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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.