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9 Disease Surveillance and International Biosecurity* David R. Franz, Midwest Research Institute Biological Security and Human Security: Biological security is funda- mental to human security; human security is fundamental to stability in this ever-smaller and more connected world. The perceived threats to our biological security today are described by a broad spectrum of risks worldwide. Where each of us finds ourselves on that spectrum depends to a great extent in which part of the world we reside. The enormous impact of chronic disease (cancer, heart disease, diabetes, and so forth) and communicable and contagious disease (HIV/AIDS, malaria, tuberculosis, and hepatitis), the potentially very significant impact of emerging diseases such as Severe Acute Respiratory Syndrome (SARS) and highly pathogenic influenza, the potentially large impact but low likelihood of bioterrorism, and the emerging concern for the exploitation of dual-use bio- technologies to cause harm all receive different attention and concern regionally across the globe. Therefore, biological risk perception is related to technological advancement, the state of public health and political factors within a given region *This report expands on and updates a paper by Franz, David R. 2007. Species-neutral disease surveillance: A foundation of risk assessment and communication. Pp. 93-99 in Risk Assessment and Risk Communication Strategies in Bioterrorism Preparedness, M. Green, J. Zenilman, D. Cohen, I. Wiser, and R. Balicer, eds. Dordrecht: Springer. 73
74 COUNTERING TERRORISM or country. Where a country or region finds itself on the spectrum will change over time with these factors as well. However, because of rapid changes in trans- portation and movement of humans and animals, we are clearly all impacted by any major event or outbreak anywhere in the world. Global Emerging Infectious Disease Risk: In December 1979 the World Health Organization declared smallpox eradicated from the globe. After this enormous victory over disease, accomplished by a serious joint effort between Russian, U.S., and collaborating public health leaders from around the globe, the infectious disease community felt good about its ability to control biologi- cal risks. Some even speculated that we would now move on from smallpox to polio, malaria, and other important scourges, until we made the world free from infectious disease. It was not to be. In 1992 the Institute of Medicine of the U.S. National Academies published a report authored by Professors Lederberg, Shope, and Oaks entitled Emerging Infections: Microbial Threats to Health in the United States. The report, while making several important recommendations for the future, stated, âDisease-causing microbes have threatened human health for centuries. The Institute of Medicineâs Committee on Emerging Microbial Threats to Health believes that this threat will continue and may even intensify in coming years.â1 Those words proved to be prophetic. An Important Lesson in the United States: In late June 1999 an unusual number of dead birds were reported in the borough of Queens, New York City. Six to 8 weeks later, an unusual number of human cases of encephalitis were noted in hospitals in the area. The human disease was soon diagnosed as St. Louis en- cephalitis, a mosquito-borne viral encephalitis, the causative agent of which does not kill birds. Approximately 2 weeks after the first human cases, the âSt. Louisâ outbreak was announced and mosquito control was begun. Then, 2 or 3 weeks later, animal disease data and human disease data were integrated, and the true causative agent, West Nile virus, was implicated in both the bird and the human deaths. We will never know if, or exactly how many, lives and dollars might have been saved by knowing 6 weeks earlier that a new, deadly zoonotic arbovirus had been introduced to North America, but experts agree daysâand sometimes even hoursâmake a real difference when dealing with infectious outbreaks. Had we been thinking in terms of diseaseâwherever it occursârather than just human disease, we might have done better. The origin of the virus in North American birds or mosquitoes is unknown, but there is little doubt that it came from outside the borders of the United States. Discovering Disease Early: Whether a disease is introduced naturally, ac- cidentally, or intentionally, one of the most important factors is discovering it as early as possible and understanding its spread through the population. Because many diseases of concern to humans are first seen in animalsâWest Nile enceph- alitis, SARS, monkey pox, and H5N1 influenza are recent examplesâit is critical that we seek to discover disease in the species of origin. Finding evidence of a zoonotic disease first in animals will very likely allow preventive or prophylactic
DISEASE SURVEILLANCE AND INTERNATIONAL BIOSECURITY 75 actions to be taken to protect the human population. The concept of species-neu- tral disease surveillance acknowledges that we must look for âdiseaseâ wherever it is found, not âhuman diseaseâ and âanimal disease.