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4
Achieving an Effective Zoonotic
Disease Surveillance System
“Surveillance for emerging diseases contributes to global security. If basic
surveillance and laboratory capacities are compromised, will health au-
thorities catch the next SARS [severe acute respiratory syndrome], or spot
the emergence of a pandemic virus in time to warn the world and mitigate
the damage?”
—Dr. Margaret Chan
Director-General of the World Health Organization
Address at the rd Forum on Global Issues
(March , 00)
Given recent experiences of rapidly spreading global outbreaks across
borders and continents, an effective emerging zoonotic disease surveillance
system will need to be global in scope and effort. A global, integrated
zoonotic disease surveillance system needs to detect disease emergence in
human or animal populations anywhere in the world at the earliest time
possible. Early detection is essential to trigger a timely disease outbreak
investigation. Multidisciplinary teams of professionals that have relevant
expertise and field experience would identify populations at risk and causes
and risk factors for infection, and then rapidly and widely disseminate this
information so that immediate and longer-term disease prevention and
control interventions can be implemented. 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 dis-
eases from occurring. However, a global zoonotic disease surveillance system
provides great benefits by conveying critical data to inform evidence-based
responses, therefore minimizing the opportunity for zoonotic disease emer-
gence, transmission, and spread in both human and animal populations.
This chapter first defines disease surveillance, discusses elements of an
effective zoonotic disease surveillance system, and describes how such a
system would need to be executed. It then presents an overview of existing
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
emerging zoonotic disease surveillance systems and capacity-building pro-
grams for creating the needed workforce. From this overview, the chapter
identifies important existing gaps and challenges in the current state of
global surveillance.
DEFINING DISEASE SURVEILLANCE
The principal purpose of disease surveillance is to “keep one’s finger
on the pulse of disease in a population.” Successful disease surveillance
detects increases in disease occurrence over expected levels early so that
effective and timely disease control interventions can be introduced and
appropriately targeted to reduce morbidity, mortality, and economic loss.
Though several definitions of disease surveillance have been used by human
and animal health agencies and experts (Thacker and Berkelman, 1988;
Teutsch and Churchill, 2000; IOM, 2007; WHO, 2007a; OIE, 2008a), the
committee chose to adopt more appropriately integrated definitions for this
report (see Box 4-1).
Disease surveillance strategies were developed to address different sur-
BOX 4-1
Definitions of Surveillance
Zoonotic disease surveillance: The ongoing systematic and timely collection,
analysis, interpretation, and dissemination of information about the occurrence,
distribution, and determinants of diseases transmitted between humans and ani-
mals. Zoonotic disease surveillance reaches its full potential when it is used to
plan, implement, and evaluate responses to reduce infectious disease morbidity
and mortality in human and animal populations through a functionally integrated
human and animal health system.
Surveillance system: The total system of surveillance comprising the compo-
nents of collection and reporting of disease outcome data from populations at risk,
confirmation of the etiological agent by laboratory scientists, and mechanisms and
pathways of data analysis, interpretation, reporting feedback, and communication
of information to those who will use the data at local, provincial, national, regional,
or international levels for response.
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.
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
veillance goals and objectives, diverse ways information would be used,
and varying human and financial resources available to support and oper-
ate the system. These disease surveillance strategies and systems employ
different methods to collect information, and they include active, passive,
sentinel, syndromic, risk-based, informal, and rumor-based disease surveil-
lance (Teutsch and Churchill, 2000).
ELEMENTS OF AN EFFECTIVE ZOONOTIC
DISEASE SURVEILLANCE SYSTEM
An effective global, integrated zoonotic disease surveillance system re-
quires 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. A surveillance system is com-
prised of cyclical elements that provide critical pieces of information, as seen
in Figure 4-1. For disease surveillance to be comprehensive, surveillance will
need to be planned and conducted across human and animal populations
Systematic monitoring of
disease occurrence,* person,**
place, and time
Implement
The Cycle of Detection of
intervention;
unusual
Surveillance
Evaluate
occurrence
effectiveness
Outbreak investigation and
intensive follow-up; Identify risk
factors and targeted points for
intervention through research
FIGURE 4-1 The cycle of elements comprising an effective infectious disease sur-
veillance system.
NOTES: *disease by clinical signs or detection and confirmation of pathogen or an-
tibody by laboratory diagnoses; **attributes of person would include demographic
Figure 4-1.eps
variables and risky behaviors.
