Achieving Sustainable Global Capacity for Surveillance and Response to Emerging Diseases of Zoonotic Origin: Workshop Summary (2008)

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6 Concluding Participant Discussions on Facilitating Communication and Developing a Globally Sustainable Surveillance System T he committee used the closing discussion session to pull together the most important themes that emerged from the presentations and dis- cussions. The conversation covered a range of issues and is organized in this chapter with a focus on some primary observations. The goal of improving communication and information exchange is widely shared, and significant progress has been made. A number of systems and mechanisms for detection and reporting are in place, and in general, working well. As previously suggested, there is overlap, and sometimes the missions of the entities involved are in conflict, or at least not well synchronized. Nevertheless, “there [is] an ever-­increasing amount and varying levels of quality of data coming in.” Networks have been established that facilitate communication on the local level and build the trust necessary to facilitate data sharing and reporting, and the number of these networks are increasing. One suggestion was that the human health community is “much better prepared to deal with risk communication—preparing the right message with the right language for the right audiences” than the veterinary com- munity has been, but that the veterinary community is catching up. Partici- pants remarked that one lesson from the H5N1 avian influenza crisis was the value of making sure that “when WHO speaks, when OIE speaks, when FAO speaks, the message is the same,” referring to the World Health Orga- nization (WHO), the World Organization for Animal Health (OIE), and the Food and Agriculture Organization of the United Nations (FAO). The crisis 81 

82 GLOBAL SURVEILLANCE OF ZOONOTIC DISEASES was an opportunity for the human and animal-concerned communities to work together and to better integrate the challenge of communicating with governments and the public while they responded to a crisis. At the same time, however, another participant noted, “We have told the world a pandemic is coming, a pandemic is coming, and it hasn’t happened.” Public attention has waned, and this illustrates the importance of “thinking carefully about addressing people’s concerns, especially non­scientific con- cerns.” Public and political attention generally flows to a crisis. The challenge of communication is not simply a matter of public relations, as several participants noted. It is the primary tool for tackling major objectives, such as changing behaviors to reduce public health risks. Understanding the needs and characteristics of a community can be critical to communicating effectively about human and animal health risks, and progress is being made in this area. A participant cited the example of WHO, which uses expertise from anthropology and risk communications to go into the field and explain the measures that need to be taken. A variety of factors complicate the pursuit of the goal of improved com- munication and information exchange. Many disease surveillance and reporting systems are in place, but the sheer volume of effort required to keep up with the flow of information can sometimes be dauting. As one participant observed, “Sometimes when you are in the field you just want to work, and you don’t want to send a report every night, and you don’t want to have 20 calls or e-mails coming in on your phone. This is something that we have to manage.” Intellectual property issues are another significant challenge to improved information sharing. Competition among disciplinary fields, as well as the pressure individual researchers and research teams may feel to publish their own results, are counter-pressures to the benefits of sharing samples and data that others could use. With regard to reporting and sharing informa- tion, however, one participant suggested that there are really two separate questions. The first is whether epidemiological information that is collected should be submitted to a national or an international entity. The second is whether the data that are collected in the course of an outbreak will be shared with other researchers or organizations. The sharing of agents, resources, and data is another gap related to the “upstream research agenda” and can be important not just for responding to an immediate crisis, but also for ensuring that longer term research chal- lenges are met. An example from activities of the World Bank illustrates this challenge. The Bank’s program for making “advance market commit- ments” involved the private sector to make sure that a necessary drug or diagnostic test can be developed without undue risk to the drug companies. 

