Workshop Overview1

INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD

Infectious disease is a kind of natural mortar binding one creature to another, one species to another, within the elaborate edifices we call ecosystems.

David Quammen (2007)


The advance of human civilization has brought people, plants, animals, and microbes together in otherwise improbable combinations and locations. While such biological introductions were once rare occurrences, human actions have all but eliminated the spatial and temporal barriers between species and ecosystems (Carlton, 2004). The profound consequences of human-mediated biological introductions include emerging infectious diseases: those caused by pathogens that have increased in incidence, geographic or host range; or that have altered capabilities for pathogenesis; or that have newly evolved; or that have been discovered or newly recognized (Anderson et al., 2004; Daszak et al., 2000; IOM, 1992).

Today, international travel and commerce (most notably the explosive growth of commercial air transportation over the past 50 years) drives the rapid, global distribution of microbial pathogens and the organisms that harbor them (IOM, 2003). These include humans, whose movements have been implicated in the

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The Forum’s role was limited to planning the workshop, and this workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop.



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Workshop Overview1 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD Infectious disease is a kind of natural mortar binding one creature to another, one species to another, within the elaborate edifices we call ecosystems. David Quammen (2007) The advance of human civilization has brought people, plants, animals, and microbes together in otherwise improbable combinations and locations. While such biological introductions were once rare occurrences, human actions have all but eliminated the spatial and temporal barriers between species and ecosystems (Carlton, 2004). The profound consequences of human-mediated biological intro - ductions include emerging infectious diseases: those caused by pathogens that have increased in incidence, geographic or host range; or that have altered capa - bilities for pathogenesis; or that have newly evolved; or that have been discovered or newly recognized (Anderson et al., 2004; Daszak et al., 2000; IOM, 1992). Today, international travel and commerce (most notably the explosive growth of commercial air transportation over the past 50 years) drives the rapid, global distribution of microbial pathogens and the organisms that harbor them (IOM, 2003). These include humans, whose movements have been implicated in the 1The Forum’s role was limited to planning the workshop, and this workshop summary has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. 

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD spread of diseases, including influenza (IOM, 2005); severe acute respiratory syndrome (SARS; IOM, 2004); drug-resistant malaria (IOM, 2003; Martens and Hall, 2000); and chikungunya2 in Europe (Angelini et al., 2007). Indeed, it is pos- sible to travel between most places in the world in less time than the incubation period for many infectious diseases (Wilson, 2003), as was illustrated in spring 2009 by the rapid, global spread of the new, swine origin, influenza A (H1N1) virus (Dawood et al., 2009; Khan et al., 2009). Travel is not only becoming increasingly rapid and more socially wide - spread, but is also more ubiquitous. Travelers and tourists connect once-remote areas, which serve as both “sources” and “sinks” for emerging infectious dis - eases, to more developed regions. International trade in food and other agricul - tural commodities, as well as in wildlife, has also increased markedly among an ever-widening network of producers and markets. Pathogens accompany live animals, plants, and their byproducts across continents and oceans; microbes and vectors also hitch rides in ballast water3 and in shipping crates and containers. Upon arrival in industrialized countries, such as the United States, potentially disease-containing goods can be redistributed nationwide within hours. Travel and trade have been linked with disease since antiquity. People instinctively feared and isolated ill travelers long before the causative agents of infectious diseases were known or described (Gushulak and MacPherson, 2000). Quarantine laws, established to prevent the importation of plague—without success—in fourteenth-century Venice, were eventually adopted throughout Europe and Asia (Fidler et al., 2007; Markel et al., 2007). International endeavors to contain infectious diseases commenced more than 150 years ago and are today embodied in the International Health Regulations (IHR), which provide the legal framework for global cooperation on infectious disease surveillance (IOM, 2007; Stern and Markel, 2004). While ideally there are strong incentives for nations to support global efforts to address infectious disease threats, such efforts have from their outset been characterized by a lack of authority for enforcement and weak inducements for participation (Stern and Markel, 2004). More subtly, but no less importantly, introduced animals, plants, and microbes can disrupt ecosystems in ways that increase the potential for infectious disease outbreaks. Such changes can be more difficult to predict than the movements of pathogens, and more daunting to prevent. The term “invasive species” is widely used to describe plants and animals that spread aggressively when introduced to and established in new environments freed from the constraints found in their native environments (Dybas, 2004). Given both the similarities and characteris- tics of such invasions with those of pathogenic microbes, it may prove fruitful to view the origins of disease emergence, establishment, and spread through the 2A mosquito-borne viral disease. 3Water that is loaded and unloaded to balance cargo weight in ships.

