Establish Surveillance and Response Strategies

Recommendation 1-1: The U.S. Departments of Health and Human Services (HHS), Agriculture (USDA), Homeland Security (DHS), and the Interior (DoI) should collaborate with one another and with the private sector and nongovernmental organizations to achieve an inte grated surveillance and response system for emerging zoonotic diseases in the United States. In addition, these government agencies, including the U.S. Department of State and the U.S. Agency for International De velopment (USAID), should collaborate with the World Health Orga nization (WHO), the Food and Agriculture Organization of the United Nations (FAO), and the World Organization for Animal Health (OIE) to spearhead efforts to achieve a more effective global surveillance and response system, learning from and informing the experiences of other nations.

Given finite resources and the complexity of the challenge, an integrated zoonotic disease surveillance and response system can succeed only if the U.S. government demonstrates its commitment to develop and strengthen the needed capacities at the national level, and to engage others at the global level. The following strategic approaches are necessary to achieve an effective, global zoonotic disease surveillance and response system:

First, departments or ministries of health, agriculture, and natural resources, with external support as needed, should work with researchers to develop and use science-based criteria to determine and measure the distribution and magnitude of the drivers of zoonotic disease emergence. Rapid changes in ecology, environmental degradation, population density, population movements, animal production systems, and close interaction of humans with livestock, poultry, and wildlife are just a few drivers to study. From these studies, targeted surveillance would then be designed to focus on countries and regions within countries where drivers increase the risk for zoonotic disease emergence.

Second, in countries where disease surveillance in animal populations is absent or weak, ministries of health, agriculture, and natural resources should collaborate as broadly as necessary to develop, enhance, and imple ment disease surveillance and response systems in human populations that are at high risk for zoonotic disease infection. For example, surveillance is needed in the following high-risk human populations:

• Occupational groups that are at high risk for infection with zoonotic diseases. Such workers include livestock, dairy, and poultry workers; live-animal market workers; veterinarians and animal health technicians; hunters of bushmeat and other wildlife; food preparers (and restaurant workers handling food prepared from bushmeat and exotic animals); slaughterhouse workers; and laboratory scientists and technicians working with animals;
• Healthcare workers who could spread zoonotic diseases to the general public;
• Household and village members who keep live animals within their living quarters or come in close contact with animals in village settings; and
• People engaging in high-risk behaviors known to increase risk of exposure to zoonotic diseases. Such high-risk behaviors include close contact with wildlife and exotic animals; preparing and consuming bushmeat; culturally traditional animal husbandry practices and livestock production systems; failure to use personal protection equipment; failure to follow recommended hand-washing practices.

Third, to reverse the trend where human outbreaks serve as sentinels for animal disease, ministries of agriculture and natural resources should develop and strengthen livestock, poultry, and wildlife zoonotic disease surveillance systems, particularly where surveillance in animal populations is currently limited. In partnership with the private sector, ministries of agriculture should conduct active and passive disease surveillance in animal populations that are raised in high-density conditions but lack good biosecurity measures, that are located in areas of dense human populations (e.g., Asia, Latin America, and Eastern Europe), and/or that are interspersed with smallholder livestock farms. Ministries of agriculture and natural resources should also conduct high-priority surveillance in livestock, poultry, companion animals, and wildlife whenever species are clustered, mixed, and inhabit areas in close proximity to human populations (e.g., co-habitation with humans in homes, villages, or are transported to, housed, and sold in live-animal markets). To detect subclinical or unnoticed infections, ministries of agriculture and natural resources should develop capacity to systematically test laboratory specimens from domesticated animals and wildlife that are at high risk of serving as zoonotic disease reservoirs (e.g., bats, wild aquatic birds, and nonhuman primates). This will enable responses to be targeted and can limit pathogen transmission and prevent or minimize their impact on the health of human and domesticated animal populations. Ministries of agriculture, natural resources, and health should build capacity to institute active sentinel surveillance in wildlife—such as bats, wild aquatic birds, great apes, and rodents—and other important reservoir species that are in close contact with humans to continuously assess the “baseline” population with pathogens of concern (e.g., influenza, Ebola, Nipah, hendra, rabies, Rift Valley fever [RVF], coronaviruses, tularemia, plague). Targeted wildlife populations should be those most likely to interact with humans, either directly or indirectly through domesticated animals. The list of pathogens needs to be established by consensus at the global, regional, and local levels (see Recommendation 3-1 on the recommended coordinating body) and resources should be commensurate to the identified need for surveillance.

