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8 Recommendations, Challenges, and Looking to the Future “Sustainability is not just about securing predictable financial resources. It is also about strengthening health systems while fighting disease, and using the extraordinary opportunities provided by disease programmes to deliver other health benefits. It is about training and empowering the health workforce. It is about drawing on the experience of the private sector to help us innovate and measure risk and results.” —Ban Ki-moon Secretary-General of the United Nations Remarks at the Forum on Global Health: The Tie That Binds (June , 00) Nations bear the responsibility to provide for the security, education, development, and the health and welfare of their citizens. This includes responsibility for disease surveillance and response. It is now clear that contemporary threats from infectious diseases require a system capable of providing sustainable global coverage, an objective that can only be achieved through more intensive cooperation among all nations, interna- tional organizations, and nongovernmental stakeholders. In studying what will be required for a sustainable global integrated system for surveillance and response to emerging infectious diseases of zoonotic origin, the committee found significant weaknesses in the abil- ity of all nations, but particularly low-income countries, to address their need for a functional, sustainable, and integrated surveillance and response system for emerging human and animal diseases. Limited surveillance and response capacities at the national level represent more than just a national threat; they are, in fact, a serious global threat, especially in countries in which the drivers of zoonotic diseases are most concentrated and where experts predict that zoonotic disease emergence is most likely to occur. The implication of this is clear: that all countries, in partnership with private and public stakeholders, should develop, maintain, and globally coordinate integrated surveillance and response capabilities to prevent, detect, and respond to the emergence of zoonotic diseases in order to limit loss of life and livelihoods. 

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES RECOMMENDATIONS The National Research Council report, Animal Health at the Cross- roads, addressed the importance of strengthening collaborations at the na- tional and international levels. The report specified the need for the United States to commit new resources and develop shared leadership roles with other countries and international organizations in order to promote global systems for preventing, protecting against, detecting, and diagnosing emerg- ing animal disease threats (NRC, 2005). The committee concurs with that report and reemphasizes the importance of U.S.-supported collaborations at the international level for the development and promotion of such a global system, including a U.S. commitment to provide technical assistance to other countries and to increase its participation in developing interna- tional animal health standards for preventing, detecting, and responding to zoonotic diseases. An effective zoonotic disease surveillance and response system needs to be integrated across sectors and disciplines so that it identi- fies and responds to human and animal disease threats at the earliest time possible, without regard to national boundaries or professional discipline. The committee therefore offers the following 12 recommendations for improving zoonotic disease surveillance and response by priority and category areas (see Table 8-1). The recommendations are grouped as tech- nical, economic, and political actions needed to achieve the desired sys- tem. Recommendations assigned as high priority are foundational for a global, integrated zoonotic disease surveillance and response system. The remaining recommendations are considered priority and are not listed in rank order, though they are all considered essential to achieving the goal. The committee understands that it may be necessary to implement these recommendations according to different timetables, depending on how the United States and its partners are able to mobilize the necessary resources. Ultimately, an effective, sustainable system will require attention to each of the 12 recommendations. High-Priority Recommendations Technical: Strengthen Surveillance and Response Capacity Establish Surveillance and Response Strategies Recommendation 1-1: The U.S. Departments of Health and Human Services (HHS), Agriculture (USDA), Homeland Security (DHS), and the Interior (DoI) should collaborate with one another and with the private sector and nongovernmental organizations to achieve an inte- grated surveillance and response system for emerging zoonotic diseases in the United States. In addition, these government agencies, including

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE TABLE 8-1 Recommendations for Improved Zoonotic Surveillance and Response by Priority and Category Areas Technical Economic Political Governance of Global Financing and Incentives Efforts to Improve Strengthen Surveillance for Surveillance and Surveillance and Response and Response Capacity Response Capabilities High Establish surveillance Establish sustainable Create a coordinating body priority and response strategies funding strategies for global zoonotic disease (Recommendation -) (Recommendation -) surveillance and response (Recommendation -) Priority Improve use of Create an audit and Deepen the engagement information technology rating framework of stakeholders to support surveillance for surveillance and (Recommendation -) and response activities response systems (Recommendation -) (Recommendation -) Strengthen the Strengthen incentives Revise OIE laboratory network to for country and governance strategies support surveillance local reporting (Recommendation -) and response activities (Recommendation -) (Recommendation -) Build human resources Mitigate disease threats capacity to support from wildlife and trade surveillance and response (Recommendation -) efforts (Recommendation -) Establish a zoonotic disease drivers panel (Recommendation -) NOTE: OIE = World Organization for Animal Health. the U.S. Department of State and the U.S. Agency for International De- velopment (USAID), should collaborate with the World Health Orga- nization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (OIE) to spearhead efforts to achieve a more effective global surveillance and response system, learning from and informing the experiences of other nations. Given finite resources and the complexity of the challenge, an integrated zoonotic disease surveillance and response system can succeed only if the

