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Section VI.

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Global Microbial Threats in the 1990s

VI. Capacity Building: What actions are taken by the U.S.Government to prevent and prepare for emerging and re-emergingdiseases?

Forward-looking, sustained efforts to control and ultimately prevent major disease threats form the essential foundation for any planto successfully address new and re-emerging diseases. The processof responding to international microbial threats encompasses amultitude of activities, including diagnosis of the disease;research to understand its modes of transmission; research todevelop adequate means to treat it or prevent its spread; andproduction and dissemination of the necessary drugs and vaccines.Effective response to outbreaks of infectious disease includesboth immediate responses to disease emergencies (discussed inSection II) and on-going activities to develop and maintain thetools to control outbreaks, or, better yet, to predict and/orprevent them before they happen.


To be ready to respond effectively to infectious diseaseoutbreaks, whenever and wherever they occur, requiresinternational preparation and planning. The response component ofa global infectious disease network must rest on a complexfoundation that includes skilled public health workers, nationaland regional laboratories for diagnosis and research,communications systems, and the commitment of national healthministries. A current goal of WHO is to assist each country todevelop its ability to provide laboratory diagnosis of diseasesendemic to its area and to refer specimens from suspected newlyemergent diseases to an appropriate regional referencelaboratory. To reach this goal, each country must train medicalworkers and laboratory technicians and supply them withappropriate equipment and diagnostic resources.

Several additional international elements must be in place toprovide the wherewithal for effective and timely disease controland prevention efforts. First, regional reference laboratoriesmust be maintained to provide diagnostic expertise and distributediagnostic tests. Second, an international communicationsmechanism should be made available to receive and analyze globaldisease surveillance information. Third, regional proceduresshould be instituted to facilitate the production, procurement,and distribution of medical supplies, including vaccines fordisease eradication programs. Fourth, enhanced public educationin simple health measures in developing countries must beinstituted.


Disease prevention is an investment in the young people of theworld and in our collective future. Every year, an estimated fourmillion infant and child deaths are prevented by vaccination andother preventive health measures, due to multilateral efforts.The elimination of smallpox would not have been possible withouta truly global effort. Similarly, multilateral leadership andresources propel the international program to eradicate polio.Both examples demonstrate the value to American citizens ofresources invested in global disease prevention.

In recent years, many countries have dramatically strengthenedtheir health-care delivery systems, even in the face of economicstagnation. Prevention efforts - vaccination, education to changeunsafe human behaviors, and other public health measures - arethe most cost-effective and beneficial of all measures thataddress the problem of new and re-emerging infectious diseases.In recent years, a few countries have dramatically strengthenedtheir public health systems even in the face of economicstagnation. However, even these gains are fragile and subject toeclipse by shorter term economic and political pressures.

1. Public health infrastructure in the United States

As a nation, our first-line of defense against infectiousdiseases is our national system for notifying health authoritiesof individual cases of infectious diseases. The legal authorityfor disease reporting rests with the states, which determinewhich diseases or conditions must be reported by doctors andmedical laboratories. In turn, the states voluntarily reportcases of more than 40 infectious diseases to CDC. To beeffective, our national surveillance system must becomprehensive, including not only reporting and investigation ofcases, but also submission of clinical specimens for testing atlocal, state, or federal public health laboratories. Thesurveillance system breaks down if any one step - diagnostictesting, case reporting, or follow-up investigation - is notaccomplished.

Neglect of the U.S. public health infrastructure

In the past, our national surveillance system for "notifiable"diseases has provided the basis for public health decisionsconcerning communicable disease prevention and control. However,during the past decade or more, state and local support forinfectious disease surveillance has diminished, largely as aresult of budget restrictions. In 12 states, for example,no personnel were dedicated to the surveillance of food-bornedisease, which is believed to be on the rise (see "Food-borne and Waterborne Infectious Diseases"). Inaddition, the notifiable disease surveillance system isunderstaffed in many states. As a result, many of the currentlyreportable diseases are in fact significantly underreported, andin many areas there is limited followup of the cases that arereported. Moreover, public health agencies are reluctant to addnew diseases to the list of notifiable diseases because theircapacity to support the surveillance system is already limited bylack of funds and personnel.

