordinated integrated disease surveillance programs for SARS or other pathogens in wildlife.
From page 147...
... Communicating and Collaborating Across Sectors, Professions, and Health Systems The negative impact of emerging zoonotic disease outbreaks these past few decades has brought increased attention to the need for disease surveillance that links and provides information across human and animal health sectors for early detection and response. Despite considerable understanding of the need for such an integrated approach, one of the biggest
From page 148...
... Examples include the failure of human health authorities in 1999 to follow up on a veterinary pathologist's alert that disease outbreaks in birds and humans could be related and caused by the same agent, WNV (GAO, 2001) ; the failure of the animal health sector to alert human health authorities of sick rodents imported from Africa and housed with prairie dogs, ultimately leading to a human outbreak of monkeypox (CDC, 2003b,c)
From page 149...
... Employing Strategic Approaches for Effective Surveillance and Response Emerging zoonotic diseases can emerge at any time in any part of the world, therefore it is difficult to predict which pathogens may emerge, which human and or animal populations it may impact, or how these pathogens may spread. From a growing number of experiences, the world has learned that it is critically important to detect and report emerging zoonotic disease outbreaks that occur in a single country or region.
From page 150...
... Thus validating the information quickly is essential to minimize false-positive alerts. Moreover, because regions with the least advanced communication infrastructure also tend to carry the greatest infectious disease burden and risk, system development would need to be aimed at closing the gaps in these critical areas.
From page 151...
... Emerging Infections Laboratory in Nairobi, the Uganda Virus Research Institute in Entebbe, the Dhaka-based International Center for Diarrheal Disease Research in Bangladesh) , it was beyond the committee's scope and task to thoroughly identify existing laboratory capacity and capability for zoonotic diseases on a global basis.
From page 152...
... Department of Defense reference laboratories and collaborating centers, many of which have a single disease or other focus mandate. Green dots are laboratories that have a broader function in zoonotic and emerging diseases.
From page 153...
... . The committee encourages similar efforts with animal health laboratories to build capacity for zoonotic diseases and additional investments in strengthening laboratory capacity.
From page 154...
... These are certainly positive developments that need to be fully supported. Laboratory networks in the African region that focus on animal diseases are in their infancy.
From page 155...
... FIGURE 4-4 Global World Health Organization Vaccine Preventable Disease Laboratory Network.
From page 156...
... Worse still, there is virtually no effort to integrate the human and animal laboratory disease surveillance systems for emerging zoonotic diseases. Laboratories need to work together as an effective network to cover testing of specimens from different species and for a broad spectrum of emerging zoonotic disease agents of high priority to human and animal populations.
From page 157...
... The few that are available are not adequately trained to recognize zoonotic diseases clinically, to conduct a quality outbreak investigation, to design and implement an effective zoonotic disease surveillance system (including risk factor and risk perception surveillance) , to provide timely and accurate laboratory confirmation of the etiologic agent causing the outbreak, or to work and communicate effectively as part of a multi-sectoral team.
From page 158...
... 2008. Surveillance sans fron tières: Internet-based emerging infectious disease intelligence and the HealthMap project.
From page 159...
... 2006. Purdue University-Banfield national companion animal surveillance program for emerging and zoonotic diseases.
From page 160...
... 2001. Hot spots in a wired world: WHO surveillance of emerging and re-emerging infectious diseases.
From page 161...
... 2005. Animal health at the crossroads: Preventing, detect ing, and diagnosing animal diseases.
From page 162...
... horses. APHIS, National Animal Health Monitoring System.
From page 163...
... 2009c. Integrated control of neglected zoonotic diseases in Africa.


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