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES U.S. government demonstrates its commitment to develop and strengthen the needed capacities at the national level, and to engage others at the global level. The following strategic approaches are necessary to achieve an effec- tive, global zoonotic disease surveillance and response system: First, departments or ministries of health, agriculture, and natural resources, with external support as needed, should work with researchers to develop and use science-based criteria to determine and measure the distribution and magnitude of the drivers of zoonotic disease emergence. Rapid changes in ecology, environmental degradation, population density, population movements, animal production systems, and close interaction of humans with livestock, poultry, and wildlife are just a few drivers to study. From these studies, targeted surveillance would then be designed to focus on countries and regions within countries where drivers increase the risk for zoonotic disease emergence. Second, in countries where disease surveillance in animal populations is absent or weak, ministries of health, agriculture, and natural resources should collaborate as broadly as necessary to develop, enhance, and imple- ment disease surveillance and response systems in human populations that are at high risk for zoonotic disease infection. For example, surveillance is needed in the following high-risk human populations: • Occupational groups that are at high risk for infection with zoo- notic diseases. Such workers include livestock, dairy, and poultry workers; live-animal market workers; veterinarians and animal health technicians; hunters of bushmeat and other wildlife; food preparers (and restaurant workers handling food prepared from bushmeat and exotic animals); slaughterhouse workers; and laboratory scientists and technicians working with animals; • Healthcare workers who could spread zoonotic diseases to the general public; • Household and village members who keep live animals within their living quarters or come in close contact with animals in village settings; and • People engaging in high-risk behaviors known to increase risk of exposure to zoonotic diseases. Such high-risk behaviors include close con- tact with wildlife and exotic animals; preparing and consuming bushmeat; culturally traditional animal husbandry practices and livestock production systems; failure to use personal protection equipment; failure to follow recommended hand-washing practices. Third, to reverse the trend where human outbreaks serve as sentinels for animal disease, ministries of agriculture and natural resources should develop and strengthen livestock, poultry, and wildlife zoonotic disease

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE surveillance systems, particularly where surveillance in animal populations is currently limited. In partnership with the private sector, ministries of agriculture should conduct active and passive disease surveillance in ani- mal populations that are raised in high-density conditions but lack good biosecurity measures, that are located in areas of dense human populations (e.g., Asia, Latin America, and Eastern Europe), and/or that are interspersed with smallholder livestock farms. Ministries of agriculture and natural re- sources should also conduct high-priority surveillance in livestock, poultry, companion animals, and wildlife whenever species are clustered, mixed, and inhabit areas in close proximity to human populations (e.g., co-habitation with humans in homes, villages, or are transported to, housed, and sold in live-animal markets). To detect subclinical or unnoticed infections, minis- tries of agriculture and natural resources should develop capacity to system- atically test laboratory specimens from domesticated animals and wildlife that are at high risk of serving as zoonotic disease reservoirs (e.g., bats, wild aquatic birds, and nonhuman primates). This will enable responses to be targeted and can limit pathogen transmission and prevent or minimize their impact on the health of human and domesticated animal popula- tions. Ministries of agriculture, natural resources, and health should build capacity to institute active sentinel surveillance in wildlife—such as bats, wild aquatic birds, great apes, and rodents—and other important reservoir species that are in close contact with humans to continuously assess the “baseline” population with pathogens of concern (e.g., influenza, Ebola, Nipah, hendra, rabies, Rift Valley fever [RVF], coronaviruses, tularemia, plague). Targeted wildlife populations should be those most likely to inter- act with humans, either directly or indirectly through domesticated animals. The list of pathogens needs to be established by consensus at the global, regional, and local levels (see Recommendation 3-1 on the recommended coordinating body) and resources should be commensurate to the identified need for surveillance. Fourth, ministries of health, agriculture, and natural resources will need to develop and formalize a system wherein surveillance information from these different human and animal populations will be integrated and synthesized for analysis. These ministries will also need to develop and formalize effective communication and reporting systems to ensure real- time reporting of linked surveillance data from human and animal popula- tions nationally and internationally to those responsible for planning and instituting prevention, protection, and response interventions. The Danish Zoonosis Centre could be a model of an effectively integrated national program for zoonoses (see Box 8-1). Finally, science-based nongovernmental organizations (NGOs) have a critical role to play in national and global efforts to develop an integrated surveillance system. In many cases these organizations have extremely

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES BOX 8-1 Model of an Integrated National Program for Zoonoses The Danish Zoonosis Centre was established in 1994 in response to the major fragmentation of the surveillance systems and increasing incidence of zoonotic diseases at that time. The Centre is part of the National Food Institute of the Technical University of Denmark, and it has special responsibilities for prevention, surveillance, and outbreak tracking of zoonotic infections by compiling surveillance data on food-borne zoonoses and by developing prevention strategies. As such, it is an integral part of the national contingency plan for outbreaks of food-borne dis- eases. Funding comes partly from the Danish government and partly from income generated through the provision of research and advisory service to the private sector. The Centre has a staff of 13 specialists but relies heavily on industry for data collection. It is an inter-sectoral center, meaning that representatives of the Danish Board of Health Food and Veterinary Administration are a part of its Steer- ing Group, and producer boards and nongovernmental organizations are included in its coordination groups. The integration of public and private sectors has been a critical element of the Centre’s success. Its excellent performance continues to make it a reference center for the World Health Organization and the European Food Safety Authority, among others, on zoonotic disease-related issues. wide geographic reach, with offices and trained staff based in countries with the highest risk for new zoonoses. They have often developed the most effective and closest relationships and collaborations with local com- munities. NGOs have the capacity to act nimbly to rapidly refocus re- sources on outbreaks during crises, and they are usually not encumbered by geopolitical constraints. Science-based NGOs—such as Wildlife Conserva- tion Society, Wildlife Trust, The Consortium for Conservation Medicine, and EnviroVet—have launched programs specifically targeted at many of this committee’s recommendations and should be actively involved in future efforts to address them. While the focus of this committee is primarily scien- tific, it recognizes that advocacy groups can also provide an important push for integrated surveillance by urging relevant policy changes involving food production, wildlife conservation, poverty alleviation, and global health. Economic: Financing and Incentives for Surveillance and Response Establish Sustainable Funding Strategies Recommendation 2-1: USAID—in partnership with international fi- nance institutions and other bilateral assistance agencies—should lead an effort to generate sustainable financial resources to adequately sup- port the development, implementation, and operation of integrated zoo-

