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2 Making the Case for Zoonotic Disease Surveillance “The difficulty of uncertainty is that we are dealing with things that are likely to emerge at some time and that need attention. We have to per- suade decision-makers to invest in surveillance systems and other actions to deal with these uncertainties in a flexible and responsive way without being able to tell them, with an absolute precision, when they are going to emerge and what their economic or social cost might be.” —Dr. David Nabarro Senior United Nations System Coordinator for Avian and Human Influenza Special Interview with the Committee (September , 00) Recent emerging zoonotic diseases have had significant impacts in in- dustrialized countries, despite well-developed health systems and sanitary infrastructures (Vorou et al., 2007; Jones et al., 2008; Murphy, 2008), and their impacts have been even more devastating for middle-income and developing countries. When emerging diseases become endemic, they not only continue to cause morbidity and mortality in human and animal populations, but also represent a threat of future epidemics if conditions for explosive transmission are reestablished. Emerging infectious disease trends suggest that the frequency of such disease events that are zoonotic in nature will not lessen in the future (McMichael, 2004; Woolhouse and Gaunt, 2007; Jones et al., 2008). If anything, with increasing human and animal populations and changing environments, the trends are more con- sistent with continual increases in the pace of emergence; however, it is simply unknown where or when they will occur (King, 2004; Morens et al., 2004). Disease surveillance represents the eyes and the ears of the global public health effort, systematically generating information that informs actions to contain, control, and mitigate the consequences in at-risk humans and animals. Detecting diseases early through surveillance and implementing early response measures can reduce the scope, magnitude, and cost of emergency response measures downstream. To better predict and prevent zoonotic disease outbreaks, scientific approaches are needed to gather and understand information about the nature of disease appearance and spread, 

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES and to understand genetic-, population-, social-, and ecological-level char- acteristics that enable zoonotic pathogens to jump species and spread easily to humans. National and international support is also critical in addressing this global issue. SOCIOECONOMIC FACTORS AFFECTING ZOONOTIC DISEASE EMERGENCE Humans and animals can serve as pathogen reservoirs and vectors, and pathogens that may have resided in one part of the world can be carried or spread across long distances to become established in another part of the world. Technological advances now allow humans, animals, animal products, and their disease vectors to circumnavigate the globe in the span of 24 hours. Distance is no longer a barrier to disease. For example, in the first half of 2003, the United States saw concurrent importation of two zoonotic agents never before seen in the country—severe acute respiratory syndrome (SARS) and human monkeypox—as well as the establishment of new geographical niches for West Nile virus (WNV), an agent new to the United States and now endemic across the country. That same year, the United States also dealt with its first diagnosed case of bovine spongiform encephalopathy (BSE) despite more than 10 years of broad preventive ef- forts by the government and industry. In 2008, international tourist arrivals reached 924 million (UNWTO, 2009), a number that is estimated to grow annually by 5 percent over the next 20 years (FAO et al., 2008). Globalization and Trade Today, more goods, people, technology, and financial resources flow between countries than ever before, making countries less self-reliant and more dependent on each other. The level of economic interdependence among countries has increased dramatically on a global scale, especially in the past decade, as illustrated in Figure 2-1. In 2008, total global trade stood at $32.5 trillion, almost equally divided between imports and exports (WTO, 2009). In 2008, the total value of food imported into the United States was $75 billion or about 7.5 percent of total imports (Collins, 2007), and more than 25,000 shipments of food regulated by the U.S. Food and Drug Administration1 arrived daily in the United States from more than 100 countries (Koonse, 2008). In particular, the international trade of live animals and animal products 1 The U.S. Food and Drug Administration inspects and monitors the safety of all foods, domestic and imported, except for meat, poultry, and egg products, which are regulated by the U.S. Department of Agriculture.

