INFECTIOUS DISEASE MOVEMENT IN A BORDERLESS WORLD

Workshop Summary

Rapporteurs: David A. Relman, Eileen R. Choffnes, and Alison Mack

Forum on Microbial Threats

Board on Global Health

INSTITUTE OF MEDICINE
OF THE NATIONAL ACADEMIES

THE NATIONAL ACADEMIES PRESS

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Rapporteurs: David A. Relman, Eileen R. Choffnes, and Alison Mack Forum on Microbial Threats Board on Global Health

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, N.W. Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. This project was supported by contracts between the National Academy of Sciences and the U.S. Department of Health and Human Services: National Institutes of Health/National Institute of Allergy and Infectious Diseases, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense, Department of the Army: Walter Reed Army Institute of Research/Global Emerging Infections Surveillance and Response System, Medical Research and Materiel Command, and Defense Threat Reduction Agency; U.S. Department of Veterans Affairs; U.S. Department of Homeland Security; U.S. Agency for International Development; American Society for Microbiology; Sanofi Pasteur; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; Infectious Diseases Society of America; and the Merck Company Foundation. Any opinions, findings, conclu - sions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. International Standard Book Number-13: 978-0-309-14447-6 International Standard Book Number-10: 0-309-14447-7 Additional copies of this report are available from the National Academies Press, 500 Fifth Street, N.W., Lockbox 285, Washington, DC 20055; (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www. iom.edu. Copyright 2010 by the National Academy of Sciences. All rights reserved. Printed in the United States of America Cover image: A geographical representation of the civil aviation traffic among the 500 largest international airports in more than 100 different countries. Reprinted with permission from Hufnagel, L., D. Brockmann, and T. Geisel. 2004. Forecast and control of epidemics in a globalized world. Proceedings of the National Academy of Sciences 101(42):15124-15129. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Suggested citation: IOM (Institute of Medicine). 2010. Infectious disease movement in a borderless world. Washington, DC: The National Academies Press.

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“Knowing is not enough; we must apply. Willing is not enough; we must do.” — Goethe Advising the Nation. Improving Health.

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Academy has a man - date that requires it to advise the federal government on scientific and technical matters. Dr. Ralph J. Cicerone is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engineers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineering programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Charles M. Vest is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sciences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its congressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy’s purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the Na - tional Academy of Engineering in providing services to the government, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Ralph J. Cicerone and Dr. Charles M. Vest are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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FORUM ON MICROBIAL THREATS DAVID A. RELMAN (Chair), Stanford University, Palo Alto, California MARGARET A. HAMBURG (Vice Chair),* Nuclear Threat Initiative/Global Health & Security Initiative, Washington, DC DAVID W. K. ACHESON, Center for Food Safety and Applied Nutrition, Food and Drug Administration, Rockville, Maryland RUTH L. BERKELMAN, Emory University, Center for Public Health Preparedness and Research, Rollins School of Public Health, Atlanta, Georgia ENRIQUETA C. BOND, Consultant, Marshall, Virginia ROGER G. BREEZE, Centaur Science Group, Washington, DC STEVEN J. BRICKNER, SJ Consulting, LLC, Ledyard, Connecticut JOHN E. BURRIS, Burroughs Wellcome Fund, Research Triangle Park, North Carolina GAIL H. CASSELL, Eli Lilly & Company, Indianapolis, Indiana MARK B. FEINBERG, Merck Vaccine Division, Merck & Co., West Point, Pennsylvania DARRELL R. GALLOWAY, Medical S&T Division, Defense Threat Reduction Agency, Fort Belvoir, Virginia S. ELIZABETH GEORGE, Biological and Chemical Countermeasures Program, Department of Homeland Security, Washington, DC JESSE L. GOODMAN, Center for Biologics Evaluation and Research, Food and Drug Administration, Rockville, Maryland EDUARDO GOTUZZO, Instituto de Medicina Tropical–Alexander von Humbolt, Universidad Peruana Cayetano Heredia, Lima, Peru JO HANDELSMAN, College of Agricultural and Life Sciences, University of Wisconsin, Madison CAROLE A. HEILMAN, Division of Microbiology and Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland DAVID L. HEYMANN, Health Protection Agency, London, UK PHIL HOSBACH, New Products and Immunization Policy, Sanofi Pasteur, Swiftwater, Pennsylvania JAMES M. HUGHES,† Global Infectious Diseases Program, Emory University, Atlanta, Georgia STEPHEN A. JOHNSTON, Arizona BioDesign Institute, Arizona State University, Tempe *Until June 9, 2009. Dr. Hamburg is currently the Commissioner of the Food and Drug Administration. †Current Vice Chair. IOM Forums and Roundtables do not issue, review, or approve individual documents. The responsibility for the published workshop summary rests with the workshop rapporteur(s) and the institution. v