Because of this breakdown, targeted federal programs concernedwith AIDS, TB, sexually transmitted diseases, andvaccine-preventable childhood diseases have been unable to relyon data from our crippled surveillance network and have developedindependent, federally supported parallel surveillance systems toobtain data for their prevention and control activities. Thus, atthe same time that AIDS surveillance was being established, otherparts of the surveillance system for communicable diseases werefailing. A 1993 nationwide survey of public health agenciesrevealed that -- except for the targeted disease programs notedabove -- only skeletal surveillance staff exist in many state andlocal health departments. At the current level of diseasesurveillance, it may take hundreds of cases before an outbreak ofa non-targeted disease in a large urban area will be detected.

Food-borne and Waterborne Infectious Diseases: Communities atRisk

In 1993, a municipal water supply contaminated with theintestinal parasite Cryptosporidium caused the largest recognizedoutbreak of waterborne illness in the history of the UnitedStates. Over 400,000 people in Milwaukee, Wisconsin, hadprolonged diarrhea, and approximately 4,400 were hospitalized.Also in 1993, hamburgers contaminated with the bacteria E. coli0157:H7 and served at a fast-food restaurant chain caused amultistate outbreak of bloody diarrhea and serious kidneydisease. More than 600 people got sick; 56 people had kidneyfailure, and 4 children died. Other outbreaks of food-borneillness in recent years have included cholera from coconut milkfrom Thailand, Shigella diarrhea linked to green onions fromMexico, and Salmonella diarrhea from an Israeli snack food.These diseases were emerging at the same time that domesticsurveillance of infectious diseases was diminishing. A number offactors were associated with the occurrence of the outbreaks ofE. coli 0157:H7 and Cryptosporidium. However, the lack of promptdiagnosis and reporting likely contributed to morbidity,mortality, and economic costs.

Three ways to improve domestic surveillance of infectiousdiseases

1. Strengthen the national notifiable disease system.

For acute infectious diseases that require prompt reporting andinvestigation of every case (such as botulism and meningococcalmeningitis), a national notifiable system works best. Localhealth departments must be made stronger and more flexible, sothat disease-reporting can be modified to include new illnessesas they arise. State, local, and federal public health officesmust work in partnership to achieve these goals.

2. Establish sentinel surveillance networks.

For many other diseases, reporting of all cases is unnecessary.Instead, sentinel networks linking groups of health careproviders and laboratories to a central data processing centermay be particularly helpful in observing rises in the incidenceof particular diseases. For instance, such networks can be usedto monitor unexplained adult respiratory distress syndrome andchildhood illnesses characterized by fever and rash. A goodexample of a sentinel network is the one established forinfluenza (see "Sentinel Surveillance for Influenza").

3. Establish public health centers for emerging diseases toprevent future AIDS-like epidemics in the United States.

A different type of sentinel system is required to detect andinvestigate newly emergent diseases, which by definition are noton any reportable list. A sentinel system for this purpose wouldperform comprehensive surveillance within several well-definedsites that offer access to various population groups. Suchcenters could be developed through cooperative agreements withlocal and state health departments in collaboration with localacademic institutions and other governmental or private-sectororganizations. Strategically located epidemiology and preventioncenters for emerging infections could also be used to monitorantimicrobial drug resistance, foodborne diseases, andopportunistic infections. Each center would conductpopulation-based surveillance projects, evaluate new diagnostictests, and implement pilot projects for disease prevention andintervention.

Sentinel Surveillance for Influenza

The influenza sentinel surveillance network was establishedthrough the American Academy of Family Physicians and includesapproximately 150 primary care physicians located throughout theUnited States. These physicians submit weekly reports of thenumber of patients seen with influenza-like illnesses by agegroup, per number of patent visits, as well as the number ofhospitalizations among patients with influenza-like illness. Asubgroup also collects nasopharyngeal specimens that are sent toa central laboratory for influenza virus identification.

The international component of influenza surveillance involves anetwork of collaborating laboratories, established in 1947, whichnow includes over 100 WHO National Collaborating Laboratories.The primary purpose of the network is to detect the emergence andspread of new strains of influenza that may signal a need toupdate the strains contained in the influenza vaccine. Toaugment the WHO network, CDC supports a surveillance system forinfluenza virus isolation at six sites in China, where manypandemic and epidemic strains have first appeared.

2. Public health infrastructure in other nations

The United States is usually informed about disease outbreaks inother countries because we are widely respected as the world'sforemost authority on infectious disease recognition and control.Individuals, laboratories, and ministries of health seek tocollaborate with CDC, either formally or informally, when theyare confronted with an infectious disease problem that theycannot resolve. To ensure that we continue to be notified, wemust ensure that we remain ready to assist in national capacitybuilding for disease surveillance, and to respond when asked forassistance.