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
(i.e., domesticated livestock, poultry, and companion animals, and aquatic
and terrestrial wildlife), and information transfer will need to be facilitated
between the human, animal, and environmental health sectors.
Disease Surveillance System Framework and Components
Designing a disease surveillance system requires decisions on various
elements. These include (1) identifying clear objectives; (2) agreeing on a
well-defined disease surveillance case definition based on the person (or in
the case of animal populations, based on the animal, herd, or flock), place,
and time, that can include suspect or probable cases based on clinical and/
or epidemiological data, as well as laboratory-confirmed cases; (3) clarify-
ing what information is needed to achieve the objective, and the frequency
with which the information is needed; (4) determining the type of dis-
ease surveillance system (i.e., active, passive, sentinel, syndromic, etc.); (5)
identifying the sources of data and information (clinical, epidemiological,
laboratory, and social and anthropological data); (6) determining methods
and channels of information dissemination and alerting; and (7) designat-
ing clear roles and responsibilities of those who use the information for
action (Teutsch and Churchill, 2000). 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.
Figure 4-2.eps
NOTES: SOPs = standard operating procedures, C3I = communications, command,
control, and intelligence.
SOURCE: IOM (2007).
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
required to design a comprehensive disease surveillance system for human
and animal health.
A goal of disease surveillance is to be useful at all levels of the human
and animal health systems. In order for the disease surveillance system to
be useful, information needs to flow back and forth easily among inter-
national, national, and local levels; be timely in detection and laboratory
confirmation; include risk factors as a component; and be specific and
reliably detect and report disease. Furthermore, the surveillance system
will need to be robust under adverse conditions; ensure that information
on individual patients and food-animal production owners or industries is
secure and remains confidential; be flexible to use innovative information
technology for data collection, collation, analysis, presentation, and dis-
semination; and be compatible for data to be electronically collected and
stored across systems.
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 ul-
timately reducing morbidity and mortality. Data sources need to correctly
distinguish an abnormal disease pattern from a typical or expected one.
As data are collected, they need to be transmitted for analysis, and such
analyses need to be presented in user-friendly, easy-to-understand formats
so that decisionmakers can properly interpret and use the information
(Mandl et al., 2004a,b). Given the technology available today, these ele-
ments are certainly possible to achieve, yet the current system falls short
from the target.
Sources of Data
Multiple sources of data from traditional and nontraditional sources
have potential use in an integrated disease surveillance system (see Box 4-2).
Data can be collected in several ways: by interviewing patients, animal
owners, community members, or healthcare providers; administering a
questionnaire by mail or phone; searching electronic disease records of
established surveillance systems; or searching records from human and
animal diagnostic laboratories. Biological samples are collected on site, then
safely transported to a laboratory performing requisite tests for laboratory
confirmation. Some national monitoring and disease surveillance programs
use mail and interview questionnaires as well as a collection of biological
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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
BOX 4-2
Summary of Data Types and Sources for Human
and Animal Health Disease Events
Human Health: Human Health:
Traditional Sources Nontraditional Sources
Emergency department chief complaints Digital detection systems
Hospital/clinic medical records Short Message Service technology
Text-based notes Syndromic surveillance data
Diagnostic laboratory data Records on pharmaceutical purchases
Radiological reports Patient self-reports
Physician reports Absenteeism data
Emergency Medical Services activity Telephone survey results
WHO reports
Animal Health
Diagnostic laboratory data
Farm worker observations
Hospital/clinic medical records
Reportable diseases
Abattoir monitoring programs
Active surveillance programs
Companion animal owner reports
Electronic record systems
Syndromic surveillance
samples for laboratory testing (Traub-Dargatz et al., 2000; USDA, 2000;
Wagner et al., 2001).