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE notic disease surveillance and response systems. An in-depth study of the nature and scope of a funding mechanism should be commissioned by these agencies, and the study should specifically consider a tax on traded meat and meat products as a potential source of revenue. The committee concluded that an integrated global surveillance and response system should be designated a national and global public good. As observed in recent outbreaks, emerging zoonotic pathogens are rapidly transmitted across borders and from one continent to another. Too often, responses are either slow but evidence-based or quick but inappropriate (e.g., non-evidence-based restrictions on travel, transport of goods, culling of animals). This has resulted in large political, economic, and social im- pacts on national and global human, animal, and economic health. Although primary responsibility for creating and maintaining such a system remains at the national level, the needs of low-income countries for assistance and the complexities of building an integrated global system will require both smarter expenditure of existing resources and additional funding. Without such financial support, the global public good that an integrated system could produce will not be achieved. The current global economic crisis underscores the need to develop sustainable financing strategies to produce this global public good. Coun- tries with greater resources will need to show leadership by supporting low-income countries and international organizations to create a global system. With the continued spread of H1N1 virus to developing countries, United Nations (UN) Secretary-General Ban Ki-moon stated that the UN would need more than $1 billion to combat the pandemic for the remain- der of 2009 alone and made a plea for assistance from developed countries (Maugh, 2009). The inadequacy of traditional donor support, the limited duration of commitment, and the competition for resources generated by other global health problems require the U.S. government, other countries, and intergovernmental organizations to design and implement strategies that will provide sustainable resources for zoonotic disease surveillance and response. National government access to realigned and new funding should be made conditional on fulfillment of agreed criteria of participation, in- cluding the willingness to conduct national assessments of surveillance and response capacity and have such assessments independently reviewed (see Recommendation 2-2). While countries need to be encouraged to invest in developing the capacity to detect, investigate, and report suspected disease outbreaks and thus prevent sporadic cases from escalating to epidemics (especially of known diseases), resource-poor countries undoubtedly will need external support and assistance for this purpose. The challenge of maintaining global surveillance capacity calls for identifying sustainable funding sources

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES rather than depending on development aid budgets, which historically have fluctuated with donor priorities or changes in leadership. Although a number of possible suggestions are provided in this report, the committee did not have the mandate or expertise to conduct a thorough investigation of the implications of these options. The committee therefore calls for an in-depth study to further identify innovative funding mechanisms that can continuously support the need for surveillance and response systems. Revenue sources should be, in principle, tied to levies on activities that increase the risk of emergence and movement of zoonotic pathogens. This has led to the committee’s recommendation for further study on a product tax for internationally traded meat and meat products, which represent an important route for the emergence and spread of zoonotic diseases. This levy would be imposed primarily on wealthier exporting countries (see Ta- ble 6-4). One of the potential adverse consequences of imposing a levy may be that it increases product smuggling in an attempt to evade taxes. There may well be other unintended consequences of this strategy; therefore the committee concluded that a thorough study of the pros and cons for this, or other sustainable approaches, is a necessary prerequisite before making final decisions on the optimal mechanism to fund the required actions. The committee considered other funding options. These include long- term commitments from high- and middle-income countries to contribute directly to a global fund established for this purpose; long-term commit- ments from governments to fund specific WHO, FAO, and OIE programs; establishment of endowment funds; increased contribution from founda- tions and nonconventional donors; and public-private partnerships. These remain options that could be considered when more intensive and targeted discussions are initiated. Initial access to global funding for a recipient country could be made dependent on its commitment and participation in an assessment of its na- tional surveillance capabilities (see Recommendation 2-2). Further funding could be conditional on its subsequent performance to integrate human and animal health systems and its contribution to pay for the surveillance and response systems’ operating costs. While the committee did not explore these options and the institutional arrangements necessary to manage them, the committee concluded that it would be prudent if the recommended independent global funding mechanism (e.g., the Global Fund) would not be administered by a government entity or international governmental organization. Political: Governance of Global Efforts to Improve Surveillance and Response Capabilities Create a Coordinating Body for Global Zoonotic Disease Surveillance and Response