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KENT KESTER, Walter Reed Army Institute of Research, Silver Spring, Maryland GERALD T. KEUSCH, Boston University School of Medicine and Boston University School of Public Health, Massachusetts RIMA F. KHABBAZ, National Center for Preparedness, Detection, and Control of Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, Georgia LONNIE J. KING, College of Veterinary Medicine, Ohio State University, Columbus, Ohio STANLEY M. LEMON, School of Medicine, University of Texas Medical Branch, Galveston EDWARD McSWEEGAN, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland PAUL F. MILLER, Pfizer, Groton, Connecticut STEPHEN S. MORSE, Center for Public Health Preparedness, Columbia University, New York MICHAEL T. OSTERHOLM, Center for Infectious Disease Research and Policy, School of Public Health, University of Minnesota, Minneapolis GEORGE POSTE, Arizona BioDesign Institute, Arizona State University, Tempe JOHN C. POTTAGE, JR., GlaxoSmithKline, Collegeville, Pennsylvania GARY A. ROSELLE, Central Office, Veterans Health Administration, Department of Veterans Affairs, Washington, DC KEVIN RUSSELL, Global Emerging Infections Surveillance and Response System, Department of Defense, Silver Spring, Maryland JANET SHOEMAKER, Office of Public Affairs, American Society for Microbiology, Washington, DC P. FREDERICK SPARLING, University of North Carolina, Chapel Hill TERENCE TAYLOR, International Council for the Life Sciences, Washington, DC MURRAY TROSTLE, U.S. Agency for International Development, Washington, DC Staff EILEEN CHOFFNES, Director KATE SKOCZDOPOLE, Senior Program Associate SARAH BRONKO, Research Associate (until April 2009) KATHLEEN C. OSTAPKOVICH, Research Associate (from May to October 2009) KENISHA PETERS, Senior Program Assistant (until August 2009) ROBERT GASIOR, Senior Program Assistant (from September 2009) ALISON MACK, Science Writer vi

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BOARD ON GLOBAL HEALTH Margaret Hamburg (Chair), Consultant, Nuclear Threat Initiative, Washington, DC Jo Ivey Boufford (IOM Foreign Secretary), President, New York Academy of Medicine, New York Claire V. Broome, Adjunct Professor, Division of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia Jacquelyn C. Campbell, Anna D. Wolf Chair, and Professor, Johns Hopkins University School of Nursing, Baltimore, Maryland Thomas J. Coates, Professor, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California Valentin Fuster, Director, Wiener Cardiovascular Institute, Kravis Cardiovascular Health Center, Professor of Cardiology, Mount Sinai School of Medicine, Mount Sinai Medical Center, New York, New York Sue Goldie, Associate Professor of Health Decision Science, Department of Health Policy and Management, Center for Risk Analysis, Harvard University School of Public Health, Boston, Massachusetts Richard Guerrant, Thomas H. Hunter Professor of International Medicine and Director, Center for Global Health, University of Virginia School of Medicine, Charlottesville Peter J. Hotez, Professor and Chair, Department of Microbiology, Immunology, and Tropical Medicine, George Washington University, Washington, DC Gerald T. Keusch, Assistant Provost for Global Health, Boston University School of Medicine, and Associate Dean for Global Health, Boston University School of Public Health, Massachusetts Michael Merson, Director, Duke Global Health Institute, Duke University, Durham, North Carolina Fitzhugh Mullan, Professor, Department of Health Policy, George Washington University, Washington, DC Philip Russell, Professor Emeritus, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, Maryland Staff Patrick Kelley, Director Allison Brantley, Senior Program Assistant IOM boards do not review or approve individual reports and are not asked to endorse conclusions and recommendations. The responsibility for the content of the report rests with the authors and the institution. vii