Screening medical and laboratory records (paper files or electronic
databases) for specific entries, or biological sample banks for specific patho-
gens or lesions, could be part of the active data collection and monitor-
ing system for a disease surveillance system. Pathogen phenotypes and
genotypes are routinely submitted to global databanks where they are
readily accessible for comparison among laboratories examining outbreak
samples. The use of such reference databanks facilitates the rapid identi-
fication of unsuspected linked outbreaks even if widely spread by global
trade. These types of data retrieval methods are routinely performed in
many developed countries, such as for testing suspect cases for rabies,
bovine spongiform encephalopathy (BSE) screening of fallen livestock and
emergency-slaughtered cattle in Europe (Doherr et al., 1999; Doherr and
Audigé, 2001) and of “downer cows” in the United States (USDA-APHIS,
2009a), screening of humans and wild birds for ongoing global influenza
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
viruses funded by the U.S. Agency for International Development (USAID),
and the genotypic comparison of food and waterborne bacterial isolates by
the U.S. Centers for Disease Control and Prevention’s (CDC’s) PulseNet
(Swaminathan et al., 2001).
Role of Information Technology (IT) in Data Collection and Analysis
Evolving IT has led to a number of breakthroughs and new ways to
collect and transmit epidemiological, clinical, demographical, and other
information in the field. Examples of new technologies include the use of
handheld computers, cell phones, remote sensing, and Internet searches
(Beck et al., 2000; Lobitz et al., 2000; Google.org, 2008). These technolo-
gies are being used to collect and transmit information from even the most
remote and resource-challenged countries. Other breakthroughs in IT in-
clude data management and decision software and systems, which facilitate
the timely analysis, presentation, interpretation, and use of information by
decisionmakers.
The increasingly electronic information stream in human healthcare
has permitted the emergence of semi- and fully-automated surveillance
systems for symptoms and for other indicators (such as healthcare or drug
utilization), which are commonly lumped under “syndromic surveillance”
(International Society for Disease Surveillance, 2009). With comparable
political will and investments, electronic systems in animal production
and conservation could be developed for several purposes including early
detection of wildlife die-offs; unexpected culling of livestock or poultry;
aberrations in veterinary drug purchases; electronic tracking of bar codes
along trade pathways; and electronic trace-back and trace-forwarding of
animal products.
Informal Data Sources and Use of Rumor-Based Disease Reporting
With greater Internet access and use and 24/7 informal reporting net-
works, information on disease outbreak occurrences is increasingly be-
ing 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). Systems that use unstructured
informal electronic information have been credited with reducing time to
outbreak recognition, preventing governments from suppressing outbreak
information, and facilitating the ability of the World Health Organization
(WHO) and others to respond to outbreaks and emerging diseases (Madoff
and Woodall, 2005). In fact, WHO’s Global Outbreak Alert and Response
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
Network (GOARN) relies on web-based data for daily disease surveillance
activities (Grein et al., 2000; Heymann and Rodier, 2001). Of major sig-
nificance, the revised International Health Regulations 2005 (IHR 2005)
authorize WHO to act on informal information to issue recommendations
to prevent the spread of diseases (see Chapter 7 on Governance) (Wilson et
al., 2008). The Program for Monitoring Emerging Diseases (ProMED-mail)
and the Global Public Health Intelligence Network (GPHIN) are two early
prototypes of such systems (see Box 4-3).
BOX 4-3
Prototypes of Web-Based Data Sources for
Surveillance: ProMED-mail and GPHIN
Founded in 1994 by the Infectious Disease Society of America, the Program
for Monitoring Emerging Diseases (ProMED-mail) pioneered the use of the In-
ternet for the detection of outbreaks by e-mailing and posting reports, including
many gleaned from its readers, with commentary from a staff of expert modera-
tors. ProMED-mail is now one of the largest publicly available emerging disease
and outbreak reporting systems, with more than 45,000 subscribers in over 165
countries. An evaluation of the extent to which ProMED-mail reports lead to timely
confirmation and human and animal disease prevention and control efforts, nation-
ally or internationally, is currently underway in collaboration with the HealthMap
system.
In collaboration with the World Health Organization (WHO), the Public Health
Agency of Canada created the Global Public Health Intelligence Network (GPHIN)
in 1997. GPHIN’s software application retrieves articles from news feed aggre-
gators based on established search queries in 15-minute intervals on a 24/7
basis to provide an early warning of the possibility of a public health emergency.