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE Recommendation 3-1: USAID, in cooperation with the UN and other stakeholders from human and animal health sectors, should promote the establishment of a coordinating body to ensure progress toward development and implementation of harmonized, long-term strategies for integrated surveillance and response for zoonotic diseases. As discussed earlier in this report, WHO, OIE, and FAO have im- proved their coordination efforts on zoonotic diseases, especially through the creation and operation of the Global Early Warning System (GLEWS) for major animal diseases including zoonoses. In addition, WHO and OIE have independently revised their central legal agreements—the International Health Regulations 2005 (IHR 2005) and the Terrestrial Animal Health Code, respectively—to facilitate better governance strategies for zoonotic disease threats. The committee concluded that these positive developments can and should be supplemented by the establishment of an overarching global coordinating body. Building on the foundation laid by GLEWS, the adoption of IHR 2005, changes to the OIE’s Terrestial Animal Health Code, and better collaboration between OIE and FAO, this coordinating body could raise the profile of zoonotic disease surveillance and response efforts and provide the necessary high-level political support to advance national, regional, and global coordination efforts. The approach devel- oped in the UN System Influenza Coordinator (UNSIC) strategy is widely perceived as an effective effort and could serve as a model for the coor- dinating body needed for an integrated zoonotic disease surveillance and response. The zoonotic disease coordinating body should work to ensure that all relevant stakeholders are consulted and involved in coordinating activities. The mechanism could also draw attention to problems and chal- lenges faced in implementation of IHR 2005, OIE agreements, OIE/FAO strategies, and GLEWS. The coordinating body could also facilitate im- proved and additional funding streams for zoonotic disease control (see Recommendation 2-1). Priority Recommendations Technical: Strengthen Surveillance and Response Capacity Improve Use of Information Technology to Support Surveillance and Re- sponse Activities Recommendation 1-2: With the support of USAID, international or- ganizations (such as WHO, FAO, OIE, and the World Bank) and public- and private-sector partners should assist nations in developing, adapting for local conditions, and implementing information and com- munication technologies for integrated zoonotic disease surveillance.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES BOX 8-2 Philanthropic Support for Information Technology Development and Management The Rockefeller Foundation supports an “eHealth” initiative, along with a port- folio of grants on surveillance networks. This initiative focuses on a number of aspects of design and implementation of eHealth including open-source software development for medical records, laboratory records, and disease reporting. In 2008, a series of Bellagio meetings were held that brought experts together from many parts of the world to discuss architecture, standards, training needs, and other activities. The Rockefeller Foundation is supporting the creation of the Cen- ters of Excellence for Informatics in a number of low-resource settings to facilitate the implementation of eHealth, including the development and implementation of standardized tools for disease reporting and public health response. The Bill & Melinda Gates Foundation recently funded a planning grant for the American Medical Informatics Association to outline plans for a global informatics scholars program. Such philanthropic input and support is critical for developing countries where such expertise will greatly advance efforts at streamlining information sys- tems for surveillance. While these initiatives are directed towards human disease, they represent technical models that can be applied to animal disease. Effective use of such technologies facilitates acquisition, integration, management, analysis, and visualization of data sources across hu- man and animal health sectors and empowers information sharing across local, national, and international levels. To establish, sustain, and maintain this technologically sophisticated system, both leadership and investment are critically needed. Leadership and investment should emerge within each country; how- ever, low-income countries will need support to engage in broader training and capacity building. This effort should integrate key nongovernmental actors, including private philanthropies with interests in infectious disease surveillance and management (see Box 8-2 for an example); industry part- ners in food production, information technology, and data management; and nongovernmental organizations involved in global health. Organiza- tions should follow the lead of actors such as Google.org., which contribute both external funding as well as internal efforts to support the development of open source surveillance technology (see Box 5-5). Strengthen the Laboratory Network to Support Surveillance and Response Activities

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE Recommendation 1-3: USAID should promote and initially fund the es- tablishment of an international laboratory working group charged with designing a global laboratory network plan for zoonotic disease surveil- lance. The working group’s objective would be to design a laboratory network that supports more efficient, effective, reliable, and timely diagnosis, reporting, information sharing, disease response capacity, and integration of human and animal health components. In addition, a long-term coordinating body for zoonotic diseases, perhaps modeled after the United Nations System Influenza Coordinator’s (UNSIC’s) of- fice (see Recommendation 3-1), should implement the global laboratory network plan, manage it, and assess its performance in consultation with the international laboratory working group. The international working group charged with developing the global laboratory network plan should include representation from several groups. These include international organizations (e.g., WHO, FAO, and OIE); na- tional human and animal health laboratories with experience in laboratory network development and support (e.g., U.S. Centers for Disease Control and Prevention [CDC], Department of Defense [DoD] Global Emerging In- fections Surveillance and Response System, USDA Animal and Plant Health Inspection Service [USDA-APHIS] National Veterinary Services Labora- tory, Canadian Science Centre for Human and Animal Health, Australian Animal Health Laboratory); professional laboratory organizations, such as the Association of Public Health Laboratories and the American As- sociation of Veterinary Laboratory Diagnosticians in the United States and their counterparts in other nations; wildlife health specialists; and private for-profit and not-for-profit entities with a stake in zoonotic laboratory network development. Integration of animal and public health laboratory infrastructure, operations, and personnel should be a driving factor in de- velopment of the global plan. To develop the plan the working group should take steps that include 1. conducting an inventory and assessing the quality of the current global capacity for laboratory diagnosis and reporting of zoonotic diseases in human and animal health laboratories; 2. based on this inventory, designing the optimal laboratory network structure with emphasis on utilizing existing regional laboratories in high- risk regions as reference labs capable of the work necessary for identify- ing emerging diseases, and sentinel surveillance laboratories within those regions; 3. identifying where new laboratory infrastructure is necessary; 4. creating the environment (e.g., common space, common platforms,