Fourth, ministries of health, agriculture, and natural resources will need to develop and formalize a system wherein surveillance information from these different human and animal populations will be integrated and synthesized for analysis. These ministries will also need to develop and formalize effective communication and reporting systems to ensure real-time reporting of linked surveillance data from human and animal populations nationally and internationally to those responsible for planning and instituting prevention, protection, and response interventions. The Danish Zoonosis Centre could be a model of an effectively integrated national program for zoonoses (see Box 8-1).

BOX 8-1

Model of an Integrated National Program for Zoonoses. The Danish Zoonosis Centre was established in 1994 in response to the major fragmentation of the surveillance systems and increasing incidence of zoonotic diseases at that time. The Centre is part (more...)

Finally, science-based nongovernmental organizations (NGOs) have a critical role to play in national and global efforts to develop an integrated surveillance system. In many cases these organizations have extremely wide geographic reach, with offices and trained staff based in countries with the highest risk for new zoonoses. They have often developed the most effective and closest relationships and collaborations with local communities. NGOs have the capacity to act nimbly to rapidly refocus resources on outbreaks during crises, and they are usually not encumbered by geopolitical constraints. Science-based NGOs—such as Wildlife Conservation Society, Wildlife Trust, The Consortium for Conservation Medicine, and EnviroVet—have launched programs specifically targeted at many of this committee’s recommendations and should be actively involved in future efforts to address them. While the focus of this committee is primarily scientific, it recognizes that advocacy groups can also provide an important push for integrated surveillance by urging relevant policy changes involving food production, wildlife conservation, poverty alleviation, and global health.

Establish Sustainable Funding Strategies

Recommendation 2-1: USAID—in partnership with international fi nance institutions and other bilateral assistance agencies—should lead an effort to generate sustainable financial resources to adequately sup port the development, implementation, and operation of integrated zoo notic disease surveillance and response systems. An in-depth study of the nature and scope of a funding mechanism should be commissioned by these agencies, and the study should specifically consider a tax on traded meat and meat products as a potential source of revenue.

The committee concluded that an integrated global surveillance and response system should be designated a national and global public good. As observed in recent outbreaks, emerging zoonotic pathogens are rapidly transmitted across borders and from one continent to another. Too often, responses are either slow but evidence-based or quick but inappropriate (e.g., non-evidence-based restrictions on travel, transport of goods, culling of animals). This has resulted in large political, economic, and social impacts on national and global human, animal, and economic health.

Although primary responsibility for creating and maintaining such a system remains at the national level, the needs of low-income countries for assistance and the complexities of building an integrated global system will require both smarter expenditure of existing resources and additional funding. Without such financial support, the global public good that an integrated system could produce will not be achieved.

The current global economic crisis underscores the need to develop sustainable financing strategies to produce this global public good. Countries with greater resources will need to show leadership by supporting low-income countries and international organizations to create a global system. With the continued spread of H1N1 virus to developing countries, United Nations (UN) Secretary-General Ban Ki-moon stated that the UN would need more than $1 billion to combat the pandemic for the remainder of 2009 alone and made a plea for assistance from developed countries (Maugh, 2009). The inadequacy of traditional donor support, the limited duration of commitment, and the competition for resources generated by other global health problems require the U.S. government, other countries, and intergovernmental organizations to design and implement strategies that will provide sustainable resources for zoonotic disease surveillance and response. National government access to realigned and new funding should be made conditional on fulfillment of agreed criteria of participation, including the willingness to conduct national assessments of surveillance and response capacity and have such assessments independently reviewed (see Recommendation 2-2).

While countries need to be encouraged to invest in developing the capacity to detect, investigate, and report suspected disease outbreaks and thus prevent sporadic cases from escalating to epidemics (especially of known diseases), resource-poor countries undoubtedly will need external support and assistance for this purpose. The challenge of maintaining global surveillance capacity calls for identifying sustainable funding sources rather than depending on development aid budgets, which historically have fluctuated with donor priorities or changes in leadership. Although a number of possible suggestions are provided in this report, the committee did not have the mandate or expertise to conduct a thorough investigation of the implications of these options. The committee therefore calls for an in-depth study to further identify innovative funding mechanisms that can continuously support the need for surveillance and response systems.

Revenue sources should be, in principle, tied to levies on activities that increase the risk of emergence and movement of zoonotic pathogens. This has led to the committee’s recommendation for further study on a product tax for internationally traded meat and meat products, which represent an important route for the emergence and spread of zoonotic diseases. This levy would be imposed primarily on wealthier exporting countries (see Table 6-4). One of the potential adverse consequences of imposing a levy may be that it increases product smuggling in an attempt to evade taxes. There may well be other unintended consequences of this strategy; therefore the committee concluded that a thorough study of the pros and cons for this, or other sustainable approaches, is a necessary prerequisite before making final decisions on the optimal mechanism to fund the required actions.