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Total Expor ts Total Impor ts Agricultural Expor ts Agricultural Imports FIGURE 2-1 Total trade versus total agricultural trade. Agricultural trade data only from 1961–2006. In 2008, total trade imports were valued at $16.1 trillion USD and total trade exports were valued at $16.4 trillion USD.  SOURCES: FAO (2009), WTO (2009). Figure 2-1.eps bitmap image broadside

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0 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES has sharply increased over the past decade (Figure 2-2). Increased trade brings increased movement of animals and animal products, thereby in- creasing the potential for disease emergence from zoonotic pathogens. The global food production system is highly competitive and increas- ingly mobile. With attractive export markets, it often pays for exporting countries to establish the necessary veterinary infrastructure to meet the sanitary requirements of the importing country, as shown by countries such as Thailand for poultry and Brazil for beef. However, even competitive mar- ket economies do not necessarily reward additional investments in animal health infrastructure or encourage disease surveillance to track changing risk factors that might signal the potential emergence of a new disease. This failure to build veterinary capacity is even more relevant in countries where the food-animal production sectors primarily serve the local economy. Only with time and adverse experience are some countries and companies now grappling with disease threats across their production and distribution sup- ply chains, including the possibility of full-fledged disease outbreaks. Evolving Animal Agriculture and Trade To remain economically viable in highly competitive environments and to produce affordable animal protein for the growing global popula- tion, there is continued pressure to seek out economies of size and scale, including expanding or establishing operations in those parts of the world offering favorable cost structures. Thus, the geographic distance between where animals are produced and where ultimate consumption occurs con- tinues to expand. North America currently supplies one quarter of global meat exports (FAO, 2006). Asia has approached the Americas in volume of poultry production in a little more than a decade (see Figure 2-3). Bra- zil is now the largest single country for poultry and beef exports, and its diversified export market enables the movement of products to more than 150 countries (FAO, 2009). Starting with more developed agricultural economies, such as the United States, but then spreading to other countries, much of the agricultural prod- ucts that flow into international trade originate from increasingly capital intensive enterprises and well-coordinated supply chains. On the supply side, improvements in technology, infrastructure, and animal health have all contributed to this growth. Along with improvements in other areas such as genetics, nutrition, and management, the growing recognition of animal and herd health programs has enabled expansion and growth of large-scale animal agriculture. Large-scale production with animal crowding and un- sanitary conditions in some settings has contributed to the use of antibiotics to fight disease, with secondary effects on selection for antibiotic-resistant microorganisms and environmental contamination.

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FIGURE 2-2 International agricultural trade (world imports + world exports) by commodity type, 1961–2006. 31 SOURCE: FAO (2009).

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 FIGURE 2-3 Trends in poultry production. SOURCE: FAO (2009). Figure 2-3.eps

