Improving Biosurveillance Systems to Strengthen Global Health Security

“People are beginning to understand there is nothing in the world so remote that it can’t impact you as a person.”—William H. Foege, Director, US Centers for Disease Control, 1977–1983

Prepared by Cecilia Huaman for the Office of the Assistant Secretary for Preparedness and Response (ASPR)

The emergence and re-emergence of infectious diseases, zoonotic, high-risk diseases worldwide are threats to public health systems. The Ebola outbreak in Western Africa in 20141, and the 2009 H1N1 pandemic2, provided us with a firm lesson: the need of a Global Biosurveillance System in place to detect, respond and prevent worldwide dissemination of infectious and public health risks. Hence, a fundamental principle: no country can ensure the health of its population in isolation from the rest of the world3. In order to prevent, detect and effectively respond to infectious disease threats, US needs to continue international partnerships and collaborations, taking into account demographic change, urbanization, socioeconomic development, cultural beliefs and behavioral practices. The 2005 International Health Regulations agreement (IHR)4 offered a legal and political framework for international engagement that ties reporting to response and promotes capacity-building in developing countries. Under the IHR, each WHO member nation must maintain or develop core competencies in disease surveillance, reporting, and response capacity, with industrialized nations providing support to developing nations in building and strengthening these competencies. In July 2012, the White House issued the National Strategy for Biosurveillance, which defines the term and sets out key functions and guiding principles.

The Department of Defense (DoD) carries out biosurveillance to monitor the health of military and affiliated populations and supports biosurveillance in other countries through a range of programs across the department.In fiscal year 2013, The Global Emerging Infectious Surveillance and Response System (GEIS) funded 33 distinct DoD and non-DoD partners and supported a network of approximately 75 countries in U.S. Africa-, U.S. Central-, U.S. European-, U.S. Pacific-, and U.S. Southern-Command. GEIS collaborates with partner countries to support their surveillance for five key syndromes of interest to the countries and to DoD: (1) respiratory infections, with an emphasis on avian and pandemic influenza (2) gastrointestinal infections (3) febrile and vector-borne infections (4) antimicrobial resistance (5) sexually-transmitted infections. Based on the RAND corporation report5, and pilot assessment reports from Peru6 and Uganda7, I present the following recommendations:Language and cultural competences are critical to support, communicate and successfully implement biosurveillance programs in the different countries. From the team that assessed Peruvian biosurveillance programs only one person spoke Spanish.Training programs: Training programs are currently insufficient to develop the personnel infrastructure for the biosurveillance mission. At implementing a biosurveillance program in any country, we need to considerate current medical workforce; in developed countries there is 4-5 physicians per 1,000 people, Peru had 1.1 physicians per 1,000 people (2012)8, and most of African countries had no data or 0.2 physicians per 1,000 people.Interdisciplinary capacity: Individuals with a wide variety of skills are needed to support biosurveillance, particularly in informatics, vector biology, behavioral epidemiology and environmental health. The deficiency on interdisciplinary capacity reflects in Uganda, for instance, the surveillance plan for antimicrobial resistance scored zero. In contrast, Uganda GHSA reporting scored 4, indicator of appropriate workforce for that task.Sustainability: Recruiting and retaining biosurveillance professionals requires a sustained funding commitment, as a biosurveillance system should remain functional once implemented. Assessment of GHSA Emergency Operations Centers scored 1 in Peru with the remark: “The space, the equipment and the facilities should be improved to be useful for the good work done”.Diagnostics: Technical innovations based on molecular techniques are needed to increase the specificity, speed, reliability, and availability of diagnostic testing. A standardized method for electronic reporting of results for early detection of emerging diseases is required as well. Appendix-D from Moore et al report5, lists Sierra Leone lacking of a plan to detect/diagnose respiratory illness. Sierra Leone, like Guinea and Liberia were unprepared for Ebola at the onset of the epidemic 1.Globally, human public health is intrinsically linked to animal health and agriculture. Biosurveillance investments in these sectors are as strategically important as investments in human health biosurveillance, and these should be included in the plans moving forward.

References:

Regmi K, Gilbert R, Thunhurst C. 2015. How can health systems be strengthened to control and prevent an Ebola outbreak? A narrative review. Infect Ecol Epidemiol. 2015 Nov 24;5:28877Stoto MA. 2014.

Biosurveillance capability requirements for the global health security agenda: lessons from the 2009 H1N1 pandemic. Biosecur Bioterror. 2014 Sep-Oct;12(5):225-30De Cock KM, Simone PM, Davison V, Slutsker L. 2013. The new global health. Emerg Infect Dis (19)8:1192-97.http://www.who.int/ihr/en/ Accessed on 11/29/2015Melinda Moore, Gail Fisher, Clare Stevens. 2013.

Toward Integrated DoD Biosurveillance Assessment and Opportunities: Research Report. RAND Corporation.GLOBAL HEALTH SECURITY AGENDA PILOT ASSESSMENT OF PERU. January 26 to 30, 2015GLOBAL HEALTH SECURITY AGENDA PILOT ASSESSMENT OF UGANDA. February 16 – 20, 2015http://data.worldbank.org/indicator/SH.MED.PHYS.ZS Accessed on 11/30/2015.

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