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 WORKSHOP OVERVIEW larger ecological lens of invasive species, and consider intervention strategies and approaches aimed at preventing and mitigating the far-reaching consequences of biological invasions. On December 16 and 17, 2008, the Institute of Medicine’s (IOM’s) Forum on Microbial Threats hosted a two-day public workshop in Washington, DC, on Globalization, Movement of Pathogens (and their hosts), and the revised IHRs. Through invited presentations and discussions, participants explored a variety of interrelated topics associated with global infectious disease emergence, detection, and surveillance including the historical role of human migration and mobility in pathogen and vector movements; the complex interrelationship of travel, trade, tourism, and infectious disease emergence; national and international biosecurity policies; and obstacles and opportunities for detecting and containing globalized pathogens, thereby reducing the potential burden of emerging infectious diseases. Organization of the Workshop Summary This workshop summary was prepared for the Forum membership in the name of the rapporteurs and includes a collection of individually authored papers and commentary. Sections of the workshop summary not specifically attributed to an individual reflect the views of the rapporteurs and not those of the Forum on Microbial Threats, its sponsors, or the Institute of Medicine. The contents of the unattributed sections are based on the presentations and discussions at the workshop. The workshop summary is organized into chapters as a topic-by-topic description of the presentations and discussions that took place at the workshop. Its purpose is to present lessons from relevant experience, to delineate a range of pivotal issues and their respective problems, and to offer potential responses as discussed and described by the workshop participants. Although this workshop summary provides an account of the individual pre- sentations, it also reflects an important aspect of the Forum philosophy. The work- shop functions as a dialogue among representatives from different sectors and allows them to present their beliefs about which areas may merit further attention. The reader should be aware, however, that the material presented herein expresses the views and opinions of the individuals participating in the workshop and not the deliberations and conclusions of a formally constituted IOM consensus study committee. These proceedings summarize only the statements of participants in the workshop and are not intended to be an exhaustive exploration of the subject matter or a representation of consensus evaluation. Globalization: Processes, Patterns, and Impacts The inexorable migration of the human species has profoundly influenced Earth’s ecology. As our ancestors wandered across the African continent, onward

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD BOX WO-1 Factors Involved in Infectious Disease Emergence • International trade and commerce • Human demographics and behavior • Human susceptibility to infection • Poverty and social inequality • War and famine • Breakdown of public health measures • Technology and industry • Changing ecosystems • Climate and weather • Intent to harm • Lack of political will • Microbial adaptation and change • Economic development and land use SOURCE: Reprinted from Lancet Infectious Diseases, Morens et al. (2008), with permission from Elsevier. to Asia, Australia, Europe, and eventually to the Americas, as we explored the ends of the Earth and beyond the confines of this planet, the vast entourage of animals, plants, and microbes that have accompanied us on our journeys has only amplified the impact of our species on every ecosystem that we have encountered. Among these “fellow travelers,” pathogens have flourished in new surround- ings, while other microbes have colonized incoming migrant host species. Such introductions, abetted by additional genetic, biological, social, and political fac - tors associated with infectious disease emergence (see Box WO-1), have given rise to epidemics throughout recorded history (IOM, 2003; Morens et al., 2008). The current era of “globalization” affords frequent and widespread opportunities for disease emergence, several of which are described in detail in later sections of this overview. This section summarizes two presentations that opened the work - shop by exploring the history and ongoing political and public health significance of human migration and mobility. Human Migration: Past, Present, and Future In his overview of the history of human migrations, speaker Mark Miller, a professor of comparative politics at the University of Delaware, emphasized migration’s growing political importance (see Miller in Chapter 1). Considering

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 WORKSHOP OVERVIEW the present status of global migration as an indicator of future trends, he observed that, “increasingly, the questions of peace and war revolve around migration.” Highlights of Miller’s whirlwind tour of historic migrations included the fourth- century convergence of a “crazy quilt” of ethic groups to establish the country we now call France; the movement of Celts and Jews into Europe; the travels of Vikings throughout the North Atlantic; and the eastward migration of Germans, counter to other population flows across Europe. He noted that between 8000 B.C.E. and the seventeenth century, four civilizations achieved “a rough kind of equilibrium” on the Eurasian steppe: one was derived from Greece and Europe, one was of Middle Eastern origin, another was Indian, and the last was Chinese. Following that era, Miller noted, Europeans migrated to the Americas driven by several factors, including: • A population explosion in Europe, • Development of resistance to diseases of the New World, • The advent of capitalism, and • The availability of affordable long distance travel. Despite the fact that this influx of Eastern Europeans at the end of the nineteenth and beginning of the twentieth centuries led to the emergence of the United States as a world power, American suspicion of the “foreign born” greatly restricted immigration between World War I and the 1960s.4,5 A “new age of migration” began in the 1970s, when longstanding migration patterns reversed, rendering Europe a destination for immigrants. Concurrently, Latin America became a net source of new migrants to the United States, and immigration from Asia and Africa also increased. Today, as a result of what Miller called the single most important relationship in the New Age of Migra- tion, approximately 10 percent of Mexico’s population resides in the United States, and Mexicans comprise about 5 percent of the U.S. workforce. These circumstances are “emblematic of the increasing impact of migration around the globe,” he concluded. Miller predicted that as the global population grows unevenly—faster in developing countries, more slowly and even negatively in developed countries— migration will increase (see also Gushulak and MacPherson in Chapter 1). “Thirty years ago there were two Europeans for every African,” he noted, citing United 4The first major wave of immigration to the United States, between 1820 and 1860, largely involved English, Scotch, Irish, and Germans. The second wave included eastern Europeans (which encom - passes many different ethnic groups including Russian and Polish Jews, people from the Balkans, and southern Italians), and in much smaller numbers Chinese, Korean, and Japanese, as well as Mexicans from the south. 5The passage of the quota systems described in the Immigration Act (Johnson-Reed Act, 43 Statutes- at-Large 153) was in 1924; it was rescinded by the Immigration and Nationality Act (Hart-Cellar Act, P.L. 89-236) of 1965.

