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Global Infectious Disease Surveillance Lindsay Martinez, BVMS, Phd, Frcpath(UK)*

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Global Infectious Disease Surveillance Lindsay Martinez, BVMS, Phd, Frcpath(UK)* Perspective Global Infectious Disease Surveillance Lindsay Martinez, BVMS, PhD, FRCPath(UK)* Infectious diseases remain the leading cause of death IMPORTANCE OF GLOBAL SURVEILLANCE among children and young adults. They account for more than 13 million deaths a year with one in two Communicable disease surveillance provides the essential deaths occurring in developing countries.Yet, as the information to monitor, evaluate, and model the impact battle to control known infectious diseases continues, of prevention and control activities for endemic com- new threats have emerged. Currently, researchers are municable and zoonotic diseases; to detect and track epi- challenged by the resurgence of epidemic diseases such demic and emerging diseases and other public health as cholera, dengue, epidemic meningitis, and hemor- threats, such as resistance to anti-infective drugs, and to rhagic fevers, as well as the devastating development of geographically locate communicable diseases in coun- the human immunodeficiency virus (HIV) and acquired tries, regions, and globally. At the national level, strength- immunodeficiency syndrome (AIDS) pandemic and ened and integrated surveillance enables countries to other new diseases. identify populations at risk, implement prevention and The propagation and transmission of infectious control strategies, detect unusual disease patterns, and agents are favored in today’s world, constituting health contain the re-emergence or emergence of communica- threats to all countries. The reasons include ble or zoonotic diseases. Strong national surveillance is a core building block changes in the food industry that facilitate wide- for effective global surveillance systems. Information from spread dissemination of foodborne disease; countries is required to guide international action and migration and urbanization and the creation of peri- make the best use of scarce resources. Effective global sur- urban slums; veillance depends on the quality of information from the human behavior, including sexual behavior that fos- countries. Global networks of laboratories and disease ters sexually transmitted infections (STIs); surveillance systems monitor specific communicable dis- environmental changes, including deforestation and eases and facilitate rapid information exchange on changing agricultural practices as well as climate unusual disease events. Global and regional networks are change, that have an impact on diseases such as needed to build the international preparedness and col- malaria, cholera, and Rift Valley fever; laboration necessary for a coordinated response. With emergence and spread of antimicrobial resistance, continuing globalization in travel and trade, global epi- now of great public health concern worldwide, as demic surveillance is essential to ensure international many infections become increasingly difficult to treat; public health security The key components of global epi- increasing volume and speed of international travel, demic surveillance are epidemic intelligence, coordina- increasing the potential for rapid international spread tion of epidemic response, and epidemic preparedness. of disease. Successful global epidemic surveillance requires a nonpolitical approach and the capacity to facilitate col- These factors allow infectious diseases to spread laboration between diverse partners. The World Health rapidly; thus, it is critical to detect any new or unexpected Organization (WHO), with its unique global health man- outbreak. Effective global surveillance is essential to date from 191 Member States, is the appropriate organi- ensure that response is triggered without delay zation to coordinate this effort. The Organization’s multidisciplinary, problem-oriented teams together with its epidemic intelligence, preparedness, and response activities, have made it the natural focus for requests for advice and assistance on epidemic surveillance and *At the time of writing, Dr. Martinez was Director of the Department of Communicable Disease Surveillance and Response at the World response worldwide. The WHO recognizes the impor- Health Organization, Geneva, Switzerland. E-mail: [email protected]. tance of its partners in global epidemic surveillance and strives to identify more effective ways of working with eWorld Health Organization 2000. The World Health Organization has granted the Publisher permission for the reproduction of this article. collaborating institutions. 222 Global Infectious Disease Surveillance /Martinez 223 Epidemic Intelligence offered. Examples of such assistance include initial inves- tigation of the outbreak on site, supply of essential ma- The WHO aims to strengthen national and international terials to the outbreak site, transport of laboratory capacity in surveillance and control of communicable specimens from the field to appropriate diagnostic facil- diseases, including timely detection and containment of ities, organization of vaccination programs, training of outbreaks. An integral part of global epidemic surveil- field staff as part of outbreak control measures, or deploy- lance, epidemic intelligence (accurate and timely infor- ment of field teams for disease control. mation) about important disease outbreaks that may Over 500 outbreaks have been investigated in the have international implications should be delivered sys- past 2 years. Cholera, viral hemorrhagic fevers, and tematically and rapidly to key professionals in interna- meningococcal meningitis comprised half of these events. tional public health. This is being achieved through two Other outbreaks included plague, anthrax, viral encephal- mechanisms: global monitoring networks and outbreak itides, dysentery, influenza, and relapsing fever. Virtually verification. all countries experienced at least one outbreak. It is planned that this process will, in future, be applied Global Monitoring Networks directly at the regional level. Unconfirmed reports of rumors of infectious disease events around the world are regularly received through Epidemic Response WHO channels as well as from other sources (including When dealing with epidemics, the response of the inter- nongovernmental organizations, the media and electronic national community needs to be coordinated. Three cri- discussion groups). Health Canada has developed the elec- teria are used to determine whether an international tronic Global Public Health Intelligence Network response is required: (GPHIN) in collaboration with the WHO to identify potentially high-impact, new, and unusual outbreaks. The 1. Humanitarian: Does the country have the capacity GPHIN systematically scans the Web, particularly news to respond to an epidemic? media networks, news wires, and newspapers for out- 2. International spread: Does the disease have the poten- break-related information. The GPHIN provides informa- tial to spread beyond national borders? tion on a real-time basis that is used to analyze and assess 3. Travel and trade: Is there a risk that the epidemic the health risk of international events. The Internet tech- may result in inappropriate international travel and nology platform used by the system enables the gather- trade restrictions? ing of information about public health risks and its dissemination to end-users (e.g., WHO) for verification. The WHO plays an active role in the coordination of international epidemic response, and the number of Outbreak Vedftcation requests to the WHO for technical and material support To investigate and follow-up outbreak reports, the WHO has increased significantly. Response can be in the form established an innovative mechanism, outbreak verifica- of investigating, verifying and disseminating information, tion, in early 1997. Outbreak verification aims to improve coordinating response efforts in the field, or direct inter- epidemic disease control by actively collecting and veri- vention in the field. fying information on reported outbreaks and informing Examples of recent outbreaks during which WHO key public health professionals about confirmed and teams were in the field include: viral hemorrhagic fever unconfirmed outbreaks that are of potential international in Afghanistan (2000); cholera in Madagascar (2000); public health importance. The outbreak verification sys- Lassa fever and shigellosis in Sierra Leone (2000); Mar- tem follows the general principles of surveillance: sys- burg virus infection in the Democratic Republic of the tematic collection; collation, analysis, and interpretation Congo (1999-2000); cholera in Somalia (1999-2000); of data; and dissemination to those who need the infor- influenza in Afghanistan (1999); relapsing fever in south- mation for action. ern Sudan (1999); Rift Valley fever in Mauritania When an unconfirmed outbreak report is received, (199% 1999); avian influenza (H5Nl) in Hong Kong, Spe- the potential public health importance of the event is cial Administrative Region of China (1997-1998); and assessed on the basis of available background informa- monkeypox in the Democratic Republic of the Congo tion, endemicity levels, and details of previous outbreaks. (1996-1997). The outbreak verification team may seek additional infor- Surveillance and response projects for emergency sit- mation from other organizations in the field, such as the uations were undertaken in East Timor, Kosovo, and south- International Red Cross, Medecins sans Front&es, and ern Sudan. Follow-up activities were then implemented Medical Emergency Relief International. in the areas of epidemiology training,
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