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES and response. The committee believes its success depends on the following factors: • Sufficient national and global surveillance and response capacities; • Enhanced compliance and implementation of relevant international agreements, especially the IHR 2005 and OIE instruments, and global strat- egies, such as the joint OIE/FAO framework and GLEWS; • Better utilization of existing financial resources and generation of new funding for zoonotic disease surveillance and response; • Effective communication and cooperation across sectors, relevant disciplines, and institutions; • Joint resource use and greater equity in resources for implement- ing surveillance and for human and animal health prevention and control interventions; • Improved cross- and interdisciplinary training in medical and vet- erinary education and allied fields; • Attention to understanding the nonbiological social, political, and economic drivers and consequences involved with zoonotic disease and hu- man and animal health; • Generation of political will to commit political, economic, and intellectual capital for zoonotic surveillance and response capabilities; • Better understanding of zoonotic disease surveillance and response capabilities as priority national and global public goods; and • Greater mutual respect and trust between human and animal health communities, academic institutions, and practitioners. Uncoordinated Approaches in Designing and Implementing Zoonotic Disease Surveillance and Response The committee frequently referred to multiple players involved in designing, implementing, and evaluating disease surveillance and response systems at local, national, and international levels. The result of these multiple players has been many different, often vertical and single-disease oriented systems that generally have incompatible implementation ap- proaches. Multiple guidelines have been developed and recommended (e.g., by USDA, CDC, WHO, and OIE), and different methods for evaluating disease surveillance and response systems have been employed. In general, there is a lack of standard or harmonized laboratory, field epidemiology, and disease prevention and control protocols. There is also considerable variation in protocols for disease surveillance in human, food-animal, and wildlife populations. In addition, aside from rabies, there are no protocols for zoonotic disease surveillance in companion animals for pathogens such

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE as toxoplasmosis or visceral larval migrans (due to Toxocara canis or T. cati). For disease agents associated with wildlife, laboratory diagnostics that are reliable, sensitive, and specific to wildlife specimens are lacking. At the same time, the generally adverse trade and tourism impacts of disease outbreak reporting can lead to political interference, thereby pre- cluding the rapid release of important information to the global community for implementing a rapid and effective response. The committee therefore believes it is essential to develop and apply a standard method for conduct- ing and evaluating the effectiveness of zoonotic disease surveillance systems in different countries, independent of political interference (such as suppres- sion of information or corruption). The Complexity of an Integrated Approach The training mechanisms and health systems necessary to build human capacity for an integrated zoonotic disease surveillance and response sys- tem have developed as separate and unequal systems. In the past, greater resources have been available for training in human health, thus additional investments to train those in animal health are needed while at the same time not reducing existing support to train human health professionals. Op- portunities to jointly train human and animal health professionals together are particularly valuable. Joint program initiatives, joint workforce educa- tion and training, and joint performance standards for emerging zoonotic diseases will need to be given priority to support the widespread changes essential for implementing a more integrated and effective system. There will likely be resistance to moving forward, funding may be difficult to find, and there will be issues at many levels over control. These problems should be anticipated and will require leadership from both the human and animal health sectors to overcome them. For many years, various scholars have argued in favor of increased collaboration among professionals in the human and veterinary health communities (Schwabe, 1983; Murphy, 1998; NRC, 2005; Hadorn and Stark, 2008). The committee is deeply concerned to note that despite these appeals for action, progress to increase collaboration between the human and animal health systems has been limited. In response to the fragmented national and international responses to human and animal health emergen- cies, there is now considerably greater attention with respect to the need to increase and strengthen multisectoral and multilateral collaborations for emerging zoonotic disease surveillance and response. This multidisciplinary approach is being promoted under the banner of “one health,” defined as “the collaborative effort of multiple disciplines—working locally, nation- ally, and globally—to attain optimal health for people, animals and the en- vironment” (AVMA, 2008, p. 4). The committee supports all such efforts.