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 MAKING THE CASE FOR zOONOTIC DISEASE SURVEILLANCE For countries such as the United States, the recognition that herds free of selected diseases could be translated into broader social and economic benefits has led to the support and implementation of national disease eradication campaigns. Freedom from brucellosis and tuberculosis not only contributes to the improvement of human and animal health, but has also lowered production costs, thereby establishing an international marketing advantage over countries that are not elevating their level of sanitary health. The public investment in animal health infrastructure includes the capacity to carry out disease surveillance, diagnosis, and treatment, and helps to facilitate export growth by enabling the movement of disease-free animals and related products into new markets and countries. To ensure that such improvements are not jeopardized or compromised, imports of susceptible animals or products are restricted from those countries that have not elimi- nated disease or achieved comparable levels of sanitary health. This allows certain exporting countries to further grow production capacity for domes- tic and international markets, largely through the adoption of standards formulated through the World Organization for Animal Health (OIE).2 The higher level of sanitary infrastructure has provided benefits to both producers and consumers. Producers benefit through factors such as de- creased costs of production (e.g., the extra cost of raising healthier animals is compensated by survival, weight gain, and increased market price), real or perceived increases in product quality, and the ability to meet consumer demand. Consumers benefit from the reduced risk of exposure to zoonotic pathogens. In many parts of the world, the public investment in national animal health infrastructure has not been commensurate with agricultural devel- opment. South and Central America provide more than one-fourth of the world’s agricultural exports (WTO, 2008), yet only 5 percent or so of national government outlays go into agriculture support. Moreover, only 5 to 10 percent of that finds its way into animal and plant health programs, and that is for a limited array of existing pathogens and pests (Pomareda, 2001). In sub-Saharan Africa, where food-animal production contributes about 30 percent of the agricultural gross domestic product (GDP) and is a part of the livelihood of about 150 million people, public expenditure on food-animal production research and development is less than 10 percent of the total public agricultural research expenditure (World Bank, 2008a).3 In addition, private-sector expenditure for agricultural research is low, 2 The Office International des Epizooties (OIE) is also known as the World Organization for Animal Health. OIE formulates standards related to animal health through committees consisting of representatives from member countries that are later adopted in its general as- sembly. OIE is recognized as a technical reference organization on animal health by the World Trade Organization. 3 Adapted from agricultural expenditure data in the 2008 World Development Report.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES although philanthropic organizations have more recently emerged to sup- port crop and livestock research. Emerging Market Economies In 2000, emerging market economies accounted for 56 percent of the global middle class. By 2030, that figure is expected to reach 93 percent; China and India alone will account for two-thirds of this expansion. Rising incomes and growing demand can increase total trade while altering exist- ing and/or creating new trade flows, resulting in new or changing risk fac- tors. For instance, rapidly growing economies fuel an increase in individual wealth, which also increases the demand for meat. In 2007, the average Chinese consumer ate 50 kg of meat, which is more than twice the amount consumed in 1985 (The end of cheap food, 2007). In 2008, an estimated 21 billion food animals were produced for a global population of 6.5 billion people (FAO et al., 2008). Market dynamics also led to more live animal auctions where animals are brought together and then shipped across great distances and traditional “wet markets” where local farmers market their live animals to local con- sumers. These trends contribute to an increase in animal densities and closer contact between humans and animals, with a considerably greater risk of dispersing pathogens. International trade can transcend geographical bar- riers that in the past may have naturally slowed the spread of disease. The global market economy can also amplify disease effects through market in- stability as characterized by price volatility, shifts in consumption patterns, and variability in supplies. International Wildlife Trade Globalization has also impacted the movement of live, wild animals. From 2000 to 2004, more than 1 billion live animals were legally im- ported into the United States from 163 countries (Jenkins et al., 2007; Marano et al., 2007). In 2007 alone, the U.S. Fish and Wildlife Service processed 188,000 wildlife shipments worth more than $2.8 billion, and recorded more than 200 million legally imported live wildlife (CRS, 2008a; Einsweiler, 2008). These animals and animal products were imported for zoo exhibitions, scientific research,4 food and products, and increasingly for the growing commercial pet trade, including many exotic animals (Marano, 4 The U.S. Centers for Disease Control and Prevention (CDC) prohibited the importation of most monkeys as companion animals in 1975, but some imported for research are now being sold in the pet trade. CDC and other enforcement agencies do not track where animals go after quarantine (Ebrahim and Solomon, 2006).

