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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. REFERENCES AFENET (African Field Epidemiology Network). 2009. AFENET: Background. http://www. afenet.net/english/background.php (accessed June 15, 2009).

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