Download Global and Regional Surveillance Networks for Emerging Infectious

Global and Regional Surveillance Networks for
Emerging Infectious Diseases
Jae-Hoon Song, MD, PhD
Chairman, Asia Pacific Foundation for Infectious Diseases (APFID)
Professor of Medicine, Division of Infectious Diseases,
Samsung Medical Center, Sungkyunkwan University
I. Emerging infectious diseases (EID)
In 1963, Dr. T. Aidan Cockburn made the statement in his book entitled “The
evolution and eradication of infectious diseases”:
“We can look forward with confidence to a considerable degree of
freedom from infectious diseases at a time not too far in the future. It
seems reasonable to anticipate that within some measurable time …. all
the major infections will have disappeared”
However, according to the recent data from WHO, infectious diseases still accounted for 25%
of deaths worldwide and new emerging infectious diseases (EID) have become the perpetual
challenges to public health in all countries. EID could be defined as “infections that have
newly appeared in a population or have existed previously but are rapidly increasing in
incidence or geographic range”. Historically, EID have been huge disasters such as plague
(„Black Death‟) in the 14th century, pandemic influenza in 1918, AIDS from the 1980s, and
recently new type influenza and SARS. EID are categorized into three major types : newly
emerging, re-emerging/resurging, or deliberately emerging. Newly emerging infections are
those that have not been previously recognized in man such as AIDS, Helicobacter pylori or
antimicrobial resistant pathogens. Re-emerging and resurging infections are those that
existed in the past but are now rapidly increasing either in incidence or in geographical or
human host range such as malaria or tuberculosis. Finally, deliberately emerging infections
are those that have been developed by man, usually as bioterrorism and bio warfare.
Major factors that can affect the emergence of EID include genetic, biological, social,
political and economic factors ; microbial adaptation and mutation, changes in climate and
weather, changing ecosystems, human demographics and behavior, deforestation,
international travel and commerce, poverty and social inequality, war and famine, and
breakdown of public health measures. Given that infectious diseases will continue to
emerge and re-emerge, global and regional efforts to control and prevent these infectious
diseases threats are very critical to public health.
II. Representative examples of EID
Fig. Global examples of emerging and re-emerging infectious diseases since the 1970s
(Morens DM et al. 430;242-9, 2004)
1) Influenza
A pandemic occurs when a new influenza virus emerges and starts spreading as easily as
normal influenza by cough and sneezing. The worst influenza pandemic in history was
the H1N1-type Spanish influenza in 1918-1919, which caused 50 million deaths
throughout the world. Subsequent pandemics occurred in 1957 by H2N2 virus (Asian
influenza) and in 1968 by H3N2 virus (Hong Kong influenza) with 2 million deaths and
1 million deaths, respectively. The most recent pandemic influenza occurred in 20092010 by H1N1 virus which was the first pandemic in the 21 st century. H1N1 influenza
was reported from 214 countries with a total of > 18,000 deaths worldwide.
Avian influenza is an infection caused by avian influenza A viruses which occur naturally
among birds. Among various types of avian influenza, highly pathogenic avian
influenza A (H5N1) virus (HPAI H5N1 virus) has caused the largest number of deaths in
humans. From 2003 to June 2011, a total of 562 cases occurred with 329 deaths,
mainly in Indonesia, Vietnam and Egypt.
2) SARS (Severe Acute Respiratory Syndrome)
SARS is an acute respiratory infection caused by SARS-coronavirus. Global outbreak
of SARS occurred in 2003 with a total of 8,422 cases and 916 deaths (case fatality rate
10.9%) throughout the world. It has originated from southern part of China and
spread all over the world within a few months. SARS virus was transmitted through
animal host, palm civets. During the SARS outbreak, global travel, trade and economy
were seriously damaged. Although the last case of SARS was reported in June 2003, it
may potentially return in the future.
3) Multidrug-resistant bacteria (“Superbacteria”)
The emergence of antibiotic-resistance in human pathogens is a global crisis.
Particularly, since the 1990s, global emergence of multidrug-resistant bacteria, socalled “superbacteria”, seriously affected the public health worldwide. The most
recent example of superbacteria was the NDM-1-producing E. coli which has originated
from India, Pakistan and Bangladesh and spread to UK and the rest of the world for the
subsequent months. Some strains with NDM-1 showed the pandrug- resistance which
means uniform resistance to all available antibiotics. Consequently, antibiotic
resistance results in increased mortality and morbidity of various bacterial infections.