The effectiveness of a global disease surveillance and responsesystem depends on each nation's capacity to detect and controlinfectious diseases. Some industrialized countries have becomesufficiently concerned about the resurgence of infectiousdiseases to devote substantial resources to a surveillanceeffort. In addition, the Executive Board of the World HealthAssembly recently passed a resolution that focuses on capacitybuilding related to emerging infectious diseases.

In many developing countries, however, health resources areextremely scarce, and U.S. health experts agree that WHO has notbeen able to fill the existing gaps in global surveillance andresponse. Furthermore, major U.S. funding for this purpose is nota likely prospect during this period of federal deficit reductionand downsizing. However, there are several inexpensive,cost-effective actions that can and should be taken.

First, we can encourage and assist other countries to makedisease prevention, surveillance, and preparedness a nationalpriority.

Second, we can build new efforts onto long- standing programs andrelationships that help other countries to strengthen diseaseprevention efforts and preparedness by improving their publichealth infrastructures such as their systems for treating wastewater and disinfecting drinking water.

Third, we can identify and preserve existing projects thatenhance other countries' capacities to detect and controlinfectious diseases.

The goal of enhancing other nations' capabilities to monitor andcontrol infectious diseases is in accord with the security andforeign policy aims of the United States. In the post-cold warperiod, a major objective of U.S. foreign policy is the promotionof sustainable economic development around the globe. Helpingother countries to help themselves - to improve the lives oftheir citizens, develop their economies, and find niches in theglobal economy - is a major guide for U.S. foreign assistance andaid. Support for international health initiatives is a valuablepart of the U.S. effort to promote economic development andpolitical stability.

The U.S. Government's role in international prevention andcontrol efforts

As mentioned above, the U.S. Government has contributed money,time, and expertise to the successful effort to eradicatesmallpox and to the continuing effort to eradicate polio andother childhood diseases. This was accomplished through asustained interagency and private sector effort. Many or most ofthe vaccines used in the disease eradication programs weredeveloped in the United States, building on many years of basicresearch by American scientists.

Many other U.S. Government activities assist developing countriesto lay the foundation for effective disease prevention andcontrol, surveillance and response. Most of these programs aresupported and organized by USAID, which is the U.S. agencyresponsible for international sustainable development,humanitarian assistance, and disaster response. Disease controlefforts are often thwarted and microbes given fertile breedinggrounds by political and economic instability and civil strife.Worldwide efforts to promote good governance, economicdevelopment and resolution of conflicts are not out of place in adiscussion of how to deal with new and re-emerging diseases. Toneglect such efforts is to potentially doom us to costly crisisresponse making long-term prevention and control difficult orimpossible. Thus, activities targeted at improving less developedcountries" abilities to conduct surveillance, prevent and controldiseases, and prepare for epidemics are integral to sustainabledevelopment efforts.

Helping countries to help themselves: U.S. Government activitiesin public health capacity building

The United States, through USAID, provides technical assistanceto health programs in over 40 countries. The agency's countrymissions supply the on-the-ground support, information, localcapacity-building, and networking that are so important to othergovernment and non-government health programs. They alsofrequently provide emergency support during disease outbreaks.Many USAID activities are carried out in collaboration with otherdonor nations and take advantage of U.S. technical leadership inhealth research and public health planning. These activities alsorely on the expertise of American research institutions,universities, and non-governmental organizations.

Several specific activities supported by USAID and other U.S.agencies are describedin boxes in this section. The overall objectives of theseactivities are:

  • Helping to strengthen developing country capacity to addressemerging health threats such as AIDS and drug-resistant malaria;
  • Developing and improving methods for detecting andresponding to microbial resistance to drugs used to treatdiseases as pneumonia, malaria, diarrhea, and TB; facilitatingthe introduction of these methodologies into country controlprograms; and improving drug management and local drugprescription patterns to reduce the development and spread ofantimicrobial resistance.
  • Strengthening communication about infectious disease-relatedhealth issues;
  • Supporting applied research relevant to emerging andre-emerging heath threats in developing countries.
  • Supporting and expanding existing programs to strengthendeveloping countries' capacities in epidemiology and laboratoryand clinical diagnosis;
  • Continuing to play a leadership role with WHO andinternational donors in addressing emerging health issues ofmajor importance to developing countries.