The committee considered other funding options. These include long-term commitments from high- and middle-income countries to contribute directly to a global fund established for this purpose; long-term commitments from governments to fund specific WHO, FAO, and OIE programs; establishment of endowment funds; increased contribution from foundations and nonconventional donors; and public-private partnerships. These remain options that could be considered when more intensive and targeted discussions are initiated.

Initial access to global funding for a recipient country could be made dependent on its commitment and participation in an assessment of its national surveillance capabilities (see Recommendation 2-2). Further funding could be conditional on its subsequent performance to integrate human and animal health systems and its contribution to pay for the surveillance and response systems’ operating costs. While the committee did not explore these options and the institutional arrangements necessary to manage them, the committee concluded that it would be prudent if the recommended independent global funding mechanism (e.g., the Global Fund) would not be administered by a government entity or international governmental organization.

Create a Coordinating Body for Global Zoonotic Disease Surveillance and Response

Recommendation 3-1: USAID, in cooperation with the UN and other stakeholders from human and animal health sectors, should promote the establishment of a coordinating body to ensure progress toward development and implementation of harmonized, long-term strategies for integrated surveillance and response for zoonotic diseases.

As discussed earlier in this report, WHO, OIE, and FAO have improved their coordination efforts on zoonotic diseases, especially through the creation and operation of the Global Early Warning System (GLEWS) for major animal diseases including zoonoses. In addition, WHO and OIE have independently revised their central legal agreements—the International Health Regulations 2005 (IHR 2005) and the Terrestrial Animal Health Code, respectively—to facilitate better governance strategies for zoonotic disease threats. The committee concluded that these positive developments can and should be supplemented by the establishment of an overarching global coordinating body. Building on the foundation laid by GLEWS, the adoption of IHR 2005, changes to the OIE’s Terrestial Animal Health Code, and better collaboration between OIE and FAO, this coordinating body could raise the profile of zoonotic disease surveillance and response efforts and provide the necessary high-level political support to advance national, regional, and global coordination efforts. The approach developed in the UN System Influenza Coordinator (UNSIC) strategy is widely perceived as an effective effort and could serve as a model for the coordinating body needed for an integrated zoonotic disease surveillance and response. The zoonotic disease coordinating body should work to ensure that all relevant stakeholders are consulted and involved in coordinating activities. The mechanism could also draw attention to problems and challenges faced in implementation of IHR 2005, OIE agreements, OIE/FAO strategies, and GLEWS. The coordinating body could also facilitate improved and additional funding streams for zoonotic disease control (see Recommendation 2-1).

Improve Use of Information Technology to Support Surveillance and Re sponse Activities

Recommendation 1-2: With the support of USAID, international or ganizations (such as WHO, FAO, OIE, and the World Bank) and public- and private-sector partners should assist nations in developing, adapting for local conditions, and implementing information and com munication technologies for integrated zoonotic disease surveillance.

Effective use of such technologies facilitates acquisition, integration, management, analysis, and visualization of data sources across hu man and animal health sectors and empowers information sharing across local, national, and international levels. To establish, sustain, and maintain this technologically sophisticated system, both leadership and investment are critically needed.

Leadership and investment should emerge within each country; however, low-income countries will need support to engage in broader training and capacity building. This effort should integrate key nongovernmental actors, including private philanthropies with interests in infectious disease surveillance and management (see Box 8-2 for an example); industry partners in food production, information technology, and data management; and nongovernmental organizations involved in global health. Organizations should follow the lead of actors such as Google.org., which contribute both external funding as well as internal efforts to support the development of open source surveillance technology (see Box 5-5).

BOX 8-2

Philanthropic Support for Information Technology Development and Management. The Rockefeller Foundation supports an “eHealth” initiative, along with a portfolio of grants on surveillance networks. This initiative focuses on a number of (more...)

Strengthen the Laboratory Network to Support Surveillance and Response Activities

Recommendation 1-3: USAID should promote and initially fund the es tablishment of an international laboratory working group charged with designing a global laboratory network plan for zoonotic disease surveil lance. The working group’s objective would be to design a laboratory network that supports more efficient, effective, reliable, and timely diagnosis, reporting, information sharing, disease response capacity, and integration of human and animal health components. In addition, a long-term coordinating body for zoonotic diseases, perhaps modeled after the United Nations System Influenza Coordinator’s (UNSIC’s) of fice (see Recommendation 3-1), should implement the global laboratory network plan, manage it, and assess its performance in consultation with the international laboratory working group.