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES Zoonotic disease surveillance and response offers an opportunity to realize the vision of integrated human, animal, and environmental health in a practical and visible way. Information sharing, laboratory infrastructure, sample collection, trained workforces, laboratory analysis, and response teams can and need to be integrated. Community health workers and paraprofessionals can be trained to collect samples from both humans and animals, or at a minimum can work side by side to assess and sample hu- man and animal populations where zoonotic agents are residing, evolving, and moving. Shared cold chains can deliver samples from humans and animals to laboratories analyzing all samples using assays that are well- characterized, validated, and equivalent, if not identical. Information from laboratories and regulatory agencies can be distributed back to the com- munity level to all human and animal health workers. When zoonotic dis- ease outbreaks occur, health teams—that at a minimum include physicians, veterinarians, public health professionals, and other disease experts when appropriate, such as medical entomologists and wildlife biologists—can work together to unravel the problem and set in motion the response com- ponent from the outset. Political Will and Elevating Integrated Surveillance and Response to Emerging Zoonotic Diseases as a Priority Among the many challenges for establishing an integrated surveillance and response system is the lack of political will to address emerging zoo- notic health threats. Furthermore, health is often assigned as a low priority by political leadership; there is an accompanying lack of commitment to finance the system; ownership of the disease surveillance system is unclear; and there are often conflicting partner priorities. The sequential emergence of infectious diseases of zoonotic origin in the past few decades—such as HIV/AIDS, Escherichia coli O157:H7, severe acute respiratory syndrome (SARS), HPAI H5N1, and most recently influenza A(H1N1) 2009, which contains genes from human, pig, and bird influenza viruses—have captured the public’s attention and raised the level of engagement of political lead- ers. With attention and engagement has come funding; however, it has been disease specific and primarily oriented to address consequences affecting hu- man health. It has also failed to build the broader surveillance and response system that is necessary and described in this report. In many developing countries where the human health system is inad- equate, it is not surprising that the priority placed on the interface of human and animal health is low. These realities for both human and animal health are amply demonstrated by the lack of funding, inadequate staffing, poor quality or inappropriate training for existing personnel, and the failure to appreciate the cost effectiveness of a reliable disease surveillance system in

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE healthcare delivery. Given the low priority and limited expertise, decision- makers often do not understand how to interpret and use available informa- tion on emerging zoonotic diseases. Even if they know what they should do, they typically lack the authority and resources needed to rapidly respond (Pappaioanou et al., 2003). Furthermore, the fear of sanctions and eco- nomic losses as immediate consequences of reporting trumps any instinct to act quickly. As these countries are also confronted with HIV/AIDS, malaria, and tuberculosis, for which considerable international assistance has been generated, it is no wonder that national policymakers are unable to allocate scarce resources to newly emerging zoonotic diseases. Any support that has been directed towards zoonotic disease control has come mainly through external and vertical targeted programs. The lack of funds for veterinary and environmental agencies is a particularly serious impediment to effective action (GAO, 2001; NRC, 2005). In Kenya, for example, the Ministry of Health could deploy five times more staff to address the recent outbreak of RVF than could the Veterinary Service that is actually charged with control- ling the main source of human RVF infection.2 Disease surveillance systems function vertically in many African coun- tries, because they were set up to support global initiatives for monitor- ing and controlling specific diseases. These include poliomyelitis, bacterial meningitis, measles, cholera, yellow fever, and other vaccine-preventable diseases. The ad hoc system of establishing specific disease surveillance systems has in many ways prevented the establishment of a reliable and comprehensive national disease surveillance system. The vertical programs may have succeeded in the use of disease-specific data collection tools, reporting formats, and disease surveillance guidelines for donor-targeted disease. However, the facilities are minimally used for disease surveillance or control of other emerging zoonotic infectious diseases. Where there are facilities, often the same person or team performs all disease surveillance activities, limiting their ability to attend to other problems. At this time, there is sufficient global concern to mobilize international leadership because of the potential for influenza A(H1N1) 2009 to return later in 2009 with considerably greater virulence, perhaps through reassort- ments with avian influenza A(H5N1) viruses. This is an opportune time for international organizations—such as WHO, FAO, and OIE—and national governments and local authorities to take ownership of the surveillance and response system. These various actors need to make the commitment and take the first steps towards creating the local to global systems: If there is no local “ownership” of the disease surveillance system, especially at the health district level where most epidemics originate, it is hard to generate and sustain political will at the higher levels to take action. On top of this, 2 Ester Schelling, International Livestock Research Centre, personal communication, 2008.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES inflexible regulatory constraints are commonly imposed by donor agencies for their own administrative and reporting requirements. This hampers the maximum use of facilities and especially human and financial resources for integrating disease surveillance systems. Implementing the International Health Regulations The adoption of IHR 2005 by the World Health Assembly represents a giant leap forward because it provides a comprehensive framework for human disease surveillance (Fidler, 2005). The committee recognizes that IHR 2005 took 10 years to develop, and its slow implementation in many countries restricts the ability to reach the full promise of IHR 2005. The committee reemphasizes that full implementation of IHR 2005 is the bed- rock for building a new integrated and sustainable human and animal surveillance and response system for emerging zoonotic diseases. With increasing disease risks related to globalization of trade, in 2007– 2008, the OIE refined an evaluation tool originally developed in collabora- tion with the Inter-American Institute for Cooperation on Agriculture to produce the Performance of Veterinary Services tool. This was developed to assist the country’s veterinary services by assessing their existing level of performance, identifying gaps and weaknesses in their capacity to comply with OIE international standards, and developing new strategies and ap- proaches for the public and private sectors to collaborate in addressing the identified gaps and challenges (OIE, 2008). In general, by strengthening veterinary services and infrastructure with enhanced capacity to imple- ment strategic and sensitive surveillance methods, this will allow local and national integrated health systems to better detect the emergence of new zoonoses. However, if IHR 2005 is not fully implemented, there is little chance that OIE efforts can be successful. For this reason, the committee recognizes the critical importance of full implementation of IHR 2005 and registers its concerns about the pace of progress. Fostering Trust An effective disease surveillance system is one in which diseases are detected early and reported in a timely fashion. That is fully dependent on achieving a level of trust between (1) the local population and (2) local, national, and international human and/or animal health authorities. Too often, those locally reporting disease in animal populations are confronted with what appears to be arbitrary loss of their food animals without com- pensation. Countries reporting zoonotic diseases internationally may face unilaterally imposed trade restrictions, often accompanied by the imposi- tion of travel advisories and a subsequent drop in tourism. In order for