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Reviewers This report has been reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council’s Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evi - dence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their review of this report: Peter Daszak, Wildlife Trust Lawrence O. Gostin, Georgetown University Law Center William B. Karesh, Wildlife Conservation Society Howard Markel, University of Michigan Medical School Kevin Russell, Department of Defense, Global Emerging Infections System Although the reviewers listed above have provided many constructive com- ments and suggestions, they were not asked to endorse the final draft of the report before its release. The review of this report was overseen by Dr. Melvin Worth. Appointed by the Institute of Medicine, he was responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. ix

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Acknowledgments The Forum on Emerging Infections was created by the Institute of Medicine (IOM) in 1996 in response to a request from the Centers for Disease Control and Prevention (CDC) and the National Institutes of Health (NIH). The purpose of the Forum is to provide structured opportunities for leaders from government, academia, and industry to meet and examine issues of shared concern regarding research, prevention, detection, and management of emerging or reemerging infectious diseases. In pursuing this task, the Forum provides a venue to foster the exchange of information and ideas, identify areas in need of greater attention, clarify policy issues by enhancing knowledge and identifying points of agree - ment, and inform decision makers about science and policy issues. The Forum seeks to illuminate issues rather than resolve them; for this reason, it does not provide advice or recommendations on any specific policy initiative pending before any agency or organization. Its value derives instead from the diversity of its membership and from the contributions that individual members make throughout the activities of the Forum. In September 2003, the Forum changed its name to the Forum on Microbial Threats. The Forum on Microbial Threats, and the IOM, wishes to express their warmest appreciation to the individuals and organizations who gave their valuable time to provide information and advice to the Forum through their participation in this workshop. A full list of presenters may be found in Appendix A. The Forum is indebted to the IOM staff who contributed during the course of the workshop and the production of this workshop summary. On behalf of the Forum, we gratefully acknowledge the efforts led by Dr. Eileen Choffnes, direc- tor of the Forum; Kate Skoczdopole, senior program associate; Sarah Bronko, research associate; K. C. Ostapkovich, research associate; Kenisha Peters, senior xi

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xii ACKNOWLEDGMENTS program assistant; and Robert Gasior, senior program assistant, for dedicating much effort and time to developing this workshop’s agenda and for their thoughtful and insightful approach and skill in planning for the workshop and in translating the workshop’s proceedings and discussion into this workshop summary. We would also like to thank the following IOM staff and consultants for their valu - able contributions to this activity: Alison Mack, Bronwyn Schrecker, Jordan Wyndelts, Jackie Turner, and Heather Phillips. Finally, the Forum wishes to recognize the sponsors that supported this activity. Financial support for this project was provided by the U.S. Department of Health and Human Services: National Institutes of Health/National Institute of Allergy and Infectious Diseases, Centers for Disease Control and Prevention, and Food and Drug Administration; U.S. Department of Defense, Department of the Army: Walter Reed Army Institute of Research/Global Emerging Infections Surveillance and Response System, Medical Research and Materiel Command, and Defense Threat Reduction Agency; U.S. Department of Veterans Affairs; U.S. Department of Homeland Security; U.S. Agency for International Development; American Society for Microbiology; Sanofi Pasteur; Burroughs Wellcome Fund; Pfizer; GlaxoSmithKline; Infectious Diseases Society of America; and the Merck Company Foundation. The views presented in this workshop summary report are those of the workshop participants and rapporteurs and are not necessarily those of the Forum on Microbial Threats or its sponsors.

