Emerging Infections Microbial Threats to Health in the United States (1992) / Chapter Skim
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3 ADDRESSING THE THREATS
3 ADDRESSING THE THREATS
Pages 113-169
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From page 113... ...
The recommendations in this section, if implemented, would strengthen U.S. surveillance activities and encourage efforts to develop a global infectious disease surveillance network.
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Centers for Disease Control \ \` ~m ,: if: HUMAN 1 __ {3~ _ ~R~ : it: ~ l SPREAD OF INFECTION ~/1 1 . / ~ At: Antimicrobials for treatment Passive immunization Supportive care Antimicrobials for prophylaxis em__ Em RESPONSE ACTIVITIES FIGURE 3-1 Recognition of and interventions for emerging infectious diseases.
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From page 115... ...
Active monitoring of such factors as population growth and migration, vector abundance, development projects that disturb the environment, and natural environmental factors (especially temperature and precipitation) is an essential component of surveillance and can influence the spread of emerging infectious diseases and the effectiveness of efforts to control them.
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global smallpox eradication program got under way in 1967 (Henderson, 1976a,b)
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The fact that vaccination was the primary tool used to combat the disease also sets smallpox apart from most other situations in which surveillance plays a role. Nevertheless, the eradication campaign illustrated a number of important principles about surveillance that might be applied to other efforts to monitor and control the spread of infectious diseases.
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international surveillance activities at this time are fragmented and inadequate to detect emerging infectious disease threats on a timely basis. DOMESTIC EFFORTS Surveillance of infectious diseases in the United States is a passive process.
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As of June 1990, aggregate or case-specific data for a total of 49 infectious diseases were being reported to the CDC by all
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Emerging infectious diseases also are not usually detected and reported through established surveillance activities. Instead, private physicians who see small clusters of unusual cases may report them in the medical literature.
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. Approaches for consideration could include simplifying current reporting forms and procedures, establishing a telephone hotline by which physicians could report unusual syndromes, and using electronic patient data collected by insurance companies to assist in infectious disease surveillance.
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The requirement that NNISS member hospitals have at least 100 beds and the fact that a relatively small sample of hospitals is included in the system are potential sources of bias (Gaynes et al., 1991~. Even so, the NNISS is the only national database for nosocomial infections, and it is a critical element in the CDC's program to monitor disease incidence.
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There is currently no single database from which a physician, researcher, health care worker, public health official, or other interested party can obtain information on disease incidence, antibiotic drug resistance, drug and vaccine availability, or other topics that might be relevant to infectious disease surveillance, prevention, treatment, and control. The need for such a database is strong; given the current communications capabilities of personal computers and the relative ease with which information on a multitude of topics can be accessed, a database is not only technologically feasible but could be a valuable addition to U.S.
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The loss of these facilities has left a major gap in U.S. overseas infectious disease surveillance, research, and training capabilities.
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Public Health Service National Institute of Allergy and Infectious Diseases (NIAID) , National Institutes of Health International Centers for Tropical Disease Research International Collaboration in Infectious Diseases Research (ICIDR)
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Army physician and engineer credited with controlling malaria and yellow fever during construction of the Panama Canal, the facility initially concentrated its research efforts on malaria, leishmaniasis, and yellow fever. Later, in fruitful collaboration with the Middle America Research Unit, an NIH field station (see below)
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In most countries, these laboratories are now central national resources for disease surveillance and infectious disease research (R. Shope, Director, YARU, personal communication, 19921.
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efforts in international infectious disease surveillance, most of which is conducted through passive monitoring. · The NIAID's International Centers for Tropical Disease Research (ICTDR)
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universities is fostered, and collaborative activities aimed at infectious disease surveillance and response to emerging diseases are possible. (This program is discussed in greater detail in the research and training section later in this chapter.)
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Currently, there is little coordination among these agencies and organizations regarding infectious disease surveillance. The committee concludes that the effectiveness of their surveillance activities, particularly those pertaining to recognition of and response to emerging microbial threats, could be greatly improved by designating a central focus for such efforts.
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From page 132... ...
The WHO often is involved in early investigative efforts of newly emerging or reemerging infectious diseases, such as Ebola and Lassa fevers, yellow fever, and dengue fever. For example, when Ebola fever outbreaks occurred in Zaire and Sudan, the WHO provided rapid-response teams, composed of consultants from a number of countries, to help the governments of these nations determine the origin of the outbreaks and develop control strategies.
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As with the smallpox eradication effort nearly 20 years earlier, surveillance has played a critical role in the PAHO polio eradication strategy. From the outset of the PAHO effort in September 1985, surveillance was a major component of the program.
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To be effective, any global infectious disease surveillance network must be interactive and reciprocal. It is especially important that U.S.-funded laboratories engaged in infectious disease surveillance in foreign countries operate in partnership with host-country facilities.