The international working group charged with developing the global laboratory network plan should include representation from several groups. These include international organizations (e.g., WHO, FAO, and OIE); national human and animal health laboratories with experience in laboratory network development and support (e.g., U.S. Centers for Disease Control and Prevention [CDC], Department of Defense [DoD] Global Emerging Infections Surveillance and Response System, USDA Animal and Plant Health Inspection Service [USDA-APHIS] National Veterinary Services Laboratory, Canadian Science Centre for Human and Animal Health, Australian Animal Health Laboratory); professional laboratory organizations, such as the Association of Public Health Laboratories and the American Association of Veterinary Laboratory Diagnosticians in the United States and their counterparts in other nations; wildlife health specialists; and private for-profit and not-for-profit entities with a stake in zoonotic laboratory network development. Integration of animal and public health laboratory infrastructure, operations, and personnel should be a driving factor in development of the global plan.

To develop the plan the working group should take steps that include

1.

conducting an inventory and assessing the quality of the current global capacity for laboratory diagnosis and reporting of zoonotic diseases in human and animal health laboratories;

2.

based on this inventory, designing the optimal laboratory network structure with emphasis on utilizing existing regional laboratories in high-risk regions as reference labs capable of the work necessary for identifying emerging diseases, and sentinel surveillance laboratories within those regions;

3.

identifying where new laboratory infrastructure is necessary;

4.

creating the environment (e.g., common space, common platforms, and quality assurance standards and practices) for integrated zoonotic disease diagnostics at the laboratory and network levels;

5.

ensuring that the operational procedures for sample collection and priority secure transport to sentinel and reference laboratories are established; and

6.

ensuring optimal information flows from the local to the national, regional, and international levels and back, in order to permit integrated data analysis and provide opportunities for networking.

Once developed, a coordinating expert body (see Recommendation 3-1) should take steps to implement the global laboratory network plan modeled after the U.S. Integrated Consortium of Laboratory Networks. Funding of the laboratory network infrastructure and network operation needs to be a primary consideration in developing a global zoonotic disease surveillance financing plan (see Recommendation 2-1 on strengthening funding for zoonotic surveillance and response). Implementation would include oversight and monitoring of infrastructure development; developing performance standards for network laboratories; reviewing, recommending, and harmonizing diagnostic assays for zoonotic diseases, standardized equipment, and standard operating procedures; overseeing development and validation of new assays when needed; assisting with the provision of reference standards and reagents; ensuring an integrated laboratory network information system (Recommendation 1-2 on information and communication technologies); identifying and providing personnel training opportunities; and conducting proficiency tests for network laboratory personnel.

The coordinating body also needs to establish a mechanism for monitoring performance of the laboratory network, by, for example, sponsoring tabletop exercises and scenario testing, and engaging in continuous monitoring of assay performance. The coordinating body and international laboratory working group would need to work closely with epidemiologists and field personnel in determining how and which samples are collected, preserved, and transported to a local or national laboratory, and with which accompanying clinical and epidemiological information. The coordinating body would also need to work closely with regulatory agencies to review what barriers may exist in transporting and submitting specimens to regional or international reference laboratories, and how these can be addressed so that delays (such as those that occurred with the transport of the influenza A(H1N1) 2009 virus from the Mexican government laboratories to the CDC) are precluded. Although there are many factors to be considered—the nature of the agents and the risk they pose, type of laboratory capacity required, security of the transport mechanism—samples need to be able to reach reference and academic laboratories with the requisite safe facilities to identify new agents, determine pathogenesis, identify targets for diagnostics, drugs and vaccines, and develop and disseminate diagnostic kits and products to prevent or treat infections in animals and/or humans.

Build Human Resources Capacity Building to Support Surveillance and Response Efforts

Recommendation 1-4: Given the need for increased human capacity to plan, conduct, and evaluate integrated zoonotic disease surveil lance and response, U.S. government agencies should take the lead in developing new interdisciplinary educational and training programs that integrate human and animal health and allied fields. Existing na tional and regional training programs in field epidemiology, clinical, and laboratory diagnosis supported by HHS, USDA, and DoI should be improved to include a better balance of human and animal health concerns, incorporate contributions from laboratory and social science professionals, and connect with one another where appropriate.

The National Institutes of Health’s Fogarty International Center—collaborating with CDC, USDA Agricultural Research Service, USDA-APHIS, USDA National Institute of Food and Agriculture (the former Cooperative State Research, Education, and Extension Service), and U.S. Geological Survey (USGS)—should be funded to partner with educational institutions and relevant ministries to develop field-based, integrated, interdisciplinary model curricula and training programs for emerging zoonotic disease surveillance and response. Educational institutions should include U.S. medical, veterinary medical, and public health schools; colleges and universities of agriculture, natural resources, and social sciences; nongovernmental organizations, especially those engaged in wildlife disease surveillance and training; and international human and animal health organizations. Model curricula and training programs would need to be interdisciplinary, field-oriented, and address the interfaces of human, animal, and environmental health. Support for open-source curricula would be valuable to ensure that the needed quality can be attained and accessed freely. In addition, countries and partner educational institutions would need to develop a strategy to retain faculty expertise and a trained professional workforce to conduct and support emerging zoonotic disease surveillance and response.