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Contents Workshop Overview 1 1 Migration, Mobility, and Health 41 Overview, 41 International Migration Past, Present, and Future, 42 Mark J. Miller, Ph.D. People, Borders, and Disease—Health Disparities in a Mobile World, 52 Brian D. Gushulak, M.D., and Douglas W. MacPherson, M.D., M.Sc. (CTM), F.R.C.P.C. References, 80 2 Travel, Conflict, Trade, and Disease 88 Overview, 88 Global Travel and Emerging Infections, 90 Mary E. Wilson, M.D., F.A.C.P., F.I.S.D.A. Armed Conflict and Infectious Disease, 104 Barry S. Levy, M.D., M.P.H. Risky Trade and Emerging Infections, 110 Ann Marie Kimball, M.D., M.P.H., F.A.C.P.M., and Jill Hodges, M.P.H., M.S.L. Globalization of the Food Supply: Time for Change in Approach, 118 David W. K. Acheson, M.D., F.R.C.P. References, 126 xiii

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xiv CONTENTS 3 Mobile Animals and Disease 132 Overview, 132 Public Health Impact of Global Trade in Animals, 134 Nina N. Marano, D.V.M., M.P.H., G. Gale Galland, D.V.M., M.S., Jesse D. Blanton, M.S., Charles E. Rupprecht, D.V.M., Ph.D., James N. Mills, Ph.D., Heather Bair-Brake, D.V.M., M.P.H., Betsy Schroeder, M.P.H., and Martin S. Cetron, M.D. A Mollusc on the Leg of a Beetle: Human Activities and the Global Dispersal of Vectors and Vector-borne Pathogens, 150 Paul Reiter, Ph.D. Predicting and Preventing Emergent Disease Outbreaks, 165 Andrew Dobson, D.Phil., and Sarah Cleaveland, Ph.D., D.V.M. References, 172 4 Global Public Health Governance and the Revised International Health Regulations 180 Overview, 180 Public Health, Global Governance, and the Revised International Health Regulations, 182 David Heymann, M.D. Capacity-Building Under the International Health Regulations to Address Public Health Emergencies of International Concern, 195 May C. Chu, Ph.D., Guenael Rodier, M.D., and David Heymann, M.D. Implementing the Revised International Health Regulations in Resource-Constrained Countries: Intentional and Unintentional Realities, 204 Oyewale Tomori, D.V.M., Ph.D. Viral Sovereignty, Global Governance, and the IHR 2005: The H5N1 Virus Sharing Controversy and Its Implications for Global Health Governance, 210 David P. Fidler, J.D. References, 229 5 Global Disease Surveillance and Response 231 Overview, 231 Of Milk, Health, and Trade Security, 233 David M. Bell, M.D. International Technical Agencies Working at the Human-Animal Interface, 238 Ottorino Cosivi, D.V.M. International Animal Health Regulations and the World Animal Health Information System, 246 Alejandro B. Thiermann, D.V.M., Ph.D.

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xv CONTENTS Incentives and Disincentives to Timely Disease Reporting and Response: Lessons from the Influenza Campaign, 256 David Nabarro, M.D., C.B.E., F.R.C.P. References, 261 Appendixes A Agenda 263 B Acronyms 267 C Glossary 270 D Forum Member Biographies 281

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Tables, Figures, and Boxes TABLES 1-1 Number of International Migrants by Region, 1960-2005 (in millions), 48 1-2 The 10 Countries with the Highest Number of International Migrants (in millions), 48 1-3 International Tourist Arrivals (in millions, ordered in 2006 ranking), 49 1-4 Population by Nation, 2008, 59 1-5 Country and Region Population with Rate of Growth, 60 1-6 Major Influences in Migration Dynamics Since the 1950s, 61 2-1 Causes of Death in Young Children (0-4 Years of Age), Western Democratic Republic of Congo, January 2006-April 2007, 105 2-2 Leading Diagnoses, Emergency Ward, Khao-I-Dang Camp for Cambodians, Thailand, 1980, 107 2-3 Cause-Specific Mortality Among Internally Displaced Persons in Camps, South Darfur, May-June 2005, 108 2-4 Incidence and Mortality for Selected Causes, United States, 2001- 2004, 109 3-1 Importations of Rabid Dogs to the Continental United States 2004- 2008, 137 xvi