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 MAKING THE CASE FOR zOONOTIC DISEASE SURVEILLANCE 2008). Most of these animals are not required under U.S. law to be screened for zoonotic diseases before or after entering the country (Marano et al., 2007). The effect of this, compounded by the lack of coordination among U.S. government agencies involved in regulating different aspects of wildlife imports, are important reasons for the failure to prevent the introduction of new pathogens into the country (Stephenson, 2003). Some exotic animals and wildlife that are banned from import are able to enter through the illegal wildlife trade.5 These are likely to include less healthy, more risky animals that pose a greater threat to human health and security (CRS, 2008a; U.S. House of Representatives, 2008). Even so, most of the zoonotic diseases reported to be caused by wildlife trade involved imports of legal wildlife (see Appendix B on monkeypox). The European Union (EU) is the top global importer of wildlife and wildlife products by value at €2.5 billion in 2005 (Engler and Parry-Jones, 2007), and it is concerned that increasing demands for wildlife importa- tion is a driver of illegal and unsustainable trade. EU member states have concluded that a major barrier to wildlife trade law enforcement and implementation is their lack of a coordinated strategic approach to monitor compliance (Theile et al., 2004; Engler and Parry-Jones, 2007). A review of the socioeconomic factors that drive the wildlife trade in Southeast Asia, which is both a consumer of wildlife products and a key supplier, revealed the inadequacy of policies and interventions aimed at decreasing the illegal and unsustainable trade of wildlife (World Bank, 2008b). Although poor populations in this region are often involved in wildlife trade, they do not necessarily drive this trade; therefore interventions for poverty reduction are not likely to reduce wildlife exports. Instead, many experts consider that the increased disposable income in consumer countries is the major con- tributor of demand for Southeast Asian wildlife, parallel to the increased access to these markets (World Bank, 2008b). These observations only serve to highlight the complexity of market forces. On the supply side, the illegal logging industry and the bushmeat trade has facilitated the extraction of certain wildlife species and threatened local wildlife populations (Chomel et al., 2007). Refugee camps set up in response to humanitarian crises, such as northwestern Tanzania, have led to serious forest degradation and have provided people with a greater proximity to wildlife habitats to hunt bush- meat, resulting in a decline of wildlife populations (Jambiya et al., 2007). The lack of a single international mechanism that captures data on wildlife trade represents a serious shortcoming of current national and international policies aimed at preventing illegal and unsustainable international wildlife trade (Gerson et al., 2008). 5 The illegal wildlife trade is difficult to quantify, although some estimates range from $5 billion to more than $20 billion annually (CRS, 2008a).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES The Need for Disease Surveillance in Food Animals Improved prevention and disease control efforts in food-animal health has led to multiple benefits for human and animal populations, including reduced human morbidity and mortality, enhanced food security, improved market access for products, economic gains, and savings on potential out- break costs (Caspari et al., 2007). Many countries have strengthened their border controls and quarantine procedures, but the advances and benefits in improving animal health through actions such as disease eradication, prevention, and education have not been uniform across all countries. However, as education has advanced and become more available, surveil- lance and prevention efforts have also advanced and become specialized in areas such as vaccines and diagnostics. Although significant investments are needed to build infrastructure and institutional and regulatory capacity, necessary investments have not yet been made to implement food-animal disease surveillance, diagnosis, and treatment. Countries such as the United States and Australia have made available significant financial and technical resources for international disease eradi- cation or control campaigns, especially in the past 5 years for the control of highly pathogenic avian influenza (HPAI) H5N1 in Southeast Asia. In 2006, the U.S. Agency for International Development (USAID) provided $161.5 million for disease surveillance and pandemic preparedness for avian influenza (CRS, 2008b). In 2009, USAID will award $260 million over 5 years for the Predict and Respond initiatives aimed at four regions of the world prone to zoonotic disease emergence (Grants.gov, 2009a,b). From 2003–2006, Australia’s Agency for International Development committed $152 million to combat avian influenza and other emerging and reemerg- ing zoonotic diseases (AusAID, 2009). The EU has supported major animal disease eradication campaigns in Asia and Africa: Specifically in Africa, the EU partnered with the Organization of African Unity in 1999, providing an overall budget of €72 million for 7 years for the Pan African Programme for the Control of Epizootics (PACE) (OAU-IBAR, 2009). PACE targeted establishing and strengthening sustainable animal disease surveillance in sub-Saharan Africa. HEALTH AND ECONOMIC IMPACTS OF ZOONOTIC DISEASES Human Health Human mortality resulting from emerging zoonotic diseases has been relatively low compared to other leading causes of death from infectious diseases, with the exception of the 1918 influenza pandemic and HIV/AIDS, a zoonosis that now transmits readily among humans. Between 2003 and