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD Nations population estimates. “Today there are about equal numbers of Africans and Europeans. In 30 years, there will be twice as many Africans as Europeans.” These differences are likely to produce a world of regions that differ greatly from each other, he continued, with “fundamental differences separating the rich countries from the poor countries.” Population Mobility and Public Health While migration issues have become increasingly salient in politics and diplomacy, Miller observed that relatively little attention has been paid to the relationship between migration and health.6 Yet as speaker Brian Gushulak, of the Canadian Immigration Department Health Branch, explained, this link is becom - ing increasingly crucial, as the widening economic gap separating countries and regions both contributes to, and results from, health disparities. “It is possible to look at migration and population mobility as a metaphor for the evolution of public health and public health security,” Gushulak remarked, as he traced the history of public health through the various means advanced against introduced diseases (see Gushulak and MacPherson in Chapter 1). Echo - ing Miller’s conclusion that we have reached a new age of unprecedented migra - tion, Gushulak noted that in the mid-1990s, approximately 200 million people—a population exceeding that of all except the worlds’ four largest nations—fit the United Nation’s definition of “migrant.” Several major changes to immigration ushered in the current era: • Post-colonial population flows; • Refugee movements and displacements associated with humanitarian emergencies and conflicts; • The development of the concept of human capital and employment of international temporary workers; and • The increasing ease and declining cost of international transportation. Together, these factors have produced unprecedented demographic changes in receiving countries, rendering disease control processes and policies based on historical patterns of migration irrelevant, according to Gushulak. “We simply can’t keep up on a policy level as fast as the ground is changing underneath our feet,” he said. Modern human movements and migration practices have also become increasingly difficult to characterize, due to the diverse origins of migrants, 6Thereis a wealth of medical historical literature on the topic. See Fairchild (2003), Kraut (1995), and Markel (1997, 2004). There have also been dozens of immigrant health articles in the Journal of the American Medical Association, New England Journal of Medicine, and other prominent medical journals in the recent past, including recent outbreaks of cholera among migrants.

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 WORKSHOP OVERVIEW their often complex journeys, the variety of their experiences upon arrival and resettlement, and the frequency with which many migrants return to their coun - tries of origins for varying lengths of time. Moreover, in addition to migration in the traditional sense (the one-way movement of people from one homeland to another), nonmigratory human travel and trade7 provide pathogens with a wealth of possibilities for relocation. Gushulak employed the more encompassing term “mobility” to describe this collection of processes, all of which contribute to the phenomenon of globalization. Since pathogens readily cross geopolitical borders, only “functional disease- based borders” matter, Gushulak argued. These boundaries occur between regions that differ not only in terms of disease epidemiology, but also reflect general health disparities due to socioeconomic factors such as poverty, education, housing, nutrition, and access to care (see Figure WO-1). Mobile people (as well as animals and plants) serve as biological bridges between such disparate regions, thwarting attempts to confine infectious diseases within—or exclude them from—national borders. Controlling the spread of infectious diseases across such functional borders will require international cooperation in surveillance and report- ing, Gushulak concluded, and mitigation or intervention strategies that focus on mobility as a determinant of global public health, rather than on the containment of specific diseases. Travel, Conflict, Trade, and Disease In discussions that focused on the rapid acceleration and expansion of inter- national travel and trade as a catalyst of pathogen movements, workshop par- ticipants considered various ways in which the movement of people and goods influences the transmission dynamics of infectious diseases, and how these influ - ences might be better understood in order to reduce the global burden of emerging infectious disease. Workshop presentations examined the role of the traveler as a sentinel—as well as a vector—for disease; the role of armed conflict in increas - ing infectious disease risks; the complex and multifaceted relationship between trade and disease; and the numerous and diverse risks associated with a global- ized food supply. Traveling Pathogens Figures WO-2, WO-3, and WO-4 provide graphic illustrations of the cur- rent state of global connectivity afforded by planes and ships (as well as cars, trucks, and trains) that transport infected travelers, goods, and disease vectors rapidly across vast distances. They also allow adventurous travelers to enter new 7 Includingthe exchange of animal- and plant-based items such as bush meat and homeopathic medicines between migrants and family members or friends residing in their country of origin.