The Center for Health and Population Research

The International Center for Diarrheal Disease Research,Bangladesh (ICDDR,B; now known as the Centre for Health andPopulation Research), is a leading international health researchinstitute in the developing world. USAID has supported theICDDR,B for over 25 years, dating back to the landmark clinicaltrials of oral rehydration therapy for cholera. Other scientificachievements include the characterization of new cholera strains;the demonstration of cholera vaccine efficacy in field trials;the development of inexpensive, simple diagnostics for diarrhealdiseases; and the development of successful integrated familyplanning and health services delivery programs through operationsresearch. The ICDDR,B also provides training to scientists fromaround the world and essential medical care for thousands ofBangladeshis. The ICDDR,B has also provided technical assistanceto humanitarian relief efforts in Peru, Zaire, and Rwanda.

Although the United States made the initial investments, thesuccess of the ICDDR/B over the years has attracted multi-donorsupport from the governments of Switzerland, Canada, and Japan;from multilateral organizations such as the UNDP, the WHO, andUNICEF; and from private foundations such as the Sasakawa andFord Foundations.

Research and Capacity Building: The Applied Diarrheal DiseaseResearch (ADDR) Project

The Applied Diarrheal Disease Research (ADDR) Project, developedby USAID and the Harvard Institute for International Development,has pioneered research capacity building through innovativeworkshops, consultancies, and research grants. ADDR providesassistance in proposal development and implementation, datacollection and analysis in developing countries. ADDR works withcollaborating groups of local scientists and policy makers (aneffective combination for policy change) to set the researchagenda and to develop national networks of investigators.ADDR-sponsored research, which emphasizes social scienceresearch, provides new health interventions, better tools forepidemiologic studies, and better case management in prioritycountries. All of the research is conducted in developingcountries.

ADDR has developed a network in 12 developing countries of over300 scientists who are collaborating successfully in the searchfor new ways to prevent and control infectious disease outbreaks.The ADDR network in Mexico, for example, is demonstrating how onedeveloping country can slow the evolution of antibiotic resistantmicroorganisms through appropriate antibiotic prescribing andcompliance practices. In an initial study, ADDR scientistsdetermined that educational and managerial interventions in aMexican Social Security (IMSS) clinic significantly reduced theproportion of children who received antibiotics andanti-diarrheal drugs, and increased the use of oral rehydrationtherapy. These changes have lasted more than 18 months after theintervention ended. Medication compliance improved among patientsin the intervention group even though improving such compliancewas not an explicit objective of the intervention.

A second study undertaken by the IMSS extended the same methodsto 17 clinics from both the IMSS and the Mexican Ministry ofHealth, and looked both at diarrheal and acute respiratorydiseases. Results from this randomized controlled trial ofclinics were very successful; medication costs decreased by 36%and medication waste due to noncompliance and over-prescribingdecreased by 51%. Mexico's Minister of Health took an activeinterest in the studies and, as a result, the IMSS is nowimplementing a new diarrheal disease treatment program in 12Mexican states. If successful, this large scale intervention maylessen the likelihood that antibiotic resistant microorganismswill emerge from Mexico.

U.S. Foreign Aid for Health Technologies: Program for AppropriateTechnology in Health (PATH)

Saving money and lives through immunization programs.

The success of the effort to immunize children throughout theworld against common childhood diseases is dependent on theavailability and quality of local immunization programs. Yetlimited health budgets in many developing countries limit thenumber of children who are immunized. USAID has invested inidentifying and developing cost-effective technical solutionsthat save money - and lives.

For example, with USAID assistance, the Program for AppropriateTechnology in Health (PATH), has worked with a U.S. company todevelop simple monitors for individual vaccine vials thatindicate when a vaccine has been exposed to heat and needs to bediscarded. Previously many vials were discarded unnecessarily. Asmuch as $20 million will be saved each year on oral polio vaccinealone, a savings that can be used by countries to purchase morevaccine and immunize a far greater number of children.

Diagnostics: Rapid and simple for surveillance and prevention.

Rapid, easy to use diagnostic tests can be invaluable to trackthe spread of emerging infectious diseases. In the developingworld, the capacity to locally manufacture high qualitydiagnostics has lagged behind pharmaceutical and vaccineproduction. Yet diagnostic tests manufactured in industrializedcountries are often inappropriate for use in developing countryhealth programs. They are too costly, too complex to use, or needsupporting laboratory equipment and highly trained technicians.Through its agreement with PATH under the HealthTech Project,USAID has supported the development of a generic low-cost, rapid"dipstick" technology that is suitable for use under fieldconditions. The dipstick technology is currently used to detectantibodies to HIV-1,HIV-2, and hepatitis B viruses in bloodsamples, and shows extremely high sensitivity and specificity.The basic technology can be adapted to allow detection of otherimportant diseases.