Education and training is needed in all nations so that trained professionals can properly detect and diagnose known diseases in animals and humans at the earliest point possible, and know how to proceed when there is the possibility of an emergence of a new pathogen or disease. Training in the areas listed below is essential for producing a skilled workforce capable of conducting surveillance and initiating proper response actions. Training programs should, to the greatest extent possible, include human and animal health professionals and paraprofessionals, together with community and public health professionals, to maximize the opportunity to improve interdisciplinary communication. Training topics would include

• Leadership, multidisciplinary and multisectoral collaboration, and communication with surveillance and response teams across local, national, and international levels.
• Clinical and pathological diagnosis of emerging zoonotic diseases in humans and animals.
• Specimen collection, storage, and transportation for laboratory-confirmed diagnosis.
• Laboratory procedures and protocols to prepare and test specimens with appropriate assays that would identify and confirm the cause of outbreaks.
• Epidemiology, routes of transmission, and methods for outbreak investigations, and prevention and control of zoonotic diseases, including knowledge of population-based, public health strategies for disease control in human populations, and population-based, herd health approaches for animal disease prevention and control.
• Advanced quantitative methods for analyzing and modeling epidemiological data.
• Monitoring human risk behaviors associated with increasing risk of human exposure to zoonotic diseases.
• Monitoring human practices associated with disease drivers that increase the risk of zoonotic disease emergence.
• Better risk communication methods and skills aimed at informing the media and the public on the extent and cause of disease outbreaks, factors that place humans and animals at risk of exposure, and evidence-based options for response.
• Monitoring the perception of risk and knowledge of risk factors and prevention options by communities in response to media messages.
• Skills in handling policy and legal concerns and challenges that arise with surveillance and response activities.

It is especially important to create and support field-based training programs in low-income countries, because it is valuable for trainees to identify social and cultural factors, incorporate local approaches, and find acceptable solutions. For instance, by identifying, training, and utilizing local trainers in low-income countries (such as surveillance personnel trained by the polio eradication program), programs can more effectively develop the human capacity to collect and preserve samples and carry out preliminary tests. It will also teach trainees to recognize emerging problems and connect with international reference laboratories.

For low- and middle-economic countries, USAID should continue supporting and providing resources for (1) the implementation and expansion of multidisciplinary applied field training programs, such as the Training Programs in Epidemiology and Public Health Interventions Network; and (2) the development, recruitment, and retention of faculty in schools of medicine, veterinary medicine, and public health who understand the importance of specializing in integrated human and animal health surveillance and response. Special attention is needed to incorporate surveillance and response strategies with wildlife populations, human risk behaviors, and risk perception in communities.

USAID, in collaboration with counterparts in other countries, should organize or sponsor workshops to (1) develop an integrated surveillance and response curricula; (2) develop protocols, procedures, and other approaches for multisectoral collaboration and communication regarding disease detection and integrated response; and (3) train human and animal health professionals and paraprofessionals together on these methods and procedures. USAID should also fund and support professional development opportunities, including participation at international conferences and workshops. Over time, a goal is for local staff in developing countries to serve as the organizing groups for such sponsored conferences and workshops. Low-income countries will need to work with the international community to accomplish these activities, gain relevant skills for training their workforce, and develop plans for retaining faculty and a trained workforce in country.

Regardless of the resources available to a country, the committee found gaps and challenges that all countries will need to address in order to ensure a competent workforce. To field a capable workforce that can prevent, detect, and respond effectively to emerging zoonotic infectious diseases, there needs to be political will, priority assigned to surveillance and response, commitment across disciplines, adequate funding, and strong coordination at national and international levels.

Establish a Zoonotic Disease Drivers Panel

Recommendation 1-5: The U.S. Department of State, in collabora tion with WHO, FAO, OIE, and other international partners, should impanel a multidisciplinary group of technical experts to regularly review state-of-the-science information on the underlying drivers of zoonotic disease emergence and propose policy and governance strate gies to modify and curb practices that contribute to zoonotic disease emergence and spread.