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 Azerbaijan Armenia Middle East inset Europe inset Norway Turkmenistan Turkey Estonia Sweden Health-Car e Capabilities Cyprus Latvia Syria Lebanon Lithuania Iraq Ir an Denmark Pal. Afg. Israel Rus. Auth. United Netherlands Jordan Ireland Kingdom Kuwait Poland Germany Bahrain Boundary representation is Egypt Belgium not necessarily authoritative. Czech Lux. S aud i Republic Qatar Slovakia U.A.E. Arabia Austria Hungary Caribbean inset France Switz. Iceland Slovenia Oman San Bos. & Serbia Sudan Finland Croatia Her. Marino R us s i a Kos. Cana da Andorra Monaco Mont. Eritrea Ital y Mace. Yemen Belarus Albania Area of Spai n Ukraine Europe Ethiopia Djibouti Kazakhstan Moldova inset Mongolia Romania Uzbekistan Bulgaria Georgia Kyrgyzstan North Malta Portugal Korea U nited Sta tes Tajikistan Greece South Korea Tunisia Afghanistan Chin a Morocco Japan Bhutan Algeria Nepal Pakistan Libya The Bahamas Western Sahara Mexico Taiwan Burma Indi a Area of Laos Mauritania Caribbean Mali Bangladesh Vietnam Belize Niger inset Thailand Senegal Chad Burkina Philippines Guatemala The Gambia Cambodia Sudan Faso Federated States Marshall Guinea-Bissau Nigeria El Salvador of Micronesia Area of Guinea Islands Suriname Benin Palau Sri Lanka Honduras Ethiopia Cen. Afr. Brunei Middle East Sierra Leone Rep. French Guiana Cameroon Nicaragua Liberia inset Somalia (France) Maldives Malaysia Ghana Equa. Costa Rica Dem. Uganda Gui. Cote Togo Singapore Rep. Kenya d’Ivoire Kiribati Gabon Ecuador Nauru of the Indonesia Rwanda Sao Tome Seychelles Congo Papua New & Prin. Rep. of Burundi Tanzania Guinea Solomon Tuvalu the Congo Peru Islands Comoros Timor-Leste Brazil French Polynesia Samoa Angola Malawi (France) Zambia Fiji Tonga Vanuatu Bolivia Madagascar New Caledonia Mauritius Botswana Zimbabwe (France) Paraguay Namibia Mozambique Australia Swaziland South Caribbean inset Africa Lesotho Uruguay The Bahamas New Chile Argentina Zealand Cuba Dominican St. Kitts Republic and Nevis E x cellent Good Fa ir Po or U nsuita bl e Antigua and Haiti Jamaica Barbuda Countries with developed health-care infrastructure, Countries with least developed health-care infrastructure. Countries with less developed health-care infrastructure. Countries with developed health-care infrastructure. Countries with modern health-care infrastructure, Guadeloupe (France) with quality care available to a large percentage of Medical care generally is unavailable or much of the Medical care is unavailable to large sectors of the Medical care generally is available, but relatively large providing high-quality care to most of the population. Dominica the population. population is poorly served. Primary, secondary, and Martinique (France) population. Tertiary care is minimally available; primary sectors of the population lack adequate care. Tertiary St. Lucia tertiary health care availability depends on humanitarian and secondary health care is rudimentary. care generally is available, at least in major urban St. Vincent and the Grenadines Barbados organizations. areas; primary health care exists but is underdeveloped. Netherlands Grenada Antilles (Neth.) Trinidad Pharmaceuticals usually are available; production Pharmaceutical availability depends on humanitarian Pharmaceutical availability generally is restricted to Pharmaceutical availability is good in urban areas; Pharmaceutical availability and production capability and Panama Tobago capability is adequate. organizations. urban areas, but production capabilities are limited. minimally available in rural areas. Production capabilities are excellent. are generally limited but may be under rapid development. Ve nezuel a Guyana Upper-middle-income economies, with sufficient Health expenditures depend on outside assistance; Lower-income economies; significant support Lower-middle-income economies; budgetary resources These high-income economies have more than budgetary resources to meet the needs of the population. lowest income economies. Suriname provided by outside assistance. generally are available but often are not efficiently used. sufficient budgetary resources. Colombia Health care is a high national priority. Health care is not a national priority. Health care is a low national priority. Health care is of national importance but may be Health care and public health education are a Br azil overshadowed by other pressing demands high national priority. (i.e., political instability, conflict). Source: National Center for Medical Intelligence. FIGURE WO-1 Typology of countries by health care status. SOURCE: NIC (2008b). Figure WO-1 COLOR.eps landscape

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 WORKSHOP OVERVIEW 10 25000 FIGURE WO-2 The rate of globalization has accelerated to the point where we are con- nected as never before via globalized travel -2 COLOR.eps Figure WO and trade networks. bitmap SOURCE: Reprinted with permission from Hufnagel et al. (2004). ecosystems and pick up new pathogens, which may then return with the traveler to a new environment and, under appropriate circumstances, persist and spread through new host populations. The mobility of the global biota is one among many interacting factors that contribute to infectious disease emergence: growing populations of humans and food animals living in increasingly close proximity to each other, climate change and extreme weather events, and changes in land use (IOM, 2003). This upheaval occurs against a backdrop of microbial evolution, remarked Mary Wilson of Harvard University, whose presentation explored the influence of human travel on the geography of infectious diseases, as well as the role of the traveler as a disease sentinel (see Wilson in Chapter 2). She noted that, in addition to enabling pathogens to span vast distances through direct transmission, travel also introduces antimicrobial resistance genes to new populations. Some pathogens spread quickly upon introduction to a new environment, while others do not survive the transition for lack of an appropriate environment, vector, or host, Wilson observed. Introduced pathogens may meet with vulnerable