III. Strategies to control and prevent EID
Basic strategy to control and prevent EID is the surveillance and response which include
detection, investigation and monitoring of EID, identify the factors influencing the
emergence and respond to problems. In order to achieve this, global and regional
capacity for surveillance should be strengthened and improved. Also, laboratory
science and epidemiology should be integrated to optimize the public health practice.
Public health infrastructures should also be strengthened to support surveillance and
research and to implement prevention and control programs. Finally, prompt
implementation of prevention strategies should be ensured against EID. All of these
strategies should be implemented not only on local or regional basis but also on an
international basis.
IV. Surveillance systems of EID
Surveillance systems are the foundation of control and prevention of EID. Surveillance
system can anticipate the emergence of diseases, support outbreak responses, and
facilitate the monitoring and evaluation of responses
1) Global surveillance networks
A. WHO surveillance networks
i. GOARN (Global Outbreak Alert and Response Network)
GOARN is a technical collaboration of existing institutions and networks for the rapid
identification, confirmation and response to outbreaks of international importance.
GOARN contributes towards global health security by combating the international
spread of outbreaks, ensuring that appropriate technical assistance reaches affected
states rapidly and contributing to long-term epidemic preparedness and capacity
building.
ii. WHO Global Influenza Surveillance Network (GISN)
WHO Global Influenza Surveillance Network performs the regular surveillance of
influenza virus strains to recommend the content of the influenza vaccine and also
serves as a global alert mechanism for the emergence of influenza viruses with
pandemic potential. WHO GISN consists of 135 National Influenza Centers (NICs)
from 105 countries.
B. Global Emerging Infections Surveillance and Response System
(GEIS)
GEIS was established by the Department of Defense of the United States to address
threats posed to the US and other nations by newly emerging and re-emerging
infectious diseases. It has the mission of performing surveillance for EID that could
affect the US military. This mission is accomplished by orchestrating a global
portfolio of surveillance projects, capacity-building efforts, outbreak investigations
and training exercises. In 2009, this portfolio involved 39 funded partners
impacting 92 countries. GEIS‟s main focus of surveillance includes respiratory
infections, gastrointestinal infection, febrile and vector-borne infection, antimicrobial
resistance, and sexually transmitted infections.
2) Regional surveillance networks
A. USA : CDC network
US CDC established the Emerging Infections Programs (EIP) network in 1995 based
on the CDC‟s 1994 strategy “Addressing emerging infectious diseases threats : a
prevention strategy for the United States”. The EIP is a network of 10 states health
departments and their collaborators in local health departments, academic
institutions, other federal agencies and public health and clinical laboratories and
healthcare providers. Major activities of EIP network include the Active Bacterial
Core surveillance (ABCs), FoodNet, Influenza activities, and Healthcare Associated
Infections-Community Interface (HAIC) projects. ABCs is a core component of the
US CDC‟s Emerging Infections Programs network (EIP), a collaboration between
CDC, state health departments, and universities. ABCs is an active laboratory- and
populatin-based surveillance system for invasive bacterial pathogens of public health
importance including group A Streptococcus (GAS), group B Streptococcus (GBS),
Hemophilus influenzae, Neisseria meningitidis, Streptococcus pneumoniae, and
MRSA.
B. Europe : European CDC (ECDC) networks
The European Surveillance System (TESSy) is a highly flexible metadata-driven
system for collection, validation, cleaning, analysis, and dissemination of data. Its
key aims are data analysis and production of outputs for public health action.
European surveillance is conducted through disease-specific networks including
European Influenza Surveillance Network (EISN), European Food- and Waterborne
disease and Zoonoses Surveillance Network (FWD-Net), European Invasive Bacterial
Disease Surveillance Network (EU-IBD), European Antimicrobial Resistance
Surveillance Network (EARS-Net), Healthcare-associated Infections Network (HAINet), European Legionnaires‟ Disease Surveillance Network (ELDSNet) and
European Diphtheria Surveillance Network (EDSN).
C. Asia : ANSORP (Asian Network for Surveillance of Resistant
Pathogens)
In Asia, there is no government-driven multinational surveillance system for
emerging infectious diseases. Instead, the Asia Pacific Foundation for Infectious
Diseases (APFID) has organized the Asian Network for Surveillance of Resistant
Pathogens (ANSORP) in 1996 to perform multinational surveillance of antimicrobial
resistance and important bacterial infections. ANSORP consists of 120 hospitals in
14 countries in the Asian region. Through this network, ANSORP has performed the
surveillance of antimicrobial resistance in S. pneumoniae, S. aureus, and enteric
pathogens as well as major infections such as community-acquired pneumonia and
hospital-acquired pneumonia in Asian countries.