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Global Microbial Threats in the 1990s
III. How can we help build a global network for infectious
disease reporting and response?
To avert the threat of emerging infections
and prevent their spread into the United
States, or into any other countries, health officials must
be aware when epidemics occur anywhere in the world. However,
reliable information can only be secured through clinical and
laboratory-based surveillance that links medical and public
health workers into a cooperative worldwide network.
"Laboratory-based surveillance" implies that diagnostic tools and
technicians are available to analyze blood, sputum, or stool
samples from sick people or animals. The public health workers in
the network must include epidemiologists who can investigate the
nature and extent of microbial threats. Moreover, the global
network should also incorporate prevention efforts by
coordinating investigations into the environmental and human
factors that promote the evolution and emergence of infectious
Many elements of a potential global network do exist - but need
to be linked, coordinated, and strengthened, working in
partnership with other countries and with WHO. Many U.S.
Government department and agencies - including DoD, CDC, USAID,
NIH, USDA, NASA, and NOAA - maintain field stations and
laboratories in Africa, Asia, and the Americas. The introduction
of inexpensive communications linkages among these facilities -
by fax, by phone, by Internet - could provide an initial
framework for global infectious disease reporting. This skeletal
network could be expanded over time to include many other
national and international resources. For instance, the U.S.
State Department and the Peace Corps maintain medical facilities
in remote areas that could be brought into the network as
important sentinel outposts. Internationally, the network would
include links with national health ministries, with hospitals and
laboratories operated by other nations, with foreign research
centers such as the French Pasteur Institutes, with American and
foreign non-governmental organizations (NGOs), and with WHO
Collaborating Centres around the world.
A Network for Global Disease Surveillance
Four strategic objectives are necessary to establish a global
system for disease surveillance and response:
Surveillance. Strengthen existing surveillance systems so that
changes in the incidence of known illnesses are routinely
reported, and information on the emergence of new or unusual
diseases is readily available to the ministries of health in
other nations, WHO, and CDC. Reliable lines of communication must
be established to ensure that surveillance information is
received promptly enough to control outbreaks before they spread.
Diagnostic Tests. Work with WHO, national public health
authorities, universities, and research centers to implement
WHO's country-level objectives. This entails determining which
"common" diseases should be diagnosed within a country and which
"uncommon" ones should be referred to reference laboratories. It
also requires that diagnostic tests be made available through a
regional laboratory referral and distribution system.
Develop simpler, more cost-effective procedures to determine the
causes of disease. Ideally, these procedures should be simple
enough for use in the field when laboratory facilities are not
Support basic and applied research on infectious microbes,
especially on pathogens for which there are no reliable
diagnostic tests. The new tools of biotechnology should be
exploited to speed these efforts.
Response. Enhance the capabilities of U.S. Government agencies
and existing disease-specific networks (see "International Resources Related to Infectious
Diseases") to respond
to recognized outbreaks identified through improved surveillance.
Also, rebuild and coordinate the relevant technical resources of
U.S. Government agencies such as CDC, DoD, USAID, and FDA.
Diseases that are transmitted by different routes will
necessarily require different control strategies. Types of
response may include sanitation and hygiene measures, controlling
populations of disease vectors (for example, malaria-carrying
mosquitoes or rabid raccoons), drug treatment, vaccination or
post-exposure prophylaxis, or education to decrease human
behaviors that cause spread.
Surveillance to Detect New Diseases
Unexplained disease symptoms or clinical circumstances that may
suggest a need for further investigation when clusters of cases
Acute respiratory disease
Encephalitis and aseptic meningitis
Fever and rash
Acute flaccid paralysis
Resistance to common treatment drugs
Unusual clusterings of deaths
Outbreaks of disease in domestic or wild animals
Each nation should be encouraged to report, as early as possible,
new events or trends in human or animal, diseases that are
affecting its own population.
Interdisciplinary Research to support Control and Prevention.
Form linkages between
Experimental biologists and epidemiologists both here and
The global infectious disease network and environmental and
climatic research programs.
Encourage collaborative research to determine the causes of
epidemics, devise strategies for control and prevention, and
identify environmental and climatic conditions that favor the
emergence of pathogenic microbes.
Prevention Through Immunization: The Search for an Effective
The largest killer of infants and young children in developing
countries are acute respiratory infections, mainly pneumonia,
which claim the lives of an estimate 3.8 million children under
age 5 every year. While appropriate case-management, using
common antibiotics, has been very successful in treating these
diseases, the emergence of antimicrobial resistant strains
suggest that this success may be relatively short-lived. One way
to avoid problems with resistance is to prevent the infection
from occurring, using safe and effective vaccines.