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0 FIGURE WO-3 World waterways network. SOURCE: Figure derived from the Ship Traffic, Energy, and Environment Model (STEEM) developed at the University of Delaware (Wang, 2006; Wang et al., 2007).

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 WORKSHOP OVERVIEW FIGURE WO-4 International tourist arrivals by region (in millions), 1950-2020. SOURCE: Reprinted with permissionWO-4 COLOR.eps Figure from the UNWTO (2008). bitmap hosts—for example, people with low levels of immunity to the pathogen, or those who live in a community with poor housing, water quality, and sanitation—or with resilient ones. If an introduced pathogen produces an epidemic, it may or may not be easy to control. The ease with which spread of infection can be inter- rupted is determined, to a large extent, by the proportion of transmission that occurs before the onset of symptoms or during asymptomatic infection (Fraser et al., 2004). For this reason, Wilson explained, SARS was relatively easy to control, while HIV/AIDS continues to spread, unabated, as a “silent” pandemic. 8 Vector-borne pathogens can travel with relative ease in the blood of viremic hosts, such as human travelers, and upon introduction to a new environment with competent vectors, spread quickly through a new host population, Wilson said. This scenario appears to have occurred in the recent emergence of chikungunya fever in new geographic areas and the expanding distribution of dengue viruses in tropical and subtropical areas. A recent study of trends in emerging infectious diseases finds that emergent events involving vector-borne diseases are occurring with increasing frequency (Figure WO-5; Jones et al., 2008). Travelers as Sentinels Travelers represent an important sentinel population for disease emergence, according to Wilson, who added that several surveillance networks have been devel- oped to monitor infectious diseases in travelers. She is involved in the decade-old 8AIDS is thought of as a “silent pandemic” because the symptoms of illness are not readily apparent until the “end stage” of illness.

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0 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD • Overall risks to human life and health are expanding and accelerating, • Incentives for political disagreement are increasing, • Limitations on governance mechanisms are increasingly apparent, and • Vulnerabilities of societies to “pathogen politics”19 are deepening. While these realities present significant challenges to the implementation and impact of IHR 2005, Fidler said, other international governance mechanisms have proven comparatively weak and ineffective in addressing the many and various drivers of infectious disease emergence and spread (e.g., migration, envi - ronmental and climate change, antimicrobial resistance, armed conflict). These failures reinforce the importance of the IHR 2005 to the future of global health, he concluded. Greater recognition of the potential of the IHR 2005 to promote global secu - rity is key to their effective implementation, Heymann added. In the face of the current global recession, he offered two arguments to dissuade those who might favor reducing support for IHR 2005 implementation: its importance to public health security and therefore, to overall global security; and to preserve the foun - dation of health for economic development and redevelopment. Bell’s presentation, entitled “Global Trade Security Depends on Implementa- tion of the IHR,” echoed Heymann’s arguments, and explored how trade and tour- ism stakeholders (e.g., international corporations, industry and trade associations, ministries of trade and tourism) might support various aspects of the implementa- tion of IHR 2005 (see Bell in Chapter 5). For example, Bell envisioned that an international scheme to compensate individuals or countries for economic hard - ships resulting from infectious disease outbreaks could be created as a public- private partnership involving trade and tourism stakeholders, and structured as a trust fund or insurance product. “Business, trade, and tourism stakeholders, and those who support them, such as the insurance industry, have a strong vested interest in working with public health authorities to promote global health security,” according to Bell (2008). “The IHR also promote global trade security, which may be provision - ally defined as maintenance of a stable trade environment by promotion of safe and unhindered travel and transport, stability of supply and distribution chains, continuity of business operations, and safety of imports and exports. . . . For businesses, industry associations, and international trade organizations and their member states, promoting IHR implementation is good risk management, since the risk of business and trade disruption is reduced in countries where the IHR are implemented.” Speaking informally with business leaders, Bell found that most had never 19 Dr. Fidler defines pathogen politics as the exercise of political power, the convergence and diver- gence of political interests, and the use of political processes in national and international responses to threats posed by pathogenic microbes.