None of these disease prevention technologies were of interest tothe commercial sector initially because they were primarilydesigned for developing country needs. By advancing thetechnology, USAID and PATH have been able to stimulate commercialsector interest and investment so that U.S. industry now isproducing new products that directly contribute to slowing thespread of diseases in the developing world.

Strategic Objectives for Capacity Building

Country-level Objectives

Comprehensive country-level objectives for capacity building havebeen concisely described by WHO in its January 12-13, 1995 reporton emerging infectious diseases.

  • All countries should have the ability to provide laboratorydiagnosis of "common" diseases endemic in their areas and theability to refer specimens from suspected "uncommon" diseases toan appropriate reference laboratory.
  • All countries should have the epidemiologic capacity toinvestigate outbreaks, collect specimens, and analyze testresults.

Implementation of the first country-level objective would befacilitated by the compilation of a country-by-country list of"common" diseases for which each country should be able toprovide laboratory diagnosis, and of "uncommon" diseases that canbe referred for diagnosis at a reference laboratory. A list ofappropriate diagnostic tests and reagents and a plan fordistributing them could also be developed.

Regional-level Objectives

Regional-level objectives recommended by U.S. agencies include

  • Provision of surveillance and response coverage at theregional level for countries that lack the resources to detectand control epidemics within their borders.
  • Linkage of local hospitals and laboratories into acoordinated regional surveillance network that provides referralsin the areas of diagnosis and epidemiologic investigation.
  • Provision of diagnostic reagents to regional surveillancecenters by WHO, the United States, and other nations.
  • Support of regional self-sufficiency in the production,quality control, and distribution of medical supplies.
  • Provide regional climate forecasts and develop the capacityto identify areas that are vulnerable to outbreaks of infectiousdisease because of changes in weather.

Implementation of the recommendations for establishing regionalsurveillance and response networks will provide significant stepstoward the fulfillment of the first three regional levelobjectives.

Four Target Areas for Capacity Building

Capacity building in support of a national surveillance andresponse system encompasses a complex set of skills andresources, many of which are readily available in industrializedcountries but not in underdeveloped ones. The components of apublic health infrastructure include human resources, physicalresources, systems for laboratory referral and informationexchange, and a favorable policy environment to encourage diseasesurveillance and permit disease reporting and cooperation withother countries. Recognizing, reporting, and responding to newdisease threats involves each of these target areas.

1. Human resources for capacity building

  • Individuals trained in disease surveillance, who anticipatethe unusual
  • Doctors, nurses, and other health practitioners whorecognize and report the unusual
  • Laboratory technicians and microbiologists who diagnose theunusual
  • Epidemiologists and laboratory scientists who investigatethe unusual
  • Social scientists who understand the human context of theunusual
  • Public health managers who use surveillance and diagnosticinformation to determine how to control and prevent the unusual

2. Physical resources for capacity building

  • Laboratories that are safe and clean and accommodateappropriate equipment and supplies.
  • Communications equipment. Depending on resources of thecountry, communications can be based on telephones and faxmachines or on computers and satellite technology.
  • Systems for treating waste water and disinfecting drinkingwater.

Both categories require people who are trained in the operation,quality control, and maintenance of the equipment.

3. National systems for disease reporting

  • Successful disease surveillance and control requires ahierarchical laboratory and communications system for
  • Reporting common and unusual clinical events
  • Collecting specimens for laboratory diagnosis
  • Providing access to diagnostic tests
  • Investigating the epidemiology of outbreaks
  • Instituting control measures
  • Providing feedback for preventing future outbreaks, withspecial attention to communication between the producers andusers of surveillance data

4. Building a policy environment conducive to participation in aglobal system

When a serious disease outbreak is suspected, the politicalauthorities of a given nation may be reluctant to report it,fearing loss of trade and/or tourism, or to seek technicalassistance for the epidemiologic and laboratory investigation. Inthe past, this reluctance has had serious consequences. In manycases, diseases have spread unchecked. In some other cases, inwhich an outbreak was quickly brought under control, unnecessaryrestrictive measures were imposed by other countries, causingeconomic damage. Governments should encourage internationalcommunication among scientists and public health personnelregarding emerging infectious diseases and request internationalassistance through WHO when disease outbreaks occurs or whenunusual infections are suspected.