Many drivers for zoonoses and the measures for controlling them are transnational in nature. The U.S. Science and Technology Advisor to the President and Department of State’s Science and Technology Advisor to the Secretary could co-lead the effort and bring the results of the panel’s findings to the attention of important stakeholders and diplomatic forums, including the UN, Group of Eight (G8), Group of Twenty (G20), and regional intergovernmental organizations. This international panel would be composed of representatives from national, international, and intergovernmental agencies, nongovernmental entities, and technical experts from academic institutions selected on the basis of demonstrated disciplinary expertise to examine the broad set of zoonotic disease drivers. The coordinating body for zoonotic disease surveillance and response (see Recommendation 3-1) would be a member of this panel. This panel could be modeled after the Intergovernmental Panel on Climate Change,¹ an international group that provides decisionmakers and other interested parties with an objective assessment of scientific, technical, and socioeconomic information about climate change. OIE has recently formed an ad hoc group to address the role of climate and environmental changes on emerging and reemerging animal diseases. It is essential that there is an organizational architecture to ensure that specialized groups such as this do not function in isolation, but are a part of an integrated global system.

Create an Audit and Rating Framework for Surveillance and Response Systems

Recommendation 2-2: USAID should convene a technical working group to design and implement, by the end of 2012, an independent mechanism to audit and rate national surveillance system capacities for detecting and responding to emerging zoonotic disease outbreaks in humans and animals.

In structuring an integrated global surveillance and response system, countries should be encouraged to develop their national capacities and be encouraged to take steps that enable them to participate in a global system. At present, there is no independent mechanism to review progress toward the needed integrated surveillance and response system capabilities, increasing the likelihood that integration will remain uneven and incomplete. By creating an independent framework to engage in constructive, transparent assessments of national efforts, this would contribute in a major way to more efficient and effective policies targeted at creating integrated zoonotic surveillance and response capabilities.

A technical working group to establish the audit and rating framework for surveillance and response systems would include representatives from WHO, FAO, OIE, and academic experts, nongovernmental organizations, and the private sector. The timing is consistent with the deadline for state parties to develop the core minimum surveillance and response capacities required by 2012 under the International Health Regulations 2005 (IHR 2005).

Countries already participate in national assessments of human and animal health systems under the IHR 2005 and OIE programs, respectively. An independent audit and rating framework can help public and private stakeholders identify problems and develop common strategies in an effort to improve national and global capabilities for integrated human and animal zoonotic disease surveillance and response. To the fullest extent possible, information generated by these reviews should be made publicly available.

Under the audit and rating framework, participating countries would provide a national assessment of the country’s risk of a disease outbreak and its reliability in reporting. The framework would then independently review and verify such information and finally rate the countries on their ability to detect and mitigate disease threats. A global emerging disease risk-rating framework that provides specific information on the risk of an outbreak by country and the likely speed of outbreak detection by national authorities would help trading partners, neighbors, and other stakeholders incorporate zoonotic disease risk into their trade and travel decisions. Participating in these audits would benefit countries because it signals a willingness to be transparent about the country’s risk of outbreaks and likelihood of detection. This then translates into trading partners and potential tourists having greater confidence in that country’s practices.

By demonstrating a commitment to co-fund their national efforts and participate in the audit and rating framework, countries would qualify to access the global funds specified in Recommendation 2-1 for improving their national surveillance and response capacity.

In order to maintain independence and credibility, this audit and rating framework would be housed within an independent global technical consortium composed of members from relevant ministries, such as the Global Fund, rather than within intergovernmental organizations that answer politically to their member states. Creating a new institution is not necessary, although that may ultimately be deemed the most feasible option.

Because information on national risk is a global public good, resources to support this activity should be sourced through the global funding mechanism described in Recommendation 2-1. The cost of auditing surveillance and response systems should be borne by this centralized global funding mechanism and not by individual countries to ensure that the process is seen as independent, unbiased, and credible.

Strengthen Incentives for Country and Local Reporting

Recommendation 2-3: To reduce incentives to conceal outbreaks and mitigate the negative social and economic repercussions of early dis ease reporting (e.g., stigma of disease, food safety concerns, culling, and trade and travel disruptions), financial incentives at the following levels are needed through partnerships among bilateral aid agencies, the international community, and national governments:

(a)

Country level: USAID—in partnership with international finance institutions and other bilateral assistance agencies—should im plement economic incentives to encourage middle- and low- income countries to report human, animal, and zoonotic disease outbreaks.

(b)

Local level: National governments, with added support from the international community, should identify and provide the resources needed for financial incentives to promote early disease reporting and to engage in effective responses at the local level.

Current methods to control outbreaks include culling of livestock and poultry, and they also influence social and economic incentives to report outbreaks. Although there is now increased sensitivity in some countries to the importance of not disincentivizing future reporting when implementing control measures, this is by no means uniform. Economic disincentives to reporting include culling of livestock and poultry without adequate compensation, and food product warnings, recalls, or bans without evidence of reasonable risk. Evidence-based practices need to be designed and implemented to assist outbreak containment. Efforts to control the international spread of zoonotic diseases include trade and travel restrictions that place significant economic hardship on reporting countries.