â Finally, we live in a much smaller world than we did just a few decades ago. Transportation and travel are such that an outbreak in one part of the world today can impact humans or ani- mals on the other side of the globe tomorrow. Therefore, there is great benefit in discovering an outbreak (1) as early as possible, (2) in the host species of origin, and (3) in the region of origin. Traditionally, disease surveillance in most countries has involved a Min- istry of Health network that monitors human disease and a Ministry of Agricul- ture system that monitors disease in animals. Even in the twenty-first centuryâin technologically advanced democraciesâit is not uncommon for these two activi- ties to go on in parallel, sometimes discovering the same outbreak in their own species of responsibility, without effective communication between them. During the U.S. introductions of West Nile virus (1999) and monkey pox (2003), for example, communication between the animal health and human health profes- sionals was less than adequate. Likewise, nations have been reticent to tell other nations that they have discovered a disease outbreak on their soil, fearing negative travel, trade, and economic consequences. The same attitudes and practices have been the norm in many nations and regions throughout the era of modern public health. Knowing that approximately 75 percent of emerging infectious diseases and many of those agents traditionally selected for use as weapons are zoonotic, it only makes sense that we must integrate our disease surveillance efforts. The situational awareness that an integrated disease surveillance program provides must be a key component of our preparation and response if we are to be prepared to minimize loss of life and economic impact when disease outbreaks occur. One Health: Supporting species-neutral disease surveillance, there has been a recent revival of the concept of âOne Health,â encouraging increased communi- cation between human, animal, and plant âhealth-care providers.â2 In the summer of 2007 the American Medical Association and the American Veterinary Medical Association formally adopted resolutions to work together to enhance âcollabo- ration between human and veterinary medical professions in medical education, clinical care, public health, and biomedical research.â3 This acknowledgment and initiative by these two prominent professional organizations should provide long-needed impetus to strengthen public and animal health in the United States. International collaboration on One Health would further improve the disease surveillance and health situation worldwide while enhancing understanding and facilitating communication and progress in the life sciences. International Compact for Infectious Disease: Dr. Harvey Rubin of the University of Pennsylvania in the United States, working with international col- leagues, has proposed an International Compact for Infectious Disease to deal with pandemic, epidemic, and endemic infectious diseases that threaten personal,
76 COUNTERING TERRORISM national, and international security. The compact would include four pillars, the first of which is focused on disease surveillance: 1. Establishment, maintenance, and monitoring of international standards for surveillance and reporting of infectious diseases using advanced information technology to ensure timeliness, interoperability, and security 2. Establishment, maintenance, and monitoring of international standards for best laboratory practices 3. Expansion of capabilities for the production of vaccines and therapeutics expressly for emerging and reemerging infections 4. Establishment, maintenance, and monitoring of a network of interna- tional research centers for microbial threats The idea of the proposed compact4 is currently being presented to medical, scientific, and public health organizations and audiences worldwide in an effort to refine the concept and seek support for its eventual adoption. This approach and the interest it has generated is further evidence that the need for global responses to global infectious disease threats is gaining visibility and support worldwide. Technical Tools for Early Discovery of an Outbreak: Both the apparently increasing frequency with which we have faced newly emerging disease in recent years and the intentional anthrax attacks experienced in the United States in 2001 have motivated some nations to take disease surveillance more seriously. Data Mining: One form of surveillance, data mining, attempts to cast a very wide net to discover the human response to a disease outbreak: ambulance calls, over-the-counter medications purchased, emergency room visits, and disease-re- lated information sought. Others, such as ProMed,5 allow users around the globe to input disease-related notices. Yet another model, ARGUS,6 employs a team of humans with skill in more than 30 languages to actively monitor Web-based news reports looking for early reporting of unusual disease or outbreaks worldwide. While these passive and active programs, exploiting the power of the Web, might highlight trends and provide enough information to help us connect the dots, the signal-to-noise problem with some of the systems has limited their utility. Efforts to develop and implement automated syndromic surveillance systems continue as we seek more efficient ways to provide situational awareness regarding new outbreaks and disease prevalence.7 Clinician-Driven Syndromic Surveillance: Amazingly, we believe that the index case of inhalational anthrax was discovered by an astute clinician follow- ing the mailing of B. anthracis-laced letters in the fall of 2001. There are several clinician-driven surveillance systems undergoing testing today.8 The greatest challenges of implementing an effective, clinician-driven system are probably (1) difficulty in down-selecting to implement just the right system, (2) failure to have widespread connectivity throughout the various venues in which clinicians see patients, (3) the time it takes from the cliniciansâ busy schedule to input required