Children's Vaccine Initiative Project, USAID is initiating a
major new program to evaluate newly developed vaccines that may
protect children in underdeveloped countries. These vaccines are
aimed against major bacterial and viral causes of pneumonia,
including Streptococcus pneumoniae and Haemophilus influenzae b.
Studies in the industrialized world and preliminary studies in
developing countries suggest that these vaccines, especially new
"conjugated" versions, hold great promise.
RECOMMENDATIONS OF THE CISET WORK GROUP
How can the United States Accomplish These Surveillance
To build an effective international surveillance and response
network, a U.S. Government Interagency Task Force should be
established and granted the authority and resources to implement
the following actions:
Work in partnership with other countries, with WHO, and with
other international organizations to improve worldwide disease
surveillance, reporting, and response by
1. Establishing regional disease surveillance and response
networks linking national health ministries, WHO regional
offices, U.S. Government laboratories and field stations abroad,
foreign laboratories and medical centers, and WHO Collaborating
These activities can be closely linked with our domestic
surveillance networks through CDC, which is responsible for
infectious disease surveillance within the United States. In
addition, several "vertical" (disease-specific) networks that are
currently sponsored by WHO (see WHO) can be integrated into
these regional networks.
Model surveillance and response projects can be established in
such regions as the Middle East, Sub-Saharan Africa, Southeast
Asia, South America, and Eastern Europe and the Newly Independent
States of the former Soviet Union. An example of a proposed
regional network in the Middle East is shown on map .
Over time, the functions of these regional "hubs" may be expanded
Surveillance of antibiotic resistance
Surveillance of zoonoses
Surveillance of insecticide resistance in parasite vectors
Warnings of potential increases in disease incidence
predicted by environmental and climatic monitoring systems
2. Ensuring that reliable communications links are available
(by post, telephone, facsimile, and Internet) between local and
national medical centers and between national and regional (or
international) reference facilities.
Some vulnerable areas of the world (such as rain forest
communities in South America, Africa, and the South Pacific) are
relatively isolated. An assessment of gaps in the global
communications network should be undertaken to avoid excluding
such communities. While WHO should initiate and support this
survey, U.S. agencies such as CDC, DoD, and USAID can supply the
technical advice and expertise to help ensure its success.
3. Developing a global alert system whereby national
governments inform appropriate worldwide health authorities of
outbreaks of infectious diseases in a timely manner.
This recommendation entails a concerted diplomatic effort to
develop a sense of shared responsibility and mutual confidence in
the international effort to combat infectious diseases.
4. Identifying regional and international resources that can
provide diagnostic reagents for low-incidence diseases, and help
identify rare and unusual diseases.
To identify and control unusual diseases such as those caused by
hantaviruses or Ebola virus, clinical diagnoses must be confirmed
using diagnostic tests. For example, to stem the spread of Ebola
virus in Zaire in May 1995 (see Lessons Learned From the Ebola Virus Outbreak in Zaire), the international team
of epidemiologists needed to distinguish between fever patients
infected with Ebola virus and febrile patients infected by other
microbes. The team shipped blood samples to CDC biohazard
laboratories in Atlanta, which had the necessary diagnostic
Many countries, both industrialized and developing, have medical
and research institutions which can serve as significant
resources in combating emerging diseases.
5. Assisting WHO to establish surveillance of antibiotic
resistance and drug use, as a first-step towards the development
of international agreements on antibiotic usage.
WHONET, an international reporting system for antibiotic
resistance, provides WHO with a starting point for this
significant work. Taking advantage of its overseas networks USAID
can provide support for surveillance of drug resistance that
hinders the treatment of internationally important diseases. In
addition, CDC can contribute technical support and data
It is also crucial to develop and implement strategies that
extend the useful life span of antibiotics and other drugs by
retarding the development of resistance. This entails behavioral
research on how to ensure correct drug use and biomedical
research on the development of alternative drugs and drug
6. Encouraging and assisting other countries to make infectious
disease detection and control a national priority.
Although international efforts must be coordinated to prevent
global pandemics, disease surveillance must be the responsibility
of each sovereign nation. To ensure that the United States is
notified when an unusual outbreak occurs, we must encourage and
support other countries' efforts in national disease surveillance
and respond when asked for assistance. It is especially important
to engage in information-sharing and dialogue with less developed
countries. The improvement of domestic disease surveillance and
response capabilities in other countries and regions is discussed
in Section VI.
7. Preserving existing U.S. Government activities that enhance
other countries' abilities to prevent and control emerging and
re-emerging health threats.
Helping other countries to help themselves by improving domestic
disease surveillance and response capabilities in other countries
and regions is discussed in Section VI. It is also important to
identify those individuals and offices in each country who have
responsibility for participating in international infectious
disease surveillance efforts.