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 MAKING THE CASE FOR zOONOTIC DISEASE SURVEILLANCE 2009, there were 421 confirmed human cases of avian influenza A(H5N1), and as of April 23, 2009, 257 deaths were reported to the World Health Or- ganization (WHO) (Figure 2-4). In contrast, between November 2002 and July 2003, 8,096 individuals were diagnosed with SARS, which resulted in 774 deaths (WHO, 2004). As shown in Table 2-1, none of the recent major emerging diseases has led to large fatality numbers. The number of people infected or number of fatal cases, however, are not the only concerns. Impacts on trade and movement of people, economic stability, and panic and societal disintegration based on perception of danger can be seriously disruptive to the global order. 450 30 0 425 40 0 Cumulative D eaths , 2 57 375 250 350 325 30 0 20 0 275 250 Cases 225 150 20 0 175 150 10 0 79 125 59 10 0 43 75 50 33 32 50 7 25 4 0 0 20 03 20 04 20 05 20 06 20 07 20 08 20 09 Total Year Vietnam Myanmar Djibouti Turkey Lao PDR China Thailand Cambodia Iraq Pakistan Indonesia Bangladesh Azerbaijan Nigeria Egypt FIGURE 2-4 Number of confirmed human cases and deaths of avian influenza A (H5N1) reported to the World Health Organization by country and year. Confirmed cases (left axis) and cumulative deaths reported (rights Figure 2-4 color.ep axis) as of April 23, 2009. SOURCE: WHO (2009).

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES on implementing disease surveillance and control. The relationship between UNSIC and the technical agencies—especially WHO, which sees itself as the lead technical agency in human health and pandemic preparedness—is still a challenge (Willitts-King et al., 2008). At the individual level, the three agencies provided a rapid reaction. For example, FAO, with input from OIE, organized an international work- shop in East Asia on HPAI H5N1 only 3 weeks after the first outbreak. FAO became involved quite early with its Special Fund for Emergency and Rehabilitation Activities in the implementation of control measures. This flexible tool, with much lighter administrative requirements than normally demanded in FAO, provided FAO with the flexibility to respond early to the disease outbreaks. The lack of funds, however, caused the initial support that FAO provided in the affected and at-risk countries to be limited and restricted to strengthening disease surveillance systems, providing protective gear, and supporting epidemiological studies. Funding included almost no support in containing the disease, such as support of public administrations to be able to enforce movement control, compensation for culling, and vac- cination. Similarly, WHO focused on the stocking of antivirals, although it could have used its much greater country presence to raise greater aware- ness and train local staff in the epidemiology and control of HPAI H5N1. National Level At the national level, cooperation among the respective ministries of health, agriculture, and the environment in many countries is cumbersome at best. They often have separate human and animal disease reporting procedures and communication channels during a disease outbreak. En- vironmental agencies are the weakest in the public sector, and efforts to bring them together are often confronted with major transaction costs, bureaucratic delays, and competency issues. The main lessons learned from the HPAI H5N1 campaign point to the importance of political support for disease control and the existence of an institutional framework. Political support is crucial for disease control. The picture, which emerges from the reviews, shows ownership and political will at the highest levels to effectively plan and implement HPAI H5N1 campaigns. In several countries, this lack of ownership has led to inadequate interministerial collaboration; grossly insufficient national funding for human, veterinary, and wildlife services; and reluctance to share animal disease incidence information. These trends will severely affect the sustainability of future HPAI H5N1 activities. The institutional framework is another critical element. Key observa- tions that emerge from the reviews concern these factors: (1) the hierarchi- cal place of HPAI H5N1 campaigns in government, and experience in the