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Eventually, additional satellites will be placed in orbit to augment the system and provide more opportunities for data transfer each day (Pool, 1991; Clements, 1992~. This technology may allow the earlier inclusion of many remote areas in a global infectious disease surveillance network.
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; · full clinical documentation of unsolved cases, with a system for archiving sera and pathological specimens; · a clinical arm for hospital-based surveillance and drug and vaccine trials; · a targeted disease approach with broad reporting criteria for maximum retrieval of data (e.g., "disease targeted: polio; reporting criterion: acute flaccid paralysis"~; · an effective specimen collection and transport system; and · an active system of data analysis and dissemination, with feedback to those providing data. The WHO's global influenza surveillance network and its collaborating centers for specific diseases, PAHO's polio eradication program, and previous efforts such as the WHO's smallpox eradication program and the Rockefeller Foundation's virus program, although all limited in scope, are nevertheless useful models to consider in the design of a global infectious disease surveillance system.
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The committee recommends that the United States take the lead in promoting the development and implementation of a comprehensive global infectious disease surveillance system. Such an effort could be undertaken through the U.S.
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health care system with its array of medical technologies is able to disarm almost any infectious disease. In the case of measles, successful vaccination programs had diminished disease incidence to such a degree that the public, health care professionals, and public health organizations reduced their levels of vigilance and effort.
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Efforts directed at the recognition of and responses to emerging public health problems, particularly emerging infectious diseases, would help to achieve this goal. The country's recent episodes of measles and TB resurgence should reinforce the importance of upgrading and maintaining the U.S.
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The nation's capacity for assessing microbial threats could be improved by strengthening the public health infrastructure to carry out assigned functions of disease assessment, policy development, and assurance of health with respect to microbial threats. Improving cooperation through the formation of consortia of schools of medicine, public health, and veterinary medicine, and departments of public health might also be an effective strategy, as would the availability of emergency funds to investigate, conduct research and surveillance on, and control major new or reemerging infectious diseases.
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From page 141... ...
Public Health Assessment strategy 1: Developing health information and health information systems that are useful to legislative and executive governmental bodies at the Federal, State, and local levels, and to other groups and organizations. · CDC: Establish 10 regional centers for prevention and control of nosocomial infection linking about a thousand hospitals in a national surveillance network.
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The United States could take a leading role, through the WHO, to develop a program of international infectious disease research
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The funding is multinational, the review steering committees are composed of scientists from many countries, and scientists from any United Nations member nation may compete for funding under either program. These efforts may be useful models for a global infectious disease research program.
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In these instances, the committee is concerned that support for training and careers for interested students is insufficient to ensure that future research programs in these disciplines will be adequately staffed. Recently, much infectious disease research has shifted toward an approach primarily based on molecular biology, a discipline that the committee believes is critical to the prevention and control of infectious diseases in general.
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· In 1978, the agency established the International Collaboration in Infectious Disease Research (ICIDR) program.
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program, initiated in 1980, encourages research in tropical infectious diseases. A wholly domestic program, the grants allow investigators to use state-of-the-art technology in the study of tropical infectious diseases including the six diseasesfilariasis, leishmaniasis, malaria, leprosy, schistosomiasis, and trypanosomiasis designated by the WHO as major health problems in tropical countries.
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. The CDC does not maintain formal overseas laboratories, but it does support a number of foreign field stations that carry out infectious disease research and training.
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Epidemic Intelligence Service program and continued support for CDC's role in the Field Epidemiology Training Program. DEPARTMENT OF DEFENSE The seven overseas medical research laboratories maintained by the DOD are the most broadly based international infectious disease research
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involvement in tropical infectious disease research is the USAID-supported International Center for Diarrheal Disease Research, Bangladesh (ICDDR,B) , earlier known as the Cholera Research Laboratory.
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Because more individuals with training in these disciplines are likely to be needed to fulfill the United States' commitments to the implementation of a global infectious disease surveillance network, the establishment of such a program, modeled after the NHSC, might help to attract individuals who otherwise would not consider public health careers. The committee recommends that Congress consider legislation to fund a program, modeled on the National Health Service Corps, for training in public health and related disciplines, such as epidemiology, infectious diseases, and medical entomology.
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From page 151... ...
In many countries, including the United States, the use of vaccines has reduced or eliminated death and illness from infectious diseases. There are now effective vaccines against a number of once common childhood illnesses, including diphtheria, pertussis, measles, mumps, rubella, and polio.
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. In most cases, public policy only indirectly influences the decision to pursue vaccine development and thus has little effect on the character of the vaccines that eventually enter the marketplace.
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Advances in immunology, molecular biology, biochemistry, and drug delivery systems have stimulated major new initiatives in vaccine development. The generation of vaccines that will come into use in the next decade is likely to be different from previous generations of vaccines.