8. Identifying and strengthening WHO Collaborating Centres that
serve as unique reference centers for diseases whose re-emergence
WHO Collaborating Centres operated in the United States by
Government agencies or by American universities require support
to build or rebuild their capacity to serve as reference
laboratories within a larger and more active global infectious
disease network. A list of the relevant WHO Collaborating Centres
is included in an inventory of resources compiled by the CISET
9. Establishing the authority of relevant U.S. Government
agencies to make the most effective use of U.S. expertise in
helping to build a worldwide disease surveillance and response
Proposed legislative changes for the implementation of this
recommendation are discussed in Section V. First, CDC's mandate
to protect the health of U.S. citizens should be expanded to
include outbreak investigations and selected responses to
epidemics overseas in coordination with appropriate U.S.
agencies, including state and local health departments, USAID,
DoD, etc. In disaster relief operations involving infectious
diseases where USAID/OFDA has the lead, CDC will operate as part
of the U.S. effort as appropriate. Second, a responsible lead
agency or agencies should be provided with the authority,
emergency procurement powers, and financial resources to
coordinate interagency responses to foreign disease outbreaks
that have the potential to spread globally.
Strengthen the U.S. capacity to combat emerging infectious
10. Enhancing collaborations among U.S. agencies to ensure
maximum use of existing resources for domestic and international
surveillance and response activities.
A U.S. Government inventory compiled by the CISET Working Group
on Emerging and Re-emerging Diseases is available as a guide for
11. Rebuilding the U.S. public health infrastructure that
protects American citizens against infectious diseases, including
those that are imported into the United States from other
countries. This includes strengthening domestic surveillance and
State and local health departments require support to restore the
surveillance and response capacity that has eroded over the past
two decades. This recommendation is discussed in detail in
Section VI of this report.
12. Working with the private and public sectors to improve U.S.
capacity for the emergency production of diagnostic tests, drugs,
antisera, and vaccines.
The U.S. Government and private sector should work together to
establish a better investment environment for the production of
urgently needed medical products. This can be accomplished by
combining the resources of national and international government
institutions with the technical expertise in the U.S.
pharmaceutical industry and in other sectors of the private
health-care industry. Improvement of the U.S. capacity for
emergency production or procurement of diagnostic tests, drugs,
antisera, and vaccines is discussed in Section IV.
13. Supporting an active community of epidemiologists, clinical
investigators and experimental scientists ready and able to seek
new solutions for new disease threats.
Research and training are the foundation of an effective disease
surveillance and response system. Scientific studies provide the
fundamental knowledge base used to develop diagnostic tests to
identify diseases, drugs to treat them, and vaccines to prevent
them. At the present time, many of the brightest young American
microbiologists are leaving the field, discouraged by the lack of
jobs and research funds.
Specific recommendations to strengthen the infectious disease
research infrastructure in the United States are provided in
14. Strengthening technical training programs in disciplines
related to infectious disease surveillance and response.
In addition to laboratory research instruction, specialized
training programs are needed in the handling of hazardous
microbes, in public health management, in patient education and
management, and in field epidemiology. Recommendations concerned
with training are discussed further in Section VII.
15. Providing accurate and timely health information to private
citizens and health providers, both in the United States and
abroad, when a disease outbreak occurs.
As much as possible, individuals should be armed with the
practical knowledge to protect themselves and their families from
infectious diseases. U.S. agencies should work with foreign
governments, multilateral organizations, NGO's, and the news
media to improve public communication and avoid misinformation
and panic. NGO's that might participate in this effort include
women's groups, international organizations concerned with
children's health, medical missionary organizations, U.S.
corporations, and medical and public health associations.
16. Strengthening screening and quarantine efforts at ports of
entry into the United States.
The likelihood of the importation of infectious diseases can be
decreased by: expanding screening and quarantine facilities at
U.S. ports of entry; making information about ill passengers more
accessible to health authorities; encouraging greater cooperation
in this area between local, state, and federal health
departments; and strengthening the training of American
physicians and microbiologists in the recognition of "tropical"
diseases and in travel medicine.
17. Strengthening the training of American physicians and
microbiologists in the recognition of "tropical diseases" and in
travel medicine in general.
18. Establishing an Interagency Task Force to coordinate the
implementation of these recommendations.
No single U.S. agency has the authority and resources to
investigate epidemics in other countries. However, each agency
can and does respond within its own disciplines. It is strongly
recommended that the disease surveillance efforts of U.S.
agencies be coordinated through an interagency task force chaired
by one or more lead agencies, as discussed in Section V.
19. Establishing a private sector Interagency Task Force
subcommittee that includes representatives of the U.S.
pharmaceutical industry, medical practitioners and educators, and
The role of the Task Force in fostering a dialogue with private
industry and with academic and private sector researchers is
discussed in Section IV.