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 MAKING THE CASE FOR zOONOTIC DISEASE SURVEILLANCE current campaigns seems to indicate that placement at a higher level (deputy prime minister, ministry of finance) than the line ministries of health or agriculture gives better results7; (2) decentralization, which, with some ex- ceptions,8 severely obstructs lines of command9; (3) the limited simulation testing and the general neglect in the preparation of most national prepared- ness and Integrated National Action Plans; and (4) the limited involvement of the private sector and, in particular, the nearly complete lack of use of private service providers (private veterinarians and paraveterinarians) under a sanitary mandate. Lessons Learned In an early phase of an emerging outbreak, countries need to de- fine a mutually agreed-upon strategy with the international organizations concerned and with other relevant institutions. As was the case with the HPAI H5NI control campaign, it is important to collaborate early on with institutions specialized in environmental health and wildlife. This could be the function of the current UNSIC, whose current mandate expires in De- cember 2010 and would have to be extended. Many developing countries lacked funding for investment in the surveillance of and response to HPAI H5N1. To avoid lack of funds to control an emerging disease at an early stage, sustainable funding is needed for highly infectious zoonotic diseases. To foster cooperation at the national level, governments need to establish special permanent, functional cross-sector coordination mechanisms, either through the exchange of memorandums of agreement between the different ministries and agencies involved, or a coordinating authority (e.g., special task force) above the sectoral human health, veterinary, and environmental agencies (e.g., the prime minister or deputy prime minister). In the case of an emerging disease outbreak, such institutions would define the control strategy, prepare contingency plans, and oversee their implementation; an option would be to let such a task force evolve into an independent agency. Finally, they need to cultivate a new style of leadership that promotes co- operation, teambuilding, and mentoring. This would need to be achieved through education and underpinned by incentive systems, which recognizes achievements in these areas rather than the current performance systems that often promote single department goals and individual achievements. 7 Other disease control campaigns (HIV/AIDS) find that strengthening line ministries might be more efficient. 8 For example, in India, where the identification of HPAI H5N1 was a national priority, with upfront government financial support and technical assistance from the central level, the full cooperation of the states was secured. 9 At the local level, early communication between the human and animal health authorities may reduce the likelihood of the spread of disease from animals to humans.

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 GLOBAL SURVEILLANCE AND RESPONSE TO zOONOTIC DISEASES CONCLUSION Recent human outbreaks of zoonotic diseases have unavoidably re- sulted in increased attention to their impacts on national economies, inter- national trade, household livelihoods, and human morbidity and mortality. Recent socioeconomic changes and the increase in international trade have also been critical drivers of zoonotic disease emergence and spread. Disease surveillance is critical for detecting the emergence of zoonotic pathogens in human populations, preventing their spread between animal populations, and preventing transmission to human populations. The ear- lier an emerging pathogen can be detected and eliminated or controlled, the smaller the emergency response and cost will be. In addition, models of disease transmission have been successful in predicting future zoonotic disease outbreaks and trends. They have been used to make informed de- cisions on the relative risks and benefits of preventive measures aimed at managing the risk at low levels prior to infection. Data from surveillance systems are necessary for more accurately predicting future disease out- breaks. Accurately predicting or anticipating a disease outbreak enables local human and animal health authorities to implement prevention and control efforts, averting the need for costly emergency responses. Accurate prediction is important for preventing an outbreak altogether, decreasing an outbreak’s duration, and lessening its impact on national and household economies and on human health. The case for systematic and sustainable zoonotic disease surveillance, as presented in this chapter, is based on the committee’s conclusion that conditions promoting the driving forces for zoonotic disease emergence are intensifying (further discussed in Chapter 3), that technologies and approaches that could be employed to develop a global system are avail- able, and that the socioeconomic and health consequences for humans and animals are too enormous for inaction. REFERENCES Anderson, R. M. 1988. Epidemiological models and predictions. Trop Geogr Med 40(3): S30–S39. Andrews, N. J. 2009. Incidence of variant Creutzfeldt-Jakob disease diagnoses and deaths in the UK January –December 00. Statistics Unit, Centre for Infections, U.K. Health Protection Agency (HPA). London, UK: HPA. http://www.cjd.ed.ac.uk/cjdq60. pdf (accessed March 25, 2009). Anyamba, A., J. P. Chretien, J. Small, C. J. Tucker, and K. J. Linthicum. 2006. Developing global climate anomalies suggest potential disease risks for 2006–2007. Int J Health Geogr 5(60):60.

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