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 WORKSHOP OVERVIEW heard of the IHR. However, he added, “they immediately understood its impor- tance to them once the issues were explained. Their question was, what exactly do you want us to do, what might the next steps be?” although their interest was subsequently diverted by the global recession. Revision of the IHR was one of the highest global health priorities of the U.S. government, but it risks sitting on the shelf because support for its global implementation is lacking. One World, One Health®20 Recognizing the importance of zoonoses as emerging diseases and the eco- nomic impact of animal diseases, several workshop participants advocated expand- ing the purview of surveillance under IHR 2005 by linking its human infectious disease networks with those focused on animal diseases. A similar argument was made to integrate infectious and foodborne disease surveillance by speaker David Nabarro of the United Nations (UN), among others. Nabarro, who serves as the UN’s coordinator for avian and human influenza, as well as for global food secu- rity, applauded the advent of such an integrated strategy, known as One World, One Health®, which he characterized as seeking “new ways of aligning action to better address diseases that emerge at the interface between animals and humans in dif- ferent ecosystems” (Schnirring, 2008). Speaker Ottorino Cosivi of the WHO described the development of the One World, One Health® strategic framework, which evolved from lessons learned in efforts to address the threat of pandemic avian influenza. Partners in this frame - work currently include the WHO, the Food and Agriculture Organization of the UN (FAO), the World Organisation for Animal Health (OIE), the UN Children’s Fund (UNICEF), and the World Bank. The concept of One World, One Health® is embodied in projects such as the Global Early Warning and Response System for Major Animal Diseases, Including Zoonoses (GLEWS), which is jointly operated by the FAO, OIE, and the WHO (WHO, 2009a). Role of the OIE Further alignment of human and animal disease surveil- lance efforts appears promising based on comparisons between surveillance as 20 One World, One Health® is a registered trademark of the Wildlife Conservation Society. Health experts from around the world met on September 29, 2004, for a symposium focused on the cur- rent and potential movements of diseases among human, domestic animal, and wildlife populations organized by the Wildlife Conservation Society and hosted by The Rockefeller University. Using case studies on Ebola, avian influenza, and chronic wasting disease as examples, the assembled expert panelists delineated priorities for an international, interdisciplinary approach for combating threats to the health of life on Earth. The product—called the “Manhattan Principles” by the organizers of the “One World, One Health®” event—lists 12 recommendations for establishing a more holistic approach to preventing epidemic/epizootic disease and for maintaining ecosystem integrity for the benefit of humans, their domesticated animals, and the foundational biodiversity that supports us all. For more information, see http://www.oneworldonehealth.org/ (accessed July 16, 2009).

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD conducted under the IHR 2005, and through the OIE’s World Animal Health Information System (WAHIS), by speaker Alejandro Thiermann of the OIE (see Chapter 5). He described that organization’s efforts to address animal disease to ensure animal health worldwide, food safety and safeguard global trade, which parallel those of the WHO. Member countries are bound to report cases that meet any of the following criteria to the WAHIS: diseases with potential for international spread, apparent emerging diseases, diseases with zoonotic poten - tial, and diseases that show significant spread in naïve populations. OIE reviews and immediately publishes such reports on its World Animal Health Information Database (WAHID), accessible by all member countries. When appropriate, OIE also issues early warnings on a webpage. Unlike IHR 2005, WAHIS can only publish official information, submitted by its delegates (the chief veterinary officers of its member countries), Thiermann explained. Nevertheless, he added, through collaborations with other surveil - lance networks, including those operated by the WHO, the OIE searches non- official sources of information for indications of “notifiable” disease events. When evidence of such an event is detected, the information is submitted to that country’s delegate for immediate confirmation or denial. In some cases, the OIE has posted alerts based on such information in the absence of official con - firmation, Thiermann said. For example, when Chinese officials did not confirm unofficial reports indicating the presence of avian influenza in ducks in southern China, the OIE nevertheless proceeded to notify its members. Official confirma - tion was forthcoming from China, but not until 24 hours after this information was posted. Thiermann noted that when a disease event occurs at the interface of animal and human health, ministries of health and agriculture within the same country often respond differently; in such cases, only the WHO, or only the OIE, may be notified. These situations are best managed through “a close collaboration” that enables the exchange of information between the two organizations, and a joint response to zoonotic threats, he said. Organizations with surveillance and response functions for zoonotic diseases—particularly OIE, FAO, and WHO— need to continually share and collaborate, he concluded. Role of the WHO A variety of interagency collaborations promote the early detection and control of disease at the animal-human interface, according to Cosivi (see Chapter 5). He described a series of such formal agreements and joint programs involving the WHO, and frequently, the OIE and the FAO as well, dat- ing back to 1948. In addition to the previously described GLEWS and GOARN, these include the following: • The International Food Safety Authorities Network (INFOSAN), which disseminates information and fosters international collaboration on food safety (WHO, 2007);

