lateral gene transfer (AAM, 2009b), and host immune responses to pathogens. Some participants at the Zagreb meeting expressed the need for the development of databases on clinical infectious disease agents, which is not currently common practice in medicine and would be a daunting task. Skowronski and Lipkin (2011) pointed out that between 1998 and 2006 there were 40 million hospital admissions for infectious diseases in the United States alone. They stated that

it is literally impossible for the etiological agent to be identified, much less to a standard that would be considered a validated fact generated by a tertiary testing facility (CDC/Laboratory Response network/State Public Health Laboratories) and that would withstand legal scrutiny.… In many cases, presumptive diagnoses and minimal screening tests are often used when clinical signs are sufficient to treat. In practice, this has been sufficient for medical care but is not adequate to address the needs of microbial forensics. (Skowronski and Lipkin, 2011:174)

Nonetheless, insights into pathogenesis and the development of drugs and vaccines require live organisms and clinical samples from individuals who have been exposed to live organisms. Skowronski and Lipkin also noted that sequencing, microarrays, high-throughput NGS, and bioinformatics represent new sensitive and exacting techniques for identifying and characterizing pathogens that will eventually have broad applicability to public health, biosurveillance, and forensics and attribution. It also is worth noting that in November 2013, the U.S. Food and Drug Administration (FDA) approved Illumina’s MiSeq Dx DNA sequencing system for diagnostics, which until then had only been used for research (Dubay, 2013).

Conclusion 5: An increased emphasis on research to determine mechanisms of pathogenicity, including virulence factors and host immune responses, is needed.

Finding: A number of the participants in the Zagreb workshop called for better global disease surveillance. Although there are a number of programs already in existence for this purpose (see discussion of biosurveillance in Chapter 2), there is considerable evidence that these programs have yet to fully bear fruit. For example, as noted previously, only 16 percent of countries were able to meet the 2012 deadline for implementing the International Health Regulations, and the U.S. government has recently announced a new Global Health Security Agenda to intensify worldwide efforts to achieve global health security.

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