Although automation is a key component, GPHIN also employs trained analysts
who provide essential linguistic, interpretive, and analytical expertise. The data are
disseminated to various public health agencies, including WHO, that can perform
the necessary public health vetting of the informal report. An early achievement of
its potential came in December 1998 when GPHIN was the first to provide prelimi-
nary information to the public health community about a new strain of influenza in
northern China. During the 2003 severe acute respiratory syndrome outbreak, the
GPHIN prototype served as an early-warning system by detecting and informing
the appropriate authorities (e.g., WHO and the Public Health Agency of Canada)
of an unusual respiratory illness outbreak occurring in Guangdong Province,
China as early as November 2002. Comprehensive global access to GPHIN is
not available because there is a fee required to join GPHIN. This precludes many
resource-challenged countries from participating, including many in areas at
higher risk of an emerging zoonotic disease occurrence.
SOURCES: Madoff (2004); PHAC (2004); Madoff and Woodall (2005); Cowen et al. (2006);
Zeldenrust et al. (2008).
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
A number of online disease surveillance systems are now delivering real-
time intelligence on emerging infectious diseases to diverse audiences on
user-friendly, open-access websites, similar to ProMED-mail and GPHIN.
One of these is HealthMap, a freely accessible, automated real-time system
that monitors, organizes, integrates, filters, visualizes, and disseminates
online information about emerging diseases (Freifeld et al., 2008). The site
pulls data from more than 20,000 sources every hour, many of which come
from news aggregators. Similarly, recent efforts using data from Google
(Ginsberg et al., 2009) and Yahoo (Polgreen et al., 2008) have shown that
search query data can be harnessed as a form of crowd-sourcing where pat-
terns of specific searches mimic and may even predict disease outbreaks.
Statistical Analysis and Disease Modeling
An infectious disease surveillance system needs to have the capacity to
detect disease trends and predict outbreaks, allowing human and animal
health authorities to respond in a timely and appropriate manner (USAID,
1998). As mentioned in Chapter 2, surveillance data are crucial for model-
ing infectious diseases to better understand the dynamics of an epidemic,
including transmission patterns, to be able to interpret and critically evalu-
ate epidemiological data, and to design treatment and control strategies.
Laboratory Capability, Capacity, and Networks
Specimen collection, analysis, and laboratory confirmation of the etio-
logical 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),
laboratory confirmation is typically required for pathogen characteriza-
tion, confirmation of infection, and further preventive actions. Given the
multiple problems caused by false-positive reports, laboratory-confirmed
cases increasingly provide the bulk of actionable alerts (Rodier et al., 2007).
When rapid assays are not available, conventional methods of confirma-
tion may result in significant time delays. Because emerging agents are at
times previously unknown organisms, the laboratory system needs to have
the capacity to know when something is new and different, have logistics
in place to move the samples to laboratories with the necessary advanced
discovery capacities, and have protocols flexible enough so that labora-
tory personnel can cooperate and collaborate to quickly identify the agent
causing the outbreak. Disease surveillance systems will therefore need to
incorporate both sentinel and reference technical capacity organized into
networks at national, regional, or global levels.
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
Standard for Laboratory Practices and Network Operations
Standards for good laboratory practices overlap with standards for
good laboratory network operations. Good laboratory practice principles
are simply applied to laboratory facilities that meet proper standards for
testing, safety, and security; employ a trained and proficiency-tested staff;
have standardized operating procedures, validated test protocols, and prop-
erly functioning equipment; and use a communication system that relies
on common platforms and accurately and reliably reports test results in a
timely manner. Communication lines and logistics need to be established
before an event occurs. If each disease emergence represents a new problem
to solve, the delay will be both unavoidable and unacceptable. 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. Laboratory accreditation
continues to be the “gold standard” by which laboratories and their quality assurance
system are assessed. The quality assurance and laboratory assessment processes
ensure continuous quality improvement.
Validated and standardized assays: Just as a case definition is essential in compar-
ing data on disease incidence and prevalence, validated and standardized assays
ideally are used in laboratories throughout a network. Validation refers to examina-
tion of a laboratory assay to establish whether it is fit for its purpose, and to establish
performance characteristics in the laboratory and in populations of naturally infected
individuals, whether humans or animals. Standardization (or harmonization) refers to
the use of a common procedure for performing an assay in every network laboratory.
Reference standards: Reference standards for assessing ongoing assay performance,
laboratory performance, and network function are necessary to validate assays and
continuously assess laboratories. Identifying, characterizing, and providing reference
standards is labor intensive and expensive and will not be available for emerging
agents in a time-sensitive fashion. Nevertheless reference standards are a critical
component to a surveillance system. Reference standards are also referred to as
reference materials.