Creating an International Community of Epidemiologists

Since 1980, the Field Epidemiology Training Programs (FETPs) haveset the standard for training in applied epidemiology in manycountries. Sponsorship of these programs has given CDC theopportunity to help strengthen the international public healthnetwork while reducing the risk that infectious diseases will beimported into the United States.

CDC established the first FETP in Thailand in collaboration withWHO and the Thai Ministry of Health, in answer to a Government ofThailand request for assistance in training in appliedepidemiology. Since then, programs have been initiated in 14countries including Australia, Colombia, Egypt, Hungary,Indonesia, Italy, Mexico, Peru, Philippines, Saudi Arabia, Spain,Taiwan, Uganda, and Zimbabwe. Programs are currently underdevelopment in South Africa and the Dominican Republic, andseveral additional programs are in the preliminary planningstages.

The FETPs are modeled on CDC's domestic Epidemic IntelligenceService (EIS), 2-year training course in applied epidemiology.The FETPs maintain the basic structure of EIS with modificationsto suit the needs of the individual host country. The objectivesof the program are to:

  • Provide a continuous supply of field-orientedepidemiologists who are able to meet their country's diseaseprevention and control needs, and
  • Provide epidemiologic services to public health programs atthe national and local levels.

FETPs directly benefit the countries in which they operate andalso provide public health partnership benefits to the UnitedStates. Empowering national programs to deal effectively withtheir own disease control and prevention problems diminishes theneed for further direct U.S. involvement. Moreover, working withFETP colleagues throughout the world has yielded a wealth ofexperience, professional collaborations, and internationalinfectious diseases surveillance connections. For example,because of CDC's participation in Peru's FETP, CDC staff were inplace in 1991 to help control the first cholera epidemic in theWestern Hemisphere in the 20th century.

Building Surveillance Capacity in Sub-Saharan Africa

During 1981-1993, USAID supported the Africa Child SurvivalInitiative, Combating Childhood Communicable Diseases (CCCD)project, which was implemented by CDC in 13 countries insub-Saharan Africa. At the outset the CCCD project, epidemiologicsurveillance systems remained fairly rudimentary, despite theadvances that the smallpox eradication program had made in theregion. There were few epidemiologists, minimal data managementcapabilities, and few programs that made use of current healthdata. The CCCD project developed health surveillance programs ina variety of Francophone and Anglophone countries. These includeda national program for sentinel infectious diseases surveillancein Zaire; a hospital-based malaria surveillance project inKinshasa, Zaire; and surveillance of resistance to antimalarialdrugs in Guinea, Nigeria, Togo, and Zaire. Several valuablelessons were learned from these projects.

  • Surveillance systems require investment and supportincluding equipment, supplies, personnel, training, andsupervision if they are to function successfully.
  • Surveillance systems are likely to be sustained only wherethey provide data that are useful in program planning andmanagement.
  • Efforts are needed to assure the quality of the data thatare collected, reported, analyzed, and communicated, and whichserve as the basis for decisions.
  • New applications of epidemiologic surveillance will becomeincreasingly important in the years to come.

Technical obstacles that had to be overcome included thestandardization of case definitions and the lack of reliableclinical diagnostic algorithms for some targeted diseases.Structural obstacles included the lack of basic laboratoryservices such as microscopy and chest X-ray facilities.

International Clinical Epidemiology Units (INCLEN): The EssentialRole of Training and Research in Surveillance and Prevention ofInfectious DiseasesIn 1980 a group of health specialists from the RockefellerFoundation, concerned about the growing crisis in global healthcare, created INCLEN, a non-profit international program to trainfaculty from medical schools in developing nations in clinicalepidemiology. Such training enables medical practitioners toevaluate the availability, effectiveness and efficacy ofhealth-care practices in their home countries. In addition, thephysician/epidemiologists extend their vision beyond theindividual patient or hospital ward to better understand thetotal impact of disease on the public and the country (medical,personal, cultural, economic, etc.) and the importance ofprevention strategies.

The multiplier effect of this training program is impressive. Itstarted with five training centers in five countries, and has now(15 years later) trained more than 300 physicians, socialscientists, and biostatisticians, who have formed adjunct unitsin over 40 medical schools in 16 developing countries. TheseINCLEN units form the backbone of an active research andsurveillance network which attempts to identify and confrontinfectious diseases before they become unmanageable, costlycrises. The physician/epidemiologists conduct high-qualityresearch on critical topics such as the economic implications ofclinical decisions, cultural factors influencing attitudes andpractices toward sickness and health.