CONCLUDING PARTICIPANT DISCUSSIONS 83 This approach also helped to avoid complications related to competition for information and data. But the issues around intellectual property are of particular importance when countries, for example, provide viral strains that are used to manufacture globally used vaccines. WHO has convened an interdisciplinary working group to address the issue of sharing influenza virus and sequencing data that would be based on mutual trust and trans- parency, but they have not yet achieved an agreement. “The issue is still the benefits. What benefits will be attached to this commitment of sharing the viruses?” The presentations demonstrate the large number of research communi- ties that have an interest in some aspect of zoonotic disease in humans and have insights to offer, which further complicates integration and communi- cation. The wildlife biology community, for example, is rarely represented in public health discussions, and “a lot of wildlife biologists don’t think disease is an issue in wildlife population ecology.” Yet ecology—the way organisms interact with each other in a changing environment—is “an orga- nizing principle” for understanding both epizootic and zoonotic diseases, and this integration is very important. Another participant described the potential contributions that could come from building on the Smithsonian Institution’s Global Earth Observatories—a network of 29 existing and 2 planned global long-term ecological monitoring sites that have been mon- itored for up to 25 years—to contribute to the development of a systematic, long-term global emerging disease wildlife surveillance research program. The benefit of this public–private partnership could offer an unprecedented opportunity to look at disease in wildlife populations and the impact of human disturbance and climate change on disease dynamics. Questions were raised about the incentives for sharing information and the potential benefits and risks of sharing. Governments or ministers with responsibility for public health may take into account the risk of severe economic disruption, unrest, or other consequences when an animal or human disease outbreak is announced. One participant offered the example of West Nile virus reporting in the United States to illustrate the power of incentives. For a time, any U.S. county that submitted a positive report of West Nile would receive federal funds to cover half of their cost of control measures. This created a competitive race to identify West Nile early in the season to secure the funds early. Indeed, the program was so successful it became too expensive and had to be discontinued for lack of funding. The value of an integrated, sustainable global disease surveillance system needs to be made clear to human and animal health communities. The issue of making the benefits clear goes beyond the challenges of sharing information among scientists and public health agencies. The ques- 

84 GLOBAL SURVEILLANCE OF ZOONOTIC DISEASES tion is, “If the main benefit is at the global level, why are we asking each country to invest in surveillance—what is the benefit for them?” In many cases, the short-term risks of identifying and reporting disease outbreaks may seem to outweigh any long-term benefits. Trade may be significantly disrupted even by the rumor of some disease, such as foot-and-mouth dis- ease (FMD). “This means that there are punitive sanctions for reporting, rather than punitive sanctions for not reporting,” one participant noted. Moreover, many countries believe they may have the internal capacity to control an outbreak within their borders. Even if they do, this sets the precedent for other countries not to report an outbreak. One proposal is to make the incentives clearer and more specific. As one participant explained, “We need to further define this ‘global public good,’ because whatever mechanisms are agreed on have high transaction costs.” For example, if the international surveillance system were suf- ficiently recognized and trusted, a country could earn an official seal of approval for its internal surveillance system and standards that would be a trusted badge of good practice and safety. That benefit, in turn, could serve as an incentive for further cooperation. For example, a country could build confidence among trading partners that it can adequately detect and control animal disease, which may lead to its ability to geographically limit trade restrictions where regulatory frameworks permit. Another proposed strategy is to better link sustainable disease sur- veillance to the broader notion of the environmental commons, which is gaining traction in the world of international finance, aid, and trade. The discussion of the interacting factors that contribute to the development of zoonotic diseases in humans demonstrated that emerging infectious diseases are an integral aspect of larger environmental concerns such as global climate. Yet, there has not been complete buy-in from the interna- tional community, and disease surveillance is too easily viewed as a kind of “old-fashioned,” smaller scale activity by governments and other potential funders of surveillance efforts. One risk of this semi-marginal status is that funding and attention come in the midst of a crisis, not in time for adequate planning and preparation. As one workshop participant observed, “When you see people dying, you are already very late in the epidemic.” A participant also questioned whether we are “missing the ball” on biosecurity because “[disease] surveillance is a critical biosecurity tool.”   false FMD rumor from a Kansas sale yard ran rapid through the market place in 2001, A causing the cattle futures to drop dramatically and major companies relying on beef to lose valuable shareholder equity. The next-day market indicators of several major companies impacted by the false scare: Tyson Foods, Inc., down 2.6%; Smithfield Foods down $0.26; ConAgra shares down 1%; Outback Steakhouse, Inc. down 3.1%; Wendy’s International down $0.07 (see http://www.newsratings.com/analyst_news/article_463143.html, “Meat Stocks Tumble,” Wachovia Securities, 2004). 