Human resources—training and proficiency testing: Trained technical staff are es-
sential to proper performance of a procedure, no matter how much detail is provided
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
animal health personnel from multiple disciplines. This will require profes-
sionals who are trained in basic clinical diagnosis of emerging zoonotic dis-
eases, field epidemiology, laboratory sciences, social sciences, information
technology, and communications at national, regional, and global levels.
In addition, personnel are needed who have leadership and management
skills; who have a vision and understand the need for a national and global
integrated system; who have the interpersonal skills to work with experts
from different disciplines; and who understand public–private partnerships
(Pappaioanou et al., 2003; Perry et al., 2007).
Clinical, Field, and Laboratory Competencies
Clinical diagnostic expertise is essential for making a timely “field” di-
agnosis of an unexpected, emerging zoonotic disease that occurs in human
and/or animal populations, whether it is in primary healthcare clinics or on
farms. When a diagnosis is not considered and subsequently missed, serious
delays can occur in implementing appropriate, necessary, and immediate
in the protocol. Ideally, training programs in a surveillance laboratory network are stan-
dardized, and include a “train the trainer” component that facilitates ongoing training
of new personnel within individual laboratories by qualified and certified trainers. Once
trained, laboratory staff will need to be proficiency tested to ascertain competence to
perform an assay.
Laboratory facilities: Zoonotic diseases by their very nature are considered trans-
missible to humans. The facility will need to provide an environment in which to safely
and securely conduct laboratory operations. Levels of biocontainment are commonly
referred to as biosafety level (BSL) and are graded from levels 1–4, with the higher
number corresponding to the higher degree of containment required to safely work with
the agent. Security will also need to be considered in operating a modern laboratory
facility. Specific laboratory techniques essential for agent discovery and characteriza-
tion (e.g., in vitro or in vivo culture and genetic and molecular analysis) require strict
environmental control and specimen flow. Only a limited number of BSL-4 laboratories
around the world are designed to work with the most dangerous organisms. Ongoing,
expensive operational and technical support is critical to ensure the proper function of
BSL-4 facilities.
Implementation of new technology: Technology advances often require costly new
equipment, maintenance and reagents, and technical capacity. When they provide a
significant advance in capability, these technological advances could be employed in
reference laboratories and ultimately reengineered for simplicity and reduced cost to
disseminate the technology throughout the laboratory surveillance network. Provisions
for funding of instrumentation, maintenance and reagent costs, and training and retain-
ing personnel are all requirements for quality and sustainability.
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
National Animal Health Laboratory Network and its Canadian equivalent,
the U.S. Laboratory Response Network for Bioterrorism, and the European
Centre for Disease Control and Prevention’s Food- and Water-Borne Dis-
ease Surveillance Network. These networks were established to focus on a
specific group of agents (e.g., those thought to be the greatest threat from
terrorist activities or food- and water-borne agents), some or all of which
may be zoonotic, and each operates on the guiding principles of laboratory
and network operation.
One of the gains of the vertically organized polio eradication initiative
in Africa is the establishment of a reliable acute flaccid paralysis disease
surveillance system, backed by a regionwide polio laboratory network
in Africa. The 16-member polio laboratory network has been technically
upgraded, is accessible to the 46 countries in the WHO African region,
and have provided timely and accurate results to national (polio) disease
control programs. The success of the polio laboratory network has led to
the establishment of other disease-specific laboratory networks, with their
associated disease surveillance systems.
Currently in the African region, there are five laboratory networks that
cover polio, integrated measles, yellow fever, rubella, HIV, pediatric bacte-
rial meningitis, rotavirus, and human papillomavirus. These networks are
functioning despite minimal collaboration among them, either as individual
laboratories or networks at large. Figure 4-4 shows the location of WHO
laboratories in these networks. Initial efforts to integrate activities of the
polio, measles, yellow fever, and rubella laboratories in their respective
networks have resulted in some sharing of equipment and facilities, as well
as human and financial resources. The similarities in standardized sample
collection and testing strategy has led to a higher level of integration of the
measles, rubella, and yellow fever laboratories; in training of laboratory
staff; use of equipment and reagents; and quality assessment and assurance.
Measles labs are routinely required to test samples for rubella when the
measles IgM is negative. For resource-constrained countries, the integration
of a disease surveillance system, including laboratory services, is required
to reduce avoidable duplication of efforts and waste of scarce resources, in-
cluding trained, skilled, competent laboratory personnel. In addition, joint
planning of activities at the laboratory level and joint conduct of internal
and external accreditation exercises has taken place. These are certainly
positive developments that need to be fully supported.