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE timely, transparent, and credible information to transfer up the line, and for information and support to come back down to the community, prior trust needs to be established between the community, scientists, and the politi- cal system at the local, national, and global levels. Building trust will also involve understanding how individuals assess risk and behave in response, and whether various stakeholders believe their concerns can be fairly ad- dressed in the surveillance and response system. LOOKING TO THE FUTURE Since the Institute of Medicine released its 1992 report Emerging In- fections: Microbial Threats to Health in the United States, there has been a growing awareness of the frequency with which new and reemerging infectious diseases are appearing. As the number and frequency of emerg- ing threats increases, the committee realizes that the old veterinary maxim, “When you hear hoofbeats on the covered bridge, don’t think about the zebra,” needs re-working in today’s environment to “When you hear hoof- beats on the covered bridge, at least think about the possibility of a zebra.” Most newly emerging infections are zoonotic in origin, for which a limited but broad-based set of microbiological, ecological, and behavioral drivers have been identified. The United States and other well-resourced nations have increased their research efforts and held conferences, leading to an increased number of scientific publications, reports, and to some extent improved disease surveillance and global response on a disease by disease basis. However, more effort is needed, as demonstrated by the first pan- demic of the 21st century caused by influenza A(H1N1) 2009, the recent emergence and rapid spread of SARS (albeit to a limited number of coun- tries), and the discovery of West Nile virus in the United States (which has become endemic across the country within a few years). With the exception of pandemic (H1N1) 2009, these examples show how delayed information reporting can result in the further spread of disease. Although subsequent catch-up efforts in the latter two examples finally enabled human and ani- mal health experts to effectively connect and collaborate with each other, those connections had to first be forged during the outbreak, enabling the disease to spread and making it more difficult to contain. Together with HPAI H5N1 as an emerging threat to both humans and animals, these events have captured public attention as never before, highlighting the ongoing risk these pathogens represent and the deficiencies in our disease surveillance and response mechanisms. They further demonstrate to the public the need for continued investment in disease surveillance, as another veterinary adage best describes how it is cheaper to invest in some good stall doors than to try to collect all the horses after they leave the barn. Perhaps the most serious concerns identified in this report are the

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES continued separation of human and animal health expertise and infrastruc- ture, the vertically organized responses to the recent threats of SARS and HPAI H5N1 infection, and the lack of coordinated governance and funding sufficient to effect change. The committee believes the longstanding cultural and organizational tendencies toward stovepiping are no longer acceptable: Disease surveillance needs to be integrated, developed, and implemented across sectors and disciplines. It would be useful to have a system that requires reporting and action; however, other incentives will surely be nec- essary to ensure full participation. Locations where the drivers of emerging zoonotic infectious diseases are most active currently coincide with the developing regions of the world, precisely where the resources for disease surveillance and response are the most limiting. This is a global concern because the impact of zoonotic dis- ease emergence is global, not just local. Because of this interconnectedness, this requires commitment among all nations to share in the cost of develop- ing effective disease surveillance and to sustain and continually improve the technical capabilities of this system. This also requires countries to ensure that responses intended to prevent spread and limit the impact on human and animal health, including the financial and economic consequences of a local or global outbreak, are evidence-based and prompt. The recommenda- tions in this report are broad in their reach and involve technical, financial, and organizational inputs, and they include significant changes in the way global governance of zoonotic disease surveillance and response should be handled. They are based on the full implementation of IHR 2005, and will necessitate significant changes in the way animal disease surveillance, reporting, and response is conducted. None of this will be simple to ac- complish, but efforts need to begin now. Future Research Needs and Considerations The disease surveillance and response system is never static. As a com- ponent of continuous quality improvement and because it is a dynamic sys- tem, additional research and other considerations will be needed to evaluate the impact of integrated disease surveillance. Zoonotic disease surveillance and response would benefit from research in the following areas: • Developing global standards and evaluation criteria for integrated zoonotic disease surveillance systems; • Adapting evolving methodologies from other basic science disci- plines that could be incorporated into integrated surveillance systems; • Identifying future pathogens (microbiome-type projects) to guide the development of diagnostics, vaccines, and drugs;