CONCLUDING PARTICIPANT DISCUSSIONS 85 He cited the example of FMD to explain his point. The disease became a problem in the United Kingdom and in neighboring countries because of the lack of early detection and a delayed governmental response (NRC, 2005). As a lesson learned, strict international standards regarding the trade of animals and animal products are now in place and many countries that have invested considerable resources to eradicating the disease are now disease-free. The participant further observed “Those countries need to sustain their surveillance efforts or they will surely be re-infected.” The countries that have already tackled their problems effectively are investing in “an insurance policy,” stated participants, by helping countries that still have the disease work on monitoring and eradication. The compelling message is that sustained global disease surveillance is a basic public health necessity because ongoing interactions among humans, animals, and the environment will inevitably lead to disease emergence or re-emergence and the impact of disease reverberates throughout national and global social, economic, and trade systems. One participant suggested canine-rabies as an example that well illus- trates the case that needs to be made. Canine-rabies is a fatal disease that is a significant problem in many parts of the world, and is both underre- ported and underestimated in terms of the harm it causes. Canine-rabies regularly travels from wildlife to domestic animals and humans, and thus is a good example of the interactions under discussion. More important, perhaps, is that when canine-rabies emerges it is an indicator that some- thing has changed in a particular area—human or animal behaviors have changed in a way that allows the disease to take hold. It could never be truly eradicated, but it is relatively easy to control with vaccines and other measures. The resource challenge cannot be ignored. Canine-rabies is just one of many diseases that could be controlled, but is not controlled in many regions because resources are inadequate. All of the goals or ideas mentioned throughout the workshop are not without cost. Most of the presenters alluded to the challenges of sustaining fund- ing for worthwhile programs and many highlighted problems in extremely poor parts of the world. These countries may lack vehicles, adequate roads, equipment, laboratory capability, and adequately trained personnel. The conditions of buildings and the varying academic rigor of medical and veterinary schools in many developing countries were cited as a significant obstacle. Others pointed out that “sustainability is not just training people once—it is a long-term investment in keeping people updated,” providing 

86 GLOBAL SURVEILLANCE OF ZOONOTIC DISEASES them with opportunities to learn and work with each other, with career development opportunities, and so much more. However, several participants commented that the human and animal health communities have not done a good job at demonstrating the return on investments for disease surveillance. It was noted that “Eventually the resource people are going to say, ‘What am I going to get out of this and what is at risk if I don’t do this?’” Demonstrating or documenting the benefits is complex and therefore is a challenge because the benefits are so complex. However, both the human and animal health communities need to make the case that the benefits of sustainable disease surveillance do not rest just in “a dollar return on investment, but in social, economic, and political stability.” Participants suggested that the justifications for fund- ing must be framed carefully: “Say you had prevented SARS, how would you prove it? Even if you made a good case, somebody else would say you didn’t, that it would never have taken off and it was all a false alarm.” Other discussants agreed, noting that if the case for disease surveillance efforts were made on the basis of a single pathogen, for example, “You are in for a line item removal when [the disease] doesn’t happen.” The stronger argument is that an investment has made the country better prepared for a range of ongoing, unpredictable risks. Gerald Keusch, one of the workshop convening co-chairs, closed the meeting with a few final observations: • Setting priorities for the expenditure of effort and resources is very important, but very difficult to do. In the case of HIV, for example, “the investments at the beginning were not consistent with the threat it actually became, but we weren’t smart enough to know when to push.” • “Gaming the system is a fact of life” when it comes to scrambling for resources, “but is it the best or only way to proceed?” • “With the exception of short-term threats from specific pathogens that are emerging, we have yet to figure out how to make a case for ongoing [disease] surveillance.” On behalf of the committee, Keusch ended the meeting by thanking the workshop presenters and participants, noting that a wide range of pertinent and interesting information had been shared with the committee and guests to address this challenging human and animal health issue.