Laboratory networks in the African region that focus on animal dis-
eases are in their infancy. FAO recently completed an effort to catalog the
existing influenza testing laboratory infrastructure for avian samples in sub-
Saharan Africa, and it is organizing these animal disease testing laboratories
into four African regional networks: Eastern, West/Central, North, and
Southern African regions (FAO, 2006). The goal is for each of these regions
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FIGURE 4-4 Global World Health Organization Vaccine Preventable Disease Laboratory Network.
SOURCE: WHO (2007b).
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GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES
to have one regional reference laboratory, and for the networks to operate
on the principles of good laboratory and network practices. Although there
are some examples of laboratory infrastructure and disease surveillance sys-
tems in developing regions, the overall disease surveillance infrastructure is
fragmented at best, and a foundation of laboratory capability and capacity
is nearly nonexistent in nearly every country. 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 spe-
cies and for a broad spectrum of emerging zoonotic disease agents of high
priority to human and animal populations.
Field-Oriented Multidisciplinary Capacity-Building Programs and
Retaining National Expertise in Resource-Challenged Countries
There is a critical shortage of trained field epidemiology and parapro-
fessional personnel in both human and animal disease surveillance. Over
the past 40 years, training for thousands of health personnel in the hu-
man health sector has occurred primarily for vertically funded infectious
disease control or disease elimination programs. Yet many such training
efforts have not led to a sustained cadre of professionals from different
sectors and disciplines, with the expertise and experience needed to imple-
ment and manage an effective global, integrated emerging zoonotic disease
surveillance system. More promising results have been observed with the
more mature FETP programs—in places such as Thailand, Mexico, and the
Philippines—where FETP graduates have moved into higher level positions
in ministries of health.
In the animal health sector, vertical training programs have also oc-
curred with similar results, but on a smaller scale to those seen in the
human health sector. Moreover, funding for training animal health profes-
sionals has been insufficient to provide the needed number of trained lead-
ers and experts in this area. Disease recording systems, if they exist, are not
coordinated between human and veterinary medical professionals, so the
capacity to integrate and synthesize findings and approaches is limited.
Joint human and animal health field epidemiology training programs
are absent and needed to improve multisectoral field training, coordination,
and communication, and to produce a workforce capable of carrying out
zoonotic disease surveillance, outbreak investigation, and response. Exist-
ing educational and field-based training programs need further improve-
ments to provide cross-disciplinary training, and new programs are needed
in areas where field training programs have not yet been established. The
CDC KEMRI FELTP program is a model that could be used for field epi-
demiology and laboratory training programs.
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EFFECTIVE zOONOTIC DISEASE SURVEILLANCE SYSTEM
Finally, in both sectors, trained medical and veterinary health officials
from developing countries frequently seek and obtain employment in inter-
national agencies, other countries and or regions that offer higher salaries
and benefits, places where resources are available for experts to apply their
training in the conduct of their work, and where there is greater potential
for professional advancement. Taken together, these factors have resulted in
many countries having neither human nor animal health personnel available
in sufficient numbers. 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 sur-
veillance 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.
Countries have the responsibility to train, employ, and retain profes-
sionals in their areas of expertise. These training programs therefore need
to be implemented through collaborations among relevant ministries, local
universities, and extension programs. Individuals could be preferentially
targeted to train in geographic areas at higher risk for zoonotic disease
emergence so they can properly detect disease.
CONCLUSION
An effective global, integrated zoonotic disease surveillance and re-
sponse system currently does not exist. National and international commit-
ment to the purpose and goal of such a system are essential. True leadership
and collaboration by leaders and professionals in both public and private
sectors, and across countries and regions of the world in all relevant health,
agricultural, natural resource, education, and other sectors, with financial
support and commitment will be critical to building an effective system that
meets the purpose and goals of this system. As the system is built, continual
assessment and evaluation of surveillance in human, animal, and linked sur-
veillance systems will be needed regarding their comprehensiveness, quality,
multisectoral collaborative aspects, and other aspects of the systems. WHO
and OIE have begun this assessment and evaluation process, but further
effort and support from the international community at large is critically
needed to support their efforts.
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