The international community can also minimize the unnecessary cost of sanctions at both levels by using existing regulatory mechanisms, like zoning and compartmentalization, where appropriate. International community application and acceptance of these initiatives allow for continued trade of safe products from countries or zones that have reported a disease.

Although efforts to date have focused on upgrading surveillance capacity in countries that are less able to report outbreaks in a timely manner, the committee recommends that bilateral aid agencies and international organizations pay closer attention to the economic incentives for reporting disease outbreaks (e.g., vaccination campaigns and reimbursements for livestock and poultry culling). Resources earmarked to upgrade surveillance capacity should consider whether these systems will actually be used in the event of an outbreak or whether these resources are simply crowding out monies that countries would have spent on their own. In addition to funding for upgrading surveillance capacity, guaranteed assistance with outbreak containment needs emphasis, including the availability of vaccines for humans or animals. Without such guarantees, countries have fewer incentives to report disease outbreaks, regardless of international legal obligations.

National governments should explicitly plan to increase incentives for surveillance and reporting by allocating financial resources to pay for adequate reimbursement to those who stand to lose from reporting, while decreasing disincentives by reviewing and reducing the unwarranted use of outbreak control measures such as travel restrictions, quarantines, and culling.

Deepen the Engagement of Stakeholders

Recommendation 3-2: In its work on zoonotic disease surveillance and response, USAID—in collaboration with WHO, FAO, and OIE—should convene representatives from industry, the public sector, academia, nongovernmental organizations (NGOs), as well as smallholder farmers and community representatives to determine how best to build trust and communication pathways among these communities in order to achieve the efficient bi-directional flow of both formal and informal informa tion needed to support effective, evidence-based decisionmaking and coordinated actions.

The complexity of achieving sustainable, integrated national and global surveillance and response systems for zoonotic diseases requires deliberate and intensified efforts to engage and connect all relevant stakeholders at each governance level—local, national, and global. Moreover, high stakes for trade or industry groups—as illustrated by the detection of bovine spongiform encephalopathy (BSE) in three cows in the United States between 2003 and 2006, causing great economic harm to that industry with a total loss of $11 billion—necessitate their involvement as well.

To achieve better surveillance and response, different players will be challenged to work effectively together, as they often have vested interests and their actions can affect or alter the occurrence, transmission, or spread of the disease. These players include animal producers and related industries that have an economic interest in the trade-off between quality and yield, governments that have a political interest in the trade-off between improving the levels of sanitary health on behalf of citizens and the freedom of international commerce, and the public that desires higher levels of health and less risk of disease. Despite these often mutually beneficial interests, different sectors can still be resistant to working together. To overcome such barriers, it is critical to engage relevant stakeholders from all levels to help build transparency and trust.

Ultimately, stronger systems of surveillance and response lead to improved sanitary environments and higher levels of health for both human and animal populations. Benefits can also extend beyond disease prevention or control, including increased productivity, higher trade competitiveness and market expansion, increased levels of availability and food security, reduction in the risk of bioterrorism targeting the safety of food, and greater options for growth in sectors such as tourism. Articulating the range of possible benefits can improve public acceptance of measures and behaviors designed to reduce the risk of zoonotic disease emergence and spread.

Starting at the local level, steps for cooperative action include a better articulation and quantification of potential benefits and costs. A greater understanding of how cooperative action can be beneficial is needed, and examining community-based models would be helpful to understand nonfinancial incentives that make such initiatives sustainable. Some community-based models have demonstrated their success and sustainability, and those benefits and costs accrue across multiple sectors. The Bangladesh Rural Action Committee serves as one example in the human health sector that is worth further exploration; however, there are likely other working models outside health sector initiatives that engage different actors to achieve common objectives. Finally, there needs to be a willingness to test different approaches in pilot applications so that they systematically build upon one another for success.

Revise OIE Governance Strategies

Recommendation 3-3: To protect animal health and international trade, and to contribute significantly to the reduction of human and animal health impacts from zoonotic diseases, OIE members states should take the necessary steps to:

(a)

Adhere to Resolution 17 (adopted on May 28, 2009), which re minds OIE member states of their obligation to make available to OIE all information on relevant animal diseases, including those that are of zoonotic potential.

(b)

Create legally binding obligations for OIE members to develop and maintain minimum core surveillance and response capabilities for animal health risks, including zoonotic diseases.

(c)

Authorize OIE to publicly disseminate information received from nongovernmental sources, in the event OIE member states fail to confirm or deny such information in a timely manner, or when de nials of such information run counter to persuasive evidence that OIE has obtained from other sources.