DISEASE SURVEILLANCE AND INTERNATIONAL BIOSECURITY 77 data, and (4) few clinician-driven disease surveillance systems being tested today integrate human and animal disease data. There are efforts under way within the Department of Homeland Security9 to deal with the first problem, by developing a higher-level integrating information system that can take inputs from numerous disparate collection systems. As with data mining, there are trade-offs in imple- menting clinician-based surveillance systems. While we will certainly discover evidence of disease wherever systems are in place, our discovery will come when there is already disease in the population. On the other hand, it may be easier to justify long-term maintenance of clinician-driven surveillance because these systems will be valuable across the entire biothreat spectrum. As preclinical diag- nostics improve and find a place in the clinic, or even the home or workplace, we may be able to move ever closer to the index case and even the index exposure, the elusive goal of environmental monitoring. Environmental Monitoring has been adapted for early warning of a bio- logical terrorism event in the United States and other countries. The advantage of environmental sensors is that, if located at the right place, programmed to sample ambient air at the right time, and designed to identify the agent being used, they could warn us of disease-causing organisms in the air we breathe even before our citizens become ill. These systems could be placed in the top 40-50 population- dense centers, operating 24 hours a day all year long, for high tens of millions of dollars or low hundreds of millions. As currently configured, systems of such sensors will likely not warn us of a naturally emerging disease outbreak or even aerosolized novel pathogens or different strains. Both the concept of dispersed environmental sensors and passive data mining may be hard to justify for the many years that the low-likelihood threat of bioterrorism may exist. The Tools Are Getting Better: Although there have been various efforts to improve disease surveillance in the United States, one that stands out by combin- ing true clinician-based syndromic surveillance across species is the Syndromic Reporting Information System (SYRIS).10 This system allows simple and direct Web-based input by physicians or veterinarians, central monitoring and colla- tion by public health authorities, andâvery importantlyârapid feedback to the clinician regarding regional disease reporting. The human portion is based on six syndromes: (1) influenza-like illness, (2) acute hepatitis, (3) acute respiratory distress syndrome, (4) fever with skin rash, (5) fever with central nervous system findings, and (6) fever with severe diarrhea. The nine veterinary syndromes are: (1) lymphadenopathy with fever, (2) severe diarrhea, (3) off feed/wasting, (4) neurological/lameness, (5) vesicular lesions, (6) pneumonitis, (7) downer animal, (8) drooling/slobbering, and (9) dead. Within 30 seconds after entering as little as a syndrome and a zip code (mail code), the clinician receives a map showing the reported syndrome and any related information from other clinicians, human and veterinary, in the area or region. This system facilitates an awareness that is unprecedented in both time and species covered. SYRIS is being used in part of the state of Texas and being tested in several locations within the United States.
78 COUNTERING TERRORISM Although available anywhere the Web can be accessed, SYRIS is not currently being implemented outside the United States. There are, of course, many new technical developments that improve our ability to identify and characterize disease-causing agents, but we still lack a universal nationwide system for early identification of disease in the population and a codified response protocol. We have the tools. Do we have the will? Exactly how to accomplish the important task of very early awareness and response to naturally emerging and intentional disease is not yet clear, but its importance is beyond question. We must watch âthat spot where the animals, humans, and bugs collide.â We now have the technical tools and know-how to implement the necessary public health infrastructure for surveillance and response nearly anywhere around the globe. The world has become too small and the potential for harm too great to stand idle. Technology allows implementation today; we must not let politics or borders stand in the way. Working together, across national boundaries on one of the most challenging and important human security issues of our time, will not only protect our citizens from natural disease but also contribute to building understanding and even trust that will reduce the likelihood that intentional outbreaks will negatively impact any of our populations. Notes 1. Lederberg, J., R. E. Shope, and S. C. Oaks, Jr., eds. 1992. Emerging Infections: Microbial Threats to Health in the United States. Washington, D.C.: National Academy Press, p. 1. Available online at www.nap.edu/catalog/2008.html#toc. Accessed December 3, 2007. 2. Zinsstag, J., et al. 2005. Potential of cooperation between human and animal health to strengthen health systems. Lancet 366: 2142-2145; Gibbs, E. P. J. 2005. Emerging zoonotic epidemics ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ï¿½ in the interconnected global community. Veterinary Record 157: 673-679. 3. American Medical Association House of Delegates, Resolution: 530 (A-07). Available online at www.ama-assn.org/ama1/pub/upload/mm/467/530.doc. Accessed December 3, 2007. 4. Rubin, H., et al. 2004. The New Arms Race: Making a Case for an International Compact for Infectious Disease. Philadelphia: ISTAR and University of Pennsylvania. Available online at www. istar.upenn.edu/compact/downloads.html. Accessed December 6, 2007. 5. See www.promedmail.org. 6. See biodefense.georgetown.edu/projects/argus.aspx. 7. See www.syndromic.org. 8. See www.zelicoff.com/SMLR/SyndromicSurveillancePage/defaultSyndrome.htm. 9. See www.dhs.gov/xlibrary/assets/mgmt/e300-prep-nbis2008.pdf. 10. Available online at www.zelicoff.com/SMLR/SyndromicSurveillancePage/defaultSyndrome. htm.