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, attenuated vaccines, which mimic the wild-type virus's ability to produce protective immunity, have been quite effective. Vaccine development for other infectious diseases, particularly those caused by protozoans, helminths, and fungi, has proved to be quite difficult, often because the responsible pathogens are able to evade the body's normal immune defenses.
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Industry currently lacks economic incentives to stimulate efforts at preventing infectious diseases with vaccines for which there is little or no foreseeable market. Nor does the public health sector (with specific exceptions)
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The United States, with only five vaccine manufacturers, is in a precarious position should an infectious disease emergency occur. Although there are vaccine manufacturing facilities outside the United States, obtaining vaccines from these facilities in an emergency would be complicated and time-consuming.
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February 17 Virus forwarded to academic laboratory for genetic reassortment March 1 First reassortant strain sent to manufacturers April 30 Second reassortant strain sent to manufacturers April Human vaccine trials May-August Political problems with vaccine liability September 2 Vaccine released by the Food and Drug Administration October-December National Influenza Immunization Program 4-0 million of 115 million doses administered Total elapsed time: Approximately one year There is no infrastructure in place today that allows for anticipatory vaccine development in response to future pandemics. The current system barely suffices for vaccines that have a predictable, established demand.
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From page 158... ...
To bring a new vaccine rapidly from the research laboratory into general use a necessary criterion if one hopes to prevent or control an emerging infectious disease will require an integrated national process that · defines the need for a vaccine and its technical requirements; · defines the target populations and delivery systems; · ensures the purchase and use of the developed product, through purchase guarantees and targeted immunization programs; · relies as much as possible on the capability of private industry to manage the vaccine development process, through the use of contracted production if necessary; · utilizes the capacity of the NIAID to manage and support basic and applied research and to conduct clinical studies and field evaluations; · utilizes the capacity of the CDC and academia to conduct field evaluations and develop implementation programs; · is centrally coordinated to take maximal advantage of the capabilities of the public and private sectors and ensures the continued existence of a competitive, efficient, reliable vaccine manufacturing industry within the United States; and · is prepared for the possible rapid emergence of novel disease threats, such as occurred in the 1918-1919 influenza pandemic. The committee recommends that the United States develop a means for generating stockpiles of selected vaccines and a "surge" capacity for vaccine development and production that could be mobilized to respond quickly to future infectious disease emergencies.
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Should a global infectious disease surveillance system be put in place, such as the one suggested in this report, tracking antimicrobial resistance worldwide may be possible. The development of public/private sector alliances, along the lines of the National Cooperative Drug Development Groups at the NIH (similar to the vaccine groups discussed above)
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From page 160... ...
And even in Lyme disease, a vectorborne illness with a known vector the Ixodes tick- there is currently no agreement on intervention strategies. Vector control generally includes the use of one or more measures to reduce vector abundance, vector longevity, and human-vector contact.
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To be effective, a vaccine must have time often several weeks to elicit an immune response in recipients. Vector control may provide this opportunity (see Box 3-51.
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Thus, to be effective, vector control efforts must be launched shortly after the disease is first recognized or, ideally, before the disease is apparent. For most vector-borne infectious diseases, the onset of winter dampens transmission or can even eliminate the vector or infectious agent.
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PESTICIDES FOR VECTOR CONTROL A growing problem in controlling vector-borne diseases is the diminishing supply of effective pesticides. Federal and state regulations increasingly restrict the use and supply of such chemicals, largely as a result of concerns over human health or environmental safety.
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Eldridge, Director, Mosquito Research Program, Department of Entomology, University of California at Davis, personal communication, 1992~. The committee recommends that the Environmental Protection Agency develop and implement alternative, expedited procedures for the licensing of pesticides for use in vector-borne infectious disease emergencies.
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These compounds affect certain biological processes of insects, such as metamorphosis, that are not present in mammals and other vertebrates. Biological control agents (the use of one organism to control another)
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It was estimated that the SLE outbreak cost the community $796,500, of which almost $200,000 was spent on vector control (Schwab, 1968~. The economic and public health consequences would certainly have been greater had pesticides not been available.
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Public Education and Behavioral Change The areas of public education and behavioral change in relation to emerging infectious diseases currently show visible activity; the media, for example, have been presenting information to the public about the control of Lyme disease and HIV transmission. The committee was not constituted to address these two issues; however, because the topics represent potentially important aspects of emerging infectious disease prevention and control, it was considered appropriate to address them briefly here.
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Evidence for similar behavioral change among those using intravenous drugs or crack cocaine is less encouraging. Even when scientists and public health officials rely on education and encourage behavioral change to prevent or limit the spread of infectious disease, the public may not be convinced.
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From page 169... ...
Instead, this committee cautiously advocates increased funding and proposes some more effective ways for organizations both domestic and international, public and private- as well as individuals both health professionals and the lay public to work together and, in some cases, combine their resources. These efforts will help to ensure that we will be better prepared to respond to emerging infectious disease threats of the future.
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