(d)

Empower the OIE Director-General to declare animal health emer gencies of international concern with respect to emerging or re emerging zoonotic diseases that constitute a serious animal or public health risk to other countries and issue recommendations about how countries should address such emergencies.

As discussed in Chapter 7, the committee analyzed existing similarities and differences in the governance strategies and legal obligations embedded within WHO’s IHR 2005 and OIE’s approaches, rules, and resolutions. Although they have more similarities than some comparative analyses have recognized, the committee concluded that the OIE rules lack important provisions found in IHR 2005 that should be operative to promote animal health. The first three parts of this recommendation identify the key provisions. These call on OIE member states to adhere to the most recent resolution on reporting relevant animal diseases to OIE, to establish binding obligations for members to develop and maintain minimal capability for zoonotic disease surveillance and response, and to provide the Director-General with the authority to make public credible information on zoonotic disease outbreaks, even without concurrence of the member state. The fourth would also provide the Director-General with the authority to declare an animal health emergency of international concern, analogous to the authority the Director-General of WHO now has under IHR 2005.

Adopting these principles will strengthen OIE’s ability to ensure that its member nations have the minimal capacity for effective surveillance and response to animal diseases, ultimately improving the potential to control animal diseases before they decimate animal populations and impact human health. In addition, their implementation by OIE would create a more harmonized set of global principles that would apply to both human and animal diseases. The committee is convinced that this would provide a stronger foundation for coordination and collaboration among human and animal health organizations, ministries, and experts.

Mitigate Disease Threats from Wildlife and Trade

Recommendation 3-4: To mitigate and decrease the threat of zoonotic diseases emerging from wildlife, U.S. government entities and their international partners, especially OIE, should proactively take the fol lowing initiatives:

(a)

Conduct a comprehensive review of federal and state laws on trade in wildlife as a prelude to optimizing the policy and regula tory options to identify gaps and weaknesses in such laws, and to enact new legislation, regulations, or administrative rule changes to strengthen the government’s ability to protect human and animal health from diseases carried by wildlife traded through foreign or interstate commerce.

(b)

Incorporate efforts and initiatives that support actions to prevent, prepare for, protect against, and respond to threats to human and animal health into current and new international negotiations and cooperative processes that address drivers of zoonotic diseases (e.g., exotic pet trade, food safety and security, environmental degradation, and climate change).

(c)

Pursue negotiations for a new international agreement on trade in wildlife species that improves international collaboration on reducing the threat that such trade presents to human and animal health. The objectives of the negotiations and the agreement would be to make wildlife-related zoonotic disease prevention and control a higher priority in the international management and control of legal and illicit trade in wildlife species, the production and distri bution of food and animals, and environmental protection.

(d)

Incorporate wildlife diseases and zoonoses into the OIE World Animal Health Information System (WAHIS) and integrate report ing on wildlife diseases and zoonoses in GLEWS. OIE should also expand the role and capability of its Working Group on Wildlife Diseases in order to more effectively meet the growing zoonotic threat that wildlife diseases represent.

U.S. government entities that should take the lead for these recommendations include the Department of Commerce, USDA, HHS, DHS, and DoI. Other relevant entities include the U.S. Postal Service and the U.S. Trade and Development Agency. There is growing awareness of the wildlife trade as a conduit for zoonotic pathogens of public health concern, and of others that directly affect livestock or wildlife, at the same time it is apparent that there is extremely limited ability to monitor and control this trade. In the United States, the Fish and Wildlife Service is responsible for inspecting import consignments for conservation and trade requirements, but not for detecting disease. The USDA is responsible for testing imported livestock for disease, but not wildlife. To overcome the current fragmentation of responsibility in the United States, a first step to address this lack of coordination would be establishing an inter-agency working group to recommend a collaborative strategy for improved oversight and action. At the same time, the USGS National Wildlife Health Center should be tasked to conduct a risk assessment of the potential health impact of imported wildlife, the extent of the illegal importation into the United States, and a cost-benefit analysis of control measures.

Internationally, OIE has authority to list a disease as notifiable to protect trade in animals. This is usually applied to diseases that would hinder trade in livestock, but it may also be applied to diseases which can affect the environment, including wild animals. OIE should adopt a broad view of its remit and form an ad hoc committee to assess the most significant disease risks in the international wildlife trade, including those of potential impact to human, livestock, and environmental health. The ad hoc committee should make recommendations on which diseases should be listed as notifiable for these reasons. It is important to remember that many diseases of zoonotic potential are nonpathogenic in traded wildlife. OIE, WHO, FAO, and U.S. government agencies (including USDA and USAID) should fund pathogen discovery programs to identify potentially zoonotic, novel agents in wildlife currently traded between countries.