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xvii TABLES, FIGURES, AND BOXES 3-2 Numbers of Individual Rodents and Rodent Species Imported into the United States Pre-CDC African Rodent Ban (1999-2003) and Post-Ban (2004-2006), 143 3-3 Some Important Rodent-Borne Zoonotic Pathogens and Their Hosts, 143 4-1 Governance Issues Compared, 215 5-1 Formal Agreements and Joint Programs to Address Zoonotic Diseases, 240 5-2 Activities for Prevention and Control of Diseases at the Animal- Human-Ecosystems Interface and Their Status as a Public Good, 245 5-3 Diseases Notifiable to the OIE, 248 FIGURES WO-1 Typology of countries by health care status, 8 WO-2 The rate of globalization has accelerated to the point where we are connected as never before via globalized travel and trade networks, 9 WO-3 World waterways network, 10 WO-4 International tourist arrivals by region (in millions), 1950-2020, 11 WO-5 Global distribution of relative risk of an emerging infectious disease (EID) event, 12 WO-6 Poultry exports from Far East Asian countries from 1961 through 2002, 15 WO-7 Approximate global distribution of chikungunya virus, 2008, 21 WO-8 Size comparison of largest green crabs caught from a parasitized population in the crab’s native range and unparasitized population in the crab’s introduced range, 22 1-1 World population growth, 1750-2150, 60 1-2 Traditional pattern of migration, 63 1-3 Modern patterns of migration, 65 1-4 Measles outbreaks associated with two modes of international travel: air and ship, 69 2-1 International tourist arrivals by region (in millions), 1950-2020, 91 2-2 Inbound tourism by means of transport, 92 2-3 Life travel over four male generations in the same family, 93 2-4 Juxtaposition of urban slums and modern buildings in São Paulo, Brazil, 94 2-5 Countries with XDR tuberculosis cases in December 2006 and June 2008, 96

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xviii TABLES, FIGURES, AND BOXES 2-6 How controllable is an infection?, 97 2-7 Global population size and lineages of dengue virus over time, 99 2-8 Increased mortality associated with chikungunya outbreak, India, 101 2-9 Trade and travel are key to global dissemination of disease, 112 2-10 Poultry exports from Far East Asian countries from 1961 to 2002, 113 2-11 Superimposed epidemics, 115 2-12 Food and other FDA-regulated imports to the United States, 119 2-13 Salmonella Saintpaul outbreak traceback and distribution, 121 2-14 Sequence of events—different routes of melamine-contaminated wheat gluten into the United States, 123 3-1 Movement of imported African rodents to animal distributors and distribution of prairie dogs from an animal distributor associated with human cases of monkeypox, 11 states, 2003, 141 3-2 Economic impacts of selected infectious diseases, 146 3-3 Ae. albopictus, the Asian tiger mosquito, 152 3-4 The Transatlantic Triangular Trade, 153 3-5 Containerization, 157 3-6 An infected person can travel to virtually any airport destination in the world in less than 48 hours, far shorter than the period of incubation and infectivity of vector-borne infections, 161 3-7 Relative risk of pathogen emergence, 167 4-1 Global Outbreak and Alert Network (GOARN): Institutions and members of partner networks, 186 4-2 Major distinctions between the IHR 1969 and the revised IHR 2005, 187 4-3 Requirements of the IHR 2005, 188 4-4 The international spread of polio from Nigeria, 2003-2005, 189 4-5 WHO Global Influenza Surveillance Network (GISN), July 2008, 191 4-6 Confirmed human and poultry infections since 2003, 192 4-7 Genetic diversity: H5N1 virus groups (clades) infecting humans since 2003, 193 4-8 The current pandemic alert phase of the H5N1 virus, 193 4-9 Timeline for implementation of the IHR to strengthen national capacity, 197 4-10 Decision instrument for the assessment and notification of events that may constitute a public health emergency of international concern, 199 4-11 Foreign policy functions, 222 4-12 The IHR 2005 and the functions of foreign policy, 223

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xix TABLES, FIGURES, AND BOXES 5-1 Global Early Warning and Response System (GLEWS), 241 5-2 INFOSAN links to all government sectors involved in food safety, 242 5-3 OIE’s disease notification criteria, 251 BOxES WO-1 Factors Involved in Infectious Disease Emergence, 4 WO-2 The Travels of Chikungunya, 21

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