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE • Determining efficacy of and resistance to antibiotics and antivirals; • Evaluating the effectiveness of laws and regulations on compliance with reporting requirements; • Evaluating the effectiveness of integrated zoonotic disease preven- tion programs; • Identifying and evaluating social and economic incentives to com- ply with and disincentives to ignore reporting requirements; • Identifying incentives for communicating, cooperating, and build- ing trust across sectors and disciplines; • Evaluating the timeliness and level of response that results from early warning systems and the separation of accurate reports from false- positive ones; • Developing community-based participatory research in the epide- miology of zoonotic diseases; • Developing social incentives at the local level to promote early disease reporting, avoid outbreak concealment, and engage in effective responses; • Evaluating how communities understand zoonoses epidemiology, prevention, and treatment in order to foster local participation in disease reporting and surveillance activities; and • Tracking media representations of zoonotic diseases and assessing how information is produced, circulated, and responded to by the commu- nity and policymakers. To evaluate its progress and impact, it is essential to periodically con- duct an in-depth review of how the zoonotic disease surveillance and re- sponse system is implemented and functions. Such an evaluation needs to be conducted by an independent, multisectoral, scientific body encompassing human, animal, and environmental expertise to monitor and evaluate the progress of this report’s recommendations. As part of that evaluation, an interim report card should be issued by 2012, which coincides with the target date for full-implementation of IHR 2005, and a full report should be issued by 2016 to allow time for responding to the interim evaluation. Closing Thoughts The 12 recommendations in this report represent the committee’s con- sensus view on how to systematically address the multiple requirements needed for an effective and sustainable system. In its deliberations, the committee attempted to ensure that its recommendations are pragmatic, focused, informed, and supported by the review of evidence, even when

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES they may challenge convention in some areas. This report reflects the broad disciplinary experience necessary to accomplish the goals it addresses, informed by the broad disciplinary expertise of the committee members. In many ways, the committee is a microcosm of the expertise needed to achieve the sustainable integrated disease surveillance and response called for by the report, and also demonstrates that reaching consensus is no simple task yet is possible. It is essential to begin the process now toward achieving this system. U.S. agencies, in particular USAID, can and should take a lead role—working together with international, intergovernmental, and multinational partners from the public and private domains—in mov- ing from discussion to action. Global sustainability of zoonotic disease surveillance is predicated on a system that assures international exchange and collaboration to contain the spread of zoonotic diseases through the creation of an atmosphere of transparency, trust, and accountability. The system needs to assist devel- oping countries through relevant capacity building, enabling countries to appropriately contribute in improving global disease surveillance and using information to promptly implement the necessary evidence-based responses. For countries to assume responsibility for zoonotic disease surveillance, the system needs to survive within available national resources and be sustain- able. It also needs to be adaptable and flexible enough to meet the needs of each country’s changing national demands and priorities and be acceptable to its stakeholders. Reaching the goal of a sustainable and better integrated global human and animal surveillance and response system for zoonotic emerging diseases depends on a number of preconditions: sufficient political and social will to accomplish it; allocation of necessary financial and technical resources in a sustainable and continuous way; and ensuring that human and animal health officials have the authority and resources to regulate the drivers associated with zoonotic disease emergence, to report emerging events as they occur, and to determine the proper interventions based on the specific nature of the agent and the circumstances of the emergence itself. This is certainly a tall order, but given that political will and financial resources have been individually marshaled for one emerging zoonotic disease after the other, the committee believes that it is possible to create a reliable and sustainable zoonotic disease surveillance system that is flexible, has assured funding, is efficiently implemented, and is acceptable to all stakeholders. REFERENCES AVMA (American Veterinary Medical Association). 2008. One health: A new professional imperative—One Health Initiative Task Force final report. Washington, DC: AVMA.

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 RECOMMENDATIONS, CHALLENGES, AND LOOKING TO THE FUTURE Fidler, D. P. 2005. From international sanitary conventions to global health security: The new International Health Regulations. Chinese J of International Law 4(2):325–392. GAO (U.S. Government Accountability Office). 2001. Challenges in improving infectious disease surveillance systems. GAO-01-722. Washington, DC: GAO. Hadorn, D. C., and K. D. Stark. 2008. Evaluation and optimization of surveillance systems for rare and emerging infectious diseases. Vet Res 39(6):57. IPCC (Intergovernmental Panel on Climate Change). 2009. Organization. http://www.ipcc. ch/organization/organization.htm (accessed July 20, 2009). Maugh, T. H., II. 2009. WHO will urge most countries to stop H1N1 testing. The Los Angeles Times, July 8. Murphy, F. A. 1998. Emerging zoonoses. Emerg Infect Dis 4(3):429–435. NRC (National Research Council). 2005. Critical needs for research in veterinary science. Washington, DC: The National Academies Press. OIE (World Organization for Animal Health). 2008. OIE tool for the evaluation of perfor- mance of veterinary services, 3rd ed. Paris, France: OIE. Pappaioanou, M., M. Malison, K. Wilkins, B. Otto, R. A. Goodman, R. E. Churchill, M. White, and S. B. Thacker. 2003. Strengthening capacity in developing countries for evidence-based public health: The data for decision-making project. Soc Sci Med 57(10):1925–1937. Schwabe, C. W. 1996. Ancient and modern veterinary beliefs, practices and practitioners among Nile Valley peoples. In Ethnoveterinary research and development, edited by C. M. McCorkle, E. Mathias, T. W. Schillhorn van Veen. London, UK: Intermediate Technology Publications.

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