USAID supports seven INCLEN units in India. Recently, these unitsin India collaborated to study the bacterial agent most commonlyassociated with pneumonia in various locations throughout thecountry. This activity was built upon the surveillance andtreatment capacities established by the INCLEN epidemiologytraining and research development program. The study showed thepneumococcal pneumonia, treatable with penicillin, was by far themost common cause of pneumonia in Indian children throughout thecountry. This finding changed the focus of vaccine developmentand caused the Ministry of health to change its policy for casemanagement of pneumonia which had previously relied on expensivebroad spectrum antibiotics rather than the far cheaper andreadily available penicillin.

The INCLEN approach demonstrated that use of public health tools(including surveillance of disease patterns and research on theeffect of drug treatment) coupled with health economic analysescan lead to efficient and cost-effective preventive and curativeinterventions.

USAID/Nepal Inaugurates Center for Surveillance and Control ofEmerging Vector-Borne Diseases

Emerging vector-borne diseases are a serious problem in Nepal andsurrounding countries, posing a continuous threat tomaternal/child survival and economic development. For example,the Terai region in southern Nepal has been the focus of apandemic of Kala-azar (visceral leishmaniasis), which has spreadfrom neighboring areas of India and Bangladesh. This parasiticdisease, spread by the bite of an infected sandfly, is rapidlyfatal if undiagnosed and untreated and the availablechemotherapeutic treatment is costly and losing its'effectiveness. It is estimated that more than 1 million childrenand adults have been affected in this region alone since themid-1980s. Sporadic but increasing outbreaks of another emergingdisease, Japanese encephalitis (JE), also causes many deaths.Adequate diagnosis and treatment are lacking. Although apreventive vaccine for JE is available, significant costreductions will be needed if it is to be made affordable fordeveloping countries.

Over the past 40 years, USAID supported the control of malaria inNepal, and move recently supported the development of aVector-borne Disease Center for the Division of Epidemiology andDisease Control of the Ministry of Health (MOH) of Nepal. TheCenter is centrally located in the Terai region where the bulk ofvector-borne diseases are found. Through its Environmental HealthProject (EHP), USAID provided overall leadership and coordinationof a multi-agency response to emerging vector-borne disease inNepal. In addition, the Government of Japan agreed to providefunding for local use of insecticides in areas in which Kala-azaris endemic. Finally, CDC is providing support for technicaltraining of key staff in surveillance and control methods for JE.

This leveraging of the resources of collaborating agencies andgovernments has proven to be an essential component in addressingemerging diseases as public health issues, and should be aprerequisite for mounting effective response strategies in thefuture. The Center in Nepal has also benefited from theenvironmental health approach of EHP as it plans to conductoperational research to improve understanding of the mechanismsof the diseases at the community level.

As a result of local commitment, hard work, and foreign aid,Nepal will have the local capacity and appropriate tools tomonitor future outbreaks of these and other emerging/re-emergingregional vector-borne diseases including malaria, denguehemorrhagic fever, and plague.

International Resources Related to Infectious Diseases

Disease-Specific ("vertical") networks:
Global Polio Eradication Program
Global Program on AIDS (now UNAIDS)
Global Tuberculosis Program
Global Influenza Network
Division of Communicable Diseases
Control of Diarrheal Diseases and Acute Respiratory Infections
Leprosy Elimination Program
Arbovirus and Hemorrhagic Fever Collaborating Centres (AHFCC)
Control of Tropical Diseases
WHO/World Bank/UNDP Joint programme for the Strengthening of
Tropical Diseases Research
Children's Vaccine Initiative
International Office of Epizootics Worldwide Information System
Collaborating Centers and Laboratories
PAHO (Pan American Health Organization)
WHO Regional Office for the Americas
Caribbean Epidemiology Centre (CAREC) , Trinidad
Instituto de Nutricion para Centro America y Panama (INCAP),Guatemala
Division of Disease Control and Prevention, Washington, DC
Special Program for Vaccines and Immunizations

International Clinical Epidemiology Network (INCLEN), Inc.

