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Final Plenary Session: Future Steps and Opportunities Glenn Schweitzer National Research Council Dr. Keene summarized the view of the American participants on how a foodborne disease surveillance system can be operationalized in a country. To begin, the purpose of a surveillance system should be clear. The sources of information must be identified, as this information can come from a number of sources, such as laboratories, physicians, hospitals and clinics, infection con- trol staffs, public reports, media reports, inspectors, and pharmaceutical distribu- tion data. There are a variety of legal considerations that should be addressed at the very outset of administering a surveillance system. Adequate legal authority to collect surveillance information and to investigate outbreaks is necessary. If such authority is not in place, new legislation may be required. The systemâs design needs to address the question of who would have access to confidential medical records and to determine whether disease reporting will be compulsory and if so, by whom and to whom. Another consideration is whether diagnostic laboratories should be required to provide isolates to reference laboratories. Attached to the legal issues of surveillance are the implications of using surveillance data. It must be clear how the data will be disseminated and to whom. At the outset there must be a determination of whether specialists have the legal authority and the motivation to take action that may hurt business interests. Similarly, will the specialists have the necessary credibility with the public and the medical com- munity? The sources of financial support should be clearly determined, and need to be stable, given the infrastructure and personnel required for a surveillance system to function. Turning to laboratory considerations, the system will require access to spec- imens for analyses. The system must be capable of confirming diagnoses and 107
108 FOOD SAFETY AND FOODBORNE DISEASE SURVEILLANCE SYSTEMS subtyping isolates to identify possible linkages. The laboratories will need to respond to requests for their services in a timely manner. In conclusion, not all diseases are well suited to comprehensive reporting. In the United States the legal framework for enteric disease surveillance is integrat- ed with other diseases, but other countries may need to find the approach that will work best in that country, keeping in mind that outbreak investigation is a developing skill. Dr. Massoumi-Asl presented Iranian views on future steps toward a food- borne disease surveillance system in Iran. The disease control system of the Iranian Center for Disease Control is a well-organized, countrywide health net- work that includes 15,000 health houses and 500 health centers. The system incorporates health specialists of 40 medical universities who monitor communi- cable and noncommunicable diseases in their districts, and the district activities are supervised by provincial and national experts. The district health centers with health laboratories are controlled by provincial health laboratories. There is a reference laboratory in Tehran for each disease control program. The foodborne disease surveillance program is a recent addition to Iranâs disease control center. It is located within the Foodborne and Waterborne Dis- ease Department. The centerâs activities since its inception include two case- control studies, as well as the investigation of nine disease outbreaks occurring between April and September 2004. Of these outbreaks 40 percent were food- borne and 60 percent waterborne. Over 1600 people were affected, with three fatalities reported. While the program is in its nascence, many important facili- ties and infrastructure already exist; however these need better linkages and coordination. Iranian specialists believe that a national commitment to link the facilities is essential. The objective of the foodborne disease surveillance program in Iran is to reduce mortality and morbidity. To this end it is necessary to establish a labora- tory-based, integrated surveillance system. Intersectoral coordination between disease control components involved in food safety and surveillance is as impor- tant as linking the local facilities. It would be possible to create local and provin- cial laboratory centers that operate under the supervision of the Research Center for Gastroenterology and Liver Disease, which would then provide a reference laboratory. The centers would provide health education for all target groups and carry out basic, clinical, and field research. Monitoring and evaluation would be important to ensure the quality of services. Dr. Jamdar and Dr. Yoe then spoke about future steps that could be taken by both Iran and the United States in the process of analyzing risks to food safety and foodborne disease surveillance. They stressed that international cooperation, and in particular regional cooperation, is important in identifying common inter- ests and in sharing resources. Iran and the United States have a number of oppor- tunities for cooperation, including data sharing by clearinghouses, jointly spon- soring professional development, exchanging personnel, and participating in a
FINAL PLENARY SESSION 109 risk assessors network. In Iran the development of risk analysis capacity is par- ticularly important. The needs of various ministries should be clarified and the relevant paradigms addressed. Risk assessment is an area that could be particu- larly fruitful for cooperation. Dr. Jackson and Dr. Djazayeri each presented their teamâs perspective on areas of common interest to both Iran and the United States in the areas of food safety and foodborne disease surveillance. Dr. Jackson stressed a common inter- est in methodology, including reporting systems, investigation tools, the latest and best laboratory tests and methods, and the comparability of standard mea- surements. Examination of established and emerging food pathogens, including those developing antibiotic resistance, is also an area of common interest. Dr. Djazayeri spoke about the possibility of establishing a food safety collaboration center, which would allow for an exchange of expertise and information. It could also hold long-term training courses and workshops on such topics as food safety and quality, help in the establishment of pilot projects, and work on technology transfer and capacity building. Dr. Matthews and Dr. Poorshafi presented a short review of the highlights of the meeting. Of the points covered in the workshop, they stressed the following topics as some of the most significant. Foodborne diseases are a significant human health issue for Iran and the United States. Many government agencies of both countries are concerned about the potential threat to public health, and many of the issues faced by agencies are common in the two countries. Among the issues of common concern are the following: poultry processing, food sold by street vendors, imported foods, mycotoxins, and bacteria. The presenters stressed the immature state of Iranian foodborne surveillance and the need for a functioning surveillance system. In the final section of the closing session the participants considered the reports of three working groups on food safety, foodborne disease surveillance, and risk assessment. All groups agreed that further exchanges of ideas were necessary. Some of the observations and suggestions for future cooperation are as follows. There is a need to identify important websites that address methodological questions in food safety. Developing consumer groups that can defend food safety principles is an important aspect of food safety in both countries. To offer specific recommendations on food surveillance in Iran, the American team would need a better understanding of the Iranian health care system. Pilot projects could probably be useful in developing an expanded surveillance program in Iran. Risk analysis is necessary for priority setting, and each relevant organiza- tion should define the specific tasks for its risk assessors. International collabo- ration in risk assessment is highly desirable. In particular, further measures are needed to stop international trade in unsafe food, which poses many risks.