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 WORKSHOP OVERVIEW • Global Salm-Surv, which promotes integrated laboratory- and epidemiology- based foodborne disease surveillance (WHO, 2009c); and • The Mediterranean Zoonoses Control Program, which supports the pre- vention, surveillance, and control of zoonoses and foodborne diseases and serves as a platform for interagency collaboration for country-level capacity building to address these diseases (WHO, 2009b). Cosivi described the development of the “One World, One Health®” strategy as a paradigm shift in public health, from the “response and rehabilitation mode” characterized by initial attempts to address avian influenza, to prevention and preparedness for all emerging infectious diseases. “To prevent human diseases,” he concluded, “we need to increase attention to prevention, surveillance, and control in wild and domestic animal health, animal production and food systems, and the environment.” Building Capacity and Trust In order to build on the foundation provided by the IHR 2005 and the “One World, One Health®” strategic framework, according to Nabarro the following three challenges must be resolved (see Chapter 5): 1. Implementing adequate systems and capacities to conduct global sur- veillance and respond to global public health emergencies (e.g., animal surveillance for H5N1 influenza); 2. The need to engage all stakeholders, and particularly the private sector, in global disease surveillance and response, recognizing that some key groups do not perceive such action to be in their best interest; and 3. Most importantly, to create the most important incentive for participation in global health initiatives: trust. Building capacity In addition to previously described workshop discussions that addressed Nabarro’s first point, regarding the need for capacity-building (and for funding to support it), Tomori advocated equal emphasis on the national and international spread of diseases. “The practice of ‘dangling the carrot’ of international resources for responding to a disease outbreak (e.g., vaccines, funding, and foreign expertise) as an incentive for reporting such an outbreak may undermine the determination of resource-constrained countries to develop, strengthen, and maintain national core surveillance and response capabilities,” he contended (see Tomori in Chapter 4). “Moreover, it is far more efficient to contain disease outbreaks than to respond to full-blown epidemics.” Making a similar argument from a global perspective, Forum member Terence Taylor, of the International Council for the Life Sciences, observed that in an age of mobile populations such as those described by Gushulak (see Chapter 1), border

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD biosecurity “is less important than building . . . national core infectious disease surveillance capacity.” Tomori stated that countries should be encouraged to develop the capacities to report, detect, and investigate suspected disease outbreaks and thus prevent sporadic cases from escalating to epidemics, and that more resources be provided for establishing and maintaining disease surveillance systems at the national level. He described the establishment of the acute flaccid paralysis (AFP) surveil- lance system, backed by an African region-wide laboratory network, as a model for such national surveillance systems. The only way to make progress on global health governance is to empower countries to develop their own surveillance capacities, Nabarro said. Developing countries must be encouraged to work with other countries in their subregions to develop networking and common approaches across nearby borders, but such efforts have to originate within countries, he insisted. Engaging all stakeholders Nabarro, whose remarks focused on the issue of conducting effective global disease surveillance and response in an atmosphere of increasing suspicion toward the value of globalized initiatives, recalled that, for a time, the threat of pandemic avian influenza generated “unity of purpose and synergy of action.” Although occasional discord arose, coordination between donors, foundations, national governments, regional bodies, and international nongovernmental groups was strong. “What was the incentive that brought so many disparate groups to work together as if in a strong magnetic field, and not to lose their separateness? Answer: It certainly wasn’t cash,” Nabarro said, because although money was available, it moved slowly, and little of it made it to those organizations that were working in concert. Instead, he observed, these groups were motivated to join a global movement. “They found it both attractive and at the same time comforting . . . to be coherent, to be together, to be joint stakeholders within a movement,” he concluded, adding that the same force has motivated recent collaborations to address HIV/AIDS, and to eradicate polio (as described by Heymann; see Chapter 1). “I believe that the best incentive for working together on surveillance, on reporting, on response, is the creation of a movement that is open enough, strong enough, inclusive enough, to enable hundreds of different stakeholders to feel at home inside it,” he concluded. Two Forum members—Gail Cassell, of Eli Lilly, and Phil Hosbach, of Sanofi Pasteur—urged that such collaborations include another stakeholder in global disease control not mentioned specifically by Nabarro: the pharmaceutical industry. For example, Hosbach said, pharmaceutical companies represent the solution to one of the critical challenges to influenza surveillance. “The benefits- sharing that these countries are looking for is . . . [protection] from influenza, and what better way to do that than with vaccine?” he asked. Heymann agreed that industry had served as “a faithful partner in the influenza pandemic and vaccine