Food and Agriculture Organization (FAO) Reference Centres

French Scientific Research institute (e.g., Senegal, Congo, Coted'Ivoire)

Pasteur Institutes (e.g., in Algeria, Central African Republic,French Guiana, Iran, Madagascar, Morocco, New Caledonia, Senegal,Vietnam)

Research Institute for Tropical Medicine, Philippines

Institute of Medical Research, Papua, New Guinea

Noguchi Center, Ghana

Office of Research and Development scientists and engineersdevelop and evaluate practical, effective techniques fordisinfecting drinking water.
Infectious Disease Field Stations (Cote d'Ivoire, Guatemala,Kenya, Sierra Leone, Thailand, Botswana)
FETPs (Australia, Canada, Columbia, Egypt, Hungary, Indonesia,Italy, Mexico, Peru, Philippines, Saudi Arabia, Spain, Taiwan, Thailand, Uganda, United States, and Zimbabwe)

U.S. Army Research Facilities (Brazil, Kenya, Thailand) NavalResearch Facilities (Egypt, Indonesia, Peru)
Armed Forces Medical Intelligence Center
U.S. Army Medical Institute of Infectious Diseases
Uniformed Services University of the Health Sciences
Armed Forces Institute of Pathology
Armed Forces Epidemiology Board
Armed Services Pest Management Board
National Institute of Allergy and Infectious Disease SupportedFacilities (e.g. Brazil, Colombia, Israel, Mali, Mexico,Philippines, Sudan, Uganda, Venezuela, Zimbabwe)

The Fogarty International Center has established a network ofinvestigators trained in HIV-related research and epidemiologyand strengthened institutions in over 65 countries in Africa,Asia, and Latin America.

Collaborative programs with U.S. universities based in developing
Program in Worldwide Control of Sexually Transmitted Diseases(STD/AIDS)
Schistosomiasis Research Project, in collaboration with the
Ministry of Health in Egypt
Center for Population and Health Research, Bangladesh
International Clinical Epidemiology Network in India(INCLEN/India)
Program for Appropriate Technology in Health (PATH)
Disease control programs in over 40 countries and researchinstitutions in over 30 countries
Other U.S. resources abroad
Peace Corps (medical surveillance system)
Department of State (medical facilities and numerous research andtraining programs administered collaboratively by American andforeign universities, with funding by Fogarty, other branches ofthe NIH, USAID, or private foundations.

Cholera in Peru: An Example of Prevention, Preparation, andMitigation in a Health Emergency

The effective response to the cholera epidemic in Peru in 1991was launched from a base of sustained research, education,training and institutional capacity building. Death rates inexcess of 7% and as high as 20% were expected, based on mortalityfrom recent cholera epidemics in other regions, such as Africa;but mortality was less than 1%.

What made the difference?

Between 1985 and 1991 USAID supported several epidemiologicsurveillance systems and child survival programs, includingdiarrheal disease control programs involving oral rehydrationtherapy. Education in the use of diarrheal disease controlmeasures, combined with a high level of political and technicalcoordination, made it possible to deal successfully with cholerawhen it re-emerged, after an absence of almost 100 years. Ascholera spread in Peru, deaths were kept to a minimum through theaggressive use of diarrheal control measures. Such measures werealready institutionalized in the public health infrastructure bythe Ministry of Health.

A U.S. Government interagency effort (USAID, EPA, DOD, CDC andthe FDA) assisted the Government of Peru in responding to theoutbreak. Disease control was established in a relatively shortperiod of time because of the programs already in place,including the human and institutional resources developed overtime to address diarrheal diseases.

What more can be done to prepare and prevent emerging infectiousdiseases?

Cholera is spread when food and drinking water are contaminatedwith fecal waste. The first line in prevention, therefore, isadequate human waste disposal, clean drinking water, and sanitarypreparation and storage of food. The technologies necessary toprevent contamination can be as simple and cheap as appropriatelyplaced and maintained latrines, household disinfection ofdrinking water and frequent hand-washing. Thus education programsin simple but effective interventions may help minimize thepotential for future cholera outbreaks.

New technologies and research may also contribute to preparingfor and preventing future outbreaks. Research is being conductedto develop a more effective cholera vaccine and to identifyuseful forecasting tools. The expertise of such institutions asthe Center for Health and Population Research is being tapped toprovide guidelines and training for NGOs involved in respondingto outbreaks of cholera and other diarrheal diseases.

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Report on International Science - Table of Contents


Executive Summary

Section I. Introduction

Section II.

Section III.

Section IV.

Section V.

Section VI.

Section VII.