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 WORKSHOP OVERVIEW production,” but he maintained that pharmaceutical companies have not “brought to the table any solutions to make vaccines available.” Resolving this impasse would require dialogue between global public health and industry groups, focused on solving this critical problem, he observed. Building trust “You can’t get results on control of H5N1 or other diseases through compulsion,” Nabarro continued. “If you compel, then people start to hide, they fail to explain, they don’t involve themselves. So it is absolutely essential to build the necessary trust so that the work can progress.” Moreover, he said, mistrust among stakeholders in a common enterprise, such as global disease surveillance and response, must be anticipated, insured against, and addressed as soon as it arises. The United States has been the strongest and most consistent leader in pro - moting global collaborations to address H5N1 influenza over the past three years, Nabarro said. While he encouraged the United States to continue this leadership, despite the risks involved, he also encouraged inclusiveness. Likening the role of the United States as the builder of a tent to be occupied by a host of stakeholders in global health, he advised the country to “make the tent so it is big enough, but also so that it is open enough . . . [and] exciting enough to bring people in.” Toward Resilience Workshop participants were compelled to discuss the unfolding worldwide economic crisis and its possible repercussions for global public health. Nabarro suggested that any among a range of potential shocks—including pandemic dis- ease, climate change, food crisis, and recession—would have similar effects on a given community or individual household, depending upon its overall resilience. “The stronger, most resilient households will survive,” he said, and “in many cases . . . resilience can be surprising.” Less resilient households, particularly those that have recently moved from a subsistence into the market economy, will not be so fortunate, he continued, and are likely to decline into subsistence; this will be especially likely for women-headed households and those in which a breadwinner becomes ill or disabled. Therefore, in the context of global recession, and in order to prepare people, communities, and countries to withstand any of the various threats looming on the horizon, Nabarro advocated the promotion of resilience. He noted that the World Bank has taken a leadership role in this effort, but this effort will require a multifaceted approach that includes public health. He also advocated continued support, led by the United States, for development assistance “geared toward efficient action, leverage, and [the] empowerment of local communities to do more for themselves.” Reflecting on workshop presentations and discussions that encompassed his- tory, public health policy, ecology, and medical science, Relman considered the

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 INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD relationship between diversity and resilience. “Is there an aspect of diversity that predicts resistance to perturbation?” he asked. “One might look for this feature in patterns of diversity amongst susceptible host species or in diversity amongst local response mechanisms, or both, to mention a few possibilities.” “It sounds to me as though many people are suggesting that there is no one global fix for the kinds of problems we are talking about,” Relman continued. Rather, he concluded, we are presented with a set of possible local solutions, based on common principles, which can be adapted and strengthened to support specific ecosystems, communities, and public health capacities. OVERVIEW REFERENCES Anderson, P. K., A. A. Cunningham, N. G. Patel, F. J. Morales, P. R. Epstein, and P. Daszak. 2004. Emerging infectious diseases of plants: pathogen pollution, climate change and agrotechnology drivers. Trends in Ecology and Evolution 19(10):535-544. Angelini, R., A. C. Finarelli, P. Angelini, C. Po, K. Petropulacos, G. Silvi, P. Macini, C. Fortuna, G. Venturi, F. Magurano, C. Fiorentini, A. Marchi, E. Benedetti, P. Bucci, S. Boros, R. Romi, G. Majori, M. G. Ciufolini, L. Nicoletti, G. Rezza, and A. Cassone. 2007. Chikungunya in north- eastern Italy: a summing up of the outbreak. Eurosurveillance 12(11):E071122.2. Bell, D. M. 2008. Of milk, health and trade security. Far Eastern Economic Review 178(8):34-37. Bertozzi, S., A. Kelso, M. Tashiro, V. Savy, J. Farrar, M. Osterholm, S. Jameel, and C. P. Muller. 2009. Pandemic flu: from the front lines. Nature 461(7260):20-21. Carlton, J. 2004. Invasions in the world’s oceans: how much do we know, and what does the future hold? Presentation given at the American Institute of Biological Sciences annual meeting, March. CDC (Centers for Disease Control and Prevention). 1990. Update: Ebola-related Filovirus infection in nonhuman primates and interim guidelines for handling nonhuman primates during transit and quarantine. Morbidity and Mortality Weekly Report 39(2):22-24, 29-30. ———. 2003. Multistate outbreak of monkeypox—Illinois, Indiana, and Wisconsin, 2003. Morbidity and Mortality Weekly Report 52(23):537-540. ———. 2008a. Chikungunya distribution and global map, http://www.cdc.gov/ncidod/dvbid/ Chikungunya/CH_GlobalMap.html (accessed July 17, 2009). ———. 2008b. Questions and answers about monkeypox, http://www.cdc.gov/ncidod/monkeypox/ qa.htm (accessed October 21, 2009). Coghlan, B., V. N. Bemo, P. Ngoy, T. Stewart, F. Mulmba, J. Lewis, C. Hardy, and R. Brennan. 2007. Mortality in the Democratic Republic of Congo: an ongoing crisis. New York and Australia: International Rescue Committee and Burnet Institute. Condon, B. J., and T. Sinha. 2009. Chronicle of a pandemic foretold: lessons from the 2009 influ - enza epidemic, http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1398445 (accessed July 16, 2009). Crosby, M. C. 2006. The American plague: the untold story of yellow fever, the epidemic that shaped our history. New York: Berkley. Daszak, P., A. A. Cunningham, and A. D. Hyatt. 2000. Emerging infectious diseases of wildlife— threats to biodiversity and human health. Science 287(5452):443-449. Dawood, F. S., S. Jain, L. Finelli, M. W. Shaw, S. Lindstrom, R. J. Garten, L. V. Gubareva, X. Xu, C. B. Bridges, and T. M. Uyeki. 2009. Emergence of a novel swine-origin influenza A (H1N1) virus in humans. New England Journal of Medicine 360(25):2605-2615. Deloitte Center for Health Solutions. 2008. Medical tourism: consumers in search of value. Wash- ington, DC: Deloitte LLP.

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